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 It also includes state-of-the-art program resources, such as tools, curricula, program reports, and unpublished research findings.

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August 2016

In Focus

This conference, held this year in Durban, South Africa from July 18–22, aimed to reinvigorate the response to HIV and AIDS by presenting new scientific knowledge and offering many opportunities for structured dialogue on the major issues in the global response to HIV. The conference, themed "Access Equity Rights Now," was the first such event in which women presented the majority of papers; and one-third of the abstracts were authored by African researchers. The conference offered a variety of session types, from abstract-driven presentations to symposia, bridging, and plenary sessions. Other related activities, including the Global Village, satellite symposia, and affiliated independent events, contributed to an exceptional opportunity for professional development and networking. For daily updates from the conference and additional discussion of the conference, please download the PDF version of this month's update.

World Health Organization (WHO), 2016.

This update of WHO's 2013 guidelines provides recommendations on diagnosing HIV infection, using antiretroviral drugs to treat and prevent HIV infection, and caring for people living with HIV (PLHIV). The audience includes national HIV program managers, clinicians, policymakers, international organizations, nongovernmental organizations, and other implementing partners, as well as PLHIV, communities, and civil society organizations. Structured along the continuum of HIV testing, prevention, treatment, and care, the guidelines present new recommendations, including provision of lifelong antiretroviral treatment (ART) to all children, adolescents, and adults, including all pregnant and breastfeeding women living with HIV, regardless of CD4 cell count. WHO has also expanded earlier recommendations to offer pre-exposure prophylaxis to selected people at substantial risk of acquiring HIV. The document discusses alternative first-line treatment regimens, including an integrase inhibitor and reduced dosage of a key first-line drug, efavirenz, to improve tolerability and reduce costs as an option in resource-limited settings. These guidelines include 10 new recommendations to improve the quality and efficiency of services for PLHIV. Implementation of the recommendation on universal ART eligibility will mean that more people will start ART earlier. WHO emphasizes the need for differentiated approaches to care for people who are stable on ART, such as reduced frequency of clinic visits and community ART distribution.

Beyrer, C., Baral, S.D., Collins, C., et al. The Lancet (July 2016), 388(10040): 198–206.

This review article updated the 2012 article published in The Lancet's series on HIV in men who have sex with men (MSM), focusing on estimates of HIV incidence in MSM in the past five years. Consistent findings on the high efficacy and effectiveness of oral pre-exposure prophylaxis (PrEP) for primary prevention of HIV infection in MSM could transform prevention for MSM, if fully implemented. Comprehensive access to medical care and early HIV treatment for those living with HIV, programs integrating sexually transmitted infections and HIV, and access to PrEP could reduce HIV transmission in MSM at community levels. Expanded research on approaches to HIV prevention, treatment, and care in MSM has been a high point of the past two years. Major new initiatives will make substantial new funds available for research on key populations. However, prevention programs are still impeded by widespread stigma and discrimination, which are often embedded in punitive policies and political actions. Also, data on MSM are missing; strong data on this population will be crucial to understanding HIV epidemics in MSM and the programmatic response to these epidemics. There is a need for more countries to include MSM in their HIV epidemiological surveys, and to adjust funding allocations to align more closely with domestic HIV epidemiology, including HIV among MSM.

Behavioral Prevention

Eggers, S.M., Mathews, C., Aarø, L.E., et al. AIDS and Behavior (June 2016), e-publication ahead of print.

This 2013 longitudinal study of 1,670 eighth-grade adolescents from 20 public schools in the Western Cape, South Africa, examined primary and secondary abstinence intentions and early sexual activity in this population. At baseline, the authors asked participants to fill out a questionnaire on abstinence, attitudes, social norms, self-efficacy, risk perception, and knowledge. At six-month follow-up, factors associated with sexual activity differed considerably among groups. For sexually inactive boys at baseline, greater knowledge about HIV and condom use were significantly associated with sexual activity at follow-up; for sexually inactive girls at baseline, lower intentions to abstain, perceiving fewer benefits from abstinence, and higher levels of knowledge about HIV and condom use were significantly associated with sexual activity. Among sexually active adolescents, lower perceptions of and weaker social norms about sexual abstinence were significantly associated with sexual activity at follow-up. Other socio-cognitive factors, such as self-efficacy to delay sex and knowledge about HIV and condom use, appeared to have less influence on intention to stay abstinent, but were still significant predictors in this study. The authors concluded that future interventions that promote sexual abstinence should address social norms, attitudes, and risk perceptions to enhance motivations to stay abstinent during adolescence.

