Drew, R.S., Rice, B., Ruutel, K., et al. HIV Medicine (2017), 18,490–499, doi: 10.111/hiv.12480.

This report assessed how the HIV continuum of care is measured across 55 European and Central Asian countries. It includes quantitative data from 40 countries; the data most often provided were the number of people diagnosed with HIV and the number of people on antiretroviral treatment (ART). Most countries defined “diagnosed with HIV” as a cumulative number ever diagnosed, without excluding individuals who may have died. Countries defined “linkage to care” in multiple ways, including registration and having specified lab tests or CD4 cell count results. The definition of “retained in care” also varied, including one visit/year and having a visit within one year of enrollment. The definition of “on treatment and undetectable viral load (VL)” most often included the number of individuals ever on ART, or on ART at the end of the year. There was a wide range of VL thresholds, from <20 to <500 copies/mL. Among countries reporting data, cumulative estimates indicated that 76 percent of people living with HIV (PLHIV) are diagnosed, 78 percent of diagnosed PLHIV are on treatment, and 88 percent of PLHIV on treatment are virally suppressed. Globally, however, only 53 percent of all PLHIV are virally suppressed. Countries need to identify standard definitions for each step within the continuum of care to improve planning for HIV testing and treatment programs in Europe and Central Asia.

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.

U.S. President's Emergency Plan for AIDS Relief (September 2017).

PEPFAR's newly issued strategy redirects HIV activities to move toward control of the global epidemic. The strategy responds to major accomplishments resulting from intensive activities to prevent, diagnose, and treat HIV during the past decades. For example, Lesotho, Malawi, Swaziland, Zambia, and Zimbabwe are approaching control of their epidemics; and HIV incidence has stabilized in Uganda. The 2017–2020 strategy provides guidance for implementation in more than 50 countries and seeks to accomplish three overarching goals: 1) maintaining treatment for those already receiving it, while making essential services, such as testing linked to treatment more accessible; 2) expanding services for orphans and vulnerable children; and 3) supporting prevention and treatment for key populations. The strategy also increases momentum in 13 countries that have the potential to achieve epidemic control by 2020 and includes these four action steps:

  • Accelerating optimized HIV testing and treatment, especially targeting men under age 35
  • Expanding HIV prevention, especially for women under age 25 and men under age 30, by scaling up best practices from the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) Initiative and expanding voluntary medical male circumcision for boys and young men aged 15–29
  • Using epidemiologic and cost data to improve implementing partners' performance and increase programmatic impact and effectiveness
  • Engaging with faith-based organizations and the private sector
  • Strengthening partner governments' policy and financial contributions to the HIV response.

Health Communication Capacity Collaborative (HC3) (June 2017).

This guide provides resources and information to help program planners and implementers to use social and behavior change for engaging men and improving their uptake of sexual and reproductive health (SRH) products and services in low- and middle-income countries. The guide includes lessons learned and best practices from programmatic implementation to promote male condoms, vasectomy, voluntary medical male circumcision, and testing and treatment for HIV and sexually transmitted infections. It includes four sections:

  • Overview of SRH Products and Services for Men. This section explains why the guide focuses on men and what products and services are included.
  • Influencing Behavior to Increase Utilization of SRH Products and Services by Men. This section summarizes the factors that influence men’s uptake of SRH products and services. It also describes how strategic behavioral communication (SBC) interacts with the SRH care cascade for men.
  • Key Considerations for Increasing Utilization of SRH Products and Services by Men. This section summarizes lessons learned and considerations to keep in mind when planning SBC interventions to improve the demand for and uptake of services and products.
  • Resources and Tools. This section provides additional resources and tools for program planners and implementers. 

Joint United Nations Programme on HIV and AIDS (UNAIDS) (2017).

This report summarizes global progress toward reaching the "90-90-90" targets (90% of people know their HIV status, 90% of people with HIV initiated on treatment, and 90% of people achieving viral suppression by the end of 2020).

  • First 90: More than two-thirds of people globally know their HIV status. This has been the most challenging to advance, particularly among young men and boys.
  • Second 90: Of those who know their HIV status, 77 percent are accessing treatment. Universal treatment, same-day treatment initiation, and scale-up of community-based approaches are critical for further progress.
  • Third 90: Of those on treatment, 82 percent have suppressed viral loads. Achieving this goal requires advancing community strategies that improve retention and reduce lost to follow-up.

The report highlights the Sustainable East Africa Research in Community Health Project, which shows that 90-90-90 can be reached at the population level in Kenya and Uganda. It summarizes the status of 90-90-90 by region, and offers chapters on the state of the epidemic, midterm progress highlights, policies facilitating community-based treatments, strategies to address gaps in the care cascade, and case studies of cities that have made significant advancements toward achieving 90-90-90.  

Stellenbosch University, U.S. Centers for Disease Control and Prevention, and United States Agency for International Development (2017).

This guidance document brings together lessons learned from the community-based HIV and tuberculosis program implemented by the Desmond Tutu TB Centre, and provides practical information for others who are establishing community-based HIV prevention services as a component of an integrated public health response. The guide targets a broad audience including program planners, clinicians, monitoring and evaluation personnel, and all stakeholders in the community-based HIV prevention response. The chapters cover:

  • Engaging stakeholders: Information and tools on engaging stakeholders before and after implementation.
  • Collaborating with nonprofit organizations: Information and tools on increasing the sustainability of HIV prevention approaches through collaboration.
  • Creating, equipping, and sustaining a team: Guidance for building an effective team.
  • Delivering holistic client-centered services: Information and best practices for effective community-based services, including integrated HIV and TB.
  • Linking clients to HIV care and treatment: Information on linkage challenges for people diagnosed with HIV, and practical information on improving linkages.
  • Providing quality assurance for rapid HIV testing: Guidance on ensuring quality HIV testing and result sharing in the community setting.
  • Managing data: Guidance on establishing a high-quality data management system.
  • Monitoring and evaluation: Guidance on data-gathering and evaluation for HIV prevention services.

Each chapter contains case studies, helpful tips, and links to related websites.

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.

HIV Resource Tracking for HIV Prevention Research and Development (October 2016).

This report examines trends in research and development (R&D) investments and spending for biomedical HIV prevention interventions. This report highlights findings for 2015 and analyzes trends over the past 15 years. Findings include:

  • Between 2014 and 2015, basic research accounted for 21 percent of investments; pre-clinical research experienced a slight increase from 42 to 44 percent. Implementation science accounted for approximately 12 percent of investments.
  • Private-sector contributions included expansion of biomedical prevention options. Commercial sector implementation research spending increased 36 percent between 2014 and 2015.
  • Seventy percent of the total USD$1.2 billion invested in 2015 come from the U.S. public sector, chiefly the National Institutes of Health. The Bill & Melinda Gates Foundation accounted for 80 percent of charitable giving. More funding diversity is needed to increase funding stability.
  • The end of the Millennium Development Goals has resulted in a $2 billion reduction in development assistance for health spending—the first reduction since 2000. Investments from development agencies in R&D for HIV fell by $11 million in 2015. To end the epidemic, R&D on HIV prevention must be reprioritized on the global agenda.
  • Lower- and upper-middle-income countries mainly rely upon donor aid and require assistance to identify domestic funding sources for R&D on HIV prevention. 

AIDSFree (2016).

The HIV Prevention Knowledge Base (PKB) is a collection of research and tools to help you find what works in prevention. Each PKB topic includes a short introduction that describes the approach, synthesizes the core elements of the intervention, and reviews the current state of practice. The PKB includes databases for combination, biomedical, behavioral, and structural prevention; entries within each database summarize evidence, tools, and resources for 29 approaches for prevention. A sample of the approaches under each category includes:

  • Combination Prevention (5 topics): This category includes approaches for various high-risk groups such as men who have sex with men, people who inject drugs, and serodiscordant couples; and describes approaches for promoting positive health while reducing risks of transmitting the virus to others.
  • Biomedical Prevention (12 topics): This category covers a wide range of procedures (such as ensuring the safety of blood supplies or injections), medical protocols (such as male circumcision and prevention of mother-to-child transmission), and medicines (such as antiretrovirals and microbicides) that prevent HIV or mitigate its effect.
  • Behavioral Prevention (9 topics): This category covers approaches for reducing high-risk behavior, including consistent condom use, peer-based interventions, partner reduction, and alcohol-related risks, among others.
  • Structural Prevention (3 topics): This category comprises an overview and sections on policy-focused and work-based interventions.

United Nations Secretary-General and Co-Chairs of the High-Level Panel on Access to Medicines (September 2016).

This report examines the potential of health technologies in relation to conflicting interactions among intellectual property (IP) policies, trade rules, and international human rights. The document contains four chapters and related recommendations:

  • Health Technology, Innovation and Access: Describes policy- and practice-related incongruities among public rights to health, IP, and international trade laws; and their impact on technology advancement and rights to use.
  • IP Laws and Access to Health Technologies: Describes aspects of IP law that can be manipulated to improve access to health technology, free-trade agreements, and their influence on IP rights; and provides recommendations on aligning public health priorities and trade laws, specifically the World Trade Organization's Trade Related Aspects of IP Rights (TRIPS) Agreement.
  • New Incentives for Research and Development of Health Technologies: Explains how coordinating and prioritizing research and development can systematically address health gaps. The chapter includes recommendations on financing and coordinating new health technologies.
  • Governance, Accountability, and Transparency: Reviews the oversight and responsibility needed to inspire innovation and access to health technology, and describes the roles of stakeholders. The chapter provides recommendations on coordinating the work of governments, the private sector, multilateral organizations, clinical trials, the patent process, and research and development to align policies and improve access to health technology. 

Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project.

Attaining the Joint United Nations Programme on HIV/AIDS (UNAIDS') 90–90–90 targets largely depends on the first 90—correctly diagnosing 90 percent of all people living with HIV. Many people with HIV have already been diagnosed; an estimated 13 million people are on antiretroviral therapy worldwide. Although most technologies for HIV testing have high sensitivity and specificity and are highly accurate when used in a validated national algorithm, the volume of tests conducted (over 150 million in 2014 alone) could result in thousands of misdiagnosed cases, particularly if tests are not conducted correctly. Misdiagnosis of HIV has significant implications for individuals and for public health.

Please join AIDSFree for a webinar on October 13, 2016 from 9:00 a.m. – 10:30 a.m. EST. Presenters will highlight the evidence collected on HIV misdiagnosis and discuss the ethical, legal, human rights, and public health implications. A list of speakers will follow.

A link to the webinar will be distributed to all registrants prior to the webinar.

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.

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.

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

This report states that since 2010, the extraordinary scale-up of antiretroviral treatment (ART) by many of the world’s most affected countries has reduced AIDS-related deaths from 1.5 million in 2010 to 1.1 million in 2015. Global ART coverage reached 46 percent at the end of 2015. Gains were greatest in eastern and southern Africa, where coverage increased from 24 percent in 2010 to 54 percent in 2015, reaching a total of 10.3 million people. However, declines in new HIV infections among adults have slowed alarmingly in recent years; the estimated annual number of new infections remains nearly static at about 9 million. Again, the largest reduction in new adult infections occurred in eastern and southern Africa. The Asia and Pacific regions and western and central Africa achieved more gradual declines. New adult infection rates were relatively stable in Latin America and the Caribbean, western and central Europe, North America, the Middle East, and North Africa. However, the annual number of new HIV infections in Eastern Europe and Central Asia increased by 57 percent. UNAIDS urges countries to continue to scale up HIV prevention programs while maintaining the rollout of treatment, and to work closely with civil society, communities, and people living with HIV, to ensure that they know where their epidemics are concentrated and that they have the right services in the right places.

United National General Assembly (June 2016).

The Political Declaration on Ending AIDS calls on the world to achieve the following goals:

  • Reduce new HIV infections to fewer than 500,000 globally by 2020
  • Reduce AIDS-related deaths to fewer than 500,000 globally by 2020
  • Eliminate HIV-related stigma and discrimination by 2020.

The Political Declaration endorses outreach for key populations (sex workers, men who have sex with men, people who inject drugs, transgender people, and prisoners). It also commits to addressing the disproportionate burden of HIV on women and girls, achieving gender equality, investing in women’s leadership, and ending all forms of violence and discrimination against women and girls. It recognizes that progress in protecting and promoting the human rights of people living with, at risk of, and affected by HIV. Countries committed to urgently addressing low treatment coverage rates among children living with HIV, eliminating new infections among children, and ensuring that their mothers have access to antiretroviral therapy. They also agreed to intensify outreach in locations of high HIV transmission. Leaders made commitments for effective allocations of funds to implement a Fast-Track HIV response; and Member States promised to enhance monitoring and accountability, while endorsing the more active involvement of people living with, affected by, and at risk of HIV. 

Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project.

The United Nations Population Fund (UNFPA), in collaboration with the World Bank, the Reproductive Health Supplies Coalition (RHSC), the United States Agency for International Development (USAID), and the International Labor Organization (ILO), has launched a new initiative to increase the availability of, access to, and use of 20 billion condoms in low- and middle-income countries by the year 2020. It is known as the 20 by 20 Initiative.

Concerns about appropriate pricing strategies, crowding out of the commercial sector, and an inefficient use of public funds have motivated several organizations to adopt or recommend a total market approach for condom programming.

Please join AIDSFree for a webinar on Tuesday, June 21 at 9 AM EST. Kim Green of PATH, Marguerite Farrell of USAID, and Doug Evans of George Washington University will present their experiences in researching and implementing a total market approach for condom programming.

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

This document gives an update on progress in the Fast-Track Strategy, adopted by the UNAIDS Programme Coordinating Board in October 2015. This strategy sets HIV service coverage targets that must be achieved by 2020 to build sufficient momentum to overcome one of history's greatest public health threats by 2030. For example:

  • Providing antiretroviral therapy (ART) to an additional 12 million people living with HIV in 2020. This will require reaching key populations with a comprehensive package of HIV services.
  • Increasing investment in HIV programs from an estimated USD$19.2 billion in 2014 to USD$26.2 billion by 2020. After 2020, the vast majority of people living with HIV will have been diagnosed. Because of this and other factors, the resources needed for HIV will then steadily decrease to USD$22.3 billion in 2030.
  • Increasing investment in outreach to key populations in low- and middle-income countries for HIV prevention and linkage to HIV testing and treatment. This investment should grow to about 7.2 percent of total investment by 2020, and the estimated resources needed for community-based delivery of ART percent should grow to about 3.8 percent of total investment.

The report also states that international assistance should continue to focus on low-income countries, which are less able to fund their HIV response.

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

This report gives an overview of harm reduction, an approach for reducing the negative outcomes of drug use. Harm reduction has been shown to benefit individuals, communities, and health and legal systems in a variety of ways. The document provides five policy recommendations, including:

  • Fully implementing harm reduction and HIV services, as outlined in guidance from the World Health Organization
  • Treating people who use drugs with support and care, rather than punishment
  • Integrating HIV services with other health and social protection services for people who inject drugs.

Additionally, the report provides ten operational recommendations, such as:

  • Ensuring that all those who use drugs have access to harm reduction services (including needle exchange, substitution therapy, and antiretroviral therapy) to prevent HIV infection
  • Supporting and empowering community and civil society organizations (including networks of people who use drugs) in the design and delivery of health and social protection services
  • Rebalancing investments in drug control to ensure fully funded public health services, including those for HIV infection, antiretroviral therapy, and treatment for drug dependence, hepatitis, tuberculosis, and other health conditions.

The report also emphasizes that harm reduction policies deliver broader social benefits, such as lower levels of drug-related crime and reduced pressure on health care and criminal justice systems.

Thior, I. Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project (March 2016).

This case study described the HIV programs developed by the Heineken and SAB Miller beverage companies to address HIV in the sub-Saharan African countries where they operate. These programs began in the 1990s and evolved from an initial focus on prevention to encompass prevention, care, and treatment for employees and dependents—reflecting concerns about the effect of HIV on the companies’ business interests. Subsequently, as an expression of corporate social responsibility or business imperative, both companies developed public-private partnerships to address HIV within communities and partner organizations. Interventions included outreach and prevention activities aimed at farmers and high-risk populations, such as bar patrons and long-distance truck drivers working for the companies and their subsidiaries. Both companies have also collaborated on HIV projects at the community and national levels by partnering with governments, nongovernmental organizations, and international agencies. The report recommended including large private-sector companies in the global HIV response as a way of reaching global goals for ending the epidemic.

Strengthening High-Impact Interventions for an AIDS-Free Generation (AIDSFree) Project Tanzania/Jhpiego (2016).

This report presented findings from a pilot study in Tanzania to test a nonsurgical device for medical male circumcision. Multiple studies have shown that voluntary medical male circumcision (VMMC) can prevent heterosexual HIV infection in uninfected men by up to 60 percent. Both the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommend promoting male circumcision as part of a comprehensive HIV treatment package. However, given the limited financial and human resources in many developing countries, alternatives to conventional procedures for medical circumcision may help countries reach their VMMC targets. This document presents findings from the Tanzania PrePex™ Acceptability and Safety Study (TZ-PASS), implemented by the AIDSFree Project to determine the benefits, acceptability, and risks of the PrePex™ device for nonsurgical circumcision in routine clinical settings in three regions of Tanzania. This device, which accomplishes VMMC nonsurgically through a procedure that can be performed by mid-level health care providers in a nonsterile setting, may make it easier for countries to reach recommended national targets. The study examined clinical outcomes, healing time, and client and partner views on the experience of circumcision with this device, and found the PrePex™ approach safe and socially acceptable in the study regions.

United Nations Secretary-General (2016).

This document from the United Nations (UN) General Assembly announces a High-Level Meeting on Ending AIDS, to convene June 8–10, 2016 at the UN headquarters in New York. The meeting responds to the need for UN member states to take a "Fast-Track" approach during the next five years to reach the goal of ending the HIV epidemic by 2030, and to achieve global goals for sustainable development. Achieving these goals will require not only increased investment in outreach, care, and treatment, but broader commitment to a rights-based approach to HIV programming that includes participation from civil society. Meeting attendees will draft a new Political Declaration on Ending AIDS. The UNAIDS Fast-Track approach aims to achieve ambitious targets by 2020, including:

  • Fewer than 500,000 people newly infected with HIV
  • Fewer than 500,000 people dying from AIDS-related illnesses
  • Eliminating HIV-related discrimination.

The Office of the U.S. Global AIDS Coordinator, December 2014.

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) released a new report titled PEPFAR 3.0 – Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation. The report documents the program’s progress and unveils PEPFAR’s strategy for working with partners to achieve an AIDS-free generation. Now in its third phase (2013 – present), PEPFAR is focusing on achieving transparency and accountability in the HIV response, and on accelerating core interventions to control the epidemic. PEPFAR is investing resources strategically to reach key high-risk populations with evidence-based programs. The report also provides insight into PEPFAR’s five Action Agendas—Impact, Efficiency, Sustainability, Partnership, and Human Rights—as the foundation for achieving an AIDS-free generation.

On World AIDS Day PEPFAR also announced the following initiatives:

  • $210 million partnership with the Bill & Melinda Gates Foundation and the Nike Foundation to reduce new HIV infections in adolescent girls and young women
  • $116.5 million investment in health systems for disease response
  • $200 million partnership with Children's Investment Fund Foundation for the Children's HIV/AIDS Treatment Initiative (ACT) in 10 African countries
  • Partnership with the multi-agency Global Pediatric Antiretroviral Commitment-to-Action to accelerate innovation and save children's lives
  • $21.5 million partnership with the Millennium Challenge Corporation to ensure data quality and transparency.

Levy, M., Messner, L., Duffy, M., and Casto, J. Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project (2016).

This document, produced by the Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project, serves as a companion guide to the 2012 Clinical Management of Children and Adolescents Who Have Experienced Sexual Violence: Technical Considerations for PEPFAR Programs, which provides step-by-step guidance on the appropriate clinical/forensic care for children and adolescents who have experienced sexual violence and exploitation. The companion guide provides a basic framework, examples, resources, and contact information to help providers and managers understand the needs of young people who have experienced sexual abuse, and to ensure comprehensive care beyond the clinical exam. Comprehensive care for this vulnerable group includes facilitating linkages with critical social and community services; taking additional steps to help children and adolescents obtain information and support their needs; and contributing to changes in sociocultural norms that perpetuate a culture of violence and silence, increasing vulnerability and the potential for HIV risk.

U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (February 2016).

PEPFAR has released technical considerations for Country/Regional Operational Plan (COP/ROP) Fiscal Year 2016. These substantially revised technical considerations include input from Chiefs of Mission and provide new details on PEPFAR’s technical support to countries. The technical considerations include funding memos and country-specific applications. PEPFAR will support countries for one-time commodities funds to immediately expand drug availability. Additionally, PEPFAR will continue working with countries to move immediately to provision of antiretroviral therapy for all persons living with HIV (Test and START) by adapting and implementing the 2015 World Health Organization (WHO) guidelines.

Friends of the Global Fight Against AIDS, Tuberculosis and Malaria (December 2014).

Faith-based organizations (FBOs) are strong partners and important stakeholders in the fight against HIV and AIDS. This guidance was developed to introduce FBOs such as churches, mosques,
synagogues, and others to the new funding model of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). The guidance also describes various ways in which participating FBOs can engage with the Global Fund to build stronger communities and expand their access to civil society groups. Specifically, the guide suggests that FBOs in countries organize as a caucus to develop a comprehensive strategy for prevention, treatment, and care as part of the overall national strategic health plan development process. Additionally, FBOs should engage with their country coordinating mechanism (CCM) to ensure that their constituents are appropriately represented. Interested FBOs can participate actively in the development of concept notes for a particular country-based initiative. Once the country receives the grant, FBOs should continue to engage with the Global Fund on the
development of the grant work plan and budget. Because of their broad networks, long-standing community presence, relationships, and knowledge of the local context, FBOs can serve as primary grant recipients or sub-recipients. They can also play a key role in resource mobilization by supporting ongoing advocacy at national and global levels, thus continuing their critical global role in addressing HIV, tuberculosis, and malaria.

Beyrer, C., Crago, A-L., Bekker, L-G., et al. The Lancet (January 2015), Vol. 385, Number 9964, pp. 287 – 301.

The authors conducted a global analysis of studies on female sex workers (FSWs) and HIV among FSWs in low-, middle-, and high-income countries. They found that over half of HIV prevalence in sex workers was in sub-Saharan Africa. Data were limited for male sex workers; of 51 countries that provided the data for this issue, six reported HIV prevalence of more than 25 percent. Global data on the burden of HIV in transgender sex workers were also limited. However, the authors cited a meta-analysis of data from 14 countries which reported that transgender FSWs had a higher burden of HIV (27 percent) than other transgender women (15 percent) and male (15 percent) and female sex workers (5 percent). They called for action through structural measures, such as decriminalizing sex work and addressing stigma; behavioral and biomedical prevention interventions, such as condoms distribution, access to pre-exposure prophylaxis (PrEP), and interventions based on antiretroviral therapy; and rights-based approaches. They also summarized promising prevention strategies such as microbicides and oral PrEP, adding that more data are needed on efficacy, acceptability, adherence, and risk compensation for these interventions for these populations. They concluded by calling for appropriately tailored implementation of promising HIV interventions for sex workers, and for recognition of the diversity of sex workers and their environments.

AVAC: Global Advocacy for HIV Prevention (February 19, 2015).

Global Advocacy for HIV Prevention (AVAC) issued its 2015 annual report in February 2015. The first part of the report provides in-depth information on the current state of global targets in HIV prevention, including an in-depth discussion on global targets and a call for advocates to work together to ensure that strategic targets are in place across the spectrum of prevention options. The second part explores resources and actions required to meet these targets. Specifically, the report identifies three recommendations for action:

  1. Align high-impact strategies with human rights and realities
  2. Invest in a paradigm shift driven by pre-exposure prophylaxis (PrEP)
  3. Demand short-term results on the path to long-term goals

The report also provides concise updates and calls to action on key prevention interventions, including HIV vaccines, voluntary medical male circumcision, microbicides, PrEP, and hormonal contraceptive use and HIV risk. This document is intended for use as a roadmap and a basis for discussion about how to advance comprehensive combination prevention—deploying existing tools, demonstrating the potential of emerging strategies, and discovering novel interventions such as an effective HIV vaccine.

U.S. President's Emergency Plan for AIDS Relief (PEPFAR) (February, 2015).

Resources for Health Strategy (HRH) 3.0. The strategy is intended to ensure availability of sufficient trained human resources to expand HIV and AIDS services in moderate- and high-volume sites or high HIV burden areas that receive PEPFAR support. PEPFAR’s HRH investments will focus on five objectives that directly support PEPFAR's realignment and strategies for achieving an AIDS-free generation:

  1. Assess HRH capacity needs for delivering HIV and AIDS services (prevention, care, and treatment) at PEPFAR-supported sites and areas.
  2. Support development of an appropriate number and skills mix of health workers to enable delivery of HIV and AIDS services in these locations.
  3. Establish recruitment, deployment, and retention strategies to ensure a consistent and sustainable supply of trained health workers.
  4. Establish sustainable financing for health workers to ensure adequate local financing for health workers who can provide HIV and AIDS services in PEPFAR sites.
  5. Improve health worker performance to build service quality at all PEPFAR-supported sites.

Some activities supporting the implementation of this strategy will be programmed as stand-alone activities; others may be combined within the technical areas of core activities and implementing mechanisms.

Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) (2015).

The Tool for Rapid Evaluation of Facility-Level Nutrition Assessment, Counseling, and Support (REF-NACS) is a generic tool that helps gather information on the capacity of health facilities to implement NACS for pregnant women, children, and people living with HIV. This tool is designed to stimulate discussions, facilitate an analytic process, and develop a prioritized plan for strengthening NACS services. The results from a REF-NACS assessment will help government policymakers, donors, program managers, service providers, and clients to:

  • Understand current service provision and human resource capacity to implement quality NACS services
  • Identify gaps in available services
  • Identify weaknesses in the health system for implementing a continuum of comprehensive NACS services
  • Prioritize interventions and identify actions to strengthen NACS-related programming.

REF-NACS is a flexible tool that can be used in a range of applications—to strengthen existing NACS capabilities, design new programs or services, or take a program to scale. It can be implemented in a sample of health facilities, or in all health facilities where a program plans to work, and is easy to administer with a modest budget.

India HIV/AIDS Alliance, April 2015.

This study described factors that influence vulnerability to sexual transmission of HIV between people who inject drugs (PWID) and their sexual partners, and discussed concerns associated with the delivery of various harm reduction services for these couples. The authors conducted 50 separate interviews and four focus group discussions in two districts in the states of Bihar and Manipur. They reported that PWID remained extremely vulnerable to HIV and other sexually transmitted infections. Stigma was reported as a main barrier preventing access to health services. Many PWID reported difficulties accessing harm reduction centers, such as the inconvenient operating hours of needle and syringe exchange programs, which in turn contributed to risky sharing behavior despite ample risk awareness. The authors also noted that group dynamics and social norms were important drivers of vulnerability in instances when reluctance to inject together (and share equipment) was viewed as suspicious. The research also revealed that female sexual partners of male injectors were often unaware of their partner’s HIV status, or felt unable to moderate their risk because of power imbalances in their relationships. This pointed to an urgent need to create effective services that meet the unique needs of women partnered with drug injectors, the authors said. They concluded that programs for PWID must address complex vulnerabilities faced by PWID and their sexual partners.

World Health Organization (May 2015).

On May 11, 2015, the World Health Organization released new guidelines that recommend simplified annual indicators to measure the reach of HIV services, and the impact achieved at both the national and global levels. The guidelines were developed in partnership with the Global Fund, the Joint United Nations Programme on HIV/AIDS, the United Nations Children's Fund, and the U.S. President's Emergency Plan for AIDS Relief. The guidelines recommend the use of 10 global indicators to collect information along the cascade of HIV care and treatment as a principal way to track national epidemics and responses. These indicators are:

  1. Number of people living with HIV
  2. Domestic funding
  3. Coverage of prevention services
  4. Number of individuals diagnosed
  5. HIV care coverage
  6. Treatment coverage
  7. Retention in treatment
  8. Percentage of people in treatment with viral suppression
  9. Number of HIV deaths
  10. Number of new infections.

The guide is primarily intended for national health sector staff engaged in the collection, analysis, and use of HIV-related strategic information, including those who set up monitoring and evaluation systems and those who use data to improve programs. It is also intended for stakeholders concerned with developing and analyzing strategic information, including nongovernmental organizations, private-sector care providers, civil society, and academic groups involved in teaching and research.

Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project.

Launched in July 2015, the AIDSFree HIV Testing Services (HTS) Community of Practice allows HTS professionals and policymakers to share knowledge and experiences with their peers; participate in moderated discussions; and access the latest HIV testing literature and news. The Community will feature moderated discussions, HIV testing literature and news updates, and the opportunity to connect with peers.

National Institutes of Health. (December 2013).

The National Institutes of Health (NIH) is committed to the goal of achieving a world without AIDS. On the 25th annual World AIDS Day, President Obama announced that over the next three fiscal years the NIH plans to invest an additional U.S.$100 million (U.S. dollars) in research to find a cure for HIV, a promising area of HIV research. According to Anthony S. Fauci, director of the NIH’s National Institute of Allergy and Infectious Diseases, in terms of the public health and scientific rationale for this research, “…the development of a cure is critically important, as it may not be feasible for tens of millions of people living with HIV infection to access and adhere to a lifetime of antiretroviral treatment.” Fauci also noted the opportune timing for expanded research, given increasing understanding of HIV reservoirs (“cellular hiding places”) and development of strategies to minimize the reservoirs. A substantial portion of investment will support basic HIV research, e.g., viral reservoirs and viral latency that will benefit HIV as well as other diseases. Other high-priority research will also continue, e.g., biomedical and behavioral prevention research (vaccines and microbicides), and examination of how genetic determinants and other factors, such as stigma, interact to affect treatment outcomes. This new research plan will require global collaboration, including public-private partnerships and innovative leadership, to share expertise and advance the search for a cure for HIV and AIDS.

The Center for Global Development (September 2013), Washington, DC.

This report from the Center's Value for Money Working Group offers practical strategies for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) to apply in its four-phase grant-making cycle. These strategies aim at achieving “more health value for the money”: investing resources cost-effectively to obtain a higher global health impact. The report describes key issues within each phase of the grant cycle—allocation, contracts, cost and spending, and performance verification—and makes several recommendations for improvement. In allocation of resources, to support evidence-based best practices, the Global Fund should specifically select scientifically proven and cost-effective interventions and commodities. To improve contracts and agreements to create stronger incentives, the Global Fund should direct some funding to the documentation of incremental performance progress, particularly against the most important indicators, and focus some funding on partners’ achievement of end-program goals. Within cost and spending, the Global Fund should improve monitoring and reporting by tracking unit costs of services delivered, sharing costing data with partners, and using unit-cost data throughout the entire grant cycle. To improve performance verification, the Global Fund should identify more rigorous measurement and reporting tools and verify data with population-based measurement. The working group suggested that the Global Fund and its partners adopt these strategies to ultimately improve their impact on reducing the global disease burden and improving health worldwide.

PEPFAR and USAID. (September 2013). Washington, DC.

This brief, directed to national policymakers, U.S. Government (USG) program managers, and implementing partners, summarizes evidence and recommendations on hormonal contraception (HC) and HIV, and identifies implications for policies and programs. The report discusses HC use in terms of whether HIV-negative women will acquire HIV, women living with HIV will infect male sexual partners, women living with HIV will have quicker disease progression, and whether women being treated for HIV will experience drug interactions. HC use does not protect against HIV, and since evidence on increased risk with use of progestogen-only injectable contraception is inconclusive, women at risk who use HC should be advised to consistently use condoms and other preventive measures. Hormonal contraception  does not protect against onward HIV transmission; thus, HIV-positive women should be advised to use condoms. If any HC method is found to increase HIV risk, it should be balanced against the life-saving benefits of effective methods to prevent unintended pregnancy. Policies should aim for the greatest public health benefit, which will vary according to the epidemiologic context. HIV testing and counseling should be available through family planning services, and the World Health Organization’s HC/HIV guidelines should be used to develop country guidelines. The USG supports research to develop multipurpose prevention technologies, and to improve understanding of potential associations between HC and HIV.

Bill & Melinda Gates Foundation (May 2013), New Delhi.

Using the experiences of the Avahan India AIDS Initiative, the Bill & Melinda Gates Foundation created this handbook on micro-planning and its application for improving peer-led outreach. It also provides nine micro-planning tools and guidance on how to apply them. Micro-planning decentralizes the outreach process and facilitates decision by outreach workers and peer educators on how best to reach the community. Since 2003, the Avahan project has reached high HIV risks groups, e.g., sex workers, people who inject drugs, high-risk men who have sex with men, and transgender persons, through peer-led HIV prevention programs. While micro-planning may differ for key populations, the handbook provides general implementation guidelines. Section 1 provides an overview on micro-planning; section 2 offers micro-planning tools, processes, and forms; section 3 provides steps for implementing a new micro-planning program; and section 4 explores related issues for consideration. The handbook is intended for government programs, nongovernmental organizations, and communities interested in using micro-planning as a tool to improve peer-led outreach.

Miller, K.S., Lasswell, S.M., Riley, D.B., et al. American Journal of Public Health (November 2013), Vol. 103 No. 11, pp. e16-e20.

This report discusses the Families Matter! Program (FMP), which is an evidence-based behavioral intervention that uses a five-session curriculum for parents and children aged 9-12. FMP seeks to delay sexual debut and decrease sexual risk behaviors through positive parent-child communication about HIV, sexually transmitted infections, and pregnancy prevention. It is implemented in eight sub-Saharan African countries with support from the U.S. Centers of Disease Control and Prevention through the U.S. President’s Plan for Emergency AIDS Relief. The intervention was initially adapted in Kenya (2003-2004) from the US-based Parents Matter! program; an evaluation in 2006 showed high acceptability and effectiveness, with an average of 90 percent of participants attending all sessions. FMP is currently being adapted to create a program for preventing sexual abuse against children, which will be tested in 2013. Several longitudinal studies on FMP are planned in 2013 and 2014, and the program may be adapted for older adolescents aged 13-18. The program’s five-step capacity building model supports FMP users to determine a community's need, engage local stakeholders to ensure cultural relevancy, ensure understanding and correct delivery by implementers; continuously monitor participants' attendance and satisfaction, and respond flexibly to the context while maintaining the vision of the intervention. It has been used by local governments and partners with high intervention fidelity and participant retention. The FMP may be useful in similar resource-constrained contexts.

UNITAID. World Health Organization (June 2013).

This report reviews current and emerging diagnostic platforms and developing technologies for point of care (POC) use - for CD4, viral load, and early infant diagnosis (EID) diagnostic tests - and assesses whether they meet the World Health Organization's "ASSURED" criteria (Affordable, Sensitive, Specific, User-friendly, Robust/Rapid, Equipment-free, and Deliverable to those in need). Many effective laboratory-based platforms are available for the three diagnostic tests, and various POC assays and platforms are in development, which may reduce costs, improve access for hard-to-reach-populations, and decrease loss-to-follow-up. Three POC CD4 tests are available. Others, including a disposable test, are expected to be on the market within two years. Access to viral load testing is inadequate in most resource-limited counties because of high costs, limited laboratory capacity, and transportation problems. ASSURED-certified viral load testing at the POC would decrease infrastructure and training costs. Only one assay is currently available, but many platforms and assays are in development, and one may be released in 2013. EID tests (which can also be performed on viral load platforms) have improved, but access is not universal. In addition to the viral load test platforms in development, at least two EID-specific POC assays are in progress, with one potential release in 2013. In addition, new platforms for high-volume testing are emerging. In conclusion, a country-specific mix of centralized, high-volume testing and POC diagnostics will likely be the most effective way to ensure access to these tests in resource-limited settings.

World Health Organization (June 2013).

The World Health Organization (WHO) released comprehensive guidance on the continuum of HIV testing, care, and treatment and the application of antiretroviral (ARV) drugs to prevent and treat HIV. This consolidated guidance is aimed at a target audience of national HIV program managers, particularly in low and middle-income countries. The guidelines include behavioral, structural, and biomedical interventions that incorporate ARV use, and highlight new technologies developed over the past three years for the HIV response. They consolidate WHO recommendations from other guidelines and provide ARV drug guidance for varied age groups and population, such as adolescents and key populations across the continuum of care, focusing on improving linkages, retention, and adherence. The document also includes the prevention benefits of HIV drugs and provides guidance for the continued scale-up of ARV drugs for treatment and prevention in resource-limited contexts. The clinical recommendations expand antiretroviral therapy eligibility to a CD4 of 500 cells/mm3. Most of the recommendations were developed based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. The WHO consolidated guidelines are a critical step towards realizing universal ARV access and improving ARV programs.

OGAC. U.S. Department of State: Diplomacy in Action (May 31, 2013).

The World Health Organization (WHO) has prequalified PrePex™, the first medical device for adult male circumcision. Prequalification ensures that medical devices and equipment for high-burden diseases meets safety and efficacy standards. The WHO conducted studies in Rwanda, Zimbabwe and Uganda as part of the prequalification process. The device has the potential to streamline the procedure and improve men’s experience of male circumcision. Given that the U.S. President’s Plan for Emergency AIDS Relief (PEPFAR) has supported implementation of voluntary medical male circumcision in 14 countries in eastern and southern Africa, OGAC’s Ambassador, Eric P. Goosby, voiced his support for countries that plan to implement PrePex™.  PEPFAR is supporting Ministries of Health and/or Defense in other African countries to conduct an initial assessment of the acceptability and safety of the device in various contexts, which is required before PEPFAR provides support for large-scale programs using the device.

Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR). (June 14, 2013). Vol. 62 No. 23, pp. 463-465.

Following a Thailand Ministry of Health and Centers for Disease Control and Prevention (CDC) randomized controlled trial of daily oral dose of tenofovir disoproxil fumarate (TDF)—showing TDF's effectiveness in reducing HIV infection among people who inject drugs (PWID—the CDC recommends that pre-exposure prophylaxis (PrEP) be considered as an HIV prevention strategy for PWID in the United States (U.S). The CDC recommends the daily TDF/emtricitabine (FCT) regimen for PrEP with PWID because TDF/FTC contains the same dosage of TDF (300 mg) that was effective in the trial; showed no additional toxicities compared to TDF alone in other trials; is indicated for those at HIV risk through sexual acquisition; and is approved in the U.S. for PrEP. Several clinical trials have shown the safety and efficacy of daily, oral PrEP, with high adherence, for other populations, and the CDC previously issued guidance for PrEP with men who have sex with men and heterosexually active adults. The current interim guidance was developed by a CDC workgroup with external experts and stakeholders. Adherence to daily oral PrEP is critical for effectiveness, and can be challenging. However, according to the CDC, PrEP for PWID could help reduce HIV incidence in the U.S.

Beck, J., Santos, G-M., and Ayala, G. The Global Forum on MSM and HIV (April 2013), Oakland, California.

Analyzing data from the Global Men’s Health and Rights Survey 2012 from the Global Forum on Men Who Have Sex with Men (MSM) and HIV, the authors explored HIV risk factors and access to health services among young men who have sex with men (YMSM) compared with older MSM. YMSM (MSM aged 30 years and below) experienced significantly less access to stable housing, health care, and HIV services, and were more likely to experience homophobia and violence, compared with older MSM. The study recruited 5,779 MSM from 165 countries, including 2,491 YMSM, primarily from Asia, Eastern Europe, and Latin America. Forty-four percent of YMSM who are eligible for HIV treatment are not on treatment, compared with 17 percent of MSM. Additionally, YMSM had lower levels of community engagement, comfort with health care providers, and association with the MSM community. The authors provided recommendations for governments, multilateral organizations, and international donors to address YMSM, including: improving housing stability and economic independence; providing comprehensive HIV prevention services that engage YMSM; improving HIV care and treatment for those living with HIV; involving YMSM to address factors that affect access to services; and advocating for leadership and involvement in the HIV response by YMSM.

Goswami, P., Rachakulla, H.K., Ramakrishnan, L., et al. British Medical Journal Open (2013), Vol. 3.

The authors assessed a large-scale HIV prevention program, the Avahan India AIDS Initiative, which targeted high-risk men who have sex with men (MSM) and transgender (TG) populations in Andhra Pradesh, evaluating program coverage, intermediate outcomes, and HIV and sexually transmitted infection (STI) rates using program monitoring data and data from two cross-sectional surveys. From initial coverage of 8 percent (2005), the Avahan program scaled up with strong outreach; peer educators contacted 83 percent of the target population monthly by 2008. MSM and TG populations were significantly more likely to report high and consistent condom use with male partners in the second survey round; however, low consistent condom use was reported with regular female partners. Those exposed to the initiative were more likely to use condoms with their male partners compared with those unexposed. The proportion who reported having ever visited an STI clinic increased from 1 to 80 percent from 2005 to 2008. There was no significant change in HIV incidence. The study’s authors argue that there is an urgent need to continue or develop new HIV prevention activities targeting this population, particularly  emphasizing regular STI clinic visits and consistent condom use with all partners, to reduce HIV transmission among MSM and TG populations in India.

PEPFAR. (March 2013).

Under the interagency Gender Technical Working Group, PEPFAR’s Gender Strategy urges all HIV programs to incorporate gender norms and inequalities within their activities. Specific actions include: increasing gender equity in HIV and reproductive health services; preventing and addressing gender-based violence (GBV); addressing social norms and behaviors among men and boys; and increasing protection of women and girls and their access to productive resources, including education. Over the past three years, PEPFAR has invested over U.S. $215 million in GBV programs. Following findings of high rates of GBV from violence against children surveys in four sub-Saharan African countries, the U.S. Government developed the U.S. Strategy to Prevent and Respond to Gender-based Violence  in August 2012. PEPFAR integrates GBV prevention into existing HIV programs. In January 2013, President Obama signed a presidential memorandum committing to improving women's and girls’ rights as a key to U.S. diplomacy. PEPFAR also has centrally-funded gender initiatives to build evidence for expanding programs, including the PEPFAR Gender Challenge Fund, the GBV Response Initiative, and the Secretary of State’s Office of Global Women’s Issues–PEPFAR GBV Small Grants program, and supports various partnerships to improve the health and wellbeing of women and girls. Through these commitments, PEPFAR has significantly improved the lives of women and girls, and has supported the cause of gender equity globally.

NAM Publications. NAM/aidsmap conference news: CROI 2013.

The NAM/aidsmap website features the 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013), which occurred on March 3-6, 2013 in Atlanta, Georgia. The website includes conference highlights, presentations, and several abstracts that were presented at the conference. The site includes an array of topics, such as "functional" HIV cure in a child, HIV risk among men who have sex with men in the United States, treatments for tuberculosis and hepatitis C, condom use, pre-exposure prophylaxis (in the Vaginal and Oral Interventions to Control the Epidemic, or VOICE, trial); and the cenicriviroc phase IIB study. Editor's choices from other related sources are also included.

Kirby, D., R. Dayton, K. L’Engle, et al. FHI 360 (2012).

To address the lack of programs focusing on multiple sexual partners among youth, FHI 360, in collaboration with the United States Agency for International Development’s Integrated Youth Working Group, developed the resource,Promoting Partner Reduction: Helping Young People Understand and Avoid HIV Risks from Multiple Partnerships. The publication includes a set of 17 participatory activities to support youth in various capacities, including educating participants on HIV transmission rates in different types of sexual partnerships; discussing reasons for engaging in multiple sexual partnerships; conducting behavior change communication to reduce partners and practice skills to refuse engagement; and examining the role of gender norms. The activities provide a forum for youth to discuss complex issues, such as transactional sex, and promote behavior change to reduce high-risk behaviors. The youth activities were field-tested in Botswana, Kenya, and the United States, and the resource was piloted by programs in South Africa and Swaziland.

Management Sciences for Health. (December 2012).

The Building Local Capacity for Delivery of HIV Service in Southern Africa (BLC) project, implemented by Management Sciences for Health, provides leadership, management and government technical assistance, and organizational development to address HIV and AIDS in Angola, Botswana, Lesotho, Namibia, South Africa, and Swaziland. BLC applies technical assistance in three areas: care and support for orphans and vulnerable children, HIV prevention, and community-based care. In October 2011, BLC, in collaboration with the Southern African Development Community (SADC), developed five technical briefs on priority HIV prevention. The briefs were intended to provide policymakers and program planners with accessible evidence and promising practices from across the region to enable technical discussion at the SADC HIV Prevention and Research Meeting in Johannesburg, South Africa in October 2012. The five briefs are: "Antiretroviral Treatment as Prevention: Opportunities and Challenges";" Positive Health, Dignity and Prevention: Engaging People Living with HIV in Prevention"; "Prevention of Mother-to-Child Transmission of HIV"; "Strengthening Behavior Change Communication for Prevention"; and "Voluntary Medical Male Circumcision for HIV Prevention." The series is helping to inform adaptation of an existing evidence-based HIV prevention training program, which will be piloted in Swaziland and then scaled up throughout the region.

World Health Organization (September 2015).

In September 2015 the World Health Organization (WHO) released early guidelines that highlight two key recommendations: (1) initiating antiretroviral therapy (ART) for every person living with HIV, regardless of CD4 cell count; and (2) using daily oral pre-exposure prophylaxis (PrEP) for individuals at high risk of HIV acquisition. These two recommendations were made available on early-release basis because of their potential to significantly reduce the number of people acquiring HIV infection and dying from HIV-related causes, and to exert a significant effect on global public health. The WHO guidelines target national HIV program managers who will be responsible for adapting the new recommendations at the country level, along with other stakeholders including national tuberculosis program managers, civil society organizations, and domestic and international funders of HIV programs. The full update of the guidelines on using antiretroviral drugs to treat and prevent HIV infection is expected in 2016. It will include comprehensive clinical recommendations and revised operational and service delivery guidance to help support implementation.

World Health Organization (WHO) Policy Brief (November 2015).

The November 2015 edition of the WHO consolidated guidelines on the use of antiretrovirals (ARVs) updates the 2013 edition following an extensive review of evidence undertaken in 2015. These new recommendations support initiation of antiretroviral treatment (ART) in all adults, adolescents, and children with HIV, regardless of CD4 cell count or disease stage. For the first time, the guidance includes recommendations specifically for adolescents (10 to 19 years old), covering when to begin ART and approaches for service delivery. The 2015 guidelines include 10 new recommendations, among them:

  • A differentiated care framework for addressing the diverse needs of people living with HIV
  • Alternative strategies for community-based ART delivery to accommodate the growing number of people on treatment
  • Principles for improving quality of care and providing people-centered care.

The updated guidelines also include recommendations on service delivery to support implementation (“the how” of providing ARVs), organized according to the continuum of HIV testing, prevention, treatment, and care. For the first time, the guidelines include “good practice statements” on interventions whose benefits substantially outweigh potential harms. The guidelines also articulate the need to expand access to HIV testing, prevention, treatment, and care in settings and populations with the highest HIV burden. Meeting this need requires concerted efforts to support long-term adherence to ARV drugs, and to eliminate stigma, discrimination, and barriers to HIV services.

U.S. President's Emergency Plan for AIDS Relief (PEPFAR) (October 2015).

Version 2 of the PEPFAR Evaluation Standards of Practice was released in October 2015 in response to the need for additional operational guidance and evolving requirements for planning and reporting on PEPFAR-supported evaluations. The interagency Evaluation Work Group assembled the guidance with the goal of improving the quality and relevance of PEPFAR evaluations and strengthening capacity to monitor progress and integrate lessons learned. This new publication adds several clarifications, including new sections on operational issues for planning, implementation, reporting, and review; an expanded section on roles and responsibilities; and a tools and templates section, describing tools and data elements contained in each. The appendices now include the required tools and templates for planning and reporting on PEPFAR-funded evaluations. The document consists of the following sections:

  • Section I - PEPFAR Evaluation Standards of Practice: lists the standards of practice in the order they are likely to be applied when conducting an evaluation.
  • Section II - Planning, Implementation, Reporting, and Review: describes the entire evaluation cycle, from planning to completion.
  • Section III - Roles and Responsibilities: presents two tables that illustrate roles and responsibilities by stakeholder entity, and roles and responsibilities for individuals. 
  • Section IV - Tools and Templates: outlines the tools and templates that will be used to plan evaluations, write evaluation reports, and assess adherence to standards.

Joint United Nations Programme on HIV/AIDS (UNAIDS) (November 2015).

In October 2015, the UNAIDS Programme Coordinating Board adopted a new strategy to end the HIV epidemic as a public health threat by 2030. The UNAIDS 2016–2021 Strategy is one of the first in the United Nations system to be aligned to the Sustainable Development Goals framework. This framework, which guides global development policy over the next 15 years, includes ending the HIV epidemic by 2030. The strategy, informed by evidence and rights-based approaches, maps out the UNAIDS Fast-Track approach to accelerate the HIV response over the next five years so as to reach critical HIV prevention and treatment targets and achieve zero discrimination. The strategy also endorses achieving 90–90–90 treatment targets, closing the testing gap, and protecting the health of the 22 million people living with HIV who are still not accessing treatment. Additionally, it urges protecting future generations from acquiring HIV by eliminating all new HIV infections among children, and by ensuring that young people can access needed services for HIV and sexual and reproductive health. The strategy emphasizes that empowering young people, particularly young women, is of utmost importance to preventing HIV. This empowerment includes ending gender-based violence and promoting healthy gender norms.

Bipartisan Policy Center (November 2015).

This report focused on the impact of the U.S. President's Plan for AIDS Relief (PEPFAR) on goodwill toward the United States and public well-being in partner countries. After controlling for regional variance, the authors compared high-prevalence PEPFAR and non-PEPFAR countries in sub-Saharan Africa. The results demonstrated that PEPFAR has contributed to a positive opinion of the United States in target countries—a finding that holds true across all 12 countries in sub-Saharan Africa that received PEPFAR funds since 2003. According to Gallup poll data on public opinion of U.S. leadership from 2007 to 2011, PEPFAR countries have had an average approval rating of 68 percent, compared with the global average of 46 percent. PEPFAR has also played a role in security, stability, and governance. According to World Bank data, since 2004, PEPFAR countries in sub-Saharan Africa reduced political instability and violent activity by 40 percent, compared to only 3 percent among non-PEPFAR countries in the region. Moreover, PEPFAR offers important lessons about successful oversight and transparency. One cited study found that a key factor of PEPFAR’s success was strong accountability, which reinforced monitoring and evaluation of health systems and facilitated development overall. The authors concluded that PEPFAR has dramatically improved health around the world, with continuing benefits expected until at least 2018: a testament to PEPFAR's long-term pledge to stem the global HIV epidemic.

Frieden, T.R., Foti, K.E., and Mermin, J. The New England Journal of Medicine (December 2015), 373:2281-2287, doi: 10.1056/NEJMms1513641.

The authors of this editorial stated that over the past decade, U.S. health departments, community organizations, and health care providers have expanded HIV screening and targeted testing. As a result, a greater proportion of HIV-positive people are now aware of their infection, new diagnoses of HIV infection have decreased, and HIV-positive people are living longer. However, an estimated 45,000 new HIV infections still occur each year in the United States—about 30,000 transmitted by those with diagnosed infection who are not receiving care, and about 10,000 by people with undiagnosed infection. Some communities across the country have implemented successful programs to reduce new infections. For example, a program in San Francisco achieved increased virologic suppression through increased rates of testing (including for recent and acute infection), partner notification, linkage, or re-engagement in care, and treatment of all HIV-positive people. These initiatives, plus access to pre-exposure prophylaxis (PrEP), were associated with a 40 percent decrease in reported new infections between 2006 and 2014. The authors concluded that it is possible to improve early diagnosis by implementing intensive testing, improving partner notification, and testing people in the social networks of HIV-positive individuals. Moreover, targeted PrEP among groups at highest risk can further reduce the number of new infections.

Bridge, J., Hunter, B.M., Albers, E., et al. The International Journal of Drug Policy (September 2015), doi: http://dx.doi.org/10.1016/j.drugpo.2015.08.001.

The authors of this study reviewed grant budget data for the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) between 2002 and 2014 to develop a comprehensive dataset on the Global Fund's investments in harm reduction for people who inject drugs (PWID).They identified 151 grants for 58 countries and one regional proposal, with a total budget of US$620 million. Of the 58 countries, 21 were from Eastern Europe and Central Asia, 17 from Asia, 10 from the Middle East and North Africa, 7 from sub-Saharan Africa, and 3 from Latin America and the Caribbean; the regional grant was for the Middle East and North Africa Harm Reduction Network. Global Fund investments targeting PWID mainly focused on the nine interventions comprising the United Nations’ ‘‘comprehensive package’’ for PWID, with 15 percent allocated overall for program management and grant overheads. The budget analysis also identified US$7.7 million for interventions and activities in compulsory drug detention centers in Asia. The authors recommended using this study as a baseline, and undertaking further analysis to understand the impact of the new funding model on harm reduction allocations as new grant agreements are signed. The analysis should also inform the development of the Global Fund’s new strategy for 2017–2021.

Hightow-Weidman, L.B, Muessig, K.E, Bauermeister, J., et al. Current HIV/AIDS Reports (September 2015), e-publication ahead of print.

The authors synthesized recent observations and experimental studies on HIV, technology-based prevention, and care for young people. The analysis included 66 articles published in English between January 1, 2014 and May 1, 2015. The authors presented data in several categories including:

  • Use of technology and sexual risk. Research suggests a relationship between online social networking and sexual risk behaviors among youth, especially the use of geosocial networking apps to find sex partners among young men who have sex with men (MSM).
  • Social media. While research indicates that social media can be an effective way to reach young people, most studies to date were preliminary, limited in methodologies, and mainly centered on evaluating how youth use social media and the resulting health implications.

Other categories included: acceptability of technology for sexual health promotion, HIV technology interventions for youth outside of the US, and MSM texting. The authors concluded that technology, including mobile technologies and social media, offers powerful tools to reach, engage, and retain youth and young adults in HIV prevention and care interventions, and called for the continued development of new technology-based HIV interventions.

Davey, D.L.J., Wall, K.M., Kilembe, W., et al. Journal of Acquired Immune Deficiency Syndromes (October 2017), 76(2): 123–131.

This study examined incidence of HIV infection from an outside partner and factors associated with HIV acquisition among cohabiting serodiscordant couples in Zambia. Among 3,049 serodiscordant couples, 478 tested HIV-positive; and analysis showed that 100 of these were infected by an outside partner. Men were more likely than women to contract HIV from an outside partner (24 percent versus 18 percent). Women who remained HIV-negative were more likely than those who acquired HIV through an outside partner to be older and have more children, and to have lived with their partner for a longer time. Women who seroconverted with an outside partner were poorer; less educated; and more likely to drink heavily, have a history of sexually transmitted infections (STIs) or genital ulceration or inflammation, and use oral contraceptive pills. Men who acquired HIV from an outside partner were more likely than those who remained negative to be younger and poorer, drink more heavily, and have a history of an STI or genital ulceration or inflammation. Pre-exposure prophylaxis interventions among serodiscordant couples may need to be adapted when outside sexual relationships are present. HIV-negative partners in serodiscordant relationships should also be routinely screened for STIs and genital inflammation to reduce HIV risk.

Nsanzimana, S., Remera, E., Kanter, S., et al. The Lancet HIV (August 2017), pii: S2352-3018(17)30124–8, e-publication ahead of print, doi: 10.1016/S2352-3018(17)30124-8.

This study examined HIV incidence in Rwanda. The authors conducted a prospective HIV incidence survey among women aged 15–49 and men aged 15–59 to understand where new infections are occurring, and among whom. Researchers tested a nationally representative sample at baseline and conducted follow-up HIV tests 12 months later on individuals who initially tested negative. During the study period, 14,691 individuals were tested for HIV, among whom 439 tested positive. HIV prevalence was higher among women and among those living in urban areas. At endline, 35 new individuals tested HIV-positive, resulting in an HIV incidence of 0.27/100 person-years. Incidence was higher in adults aged 46–55; women; those never married, divorced, or widowed; and urban residents. Incidence was also higher among adults aged 36–45 than in those aged 16–25, and among those living in the Western Province. Sexual violence in the past year also significantly increased the risk of HIV infection. The authors concluded that Rwanda's HIV incidence is higher than previously reported, which places the country's large population of young people at risk for contracting HIV. These data provide important information that can be used to plan the HIV response more precisely to help Rwanda meet its targets.

Evans, M., Maughan-Brown, B., Zungu, N., George, G. AIDS and Behavior (March 2017), 21:2533–2542, doi: 10.1007/s10461-017-1741-6.

This study used data from South Africa to examine HIV prevalence among men who used antiretroviral treatment (ART) in age-disparate relationships with women in the 15–29-year age group, comparing them to men in age-similar relationships with women in this age group. Among the 1,463 men in a relationship with a woman aged 15–29 years, HIV prevalence was 16.4 percent; among these men, 15.9 percent were on ART. Men in age-disparate partnerships were less likely to be on treatment than those in age-similar unions. Two-fifths of relationships (41.4%) were age-disparate (the woman was ≥5 years younger). Men in age-disparate relationships with partners aged 15–24 years were more likely to be HIV-positive than men in age-similar relationships. Older men with partners aged 25–29 had only slightly greater HIV risk than men in age-similar relationships. Men who were 5–9 years older than partners aged 25–29 had HIV positivity and treatment rates similar to men in age-similar relationships. Men ≥10 years older than their partners were less likely to be HIV-positive than men in age-similar relationships. Prevention interventions should focus on reducing HIV risk for young women in age disparate relationships.

Schaefer, R., Gregson, S., Eaton, J.W., et al. AIDS (April 2017), 31:1461–1470, doi:10.1097/QAD.0000000000001506.

This study examined the association between HIV incidence in young women aged 15–24 years and participation in an age-disparate relationship. Data were taken from a population study in Manicaland, Zimbabwe, that conducted six surveys, each three years apart, between 1998 and 2013. The findings indicated that 44.5 percent of 3,082 young women surveyed had a partner who was 5–9 years older, and 20.5 percent had a partner at least 10 years older. HIV prevalence in men over 30 was higher than in younger men, and treatment coverage was lower in men age 30–34 than in older men. The greater the age difference between young women and their partners, the higher the risk of HIV infection was for the woman, especially with a male partner more than 10 years older. Older women and educated young women had fewer age-disparate relationships. Women who were poor, married, or divorced were more likely to have age-disparate relationships. There were no changes in HIV incidence over time, as HIV treatment uptake in men remained relatively low throughout the study. As more men achieve viral suppression through increasing treatment uptake, there may be a reduced incidence of HIV infection in young women in age-disparate relationships over time.

Mmbaga, E.J., Moen, K., Makyao, N., Mpembeni, R., and Leshabari, M.T. Sexually Transmitted Infections (February 2017), pii: sextrans-2016-052770, e-publication ahead of print, doi:10.1136/sextrans-2016-052770.

