AIDSFree Prevention Update

The AIDSFree Prevention Update provides a sample of summaries and abstracts of recent articles on global HIV prevention issues from a variety of scientific, peer-reviewed journals. It also includes state-of-the-art program resources, such as tools, curricula, program reports, and unpublished research findings.

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January 2017

In Focus

World Health Organization (WHO) (December 2016).

On World AIDS Day 2016, WHO released the supplement to the consolidated guidelines on HIV testing services released in 2015. The supplement includes new recommendations and additional guidance on HIV self-testing (HIV ST) and assisted HIV partner notification services (PNS) to the following groups: general populations; pregnant and postpartum women; couples and partners; adolescents (10–19 years) and young people (15–24 years); key populations; and vulnerable populations. The supplement will support countries, program managers, health workers, and other stakeholders in achieving the United Nations (UN) 90-90-90 global HIV targets—and specifically the first target of diagnosing 90 percent of all people with HIV. The supplement aims to:

  • Support the implementation and scale-up of ethical, effective, acceptable, and evidence-informed approaches to HIV ST and PNS
  • Support the routine offer of voluntary assisted HIV PNS as part of a public health approach to delivering HIV testing services (HTS)
  • Provide guidance on how HIV ST and assisted HIV PNS could be integrated into both community- and facility-based HTS approaches and be tailored to specific population groups
  • Support the introduction of HIV ST as a formal HTS intervention using quality-assured, approved products
  • Position HIV ST and assisted HIV PNS as HTS approaches that will contribute to closing the testing gap and achieving the UN’s 90-90-90 and 2030 global goals.

Center for Health and Gender Equity (CHANGE) (November 30, 2016).

The purpose of this report is to inform U.S. policymakers, donors, and advocates about the DREAMS Initiative (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe). The report also identifies some of the challenges and opportunities for successful HIV prevention for adolescent girls and young women, who are disproportionately affected by HIV in sub-Saharan Africa. The DREAMS initiative aims to reduce HIV infections among adolescent girls and young women in 10 sub-Saharan African countries. In July 2016, CHANGE staff traveled to Kenya and South Africa, two countries that according to the U.S. President's Emergency Plan for AIDS Relief, were the farthest along in implementation, according to the U.S. President's Emergency Plan for AIDS Relief. CHANGE staff conducted interviews with adolescent girls and young women, prime partners, civil society, and U.S. Government officials to understand the experiences of DREAMS program participants, implementers, and funders. This report describes the implementation of DREAMS and assessed its attention to sexual and reproductive health and rights, strengths, and challenges in Kenya and South Africa. In addition to highlighting findings from the field, the report identifies U.S. policy restrictions that pose significant barriers to the DREAMS targets for HIV reduction among adolescent girls and young women. It offered several recommendations for improving outcomes, including improving engagement with community-based and grass-roots organizations.

Joint United Nations Programme on HIV/AIDS (UNAIDS) (November 2016).

In this report released by UNAIDS on World AIDS Day 2016, UNAIDS announced that 18.2 million people now have access to HIV treatment, and that the Fast-Track response was working. Increasing treatment coverage is reducing AIDS-related deaths among adults and children. However, the life-cycle approach (which encompasses the dynamics of HIV risk at different life stages) must focus on more than treatment. The report emphasized that the expansion of HIV prevention, testing, and treatment must continue at the Fast-Track pace agreed on by the United Nations General Assembly. Additionally investments must be made across the life cycle, using a location-population approach to ensure that evidence-informed, high-impact programs are available in the geographical areas and among the populations that are in greatest need.

United Nations International Children’s Emergency Fund (UNICEF).

This UNICEF report shows that both young children and adolescents continue to face high risk of HIV-related illness and death, despite recent improvements in access to treatment, life-saving drugs, and services for prevention of mother-to-child transmission. Children living with HIV (aged 0–4 years) face the highest risk of AIDS-related death compared to all other age groups. And even if recent progress is maintained, HIV incidence among adolescents (10–24 years) in Africa is projected to rise, given the rapid expansion of this population. In 2015, approximately 55 percent of new HIV infections (1.1 million of 2.1 million) were among women, children and adolescents. The report, released on World AIDS Day 2016, calls on stakeholders to focus on solutions for these extremely vulnerable populations. Ending HIV among children and adolescents will entail preventing new infections through improved access and retention in care, along with early testing and treatment, support for education, and social protection. The report also calls on stakeholders to work with partners and other development sectors to address funding gaps and build sustainable health care systems.

