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 It also includes state-of-the-art program resources, such as tools, curricula, program reports, and unpublished research findings.

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May 2017

In Focus

Seidman, D.L., Weber, S., Cohan, D. Journal of the International AIDS Society (March 2017), 20 (Suppl 1): 24–30, doi:10.7448/IAS.20.2.21295.

Studies suggest that HIV acquisition during the perinatal period significantly increases the risk of vertical transmission. Thus, this period offers important opportunities for HIV prevention or treatment services. The authors of this commentary reviewed the safety of oral pre-exposure prophylaxis (PrEP) with tenofovir/emtricitabine in pregnant and lactating women. They described a "shared decisionmaking" clinical approach for identifying high-risk women and addressing their risk during pregnancy, including using (or not using) PrEP during periods of higher vulnerability. Evidence suggests that PrEP with tenofovir/emtricitabine is safe during pregnancy and lactation. However, numerous factors make it difficult to identify high-risk women who could be candidates for PrEP. The shared decision making approach uses provider–client interaction to identify vulnerability. In this approach, implemented at set intervals during the perinatal period, the client is tested for HIV and sexually transmitted infections, and the provider and client assess her vulnerability and decide together the best options for HIV prevention, including PrEP, for periods of high vulnerability. This approach, the authors said, would facilitate the difficult task of identifying women at high risk of HIV, but would need to be tested in diverse clinical settings. They added that future prevention research must include pregnant and breastfeeding women to strengthen development of evidence-informed public health policies and clinical guidelines.

Chan, B.T., Tsai, A.C. Journal of the International AIDS Society (January 2017), 20(1): 1–8, doi:10.7448/IAS.20.1.21395.

This study examined the "contact hypothesis" and its relevance to addressing HIV-related stigma in sub-Saharan Africa. This hypothesis suggests that personal contact with people living with HIV (PLHIV) may reduce stigmatizing attitudes in the general population. The authors analyzed data on 206,717 women and 91,549 men derived from Demographic and Health Surveys and AIDS Indicator Surveys from 26 African countries between 2003 and 2008. They focused on associations between contact with PLHIV and indicators for social distance (desire to avoid PLHIV) and anticipated stigma (desire to hide the status of a known PLHIV to avoid stigma). Findings indicated that those who had personal contact with PLHIV were significantly less likely to desire social distance; a sensitivity analysis of community-level indicators had similar results. The authors found no association, either at the community or individual level, between contact with PLHIV and anticipated stigma. The association between contact with PLHIV and reduced desire for social distance does not imply a causal link, the authors said; but it does suggest that interventions to reduce stigma could benefit from extensive participation by PLHIV. They recommended further study to test the efficacy of such interventions in sub-Saharan Africa and elsewhere.

De Beaudrap, P., Beninguisse, G., Pasquier, E., et al. The Lancet HIV (April 2017), doi:10.1016/S2352-3018(16)30209-0.

Globally, people with disabilities experience greater health risks compared to those without disabilities; yet they have been left behind in the response to HIV. The HandiVIH study, a cross-sectional, population-based, observational study, compared HIV prevalence and associated risk factors between people with and without disabilities. From October 2014 through November 2015, the authors recruited 807 adults with disabilities and 807 matched control participants in Yaoundé. Participants were offered voluntary HIV testing and counseling and took part in structured interviews. Participants with disabilities had less education, lower income, and less access to transportation and health services relative to those without disabilities. HIV prevalence in participants with disabilities was higher than in those without (6.8% versus 3.9%). Women with disabilities were more often involved in paid sexual relationships (2.5% versus 1%), and they were also at increased risk of sexual violence relative to their non-disabled counterparts (34% versus 27%). Sexual violence and sex work were strongly associated with increased risk of HIV infection among participants with disabilities, but not among controls. The authors said that the higher prevalence of HIV in people with disabilities reflected greater exposure to HIV, which appeared to be shaped by social and environmental factors. They recommended research to inform actions for preventing HIV in this vulnerable population.

Behavioral Prevention

Hurley, E.A., Brahmbhatt, H., Kayembe, P.K., et al. Journal of Adolescent Health (January 2017), 60(1): 79–86, doi:10.1016/j.jadohealth.2016.08.023.