This cross-sectional study examined the prevalence of HIV, sexually transmitted infections (STIs), and related risks among men who have sex with men (MSM) in Dodoma Municipality, Tanzania. They used respondent-driven sampling to recruit 409 MSM aged 18 years and over. Participants completed a survey on sociodemographics, knowledge of HIV and STIs, and sexual practices and were tested for HIV and selected STIs. The findings showed an HIV prevalence of 17.4 percent; STIs were also present, particularly herpes simplex virus 2 (HSV-2) (present in 38.5% of participating MSM). Enrollees reported various modes of anal intercourse as their last anal intercourse: receptive (37.5 %), insertive (47.5%), or both insertive and receptive (15%). Overall, 13.9 percent of participants reported using a condom with their last male partner. The likelihood of being HIV-positive was significantly higher for MSM with certain characteristics, including (among numerous others) testing positive for HSV-2, being in a relationship with a woman, engaging in receptive anal intercourse, perceiving themselves to have low HIV risk, engaging in unprotected sex, and taking part in group sex. These findings, the authors said, underscored the urgency of intensifying tailored programs to prevent HIV in MSM, including interventions for behavioral change communication; prevention and management of HSV-2 and other STIs; and HIV care and treatment.

Cowan, F.M., Davey, C.B., Fearon, E., et al. Journal of Acquired Immune Deficiency Syndromes (April 2017), 74(4):375-382, doi:10.1097/QAI.0000000000001255.

The authors of this study conducted cross-sectional respondent-driven sampling (RDS) surveys of female sex workers (FSWs) in 14 sites across Zimbabwe as the baseline for the SAPPH-IRe cluster-randomized, controlled trial (2013–2016), which investigated a combination HIV prevention and care package for this population. They recruited 2,722 women aged 18–65 years (approximately 200 per site), administered a questionnaire, tested the women for HIV, and measured viral load. The mean HIV prevalence was 57.5 percent. Of HIV-positive women, 64.0 percent knew their status. Among women with known status, 67.7 percent reported taking antiretroviral therapy (ART); and 77.8 percent of FSWs on ART had a suppressed HIV viral load (<1,000 copies/mL). Among all HIV-positive women, 49.5 percent had a viral load <1,000 copies/mL. A substantial proportion of women had experienced violence (40.3% from partners, 27.7% from clients, and 9.7% from police). These findings, the authors said, pointed to an urgent need to invest in testing, care, and treatment programs to address the high HIV prevalence among FSWs in Africa.

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.

Polis, C.B., Curtis, K.M., Hannaford, P.C., et al. AIDS (August 2016), doi: 10.1097/QAD.0000000000001228.

Previous research has shown an association between injectable depot medroxyprogesterone acetate (DMPA) and the risk of HIV acquisition. The authors of this review update analyzed 31 studies, 10 of which provided new data, from 2014–2016, about the influence of hormonal contraceptive types on HIV risk. Most of the studies examined oral contraceptive or injectable methods (DMPA and norethisterone oenanthate [NET-EN]). None examined hormonal patches, rings, combined injectables, or levonorgestrel intrauterine devices. Results indicated that levonorgestrel implants do not increase HIV risk; but data were limited, and more research is needed. Of 11 studies on oral contraceptive, only 1 reported slightly elevated HIV risk. Five of twelve studies on injectables showed higher HIV risk. Two additional studies found a 41 percent greater HIV acquisition risk with DMPA compared to NET-EN; NET-EN injectable did not increase HIV acquisition risk. DMPA again was found to have increased HIV acquisition risk when compared to combination oral contraceptives. Women who took DMPA were also more likely to acquire HIV than those using no hormonal methods. The authors concluded that despite questions about confounding factors and study methodology, and variance among study findings, the newer studies reinforce the associations between DMPA and HIV risk that were noted by previous research. They recommended that the World Health Organization consider reevaluating guidance on DMPA.

Telisinghe, L., Charalambous, S., Topp, S.M., et al. The Lancet (July), doi: 10.1016/S0140-6736(16)30578-5.

This review of 48 grey and white articles published between 2011 and 2015 examined HIV and TB epidemiology, services, and research priorities in sub-Saharan African (SSA) prisons. Data were available for 24 of 49 countries. The authors found higher HIV and TB prevalence in imprisoned populations generally, and in incarcerated females, relative to non-incarcerated populations. Policies for HIV and TB testing, care, and treatment in SSA prisons are scarce. Most prisoners with TB also experienced HIV coinfection; one study estimated that the spread of TB could be as high as 90 percent in prison. Shortages of health staff, and transfers within and out of prisons, present challenges for treatment continuity. Prisoners are often in and out of prison, indicating that addressing HIV and TB in prisons will also benefit the communities to which they return. International recommendations, which are rarely followed due to financial and policy challenges, include structural interventions that reduce the spread of TB, harm reduction/HIV prevention activities, and voluntary testing and treatment for both HIV and TB. The authors concluded that improving the HIV/TB situation in prisons would require significant political commitment, including sustainable funding, strong management, and research, along with prison system reforms to decrease exposure by reducing pre-trial court delays, and reduced sentences to limit the duration of imprisonment.

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.

Morris, B.J., Wamai, R.G., Henebeng, E.B., et al. Population Health Metrics (March 2016), 14(4), doi:10.1186/s12963-016-0073-5.

The authors determined the current country-by-country and global prevalence of male circumcision (MC) by reviewing articles through a PubMed search and examining country-level Demographic and Health Surveys, AIDS Indicator Surveys, and Behavioral Surveillance Surveys. They developed estimates for every country and territory in the world (N = 237) by using 2015 figures on sex ratios, total populations, and males aged 15–64 years derived from the U.S. Central Intelligence Agency and the United Nations. Their findings suggested a global MC prevalence of approximately 37.7 percent, although the real percentage could be slightly higher or lower. In some countries, the authors estimated MC prevalence based on populations of ethnic/religious groups known to perform it, most notably Muslims and Jews. However, the authors noted that this was not a completely accurate estimation because 1) uncircumcised Muslims and Jews do exist, so the proportion of circumcised males in these groups is less than 100 percent, and 2) a percentage (possibly 5–10% in developed countries) of males are circumcised for medical reasons unrelated to HIV, such as conservative treatment of early-stage penile cancer. The authors concluded that their findings on the current prevalence of MC across geographies and cultures may help guide policy development and resource allocation in all countries.

Visavakum, P., Punsuwan, N., Manopaiboon, C., et al. The International Journal on Drug Policy (February 2016), pii: S0955-3959(16)00053-0. doi: 10.1016/j.drugpo.2016.01.021.

From March to October 2010, the authors used respondent-driven sampling (a recommended methodology for sampling hard-to-reach populations) to describe the characteristics of people who inject drugs (PWID) in Songkhla and subsequently to help inform the development of evidence-based interventions and a more robust surveillance system. A total of 202 participants were interviewed and tested for HIV and other sexually transmitted infections. The authors found that the most-injected drug in the past month was heroin (injected by 90%), followed by methamphetamine (22%) and midazolam (2%). One-third (37%) of participants injected multiple drugs, and most (87%) had been injecting for more than two years. Moreover, 7 percent of participants reported sharing equipment during their last injection. Among those reporting having had sexual intercourse in the past three months, only 27 percent reported using a condom during their last sex act. HIV prevalence was high (22%). The authors also reported that 42 percent of participants were currently on methadone treatment. However, only a few received new needles (10%) and condoms (11%) from drop-in centers and/or peer outreach workers. Findings from this survey, the authors said, enhance understanding of the HIV epidemic among PWID in Songkhla, and the programmatic response to it.

Makinde, O. A., & Oyediran, K. A. AIDS Care (August 2014), E-publication ahead of print.

The authors of this article described the advantages of routinely collecting HIV prevalence data generated during routine HIV testing and counseling (HTC) and routine prevention of mother-to-child transmission (PMTCT). This model would utilize information and communications technology, the Internet, and the mobile telephone system to connect HTC and PMTCT centers to a national database. Data from the national database archive could then be analyzed to determine HIV prevalence, but also to identify predominant risk factors in specific geographic locations. Geographic risks would be assessed by aggregating all sites providing HTC and PMTCT services enrolled into the system, using specific geographic identifier data as a unit of analysis. This would facilitate the design of intervention programs to target the behavioral or other risk factors for that area. The authors noted the challenges associated with collecting data through HTC and PMTCT surveillance systems, including the absence of a standardized process for collecting data and incorporating it into data management systems. Technical challenges, such as power outages and Internet connectivity, as well as non-technical challenges, such as lack of political will, poor technical support, and lack of funding, could also stymie implementation of this approach. Challenges notwithstanding, the expansion would allow access to data from a larger and more diverse cadre of respondents, compared to the sentinel surveillance data that is presently being derived from antenatal clinics.

Eaton, J. W., Rehle, T. M., Jooste, S., et al. AIDS (November 2014), Vol. 28, Supplement 4, pp. 507–514.

This study examined data from 13 sub-Saharan African countries to determine whether recent HIV prevalence trends among pregnant women are representative of general population trends. The authors used nationally representative household-based HIV prevalence survey data from the 13 countries, dividing their examination into two time periods: 2003–2008, and 2009–2012. For each time period, they calculated the percentage of pregnant women, HIV prevalence among all women, and HIV prevalence among currently pregnant women; they then compared HIV prevalence trends among all women aged 15–49 years. The results showed that HIV prevalence trends among currently pregnant women aged 15–24 years were similar to trends for all women aged 15–24 years. This is consistent with previous research findings, suggesting that prevalence trends among young women attending antenatal care (ANC) were in fact representative of prevalence trends in all young women. However, HIV prevalence trends among older pregnant women were significantly lower than HIV prevalence for all older women. The authors concluded that given the difference in prevalence patterns for older pregnant women versus those for all older women, HIV prevalence surveillance among ANC attendees should be collected by age.

Clark, J. L., Konda, K. A., Silva-Santisteban, A., et al. AIDS and Behavior (December 2014), Volume 18, Issue 12, pp. 2338-2348.

This pilot evaluation compared convenience sampling (CS), time space sampling (TSS), and respondent-driven sampling (RDS) for recruiting and enrolling men who have sex with men (MSM) and transgender women (TW) for epidemiological surveillance in Lima, Peru. A total of 748 participants were recruited through CS, 233 through TSS, and 127 through RDS. The authors reported both advantages and drawbacks for each strategy. CS was effective at recruiting a large number of participants within a brief time and exacted minimal resource requirements. However, CS lacked the statistical representation necessary for population-level estimates of HIV and STI prevalence and associated risk behaviors. RDS recruitment resulted in a large number of non-productive seeds and a small number of recruitment waves, which made it inefficient and potentially not valid in population estimates. TSS was effective in recruiting a large number of participants from previously under-sampled populations over a brief time frame, but was limited by a low rate of participant enrollment. The authors concluded that researchers should take into consideration the characteristics of MSM and TW social networks and community structures when making decisions about which sampling methods to use.

Santelli, J. S., Edelstein, Z. R., Wei, Y., et al. AIDS (January 2015), DOI: 10.1097/QAD.0000000000000533.

This study examined how changes in local conditions and risk factors affected HIV acquisition among youth (adolescents and young adults) in Rakai, Uganda. Using data from 22,164 participants collected from nine Rakai Community Cohort Study survey rounds between March 1999 and June 2011, the authors compared trends in HIV incidence with trends in previously identified HIV risk factors, social factors, and HIV programs. Overall, the study found significant declines in sexual experience, number of multiple partners, and sexual concurrency among adolescents and young adults. Among adolescent women, HIV incidence decreased by 86 percent between 1999 and 2011; prevalence among all young women declined from 9.1 percent to 6.1 percent. The authors attributed changes in HIV incidence and risk behaviors to several social and environmental factors. These included increases in school enrollment (from 26 percent to 58.9 percent in adolescent women and from 42.6 percent to 65.9 percent in adolescent men); fewer adolescent marriages (from 46.4 percent to 23.7 percent among adolescent women); availability of antiretrovirals; and increased access to medical male circumcision. However, much of the decline in HIV incidence among adolescent women (71 percent) was attributable to reduced sexual experience, which in turn was mainly due to increased school enrollment. The authors called for efforts to increase school attendance as an important component of combination prevention in Uganda.

Abdool Karim, Q., Kharsany, A., Leask, K., et al. Sexually Transmitted Infections (December 2014), doi: 10.1136/sextrans-2014-051548.

This cross-sectional biobehavioral study described the demographic and biological characteristics of high school students in rural South Africa. The study enrolled 1,423 females and 1,252 males from 14 high schools. All participants completed self-reported questionnaires and provided dried blood spot specimens for HIV and HSV-2 testing and urine specimens for pregnancy testing. The median age of coital debut for sexually experienced students was 15 years for boys and 16 years for girls, with boys reporting more experience than girls (33. 1 percent versus 21.6 percent). Boys were more likely than girls to have a sexual partner of their own age or younger. The prevalence of HIV was 1.4 percent in boys and 6.4 percent in girls, and a greater proportion of girls than boys were HIV-positive by age 18. HSV-2 prevalence was 2.6 percent in boys and 10.7 percent in girls, and increased rapidly in both from age 15. Risk factors associated with higher prevalence of HIV and HSV-2 among girls included being over age 18, previous pregnancy, and two or more deaths in the household over the previous year. The authors concluded that the high prevalence of HIV, HSV-2, and pregnancy among high school students indicates a need for school-based sexual and reproductive health services and the inclusion of adolescents in behavioral and biomedical HIV trials.

Winston, S. E., Chirchir, A. K., Muthoni, L. N., et al. Sexually Transmitted Infections (February 2015), doi: 10.1136/sextrans- 2014-051797.

This study characterized the sexual risk behaviors of street-connected children and youth (SCCY)
(children who spend their days or nights on the streets) in Eldoret, Kenya and analyzed the gender disparities of these risks to estimate the prevalence of and factors associated with sexually transmitted infections (STIs), including HIV. The study enrolled 200 participants between the ages of 12 and 21. Participants completed structured interviews detailing their sociodemographics, street life, risk behaviors, abuse and exploitation, and access to reproductive health care. All participants self-collected vaginal and rectal swabs. Because all HIV-positive participants were female (15 percent of all participants), the authors analyzed only factors associated with HIV in females. More than a quarter of adolescents in this study had at least one STI, and young women were again disproportionately affected (35 percent with HSV-2, compared to 27.1 percent among women aged 20–24 years nationally). The authors also found that the SCCY were engaged in high-risk sexual behaviors, including early sexual debut, multiple partners, transactional sex, and inconsistent condom use. Young women were at particularly high risk, reporting significantly more forced sex, transactional sex, and prior STIs. The authors concluded that SCCY in Eldoret, females particularly, were at high risk for STIs and HIV, and called for programmers and implementers to target prevention and education programs specifically to
this population.

Solomon, S. S., Mehta, S. H., Srikrishnan, A. K., et al. AIDS (March 2015), Vol. 29 Issue 6, pp. 723–731.

This study, one of the largest population-based studies among men who have sex with men (MSM) conducted in India, focused on prevalence, incidence, and associated correlates of HIV among MSM in 12 Indian cities. Participants included 12,022 self-identified men over age 18 who reported oral and/or anal intercourse with a man during the prior year. The analysis showed a 7 percent weighted HIV prevalence in MSM across all sites. Syphilis prevalence ranged from 0.8 percent to 4.4 percent. The study found higher odds of HIV infection among men who were older, were currently married, practiced only receptive or both receptive and penetrative sex, had a lifetime history of sexually transmitted infections, or had more lifetime male partners. Higher education was associated with decreased odds of HIV infection. The analysis also showed an overall HIV incidence of 0.87 percent among MSM. In multivariate analyses, men who had a larger number of male partners, or who had herpes simplex 2 infections, syphilis, or genital discharge, had a significantly higher chance of acquiring a new HIV infection. The authors noted that discordance between HIV prevalence and incidence in some cities may suggest emerging HIV epidemics in areas previously described as having a lower HIV burden, and called for targeted prevention programming in these areas.

Larney, S., Mathers, B.M., Poteat, T., et al. Journal of Acquired Immune Deficiency Syndromes (June 2015), doi: 10.1097/QAI.0000000000000623.

The authors conducted a literature review focused on women and girls who use and/or inject drugs to explore risk factors and determine HIV prevalence and mortality rates among these groups. They found that although crude mortality rates were consistently lower among women who use and inject drugs compared with men, standardized mortality ratios were higher among women who use and inject drugs. Their findings suggest that these women experienced relatively greater mortality than their age-matched peers in the broader community compared with men who use drugs. Social exclusion, stigma, and discrimination can increase HIV risk and undermine HIV prevention and treatment programs for this group. These women and girls are reluctant to disclose their drug use and do not access health services, including drug treatment, for fear of discrimination. Moreover, they may be excluded from family support structures, and those with limited financial or employment options may be more likely to engage in sex work, increasing sexual HIV risk and attracting additional stigma. The authors concluded that special efforts (such as stratified sampling) may be needed to recruit women and girls into studies of drug use and HIV prevalence and risk among people who inject drugs, to ensure adequate recruitment of women and improve the reliability of sex-specific prevalence statistics.

Johnson, L.F., Rehle, T.M., Jooste, S., and Bekker, L-G. AIDS (July 2015), 29(11): 1401–1409.

The authors of this article investigated South Africa's progress towards the HIV counseling and testing (HCT) goals set by the Joint United Nations Programme on HIV/AIDS (90 percent of HIV-positive individuals knowing their status). Using a mathematical model, they estimated changes in HCT up to mid-2012 and projected the likely change in the proportion of undiagnosed HIV-positive adults during the 2012–2020 period. After analyzing HCT data from public and private health sectors and household survey estimates on HIV testing, they found that 5.7 million HIV-positive adults aged 15 or over lived in SA in mid-2012. Of these, 23.7 percent (31.9 percent of men and 19 percent of women) were undiagnosed. Although estimates suggest substantial declines in the number of undiagnosed HIV-positive adults in South Africa over the last decade, the number remains high (664,000 men and 679,000 women in 2012). The authors said that if the Department of Health targets of 10 million HIV tests per annum are met, the undiagnosed numbers should decline to 249,000 men and 286,000 women by 2020, or 8.9 percent; and South Africa could meet the 10 percent target set by UNAIDS by 2018. They concluded that South Africa is on track to meet the UNAIDS target of fewer than 10 percent undiagnosed by 2020, provided the country continues to test 10 million individuals per annum.

Gonese, E., Mapako, T., Dzangare, J., et al. PLOS ONE (July 2015), 10(7): e0129611, doi: 10.1371/journal.pone.0129611.

Demographic and Health Surveys conducted in Zimbabwe showed a decline in HIV prevalence from 18.1 percent in 2005/2006 to 15.2 percent in 2010/2011. In this cross-sectional study, the authors focused on key factors influencing the change in prevalence by examining differences in geographic location along with demographic, behavioral, and biological characteristics. They found a greater decline in prevalence for men in urban than rural settings (17 versus 13 percent, respectively). However, among women, a greater and significant decrease occurred in rural areas (19 percent), with no significant change in urban areas (9 percent). Significant declines were observed in both men and women with more than secondary education. The authors also noted a high proportional decline in sexual risk behaviors and increased condom use among both men and women who were in union, and for men and women who experienced sexual debut at 16 years and older. Geographic locations influenced prevalence, which declined significantly among men in Harare and women in Mashonaland Central, but increased among men in Matebeleland North and women in Bulawayo. The authors stated that their findings indicate the need for further research to determine reasons behind these variations by gender and provincial location.

Laeyendecker, O., Kulich, M., Donnell, D., et al. PLOS One (November 2013), Vol. 8 No. 11, p. e78818.

The authors described the development of laboratory and statistical methods used to estimate HIV incidence in Project Accept, a Phase III community randomized controlled trial in Africa and Thailand. They focused on identifying a multiple-assay algorithm (MAA) to estimate HIV incidence in the trial’s African communities, using validation samples from seven cohorts (4,166 samples from approximately 2,300 individuals; subtype D samples were removed). Findings demonstrated that HIV incidence and intervention effects can be accurately estimated using MAA in cross-sectional surveys. In total, 403 MAAs were evaluated, including the BED capture immunoassay (BED-CEIA) alone, an avidity assay alone, and combinations of these assays with various cutoff values and without CD4 or viral load testing on samples. Testing algorithms that included multiple assays outperformed single serologic assays; incidence estimates had lower bias and better precision. Epidemic simulation exercises were conducted to demonstrate that the chosen MAA provided more accurate estimates of intervention and control incidence rates than would have been found by monitoring a cohort for seroconversion over a six-month period. Future studies should evaluate different test methods (e.g., different assays and/or different cutoffs) to identify an effective method for cross-sectional HIV incidence estimation in subtype D epidemics. The authors' methods could be applied for cross-sectional incidence assessment in non-subtype D epidemics in Southern Africa for HIV surveillance and prevention research.

Wertheim, J.O., Brown, A.J.L., Hepler, N.L., et al. Journal of Infectious Diseases (October 2013), E-publication ahead of print.

To characterize the current global HIV-1 transmission network, the authors applied a network approach by constructing HIV-1 transmission clusters using close genetic links to identify potential transmission partners. Clusters were defined as connected groups of potential transmission partners. The global transmission network included all published HIV-1 sequences (n=84,527), representing 141 countries or regions, and incorporated expanded known transmission clusters and previous transmission clusters not considered in the global context. The analysis showed the contemporary pattern of HIV-1 transmission across international borders, with “local” epidemics often including international transmission links; individuals from 72 of the 106 countries or regions represented in transmission clusters had a potential transmission partner from another country. Furthermore, nearly 23 percent of potential transmission partners were from different countries, likely associated with the interconnectedness of larger, international transmission networks. The current network appears to have been established by the early 2000s. The authors argued that analysis at the global scale is critical for assessing the scope of transmission clusters, and should be standard practice. They suggested that using this approach with HIV surveillance data would yield a more robust analysis, and concluded that the global-network approach enables researchers to determine, nearly in real-time, if newly isolated HIV-1 sequences occur in known transmission clusters.

Cowan, F.M., Mtetwa, S., Davey, C., et al. PLOS One (October 213), Vol. 8 No. 10, p e77080.

As part of a national program for female sex workers (FSWs) established in 2009, the authors conducted a survey to estimate FSWs' HIV prevalence and use of HIV prevention, treatment, and care services at three sites in Zimbabwe. They found exceptionally high HIV prevalence and inadequate HIV service uptake among Zimbabwean FSWs. The study confirmed that FSWs are at an increased risk of HIV compared to the general population, and also revealed that they experience high rates of intimate partner violence, police harassment, and discrimination. Using respondent-driving sampling, the authors recruited 370, 237, and 229 FSWs in Mutare, Hwange, and Victoria Falls, respectively. The majority of FSWs (50 to 70 percent) were HIV-positive. Of most concern were FSWs with laboratory-confirmed HIV (finger prick blood samples were collected and tested as part of the study) but unaware of their status, either because they had never previously been tested or collected HIV test results before the study. In all three sites, these FSWs accounted for half of all HIV-positive participants. Further, the majority (62 to 74 percent) with confirmed HIV were not on antiretroviral therapy. Most HIV-negative FSWs were also unaware of their status. FSWs were more likely to report consistent condom use with commercial partners than with permanent partners. Interventions to increase Zimbabwean FSWs’ engagement with HIV services are critical to protect both FSWs and general public health.

Wirtz, A.L., Kirey, A., Peryskina, A., et al. Drug and Alcohol Dependence (2013), E-publication ahead of print.

The authors reviewed 43 publications on evidence on the HIV prevalence and socio-behavioral risk factors of men who have sex with men (MSM) in five Central Asian countries and Mongolia, Afghanistan, and Xinjiang Province, China to understand HIV risks, identify data gaps, and suggest priorities for future research and surveillance. HIV research on MSM in Central Asia is still emerging; however, available data suggest that MSM in the region are at risk of HIV. Methodological, recruitment, and reporting variations among the studies made comparisons and generalization difficult. For example, surveillance data showed HIV prevalence between 1 and 2 percent in Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan, while a behavioral study found HIV prevalence as high as 20 percent in Kazakhstan; thus, differences in estimates were considerable. HIV risks among MSM included multiple and/or concurrent sexual partners, unprotected anal sex, transactional sex, and non-injection drugs and alcohol. HIV prevention and testing coverage for MSM ranged from 25 to 49 percent for Kyrgyzstan, Tajikistan, and Uzbekistan. MSM practices were documented among people who inject drugs. No current estimates of HIV treatment coverage were documented. The prevalence of violence, discrimination, and criminalization towards MSM was evident, and should be addressed. According to the authors, in-country leadership will be essential to improving the HIV response, and further research on risk behavior is needed.

Montealegre, J.R., Johnston, L.G., Murrill, C., et al. AIDS and Behavior (September 2013), Vol. 17 No. 7, pp. 2313-2340.

In this review of respondent-driven sampling (RDS) recruitment for HIV biological and behavioral surveillance surveys (BBSS) among key populations in Latin America and Caribbean (LAC) countries, the authors described RDS approaches, challenges, and considerations for future studies using RDS. Respondent-driven sampling has commonly been used in HIV BBSS to access high-risk, hard-to-reach populations in LAC. However, many studies encountered operational challenges. The authors identified 87 studies (conducted between 2005 and 2011) in 15 countries, mainly in South America and primarily on men who have sex with men. All studies conducted formative research before applying RDS. The studies mainly identified social network size using face-to-face interviews, and nearly all studies that reported information about analysis, adjusted for biases in chain-referral sampling. All but three studies collected biological specimens, usually conducting non-invasive HIV screens, with few reported challenges. There were challenges regarding appropriate incentives for participants, but most studies did not alter the incentives during data collection. Most studies adequately defined eligibility criteria, but 11 percent lacked a geographic parameter. The authors recommended addressing challenges by conducting formative research to understand social networks and define operational issues; using strategies to estimate social network size, monitor recruitment, and account for sub-populations; and analyzing data to counter biases in chain-referral sampling. Lastly, the authors suggested using the same sampling methods in the same populations over time as a best practice for monitoring HIV trends or evaluating program effectiveness.

Decker, M.R., Wirtz, A.L., Moguilnyi, V., et al. AIDS and Behavior (August 2013), E-publication ahead of print.

The authors conducted a mixed methods assessment in Kazan, Krasnoyarsk, and Tomsk, Russia, to understand the environment of female sex workers (FSWs); determine HIV prevalence and risk factors; and review the acceptability of the Globus Consortium’s FSW-targeted HIV prevention services. Analysis confirmed high HIV risk among FSWs, and the need for increased HIV prevention and services to address their key risk factors: injecting drug use (IDU) and sexual violence. FSWs found the FSW-targeted prevention services highly acceptable, valuable, and non-stigmatizing. The authors conducted secondary analysis of the program evaluation; 35 in-depth interviews; 11 focus group discussions with  81 FSWs; and a survey and HIV screening with 754 FSWs. HIV prevalence was 3.9 percent across the sample of FSWs, and lifetime IDU, client violence, and physical violence from a pimp, or momka, were common and significantly associated with HIV. Sexual risk behaviors were also identified (e.g., more than three clients per day [46 percent] and inconsistent condom use [17 percent]). FSWs cited protection as the primary benefit of working with pimps, although many found the protection limited; and reported experiencing violence or exploitation. The acceptability of FSW-targeted services was reflected in high uptake of HIV testing and free condoms, and greater HIV knowledge. While further research is necessary, Russian FSWs should be considered a key high-risk population.

Kouyoumdjian, F.G., Calzavara, L.M., Bondy, S.J., et al. AIDS (May 2013), Vol. 27 No. 8, pp. 1311-1338.

The authors used longitudinal data of 10,252 women to compare the risk of incident HIV infection among women who had and had not experienced intimate partner violence (IPV), as well as potential mediators of HIV and IPV interaction in Rakai, Uganda. IPV and incident HIV infection were significantly associated; women who had ever experienced any form of IPV had an adjusted incidence rate ratio (IRR) of 1.55 compared to women who had not experienced IPV. The adjusted population proportion of HIV attributable to IPV was approximately 22 percent. No evidence was found that condom use or number of partners changed the degree of association between IPV and HIV. Verbal abuse was most common, followed by physical and then sexual IPV, but many women experienced these concurrently. Further, long-term, frequent IPV led to a higher HIV risk than less frequent IPV (from an IRR of .84 for having experienced IPV once to 3.03 for having experienced IPV more than 20 times in the past year). The authors said that the findings are likely generalizable throughout Uganda. They concluded that HIV prevention programs should discuss IPV during HIV testing and counseling, and programs to prevent violence towards children and IPV in adulthood are critically needed, not only to address the physical and emotional consequences, but also to prevent HIV.

Dokubo, E.K., Kim, A.A., Linh-Vi, L. et al. AIDS Reviews (2013), Vol. 15, pp.  67-76.

The authors conducted a systematic review of studies on HIV incidence in Asia (Bangladesh, Cambodia, China, India, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Taiwan, Thailand and Vietnam) conducted in the past 30 years. The results showed that studies on HIV incidence are not routinely conducted or published across Asia, but shed light on estimated HIV incidences and risk factors, mostly among key populations. HIV incidence rates varied; the highest were 43.6 among people who inject drugs (PWID); 27.8 per 100 person-years among commercial sex workers (CSW); and 15.0 among men who have sex with men (MSM). A few studies identified commonly known HIV risk factors, e.g., cervical infection among CSW; young age and frequent needle sharing among PWID; and having multiple sexual partners among MSM. Of the 111 studies included (70 publications and 41 conference abstracts), most were from Thailand, China, and India (53, 26, and 17 studies, respectively). The prospective cohort methodology remains most commonly used in studies of HIV incidence, and the use of antibody-based laboratory assays for detecting HIV infection has recently increased. While surveillance can be challenging among hidden key populations, it is necessary to establish routine surveillance systems to obtain data on new HIV infection rates and risk factors, both among key populations and the general population, to better understand and address the HIV epidemic in Asia.

Okal, J., Geibel, S., Muraguri, N., et al. Sexually Transmitted Infections (June 2013), E-publication ahead of print.

To estimate the size of three key populations - men who have sex with men (MSM), female sex workers (FSWs) and people who inject drugs (PWID) in Nairobi, Kenya, the authors triangulated data using three size estimation methods for each population as part of a larger behavioral surveillance study that recruited participants from 2010 to 2011. Estimates of 29,494 FSWs (range: 10,000-54,467); 11,042 MSM (range: 10,000-22,222); and 6,216 (5,031-10,937) PWID in Nairobi were determined, which underscores that these high-risk key populations do in fact exist in Nairobi. Also, because MSM subgroups may be hidden, the upper plausible estimate for this population could be two times greater. The authors used the service multiplier method, the "Wisdom of the Crowds" method, and literature and demographic data. Based on this analysis, the authors then presented the population estimates to community representatives and stakeholders, such as the Kenyan government and HIV program representatives, who helped synthesize, verify, and build consensus on the population estimates. These key population estimates may serve as a foundation for planning HIV prevention, care, and treatment activities by the Kenyan government and donor groups. The authors concluded that future HIV surveillance activities should include population size estimates, and apply additional methods to improve these estimates.

Izulla, P., L.R. McKinnon, J. Munyao, et al. Journal of Acquired Immune Deficiency Syndromes (February 2013), Vol. 62 No. 2, pp. 220-225.

The authors examined efficacy of post-exposure prophylaxis (PEP) among HIV-uninfected female sex workers (FSWs) in Nairobi, Kenya, and explored determinants of PEP use, adherence, and subsequent HIV incidence. The findings showed that PEP was fairly acceptable, and no HIV infections were observed during the year after PEP initiation, although the precise efficacy was undetermined. Of 2,900 FSWs recruited from 2008-2010, 11 percent (n=326) requested PEP. In multivariate regression analysis, PEP users were less likely than non-users to have a regular partner (55 vs. 73 percent); were more likely to report consistent condom use (85 vs. 68 percent); had a history of HIV testing (89 vs. 76 percent); used alcohol (84 vs. 76 percent); had higher gonorrhea rates (6.9 vs. 2.6 percent); and reported a previous abortion (average 0.74 vs. 0.62).  Requests for PEP were mostly from FSWs with “first-time” clients; and 85 percent of women reported condom breakage as the reason for seeking PEP. Delayed timing was an issue; 25 percent initiated PEP 36 hours post-exposure, suggesting an opportunity to improve risk reduction counseling. Fifty-six percent of users adhered for at least 10 days. The authors concluded that PEP may be useful as HIV prevention for FSWs; but research should further assess reasons associated with PEP use. PEP guidelines for FSWs in sub-Saharan Africa are needed.

Gómez-Olivé, F.X., Angotti, N., Houle, B., et al. AIDS Care (January 2013)

To address gaps in understanding the HIV epidemic in South Africa, the authors conducted a cross-sectional biomarker survey of randomly selected rural adults aged 15 and older, and estimated HIV prevalence and associated socio-demographic factors. They compared their results with two previous studies in different contexts. Findings showed high HIV prevalences, similar to the country's highest in KwaZulu-Natal and nearby Swaziland. Prevalence among those aged 35-39 peaked at 45.3 percent among men and 46.1 percent among women. Of 7,193 eligible participants recruited from August 2010 to May 2011, 70 percent were located, with 4,362 participants (87 percent) consenting to both the interview and HIV testing. Overall, HIV prevalence was 19 percent, with prevalence for adults aged 50 or older at nearly 17 percent, suggesting that HIV infection occurs at an older age. Individuals in the high socioeconomic quintile were less likely to be HIV-positive than those in the low quintile. Younger men (ages 15-19, 20-24, and 25-29) were less likely to be HIV-positive than women in the same age groups, while older men (aged 55-59, 60-64, and 65-69) had greater chances of being HIV-positive compared to women. Two follow-up studies are being considered to estimate HIV incidence and entry into HIV care and treatment services. The authors recommended increasing HIV prevention activities for older adults and including them in health care treatment plans.

Celum, C. & J.M. Baeten. The Lancet (February 2013), e-publication ahead of print.

The authors provide commentary on advances in HIV prevention, specifically focusing on approaches for serodiscordant couples and other high-risk groups in sub-Saharan Africa. Prevention strategies, e.g., pre-exposure prophylaxis, should be prioritized to highest-risk populations (ensuring linkages to services), and combined with other prevention inventions. HIV prevention should not only target serodiscordant couples; this would be insufficient to reverse the epidemic. While HIV transmission within serodiscordant couples comprises an important portion of HIV incidence, HIV risk from outside partners is another mode of transmission. The authors referred to a modeling study by Bellan et al. (2013) estimating that extra-couple transmissions accounted for 32-65 percent and 10-47 percent of new HIV infections in men and women, respectively. HIV prevention strategies should both target couple-focused activities, e.g., couples HIV testing and counseling, and persons who have partners with HIV-positive or unknown serostatus, while also aiming to reduce extra-couple transmission. Additionally, young women are at high HIV risk before forming a partnership; therefore, continued prevention activities are needed for this group. The authors concluded that evidence-based combination prevention strategies should focus on high-risk groups, including serodiscordant couples, and on achieving high coverage for these groups, to achieve substantial impact on the epidemic.

Stanecki, K., Garnett, G.P., & Ghys, P.D. Sexually Transmitted Infections (December 2012), Vol. 88 No. S2.

Continuously updating and improving data quality and explaining data and analytic methods are essential to improving the estimation and understanding of HIV worldwide. The authors of this editorial introduce a collection of 15 articles that provide an update on improvements in HIV estimation methods and assumptions, exploring various methods and analyses of primary data. While national surveys have been the gold standard for over 10 years, there is doubt as to whether the surveys provide unbiased estimates of prevalence because of those who do not participate in them. Another issue explored is risk and size of key groups, particularly the length of time individuals remain at risk. The authors further highlight the range of articles about HIV estimates, methods, and trends. These include mortality after initiating HIV treatment despite improving treatment coverage, new estimates of mother-to-child transmission risks, trends in HIV prevalence among young people, HIV transmission dynamics in different regions, and use of alternative data sources such as registered deaths to help assess the validity of model estimates. While the authors recognize the challenges of accurately estimating the extent of the HIV pandemic, they also note that collaborative efforts to improve estimation processes have been useful. Although continued improvements and updates are needed, this approach should be a model for tracking other diseases.

Manopaiboon, C., Prybylski, D., Subhachaturas, W., et al. International Journal of STD & AIDS (March 2013), pp. 1-5.

Using respondent-driven sampling (RDS) from August to November 2007, the authors aimed to reach venue- and non-venue-based female sex workers (FSWs) in Bangkok, Thailand for a survey to estimate HIV risk behaviors and prevalence. Non-venue-based FSWs had higher HIV prevalence, and overall FSW HIV prevalence was considerably higher than in previous survey estimates (20 percent in the RDS survey versus 2.5 percent in the 2007 sentinel surveillance survey). The RDS method effectively recruited FSWs, and findings suggest that subpopulations of FSWs may not be reached by routine sampling. A total of 707 FSWs were recruited using the cascade model; 98 percent agreed to HIV testing and 97 percent agreed to testing for other sexually transmitted infections (STIs). Twenty-seven percent (n=190) returned for test results. Overall STI prevalence was low. Most FSWs were non-venue-based and 93 percent reported condom use with their last client. Younger age was associated with lower HIV prevalence. In multivariate analysis, a lower price and a current STI remained independently associated with HIV after adjusting for other factors. The Thai Ministry of Public Health adopted the RDS method to supplement routine surveillance activities in areas with many FSWs. The authors concluded that HIV prevention programs in Thailand should be customized to subpopulations of FSWs.

Kahle, E.M., J.P. Hughes, J.R. Lingappa, et al. Journal of Acquired Immune Deficiency Syndromes (March 2013), Vol. 62 No. 3, pp. 339-347.

Using data from three prospective studies on heterosexual HIV serodiscordant couples in seven African countries, the authors developed and validated a quantitative risk scoring tool to determine couples at highest HIV risk. The analysis found that a separate set of factors, applied together and quantified, can identify serodiscordant couples at high risk of HIV transmission. Scores greater or equal to 5, of a maximum score of 12, were related to annual HIV incidence of more than 3 percent; e.g., a score ≥ 6 identified 67 percent of the observed HIV seroconversions among only 28 percent of the study population. The risk score model included the following factors: plasma HIV-1 RNA concentrations, unprotected sex, young age, marital status, no or few children in the partnership, and uncircumcised status of uninfected men; the combination of risk factors allows for more predictive capability. The risk scoring tool can be applied to clinical and research studies and to inform implementation of HIV prevention strategies to target those at highest risk and maximize cost-effectiveness. The authors concluded that a simple risk scoring tool could be an effective approach to identifying HIV serodiscordant couples at highest risk of HIV.

Dahab, M., Spiegel, P.B., Njogu, P.M., et al. AIDS Care (January 2013), Epub ahead of print.

To address research gaps about the relationship between sexual risk behaviors among refugees, the United Nations Refugee Agency and the Great Lakes Initiative on HIV/AIDS conducted behavioral surveillance surveys (baseline years were 2004 and2005; follow-up years were 2010 and 2011) to estimate the change in prevalence of key HIV-related indicators among refugee camp inhabitants and members of neighboring communities in Kenya, Tanzania, and Uganda. In total, 11,582 participants were interviewed (6,448 at baseline and 5,134 at follow-up). The results indicated a significant and consistent decrease in multiple and casual partnerships among adults, and the same results were also generally observed across age and gender subgroups. Notably, the prevalence of multiple partners and casual sex in Kenyan and Ugandan refugee camps was slightly lower than in the surrounding community. Rates of HIV testing substantially increased at all sites, and improvements in HIV knowledge were also found in the Tanzanian refugee camp and community and in the Ugandan refugee camp. Although the authors note that the positive behavioral changes may be associated with recent increases in HIV prevention efforts, this data is not reflected in the study. Abstinence and condom use significantly increased in all of the groups studied, and forced sex against females decreased in the Kenyan camp. However, despite these improvements, the overall levels of risky sexual partnerships remained high in casual sex among youth and multiple partners among men.

Mumtaz, G., Weiss, H., Vickerman, P., et al. AIDS (August 2015), 29(13): 1701–1710, doi: 10.1097/QAD.0000000000000761.

The authors of this study examined the association between HIV and hepatitis C virus (HCV) among people who inject drugs (PWID) in the Middle East and North Africa (MENA) region, and used HCV prevalence to estimate the HIV epidemic potential among PWID. They based their analysis on data from a recent systematic review assessing the status of the HIV epidemic among PWID in 23 MENA countries. Their analysis showed that HCV prevalence was not associated with HIV in low-level HIV epidemics, but was a significant predictor of HIV prevalence in settings where the HIV epidemic is emerging or established. In emerging epidemics, HCV was significantly associated with the highest increase in HIV prevalence compared with other epidemic states; country and study site were also significant predictors. In established epidemics, HCV prevalence was the only predictor of HIV. The authors concluded that HCV prevalence could be a predictor of future endemic HIV prevalence, and predicted further growth of the HIV epidemic in MENA countries. They also stated that their methodology can identify PWID populations that should be prioritized for HIV prevention interventions.

Eaton, J.W., Bacaër, N., Bershteyn, A., et al. The Lancet Global Health (October 2015), 3(10): e598–608, doi: 10.1016/S2214-109X(15)00080-7.

This study compared 10 mathematical model projections of HIV prevalence, HIV incidence, and antiretroviral therapy coverage for South Africa against data from a large household survey done in 2012, seeking to validate past model projections. The authors reported that five models projected that prevalence in adults aged 15–49 years in 2012 would change by ≤ 0.3 percentage points from prevalence in 2008. Three models projected declines of 0.7 to 1.3 percentage points; one projected an increase of 0.9 percentage points. However, the household survey estimated that adult prevalence increased from 16.9 percent in 2008 to 18.8 percent in 2012. The disparity between the 2012 survey estimate and those in the 10 models was mainly because eight of the models projected that prevalence would decline among men, whereas 2012 household survey data estimated that prevalence increased by 2.9 percent among men. The authors concluded that the models might have been overly optimistic, especially for mid-aged adults (age 25–49 years), among whom prevalence and incidence were consistently higher than anticipated. However, they urged program planners and implementers to continue to collect surveillance and trial data to validate and improve the information provided through mathematical models.

Kharsany, A.B., Frohlich, J.A., Yende-Zuma, N., et al. Journal of Acquired Immune Deficiency Syndromes (November 2015), 70 (3): 289–295, doi: 10.1097/QAI.0000000000000761.

This study assessed HIV prevalence trends in 5,075 pregnant women in the rural Vulindlela sub-district of KwaZulu-Natal, South Africa following the introduction and scale-up of antiretroviral therapy (ART), and described risk factors associated with HIV transmission. The authors conducted cross-sectional surveys from October through November of each year from 2001 to 2013 among pregnant women presenting at primary health care clinics for their first prenatal care visit. The time periods 2001 to 2003 were defined as pre-ART, 2004 to 2008 as early ART, and 2009 to 2013 as contemporary ART rollout, to correspond with the substantial scale-up of ART program. The authors reported that overall, HIV prevalence increased during each period (35.3%, 39.0%, and 39.3%, respectively). However, age-stratified analysis revealed nuances. Among teenage women (<20 years), HIV prevalence declined during these same periods (22.5%, 20.7%, and 17.2%), while increasing significantly in women 30 years and older. Moreover, teenage girls with male partners aged 20–24 and >25 years had a 1.7-fold and 3-fold higher HIV prevalence, respectively. The authors concluded that targeted interventions for pregnant women, especially for those in age-disparate relationships, are needed to change the trajectory of this HIV epidemic.

Ramakrishnan , L., Ramanathan, S., Chakrapani, V., et al. AIDS and Behavior (December 2015), 19(12): 2255–2269.

This study used data from a cross-sectional bio-behavioral study among men who have sex with men (MSM) in India to compare HIV-related sexual risk behaviors among MSMW and MSMO. Among the total sample of 3,739 MSM, about one-third (n=1,343) were classified as MSMW, and the rest (n=2396) as MSMO. A lower proportion of MSMW than MSMO perceived themselves at risk for HIV (21% versus 27%), and had ever been tested for HIV or collected test results (75% vs. 81%). MSMW reported concurrent relationships in the past month with male casual partners (77%), male regular partners (55%), and paying partners (47%). Most MSMW (93%) had a current female regular partner, and 14.6 percent reported having sex with a female sex worker in the past month. MSMO reported a higher proportion of male regular partners (74%) and male paying partners (73%), with fewer male paid or casual partners. MSMW were less likely than MSMO to use condoms inconsistently. The authors concluded that HIV interventions among MSM should acknowledge bisexual behavior among even self-identified MSM; counsel these clients on the risks of unprotected anal and vaginal sex; and support consistent condom use with partners of either gender.

Chinomona, A., Mwambi, H.G. PLOS ONE (December 2015), 10(12):e0140896, doi: 10.1371/journal.pone.0140896.

This study described how HIV prevalence varies with demographic, socioeconomic, sociocultural, and behavioral risk factors. Using data from the 2010–11 Zimbabwe Demographic and Health Surveys, the authors constructed graphical presentations of HIV prevalence for categories like marital status, five-year age-group, and recent sexual activity, and assessed these groups across Zimbabwe's administrative provinces. They found significant differences in the HIV prevalence rates among those who were single, married, divorced, and widowed. The highest HIV prevalence by marital status was among the widowed, and the lowest was among the single/never married individuals. Within five-year age categories, the highest prevalence was among the 35–39-year group, and the lowest was among the 15–19-year group. HIV prevalence was significantly higher among urban compared to rural residents. In terms of recent sexual activity, those who had never had sex had a significantly lower HIV prevalence than those in other categories; those who had not been sexually active during the previous month had the highest prevalence rate. Religion and wealth index were not significantly associated with HIV. The authors concluded that their study, which provided estimates of HIV prevalence at the national level and on major risk factors, could be used as a baseline for future estimates of HIV prevalence using population-based data.

Matlho K., Lebelonyane, L., Driscoll, T., et al. Journal of Social Aspects of HIV/AIDS (2017), 14(1).

This qualitative study examined the attitudes of Botswanan policymakers (n=15: providers and staff of the Ministry of Health and nongovernmental organizations, or NGOs, involved in developing policies) toward HIV-positive adults aged 50 years and older. Interviews revealed that although activism and coordination with civil society organizations often influence government leaders, there are no elderly activists, and NGOs do not focus on older people. Respondents noted that though health care for the elderly is important, there are no geriatric services, nursing homes, or other specialized services available. It is assumed that family will take care of their elders. Yet urban migration leaves the elderly vulnerable as their families move away. Integrated services are needed that link facility- and community-based health services with mental, spiritual, and social health care for this population. Interviewees described the need to either integrate elder care services, or to simply expand siloed HIV care to include older adults. Providers of preventive services overlook the elderly because they assume that they are not sexually active. HIV interventions mainly focus on preventing HIV among younger populations versus preventing HIV or providing services to older adults who are living with a chronic HIV infection. HIV policy should be adapted to reflect the changing epidemic in Botswana and address the needs of the elderly.

Ghanotakis, E., Hoke, T., Wilcher, R., et al. Global Public Health (2017), 12(10):1297–1314, doi: 10.1080/17441692.2016.1168863.

This study examined a male engagement intervention that sought to change harmful gender norms, attitudes, and behaviors that influence women’s family planning (FP) and HIV service uptake in Uganda. In the community-based arm of the intervention, 32 men in the community were recruited to increase their male community members’ FP and HIV knowledge, encourage their use of health services, and reduce harmful gender norms. In the facility-based arm, HIV counseling and testing providers were trained to counsel both men and women on FP and provide HIV testing for couples. The Gender Equitable Men (GEM) scale measured the interventions’ impact. Post-intervention findings indicated some small, but significant shifts toward more equitable gender norms; but overall, the intervention did not create real changes in gender equity. There was little change in GEM items pertaining to childrearing responsibility, contraceptive decision-making, and women tolerating violence to keep their family together. However, respondents reported increases in condom use, HIV testing, discussions of contraception between partners, and health-seeking behaviors for themselves, and were more likely to accompany their partner to services. Future interventions should conduct a field test to inform adaptation before rollout, invest more time in training peer educators, and consider using existing community health workers as peer educators. 

Williams, S., Renjy, J., Ghilardi, L., and Wringe, A. Journal of the International AIDS Society (September 2017), 20:21922, doi: 10.7448./IAS.21.1.21922.

This meta-analysis of 24 qualitative studies examined prominent issues that affect initiation and retention in care for adolescents living with HIV (ALHIV) in sub-Saharan Africa. All studies identified anticipated, internal, and external stigma as having significant negative impacts on receiving test results, treatment initiation and retention, and adherence. Diminished self-efficacy interfered with HIV testing and self-care behaviors, including adherence. Insufficient family support led to lack of full disclosure to ALHIV, lack of consent for ALHIV to access health services, and neglect or abuse. When available, community-based social support positively influenced engagement in the care cascade. Services that cater to ALHIV’s needs and increase retention in the care cascade include youth-friendly hours, trained health care workers, and integrated sexual and reproductive health services. Past experiences with illness also served as a reminder for ALHIV to remain adherent and engaged. Financial instability reduced ALHIV’s ability to pay for transport and food. The authors noted that mass media were effective in reaching ALHIV, but did not always translate to changed behaviors. The authors said that while there are multiple barriers for ALHIV, stigma is the most pervasive, affecting engagement in each step of the care cascade. They urged prioritizing psychosocial interventions to increase ALHIV’s engagement in care.

Brown, L.L., Van Zyl, M.A.R. AIDS Care (July 2017), doi: 10.1080/09540121.2017.1366414.

This clinical trial tested an assessment and protocol among 255 women who had experienced intimate partner violence (IPV) and tested HIV-positive during mobile counseling and testing in South Africa. Women in the control group (n=83) received the standard of care (SOC) including mobile testing, “edutainment,” and call center linkages to care. Women in the intervention group (n=167) received SOC plus either a risk assessment and safety plan, or a risk assessment, safety plan, and a follow-up safety plan. During the pre-test, almost all women reported nonviolent controlling acts; 41 percent reported physical abuse, 45 percent sexual abuse, and 67 percent physical or sexual abuse. Nearly 42 percent linked to services within 30 days of testing. SOC group participants were less likely to link to care (particularly women ≤23 years, and 33¬–44 years) than in either of the intervention groups. The majority found the intervention as helpful, and 80 percent reported using at least one safety strategy. Intervention participants experienced less violence than SOC group participants (98 percent versus 88 percent) when notifying their partner of their HIV status; but women in both groups reported still feeling unsafe getting to medical appointments. The authors concluded that women in the intervention groups were four times less likely to experience violence after they notified their partner, but given the small effect size, more research is needed.

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.

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.

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.

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.

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.

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.

Asiimwe, S., Ross, J.M., Arinaitwe, A., et al. Journal of the International AIDS Society (July 2017), 20(S4): 21633, doi: 10.7448/IAS.20.5.21633.

This study examined an intervention that used community health extension workers (CHEWs) to implement community-based HIV counseling and testing with facilitated linkages in rural Uganda. CHEWs, who administered rapid tests within homes, provided each newly identified HIV-positive person with a referral that included their result and the contact information of a specific provider at the clinic. Once at the clinic, the individual received documentation that they had attended the visit, which the CHEW reviewed during a follow-up home visit. During six months of implementation, CHEWs provided 43,696 home-based HIV counseling and testing visits (69.4% of adults in the study district); 2.2 percent of tests were positive, and 64 percent resulted in a linkage to a health facility. Men made up 47 percent of HIV tests, a greater proportion than in comparable studies. Regional public health facilities, which served as control sites, tested 15,117 individuals during the same time period, with a positivity rate of 5.1 percent and 76.1 percent linking to treatment. Total program cost was USD$132,167 and the cost per positive test was $135.70. Although more people were linked within the public health system, the number linked by CHEWs was still satisfactory in comparison to similar home-based testing programs. Additional CHEW follow-up visits could improve linkages.

Akullian, A., Bershteyn, A., Klein, D., et al. AIDS (May 2017), 31: 1755–1764, doi: 10.1097/QAD.0000000000001553

This modeling study estimated HIV incidence among male/female age pairings to identify high-risk age groups and high-risk age pairings for HIV transmission. The authors analyzed data from a longitudinal surveillance system (2004–2015) in KwaZulu-Natal, South Africa, that included 10,260 women and 7,839 men. New HIV infections were documented in 1,788 women and 579 men. The highest incidence occurred among women aged 15–24 years who reported a male partner aged 30–34 years, followed by women of the same age group with a partner aged 25–29 years and women between ages 25 and 49 with a male partner aged 25–29. Men aged 25–30 years with a female partner of the same age group experienced the highest risk of HIV transmission. Women with a male partner under age 35 had three times greater risk of acquiring HIV than those with partners ≥35 years. Men with a female partner aged 25–34 experienced higher risk than those with partners aged 15–19. HIV acquisition risk may be driven more by exposure to a partner in a high-risk age group than by age gaps, and is determined by a sexual partner’s profile (including age), as well as community-level determinants, including viral load, antiretroviral treatment coverage, and risky sexual behaviors. Prevention interventions should focus on those most at risk of both acquiring and transmitting HIV.

Choko, A.T., Kumwenda, M.K., Johnson, C.C., et al. Journal of the International AIDS Society (June 2017), 20:2161, doi:1 0.7448/IAS.20.1.21610.

This qualitative study, conducted in anticipation of a randomized controlled trial (RCT) in Malawi, examined perceptions of female-delivered HIV self-testing (HST) kits delivered to male partners during antenatal care. The authors examined perceptions via focus group discussions and in-depth interviews. These discussions identified barriers to HST, including stigma, cost and time requirements, and fear of blame from partner following a positive diagnosis. Both men and women were willing to accept HST kits delivered by pregnant women; they also noted that HST offered privacy for men and addressed the stigma associated with visiting a clinic. Concerns included lack of immediate post-test counseling and the potential for abuse if the partner feels that he was not consulted or that the woman does not trust him. Participants said that the manner in which a woman raised the subject of HST to her partner was critical, and suggested using bedtime or a letter from the clinic to support the discussion. Strategies for increasing HST and linkages included financial incentives, transport costs, lottery, and either text or telephone reminders, although participants preferred the latter, given the increased ability to dialogue. The researchers adapted the upcoming RCT’s methodology to include USD$10 cash or lottery participation as incentives, and telephone call reminders instead of texting.

Ma, P.H.X., Chan, Z.C.Y., and Loke, A.Y. AIDS and Behavior (June 2017), doi:10.1007/s10461-017-1818-2.

The authors of this review applied the socioecological model to examine behaviors associated with accessing health services among sex workers (SWs) globally. The 30 eligible papers identified barriers at several levels that kept SWs from accessing health services, along with factors that facilitated access at each level:

  • Interpersonal: Barriers included insufficient information, cost, lack of social support, and fears about the consequences of a positive diagnosis. Facilitators included health knowledge including the benefits of treatment, perceptions of personal risk, social support, and peer support.
  • Institutional: Barriers included poor perceived quality of care, poor staff attitudes, confidentiality breaches, services that did not attend to their multiple health needs, and inconvenient hours and locations. Facilitators included perceived high-quality, convenient, and stigma-free care from health care workers.
  • Community: Barriers included stigma related to HIV, drug use, or sex work. Facilitators included nongovernmental advocacy groups that help SWs overcome health access barriers.
  • Policy: Barriers included criminalization and citizenship status requirements. Facilitators included government health care subsidies for SWs.

The authors called for interventions to address multilevel barriers and continue developing facilitating elements to improve health care access for SWs.

Scheibe, S., Shelly, S., Lambert, A., et al. Harm Reduction Journal (2017), 14:35, doi:10.1186/s12954-017-0164-z.

This study estimated population size in Cape Town, eThekwini, and Tshwane in South Africa and gathered information about safe injection practices, mobility patterns, and location coordinates of people who inject drugs (PWID). The study team visited injection sites, assessed the availability of HIV prevention supplies, and conducted interviews with PWID. Participants answered questions about number of daily injection sites visited, their ability to access HIV prevention supplies, and if their health needs were addressed; they also identified the locations of other sites, which the study team later visited. Geospatial mapping identified information about each PWID location and estimated PWID population sizes to determine service needs and routes. In Cape Town and Tshwane, 69 and 37 PWID locations were confirmed, respectively. No clean injecting supplies were available at any location in either city. In both cities 92 percent of PWID identified a nearby pharmacy where injecting supplies could be purchased. In eThekwini, 39 PWID locations were confirmed. Sterile supplies were available at one location and near six others, and 98 percent of PWID were able to identify a pharmacy to purchase clean needles. Across cities, only one-third felt that their health needs were being met. These findings indicated that PWID are accessible and need HIV prevention services, which require significantly more attention and financing.

LeGrand, S., Muessig K.E., Horvath, K.J., et al. Current Opinion in HIV and AIDS (June 2017), doi:12:000–000, 10.1097/COH.0000000000000400.

This review of 15 studies summarized HIV self-testing (HST) technologies that address barriers to HIV testing among men who have sex with men (MSM). Grindr, a geospatial dating application for gay and bisexual men, advertised free HST kits available through a study. Post-test surveys found that most MSM preferred HST over clinic-based testing. HST kits were also reported as easy to use. In China, HST was provided by mail to 198 online survey participants. Participants reported a preference for HST use due to convenience (46%) and privacy (40%); 67 percent said that they would self-test again if it was free. The application, HealthMindr, was developed for MSM and included health self-assessment tools and reminders of HIV service locators, along with access to free condoms and HST. The application was well-received; participants most often used access to free condoms and HST. Pre-test counseling has been provided to MSM via videoconferencing, and peer-based counseling to young MSM via video chat. An application currently under development will provide a "virtual reality experience” for users to improve adolescent HST experiences. Bluetooth® technology is also being applied to HST so when a kit is opened, the user receives a phone call within 24 hours to receive post-test counseling. The authors endorsed using technology that is available in low-resource settings to increase HST globally.

Mark, D., Taing, L., Cluver, L., et al. Journal of the International AIDS Society (May 2017), 20(Suppl 3):21491, doi:10.7448/IAS.20.4.21491.

This commentary discussed the challenges of the transition of HIV care for adolescents living with HIV. This transition entails changing from pediatric- to adult-focused services while increasing self-management responsibilities. Poorly planned transitions can result in poor treatment outcomes. There are few policies with clear definitions, tools, and standard operating procedures to support the transition process. Age of consent laws for testing, care, and treatment and the criminalization of sex work, drug use, and same-sex relationships reduce access to services. At the facility level, it is challenging to implement individualized approaches in low-resource settings. Where protocols exist, they are often ignored due to lack of time and resources, as well as misconceptions that adolescents already possess sufficient knowledge regarding self-care. The authors recommended identifying barriers to transition and addressing them at the community, family, and social levels. There is insufficient evidence for effective transition implementation, which reduces the capacity of governments and programs to prioritize interventions. Governments should adopt adolescent-specific policies and provide guidance on appropriate transitional care, the authors said. HIV services should be tailored to meet the individual needs of adolescents; and transition policies should be enacted at the facility level. It is critical to involve youth in designing appropriate programs, and to conduct community mobilization to enhance linkages and supportive services.

McCoy, S.I., Fahey, C., Rao, A., et al. PLOS ONE (May 2017), 12(5): e0177394, doi:10.1371/journal.pone.0177394.

This study evaluated an adherence intervention that incorporated social norms and priming concepts (using associations to influence behaviors) among 405 people living with HIV in Tanzania. The patient-centered design used the primer image of a Baobab tree, “the tree of life,” which has positive cultural associations in this setting. The clinic-based component included participants placing a sticker with the words “brave” or “courageous” on a poster of the tree after successfully attending three consecutive visits—rewarding them for participating, and demonstrating that clinic attendance is a norm. The home-based interventions included a calendar with images of the tree and other positive-association images to help keep track of appointments; and a plastic pillbox, also with a small tree image, shaped like a telephone to prevent unintentional disclosure. At endline there were significant increases in staff support of treatment goals, support from other patients, and satisfaction with the clinical care received. Patients were also significantly more likely to have their questions answered by a provider and to be retained in care after six months. The authors concluded that using social norms and priming can improve the effectiveness of treatment as prevention programs and should be considered at the health system level, given the cost-effectiveness of the approach.

