Articles tagged as "Key populations"

High spatial variation of HIV – implications for focused responses

Heterogeneity of the HIV epidemic in agrarian, trading, and fishing communities in Rakai, Uganda: an observational epidemiological study.

Chang LW, Grabowski MK, Ssekubugu R, Nalugoda F, Kigozi G, Nantume B, Lessler J, Moore SM, Quinn TC, Reynolds SJ, Gray RH, Serwadda D, Wawer MJ. Lancet HIV. 2016 Aug;3(8):e388-96. doi: 10.1016/S2352-3018(16)30034-0. Epub 2016 Jul 9.

Background: Understanding the extent to which HIV burden differs across communities and the drivers of local disparities is crucial for an effective and targeted HIV response. We assessed community-level variations in HIV prevalence, risk factors, and treatment and prevention service uptake in Rakai, Uganda.

Methods: The Rakai Community Cohort Study (RCCS) is an open, population-based cohort of people aged 15-49 years in 40 communities. Participants are HIV tested and interviewed to obtain sociodemographic, behavioural, and health information. RCCS data from Aug 10, 2011, to May 30, 2013, were used to classify communities as agrarian (n=27), trading (n=9), or lakeside fishing sites (n=4). We mapped HIV prevalence with Bayesian methods, and characterised variability across and within community classifications. We also assessed differences in HIV risk factors and uptake of antiretroviral therapy and male circumcision between community types.

Findings: 17 119 individuals were included, 9215 (54%) of whom were female. 9931 participants resided in agrarian, 3318 in trading, and 3870 in fishing communities. Median HIV prevalence was higher in fishing communities (42%, range 38-43) than in trading (17%, 11-21) and agrarian communities (14%, 9-26). Antiretroviral therapy use was significantly lower in both men and women in fishing communities than in trading (age-adjusted prevalence risk ratio in men 0.64, 95% CI 0.44-0.97; women 0.53, 0.42-0.66) and agrarian communities (men 0.55, 0.42-0.72; women 0.65, 0.54-0.79), as was circumcision coverage among men (vs trading 0.48, 0.42-0.55; vs agrarian 0.64, 0.56-0.72). Self-reported risk behaviours were significantly higher in men than in women and in fishing communities than in other community types.

Interpretation: Substantial heterogeneity in HIV prevalence, risk factors, and service uptake in Rakai, Uganda, emphasises the need for local surveillance and the design of targeted HIV responses. High HIV burden, risk behaviours, and low use of combination HIV prevention in fishing communities make these populations a priority for intervention.

Abstract access  


Editor’s notes: National estimates of HIV prevalence often conceal concentrated ‘sub-epidemics’ in particular geographical areas or populations. In this paper, the authors illustrate that within the Rakai region of Uganda, there is extensive community-level variation in HIV prevalence, behavioural risk factors, and HIV service coverage. Such clustering of HIV infections can reduce the impact of population-based prevention. UNAIDS, along with other organisations, have called for a more focused response to HIV treatment and prevention, concentrating efforts on key populations to increase the effectiveness of programmes. While regional and national data are important to provide an overview of the epidemic, they do not provide the in-depth picture that is necessary. Understanding the extent to which HIV prevalence differs across communities and the drivers of these differences is crucial to provide an effective, community-specific HIV response. In Rakai, HIV prevalence was 2-3 times higher, and ART use was nearly 50% lower, in fishing communities than in trading and agrarian communities.  However, the areas with the highest number of people living with HIV were in the larger, lower risk populations. One of the challenges of focused treatment and prevention programmes is the identification of geographical areas or sub-populations at highest risk. A better understanding of the community-level heterogeneity and transmission links between high and low risk areas is necessary. In this study, detailed household surveillance and epidemiological data were available; however, such fine-scale data are often not available. This finding of extensive heterogeneity across relatively close and seemingly similar communities has implications for focused approaches to HIV programmes, and demonstrates the importance of strong local HIV surveillance data.