Behavioral Prevention

Nugroho, A., Erasmus, V., Zomer, T.P., Wu, Q., and Richardus, J.H. AIDS Care (June 2016), 29(1): 98–104. doi:10.1080/09540121.2016.1200713.

The purpose of this report is to inform U.S. policymakers, donors, and advocates about the DREAMS Initiative (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe). The report also identifies some of the challenges and opportunities for successful HIV prevention for adolescent girls and young women, who are disproportionately affected by HIV in sub-Saharan Africa. The DREAMS initiative aims to reduce HIV infections among adolescent girls and young women in 10 sub-Saharan African countries. In July 2016, CHANGE staff traveled to Kenya and South Africa, two countries that according to the U.S. President's Emergency Plan for AIDS Relief, were the farthest along in implementation, according to the U.S. President's Emergency Plan for AIDS Relief. CHANGE staff conducted interviews with adolescent girls and young women, prime partners, civil society, and U.S. Government officials to understand the experiences of DREAMS program participants, implementers, and funders. This report describes the implementation of DREAMS and assessed its attention to sexual and reproductive health and rights, strengths, and challenges in Kenya and South Africa. In addition to highlighting findings from the field, the report identifies U.S. policy restrictions that pose significant barriers to the DREAMS targets for HIV reduction among adolescent girls and young women. It offered several recommendations for improving outcomes, including improving engagement with community-based and grass-roots organizations.

Rosenberg, M.S., Gómez-Olivé, F.X., Rohr, J.K., et al. Journal of Acquired Immune Deficiency Syndromes (August 2016), 74(1): e9–e17. doi:10.1097/QAI.0000000000001173.

This study examined HIV risk behaviors among 5,059 adults over age 40 in South Africa, using data from the Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities (HAALSI) study. The study showed an HIV prevalence of 23 percent, with no differences by sex. Participants reported multiple sexual risk behaviors; 67 percent reported having multiple sexual partners in their lifetime, and 57 percent had at least one sexual partner in the last two years. Three-quarters of recently sexually active participants reported never using condoms with their most recent partner. Men reported sexual activity at higher rates than women at older ages (52% versus 17% at age 80). HIV-positive individuals who knew their status were most likely to use condoms, followed by HIV-positive individuals unaware of their status, and then by HIV-negative individuals. Twelve percent of participants reported having had casual sex; HIV-negative individuals were least likely to do so (9%), compared to HIV-positive participants who were aware of their status (29%) and those who were unaware (18%). HIV-negative individuals were least likely to report multiple partners (8%); 9 percent of HIV-positive unaware individuals and 13 percent of status-aware individuals reported multiple partners. The authors concluded that adults over age 40 face significant HIV acquisition risk and require targeted prevention interventions.

Biomedical Prevention

McGowan, I., Dezzutti, C.S., Siegel, A., et al. The Lancet HIV (September 2016), 3: e569–78. doi:10.1016/S2352-3018(16)30113-8.

This study, conducted at the University of Pittsburgh, examined the safety of long-acting injectable pre-exposure prophylaxis (PrEP) rilpivirine. Participants (n=36) were injected with either 600 or 1200 mg doses of rilpivirine and followed for 112 days. There were 204 adverse events reported; 32 participants reported reactions at the injection site consisting of mild to moderate pain; 28 experienced prolonged QT intervals on electrocardiogram (but still within the acceptable range of U.S. Food and Drug Administration limits); one participant had a skin rash; one had post-exercise elevated blood enzyme levels; and one experienced bleeding following a vaginal biopsy. Participants reported high likelihood of uptake, particularly when lower price ranges were listed. Barriers to uptake included high price, side effects, and potential harm to health. At the 28-day follow-up, drug concentrations were higher in women than in men for both doses. Tissue-to-plasma samples showed higher concentrations of rilpivirine in rectal tissue versus vaginal and cervical tissue. Viral replication in rectal tissues was significantly reduced. However, it was not reduced in vaginal or cervical tissue, suggesting increased protection for rectal versus vaginal HIV transmission. Studies on multiple-injection long-acting rilpivirine are ongoing, and will provide further information on safety and acceptability.

