AIDSFree Prevention Update

Thank you for being a valued reader of the AIDSFree Prevention Update. For 10 years, the Prevention Update has served as a resource to keep you up-to-date with the latest research, tools, and reports on HIV prevention. Moving forward, we will not be publishing further issues of the 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 It also includes state-of-the-art program resources, such as tools, curricula, program reports, and unpublished research findings.

December 2017

In Focus

Price, J.T., Rosenberg, N.E., Vanisa, D. et al. Journal of Acquired Immune Deficiency Syndromes (e-publication ahead of print), doi:10.1097/QAI0000000000001567.

This study examined the effectiveness of integrating provider-initiated HIV testing services into pediatric care at 33 facilities in Zimbabwe. The intervention included community awareness raising using village health workers to increase referrals for HIV testing at health facilities. Nurses were also trained to test all children under five years old who had never received HIV testing services, and all children below two years old who had a negative HIV test more than three months prior. All results were recorded in child health booklets. The results showed that 75 percent of children had HIV information in their booklet. Of these, nearly 78 percent were tested and 76 percent had an HIV test result; 1.7 percent were found to be HIV-positive. Children were more likely to be HIV-positive if they were malnourished, were exposed to tuberculosis, or had an HIV-positive mother. The number of children tested for HIV increased by 94 percent during the intervention period; and the number of diagnosed as HIV-positive by 55 percent. The authors concluded that integrating HIV testing within a wide range of pediatric health services is achievable and increases the likelihood of a child receiving and HIV test and being identified as HIV-positive.

Odoyo-June, E., Agot, K., Grund, J.M., et al. Journal of Acquired Immune Deficiency Syndromes (October 2017), 12(10), doi: 10.1371/journal.pone.0185872.

This study in Malawi examined risk factors associated with HIV infection and determined if risk factors were associated with HIV risk perception and worry among adolescent girls and young women (AGYW) ages 15–24. Baseline surveys were disseminated among AGYW enrolled in a Girl Power study. Among the 1,000 girls, 33 reported being HIV-positive; 69 percent reported having a negative HIV test within the past six months; 17 percent reported having a negative HIV test over six months earlier; and 14 percent had never been tested. The study identified several factors associated with HIV infection, including having no running water, having sex with three or more partners in the past year, and drinking heavily. Having more HIV risk factors was associated with higher risk perception and worry about HIV. However, many AGYW who had multiple risk factors did not perceive themselves to be at risk for contracting HIV and/or did not worry about contracting HIV. The authors concluded that it is possible to identify those AGYW who are most at risk for HIV by examining HIV-related risk factors. Once identified, these women should be targeted for HIV prevention interventions.

Joint United Nations Programme on HIV/AIDS. 2017.

This roadmap provides guidance for countries to accelerate HIV prevention strategies to reach national and global goals to end the threat of AIDS by the year 2030. The document focuses on the 25 countries with the highest adolescent and adult HIV incidence, and outlines a call for governments to take key actions, including:

  • Strategically assessing key prevention needs and identifying policy and program barriers to progress.
  • Developing or revising national targets and roadmaps for prevention 2020.
  • Making institutional changes to enhance HIV prevention leadership, oversight, and management.
  • Introducing legal and policy changes to create an enabling environment for prevention.
  • Developing national guidance, intervention packages, and service delivery platforms.
  • Developing a consolidated prevention capacity building and technical assistance plan.
  • Strengthening civil society engagement and expanding community-based responses.
  • Assessing available prevention resources and developing a strategy to close financial gaps.
  • Establishing and strengthening prevention program monitoring systems.
  • Strengthening national and international accountability for prevention.

The guidance emphasizes the five prevention pillars: combination prevention for adolescent girls/young women and their partners and for key populations; strengthened national condom and behavioral change programs; voluntary medical male circumcision; and pre-exposure prophylaxis. It also summarizes commitments to reducing new HIV infections by governments, civil society, donors, and the business community.

Combination Prevention

Zanolini,, A., Chipungu, J., Vinikoor, M.J., et al. AIDS Research and Human Retroviruses (e-publication ahead of print), doi:10.1089/AID.2017.0156.