Kim, M.H., Mazenga, A.C., Yu, X., et al. Journal of the International AIDS Society (March 2017), 20(1):1–12, doi:10.7448/IAS.20.1.21437.

Reaching 90-90-90 goals will be impossible without addressing HIV in adolescents and young adults, who account for more than 40 percent of new HIV infections. However, there is a paucity of research on adherence among adolescents living with HIV (ALHIV) in Southern Africa. This cross-sectional study examined antiretroviral therapy (ART) adherence, barriers to adherence, and factors associated with non-adherence among ALHIV in Malawi. ALHIV attending two large HIV clinics self-reported missed doses (past week or month) and barriers to adherence, and completed questionnaires on stress factors, disclosure, depression, substance use, treatment self-efficacy, and social support. Biomedical data were retrieved from existing medical records. Of the 519 participants, nearly half reported non-adherence to ART: 153 (30%) within the past week, and 234 (45%) in the past month. The most frequently self-reported barriers to adherence were forgetting (39%), travel from home (14%), and being busy with other things (11%). Analysis revealed several factors that were independently associated with missing a dose in the past week: drinking alcohol in the past month, missing a clinic appointment in the past six months, witnessing or experiencing violence in the home, and poor treatment self-efficacy. Suboptimal adherence, the authors concluded, is a major issue for ALHIV that urgently requires strong, tailored interventions to meet the needs of this key risk group.

Turan, B., Hatcher, A.M., Weiser, S.D., et al. American Journal of Public Health (April 2017), 20: e1–e7, e-publication ahead of print, doi:10.2105/AJPH.2017.303744.

Addressing HIV and reaching 90-90-90 goals require addressing structural factors such as stigma, which affect the wellbeing of people living with HIV (PLHIV) and impede their access and adherence to treatment. However, it is not fully understood how stigma leads to worse health behaviors or outcomes. This article presented a conceptual framework that highlights how individual-level HIV-related stigma (perceived community stigma, experienced stigma, internalized stigma, and anticipated stigma) might affect the health of those living with HIV. The framework was based on research on stigma and existing models and theories. It described how structurally embedded stigma could affect individuals in terms of interpersonal factors, mental health, psychological resources, and biological stress—and subsequently, could affect PLHIV directly (physiologically) and indirectly (in terms of engagement in care and HIV-related health). A conceptual framework such as this one, the authors said, could inform future research and interventions aiming to address stigma as a driver of HIV-related health. As a next step, they recommended longitudinal studies to strengthen evidence on the causal effects and pathways of stigma, and development of improved measurement strategies.

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.

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.

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.

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.

Aibibula, W., Cox, J., Hamelin, A.M., et al. AIDS and Behavior (March 2017), 21(3): 754–765, doi:10.1007/s10461-016-1605-5.

The authors of this systematic review focused on clarifying the relationship between food insecurity and poor viral suppression in HIV-positive people who are receiving antiretroviral therapy. The authors searched five electronic databases for studies on this topic published through April 2015 and identified 11 eligible studies (9 from North America, 1 each from Brazil and Uganda). Their analysis showed that experiencing food insecurity reduced the likelihood of achieving complete HIV viral suppression by 29 percent across all studies and study designs. The authors noted that these findings did not demonstrate a causal link between food insecurity and incomplete viral response. In addition, they suggested that because of the provenance of most of the eligible papers, these findings may not be generalizable to low-income countries. However, they concluded that HIV-positive persons who are food-insecure may represent a more vulnerable population needing greater attention from providers and programmers.

Jennings, L., Pettifor, A., Hamilton, E., et al. AIDS and Behavior (March 2017), 21(3): 665–677, doi:10.1007/s10461-016-1435-5.

This study examined associations between individual economic resources and HIV preventive behaviors among rural South African women who were enrolled in school. The authors used baseline data from the HIV Prevention Trials Network (HPTN) 068 study to examine links between resources and delayed sexual debut, along with six HIV prevention behaviors, among 2,533 young women aged 13–20 years. Age-adjusted results showed that among all participants, employment significantly increased the likelihood of ever having sex. Food sufficiency and lack of indebtedness, by contrast, significantly decreased the likelihood of sexual experience. Among sexually experienced women, paid work was significantly linked to HIV preventive practices in terms of selection of sexual partners and periodic abstinence. Women who worked for pay, had money to spend on themselves, or had a bank account were significantly more likely to use three or more HIV prevention strategies than women who lacked these resources.  For example, women who had a bank account were more likely to use condoms, and those with money to spend on themselves were more likely to have fewer sexual partners, discuss HIV testing with partners, and discuss condom use. Economic hardship was positively associated with ever having sex, but not with sexually protective behaviors. The authors concluded that maximizing women's individual economic resources may complement future prevention initiatives.

Chow, J.Y., Konda, K.A., Calvo, G.M., et al. Sexually Transmitted Diseases (March 2017), 44(3):143–148, doi:10.1097/OLQ.0000000000000566.

This study compared the demographic and sexual characteristics of men who have sex with men (MSM) and transgender women (TW) who did and did not use social media to make sexual connections. A total of 312 MSM and 89 TW received testing for HIV and sexually transmitted infections (STIs) and answered a survey covering demographics, behaviors, sexual health, and social media practices. Fewer than half of MSM and TW used social media to find sex partners (115 and 29, respectively), using a variety of sites and applications. MSM who used social media were younger, more educated, and more likely to identify as gay. They were significantly more likely to report high-risk behavior (more sex partners; sex in higher-risk venues and contexts) and to present with a rectal STI. TW with social media sex partners were younger, less educated, and more likely to participate in sex work; they had a lower rate of rapid plasma reagin positivity or history of syphilis. About one-third of participants (118) were HIV-positive. The authors called for strategies targeting Peruvian MSM and TW who use social media to address their higher-risk sexual behavior and the high burden of STIs in these two groups.

Lyons, C., Ketende, S., Drame, F., and Grosso, A., et al. Journal of Acquired Immune Deficiency Syndromes (February 2017), e-publication ahead of print, doi:10.1097/QAI.0000000000001310.

This study estimated the prevalence of violence (physical and sexual) among female sex workers (FSWs) in Côte d'Ivoire, where sex work is legal but soliciting is criminalized, and examined structural risks for HIV in this context. The authors used respondent-driven sampling to recruit 466 FSWs aged over 18 years in Abidjan and administered HIV testing and a socio-behavioral questionnaire that included information on work-related risks, payment arrangements, police practices, and health service indicators. One-quarter (24.1%) of participants reported that police refused to protect them because of their work; 31.2 percent reported harassment or intimidation; both were significantly associated with physical and sexual violence. One-fifth of the FSWs reported being blackmailed, which was associated with physical and sexual violence, and the majority (80.5%) had been offered more money for condomless sex, which was associated with sexual violence. HIV prevalence among participants was 11 percent, but 25 percent overall said that they avoided health services because of their profession. These findings, the authors said, indicate the need for structural interventions and policy reforms to improve work environments and to address police harassment, stigma, and rights violations to reduce violence and improve access to HIV interventions for FSWs in Côte d'Ivoire.

Kiwanuka, N., Ssetaala, A., Ssekandi, I., et al. PLOS ONE (February 2017), 12(2):e0171200, eCollection 2017, doi:10.1371/journal.pone.0171200.

This community-based cohort study examined the population-attributable fraction (PAF) of alcohol-related HIV incidence. The authors enrolled 1,607 HIV-negative participants aged 18–49 years and followed up with 1,288 (80.1%) of this group one year later. At baseline and in follow-up visits, participants completed interviewer-administered questionnaires on alcohol consumption, demographics, and sexual risk behavior, and were tested for HIV infection. Over half of participants (53.5%) reported drinking alcohol; of these, about one-fourth drank occasionally or often (24.4% and 29.1%, respectively). At follow-up, 48 incident infections had occurred: 10 among nondrinkers, 12 among occasional drinkers, and 26 among regular drinkers. Compared to nondrinkers, the adjusted incident rate ratio (IRR) of HIV was 3.09 (1.13-8.46) among occasional drinkers and 5.34 (2.04-13.97) among regular drinkers. The overall adjusted PAF of incident HIV infections due to alcohol was 64.1, ranging from 52.3 (11.9-74.2) among Muslims to 71.2 (32.6-87.7) for participants who reported two or more sexual partners in the past 12 months. Alcohol consumption was associated with HIV risk behaviors such as multiple partners, though consistent condom use was higher among regular drinkers than among occasional drinkers and nondrinkers. The authors concluded that alcohol contributes to new infections in these communities and recommended integrating interventions to reduce alcohol consumption within prevention activities for similar high-risk communities.

Lambert, R.F., Orrell, C., Bangsberg, D.R., et al. AIDS and Behavior (February 2017), doi:10.1007/s10461-017-1704-y.

To clarify factors motivating healthy individuals to seek HIV testing and treatment, the authors conducted in-depth interviews with 25 HIV-positive young adults (age 18–35 years) with a CD4 count >350 cells/mm3 who recently started or decided to start antiretroviral therapy in Gugulethu, South Africa. They found that several factors influenced a participant’s decision to seek testing. Avoiding stigma (by appearing healthy) was a primary motivator. Other factors included social support—a close associate who advocated testing—responsibility for a child or desire to be healthy and achieve goals and aspirations, the perceived "normalcy" of having HIV, and availability of accessible services. Participants also mentioned concerns about side effects from treatment or the difficulty of maintaining the medication schedule as barriers requiring serious thought. The authors noted that stigma can serve as both a barrier and a motivator for testing and treatment. They said that the study shows the importance of health maintenance as a driver of early treatment initiation, and urged including maintenance of physical appearance in the development of novel testing and treatment interventions.

Witzel, T.C., Lora, W., Lees, S., and Desmond, N. PLOS ONE (February 2017), 12(2): e0170588, eCollection 2017, doi:10.1371/journal.pone.0170588.

This meta-ethnography examined the context and efficacy of HIV testing and counseling (HTC) uptake in East and Southern Africa and analyzed the perceived impacts of counseling on sexual behavior and linkage to care. HTC is usually delivered through voluntary counseling and testing (VCT), provider-initiated counseling and testing (PITC), and home-based voluntary counseling and testing (HBVCT). Following a systematic literature review, the authors identified 20 qualitative and mixed-method studies conducted from 2003 through April 2014. They found that decisions on VCT were made individually, usually related to prolonged illness or perceived risk, and also in the context of mutual encouragement by peers. Decisions on HBVCT were made in families and communities, often through the influence of partners, village chiefs, and counselors. PITC was associated with coercion from providers, especially in antenatal care settings where women did not feel able to refuse testing. Numerous factors, especially stigma, the quality of health services, fear of test outcomes, and gender norms, facilitated or impeded uptake of the different testing models. The authors concluded that HBVCT, which minimizes stigma, should be prioritized. They added that although good counseling can effectively convey information on HIV and sexual risk, it was seen as ineffective in addressing broader personal circumstances that affect sexual risk behavior and access to care.

Yotebieng, M., Moracco, K., Thirumurthy, H., et al. Journal of Acquired Immune Deficiency Syndromes (February 2017), 74(2)150–157, doi:10.1097/QAI.0000000000001219.

This study examined the mechanisms by which a cash incentive intervention increased retention in the prevention of mother-to-child transmission (PMTCT) programs. It used data from a randomized controlled trial in Kinshasa, Democratic Republic of Congo (2013–2014) of 433 newly diagnosed HIV-positive women who received either the standard of care or the standard of care plus small and increasing payments (starting at USD$5 and increasing by $1 under various conditions (i.e., that the woman attended clinic visits; accepted a referral for antiretroviral therapy [ART]; delivered in a facility; and provided a blood sample at six weeks postpartum for early infant diagnosis). Results showed that better knowledge of PMTCT and a greater understanding of and belief in the effectiveness of ART were positively associated with higher adherence to PMTCT services. They also indicated that cash transfers may improve retention in PMTCT services by mitigating the barrier of not having money to come to the facility. The authors noted that the minimum financial incentive proposed should be at least equal to the cost of attending clinic visits. They concluded that interventions that combine sufficient cash incentives to retain pregnant women who are likely to be lost to follow-up with education programs to improve understanding of HIV risk may achieve sustained retention.

Kassaye, S.G., Ong'ech, J., Sirengo, M., et al. AIDS Research and Treatment (December 2016), doi:10.1155/2016/1289328.

This study assessed the utility of short message service (SMS) text messages to improve uptake of antenatal and prevention of mother-to-child transmission (PMTCT) services by improving communication between women and their health providers in Nyanza, Kenya. The cluster-randomized study focused on government-supported clinical sites, enrolling 550 women (June 2012–July 2013). Results indicated that SMS text messages had no significant effect on key PMTCT milestones (uptake and adherence to antiretrovirals, or ARVs, among mothers and infants, facility-based deliveries, or infant HIV testing at six weeks of age). However, communication increased in both groups during successive visits, with the intervention arm showing greater cumulative increases in communication by the time of delivery compared to the control arm. Additionally, very high uptake of ARVs and infant HIV testing was noted in both the intervention and control arms (86.8% and 83.7%, respectively)—higher than that reported in program data from facilities within the region. The authors said that retraining health workers on PMTCT may have led to improvements in program implementation, and that improvement may have been mediated through the increase in communication observed in both the intervention and control sites. They concluded that the study provides evidence for the potential role of increased communication, by text messages, phone calls, or in person visits, on effective PMTCT program implementation.

Flynn, D.E., Johnson, C., Sands, A., et al. BMC Research Notes (January 2017), 10(1): 20, doi:10.1186/s13104-016-2339-1.

Since 2008 the World Health Organization has recommended increasing the scope of work of trained lay providers. However, in many settings lay providers have not been used for HIV testing services (HTS). This paper analyzed national HIV testing policies from 50 countries to determine the role of lay providers in delivering HIV testing as well as pre- and post-test counseling. Of the 50 countries, 21 allowed lay providers to use rapid diagnostic tests using fingerstick blood; 15 explicitly prohibited lay providers from performing them; and 14 did not specify. Twenty-eight of the 50 countries permitted lay providers to provide pre- and post-test counseling; 12 prohibited them from performing counseling; and 10 did not specify. Overall, 42 percent of countries permitted lay providers to perform HIV testing; 56 percent permitted them to administer pre- and post-test counseling. The authors compared these findings with Global AIDS Response Progress Reporting data to understand if national HIV health policy reflects what happens in health care systems. They found that less than half of reported data from countries aligned with their national HIV testing policies regarding lay counselors. The authors said that given the low use of lay providers globally, and their proven effectiveness in increasing HIV testing, countries should consider revising policies to support lay provider testing using rapid diagnostic tests.

Lafort, Y., Greener, R., Roy, A., et al. Reproductive Health (January 2017), 14(1):13, doi:10.1186/s12978-017-0277-6.

This paper shared results from the cross-sectional baseline survey of the Diagonal Interventions to Fast-Forward Enhanced Reproductive Health implementation research project on female sex workers' (FSWs) use of sexual and reproductive health (SRH) services (looking specifically at use of contraceptive methods [hormonal, intrauterine device, or sterilization] and services for cervical cancer screening, unwanted pregnancies, and sexual violence). The FSWs were recruited from Durban, South Africa (n=400), Mombasa, Kenya (n=400), Mysore, India (n=458) and Tete, Mozambique (n=308). Findings varied considerably across cities, after controlling for socioeconomic characteristics. Current use of any modern contraception ranged from 86.2 percent in Tete to 98.4 percent in Mombasa. Non-barrier contraception use varied from 33.4 percent in Durban to 85.1 percent in Mysore. The proportion ever screened for cervical cancer ranged from 0.0 percent in Tete to 29.0 percent in Durban; the proportion that had ever gone to a facility to terminate an unwanted pregnancy ranged from 15.0 percent in Durban to 93.7 percent in Mysore. Between 34.4 percent (Mombasa) and 51.9 percent (Mysore) had sought medical care after forced sex. The authors concluded that differences in results may reflect variations in the availability and accessibility of SRH services. They concluded that intervention packages to improve use of contraceptives and SRH services should be tailored to local gaps.

Kohli, A., Kerrigan, D., Brahmbhatt, H., et al. AIDS Care (January 2017), e-publication ahead of print, doi:10.1080/09540121.2017.1280127.

This analysis described social and structural factors contributing to HIV risk among truck drivers who visited rest stops along the Tanzania–Zambia Highway in Iringa, Tanzania. The authors conducted thematic data analysis (as part of a larger, comprehensive strategic assessment examining HIV risk factors in Iringa) based on 11 in-depth interviews with truck drivers and a transport owner. Interviewees described structural risk factors for HIV, including work conditions, the power imbalance between male drivers and their sexual partners, and low perceived HIV risk with certain partners (e.g., regular partners). The analysis indicated that multiple interrelated social norms associated with truck stop environments influenced HIV risk, including peer influence and expectations, the presence of sex workers, the ability to purchase sex, and alcohol consumption. All drivers interviewed described alcohol consumption as common and often excessive. These factors all contributed to behavior that participants said they would not commonly engage in elsewhere. The authors concluded that HIV prevention strategies with truck drivers should address individual, social, and structural barriers to HIV prevention, and should partner with the health and transportation sectors, local government, and local communities. Strategies suggested by participants included adapting services to drivers’ schedules, offering positive messaging, and addressing the risk environment holistically.

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.

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.

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.

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.

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.

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.

Sani, A.S., Abraham, C., Denford, S., and Ball, S. BMC Public Health (2016) 16: 1069, doi: 10.1186/s12889-016-3715-4.

This review examined the impact of school-based sexual health programs on sexually transmitted infections (STIs), including HIV, and condom use. Results showed that all 31 programs examined provided education on STI transmission and prevention, safe sex, and pregnancy prevention. Programs were delivered via multiple media, including lectures, discussions, role-plays, movies, songs, counseling, and quizzes administered by a range of figures including teachers, peer educators, and health educators and providers. Condom distribution occurred in three programs. Two studies examined program exposure and HIV outcomes, and found no impact. Studies similarly found no impact on incidence of herpes simplex virus 2 infections; for other STIs, studies showed mixed results. One study found no impact; another found reduced gonorrhea, chlamydia, and trichomonas at 42 months post-intervention, but not at 54 months. Fifteen programs reported significant increases in condom use, but sixteen did not. Meta-analysis found participants were more likely to use condoms following both randomized controlled trials (RCTs) and non-RCTs at 6 months post-intervention, but this effect was sustained only for RCTs at 6–10 months and >10 months follow-up periods. The authors concluded that program planners should base programs in theory; adapt programs based upon pre-existing models; and link programs to health services. Future programs should also report on the processes of the intervention to clarify the mechanisms behind effective and ineffective program elements.

Roberts, S.T., Haberer, J., Celum, C., et al. Journal of Acquired Immune Deficiency Syndromes (November 2016), 73(3): 313–322.

This study examined the impact of intimate partner violence (IPV) on PrEP adherence among 1,785 women participating in a clinical trial. The authors conducted monthly in-person interviews during routine risk reduction counseling to assess IPV incidence; and assessed adherence through pill counting and testing serum tenofovir PrEP levels. Results showed that 16.1 percent of women reported experiencing IPV in the course of 437 interviews. The majority (68.8%) reported one IPV incident, but nearly 5 percent reported experiencing five or more. The most common IPV type was verbal, followed by physical and economic IPV. Women who experienced IPV were less likely to report recent sex, but more likely to report condomless sex, and that their partner had other sexual partners. Women who experienced IPV in the past three months were 50 percent more likely to have reduced PrEP adherence. No significant associations were found between HIV incidence and experiencing IPV in the past three months. Women reporting IPV explained that emotional trauma or fleeing to safety led to forgetting to take pills, or that their partner threw away their pills. PrEP projects that work with women who experience IPV should collect data to understand the impact of IPV on adherence in this group.

Musheke, M., Merten, S., and Bond, V. BMC Public Health (2016) 16:882, doi:10.1186/s12889-016-3396-z.

This qualitative study examined barriers to HIV testing for marriage partners of an HIV-positive person. The authors conducted interviews with 30 HIV-negative partners who refused testing and 10 health care providers and held a focus group discussion with 8 HIV counselors. The results showed that some partners identified self-perceived wellness as a reason not to test, although others voiced assumptions that they were already HIV-positive, given their partner’s status. Men discussed their fear of emasculation due to illness and medication, although they often took natural or traditional supplements to address symptoms of opportunistic infection. Both men and women avoided HIV testing out of concern that their partner would view a positive diagnosis as proof of infidelity. They also expressed concerns about the impact of HIV on their mental health and their lack of confidence in their ability to adhere to treatment. Many cited the misconception that antiretroviral treatment causes illness or death, and said that they preferred herbal and traditional medicine and faith healing. The authors concluded that increasing awareness of serodiscordant relationships and providing education on treatment and the benefits of HIV testing (despite feelings of wellness) could decrease barriers to testing among partners of seropositive persons.

Altice, F.L., Azbel, L., Stone, J., et al. The Lancet (July 2016), 388: 1228–4, doi: org/10.1016/ S0140-6736(16)30856-X.

This review examined the junction of HIV, tuberculosis, hepatitis C virus (HCV), and imprisonment among people who inject drugs (PWID), and HIV risk factors that are associated with incarceration. The region of Eastern Europe and Central Asia is the only area where HIV incidence and mortality, largely associated with PWID, are increasing. In this region, opioid agonist therapies and needle and syringe exchange programs are banned or limited, and HIV diagnosis and treatment availability is limited. Modeling studies show that opioid agonist therapy would be the most cost-effective HIV prevention intervention, and would be even more effective when combined with HIV treatment. Criminalization of injection drug use, high HIV prevalence among PWID within prisons, and needle sharing facilitate high HIV transmission among prisoners. Policies that require PWID to register for opioid agonist therapy outside of prison, allow arrest for accessing harm reduction services, and criminalize same-sex behaviors and sex work increase the risk of arrest and imprisonment. The authors concluded that structural factors significantly contribute to the incarceration of vulnerable populations including PWID, increasing their risk of HIV. Approaches that reduce incarceration risk and increase availability of opioid agonist therapy during and after imprisonment have the potential to reduce HIV and HCV transmission among PWID in the criminal justice system.

Rubenstein, L.S., Amon, J.J., McLemore, M., et al. The Lancet (July 2016), 388: 1202–14, doi:10.1016/S0140-6736(16)30663-8.

This review focused on criminal laws, policies, and practices around law enforcement and judicial systems, and their effect on rights to HIV prevention and treatment among incarcerated people at risk of or living with HIV. Nearly half of all new HIV infections occur among key populations, who are often arrested without reason, do not receive pretrial release, and are subject to biased sentencing and higher likelihood of imprisonment. Punitive law enforcement practices, such as exchanging sex for freedom, using possession of condoms as proof of sex work, and criminalizing harm reduction services, increase prisoners’ HIV risks. Prolonged incarceration periods increase HIV risk and reduce access to HIV treatment. Prisoners also face human rights violations, including overcrowding, sexual violence, and inadequate health care (including discontinuity of health services), that further increase their vulnerability. The quality of prison health services is low due to structural barriers, inadequate staffing, non-alignment between prison services and national standards and negative attitudes among providers. Often, HIV testing lacks confidentiality, and treatment and associated laboratory testing are not available. Limited discharge planning and linkages to post-prison clinical services lead to reduced adherence to HIV treatment and increased virologic failure, particularly among minority populations. The authors concluded that a foundational step is to address factors that lead to disproportionate incarceration of individuals at risk for HIV, as a way to minimize imprisonment and improve HIV outcomes.

Toska, T., Cluver, L.D., Boyes, M.E., Isaacsohn, M., Hodes, R., and Sherr, L. AIDS and Behavior (September 2016), doi:10.1007/s10461-016-1539-y.

The study examined the impact of social protection provisions on unprotected sex among 1,060 HIV-positive adolescents eligible for treatment. Nine different types of social protection provisions were included. Cash/cash in-kind provisions comprised social cash transfers, past-week food security, free education, free food in school, and free clothing. Psychosocial provisions comprised positive parenting, strong parental supervision, support groups, and adolescent-sensitive care. Results showed that 18 percent of adolescents reported condomless sex at last intercourse; girls reported significantly higher rates of condomless sex than boys did. Among adolescents who provided a viral load, it was found that viral failure was strongly associated with condomless sex, indicating high risk of HIV transmission. Adolescents who received free education, strong parental supervision, and (particularly for girls) adolescent-sensitive care were less likely to have unprotected sex. The findings also indicated that adolescents exposed to free school, strong parental supervision, and adolescent-sensitive care were least likely to have condomless sex when exposed to all three of these interventions, and were incrementally more likely to have condomless sex when exposed to fewer social protection provisions.

Yamanis, T.,J., Dervisevic, E., Mulawa, M., et al. AIDS and Behavior (August 2016), doi 10.1007/s10461-016-1513-8.

This study in Dar es Salaam, Tanzania examined perceptions of links between social networks and HIV testing among men in camps, which are formalized social networks with formally selected leaders. A total of 923 men from 48 social networks were interviewed using a structured survey. Results showed that 51.5 percent of the men had ever been tested for HIV (range 20–84.2%). Higher age and having children, more household assets, and higher education were associated with ever being tested. If a man was a socially important component of the camp, rather than at the social periphery, he was more likely to be tested, given that more socially connected men are often rich sources of information and can reach other men with HIV testing messages. Camps with higher female membership were also more likely to have men who had been tested. Men who thought that a close friend had been tested were also more likely to be tested. High levels of HIV stigma within a social network decreased the likelihood of testing—men who test for HIV are more likely to be stigmatized than women. The authors concluded that interventions targeting social networks should seek to reduce stigma. Future interventions among male social networks should increase discussions around HIV testing among men, including their friends, to increase testing uptake.

McMahon, S.A., Kennedy, C.E., Winch, P.J., et al. AIDS and Behavior (August 2016), doi: 10.1007/s10461-016-1505-8.

This qualitative study (2011–2013) examined reasons why pregnant women fall out of HIV care during pregnancy. The authors interviewed 40 women in Tanzania who had begun services for prevention of mother-to-child transmission (PMTCT) but stopped attending. Most women (n=38) fell out of care during pregnancy, most often after one or two antenatal care visits. Two defaulted after four postnatal visits. The authors grouped findings into three categories. Category 1, “Antiretroviral therapy (ART) as beneficial but inaccessible,” described observed and experienced stigma associated with ART, lack of privacy at facilities, and insufficient time and funds to access ART, since women often travel to more remote facilities to maximize privacy. Stigma was the most powerful and common obstacle experienced. Category 2, “ART as unnecessary or harmful,” described women who did not believe that ART was necessary because they felt healthy or were in denial about their status; and women who preferred alternative healing techniques, were concerned about side effects, or no longer cared to live. Category 3, “Not knowing or forgetting to use ART,” described lack of information from clinicians about appointments and medications, or forgetting to take ART, as a cause of drop-out. The authors concluded that programmers must address stigma, limitations of facilities, and patient denial to improve retention in PMTCT care.

Bautista-Arrendondo, D., Sosa-Rubi, S.G., Opuni, M., et al. AIDS (2016), doi: 10.1097/QAD.0000000000001208

This study examined 230 HIV testing and counseling (HTC) and 212 prevention of mother-to-child transmission (PMTCT) sites to examine site-level average yearly cost per client along the cascades in Kenya, Rwanda, South Africa, and Zambia. Retrospective data was collected from facility records covering a period of one year. Data collection include five cost categories including personnel, recurrent inputs and services, equipment and vehicle operating costs, training, and supervision. For HTC, average yearly cost per client tested ranged from USD$5 to $31, and $122 to $1,367 per HIV-positive client. Costs ranged widely between and within countries with some facilities skewing results with higher costs. On average, cost per HTC client in South Africa and Zambia was significantly higher than in Rwanda and Kenya. Average cost per PMTCT client ranged from $18–89 and $565–$2,021 per HIV-positive client. Average cost per PMTCT client was significantly less in Rwanda than other countries and per HIV-positive client, significantly higher in Rwanda than Kenya and Zambia. For HTC and PMTCT, per HIV-positive client average cost in Rwanda was significantly higher due to the low positivity rate encountered. Staffing for HTC and PMTCT comprised the majority of costs in all countries with the exception of PMTCT in Rwanda. Study findings indicated that improving intervention targeting, altering staffing, or adapting service models could improve efficiency.

Bhattacharjee, P., Isac, S., McClarty, L.M., et al. Journal of the International AIDS Society (2016), 19(Suppl 3): 20856, doi: http://dx.doi.org/10.7448/IAS.19.4.20856.

This study (2005–2011) examined a structural intervention to reduce police arrest among female sex workers (FSWs) in India. Arrested FSWs may be sexually abused by police; engage in risky (including condomless) sex to pay arrest costs; have condoms confiscated by police; and move to avoid arrest—reducing their community support and increasing HIV vulnerability. The intervention included one-day sensitization workshops with police to educate them on existing laws covering FSWs, human rights and abuse penalties, and FSWs' daily struggles. Interventions for FSWs entailed formation of peer support groups, training on rights and how to report violence to police, and development of crisis management teams, including a 24-hour hotline and a human rights lawyer to address emergencies. As part of integrated biological and behavioral assessment surveys, FSWs were interviewed at 20-month intervals about their experiences. Interviews with 4,110 FSWs, showed that while 5.5 percent initially reported experiencing arrest, only 2.8 percent did 20 months later. Peer support also increased: 40.75 percent of FSWs initially reported having peer support, which increased to nearly 70 percent 20 months later. The authors concluded that in settings where sex work is criminalized, structural interventions that educate police officers can be an effective approach for reducing HIV risk among FSWs.

Schneiders, M.L., and Weissman, A. Journal of the International AIDS Society (2016), 19(Suppl 3): 20878, doi: 10.7448/IAS.19.4.20878.

Enforcement of Cambodian laws creates barriers to HIV service implementation for key populations, including men who have sex with men (MSM), people who inject drugs (PWID), and sex workers. The authors conducted a baseline study in advance of a harm-reduction intervention among police, clinicians, key population members, and implementing partners. The study was carried out to understand: 1) police attitudes and actions toward key populations, and 2) HIV prevention actions and actions toward police among key populations. The authors conducted structured interviews with 798 participants from key populations (MSM, PWID, transgender women, and female entertainment workers) and 199 police officers. Findings indicated that 11 percent of respondents had experienced arrest in the previous six months; 29 percent experienced verbal intimidation; and 25 percent experienced a body search. PWID reported higher incidence of these events than other key population groups. Among police, 58 percent reported arresting a key population member in the past six months; and 75 percent reported performing a body search. All police voiced support for HIV prevention; 94 percent stated that arrest/detention supported prevention activities. Future HIV prevention and harm reduction interventions must improve negative perspectives among key population members and police with specific research-informed interventions for each key population group.

Chikovore , J., Gillespie, N., McGrath, N., et al. AIDS Care (2016) 28:S3, 74–82, doi: 10.1080/09540121.2016.1178953.

This qualitative study examined how perceptions of masculinity affect men’s engagement in HIV care in the context of a test-and-treat trial in South Africa. The authors conducted 20 interviews (10 men, 10 women), 10 of them repeated three times, with participants recruited from households and a clinic. They also formed four focus groups—of younger individuals, older individuals, traditional healing practitioners, and mixed participants—that met four times. Findings showed that men avoided HIV testing due to fear of a positive diagnosis, preference for traditional medicine, and concern that health facilities are for women. Female partners who tested positive faced disclosure challenges, including blame and financial neglect; they sometimes relied on an antenatal care visit for support in disclosure. Men acknowledged their likely role in transmitting HIV to their partner, but still avoided the subject, and delayed testing and treatment. The literature indicates that for men, HIV is a threat to sexual capability, independence, and earning potential—all "masculine" traits. The authors concluded that to successfully promote test-and-treat approaches, policy and service delivery models must take into account family dynamics, including men’s concerns about masculinity; and also consider service delivery models that reach men in alternative settings.

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.

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.

Muthengi, E., Gitau,T., Austrian, K. PLOS ONE (May 2016), doi: 10.1371/journal.pone.0155988.

This study focused on the association between work and experience of physical violence among married adolescents, and looked at the impact of access to independent financial resources on this risk. Between August and December 2013 the authors used a dataset of 452 adolescent girls residing in low-income, informal settlements (slums) in four Kenyan cities and towns: Nairobi, Kisumu, Nakuru, and Thika. This activity was part of a baseline survey for an intervention to build social, health, and economic assets for vulnerable young women in these cities. About one-fourth of girls who worked had experienced physical violence during the previous six months, compared with 16 percent of girls who did not work. Major factors associated with reduced odds of experiencing physical violence were primary education, secondary education, and ownership of jewelry. Working with no regular savings was associated with greater odds of intimate partner violence, compared to girls not working. Saving regularly was not associated with violence; and partner trust regarding money was associated with 63 percent lower likelihood of violence compared with not having partner trust. The authors concluded that while economic empowerment in the form of work for married adolescent girls may increase their risk of experiencing violence, having savings can be protective.

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

This cluster-randomized controlled trial, PREPARE, conducted among young adolescents (average age 13 years) in Western Cape, South Africa, evaluated an HIV prevention program that included a focus on reducing IPV and sexual violence. The multi-component intervention at the 20 intervention schools included an educational program (21 sessions delivered once a week, immediately when school ended, on the school premises); a school health service (education on sexual and reproductive health or SRH, identification of need for SRH services or commodities, and referral to the nearest community clinic if needed); and a school safety program. Participants in the 22 control schools received school as usual, which excluded the after-school program, the school health service, and the safety program. Of 6,244 sampled adolescents, 55.3 percent participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviors. However, participants in the intervention arm were less likely to report IPV victimization (35.1% versus 40.9%), suggesting that behavioral HIV prevention programs that include a focus on IPV prevention can reduce self-reported intimate partner violence. The authors concluded that interventions such as PREPARE have potential beneficial effects on one of the factors that strongly affects adolescents’ risk of sexually transmitted infections and HIV.

Ojikutu, B.O., Pathak, S., Srithanaviboonchai, K., et al. PLOS ONE (May 2016), 11(5): e0153600, doi: 10.1371/journal.pone.0153600, eCollection 2016.

This study explored the disclosure patterns of HIV-positive women in three settings with concentrated or generalized epidemics: Brazil (n = 99), Thailand (n = 100), and Zambia (n = 100). The authors assessed disclosure to sexual partners, sexual risk behavior, and clinical status were assessed at baseline and at 3, 6, 9 and 12 months via audio computer-assisted survey. At baseline, half of all women (45.3%) reported perceived community HIV stigma at baseline; and 42.9 percent acknowledged perceived community gender norms (marriage and procreation). More Zambian women (66%) endorsed these norms than Thai (38%) or Brazilian women (24%). Two-thirds (67%) of women reported disclosing to their sexual partner at baseline. No significant difference was noted in disclosure to sexual partners over time among the total group or within and across sites. Women who were older (24–44 versus 18–24), had symptoms of severe depression, and those who reported anticipated stigma, were less likely to disclose. Women who were unmarried and those who were not cohabiting with their partner were also less likely to disclose to their sexual partners. The authors concluded that interventions to promote disclosure among women in serodiscordant relationships should incorporate community-level interventions to reduce stigma and promote gender equality.

Stahlman, S., Beyrer, C., Sullivan, P.S., et al. AIDS and Behavior (April 2016), e-publication ahead of print.

The authors gave an overview of the drivers of the HIV epidemic and the relevance of these drivers to the global and local epidemics, including concentrated and generalized epidemics in high- and low-income settings. They posited that engaging and retaining gay men and other MSM in treatment and prevention services is critical to controlling the HIV epidemic worldwide. The article described how drivers of HIV risk among MSM could accelerate the spread of the virus:

Individual: condomless anal intercourse with serodiscordant and viremic sexual partners, high frequency and lifetime number of casual partners, drug use (injection and non-injection, and before and during sex)

  • Network: social and peer-group norms, condomless sex, high prevalence of HIV and other sexually transmitted infections within networks
  • Community: societal and internalized homophobia that limits the provision and uptake of HIV prevention, treatment, and care services
  • Structural: administrative policies such as criminalization of same-sex practices and exclusion of MSM from national surveillance programs and HIV responses.

Universal HIV treatment, HIV self-testing, and daily oral pre-exposure prophylaxis have emerged as integral to the prevention of HIV transmission, the authors said. They urged immediate expansion of these approaches to address HIV among MSM and other populations that are disproportionately affected by HIV.

Conroy, A.A., Tsai, A.C., Clark, G.M., et al. AIDS and Behavior (April 2016), e-publication ahead of print.

This study examined the association between relationship power and two variables—forced sex and transactional sex—among HIV-positive women in Uganda. The authors recruited 307 participants from a clinic that dispenses free antiretroviral therapy to HIV-positive individuals living in southwestern Uganda. Relationship power was measured using the Sexual Relationship Power Scale (SRPS), a validated measure consisting of two subscales: relationship control (RC) and decision-making dominance (DMD). The authors reported that in bivariate analysis both higher sexual relationship power (full SRP) and higher RC were associated with reduced odds of recent forced sex and of recent transactional sex. The DMD subscale did not have a statistically significant association with recent forced sex or transactional sex. The authors concluded that interventions with HIV-positive women should consider approaches that increase women’s power in their relationships.

Ssewamala, F.M., Karimli, L., Torsten, N., et al. Prevention Science (January 2016), 17(1): 134¬–43, doi:10.1007/s11121-015-0580-9.

This two-arm cluster-randomized controlled trial assessed whether a Suubi-Maka intervention (a family-level economic strengthening intervention) would improve developmental outcomes (education, health, and psychosocial functioning) in children between ages 12 and 16 who had been orphaned by AIDS. Participating children from 10 schools were randomly assigned to Suubi-Maka (5 schools, 179 children) or bolstered usual care (5 schools, 167 children). Bolstered usual care consisted of counseling, school uniforms, school lunches, notebooks, textbooks, and mentorship from a near-peer. Children in the Suubi-Maka arm received bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account. The authors collected data at baseline (pre-intervention) and at 24 months after the intervention. They reported significant differences in health outcomes between the two groups; children in the Suubi-Maka group reported significantly lower levels of hopelessness, and had significantly higher academic scores, than those in the control group. Additionally, children in the intervention group had much higher confidence in their educational plans than did their counterparts in the control group. The authors concluded that family-level economic strengthening programs, over and above bolstered usual care, may have positive developmental impacts on education and health.

MacQueen, K.M., Dlamini, S., Perry, B., et al. AIDS and Behavior (March 2016), e-publication ahead of print.

CAPRISA 106, an ancillary study of the Centre for the AIDS Programme of Research in South Africa (CAPRISA 008) trial, assessed the acceptability of tenofovir gel among women and men; the influence of gender dynamics on tenofovir gel use disclosure; and social barriers and facilitators of tenofovir gel use. The authors conducted interviews with 63 CAPRISA 008 participants and 13 male partners in rural and urban KwaZulu-Natal. For women, disclosure of tenofovir gel use was determined by relationship dynamics, including the duration of the relationship, the living situation, and an evaluation of the relationship (e.g., partner intimacy and expectations about the relationship). Whether or not they disclosed, women reported using the gel effectively; in some situations, disclosure was itself a barrier to adherence. Women were least likely to disclose to their partners that the gel's active ingredient is tenofovir, which is an antiretroviral (ARV), because of the prevalent understanding of ARVs as treatment for HIV infection and the social stigma surrounding HIV. The authors concluded that women should be supported in their choice about what to disclose to their partners, and should have opportunities to use tenofovir gel and similar products without their partners’ knowledge.

Audet, C.M., Blevins, M., Chire, Y.M., et al. AIDS and Behavior (February 2016), e-publication ahead of print.

This study, implemented from June 2012 through March 2015, investigated the impact of a community-based intervention on male engagement in antenatal care (ANC) services; and the impact of male partner engagement on uptake of ANC services, including antiretroviral therapy (ART) and health center delivery in four rural communities in Mozambique. The authors partnered with the traditional birth attendants (TBAs) and trained a new type of male-to-male community health agent, "male champions" (MCs), who focused on counseling male partners to create male-friendly community norms around engagement in spousal/partner pregnancies. Male engagement was defined as accompanying a partner to ANC services at least once during the pregnancy. During the intervention period, MCs reached 2,928 male partners and TBAs reached 4,024 pregnant women. Compared to baseline, the intervention period was associated with increased male engagement at first ANC (5% versus 34%) or any ANC appointment (10% versus 37%); male partner testing during ANC (9% versus 34%); women testing for HIV during ANC (81% versus 92%); and attendance at three ANC appointments (33% versus 40%) during the pregnancy. The authors concluded that given the increased acceptability of the intervention and reports from MCs and TBAs, it is likely that male engagement in ANC will become a social norm in this community.

Lane, J., Verani, A., Hijazi, M., et al. PLOS ONE (February 2016), 11(2):e0146720, doi: 10.1371/journal.pone.0146720.

In fall 2012, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funded workshops in the Africa and Americas regions to strengthen stakeholders' capacity to monitor and implement HIV-related policy reforms in PEPFAR-supported countries. Participants (33 in the Africa region and 31 in the Americas region) received training on PEPFAR's Road Map for Monitoring and Implementing Policy Reforms (Road Map). This article described the results of a three-month follow-up evaluation of participants' experiences. The majority of respondents considered the workshops useful; 85 percent of respondents from the Africa workshop and 100 percent of respondents from the Americas workshop said they felt they were better prepared to monitor policy reforms after the workshops. While some countries made quick progress in implementing elements of the action plans developed during the workshops, other countries struggled to gain traction. Reasons included inability to meet or lack of time, personnel, or governmental support. Additionally, participants requested more follow-up, real examples of policy monitoring indicators and best practices, country-specific training in monitoring and evaluation, and development of a participant listserv. The authors concluded that the Road Map was a useful tool for strengthening policy development, monitoring capacity, and moving closer to an AIDS-free generation.

Harling, G., and Bärnighausen, T. Journal of the International AIDS Society (February 2016), 19(1): 20038, doi: 10.7448/IAS.19.1.20038.

The authors analyzed data from 14 Demographic and Health Surveys from seven sub-Saharan African countries with generalized HIV epidemics, investigating whether educational parity between partners was associated with HIV serostatus in women aged 15–34. Findings showed that partners tended to have similar attainments in both urban and rural areas of every survey. This correlation was not associated with HIV prevalence; however, there was a small but significant individual-level association between educational differences within relationships and women’s likelihood of being HIV-positive. Women aged 25–34 with secondary or higher education and a more educated partner had lower HIV prevalence. Overall, in all surveys, each person's educational level was associated with a specific level of risk of HIV infection, with risk rising among those with only primary education. In almost all countries, the relative odds of HIV infection fell for more educated individuals. Educational attainment and HIV prevalence varied widely across survey countries. The authors concluded that efforts to locate HIV-positive or at-risk women should consider not only the women's own characteristics but also those of their sexual partners.

Kevany, S., Khumalo-Sakutukwa, G., Singh, B., et al. PLOS ONE (February 2016), 11(2):e0149335. doi: 10.1371/journal.pone.0149335.

The authors described the methodology, results, and effects of quality assurance and control (QAC) monitoring during the three-year implementation of the Project Accept trial (HPTN 043), a community-based HIV counseling and testing study conducted in sub-Saharan Africa and Thailand. The QAC monitoring comprised steps to the intervention's three components—mobile voluntary counseling and testing (MVCT), community mobilization (CM), and post-test support services (PTSS). Supervisors observed a random sample of 5 to 10 percent of sessions each month, and evaluated staff against multiple criteria on scales of 1–5. A score of 5 indicated 100 percent adherence, 4 indicated 95 percent adherence, and 3 indicated 90 percent adherence. The authors reported that the QAC scores of MVCT and CM staff across the study sites were 4 or higher, and continued to improve over time. QAC scores for the PTSS component were initially lower, because of the wide range of activities in the PTSS component and new staff hires or changes in staff responsibilities, but increased to 4 by Year 2. The authors concluded that the constant staff monitoring and support provided by QAC monitoring is essential to ensure quality implementation in large-scale interventions.

Chávez, N. R., Shearer, L. S., & Rosenthal, S. L. Journal of Pediatric and Adolescent Gynecology (October 2014), Vol. 27, Issue 5, pp. 244–257.

The authors of this literature review presented seven factors that can affect the effectiveness of digital media technology (DMT) interventions for the primary prevention of sexually transmitted infections (STIs) and HIV in adolescents and young adults aged 11–29 years. They reviewed 29 articles that reported on the cognitive, psychosocial, behavioral, or biological outcomes of DMT interventions to prevent sexually transmitted infections and HIV. Seven issues emerged that should be addressed to improve design and evaluation of DMT-based HIV prevention interventions: (a) balancing the focus (targeting broad-based groups versus a specific sub-group), (b) developing a framework for DMT intervention, (c) applying DMT in resource-limited contexts, (d) keeping up with the rapidly changing nature of DMT, (e) building in measures of biological outcomes, (f) designing interventions with comparison and control groups to assess the impact of DMT, and (g) addressing limited temporal follow-up. The authors added that implementing DMT interventions would require availability of (or support for) infrastructure to support digital technology, and emphasized that targeting interventions to specific groups based on gender, ethnicity, or age may increase their effectiveness.

Vassall, A., Chandrashekar, S., Pickles, M., et al. PLoS One (October 2014), 9(10): e110562.

The authors of this cost-effectiveness analysis found that the addition of community mobilization (CM) and empowerment interventions to a core package of HIV prevention interventions could improve the impact of HIV prevention interventions for female sex workers (FSWs). The analysis was based on data gathered between 2004 and 2011 from two districts in Karnataka, India: Belgaum and Bellary. A package of core HIV prevention services provided by Avahan’s nongovernmental organization partners included outreach through peers, behavior change communication, condom distribution, and clinical services for sexually transmitted infections (STIs). To empower FSWs, CM services and actions to create an "enabling environment" were added to core services. Incremental costs for CM and empowerment were US$307,711 in Belgaum and US$592,903 in Bellary. The incremental mean impact of CM and empowerment was 1,256 infections averted in Belgaum, and 2,775 infections averted in Bellary, compared to regions where no CM and empowerment activities were implemented. The authors concluded that investing in CM and empowerment was cost-effective, and noted that with the CM activities, the FSWs also received broader benefits, including access to income generation, education, and other social entitlements. They recommended including sustained funding for CM and empowerment activities as part of HIV prevention for FSWs in India, and suggested that program managers consider scaling up similar interventions in other countries.

Shisana, O., Risher, K., Celentano, D.D., et al. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV (November 2015), 28(2):234-241, doi: 10.1080/09540121.2015.1080790.

The authors of this study analyzed findings from the 2012 South African National HIV Prevalence, Incidence and Behavior Survey to clarify the relationship between marital status and HIV in the South African population. Of 17,356 respondents aged 16 years or older who provided specimens for HIV testing, 5,930 (34.2%) were married and living together; 589 (3.4%) were married but living separately; 1,743 (10.0%) were cohabitating with their partner; 3,958 (22.8%) were in a steady relationship but not living with their partner; and 5,136 (29.6%) were single, divorced, or widowed. Analysis showed that individuals who were married and living together were significantly less likely to be HIV-positive compared to all other marital status groups. Being married and living apart was associated with significantly increased odds of being HIV-positive, compared to being married and living together. The highest HIV incidence rate was found in the cohabiting group: 10.8 times higher than the incidence among participants who were married and living together. The authors concluded that given declining marriage rates and poor economic conditions in South Africa, messages on prevention should target unmarried and cohabiting people, and communicate that living together while unmarried carries the highest risk among all marital statuses in South Africa.

Treves-Kagan, S., Steward, W.T., Ntswane, L., et al. BMC Public Health (January 2016), 16(1):87. doi: 10.1186/s12889-016-2753-2.

This study examined the effect of stigma on access to antiretroviral therapy (ART) in settings where ART was available in almost all local health clinics. The authors conducted secondary analysis of data from a rapid community-based qualitative assessment for a combination HIV prevention project in two districts of South Africa. Transcriptions of 31 interviews and focus group discussions showed that community perceptions still strongly associated HIV with promiscuity and adultery. HIV-positive community members could thus be treated differently or be socially isolated both from the general community and from family. Participants, especially those from key populations (youth, sex workers, and men who have sex with men) also reported feeling stigmatized by health care providers. They described using strategies to manage who learns of their HIV status, mostly avoiding disclosure by describing their HIV infection as some other condition. Simply being seen at a health clinic meant risking exposure of one’s HIV status. This perception was considered a major barrier to accessing health facilities for testing or treatment, and a reason for delaying access to care until advanced sickness. The authors underlined the urgency of increasing cultural acceptance of being seropositive, integrating HIV care into general primary care, and normalizing access to health care by men and young people.

Lépine, A., Chandrashekar, S., Shetty, G., et al. Health Economics (February 2016), 25(1):67–82, doi: 10.1002/hec.3296.

To inform the design of HIV programs that provide grants to nongovernmental organizations (NGOs), the authors collected economic costs of HIV prevention delivered during the first four years of the Indian Avahan initiative, the world's largest HIV prevention project. Avahan has produced one of the largest cost datasets globally, collected from 138 NGOs in 64 districts of four Indian states from 2004 to 2007. The program monitored all recurrent costs (personnel, building operating expenses, travel, supplies for addressing sexually transmitted infections or STIs, monitoring, outreach and training, condom supplies, and indirect expenses) and capital costs (buildings, equipment, furniture, vehicles, initial training, insurance and deposits, and start-up). For each participating NGO, costs were disaggregated by activity and input type. The authors found that program design characteristics (such as NGO size, community involvement, the quality of outreach, and STI service delivery strategy) significantly influenced average costs; environmental or population influences had less impact. Higher total costs did not necessarily suggest increased inefficiency. Sometimes, higher total costs included technical assistance that improved efficiency at the NGO level by enhancing service quality. The authors urged program managers to consider these findings when designing and implementing HIV prevention and other public health programs to ensure that the greatest number of beneficiaries can receive essential services using the resources available.

Logie, C.H., Newman, P.A., Weaver, J., et al. AIDS Patient Care and STDs (February 2016), 30(2):92-100, doi: 10.1089/apc.2015.0197.

This study explored associations between HIV-related stigma and (1) socio-demographic variables; (2) types of HIV vulnerability (gay entertainment employment, sex work, forced sex, and stigma); and (3) HIV prevention uptake (condom use, HIV testing, rectal microbicide) among men who have sex with men (MSM) and transgender (TG) women in Thailand. A total of 408 young MSM and TGs aged 18–30 years, recruited from April to August 2013, completed self-administered questionnaires. Two-thirds (65.7%) of participants worked at gay entertainment venues; 55.6 percent reported having been paid for sex, and 33.8 percent reported having paid other partners for sex during the past three months. There were no significant differences by type of HIV vulnerability between HIV-positive and HIV-negative or untested participants. Participants reporting higher total HIV-related stigma scores were less likely to have been tested for HIV, and were less willing to use a rectal microbicide. The authors concluded that having experienced HIV-related stigma was directly associated with low uptake of both HIV testing and microbicide use. The authors suggested that HIV interventions and research among young MSM and TGs in Thailand should address multiple dimensions of HIV-related stigma as a correlate of risk and a barrier to accessing prevention.

Mulawa, M., Kajula, L.J., Yamanis, T.J., et al. Journal of Interpersonal Violence (January 2016), pii: 0886260515625910, e-publication ahead of print.

This analysis compared baseline rates of victimization and perpetration of three forms of intimate partner violence (IPV)—psychological, physical, and sexual—among sexually active men and women. Participants comprised 1,113 men and 226 women who were enrolled in an HIV-and gender-based violence prevention trial in Dar es Salaam, Tanzania from October 2013 to March 2014. Both men and women (34.8% and 35.8%, respectively) reported experiencing any form of IPV victimization over the past year. Men and women reported similar prevalence of psychological and sexual victimization; however, more women than men reported physical IPV victimization. Men and women reporting psychological victimization reported only that form of IPV, while most men and women experiencing either physical or sexual victimization also experienced psychological violence. Rates of IPV victimization among perpetrators were remarkably high; both male and female perpetrators (approximately 70% and 80%, respectively) also reported IPV victimization within the last year. While this study could not assess whether victimization and perpetration occurred within the same relationship, the high overlap between victimization and perpetration suggested that IPV may be bidirectional, with men and women concurrently engaging in conflict in their relationships. The authors concluded that interventions should include a broader “family violence” or “partner violence” approach to reduce violence perpetrated by both genders.

Montgomery, E. T., van der Straten, A., Stadler, J., et al. AIDS and Behavior (November 2014), E-publication ahead of print.

Male partners are believed to have significant influence over their female partner’s ability to negotiate about and use female-controlled HIV prevention methods. The authors of this study investigated how men influenced their female partner’s ability to participate in the ongoing Vaginal and Oral Interventions to Control the Epidemic (VOICE) trial, specifically the VOICE C arm, which examined social and structural influences on women’s use of antiretroviral tablets or a vaginal gel. The authors recruited 102 randomly selected trial participants in Johannesburg, South Africa. They conducted in-depth and ethnographic interviews and focus group discussions with the female participants, and in-depth interviews and focus group discussions with 22 male partners. Data analysis showed that many male partners did not fully understand or trust the research, and as a result discouraged their female partner's use of the product or participation in the study. The study also found that because of the men's reluctance to agree with their participation in the study, women were less likely to disclose their use of the product. The authors concluded that research is needed to identify and test strategies to proactively involve male partners in order to enhance women’s involvement and commitment to these trials.

Dunbar, M. S., Kang Dufour, M. S., Lambdin, B, et al. PLoS ONE (November 2014), doi: 10.1371/journal.pone.0113621.

Shaping the Health of Adolescents in Zimbabwe (SHAZ!) is a randomized controlled trial comparing the HIV prevention impact of a combined intervention package (including life-skills and health education, vocational training, micro-grants, and social supports) to the impact of life skills and health education alone. This study assessed the impact of adding a livelihoods intervention (financial literacy education and a choice of vocational training); and integrated social support (guidance counseling to help participants navigate challenges, along with self-selected adult mentors) to the combined SHAZ! intervention package. The study included 315 eligible female adolescents aged 16–19 years who were randomly assigned to the intervention or control group. Intervention participants received the livelihood and integrated social support interventions, in addition to the other SHAZ! interventions that all participants received. The study found that intervention participants had lower risk of transactional sex [IOR = 0.64, 95% CI (0.50, 0.83)], and a higher likelihood of using a condom with their current partner [IOR = 1.79, 95% CI (1.23, 2.62)] over time compared to baseline. There was also evidence of fewer unintended pregnancies among intervention participants [HR = 0.61, 95% CI (0.37, 1.01)], although this relationship achieved only marginal statistical significance. The authors concluded that future HIV prevention packages for adolescent females should include interventions for vocational training and micro-grants along with other interventions.

Pilgrim, N. A., Ahmed, S., Gray, R. H., et al. International Journal of Adolescent Medicine and Health (November 2014), doi: 10.1515/ijamh-2014-0032, E-publication ahead of print.

Family structure and school attendance are believed to play a critical role in adolescents' sexual behaviors, providing direct emotional, social, and economic support, as well as positive or negative role models. The authors of this study sought to clarify the influence of families and school attendance on young women's sexual risk behaviors, so as to identify new HIV prevention strategies for this group. The authors analyzed the most recent available survey interviews for 2,337 unmarried girls aged 15–19 years who were enrolled in the Rakai Community Cohort Study in rural Uganda between 2001 and 2008. The analysis was stratified by age (15–17 and 18–19 years) and school status (in or out of school). The findings showed that in both age groups, girls living with their biological father reported lower risk behaviors, including fewer sexual partners, compared do those living with a stepfather or in another family structure. In addition, adolescents currently enrolled in school reported fewer partners over the past year, suggesting that school attendance is associated with lower risk behavior. The authors concluded that HIV prevention interventions for adolescent girls should consider both family structures and school attendance status.

Durevall, D., Lindskog, A. The Lancet Global Health (November 2014), doi: 10.1016/S2214-109X (14)70343-2, E-publication.

This study systematically analyzed the association between intimate partner violence (IPV) and HIV in women in 10 sub-Saharan African countries. The authors used data from 2014 Demographic and Health (DHS) surveys to determine the conditions in which the association between IPV and HIV infection was recorded. These DHS datasets, nationally representative for women aged 15–49 years, included HIV testing and a complete domestic violence module. The authors collected data (findings from blood spot samples from eligible men and binary indicators [yes or no] from eligible women in randomly selected households) to assess physical, sexual, and emotional violence, controlling behavior, and combinations of the above; and compared these indicators in IPV-exposed women with those in non-exposed women. The findings confirmed that IPV was associated with significantly higher risk of HIV among women. Analysis of risks by indicator also revealed details about the effects of specific male behavior. For example, controlling male behavior and physical and emotional violence increased the probability of HIV infection for all women, whereas sexual violence was a significant HIV risk only in the sample of women in their first union. The authors concluded that HIV prevention programs in high HIV prevalence areas should focus on men with controlling behavior in addition to those with violent behavior.

Kyegombe, N., Abramsky, T., Devries, K. M., et al. Journal of the International AIDS Society (November 2014), Vol. 17, E-publication.

Start, Awareness, Support and Action (SASA!) is a community mobilization intervention that seeks to prevent intimate partner violence (IPV) and reduce HIV-related risk behaviors at the community level. The authors assessed the community-level effect of SASA! on primary and secondary outcomes for IPV, HIV-related risk behaviors, and relationship dynamics. This research, conducted between 2007 and 2012 in two administrative divisions of Kampala, Uganda, included four intervention and four control sites. Two cross-sectional surveys were conducted at baseline and follow-up (1,583 and 2,532 participants, respectively, from randomly selected households), with separate quantitative analyses for male and female respondents. Men's reported condom use at last intercourse with their partner was higher in the intervention group (41 percent) compared to men in the control group (22 percent). Men in the intervention group were also 50 percent more likely to have tested for HIV. Women in the intervention group felt significantly more able to refuse sex with their partner than women in the control groups. In addition, more women in the intervention group reported relationship improvements, including joint decision-making and open communication with their partner. The authors concluded that a community-level intervention such as SASA! can improve relationship dynamics and reduce HIV-related risk behaviors between intimate partners.

Murithi, L. K., Masho, S. W., & Vanderbilt, A. A. AIDS and Behavior (November 2014), E-publication ahead of print.

This study investigated enabling social, structural, and individual factors that increased utilization of and adherence to prevention of mother-to-child transmission (PMTCT) services among HIV-positive women with HIV-negative infants, and examined the reasons for success as explained by the women themselves. Fifty-five women completed a structured interview, and a subset of 15 women participated in in-depth interviews. The findings pointed to four key factors in successful PMTCT: supportive counseling; striving for motherhood (desiring children); assurance of confidentiality; and confirmation, affirmation, and admiration. Supportive counseling was by far the most important factor in influencing the women’s decision to test for HIV, disclose their status, initiate antiretrovirals, and discontinue breastfeeding at six months. For women who were striving for motherhood, adherence to PMTCT programs made it possible to ensure that their infants were born HIV-negative. Confidentiality of services was vital: women expressed willingness to travel long distances and endure long waiting times at a clinic offering such services. Women also emphasized confirmation, saying that a successful PMTCT experience by a close friend, or even a public figure, helped them with their PMTCT adherence. The authors concluded PMTCT programs should consider these enabling factors, along with attention to access, health education, and functional health care systems, to ensure that women are provided with services that meet their needs.