Biomedical Prevention

Renee, R., Reed, J., Sgaier, S., et al. Journal of Acquired Immune Deficiency Syndromes (June 2016), 72: S1–S4, doi: 10.1097/QAI.0000000000000967.

This collection of 16 articles published in the June 2016 supplement of the Journal of Acquired Immune Deficiency Syndromes examined research on the introduction of two devices prequalified by the World Health Organization: PrePex™ and the ShangRing™. These studies provided a firm body of evidence to inform recommendations about introducing the devices into programs for voluntary medical male circumcision (VMMC) that are already operating at scale. Studies on introducing PrePex in adults in Botswana, Malawi, Mozambique, South Africa, Zambia, and Zimbabwe confirmed that the device is safe, including in the context of routine service delivery by nurses; and that clients are satisfied and would recommend it to their peers. A study of PrePex in Zimbabwean adolescents aged 13–17 years provided the first safety data in this important young age group, which constitutes the largest number of clients who have sought VMMC services thus far. The studies also included information on costing and supply and demand. Articles included in this supplement covered some of the operational aspects of device introduction, including the need for pilot studies, objective data on safety, examination of acceptability and costs, and documentation of the challenges encountered.

Oldenburg, C.E., Bärnighausen, T., Tanser, F., et al. Clinical Infectious Diseases (May 2016), e-publication ahead of print.

This study (January 2005 to December 2013) assessed how antiretroviral therapy (ART) status affected HIV transmission risk in stable serodiscordant relationships in “real-life” population-based settings. The study included data from a total of 17,016 HIV-uninfected individuals. Of 2,029 individuals with a cohabiting partner during the follow-up period, 196 had an HIV-positive partner, and 1,846 had an HIV-negative stable partner. Of those with positive partner, 20 were receiving ART at baseline, and a further 56 started ART during the follow-up period. Participants were tested for HIV between two and nine times. The authors observed 1,619 HIV seroconversions over 60,349 person-years (PY) of follow-up time; overall HIV incidence was 2.7 new infections per 100 PY. The incidence was 5.6/100 PY among individuals with an HIV-positive partner not receiving ART; 1.4/100 PY among those with an HIV-positive partner receiving ART; and 0.3/100 PY among those with an HIV-negative partner. Where the partner was HIV-positive, ART use was associated with a 77 percent reduction in HIV incidence compared with no ART use. The authors concluded that ART was a highly effective strategy for preventing HIV transmission in serodiscordant couples, even when it was provided through a resource-poor, public-sector health care system to a population with low levels of HIV status disclosure.

Llenas-García, J., Wikman-Jorgensen, P., Hobbins, M., et al. Tropical Medicine & International Health (May 2016), e-publication ahead of print.

This study evaluated retention in care of pregnant and lactating women (PLW) who began antiretroviral therapy (ART) under Option B+ in rural Mozambique, and compared their outcomes with those of women who started ART for their own health. Between July 2013 and June 2014, the authors classified 625 patients as follows: “B+ pregnant” (pregnant women starting ART under Option B+); “B+ lactating” (breastfeeding women starting ART under Option B+); and “own-health” (non-pregnant, non-lactating women starting ART based on clinical and/or immunological criteria). Over 333 woman-years of follow-up, 3.7 percent of women died and 48.5 percent were lost to follow-up (LTFU). Among the LTFU women, 25 .6 percent were lost after the first visit. Overall one-year retention was 41.8 percent in the B+ pregnant group, 40.4 percent in the B+ lactating group, and 61.9 percent in the own-health group. The risk of LTFU was higher in both Option B+ groups than in own-health ART users. The authors noted very high proportions of early LTFU in patients initiating ART under the Option B+ strategy in rural Mozambique, a setting with weak health care systems and insufficient ART counseling and retention measures. They called for innovative strategies to improve retention, and new service delivery models to address barriers to successful HIV care for PLW.

Combination Prevention

Bergmann, J.N., Legins, K., Sint, T.T., et al. AIDS and Behavior (April 2016), e-publication ahead of print.