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Negative police activity a structural determinant of HIV

Policing practices as a structural determinant for HIV among sex workers: a systematic review of empirical findings.

Footer KH, Silberzahn BE, Tormohlen KN, Sherman SG. J Int AIDS Soc. 2016 Jul 18;19(4 Suppl 3):20883. doi: 10.7448/IAS.19.4.20883. eCollection 2016.

Introduction: Sex workers are disproportionately infected with HIV worldwide. Significant focus has been placed on understanding the structural determinants of HIV and designing related interventions. Although there is growing international evidence that policing is an important structural HIV determinant among sex workers, the evidence has not been systematically reviewed.

Methods: We conducted a systematic review of quantitative studies to examine the effects of policing on HIV and STI infection and HIV-related outcomes (condom use; syringe use; number of clients; HIV/STI testing and access) among cis and trans women sex workers. Databases included PubMed, Embase, Scopus, Sociological Abstracts, Popline, Global Health (OVID), Web of Science, IBSS, IndMed and WHOLIS. We searched for studies that included police practices as an exposure for HIV or STI infection or HIV-related outcomes.

Results: Of the 137 peer-reviewed articles identified for full text review, 14 were included, representing sex workers' experiences with police across five settings. Arrest was the most commonly explored measure with between 6 and 45% of sex workers reporting having ever been arrested. Sexual coercion was observed between 3 and 37% of the time and police extortion between 12 and 28% across studies. Half the studies used a single measure to capture police behaviours. Studies predominantly focused on "extra-legal policing practices," with insufficient attention to the role of "legal enforcement activities". All studies found an association between police behaviours and HIV or STI infection, or a related risk behaviour.

Conclusions: The review points to a small body of evidence that confirms policing practices as an important structural HIV determinant for sex workers, but studies lack generalizability with respect to identifying those police behaviours most relevant to women's HIV risk environment.

Abstract  Full-text [free] access 

Editor’s notes: The paper reports on a systematic review, which explored how quantitative research to date has operationalized the measurement of law enforcement practices as a structural determinant of HIV for female (including transgender) sex workers. The authors reviewed 14 quantitative studies using policing practices as a micro-structural determinant for HIV risk among sex workers. They found substantial heterogeneity in both the police measures and the health outcomes considered by the different studies. Overall, the studies found that police measures were regularly reported by sex workers, with an average of 34% of sex workers experiencing at least one police measure. They found that arrest was the most commonly explored measure in the studies. Following this, sexual coercion and then police extortion were important.

The studies reported that these police measures were consistently, positively, associated with either HIV infection or STI symptoms or with inconsistent condom use. Having ever been arrested, sexual coercion, police extortion, and syringe confiscation was associated with an increased risk of acquiring an HIV infection or an STI. These measures, and displacement by the police, were also associated with inconsistent condom use. Intervening on interactions between sex workers and the police reduced HIV risk over the time of the programme.

The authors argue that these findings point to the potentially pivotal role that the police have as a structural determinant for HIV in vulnerable populations. However, they argue that nearly all the papers identified in this review fail to take account of the complexities of the risk environment in which law enforcement occurs. The authors thus suggest a need for better measures for legal and extra-legal enforcement practices as mechanisms through which sex workers’ HIV risk is mediated.

Africa, Asia, Europe, Latin America
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New evidence in support of opioid substitution therapy as a key HIV programme for people who inject drugs

Impact of opioid substitution therapy on antiretroviral therapy outcomes: a systematic review and meta-analysis.

Low AJ, Mburu G, Welton NJ, May MT, Davies CF, French C, Turner K, Looker KJ, Christensen H, McLean S, Rhodes T, Platt L, Hickman M, Guise A, Vickerman P. Clin Infect Dis. 2016 Jun 25. pii: ciw416. [Epub ahead of print]

Background: HIV-positive people who inject drugs (PWID) frequently encounter barriers accessing and remaining on antiretroviral treatment (ART). Some studies have suggested that opioid substitution therapy (OST) could facilitate PWID's engagement with HIV services. We conducted a systematic review and meta-analysis to evaluate the impact of concurrent OST use on ART-related outcomes among HIV-positive PWID.