Jewkes, R., Gibbs, A., Jama-Shai, N., et al. BMC Public Health (December 2014), E-publication ahead of print.

Stepping Stones was a participatory intervention designed to strengthen HIV prevention and relationship skills, conducted in rural Eastern Cape province of South Africa. The project's results indicated a 38 percent reduction in male self-reported violence against women, but women's reported experience of violence did not diminish. The authors of this study investigated whether combining Stepping Stones with Creating Futures, an intervention to enhance the livelihoods of young women and men without microfinance or cash transfers, could reduce gender-based violence against women. The authors recruited 232 out-of-school young people aged 18 to 34 from two urban settlements. Participants attended 10 Stepping Stones learning sessions and 11 three-hour Creating Futures learning sessions, where they discussed using existing local resources to improve their livelihoods. The findings showed improvements in reported earnings among both men and women. The authors also noted that the combined intervention led to improved attitudes toward gender among men and women, and reductions in men's controlling behaviors toward female partners. In addition, women reported experiencing less sexual and/or physical intimate partner violence. The authors concluded that combining the two interventions can strengthen livelihoods, improve gender relationships, and reduce violence against women in South Africa’s informal settlements.

Maughan-Brown, B., Kenyon, C., & Lurie, M. N. AIDS and Behavior (December 2014), Volume 18, Issue 12, pp. 2469-2476.

The authors collected data on age-disparate partnerships (defined as heterosexual partnerships in which the woman is five or more years younger than her male partner) and concurrent relationships (defined as any temporal overlap of one or more sexual partnerships) from 7,476 South African participants aged 16–49 years (3,530 men and 3,946 women). The authors collected data on participants’ three most recent sexual partners (including dates of first sex, last sex, and anticipated future sex), distinguishing between partnerships with age disparities of ≥ 5 years and ≥ 10 years. Data analysis showed that a significant proportion (43 percent) of 16- to 49-year-old women were in partnerships with a man five or more years older. Among young women (ages 16–24), about one-third of recent sexual contact involved a man five or more years older, and 7 percent involved a man 10 or more years older. Further, among women aged 16–24 years, male partners five or more years older were more likely to have concurrent female partners. The authors concluded that younger women are more likely to be in concurrent male partnerships (that is, the male partner has another female partner) and age-disparate relationships, which increases their risk of HIV transmission by connecting them to larger and older sexual networks.

Tsai, A. C., Weiser, S. D. AIDS and Behavior (November 2014), Volume 18, Issue 11, pp. 2187-2197.

The authors used nationally representative data on 2,322 linked couples (men and women in the same household) from the 2011 Demographic and Health Survey in Nepal to assess how food insecurity may affect HIV transmission risk behaviors or symptoms of sexually transmitted infections (STIs) such as recent condom use, consistent condom use, and self-reports of an abnormal genital discharge or genital sore or ulcer within the previous 12 months. Bivariate analysis showed that women in severe, mild, or moderate food insecurity categories had statistically significant associations with self-reported abnormal vaginal discharge and vaginal sores or ulcers. However, only women in severely food-insecure households were less likely to report recent condom use and consistent condom use compared to those in mildly or moderately food-insecure households. Among men, none of the food insecurity categories had a statistically significant association with any of the outcomes under study. The study showed that women and men are differently affected by food insecurity, as evidenced by higher HIV transmission risk behaviors and symptoms of STIs among women, but not men, in food-insecure households. The authors concluded that interventions to improve food insecurity can contribute to reduced HIV and STI transmission among women in Nepal.

Sgaier, S. K., Anthony, J., Bhattacharjee, P., et al. Global Health: Science and Practice (November 2014), doi: 10.9745/GHSP-D-14-00141.

The authors described the Karnataka Technical Support Unit (TSU), a team of private and nongovernmental experts created to collaborate with governments to oversee and scale up HIV prevention interventions. The TSU in Karnataka provided support to the state in five key areas: assisting in strategic planning, comprehensive monitoring and evaluation, supportive supervision to intervention units, training, and information, education, and communication activities. The authors noted that creation of TSU increased the number of prevention interventions statewide from 40 to 126 between 2009 and 2013. Moreover, the state budget for HIV prevention increased from US$8.0 million in 2007–2008 to US$13.1 million in 2011–2012, while the portion of the state budget allocated to prevention interventions among key populations tripled, from US$0.7 million to US$2.1 million. Monthly contacts with female sex workers increased from 5 percent of sex workers in 2008 to 88 percent in 2012; with men who have sex with men, from 36 percent in 2009 to 81 percent in 2012. The authors concluded that the Karnataka TSU was successful in helping the government enhance managerial and technical resources and leverage funds more effectively. This experience suggested that TSUs could be used by other state governments to improve and scale up programs, and to support previously donor-funded programs.

Mathur, S., Wei, Y., Zhong, X., et al. Journal of Acquired Immune Deficiency Syndromes (January 2015), E-publication ahead of print.

This study examined a range of sexual partner characteristics associated with HIV acquisition among youth in rural Uganda, and assessed how these characteristics independently contribute to HIV acquisition. The authors analyzed the data from Rakai Community Cohort Study (RCCS), an annual survey in which participants aged 15–24 years from 50 communities were administered an interview and offered testing for HIV and sexually transmitted infections. The authors analyzed four rounds of RCCS data collection (2005–2011) that provided the most detailed information on up to four sexual partners in the past year. After controlling for individual risk factors, the analysis showed that among the 1,969 male and 2,826 female participants, both reported having sex with non-marital partners. For young women the risk of HIV acquisition increased if their partner was a truck driver, drank alcohol before sex, and used condoms inconsistently. In young men, the risk increased with partners who were not enrolled in school and in partnerships where respondents were unable to assess their partner's HIV risk. The authors concluded that HIV prevention interventions need to take into account how to develop HIV risk and prevention messages for different types of partners. Since partner characteristics can influence HIV risk, young people need to learn how to negotiate and potentially influence the behaviors of their partners within the relationship.

Wamoyi, J., Mshana, G., Mongi, A., et al. Reproductive Health (December 2014), doi: 10.1186/1742-4755-11-88.

This literature review summarized interventions addressing structural drivers for the sexual and reproductive health risks facing young people (aged 14–24 years) in sub-Saharan Africa. The authors reviewed 15 articles published between 2000 and 2013 on interventions that tackled gender norms and livelihoods or poverty reduction, and that were aimed at vulnerable young people in sub-Saharan Africa. They found that most interventions addressed multiple structural factors. Seven interventions focused on HIV prevention through addressing gender norms, improving school attendance, improving participants' economic situations, and creating safe spaces; eight focused on either economic empowerment alone or economic empowerment and school attendance. Three studies focused on livelihoods and safe spaces; three on comprehensive sexuality and behavior change and communication; and two on parent-child communication and relationship. Because these interventions varied substantially in design and methods of evaluation, this review was not able to identify the effectiveness of any specific intervention. However, the review provided lessons learned from each intervention design that can be used when developing programs for adolescents. The authors concluded that while numerous interventions are addressing structural drivers among adolescents in sub-Saharan Africa, additional evaluations are needed to assess how these interventions work to reduce vulnerability to HIV.

Maxwell, L., Devries, K., Zionts, D., et al. PLOS ONE (February 2015), doi: 10.1371/journal.pone.0118234. eCollection 2015.

Studies from a number of countries have demonstrated that intimate partner violence (IPV) is associated with negative women’s reproductive health outcomes, specifically those linked to contraceptive use, such as rapid repeat pregnancy, unintended pregnancy, pregnancy termination, and HIV infection. The authors of the study conducted a systematic review to estimate the causal effect of IPV on contraceptive use. Analysis of the 12 eligible articles showed that, overall, IPV had an impact on women’s use of contraception. IPV was associated with a decrease in women’s use of partner-dependent methods; women who experienced IPV were less likely to report that their male partners used condoms than women who did not. However, the authors also noted that the specific context influenced the association between IPV and contraceptive use. In Nicaragua, for example, open access to contraceptive methods and the wide cultural acceptability of contraception may mean that women who experience IPV are more likely to use contraception than women who do not. The authors concluded that more research was needed to define the relationship between IPV and women’s use of modern contraceptive methods so as to better understand women’s adoption of contraception. Additionally, because sexual and physical IPV can affect contraceptive use differently, the authors called for new research to clarify these effects.

Dellar, R. C., Dlamini, S., Karim, Q. A. Journal of the International AIDS Society (February 2015), Vol 18, Issue 2, Supplement 1, doi: 10.7448/IAS.18.2.19408.

This article urged attention to girls and young women as critical populations within the HIV epidemic. Young women are at increased risk for HIV acquisition for many reasons: age-disparate and intergenerational sexual relationships, early sexual debut, limited schooling, food insecurity, loss of a family member, and gender-based violence. Additionally, younger women are more biologically susceptible to HIV infection compared to older women. Some programs have demonstrated success in improving young women's HIV knowledge and attitudes and uptake of HIV testing. For example, a recent randomized controlled cash transfer trial in Lesotho of financial incentives reduced the probability of acquiring HIV by 25 percent over two years. School and community-based education programs are commonplace in many settings, but the few that were evaluated did not demonstrate efficacy in preventing HIV infection. The authors stressed that action is needed to mobilize and empower this key population to mediate their own risk, especially for those women who cannot negotiate monogamy, condom use, or male circumcision with their sexual partners. Efforts should focus on the development of new biomedical, structural, and behavioral HIV prevention programs for this group. The authors also recommended including adolescents in biomedical HIV prevention trials, and providing accessible and integrated sexual and reproductive health and HIV prevention services for this population.

Wheeler, T., Wolf, R. C., Kapesa, L., et al. Journal of Acquired Immune Deficiency Syndromes (March 2015), Issue 68, Supplement 2, pp. S69-S73.

HIV prevalence among men who have sex with men in West and Central Africa (WCA) is between 13.5 percent and 25.3 percent, and prevalence among female sex workers is at least eight times higher than in the general population; there are very few studies on people who inject drugs and transgender women. However, HIV responses in most WCA countries do not focus on key populations. This article summarized new studies that improve understanding of the HIV epidemic in WCA's key populations and recommended ways to target these populations effectively with HIV services. The authors stressed that all WCA countries should define a specific key population strategy within their national HIV strategic and operational plans. This approach should include soliciting inputs from members of key populations who can fill gaps in data to inform the response. Interventions for key populations should be comprehensive, including both immediate access to HIV and other health services and interventions to address structural issues, such as violence and community empowerment. Budgetary and other resources should be prioritized to address the disproportionate burden of HIV and poor access to services among key populations. The authors emphasized the importance of ensuring development of human rights-based policies, access to HIV services, and organizational development as critical strategies for addressing HIV in these populations.

Parker, L., A., Jobanputra, K., Rusike, L., et al. Tropical Medicine and International Health (March 2015), doi: 10.1111/tmi.12501, e-publication ahead of print.

This study compared the costs of home-based versus mobile-based HIV testing and counseling (HBHTC and MHTC, respectively) and described the populations reached through each method. The authors reviewed HIV test records for 2,034 people tested through MHTC and 7,026 tested through HBHTC. They found that HBHTC was significantly cheaper than MHTC (US$11 per person tested versus $24, respectively). The study showed that the two models reached different populations. HBHTC reached a greater proportion of children and adolescents (<20 years) compared to MHTC (57 percent versus 17 percent) and adolescents (27 percent versus 12 percent). By contrast, MHTC outperformed HBHTC in reaching those aged 20 or older (83 percent versus 43 percent). Among adults, more men were tested by MHTC than HBHTC (42 percent versus 39 percent). Of the adults tested through HBHTC, 34 percent were testing for the first time—significantly higher than for MHTC (22 percent). The study showed no difference in linkage to care between the two testing strategies or between men and women. However, linkage to care was highest for children and older individuals and lower for individuals aged 20–39 years. The authors concluded that both HBHTC and MHTC are feasible and affordable ways to improve HTC coverage in high-prevalence settings, adding that strategies to ensure linkage to care are indispensable.

Anderson J. E., and Kanters, S. LGBT Health (March 2015), Vol. 2 Issue 1, pp. 16-26, doi:10.1089/lgbt.2014.0024.

The authors of this study developed a tool, the Sexual Orientation and Gender Identity (SOGI) Human Rights Index, to assess the relationship between human rights for sexual minorities in Asian countries and indicators of HIV prevention among men who have sex with men (MSM) and transgender women (TGW), with scores ranging from 0.0 to 1.0 (highly punitive to full recognition). They conducted a meta-analysis of 237 epidemiological and behavioral studies from 22 countries in Asia and calculated the SOGI Human Rights score for each country. Analysis showed that a change in SOGI Human Rights score from 0.0 to 1.0 had better indicators for HIV prevention efforts targeting MSM—specifically, lower proportions of MSM who engaged in unprotected anal intercourse, and greater proportions of MSM who had been tested for HIV recently and had adequate HIV knowledge. Moreover, countries that were supportive, such as Thailand, had established men’s health clinics and services for MSM and TGW. The authors concluded that there was a strong correlation between human rights and indictors of HIV prevention, and called for increased efforts to ensure the human rights of marginalized populations.

Amirkhanian, Y. A., Kelly, J. A., Takacs, J., et al. AIDS (March 2015), Vol. 29 Issue 5, pp. 583–593.

This study assessed the impact of social network interventions on sexual risk behavior among men who have sex with men (MSM). Between 2007–2012, the authors recruited 626 high-risk MSM from 18 networks (10 networks in Russia and 8 in Hungary) and randomized entire networks to receive either voluntary HIV counseling and testing (HTC) for sexually transmitted infections (STIs) and HIV alone, or HTC in addition to a social network intervention. The social network intervention included training and guidance to help network leaders advise members on HIV prevention. All participants completed self-administered behavioral questionnaires three months after the intervention, and both behavioral assessment and repeat HIV/STI testing at 12-month follow-up. Among intervention participants, the proportion who engaged in any unprotected anal intercourse (UAI) declined from 54 percent at baseline to 38 percent at the three-month follow-up and 43 percent at 12-month follow-up, whereas UAI incidence among comparison participants was largely unchanged. Additionally, the proportion of men who engaged in UAI with a non-primary sexual partner declined significantly in intervention networks (from 18 percent at baseline to 9 percent at 12 months) while again remaining almost unchanged among comparison networks. The authors concluded that MSM could be reached with prevention messages through their social networks, even in environments where same-sex behavior was highly stigmatized.

Mushamiri, I., Luo, C., Iiams-Hauser, C., and Ben Amor, Y. BMC Public Health (December 2015), doi: 10.1186/s12889-015-1358-5.

This study analyzed the impact of a mobile health tool that uses text messages to coordinate community health worker (CHW) activities in antenatal care (ANC), postnatal care (PNC), and prevention of mother-to-child transmission of HIV (PMTCT); and assessed end-user health-seeking behaviors. The authors interviewed 67 pregnant women and new mothers and 20 CHWs about the tool, called the ANC/PMTCT Adherence System (APAS), and analyzed 650 health registers. They found that women enrolled in the APAS were three times more likely to undergo the four recommended ANC visits compared to women who were not enrolled. Enrollment in APAS also increased the likelihood that women would attend the six recommended post-delivery follow-up visits—leading to a 0 percent transmission rate at both the 9-month and 18-month follow-up visits. For CHWs, a major benefit of the APAS was the ability to send text-message updates on appointments to the clients. The authors concluded that using a combination of CHW programs and text messages not only strengthened adherence to ANC and PNC, but also allowed communities that were well integrated into the primary health system to move closer to the goal of eliminating vertical HIV transmission in PMTCT programs.

Aninanya, G. A., Debpuur, C. Y., Awine, T., et al. PLOS ONE (April 2015), doi: 10.1371/journal.pone.0125267.

The study investigated whether a community-based adolescent sexual and reproductive health intervention in northern Ghana was associated with increased adolescent use of selected reproductive health services. A total of 2,664 adolescents in 26 communities were allocated to intervention or comparison groups. The intervention group (n = 1,288) received a school-based curriculum, out-of-school outreach, community mobilization, and health worker training in youth-friendly health services, while the comparison group (n = 1,376) received community mobilization and youth-friendly health services training only. Comparison of the baseline (2005) and endline (2008) data showed significantly greater increases in the use of services for sexually transmitted infections (STIs) in the intervention group (from 3 to 17 percent) relative to the control group (from 5 percent to 8 percent). More young men than young women used STI services at endline (64 percent versus 36 percent in the intervention communities and 57 percent versus 36 percent in the comparison communities). Use of antenatal services increased in the intervention group (from 3 percent to 12 percent). Satisfaction with services received increased more among adolescents in intervention communities (from 18 percent to 43 percent) than in comparison groups (from 17 percent to 28 percent). The authors concluded that school-based and peer-outreach interventions were associated with increased service usage and could be used in future programming.

Muturi, N. African Journal of AIDS Research (March 2015), doi: 10.2989/16085906.2015.1016986.

This study assessed the perspectives of rural communities on risk factors for HIV infection among women who are in alcohol-discordant relationships with male partners who consume alcohol excessively. The authors conducted seven focus group discussions with 30 men and 30 women aged 27 to 57 years, who were recruited through community-based organizations. Both male and female participants described the severe alcoholism in Central Kenya, especially affecting men aged 15 and older, and exerting widespread impacts on the socioeconomic welfare of rural families. Participants reported that since alcoholism has become widespread, more women are engaging in extramarital relationships. Women in these relationships also engaged in risky sexual practices for economic reasons, since their partners were spending more money on alcohol. An additional consequence of excessive alcohol consumption was the escalation of sexual violence in rural communities, which made women and girls more vulnerable to HIV infection. The authors concluded that considering the widespread prevalence of alcoholism, and the association between alcoholism and HIV infection, there is an urgent need for HIV prevention programs to focus on older married women in rural areas and include remediation measures for alcoholism.

Kaufman, M. R., Tsang, S. W., Mooney, A., et al. Qualitative Health Research (April 2015), E-publication ahead of print.

The Fataki campaign (about a girl-chasing older man) aired on Tanzanian radio from 2008 to 2011 and addressed cross-generational sex, a major driver of HIV in the region. The authors conducted individual interviews and focus groups with community members and leaders in Pwani and Iringa regions of Tanzania to assess community reactions to the Fataki campaign, its reach, and how it affected interpersonal communication about cross-generational sex (CGS) two years after the campaign was completed. They found that the Fataki campaign was generally well received; participants commented on the importance of messages about protecting loved ones from CGS. Exposure to the campaign was associated with a higher likelihood of engaging in interpersonal discussions about CGS, and participants reported having discussed CGS and Fataki with other young women as a result of the campaign. Most commonly, discussions focused on encouraging young women to avoid "Fatakis" and to focus on school rather than risk pregnancy because of the cost and value of education. Participants also reported discussing strategies young women could use to avoid Fatakis. These often included approaches modeled in campaign messages, such as refusing offers of rides, money, and gifts from Fatakis. The authors concluded that the Fataki campaign was successful in encouraging interpersonal communication about CGS, and suggested that future campaigns should model both men and girls to avoid such relationships.

McCoy, S. I., Buzdugan, R., Mushavi, A., et al. BMC Public Health (April 2015), E-publication ahead of print.

This study examined the relationship between food insecurity (FI) and prevention of mother-to-child HIV transmission (PMTCT). The authors used data from a 2012 cross-sectional survey of mother/caregiver-infant pairs conducted as part of Zimbabwe’s Accelerated National PMTCT Program, which was developed to examine HIV transmission patterns for mothers or caregivers aged 16 years or older during pregnancy, delivery, and breastfeeding. The authors found that the degree of FI significantly influenced use of antenatal care (ANC): attendance of at least one ANC visit was 95 percent among women from food-secure households, 94 percent for women with moderate FI, and 92 percent for women with severe FI. Furthermore, women from moderately or severely food-insecure households were significantly less likely to know their HIV status during pregnancy, or labor and delivery, or to deliver in a health facility; and were less likely to report attending the postnatal visit. Overall, completion of all key steps in the PMTCT cascade was reported by 49 percent of women from food-secure households, 45 percent of women with moderate FI, and 38 percent of women with severe FI. The authors concluded that FI may be an important barrier to uptake of some PMTCT services, and called for integrated food and nutrition programs for pregnant women.

Haberland, N.A. International Perspectives on Sexual and Reproductive Health (March 2015), Vol. 41, Issue 1, pp. 31–42, doi: 10.1363/4103115.

The author reviewed 22 studies on sexuality and HIV education interventions to explore whether including content on gender and power affects programmatic efficacy; and how effective curriculum-based programs have addressed gender and power. Of the 10 studies that included gender and power content, 80 percent led to significant decreases in at least one of the health outcomes examined (pregnancy, childbearing, or sexually transmitted infections [STIs]). Among the 12 programs that did not address gender and power, by contrast, only two (17 percent) recorded significantly reduced rates of pregnancy or STIs. Additionally, in the 17 studies that included a post-intervention follow-up of one year or longer, 78 percent demonstrated reduced adverse health outcomes, compared to 25 percent of interventions with no follow-up. Clinic-based programs were far more likely to reduce adverse health outcomes than programs implemented in other settings (such as school-based programs).The author noted some common characteristics among all programs, including interactive and learner-centered approaches that focused on gender and power in relationships; fostered critical thinking about how gender norms or power manifest and operate; and promoted valuing oneself and recognizing one’s own power. The author concluded that discussion of gender and power should be considered a key characteristic of effective sexuality and HIV education programs.

Kohler, P.K., Campos, P.E., Garcia, P.J., et al. International Journal of STD & AIDS (May 2015), E-publication ahead of print.

The authors analyzed the uptake of health screening and preventive behaviors among female sex workers (FSWs) in mid-sized Peruvian cities that were associated with a community randomized trial on preventing sexually transmitted infections (STIs), including HIV. The study interventions included mobile FSW outreach to increase condom use and care-seeking for screening, diagnosis, and treatment of STIs by FSWs. The authors conducted cross-sectional surveys among 4,156 FSW (2,063 from control and 2,093 from intervention cities) at baseline in 2002–2003, during 2005, and at the end of the intervention in 2006. Among FSWs surveyed in 2006, 4 percent in the control arm and 75 percent in the intervention arm reported receiving services from, or ever participating in activities with the mobile study outreach team. FSWs in the intervention group were more likely to report condom use with the last non-client; ever seeking an STI screening exam; ever receiving HIV testing; receiving recent HIV testing; knowledge of STIs; and awareness of female and male STI symptoms. Among intervention participants, there was also a trend towards increased frequency of recent screening exams at a public STI clinic. The authors concluded that mobile outreach and peer services can play a significant role in health promotion interventions for FSWs in Peru.

Blankenship, K.M., Reinhard, E., Sherman, S.G., and El-Bassel, N. Journal of Acquired Immune Deficiency Syndromes (June 2015), doi: 10.1097/QAI.0000000000000638.

The authors provided a global overview of contextual sources of HIV risk among women who use drugs (WWUD) and structural interventions (SIs) to address WWUDs' vulnerability to HIV. They argued that there is a need to modify SIs to meet the needs of WWUDs—for example, engaging more women's peer networks—and identified challenges to policies that affect WWUD disproportionately, if not exclusively. Additions to existing harm reduction programs, such as providing on-site child care; employing female, nonjudgmental staff; offering mobile services; and being located in relatively safe and discreet areas, can make these programs more accessible to women. Additionally, given the potentially harsher consequences to women of revealing their drug use, and their reluctance to interact with men (possibly ensuing from histories of abuse), SIs for WWUD have also involved offering “women-only” hours and services, such as women-only drug treatment programs. The authors suggested that a potentially powerful set of SIs for WWUD could integrate health and social service models, such as “one-stop shops” that enable WWUD to access multiple services at one site. Thus, women could receive a constellation of services at a single site, including harm reduction; screening, treatment, and care for substance use, HIV, tuberculosis, hepatitis, sexually transmitted infections, mental health, trauma, and interpersonal violence; and other physical, social, and emotional health services.

Ybarra, M.L., Korchmaros, J.D., Prescott, T.L., et al. Annals of Behavioral Medicine (June 2015), Vol. 49, Issue 3, pp. 473–485, doi: 10.1007/s12160-014-9673-0.

This study focused on the impact of an Internet-based HIV prevention program, CyberSenga, on information, motivation, and behavioral skills among adolescents. The participants (366 sexually experienced and inexperienced youth aged 13 years and older) were randomly assigned to either the five-week CyberSenga (intervention group),covering topics such as how HIV is contracted, how to reduce HIV risk, motivation to have sex or abstain, and condom use skills, or the treatment-as-usual (control) group receiving the sexual health education offered at their schools. Half of the intervention participants were further randomized to a booster session. Follow-up data were collected at three and six months post-intervention. The authors reported that at six months post-baseline, the control group correctly answered 72.4 percent of HIV prevention-related questions; the intervention-only and intervention+booster groups correctly answered 77.6 percent and 82.8 percent of questions, respectively. Intentions to be abstinent did not change over time for any of the groups. However, at the six-month follow-up, intentions to use condoms became stronger, with the intervention+booster group showing the strongest intentions to use condoms, followed by the intervention-only group. The authors concluded that as the Internet becomes more affordable, and therefore more widely accessible, programs such as CyberSenga have the potential for wide dissemination to reach a greater number of young people.

Minnis, A.M., Doherty, I.A., Kline, T.L., et al. International Journal of Women’s Health (May 2015), Vol. 11, Issue 7, pp. 51–525, doi: 10.2147/IJWH.S77398.

From June 2010 through April 2012, the authors studied 290 heterosexual couples from a high-HIV-prevalence South African township to examine the effects of HIV prevention interventions on power dynamics within relationships. The first intervention, the Couples Health CoOp (CHC), engaged both men and their female partners; in the second intervention, women received the Women’s Health CoOp (WHC), and men received the Men’s Health CoOp (MHC). The interventions consisted of two three-hour sessions delivered one week apart by community peer leaders. Sessions included modules on a variety of topics, including alcohol and other drug use, sexually transmitted infections, HIV, safer sex methods, gender roles, effective communication and conflict resolution skills, dealing with stress, and preventing violence. At the six-month follow-up, only CHC participants reported positive changes in power within their relationships. For the second measure of relationship power— equity in shared decision-making—the most substantial improvements occurred in the WHC model. The authors also found that women from MHC/WHC couples were less likely to report experiencing violence during the follow-up period, compared with women in the CHC arm. This study highlighted the need for both gender-separate and joint couples’ interventions to address gender-based inequities in settings where women remain at high risk of HIV infection.

De Neve, J-W., Fink, G., Subramanian, S.V., and Bor, J. The Lancet Global Health (June 2015), doi: 10.1016/S2214109X(15)00087-X.

In 1996, Botswana reformed the grade structure of secondary schools, expanding access to grade 10 and increasing educational attainment for affected cohorts (those who entered secondary school in 1996 or later). Using HIV biomarkers and demographics for 3,965 women and 3,053 men from two nationally representative surveys (2004 and 2008), the authors examined the effect of education on the cumulative risk of HIV infection and assessed the cost-effectiveness of secondary schooling as an HIV prevention intervention. Analysis showed that secondary schooling had a large protective effect against risk of HIV infection in Botswana, with particularly large impacts among women. Moreover, each additional year of secondary schooling caused by the policy change led to a reduction in the cumulative risk of HIV infection (by 8.1 percentage points), relative to a baseline prevalence of 25.5 percent in the pre-reform cohort. The authors also reported that secondary school was cost-effective as an HIV prevention intervention, based on standard metrics (cost per HIV infection averted was US$27,753). They concluded that investment in expanded access to secondary schooling is an effective HIV preventive measure and should be included in combination HIV prevention strategies in countries with large, generalized HIV epidemics.

Pitpitan, E.V. and Kalichman, S.C. AIDS and Behavior (June 2015), e-publication ahead of print.

This qualitative literature review assessed research on alcohol venues to determine the social and structural factors that might influence risk for HIV in these settings. Despite the many established HIV risk factors at play in alcohol venues, limited prevention strategies have been implemented in such places. The authors identified a total of 11 HIV prevention interventions or programs: five carried out at the social level and aimed at changing social norms, two at the structural level, and two combining social and structural approaches (multilevel). The five interventions at the social level included staff training on responsible alcohol serving, HIV prevention messages at venues, and condom availability. The two structural intervention studies were conducted as public health program evaluations, and offered diagnosis and treatment for sexually transmitted infections on-site. The multilevel studies delivered a peer-led intervention, as well as a structural intervention entailing HIV education for venue managers. The authors concluded that alcohol venues play an important role in influencing risks for
HIV, and recommended that HIV prevention programs consider behavioral interventions beyond condom use and HIV prevention messaging. In particular, as antiretroviral therapy and other new prevention technologies are brought to scale, alcohol venues will be important places for promotion and intervention.

Haberlen, S., Nakigozi, G., Gray, R.H. et al. Journal of Acquired Immune Deficiency Syndromes (June 2015), 69(2): 241–247, doi: 10.1097/QAI.0000000000000600.

In rural Rakai district, Uganda, the authors used longitudinal population-based data collected between 2000 and 2008 to evaluate the association between availability of antiretroviral therapy (ART) and disclosure of newly diagnosed HIV infection to spouses by men and women in stable unions. ART was introduced in this population in mid-2004 and became widely available through fixed and mobile clinics by 2005. The study included 557 married adults; 264 were diagnosed with HIV before ART was available (2000–2004), and 293 were diagnosed after ART was introduced (2005–2008). The authors reported that disclosure increased from an estimated 58 percent in the pre-ART period to 75 percent following ART introduction. Disclosure increased between the pre-ART and post-ART periods among both men (63 percent to 78 percent, respectively) and women (55 percent to 73 percent). Additionally, 127 of the 139 disclosures in the pre-ART period, and 190 of the 198 disclosures in the post-ART period, occurred within the first follow-up interval after HIV diagnosis. Disclosure to a spouse was strongly associated with utilization of HIV treatment services. However, the likelihood of disclosure was lower among adults who reported alcohol use. The authors concluded that access to ART can help to prevent transmission to uninfected partners and can enhance linkage to treatment for infected couples.

Ahmad, J., Khan, M.E., Mozumdar, A., and Varma, D.S. Journal of Interpersonal Violence (May 2015), pii: 0886260515584341, e-publication ahead of print.

During a large household survey carried out in 2009–2010 in Uttar Pradesh, India, the authors interviewed 4,223 married women aged 15–49 years and 2,274 husbands of these women to explore the prevalence of different forms of gender-based violence (GBV) and its impact on women’s reproductive health behavior. Thirty-seven percent of participants had experienced any form of GBV during the last 12 months, including emotional violence (31 percent), physical violence (28 percent), and sexual violence (6 percent). The majority (47 percent) experienced violence during their last pregnancy; 34 percent of these women also reported pregnancy complications. Women who reported violence were less prepared for delivery and less likely to have an institutional delivery, seek postnatal care within seven days of delivery, and have spousal communication on family planning. Moreover, women from non-Hindu families, along with those without any formal education, from families with a low standard of living index, and working outside the home, reported experiencing more violence compared to their counterparts. The authors concluded that GBV alone can increase the chances of serious reproductive morbidity and mortality among women, sometimes leading to abortion and stillbirths. They recommended that health care workers be trained to identify high-risk women and advise them on how to protect themselves from GBV during pregnancy.

Erausquin, J.T., Reed, E., and Blankenship, K. AIDS and Behavior (June 2015) 19(6): 1108–1115, doi: 10.1007/s10461-014-0926-5.

The authors of this study examined changes in relations between police and female sex workers (FSWs), and links between negative police actions and risk of sexually transmitted infections (STIs) among FSWs, in the context of a community-led structural HIV prevention intervention. The analysis also examined the effects of two strategies (sensitization to challenge stigma, and a crisis intervention strategy, which was implemented later in the project) to reduce negative policing practices. The authors used cross-sectional data from 1,680 FSWs over three time periods (2006, 2007, and 2009– 2010, when the crisis intervention strategy was in place) to determine (1) whether FSWs' reports of negative interactions with police declined over time and (2) whether any association between FSWs’ reports of negative police interactions and HIV risk behaviors varied over time. Raids and arrests of FSW were lower in Round 3 than during the prior survey rounds. However, negative police practices remained linked to sexual risk-taking among FSWs. Women who had more than one negative police interaction were more likely to experience STI symptoms, use condoms inconsistently with clients, and accept higher fees for unprotected sex. The authors concluded that experiences with police were strongly associated with HIV risk in this sample of FSWs and recommended strategies to end negative police practices toward this vulnerable group.

Harling, G., Newell, M-L., Tanser, F., and Bärnighausen, T. AIDS and Behavior (July 2015), 19(7): 1317–1326.

The authors examined the association between partner age disparity and HIV acquisition among older women through a quantitative analysis of a population-based, open cohort of 1,734 women aged 30 years or older in a rural community in KwaZulu-Natal, South Africa between January 2003 and June 2012. Each woman was tested for HIV between two and nine times during the study period. When they compared women with same-age partners to women with partners five years older, the authors found that having an older partner reduced the risk of HIV acquisition by one-third. Having a partner who was 10 years older reduced the risk by half. The authors also noted that while overall, women's sociodemographic status did not significantly affect the association between age disparity and HIV acquisition risk, those with higher levels of education had the strongest decline in risk as the age disparity increased. More educated women also had the smallest average age disparity in their relationships and the lowest risk of HIV infection among those with partners of similar age. The authors concluded that the sexual behaviors of middle-aged individuals differ from those of younger groups, adding that campaigns that warn young women about older partners and HIV risk may not be appropriate for older women. They called for HIV prevention interventions specifically targeting older women.

Kalichman, S.C., Simbayi, L.C., Cain, D., et al. European Journal of Public Health (November 2013), E-publication ahead of print.

The authors evaluated a randomized individual- and community-level HIV prevention intervention seeking to reduce HIV-related sexual risks and shift social norms among South African men at high-risk, informal drinking venues (shebeens) in 12 Cape Town townships. Men randomized to the intervention workshops (497) received skill-building on risk reduction and communication to promote conversations about safer sex within social networks, along with related community events. Men in the control workshops (478) received messages on preventing violence in relationships. The intervention had greatest impact on condom use at the individual level, and a modest, inconsistent impact on community-level risk reduction and social norms. Men in the intervention group demonstrated significantly greater use of condoms over the one-year follow-up period, and engaged in more conversations about HIV and condom use. At the community level, at eight months post-baseline, condom use increased by 9 percent in the intervention shebeens while decreasing by 12 percent in the control communities. However, increased condom use was not found at the final follow-up at the community level. The authors suggested that individual- and community-level behavior, conversation, and normative changes may have synergistic effects. While more research is needed to evaluate multi-level interventions, the findings support previous research showing that shebeens may serve as platforms for HIV prevention.

Kuhlmann, A.S., Galavotti, C., Hastings, P., et al. AIDS and Behavior (October 2013), E-publication ahead of print.

To address the limited documentation of the impact of community mobilization on HIV prevention outcomes, the authors conducted a theory-based evaluation of the Avahan-India AIDS Initiative, describing the impact of community mobilization on HIV prevention outcomes among female sex workers (FSWs) in the state of Andhra Pradesh. They presented findings on community mobilization, measured by geographical clusters (104 clusters sampled; 1,986 FSWs) and used psychosocial scales to measure mobilization within the population. The authors’ model hypothesized that stronger community mobilization would act on psychosocial factors, which in turn would support positive HIV prevention outcomes. The findings demonstrated that Avahan’s community mobilization added value in key HIV prevention outcomes, e.g., positive indirect effects on consistent condom use and perceived discrimination. Although each cluster received the same intervention activities, the level of community mobilization varied; clusters with greater community mobilization showed more positive outcomes. Greater social cohesion and increased collective efficacy were associated with improved consistency of condom use and higher reported levels of equitable treatment in public places, respectively.  The average rate of volunteering for program committees (a measurement of the strength of community mobilization) was 45 percent among FSWs. Future interventions should incorporate evaluation of community mobilization processes and outcomes. More robust measures of community mobilization are needed.

Xun, H., Kang, D., Huang, T., et al. PLOS One (November 2013), Vol. 8 No. 11, p. e80594

The authors assessed acceptability of oral fluid HIV rapid testing among most-at-risk populations (MARPs) in Shandong Province, China (n=1,137). Results showed that despite limited knowledge and experience of taking oral fluid HIV rapid tests, 71 percent of MARPs surveyed found the test acceptable, with no statistical differences among men who have sex with men (MSM), female sex workers (FSWs), or voluntary counseling and testing (VCT) clients. The most commonly cited factors associated with willingness to accept the test were its noninvasiveness, painlessness, and rapid test results; common concerns were having never heard of the method and test accuracy. Approximately half of participants considered using the test. Independent predictors of willingness to accept the test were previous HIV testing (VCT clients and MSM) educational levels (MSM), and risk behaviors over the past three months (FSW). Less educated MSM and FSWs engaged in HIV risk behaviors should be targeted for this type of testing, along with HIV prevention education. The median price participants were willing to pay for this test was: U.S.$6.50, $4.80, and $8.10 among MSM, FSWs, and VCT clients, respectively. Oral fluid HIV rapid testing provides an alternative testing option that may increase test acceptance rates among Chinese MARPs; yet appropriate pricing, safe testing venues, and increased education about the method may increase the method's acceptability.

Strengthening Health Outcomes through the Private Sectors (SHOPS) Project (October 2013).

The SHOPS project collaborated with the public and private sectors in Namibia – the first country to cover voluntary medical male circumcision (VMMC) through private health insurance – to standardize the private-sector fee for VMMC and train health care providers, with the aim of increasing opportunities for and access to VMMC through the private sector. With approval from the Ministry of Health and Social Services (MOHSS), the SHOPS project worked with actuaries to conduct a cost analysis of VMMC, using an activity-based costing method. The Namibia Association of Medical Aid Funds (NAMAF), regulators of the private health insurance industry, recommended in 2012 that private insurance companies include the fee; by January 2013, nine of 10 insurers opted for its inclusion. The SHOPS project and MOHSS invested in a VMMC training program for private providers to ensure quality and standardize VMMC provision. In next steps, SHOPS will give the curriculum to local training partners to allow flexibility and ensure consistency, and will establish linkages between NAMAF and MOHSS to create a reporting system. While the adoption of the fee for VMMC by most private health insurances is an important step for scale-up, it may be necessary to enhance demand creation to complement the supply-side investment. The success of the fee-standardization initiative illustrates how private-sector resources can be leveraged to help sustain donor-funded projects.

Nyblade, L., Jain, A., Benkirane, M., et al. Journal of the International AIDS Society (November 2013), Vol. 16 Suppl. 2, p. 18718.

The authors described an international collaboration to develop, test, and refine two tools for measuring HIV stigma among health care providers, focusing on the first tool, a questionnaire that measures drivers of HIV-related stigma within health facilities. Early findings demonstrated the feasibility of a standardized stigma measurement tool that is applicable across diverse settings and health worker cadres, and showed that stigma remains widespread. The collaboration entailed developing a pool of questions through a comprehensive literature search; implementing a content-development workshop in which 22 experts, including people living with HIV (PLHIV), reviewed and prioritized the items finally chosen for inclusion; field-testing in the six countries between February 2012 and January 2013; and analyzing data to evaluate performance and refine as needed. Workshop participants were asked to identify gaps in current measures. They noted that health facility policies and stigma towards key populations were two gaps, and developed related questions to fill them. Future research should assess the tool’s performance over time, and in other high-prevalence settings, to expand measurement of stigma toward key populations; but this brief questionnaire, currently available in five languages, can be used now to help address HIV stigma in facilities and ensure that PLHIV receive quality, stigma-free care.

Prudden, H.J., Watts, C.H., Vickerman, P., et al. AIDS (October 2013), Vol. 27 No. 16, pp. 2623-2635.

The Modes of Transmission Model (MoT), developed by the Joint United Nations Program on HIV/AIDS (UNAIDS), uses the HIV prevalence and behavioral patterns of subpopulations to estimate the distribution of HIV infections. The authors acknowledged the benefits of the model's simplicity, but called for its revision on the grounds that the current MoT may provide misleading estimates, particularly in settings with key differences in subpopulations. The authors compared current MoT projections for Cross River state in Nigeria (2009) with a revised MoT projection that more explicitly defined heterogeneous subgroups and used updated parameters. In the revised MoT projection, "female sex workers (FSWs)" are recategorized as "brothel-based," "non-brothel-based," and "engaging in transactional sex," and "discordant couples" are disaggregated from the category "low-risk group." While the original analysis showed most new HIV infections (73 percent) occurring through heterosexual sex in the general population, the revised model revealed a higher burden (34 percent) among discordant couples. The revised model also indicated significantly more infections among key populations compared to the original MoT (45 versus 21 percent), and showed that brothel-based FSWs and women involved in transactional sex contribute most of the HIV infections that occur within key populations. These results emphasize the importance of identifying high-risk subpopulations to provide them effective prevention options.

Subramanian, T., Ramakrishnan, L., Aridoss, S., et al. BMC Public Health (September 2013), Vol. 13 No. 1, pp. 857.

This evaluation of Avahan, an Indian AIDS initiative that engaged high-risk men who have sex with men (MSM) and transgender persons (TG) in Tamil Nadu (January 2005-March 2009), assessed Avahan's coverage and impact on condom use and HIV and sexually transmitted infections (STIs) prevalence. Avahan attained high coverage and service uptake by both populations, increased in program scale, and was associated with increased condom use by MSM with commercial and regular partners (81 to 94 percent and 33 to 46 percent, respectively). Condom use with casual male partners among TGs improved slightly, but declined significantly with commercial male partners (from 93 to 80 percent). The proportion of MSM and TGs ever contacted by peer educators increased from 82 percent to 100 percent of estimated populations between 2006 and 2009; the proportion of these who had ever visited STI clinics saw similar increases. Changes in HIV prevalence were not significant (9.7 to 10.9 percent, MSM; 12 to 9.8 percent, TG); however, the prevalence of urethral syphilis declined significantly among MSM and TG (14.3 to 6.8 percent and 16.6 to 4.2 percent, respectively). The authors concluded that public health programs should target MSM and TG separately. Although further research is needed to better understand factors that affect MSM and TG individuals’ condom use with different partners, these findings could be used to improve behavior change communication programs.

Wagner, K.D., Pitpitan, E.V., Chavarin, C.V., et al. Sexually Transmitted Diseases (August 2013), Vol. 40 No. 8, pp. 619-623.

The authors conducted a cross-sectional study (from June 2011-August 2012) in Tijuana, Mexico to assess the extent to which 170 drug-using male clients of female sex workers (FSWs) have also been paid for sex; to estimate the prevalence of sexual partner types; and to understand the association between sexual partner type and HIV risk. Overall, 45 (26.5 percent) of male clients reported having any paying sexual partners in the previous four months, with 11 (24 percent) reporting both male and female partners. This suggests that drug-using male clients and male sex workers may overlap within a group who both pay and are paid for sex. Having a paying partner was significantly associated with an increased probability of being positive for HIV or another sexually transmitted infection—HIV-positive persons were 3.5 times more likely to report this behavior. Injection drug and cocaine use in the previous four months was also independently associated with reporting paying sexual partners. Further research should explore behavioral characteristics, including injecting drug and cocaine use and condom use practices with varying partner types, among this group. The authors concluded that HIV prevention activities for drug-using male clients should aim to increase the availability and correct use of condoms in sex work venues.

Kacker, S., Frick, K.D., Quinn, T.C., et al. Sexually Transmitted Diseases (July 2013), Vol. 40 No. 7, pp. 559-568.

The authors modeled the short- and long-term financial implications of the scale-up of male circumcision (MC), taking into account infections shown to be averted by MC. They simulated four strategies with various rates and extents of MC scale-up, and compared the results with a baseline scenario of current MC prevalence and trends in Rakai District, Uganda. The strategies included a combination of gradual and rapid scale-up with either adolescents/adults (aged 15-49) only or including infants (aged 0-1). Cost savings from MC-related reduction in infections varied from US $197,531 after five years of scale-up focused on adolescents/adults, to US $13.7 million after 25 years with infant circumcision included. Including infants in MC strategies is more costly in the short term but achieves considerable savings long-term. Also, rapid scale-up of MC may lead to greater savings earlier, and over time, compared to gradual strategies, due to averted infections. Reduced HIV incidence accounted for approximately 46 percent of reductions in infection-related costs and 50 percent of cost savings; 79 percent of costs in five years; and 90 percent of cost savings in 25 years. The authors concluded that investment in MC strategies that incorporate both infants and adolescents/adults may have greater long-term impact than targeting the latter population only. The findings support health and economic benefits of MC scale-up.

Dworkin, S.L., Treves-Kagan, S., and Lippman, S.A. AIDS and Behavior (November 2013), Vol. 17 No. 9, pp. 2845-2863.

The authors conducted a systematic review of published evidence on the effect of gender-transformative interventions targeting heterosexual men on outcomes for HIV and sexually transmitted infections (STIs) and gender. Evidence from 15 eligible studies in four continents suggests that gender-transformative strategies can lead to protective sexual behaviors, attitude changes, violence prevention, and reductions in STIs/HIV. Twelve interventions used small group learning, which was the most common intervention; five of these incorporated a community-level component. Three studies were randomized control/cluster trials. One study, Stepping Stones (South Africa), included biomarkers to evaluate impacts on HIV and herpes simplex virus-2 (HSV-2); although no effect on HIV was found, there was a 28 percent reduction in HSV-2 incidence among men. Further, results on sexual risk behavior outcomes (11 interventions; nine statistically significant reductions) provided partial evidence that these interventions decreased sexual risk behavior. Findings suggested that these interventions help reduce perpetration of violence against women (eight interventions; six statistically significant outcomes). Of 12 programs assessing change in gender norms, 11 found at least some statistically significant changes in normative attitudes. More rigorous study designs and intervention formats are needed, including initiatives to modify community-level norms. Future research should include interventions engaging both men and women. The authors concluded that gender-transformative interventions can reduce risk behaviors and partner violence, and should continue and be scaled up.

Kennedy, C.E., Brahmbhatt, H., Likindikoki, S., et al. AIDS Care (August 2013), E-publication ahead of print.

As part of a study examining combination HIV prevention interventions in Tanzania, the authors conducted qualitative, formative research through 116 in-depth interviews with Iringa residents and stakeholders, seeking to understand participants' perspectives on cash transfer programs for young women with high HIV risk. Qualitative analysis showed that respondents generally favored such a program, which could address poverty-driven behaviors associated with HIV vulnerability. However, informants highlighted concerns about jealousy, sustainability issues, dependence on the program, and corruption. The authors identified recommendations based on the findings for cash transfer programs, stressing that program planners should work with local stakeholders and educate communities on the goal of cash transfers. Most respondents believed that providing the funds directly to the target group would be most effective, and that the parents of younger girls in school should also receive funds. While many respondents had favorable attitudes towards cash transfers, others said that providing micro-credit loans to invest in small business may be more suitable for this population. The study did not explore linking transfers to complementary services, but respondents emphasized the need for education on HIV and financial management. The authors concluded that there was general understanding of the benefits of an intervention targeting the economic vulnerability of young women in Iringa, and provided additional considerations for implementing cash transfer programs.

Stephenson, R., Elfstrom, K.M., & Winter, A. AIDS and Behavior (September 2013), Vol. 17 No. 7, pp. 2352-2366.

The authors investigated associations among individual-, household-, and community-level factors and HIV testing uptake among men in eight African countries, using Demographic and Health Surveys (DHS) (from 2001-2006). The findings showed that a variety of site-specific community-level factors help to explain factors affecting men’s testing behavior. The proportion of men who reported having ever testing for HIV ranged from 7 percent to 29 percent, in Chad and Uganda, respectively. At the individual level, more education and media exposure were positively associated with HIV testing.  Factors associated with increased testing included higher levels of education among both men and women; larger proportions of men employed; greater knowledge of HIV prevention measures among both men and women; and larger proportions of men reporting condom use at last sex.  Associations between testing and other factors were mixed. For instance, the link between average number of sexual partners and testing behavior varied; in Zambia, Zimbabwe, and Nigeria, those with more sexual partners were more likely to report HIV testing. For Nigerian men, there was positive association between HIV testing and living in a community with higher tolerance for violence against women; however, this association was negative in Uganda. Further research on the determinants of testing uptake is critical, particularly in sub-Saharan Africa where heterosexual adults are at high HIV risk.

Hoffman, I.F., Latkin, C.A., Kukhareva, P.V., et al. AIDS and Behavior (September 2013), Vol. 17 No. 7, pp. 2510-2520.

In Russia, people who inject drugs (PWID) typically interact within small networks that may influence the HIV epidemic. The authors described the results of a randomized controlled trial assessing the effectiveness of a peer-educator intervention for PWID and their network members in St. Petersburg, aimed at reducing HIV incidence and risk behaviors. The findings indicated that peer-education interventions may reduce HIV incidence within marginalized PWID networks and should be included in a comprehensive HIV prevention approach. From December 2004 to November 2007, index participants were recruited and encouraged to identify network participant(s). In total, 432 participants enrolled and were randomized to the intervention or control. Intervention index participants attended eight training sessions on the risks of injecting drug use, sexual risk behavior, and risk reduction and communication skills. Control index participants attended sessions on social development skills and lifestyle discussions. Of 240 HIV-negative participants (at baseline), 160 participants received follow-up visit(s). At follow-up, estimated HIV incidences were 7.8 and 19.6 in the intervention and control groups, respectively. Analysis comparing HIV incidence between the groups using parametric, semi-parametric, and non-parametric estimates had similar results, showing that incidence in the control group was approximately two times greater. Future research may benefit from measuring a community effect instead of individual HIV incidence.

George, G., Chitindingu, E., and Gow, J. BMC International Health and Human Rights (2013), Vol. 13 No. 1, pp. 45. E-publication ahead of print.

The authors implemented a cross-sectional survey in 2010 with 186 traditional healers (THs) in South Africa, assessing their knowledge of HIV and their willingness to collaborate with the formal medical system, to determine whether THs can adequately support HIV prevention and treatment efforts. The findings suggest that THs are a suitable but underused cadre for HIV services, particularly at the community level. South African THs reported regularly interacting with HIV-positive individuals. Sixty percent had previously received formal HIV training. Although HIV knowledge levels were relatively low, THs with previous HIV training had better outcomes. Most THs reported a willingness to collaborate with the medical system (70 percent of trained participants; 83 percent with no previous training). Thirty-six and 43 percent of trained and non-trained THs, respectively, believed that there is a cure for HIV. However, a significant proportion of all THs understood that having unprotected sex with an HIV-positive person poses a risk for HIV transmission, and the majority (61 percent) reported that they recommend condom use. Respondents in both groups (89 percent of trained and 61 percent of non-trained THs) agreed that HIV can become resistant if antiretroviral doses are skipped. The authors concluded that an important next step is to develop HIV training programs to further educate THs.

Page, K., Stein, E., Sansothy, N., et al. BMJ Open (September 2013), Vol. 3 No. 9, pp. e003095.

In 2008, the Cambodian government implemented laws to combat human trafficking and sexual exploitation, including banning brothel-based sex work and labeling female sex workers (FSWs) "entertainment workers” (EWs). The authors conducted two prospective studies on high-risk FSWs, aged 15-29, in Phnom Penh (cohort 1: 2007-2008, n=160 and cohort 2: 2009-2010, n=153) to explore changes in the HIV risk environment. Women in cohort 2 had higher education, fewer sexual partners, less time working as FSWs, and significantly lower HIV prevalence compared to those in cohort 1 (9.2 versus 23 percent). More women from cohort 2 had worked in entertainment establishments during the previous 30 days. Women in cohort 2 reported more alcohol use but fewer days drunk during the previous 30 days, and fewer reported ever using amphetamine-type stimulants (ATS). Cohort 2 EWs reported less alcohol and ATS use, but brothel-based or street FSWs reported significantly more ATS use. The protective effects of entertainment-based venues may include having a manager; the odds of having HIV were lower among women who reported having a manager than among those who did not. The authors noted that HIV incidence may increase among FSWs at the population level because of the increase of women engaging in sex work; hence a possible increase in occupational HIV risk among FSWs. While more research is needed, the need for combination HIV prevention services for Cambodian FSWs is evident.

McNairy, M.L., Deryabina, A., Hoos, D., et al. Drug and Alcohol Dependence (July 2013), E-publication ahead of print.

The authors reviewed HIV services available for people who inject drugs (PWID) in Central Asian countries and discussed concerns about research on and implementation of antiretroviral therapy (ART) for prevention in this group. Overall, ART for HIV prevention among PWID in this region must be coordinated with current HIV services, ensuring that those who are HIV-positive have access to ART for treatment. HIV incidence continues to rise in Central Asia, particularly among PWID. Injection drug use accounts for nearly 63 percent, 57 percent, and 50 percent of HIV infections in Kazakhstan, Kyrgyzstan, and Tajikistan, respectively, and a high proportion of PWID engage in risky sexual behaviors. Stigma, marginalization, and restrictive policies prevent PWID from accessing HIV prevention services or drug-related treatment; creating gaps in the cascade of HIV care, including HIV testing and linkage to care and treatment. Poor adherence to ART may stem from discrimination or lack of support and counseling from trained providers to address issues for PWID. Risk-reduction strategies, such as pre-exposure prophylaxis and opioid substitution therapy, should be evaluated within a combination approach. The gaps in the HIV continuum must be addressed in a comprehensive strategy, combined with research on feasibility and interventions to increase demand for HIV testing and to strengthen retention and adherence.

Lippman, S.A., Maman, S., MacPhail, C., et al. PLOS One (October 2013), Vol. 8 No. 10, p. e78208.

The authors classified key domains of community mobilization (CM) and applied them to the South African context to guide CM efforts, particularly within HIV prevention programs. First, they synthesized literature from various disciples and hypothesized six CM domains: shared concern, critical consciousness/community sensitization, organizational structure/networks, leadership, collective actions, and shared cohesion. Secondly, to explore the relevance of these domains to CM processes in South Africa, they conducted qualitative research with 64 community members in a rural setting where an HIV prevention trial that includes a CM intervention is underway. Findings showed that most of the domains were relevant with little adaptation to CM processes in South Africa. For instance, addressing challenges required leadership and promotion of critical consciousness, collective action, and community dialogue. Two domains— organizations/networks and social cohesion—were not as applicable in this context and would require some adaptation. For instance, community networks tended to be family-based. The authors suggested that interventions should focus on CM objectives simultaneously with program objectives. In similar contexts, HIV programs that include CM should re-frame HIV as a community rather than individual concern, and implementers should identify ways to promote leadership. The authors plan to validate these domains during this trial by monitoring changes in gender norms and HIV prevention behaviors, and are validating measurements of CM domains for use as evaluation tools.

Werb, D., Buxton, J., Shoveller, J., et al. Drug and Alcohol Dependence (September 2013), E-publication ahead of print.

The authors systematically examined peer-reviewed evaluations of interventions to prevent initiation of injection drug use (IDU) to assess their effectiveness and inform development of preventive policies. Of 78 candidate studies, eight studies published between 1992 and 2011 were included. The findings suggested that interventions involving peer-based behavior change or enrollment in treatment addiction programs may be effective in preventing IDU initiation. However, further research and new approaches to prevention are warranted, given the limited evidence and the proven risks of IDU, including HIV. Five studies were implemented in North America, and one each in Europe, Australia, and Central Asia. Four types of prevention interventions were evaluated: social marketing, peer-based behavior change, access to addiction treatment programs, and drug law enforcement/deterrence. Half of the studies found that peer-based behavior change and treatment-based approaches had significant impacts in reducing the exposure of injection-naïve drug users to injection environments. Interventions that applied drug law enforcement as a deterrent were less effective. The positive impact of peer-based behavior modification interventions shows that the impact of social networks should not be overlooked. Overall, though, there is insufficient evidence on these interventions to inform scale-up. The authors called for further research, concluding that there must be clear scientific evidence of impact before taking broad actions to scale up policies or interventions to prevent IDU initiation.

Des Jarlais, D.C., Pinkerton, S., Hagan, H., et al. Advances in Preventative Medicine (June 2013), Vol. 2013.

The authors reviewed the history of and lessons learned from the past three decades in HIV prevention for people who inject drugs (PWID) and discussed critical issues for future research and public health programs. Despite successes in HIV prevention among PWID, including large-scale syringe access programs, combination prevention, and integrated health and social approaches (primarily in high-income countries), lack of resources and political will, stigmatization, and other factors, hinder effective HIV prevention for PWID in resource-limited countries. Long-term data for HIV prevention among PWID are inadequate because of stigmatization, friction between law enforcement and drug users, and political leaders’ belief that drug use is a “Western issue.” The authors described two modeling studies which indicated that combination programs would dramatically reduce HIV incidence among PWID in two countries. Current economic pressures point toward reducing programming for PWID, particularly in low-prevalence epidemics; the authors argued against scaling these programs down because other factors, e.g., sexual transmission, could increase HIV. Lastly, the authors described two opposing policy perspectives to injecting drug use: the proscriptive “war on drugs” and the pragmatic “harm reduction” approach, which focuses on public health and human rights. The authors concluded that the successes in HIV prevention among PWID have informed global goals for improving overall health (including HIV prevention and care) through a rights-based, politically supportive environment.

Smith, K.A. and Harrison, A. Sex Education (2013), Vol. 13 No. 1, pp. 68-81.

The authors conducted qualitative research with 43 secondary school teachers and administrators from 19 schools in rural KwaZulu Natal, South Africa to understand their attitudes towards sexuality education, HIV, and adolescent sexuality; and to determine the level of implementation of the school-based life skills curriculum for HIV prevention. Informants’ strong views on morality and young people’s sexuality, particularly regarding girls and pregnant students, may pose barriers to implementing education on HIV prevention and sexuality. Stigma towards HIV within the general community was apparent. Pregnant students were often pressured to leave school, and sexual behaviors and relationships were discouraged. Most respondents reported that dissemination of the life skills curriculum was very informal because of limited time and high workloads, but they discussed other school-based sexual education, which revealed varying levels of comfort in presenting these topics. Most informants ardently supported this education, including for teachers, and offered strategies, e.g., inviting external HIV programs into schools. Most teachers were knowledgeable about HIV transmission and prevention but less knowledgeable about testing and treatment. Some teachers supported traditional practices such as virginity testing and believed themselves socioeconomically superior to the student community. School-based initiatives may enhance HIV prevention in South Africa, yet future interventions should assess teachers’ knowledge of HIV and perceptions of adolescent sexuality, and should address young people's varied life and sexual experiences.

Rachlis, B., Sodhi, S., Burciul, B. et al. Global Health Action (April 2013), Vol. 6.

The authors conducted a literature review to classify HIV-related community-based care (CBC) programs in terms of key characteristics, programming gaps, and roles in HIV programming. They identified 21 CBC programs, primarily in sub-Saharan Africa, that met the inclusion criteria. The taxonomy specified nine programmatic characteristics, classified by region, and the authors developed a logic model for effective and sustainable CBC programs. The most common and second most common visions were to improve the lives of people living with HIV and the lives of other populations affected by HIV, respectively. Few programs targeted vulnerable or marginalized populations, and gender-specific data were limited. Programs offered a range of HIV services and most services were offered in homes and community settings. Operational models differed, often according to the level of community engagement and collaboration among community groups, members, and leaders. Funding sources varied, as did organizational structures, in terms of the type of community health worker involved. Key factors that influenced sustainability were availability of funding and retention of staff. The authors also noted that the majority of programs included some regular monitoring, but many provided limited information about their monitoring and evaluation strategies. The authors concluded that although further research is needed, the findings provide an understanding of CBC models and could be used to develop an evidence base for sustainable HIV services in resource-constrained countries.