Dionne-Odom, J., Welty, T.K., Westfall, A.O., et al. AIDS Research and Treatment (June 2016), 2016: Article ID 2403936. doi:10.1155/2016/2403936AIDS.

The authors used data from the multi-country PMTCT Effectiveness in Africa: Research and Linkages to Care or PEARL study (2007–2009) to identify factors associated with completing the prevention of mother-to-child transmission (PMTCT) care cascade. The care cascade is defined as having five steps: at least one antenatal care visit; HIV testing; HIV test result received; maternal antiretroviral therapy (ART) initiation for prophylaxis; and infant ART initiation for prophylaxis. Findings demonstrated that only 36 percent of women completed the entire care cascade. Incremental drop-off was noted at each step. Of 976 HIV-positive women, 98 percent attended ANC; 87 percent received an HIV test; 47 percent received test results; and 42 percent initiated maternal ART; 39 percent of infants received ART prophylaxis. Factors associated with care cascade retention included being diagnosed with HIV prior to the pregnancy, knowing the partner’s HIV status, being older (>30 years), having at least four children and at least three household members, and using a long-acting form of contraception. The authors concluded that to reduce HIV transmission from mothers to children in sub-Saharan Africa programmers and policymakers should view knowledge of the male partner’s HIV status, HIV diagnosis before pregnancy, and use of long-acting contraception as key indicators that pregnant women will complete the PMTCT care cascade.

Morton, J.F., Celum, C., Njoroge, J., et al. Journal of Acquired Immune Deficiency Syndromes (January 2017), 74(Suppl 1): S15–S22. doi: 10.1097/QAI.0000000000001210.

The Partners Demonstration Project in Kenya developed a counseling framework for serodiscordant couples receiving antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) to provide patient education and identify barriers to use. The counseling framework included education on serodiscordance, ART and PrEP use, and combined and time-limited PrEP and ART to reduce HIV transmission. The counseling presented ART as beneficial for treatment of the HIV-positive partner and prevention for the HIV-negative partner. It emphasized the safety of PrEP during pregnancy, and the importance of PrEP adherence for HIV prevention. For both ART and PrEP, the counseling covered tips on adherence, potential side effects, and the importance of condom use. Counseling on integrated ART and PrEP focused on each partner taking their medication instead of sharing their medication; encouraging each other to be adherent; and building confidence in ART's effectiveness in preventing HIV once PrEP was discontinued. In cases where an HIV-positive partner was non-adherent, or believed to have a high viral load, counselors also brought up the possible need to continue PrEP. The authors concluded that counselors were able to confidently and effectively implement the counseling framework, and urged its adoption and scale-up in similar programs.

George, G., Govender, K., Beckett, S., Montague, C., Frohlich, J. PLOS ONE (November 2016), 11(12). doi:10.1371/journal.pone.0168091.

This study in South Africa examined factors associated with early return to sexual activity (within 6 weeks) following voluntary medical male circumcision (VMMC) among in-school boys aged 16–24. Participants completed a pre-VMMC questionnaire that gathered information on education/information received as part of the VMMC procedure and intentions to have sex. They were also interviewed by researchers six weeks post-VMMC. Of the 321 respondents, 128 reported sexual experience prior to the VMMC procedure. Among these, 29 percent reported anal or vaginal intercourse within six weeks following VMMC; they had on average two sexual partners. Only 36 percent of boys in this group reported consistent condom use during this period. Participants who reported sexual activity within six weeks after VMMC were more likely to consume alcohol. Post-VMMC interviews showed that participants who had engaged in early sexual activity following VMMC were less likely to engage in protective sexual behaviors or to be sexually monogamous, compared to those who had not had early sex. To reduce sexual activity within the post-VMMC healing period and reduce risk of HIV acquisition among newly circumcised males, education and information should target both VMMC clients and their peers, including their female sexual partners.

Gamell, A., Glass, T. R., Luwanda, L., et al. Journal of Acquired Immune Deficiency Syndromes (December 2016), 73(5)e67–e75. doi:10.1097/QAI.0000000000001178.