The authors of this study examined the role of individual alcohol expectancies (belief that a specific result will ensue from alcohol use) in risk behaviors among youth in Democratic Republic of the Congo. Data came from a 2010 survey of 1,396 adolescents (ages 15–19) and young adults (ages 20–24) on alcohol and sexual behaviors. The study focused on expectancies that alcohol use would (1) lead to sex or positive sexual experiences, (2) diminish one's ability to resist unwanted sex, and (3) diminish one’s ability to use or negotiate use of condoms. Participants who drank were significantly more likely than nondrinkers to be sexually experienced and to have engaged in every type of sexual risk assessed, including unprotected sex and multiple sex partners (MSP). Moderate expectancies of alcohol leading to positive sexual experiences were significantly associated with MSP among adolescent boys, whereas high expectancies were significant among young adult men. Among adolescent girls who used alcohol, the likelihood of unprotected sex was elevated among those with expectancies of diminished ability to refuse unwanted sex or negotiate condom use. The authors endorsed incorporating the role of alcohol expectancies in sexual risk behaviors for youth, and tailoring programs to address different roles of expectancies in males and females.

Combination Prevention

Kahabuka, C., Plotkin, M., Christensen, A., et al. AIDS and Behavior (March 2017), e-publication ahead of print, doi:10.1007/s10461-017-1750-5.

This cross-sectional study was conducted in 2015 as a "real-world" examination of the effectiveness and feasibility of partner notification for HIV testing services (HTS) in Njombe, Tanzania. At three high-volume hospitals, men and women who were newly diagnosed with HIV were enrolled as index clients. Consenting clients completed a questionnaire on demographics and sexual history and provided information on their past and current sexual partners. They were then given options for notifying their partners and linking them to HTS. Of 653 newly diagnosed individuals, 390 index clients were enrolled—chiefly through the passive approach, in which clients contacted partners according to a timeline developed jointly by the index client and the provider. Enrollees listed 438 sexual partners, of whom 249 (56.8%) came to the facility for testing. Nearly all of these referred partners (96%) were tested for HIV; 148 tested positive (61.9%), with women more often testing positive than men. Among partners testing positive, 104 (70.3%) were enrolled into HIV care and treatment. The authors noted the high rate of positivity found in this study, and concluded that partner notification could dramatically increase the number of undiagnosed HIV-positive persons who are identified and linked to care. They recommended this approach as an important strategy for reaching global 90-90-90 goals.

Maheswaran, H., Petrou, S., MacPherson, P., et al. Journal of Acquired Immune Deficiency Syndromes (March 2017), e-publication ahead of print, doi:10.1097/QAI.0000000000001373.

This study in Malawi compared the economic and health outcomes of HIV self-testing (HIVST)—a recommended approach in Africa—with outcomes of facility-based HIV testing and counseling (HTC). The authors conducted a prospective cohort study of 325 HIV-positive participants who had been diagnosed through HIVST (60) or facility-based HTC (265) as part of a community cluster-randomized trial (ISRCTN02004005). They followed these participants for one year from initiation on antiretroviral therapy (ART) and measured health care resource use, health provider costs, direct nonmedical and indirect costs, and health-related quality of life (using the EuroQol EQ-5D tool) during this period. Mean total health provider assessment costs for ART initiation were USD$22.79 and $19.92 for HTC and HIVST participants, respectively. Health provider costs for the first year of ART were $168.65 and $164.66, respectively, for facility-based HTC and HIVST participants. EQ-5D utility scores were comparable between the two groups; quality of life was lower among those with lower CD4 counts but improved after ART initiation, irrespective of the HIV testing mode. The authors concluded that after HIV self-testers are linked to HIV services, their economic and health outcomes are comparable to those linking to services after facility-based HTC, but they cautioned that the high cost of ART could limit adherence.

Ngure, K., Kimemia, G., Dew, K., et al. Journal of the International AIDS Society (March 2017), 20(Suppl 1): 52–58, doi:10.7448/IAS.20.2.21309.

The authors of this qualitative study examined the views and experiences of providers and serodiscordant couples in Thika, Kenya, to inform strategies for safer contraception among mixed-status couples. Between August 2015 and March 2016, they interviewed 20 providers from public and private clinics providing HIV or fertility care; and they conducted 20 interviews and four focus group discussions with serodiscordant couples who were participating in the Partners Demonstration Project assessing antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) for serodiscordant couples. Findings showed that participants often favored methods they were familiar with and revealed gaps in knowledge among both providers and clients. Providers from HIV clinics frequently discussed timed condomless sex and ART; providers from fertility centers favored medically assisted reproduction and were often uninformed about ART. Couples experienced with ART and PrEP were willing to use these strategies to reduce HIV risk when attempting pregnancy. Couples also found condomless sex, combined with ART and PrEP, an acceptable strategy; but they often revealed insufficient knowledge of fertility cycles. The authors concluded that strategies based on ART, PrEP, and timed condomless sex were acceptable to serodiscordant couples. They recommended cross-training for medical providers to strengthen services for safe conception, and they endorsed frequent discussions of the fertility desires of serodiscordant couples.