Venkataramani, A.S. and Maughan-Brown, B. AIDS and Behavior (2013), Vol. 17, pp. 1668-1674.

The authors assessed the impact of household shocks, including economic losses, illness, or death, on traditional circumcision age among Xhosa men in Cape Town, South Africa. The results showed a relationship between such shocks and delayed age at traditional circumcision, especially among respondents in poorer households. With growing indication that male circumcision can reduce the risk of HIV, the findings support evidence on the impact of poverty on vulnerability to HIV. Respondents in the poorest households were circumcised more than two years later if their household experienced a shock compared with respondents who experienced no shocks. The initial sample, 930 men between the ages of 15 and 22, were surveyed at baseline; surveys in 2002, 2005, and 2006 assessed household shocks, and a 2009 survey captured traditional circumcision data. In total, 480 African men provided data on both shocks and circumcision. The average age at circumcision was 20 years. Forty-two percent of respondents experienced shocks during the two years before the 2005 survey. The findings suggested policy strategies, including educating traditionally circumcised groups about the importance of early circumcision, and improving access to financial support. Finally, additional research should investigate interventions to address the complex relationship between poverty and HIV risk.

Stephenson, R., Winter, A., and Elfstrom, M. AIDS Care (2013), Vol. 25 No. 6, pp. 784-792.

The authors analyzed Demographic and Health Surveys to examine how individual- and community-level factors affect reported risky transactional sex among men. The analysis included 2,893 men in Malawi, 2,110 in Tanzania, and 1,799 in Nigeria. While several community characteristics are linked to higher reported engagement in risky transactional sex, community-level variations remained in all countries. Reports of risky transactional sex were 12.4 percent, 9.8 percent and 6.7 percent in Malawi, Nigeria, and Tanzania, respectively. Tanzanian men with any education, and Nigerian men with primary education, were more likely to engage in risky transactional sex. In Nigeria, fewer never-married men reported risky transactional sex than married, cohabitating, or divorced men; and more men in lower wealth quintiles reported the behavior. Gender equity appeared to affect risky transactional sex: where a greater proportion of women had at least some education (and, in Nigeria, where more women were employed), men were less likely to report risky transactional sex. The average number of sexual partners in the past 12 months was associated with more risky transactional sex. Factors associated with reduced reporting of the behavior include condom use at last intercourse (Malawi),  greater knowledge among men and women of three HIV prevention measures (Nigeria and Tanzania), and women's older average age at first birth (Malawi and Tanzania).  The authors advocated for incorporating gender issues and community-level factors into HIV interventions.

Taegtmeyer, M., Davies, A., Mwangome, M. et al. PLOS One (June 2013), Vol. 8 No. 6.

The authors conducted in-depth interviews with 16 health care providers near Mombasa, Kenya who had interacted with high-risk men who have sex with men (MSM) to explore their attitudes and perceptions about working with MSM. Four interviewees self-reported as being from the local MSM community. Overall, providers were concerned that they had insufficient skills for providing MSM with HIV risk-reduction counseling and addressing other client challenges. The findings underscored the need for tailored training and supervisory support to improve counseling for MSM. The research also revealed other themes including personal, cultural, and religious beliefs that impeded maintenance of neutral attitudes towards MSM; lack of distinction between male sex work and sexual orientation; limited exposure to MSM clients (although continued exposure improved professionalism); sexual attraction (by both clients and counselors); and stigma towards and criminalization of MSM. The authors highlight areas for improvement in training and supervisory support, such as developing separate HIV counseling protocols for MSM; training in professionalism; and supervision skills-building. The findings uncover specific challenges to meeting the needs of MSM in the African context, and show the importance of training, support, counseling, and consideration of the local context to guide HIV prevention programs for MSM.

Kim, L.H., Cohan, D.L., Sparks, T.N., et al. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 No. 2, pp. 195-200.

The authors assessed the cumulative cost-effectiveness of three HIV testing strategies, compared to standard care, for the prevention of perinatal transmission in Uganda. The four strategies assessed were: 1) standard of care–rapid HIV antibody testing at the first prenatal visit; 2) standard of care plus HIV RNA (viral load) at initial visit; 3) standard of care plus repeat HIV antibody testing at delivery; and 4) strategy 3 plus HIV RNA at delivery. The results indicated that repeat rapid HIV testing at delivery (strategy 3) was cost-effective and led to the greatest total maternal and child life-years saved. The authors applied a decision analytic model from a health care system perspective to follow a hypothetical cohort of 10,000 Ugandan women in antenatal care. Life-years saved for each strategy were: 414,227 (strategy 1); 414,296 (strategy 2); 415,765 (strategy 3); and 415,794 (strategy 4). Standard care was least expensive. Applying the World Health Organization’s definition (≤3 times the gross domestic product per capita) as the cost-effectiveness threshold, strategy 3 was the most economical option in terms of life-years and remained so in univariate sensitivity analysis. Yet when HIV incidence was more than 8 percent, strategy 4 became the most cost-effective strategy. The findings should inform policies on HIV testing during pregnancy in sub-Saharan Africa.

Vasquez, C., Lioznov, D., Nikolaenko, S., et al. AIDS Patient Care and STDs (2013), Vol. 27 No. 5, pp. 304-310.

The authors assessed differences in risk factors between male and female HIV clients at two HIV referral facilities in St. Petersburg, Russia. Injecting drug use and sex were the main HIV risks in both males and females, but significant differences affected their uptake of HIV and related services. From March to May 2011, surveys were conducted with 152 clients (52 percent of these were women). Comorbidities included tuberculosis among men and sexually transmitted infections among women. Men were more likely than women  to report HIV risk related to drug use (78 percent to 45 percent, respectively) and a history of injecting drug use (86 percent versus  49 percent). More women than men reported unprotected sex (61 percent to 18 percent). Men cited drug use as the primary reason for seeking HIV testing; women cited drug use, unprotected sex, and worries about their partner’s health. About half of males and females abused alcohol. Participants had high levels of HIV treatment knowledge, but delayed seeking care (47 percent and 35 percent); anecdotal reports identified stigma as a barrier. Women were more likely to access psychosocial services, yet men and women similarly accessed services for mental health care and injecting drug use, HIV, and group meetings. Gender-related differences in access and uptake of services should help inform HIV resource distribution in Russia.

Shamu, S., Abrahams, N., Zarowsky, C., et al. Tropical Medicine & International Health (February 2013), e-publication ahead of print.

This cross-sectional study of 2,042 post-natal women in six low-income clinics in Harare, Zimbabwe determined the prevalence of and factors associated with intimate partner violence (IPV) during pregnancy. Forty-six percent of participants reported physical and/or sexual violence; 63 percent reported physical, sexual, and/or emotional violence. Approximately 30 percent reported three or more severe sexual violence events, and 10 percent reported six or more events during pregnancy. More IPV was reported if partners were younger and more educated, had multiple wives, did not pay a bride price, and did not live with families. IPV was more frequently reported if a woman or partner made an independent decision about pregnancy, a partner prevented contraception use, or if a woman did not desire/refused to become pregnant. Greater violence was reported by women who had more sexual partners, were treated for a sexually transmitted infection (STI) during pregnancy, ever had transactional sex, were HIV-positive, or had a partner with an STI but unknown HIV status. The study did not find associations between IPV and HIV infection. Further research should address the relationships between violence and reproductive health decision-making among couples, and between IPV and HIV status disclosure. It is vital to include men in reproductive health programs and to conduct interventions addressing gender norms and IPV.

Pinkham, S., Stoicescu, C., & Myers, B. Advances in Preventive Medicine (September 2012), Vol. 2012.

The authors use existing evidence to review the experiences of females who inject drugs (FWID) compared with men who inject drugs, and to suggest strategies for HIV prevention interventions. Findings showed that FWID are at an elevated risk for HIV, and face barriers accessing health care. Overlap between sexual and drug social networks was common in FWID. Intimate partner violence was more commonly reported among FWID than among women in the general population. Evidence suggested an overlap between FWID and sex work. Women's motivations for seeking treatment for drug use varied from that of men; pregnancy, or a partner initiating treatment, were common. Females who injected drugs had limited access to prenatal care, and the authors warn that harm reduction programs may not address all their sexual and reproductive health needs. Further, an increasing number of women were being incarcerated for injection drug use and in need of healthcare; in some contexts, the HIV rate was higher among incarcerated women than men. While harm reduction programs have been successful in reducing drug-related risk, there has been less improvement with unsafe sexual behaviors. However, many interventions for FWID have been successful. The authors conclude that comprehensive, multidisciplinary interventions specific to the needs of FWID, accompanied by policies that empower women to seek health care, are necessary.

Church, K., Wringe, A., Fakudze, P. et al. Journal of Acquired Immune Deficiency Syndromes (January 2013), 16:17981.

A mixed-methods comparative case study that explored HIV stigma experiences across four HIV care models in Swaziland found that the model of care influenced stigma associated with perceived HIV status exposure; however, the relationship was complex. Antiretroviral therapy (ART) was offered in the same room as sexual and reproductive health (SRH) (integrated), in the same building as SRH (partially-integrated), in an outpatient clinic on a hospital campus (partially stand-alone), in an HIV testing- and ART-only site (stand-alone). Integrated care increased confidentiality for some clients. Partially integrated/stand-alone models were associated with the greatest risk of exposure; yet most clients at stand-alone sites preferred ART to remain separate due to mutual support from other people living with HIV. The results indicated an overall perception that HIV status could be exposed at the clinics, yet most clients trusted staff to maintain confidentiality. Forty-four percent of participants had a high perceived risk of exposure. Interviews showed that clients who accepted their own HIV status were more comfortable in HIV clinics. HIV services should include strategies to ensure privacy and reduce stigma related to structural factors, e.g., room labeling or ART client cards. The authors recommended considering the benefits of stand-alone models, particularly in high-prevalence settings, while consideration of integrating HIV care into other health services continues.

Stöckl, H., Kalra, N., Jacobi, J., et al. American Journal of Reproductive Immunology (February 2013), Vol. 69 Suppl. 1, pp. 27-40

The authors conducted a systematic review to summarize evidence on the association between early sexual debut and women's risk of HIV in sub-Saharan Africa. The review found mixed results in all published evidence. Twenty-five studies met the inclusion criteria; the majority were cross-sectional studies. Among high-quality studies with large sample sizes, there was a consistent finding of bivariate association between early sex and HIV risk, which remained after controlling for socio-demographic factors and other confounders. Yet there were mixed results regarding the association, controlling for later high risk behavior. Half of the studies suggested that increased HIV risk was related to later engagement in sexual risk behaviors, as opposed to the age of sexual debut. Risk may also be related to biological factors. Because of methodological limitations, the review findings need to be interpreted with caution. The authors state that the findings highlight the need for additional research to improve understanding of the determining factors and implications of women's early sexual debut, associations with HIV risk, and areas for intervention.

Ditmore, M.H., & Allman, D. Journal of the International AIDS Society (2013), 16:17354.

The authors discuss the U.S. President's Emergency Plan for AIDS Relief's (PEFPAR) anti-prostitution pledge and illustrate its implications for HIV prevention through a case-study approach that uses cases from over 25 organizations and projects in 14 countries. Guidance on the implementation of the anti-prostitution pledge has been unclear and unpredictable, and many organizations interpret the restrictions subjectively, with varying outcomes. Analysis shows that some organizations have refused to work with sex workers out of fear of losing contracts with the U.S. Agency for International Development; others recognize that this refusal would discriminate against sex workers and deny them HIV prevention and health care. No clear guidance exists for HIV programs with sex workers, although there are guidelines for other high-risk populations. This guidance should be established so that no one, including sex workers, is denied services. The current U.S. Global AIDS Coordinator has said that "turning away anyone who should receive services would not be tolerated." Some programs and access to services for these populations have been eliminated as a result of the funding restrictions, and reporting and information about successful HIV prevention programs for sex workers is lacking, which impedes future development and implementation. The authors suggest re-evaluating funding restrictions and implementing evidence-based HIV programs for these populations.

Gruskin, S. Reproductive Health Matters (December 2012), Editorial, Vol. 20 No. 39S, pp. 1-4

The author of this editorial presents an overview of articles that offer multidisciplinary perspectives on aspects of pregnancy decisions for HIV-positive women. There are concerns about the direction of policy of the global response to HIV and pregnancy. Recently, limited evidence regarding whether injectable hormonal contraception increases HIV risk has made policy decisions challenging. Postnatal services, in addition to abortion services and policies, are lacking, and reproductive health services are generally inadequate for HIV-serodiscordant couples. Yet, while more programs are available for HIV-positive women, health services need to offer quality support and respond to all reproductive health needs in a stigma and discrimination-free setting, because stigma limits women's access to care and may influence reproductive health decisions. Essential health services are associated not only with prevention of mother-to-child transmission, but also improved maternal health. The collection of articles also included a proposed framework for designing and implementing integrated services that identifies influences on reproductive decision making by serodiscordant couples. A study from the Asia-Pacific region was included that identified issues women encounter when accessing reproductive health services. The author urges researchers and program planners to use the evidence presented to drive multidisciplinary research studies, policies, and program design and implementation for reproductive health.

Watthayu, N., Wenzel, J., and Panchareounworakul, K. The Journal of the Association of Nurses in AIDS Care (September–October 2015), 26(5):6 02–612, doi: 10.1016/j.jana.2015.05.002.

The authors used the Rapid Assessment and Response (RAR) method to obtain input relevant to the design of a community-based and culture- and age-appropriate HIV prevention program for adolescents in Bangkok. They conducted focus group discussions with community members including 19 adolescents aged 12–22 years and 9 adults aged 23 years and older. Participants were asked questions regarding perceived HIV risk for adolescents; specific language/slang about HIV used by adolescents; awareness of available adolescent HIV programs; and views about such programs or services. Adolescents expressed a need for information on how individuals were infected; how to protect themselves; and how to live with affected individuals. Most participants expressed discomfort with the use of slang and preferred that more formal language be used in education programs. All adolescents recommended that group sessions consist of practical demonstrations of condom use and other practical life skills. They also suggested that programs be led by providers such as physicians or nurses, whom adolescents would see as experts. The authors concluded that the RAR method is a viable method for engaging communities to ensure that programs meet the needs of their intended beneficiaries.

Kerrigan, D., Kennedy, C.E., Cheng, A.S., et al. Journal of the International AIDS Society (August 2015), 18(1): 20029, doi: 10.7448/IAS.18.1.20029, eCollection 2015.

The authors of this paper highlighted four case studies from the Research to Prevention project to demonstrate how context-specific operations research (OR) can help prioritize strategies and improve local HIV prevention programs and policies. The case studies, drawn from OR conducted in the Caribbean and sub-Saharan African regions, illustrated several ways in which OR can support positive change. These included (1) translating findings from clinical trials to real world settings; (2) adapting promising structural interventions to a new context; (3) tailoring effective interventions to underserved populations; and (4) prioritizing key populations within a national response to HIV. These examples, the authors said, show how OR can lead to "real-world" change, and expand expectations about the role and utility of OR. They concluded that OR studies and their findings should be brought into national dialogues and policy debates to strengthen HIV responses at national and global levels.

Eluwa, G.I., Adebajo, S., Idogho, O., et al. Journal of Acquired Immune Deficiency Syndromes (September 2015), 70(1): 67–74, doi: 10.1097/QAI.0000000000000701.

The Enhancing Nigeria’s Response to HIV/AIDS health system strengthening (HSS) project was launched in 2009 to reduce the prevalence of HIV in focus states across the country. This study evaluated the impact of this HSS initiative on HIV prevalence and sexual risk behaviors in the general population in seven states, and compared outcomes in the HSS states to those of seven socio-demographically similar control states. A total of 4,856 and 11,712 respondents were surveyed in 2007 and 2012, respectively. HIV prevalence in HSS and non-HSS states was 6.3 percent versus 5.3 percent, respectively, in 2007; and 2.96 percent versus 5.08 percent in 2012. Prevalence in rural regions declined between 2007 and 2012 in HSS states (from 7.58 percent to 5.93 percent), but increased significantly in non-HSS states (from 2.46 percent to 4.81 percent). Moreover, respondents in HSS states were more likely to report using condoms consistently in the past three months with a boyfriend or girlfriend, and had more comprehensive HIV knowledge. The authors concluded that HIV prevalence decreased, and sexual risk behaviors declined, in HSS states between 2007 and 2012, and called for wider rollout of HSS intervention in order to achieve greater success.

Yamanis, T.J., Fisher, J.C., Moody, J.W., and Kajula, L.J. AIDS and Behavior (August 2015), E-publication ahead of print.

This 2011 study described networks, referred to as “camps,” of mostly young men in Dar es Salaam, Tanzania. The authors conducted surveys of 10 camp networks (490 men and 160 women). All participants were asked to complete a one-time, hour-long, structured survey with a study interviewer. The authors reported that 55 percent of male camp members engaged in concurrent sexual relationships. Younger men in the camps who had older, rather than younger, friends in their networks were more likely to engage in concurrency. The authors also found a direct association between inequitable gender norms and concurrency, and suggested that addressing gender norms during interventions with men may have an effect on concurrency behavior. In addition, being in school was negatively associated with concurrency among the men in the study. This suggests that keeping men in school would have a protective effect similar to that observed when girls are kept in school. The authors concluded that the men were more likely to have engaged in concurrent partnerships if they were in close-knit camps where most male members reported concurrency. They suggested that further research on networks and HIV risk behavior could help to develop interventions targeted to specific social contexts.

Crepaz, N., Tungol-Ashmon, M.V., Vosburgh, H.W., et al. AIDS Care (November 2015), 27(11):1361-1366, doi: 10.1080/09540121.2015.1112353.

This systematic review and meta-analysis examined studies that compared the effects of couple-based versus individual-level interventions, and estimated the strength of couple-based intervention effects on HIV protective behaviors. A total of 15 couple-based interventions conducted between January 1988 and December 2014, with a total of 21,882 participants, met the inclusion criteria. The authors found that the results of random-effects models showed statistically significant intervention effects for protected sex, HIV testing, and nevirapine uptake. They concluded that couple-based interventions were more effective in promoting these protective behaviors when directly compared to interventions delivered to individuals. They added that couples HIV counseling and testing allowed both members of a couple to learn their HIV status and make informed choices about antiretroviral prophylaxis during pregnancy (for heterosexual couples) and antiretroviral therapy.

Catlin, A.C., Fernando, S., Gamage, R., et al. AIDS Care (November 2015), 27(1):99-107, doi: 10.1080/09540121.2015.1023246.

The authors of this article described the Sankofa project database system testing in Ghana, the first system in sub-Saharan Africa to use an electronic data capture tool for recording and managing clinical research data. The Sankofa Project database system is built on the open-source HUBzero software platform, which offers in-country research personnel interactive access to training in good clinical practices, guidelines and tools for data acquisition, and built-in analytics for the data acquired. It also offers fully supported user-friendly, secure, and systematic collection of all data envisioned for carrying out the Pediatric HIV Disclosure Intervention Study. The database was designed and developed from October 2012 to January 2013, and opened for participant screening and enrollment in February 2013. The authors screened more than 400 clients, enrolled nearly 300 clients, and collected tens of thousands of data elements to describe demographic, medical, and psychosocial events during the course of the study period. The database successfully supported all of the data exploration and analysis needs of the Sankofa Project. Moreover, the ability of the database to query and view data summaries proved to be an incentive for collecting complete and accurate data. The authors concluded that the Sankofa data management tool was cost-effective and could be deployed for clinical trials and translational research activities in other resource-limited settings.

Vagenas, P., Azar, M.M., Copenhaver, M.M., et al. Current HIV/AIDS Reports (September 2015), e-publication ahead of print.

The authors reviewed 53 papers published between 2010 and 2015 on the impact of alcohol use and related disorders (AUDs) upon each stage of the HIV treatment cascade, given recommendations to provide antiretroviral therapy (ART) earlier in the course of their disease. Most of the studies (77%) found that alcohol use negatively affected one or more stages of the HIV care continuum. Two studies that addressed more than one step in the cascade found a negative link between alcohol use and at least one stage of the cascade. One study found a negative association between alcohol use and a specific stage of the HIV cascade, ART adherence—demonstrating lower adherence with greater alcohol use. Negative links between alcohol use and specific steps in the HIV treatment cascade were seen in countries with both low and high levels of per capita alcohol use. The authors concluded that the best approach for improving HIV treatment outcomes in HIV-positive persons with AUDs will be to ensure high-quality integration of prevention and treatment services, including alcohol treatment, within clinical care settings.

Leddy, A., Chakravarty, D., Dladla, S., et al. AIDS Care (September 2015), e-publication ahead of print.

This study examined the relationship between couple-level sexual communication self-efficacy (SCSE) and consistent condom use, adjusting for the male partner’s endorsement of hegemonic masculine norms (HMNs). HMNs, which value male “toughness,” virility, and dominance over women, are believed to play a key role in the heterosexual HIV epidemic in South Africa. Couples SCSE, defined as a couple’s confidence in their ability to communicate about sexual risk reduction, could be a key leverage point for HIV prevention interventions for this high-risk group. The authors interviewed 163 sexually active heterosexual couples to collect information on demographics, relationship dynamics, and sexual activity. Analysis showed that the odds that couples used condoms were lower when male partners reported moderate to high endorsement of HMNs, compared to couples whose male partner reported low endorsement of HMNs. Additionally, couples with higher levels of SCSE, and those who participated in couple HIV testing and counseling, had increased odds of consistent condom use. Mutual knowledge of joint serostatus and relationship duration were not significantly associated with condom use. The authors concluded that future interventions should focus on promoting gender-equitable norms while also equipping couples with the tools for improving SCSE and fostering partners’ ability to work together to achieve improved sexual and reproductive health outcomes.

Balkus, J.E., Brown, E.R., Hillier, S.L., et al. Contraception (October 2015), pii: S0010-7824(15)30033-0. doi: 10.1016/j.contraception.2015.10.010, E-publication ahead of print.

The authors estimated the association between self-reported use of injectable hormonal contraceptives or HCs (depot medroxyprogesterone acetate, or DMPA, or norethisterone oenanthate, or NET-EN) or oral contraceptive pills and HIV acquisition risk among 2,830 African women enrolled in the analysis. The HIV Prevention Trials Network (HPTN) 035 microbicide trial, a multi-site, randomized, controlled trial, compared BufferGel and 0.5 percent PRO 2000 gel against two comparator arms (hydroxycellulose placebo and no gel). During the study, participants were given HIV testing and were interviewed about self-reported contraceptive use and sexual behaviors. The authors reported that they did not observe a significant increased risk of HIV acquisition among women using injectable or oral contraceptive methods. They did not observe statistically significant interactions between baseline age or herpes simplex virus status and HC method. They concluded that these findings supported the World Health Organization's recommendation that women at high risk for HIV, including those using progestogen-only injectable HC, should be strongly advised to always use condoms in addition to other HIV prevention measures. 

Tenni, B., Carpenter, J., and Thomson, N. PLOS ONE (October 2015), 10(10): e0134900, doi: 10.1371/journal.pone.0134900, eCollection 2015.

This review highlighted examples of positive partnerships between police and sex workers or sex worker organizations to prevent HIV transmission and examined factors contributing to the success of these partnerships. Despite the continuing criminalization of sex work, there are examples in the literature in which programs that focused on sex workers collaborated with police to increase policemen's understanding of the sex industry, and to solicit police support in ensuring sex workers’ access to services. For example, the Resourcing Health and Education in the Sex Industry (RhED) program in Victoria, Australia uses a social model of health to promote physical, emotional, and social health among sex workers through harm minimization, health promotion, social inclusion, and community participation. RhED’s Ugly Mugs project liaises with local police to report and prosecute perpetrators of violence against sex workers. Another program, Thailand’s Sex Workers in Network Group, provides services for male sex workers in Bangkok, and includes an intern program for police recruits, designed to build mutual respect to enable sex workers to access prevention and treatment services without fear of arrest. The authors emphasized that developing police strategies, instructions, and standard operating protocols has been shown to have some impact in addressing HIV risk among key affected populations, including sex workers.

Carrasco, M.A., Esser, M.B., Sparks, A., and Kaufman, M.R. AIDS and Behavior (October 2015), E-publication ahead of print. 

The authors reviewed 19 peer-reviewed studies on HIV-alcohol risk reduction interventions in sub-Saharan Africa and summarized their findings and characteristics. All the interventions (implemented in Angola, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe) promoted individual behavior change using strategies such as peer education, health trainings and workshops, and health education videos. The authors reported that 12 of the 16 interventions that reported on sexual risk behavior outcomes (condom use) found significant effects, while four interventions found no significant effects. While studies targeting youth in schools had limited efficacy, those targeting women who use drugs, sex workers, and clients at clinics for testing and diagnosis were more efficacious. These showed significant effects in reducing alcohol consumption or changing HIV-alcohol or sexual risk behaviors. Studies targeting drinking venue patrons were efficacious when delivered as a short intervention in a community setting, but not when delivered in these venues by peers. Studies targeting soldiers showed efficacy when implemented at the community level, but not at military bases. The authors concluded that community-based interventions, when embedded into ongoing prevention and treatment programs of various kinds, may be effective in addressing HIV-alcohol risk behaviors in the short term.

Abara, W.E. and Garba, I. Global Public Health (October 2015), E-publication ahead of print.

This review paper examined the HIV epidemic among men who have sex with men (MSM) in sub-Saharan Africa (SSA) and highlighted factors that facilitate its spread. The authors organized by these categories:

  • Epidemiology: Studies under this category demonstrated the concentrated nature of the HIV epidemic and transmission risk among MSM in SSA; the public health impact of ignoring the epidemic on the continent’s current HIV prevention efforts; and the need to prioritize HIV prevention and care, surveillance, and research programs for MSM.
  • Social determinants: Among MSM, internalized homophobia leads to negative attitudes and actions that can manifest as shame, fear, anxiety, and loss of self-worth. Additionally, stigma affects social vulnerability and is fundamental to access to health care.
  • Stigma, discrimination, the law, and HIV risk among MSM: Many countries in SSA criminalize male-to-male sexual relationships. These laws obstruct HIV prevention, care, and health policies that target MSM, while prompting behaviors and practices that facilitate HIV transmission.

The authors urged implementation of rights-based standards, along with continued collaborative partnerships, collective advocacy, and concerted action to ensure that MSM and all HIV-positive individuals in SSA have access not only to HIV prevention and care, but also to the full range of rights that help ensure equal opportunities for health and wellness.

Micheni, M., Rogers, S., Wahome, E., et al. AIDS (December 2015), 29(3):S231-S236, doi: 10.1097/QAD.0000000000000912.

This study compared the incidence of sexual, physical, and verbal assault among men who have sex with men (MSM) to that among female sex workers (FSWs) in coastal Kenya between 2005 and 2014. The study enrolled 1,425 adults aged 18–49 years who demonstrated high-risk sexual behavior in the past three months. All participants were followed up at monthly or quarterly clinic visits that included behavioral risk assessment, a standardized physical and genital examination, and HIV testing. The authors found that the individual risk of rape among MSM was similar to that experienced by FSWs. However, FSW had higher incidence of reported physical and verbal assault than MSM (21.1 versus 12.9 per 100 person-years). Among MSM, alcohol use was associated with reporting of all forms of assault by MSM. Perpetrators of sexual and verbal assault against MSM were usually unknown, whilst perpetrators of physical violence toward FSWs were usually regular sexual partners. The authors concluded that to complement existing services, programs should develop interventions to prevent violence toward key populations and deliver accessible care for survivors. They also recommended further research to clarify the direct and indirect consequences of violence on HIV incidence and other health risks, including impairment of psychological and social well-being.

Leblanc, N.M., Flores, D.D., and Barroso, J. Qualitative Health Research (February 2016), 26(3):294-306, doi: 10.1177/1049732315616624.

The authors of this study examined barriers to and motivators for HIV screening and receipt of test results by assessing 128 qualitative studies published from 2008 to 2013. They found that several salient factors influenced individuals to seek screening and receive their results: an individual’s general perception of health and disease; individual experiences; and broader contextual dynamics. Among individual attributes, fear was the most prevailing barrier to screening and testing. Dissolution of an intimate relationship or abandonment by family and friends, and lack of awareness about HIV screening, diagnosis, and treatment also discouraged individuals from seeking testing and results. At the interpersonal level, the attributes of both clinical providers and lay health workers were the sole motivator for obtaining HIV screening services. Broader contextual influences centered on the physical location of clinical services: whether service settings were freestanding, within a larger facility, or provided as part of other health services; and their proximity to home or the workplace. The authors concluded that these findings could clarify aspects to consider in the effort to increase HIV screening uptake and clients' knowledge of test results.

Jalil, E.M., Wilson, E.C., Luz, P.M., et al. Journal of the International AIDS Society (September 2017), 20: 21873, doi: 10.7448/IAS.20.1.21873.

This study estimated population-level indicators for the HIV care cascade and elements associated with viral suppression among transwomen in Rio de Janeiro, Brazil. The authors conducted a secondary analysis of a respondent-driven sampling study among 141 self-identified transwomen. Among these women, 89.2 percent had been tested for HIV, 77.5 percent had been diagnosed with HIV, 67.2 percent had been linked to care, 62.2 percent were on antiretroviral treatment (ART), and 35.4 percent had an undetectable viral load. Among the 101 transwomen who knew their HIV status, 80 percent were on ART, and 45 percent had an undetectable viral load. Transwomen who knew their HIV status and were on ART had a higher CD4 count than those who knew their status and were not on ART (695 cells/mm3 versus 398 cells/mm3). Nine transwomen had not been linked to care. Transwomen who were black, earned <US$160/month, or reported unstable housing were less likely to achieve viral suppression. Only around 12 percent of transwomen had access to trans-specific health care services. The authors concluded that transwomen experience significantly lower rates of viral suppression compared to other populations.Focused interventions are required that help them to link to and engage in HIV care and treatment services.

Grant, H., Mukandavire, Z., Eakle, R., et al. Journal of the International AIDS Society (September 2017), 20: 2174, doi:10.7448/IAS.21.1.21744.

This modeling study assessed the possible outcomes of behavioral disinhibition (specifically, reduced use of condoms) related to the use of pre-exposure prophylaxis (PrEP) among female sex workers (FSWs) in South Africa. The authors modeled outcomes of PrEP and condom use based on three scenarios: 1) an FSW and her clients; 2) an FSW and her clients while accounting for exposure to sexually transmitted infection (STI); and 3) an FSW, her clients, and regular partners while accounting for STI exposure. Analysis of interactions with clients showed that if the effectiveness of PrEP use equaled or exceeded that of condom use, the FSW could stop using condoms without increasing HIV risk. FSWs who used condoms less than half the time (and thus had greater exposure to STIs) had reduced HIV risk if their adherence to PrEP was high. Analysis of the "clients and regular partners" scenario showed that FSWs with low baseline condom use, or with high PrEP effectiveness, had minimal HIV risk when reducing condom use. However, the authors cautioned that their study did not address the potential for developing resistance, or the effects of different stages of disease. Programmers should prioritize reaching FSWs who have high condom use and limited expected PrEP adherence, and provide support for PrEP adherence and continued condom use.

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.

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.

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.

Knight, L., Makusha, T., Lim, J., et al. BMC Research Notes (2017), 10: 486, doi: 10.1186/s13104-017-2810-7.

This qualitative study examined the acceptability and usability of HIV self-testing (HIVST) prototypes (including oral swab and finger-prick) among 50 lay-users in South Africa. Eighty percent found the tests easy to use, regardless of prototype. Respondents praised the convenience and confidentiality of HIVST and liked that they could test alone. A few respondents mentioned a need for counseling, information, and follow-up, suggesting several solutions, including printed counseling inside the test package, SMS messaging, and a telephone number to call. Suggestions for future HIVST use included improved instructions for finger-prick tests, though some respondents expressed concerns about the pain associated with the finger-prick. Participants felt that HIVST should be offered free of charge, or made available to buy at health facilities, pharmacies, or supermarkets. Ninety-eight percent stated that they would use the HIVST again if it was free, and 86 percent would purchase an HIVST. The 14 percent who were neutral or would not buy a test used the finger-prick test. Respondents said that HIVST would likely encourage greater testing coverage. The authors concluded that HIVST is acceptable among lay users, and that the oral swab was found the most acceptable. Policymakers should further consider these findings when considering the rollout of 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.

Wall, K.M., Kilembe, W., Vwalika, B., et al. Journal of Women’s Health (2017), 26(8), doi: 10.189/jwh.2016.6169.

This study in Zambia examined predictors of dual protection for HIV and pregnancy, including condom use only (offering suboptimal pregnancy protection), and modern contraceptive use with irregular condom use (offering suboptimal HIV protection). The 3,049 participating serodiscordant couples were followed for two years. Condom use only was associated with couples with HIV-positive males; stage III‒IV HIV disease with high viral loads; women with a high number of lifetime sexual partners; baseline use of contraceptive pills, injectables, or intrauterine devices; desire to become pregnant in the next year; and being postpartum. Among these couples, 37 percent indicated some instances of unprotected sex, increasing risks of both HIV and pregnancy. Among couples who used modern contraception, irregular condom use was more likely among young men and women; those who used injectables or implants at baseline; women who wanted to become pregnant in more than one year; and couples in which the male partner was HIV-positive and circumcised. Among couples using contraception, 38 percent reported a condomless sex act, leading to increased risk of HIV, but not of pregnancy. Consistent condom use with modern contraceptive use was reported among 23–28 percent of couples across follow-ups. Although ≥50 percent of couples did not want children, 59 percent of follow-up check-ins reported condom use only. The authors recommended integrating couples voluntary counseling and testing with couples family planning services.

Poteat, T., Malik, M., Scheim, A., Elliot, A. Current HIV/AIDS Reports (July 2017), 14: 141–152, doi: 100.1007/s11904-017-0360-1.

This literature review described available evidence on HIV prevention for transgender populations, who face elevated HIV risk due to a number of risk factors. Evidence is limited; the authors found 13 studies describing three types of interventions:

  • Behavioral (11 interventions): Includes group learning comprising lectures and role-playing to address individual and psychosocial risk factors. Eleven of the 13 interventions were behavioral.
  • Biomedical (one intervention): Includes pre-exposure prophylaxis, which has been found highly efficacious among transgender populations if adherence is good. However, adherence has been found to be low among transgender populations. Most studies have insufficient numbers of transgender participants to identify significant results. Treatment as prevention has been implemented targeting transgender women using community-based peer-led approaches, case management, motivational interviewing, incentives, and training to improve adherence.
  • Structural (one intervention): These interventions are more complex and expensive to implement. There are no outcome data available, but three small-scale projects are underway that strengthen the gender–affirming components of HIV services and provide case management, skills building, and legal and social assistance for transgender people.

Interventions and research should disaggregate data on transgender populations, develop interventions that include gender affirmation components, and prioritize HIV risk-drivers for transgender populations. Evidence-based interventions should also be adapted and evaluated, and future research should have relevance for transgender populations. 

Fatti, G., Shaikh, N., Jackson, D. et al. PLOS ONE (July 2017), 12(7): e0181691, doi: 10.1371/journal.pone0181691.

This study examined the impact of a combination HIV prevention intervention among HIV-negative young women, and identified elements associated with acquiring HIV. The combination intervention included a range of behavioral, biomedical, and structural interventions. The 1,356 participants were assigned community health workers who provided home-based care two to three times weekly until six weeks postpartum and then monthly. Among 5,289 HIV tests provided, 11 new HIV infections were identified, eight during pregnancy and three postpartum. Mother-to-child transmission was 22.2 percent. Women ≥25 years, and those who had the first antenatal care appointment later in pregnancy, were more likely to be lost to follow-up. Women who received social security grants or family planning counseling, and those whose partners received HIV testing and counseling, were less likely to be lost to follow-up. Five of 722 male partners who received HIV testing and counseling were diagnosed with HIV. All were linked to HIV services, but only one initiated treatment. Prevention packages, including home-based counseling for pregnant women and their partners should be considered to reduce maternal and pediatric HIV infections in low-resource settings.

Eba, P.M., and Lim, H. Journal of the International AIDS Society (August 2017), 20: 21456, doi: 10.7448/IAS.21.1.21456.

This literature review examined 28 HIV-specific laws for adolescents in sub-Saharan Africa to understand how legislation affects their access to HIV services. Three out of 28 laws did not address pediatric testing, counseling, or treatment; one law provided minimal information. Twenty-four laws included at least one aspect of World Health Organization (WHO) guidance for adolescents, but none addressed all four WHO recommendations. Eleven countries identified an age of consent (between 11 and 18 years); seven of these allowed adolescents under age 18 to independently access HIV testing. In 13 countries, only adults can independently access HIV testing; eight of these countries allow various exceptions including for pregnancy, high HIV risk, and legal emancipation. Madagascar is the only country that does not require parental consent for HIV treatment. Only five countries have protections against disclosing minors' test results. Laws for adolescents on testing, care, and treatment generally have not incorporated WHO guidance and are not based on human rights principles. Existing laws also largely address only testing, and neglect consent for treatment. The authors stressed the need to reform laws to maximize service access, remove legal barriers (including age of consent laws), and support implementation of these laws by developing guidelines, including through guideline development, training providers, and sensitizing youth and parents/caregivers.

Wringe, A., Moshabela, M., Nyamukapa, C., Sexually Transmitted Infections (September 2017), 0: 1–5, doi:10.1136/sextrans-2016-052969

This qualitative study examined how clients' HIV testing experiences influenced their subsequent engagement in care. Interviews were conducted with 5–10 counselors and 28–59 people living with HIV in each of six countries. HIV-positive respondents found provider-initiated testing acceptable, but neither counselors nor clients always viewed it as optional. Several counselors provided messages based upon their beliefs about appropriate sexual behaviors, whereas clients sought testing simply to learn their HIV status. However, some clients reported that counseling gave them hope and energized them to continue seeking HIV services. Some clients returned multiple times for testing, even after testing positive. This was considered part of the process of accepting one’s diagnosis, but also served to increase familiarity with health workers and the health facility, further encouraging clients to continue care-seeking behaviors. Providers addressed consent and confidentiality inconsistently; sometimes justifying a breach based on a client’s physical status, including illness and pregnancy, because they thought it could benefit an unborn child or ensure that clients did not die because they gave their medication to relatives. However, the authors noted that removing clients' testing autonomy may result in reduced trust in HIV services and providers, which is needed to optimize adherence and therapeutic outcomes.

Chizona, A.F., Pharr, J.R., Oodo, G., et al. AIDS Care (March 2017), 29 (9):1094–1098, doi: 10.1080/09540121.2017.1317325.

This study examined the impact of training 46 traditional birth attendants (TBAs) to provide HIV testing services (HTS) and prevention of mother-to-child transmission (PMTCT) in Nigeria to influence rapid HIV testing uptake among pregnant women. The intervention entailed identifying and training 1–5 TBAs at each primary health care center (PHC) on national guidance for HTS and use of the antenatal register. The TBAs were also trained to refer women who tested positive to the PHC for confirmatory testing, and to document client encounters. They visited the PHC each month to provide documentation and resupply HIV test kits. TBAs also received quarterly supportive supervision by PHC representatives for quality improvement. The number of women who received HTS increased from 2,501 (in the six months before the intervention) to 5,346 (in the six months post-intervention), with TBAs contributing greater than half of the HTS services. Intervention sites offered nearly three times as many types of HTS as control sites. The authors concluded that TBAs can fill an important gap in identifying HIV-positive pregnant women, including those in rural areas, and linking them to PMTCT and other health services.

Mudiope, P., Musingye, E., Makumbi, C.O., et al. BMC Health Services Research (2017)17:444, doi: 10.1186/s12913-017-2386-x.

This study examined the impact of the Peer Champion intervention at Mulago National Referral Hospital in Kampala, Uganda. Peers (HIV-positive mothers) were trained to provide family planning (FP) education, counseling, and referrals with accompaniment to FP appointments for HIV-positive women attending services for prevention of mother-to-child transmission (PMTCT)/postnatal care (PNC) services. Women attending their 6-, 12-, 24-, and 36-week PNC appointments who chose to use FP were accompanied by a peer champion to receive either oral contraceptive services (available through PMTCT care) or other long-acting or permanent FP options (available at other on-site clinics). Clinic attendance did not increase significantly during the intervention. Pre-intervention, intervention, and post-intervention referrals were 52.7 percent, 83.2 percent, and 72.4 percent, respectively. Following introduction of the intervention, FP referrals increased by 30.4 percent relative to baseline. After the intervention ended, FP referrals decreased by 10.8 percent. Similarly, FP method uptake increased by 31.3 percent during the intervention, and decreased by 10.8 percent afterwards. Injectable Depo-Provera was the most commonly used FP method (57.6%), followed by oral contraceptives (14.2%). The authors concluded that shifting FP tasks to well-trained peers can increase uptake of FP services in settings with insufficient human resources and high client burdens.

Harichund, C., and Moshabela, M. AIDS and Behavior (July 2017), 13:735, doi: 10.1007/s10461-017-1848-9.

This review summarized the literature on HIV self-testing (HIVST) in sub-Saharan Africa. The 11 eligible studies showed that men were more likely to find HIVST acceptable than women because this option incurred lower nonmedical costs and required no absenteeism from work. Advantages also included improved confidentiality and privacy, burdens on the health care system, lower risk of providers coercing patients into testing, and absence of stigma and discrimination. Participants expressed concerns about lack of in-person counseling, but the findings showed that telephone counseling may be an acceptable alternative. Linkage to care is a significant concern; one study found only 41.7 percent of individuals who used HIVST linked to care after a positive result. Additional concerns included risk for suicide and gender-based violence. The cost of the HIVST kit was a limiting factor for disadvantaged individuals. Some participants said that governments should provide HIVST without cost; others said that they would pay for HIVST if they could buy the kit in a confidential manner. Stakeholders from all three countries advocated for including HIVST within policy and regulatory frameworks for scale-up. The authors concluded that HIVST may work as a complementary approach to other HIV testing models, but additional research is required to inform its scale-up.

Sebastian, M.P., Dasgupta, A., Saraswati, L.R., et al. Harm Reduction Journal (June 2017), 14:38, doi:10.1186/s12954-017-0165-y.

This article described service uptake during a study of 3,774 people who inject drugs (PWID), and the costs associated with a comprehensive package of HIV prevention, care, and treatment services. The comprehensive package, implemented between 2011 and 2014 in Delhi, India, included HIV and hepatitis B and C virus (HBV, HCV) counseling and testing, treatment of sexually transmitted infections, clean needles and syringes, condoms, wound care, bathing facilities, and education. Referrals for HIV and TB treatment, opioid substitution therapy, and substance rehabilitation also were provided. The program provided 7,334 HIV tests. Nutrition services were provided for 3,494 participants and wound care to 1,219; however, only 692 continued care until wound healing was complete. Of 2,331 PWID receiving HBV testing, 1,875 returned for their result. HBV vaccination was provided to 1,706 PWID, but only 492 completed all three doses. The needle/syringe exchange and condom distribution services were provided to 2,508 and 2,392 participants, respectively. Education and awareness activities reached 2,840 PWID. At the study's end, 82 PWID were on antiretroviral treatment. Over the three-year implementation period, costs were USD$1,067,629.88. HIV prevention and care services accounted for around 50 percent of the cost. The authors concluded that providing comprehensive services for PWID is challenging, and requires significant efforts to address uptake and retention of services.

Garrison, L.E., and Haberer, J.E. Current Opinion in HIV and AIDS (June 2017), 12:000–000, doi:10.1097/COH.0000000000000393.

This review summarized technologies for measuring adherence to antiretroviral treatment and pre-exposure prophylaxis (PrEP). The document includes:

  • Real-time electronic adherence monitors, including electronic pill boxes, bottles, and blister packs, record and send opening time and date information to a central server via cellular network. Benefits include facilitating immediate intervention and enabling risk assessment for viral rebound. Challenges include under- and overestimation of adherence due to non-use or openings out of curiosity.
  • Digital medicine systems comprise a sensor embedded within a pill that, when in contact with gastric acid, sends a message via Bluetooth® or radio frequency technology. No published data are available yet, though the technology has been deemed “moderately” acceptable in hypertension and schizophrenia studies.
  • Short message service surveys have been used to determine self-reported adherence and related behaviors including sexual activity and perceived risk to determine if PrEP is being used to its maximum benefit. Cell phone access, shared cell phones, reading ability, and confidentiality are concerns, but recent studies found high rates of feasibility and acceptability.
  • Pharmacokinetic measures quantify drug concentrations within various body tissues to measure drug concentrations. Feasibility, acceptability, and cost all present potential challenges to implementation.

The authors recommended considering these novel approaches in tandem with current evidence-informed approaches to measure adherence.

Haldane, V., Cervero-Liceras, F., Chuah, F.L.H., et al. Journal of the International AIDS Society, 20:21585, doi:10.7448/IAS.20.1.21585.

This systematic review examined global evidence from programs that integrated HIV care and substance use. Each of the 51 eligible studies were classified as one of  three integration models:

  • Model 1 comprised HIV facilities that integrated substance use services. The model was further broken down into three types of HIV services: services that integrated substance use assessments, those integrating substance use treatment, and those integrating substance use treatment and other services.
  • Model 2 comprised substance use facilities that integrated HIV services, with subcategories of substance use services that integrated HIV screening and counseling, HIV treatment, and treatment of HIV and other illnesses.
  • Model 3 included integration at facility types, such as other clinical settings, mobile clinics, or harm reduction sites.

The benefits of integration included increased ability to identify HIV and/or substance use and support treatment adherence; decreased likelihood of drug interactions; and reduced costs for clients. Challenges to integration included high service delivery costs, a higher provider training burden, and difficulties with implementing integration. Staff at substance use facilities expressed lack of confidence in administering HIV tests and delivering positive results to clients. The findings also showed linkages to other community services also present challenges. The authors concluded that though more research is necessary, integrating HIV and substance abuse services confers benefits to patient and service outcomes.

Naik, R., Zembe, W., Adigun, F., et al. AIDS and Behavior (June 2017), doi:10.1007/s10461-017-1830-6.

This qualitative study examined factors that influenced linkage to care among 30 HIV-positive clients who were tested in a home-based HIV counseling and testing (HBHCT) approach in South Africa. The authors categorized findings into individual, relationship, community, and health system levels. In-depth interviews revealed that at the individual level, a client’s ability to cope influenced the time between diagnosis and linkage to care. Clients who linked directly to care accepted their diagnosis, and had sought testing because they believed that something was wrong with their health. At the relationship level, clients who lacked close personal relationships were more likely to delay care. Those who linked quickly to care described receiving strong emotional and financial support from their relationships. At the community level, poor clients, those living in rural areas, and those who were busy taking care of others or searching for jobs were more likely to delay care. At the health system level, long waiting times, being turned away, poor staff attitudes, supply shortages, and a break in client confidentiality presented barriers to care, including for those who did not experience barriers on any other level. The authors stressed the need to assess factors that influence linkage to care during HBHCT, including social support, personal motivations, and available resources. They also endorsed integrating monitoring of linkage to care into HBHCT services.

Cremin I., McKinnon, L., Kimani, J., et al. The Lancet HIV (February 2017), 4 : e214-222, doi:10.1016/

The authors developed a mathematical model to examine the optimal mix of interventions, including pre-exposure prophylaxis (PrEP), to reduce HIV incidence among a population of female and male sex workers (FSWs, MSWs) and men who have sex with men (MSM) in Nairobi, Kenya. The model showed that new infections likely will decrease from 5,110 in 2015 to 3,120 by 2030—however, the epidemic will likely be maintained among MSM. The authors provided 15 strategies that identify priority interventions (including increased condom use; improved retention in antiretroviral treatment, or ART; earlier ART; PrEP; and voluntary medical male circumcision) for each sub-population, along with the total anticipated cost of each strategy. The lowest-budget strategy was increasing condom use among MSW, followed by increasing condom use among MSM, increasing ART retention, and finally, expanding ART among all sub-populations. Prioritizing PrEP for the most vulnerable FSWs would improve the cost-effectiveness of the intervention, but would affect only a small FSW population. PrEP should be prioritized for the most vulnerable MSWs, then for MSM, and next for FSWs, as budgets allow. PrEP is less urgent for FSWs than for other populations, because of FSWs' high use of condoms. Ongoing incidence monitoring is required to determine future PrEP prioritization, especially given the high cost per infection averted.

Philbin, M.M., Tanner, A.E., DuVal, A., et al. The Adolescent Trials Network for HIV/AIDS Interventions, AIDS Education and Prevention (2017), 29(2), 93–104.

This qualitative study examined providers of HIV care for adolescents’ perspectives on linkages and adolescent engagement to: (1) inform programs specifically designed to address barriers for adolescents; (2) inform planning of appropriate resource disbursement; and (3) understand assistance required for identified needs. The authors conducted 183 semi-structured interviews with HIV care providers who treat adolescents (outreach workers, linkage coordinators, clinicians, and social service providers) in 15 clinics across the United States. Interviewees described linkage as a standard procedure that was provided for an adolescent, but did not accommodate the adolescent’s individual characteristics. Linkages were said to occur quickly, typically within a week. Participants described engagement as an individualized process in which the adolescent played an active role—carrying out self-care activities, showing up to appointments, and taking responsibility for housing and work. Interviewees described engagement and the resulting retention as a process that takes place over time and that can be hindered by stigma and difficultly accepting one’s diagnosis. They said that strong adolescent–provider relationships are critical to adolescent engagement, and noted that participation in additional services, including housing and food stamps, was essential to help adolescents to stay engaged in care. The authors concluded that effective linkages and engagement require adolescent services that are easily accessed and sustainable.

Ruzagira, E., Baisley, K., Kamali, A., et al. Tropical Medicine & International Health (April 2017), e-publication ahead of print, doi:10.1111/tmi.12888.

Home-based HIV counseling and testing (HBHCT) has the potential to increase HIV testing uptake in sub-Saharan Africa (SSA), supporting 90-90-90 objectives. However, data on linkage to HIV care after HBHCT are scarce. This systematic review examined linkage to care after HBHCT in SSA—specifically, initiation of cotrimoxazole (CTX) prophylaxis and antiretroviral therapy (ART). The authors identified 14 eligible studies from six countries. HIV-positive clients were referred for care in all studies; nine studies described specific strategies for facilitating linkage. Time intervals for ascertaining linkage ranged from one week to 12 months post-HBHCT. Linkage rates varied widely (from 8.2% to 99.1%), and were generally lower (<33%) if HBHCT was followed by referral only, and higher (>80%) if additional strategies were used. Of the 14 studies, 5 included data on CTX prophylaxis and 12 on ART initiation. CTX uptake among those eligible ranged from 0 to 100 percent. ART initiation also varied: among those eligible, the proportion starting ART ranged from 14.3 percent to 94.9 percent. The authors concluded that few studies from SSA have investigated linkage to care among adults newly diagnosed with HIV through HBHCT. They called for randomized controlled trials to confirm the effectiveness of linkage strategies.

Wirtz, A., Clouse, E., Veronese, V., et al. Journal of the International AIDS Society (April 2017), 20(1): 21796, doi:10.7448/IAS.20.01.21796.

Reaching 90-90-90 goals will require novel approaches for reaching men who have sex with men (MSM), transgender women (TW), and other populations who face stigma. This formative study in Myanmar investigated the feasibility of HIV self-testing (HIVST) to improve testing and diagnosis among MSM and TW. In 2015 the authors conducted in-depth interviews in Yangon with 12 MSM and 13 TW and carried out focus group discussions with 35 participants. Both MSM and TW believed that HIVST would benefit their communities. Participants cited privacy (enabling them to avoid stigma), ease and convenience, and painlessness as advantages of HIVST. However, participants voiced concerns about the potential mental health consequences of a positive home test, especially since they believed that HIVST did not include counseling or linkage to care. Participants made the following suggestions for implementation: including some form of pre-test counseling; including psychological support; ensuring access to confidential, nondiscriminatory treatment; and launching communication initiatives to provide accurate information on HIVST and related care. The authors concluded that if implemented appropriately, HIVST could play an important role in reducing the number of undiagnosed infections and improving the overall HIV response for these key populations in Myanmar.

Kiragu, K., Collins, L., Von Zinkernagel, D., and Mushavi, A. Journal of Acquired Immune Deficiency Syndromes (May 2017), 75 Suppl 1:S36–S42, doi:10.1097/QAI.0000000000001323.

In 2011, the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive (Global Plan) urgently advocated expanding delivery of services for prevention of mother-to-child transmission (PMTCT) services through greater integration with sexual and reproductive health and child health services. This article gave an overview of approaches taken by some of the Global Plan's 22 focus countries and identified key programmatic considerations. PMTCT has become progressively integrated within a range of services, including maternal health, pediatrics, antiretroviral therapy, and family planning. Integration has increased access to PMTCT services, and has generally been acceptable to both clients and providers. Promising practices for successful integration included:

  • Foster national-level political will to facilitate the policy and system changes needed for full integration.
  • Ensure that systems for commodity management are in place at all levels and throughout the services that are to be integrated.
  • Support task shifting to accommodate the extra duties and prepare providers fully for the new services.

The authors concluded that full integration will call for strong leadership. They called for a rigorous assessment of the impact of integrating PMTCT into existing programs, including costs, the effects on the wider health care system, and outcomes.

Haberlen, S.A., Narasimhan, M., Beres, L.K., and Kennedy, C.E. Studies in Family Planning (March 2017), e-publication ahead of print, doi:10.1111/sifp.12018.

Integrating family planning (FP) and HIV services is associated with increased knowledge and use of modern contraceptives and supports international targets for reproductive health and the 90-90-90 goals for HIV. The authors reviewed 14 eligible articles and characterized the range of models used to integrate FP into HIV care and treatment and synthesized evidence on integration outcomes among women living with HIV. Eligible studies all described facility-based models delivered in a range of facilities, from small health centers to large hospitals. In many models, HIV-positive peers delivered the FP information. Overall, integration was associated with higher knowledge and use of modern method contraceptives, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Most "one-stop shops" offered a wide range of contraceptive options, including short- and long-acting methods, but few offered female condoms or emergency contraception. Only a few studies measured the prevalence of dual contraceptive use to prevent pregnancy and HIV transmission. Providers' attitudes about respecting the fertility intentions of HIV-positive women improved in some studies, but overall remained negative. The authors concluded that especially where contraceptive use is low, integration must address community-wide and HIV-specific barriers to using effective FP methods while also improving access to information, commodities, and services within routine HIV care.

Rosenberg, N.E., Graybill, L.A., Wesevich, A., et al. Journal of Acquired Immune Deficiency Syndromes (April 2017), e-publication ahead of print, doi:10.1097/QAI.0000000000001398.

In sub-Saharan Africa, couples HIV testing and counseling (CHTC) has been associated with substantial increases in safe sex, especially when at least one partner is HIV-positive. This observational study, conducted in an antenatal clinic in Lilongwe, Malawi, examined CHTC in the context of an Option B+ program. In 2016, the authors interviewed heterosexual pregnant couples (90 female-positive and 47 female-negative, including both seroconcordant and serodiscordant couples). They provided condoms and information about their use and assessed their behavior just before and one month after CHTC, focusing on safe sex (abstinence or consistent condom use in the last month). The authors then modeled changes in safe sex before and after CHTC and compared reports of safe sex between female-positive and female-negative couples. Before CHTC, safe sex was comparable between female-positive couples (8%) and female-negative couples (2%). One month after CHTC, reported safe sex increased markedly among female-positive couples, to a prevalence of 75 percent, compared to 3 percent among female-negative couples. Serodiscordant couples in both groups reported nearly universal condom use after CHTC. The authors concluded that engaging pregnant couples in CHTC can have prevention benefits for couples with an HIV-positive pregnant woman, but additional prevention approaches may be needed for couples with an HIV-negative pregnant woman.

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.

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.

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.

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.

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.

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.

Stackpool-Moore, L., Bajpai, D., Caswell, G., et al. Journal of Adolescent Health (February 2017), 60(2S2):S3-S6. doi:10.1016/j.jadohealth.2016.11.008.

This commentary provided an overview of Link Up, a three-year project (2013–2016) to improve the sexual and reproductive health and rights (SRHR) of over 800,000 10–24-year-olds affected by HIV in Bangladesh, Burundi, Ethiopia, Myanmar, and Uganda. The project aimed to enable and scale up access to integrated HIV services and SRHR for marginalized young people, including young men who have sex with men, sex workers, people who use drugs, trans people, homeless people, and other youth. Link Up demonstrated the need to tailor project implementation to address sensitive issues within diverse country contexts. The project focused on interventions led by young people. Over 10,000 peer educators and youth leaders were trained to provide HIV and SRHR information, education, counseling, and communication materials (including hotlines and social media) within their communities. They created demand for integrated HIV and SRHR services and distributed vouchers to facilitate referrals to public or private services. The project supported the integration of HIV and SRHR programming and facilitated service outreach through support groups, youth clubs, and other activities. Link Up also provided training to over 3,300 public and private providers and community workers on topics including stigma reduction and service integration. More information on the research and programmatic activities of Link Up is included throughout this issue of the AIDSFree Prevention Update.

Wall, K.M., Kilembe, W., Vwalika, B., et al. Sexually Transmitted Infections (January 2017), pii: sextrans-2016-052743, doi:10.1136/sextrans-2016-052743, e-publication ahead of print.

This study examined the impact of couples' voluntary HIV counseling and testing (CVCT) services on sexual risk behavior in a cohort of HIV-serodiscordant heterosexual couples in Zambia. The study enrolled 3,049 heterosexual Zambian HIV-serodiscordant couples (M+F−, M−F+) with longitudinal follow-up over time (1994–2012); and compared self-reported and biological markers of unprotected sex. The findings showed substantial reductions in self-reported unprotected sex after CVCT among participants:

  • M+F– couples reported an average of 16.6 unprotected sex acts in the three months before enrollment, which dropped to 5.3 in the >0–3-month interval, and 2 in >6-month intervals.
  • M−F+ couples reported 22.4 unprotected sex acts in the three months before enrollment, dropping to 5.2 in the >0–3 month interval, and 3.1 in >6-month intervals.

Neither group showed evidence of relapse in these risk behaviors over time. The study also showed significant reductions in self-report and biological markers of outside partners. However, almost 40 percent of couples continued to have some indicator of unprotected sex, highlighting the need for targeted risk reduction counseling (especially for pregnant couples, those wanting children, and those in which HIV– negative women have outside partners or use alcohol or injectable or oral contraception). These results supported the World Health Organization’s recommendation to provide joint HIV testing and counseling for prevention.

Vu, L., Burnett-Zieman, B., Banura, C., et al. Journal of Adolescent Health (February 2017), 60(2S2):S22-S28, doi:10.1016/j.jadohealth.2016.09.007.

