Condom effectiveness in reducing heterosexual HIV transmission

Modeling a dynamic bi-layer contact network of injection drug users and the spread of blood-borne infections

Injection drug users (IDUs) are at high risk of acquiring and spreading various blood-borne infections including human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) and a number of sexually transmitted infections. These infections can spread among IDUs via risky sexual and needle-sharing contacts. To accurately model the spread of such contagions among IDUs, we build a bi-layer network that captures both types of risky contacts. We present methodology for inferring important model parameters, such as those governing network structure and dynamics, from readily available data sources (e.g., epidemiological surveys). Such a model can be used to evaluate the efficacy of various programs that aim to combat drug addiction and contain blood-borne diseases among IDUs. The model is especially useful for evaluating interventions that exploit the structure of the contact network. To illustrate, we instantiate a network model with data collected by a needle and syringe program in Chicago. We model sexual and needle-sharing contacts and the consequent spread of HIV and HCV. We use the model to evaluate the potential effects of a peer education (PE) program under different targeting strategies. We show that a targeted PE program would avert significantly more HIV and HCV infections than an untargeted program, highlighting the importance of reaching individuals who are centrally located in contact networks when instituting prevention programs.

Systematic review of the literature on viral persistence and sexual transmission from recovered Ebola survivors: evidence and recommendations

OBJECTIVE

The main aim of this article is to present a comprehensive, systematic review on evidence of sexual transmission from Ebola survivors and persistence of Ebola virus in body fluids of relevance to sexual transmission, and additionally to review condom effectiveness against sexual transmission of Ebola.

DESIGN

We performed a systematic review of viral persistence in body fluids of relevance to sexual transmission of Ebola survivors and evidence of sexual transmission of Ebola, and carried out a targeted review of condom effectiveness.

RESULTS

We identified nine published original articles presenting results on persistence of Ebola virus in relevant body fluids, or reporting suspect sexual transmission from Ebola survivors. We also included unpublished reports from the current 2014/2015 Ebola epidemic in West Africa. We found no articles reporting on condom effectiveness, but have included a targeted review on general condom efficacy and effectiveness.

CONCLUSIONS

We conclude that the risk of sexual transmission from people who have recovered from Ebola cannot be ruled out. We found the longest duration of persistent Ebola RNA in a relevant body fluid from a survivor, to be reported from a man in Sierra Leone who had reverse transcriptase PCR (RT-PCR) positive semen 284 days after symptom onset. In line with current WHO recommendations. We recommend that men are offered the possibility to test their semen regularly for presence of Ebola RNA from 3 months post-symptom onset. Safe sex practices including sexual abstinence, or else condom use, are recommended by WHO until semen has tested negative twice, or in absence of testing for at least 6 months post-symptom onset. Based on evidence reviewed, we conclude that male and female latex condoms offer some protection against EBOV compared to no condom use. Survivors should be offered access to care and prevention, in order to provide them with possibilities to mitigate any risks that may occur, and efforts should be linked to destigmatising activities.

A comparison of sexual risk behaviours and HIV seroprevalence among circumcised and uncircumcised men before and after implementation of the safe male circumcision programme in Uganda

BACKGROUND

Although male circumcision reduces the heterosexual HIV transmission risk, its effect may be attenuated if circumcised men increase sexual risk behaviours (SRB) due to perceived low risk. In Uganda information about the protective effects of circumcision has been publicly disseminated since 2007. If increased awareness of the protection increases SRB among circumcised men, it is likely that differences in prevalence of SRB among circumcised versus uncircumcised men will change over time. This study aimed at comparing SRBs and HIV sero-status of circumcised and uncircumcised men before and after the launch of the safe male circumcision programme.

METHODS

Data from the 2004 and 2011 Uganda AIDS Indicator Surveys (UAIS) were used. The analyses were based on generalized linear models, obtaining prevalence ratios (PR) as measures of association between circumcision status and multiple sexual partners, transactional sex, sex with non-marital partners, condom use at last non-marital sex, and HIV infection. In addition we conducted multivariate analyses adjusted for sociodemographic characteristics, and the multivariate models for HIV status were also adjusted for SRB.

RESULTS

Twenty six percent of men were circumcised in 2004 and 28% in 2011. Prevalence of SRB was higher among circumcised men in both surveys. In the unadjusted analysis, circumcision was associated with having multiple sexual partners and non-marital partners. Condom use was not associated with circumcision in 2004, but in 2011 circumcised men were less likely to report condom use with the last non-marital partner. The associations between the other sexual risk behaviours and circumcision status were stable across the two surveys." In both surveys, circumcised men were less likely to be HIV positive (Adj PR 0.55; CI: 0.41-0.73 in 2004 and Adj PR 0.64; CI: 0.49-0.83 in 2011).

CONCLUSIONS

There was higher prevalence of SRBs among circumcised men in both surveys, but the only significant change from 2004 to 2011 was a lower prevalence of condom use among the circumcised. Nevertheless, HIV prevalence was lower among circumcised men. Targeted messages for circumcised men and their sexual partners to continue using condoms even after circumcision should be enhanced to avoid risk compensation.

The impact of criminalization of HIV non-disclosure on the healthcare engagement of women living with HIV in Canada: a comprehensive review of the evidence

Introduction

In 2012, the Supreme Court of Canada ruled that people living with HIV (PLWH) must disclose their HIV status to sexual partners prior to sexual activity that poses a “realistic possibility” of HIV transmission for consent to sex to be valid. The Supreme Court deemed that the duty to disclose could be averted if a person living with HIV both uses a condom and has a low plasma HIV-1 RNA viral load during vaginal sex. This is one of the strictest legal standards criminalizing HIV non-disclosure worldwide and has resulted in a high rate of prosecutions of PLWH in Canada. Public health advocates argue that the overly broad use of the criminal law against PLWH undermines efforts to engage individuals in healthcare and complicates gendered barriers to linkage and retention in care experienced by women living with HIV (WLWH).

Methods

We conducted a comprehensive review of peer-reviewed and non-peer-reviewed evidence published between 1998 and 2015 evaluating the impact of the criminalization of HIV non-disclosure on healthcare engagement of WLWH in Canada across key stages of the cascade of HIV care, specifically: HIV testing and diagnosis, linkage and retention in care, and adherence to antiretroviral therapy. Where available, evidence pertaining specifically to women was examined. Where these data were lacking, evidence relating to all PLWH in Canada or other international jurisdictions were included.

Results and discussion

Evidence suggests that criminalization of HIV non-disclosure may create barriers to engagement and retention within the cascade of HIV care for PLWH in Canada, discouraging access to HIV testing for some people due to fears of legal implications following a positive diagnosis, and compromising linkage and retention in healthcare through concerns of exposure of confidential medical information. There is a lack of published empirical evidence focused specifically on women, which is a concern given the growing population of WLWH in Canada, among whom marginalized and vulnerable women are overrepresented.

Conclusions

The threat of HIV non-disclosure prosecution combined with a heightened perception of surveillance may alter the environment within which women engage with healthcare services. Fully exploring the extent to which HIV criminalization represents a barrier to the healthcare engagement of WLWH is a public health priority.