The authors used a population-based survey of 1,617 adolescents and adults in Zambia to describe preferences for HIV self-testing (HIVST). They also conducted a discrete choice experiment (DCE) in which participants could choose among several testing models. Participants received HIVST instructions via either a visual aid sheet or video, and were tested on their comprehension. Following the video, 91 percent of respondents reported finding HIVST acceptable, and 87 percent reported that HIVST increased the likelihood of testing. Thirty-five percent expressed concerns about lack of counseling and suicide risk, but only 2.1 percent indicated that these concerns should reduce access to HIVST. Findings from the DCE demonstrated that counseling and HIVST motivated HIV testing. For those who had not been tested previously, having HIVST was the most important influence. Most participants who received the visual aid sheet (73%) expressed confidence about self-testing. Most participants who looked at the instructional video expressed confidence about using HIVST (79%), but the video did not increase knowledge on how to test. Participants were willing to pay US$3–5 for HIVST. The authors concluded that HIVST is highly acceptable and should be introduced via a pilot activity in Zambia; they urged further research to guide development of national guidance on HIVST.

Rosenberg, N.E., Gross, R., Mtande, T., et al. African Journal of AIDS Research (October 2017), 16(3), 215–223, doi:10.2989/16085906/2017.

This qualitative study described experiences of participants in a randomized controlled trial that examined male partner recruitment strategies for couples HIV testing and counseling within an antenatal unit in Malawi. Strategies included inviting the man to attend an appointment with his partner, and providing the invitation plus phone and community tracing for individuals who did not follow up at the clinic. All women disclosed their HIV status and gave the invitation to their partner. Motivators for disclosure included to protect the baby and their own health, help the partner know their status, and avoid secrecy. Women and men appreciated the formality of the invitation and reported that it provided a sense of importance. Those traced via telephone also reported a sense of importance, but some indicated that they would have attended the clinic anyway. Most men knew that they would receive HIV testing, which was both a motivator (love for their partner) and a deterrent (fear of the result or lack of interest). Receiving results as a couple enabled mutual support, including adherence support and discussions of condom use. There were no reports of worsened relationships or economic consequences. The authors concluded that invitations and tracing can support couples counseling interventions, including disclosure and male partner testing.

Inghels, M., Niangoran, S., Minga, A., et al. PLOS ONE (October 2017), 12(10), doi:e0185117.

This study examined types of missed opportunities for HIV testing among 273 recently diagnosed individuals who had previously attended clinical appointments in Abidjan. A missed opportunity was defined as a medical consultation for a clinical indicator (symptoms, hospitalization, or pregnancy) or a nonclinical indicator (high-risk sex and an HIV-positive partner). The most common reasons for HIV testing were illness (41.7%) and voluntary testing without illness (31.7%). Among participants, 159 reported a total of 312 indicators, with a median of 17 months between the missed opportunity and HIV diagnosis. Two-thirds of reported indicators (216) were testing opportunities; in 67.6 percent of these were missed opportunities, because testing was not proposed. The most common clinical indicators for missed opportunities were hospitalization, unexplained weight loss, chronic or repeat fever, and herpes zoster. The most common nonclinical indicators were having unprotected sex and having an HIV-positive partner. Patients with missed opportunities had lower CD4 cell counts, were diagnosed at later disease stages, had lower hemoglobin concentrations, and were more likely to be diagnosed with HIV due to illness. The authors concluded that HIV testing should be offered more often in clinical settings and in response to the presence of HIV-related illnesses or symptoms. In-depth assessments of patient’s nonclinical indicators should also be routinely conducted.

Ruzagira, E., Grosskurth, H., Kamali, A., Baisley, K. Journal of the International AIDS Society (October 2017), 20:e25014, doi: 10.1002/jia2.25014.

This open-label, cluster-randomized trial compared the effectiveness of a counseling intervention on linkage to care versus a referral-only intervention for clients who tested positive during home-based HIV testing in 28 rural communities in Uganda. Two counseling sessions, provided at one and two months after diagnosis, covered acceptance of diagnosis, care-seeking plans, stigma, disclosure, psychosocial support for linkage to care, information on care services, antiretroviral treatment (ART), and reasons for early linkage to care. Of 302 individuals enrolled in the study, 134 were reported linked to care. However, facility records (and confirmation with 7 patients) showed that only 127 individuals had actually linked to care. Those in the intervention arm were significantly more likely to link to care than those in the control arm (51% versus 33%). This effect increased after the second month of follow-up when counseling had been provided. Clients in the intervention arm were also more likely to obtain CD4 cell count results, initiate ART, and report higher adherence to cotrimoxazole. The authors concluded that counseling has significant impacts on both linkage to care and other service access, including ART, among clients who test positive during home-based counseling and testing.