This study reviewed the effectiveness of Link Up, a peer-led intervention model to address barriers to care for youth living with HIV (YLHIV) in Uganda. The model provided a comprehensive package of HIV and sexual and reproductive health and rights (SRHR) services through community-based peer support groups for YLHIV. Peer educators delivered targeted counseling and health education, and referred or linked YLHIV to antiretroviral therapy (ART) and reproductive health services at youth-oriented SRHR facilities staffed with trained providers. The study used a pre-post cohort design, following individuals over a nine-month intervention period (January–September 2015). Eligible participants were male and female Link Up peer support group members aged 15–24 years in rural Luweero and Nakasongola districts. A cohort of 473 youth was recruited, and an endline survey captured 350 members of the original cohort. The results showed significant increases in self-efficacy, comprehensive HIV knowledge, HIV disclosure, condom use at last sex, uptake of services for sexually transmitted infection and ART, ART adherence, CD4 testing, and current use of a modern contraceptive method. The authors concluded that this SRHR and HIV intervention strategy shows promise, and should be further evaluated and adapted for use among YLHIV in similar settings.

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.

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.

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.

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.

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. 

Irungu,E.M., Heffron, R., Mugo, N., et al. BMC Infectious Diseases (2016), 16:571, doi: 10.1186/s12879-016-1899-y.

This study examined the feasibility of a validated risk screening tool to identify high-risk serodiscordant couples for enrollment in a study on pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for HIV prevention. The risk screen assessed recent unprotected sex, number of children, marital status, circumcision status, age of the HIV-negative partner, and HIV-1 RNA levels in the HIV-positive partner. A score ≥5 (of 12 maximum) indicated high risk (>3% annual risk of HIV transmission). Of 1,013 couples, 78.6 percent scored ≥5; 76 percent were enrolled. Among those enrolled, 67 percent of the HIV-negative partners were male. Almost all (97.8%) had been married or living with their partner for an average of two and a half years, and had learned their partner's HIV-positive status within a month before participating in the screen. Over half (64.8%) reported condomless sex during the month before the screen. CD4 counts >500 were found among 41 percent of HIV-positive participants. The authors concluded that the validated screen was easy to use, low-cost, and effective at identifying high-risk couples. Counseling among serodiscordant couples should stress the benefits of early antiretroviral therapy for the HIV-negative partner.

Zablotska, I., Grulich, A.E., Phanuphak, N., et al. Journal of the International AIDS Society (October 2016), 19(Suppl 6): 21119, doi: 10.7448/IAS.19.7.21119.

This review summarized advances, opportunities, and challenges in implementing pre-exposure prophylaxis (PrEP) in 12 countries in the Asia-Pacific Region. Men who have sex with men (MSM) experience HIV at 5–15 times higher rates than the general population. HIV incidence among female sex workers (FSWs) has decreased, but remains elevated. Prevention interventions for MSM and FSWs, including HIV testing services (HTS), condoms, and needle exchanges, have been largely inadequate. PrEP may be a viable option, given the concentrated epidemic in the region. Awareness of PrEP is generally low, but acceptability is high among those with knowledge of the approach; and PrEP clinical trials and demonstration projects involving MSM and transgender people are underway in several countries. Access to PrEP by key populations is limited by lack of knowledge, education, and availability, or by cost and stigma and discrimination; and use of HTS, which acts as a conduit to PrEP services, is very low among MSM. The World Health Organization has released guidance on administering PrEP among key populations; some countries in the region are developing their own guidance and policy documents. Community advocacy projects in Australia and Thailand are increasing awareness and demand, but further advocacy by communities is required to build awareness of the need for PrEP in the region, especially among MSM and FSWs. 

Helleringer, S. AIDS and Behavior (October 2016), doi: 10.1007/s10461-016-1577-5.

This study used survey data (2009–2015) to examine why adolescents are tested for HIV at lower rates in 21 West and Central African countries. Low socioeconomic status (SES), stigma and discrimination, reduced social support, marriage power dynamics, and lack of education contribute to high adolescent fertility rates and lead to reduced uptake of HIV testing services (HTS) during antenatal care (ANC); this in turn leads to higher rates of mother-to-child transmission (MTCT). Findings across countries showed that >80 percent of women attended at least one ANC visit during their pregnancy. Adolescents were significantly less likely to receive HTS in 12 of the 21 countries. In several countries, marriage was associated with increased or decreased likelihood of receiving HTS; but for most countries there was no association. School attendance and household wealth were both associated with increased HTS. Women living in urban areas who attended ANC during the first trimester, and who attended ANC multiple times throughout the pregnancy, were also more likely to receive HTS. Reduced SES (in 8 of 12 countries) and low knowledge of MTCT (in 11 countries) were strongly associated with lower adolescent HTS uptake. The authors suggested that targeting low-income households, implementing education campaigns, providing incentives for ANC attendance, and developing interventions that prompt providers to provide adolescent HTS may help to address the HTS gap among adolescents.

Kim, H.B., Haile, B., and Lee, T. Health Economics (August 2016), doi:10.1002/hec.3425.

This study used data from a randomized controlled trial to determine voluntary counseling and testing (VCT) uptake among households exposed to HIV education, home-based VCT, or conditional cash transfers (CCTs) to incentivize clinic-based VCT. The authors developed four experimental groups: 1) home-based HIV education with VCT promotion; 2) home-based HIV education with VCT provided that day or within the following 10 days; 3) home-based HIV education for clinic-based VCT with CCT on receiving test results (to compensate for missed wages and required travel for clinic-based VCT); and 4) a control group. To examine recurrent HIV testing, the authors subsequently randomized the four groups into a group receiving home-based VCT and a clinic-based VCT group using CCT. The results showed that relative to those in the control group, individuals receiving home-based VCT, clinic-based VCT, and education only were 63, 57, and 8 times more likely, respectively, to know their status. Despite similar uptake in HIV testing between home- and clinic-based VCT, those who tested at home were more likely to have a positive test result. Previous history of HIV testing did not decrease the likelihood of future HIV testing uptake. The authors concluded that HIV testing uptake is most effective when HIV education is paired with home- or clinic-based VCT, and that VCT promotion campaigns should be linked to improved VCT access.

Cohn, J., Whitehouse, K., Tuttle, J., Lueck, K., and Tran, T. The Lancet (August 2016), doi:10.1016/S2352-3018(16)30050-9.

This systematic review (2004–2016) examined 26 articles on HIV prevalence in children (ages 0–5) identified through screening provided in inpatient, outpatient, nutrition, and immunization settings. Across sites, HIV prevalence was 15.6 percent, with the highest prevalence in inpatient sites, followed by nutrition centers, immunization centers, and then outpatient sites. Symptom-based versus universal testing in inpatient settings trended towards slightly higher HIV prevalence, but findings were not significant. Caregiver acceptance of testing was 92.2 percent. Agreement to testing was often attributed to concerns about the frequency of a child’s illness and a desire to learn a child’s HIV status; reasons for rejecting a test included anxiety about a potentially positive result, not being emotionally prepared, and needing to speak with the male partner before testing. Provider-initiated testing and counseling (PITC) was more likely to be provided in inpatient settings; recurrent trainings are needed to maintain PITC uptake. Rationales for not providing PITC included children's young age, severe illness, and being over-burdened with work. Inpatient settings had the highest retention in care as measured by parents returning for test results. The authors concluded that pediatric health services, outside the prevention of mother-to-child transmission context, represent an important avenue for identifying HIV-positive children, especially in settings that provide inpatient and nutrition services.

Krishnaratne, S., Hensen, B., Cordes, J., et al., The Lancet HIV (2016), 3: e307–17, doi: 10.1016/S2352-3018(16)30038-8.

This systematic review of 292 studies (1995–2015) mapped the current evidence for HIV prevention, using the HIV prevention cascade to classify interventions. Studies were categorized into four intervention areas:

  • Demand-side interventions (n=194) included information, education, and communication to increase knowledge of risk and change attitudes towards prevention practices. These interventions consisted of multimedia, text messages, posters, and peer-to-peer approaches. Demand-side interventions generally did not influence HIV outcomes; the exact mix of interventions to influence population level HIV acquisition requires further analysis.
  • Supply-side interventions (n=35) included HIV integration, and policy changes to influence needle/syringe and condom distribution program access. Supply-side interventions generally proved efficacious. The authors called for further studies, including randomized controlled trials (RCTs), to understand how supply-side interventions influence HIV outcomes.
  • Adherence interventions (n=51) included individual and couples HIV testing and counseling, prevention for positives, and cash transfer and microfinance interventions. These interventions comprised counseling in health facilities and community settings, cash transfers for school attendance and school performance, and small loans for income-generation activities, at times combined with life skills training. There remain significant evidence gaps for adherence interventions.
  • Direct mechanism interventions for HIV prevention (n=98) included voluntary medical male circumcision, condoms, pre-exposure prophylaxis, microbicides, treatment of sexually transmitted infections, and vaccines. Multiple RCTs provided evidence for direct mechanism interventions, although vaccine trials have provided mixed results. 

Ssemmondo, E., Mwangwa, F., Kironde, J.L., et al. Journal of Acquired Immune Deficiency Syndromes, epub ahead of print (2016), doi: 10.1097/QAI.0000000000001142.

The authors of this study conducted integrated multi-disease community campaigns, including HIV and tuberculosis (TB) testing and screening, in seven rural Ugandan communities, and examined TB screening yield and TB treatment outcomes. The campaigns comprised a community census, a two-week public rapid HIV test and TB symptom screening campaign, and household follow-up for those not yet accessing testing and screening services. Individuals with positive TB symptoms provided sputum samples at the campaign; these were evaluated by a lab the same day. Those with positive sputum results were directed to come to the clinic for treatment within 24 hours. A total of 2,876 individuals reported persistent (>2 weeks) cough, but only 1,099 individuals provided sputum samples. Of these, 10 adults were identified as having TB; nine were newly diagnosed. TB screening yield for newly diagnosed individuals with persistent cough was 9/2,876. To identify one new individual with TB through sputum microscopy, 320 had to be screened for those with persistent cough, and 80 for those who were HIV-positive with persistent cough. This approach successfully integrated TB case finding through an integrated community campaign. Nine individuals diagnosed with TB were enrolled in TB services; six successfully completed treatment; one experienced treatment failure and started second-line therapy, one was lost to follow-up, and one died from other causes.

Rosenberg, N.E., Hauser, B.M., Ryan, J., et al., Sexually Transmitted Infections (August 2016), 0:1–8, doi: 10.1136/sextrans-2016-052651.

This systematic review of eight articles examined the influence of HIV counseling and testing (HCT) on risk of acquiring HIV among HIV-negative individuals. The authors compared sites that provided complete HCT services versus those that did not; individuals who received HCT versus those who did not; and provision of individual versus couples HCT. The site comparisons, which compared full workplace HCT versus workplace HCT with provision of off-site results, did not show that the HCT site had an impact on HIV acquisition. Of the five studies that examined individual HCT HIV acquisition, four were conducted in households and one in the work setting. There was no statistically significant difference in HIV positivity between those who received individual HCT and those who did not. One study that adjusted for sexual behavior found that HCT was protective. Two studies examining individual versus couples testing showed that couples HCT tended to be more protective, though one study indicated that this effect was stronger for women. All results indicated that individual HCT does not change the risk of HIV positivity; and that couples HCT reduces the risk of HCT positivity by nearly half. These findings, the authors said, are consistent with other studies that show larger behavioral changes following couples HCT versus individual HCT.

Kelley, A.L., Hagaman, A.,K., Wall, K.M., et al. BMC Public Health (2016) 16:744, doi 10.1186/s12889-016-3424-z.

This study examined couples’ voluntary counseling and testing (CVCT) led by the Rwanda Zambia HIV Research Group. Influential network leaders (INLs) were trained to encourage CVCT, and recruit and mentor influential network agents (INAs), who were trained to educate and invite couples to CVCT. Through surveys distributed to INLs (31 in Zambia, 27 in Rwanda), INAs (53 in Zambia, 33 in Rwanda), and couples who underwent testing (1,271 in Zambia, 3,895 in Rwanda), this study examined INL and INA supportive mentoring, their CVCT promotion activities, and where couples received CVCT information. The results showed that Rwandan INLs and INAs reported speaking with couples more often in comparison to those in Zambia, who more often spoke to married women and community groups. In Rwanda and Zambia, each INL supported on average 2 and 3 INAs, respectively, meeting 7 times per month for 32–45 minutes. Zambian couples were twice as likely to learn about CVCT from an INA, whereas Rwandan couples more often learned about CVCT from another couple. More couples were tested in Rwanda than Zambia (6% versus 18%). The authors concluded that Rwanda may have had higher CVCT rates due to the Rwandan INA’s personal experience undergoing HIV testing services themselves, more hours per week spent promoting CVCT, and promotion of group and couples CVCT.

Chang, W., Chamie, G., Mwai, D., et al. Journal of Acquired Immune Deficiency Syndromes (2016), E-publication ahead of print. doi: 10.1097/QAI.0000000000001141.

This study examined the costs of community-based HIV testing and counseling provided through multi-disease testing campaigns in 32 Ugandan and Kenyan communities (2013–2014). The initiative consisted of a community census, followed by two weeks of a community health campaign (CHC) including public screening for HIV, tuberculosis, malaria, hypertension, and diabetes. After CHC, individuals who had not yet accessed testing were identified and offered home-based testing (HBT). Researchers examined the testing costs in 12 of the 32 communities. The average cost for implementing the approach was USD$92,403 per community. The average cost per adult test was USD$20.50, including CD4 test for those testing positive. For each HIV-positive adult, the associated cost was $230.70, although costs varied among study communities ($87–$1,245) given variations in HIV incidence across settings. Testing during CHC cost $13.80 for each adult, while HBT cost $31.70. The cost per HIV-positive diagnosis was $153.30 for CHC and $298.50 for HBT. During CHC, 74 percent of adult community members were tested; follow-up HBT increased coverage to 89 percent. While costs associated with CHC testing were lower, more HIV-positive individuals were identified through HBT. The authors suggested using these findings to inform programs seeking to scale up HIV testing, and to support decisions on resource distribution and policies.

Karita, E., Nsanzimana, S., Nsanzimana, F., et al. Journal of Acquired Immune Deficiency Syndromes (2016), e-publication ahead of print, doi: 10.1097/QAI.0000000000001138.

This paper described the approaches Rwanda used to achieve 88–90 percent testing among married couples between ages 25–29. Over 90 percent of new infections are among couples who live together. In 1998, a research team introduced HIV testing to women, many of whom also requested it for their spouses. Follow-up data showed that HIV infection rates were twice as high among women whose partners had not been tested. Initial challenges with disclosure inspired development of procedures for couples pre- and post-test counseling. In 1999, the model was scaled up to antenatal care (ANC) clinics. Trained community leaders promoted couples testing, and 41,852 couples were tested from 2003–2008. By 2008, after a country-wide initiative for prevention of mother-to-child transmission in which community health workers promoted couples testing during home visits, 78 percent of male partners had tested at ANC clinics. In 2009, new national guidelines called for joint couples testing and counseling with shared disclosure. Initial findings indicated that counselors needed further training on joint counseling, as well as adapted data collection tools and procedures. As of 2012, more than 400 health facilities were offering couples HIV testing, with 84 percent of pregnant women’s husbands accepting testing. The authors concluded that programs should emphasize couples counseling, given its potential for risk reduction. 

Baxter, C., and Karim, S.A. African Journal of AIDS Research (2016), 15(2): 109–121, doi: 10.2989/16085906.2016.1196224.

This review examined combination prevention strategies available for young women in Africa. The authors found some successes, but also numerous challenges:

  • Structural and behavioral interventions: Abstinence, monogamy, and condom strategies present numerous behavioral challenges, including partner fidelity, mixed availability of condoms, and agreement on partner condom use. Peer and mass media education, sex education programs, and skills-building projects have improved HIV awareness and condom use and reduced risky behaviors, but have not demonstrated reduced HIV infection rates. HIV counseling and testing have reduced risk-taking behaviors, but stigma and discrimination limit uptake. Cash transfer programs have demonstrated success in school retention, condom use, delayed sexual debut, and reduced sexual risk-taking; but studies have not shown reduced HIV incidence.
  • Biomedical interventions: Antimicrobial approaches and pre-exposure prophylaxis have had mixed results, requiring optimal adherence to improve effectiveness. Treatment as prevention is effective; two trials demonstrated zero transmission with viral loads below 400 copies/mL and 200 copies/mL. Although voluntary medical male circumcision reduces female-to-male transmission, it offers little immediate protection for women. Treatment for sexually transmitted infections reduced HIV incidence by 42 percent in one study, but the findings have not been replicated.

The authors concluded that HIV prevention in women requires flexible combination prevention packages that include context- and population-specific biomedical, behavioral, and structural interventions. Further research is needed to identify effective female-controlled prevention strategies. 

Kelvin, E.A., Cheruvillil, S., Christian, S., et al., African Journal of AIDS Research (2016), 15(2): 99–108, doi: 10.2989/16085906.2016.1189442.

Increasing HIV testing rates is essential to the scale-up of combination prevention packages, including treatment as prevention and pre-exposure prophylaxis. Alternative HIV testing models may increase uptake among populations who are hesitant to access clinic-based testing. This qualitative study explored perceptions of home-based HIV self-testing through 20 semi-structured interviews with primary health care patients in South Africa in 2010. Nine interviewees viewed home testing favorably; eight viewed it unfavorably; and three had no preference. Despite mixed opinions, the majority of participants (n=16) thought that uptake of self-testing in South Africa would be common; and 14 said that they would use a home test. Positive perceptions of home testing included privacy, time savings, increased potential for repeat self-testing, and convenience. Half the participants mentioned negative consequences such as emotional trauma, including self-inflicted harm when positive results occur. Individuals who had previously been tested, were in a committed relationship, and considered themselves unlikely to be HIV-positive were more likely to view home testing positively. Men were also more open to self-administered testing than women. Couples home testing was more likely within a committed relationship, rather than in a casual relationship, where condom use was more likely. Providing a variety of testing options may permit people to select the testing method that best suits their specific needs.

Maeri, I., El Ayadi, A., Getahun, M., et al. AIDS Care (2016), 28: S3, 59–66, doi: 10.1080/09540121.2016.1168917.

This qualitative study examined disclosure experiences among couples in Kenya and Uganda. Through semi-structured interviews with 50 HIV providers, 32 community leaders, and 112 residents (HIV-positive and -negative) in 8 communities, the authors examined experiences with disclosure to close partners; customs, opinions, and actions related to HIV testing; and practices for accessing HIV care. Barriers to disclosure varied by sex. HIV-positive women feared their partner leaving them or behaving violently, whereas HIV-positive men feared marital conflicts over infidelity. To maintain secrecy, partners reported accessing HIV services at remote facilities, hiding medication, and falling out of care, resulting in loss to follow-up and poor adherence to medication. Positive disclosure experiences led respondents to improve their care-seeking behaviors, encourage others to test, begin treatment, and use protection with serodiscordant partners. Negative experiences included partner desertion, blocking access to care, and physical violence. Couples testing at health facilities facilitated positive disclosure experiences, as facility staff were able to offer assistance with disclosure and helped minimize partners placing blame when both tested positive. The authors recommended exploring such approaches as addressing male and female partners' concerns, supporting providers to offer disclosure services, exploring alternative testing locations to increase male uptake, and developing community disclosure support services.

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.

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.

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.

Barnabas, R.V., van Rooyen, H., Timwesigye, E., et al. The Lancet HIV (May 2016), doi: 10.1016/S2352-3018(16)00020-5.

This study investigated whether community-based HIV testing with counselor support and point-of-care CD4 cell count testing would increase uptake of antiretroviral therapy (ART) and male circumcision (MC). Between June 2013 and March 2015, 15,332 participants were tested in South Africa and Uganda. Those found positive (n = 1,325) were randomly assigned in a factorial design to receive (1:1:1) lay counselor clinic facilitation, lay counselor follow-up visits, or standard clinic referral; and subsequently (1:1) either point-of-care CD4 testing or referral for CD4 testing. HIV-negative uncircumcised men (n = 750) were randomly assigned to receive mobile phone text message reminders, home visits, or standard referral for MC. Lay counselor facilitation of clinic visit increased clinic linkage; and lay counselor follow-up increased ART uptake. Text message reminders and lay counselor visits increased uptake of MC; with text messages, MC uptake nearly doubled relative to standard referral. Half of HIV-positive individuals in both groups (community-based and standard clinical care) achieved viral suppression at nine months. The authors concluded that community-based approaches and use of trained lay people are key components of combination HIV prevention strategies.

Ying, R., Sharma, M., Celum, C., et al. The Lancet HIV (May 2016), doi: http://dx.doi.org/10.1016/S2352-3018(16)30009-1.

This study used a mathematical model of HIV transmission in KwaZulu-Natal to estimate the effectiveness and cost-effectiveness of expanding antiretroviral therapy (ART) through home HIV testing and counseling (HTC), with linkage to care and ART initiation based on either CD4 count alone, or CD4 combined with viral load data. For a scenario of home HTC every five years, the authors calculated the incremental cost-effectiveness ratio per HIV infection, HIV-associated death averted, and quality-adjusted life-years gained. The model showed that home HTC every five years, with linkage to care and ART initiation at CD4 counts of 350 cells/μL or less, reduced HIV incidence by 40.6 percent over ten years. Expanding ART to people with CD4 counts above 350 cells/μL who also have a viral load of 10,000 copies/mL or more showed an additional decrease in HIV incidence by 51.6 percent. Thus, combining CD4 and viral load counts was the most cost-effective strategy for preventing HIV infections, at USD$2,960 per infection averted. The authors concluded that providing province-wide home HTC every five years was a cost-effective strategy for increasing ART coverage and reducing HIV burden. They recommended expanding home HTC and integrating these strategies into existing HIV programs.

Center, K.E., Gunn, J.K., Asaolu, I.O., et al. PLOS ONE (April 2016), 11(4): e0154213, doi: 10.1371/journal.pone.0154213. Relationship Power and Sexual Violence Among HIV-Positive Women in Rural Uganda Conroy, A.A., Tsai, A.C., Clark, G.M., et al. AIDS and Behavior (April 2016), e-publication ahead of print.

The authors used data from 35,748 women described in Demographic and Health Surveys from the Republic of Congo (20112012), Mozambique (2011), Nigeria (2013), and Uganda (2011) to examine how modern and traditional forms of contraception were associated with uptake of HIV testing. The authors reported that women in Mozambique demonstrated increased odds of being tested for HIV if they were using modern forms of contraception compared to those who used no contraception. This association was not found in Congo, Nigeria, or Uganda. Women in Congo (but not other countries) demonstrated decreased odds of being tested for HIV if they used traditional forms of contraception, such as periodic abstinence and withdrawal, compared to those who used no contraception. The authors concluded that because some forms of modern contraception (such as hormonal methods) require a clinical visit appointment, family planning appointments could provide women with additional opportunities to access HIV testing, education, and treatment. 

Go, V.F., Morales, G.J., Mai, N.T., et al. Implementation Science (April 2016), 11(1): 54, doi: 10.1186/s13012-016-0420-8.

Between December 2014 and February 2015, the authors used a two-phase process, adapted from the Expert Recommendations for Implementing Change (ERIC) protocol, to assess barriers and facilitators to methadone maintenance therapy (MMT)/HIV integration; and used this assessment to identify appropriate implementation strategies in Vietnam. In Phase 1, they conducted 16 in-depth interviews with stakeholders and developed matrices to display barriers to integration. In Phase 2, they selected implementation strategies that addressed the barriers identified in Phase 1, and conducted a poll to determine the most important and feasible strategies. Overall, participants were receptive to service integration, noting the benefits to both patients and the health system. The most important benefit identified was better access to services and care for MMT and HIV patients. Barriers were grouped into five main domains: two at the policy level (service and staffing structures) and three at the programmatic level (technical assistance for clinic staff, staff accountability, and local commitment). Strategies selected during Phase 2 included technical assistance, building staff accountability, and securing local commitment to address the barriers identified earlier. The authors concluded that this process for identifying implementation strategies was simple, low-cost, and potentially replicable in other settings.

Lippman, S.A., Shade, S.B., El Ayadi, A.M., et al. Journal of Acquired Immune Deficiency Syndromes (April 2016), e-publication ahead of print.

From January to March 2014, the authors conducted a population-based survey (n=1,044), HIV rapid testing, point-of-care CD4 testing, and viral load measurement to characterize the HIV care continuum in a rural district of North West Province, South Africa. Overall, 20.0 percent of men and 26.7 percent of women were HIV-positive; prevalence was higher among females than males in every age group. Over half of men and one-quarter of women first learned their status at diagnosis. Men's prevalence increased with age, peaking at 40–49 years; women's prevalence peaked at 30–39 years. Throughout the HIV-positive population, there was major attrition along the HIV continuum of care for the full HIV-positive population. The most significant drop occurred at the gateway to the care continuum—HIV testing, particularly for men. Additionally, while most HIV-positive individuals began antiretroviral therapy, only 33.1 percent of men and 58.4 of women were retained in care. Of those receiving treatment, only 33.1 percent and 53.5 percent of HIV-positive men and women, respectively, reported adherence to medication, and only 21.6 percent and 50.0 percent had attained viral suppression. This study, the authors concluded, provided a comprehensive picture of the HIV care continuum in the North West Province, and should be used to inform targeted programming.

Kaufman, M.R., Smelyanskaya, M., Van Lith, L.M., et al. PLOS ONE (March 2016), http://dx.doi.org/10.1371/journal.pone.0149892.

This systematic review synthesized literature published between 1990 and 2014 on services for sexual and reproductive health (SRH) and voluntary medical male circumcision (VMMC) for male adolescents in sub-Saharan Africa. The authors' aim was to determine the best age-appropriate practices for this population, and to recommend future research to understand the characteristics of effective adolescent VMMC services. The 70 articles included in the review described numerous barriers that impeded both access to and appropriate delivery of SRH services. These barriers included structural factors, imposed feelings of shame, negative interactions with providers, violations of privacy, fear of pain from the VMMC procedure, and desire to integrate traditional non-medical circumcision methods into medical forms. The studies also pointed to factors that increased service uptake and satisfaction among adolescent males. These included parental and community involvement, a youth-friendly service environment, perception of other benefits from VMMC (aside from HIV risk reduction), and clear understanding of VMMC messages. The authors concluded that reaching male adolescents with a meaningful, comprehensive package that includes SRH and VMMC services would require more action to tailor guidelines, services, and messages to younger clients. 

Kaufman, M.R., Smelyanskaya, M., Van Lith, L.M., et al. PLOS ONE (March 2016), 11(3):e0149892, doi:10.1371/journal.pone.0149892.

The authors of this systematic review synthesized research on sexual and reproductive health (SRH) and voluntary medical male circumcision (VMMC) services for male adolescents in sub-Saharan Africa, and identified the best age-appropriate practices for this population. The 79 eligible studies, which were published between January 1990 and March 2014, tended to focus on SRH services for adolescents and VMMC services for males in general. Factors that facilitated effective services for adolescent males included involving parents and the community, creating a youth-friendly service environment, promoting additional perceived benefits of VMMC, and creating messages specifically for young males. National and media campaigns have been effective in reaching male adolescents with specific information about VMMC and its protective effects. Such factors as feelings of shame, negative interactions with providers, violations of privacy, and fear of pain comprised barriers to SRH and VMMC services. The authors called for more research to explore how to tailor counseling on SRH during the VMMC process to adolescents of different ages, levels of maturity, and sexual experience.

Mukandavire, Z., Mitchell, K.M., Vickerman, P. Epidemics (March 2016), doi:10.1016/j.epidem.2015.10.002.

This modeling study estimated the relative impact of PrEP and condom use by female sex workers (FSWs) to clarify the importance of PrEP for preventing HIV transmission in this group and compare the benefits of introducing PrEP versus prioritizing the scale-up of condom use among FSWs. The authors stratified the population into three classes, denoting the HIV prevalence among FSWs, their clients, and pimps (boyfriends and "others" in the sex industry). Analyses showed that increasing PrEP use among FSWs was unlikely to result in the same population-level impact as increasing condom use. Furthermore, the relative impact of PrEP was lower than that of condoms for HIV infections averted over 10 years; a >3 percent increase in PrEP coverage achieved the same impact as a 1 percent increase in condom use. A potentially important use for PrEP, the authors said, was to protect FSWs against HIV transmission from pimps and other male sexual partners involved in the sex industry, who might be reluctant to use condoms. The authors concluded that PrEP could be an effective HIV prevention tool for FSWs, but is unlikely to achieve the same population-level impact as existing condom use promotion interventions among FSWs. They recommended that PrEP only be implemented once condom promotion interventions have reached their maximum impact.

DiClemente, R. J., & Jackson, J. M. Sex Education (July 2014), Vol. 14, No. 5, pp. 609–621.

The authors of this opinion paper highlight approaches to, challenges, and gaps in HIV prevention programming for young people and adolescents (aged 13–24 years)—a group of global concern in terms of HIV-related morbidity and mortality—and advocated for an adapted, integrated combination prevention approach for this group. While numerous biomedical interventions exist, their use with young people raises challenges, including the absence of appropriate testing for safe use in young people and adolescents, and limited knowledge and low adherence to medication in this population. The authors noted that existing evidence-based behavioral, biomedical, and structural interventions could be adapted for young people. Meta-analysis has shown that behavioral interventions are effective in reducing risky sexual behavior among young people—for example, by increasing condom use and increasing sexual negotiation skills. The authors added that community mobilization strategies have been shown effective in achieving large-scale uptake of HIV prevention strategies among adolescents and youth. Furthermore, cost-effective, technology-driven, evidence-based interventions can be effective for reaching young people, who are often already using that technology. The authors concluded that an integrated implementation approach consisting of tailored biomedical, behavioral, and structural interventions is necessary for successful HIV prevention programming among young people.

Brown, J. L., Sales, J. M., & DiClemente, R. J. Current HIV/AIDS Reports (September 2014), E-publication ahead of print.

To assess the effectiveness of integrated behavioral and biomedical interventions, the authors conducted a literature review on efficacy data and factors associated with the acceptability and uptake of three biomedical HIV prevention approaches: microbicides, pre-exposure prophylaxis (PrEP), and HIV vaccination. They searched online databases to identify published articles in peer-reviewed journals that either (a) provided efficacy data or evaluated the acceptability of microbicides, PrEP, or an HIV vaccine or (b) discussed strategies for optimizing the implementation and dissemination of combination HIV prevention interventions. The study showed that microbicides and HIV vaccination have limited efficacy for HIV prevention, but PrEP has been shown to be effective. The authors noted that while many efficacious biomedical prevention strategies exist, numerous factors may affect their acceptability, uptake, and dissemination among key populations. The review showed that there are no available strategies to effectively incorporate biomedical and behavioral interventions, and identified concerns about the potential negative consequences of biomedical HIV prevention on behavioral prevention interventions, such as condom use. Additionally, challenges such as access to services, cost, and patient comfort can impede dissemination of biomedical HIV prevention methods. The authors called for more research to identify strategies for effectively integrating and evaluating combination HIV prevention interventions, and stressed that these interventions should be tailored to specific populations.

El-Bassel, N., Gilbert, L., Terlikbayeva, A., et al. Journal of Acquired Immunodeficiency Syndrome (October 1, 2014), Vol. 67, No. 2, pp. 196–203.

The authors of this article described a randomized controlled trial in Kazakhstan to address the co-occurring epidemics of HIV and hepatitis C virus (HCV) infection among persons who inject drugs (PWID). This study tested the efficacy of a behavioral, couple-based intervention aimed at reducing: (1) incidence of unprotected sex and of HIV, HCV, and other sexually transmitted infections (STIs), and (2) unsafe injection practice among PWID and their partners. A total of 300 eligible participants were recruited from health clinics, harm reduction service centers, and PWID networks in the city of Almaty. Participants were randomly assigned to either a five-session risk reduction (RR) intervention, or a five-session wellness promotion (WP) intervention (the control group). At the 12-month follow-up, participants in the RR arm had 51 percent lower incidence of HIV infection and 69 percent lower HVC infection than the WP control participants. Participants in the RR arm also showed a 42 percent lower incidence of unprotected sex with their partners, compared to those in the WP arm. The authors concluded that behavioral interventions can provide significant impact to HIV/HCV/STI prevention efforts, and should be scaled up for PWID in harm reduction programs, drug treatment, and criminal justice settings.

Young, S. D., Cumberland, W. G., Nianogo, R., et al. The Lancet HIV (January 2015), DOI: http://dx.doi.org/10.1016/S2352-3018(14)00006-X,

This cluster randomized controlled trial tested the efficacy of the Harnessing Online Peer Education (HOPE) social media intervention to increase HIV testing among men who have sex with men (MSM) in Peru. Participants were randomized to intervention (n = 252) or control groups (n = 246) on Facebook for 12 weeks. Thirty-four Peruvian MSM were trained as HIV mentors (peer leaders) who interacted with intervention participants on Facebook, discussing the importance of HIV prevention and testing by sending messages, chats, and wall posts. Participants in control groups received standard care, including routine care and participation in Facebook groups that provided study updates and HIV testing information. Data analysis at 12 weeks' follow-up showed that more intervention than control participants requested an HIV test, and 17 percent of intervention participants tested for HIV, compared to 7 percent of participants in the control group. In addition, participants in the intervention group remained highly engaged in group discussions throughout the duration of the study compared to the control group. The authors concluded that an almost three-fold increase in HIV testing rate between the intervention and control group participants, and a 90 percent retention rate in the intervention group, suggest that peer-mentored social media interventions can be an efficient way of increasing HIV testing among MSM in Peru.,/p>

Becker, S., Taulo, F. O., Hindin, M. J., et al. BMC Public Health (December 2014), E-publication ahead of print.

This pilot study examined the uptake of couple HIV counseling and testing (CHCT) and couple family planning (CFP) services during a single home visit. The authors enrolled 180 couples from the three villages in Mpemba, a peri-urban area of Blantyre, Malawi. A pair of counselors (male and female) visited each couple and conducted a baseline interview assessing reproductive and health risks within the partnership, along with attitudinal questions about the partners' emotional closeness and likeliness to discuss pregnancy. The counselors then privately asked the female partner about her consent to CHCT + CFP, CHCT only, or CFP only. The man was offered whichever service(s) the woman had accepted. The authors reported that 89 percent of the couples accepted at least one of the services offered. Among untested participants, 78 percent of women and 91 percent of men accepted HIV testing. Additionally, reported condom use increased from 6 percent to 25 percent. Moreover, each couple’s acceptance of services was positively and significantly associated with several factors specific to the female partner: the woman’s number of live births, reported emotional closeness to her partner, and prior HIV testing. The authors concluded that home-based CHCT and CFP can increase access to HIV testing and contraceptive services to couples and prevent unplanned pregnancies and sexually transmitted infections.

Denno, D. M., Hoopes, A. J., and Chandra-Mouli, V. Journal of Adolescent Health (January 2015), doi: 10.1016/j.jadohealth.2014.09.012.

This review summarized initiatives to improve adolescent access to and use of sexual and reproductive health services (SRHS) in low- and middle-income countries. The authors examined four types of SRHS initiatives: (1) facility-based, (2) non-facility-based, (3) interventions to reach marginalized or vulnerable populations, and (4) interventions to generate demand and/or community acceptance. For the facility-based interventions, the authors found that combining health worker training, adolescent-friendly facility improvements, and broad information dissemination via the community, schools, and mass media was more effective than initiatives that only provided adolescent-friendliness training for health workers. Moreover, non-facility interventions (taking the services where adolescents live and congregate such as schools) were not well used, and did not improve sexual and reproductive health outcomes. Also, out-of-facility interventions were not likely to be cost-effective because of the high operating costs associated with providing multiple (including non-health-related) services. Interventions to generate demand and/or community acceptance were associated with adolescent SRHS use, and interventions to foster approval of SRHS among parents and other gatekeepers showed positive results. The authors could not identify any interventions that reported outcomes specifically for vulnerable or marginalized groups. They recommended additional research to identify the best mechanisms for delivering packages of interventions that train health workers, improve facility adolescent-friendliness, and generate demand for services among adolescents.

Bekker, L-G., Johnson, L., Cowan, F., et al. The Lancet (January 2015), Vol. 385, Number 9962, pp. 72 – 87.

The authors conducted a review of observational studies, randomized controlled trials, and consensus papers or program reports from implementing organizations, and a targeted web-based search of reports from the World Health Organization and the Joint UN Programme on HIV/AIDS, to identify new policy guidelines on female sex workers (FSWs) and the latest evidence on HIV prevention for this group. Behavioral and structural prevention strategies and sexual and reproductive health services for FSWs include condom distribution programs, counselling, testing, and supportive linkages to care. They found that programs for FSWs have reported more significant success in uptake and adoption of condoms than programs for any other affected population. The authors also noted that community-based programs, such as India's Sonagachi and Empower Thailand, are associated with both increased condom use and decreased HIV prevalence, not only among FSWs but also among bridge populations. Community-based programs are feasible to implement and take to scale; they are safe and are highly acceptable to FSWs. The authors stressed that new biomedical interventions, including topical and oral antiretroviral-based pre-exposure prophylaxis and earlier antiretroviral treatment as prevention, must be added to more established structural interventions such as law reform and protective policing. In addition, high levels of coverage and quality, and sustainability of services, are critical for maximizing the effect of structural interventions.

Kurth, A. E., Lally, M. A., Choko, A. T., et al. Journal of the International AIDS Society (February 2015), Vol. 18, Issue 2, Supplement 1, doi: 10.7448/IAS.18.2.19433.

In both low- and high-income countries, HIV testing is an important entry point for primary and secondary prevention, as well as care and treatment for young people, including young key populations (YKPs). The authors of this paper discussed critical issues for young people, including YKPs, along the HIV testing-prevention-treatment continuum. They noted that existing school-based HIV education does not always encourage youth to seek testing, and there are few youth-friendly facilities available. In most countries, minors require consent from parents or guardians for HIV testing, and providers deny unaccompanied adolescents an HIV test. Youth who discuss testing with their parents are more likely to test for HIV. However, young people often rightfully fear negative reactions from parents and providers, and also from schools, where they fear isolation and missed opportunities and employment prospects, if they are known to be HIV positive. In some communities, women cannot give consent without the consent of family members. The authors suggested making testing venues more youth-friendly, and monitoring promising new approaches, such as self-testing, to assess how well they work for youth. They also recommended that, in general, HIV testing venues encourage empathetic and professional health provider behaviors, including assurance of confidentiality about test results, and social and clinical support for those testing positive for HIV.

Delany-Moretlwe, S., Cowan, F. M., Busza, J., et al. Journal of the International AIDS Society (February 2015), Vol. 18, Issue 2, Supplement 1, doi: 10.7448/IAS.18.2.19833.

This review summarized the health needs of young key populations (YKPs) aged 10–24, including sexual and reproductive health, mental health, violence, and substance use problems, and barriers to care for young sex workers, men who have sex with men, transgender people, and people who inject drugs. The findings from the 110 eligible articles demonstrated, overall, that YKPs experienced a higher burden of disease relative to both older key population members and their age peers in the general population. For example, younger sex workers are less experienced in condom negotiation than older sex workers and thus, are more vulnerable to forced sex without a condom. In addition, stigma, discrimination, social exclusion, and victimization contributed to higher rates of mental health problems in YKPs compared to their peers in the general population. Barriers to care for YKPs occur at the individual, health system, and structural levels; these include low levels of education and HIV knowledge or risk perception, concerns about privacy and confidentiality, lack of “youth-friendly” facilities, and the requirement, in many countries, of parental permission to access testing, treatment, or procedures. The authors concluded that programming for YKPs requires comprehensive, integrated services that respond to their specific developmental and health needs, along with educational and social services within the context of a human rights-based approach.

Ostermann, J., Njau, B., Mtuy, T., et al. AIDS Care (January 2015), doi: 10.1080/09540121.2014.998612, pp. 595-603.

This study assessed the HIV testing preferences of female bar workers and male Kilimanjaro porters, two important high-risk groups in the Kilimanjaro Region of Tanzania. The authors used direct assessment and discrete choice experiment (DCE) methods to identify the HIV testing preferences of 162 bar workers and 194 porters, and compared them to 486 randomly selected community members. They found that bar workers, who are required to participate in a municipality-mandated health screening program, had significantly higher rates of HIV testing within the past year compared to female community members (59.3 percent versus 37.9 percent), while testing rates among porters versus males in the community were similar (25.1 percent versus 20.6 percent). Bar workers were less likely than other female community members to report a preference for home testing over facility-based testing (23 percent versus 68.6 percent). Both methods showed that porters preferred testing in venues where antiretroviral therapy was readily available (42.4 percent versus 59.4 percent in the general male population). Additionally, bar workers and porters were more likely to travel longer distances for testing compared to their community counterparts. The authors highlighted the differences in testing preferences between high-risk populations and others in the community, and called for better alignment of HIV testing services with the preferences of key populations.

Nkala, B., Khunwane, M., Dietrich, J., et al. AIDS Care (January 2015), Vol. 27 No. 6, pp. 697–702.

This retrospective cross-sectional analysis described HIV testing and prevalence among youth attending the Kganya Adolescent Centre (KMAC), South Africa, and outlined the cascade of care for KMAC's HIV-positive clients. KMAC is a comprehensive HIV management center that works to increase access to HIV care and management for in- and out-of-school adolescents. The study showed that between 2008 and 2012, a total of 11,522 young people (aged 14–24 years) and young adults (25+ years) were tested for HIV at KMAC, the majority (67 percent) female. Of those, 410 (3.6 percent) tested HIV-positive. Of these, 109 (27 percent) had their CD4 cell count measured, and 12 (11 percent) were referred for antiretroviral treatment; 41 participants (25 percent of youth) did not return for their CD4 count results. More young women than young men were HIV-positive (4 percent versus 2 percent). These findings showed that a large number of young people testing positive for HIV were not initiated into care. Reasons for non-retention included stigma, denial, and inability to cover transportation costs. The authors concluded that reaching HIV-positive adolescents but failing to retain them in care defeated the objective of the KMAC program, adding that the program needed to establish proper linkages to ensure that HIV-positive youth can succeed in obtaining care.

Adebajo, S., Eluwa, G., Njab, J., et al. Sexually Transmitted Infections (April 2015), doi: 10.1136/sextrans-2014-051659.

This cross-sectional study evaluated the effects of three strategies to increase the uptake of HIV counseling and testing (HCT) in Nigeria among 1,988 male most-at-risk populations (M-MARPs), such as men who have sex with men (MSM) and people who inject drugs (PWID). In the first strategy (S1), key opinion leaders referred M-MARPs to health facilities for HCT; in the second (S2), opinion leaders referred them to nearby mobile HCT teams; and in the third strategy (S3), mobile M-MARPs’ peers conducted the HCT. HCT uptake was 78 percent with S1, 84 percent with S2, and 94 percent with S3. Among M-MARPS who tested HIV-positive, 84 percent, 83 percent, and 98 percent of those reached via S1, S2 and S3, respectively, received their results. Among the first-time testers, S3 accounted for the highest proportion of HIV-positive clients (13 percent) while S2 reported the lowest proportion (3 percent). MSM and PWID reached through S1 and S2 were less likely to accept HCT compared to those reached through S3. The authors concluded that S3 (peer-led HCT) provided the highest impact on the number of M-MARPs reached, the identification of HIV-positive M-MARPs and new testers, and called for interventions to train M-MARPs peers to provide HCT.

Shanaube, K., Bock, P. Current HIV/AIDS Reports (June 2015), Vol. 12, Issue 2, pp. 231–237, doi: 10.1007/s11904-015-0262-z.

This review highlighted key drivers of the epidemic in sub-Saharan Africa (SSA) and discussed innovative strategies for the scale-up of effective combination HIV prevention strategies, with a focus on treatment as prevention. While many countries are implementing combination HIV prevention strategies, extreme rates of poverty, combined with weak health systems and health inequalities, and the failure to prioritize HIV prevention among key populations, continue to drive the epidemic. The authors emphasized that while knowing one’s HIV status is the first step in accessing prevention and treatment services, and may positively influence sexual risk behavior, more than half of the people living with HIV in SSA remain undiagnosed. To be effective, interventions addressing behavior change need to be combined with biomedical interventions, such as pre-exposure prophylaxis, voluntary medical male circumcision, and treatment as prevention. The authors emphasized that innovative strategies, such as home-based HIV testing and counseling, could lead to higher service uptake, especially among men. Treatment strategies that expand access into the community may also enhance linkages. The authors concluded that the SSA context requires multiple strategies to (1) expand knowledge of HIV status, and (2) scale up innovative strategies to increase access to counseling, testing, and treatment. They called for strong community leadership to implement and scale up effective combination prevention programs.

Leber, W., McMullen, H., Anderson, J., et al. The Lancet HIV (June 2015), 2(6), doi: 10.1016/S2352-3018(15): 059-4.

This cluster-randomized controlled trial examined whether including educational outreach promoting rapid HIV testing within general practice leads to increased and early diagnosis of HIV. Between April and August 2011, the authors randomly assigned 40 general practices in the United Kingdom to either intervention (n=20) or control (n=20) groups. Intervention practices included an HIV education program, follow-up training for an HIV lead nurse or assistant, integration of opt-out rapid HIV testing within routine health checks, and provision of free rapid HIV tests. Control practices offered the usual care only, which included HIV testing on client request. The authors reported that intervention practices made a total of 32 new HIV diagnoses, compared to 14 new diagnoses made by control practices. Additionally, the frequency of HIV diagnosis was significantly higher in the intervention than the control practices (0.30 and 0.07 per 10,000 patients per year, respectively). The authors concluded that promoting opt-out rapid testing in general practice health facilities increased the rate of HIV diagnosis. They recommended implementing routine HIV screening in general practices in areas with high HIV prevalence.

Wagman, J.A., King, E.J., Namatovu, F., et al. Health Care for Women International (June 2015), e-publication ahead of print.

The Safe Homes and Respect for Everyone (SHARE) intervention was implemented by Rakai Health Services Programs (RHSP) between 2005 and 2009 in rural Uganda and combined HIV services with community outreach and messages on preventing intimate partner violence (IPV). The program reached 3,236 households in Rakai and was associated with significant declines in IPV. The authors of this article described how SHARE’s IPV prevention strategies were integrated into RHSP's existing HIV programming. SHARE partnered with RHSP’s Health Education and Community Mobilization (HECM) team to raise awareness in intervention regions about how IPV increases women’s risk for HIV infection, and contracting HIV increases women's vulnerability to abuse. SHARE also trained the HECM team to incorporate messages about HIV and IPV prevention within educational materials and during occasions when people gather. SHARE participants also received general medical and HIV prevention and treatment services via 17 mobile clinics. Additionally, SHARE established peer groups in each intervention region and implemented a 10-session learning program in schools and central locations on topics including sex and love, HIV and sexually transmitted infections, gender equality, and the importance of mutually consensual sex. The authors concluded that HIV programmers in other sub-Saharan African settings should consider adopting SHARE's approach as a standard of care for preventing IPV and HIV infection.

Doherty, I.A., Myers, B., Zule, W.A., et al. Sexually Transmitted Infections (July 2015), pii: sextrans-2014-051882; doi: 10.1136/sextrans-2014-051882.

This study analyzed data on 290 high-risk couples from Khayelitsha, South Africa to investigate couple’s knowledge about their partners' HIV testing and serostatus. All participants were tested for HIV at baseline and asked about their partner’s past HIV testing and current status. Of the 108 women (38 percent) reporting that their partner was not infected, 95 percent were correct; 58 percent of women did not know their partner’s status. Among men, 29 percent believed their partner was HIV-negative, and most were correct (83 percent and 4 percent newly diagnosed). However, the majority of men (66 percent) did not know their partner’s HIV status. Moreover, only in 17 percent of couples did both partners correctly report one another's HIV status. Men in this population did not seek HIV testing nearly as often as women, but when they received counseling and tested, or a positive diagnosis, both members of the couple were more likely to know their partner’s status. Most women did not disclose their HIV serostatus to their partners; only 13 percent of women were in a partnership with mutually correct knowledge of partner serostatus. The authors concluded that to reduce onward transmission of HIV in South Africa, programs must improve HIV testing uptake among men and HIV disclosure among women in heterosexual partnerships.

Henley, C., Forgwei, G., Welty, T., et al. Sexually Transmitted Diseases (December 2013), Vol. 40 No. 12, pp. 909-914.

HIV partner services—wherein trained staff interview persons diagnosed with HIV about their sexual partners in an effort to notify and test partners—are uncommon in low-income countries. The authors evaluated a HIV partner services program implemented in Cameroon since 2007. The findings showed that the HIV partner services implemented in various testing facilities were feasible, can identify many HIV-positive persons and link them to care, and offer an avenue for reaching HIV-positive men. Health providers interviewed 1,462 index cases during the study (73 percent female), receiving information on 1,607 partners. A notification plan was developed for 93 percent of partners; 60 percent of clients chose to have providers notify their partners. In total, 1,347 (84 percent) of partners were successfully notified; partners of married index cases were more likely to be informed. Nine hundred partners (67 percent) were tested for HIV; 50 percent were positive (and most were linked to HIV care and treatment). The program has expanded into prevention of mother-to-child transmission programs. Future research should evaluate the effect of HIV partner services on partnerships, and the program’s cost-effectiveness, potential negative consequences, and impact on perinatal transmission and sexual risk behavior in discordant couples; operational studies should investigate populations where partner services programs can be most effective.

Boltaev, A.A., El-Bassel, N., Deryabina, A.P., et al. Drug and Alcohol Dependence (November 2013), Vol. 132 Suppl. 1, pp. S41-S47.

Boltaev et al. reviewed the status and trends of national HIV responses for people who inject drugs (PWID) in Central Asia, highlighting structural and social barriers that enable HIV transmission among PWID, including barriers to key harm reduction services. While an increasing number of health facilities provide evidence-based interventions for PWID, structural causes of HIV risk behavior and transmission remain inadequately addressed. Barriers to an effective HIV response include discriminatory legal environments that violate the human rights of PWID, though Tajikistan and Kazakhstan have taken some action toward liberalizing drug laws. Several challenges limit implementation of evidence-based interventions. Opioid substitution therapy remains one of the region’s most politicized interventions. Other barriers include lack of qualified health care providers to address the needs of PWID, dependence on external donors, low resource allocation for key services for PWID, poorly integrated HIV services, and limited engagement of PWID in the HIV response. Effective responses to the HIV and drug use epidemics must eliminate stigma and discrimination, which requires more research. PWID must contribute to strengthening HIV service delivery. Central Asia must recognize the need for increased coverage through combinations of services to reduce HIV among PWID, and identify strategies to implement multi-level interventions.

van Rooyen, H., Barnabas, R.V., Baeten, J.M., et al., Journal of Acquired Immune Deficiency Syndromes (September 2013), Vol. 64 No. 1

The authors assessed an innovative model of home-based counseling and testing (HBCT), HBCT Plus –included point-of-care (POC) CD4 testing and referrals to HIV care in rural KwaZulu-Natal, to determine if the model achieved high testing coverage; reached persons unaware of their HIV status; and reduced infectiousness and barriers to accessing HIV care through antiretroviral therapy (ART) adherence. HBCT Plus achieved high uptake of HIV testing and increased knowledge of HIV status; POC CD4 testing, referral, and follow-up from lay counselors attained nearly 100 percent linkage to HIV care and ART initiation. From March 2011 to March 2012, 671 participants were tested; of these, 201 were HIV-positive, and 73 (36 percent) newly identified as positive.  The number of participants reporting ever visiting a HIV clinic increased from 116 (57 percent) to 196 (96 percent) at baseline and six-month follow-up, respectively. At follow-up, there was a significant reduction in the mean HIV viral load, and an increase in the proportion with a viral load <1000 copies per milliliter among those ART-eligible. The model could be combined with other effective mobile testing strategies; and while it is promising, its impact and cost-effectiveness should be assessed in remote areas with greater distances to referral clinics to inform national HIV programs.

Onyango, O.A., Grace, J.-S., James, K., et al. AIDS (August 2013), E-publication ahead of print.

The authors implemented a randomized, single-blind clinical trial in Nyanza Province, Kenya, to compare the accessibility and uptake of couples HIV testing and counseling (HTC) by male partners during home visits versus appointments at antenatal care (ANC) clinics. Home visits reached and tested at least twice as many partners, and identified and referred more HIV-positive men, compared with the clinic group. Pregnant women seeking ANC were randomized to receive home visits for couples HTC (n=150) or to invite their male partner to the clinic (n=150); 128 (85 percent of those reached) and 54 (36 percent of those reached) male partners underwent couples HTC at homes and the clinic, respectively. Couples were significantly more likely to learn that they were concordant negative tested at home (66 percent) rather than at the clinic (26 percent); yet home-visit couples were also three times more likely to be HIV-serodiscordant. Women whose partners were tested at home were more likely to report improved quality in the relationship (67 to 28 percent). Long-term studies are needed to monitor relationship outcomes. Home HTC visits were highly acceptable for couples, which may lessen barriers to reaching male partners. The authors concluded that the home visit strategy for couples HTC during pregnancy may achieve public health impact and increase uptake of prevention of mother-to-child transmission services in high-prevalence and low-income settings.

Verguet, S., Stalcup, M., and Walsh, J.A. Sexually Transmitted Infections (August 2013), E-publication ahead of print.

The authors used a deterministic epidemiologic model to assess the impact and cost-effectiveness of implementing a pre-exposure prophylaxis (PrEP) intervention from 2013 to 2017 for the general adult population in 42 countries in sub-Saharan Africa. The findings suggest a large impact on HIV, with maximum impact and cost-effectiveness in general adult populations with low levels of male circumcision (MC) and high HIV prevalence. Southern African countries would benefit most from PrEP, whereas West and Central African countries would benefit least. PrEP would be most cost-effective in generalized epidemics; but in other contexts, PrEP should be prioritized for key populations. Over five years, PrEP could prevent 390,000 HIV infections, 53,000 deaths, and 5,400,000 disability-adjusted life years (DALYs) if implemented at 10 percent coverage in the region. The greatest impact would be in South Africa; the smallest in Djibouti (94,0000 and 200 infections averted, respectively). Overall, the cost-effectiveness of PrEP was U.S. $5,800/DALY. PrEP was very cost-effective in South Africa ($1,100/DALY) compared to in the Democratic Republic of the Congo ($18,500/DALY). In high-risk populations, PrEP would substantially increase protection (557,000 infections averted at $3,800/DALY). The authors provided a model that can be adapted to help make health policy decisions about PrEP interventions; decisions should align with country economic indicators and epidemiologic contexts. PrEP would likely be most cost-effective as a targeted intervention within a combination of HIV prevention strategies.

Uwimana, J., and Jackson, D. The International Journal of Tuberculosis and Lung Disease (October 2013), Vol. 17 No. 10, pp. 1285-1290.

The authors assessed the integration of tuberculosis (TB) services with prevention of mother-to-child transmission (PMTCT) services at antenatal care (ANC) clinics in Sisonke District in South Africa’s KwaZulu-Natal province. They conducted surveys with 150 ANC clients and interviews with 26 program managers, and reviewed data from 1,700 registered ANC clients (2008 to 2009). While there was some integration, active TB case finding among pregnant HIV-positive women was substandard. TB prevalence among pregnant clients was 1.3 percent overall and 8 percent among HIV-positive clients (2 of 26 HIV-positive women). TB diagnosis was statistically associated with HIV status. In total, 83 clients (56 percent) reported being screened for TB; 75 percent of clients interviewed reported receiving education about TB. Among all registered clients, 55 percent of HIV-positive pregnant women (n=298) were screened for TB, with four women diagnosed and on TB treatment. However, there was no record of treatment outcomes or screening for isoniazid preventative therapy (IPT) for latent TB infection. Most key informants found integration inadequate because of insufficient coordination and supervision, staff shortages, referral structures between services, and poor monitoring and evaluation of integrated services. Programs need to address health system barriers and develop key indicators to measure integration. The authors concluded that improving integration is vital and will require strong leadership and supportive supervision for health care workers.

Rausch, D.M., Grossman, C.I., and Erbelding, E.J. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 No. 1, pp. S6-S11.

The authors presented efficacy challenges experienced in recent antiretroviral therapy (ART) prevention trials; discussed behavioral challenges to ART and their effects on the design and implementation of prevention trials; and outlined priorities for future research within combination HIV prevention. A multidisciplinary approach that includes current behavioral science is essential to maximizing and sustaining the benefits of ART-based and integrated combination prevention. Clinical trials of both oral and topical approaches for pre-exposure prophylaxis have yielded both promising findings and failure, even when the same product and dose was tested. In several of these tests, adherence was a critical factor. The HIV Prevention Trials Network (HTPN)-052, which incorporated a counseling intervention, was highly successful in preventing HIV transmission among serodiscordant couples. The authors stated that because trials of biomedical approaches to HIV prevention yield conflicting results, sociobehavioral factors that may affect trial outcomes should be examined. Behavioral theories or models have influenced HIV prevention interventions, but cannot in themselves effectively address the HIV epidemic. Theoretical behavior models must evolve to complement and advance combination HIV prevention efforts—including in intervention design and potential behavioral impacts on the outcomes of clinical trials—and assessment of behavioral outcomes must be improved. Integrating behavioral and biomedical approaches is critical if global HIV prevention is to achieve maximum impacts.

Uwimana, J., Zarowsky, C., Hausler, H., et al. The International Journal of Tuberculosis and Lung Disease (October 2013), Vol. 17 No. 10, pp. S48-S55.

The authors assessed the effectiveness of a community-based intervention to integrate tuberculosis (TB), HIV, and prevention of mother-to-child transmission (PMTCT) services in Sisonke District of KwaZulu Natal, South Africa. The intervention entailed training community care workers (CCWs) to provide comprehensive services. Integrated TB/HIV/PMTCT services provided by CCWs were feasible, acceptable, and effective. Pre- and post-intervention data were collected and analyzed from 1,976 intervention and 1,608 control households. Significantly more intervention respondents received health education, HIV testing and counseling (HTC), screening for TB and sexually transmitted infections, and support for anti-TB and antiretroviral therapy; had sputum collected; and had access to PMTCT services. Intervention households were nearly five times more likely to be screened for TB. Higher education and income were associated with access to these services. Willingness to disclose HTC history increased from 68 percent to 92 percent among 2,449 respondents pre-intervention and 3,584 respondents post-intervention, respectively; and reports of receiving HTC increased from 57 to 75 percent. Community care workers performed more poorly than control providers in furnishing education on integrated management of childhood illnesses, vital documents, and referral for social grants, but performed better in referral for weighing and immunization. The authors highlighted the need to ensure comprehensive TB/HIV services, and to examine socioeconomic inequalities and access to community-based services and intervention cost-effectiveness.

Vu, L., Adebajo, S., Tun, W., et al. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 No. 2, pp. 221-227.

The authors of this study aimed to provide HIV prevalence estimates and understand risk factors of men who have sex with men (MSM) in Abuja, Ibadan, and Lagos, Nigeria. The results indicated a high HIV burden among MSM: 4 to 10 times the general HIV prevalence. MSM also reported risky sexual behaviors, yet many had never tested for HIV (44, 68, and 62 percent in Abuja, Ibadan and Lagos, respectively). In total, 712 participants in Abuja (n=194), Lagos (n=308), and Ibadan (n=210) were interviewed between August and September 2010. Population-based HIV estimates among MSM were 35 percent (Abuja), 11 percent (Ibadan), and 15 percent (Lagos). More MSM reported having sex with both men and women in Ibadan and Lagos than in Abuja. Approximately 20 to 30 percent and over 50 percent of MSM reported multiple female and multiple male partners, respectively. Unprotected intercourse was common. In Lagos, one-third of MSM reported that their last male sexual partner had been a commercial sex worker, and over half of MSM reported transactional sex in the past six months. A comprehensive combination prevention approach, including structural interventions to build a supportive and less homophobic environment will be essential to mitigate HIV among MSM, their female partners, and hidden MSM subgroups. The authors advocated considering antiretroviral-based prevention and decriminalization of same-sex relationships.