HIV knowledge and risky sexual behavior among men in Rwanda

Introduction

New infections of Human Immunodeficiency Virus (HIV) remain a big problem in many countries. Different interventions have been implemented to improve the general knowledge of HIV, with the hypothesis that increasing HIV knowledge will reduce risky sexual behavior (RSB). However, HIV knowledge may not necessarily reduce RSB. This study explores HIV knowledge and its effect on RSB.

Methods

The study used data from the 2005 and 2010 Rwanda Demographic and Health Surveys to analyze the association between HIV risk factors and two types of RSB (having two or more partners in the past 12 months; and among those with two or more partners, not using a condom at last sex) and the association between HIV knowledge and those RSB. Multivariate logistic regression was used to determine predictors of RSB.

Results

Among 2,773 men in 2005 and 3,772 men in 2010, 5% and 7% respectively reported having two or more sexual partners. Among them, 93% in 2005 and 74% in 2010 did not use a condom at the last sex. Between 2005 and 2010, knowledge of the protective effect of having just one uninfected faithful partner, and basic knowledge of HIV decreased. Knowledge of the protective effect of using condoms increased from 90% to 94%. However, HIV knowledge was not associated with either type of RSB.

Conclusion

In setting up policies and strategies related to HIV prevention, policymakers should consider that focusing on HIV knowledge is not sufficient in itself.

Risk Factors for HIV Acquisition in a Prospective Nairobi-Based Female Sex Worker Cohort

With two million new HIV infections annually, ongoing investigations of risk factors for HIV acquisition is critical to guide ongoing HIV prevention efforts. We conducted a prospective cohort analysis of HIV uninfected female sex workers enrolled at an HIV prevention clinic in Nairobi (n = 1640). In the initially HIV uninfected cohort (70 %), we observed 34 HIV infections during 1514 person-years of follow-up, i.e. an annual incidence of 2.2 % (95 % CI 1.6-3.1 %). In multivariable Cox Proportional Hazard analysis, HIV acquisition was associated with a shorter baseline duration of sex work (aHR 0.76, 95 % CI 0.63-0.91), minimum charge/sex act (aHR 2.74, 0.82-9.15, for low vs. intermediate; aHR 5.70, 1.96-16.59, for high vs. intermediate), N. gonorrhoeae infection (aAHR 5.89, 95 % CI 2.03-17.08), sex with casual clients during menses (aHR 6.19, 95 % CI 2.58-14.84), Depo Provera use (aHR 5.12, 95 % CI 1.98-13.22), and estimated number of annual unprotected regular partner contacts (aHR 1.004, 95 % CI 1.001-1.006). Risk profiling based on baseline predictors suggested that substantial heterogeneity in HIV risk is evident, even within a key population. These data highlight several risk factors for HIV acquisition that could help to re-focus HIV prevention messages.

Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby

An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.

Comparing the impact of increasing condom use or HIV pre-exposure prophylaxis (PrEP) use among female sex workers

In many settings, interventions targeting female sex workers (FSWs) could significantly reduce the overall transmission of HIV. To understand the role HIV pre-exposure prophylaxis (PrEP) could play in controlling HIV transmission amongst FSWs, it is important to understand how its impact compares with scaling-up condom use-one of the proven HIV prevention strategies for FSWs. It is important to remember that condoms also have other benefits such as reducing the incidence of sexually transmitted infections and preventing pregnancy. A dynamic deterministic model of HIV transmission amongst FSWs, their clients and other male partners (termed 'pimps') was used to compare the protection provided by PrEP for HIV-negative FSWs with FSWs increasing their condom use with clients and/or pimps. For different HIV prevalence scenarios, levels of pimp interaction, and baseline condom use, we estimated the coverage of PrEP that gives the same reduction in endemic FSW HIV prevalence or HIV infections averted as different increases in condom use. To achieve the same impact on FSW HIV prevalence as increasing condom use by 1%, the coverage of PrEP has to increase by >2%. The relative impact of PrEP increases for scenarios where pimps contribute to HIV transmission, but not greatly, and decreases with higher baseline condom use. In terms of HIV infections averted over 10 years, the relative impact of PrEP compared to condoms was reduced, with a >3% increase in PrEP coverage achieving the same impact as a 1% increase in condom use. Condom promotion interventions should remain the mainstay HIV prevention strategy for FSWs, with PrEP only being implemented once condom interventions have been maximised or to fill prevention gaps where condoms cannot be used.

Prevalence and correlates of HIV-risky sexual behaviors among students attending the Medical and Social Welfare Center of the University of Maroua, Cameroon

BACKGROUND

Data on sexual behaviors in Cameroonian youths are needed to design and implement effective preventive strategies against HIV/AIDS. This study aimed at assessing sociodemographic and religious factors associated with sexual behaviors among university students in Cameroon.

METHODS

In 2011, 411 university students were surveyed by a self-administered questionnaire at the Medical and Social Welfare Center of the University of Maroua. Logistic regression analyses were used to determine correlates of sexual behaviors.

RESULTS

80.8 % of students were sexually active. The mean age at sexual debut was 18.1 years (SD = 3.1). The frequency of premarital sex was 92.8 %. Pornography viewing [adjusted odds ratio (aOR): 4.0, 95 % CI 2.1-7.6; p < 0.0001] and an increased age of 1 year (aOR: 1.3, 95 % CI 2.0-7.6; p < 0.0001) were significantly associated with having previously had sex. The likelihood to have a lower (<18) age at sexual debut was increased by male gender (aOR: 2.5, 95 % CI 1.7-5; p < 0.001), and urban origin (aOR: 2.9, 95 % CI 1.5-5.7; p < 0.01). The probability to have a high number (#3) of lifetime sexual partners was increased by age (aOR: 1.1, 95 % CI 1.0-1.2; p < 0.001), pornography viewing (aOR: 4.3, 95 % CI 1.9-9.5; p < 0.001), an early sexual debut (aOR: 2.8, 95 % CI 1.6-5.0; p < 0.001), having had occasional sexual partners (aOR: 7.0, 95 % CI 3.7-13.1; p < 0.0001), and was decreased by Muslim religious affiliation (aOR: 0.2, 95 % CI 0.1-0.9; p < 0.05). Having had casual sexual partners was associated with less inconsistent condom use (aOR: 0.5, 95 % CI 0.2-0.9; p < 0.05).

CONCLUSIONS

Our findings indicate that there is an alarming level of risky sexual behaviors among the study population. Strong and efficient measures should be undertaken to handle such harmful behaviors, this for the prevention and control of HIV/AIDS and other STIs in this vulnerable population.

Factors associated with HIV infection among sexually experienced adolescents in Africa: a pooled data analysis

The article examines the factors associated with HIV status among adolescents aged 15-19 years in 13 African countries: Côte d'Ivoire, Democratic Republic of Congo, Guinea, Kenya, Liberia, Mali, Malawi, Rwanda, Sierra Leone, Swaziland, Tanzania, Zambia and Zimbabwe. The data were derived from demographic and health surveys or AIDS indicator surveys conducted between 2004 and 2009. The levels of HIV prevalence among adolescents varied considerably across the countries. There was significantly higher HIV prevalence among female adolescents as compared with their male counterparts. For male adolescents, circumcision was the only variable significantly associated with HIV status. Nonetheless, the data suggest that the association between male circumcision and HIV status may be exaggerated. Indeed, regional-level random effects became insignificant once male circumcision was introduced into the estimated models, indicating a strong correlation between unmeasured regional-level factors and male circumcision. For female adolescents, multiple sexual partnerships, time elapsed since sexual debut, marital status, household wealth, and the regional prevalence of male circumcision were strongly and positively associated with HIV status. Moreover, for female adolescents there appear to be significant unmeasured variables operating at the regional level which influence the levels of HIV infection. The implications of the findings for HIV-prevention programming, policy and research are discussed.

Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations

This article provides an overview of the current literature on seven cancer sites that may disproportionately affect lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. For each cancer site, the authors present and discuss the descriptive statistics, primary prevention, secondary prevention and preclinical disease, tertiary prevention and late-stage disease, and clinical implications. Finally, an overview of psychosocial factors related to cancer survivorship is offered as well as strategies for improving access to care.

Preventing HIV Transmission Among Partners of HIV-Positive Male Sex Workers in Mexico City: A Modeling Study

Mexico has a concentrated HIV epidemic, with male sex workers constituting a key affected population. We estimated annual HIV cumulative incidence among male sex workers' partners, and then compared incidence under three hypothetical intervention scenarios: improving condom use; and scaling up HIV treatment as prevention, considering current viral suppression rates (CVS, 60.7 %) or full viral suppression among those treated (FVS, 100 %). Clinical and behavioral data to inform model parameterization were derived from a sample (n = 79) of male sex workers recruited from street locations and Clínica Condesa, an HIV clinic in Mexico City. We estimated annual HIV incidence among male sex workers' partners to be 8.0 % (95 % CI: 7.3-8.7). Simulation models demonstrated that increasing condom use by 10 %, and scaling up HIV treatment initiation by 50 % (from baseline values) would decrease the male sex workers-attributable annual incidence to 5.2, 4.4 % (CVS) and 3.2 % (FVS), respectively. Scaling up the number of male sex workers on ART and implementing interventions to ensure adherence is urgently required to decrease HIV incidence among male sex workers' partners in Mexico City.

Programmatic Implications of Acute and Early HIV Infection

Human immunodeficiency virus (HIV) infection includes acute, early, chronic, and late stages. Acute HIV infection lasts approximately 3 weeks and early HIV infection, which includes acute HIV infection, lasts approximately 7 weeks. Many testing and blood screening algorithms detect HIV antibodies about 3 weeks after HIV infection. Incidence estimates are based on results of modeling, cohort studies, surveillance, and/or assays. Viral load is the key modifiable risk factor for HIV transmission and peaks during acute and early HIV infection. Empirical evidence characterizing the impact of acute and early HIV infection on the spread of the HIV epidemic are limited. Time trends of HIV prevalence collected from concentrated and generalized epidemics suggest that acute and early HIV infection may have a limited role in population HIV transmission. Collectively, these data suggest that acute and early HIV infection is relatively short and does not currently require fundamentally different programmatic approaches to manage the HIV/AIDS epidemic in most settings. Research and surveillance will inform which epidemic contexts and phases may require tailored strategies for these stages of HIV infection.

In developed countries male circumcision prevalence is inversely related to HIV prevalence

A study by Chemtob and co-workers found significantly lower prevalence of HIV amongst heterosexual men and women in Israel compared with the Netherlands and France. Risk factors for heterosexual HIV infection in these countries were similar, apart from one, namely, a strikingly higher prevalence of male circumcision (MC) in Israel compared with the Netherlands and France. It is now well established that MC protects heterosexual men against becoming infected with HIV during sexual intercourse with an infected woman. In epidemic settings, such as countries in sub-Saharan Africa, in which heterosexual contact is the primary driver for HIV infection, MC is being implemented to reduce HIV prevalence. The results of the new study by Chemtob and co-workers support the evidence and recent polices in the United States advocating MC to reduce the spread of HIV. While prevalence in developed countries is generally low, it is rising. In the long term, neonatal MC is the most desirable option, since not only is it simpler, safer, cheaper and more convenient than MC later, it provides immediate protection from infections, penile inflammation, genital cancers and physical problems. It is also cost-effective. European countries have not supported MC for its public health benefits. The new findings add to calls for European and other countries with low MC prevalence to consider developing evidence-based policies favoring MC in order to reduce HIV and other infections and diseases and at the same time reduce suffering, mortality and the cost of treating these.

Minimal coital dilution in Accra, Ghana

BACKGROUND

Coital dilution, the reduction in the coital frequency per partner when an additional ongoing partner is added, may reduce the transmission potential of partnership concurrency for HIV and other sexually transmitted infections. Empirical estimates of dilution, especially dilution of sexual acts unprotected by condoms, are needed to inform prevention research.

METHODS

Sexually active adults in Accra, Ghana were recruited in a multistage household probability sample. Degree (number of ongoing partners), total acts, and unprotected acts were measured retrospectively for each month in the past year through an event history calendar. Random-effects negative binomial models estimated the association between degree and coital frequency.

RESULTS

Compared with person-months with a single partner (monogamy), 2.06 times as many total acts and 1.94 times as many unprotected acts occurred in months with 2 partners. In months with 3 partners, 2.90 times as many total acts and 2.39 times as many unprotected acts occurred compared with monogamous months. Total acts but not unprotected acts also declined with partnership duration.

CONCLUSIONS

No dilution was observed for total acts with up to 3 concurrent partners, but a small amount of dilution was observed for unprotected acts for months with multiple concurrencies. This suggests moderate selective condom use in months with multiple concurrencies. The implications of the observed dilution for future HIV transmission must be investigated with mathematical models.

A Randomized Trial to Evaluate the Efficacy of a Web-Based HIV Behavioral Intervention for High-Risk African American Women

The aim of this study was to develop and test a cost-effective, scalable HIV behavioral intervention for African American women. Eighty-three African American women were recruited from a community health center and randomly assigned to either the web-based Safe Sistah program or to a delayed HIV education control condition. The primary outcome was self-reported condom use. Secondary measures assessed other aspects of the gender-focused training included in Safe Sistah. Participants completed self-report assessments prior to randomization, 1- and 4-months after their program experience. Across the entire study period, women in the experimental condition significantly increased their condom use relative to controls (F = 5.126, p = 0.027). Significant effects were also found for sexual communication, sex refusal, condom use after alcohol consumption, and HIV prevention knowledge. These findings indicate that this web-based program could be an important component in reducing the HIV disparities among African American women.

Obstacles to HIV prevention, treatment and care in selected public universities in South Africa

South Africa, like the rest of Southern Africa, is ravaged by AIDS. Higher education in South Africa has a significant role to play in the fight against the spread of HIV and AIDS. This article reports the factors contributing to the spread of HIV and AIDS in three selected public universities in South Africa. To achieve the stated aim, the study answered the following research question: What are the factors contributing to the spread of HIV and AIDS in South African public universities? The problem in this study stems from South Africa's HIV and AIDS infection rate, one of the highest in the world, especially in KwaZulu-Natal. A qualitative approach was adopted by conducting focus group interviews with the students. The data were analysed using axial coding and open coding, where dominant themes from the discussions were identified and discussed in detail. The findings show that barriers to HIV and AIDS prevention, care and treatment exist in the tertiary institutions under study. Social and economic interventions are needed to stem the spread of HIV and AIDS at tertiary institutions. A range of recommendations for halting the spread of HIV and AIDS in these institutions is provided.