Davies, N.E., Matthews, L.T., Crankshaw, T.L., et al. Journal of the International AIDS Society (March 2017), 20(Suppl 1): 36–42, doi:10.7448/IAS.20.2.21271.

The authors of this commentary used examples from South Africa to identify key obstacles to implementation of policies to help serodiscordant couples meet their reproductive goals and discussed ways of improving implementation of such policies. They identified four key barriers to policy implementation: poor translation of policies into implementation strategies; entrenched negative attitudes about people living with HIV (PLHIV) among organizations and providers; insufficient training, including training on safe conception; and insufficient engagement and education of communities on HIV and opportunities for receiving treatment and safely making reproductive choices. Two challenges—the high rate of unintended pregnancies and low awareness of HIV status in the general population—also limit uptake of options for safer conception. The authors recommended the following approaches for addressing these barriers: incorporating safe conception programs (along with routine monitoring) into existing programs for test and treat and eliminating mother-to-child transmission; a stepped care approach to training for primary health care nurses; and extensive activities to engage communities in actions to address HIV. These steps, the authors said, could be used to inform policy development and implementation in South Africa and other HIV high-burden countries.

Mukandavire, C., Low, A., Mburu, G., et al. AIDS (March 2017), e-publication ahead of print, doi:10.1097/QAD.0000000000001458.

The authors of this article used modeling to determine whether introducing opioid substitution therapy (OST) could improve the coverage of antiretroviral therapy (ART) across a population of people who inject drugs (PWID) for different baseline ART coverage levels. Using data from a previous meta-analysis, they examined the effect of OST on ART at different levels of ART coverage, along with changes in levels of viral suppression, to project the relative reduction in yearly HIV transmission risk achieved by ART (with or without OST). They then compared these findings to models in which no ART was present (defined as the prevention effectiveness of ART). They found that OST could significantly increase the benefit of ART for HIV prevention among PWID, depending on the baseline ART coverage level (by 44% for low coverage, 31% for moderate coverage, and 20% for high coverage), compared to PWID not on OST. Their findings also indicated that introducing OST would improve the population-level prevention effectiveness of ART across all PWID, compared to OST not being introduced. They concluded that introducing OST could markedly improve the HIV prevention benefit of ART, but cautioned that this improvement would require removing policy barriers, such as stigma and the criminalization of drug use.

Maheu-Giroux, M., Tanser, F., Boily, M.C., et al. AIDS (April 2017), 31(7):1017–1024, doi:10.1097/QAD.0000000000001435.

Traditionally, the time of linkage to care has been defined using HIV diagnosis as the starting point. The authors of this study estimated the time elapsing between HIV infection and linkage to care, and sought to identify factors that determined this time. They used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal, South Africa (2004–2013) to estimate time of HIV infection; they then linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage. They also examined various factors (sex, age, education, food security, economic status, and others) in terms on their effect on the time to linkage. They found an average lapse of 4.9 years for half (50%) of HIV seroconverters to be linked to care. For all cohort members who were linked to care, the median CD4 cell count at linkage was 350 cells/μl. Women comprised 76.9 percent of seroconverters; but men and participants below age 30 were found to have the slowest rates of linkage to care. The authors concluded that the average time from HIV infection to linkage to care is long and must be reduced to ensure the effectiveness of HIV treatment-as-prevention policies. They said that targeted interventions for men and young individuals have the largest potential to improve linkage rates.

Structural Prevention

Knopf, A.S., McNealy, K.R., Al-Khattab, H., et al. PLOS ONE (March 2017), 12(3): e0173225, doi:10.1371/journal.pone.0173225, eCollection 2017.

The authors of this study described the process of sexual learning among East African adolescents living in the context of generalized HIV epidemics. Following a systematic search procedure, which identified 32 reports for inclusion, they constructed a framework depicting a lifelong process of sexual learning in this population. The framework includes three phases of sexual learning: (1) being primed for sex, (2) making sense of sex, and (3) having sexual experiences. Adolescents were primed for sex through messages on sexuality that they received through daily life and understanding gender norms, cultural practices, and economic structures, as well as through conversations and formal instruction. They made sense of sex by acquiring information about sexual intercourse (though levels of knowledge varied significantly), reproduction and pregnancy, sexually transmitted infections, and relationships; and by developing beliefs and attitudes about these topics. Some adolescents described having sexual experiences that met wants or needs, but many experienced sex that was coerced or violent; all adolescents worried about sexually transmitted infections after sexual experiences. The authors said that these three phases of sexual learning interact to shape adolescents' sexual lives and their risk for HIV infection. They expressed hopes that this framework would contribute to the development of sex education programs that address HIV risk within the broader context of sexual learning.