Kato, M., Granich, R., Duc Bui, D. et al. Journal of Acquired Immune Deficiency Syndromes (2013), E-publication ahead of print.

The authors developed a mathematical model using HIV prevalence data for key populations including people who inject drugs (PWID), men who have sex with men, and female sex workers (FSWs), in addition to male clients of FSWs and low-risk women in Vietnam, to analyze potential benefits of and strategies for increasing access to periodic testing and immediate treatment (PTIT)—routine HIV testing and counseling (HTC) with immediate antiretroviral therapy (ART) initiation if positive—along with other prevention interventions. Thirteen scenarios were analyzed within scenario sets: current intervention levels, PTIT for all adults, PTIT targeted to sub-populations, and policy scenarios (assuming PTIT was implemented in 2011, scaled up, and sustained through 2050). Adding PTIT for key populations, with other combination prevention interventions, had the greatest impact, reducing HIV infections by 81 percent and mortality by 73 percent, and costing only three percent more than current interventions (22.7 million U.S. dollars [U.S.$] versus 22.1 million U.S.$). This scenario would reduce HIV incidence to 1/100,000 in 14 years and obtain annual cost savings after 20 years. By maintaining the current intervention levels from 2011 to 2050, 18,000 people would become infected. Providing annual PTIT to all adults would reduce HIV incidence by 80 percent but at a cost of $76.9 million. PTIT targeted to PWID resulted in the largest decrease in new infections (75 percent) and cost $23.6 million. High- and lower-risk populations should be targeted with different strategies.

Medley, A., Baggaley, R., Bachanas, P., et al. AIDS Care (May 2013). E-publication ahead of print.

The authors described HIV interventions that should be offered to couples, both in generalized and concentrated epidemics, to decrease the risk of transmission to HIV-negative partners and children and to support HIV-positive partners in accessing necessary HIV services. An emphasis on couples-focused HIV services, rather than traditional, individual HIV services, is urgently needed, and could potentially reduce population-level HIV incidence. This article complements the World Health Organization’s couples HIV testing and counseling (CHTC) guidelines. Interventions appropriate for couples included antiretroviral treatment (ART) for the HIV-positive partner; ART adherence counseling and support; risk reduction counseling (including supplying condoms); linking HIV-positive mothers with services for prevention of mother-to-child transmission; counseling on family planning and safer contraception and pregnancy; pre-exposure prophylaxis treatment for the HIV-negative partner; voluntary medical male circumcision for the HIV-negative male partner in serodiscordant relationships; screening and treatment for sexually transmitted infections; and routine HTC for HIV-negative partners or for HIV-negative couples in high-prevalence contexts.  Reaching and engaging men in HIV prevention, care and treatment services will be critical to the scale-up of couple-focused HIV interventions, the authors said. Also, because of reported high rates of intimate partner violence (IPV) and the potential barriers they create for access and utilization, health care workers should be aware of and trained to screen for and address IPV.

Singh, J.A. AIDS (March 2013), Vol. 27 No. 6, pp. 863-865.

In this article, J.A. Singh discusses the ongoing debate surrounding the designation of antiretroviral (ARV) resources for HIV treatment versus HIV prevention. According to Singh, HIV treatment and prevention, utilizing pre-exposure prophylaxis (PrEP), should be implemented simultaneously, and also concurrently with an expanded HIV testing and counseling (HTC) program. Treatment and prevention should not be viewed as incompatible. It is unethical to deny ARV treatment for prevention because many people are at high risk of HIV, yet unable to protect themselves. Treatment as prevention, with its dual objectives of treatment and prevention is flawed in settings where HIV prevalence is high, multiple concurrent partnerships are common, and the implementation of HTC for couples is challenging. ARV allocation for HIV prevention is a human rights responsibility. Many countries have accepted the International Covenant on Economic, Social and Cultural Rights to provide “minimum core obligations.” Importantly, this covenant includes vulnerable populations with limited or no access to HIV services. Multisectoral stakeholders must identify vulnerable groups that are in urgent need of prioritized access. Policies will need to be adopted to ensure sustainable programmatic implementation of HIV treatment and PrEP. The author concluded that implementing the strategies concurrently, with scaled-up HTC access, may help achieve the "AIDS-free generation" goal of the Joint United Nations Program on HIV and AIDS.

Celum, C., Baeten, J., Hughes, J., et al. Journal of Acquired Immune Deficiencies Syndromes, (July 2013), Vol. 63 Suppl. 2, pp. S213-S220.

The authors discussed HIV risk factors and combination HIV prevention interventions for three populations - (1) men who have sex with men (MSM), including transgender women, in the Americas, (2) young women in sub-Saharan Africa, and (3) heterosexual serodiscordant couples in sub-Saharan Africa. For MSM, the authors propose combining interventions resulting in high uptake and adherence to assess potential synergies to reduce HIV in MSM. The interventions should address components of the transmission chain (e.g., reduce multiple partnerships) and target populations with marginal overlap (e.g., pre-exposure prophylaxis [PrEP]). Strategies targeting young women should include interventions that combine youth-friendly reproductive health and HIV prevention services to increase HIV testing uptake, PrEP with adherence counseling, and contraceptive options. Interventions for heterosexual couples should incorporate understanding of couples' adoption of HIV prevention behaviors and prioritize prevention activities, e.g., couples testing. The HPTN 052 trial, which aimed to determine effectiveness of early antiretroviral therapy on reducing HIV transmission in serodiscordant couples; and the Partners PrEP trial, which aimed to determine effectiveness of daily oral PrEP in preventing HIV transmission among serodiscordant couples, both resulted reduced HIV transmission. While the trials demonstrated effectiveness, implementing the strategies in real-world settings will require further assessment and integration with other strategies. The authors concluded that combination HIV prevention activities must align with epidemiologic HIV drivers, and future research should assess the feasibility, acceptability, impact, potential for synergies, and economic effectiveness of interventions.

Miller, W.C., Powers, K.A., Smith, M.K., et al. The Lancet Infectious Diseases (March 2013).

The authors presented the limitations of using community viral load as a measure for assessing HIV epidemics, saying that the strategy has two potential uses: as a routine measure of a community's uptake of antiretroviral therapy, and as an indicator of HIV transmission within a community. The authors recommended caution in interpreting aggregate measures of viral load. The measurement is centered on individuals linked to and retained in HIV care, which creates a biased estimate by excluding undiagnosed individuals or those who are HIV-positive, yet not in care. Most communities do not have sufficient numbers of individuals retained in care to provide accurate estimates. Further, viral load varies over time; thus, the timing of measurement could affect accuracy. Accounting for a population's HIV-infected and uninfected people is important for understanding HIV transmission; current measures do not address HIV prevalence effects. Moreover, viral load distributions are often multimodal, which complicates aggregate measures. Community viral load is an inadequate measure of the potential for ongoing HIV transmission, because it represents a combination of sexual behaviors, networks, and viral loads among HIV-positive individuals, and does not identify individual transmission routes. According to the authors, a combination of measures monitoring the different aspects of the care cascade--including HIV testing, diagnosis, engagement in care, retention in care, and viral suppression--will be critical to an accurate understanding of an HIV epidemic.

Sarna, A., Luchters, S., Musenge, E., et al. Global Health: Science and Practice (March 2013), Vol. 1 No. 1, pp. 52-67.

In a controlled cohort study, the authors found that an HIV risk reduction intervention implemented by community health workers (CHW) for Kenyan people living with HIV (PLHIV) who knew their status, yet were not on HIV treatment, decreased reported risky sexual behaviors and increased antiretroviral therapy (ART) uptake. Of 325 participants in the intervention arm, 97 percent completed six months of follow-up, as did 94 percent of the 309 participants in the control arm. Among intervention participants, reported concurrent relationships in the past three months decreased from 42 percent at baseline to 18 percent at follow-up, and ART uptake increased significantly (from 0.3 percent to 35 percent) relative to the control group (0.3 percent to 12 percent). Intervention participants reported significantly less unprotected sex in the past month compared with the controls. Knowledge of HIV transmission and self-efficacy of condom use were higher among the intervention participants; however, they reported reduced concern about HIV transmission due to ART availability. More control participants had low internalized stigma scores at follow-up. The findings indicate that CHWs can deliver HIV interventions effectively in communities. The authors concluded that this intervention is suitable for scale-up and replication in similar resource-limited contexts to reach PLHIV who are not accessing HIV services.

Alsallaq, R.A., J.M. Baeten, C.L. Celum, et al. PLoS One (January 2013), Vol. 8 No. 1, pp. e54575.

The authors applied a mathematical model to assess the potential effect of an HIV combination intervention on HIV incidence in KwaZulu-Natal, South Africa. The combination intervention included high HIV testing coverage every four years, risk behavior reduction following diagnosis, antiretroviral therapy (ART) initiation at CD4 count of ≤350 cells/ml, and medical male circumcision. The authors analyzed individual components and then combined components to estimate population-level impact; explored the effect of expanding ART to all persons testing positive; assessed factors that determined impact; and measured the short- and long-term effect of the combined components. The combination intervention showed major reductions in HIV incidence-nearly 50 percent in four years and 60 percent after 25 years. The combined components had synergistic effects. ART had the greatest individual effect, reducing incidence by 33 percent. Expanding ART to all persons diagnosed HIV positive could reduce incidence by 63 percent at four years, and by 76 percent after 15 years. Uptake of testing and risk behavior reduction had the greatest short-term impact; periodic testing and ART retention had the greatest long-term impact. The full impact of combination prevention could be achieved in 10-15 years. The authors concluded that reducing HIV incidence is feasible in high-prevalence settings with combination interventions implemented at high coverage and with robust evaluation to assess population-level impact.

McNairy, M.L., M. Cohen, & W.M. El-Sadr. Current HIV/AIDS Reports (January 2013), e-publication ahead of print.

The authors discussed “treatment as prevention” (TasP) in the framework of a combination intervention: HIV testing, linkage to care, retention in care, and adherence. TasP can increase demand for testing, expand testing services, and improve linkage and retention in care and adherence to treatment, yet the challenge is to improve each component to attain effectiveness. Several modeling studies have suggested that TasP can potentially eliminate HIV in a high-burden setting. However, testing coverage, linkage and retention in care rates, and ART adherence are substantially lower in real settings, highlighting that each element needs strengthening. HIV testing is the entry point for TasP, while linkage to care is considered the weakest component in the continuum of care. TasP requires life-long retention in care, unlike other biomedical prevention interventions. TasP as a combination prevention intervention needs to be tailored to contexts and populations, and it may impact the greater health system. Integrated prevention and care services for high-risk groups may achieve positive results in reducing risk behaviors. In one study the authors discussed, Gardner et al. (2011) found only trivial improvements in viral load suppression when improving only one element in the continuum of care; however, with improvements across all elements, viral load suppression increased from 19 percent to 66 percent. The authors concluded that only by strengthening each component can TasP achieve impact at the population level.

Osoti, A.O., John-Stewart, G., Kiarie, J.N., et al. BMC Infectious Diseases (July 2015), 15:298. doi: 10.1186/s12879-015-1053-2.

This cross-sectional study, conducted within a randomized trial in rural Nyanza province, Kenya, compared the acceptability of three approaches—facility-based HIV testing services (HTS), home-based voluntary counseling and testing (VCT), or antenatal (ANC) clinic-based HTS—for testing the male partners of pregnant women. The authors interviewed 300 pregnant women and 188 male partners on their preferred setting and compared setting preference at baseline and at a six-week follow-up visit. They reported that 59.4 percent of all participants (women and partners) preferred home-based HTS for male partner HTS during pregnancy, compared to ANC clinic-based (28.3 percent) and VCT center-based (12.3 percent). In addition, more men than women (68.1 percent versus 54.0 percent) preferred home-based male partner HTS. Only 19.2 percent of men (compared to 34 percent of women) preferred ANC clinic-based HTS.VCT center-based testing was the least preferred setting, both among men (12.8 percent) and women (12.0 percent). At six-week follow-up, 81 percent of men and 65 percent of women preferred home-based over alternative HTS venues. The authors concluded that home-based HTS during pregnancy was the most acceptable for both female and male partners, and suggested that adopting home-based models may improve men's uptake of HTS and involvement in prevention of mother-to-child HIV transmission.

McNaghten, A.D., Schilsky, M.A, Farirai, T., et al. Journal of Acquired Immune Deficiency Syndromes (August 2015), E-publication ahead of print.

This study compared three models of HIV testing services (HTS) in outpatient departments (OPDs) in South Africa, Tanzania, and Uganda. The authors conducted client interviews and focus group discussions with participants at 12 OPDs in each country that had been randomized to one of three HTS models: Model A (clients received HTS after clinical consultation); Model B (providers offered and delivered HTS during clinical consultation); and Model C (nurses or lay counselors provided HTS before clinical consultation), and conducted client interviews and focus group discussions. More age-eligible clients were tested in Model C (54.1 percent), followed by Model A (41.7 percent) and Model B (33.9 percent). Of newly identified HIV-positive clients (1,596 in total from the three models), 96.1 percent of those receiving Model A were referred to care, 94.7 percent in Model B, and 94.9 percent in Model C. Additionally, 74.4 percent entered on-site care in Model A, 54.8 percent in Model B, and 55.6 percent in Model C. The authors concluded that Model C, where nurses or counselors provided HTS before clinical consultation, resulted in the highest percentage of client testing for eligible clients. This model was convenient for clients and incurred no additional waiting time; and HTS was provided by specifically trained staff.

Feelemyer, J., Jarlais, D. D., Arasteh, K., & Uusküla, A. AIDS and Behavior (October 2014), E-publication ahead of print.

The authors of this literature review examined adherence to antiretroviral therapy (ART) in transitional-, low-, and middle-income countries (TLMIC) among people who inject drugs (PWID) and persons with a history of injection drug use. The authors conducted a systematic review of articles and conference presentations presented between 1996 and 2012 that reported adherence to ART among these groups in TLMIC. They found 15 articles from seven countries that met the inclusion criteria (including documentation of ongoing ART therapy) in a sample of current or past opiate users, and measurement of ART adherence, and follow-up data. ART adherence was associated with different methods of measuring adherence in Eastern Europe and East Asia. The review found that adherence levels reported in the articles ranged from 33 percent to 97 percent; mean weighted adherence was 72 percent. The authors noted that adherence in TLMIC remains suboptimal, and is probably well below the levels needed to achieve positive treatment outcomes for individuals and a population-level effect on HIV transmission. The authors called for more research on ART adherence among PWID in TLMIC, and recommended using standardized methods for reporting adherence to ART in this group.

Bassett, I.V., Regan, S., Mbonambi, H., et al. AIDS and Behavior (September 2015), 19(10): 1888–1895.

To optimize the effectiveness of community-based mobile HIV testing by the iThembalabantu Clinic in Umlazi Township, South Africa, the authors evaluated the number and characteristics of the population being tested during site visits. From July to November 2011, the researchers collected programmatic data from adults who self-presented for testing at the mobile HIV testing units at malls, taxi stands, and markets in Umlazi (mobile testers) and at the iThembalabantu HIV clinic (IPHC testers). The authors found that the mobile testing units attracted hard-to-reach populations, specifically men, who are less likely than women to seek HIV testing in clinic-based programs. Mobile testing also attracted proportionally more young people, which is especially important, since their HIV prevalence is high and increases rapidly with age. The sites demonstrating the highest HIV prevalence were supermarkets and taxi ranks. Almost a quarter of mobile clients sought HIV testing more than five kilometers from their homes, indicating that some people prefer being tested for HIV in more remote locations where they will not be recognized. The authors concluded that using mobile units in the highest-yield (hot spot) locations could dramatically increase the number of HIV cases detected, particularly among hard-to-reach populations such as men and young people.

Treves-Kagan, S., Naidoo, E., Gilvydis, J.M., et al. Global Public Health (September 2015), e-publication ahead of print.

This paper described the methodology used for a situational analysis in 2012 in two districts in North West Province, South Africa, conducted to ensure that a planned comprehensive prevention program would respond to the local needs. The analysis focused on characterizing communities’ needs, existing resources, and cultural and structural barriers to health care. Specifically, the study sought to: (1) characterize the local epidemic profile (key populations, key drivers); (2) identify how sociocultural and service delivery contexts affected the epidemic; and (3) document opportunities for program partnerships and existing best practices. The authors described the analysis in terms of (1) laying the foundation (obtaining permission to conduct research); (2) preparing for field work (developing data collection tools and gathering existing data); (3) field work (interviews, focus groups, and service delivery assessments); (4) sampling (determining the sample size and ensuring inclusion of diverse conditions and populations); (5) data analysis (qualitative and quantitative analysis that includes coding transcripts and field notebooks). The report also described the method’s strengths: yielding acceptable data breadth and saturation; producing data that translated into actionable findings to inform comprehensive HIV programming; and building community partnerships, buy-in, and support for intervention strategies. The authors said that this methodology could be used to guide community engagement and develop locally appropriate combination HIV prevention programs.

Traore, I.T., Meda, N., Hema, N.M., et al. Journal of the International AIDS Society (September 2015), 18(1):20088. doi: 10.7448/IAS.18.1.20088, eCollection 2015.

This prospective, interventional cohort study among 321 HIV-uninfected female sex workers (FSWs) aged 18–25 years in Ouagadougou, Burkina Faso, conducted from 2009 to 2011, assessed the impact of a comprehensive, dedicated intervention targeting FSWs. The intervention included locally available combined prevention and care, including peer-led education sessions, free syndromic management of sexually transmitted infections, condoms and hormonal contraceptives, psychological support, and free general medical and HIV care. At enrolment and during subsequent quarterly visits, participants completed a standardized questionnaire documenting sexual behaviors and alcohol consumption during the previous week, including the number and type of sexual partners; received a physical examination; and provided urine, vaginal, and endocervical samples, as well as a blood sample after a voluntary HIV counseling session. No seroconversion occurred during the study, though the modeled seroconversion rate was 1.23 infections per 100 person-years. Although the average number of casual clients did not change during follow-up, the odds of consistent condom use significantly increased; and the adjusted odds of having more than one regular client diminished significantly. Moreover, the odds of consistent condom use with regular clients increased over time. The authors concluded that integrating community-based prevention had a significant impact on HIV incidence among young FSWs in Burkina Faso.

Khademi, A., Anand, S. and Potts, D. Medicine (September 2015), 94(37):e1453, doi: 10.1097/MD.0000000000001453.

The authors of this study developed an analytical framework to estimate the effects of scaling up HIV education and providing universal access to treatment on HIV incidence, prevalence, and mortality. Using demographic and epidemiologic data from South Africa, they compared the HIV prevalence generated by the model with the actual HIV prevalence observed in South Africa from 1990 to 2000. The results showed that combining expanded HIV education and universal access to treatment significantly decreased both incidence rates (declining from 2.3% to 0.6%) and prevalence (declining from 15.1% to 9.3%) over the course of 15 years. Thus, the benefit of a combined strategy of universal access to treatment and HIV education scale-up was greater than the benefit of the two strategies implemented individually. The combined strategy decreased the incidence rate by 74 percent over the course of 15 years, whereas universal access to treatment and HIV education scale-up separately decreased incidence by 43 percent and 8 percent, respectively. Additionally, universal access to treatment alone averted 7,596,439 deaths, whereas combining universal access with HIV education scale-up averted 7,679,917 deaths over 15 years. The authors concluded that comprehensive combination prevention might have a larger impact on containing the epidemic than implementing separate prevention programs. They recommended designing effective combination prevention programs in sub-Saharan Africa.

Govindasamy, D., Ferrand, R.A., Wilmore, S.M., et al. Journal of the International AIDS Society (October 2015), 18(1): 20182, doi: 10.7448/IAS.18.1.20182, eCollection 2015.

This electronic review of literature on HIV testing and counseling (HTC) among children and adolescents (5–19 years) from 2010 to 2013 investigated the acceptability, yield, and prevalence of different HTC strategies for this group in sub-Saharan Africa (SSA). A total of 21 studies across eight countries (Kenya, Malawi, South Africa, Sudan, Tanzania, Uganda, Zambia, and Zimbabwe) were included. Seven studies used provider-initiated testing and counselling (PITC) in either inpatient or outpatient settings. Six studies were conducted in the context of seroprevalence surveys; of these, two provided HTC in the home environment, and four used a mobile or outreach approach. Four studies reported data from mass testing campaigns that used outreach or home-based strategies. A family-centered approach was used in five studies, and one study reported results from a school-linked testing campaign among primary schoolchildren aged 5–11 years. The authors reported that acceptance, yield, and prevalence were highest when testing was offered in inpatient settings (86.3%, 12.2%, and 15.4%, respectively) and outpatient settings (69.5%, 7.4%, and 11.3%) as part of PITC. Outreach HTC strategies had the lowest acceptance (60.4%), yield (0.6%), and prevalence (1.3%). The authors concluded that HTC approaches delivered within communities outside of a health care facility have a high acceptance among this priority age group.

Jefferys L.F., Nchimbi, P., Mbezi, P., et al. Reproductive Health (October 2015), 12(1), doi: 10.1186/s12978-015-0084-x.

This study in Mbeya Region, Tanzania assessed the acceptability and effectiveness of written invitations for male partners to attend joint antenatal care (ANC) and couples voluntary testing and counseling (CVCT). Data were collected from a prospective, longitudinal cohort at three health centers at different locations in Mbeya Region. ANC clients (n=318) received a letter inviting their partners to attend the next routine ANC visit, explaining that information on pregnancy, parenthood, and other important health issues would be given (but not mentioning HIV testing). Nearly all women who returned to the clinic (98%) reported handing the letter to their partners, and said that partners who received an invitation were supportive. Partner attendance rate ranged between 31 percent and 75.8 percent, and averaged 53.5 percent across all sites. When the partner attended a joint ANC session, 81 percent of the couples received CVCT, (in the remaining 19%, only the women tested). Women overall found the experience very positive—saying that the counselor was helpful (95%), the experience was good (91%), and there were no difficulties during mutual disclosure of HIV status (90%). The authors concluded that official invitation letters are a feasible intervention in a resource-limited sub-Saharan context, and an effective way to encourage men to attend ANC and CVCT. 

Ezeanolue, E.E., Obiefune, M.C., Ezeanolue, C.O., et al. The Lancet Global Health (November 2015), (11): e692–700, doi: 10.1016/S2214-109X(15)00195-3.

Between January 2013 and August 2014, this two-arm cluster randomized trial compared the effects of a congregation-based intervention versus standard referral for testing on uptake of HIV testing by pregnant women in rural Enugu State, Nigeria. The church-based Healthy Beginning Initiative provided free, integrated, on-site laboratory tests during baby showers in 20 intervention churches, while women at baby showers at 20 control churches received referral to a health facility (the standard of care). The 3,002 participants in both intervention and control groups received three study visits: one at baseline (recruitment), one during the baby shower, and one at 6–8 weeks after delivery. The primary outcome was a confirmed HIV test during pregnancy. HIV prevalence did not differ between groups. However, women in the intervention group were more likely than those in the control group to be linked to care before delivery, and were more likely to access care and receive antiretroviral therapy during pregnancy. The authors concluded that a culturally adapted, congregation-based approach delivered by trained volunteer health advisors can be used effectively to increase HIV testing in pregnant women in remote regions of the country.

Technau, K.G., Kunn, L., Coovadia, A., Murnane, P.M., Sherman, G. The Lancet HIV (July 2017), doi: 10.1016/52352-3018(17)030097-8.

This study described point-of-care testing (POCT) for HIV-exposed newborns and compares outcomes to universal laboratory-based testing (LABT). Mothers of 3,097 infants agreed to participate; 2,238 of these infants concurrently received POCT and LABT. Of the 3,970 infants undergoing LABT at birth, 57 were positive. Of the 2,238 infants undergoing POCT, 32 were positive. All infants identified as HIV-positive by LABT were also identified by POCT. There were two false positives among infants undergoing POCT. For LABT, median turnaround time from blood draw to return of result was 43 hours; for POCT it was 2.6 hours. Mothers whose infants received POCT and LABT received their results in 96 percent of cases, while only 53 percent of mothers whose infants received LABT received their results. Of the 30 infants diagnosed through POCT as HIV-positive, all mothers received the result, and all infants started antiretroviral therapy (ART). Of the 27 infants diagnosed through LABT as HIV-positive, 24 mothers received the result, and all of their infants started ART. Infants diagnosed via POCT initiated treatment earlier than infants diagnosed via LABT (one day versus six days). The authors concluded that POCT is accurate, increases the likelihood of the mother receiving the result, reduces waiting time for the result, and decreases time to ART initiation.

Veloza, J., Watt, M.H., Abler, L., et al. AIDS and Behavior (July 2017), doi: 10.1007/s10461-017-1853-z.

The authors of this study surveyed 496 male and female patrons of alcohol-serving venues to examine the relative influences of frequency of attendance at the venues, substance use, HIV-associated risk behaviors, and protections offered by social support. More men than women reported meeting new sex partners at such venues (31% versus 16%, respectively). Men reported having an average of 4.4 partners during the past 4 months; women reported 1.2. Both sexes reported using protection during about half of the sexual encounters. Women who visited bars daily reported high social support, binge drinking, and substance use. Women with social support were less likely to look for a sex partner, have sex at the venue, or have unprotected sex. Men who visited daily did not have high social support, were more likely to binge drink, and exhibited hazardous alcohol consumption. However, men who had high social support at the venue were more likely to use protection during sex. Women who visited daily were more likely to have a higher number of sexual partners, including outside the venue; but this was not the case among men who visited daily. Future interventions should address the risks and benefits of social support and gender in regular bar patrons to reduce harmful alcohol use and related risk behaviors among these customers.

Icard, L.D., Jemmott, J.B., Carty, C., et al. Prevention Science (May 2017), e-publication ahead of print, doi: 10.1007/s11121-017-0793-1.

This study examined strategies that affected adolescent retention in an HIV/sexually transmitted infection risk reduction trial at 42 and 54 months post-enrollment. Before the 42-month assessment, additional staff were hired and trained to address retention through a case management approach. Retention staff met with participants’ teachers and posted study contact information within schools, which encouraged participants to update their contact information for the study. Participants not found within schools received home visits and text messages. Teachers were recruited to provide participants with transportation to their appointments. Local radio stations and a free newspaper also issued reminders about the reestablishment of study activities. Participants who attended the 42-month session were sent thank-you cards as incentive to return to the 54-month session. There were 1,056 grade six study participants who initially enrolled; at long-term follow-up they had entered into 200 different high schools. The retention rate at 42 months was 91 percent, and retention at 54 months was 99.2 percent. Participants aged 9–13 were more likely to be retained than those aged 14–18 years. The authors concluded that addressing adolescent retention required building relationships with community leaders, including teachers and community advisory boards, as well as using a case management approach and developing a database to monitor participant contact information frequently.

Harwood, J.M., Weiss, R.E., Comulada, W.S. Prevention Science (April 2017), e-publication ahead of print, doi:10.1007/s11121-017-0788-y.

The authors proposed an alternative approach for comparing intervention versus control outcomes in complex interventions. Behavioral interventions are generally measured using multiple endpoints, including risk behavior, biological measurements, and health outcomes. Often, these outcomes are difficult to measure because of multiple correlations, making it difficult to ascribe specific outcomes to the intervention. The usual approach is to use the "sign test" to highlight differences, such as in pre- and post-intervention outcomes. The proposed binomial approach counted the number of significant treatment/control differences, and accounted for correlations among the outcomes. The authors used Monte Carlo simulation (which adjusts for correlation and provides updated critical values and p values) to examine the Philani Intervention Program (PIP) in South Africa, an intervention targeting mothers and children that measured 28 outcomes including maternal alcohol use, malnutrition, and HIV. This approach overcame the risk of false positive results and showed, for example, that PIP yielded significantly better outcomes in maternal and infant wellbeing over six months, compared to standard care. The authors advocated for further research on other solutions for identifying the outcomes of multi-outcome studies.

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.

Gottert, A., Barrington, C., McNaughton-Reyes, H.L., et al. AIDS and Behavior (February 2017), e-publication ahead of print, doi:10.1007/s10461-017-1706-9.

This study examined associations between both gender norms and men's gender role conflict and stress (GRC/S) (men's stress about playing their expected roles as men) and HIV risk behaviors. The authors used data from a population-based survey of 579 men aged 18–35 years in rural northeast South Africa, and they developed a GRC/S scale focused on three behaviors: sexual partner concurrency, intimate partner violence (IPV), and alcohol abuse. The GRC/S scale incorporated sub-elements describing men's views on gender equity (such as tolerance for violence); success (the ability to earn money or "win" in competition); subordination to women (the need to earn more than women); emotional expression; and sexual prowess. The findings showed high prevalence of concurrency and IPV perpetration in the past 12 months (38.0% and 13.4%, respectively); 19.9 percent of men abused alcohol. More inequitable gender norms and higher GRC/S were each significantly associated with greater likelihood that each of the three risk factors would be present. Further analysis suggested that subordination to women was strongly linked to concurrency; that constricted emotional expression was key to IPV perpetration; and that limited success was linked to alcohol abuse. These findings, the authors said, pointed to a strong need for programs to transform gender norms; these should be coupled with effective strategies for addressing men's GRC/S.

Gonçalves, T.R., Faria, E.R., Carvalho, F.T., et al. Cadernos de Saúde Pública (January 2017), 33(1): e00202515, doi:10.1590/0102-311X00202515.

This study updated a previous systematic review and meta-analysis (1980–2010) on behavioral interventions promoting condom use among women living with HIV. The authors broadened the previous review, including newly published studies (2010–2014). They identified recent randomized controlled trials (RCTs) or controlled studies investigating behavioral interventions that: included women living with HIV; focused on condom use promotion; presented/analyzed outcomes by gender; used a three-month follow-up or more; and considered at least one HIV-related behavioral or biological outcome. Eight studies comprising a total of 1,355 women living with HIV were included in the meta-analyses, and 13 studies were qualitatively described. The authors noted that data on how behavioral interventions affect HIV-positive women's condom use remain limited. The meta-analysis showed that behavioral interventions did not have a greater impact on consistent condom use or unprotected sex when compared to standard care or minimal support interventions. However, the qualitative syntheses showed improvements in consistent condom use and fewer unprotected sexual acts in all but one intervention. The authors suggested interpreting the findings with caution (they were based on a few small trials). They said that behavioral change interventions appear to be difficult to evaluate through RCTs and called for additional research to assess potential gains from interventions that promote safe sexual behavior.

Embleton, L., Nyandat, J., Ayuku, D., et al. Journal of Adolescent Health (January 2017), pii: S1054-139X(16)30868-0, doi:10.1016/j.jadohealth.2016.11.015, e-publication ahead of print.

This study used baseline data from the Orphaned and Separated Children’s Assessment Related to their Health and Well-Being Project to examine whether risky sexual behaviors and sexual exploitation in orphaned adolescents differed between family-based and institutional care environments. It included a cohort of 1,365 orphaned adolescents aged 10–18 years, 712 (52%) living in institutional environments and 653 (48%) in family-based care in Uasin Gishu County, Kenya. Multivariate logistic regression compared primary outcomes (ever having consensual sex, number of sex partners, transactional sex, and forced sex) among participants, adjusting for age, sex, orphan status, importance of religion, caregiver support and supervision, school attendance, and alcohol and drug use. The findings suggested that the care environment influenced orphaned adolescents’ sexual behaviors and risks. Participants in institutional care were less likely to report engaging in transactional sex or experiencing forced sex. Adult supervision played a role in reducing the risk of a forced first sexual encounter; being in school was associated with reduced sexual risks. The authors suggested cautious interpretation of study findings, but concluded that adolescents in family-based care may be at increased risk of transactional sex and sexual violence compared to those in institutional care. Institutional care may reduce vulnerabilities by providing basic material goods and improved living standards.

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.

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.

Rodriguez-Hart, C., Liu, H., Nowak, R.G. AIDS and Behavior (February 2016) 20(11): 2762–2771, doi: 10.1007/s10461-016-1311-3.

The study examined participation in seroconcordant sexual relationships among 433 Nigerian men who have sex with men (MSM) and up to 5 of their sexual partners; and analyzed HIV infection risk among serodiscordant versus seroconcordant partners. Participants responded to a questionnaire to provide information on their demographics, HIV testing history, discussions about HIV status with sexual partners, sexual behaviors, and drug use. Results showed that 220 MSM knew their HIV status before the study; 95 were HIV-positive. Four men reported only participating in seroconcordant relationships, while 91 reported serodiscordant sexual activity with at least one of their sexual partners. Of the 125 participants who knew they were HIV-negative, 36 reported only participating in sexual activity with HIV-negative partners; 89 reported having sex with at least one HIV-positive partner. The majority of the 220 MSM who knew their HIV status reported sexual activity with both HIV-negative and HIV-positive partners; however, in 66.1 percent of encounters, participants did not know their partner's HIV status. Serodiscordant couples were less likely to use condoms, and more likely to have casual sex and inject drugs. The authors said that these findings demonstrated the importance of promoting HIV status awareness for oneself and partners and of encouraging safer sexual activity.

Ankunda, R., Atuyambe, L.M., Kiwanuka, N., Pan African Medical Journal (November 2016), 24:49, doi:10.11604/pamj.2016.24.49.6633.

The authors used structured questionnaires to explore factors associated with sexual risk-taking and abstinence among 338 15- to 24-year-old unmarried HIV-positive youth. They found that 83 percent of youth reported a future desire to marry, and 50 percent would prefer to have an HIV-negative partner. Fewer than half (45%) reported ever having had sex; average age of sexual debut was 16.9, and girls were significantly more likely to have had sex than boys. In bothboys and girls, 37 percent were currently in a heterosexual relationship. Sixty-nine percent had not shared their HIV-positive status with their partner and 37 percent were unaware if their partner was HIV-positive. Among sexually active youth, 30 percent had more than one sexual partner, and 46 percent reported using a condom during each sexual act during the last six months. About one-fourth (24%) had not had sex within the past six months. Factors associated with abstinence included being younger, not having a biological child, and not consuming alcohol in the month before the study. The authors emphasized that developing interventions that specifically address adolescent HIV transmission risk, including disclosure, condom use, and reducing alcohol use among HIV-positive youth, may help to reduce HIV transmission.

Gust, D.A., Soud, F., Hardnett, F., et al. Journal of Acquired Immune Deficiency Syndromes (August 2016), Epub ahead of print, doi: 10.1097/QAI.0000000000001143.

This longitudinal study (2007–2010) examined whether heterosexual men and women participating in a pre-exposure prophylaxis (PrEP) trial changed sexual behaviors, including condom use and number of sexual partners. The 1,200 participants received PrEP, risk reduction counseling, condoms, and screening for sexually transmitted infections. They were interviewed about their sexual behaviors at baseline and each month to determine if risk compensation was taking place. Among participants, the odds of reporting using a condom during sex increased by 23 percent each year. Participants who reported having at least one condomless sexual encounter were more likely to have herpes simplex virus 2, be male, and report early sexual debut (≤15 years). The odds of reporting no sexual activity increased by 2 percent each year. Among participants who reported at least one sexual encounter in the past 30 days, the rate of reported sexual activity diminished by 3 percent each year. Men and participants who initiated sexual activity at ≤15 years were more likely to increase the number of their sexual partners during the study. Overall findings indicated that PrEP programs can be effectively implemented without increasing risk compensation. This study actually showed a reduction in the number of condomless sexual acts and an increase in the number of participants reporting no sexual partners.

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.

Parcesepe, A.M., L'Engle, K.L., Martin, S.L., et al. Sexually Transmitted Infections (May 2016), pii: sextrans-2016-052549, doi: 10.1136/sextrans-2016-052549.

Between March and September 2011, the authors investigated whether early initiation of sex work was associated with consistent condom use and self-efficacy in condom negotiation among alcohol-using female sex workers (FSWs) in Mombasa, Kenya. At three drop-in HIV service centers, they interviewed 818 FSWs aged 18 or older who screened positive for hazardous or harmful drinking. Participants were asked about the age at which they first received money for sex, and the frequency of their condom use in the past 30 days. Nearly one-fifth (19.9%) reported early initiation of sex work (defined as initiation at age 17 or younger). These FSWs were less likely to report consistent condom use with paying partners compared with FSWs who began sex work when older. Early initiators reported feeling significantly less self-efficacy to refuse sex with a paying partner if a condom was not available compared with those who began sex work later. However, there was no significant difference between groups in consistent condom use with non-paying partners. The authors concluded that interventions for adolescent and adult FSWs who initiated sex work early should focus in particular on risk reduction with paying partners, and should incorporate strategies that do not require partner consent, such as pre-exposure prophylaxis, where available.

Karki, P., Shrestha, R., Huedo-Medina, T.B., and Copenhaver, M. Evidence-based Medicine & Public Health (March 2016), pii: e1229.

This literature review found a significant association between methadone maintenance treatment (MMT) and reduction of sex- and drug-related HIV risk behaviors among high-risk people who inject drugs (PWID). The 12 eligible studies, identified from among articles and dissertations published between 2005 and 2015 consistently revealed a decrease in the reported use of injection, frequency of injection, sharing of injecting equipment, and drug-related HIV risk scores. MMT was also associated with a lower likelihood of multiple sex partners or unprotected sex. The studies also showed significantly lower prevalence of unprotected sex and drug use risk behavior among PWID who received both MMT and HIV testing services (HTS), compared to HTS alone. The authors concluded that their findings pointed to a close and direct association between MMT and reduced HIV risk behaviors, and recommended that policymakers and implementers ensure high rates of access and adherence to MMT.

Thurman, T.R., Kidman, R., Carton, T.W., and Chiroro, P. AIDS Care (February 2016), 28(1): 8–15, doi: 10.1080/09540121.2016.1146213.

This cluster-randomized controlled trial evaluated the effectiveness of two interventions, offered independently and in combination, on sexual risk behaviors among 14- to 17-year-old orphaned and vulnerable adolescents in South Africa (N = 1016). Participants were randomized into one of the four experimental conditions:

  1. The Vhutshilo (Life) intervention only (13 weekly 60-minute sessions covering alcohol and substance abuse, crime and sexual violence, HIV, healthy sexual relationships, transactional sex, and condom use)
  2. Interpersonal psychotherapy for groups (IPTG) only (16 weekly 90-minute group sessions that included practice on interpersonal skills and emotional support among group members)
  3. IPTG followed immediately by Vhutshilo
  4. No new interventions aside from standard care (control group).

The authors interviewed each participant three times over 22 months. They reported 95 percent retention, and observed significant effects (which varied by gender) among adolescents enrolled in both interventions. Girls enrolled in both interventions showed significant increases in consistent condom use relative to the control group; boys had significant decreases in the prevalence of risky sexual partnerships relative to those in the control group at the final follow-up survey. The authors concluded that strategically packaging psychological and behavioral interventions together may achieve greater reductions in sexual risk behavior among adolescents. 

Mthembu, J.C., Khan, G., Mabaso, M.L., and Simbayi, L.C. AIDS Care (February 2016), e-publication ahead of print.

This study explored whether intimate partner violence (IPV) perpetration by men was a risk factor for engaging in other high-risk behaviors, especially risky sexual behaviors and alcohol misuse. The authors used data from a multilevel intervention study on alcohol abuse and HIV prevention among 975 South African men aged 18 years and older. They were recruited from informal drinking places within 12 communities in Cape Town townships, and asked to complete a confidential survey. Over one-third (39.9%) of participants reported having been involved in IPV. Men who reported having a child were more likely than childless men to perpetrate IPV. Men who reported having a casual sexual partner were significantly more likely to be involved in IPV, and those with possible alcohol dependence were three times more likely to perpetrate IPV compared to abstainers. However, men who reported using a condom at last sex were significantly less likely to engage in IPV than those who had not used condoms. The authors concluded that fatherhood, having a casual sexual partner, not using a condom at last sex, and alcohol dependence were significantly associated with self-reported perpetration of IPV. They added that interventions to reduce IPV need to address risky sexual and drinking behaviors among men, as well as power dynamics and gendered norms among couples.

Fleming, P. J., Mulawa, M., Burke, H., et al. AIDS Care (October 2014), E-publication ahead of print.

Multiple concurrent partnerships are considered one of the important drivers of HIV transmission. This study examined how different combinations of concurrent partnerships (with a wife, girlfriend, casual partner, and/or sex worker in various combinations) affect condom use. The authors looked at survey data from a sample of heterosexual men aged 18–49 years from Ghana (n = 807) and Tanzania (n = 800) who had at least three sexual partners in the last three months before the study. Each man self-reported condom use at last vaginal sex for each of his last three partners. Study participants reported 34 (Ghana) and 32 (Tanzania) relationship type combinations, the most prevalent being three girlfriends (GH: 37.5 percent of men; TZ: 34.8 percent of men). The authors focused on condom use with girlfriends, since this was the only relationship type with a sufficient sample size. In both countries, men viewed a girlfriend as a steady partner. The study found that men were more likely to use a condom with a girlfriend if their other partner was a wife than if the partner was a sex worker. The authors concluded that condom use seems to be associated with the types of partners that comprise men’s concurrent relationships. More research is needed to see how different combinations of relationships influence HIV risk behaviors and condom use.

Zajac, K., Kennedy, C. E., Fonner, V. A., et al. AIDS and Behavior (September 2014), E-publication ahead of print.

The authors of this review found that behavioral counseling (BC) programs and interventions exerted limited to moderate effects on risky sexual behaviors and prevalence of HIV and sexually transmitted infections (STIs) in low- and middle-income countries. The authors examined 30 studies published between 1990 and 2011 that used multi-arm or pre-post designs and provided post-intervention data. They presented results on BC interventions in five groups: (a) people living with HIV; (b) people who use drugs and alcohol; (c) serodiscordant couples; (d) key populations for HIV prevention; and (e) people at low to moderate HIV risk. Changes in sexual behavior and HIV or STI prevalence were at best moderate across all target groups. The authors added that some studies indicated improvements in sexual behaviors and biological indicators following BC interventions, but it was unclear whether the improvements were due to BC interventions or to services already available in the communities. The authors concluded that BC strategies alone are insufficient for reducing sexual transmission risk in people living with HIV, people who abuse drugs and/or alcohol, and those at high risk for HIV transmission. However, additional research is needed to clarify the efficiency of BC interventions for serodiscordant couples and people at low to moderate risk for HIV.

Reisner, S.L., Murchison, G.R. Global Public Health (January 2016):1–22, e-publication ahead of print.

Assessing the risks of HIV infection and sexually transmitted infections (STIs) in female-to-male transgender persons (FTMs) is difficult because data on this population are very limited. The authors reviewed 25 peer-reviewed studies published online before August 2014 and 11 grey literature reports providing FTM-specific data on sexual risk behavior, HIV status, or STI infection. They were unable to identify any data on biomedical prevention strategies, such as microbicides or HIV pre-exposure prophylaxis in FTMs. Moreover, FTMs were typically excluded from drug efficacy trials, even those that include transgender women. There were no studies using longitudinal cohort designs to examine FTMs' sexual behavior over time, and epidemiologic studies on sexual risk among FTMs were mainly from the U.S. or Canada. The authors made several recommendations to guide future research efforts: (1) capture transgender identity in health surveillance systems to understand HIV and STI prevalence in these populations; (2) develop validated and standardized sexual risk assessments that are acceptable to transgender and non-transgender populations alike; and (3) acknowledge the range of gender identities in FTMs, considering both the potential challenges and protective effects of non-binary identity (gender identity that is neither exclusively male nor exclusively female) for sexual health.

Nkosi, S., Sikweyiya,Y., Kekwaletswe, C. T., et al. AIDS Care (November 27, 2014), pp. 1–6, E-publication ahead of print.

The authors of this study examined the relative importance of alcohol consumption and both medical male circumcision (MMC) and traditional male circumcision (TMC) as correlated with unprotected sex; and compared the risk of unprotected sex between traditionally circumcised and medically circumcised tavern-going men from two rural villages in North West province, South Africa. The 314 study participants were asked to respond to an interviewer-administered structured questionnaire about their demographic characteristics, alcohol use, circumcision status, method of circumcision (i.e., traditional or medical), and condom use behavior in the past six months. The authors used a 10-item Alcohol Use Disorders Identification Test (AUDIT) approach to assess the participants’ alcohol consumption. Using descriptive analyses and bivariate and multivariate logistic regression analysis, they showed that age, education, relationship status, alcohol consumption, and TMC were independently significantly associated with unprotected sex. Additionally, the study found that TMC men had a higher risk of engaging in unprotected sex than MMC men. The authors concluded that more research is needed to better understand factors that could account for differences in behavior between TMC and MMC men. They also urged including interventions to reduce alcohol consumption and encourage protective behavior among TMC men within HIV prevention education.

Price, J. E., Phiri, L., Mulenga, D, et al. PLoS ONE (November 2014), Vol. 9, No. 11, e111602.

This qualitative study showed that tailored messages, delivered by an appropriate "messenger," are critical to the acceptance of voluntary medical male circumcision (VMMC). The authors interviewed a sample of 40 married and unmarried men over age 18 in two VMMC clinics in Lusaka, Zambia to understand how these men first became interested in circumcision, what brought them to the VMMC clinic, and whether the medical sector met their needs. At the two high-volume clinics (>30 VMMC services daily), the authors conducted interviews in line with the Stages of Change behavioral theory to document the men’s VMMC-seeking behavior from the time they first learned about adult circumcision to the time when they entered the medical facility to seek the procedure. A major finding was that the messenger was as important as the message in the decision-making process. The interviews showed that messages about VMMC play an important role on men's behavior change; but the men also expressed the need for messages tailored to their specific needs and concerns about VMMC. Also, their frequent reference to peers and friends underscored that peer-to-peer messages play an important role in behavior change. The interviewees stressed that clinics should avoid turning men away (due to lack of supplies, for example), since this may discourage some men from returning to the clinic.

Protogerou, C., & Johnson, B. T. AIDS and Behavior (October 2014), Vol 18, pp. 1847–1863.

The authors analyzed quantitative and qualitative reviews published to date to identify characteristics of successful HIV prevention interventions for adolescents aged 10–19, focusing on reduction of sexual risk-taking. After examining five eligible meta-analyses and six qualitative reviews, they identified four categories (factors) of interventions that were associated with reduced sexual risk-taking: (1) use of behavior change techniques (e.g., training to enhance motivation and build skills in cognitive behavior); (2) participant characteristics (e.g., age and vulnerability to contracting sexually transmitted infections including HIV); (3) application of design features (e.g., application of theory, formative research); (4) and socio-ecological features (e.g., supportive school environment). The findings showed that behavioral interventions had positive outcomes in at least one of the following: improving knowledge about HIV or safer sex, self-efficacy, delaying next sexual intercourse, encouraging abstinence, decreasing frequency of sex or number of partners, and increasing condom use. Of the four categories examined, the first, use of behavior change techniques (such as practicing communication and negotiation skills) was most closely linked to reduced sexual risk-taking; the fourth category, socio-ecological features, was the least effective. The authors concluded by endorsing the efficacy of behavioral HIV prevention interventions for adolescents, and called for formative research for full implementation of each of the four elements discussed.

Bao, Y., Jing, J., Zhang, Y., et al. Chinese Medical Journal (English), (December 2014), Vol. 127, Issue 24, pp. 4177–4183.

This cohort study examined differences in the risk of sexual HIV transmission between people who knew their HIV status and those who did not. The study comprised two surveys of newly diagnosed HIV-positive participants in Shanghai, Chongqing, and Kunming, China. The first survey of 823 HIV-positive participants took place before participants learned their status. The second study, with 650 participants, was conducted six months after HIV status notification. Both surveys asked questions about sexual behaviors in the past six months, including unsafe sex practices (unprotected anal and vaginal sex with partners of positive or unknown HIV status), number of unsafe sexual partners, and frequency of unsafe sexual behaviors. Comparison of the behavior of participants with known versus unknown HIV status showed a large reduction (84.65 percent) in reports of unsafe sex (from 58.25 percent before HIV status notification to 8.94 percent after notification). Moreover, the average number of partners in unsafe sex practices dropped by over 35 percent (from 2.33 partners to 1.51 partners pre- and post-notification, respectively). The average frequency of unsafe sex dropped from 9.02 percent of all encounters before HIV status notification to 7.85 percent after notification. The authors concluded that HIV status notification can reduce the incidence of unsafe sexual practices, leading to reduced sexual transmission of HIV.

Hammett, T. M., Phan, S., Nguyen, P., et al. Journal of Acquired Immune Deficiency Syndromes (December 2014), doi: 10.1097/QAI.0000000000000512.

Vietnam's HIV epidemic is concentrated among people who inject drugs (PWID), and female sexual partners (SPs) of male PWID may be at high risk for HIV infection due to incorrect knowledge of their partner's HIV status. This study assessed the level of accuracy of SPs’ knowledge of their male PWID partners’ HIV status following interventions that provided individual and group counseling and outreach, distribution of informational materials, condoms, and/or HIV service referral to HIV-negative SPs in Dien Bien, Hanoi, and Ho Chi Minh City (HCMC). Between 12 and 48 months after the interventions, the authors conducted linked surveys (behavioral interviews and HIV testing) among PWID-SP couples at all study sites. A comparison of SPs’ beliefs about their PWID partners’ HIV status and the PWIDs’ actual test results showed that a significant proportion of SPs (32 percent in Dien Bien and 44 percent in Hanoi and HCMC) lacked correct knowledge of their male partners’ status. This proportion was lower among SPs whose partners reported being tested previously (21 percent) and receiving positive results (33 percent), due to male PWID’s self-reported disclosure of HIV status to their female SPs. The authors concluded that HIV testing, disclosure, and treatment for SPs in Vietnam, as well as their empowerment within couples, can help SPs avoid acquiring HIV.

Abler, L., Sikkema, K. J., Watt, M. H., et al. Journal of Acquired Immune Deficiency Syndromes (March 2015), Vol. 68, Issue 3, pp. 322–328.

Following a secondary analysis of data from a 2009–2012 study of 560 women patrons of 12 alcohol serving venues in Cape Town, South Africa, the authors developed a model estimating the effects of and interrelationships among traumatic stress, alcohol use, and unprotected sex. Eighty percent of participants reported elevated levels of traumatic stress, and 88 percent reported hazardous alcohol use. The authors' analysis showed that alcohol use was a significant behavioral facilitator that influenced the effect of traumatic stress on sexual risk behavior. Also, women with significant symptoms of traumatic stress (independent of alcohol use) were 82 percent more likely to have unprotected sex than women without traumatic stress. Similarly, high alcohol use was associated with higher rates of unprotected sex, regardless of traumatic stress levels. The authors concluded that women who had both traumatic stress and alcohol abuse were at higher risk for HIV, and that problem drinking exacerbated the relationship between trauma experiences and sexual risk behavior. They recommended that interventions to reduce the impact of alcohol use on HIV risk should be adapted to address both traumatic stress and alcohol use.

Du, H., and Li, X. Health Psychology Review (March 2015), Vol. 9 No. 1, pp. 103–122, doi:10.1080/17437199.2013.840952.

This systematic review and meta-analysis of 64 studies examined the associations between acculturation among migrants and HIV-related sexual behaviors, including condom use, multiple partnerships, unsafe sex, and the presence of sexually transmitted infections (STIs). The authors categorized the effects of acculturation by gender, ethnicity, and degree of acculturation (including length of time living in the host culture and language use). They found no associations between acculturation and condom use. However, increased acculturation was positively associated with multiple partnerships, early sexual initiation, STIs, and unsafe sex, with greater risk for women. The authors concluded that acculturation was a high risk factor for HIV and called for the implementation of culturally appropriate prevention and intervention programs among growing immigrant populations.

Laisaar, K-T., Raag, M., Rosenthal, M., and Uusküla, A. AIDS Patient Care and STDs (May 2015), Vol. 29 Issue 5, doi:10.1089/apc.2014.0240.

The authors searched electronic biomedical databases and conference abstracts from 1981 to 2013 to identify and synthesize research on individual-level, facility-based behavioral interventions for people living with HIV (PLHIV) to determine their efficacy in reducing sexual risk behavior. The five studies they identified reported widely varying sexual behaviors, since some studies only recruited people who had engaged in sexual acts without condoms during the past three months, while others had no history of recent sexual activity. Overall, the quality of evidence in the included studies was low; only two of the five studies showed low risk of bias. The authors found no evidence on the effect of sexual risk reduction interventions on biological measures, since none of the studies measured the acquisition of hepatitis or sexually transmitted infections. They also found limited evidence that individually administered sexual risk reduction interventions reduced the number of casual sex partners or increased the consistency of condom use in acts posing a risk of HIV transmission. Nevertheless, the authors found that regular interactions between HIV care providers and PLHIV provided valuable opportunities to implement sexual risk reduction interventions to restrain the spread of HIV.

Meng, X., Zou, H., Fan, S., et al. AIDS and Behavior (May 2015), Vol. 19, Issue 5, pp. 882–889.

The authors of this review examined global data on the relative HIV risk of different modes of anal sex among men who have sex with men (MSM). They analyzed 21 papers published before September 2013 and conducted a meta-analysis of HIV prevalence and relative risk for HIV infection for two time periods: 1981–1985 and 1986–2010. Their analysis showed that men engaging in receptive anal intercourse only (MRAI) were 6.9 and 1.8 times more likely to be HIV-positive in 1981–1985 and 1986–2010, respectively; and 6.2 times more likely to develop incident HIV infection overall, compared to men engaging in insertive anal intercourse only (MIAI) during those time periods. Overall, MRAI and men engaging in both insertive and receptive anal sex were 6.2 and 6.6 times more likely to develop incident HIV infection compared to MIAI. This study is the first to provide concrete data evidence that sexual positioning is significantly associated with HIV transmission among MSM. The authors concluded that despite relatively lower prevalence and incidence of HIV in men engaging in insertive anal sex only, the prevalence and incidence of HIV were invariably high among men engaging in any variation of anal sex.

Duby, Z., Hartmann, M., Montgomery, E.T., et al. AIDS and Behavior (July 2015), doi: 10.1007/s10461-015-1120-0.

This study investigated condom and lubricant use, rectal cleansing, and rectal gel use for penile-anal intercourse (PAI) during in-depth interviews with 88 women from four sites in South Africa, Uganda, and Zimbabwe who formerly participated in VOICE, a five-arm HIV prevention trial of two antiretroviral tablets and a vaginal gel. The study found that the majority of Zimbabwean participants (65 percent) and South African participants (73 percent) believed that condoms could be used for PAI. In Uganda, however, the majority (59 percent) of participants did not think it was possible to use condoms for anal sex, for reasons including the anus being too tight and that the condom would tear or get stuck. Some participants in all three countries believed that it was not necessary to use condoms for PAI, suggesting that some men and women choose to engage in PAI for HIV prevention, as PAI is seen as a safer alternative to penile-vaginal intercourse. When asked about
vaginal gel use, some participants suggested that if the gel provided protection from HIV, women might use it vaginally or rectally. The authors concluded that results of this first study related to practices associated with PAI among heterosexual women show that women need to be included in rectal microbicide trials in Africa.

Mantell, J.E., Smit, J.A., Exner, T.E., et al. AIDS and Behavior (July 2015), 19(7): 1129–1140.

This study compared the efficacy of two approaches for promoting the use of female condoms. Female students at a South African university were randomized to either a single group session featuring information on female condoms (control, n = 149), or a two-session enhanced intervention (EI, n = 147) that included information on female condoms, rehearsal of their use, and skill-building on partner negotiation. Follow-up assessments were conducted at 2.5 and 5 months after completion of the intervention. At both follow-up periods, participants in both groups reported significant reductions relative to baseline in instances of vaginal intercourse without condoms (either male or female). In the control group, the number of female condoms used increased 135.6 times between baseline and the 2.5-month follow-up; and 58 times at the 5-month follow-up. In the EI group, use of female condoms increased 16.8 times at 2.5 months and 12.7 times at 5 months. The authors concluded that both interventions led to significant reductions in unprotected sex and significant increases in the use of female condoms during sexual encounters at five months post-intervention. They recommended a brief one-session intervention on using female condoms, delivered over a 60–90 minute period, especially in resource-constrained settings.

Yamanis, T.J., Doherty, I.A., Weir, S.S., et al. AIDS and Behavior (2013), Vol. 17, pp. 2405-2415.

Within a project to assess determinants of sexual risk behavior among young men in a high-risk ward of Dar es Salaam, Tanzania, the authors present findings from a cross-sectional survey of men ages 15-19 (n=663) who socialized at 66 venues known for meeting sexual partners. They found that as male youth transitioned from early to late adolescence, engaging in concurrent sexual partnerships became a normative behavior. Increasing age was correlated with increasing sexual experience and gradually increasing prevalence of concurrency. The authors applied stratified models at ages 15-17 and 18-19. The six-month aggregate prevalence of concurrency was 29 percent; prevalence among sexually experienced youth was 42 percent. Concurrency increased by age: 5 and 44 percent among males age 15 and age 19, respectively. In both age groups, concurrency was associated with having had at least two sexual partners; visiting multiple social venues on the day the survey was conducted; and having met at least one partner at a venue. Alcohol use was frequently reported by older youth. Future studies should assess whether peer pressure to engage in risky sexual behavior is more common for young men than women, as the authors hypothesized. The authors called for further research to understand how venue-based social networks may influence young men's sexual risk behavior.

Gorbach, P.M., Kelly, C.W., Borgerding, J.A., et al. AIDS and Behavior (October 2013), E-publication ahead of print.

The authors examined the effect of sexual partnership changes on women’s adherence to microbicide gel use in the HIV Prevention Trial Network (HPTN) 035 trial. Self-reported adherence among women with ongoing partners (n=1,571) and among women with new partners (n=123) was compared. The findings showed that having a new partner affected self-reported adherence to a microbicide gel—those who indicated having a new partner reported using a microbicide gel less frequently than women reporting having an ongoing partner. Reported gel use at last vaginal sex was 100 percent among women with ongoing partners compared to 75 percent for women with new partners. Factors associated with self-reported high adherence included having an ongoing partner, older age, and higher rates of reported sex in the past week. Further, more women with new partners acquired HIV compared to those with an ongoing partner (9.8 versus 4.5 percent). The findings emphasize the importance of evaluating partnership status among women in similar trials. However, the authors suggested that future studies refine methods for measuring partner status to further understand its effects. They advocated for male-focused outreach to promote awareness of new HIV prevention methods, along with high-quality counseling for women to encourage them to introduce these methods to new partners.

Kiene, S.M., Sileo, K., Wanyenze, R.K., et al. Journal of Health Psychology (September 2013), E-publication ahead of print.