Methods: We searched Medline, PsycInfo, Embase, Global Health, Cochrane, Web of Science, and Social Policy and Practice databases for studies between 1996 to November 2014 documenting the impact of OST, compared to no OST, on ART outcomes. Outcomes considered were: coverage and recruitment onto ART, adherence, viral suppression, attrition from ART, and mortality. Meta-analyses were conducted using random effects modelling, and heterogeneity assessed using Cochran's Q test and I2 statistic.

Results: We identified 4685 articles, and 32 studies conducted in North America, Europe, Indonesia and China were included. OST was associated with a 69% increase in recruitment onto ART (HR=1.69, 95% confidence interval (CI): 1.32-2.15), a 54% increase in ART coverage (OR=1.54; 95% CI: 1.17-2.03), a two-fold increase in adherence (OR=2.14, 95% CI: 1.41-3.26), and a 23% decrease in the odds of attrition (OR=0.77, 95% CI:0.63-0.95). OST was associated with a 45% increase in odds of viral suppression (OR=1.45, 95%CI:1.21-1.73), but there was limited evidence from six studies for OST decreasing mortality for PWID on ART (HR=0.91, 95% CI:0.65-1.25).

Conclusions: These findings support the use of OST, and its integration with HIV services, to improve the HIV treatment and care continuum amongst HIV-positive PWID.

Abstract access

Editor’s notes: This is a very important study contributing new evidence on how opioid substitution therapy can help in the treatment and prevention of HIV among people who inject drugs. This review provides key evidence in support of opioid substitution therapy as a cornerstone HIV treatment and prevention programme. This evidence is essential given the growing number of HIV infections among people who inject drugs globally, particularly in eastern Europe and sub-Saharan Africa. There is a wealth of evidence from systematic reviews and mathematical modelling to illustrate how the use of opioid substitution therapy decreases risk of HIV acquisition at an individual-level.  It can also reduce HIV prevalence and incidence at the population level. This review is important in that it illustrates how opioid substitution therapy can facilitate HIV treatment.  Findings illustrate that opioid substitution therapy works by increasing adherence to HIV treatment, decreasing attrition from treatment and increasing odds of viral suppression reducing the odds of onwards HIV transmission. In addition to this important review, there is also a need to understand the role opioid substitution therapy might have in increasing uptake of HIV testing. This review does not address that question. It is notable that few studies on impact of opioid substitution therapy on HIV treatment outcomes and uptake included in the review were identified in low-income countries or eastern Europe where need is greatest. This partly reflects the lack of opioid substitution therapy programmes in that region, particularly the Russian Federation. This is also the case in sub-Saharan Africa where opioid substitution therapy programmes are newly established and yet to be evaluated. Future research is necessary to understand how opioid substitution therapy might work: (1) where transmission of HIV is predominantly sexual and (2) where injecting drug use occurs within very different social and economic contexts.

Asia, Europe, Northern America
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Unique needs of gay men in sub-Saharan Africa identified with respondent-driven sampling

Respondent-driven sampling as a recruitment method for men who have sex with men in southern sub-Saharan Africa: a cross-sectional analysis by wave.

Stahlman S, Johnston LG, Yah C, Ketende S, Maziya S, Trapence G, Jumbe V, Sithole B, Mothopeng T, Mnisi Z, Baral S. Sex Transm Infect. 2016 Jun;92(4):292-8. doi: 10.1136/sextrans-2015-052184. Epub 2015 Sep 30.

Objectives: Respondent-driven sampling (RDS) is a popular method for recruiting men who have sex with men (MSM). Our objective is to describe the ability of RDS to reach MSM for HIV testing in three southern African nations.