Use of injectable hormonal contraception and women's risk of herpes simplex virus type 2 acquisition: a prospective study of couples in Rakai, Uganda

BACKGROUND

The injectable hormonal contraceptive depo-medroxyprogesterone acetate (DMPA) has been associated with increased risk of HIV acquisition, but findings are inconsistent. Whether DMPA increases the risk of other sexually transmitted viral infections is unknown. We assessed the association between DMPA use and incident herpes simplex virus type 2 (HSV2) infection in women.

METHODS

In this prospective study, we enrolled HIV-negative and HSV2-negative women aged 15-49 years whose HIV-negative male partners were concurrently enrolled in a randomised trial of male circumcision in Rakai, Uganda. We excluded women if either they or their male partners HIV seroconverted. The primary outcome was HSV2 seroconversion, assessed annually. The male circumcision trial was registered with ClinicalTrials.gov, number NCT00425984.

FINDINGS

Between Aug 11, 2003, and July 6, 2006, we enrolled 682 women in this study. We noted HSV2 seroconversions in 70 (10%) women. Incidence was 13·5 per 100 person-years in women consistently using DMPA (nine incident infections per 66·5 person-years), 4·3 per 100 person-years in pregnant women who were not using hormonal contraception (18 incident infections per 423·5 person-years), and 6·6 per 100 person-years in women who were neither pregnant nor using hormonal contraception (35 incident infections per 529·5 person-years). Women consistently using DMPA had an adjusted hazard ratio for HSV2 seroconversion of 2·26 (95% CI 1·09-4·69; p=0·029) compared with women who were neither pregnant nor using hormonal contraception. Of 132 women with HSV2-seropositive partners, seroconversion was 36·4 per 100 person-years in consistent DMPA users (four incident infections per 11 person-years) and 10·7 per 100 person-years in women who were neither pregnant nor using hormonal contraception (11 incident infections per 103 person-years; adjusted hazard ratio 6·23, 95% CI 1·49-26·3; p=0·012).

INTERPRETATION

Consistent DMPA use might increase risk of HSV2 seroconversion; however, study power was low. These findings should be assessed in larger populations with more frequent follow-up than in this study, and other contraceptive methods should also be assessed. Access to a wide range of highly effective contraceptive methods is needed for women, particularly in sub-Saharan Africa.

FUNDING

Bill and Melinda Gates Foundation, Doris Duke Charitable Foundation, US National Institutes of Health, and Fogarty International Center.

Prevalence and risk factors of HIV and syphilis, and knowledge and risk behaviors related to HIV/AIDS among men who have sex with men in Chongqing, China

High HIV prevalence and incidence burdens have been reported in men who have sex with men (MSM) in Chongqing, China. We aimed to estimate the prevalence of HIV and other sexually transmitted infections (STIs), to appraise the knowledge and risk behaviors related to HIV/AIDS among MSM, and to analyze the possible causes of deviation between behavior and knowledge to make better strategies. We recruited 617 MSM from February to July in 2008 by using a respondent-driven sampling (RDS) method in Chongqing, China. Through the collection of questionnaire-based data and biological testing results from all objects, we launched a cross-sectional survey. STATA/SE was used for data analysis by frequency, ANOVA, rank sum test and logistic regression models. MSM with syphilis (OR=4.16, 95%CI: 2.35-7.33, P<0.0001) were more likely to be HIV infected. Being a company employee (OR=3.64, 95%CI: 1.22-10.08, P<0.0001) and having bought male for sex (OR=3.52, 95%CI: 1.10-11.32, P < 0.034) were associated with a higher probability of syphilis. MSM with younger age, higher education and greater monthly income had a higher mean knowledge score. MSM who had HIV testing had a higher mean knowledge score than those who never had. Students, venues for finding sex partners by Internet and homosexuals in MSM had a higher mean knowledge score compared to other occupations, venues for finding sex partners and sexual orientation. There is an urgent need for delivery of barrier and biomedical interventions with coordinated behavioral and structural strategies to improve the effect of HIV interventions among MSM.

Time Since Release from Incarceration and HIV Risk Behaviors Among Women: The Potential Protective Role of Committed Partners During Re-entry

After release from incarceration, former female inmates face considerable stressors, which may influence drug use and other risk behaviors that increase risk for HIV infection. Involvement in a committed partnership may protect women against re-entry stressors that may lead to risky behaviors. This study measured the association between time since release from incarceration (1-6 months ago, and >6 months ago versus never incarcerated) and HIV risk behaviors and evaluated whether these associations differed by involvement in a committed partnership. Women released within the past 6 months were significantly more likely to have smoked crack cocaine, used injection drugs and engaged in transactional sex in the past month compared to never-incarcerated women and women released more distally. Stratified analyses indicated that incarceration within the past 6 months was associated with crack cocaine smoking, injection drug use and transactional sex among women without a committed partner yet unassociated with these risk behaviors among those with a committed partner.

Self-objectification and condom use self-efficacy in women university students

This study investigated the roles of indicators of the self-objectification process in women's condom use self-efficacy. Data were collected from 595 college women. Self-objectification variables were assessed with measures of internalization of cultural standards of beauty, body surveillance, and body shame. Participants also completed measures of perceived control over sexual activity, acceptance of sexuality, and condom use self-efficacy. Measurement and structural invariance were supported, indicating that the measurement model and hypothesized structural model did not differ across participants who were or were not sexually active. Structural equation modeling results were consistent with hypotheses and prior evidence indicating that body surveillance partially mediated the link between internalization of cultural standards of beauty and body shame. Results also indicated that body shame was associated with lower condom use self-efficacy both directly and indirectly through the partial mediation of perceived control over sexual activity; acceptance of sexuality was not a significant mediator of this link but was associated directly with greater condom use self-efficacy. These results connect the substantial literature on the self-objectification process with women's condom use self-efficacy. Specifically, these results point to interrupting the self-objectification process and reducing body shame as well as to enhancing acceptance of sexuality and control over sexual activity as potentially fruitful targets for interventions to promote women's condom use self-efficacy.

Meta-analysis of incidence rate data in the presence of zero events

Background

When summary results from studies of counts of events in time contain zeros, the study-specific incidence rate ratio (IRR) and its standard error cannot be calculated because the log of zero is undefined. This poses problems for the widely used inverse-variance method that weights the study-specific IRRs to generate a pooled estimate.

Methods

We conducted a simulation study to compare the inverse-variance method of conducting a meta-analysis (with and without the continuity correction) with alternative methods based on either Poisson regression with fixed interventions effects or Poisson regression with random intervention effects. We manipulated the percentage of zeros in the intervention group (from no zeros to approximately 80 percent zeros), the levels of baseline variability and heterogeneity in the intervention effect, and the number of studies that comprise each meta-analysis. We applied these methods to an example from our own work in suicide prevention and to a recent meta-analysis of the effectiveness of condoms in preventing HIV transmission.

Results

As the percentage of zeros in the data increased, the inverse-variance method of pooling data shows increased bias and reduced coverage. Estimates from Poisson regression with fixed interventions effects also display evidence of bias and poor coverage, due to their inability to account for heterogeneity. Pooled IRRs from Poisson regression with random intervention effects were unaffected by the percentage of zeros in the data or the amount of heterogeneity.