The authors conducted formative research to identify factors affecting the HIV prevention behaviors of Ugandan men and women receiving provider-initiated testing and counseling (PITC) in a public hospital. They conducted focus group discussions with 56 clients and 23 hospital staff, and key informant interviews with four additional staff, to obtain perspectives about the community’s HIV prevention behaviors and how to improve PITC services. The findings revealed important individual, interpersonal, and structural or community-level factors that influenced HIV prevention behaviors and PITC acceptability. While clients were knowledgeable about the benefits of HIV testing and counseling, information gaps and misconceptions were common. Attitudes toward PITC were generally favorable; however, motivation to test was hindered by fear of testing, finding out one’s status, and disclosing results to a partner. Fear of lack of confidentiality and poor provider counseling skills also limited clients' motivation. Structural factors also exerted significant impacts. Gender inequity influenced behavior, including women’s ability to negotiate safe sex. Stigma towards HIV-positive persons comprised a barrier to PITC and prevention behaviors, and affected confidentiality and trust in client-provider relationships, which emphasized the need to conduct PITC privately. Interventions must address structural-level factors, e.g., stigma and gender norms, to increase HIV prevention behaviors. Client-centered, non-judgmental counseling during PITC may increase positive prevention behaviors among clients.

Mhalu, A., Leyna, G.H., and Mmbaga, E.J. Journal of the International AIDS Society (October 2013), Vol. 16 No 1., pp. 17342.

The authors conducted a cross-sectional study to describe common HIV risk behaviors among 282 youth living with HIV (ages 15-24; 73 percent female) at eight urban care and treatment sites in Tanzania. The prevalence of unprotected sex was 40 percent among males and 37.5 percent among females. Approximately 16 and 11 percent of females and males, respectively, reported engaging in multiple sexual partnerships. Knowledge about sexually transmitted infection (STI) prevention and transmission was low overall, but knowledge about STI symptoms and complications was relatively high. The majority reported engaging in risk behaviors with partners of unknown HIV status, and younger respondents (ages 15-19) were three times more likely than older youth to engage in unprotected sex. Respondents with family support reported having fewer sexual partners (0-1) compared to those without family support (87 versus 75 percent). Respondents who were using antiretroviral therapy (ART) were significantly less likely to engage in risky sexual behaviors, including multiple sexual partners, compared to those not on ART. Those who did not drink alcohol were 60 percent less likely to report unprotected sex. The authors advocated for prevention with a positive approach in HIV care to address STI knowledge gaps and target alcohol use and other risky behaviors.

Santelli, J.S., Edelstein, Z.R., Mathur, S., et al. Journal of Acquired Immune Deficiency Syndromes (March 2013), E-publication ahead of print.

The authors conducted a prospective longitudinal study to assess demographic, behavioral, and biological factors associated with HIV incidence among 6,722 HIV-negative sexually experienced youth (ages 15-24) from 1999 to 2008 in southwestern Uganda. While behavioral and biological factors influenced HIV risk, social transitions such as leaving school and having been married were associated with high HIV risk, suggesting that increasing school attendance and addressing the high-risk group(s) of those formerly married are important HIV prevention initiatives. A total of 207 HIV infections occurred among youth. Young women were at a higher risk for HIV compared with young men. Gender-related risk was greatest among 15- to 19-year-old women; HIV incidence was 14.6 versus 3.5 per 1,000 person-years relative to young men. Multivariate analyses suggested that having multiple partners had the strongest link to increased HIV risk. Young women who lived in a trading village were also at a significantly increased risk. Young men were more likely to drink alcohol, which increased HIV risk, suggesting the need to address substance use in HIV prevention efforts. The authors found that youth were realistic about their HIV risk and were willing to disclose sensitive information about sexual behavior. These findings, they said, indicate opportunities to improve HIV prevention efforts for youth in Uganda and other resource-limited contexts.

Clark, J., Salvatierra, J., Segura, E., et al. AIDS and Behavior (May 2013), Vol. 17 No. 4, pp.1313-1328.

This study analyzed social and behavioral factors that influence sexual identities, and how they affect patterns of HIV among men who have sex with men (MSM) in Lima, Peru.  Findings showed that gender-based sexual roles among MSM were both reinforced and transformed by new sexual identities, roles, and practices. Further, social networks and behaviors affect HIV transmission by influencing relationship dynamics. Of 532 MSM, 38 percent categorized themselves as homosexual, 20 percent as transgender, 4 percent as bisexual, and 25 percent as heterosexual and were evenly divided between activo, pasivo, and moderno (a role-based, gender-versatile identity). Focus groups in 2008 and 2011 revealed four themes: 1) the pasivo MSM role is culturally associated with femininity; 2) the activo role is associated with masculinity, though sexual behaviors may threaten heterosexual masculinity; 3) moderno MSM viewed themselves as representing homosexuality and masculinity, while other MSM viewed the moderno identity as disrupting traditional gender and sexual norms; and 4) defined sexual roles provide a structure for sexual practices, identities, and social and sexual networks. Seventy-two percent of moderno and over half of other MSM reported unprotected sex. HIV prevalence was highest among pasivo and moderno MSM. The authors conclude that, although further research is needed to understand how the identities are defined and influence HIV transmission, sexual and identity roles among MSM in Peru provide a framework for HIV prevention.

Chikovani, I., Goguadze, K., Bozicevic, I., et al. AIDS and Behavior (June 2013), Vol. 17 No. 5, pp. 1906-1913.

The authors described HIV risk behaviors among 1,112 men who inject drugs in five Georgian cities through a cross-sectional and respondent-driven sampling methodology. They found that male people who inject drugs (PWID) who have multiple heterosexual partnerships tend to engage in high-risk sexual behaviors. Occasional sexual relationships were common among married PWID. Among 661 male PWID who reported occasional and paid sex partners in the previous year, the prevalence of inconsistent condom use was 64 percent. Most (72 percent) of the PWIDs who were inconsistent condom users had never been tested for HIV, and 75 percent also reported having regular partners. More than half reported having five or more sexual partners. While the majority did not practice high-risk injection behaviors, only 19 percent reported receiving condoms from HIV prevention programs. Multivariate analysis showed that predictors of unprotected sex with occasional and paid sex partners included: not having a regular sexual partner; risky injection behavior; residence in Telavi; and drug type (i.e., buprenorphine injectors were less likely to engage in risk behaviors than heroin injectors). Those who reported high-risk injection behaviors had increased odds of inconsistent condom use. Although the majority of interventions for PWID target unsafe injection behaviors, it is critical to increase focus on creating integrated programs to reduce risky sexual behaviors among PWID in Georgia.

Pitpitan, E.V., Wagner, K.D., Goodman-Meza, D., et al. AIDS and Behavior (May 2013), E-publication ahead of print.

The authors assessed the interaction between alcohol use during sex and the physical setting to examine condom use with female sex workers (FSWs) among male clients in Tijuana, Mexico. They focused on whether having sex at a bar determines the association between alcohol or drug use during sex and sexual risk behavior. Of 375 male clients (191 from Tijuana, 184 from San Diego)  recruited from September 2012 to March 2013, 14 percent reported having sex with a FSW in a bar in the past four months and were less likely to live in the United States and more likely to be married. Among these clients, more frequent intoxication with alcohol during sex was associated with more unprotected sex. This association was not found among clients who did not report having sex with FSWs at a bar. Clients who reported having sex with a FSW in a bar indicated various reasons for inconsistent condom use, such as unavailability of condoms, belief that the FSW did not have sexually transmitted infections, and withdrawal before ejaculation. The authors recommended an integrated approach entailing structural- and individual-level HIV prevention interventions, e.g., targeting sex work venues and clients’ HIV knowledge and risk perceptions.

Uusküla, A., McMahon, J.M., Kals, M., et al. AIDS and Behavior (March 2013), Vol. 17 No. 3, pp. 879-888.

The authors assessed HIV prevalence among injection drug users (IDUs) and their heterosexual non-injecting main sexual partners. They applied HIV transmission modeling using data collected on self-reported behaviors to estimate HIV risk from IDUs to their sex partners in Kohtla-Järve, Estonia. The estimated risk of HIV transmission for non-IDU females with a male IDU partner was high– between 3.24 and 4.94 HIV seroconversions per 100 person-years. Condom use accounted for notable differences in estimated incidence: estimates were five times greater among women who did not use or inconsistently used condoms with partners compared to those who consistently used condoms. The estimated range of incidence highlights the impact of acute-stage HIV infection on transmission rates. The study used respondent-driven sampling to recruit IDUs. The majority of recruited IDUs were men (n=298); 69 male IDUs successfully recruited a non-injecting partner. Of 82 women screened, 69 enrolled. HIV prevalence among male IDUs and among non-IDU partners was estimated at approximately 70 percent and 35 percent, respectively. Slightly over half of the couples were concordant in HIV status. The authors concluded that non-IDUs who have sexual partners who inject drugs are at an increased risk for HIV, and future studies should assess whether this will contribute to advancing the HIV epidemic beyond key populations in Estonia.

McGrath, N., Eaton, J.W., Bärnighausen, T.W., et al. AIDS (July 2013). E-publication ahead of print.

Using annual surveillance data in KwaZulu-Natal, South Africa, the authors analyzed population-level trends in reported sexual behavior among men (aged 17-54) and women (aged 17-49) during the rollout of antiretroviral therapy (ART) from 2005 to 2011. They found no evidence of increased risky sexual behavior during this period. Further, after adjusting for missing data, trends indicated some evidence of reductions in reported risky sexual behaviors, e.g., reported reductions in the number of multiple and concurrent sexual partnerships. Knowledge of HIV status increased, especially among women. Condom use at last sex with a regular partner increased significantly (by nearly 3 percentage points and 4 percentage points per year among men and women, respectively); the average proportion of men and women reporting this behavior in 2005 (26 percent) increased to an average of 49 percent in 2011. Condom use at last sex with casual partners did not increase significantly, but condom use with these partners was already relatively high. Condom use was highest at younger ages and lowest among married persons. There are still opportunities to promote HIV testing and counseling and informed use of condoms. The authors concluded that continued monitoring of population-level sexual behavior is needed to further assess the effectiveness of combination prevention programs and the long-term impact of ART on risky sexual behavior.

Limaye, R.J., Babalola, S., Kennedy, C.E., et al. Health Education Research, (June 2013), e-publication ahead of print.

The authors of this qualitative study conducted 40 focus group discussions and 20 in-depth interviews with men and women of reproductive age in five districts of Malawi, seeking to understand perceptions of and attitudes towards concurrent sexual partnerships, particularly to inform HIV prevention interventions. Malawian men and women largely view concurrent sexual partnerships (except polygamy) as unacceptable and stigmatize or have negative opinions of those who engage in this behavior. However, the behavior is considered widespread. This finding suggests inconsistency between the descriptive norm (perceived widespread engagement in the behavior) and the injunctive norm (belief that others disapprove of the behavior).Thematic analysis revealed additional themes. Participants perceived not only that multiple concurrent partnerships are common, but that men and women, as well as religious leaders, engage in this behavior. Concurrency was associated with disease and other negative consequences, such as family or community conflict. Interestingly, women who engaged in this behavior were reportedly very stigmatized, while men were both stigmatized and admired. There is a need to enhance the validity of self-reported behavior to ensure accuracy and assess whether HIV messaging on mitigating multiple concurrent partnerships has inadvertently influenced the behavior. The authors called for further research on perceived norms and sexual behavior, and stressed the need for improved education on concurrent sexual partnerships.

Jones, D.L., Peltzer, K., Villar-Loubet, O., et al. AIDS Care (2013), Vol. 25 No. 6, pp. 702-709.

The authors used a group-randomized controlled study in rural South Africa to evaluate a “PartnerPlus” prevention of mother-to-child transmission (PMTCT) intervention. The intervention was conducted with 239 couples at 12 antenatal care (ANC) clinics. Of these couples, 119 were randomly assigned to receive the intervention (increasing male participation during pregnancy, condom use and HIV knowledge, and sexual communication through four weekly sessions on cognitive skills), and 120 couples received standard PMTCT with time-matched health education videos (control). At baseline, 32 percent of women and 16 percent of men were HIV-positive (24 percent of men declined testing); 26 couples were serodiscordant. At follow-up (32 weeks' gestation) unprotected sex had decreased, and no women had seroconverted in the intervention. While baseline HIV knowledge scores were similar, knowledge increased among intervention participants. The intervention group had an estimated 5.1 odds of increased condom use compared with the control. Further, sexual communication/negotiation strategies increased, and intimate partner violence diminished among intervention couples. Findings suggest that interventions targeting men during pregnancy may be more effective than only encouraging ANC attendance. Because neither group attained complete coverage of male HIV testing or mutual disclosure, future research should explore relevant interventions. The authors emphasized the importance of shared engagement between couples to reduce sexual risk behaviors during pregnancy.

Dunkle, K.L., Jewkes, R.K., Murdock, D.W., et al. PLOS Medicine (June 2013), Vol. 10 No. 6.

The authors conducted a cross-sectional household survey with 1,705 adult men in the Eastern Cape and KwaZulu-Natal, South Africa in 2008 to assess the prevalence of men who have sex with men (MSM) in consensual relationships, male-on-male sexual violence and victimization, and sociodemographic factors and HIV prevalence associated with these behaviors. One in twenty men, or 5.4 percent, reported having consensual sexual activity with another man; of these, 48 percent reported having had oral or anal sex with another man. MSM behavior was reported more frequently by men in lower socioeconomic households. Nearly all men also reported having sex with women. Further, 1 in 10 reported male-on-male sexual violence, including oral or anal rape (3.3 percent), and perpetration of this behavior (2.9 percent). MSM with a history of consensual sex with men were seven times more likely to experience sexual violence from another man, and three times more likely to perpetrate this sexual violence against another man, compared to those who did not. Among 1,220 men who consented to an HIV test, prevalence was higher among men with a history of consenting to sex with a man and among perpetrators of male sexual violence. Research is needed on the overlap between male-male and heterosexual behaviors, and on male-on-male sexual violence, and the implications for HIV risk and prevention strategies.

Wingood, G.M., DiClemente, R.J., Robinson-Simpson, L., et al. Journal of Acquired Immune Deficiency Syndromes (June 2013), Vol. 63 Suppl. 1, pp. S36-S43.

In this randomized controlled trial, 848 unmarried, sexually active African American women clients of three health facilities in Atlanta, Georgia, were randomly assigned to a two-session HIV intervention (providing education on prevention strategies addressing behavioral, economic, biological factors, and gender issues that influence HIV risk [n=605]) or a health promotion session (control) focusing on nutrition (n=243). The results indicated that the HIV intervention was associated with improvements in biological and behavioral outcomes. Intervention participants were 45 percent, 38 percent, and 63 percent less likely to have a concurrent partner, a non-viral sexually transmitted infection, and high-risk human papillomavirus, respectively, compared with the control group at 12-month assessment. Survey data were collected at baseline and at six- and 12-month follow-up. Women in the intervention were also more likely to engage in other safe sex practices, e.g., more likely to use condoms during oral sex. Further, compared with the control group, women in the intervention had higher HIV knowledge scores and greater self-efficacy for using condoms, and identified fewer partner-related barriers to practicing safe sex. The authors concluded that future HIV programs targeting Southern African American women should emphasize reducing concurrent partnerships, address structural factors, and explore biomedical strategies that women can control.

Geibel, S. Journal of the International AIDS Society (2013), Vol. 16.

Geibel reviewed evidence on lubricants in terms of their effects on and compatibility with condoms and their biological safety. The author also discussed documentation of lubricant use and relevance to current guidance for HIV prevention in Africa. While improving, evidence on the safety of and compatibility between lubricants and condoms is not well documented, and criteria for lubricant safety and procurement are needed. Water-based lubricants remain expensive in sub-Saharan Africa, and their potential HIV risks are insufficiently documented. Because of the scarcity and high cost of water-based lubricants, the author explained that many Africans use numerous lubricants, including household or oil-based products of unknown safety. Safety regulations on lubricants, particularly products not marketed for sexual use, may not be rigorous. Current guidance does not indicate preferred lubricants or clarify the safety of lubricants, but some guidelines from international organizations advise avoiding oil-based products and list products that damage latex. Organizations such as the International Rectal Microbicides Advocates monitor research to provide guidance on lubricant safety and to advocate for continued research. Population-based surveys in Africa, not only with key populations, should further evaluate lubricant use, type, and accessibility. Further research and guidance from the Food and Drug Administration are needed to address safety and ensure that public health professionals market lubricants that do not increase HIV risk.

Rosenberg, N.E., Westreich, D., Bärnighausen, T. AIDS (July 2013), E-publication ahead of print.

The authors conducted a cohort study from 2006 to 2011 among youth (ages 15-24) in high-prevalence KwaZulu-Natal, South Africa, using household surveillance and HIV and health surveys to compare HIV acquisition among youth who had and had not been exposed to HIV testing and counseling (HTC). Analysis suggested that HTC is effective in reducing HIV acquisition among uninfected youth; specifically, after HTC, there was a 41 percent reduction in the hazard of HIV acquisition over 4.5 years. While longitudinal multivariate analysis of risk factors showed that HTC was associated with lower incidence, in the short term, HTC-exposed youth were at greater risk. Of 3,959 youth eligible, 29 percent and 71 percent were initially HTC-exposed and-unexposed, respectively. HTC-exposed youth were more likely to be female, sexually experienced, and previously pregnant. Of those unexposed, 1,064 (38 percent) became HTC-exposed during follow-up. Initially, approximately one-third of respondents reported experiencing sexual debut and 43 percent of sexually active youth reported using a condom during their last sexual intercourse. Future research should examine the effect of HTC on sexual behaviors. Scaling up access to youth-friendly HTC, particularly as part of a combination prevention approach, and ensuring linkages to appropriate treatment and care could have substantial public health effects. The authors also concluded that these findings support South Africa’s recent action to provide HTC in secondary schools.

Townsend, L., C. Mathews, and Y. Zembe. Prevention Science (2013), Volume 14, pp. 88-105.

The authors of this review assessed 19 studies and summarized the effectiveness of several interventions for HIV prevention activities in low- and middle-income countries (LAMIC). All studies either targeted or measured condom use; the majority found increased condom use (n=13); with 12 of these interventions providing condoms. Individual counseling based on information, motivation, and behavior skills (IMB) was a relatively effective strategy to increase condom use. Thirteen studies included interventions to reduce multiple sexual partnerships, but findings showed little effect on decreasing them. However, interventions that did succeed in reducing the number of partners incorporated group, large-scale, or community-based activities based on IMB values. Five studies that addressed the effects of alcohol use found mixed results, but again, group settings, particularly those including IMB components, were successful in reducing harmful alcohol consumption. Only two studies addressed gender-based violence, and one intervention was found effective. The authors recommended supplying condoms as an intervention component and addressing challenges such as access to or inconsistency of condom use for some populations. In settings where multiple sexual partnerships are customary, interventions should address social norms. The authors concluded that interventions targeting heterosexual men in LAMIC should address multiple sexual partners and alcohol use, and utilize combinations of effective behavioral interventions. Additional interventions targeting heterosexual males in LAMIC are needed.

Laurent, C. Journal of Public Health Policy (December 2012), pp. 1-5, e-publication ahead of print.

The author provides commentary on the status of HIV testing in low- and middle-income countries, which remains critically low among countries where HIV prevalence is high. Only 20 percent of adults and 28 percent of infants born to an HIV-positive mother are tested promptly. HIV testing, combined with adequate counseling, is beneficial to persons who test positive (e.g., facilitating assessment of eligibility for antiretroviral therapy or ART, psychosocial support, and other services), persons who test negative (allowing for risk reduction counseling), and at the population level. HIV testing approaches include facility-based, community-based, couple- or partner-based, and self-testing. Earlier HIV diagnosis is critical for improved health outcomes and aligns with the World Health Organization's (WHO) recommendation for earlier initiation of ART. Expanding HIV testing supports the WHO's objective of universal access to HIV prevention, treatment, and care and support, as well as the United Nations' Millennium Development Goals related to HIV. However, various barriers to HIV testing remain at the individual (e.g., lack of awareness and fear of stigma) and structural levels (e.g., limited laboratory equipment and negative health care workers' attitudes). The author highlights a successful scale-up of early infant HIV testing in facilities in Rwanda. This was a comprehensive program, supported with national leadership, that can serve as a model for other countries.

Townsend, L., Zembe, Y., Mathews, C., et al. Journal of Acquired Immune Deficiency Syndromes (April 2013), Vol. 62 No. 4, pp.457-464.

The authors utilized respondent-driven sampling (RDS) from March to July 2011 to recruit women who have multiple concurrent partners (MCP) near Cape Town for an HIV biological and behavioral surveillance survey to determine RDS effectiveness, HIV prevalence and characteristics, and risk differences between women who had and had not attended public health clinics. Women who had MCP also had high prevalence of HIV risk behaviors. In total, 845 women (ages 16-44) participated, and nearly 40 percent accepted rapid HIV testing, revealing a high prevalence rate (29 percent). Younger women (ages 20-24) had the highest prevalence (32 percent). Fifty percent reported sexually transmitted infection (STI) symptoms, and the majority (86 percent) reported MCP within the previous three months. Approximately 78 percent of women suspected partner infidelity, but their condom use was the same as women who did not suspect infidelity; overall use with main partners was low. Ten percent of participants had not previously attended health clinics and were younger, had early sexual debut, and reported STI symptoms and drug use. Strategies are needed to increase their engagement in sexual and reproductive health care. RDS recruitment was effective, and the authors concluded that HIV prevention programs should address HIV risk behaviors within this population.

Tetrault, J., M.J. Kozal, J. Chiarella, et al. Journal of Addiction Medicine (February 2013), e-publication ahead of print.

The authors conducted a cross-sectional analysis of 59 HIV-infected persons receiving opioid agonist treatment (OAT) – an effective treatment for reducing injection-related sharing and HIV risk in persons with opioid dependency – to assess the prevalence of risk behaviors, antiretroviral (ARV) resistance, and ARV resistance among persons with risk behaviors. Eighty percent of the participants had been receiving OAT for at least 12 weeks. The findings overall showed a presence of both continued risky behaviors and resistance: 14 percent of individuals receiving OAT engaged in unprotected sex; 7 percent shared injection drug equipment; 32 percent had a measureable viral load; and 15 percent had evidence of ARV resistance. In terms of ARV resistance by evidence of risk behavior, 22 percent of individuals engaging in risk behaviors had ARV resistance, and 14 percent with no risk behavior evidence also had resistance. These findings, which suggest that HIV-positive people on OAT continue to engage in risky behavior, placing partners at risk, show that addressing HIV resistance is essential. The authors concluded that improving HIV prevention and treatment programs for HIV-infected individuals with opioid dependence is necessary, especially in low-resource contexts.

Crosby, R. Current HIV/AIDS Reports (March 2013), Vol. 10 No. 1, pp. 59-64.

The authors explored four areas of research on advances in condom use for HIV prevention. These included improved assessment of condom use (e.g., technology for data collection and use of event-specific and partner-specific assessments), condom efficacy research (e.g., establishment of essential research designs to evaluate effectiveness), innovative condom design to reduce errors in condom use-often related to the size and fit of condoms-and to improve correct and consistent use, and evidence-based interventions that use condoms as a key prevention activity. Moving forward, the authors conclude that condom innovation is critical, but also acknowledge that other biomedical interventions may lead to reduced condom use. Research should emphasize condom use among most-at-risk groups, particularly among men who have sex with men. According to the authors, condom promotion efforts should be scaled up as part of combination prevention, and condom use should be re-marketed as a practice that makes sex healthy and pleasurable.

Dennis, A.M., Murillo, W., de Maria Hernandez, F., et al. Journal of Acquired Immune Deficiency Syndromes (May 2013), Vol. 63 No. 1, pp. 135-141.

Through cross-sectional analysis, the authors compared social recruitment chains and HIV phylogenetic clusters-individuals who share HIV strains-among men who have sex with men (MSM) and female sex workers (FSWs) to understand contributing factors of HIV transmission in three cities in El Salvador. Individuals were recruited through respondent-driven sampling (RDS). Many HIV-positive individuals were identified through RDS, and by subsequently applying phylogenetic analysis. The results showed that 14 percent of MSM recruited were HIV-positive and many were recently infected. Of nearly 700 MSM and 760 FSWs who consented to HIV testing, 141 were diagnosed HIV-positive, with 84 percent (n=119) providing a specimen for genotypic sequencing. The majority (67 percent) who tested positive were MSM, and tended to be younger and recently infected, compared to FSWs. Both groups had some prevalence of antiviral drug resistance. Among MSM, 43 percent were members of phylogenetic clusters, demonstrating that RDS successfully identified transmission networks. However, few HIV transmissions linked directly to social recruitment. The results emphasize the need to diagnose and link HIV-positive individuals to care earlier, especially young MSM. The authors concluded that utilizing a combination of social and molecular biomedical data could benefit HIV prevention by reaching high-risk groups early.

Higa, D.H., N. Crepaz, K.J. Marshall, et al. AIDS and Behavior (February 2013), e-publication ahead of print.

To address gaps and facilitate implementation of effective behavioral interventions for men who have sex with men (MSM), the authors conducted a systematic review of HIV behavioral prevention interventions for MSM in the United States to identify how many targeted MSM; assess challenges to obtaining effective results in interventions that did not meet criteria to be deemed an evidence-based intervention (EBI); and compare non-EBI with EBIs. Of 33 MSM behavioral intervention studies identified, 27 percent (n=9) were EBIs. Seventy-three percent (n=24) were considered non-EBI, primarily because these did not show significant positive effects on a behavioral or biological outcome. Overall, compared with EBIs, non-EBIs significantly targeted HIV-negative MSM more frequently, and were less likely to be piloted or include peer and sexual communication components. The majority of non-EBIs were small group designs. Also, non-EBIs were significantly more likely to include substance use and use a non-HIV related comparison group. The authors provided several lessons learned from non-EBIs and considerations for MSM behavioral interventions, including involving MSM in the program design, pilot testing interventions, and utilizing peer and sexual communication components. Future behavioral interventions for MSM of color, particularly African Americans and Latinos, are necessary. Behavioral interventions targeting MSM need to be strengthened and should be included in comprehensive combination approaches.

Kacanek, D., Bostrom, A., Montgomery, E.T., et al. Journal of Acquired Immune Deficiency Syndromes (December 2013), Vol. 64 No. 4, pp. 400-408.

The authors conducted a longitudinal study investigating the relationship between patterns of intimate partner violence (IPV) and condom and diaphragm nonadherence among 4,505 women participating in the Methods for Improving Reproductive Health in Africa study. Over half (55 percent) of women reported recent IPV, which was associated with nonadherence to using a diaphragm and condoms throughout the study. These findings imply that IPV may hinder adherence to HIV prevention interventions, including those designed to enhance women’s self-protection. Forty-one, 38, 16, and 15 percent of women reported fearing violence, emotional violence, physical assault, and forced sex, respectively, from their regular male partner. Women who reported fearing or experiencing IPV had higher odds of diaphragm nonadherence than women without such fears. Continuing forced sex was associated with condom nonadherence. Policies and interventions that specifically address IPV and related HIV risk are urgently needed, and clinical trials should include counseling and protection for women who experience IPV. It is critical to target men in IPV prevention and promote their involvement in women’s product use. Research priorities include understanding determinants of men’s perpetration of IPV and interventions targeting young men and women.

Gamarel, K.E., Reisner, S.L., Darbes, L.A., et al. AIDS Care (August 2015), E-publication ahead of print.

The authors of this study used data from a community sample of transgender women and their primary male sexual partners (N = 191 couples) to examine (1) the prevalence and type of sexual agreements among these couples; (2) whether intentions for sexual agreement were associated with extra-dyadic HIV risk (condomless sex with outside partners); and (3) whether these intentions were associated with HIV serodiscordant intra-dyadic risk (condomless sex with main partners). Overall, 55.1 percent (n = 102) of couples reported concordance in their sexual agreement; 40.0 percent (n = 74) had monogamous agreements and 15.1 percent (n = 28) had open agreements. However, 44.9 percent of couples reported discrepant agreements (one partner indicated having an open agreement and the other reported a monogamous agreement). For male partners, extra-dyadic risk was associated with their own and their partners’ reasons for sexual agreement and male partners who engaged in extra-dyadic HIV risk were more likely to have condomless (and risky) sex within the partnership. The authors concluded that researchers and prevention providers should involve both transgender women and their male partners to understand the couples’ agreements and equip them with skills to discuss their agreements openly, so that both partners can make informed choices about their acceptable levels of risk.

Vejella, S., Patel, S.K., Saggurti, N., and Prabhakar, P. AIDS and Behavior (August 2015), E-publication ahead of print.

This study assessed how community collectivization influenced consistent condom use (CCU) by female sex workers (FSWs) with different types of partners. Community collectivization empowers key populations as a group to reduce their vulnerability and improve their ability to control and make decisions about their own behaviors and ultimately, to adopt and maintain healthy behaviors. The authors collected data from two rounds of cross-sectional surveys in 2010 (N1 = 1,986) and 2012 (N2 = 1,973) among FSWs in Andhra Pradesh, India. The authors found that CCU with occasional clients increased significantly from 2010 (72 percent) to 2012 (85 percent). CCU with regular clients also increased, from 64 percent (2010) to 76 percent (2012). Moreover, FSWs who reported a high degree of collective efficacy were more likely than those who reported low levels of collective efficacy to report CCU with occasional clients (72 percent versus 73 percent in 2010, and 59 percent versus 90 percent in 2012). The authors concluded that structural interventions such as community collectivization for HIV prevention can have a positive, sustained impact on behavior change among FSWs, both by enhancing FSWs’ self-efficacy and self-confidence, and ensuring the continued practice of safe sex behaviors. They recommended that new and existing structural interventions programs consider including community mobilization.

Stanton, B., Dinaj-Koci, V., Wang, B., et al. AIDS and Behavior (October 2015), E-publication ahead of print.

The authors of this article used data from two studies that examined the effects of a longitudinal, school-based, combined parent-child HIV prevention intervention conducted during pre- and mid-adolescence. The study involved 598 students in New Providence, Bahamas who had enrolled in the studies in both grade 6 (2005) and grade 10 (2009). The student intervention in both studies included interactive discussions, role-plays, and games to increase knowledge and skills regarding sexual-risk avoidance. Also, in both studies, the students' parents were randomized to participate with their children in a parental monitoring and communication intervention, an intervention about career planning, or no intervention. Findings showed high intention to use condoms in all groups. However, only students whose parents had attended interventions reported significantly higher condom use, suggesting the importance of parents to HIV prevention in youth. Additionally, while recipients of only the grade-6 intervention showed protective effects that were sustained over time, recipients of both grade 6 and grade 10 interventions appeared to receive additional benefits spanning a greater time period. These findings suggested that school-based programs delivered at different developmental periods are important, both to reach youth who may have missed the intervention earlier in adolescence and to reinforce the effects of the earlier intervention.

Menna, T., Ali, A., and Worku, A. Reproductive Health (September 2015), 12:84, doi: 10.1186/s12978-015-0077-9.

This quasi-experimental study, conducted from March to June 2013, assessed whether peer education is an effective method of HIV prevention in high school settings. The authors assigned 560 grade 11 students from four purposely-selected secondary schools in different areas of Addis Ababa, Ethiopia into intervention and control groups. Only the intervention group received the peer education. Data for both groups were collected using self-administered questionnaires. The intervention students received twice-weekly 40-minute educational sessions on topics such as the structure and functions of human reproductive organs, HIV and AIDS, HIV prevention methods, and risky sexual behaviors among in-school youth delivered by peer education facilitators (students nominated by their peers based on their active class participations and good communications with other students), who had received two days of training. Comparison of pre- and post-intervention data revealed significant increases in comprehensive knowledge of HIV, willingness to accept HIV testing services, and likelihood of condom use in the intervention group, relative to the control group. The authors concluded that implementing peer-led HIV education programs in secondary schools could have significant positive effects on sexual behaviors and HIV prevention among in-school youth.

Nyblade, L., Reddy, A., Mbote, D., et al. AIDS Care (March 2017), 29 (11);1364-1372, doi: 10.1080/09540121.2017.1307922.

This study examined sex work-associated stigma from health care workers (HCWs) directed toward male and female sex workers (MSWs and FSWs) and the impact of stigma on uptake of HIV counseling and testing (HCT) services and non-HIV-health-related services. A total of 497 FSWs and 232 MSWs were interviewed in four counties across Kenya. Half of the participants reported expecting to be stigmatized by an HCW in the past 12 months. Around half of FSWs and MSWs reported experiencing verbal stigma from HCWs; 72 percent of FSWs and 54 percent of MSWs reported experiencing any form of stigma. MSWs and FSWs who experienced stigma were more likely to avoid HCT and men were also more likely to delay HCT. FSWs and MSWs who experienced stigma were more likely to delay non-HIV-health-related services, and FSWs who anticipated stigma were more likely to avoid non-HIV-health-related services. The authors concluded that addressing HCWs' stigma toward key populations is critical to achieving the goal of having 90 percent of all people know their HIV status.

Heffron, R., Thomson, K., Celum, C., et al. AIDS and Behavior (September 2017), doi: 10.1007/s10461-017-1902-7.

This study examined fertility desires, pregnancy incidence, use of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP), and HIV transmission during pregnancy among 1,013 serodiscordant couples in Kenya and Uganda. The majority of couples (80 percent) reported wanting to have children in the future and 9 percent reported actively trying to become pregnant; 50 percent of women were not using any form of contraception. Couples reported having sex a median of five times monthly; 64 percent reported having sex without a condom at least once in the past month. Pregnancy incidence was 18.5/100 person-years for HIV-negative women, and 18.7/100 person-years for HIV-positive women. Ninety percent of women on ART had high adherence. In the six months prior to conception, 82.9 percent of couples used ART or PrEP consistently, 14.5 percent used ART or PrEP irregularly, and 2.6 percent did not use anything. Among consistent users, 31.7 percent used both PrEP and ART, 21.7 percent only used PrEP, and 46.6 percent only used ART. There were no seroconversions in the six months prior to pregnancy; during pregnancy, three women and one man were diagnosed with HIV. One of the women reported the pregnancy as unplanned and had no detectable tenofovir levels. The authors concluded that integrating sexual and reproductive health and HIV prevention services can meet the needs of serodiscordant couples who wish to conceive.

Sandfort, T.G.M., Knox, J.R., Alcala, C., et al. Journal of Acquired Immune Deficiency Syndromes (October 2017),76: e34-e46.

This systematic review of 68 studies examined associations between substance use and HIV among men who have sex with men (MSM) in sub-Saharan Africa. Only one of eight studies describing alcohol use found any link between alcohol use and HIV infection, though in one study alcohol consumption was marginally associated with lower pre-exposure prophylaxis adherence. One study found that alcohol consumption was associated with increased likelihood of numerous risky behaviors, including unprotected anal intercourse, multiple sexual partners, and lack of partner disclosure. The proportion of men reporting sex under the influence of alcohol ranged from 47.3 percent in South Africa to 77.5 percent in Kenya. Drug use and its association with HIV depended on the type of drug, whether/how it was injected, and HIV prevalence. The proportion of men reporting drug use ranged from 7 percent in the past year in Nigeria to 61.2 percent in the last three months in Zanzibar. Reported injection drug use ranged from 1.4 percent in Kenya to 13.9 percent in Tanzania, and was associated with having two or more male receptive partners, group sex, and symptoms of sexually transmitted infections. The authors concluded that future interventions for MSM should be contextually based on local alcohol and drug use practices and their link to risky sex.

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.

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.

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.

Sibanda, E.L., Tumushime, M., Mfuka, J., et al. The Lancet Global Health (September 2017), 5: e907-15.

This randomized controlled trial examined the uptake of mobile couples HIV testing and HIV diagnosis rates in 68 Zimbabwean communities, comparing participants who received USD$1.50 worth of grocery items and participants who did not receive incentives. In the intervention group, 55.7 percent of participants tested with a partner, compared to only 10 percent of testers in the control group. Intervention communities had higher HIV counseling and testing rates, and higher rates of HIV diagnosis, than control communities. Participants who tested with a partner were more likely than those testing alone to have an HIV-positive diagnosis. Post-intervention telephone interviews revealed that couples most often tested because they wanted to know their partner’s HIV status. Other reasons included planning for children and being nonmonogamous. Nearly 21 percent in the intervention group stated that they would not have tested with their partner without the grocery incentive. Harms from the intervention included feeling pressured or pressuring a partner to test, relationship unrest after a partner tested HIV positive—including one case of physical violence—separation/divorce, and regret about testing. However, the incidence of harm was low, reported by 1.2–2.1 percent of interviewees. Programs should consider using non-monetary incentives that are context-specific to increase couples’ testing rates.

Koenig, S.P., Dorvil, N., Devieux, J.G., et al. PLOS Medicine (July 2017), 14(7), doi: e1002357.

This randomized controlled trial examined whether same-day testing and antiretroviral therapy (ART) initiation, versus the standard of care, improved retention and virologic suppression among 762 outpatients in Haiti. Standard of care participants received care that followed national guidelines, including ART initiation on day 21 following a positive HIV test, in addition to other laboratory and social work visits that took place before initiation. The control and study groups received the same number of visits; the schedule of visits, including day of initiation, was the only difference between the two study arms. All participants had monthly visits and were followed for 12 months. In the standard group, 72 percent were retained, 6 percent died, and 23 percent were lost to follow-up (LTFU). Among retained patients in the standard care group, 61 percent had a viral load <50 copies/mL. In the study group, 80 percent were retained, 3 percent died, and 17 percent were LTFU. Among those retained in the study group, 66 percent had a viral load <50 copies/mL. In comparison to the standard of care, same-day treatment initiation resulted in improved retention, increased viral suppression, and decreased mortality. The authors concluded that same-day ART initiation can be effectively implemented in resource-poor settings, and does not require additional resources.

Ranganathan, M., MacPhail, C., Pettifor, A., et al. BMC Public Health (2017), 17:666, doi: 10.1186/12889-017-4636-6.

This qualitative study examined how young women enrolled in the Conditional Cash Transfer Trial perceived their role in relationships, and their understanding of HIV risks associated with transactional sex. Following five focus group discussions and 19 individual interviews with young women aged 13–31 years, four themes emerged.

  1. Hopes for education and financial independence: Most participants desired financial independence, which required performing well academically to find a good job. Participants believed that financial independence reduced the need for transactional sex.
  2. Character of sexual relationships: Reasons for initiating a relationship included love, and financial and material support. Two-thirds of focus group discussion participants reported the latter reason, and most reported receiving gifts from their partner.
  3. Thoughts about sexual transactions: Participants described relationships as purely transactional. They reported seeing love as more important than material transactions; they wanted financial independence but were materially dependent upon the boyfriend.
  4. Control over sexual encounters and HIV risk perceptions: Participants said they had control over choosing and ending relationships; however, once in a relationship, they reported challenges negotiating condom use.

The authors concluded that educational programs for HIV prevention should include income generation components to boost young women's opportunities for financial independence and increase their negotiating power in their romantic relationships. 

IAS 2017.

This conference, held this year from July 23–26 in Paris, France, focused on the criticality of scientific research to addressing HIV. Conference organizers called for continued investments in basic research in multiple arenas, including a continued search for a cure; new technologies and potential synergies with cancer and other diseases; vaccinations and other approaches for HIV prevention and treatment; improved treatment formulations and therapies that reduce viral resistance and support long-term adherence; and economic and financing for sustainable, innovative HIV program models. The conference had five objectives:

  1. Accelerate basic science and clinical innovation to support development and application of new HIV prevention, treatment, and care technologies.
  2. Strengthen the implementation science research agenda to address key barriers and challenges (structural, service delivery, and policy) across the HIV cascade and in various epidemic scenarios.
  3. Amplify the synergies between HIV and coinfections, and between HIV emerging comorbidities and other noncommunicable diseases.
  4. Demonstrate the links between HIV and other public health and human rights emergencies and identify strategies for integrated responses.
  5. Strengthen research toward cure/treatment remission and vaccine.

Over 6,000 people attended the conference sessions, which included abstract-driven presentations, symposia, and plenary sessions. Related activities, including satellite symposia and affiliated independent events, contributed to an exceptional opportunity for professional development and networking. For daily recaps from the conference and additional discussion of the conference, please download the PDF version of this month's update.

Van Griensven, F., Guadamuz, T.E., de Lind van Wijngaarden, J.W., et al. Sexually Transmitted Infections (June 2017), 93:356-362, doi: 10.1136/sextrans-2016-052669.

This paper examined biomedical prevention strategies, national prevention policies and guidelines, and HIV cascade data for men who have sex with men (MSM) to understand evidence for treatment for prevention (TFP) for MSM in the Asia-Pacific Region. TFP is a common prevention intervention in this region, despite a lack of evidence on its use among MSM. The authors found no evidence of TFP efficacy among MSM. Countries' guidelines and policies were largely based on evidence available from heterosexual intercourse, which does not reflect the increased risk of HIV transmission during anal intercourse, particularly during acute HIV infection, which has been shown to be the period when MSM are likely to acquire and transmit HIV. Pre-exposure prophylaxis (PrEP) is an important prevention mechanism for MSM because they are likely to have acquired HIV by the time TFP takes effect. However, national guidelines in Asia-Pacific countries do not include or prioritize PrEP for MSM. The authors urged prioritizing PrEP for HIV prevention among MSM, and presented a double-sided protocol which included both a care and a prevention cascade, including PrEP. International donors and governments need to include prevention for MSM within the HIV care cascade and national policies.

Hakim, J., Musiime, V., Szubert, A.J., et al. New England Journal of Medicine (July 2017), 377:233–245, doi: 10.1056/NEJMoa1615822.

This multi-country trial examined outcomes among treatment-naïve adults and children with CD4 counts below 100 who were given enhanced antimicrobial prophylaxis including trimethoprim-sulfamethoxazole, isoniazid-pyridoxine, fluconazole, azithromycin, and albendazole in addition to antiretroviral therapy (ART). Among the 1,806 patients enrolled in the trial, 906 were randomized to the enhanced prophylaxis group and 899 were randomized to the standard prophylaxis group. At 12 weeks, patients in the enhanced prophylaxis group reported lower adherence to prophylaxis, but adherence at 24 and 48 weeks was similar between the groups. ART adherence was also similar in both groups. At 24 weeks, 8.9 percent of patients in the enhanced prophylaxis group had died, compared to 12.2 percent in the standardized prophylaxis group. At 48 weeks, 11 percent of patients in the enhanced prophylaxis group had died, versus 14.4 percent in the standardized prophylaxis group. This translated to a 27 percent and 24 percent reduction in death rates at 24 and 48 weeks, respectively. Participants in the enhanced prophylaxis group experienced significantly fewer hospitalization days, deaths, World Health Organization stage 3 or 4 occurrences, new tuberculosis diagnoses, and cryptococcal or candidiasis infections. There were also fewer immune reconstitution inflammatory events. The authors concluded that enhanced prophylaxis offers increased survival rates, has a low pill burden, is relatively low cost, has few side effects, and is easily implemented.

The Global Forum on MSM & HIV and OutRight Action International (2017).

This review paper describes the relevance of the United Nations' Sustainable Development Goal 3 (SDG 3), “Ensure Healthy Lives and Promote Well-Being for All at All Ages,” to lesbian, gay, bisexual, transgender, and intersex (LGBTI) populations. Since information on these populations is incomplete, the paper also describes the data needed to implement and monitor programs for LGBTI groups to achieve seven broad targets within SDG 3. Each chapter summarizes available data and data gaps for each target. The authors also highlight the importance of: 1) disaggregating data for LGBTI populations, 2) addressing human rights challenges, including the right to health, for LGBTI populations; 3) acknowledging that LGBTI health needs, experiences, and outcomes are diverse, and that there are neglected populations within this group; and 4) engaging LGBTI-led community organizations in planning, implementing, monitoring, and evaluating interventions. The review provides specific recommendations for each target. It also offers nine cross-cutting recommendations for advancing SDG 3 by improving the wellbeing of LGBTI individuals, including repealing laws that punish same-sex and transgender behaviors, banning nonconsensual medical procedures, equipping health care providers to provide services to LGBTI individuals, and funding organizations that reach LGBTI populations.

Allen, E., Gordon, A., Krakower, D., Hsu, K. Current Opinion in Pediatrics (2017), 29:000–000, doi:10.1097/MOP.0000000000000512.

This review described available evidence for the use of pre-exposure prophylaxis (PrEP) in the form of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) among adolescents (<18 years old) and young adults (15–25 years old). A trial in South Africa among young women was stopped early because plasma levels showed that fewer than one-third of participants used PrEP. Three other randomized controlled trials found no difference between young adults and older adults in PrEP effectiveness, although adherence was lower among the younger group. Several additional studies have also demonstrated lower adherence among adolescents and young adults in comparison to their older counterparts. Studies have also shown that adherence declines over time as the frequency of clinic visits diminishes. Reduced adherence was attributed to a combination of developmental, psychosocial, socioeconomic, and structural factors. Concerns about the safety of PrEP in younger patients include the impact of TDF on bone mineral density (BMD), which is important among youth who are still developing. However, studies also show that BMD impacts can be reversed in those under age 25. Studies on risk compensation have yielded mixed results, underscoring the importance of patient counseling, adherence, and services for sexually transmitted infections. The studies revealed an interest in PrEP across young population groups. Challenges for PrEP use include lack of provider experience, cost, and issues surrounding consent.

Toska, E., Pantelic, M., Meinck, F., et al. PLOS ONE (June 2017), 12(6): e0178106, doi:10.1371/journal.pone.0178106.

This review examined sexually risky behaviors among HIV-positive youth and adolescents in sub-Saharan Africa, focusing on eight outcomes that included early sexual debut, irregular condom use, and age-disparate relationships. Findings from 35 studies showed overall high rates of unprotected sex and early sexual debut among HIV-positive youth and adolescents of all ages, and increased risky behaviors among those under 19 years of age in particular. Between one-third and one-half of youth and adolescents had an older partner at their first sexual encounter, and one-fifth reported participating in transactional sex. Nearly 75 percent of pregnancies were unplanned. Across most studies, one in ten participants reported at least two partners in the past year; men were much more likely to have multiple sexual partners than women. Prevalence of genital herpes and human papillomavirus was 50 and 88 percent, respectively. The authors said that high rates of sexually risky behaviors among youth indicate a need to integrate sexual and reproductive health services into HIV programs for youth and adolescents. Psychosocial services and combined interventions may reduce sexually risky behaviors. Policies and programs should take into account the unique needs of HIV-positive adolescents to prevent onward transmission.

Gage, A.J., Do, M., and Grant, D. MEASURE Evaluation (March 2017).

Through funding from the United States Agency for International Development, MEASURE Evaluation conducted a review to understand best practices for adolescent- and youth-friendly program interventions. Given the scant available evidence on such programs, this review seeks to provide program planners and policymakers with evidence-informed information to determine how to invest resources effectively to meet 90-90-90 targets for adolescents and youth. The review specifies adolescent-friendly approaches that do and do not work (and why); lays out lessons learned on providing successful HIV services for adolescents; and encourages uptake of best practices to attract youth and keep them in care. The report summarizes 13 programs that were selected based upon relevance, impact, and feasibility criteria, among others. The programs were divided into four categories: three clinic-based programs with or without a community component; three clinic- and school-based programs with or without a community component; six community-based programs; and one mobile- or web-based program. The authors summarize features that make the programs adolescent- and youth-friendly, discuss the programs' impact on HIV outcomes, describe lessons learned, and consider factors that contribute to sustainability. A summary table gives each study location and program name, specifies the type of program and its intended population, describes the program, and reviews best practices.

Haber, N., Tanser, F., Bor, J., et al., The Lancet HIV (May 2017), doi:10.1016/S2352-3018(16)30224-7.

This study collected longitudinal, individual-level data on the HIV care cascade to determine where losses in the cascade occur, and to demonstrate differences between longitudinal estimation methods versus standard cross-sectional methods. The authors linked data from longitudinal population health surveillance with local HIV treatment records and examined the data by cascade stage, population stage, and clinical stage; and compared estimates to those obtained from standard cross-sectional data. The findings showed that transition rates varied among different cascade stages. Transition through initial population-based stages—including testing HIV-positive, knowing one’s HIV status, and being linked to care—were significantly slower than transition through clinical stages, particularly the later ones, which include being treatment-eligible, initiating treatment, and demonstrating a successful treatment response. Median transition times from stage to stage were:

  • Between testing for HIV and knowing one’s HIV status: 52.1 months
  • From HIV status knowledge to care linkage: 52.9 months
  • From initiating care to being treatment-eligible: 19.5 months
  • From treatment eligibility to treatment initiation: 3.1 months
  • From treatment initiation to successful treatment response: 9.3 months.

The authors recommended longitudinal cascade estimation over cross-sectional estimation, because
it captured both cross-sectional data plus changes in cascade progress—although cross-sectional approaches require fewer resources. Cascade estimations should begin with population stages, where bottlenecks in the cascade are greatest.

Johnson, C.C., Kennedy, C., Fonner, V., et al. Journal of the International AIDS Society (May 2017), doi:10.7448/IAS.20.1.21594.

This systematic review examined the impact of HIV self-testing (HIVST) on HIV testing use and frequency, identification of HIV-positive individuals, care linkages, social harm, and risk behaviors.The study's objective was to inform the World Health Organization’s (WHO’s) guidance on HIV testing. Among the five randomized controlled trials identified in Australia, Hong Kong SAR, Kenya, and the United States, one examined couples testing and four examined testing among men who have sex with men. The findings indicated that HIVST doubled testing uptake and frequency. Those who participated in HIVST were twice as likely to be HIV-positive, compared to individuals who tested at facilities. Linkage to three-month facility-based confirmatory testing uptake was 25 percent. Evidence on conflicting risk behavior revealed that in the United States, HIVST participants did not report increased anal sex without condoms, while men in Hong Kong reported increased anal sex without condoms. One trial also identified two cases of intimate partner violence; one of the cases was attributed to the woman not asking for permission to enter the trial. The authors concluded that HIVST may offer sustainable increases in testing uptake and frequency, which can lead to earlier HIV diagnosis and treatment and lower mortality, particularly among men. WHO recommends HIVST as an additional HIV testing approach.

Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project (April 2017).

Meeting global 90-90-90 goals will require addressing and preventing HIV in children while also helping HIV-positive children and young people to live healthy and productive lives. These khutbah (Islamic) and sermon (Christian) guides were developed to empower religious leaders with the tools and skills to reach their congregations with key messages on pediatric HIV transmission and prevention; stigma and discrimination; treatment, care, and support; and male involvement in the HIV prevention and response continuum. The five sections suggest material and evidence to use while (1) discussing the importance of addressing HIV in children; (2) knowing one's HIV status; (3) enrolling and retaining children in HIV care; (4) ensuring family and community support; and (5) enabling healthy lifestyles for children living with HIV. Both guides were developed in collaboration with religious leaders.

Kennedy, C.E., Yeh, P.T., Johnson, C., Baggaley, R. AIDS Care (April 2017), 24: 1–7, e-publication ahead of print, doi:10.1080/09540121.2017.1317710.

This article examined using trained lay providers for HIV testing services (HTS) as a means of achieving the 90-90-90 targets proposed by the Joint United Nations Programme on HIV/AIDS. The authors conducted a systematic review of five studies comparing the outcomes of HTS by trained lay providers using rapid diagnostic tests versus no intervention, as well as six studies assessing end users' perceptions of these services. One U.S.-based randomized trial found that patients' uptake of HTS with lay providers was twice that with health care providers (57% uptake versus 27%). In Malawi, a pre-/post-intervention study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity. Studies on values and preferences generally found support for lay providers conducting HTS. The authors noted that since many countries still mandate that only professional staff can perform HTS, expanding guidance to include lay workers could increase HTS uptake cost-effectively. They also urged further studies on the effectiveness of lay-based HTS provision and community views of such services.

Kalua, T., Tippett Barr, B.A., van Oosterhout, J.J., et al. Journal of Acquired Immune Deficiency Syndromes (May 2017), 75 (Suppl 1): S43–S50, doi:10.1097/QAI.0000000000001326.

Option B+ for prevention of mother-to-child transmission (PMTCT) specifies treating all HIV-positive women with antiretroviral therapy (ART) regardless of CD4 count. This simplified approach enhances countries' capacity to reach national HIV targets and contribute to the global 90-90-90 goals. This article reviewed the progress of Malawi's adoption of Option B+ for PMTCT and briefly described its implementation in Cameroon and Tanzania. Option B+ was developed in Malawi in response to numerous systemic barriers to the rapid scale-up of ART and PMTCT services. Operationalizing Option B+ required several critical considerations, including integrating ART and PMTCT programs, developing systems for following up mother–baby pairs, reducing systemic barriers to rapidly increase access to ART, building consensus with stakeholders, and securing funding for the new program. The authors detailed several lessons that could be of interest to countries adopting the approach of treating all HIV-positive pregnant women, as follows:

  • Comprehensive change requires effective government leadership and coordination.
  • ART services and commodities should be decentralized for broader access.
  • National clinical guidelines must accommodate health system limitations.
  • Regular monitoring and validation of program data support rapid program improvements.

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.

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.

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.

O'Reilly, K.R., d'Aquila, E., Fonner, V., et al. AIDS and Behavior (March 2017), 21(3):626-642. doi: 10.1007/s10461-016-1615-3.

This study systematically reviewed existing evidence on the effect of HIV policy interventions on changing HIV-related behaviors in low- and middle-income countries. They defined "HIV policy interventions" as those in which a policy or law enacted by a local or national government or workplace was implemented with the goal of influencing HIV-related behavior change. The authors reviewed 15 interventions focused on HIV prevention policy (1990–2013) and identified strong evidence that prevention policies implemented among multiple populations can be effective in changing HIV-related behaviors. All policies examined led to significant changes in HIV-related outcomes—though some were negative and unanticipated (for example, some policies included in the review resulted in severe human rights violations). Other outcomes, such as a fourfold increase in condom use among sex workers with new clients or in pregnant women accepting HIV testing in prenatal care, suggested the potential of interventions promoted through policies. The authors found no studies examining HIV policy interventions among populations such as men who have sex with men, adult females not employed in sex work, or serodiscordant couples; a limited number examined patients with tuberculosis, students, and people who inject drugs. Their study, they said, suggested that combining behavioral interventions with policy interventions can be more effective than a behavioral intervention alone. They called for more policy evaluation.

Downs, J.A., Mwakisole, A.H., Chandika, A.B., et al. The Lancet (February 2017), pii: S0140-6736(16)32055-4, e-publication ahead of print, doi:10.1016/S0140-6736(16)32055-4.

This cluster-randomized trial in northwest Tanzania (June 2014–December 2015) examined whether educating village religious leaders about male circumcision (MC) could increase its uptake within their communities. The Ministry of Health (MOH) carried out MC outreach in 16 villages, and services were divided into 8 pairs. One village in each pair was randomly selected to receive either education for Christian church leaders on scientific, religious, and cultural aspects of MC (intervention) or standard MC outreach (control). Religious leaders in the intervention group received a one-day seminar taught by a pastor and a clinician from the MOH and participated in biweekly meetings with the study team throughout the circumcision campaign. In the intervention villages, 30,889 men (52.8% of all men) were circumcised, versus 25,434 men (29.5% of all men) in the control villages. The authors said that although this study took place in a specific region of Tanzania, their approach was to provide church leaders with knowledge and tools, leaving the leaders to promote MC in the most appropriate way for their communities. This approach could thus be applied generally. They concluded that working through religious leaders is an innovative way to promote healthy behaviors for HIV prevention and other clinical outcomes in a variety of settings.

Ngure, K., Heffron, R., Mugo, N., et al. Journal of the International AIDS Society (February 2017), 20(1): 21234, doi:10.7448/IAS.20.1.21234.

This mixed-method, prospective study (November 2013–June 2015) examined the feasibility, acceptability, and use of HIV self-testing among HIV-negative individuals who were using pre-exposure prophylaxis (PrEP) within the Partners Demonstration Project on HIV prevention among serodiscordant couples. During routine quarterly visits, the 222 participants received fingerstick rapid HIV tests; between visits, they administered an oral self-test kit once monthly. Quantitative and qualitative findings showed that:

  • Of 219 enrollees who had at least one follow-up visit, 93.2 percent reported conducting at least one HIV self-test.
  • Most of the 1,282 kits dispensed (95.6%) were reported used, and most participants (98.7%) reported not sharing the kits. Median follow-up time for enrollees was 11 months.
  • Nearly all participants (96.8%) found the self-testing kit easy or very easy to use; and most (90.8%) reported using it without help. Over half (54.5%) said that they did not share their test results with anyone.

Interviews showed that a main motivator for self-testing was that it reduced the anxiety of the wait for clinic-based testing; also, participants appreciated the convenience of testing at home. The authors concluded that self-testing could support PrEP delivery in similar populations and could save time for both clinicians and clients. They suggested examining self-testing for PrEP users over longer intervals, such as quarterly self-testing with visits every six months. 

Awad, S.F., Sgaier, S.K., Lau, F.K., et al. PLOS ONE (January 2017), 12(1): e0170641, doi:10.1371/journal.pone.0170641.

This paper modeled the epidemiological and programmatic implications of including HIV-positive males in voluntary medical male circumcision (VMMC) programs, with Zambia as an illustrative example. Using the Age-Structured Mathematical model, the authors evaluated the effectiveness (potential number of VMMCs needed to avert one HIV infection) of including varying proportions of HIV-positive males in VMMC programs; and the potential reduction in incidence rate. They concluded that implementing VMMCs regardless of HIV status can reduce the number of VMMCs needed to avert one infection. Programs that inadvertently focus on HIV-negative males may discourage VMMC uptake in higher-risk males, the authors said. They suggested that including HIV-positive males in VMMC programs could achieve reductions in HIV incidence rates equal to those of some lifelong antiretroviral programs. This enhanced effectiveness would occur with only moderate increases (i.e., 20%) in the uptake of VMMC among higher-risk males, and/or if male circumcision has moderate efficacy against male-to-female HIV transmission. Under these conditions, VMMC's efficacy in preventing male-to-female transmission means that programs can benefit females nearly as much as males. They suggested framing VMMC recruitment messages broadly as a sexual and reproductive health service; emphasizing that HIV testing services are offered but not required; and ensuring that providers offer VMMC to clinically eligible males regardless of HIV status and willingness to test for HIV.

Martin, M., Vanichseni S., Suntharasamai P., et al. The Lancet HIV (February 2017), 4: e59–66, doi:10.1016/S2352-3018(16)30207-7.

Results of the Bangkok Tenofovir Study (BTS), a randomized, double-blind, placebo-controlled, HIV pre-exposure prophylaxis (PrEP) study in Thailand, showed that taking tenofovir daily as PrEP can reduce the risk of HIV infection by 49 percent among people who inject drugs (PWID). Between 2013–2014, an extension to the trial offered non-pregnant, non-breastfeeding, HIV-negative BTS participants (all current or previous PWID at the time of enrollment in BTS) daily oral tenofovir via 17 Bangkok Metropolitan Administration drug treatment clinics. Afterward, researchers followed up with participants to examine demographic characteristics, drug use, and risk behaviors. Of the BTS participants, 798 chose to start taking daily PrEP (35% of all surviving participants and 61% of those who returned and were eligible). Although overall adherence was low, 25 percent of participants who returned for at least one open-label follow-up visit were more than 90 percent adherent; and 59 percent returned for the 12-month visit. Participants who injected heroin or had been in prison were more likely to choose to take PrEP, suggesting that participants partly based their decision on their perceived risk of infection. The authors note that findings suggest that PWID can assess their risk of HIV infection and decide appropriately whether or not to take PrEP.

Mugo P.M., Micheni M., Shangala J., et al. PLOS ONE (January 2017), 12(1): e0170868, doi:10.1371/journal.pone.0170868.