Methods: Data collected via RDS among MSM in Lesotho (N=318), Swaziland (N=310) and Malawi (N=334) were analysed by wave in order to characterise differences in sample characteristics. Seeds were recruited from MSM-affiliated community-based organisations. Men were interviewed during a single study visit and tested for HIV. X2 tests for trend were used to examine differences in the proportions across wave category.

Results: A maximum of 13-19 recruitment waves were achieved in each study site. The percentage of those who identified as gay/homosexual decreased as waves increased in Lesotho (49% to 27%, p<0.01). In Swaziland and Lesotho, knowledge that anal sex was the riskiest type of sex for HIV transmission decreased across waves (39% to 23%, p<0.05, and 37% to 19%, p<0.05). The percentage of participants who had ever received more than one HIV test decreased across waves in Malawi (31% to 12%, p<0.01). In Lesotho and Malawi, the prevalence of testing positive for HIV decreased across waves (48% to 15%, p<0.01 and 23% to 11%, p<0.05). Among those living with HIV, the proportion of those unaware of their status increased across waves in all study sites although this finding was not statistically significant.

Conclusions: RDS that extends deeper into recruitment waves may be a promising method of reaching MSM with varying levels of HIV prevention needs.

Abstract access  

Editor’s notes: The HIV risk profile of gay men and other men who have sex with men have not been well-characterised within sub-Saharan African countries. These key populations are traditionally difficult to reach for purposes of estimating the prevalence of HIV and of behavioural risk factors, and for prevention outreach. This study enrolled recruiters from community based organizations which served gay men and other men who have sex with men in Malawi, Lesotho and Swaziland. Each of these ‘seeds’ could recruit up to three participants. Each subsequent participant could recruit another three participants into a new ‘wave’. The profiles of participants changed in each setting with each additional recruitment wave. Men in Swaziland were less likely to know that anal sex was the riskiest type of sex, men in Malawi were less likely to have ever tested for HIV, and men in Lesotho were less likely to have disclosed their sexual orientation to family members. This type of respondent-driven sampling can be replicated to identify men who are removed from community-based organisations, and to identify their unique service needs. Future research can consider whether the hardest-to-reach men are also people at highest risk of HIV infection.

Lesotho, Malawi, Swaziland
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Does place of sex change risk behaviours among men who have sex with men?

Is location of sex associated with sexual risk behaviour in men who have sex with men? Systematic review of within-subjects studies.

Melendez-Torres GJ, Nye E, Bonell C. AIDS Behav. 2016 Jun;20(6):1219-27. doi: 10.1007/s10461-015-1093-z.

To understand associations between location of sex and sexual risk, it is most helpful to compare sexual encounters within persons. We systematically reviewed within-subjects comparisons of sexual encounters reported by men who have sex with men (MSM) with respect to location of sex. Within-subjects comparisons of sexual risk and location of sex were eligible if they collected data post-1996 from samples of MSM. We independently screened results and full-text records in duplicate. Of 6336 de-duplicated records, we assessed 138 full-text studies and included six, most of which compared unprotected anal intercourse against other anal intercourse. This small, but high quality, body of evidence suggests that associations between attendance at sex-on-premises venues and person-level sexual risk may be due to overall propensity towards unprotected sex. However, there may be some location factors that promote or are associated with serononconcordant unprotected anal intercourse. Health promoters may wish to focus on person-level characteristics.

Abstract access

Editor’s notes: Venues where gay men and other men who have sex with men, have sex, fit broadly into three categories. These are: i) sex-on premises venues (indoor locations outside the home e.g. bathhouses, saunas, sex clubs, porn cinemas, public sex parties), ii) public sex environments (cruising locations / beats e.g. outdoor parks) and iii) homes of sexual partners. Men will usually have anonymous sexual encounters or sex with casual partners in the first two location categories. Use of specific locations for sex may be associated with specific sexual risk-taking at the person level. However, it is unclear if sexual risk is greater in certain venues compared to others. Is there a ‘location effect’ on sexual risk? Or put in a different way, does the same person behave differently (in terms of sexual risk), depending on the venue where they are having sex? To examine this, it is necessary to compare several sexual encounters within respondents at different sex locations. The authors of this paper systematically reviewed studies which reported within-subjects comparisons analysing the encounter-level association between location of sex and sexual risk behaviours among gay men and other men who have sex with men.