Mohammed, B.H., Johnston, J.M., Harwell, J.I., et al. BMC Health Services Research (March 2017), 17(1): 178, doi:10.1186/s12913-017-2121-7.

This cross-sectional study focused on the association between intimate partner violence (IPV) and use of maternal health care (MCH) services in Ethiopia. A total of 210 women with an infant under 6 months (participants in a larger study on use of MCH services in Addis Ababa) filled out a questionnaire that included information on IPV. Findings showed that over three-quarters of participants (75.2%) had experienced IPV in their current relationship, including control by partners (69%), sexual violence (37.6%), emotional violence (23.3%), and physical violence (18.6%). Regression analysis showed that though nearly all women had at least one antenatal care (ANC) visit, women who experienced emotional violence were less likely to attend ANC during their first trimester. Women who had experienced physical abuse were less likely to have had HIV testing, a skilled birth attendant, or birth at a facility. Women who had experienced physical or sexual abuse or control by their partner were less likely to attend four or more ANC visits. Over half of the women believed that IPV was acceptable. The authors concluded that all types of IPV were significantly associated with poor use of MCH services. They recommended that to sustain recent improvements in MCH services in Addis Ababa, and to continue improving them, programs should address the effects of IPV on women's use of services.

Ghosh, D., Krishnan, A., Gibson, B., et al. AIDS and Behavior (April 2017), 21(4):1183-1207. doi:10.1007/s10461-016-1413-y.

This systematic review described the advantages and disadvantages of social network-based interventions (SNI) for addressing HIV and outlined gaps for SNI use in the HIV continuum. The authors identified 58 studies published from the 1990s through 2014 that focused on HIV in substance users that had utilized social network analysis (SNA) or SNI as part of their methodology. The majority of studies (43) used SNA, but used this approach to facilitate or confirm a broader analysis rather than focusing on the networks. Only 13 studies used SNI. All 13 of the SNI studies implemented variants of peer-driven interventions; of these, the 9 that included controls showed substantial improvements in more than one HIV risk reduction behavior. The study revealed several challenges of SNIs: the potential for contamination; rapid network turnover, which might impede diffusion of interventions; concerns about the accuracy of peer-distributed information; and disclosure dynamics. The authors concluded that SNIs are cost-effective for reaching larger populations, including hard-to-reach groups, and enable members of key groups to serve as role models. They advocated for research to explore social network dynamics and optimize their potential to reduce HIV transmission and improve HIV care.

Coburn, B.J., Okano, J.T., Blower, S. Science Translational Medicine (March 2017), 9(383), pii:eaag0019, doi:10.1126/scitranslmed.aag0019.

The World Health Organization and the Joint United Nations Programme for HIV/AIDS (UNAIDS) have proposed treatment as prevention (TasP) as a global strategy for eliminating HIV by reducing the infectivity of the virus in people living with HIV (PLHIV). The authors of this article developed a geostatistical framework for designing TasP-based HIV elimination strategies in sub-Saharan Africa, focusing on Lesotho, where approximately one-quarter of the population is HIV-positive. By combining several large datasets, they created a map that showed the countrywide geographic dispersion pattern of PLHIV. This map showed that about 20 percent of PLHIV live in urban areas, and that almost all rural communities have at least one HIV-positive individual. Using the map, they then designed an optimal elimination strategy and identified which communities should use TasP. This strategy minimized the area that needed to be covered to find and treat PLHIV. Their findings indicated that UNAIDS's elimination strategy would not be feasible in Lesotho because it would require deploying treatment in areas where there are approximately four HIV-positive individuals/km2. Thus, the spatial dispersion of Lesotho's population hinders, and may even prevent, the elimination of HIV.

Reports, Guidelines, and Tools

Clearinghouse on Male Circumcision for HIV Prevention.

In February 2017, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) sponsored a webinar on continuous quality improvement of voluntary medical male circumcision (VMMC) programs. This summary presents the highlights from five presentations given by representatives from the U.S. Agency for International Development (USAID), AIDSFree, the USAID Applying Science to Strengthen and Improve Programs (ASSIST) Project, and the Health Communications Capacity Collaborative (HC3), showcasing quality improvement interventions in Lesotho, Mozambique, Namibia, South Africa, Swaziland, Tanzania, and Uganda. The summary includes a link to a recording of the webinar.