Conclusion

Inverse-variance methods perform poorly when the data contains zeros in either the control or intervention arms. Methods based on Poisson regression with random effect terms for the variance components are very flexible offer substantial improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-015-0031-0) contains supplementary material, which is available to authorized users.

Factors of the HIV Transmission in Men Who Have Sex with Men in Suizhou City from 2009 to 2013

Introduction

The primary transmission of human immunodeficiency virus (HIV) has been recently changing worldwide. In China, HIV transmission through heterosexual contact remains the predominant mode, but the prevalence of men who have sex with men (MSM) has been increasing.

Aim

This article investigated the overall epidemic trend and associated high-risk behavior among MSM in Suizhou City and explored the government's responses to the epidemic.

Methods

We conducted yearly cross-sectional behavioral surveillance surveys among MSM in Suizhou City from 2009 to 2013. Participation was anonymous and self-completed. Recruitment methods were consistently applied in each survey.

Main Outcome Measures

Semi-structured questionnaire surveys and yearly work summaries were conducted.

Results

Most of the MSM groups in Suizhou City were young adults (P < 0.05), well educated (P < 0.05), and married (P < 0.05). Two years after our interventions, we found an increasing trend of condom use during anal sex (P < 0.05), as well as commercial sex trade (P < 0.05).

Conclusions

HIV continues to spread rapidly among MSM in Suizhou City. The high-risk behavior among MSM remains a hindrance to HIV prevention. Innovative intervention approaches are essential for HIV surveillance and prevention among MSM in Suizhou City. Yang F, Shi X, He W, Wu S, Wang J, Zhao K, Yuan H, Martin K, and Zhang H. Factors of the HIV transmission in men who have sex with men in Suizhou City from 2009 to 2013. Sex Med 2015;3:24–31.

Evaluating HIV prevention strategies for populations in key affected groups: the example of Cabo Verde

OBJECTIVES

We used an individual-based model to evaluate the effects of hypothetical prevention interventions on HIV incidence trajectories in a concentrated, mixed epidemic setting from 2011 to 2021, and using Cabo Verde as an example.

METHODS

Simulations were conducted to evaluate the extent to which early HIV treatment and optimization of care, HIV testing, condom distribution, and substance abuse treatment could eliminate new infections (i.e., reduce incidence to less than 10 cases per 10,000 person-years) among non-drug users, female sex workers (FSW), and people who use drugs (PWUD).

RESULTS

Scaling up all four interventions resulted in the largest decreases in HIV, with estimates ranging from 1.4 (95 % CI 1.36-1.44) per 10,000 person-years among non-drug users to 8.2 (95 % CI 7.8-8.6) per 10,000 person-years among PWUD in 2021. Intervention scenarios prioritizing FWS and PWUD also resulted in HIV incidence estimates at or below 10 per 10,000 person-years by 2021 for all population sub-groups.

CONCLUSIONS

Our results suggest that scaling up multiple interventions among entire population is necessary to achieve elimination. However, prioritizing key populations with this combination prevention strategy may also result in a substantial decrease in total incidence.

Risk behaviours among female sex workers in China: a systematic review and data synthesis

BACKGROUND

Commercial sex is one of the major modes of HIV transmission in China. Understanding HIV risk behaviours in female sex workers (FSW) is of great importance for prevention. This study aims to assess the magnitude and temporal changes of risk behaviours in Chinese FSW.

METHOD

Five electronic databases were searched to identify peer-reviewed English and Chinese language articles published between January 2000 and December 2012 that reported risk behaviours among FSW in China, including condom use, HIV testing, and drug use. Linear regression and Spearman's rank correlation were used to examine temporal trends in these risk factors. The study followed PRISMA guidelines for meta-analyses and was registered in the PROSPERO database for systematic reviews.

RESULTS

A total of 583 articles (44 English, 539 Chinese) investigating 594,583 Chinese FSW were included in this review. At last sex, condom use was highest with commercial partners (clients), increasing from 53.7% in 2000 to 84.9% in 2011. During this same time period, condom use increased with regular partners from 15.2% to 40.4% and with unspecified partners from 38.6% to 82.5%. Increasing trends were also found in the proportion of sampled FSW who reported testing for HIV in the past 12 months (from 3.2% in 2000 to 48.0% in 2011), while drug use behaviours decreased significantly from 10.9% to 2.6%.

CONCLUSION

During the first decade of 2000, Chinese FSWs' self-reported risk behaviours have decreased significantly while HIV testing has increased. Further outreach and intervention efforts are needed to encourage condom use with regular partners, continue promotion of HIV testing, and provide resources for the most vulnerable FSW, particularly low tier FSW, who may have limited access to sexual health and prevention programs.

High HIV, HPV, and STI prevalence among young Western Cape, South African women: EVRI HIV prevention preparedness trial

BACKGROUND

This study sought to assess the feasibility of conducting a phase III HIV prevention trial using a multivalent human papillomavirus (HPV) vaccine (Gardasil; Merck, Whitehouse Station, NJ).

METHODS

A total of 479 sexually active women aged 16-24 years in the Western Cape, South Africa, were enrolled in the Efficacy of HPV Vaccine to Reduce HIV Infection (EVRI) Trial. Of these, 402 were HIV negative, nonpregnant, and randomized 1:1 to receive Gardasil or a saline placebo vaccine. Vaccine doses were administered at enrollment, month 2, and month 6, and participants were followed for 1 month after the third dose. Enrollment HIV, HPV, other sexually transmitted infections (STIs), and cervical cytology were evaluated. Rates of accrual, vaccine compliance, and adherence to protocol were monitored.

RESULTS

High rates of accrual of eligible females to study (93%) and completion of the 3-dose vaccine series (91%) were noted, with few protocol violations. Ineligibility due to reported HIV positivity was 19%, and another 12% of those enrolled tested HIV positive. STI prevalence was high, with 6.2%, 10.9%, and 32.8% testing positive for syphilis, gonorrhea, and chlamydia, respectively. Cervical prevalence of ≥1 of 37 HPV types was 71%. STI and HPV prevalence was highest among the youngest women (<19 years).

CONCLUSIONS

Feasibility (successful accrual, retention, and vaccination) of conducting randomized placebo-controlled trials of HPV vaccines among HIV high-risk women in South Africa was demonstrated. This work demonstrates that phase III HIV prevention trials need to intervene at young ages and screen and treat multiple STIs concurrently to have a measurable impact on HIV acquisition.

Sexual experiences of married HIV positive women in Osogbo, southwest Nigeria: role of inappropriate status disclosure

Background

Worldwide heterosexual sex is the most common mode of HIV transmission, with the marital heterosexual route becoming a major contributor in sub-Sahara Africa. This study examined the role of inappropriate HIV status disclosure, after diagnosis, on marital sexual experiences of HIV positive women.

Methods

The study employed a descriptive cross-sectional design. An interviewer administered questionnaire that elicited information about HIV status disclosure to partners, sexual experiences, condom use and parity was administered to 122 married women living with HIV/AIDS. Participants were referred from peripheral health centres to receive comprehensive HIV care at the State Specialist Hospital, Osogbo, Nigeria.