Six studies were included in the final review – four from the United States and two from Australia. It was not possible to conduct a meta-analysis due to differences in defining venue and sexual risk behaviours. Overall, the authors found little evidence of differences between condomless versus protected anal intercourse between public and private locations for sex. Additional studies are necessary, including how smartphone-mediated sex seeking is changing the locations and risk environment where gay men and other men will have sex with men. Research from other countries and contexts is also warranted.    

Northern America, Oceania
Australia, United States of America
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Fishing, injection drug use and HIV risk

The association between psychosocial and structural-level stressors and HIV injection drug risk behavior among Malaysian fishermen: a cross-sectional study.

Michalopoulos LM, Jiwatram-Negron T, Choo MK, Kamarulzaman A, El-Bassel N. BMC Public Health. 2016 Jun 2;16(1):464. doi: 10.1186/s12889-016-3125-7.

Background: Malaysian fishermen have been identified as a key-affected HIV population with HIV rates 10 times higher than national rates. A number of studies have identified that psychosocial and structural-level stressors increase HIV injection drug risk behaviors. The purpose of this paper is to examine psychosocial and structural-level stressors of injection drug use and HIV injection drug risk behaviors among Malaysian fishermen.

Methods: The study employs a cross-sectional design using respondent driven sampling methods. The sample includes 406 fishermen from Pahang state, Malaysia. Using multivariate logistic regressions, we examined the relationship between individual (depression), social (adverse interactions with the police), and structural (poverty-related) stressors and injection drug use and risky injection drug use (e.g.., receptive and non-receptive needle sharing, frontloading and back-loading, or sharing drugs from a common container).

Results: Participants below the poverty line had significantly lower odds of injection drug use (OR 0.52, 95 % CI: 0.27-0.99, p = 0.047) and risky injection drug use behavior (OR 0.48, 95 % CI: 0.25-0.93, p = 0.030). In addition, participants with an arrest history had higher odds of injection use (OR 19.58, 95 % CI: 9.81-39.10, p < 0.001) and risky injection drug use (OR 16.25, 95 % CI: 4.73-55.85, p < 0.001). Participants with depression had significantly higher odds of engaging in risky injection drug use behavior (OR 3.26, 95 % 1.39-7.67, p = 0.007). Focusing on participants with a history of injection drug use, we found that participants with depression were significantly more likely to engage in risky drug use compared to participants below the depression cutoff (OR 3.45, 95 % CI: 1.23-9.66, p < 0.02).

Conclusions: Findings underscore the need to address psychosocial and structural-level stressors among Malaysian fishermen to reduce HIV injection drug risk behaviors.

Abstract  Full-text [free] access 

Editor’s notes: There is an increasing amount of research on high rates of HIV infection among people living in fishing communities in parts of Africa and Asia. There is also a lot of information on factors which put people in these fishing communities at risk of HIV infection. This paper is, however, the first study to look in detail at the association between risky injection drug use behaviours and HIV among fishermen. The authors of this fascinating and important paper provide a detailed analysis on the association between, what they call, individual, social and structural factors which contribute to risk. Interestingly, poorer fishermen were at less risk than fishermen who were better off, perhaps because poorer men could not afford the costs of injection drugs. However, the fear of the police, and the risk of arrest, resulted in injection practices which increased the risk of HIV infection. The authors note that the association between symptoms of depression and risky injection drug use may be an outcome of this behaviour rather than the cause. The authors highlight how fishermen using injection drugs to manage stress and risk in their lives, may compound the stress they face by this behaviour. The paper illustrates, very clearly, the complex relationship there often is between individual behaviours and the structural and social context. The authors provide very useful pointers for unpacking risk and HIV-infection in other similar populations. 