This study described findings from operational research in rural Tanzania to improve prevention of mother-to-child transmission (PMTCT). The multipronged approach included forming a PMTCT/pediatric HIV team; integrating services into reproductive and child health clinics; employing Open Medical Record System for HIV; and optimizing provider-initiated testing and counseling (PITC) and HIV-exposed infant (HEI) testing. The number of mother-baby pairs enrolled into care nearly doubled after the intervention. Among the 547 babies enrolled, there were significant increases in children diagnosed with HIV via PITC and HEI testing and prescribed antiretroviral therapy; tuberculosis identification and nutrition screening also increased significantly. Among HEI, 56 percent had mothers who were diagnosed pre-pregnancy and 33 percent during pregnancy. Babies whose mothers were diagnosed with HIV before or during pregnancy had a mother-to-child transmission rate of 4.8 percent while babies whose mothers were diagnosed after pregnancy had a transmission rate of 44 percent, the majority of whom were diagnosed via PITC. Loss to follow-up was reduced by nearly half (20.4% to 10.8%) following the intervention, but mortality could not be excluded as a contributing factor. The authors concluded that the low mother-to-child transmission rate among infants who received one-stop shop services provides evidence for PMTCT/pediatric and reproductive health service integration.

Combination Prevention

Cherutich, P., Golden, M.R., Wamuti, B. The Lancet HIV (November 2016), e-publication ahead of print. doi:10.1016/S2352-3018(16)30214-4.

This study examined whether assisted partner services (APS) increased access to HIV testing services (HTS) and treatment for partners of newly diagnosed individuals. APS entails interviewing newly diagnosed individuals to gain information on sexual partners; contacting sexual partners; and linking them to HTS and treatment as needed. Study participants (n=1119) were divided into an “immediate" group that advised HIV-positive clients to notify partners, and provided immediate follow-up partner notification support; and a "delayed" group, which also advised HIV-positive clients to notify partners, but did not provide partner notification support until the six-week follow-up. In the immediate group, 63 percent of sexual partners agreed to HTS; among these, 35 percent tested HIV-positive. For refusals, 26 percent were due to prior knowledge of their HIV status, and 11 percent were due to recent testing or preferring to delay testing. In the delayed group, at six-week follow-up, only 13 percent of partners had accessed HTS. Partners of clients in the immediate group were 15 times more likely to access HTS for the first time than partners of clients in the delayed group, and 5 times more likely to be diagnosed with HIV. Immediate testing also resulted in significantly higher enrollment. The authors concluded that APS is effective and acceptable, and should be scaled up in sub-Saharan Africa to help identify HIV-positive individuals and initiate early antiretroviral treatment. 

Browna, L.B., Havlira, D.V., Ayiekoc, J., et al. AIDS (August 2016), 30:2855–2864. doi:1097/QAD.0000000000001250.

This study examined non-retention factors among clients enrolled in a “test and treat” trial in Uganda and Kenya. Study participants (n=5,683) received “streamlined care” which included antiretroviral treatment (ART) at first visit, reduced wait times, quarterly visits for clinically stable patients, patient-friendly services, call-in center services for clients with medical or appointment questions, text reminders, and viral load results. In cases where clients missed appointments, “trackers” followed up at home to optimize retention. At 12-month follow-up, nearly 88.6 percent of clients were retained at their initiating site; 4.6 percent transferred to an alternative site; 1.1 percent died; 1.9 percent were residing in the same community (but not in treatment); and 1.1 percent transferred to a different site without documentation. Fifteen to twenty-four-year-olds and those without a cell phone were less likely to be retained in care. Clients who were newly linked to services and lived in Eastern Uganda, and clients who took longer than 30 days to link to care, were also less likely to be retained in care. Retention tracking to stay in care was more often required among Ugandans, young clients, and those with pre-ART CD4 cell counts above country guidelines before enrollment. The authors concluded that as test-and-treat services roll out, retention barriers must be addressed, particularly among young people, to optimize treatment outcomes.

Sutton, R., Lahuerta, M., Abacassamo, F., et al. Journal of Acquired Immune Deficiency Syndromes (January 2017), 74(1):S29–S36. doi:10.1097/QAI.0000000000001208.