This paper examined the impact and cost-effectiveness of integrated HIV and nutrition service delivery small-scale pilot programs supported by the United Nations Children's Fund in Malawi and Mozambique. The authors used a four-step process to analyze program impact and cost-effectiveness: (1) identifying key components of a program; (2) linking program components to outcome indicators; (3) measuring trends in outcome indicators; and (4) analyzing cost-effectiveness. They presented separate results for each country. The integrated program in Malawi included use of text messaging technology; training and deployment of male motivators; and the creation and implementation of "child health passports." The integrated program in Mozambique was implemented in two provinces and comprised four key components: one-stop shops, flowcharts to streamline services and demonstrations of proper nutrition, and expansion of early infant diagnostic services. Cost-effectiveness in the Malawi program was USD$11–29 per disability-adjusted life year (DALY), while that in Mozambique’s program was USD$16–59/DALY. However, some components were more effective than others ($1–4/DALY for Malawi’s male motivators compared to $179/DALY for Mozambique’s one-stop shops). The authors concluded that integrating HIV and nutrition programming led to positive impacts on health outcomes.

Huerga, H., Van Cutsem, G., Ben Farhat, J., et al. Journal of Acquired Immune Deficiency Syndromes (May 2016), e-publication ahead of print.

This study assessed the prevalence of HIV testing, HIV positivity awareness, antiretroviral therapy (ART) uptake, and viral suppression in KwaZulu Natal, South Africa, and investigated factors associated with being untested, unaware, untreated, and virally unsuppressed. From July to October 2013, the authors surveyed a total of 2,377 households. At participants' homes they conducted interviews, administered HIV tests, and collected blood to test for antiretroviral drugs, CD4 levels, and viral load. Men and persons under age 35 accounted for most of the untested people (63.3% and 75.5%, respectively). Individuals aged less than 35 years and women accounted for most of the status-unaware HIV-positive people (73.2% and 68.7%); in need of treatment (66.4% and 65.2%); and with a viral load above 1,000 cp/mL (66.3% and 71.1%). Reasons for these findings included lower access to testing and treatment in people under age 35 and the higher proportion of women in the population in this area (62.3%). Additionally, people with more than one sexual partner were more likely to be untested, unaware, and untreated. The authors concluded that programs should prioritize increasing access to testing and treatment for young people and women, and should also adapt HIV testing strategies to better target men.

Krakowiak, D., Kinuthia, J., Osoti, A.O., et al. Journal of Acquired Immune Deficiency Syndromes (August 2016), 72(2): S167–S173.

This study in Kenya compared two approaches—home visits versus written invitations—for encouraging male partners of pregnant women to accept HIV testing. Consenting pregnant women were randomly assigned to receive a home-based partner education and testing (HOPE) (n=306) visit within two weeks of enrollment, or a written invitation encouraging the male partner to attend the clinic for couple HIV counseling and testing and a delayed home-based partner education and testing visit at six months postpartum (INVITE) (n=295). The authors reported that at six-month follow-up, male partners in the HOPE arm were more than twice as likely to have been tested (87%) compared with men in the INVITE arm (39%). Couples in the HOPE arm (77%) were three times as likely to have been tested as a couple as those in the INVITE arm (24%); and women in the HOPE arm (88%) were twice as likely to know their partner’s HIV status as women in the INVITE arm (39%). Moreover, more serodiscordant couples were identified in the HOPE arm (13%) than in the INVITE arm (4%). The authors concluded that scheduled home visits are an effective, acceptable, and feasible strategy for conducting couple HIV testing for pregnant women and their partners.

Structural Prevention

Smith, J.A., Anderson, S-J., Harris, K., et al. The Lancet HIV (June 2016), 3(7): e289–296, doi: 10.1016/S2352-3018(16)30036-4.

To identify optimum resource allocations, the authors of this study developed a model of the HIV epidemic in South Africa that simulated the cost and effects of a wide portfolio of options for HIV prevention. The model incorporated current interventions (including condoms, antiretroviral therapy, and pre-exposure prophylaxis or PrEP) and potential interventions to be added in the short or long term (vaginal rings and broadly neutralizing HIV-1 antibodies, or bNAbs). For each intervention, the authors defined coverage levels for seven population subgroups (female sex workers aged 15–49 years and high- and low-risk men and women in various age categories). All interventions had the potential to reduce HIV incidence substantially from 2016–2050. Vaccination showed the largest potential impact when scaled up to maximum coverage, followed by long-acting antiretroviral drugs, oral PrEP, bNAbs, and condoms. The mix of current and future interventions that showed the highest potential included scale-up of male circumcision and early ART initiation with outreach testing (which are available immediately and are low-cost and highly efficacious); intravaginal rings targeted to sex workers; and vaccines which can achieve a large effect if scaled up even if imperfectly efficacious). The authors concluded that scaling up existing interventions and developing a successful vaccine would have the greatest long-term impact on the epidemic.