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Routine programmatic data used to estimate HIV incidence and service uptake among female sex workers in Zimbabwe

Implementation and operational research: cohort analysis of program data to estimate HIV incidence and uptake of HIV-related services among female sex workers in Zimbabwe, 2009-2014.

Hargreaves JR, Mtetwa S, Davey C, Dirawo J, Chidiya S, Benedikt C, Naperiela Mavedzenge S, Wong-Gruenwald R, Hanisch D, Magure T, Mugurungi O, Cowan FM. J Acquir Immune Defic Syndr. 2016 May 1;72(1):e1-8. doi: 10.1097/QAI.0000000000000920.

Background: HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource.

Methods: Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach.

Results: Data were available for 13 360 women, 31 389 visits, 14 579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the program only once. FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9).

Conclusions: Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.

Abstract access

Editor’s notes: Female sex workers in resource poor regions have been shown to have higher levels of HIV incidence and prevalence than people in the general population. Due to the highly stigmatised and often illegal nature of their work, these individuals are often marginalised in society. This can lead to poor engagement with the HIV testing and treatment programmes provided for the general population. Targeted outreach programmes for female sex workers such as the “Sisters for Change” programme in Zimbabwe described in this paper, aim to improve the engagement with testing and care for this group.

Collecting reliable data from female sex workers using a convenience sampling approach in order to estimate the prevalence of HIV is challenging due to the difficulty in ensuring the survey sample is representative of the wider female sex worker population. An alternative approach is respondent driven sampling (RDS) in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations. The results from RDS are however complex to analyse and interpret.

This paper presents an alternative approach using routinely collected data. Using the dates of programme visits, HIV tests (conducted both within and outside of the programme) and dates of antiretroviral initiation, the researchers generated estimates of HIV prevalence (number of positive tests/total number of tests) and HIV incidence (time at risk calculated from the first visit to an imputed date of seroconversion). They also identified risk factors associated with socio-demographic parameters or HIV testing history that were associated with a failure to continue engagement with the programme after a first visit. The prevalence and incidence results are consistent with results from a series of RDS surveys previously conducted in Zimbabwe by this research team.

A difficulty highlighted by the authors is that while this method improves on convenience sampling, it is still difficult to know how HIV incidence and prevalence among programme participants compares to that in the wider female sex worker population. 

In summary this paper presents an approach by which similar programmes elsewhere could make better use of routinely collected data in order to generate estimates of impact and also identify sub-groups of female sex workers with poorer engagement with care. This in turn could lead to a more effective targeting of limited resources.

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Oral PrEP reduces risk of HIV and does not result in riskier sex

Effectiveness and safety of oral HIV pre-exposure prophylaxis (PrEP) for all populations: A systematic review and meta-analysis.

Fonner VA, Dalglish SL, Kennedy CE, Baggaley R, O'Reilly K R, Koechlin FM, Rodolph M, Hodges-Mameletzis I, Grant RM. AIDS. 2016 May 5. [Epub ahead of print]

Objective: Pre-exposure prophylaxis (PrEP) offers a promising new approach to HIV prevention. This systematic review and meta-analysis evaluated the evidence for use of oral PrEP containing tenofovir disoproxil fumarate (TDF) as an additional HIV prevention strategy in populations at substantial risk for HIV based on HIV acquisition, adverse events, drug resistance, sexual behavior, and reproductive health outcomes.

Design: Rigorous systematic review and meta-analysis.

Methods: A comprehensive search strategy reviewed three electronic databases and conference abstracts through April 2015. Pooled effect estimates were calculated using random-effects meta-analysis.