Results

Mean age (SD) of respondents was 33.8 (8.9) years. Only 23.8% of partners had HIV screening, with 3.3% being HIV positive. A majority (62%) of respondents reported experiencing marital sex deprivation since their partners became aware of their HIV status. There was a reported rejection (74.3%) of condom use by partners during sexual intercourse. Fear of becoming infected (85.7%) and blaming the women for their positive status (85.7%) were the main reasons the respondents gave for being sexually deprived by their partners.

Conclusion

Inappropriate status disclosure due to poor HIV counseling and testing (HCT) practices resulted in sexual deprivation of married HIV positive women. Adequate training and retraining of health care workers on HCT and HIV status disclosure will reduce experience of sexual deprivation among married HIV positive women.

Correlates of unprotected anal intercourse: the influence of anal sex position among men who have sex with men in Beijing, china

Understanding barriers to consistent condom use among men who have sex with men (MSM) requires consideration of the context in which risk behaviors occur. Anal sex position is one such context. This pooled cross-sectional study used survey data from 1,230 MSM and their 2,618 reported male sexual partnerships. Overall, nearly half of the participants engaged in unprotected anal intercourse (UAI) with at least one of upto three partners in the past 6 months. "Insertive" men engaged in less UAI (39 %) than "receptive" (53 %) or "versatile" (51 %) men. Regardless of sexual position, UAI was associated with cohabiting with a male or female partner and perceiving great or moderate risk of HIV from male contact at the individual level, and steady (vs. casual) partnership at the dyad level. However, early MSM anal sex debut, high number of male partners, alcohol use, receiving and buying condoms, HIV testing, and MSM sex-seeking venues were found to be only statistically significantly correlated with UAI among some but not all sexual positions, implying that interventions to increase condom use should take into account how anal sex position may influence willingness and ability to engage in safer sex. Dyad level data appear to provide additional insight into the influence of sexual positions, and should be used to complement individual data for future intervention designs.

Prevalence of consistent condom use with various types of sex partners and associated factors among money boys in Changsha, China

INTRODUCTION

Money boys with inconsistent condom use (less than 100% of the time) are at high risk of infection by human immunodeficiency virus (HIV) or sexually transmitted infection (STI), but relatively little research has examined their risk behaviors.

AIM

We investigated the prevalence of consistent condom use (100% of the time) and associated factors among money boys.

METHODS

A cross-sectional study using a structured questionnaire was conducted among money boys in Changsha, China, between July 2012 and January 2013.

MAIN OUTCOME MEASURE

Independent variables included socio-demographic data, substance abuse history, work characteristics, and self-reported HIV and STI history. Dependent variables included the consistent condom use with different types of sex partners.

RESULTS

Among the participants, 82.4% used condoms consistently with male clients, 80.2% with male sex partners, and 77.1% with female sex partners in the past 3 months. A multiple stepwise logistic regression model identified four statistically significant factors associated with lower likelihoods of consistent condom use with male clients: age group, substance abuse, lack of an "employment" arrangement, and having no HIV test within the prior 6 months. In a similar model, only one factor associated significantly with lower likelihoods of consistent condom use with male sex partners was identified in multiple stepwise logistic regression analyses: having no HIV test within the prior six months. As for female sex partners, two significant variables were statistically significant in the multiple stepwise logistic regression analysis: having no HIV test within the prior 6 months and having STI history.

CONCLUSIONS

Interventions which are linked with more realistic and acceptable HIV prevention methods are greatly warranted and should increase risk awareness and the behavior of consistent condom use in both commercial and personal relationship.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

How Many HIV infections may be averted by targeting primary infection in men who have sex with men? Quantification of changes in transmission-risk behavior, using an individual-based model

In the United Kingdom, human immunodeficiency virus (HIV) transmission among men who have sex with men (MSM) is not under control, despite readily available treatment, highlighting the need to design a cost-effective combination prevention package. MSM report significantly reduced transmission risk behavior following HIV diagnosis. To assess the effectiveness of HIV diagnosis in averting transmission during highly infectious primary HIV infection (PHI), we developed a stochastic individual-based model to calculate the number of HIV-transmission events expected to occur from a cohort of recently infected MSM with and those without the behavior changes reported after diagnosis. The model incorporates different types of sex acts, incorporates condom use, and distinguishes between regular and casual sex partners. The impact on transmission in the 3 months after infection depends on PHI duration and testing frequency. If PHI lasts for 3 months and testing is performed monthly, then behavior changes after diagnosis would have reduced estimated transmission events by 49%–52%, from 31–45 to 15–23 events; a shorter duration of PHI and/or a lower testing frequency reduces the number of infections averted. Diagnosing HIV during PHI can markedly reduce transmission by changing transmission-risk behavior. Because of the high infectivity but short duration of PHI, even short-term behavior change can significantly reduce transmission. Our quantification of the number of infections averted is an essential component of assessment of the cost-effectiveness of strategies to increase detection and diagnoses of PHI.

Factors influencing the uptake of family planning services in the Talensi District, Ghana

INTRODUCTION

Usage of family planning services in developing countries have been found to avert unintended pregnancies, reduce maternal and child mortality, however, it's usage still remains low. Hence, the objective of this study was to investigate the factors that influence the decision of women in fertility age to go for family planning services.

METHODS

This was a descriptive cross-sectional study conducted in Talensi district in the Upper East Region of Ghana. Systematic random sampling was used to recruit 280 residents aged 15-49 years and data was analysed using SPSS version 21.0.

RESULTS

The study revealed that 89% (249/280), of respondents were aware of family planning services, 18% (50/280) of respondents had used family planning services in the past. Parity and educational level of respondents were positively associated with usage of family planning services (P<0.05). Major motivating factors to the usage of family planning service were to space children, 94% (47/50) and to prevent pregnancy and sexual transmitted infections 84% (42/50). Major reasons for not accessing family planning services were opposition from husbands, 90% (207/230) and misconceptions about family planning, 83% (191/230).

CONCLUSION

Although most women were aware of family planning services in the Talensi district, the uptake of the service was low. Thus, there is the need for the office of the district health directorate to intensify health education on the benefits of family planning with male involvement. The government should also scale up family planning services in the district to make it more accessible.

Relationship between exposure to the Avahan intervention and levels of reported condom use among men who have sex with men in southern India

BACKGROUND

The Avahan intervention promotes consistent (100%) condom use amongst men who have sex with men in southern India. We assessed how condom use varies with intervention exposure for men who have sex with men in Bangalore.

METHODS

Self-reported condom use and intervention exposure data were derived from a cross-sectional survey. Consistent condom use and condom use at last sex act with all, main, and casual male sex partners were assessed. Binary and continuous variables reflecting intervention exposure (including contact(s) with intervention staff, receiving condoms and seeing condom demonstrations) were used. Multivariable logistic regression was employed to assess the relationship between condom use with each type of partner and each exposure variable independently, controlling for socio-demographic and behavioural factors associated with condom use or intervention exposure.

RESULTS

Condom use with all partners was higher among those who had ever been contacted by, received condoms from, or seen a condom demonstration by intervention staff (adjusted odds ratio >2, p < 0.02 for all). Consistent condom use with all types of partner increased with the number of condom demonstrations seen in the last month (adjusted odds ratio = 2.1 per demonstration, p < 0.025), while condom use at last sex act with a casual (but not main) partner increased with the number of condoms received from the intervention (adjusted odds ratio = 1.4 per condom, p = 0.04).