Leclerc-Madlala, S., Green, E., and Hallin, M. African Journal of AIDS Research (2016), 15:2, 185–193, doi: 10.2989/16085906.2016.1204329.

This article argued that traditional healers are highly regarded in their communities, and said that the traditional health sector is a major resource that has yet to be sufficiently mobilized against HIV. In December 2015 the authors searched electronic databases and grey literature to identify the ways in which traditional healers have collaborated with the biomedical sector to address HIV in sub-Saharan Africa. The search revealed a wide variety of roles. Traditional healers have functioned as condom promoters; advocated for testing and treatment, and against stigma toward people living with HIV (PLHIV); helped PLHIV to obtain and stay on treatment; and cared for AIDS orphans in their homes. The authors included brief descriptions of five successful models of collaboration from different sub-Saharan countries, including Traditional and Modern Health Practitioners Together Against AIDS (Uganda), Rural Health Initiative (Lesotho), and Integration of TB Education and Care for HIV/AIDS (South Africa). They concluded that working in collaboration with the traditional healers would mobilize a significant resource that is already functioning in communities.

Epidemiology

Evans, M.G., Cloete, A., Zungu, N., and Simbayi, L.C. The Open AIDS Journal (April 2016), 10: 49–64, doi: 10.2174/1874613601610010049, eCollection 2016.

The authors reviewed articles published between 2006 and 2014 on HIV prevalence and risk for lesbian, gay, bisexual, and transgender (LGBT) populations in South Africa. Findings from 35 articles were grouped into categories for gay, bisexual, and other men who have sex with men (MSM):

  • HIV prevalence estimates and risk: In all studies, HIV prevalence estimates revealed that MSM had at least four times greater risk of HIV infection than their heterosexual counterparts; prevalence ranged from 10 percent to 50 percent
  • Behavioral, social, and structural risks:  Structural violence, high levels of poverty, unemployment, and an intolerant cultural and social context were structural risk factors.
  • Stigma, mental health, and drug use: For MSM, the review found evidence of stigma, internalized homophobia, poor mental health, and risk of drug use. However, the authors found no peer-reviewed articles on transgender populations and HIV in South Africa, suggesting that although transgender people have been identified as a key population, there is a stark gap in the literature. The authors concluded that HIV research in South Africa should prioritize research with MSM, women who have sex with women, and LGBT populations to inform prevention strategies that meet the specific needs of these marginalized populations.

Reports, Guidelines, and Tools

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

This report summarizes the experiences of six countries that have supported community-based HIV programs through a variety of government mechanisms: Argentina, Brazil, India, Malawi, Malaysia, and the Republic of Moldova. The report emphasizes that countries finance the community components in their HIV response in many ways, including decentralizing services, forming stronger partnerships with community-based organizations, and focusing investments to reach the most vulnerable people. Examples from Argentina, Brazil, India, and Malaysia demonstrate how national resources available for the HIV response can be allocated to civil society. By contrast, Malawi and the Republic of Moldova demonstrate how donor resources, such as funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria, can be allocated to the government and directed to civil society organizations. Because of these funding approaches, governments in these countries expanded the reach of services by transferring some tasks to community health workers and volunteers; and community organizations were able to maintain a continuum of care and facilitate access to services for hard-to-reach groups. The innovative approaches showcased in this report illustrate ways of addressing challenges common to many countries.

U.S. President’s Emergency Fund for AIDS Relief (PEPFAR, 2016).

The Key Populations Investment Fund was announced during the 2016 United Nations High-Level Meeting on Ending AIDS. The $100 million fund will support both proven approaches and innovative, tailored, community-led strategies to address critical gaps in HIV programming for key populations. The report defines key populations in line with the Joint United Nations Programme on HIV/AIDS-developed definitions, including gay men and other men who have sex with men, transgender people, sex workers, people who inject drugs, and prisoners. The Investment Fund provides an opportunity to expand and widely disseminate effective programs. It will address complex issues that create barriers to HIV prevention and treatment services and keep vulnerable communities at the margins of the HIV response. These include:

  • Acceptance of human rights of all persons, without distinction
  • Access to quality services for key populations
  • Systematic and rigorous monitoring of stigma and discrimination, combined with clear actions to mitigate them
  • Availability of data on the size of key populations and their use of prevention and treatment services
  • Improved capacity of organizations led by key populations to advocate for changes in policies and directly implement services.

All stakeholders, partners, and other interested parties are invited to provide thoughts, comments, and feedback on the implementation and planning of the fund.