This article shared findings from a process evaluation comparing the feasibility and acceptability of a combination intervention strategy to increase linkage and retention among adults recently diagnosed with HIV. The evaluation was part of the Engage4Health implementation science study conducted at 10 health facilities in urban Maputo City and rural Inhambane Province, Mozambique. It included three structural interventions—point-of-care CD4 testing immediately post-diagnosis, fast-tracked antiretroviral therapy (ART) initiation for eligible clients, and noncash financial incentives; and two health communication interventions—pre-ART counseling and cell phone appointment reminders. The study examined the extent to which each intervention was delivered as planned and accepted by clients. For structural interventions, 74 percent of clients received CD4 testing, and 53 percent of those eligible initiated ART within one month. For health communication interventions, 98 percent of eligible clients received pre-ART counseling, and 90 percent of participants received at least one cell phone reminder. Results indicated fewer barriers to the delivery of the health communication interventions as compared with the structural interventions. Challenges with the latter included absorbing the increased number of clients eligible for ART initiation, machine breakdowns, and staff limitations (lack of knowledge, low trust in results, and absenteeism). The authors noted the potential usefulness of implementing health communication interventions within combination intervention strategies.

Kerrigan, D., Mbwambo, J., Likindikoki, S., et al. Journal of Acquired Immune Deficiency Syndromes (January 2017), 74(Suppl 1): S60–S68. doi:10.1097/QAI.0000000000001203.

The authors presented baseline results from this study that will examine the effectiveness of an HIV prevention empowerment approach among 496 HIV-positive and -negative female sex workers (FSWs) in Tanzania. The approach includes peer education; condom distribution; HIV testing services (HTS) in entertainment venues; peer assistance for linkages and retention; clinician sensitivity training; text messaging to increase HIV knowledge and adherence; and community drop-in centers to foster social cohesion and confront stigma and discrimination, violence, and financial challenges. At baseline 48.6 percent of the participants experienced FSW-associated stigma; 50.8 percent experienced physical or sexual gender-based violence; and 49.2 percent reported drinking alcohol four or more days per week. Fewer than half of FSWs reported condom use; condoms were most often used with new clients. Nearly 48 percent reported receiving HTS within the past six months; 40.9 percent tested positive, and of these, 30.5 percent previously knew they were HIV-positive. Nearly 79 percent reported antiretroviral therapy (ART) use, and 48.4 percent experienced viral suppression, which was associated with being older, making less money, having few customers, being self-employed, and experiencing higher social cohesion with other FSWs. Significant gaps in HTS, ART adherence, and viral suppression indicated access challenges. These findings will inform implementation of the HIV prevention empowerment approach.

Venables, E., Edwards, J.K., Baert, S., et al. PLOS ONE (October 2016), 11(10). doi:10.1371/journal.pone.0164634.

This qualitative study examined clients' and health care workers' (HCWs) experiences with medication adherence clubs (MACs) in the informal urban settlement of Kibera, Kenya. The MACs enable clients with stable noncommunicable diseases (NCDs) and HIV to collect medication every three months through a group setting, rather than through individual appointments. Researchers conducted 10 focus groups, 19 interviews, and 15 participant observation sessions. Results indicated that participants (106 total) viewed MACs as a useful and acceptable way to provide and receive medication. MAC members appreciated the reduced number of appointments and waiting time (saving time and money), the provision of health information, and the support provided by HCWs and peers in a communal setting. Some clients and HCWs felt that MACs reduced stigma for HIV-positive individuals by treating HIV like a NCD. Overall, the majority of clients and HCWs supported integrating HIV and NCD clients into MACs. Challenges may include ensuring that clients have sufficient information during recruitment and development of peer networks. Experiences from MACs in providing decentralized antiretroviral therapy can inform the extension of this model of care to NCD clients. The authors noted that this approach to client-centered drug refill systems for chronic diseases is a feasible and acceptable approach in resource-poor settings.

Structural Prevention

Wagner, A.D., Mugo, C., Njuguna, I.N., et al. Journal of Acquired Immune Deficiency Syndromes (December 2016), 73(5):e83–e89. doi:10.1097/QAI.0000000000001184.