Results: Eighteen studies were included, comprising data from 39 articles and six conference abstracts. Across populations and PrEP regimens, PrEP significantly reduced the risk of HIV acquisition compared to placebo. Trials with PrEP use >70% demonstrated the highest PrEP effectiveness (RR = 0.30, 95% CI: 0.21-0.45, p < 0.001) compared to placebo. Trials with low PrEP use did not show a significantly protective effect. Adverse events were similar between PrEP and placebo groups. More cases of drug-resistant HIV infection were found among PrEP users who initiated PrEP while acutely HIV-infected, but incidence of acquiring drug-resistant HIV during PrEP use was low. Studies consistently found no association between PrEP use and changes in sexual risk behavior. PrEP was not associated with increased pregnancy-related adverse events or hormonal contraception effectiveness.

Conclusion: PrEP is protective against HIV infection across populations, presents few significant safety risks, and no evidence of behavioral risk compensation. The effective and cost-effective use of PrEP will require development of best practices for fostering uptake and adherence among people at substantial HIV-risk.

Abstract access

Editor’s notes: This systematic review is the first to aggregate data from across oral pre-exposure prophylaxis (PrEP) studies, including randomized control trials and observational studies, to present clear evidence on the effectiveness of oral PrEP use. The findings confirm that oral PrEP significantly reduces the risk of acquiring HIV if taken consistently and correctly across populations, countries, and most age groups. Differences in efficacy directly correlate with adherence, which accounts for the lower efficacy seen in some subgroups. Perhaps two of the most compelling analyses presented in this paper relate to resistance and behavioural disinhibition. The risk of resistance was shown to be quite low, and study participants exhibiting resistant HIV either enrolled in the studies during an acute infection stage or acquired resistant strains during the course of the research. Regarding behavioural disinhibition, indicators measured such as rates of sexually transmitted infections revealed that PrEP use in the efficacy trials was not associated with behavioural disinhibition and in some studies, resulted in even safer sexual behaviour than what was reported at baseline. Recently completed demonstration projects have reported increased rates of STIs among gay men and other men who have sex with men. However, in the open-label extensions included in this review, where counselling was more intensive, safer sex practices were maintained, thus suggesting that counselling can be effective in preventing behavioural disinhibition. 

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How research can both provide evidence of burden of disease and facilitate access to services

Integrated respondent-driven sampling and peer support for persons who inject drugs in Haiphong, Vietnam: a case study with implications for interventions.

Des Jarlais D, Duong HT, Pham Minh K, Khuat OH, Nham TT, Arasteh K, Feelemyer J, Heckathorn DD, Peries M, Moles JP, Laureillard D, Nagot N. AIDS Care. 2016 May 13:1-4. [Epub ahead of print]

Combined prevention for HIV among persons who inject drugs (PWID) has led to greatly reduced HIV transmission among PWID in many high-income settings, but these successes have not yet been replicated in resource-limited settings. Haiphong, Vietnam experienced a large HIV epidemic among PWID, with 68% prevalence in 2006. Haiphong has implemented needle/syringe programs, methadone maintenance treatment (MMT), and anti-retroviral treatment (ART), but there is an urgent need to identify high-risk PWID and link them to services. We examined integration of respondent-driven sampling (RDS) and strong peer support groups as a mechanism for identifying high-risk PWID and linking them to services. The peer support staff performed the key tasks that required building and maintaining trust with the participants, including recruiting the RDS seeds, greeting and registering participants at the research site, taking electronic copies of participant fingerprints (to prevent multiple participation in the study), and conducting urinalyses. A 6-month cohort study with 250 participants followed the RDS cross-sectional study. The peer support staff maintained contact with these participants, tracking them if they missed appointments, and providing assistance in accessing methadone and ART. The RDS recruitment was quite rapid, with 603 participants recruited in three weeks. HIV prevalence was 25%, Hepatitis C (HCV) prevalence 67%, and participants reported an average of 2.7 heroin injections per day. Retention in the cohort study was high, with 86% of participants re-interviewed at 6-month follow-up. Assistance in accessing services led to half of the participants in need of methadone enrolled in methadone clinics, and half of HIV-positive participants in need of ART enrolled in HIV clinics by the 6-month follow-up. This study suggests that integrating large-scale RDS and strong peer support may provide a method for rapidly linking high-risk PWID to combined prevention and care, and greatly reducing HIV transmission among PWID in resource-limited settings.