Structural Prevention

Gordon, S., Rotheram-Borus, M.J., Skeen, S., et al. AIDS and Behavior (October 2017), 21(262–273), doi:10.1007/s1046-017-1921-4.

This paper outlined research priorities for the connection between alcohol use and HIV in low- and middle-income countries. The authors used a consensus-building framework to bring together the views of 171 global experts, and employed a scoring methodology to identify priorities. The most common intervention research themes focused on the intersection of alcohol and HIV, the impact of HIV risk in the setting of harmful alcohol use, and risk and protective factors for alcohol and HIV. The three highest-scoring questions were on 1) defining the link between alcohol use and HIV medication: 2) determining the effectiveness of health system interventions in which staff are trained to engage HIV-positive alcohol abusers; and 3) determining the prevalence and correlates of alcohol use among HIV-positive pregnant women in Africa. The authors concluded that policymakers should use these research priorities for decision-making purposes.

Miiro, G., DeCelles, J., Rutakumwa, R., et al. PLOS ONE (October 2017), 12 (10), doi:e0185929.

This study examined the feasibility of a soccer program to impart voluntary medical male circumcision (VMMC) messages to school-aged boys in Uganda. The authors used surveys and in-depth interviews to examine knowledge and attitudes about VMMC. The pilot intervention included a coach who shared stories about his decision to become circumcised and the protective benefits of VMMC. Coaches also accompanied boys who chose VMMC to the procedure. Among the 58 boys exposed to the first intervention, 41 percent reported interest in VMMC, and 10 percent had a circumcision. Challenges included difficulty receiving parental consent, low attendance (since the program was only available after school), and timing, because most boys preferred to undergo VMMC during school holidays. Based on these findings, coaches made home visits to educate parents, and made arrangements to implement the intervention during school hours and just before the holidays. Following the adapted program intervention, 55 percent expressed interest in VMMC and 23 percent had a circumcision. Qualitative results demonstrated that although the attitudes of family and friends toward VMMC were important, coaches strongly influenced the decision to be circumcised. Reasons for circumcision included improved hygiene and reduced HIV risk. Fear was the principal deterrent. The authors concluded that the adapted intervention is time-intensive, but may significantly influence uptake of VMMC.

Odoyo-June, E., Agot, K., Grund, J.M., et al. PLOS ONE (October 2017), 12 (10), doi:e0185872.

The authors summarized findings from a household survey on the prevalence and predictors of voluntary medical male circumcision (VMMC) among men aged 25–39. The survey was a first step in preparation for a randomized controlled trial that will examine the impact of demand creation interventions on VMMC uptake in western Kenya. A total of 5,639 men participated in the study, among whom 50.6 percent were circumcised. The average age among participating men was 31.3 years; almost all were Christians; and 86.2 percent were married. Men who were circumcised were more likely to be non-Christian, have secondary education or post-secondary education, and be employed. Men who were married, divorced, separated, or widowed, or who were between the ages of 35 and 39, were less likely to be circumcised. The authors concluded that these predictors should be used to increase VMMC uptake in western Kenya—focusing on those groups of men who were less likely to be circumcised.

Thomas, R., Burger, R., Harper, A., et al. The Lancet Global Health (September 2017), 5(11): e1133-41, doi:10.1016/52214-109X(17)30367-4.

This paper used cross-sectional population surveys to compare differences in the health-related quality of life (HRQoL) between HIV-positive and HIV-negative individuals in Zambia and South Africa The authors randomly sampled households with individuals aged 18–44 years to measure five domains: mobility, self-care, daily activities, pain, and anxiety or depression. In Zambia, 19,750 individuals were included and 21 percent were HIV-positive. In South Africa, 18,941 individuals were included and 22 percent were HIV-positive. In Zambia, HIV-positive individuals reported lower HRQoL than HIV-negative individuals, with pain scores significantly higher among HIV-positive individuals. In South Africa, there were no differences, except for anxiety or depression which was slightly higher among HIV-positive individuals. Among individuals who were of aware of their HIV-positive status but had not yet started antiretroviral treatment (ART) or enrolled in care, there was a slightly lower HRQoL in comparison to HIV-negative individuals. Those who had never started ART were also more likely to report challenges with mobility, self-care, or daily activities. In both countries, those who knew they were HIV-positive but had not yet enrolled in care were more likely to report depression or anxiety. The authors concluded that ART can improve the HRQoL of HIV-positive individuals.