This prospective cohort study in Kenya evaluated uptake of an HIV intervention to determine if testing young children of HIV-positive adults can help identify undiagnosed HIV-positive children. Caregivers were eligible if they were HIV-positive and had at least one child ≤12 years of unknown HIV status. During the intervention period (2013–2014), 10,426 HIV-positive adults enrolled in a treatment program were interviewed. Of these, 3,477 (42%) had children of unknown HIV status, and 611 (7%) children under age 12; 116 adults in this category enrolled. These parents were given the choice of home-based, clinic-based, or no HIV testing for their children. This differed from the standard of care, in which health care workers may or may not determine if the client had children who should be referred. Among the 116 parents of younger children, 74 (64%) had 108 children tested. Results showed that this "active" referral for testing identified a large number of untested older children and increased pediatric HIV testing rates (from 3.5 to 13.6 children tested per month). HIV prevalence among the tested children was 7.4 percent—higher than in the general population (1%) and higher than estimated for early infant diagnosis programs with prevention of mother-to-child transmission (1–3%). However, only 14 percent of caregivers in the study tested their children.

Dobra, A., Bärnighausen, T., Vandormael, A., et al. AIDS (January 2017), 31(1):137–145. doi:10.1097/QAD.0000000000001292.

This population-based cohort study examined the causal relationship between patterns of mobility and risk of HIV acquisition in rural KwaZulu-Natal, South Africa. The study used data (2004–2014) from a demographic information system of the Africa Health Research Institute, along with complete geolocated residential histories. The study geolocated 8,006 migration events for 17,743 individuals with two recorded HIV tests (who were HIV-negative at baseline). Findings showed that even relatively short migration activities substantially increased HIV risk for both men and women. The risk of acquiring HIV infection increased by 50 percent for distances of 40 kilometers (men) and 109 kilometers (women). Those who spent larger periods of time outside the study site were at a significantly higher risk of acquiring HIV; risk increased by 50 percent when participants spent 44 percent (men) and 90 percent (women) of their time outside the community. Distances and periods of residence outside the study area served as proxies for HIV risk factors (increased number of sexual partners, increased likelihood of risky sexual behavior, separation from social networks, increased vulnerability, or lower socioeconomic status). The authors said that this was the first study they knew of that employed complete geolocated residential histories to quantify the space–time dimensions of mobility in relationship to HIV acquisition risks, and noted the potential usefulness of this methodological approach.

Tucker, A., Liht, J., de Swardt, G., et al. LGBT Health (December 2016), 3(6): 443–450, e-publication ahead of print. doi:10.1089/lgbt.2016.0055.

This review presented findings from an evaluation of a 2015 training for health care workers, MSM Competency Training, in the Western Cape of South Africa. The training aimed to improve staff knowledge and reduce negative attitudes toward men who have sex with men (MSM). Implemented for 196 clinicians and clinic support staff, the training consisted of eight modules on related topics, including the need to acknowledge MSM and understand their health needs, technical training to enable clinicians to offer appropriate care, and techniques for working sensitively with this stigmatized group. Participants were evaluated via surveys at baseline and post-training on knowledge about MSM and prejudicial attitudes. The results indicated significant improvements in knowledge of MSM and significant reductions in prejudicial attitudes. After the training, knowledge and sensitivity improved for clinic support staff, although this increase was statistically lower as compared to that of clinicians (suggesting a need to develop more ways of improving knowledge among support staff). Overall, the study findings suggested that educating health care workers about stigmatized groups may be effective in reducing negative attitudes toward the group. The study also demonstrated that gaining limited improvements in knowledge is not always associated with a reduction in prejudicial attitudes.

Besada, D. Rohde, S., Goga, A., et al. Global Health Action (November 2016), 7(9): 33507, e-publication ahead of print. doi:10.3402/gha.v9.33507.

This article presented findings from a rapid appraisal of strategies to increase male partner involvement in services for prevention of mother-to-child transmission (PMTCT) and reproductive, maternal, neonatal, and child health services in Côte d'Ivoire, Democratic Republic of Congo, Malawi, and Uganda in the context of scale-up of the Option B+ protocol. A mixed-skill team of 34 researchers conducted desk reviews and in-country field work; and held key informant interviews and focus group discussions with stakeholders including government, implementing partners, and district-, facility-, and community-based health workers. The authors grouped their findings into community and facility-based strategies. Common community-based strategies for increasing men's participation included community mobilization and sensitization, such as engaging community leaders and involving community health workers. Common facility-based strategies focused on integrating male-friendly services within the maternal/child health setting, such as offering incentives for participation and offering couple and family-centered services. The authors noted that all strategies must be tailored to the local context, and pointed out that unintended negative consequences can occur, and need to be addressed in program design. They suggested that developing national policies around male partner involvement could help streamline approaches across implementing partners and achieve scale-up. They also urged further exploration of how specific strategies affect male engagement.