CONCLUSIONS

Direct contact with Avahan program staff is associated with increased reported condom use among men who have sex with men in Bangalore. Reported consistent condom use and condom use at last sex act are associated with contacts involving demonstrations of correct condom use, and with receiving condoms, respectively.

HIV-related characteristics among female partners of injecting drug users in Kelantan, Malaysia: a descriptive study

Kelantan, a northeastern state in Peninsular Malaysia, is one of the states that has been acutely hit by injecting drug user (IDU)-driven HIV epidemic, in addition to having a high number of infected women in Malaysia. This cross-sectional study describes the socio-demographic characteristics, HIV risk factors, risk perception, and adoption of preventive behaviors among female partners of IDUs in Kelantan. Out of 101 women, the majority of them are from low socioeconomic background and have no other risk factors besides heterosexual HIV transmission from their male IDU partners. Although 45.5% have not been tested for HIV and more than half (53.5%) of them did not use condoms during sexual intercourse, only 44.6% of the women perceived themselves to be at risk of being infected with HIV. Most of the women (86.1%) were willing to undergo voluntary counseling and testing (VCT). Female partners of IDUs continue to be vulnerable to HIV due to having sexual contact with IDUs, and also due to their socioeconomic position in the community. To prevent HIV transmission among female partners of IDUs, consolidating HIV prevention efforts from multiple approaches is needed.

Systematic assessment of condom use measurement in evaluation of HIV prevention interventions: need for standardization of measures

When evaluating HIV prevention interventions, condom use is a common outcome measure used to assess changes in HIV-related behaviors; however, no widely accepted standards exist for its measurement. Using systematic review data on HIV prevention interventions conducted in low- and middle-income countries, we examined trends in condom use measurement since 1990. We abstracted data from standardized forms on six dimensions of condom use: partner type, temporal period, measurement scale, consistency, controlling for abstinence, and type of sex. Of 215 studies reviewed, 109 studies (51 %) measured condom use as a primary outcome. Outcomes were stratified by partner type in 47 studies (43 %). Assessing condom use at last sex was the most common measurement. Consistency of condom use was assessed in 47 studies (43 %). Developing and utilizing standards for condom use measurement would increase comparability of findings across studies and benefit HIV prevention research. Recommendations include measuring condom use at last sex, frequency of condom use, and number of protected sex acts in studies evaluating the efficacy of behavioral interventions on sexual risk behavior.

Barriers to uptake and use of pre-exposure prophylaxis (PrEP) among communities most affected by HIV in the UK: findings from a qualitative study in Scotland

OBJECTIVES

To explore the acceptability of pre-exposure prophylaxis (PrEP) among gay, bisexual and men who have sex with men (MSM) and migrant African communities in Scotland, UK.

DESIGN

Consecutive mixed qualitative methods consisting of focus groups (FGs) and in-depth interviews (IDIs) explored PrEP acceptability. Data were digitally recorded, transcribed and analysed thematically to identify anticipated and emerging themes.

SETTING

Participants were recruited through community sexual health and outreach support services, and from non-sexual health settings across Scotland.

PARTICIPANTS

Inclusion criteria included identification as either MSM and/or from migrant African communities; 18 years and older; living in Scotland at the time of participation. 7 FGs were conducted (n=33): 5 with MSM (n=22) and 2 mixed-sex groups with African participants (n=11, women=8), aged 18-75 years. 34 IDIs were conducted with MSM (n=20) and African participants (n=14, women=10), aged 19-60 years. The sample included participants who were HIV-positive and HIV-negative or untested (HIV-positive FG participants, n=22; HIV-positive IDI participants, n=17).

RESULTS

Understandings of PrEP effectiveness and concerns about maintaining regular adherence were identified as barriers to potential PrEP uptake and use. Low perception of HIV risk due to existing risk management strategies meant few participants saw themselves as PrEP candidates. Participants identified risk of other sexually transmitted infections and pregnancy as a concern which PrEP did not address for either themselves or their sexual partners. PrEP emerged as a contentious issue because of the potentially negative implications it had for HIV prevention. Many participants viewed PrEP as problematic because they perceived that others would stop using condoms if PrEP was to become available.

CONCLUSIONS

PrEP implementation needs to identify appropriate communication methods in the context of diverse HIV literacy; address risk-reduction concerns and; demonstrate how PrEP can be part of a safe and comprehensive risk management strategy.

Barrier methods for human immunodeficiency virus prevention

Condoms remain the most effective barrier against the sexual transmission of the human immunodeficiency virus (HIV). Male condoms have proven to be 80% to 90% effective, and female condoms have similar results. Poor adherence and improper use limit their effectiveness. In addition to condoms, microbicides are a promising barrier against HIV transmission. More than 50 candidate topical microbicide compounds have undergone preclinical or clinical testing in the last 10 years, but there are currently no US Food and Drug Administration (FDA)-approved compounds. Rectal microbicides are also being developed, as anal receptive sex is an effective mode of HIV transmission.

Effectiveness of ART and condom use for prevention of sexual HIV transmission in serodiscordant couples: a systematic review and meta-analysis

BACKGROUND

Consistent and correct condom use and suppressive antiretroviral therapy for the infected partner are two of the primary strategies recommended for prevention of heterosexual HIV transmission in serodiscordant couples today. The applied effectiveness of treatment as a prevention strategy in China is still under investigation, and much less is known about its effects in the presence of other prevention strategies such as consistent condom use.

METHODS

We conducted a systematic search in PubMed and three Chinese language databases to identify relevant articles for the estimation of relative effectiveness of a) consistent condom use and b) ART use by index partners for preventing HIV transmission in serodiscordant couples. We also estimated the prevention effectiveness of ART stratified by condom use level and the prevention effectiveness of consistent condom use stratified by ART use level.

RESULTS

Pooled results from the eleven eligible studies found a pooled HIV seroconversion incidence of 0.92 cases per 100 person years (PY) among HIV-negative spouses whose index partners were taking ART versus 2.45 cases per 100 PY in untreated couples. The IRR comparing seroconversion in couples where the index-partner was on ART versus not on ART was 0.47 (95%CI: 0.43, 0.52), while stratified by condom use, the IRR was 0.33(0.17,0.64). The IRR comparing incidence in couples reporting "consistent condom use" versus those reporting otherwise was 0.02(95%CI:0.01,0.04), after stratified by ART use level, the IRR was 0.01(95%CI: 0.00, 0.06).

CONCLUSIONS

ART use by index partners could reduce HIV transmission in serodiscordant couples, and the effectiveness of this prevention strategy could be further increased with consistent condom use.

Examining delay discounting of condom-protected sex among opioid-dependent women and non-drug-using control women

BACKGROUND

Opioid-dependent (OD) women tend to engage in unprotected sex with high-risk partners, placing themselves at elevated risk for sexually transmitted HIV infection. This behavior generally persists after completion of interventions that increase sexual HIV risk reduction knowledge and skills, suggesting that decision-making biases may influence HIV transmission among OD women.

METHODS

The primary aim of this report is to examine delay discounting of condom-protected sex among OD women and non-drug-using control women using the novel Sexual Discounting Task (SDT; Johnson and Bruner, 2012). Data were collected from 27 OD women and 33 non-drug-using control women using the SDT, a monetary discounting task, and the Barratt impulsiveness scale (BIS-11).