Clouse, K., Mongwenyana, C., Musina, M., et al. AIDS Care (October 2017), doi:10.1080.09540121.2017.1394436.

This study in South Africa examined the acceptability and feasibility of a one-time supermarket voucher of US$4 as an incentive for women to attend a postpartum visit within 10 weeks of giving birth. Among the 100 participants, 71 percent had been diagnosed during antenatal care for the pregnancy under study, 81 percent described the pregnancy as unplanned, and all participants had been prescribed antiretroviral treatment. Sixty-four percent of women attended a postpartum visit within 10 weeks, making them eligible for the voucher; of these, nearly 80 percent received the voucher. Thirty participants did not return within the 10-week time period and did not receive vouchers. At study enrollment, 86 percent reported that the voucher would give them incentive to return for a postpartum check. Most women (71%) stated that they would use the voucher to buy products for the baby; 20.3 percent stated that they would buy food. Most participants who stated that the voucher would not serve as an incentive said that it was because they already felt motivated to maintain their health. The authors concluded that though financial incentives is acceptable and feasible for retaining women in postpartum care, many participants said that they preferred improved integrated services, HIV counseling, and health education.

Sheehan, P., Sweeny, K., Rasmussen, B., et al. The Lancet (April 2017), 390: 1792–806, doi:10.1016/ S0140-6736(17)30872-3.

This study examined investments in adolescent interventions in low-, middle-, and high-income countries using modeling techniques to identify costs and returns on the investments. The authors modeled 66 adolescent health interventions, with an annual cost of US$4.50 per participant, over the years 2015–2030. Overall, investments in low-income countries yielded a higher return. Other findings included:

  • Programs that increase girls’ school attendance could reduce child marriage for a cost of $3.80 per individual.
  • Interventions to reduce traffic injuries ranged in cost per individual from $0.30 in low-income countries to $1.00 in upper middle-income countries.
  • Education initiatives (improving school attendance and education quality) cost $22.60 per individual annually, representing only a 30 percent increase from models without improvements.

Overall, adolescent interventions could prevent 7 million adolescent deaths and 1.5 million cases of adolescent disability. Increasing contraceptive availability would prevent 33.9 million unintended births. Investments in policy changes for child marriage could reduce child marriage by 29 percent. Educational interventions could improve secondary education achievement by 75.4 percent for girls and 57.7 percent for boys by 2030, leading to a 36.7 percent increase in work productivity. The authors concluded that investments in adolescent interventions yield high rates of returns and result in millions of deaths prevented and increases in healthy life-years.

Reports, Guidelines, and Tools

Staveteig, S., Croft, T.N., Kampa, K.T., and Head, S.K. PLOS ONE (October 2017), e0186316, doi:10.1371/journal.pone.0186316.

This study used Demographic and Health Surveys and AIDS Indicator Surveys in 16 sub-Saharan African countries to measure the proportion of people living with HIV (PLHIV) who know their status, and to identify associations between background and behavioral characteristics and gaps in testing. The proportion of respondents who had ever tested for HIV ranged from 34 percent in Sierra Leonne to 94 percent in Rwanda. In the average country, 54 percent of PLHIV knew their status; women of reproductive age comprised the majority of PLHIV in every country. In 10 countries, the majority of PLHIV reside in urban areas. PLHIV tended to be wealthier than their HIV-negative counterparts, and in half of countries, at least 50 percent of PLHIV were in the top third of wealth. Most PLHIV reported two to three lifetime sexual partners. In 12 countries, adolescents and individuals who had not had sex were less likely to be tested for HIV. In nine countries, HIV-positive men were less likely than HIV-positive women to ever have been tested. In nine countries, PLHIV in the lowest third of wealth and those without education were less likely to be tested. The authors concluded that testing interventions should be targeted toward men, adolescents, and those with no to minimal education.