AIDSFree Prevention Update: August 2015 Edition

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.

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.

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.

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.

Kanyuuru, L., Kabue, M., Ashengo, T.A., et al. International Journal of Gynecology and Obstetrics (June 2015), doi: 10.1016/j.ijgo.2015.04.002.

The authors reported the results and program experience of a pilot adaptation of Reaching Every District (RED) for prevention of mother-to-child transmission of HIV (PMTCT) in Bondo District of Kenya between July 2010 and June 2012 as a way of improving PMTCT care. The RED approach emphasizes five operational components designed to improve programmatic coverage: (1) better resource planning and management; (2) outreach services for all target populations; (3) supportive supervision for service providers; (4) links between communities and services; and (5) program monitoring. Community health workers from area villages were recruited and trained on the community strategy, community-based health information systems, and RED for PMTCT. Between 2010 and 2012, the proportion of pregnant women who completed four prenatal care visits increased significantly, from 25 percent to 41 percent; six-week testing for HIV-exposed infants also increased significantly (from 27 percent to 78 percent). Uptake of partner testing increased as well, from 1.8 percent to 19.3 percent. The authors concluded that RED for PMTCT was successful at increasing access to and utilization of PMTCT services among those who attended prenatal care in Bondo District, and recommended scaling up this model to other districts.

Weiss, S.M., Zulu, R., Jones, D., et al. The Lancet HIV (April 2015), doi: 10.1016/S2352-3018(15)00042-9.

This cluster-randomized controlled study tested the effect of the Spear and Shield intervention on demand for voluntary medical male circumcision (VMMC) among hard-to-reach men in Zambia. The authors provided staff at 13 community health centers with training on performing VMMC and then randomly assigned five centers as intervention sites, five as control, and three as observation only. Counselors or nurses from the five experimental sites were trained to carry out the Spear and Shield intervention, which promotes sexual risk reduction and VMMC. The intervention included sessions on HIV and sexually transmitted infections, male condoms, male circumcision, and sexual communication followed by hands-on demonstrations and practice with penis models. Eight hundred men were recruited from the five experimental and five control centers between February 2012 and September 2013 and were followed up for one year; men who accepted VMMC during the study received an additional assessment three months after circumcision. Men in the intervention group were 2.5 times more likely than control participants to accept circumcision. In addition, condom use increased in the experimental group, but not in the control group. The authors concluded that comprehensive HIV prevention programs can increase the demand for and uptake of VMMC services.

Feinstein, L., Edmonds, A., Okitolonda, V., et al. Journal of Acquired Immune Deficiency Syndromes (July 2015), 69(3): e93–e99, doi: 10.1097/QAI.0000000000000644.

This study assessed whether providing combination antiretroviral therapy (cART) to HIV-positive mothers was associated with reduced loss to follow-up (LTFU) of their HIV-exposed infants. The authors analyzed data for 1,318 HIV-exposed infants; of those, 1,008 infants (76 percent) had mothers who had not yet initiated cART. The control group included infants whose mothers initiated cART by the day of infant enrollment. Infants were considered LTFU after a missed appointment and three failed tracking attempts, or if their last clinic visit was over six months ago. Analysis revealed that providing HIV-positive mothers with cART reduced the likelihood that their HIV-exposed infants would be lost to follow-up. The 18-month cumulative incidence of LTFU was 8 percent among infants whose mothers had initiated cART by the time they enrolled their infants in post-exposure care, compared to 20 percent among infants whose mothers were not yet on cART. Five percent of infants never returned for a visit after enrolling in care, 9 percent were LTFU within three months, and 13 percent were LTFU within six months. The authors reported that older infant enrollment age, younger maternal age, and shorter maternal time receiving cART were associated with increased LTFU. They concluded that increasing access to cART for pregnant women could improve retention of HIV-exposed infants.

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.

Sgaier, S.K., Baer, J., Rutz, D.C., et al. Global Health: Science and Practice (June 2015), doi: 10.9745/GHSP-D-15-00020.

The authors reviewed available literature on demand generation for voluntary medical male circumcision (VMMC) and visited VMMC programs in seven countries to assess current demand-generating strategies and identify gaps. They then developed a four-component framework for VMMC demand generation, consisting of:

  1. Insight development: implementation of quantitative and qualitative research to understand what drives or limits demand for VMMC, and how to increase its appeal at the individual and population levels.
  2. Intervention design: development of innovative solutions to generate demand that address the cognitive, emotional, cultural, and structural barriers affecting a man’s decision to be circumcised.
  3. Implementation and coordination to achieve scale: strategic program implementation to avoid mismatches between supply and demand, as well as coordination among all partners and stakeholders to expand implementation.
  4. Measurement, learning, and evaluation: data-gathering on the levels of demand and the effectiveness and cost-effectiveness of demand generation programs.

The authors noted that the first three components are interdependent and may overlap. The fourth component underpins the others, since measurement, learning, and evaluation are foundational for all stages of demand generation. The authors concluded that this approach, and the lessons from VMMC scale-up, may also be applicable to other public health programs seeking new or improved evidence-based approaches to increase service uptake, retention, and adherence.

Piot, P., Abdool Karim, S.S., Hecht, R., et al., on behalf of the UNAIDS–Lancet Commission (June 2015), 38(9989), pp. 171–218, doi: 10.1016/S0140-6736(15)60658-4.

The United Nations Joint Commission on HIV/AIDS (UNAIDS)–Lancet Commission is a multi-stakeholder entity established in May 2013 to investigate how the AIDS response could evolve in a new era of sustainable development. In this report, the Commission makes the following seven key recommendations based on analysis and discussions:

  • All aspects of a comprehensive HIV response must be funded, and resources should be targeted to where they will make the greatest difference.
  • Countries with financial capacity should fund more of their HIV responses; international funding remains necessary in low-income countries.
  • Translating evidence into policy requires transparent data review and establishment of robust accountability mechanisms at national and sub-national levels.
  • Practical solutions are needed to expedite changes in laws, policies, and public attitudes that violate the human rights of vulnerable populations.
  • Leadership and increased political commitment at the highest level are critical to the difficult processes of developing HIV policies and securing funding.
  • Research must remain a core component of the HIV response, with priorities including epidemiology of key populations and implementation research, among others.
  • HIV programs must establish new alliances with other sectors and constituencies that pursue shared goals, and identify effective models for collaboration.

United Nations Population Fund, World Health Organization, and Joint United Nations Programme on HIV/AIDS (July 2015).

The joint position statement issued by the United Nations Population Fund, the World Health Organization, and the Joint United Nations Programme on HIV/AIDS emphasizes the critical role of condoms in any comprehensive and sustainable approach to the prevention of HIV, other sexually transmitted infections (STIs), and unintended pregnancies. Consistent and correct use of both female and male condoms prevents sexual transmission of HIV from men to women and women to men, and reduces the risk of contracting other STIs, including genital warts and cervical cancer. Condoms have helped to reduce the spread of HIV. They have averted an estimated 50 million new HIV infections since the onset of the HIV epidemic, and remain a key component of high-impact HIV prevention programs. The statement recommends universal availability of free or low-cost, quality-assured condoms to ensure safety, efficacy, and effective use. Condom promotion should also address structural factors that hinder effective access to and use of condoms. The position statement ends by advocating for adequate investment for condom programming to sustain global and national responses to HIV, other STIs, and unintended pregnancy.

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