Strode, A.E., Toohey, J.D., and Slack, C.M. South African Medical Journal (December 2016), 106(12):1173–1176. doi:10.7196/SAMJ.2016.v106.i12.11215.

This article reviewed the regulatory, normative, and protective frameworks governing adolescent access to male circumcision (MC) in South Africa—specifically the Children’s Act (No. 58 of 2005); the General Regulations Regarding Children, 2010; and the National Department of Health’s national guidelines. In South Africa, MC is practiced for religious reasons or as part of cultural initiation practices, as well as for medical reasons to reduce the risk of HIV infection. The authors identified ambiguities and inconsistencies among MC regulations, in regards to counseling, parental involvement, and consent. For example, for boys aged 16 and 17, the Children's Act implies that self-consent is sufficient, while the national guidelines imply that parental involvement is necessary. The authors also noted variations in the terminology used in MC regulatory documents. They made recommendations for law and policy reform to ensure better access to MC for adolescent males, including specifying minimum standards for circumcisions done for medical, religious, and/or cultural reasons; and being more consistent and specific regarding consent for health-related circumcisions. They further recommended that the national guidelines make clear that HIV prevention is a valid medical reason for circumcision of boys under age 16.

Orr, N., Hajiyiannis, H., Myers L., et al. Journal of Acquired Immune Deficiency Syndromes (January 2017), 74(Suppl 1): S69–S73. doi:10.1097/QAI.0000000000001204.

This qualitative study examined male thoughts and behaviors that affect HIV testing services (HTS) and access to antiretroviral therapy (ART) in South Africa. The authors conducted 11 focus group discussions (n=88) and 9 individual interviews across 4 provinces in districts with high HIV prevalence rates. All men reported knowing where to access HTS, but commonly said that clinics are primarily spaces for women, and that male attendance implies HIV-positivity. Men reported receiving poor treatment and violations of privacy from facility staff, and as a result avoided public services and accessed care in alternative locations, including private sites. They highlighted the importance of "pride" and expressed concerns about appearing weak and losing their dignity by attending services or being ill. Participants also described keeping ART use private to avoid having a reputation for sexual promiscuity or suggesting that their partner is at risk for HIV. They voiced increased inclination to access HTS if they participated in risky sexual behaviors, and if they heard a rumor or discovered that their partner was HIV-positive. Most often, men only sought treatment when they experienced ongoing illness. Participants concluded that communication messages that provoke fear are ineffective, and that messages should be humorous so that they spark communication. Findings led to development of a national communication campaign.

Epidemiology

Lane, T., Osmand, T., Marr, A., et al. Journal of Acquired Immune Deficiency Syndromes (December 2016), 73(5): 609–611. doi:10.1097/QAI.0000000000001162.

The Mpumalanga Men’s Study comprised a series of integrated biological–behavioral surveillance surveys (IBBS), conducted in Mpumalanga Province, South Africa to assess HIV incidence among men who have sex with men (MSM). Between 2012 and 2015, the authors conducted three cross-sectional IBBS surveys of a respondent-driven sampling of 307 MSM, to evaluate the impact of Project Boithato, which aimed to reduce sexual risk behavior and increase regular uptake of HIV testing and care among MSM. Findings showed high HIV prevalence (28.9%), low levels of regular HIV testing, and poor linkage to care among MSM who knew their HIV-positive status. Successive surveys, conducted between 12 and 30 months after Boithato ended, allowed for follow-up for a recaptured cohort of 179 MSM. HIV prevalence in this cohort was 32.4 percent at baseline. The study observed 18 seroconversions, or incidence of 12.5/100 person–years. The authors noted that to their knowledge, this was the first incidence rate calculated from repeated IBBS observations of an MSM community in sub-Saharan Africa; and yielded an alarming representation of the HIV epidemic among MSM in a rural, resource-challenged community. They concluded that these findings indicate the urgent need for biomedical prevention and treatment programming for MSM in South Africa.