Abstract access

Editor’s notes: This paper highlights that evidence on the effectiveness of harm reduction programmes including opioid substitution therapy, needle-syringe programmes and antiretroviral therapy, alone, and in combination have been shown to be effective in reducing incidence of HIV and hepatitis C in Europe, northern America and Australia. But evidence is lacking in countries with the largest or growing populations of people who inject drugs and high prevalence of HIV and hepatitis C. This is particularly true in low-income settings including South-East Asia and East Africa. But this is also true in high income countries such as the Russian Federation which has the fastest growing epidemic of HIV in the world, primarily among people who inject drugs. But opioid substitution therapy is prohibited. The paper is methodologically interesting. It demonstrates the feasibility of following-up a cohort of people who inject drugs over six months. More importantly, it illustrates how research can be used to link the most vulnerable members of the population, including people who inject frequently and people living with HIV who are not on treatment, into opioid substitution therapy and HIV treatment services. As well as demonstrating the practical use of research in increasing access to services, the research is also important for advocacy purposes. The authors illustrate the burden of HIV and hepatitis C among the population, further highlighting the need for harm reduction services and HIV/hepatitis C treatment. 

Viet Nam
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Sex on the move

Exploring the relationship between population mobility and HIV risk: evidence from Tanzania.

Deane KD, Samwell Ngalya P, Boniface L, Bulugu G, Urassa M. Glob Public Health. 2016 May 27:1-16. [Epub ahead of print]

Migration and population mobility has long been regarded as an important structural driver of HIV. Following initial concerns regarding the spatial spread of the disease, mobile populations are viewed to engage in higher levels of risky sexual behaviours than non-mobile groups. However, beyond the case studies of mineworkers and truck drivers, the statistical evidence is inconclusive, suggesting that the relationship between mobility and risk is not well understood. This study investigated how engaging in specific livelihoods that involve mobility influences sexual behaviour and HIV risk. A qualitative research project, including focus groups and in-depth interviews with key mobile groups, was conducted in Northern Tanzania. The findings show that the patterns and conditions of moving related to the requirements of each different economic activity influence the nature of relationships that mobile groups have whilst away, how and where local sexual networks are accessed, and the practicalities of having sex. This has further implications for condom use. Risk behaviours are also shaped by local sexual norms related to transactional sex, emphasising that the roles of mobility and gender are interrelated, overlapping and difficult to disentangle.

Abstract access  

Editor’s notes: Case studies with truck drivers and mineworkers have clearly shown a relationship between migration, mobility and HIV risk in sub-Saharan Africa. It remains unclear to what extent findings from these case studies can be extrapolated across all mobile populations. Evidence from studies in other populations is inconclusive, inconsistent and in some cases contradictory. This, in part is due to the limitations of the statistical frameworks used which tend to reduce migration to an abstract individual variable and fail to recognise migration as a dynamic socio-economic phenomenon. These frameworks may also inadequately reflect the variability of migratory behaviour offering limited policy conclusions for addressing HIV risk arising from migration or population mobility.

This qualitative study was conducted in North-western Tanzania in a population in which 60% of men and 43% of women were classified as mobile. Data were collected through focus group discussions and individual interviews with both female and male farmers and maize traders.

The findings of this study suggest that patterns and conditions of moving can influence the nature of sexual relationships that mobile individuals have while away. The findings offer important insights for future, more nuanced statistical work. This would include considering why people move, where they go, patterns of movement, the specific economic activities in which they engage, and where they stay while they are away. The findings also highlight the importance of situating the risk behaviours of mobile individuals within the sexual norms and practices around sex and exchange, and particularly transactional sex. The authors note that being mobile may exacerbate gendered and economic inequalities making the relative influences of mobility and sexual norms difficult to disentangle. This further highlights the value of HIV prevention programmes being specifically tailored to the specific needs of mobile populations.

United Republic of Tanzania
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