RESULTS

OD women discounted the value of delayed condom-protected sex more steeply than controls for hypothetical sexual partners in the two sets of paired partner conditions examined. Overall, women discounted condom protected sex more steeply for partners they perceived as being lowest STI risk vs. those they perceived as being highest risk. Steeper discounting of condom-protected sex was significantly associated with higher scores on the BIS-11, but not with discounting of money.

CONCLUSIONS

Delay discounting of condom-protected sex differs between OD women and non-drug-using women, is sensitive to perceived partner risk, and is correlated with a self-report measure of impulsivity, the BIS-11. The effect of delay on sexual decision-making is a critical but underappreciated dimension of HIV risk among women, and the SDT appears to be a promising measure of this domain. Further investigation of these relationships is warranted.

Contraceptive use and unmet need for family planning among HIV positive women on antiretroviral therapy in Kumasi, Ghana

BACKGROUND

A key strategy for minimizing HIV infection rates especially via reduction of Mother- to-Child transmission is by reducing the unmet need for family planning. In Ghana, the integration of family planning services into Antiretroviral Therapy services for persons living with HIV/AIDS has largely been ignored. We set out to measure the prevalence of modern methods of contraception, the unmet need for family planning and to identify factors associated with the use of modern methods of contraception among HIV positive women on anti retroviral therapy.

METHODS

This was a descriptive cross sectional study of HIV positive women in their reproductive ages accessing care at an adult Antiretroviral Therapy Clinic in Kumasi, Ghana. Data was collected using a structured questionnaire. Data analysis was conducted using Epi Info version 7.1.2.0.

RESULTS

A total of 230 women were included in the study. Fifty six percent were in the 30-39 year age group. The mean age (SD) was 36.3 (5.4) years. While 53.5% of respondents desired to have children, partner desire for children was reported by 54.6% of respondents with partners. About 74% had received information on contraception from their provider. 42.6% of participants and/or their partners were using a contraception method at the time of study; the male condom (79.6%) being the most commonly used method. The estimated unmet need for contraception was 27.8%. Contraceptive use was strongly associated with partner knowledge of HIV status (AOR = 3.64; 95% CI 1.36-9.72; p = 0.01) and use of a contraceptive method prior to diagnosis of HIV (AOR = 6.1; 2.65-14.23; p < 0.001).

CONCLUSION

Contraceptive Prevalence is high among HIV positive women in Kumasi compared with the general Ghanaian population. Despite this, there still is a high unmet need for family planning in this population. We recommend continuous education on contraceptives use to HIV patients accessing HAART services to further increase contraceptive uptake.

Clinical effectiveness and cost-effectiveness of HIV pre-exposure prophylaxis in men who have sex with men: risk calculators for real-world decision-making

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) can be clinically effective and cost-effective for HIV prevention in high-risk men who have sex with men (MSM). However, individual patients have different risk profiles, real-world populations vary, and no practical tools exist to guide clinical decisions or public health strategies. We introduce a practical model of HIV acquisition, including both a personalized risk calculator for clinical management and a cost-effectiveness calculator for population-level decisions.

METHODS

We developed a decision-analytic model of PrEP for MSM. The primary clinical effectiveness and cost-effectiveness outcomes were the number needed to treat (NNT) to prevent one HIV infection, and the cost per quality-adjusted life-year (QALY) gained. We characterized patients according to risk factors including PrEP adherence, condom use, sexual frequency, background HIV prevalence and antiretroviral therapy use.

RESULTS

With standard PrEP adherence and national epidemiologic parameters, the estimated NNT was 64 (95% uncertainty range: 26, 176) at a cost of $160,000 (cost saving, $740,000) per QALY--comparable to other published models. With high (35%) HIV prevalence, the NNT was 35 (21, 57), and cost per QALY was $27,000 (cost saving, $160,000), and with high PrEP adherence, the NNT was 30 (14, 69), and cost per QALY was $3,000 (cost saving, $200,000). In contrast, for monogamous, serodiscordant relationships with partner antiretroviral therapy use, the NNT was 90 (39, 157) and cost per QALY was $280,000 ($14,000, $670,000).

CONCLUSIONS

PrEP results vary widely across individuals and populations. Risk calculators may aid in patient education, clinical decision-making, and cost-effectiveness evaluation.

Preconception care: preventing and treating infections

Introduction

Infections can impact the reproductive health of women and hence may influence pregnancy related outcomes for both the mother and the child. These infections range from sexually transmitted infections (STIs) to TORCHS infections to periodontal disease to systemic infections and may be transmitted to the fetus during pregnancy, labor, delivery or breastfeeding.

Methods

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

Results

Preconception behavioral interventions significantly declines re-infection or new STI rates by 35% (95% CI: 20-47%). Further, condom use has been shown to be the most effective way to prevent HIV infection (85% protection in prospective studies) through sexual intercourse. Intervention trials showed that preconception vaccination against tetanus averted a significant number of neonatal deaths (including those specifically due to tetanus) when compared to placebo in women receiving more than 1 dose of the vaccine (OR 0.28; 95% CI: 0.15-0.52); (OR 0.02; 95% CI: 0.00-0.28) respectively.

Conclusion

Preconception counseling should be offered to women of reproductive age as soon as they test HIV-positive, and conversely women of reproductive age should be screened with their partners before pregnancy. Risk assessment, screening, and treatment for specific infections should be a component of preconception care because there is convincing evidence that treatment of these infections before pregnancy prevents neonatal infections.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Patterns and risk factors of inconsistent condom use among men who have sex with men in Viet Nam: Results from an Internet-based cross-sectional survey

Survey data from men who have sex with men (MSM) in Asian cities indicate drastic increases in HIV prevalence. It is unknown which factors are most important in driving these epidemics. The objective of this study was to identify patterns of condom use among MSM Internet users living in Viet Nam, as well as risk factors associated with inconsistent condom use and non-condom use. A national Internet-based survey of sexual behaviours was administered in 2011. Results showed that 44.9% of MSM reported not using a condom during their last anal sex encounter with a male partner. MSM were less likely to report condom use during anal sex with long-term partners than with casual partners. Twenty-three and a half per cent of MSM surveyed had ever taken an HIV test and received the results. Study findings highlight the urgent need for targeted strategies focused on increasing the rate of consistent condom use during anal sex with male partners among MSM in Viet Nam.

HIV transmission among men who have sex with men due to condom failure

Background

Despite preventive efforts, HIV incidence remains high among men who have sex with men (MSM) in industrialized countries. Condoms are an important element in prevention but, given the high frequency of condom use and their imperfect effectiveness, a substantial number and proportion of HIV transmissions may occur despite condoms. We developed a model to examine this hypothesis.

Methods

We used estimates of annual prevalent and incident HIV infections for MSM in Ontario. For HIV-negative men, we applied frequencies of sexual episodes and per-contact HIV transmission risks of receptive and insertive anal sex with and without a condom and oral sex without a condom. We factored in the proportion of HIV-infected partners receiving antiretroviral therapy and its impact in reducing transmissibility. We used Monte-Carlo simulation to determine the plausible range for the proportion of HIV transmissions for each sexual practice.

Results

Among Ontario MSM in 2009, an estimated 92,963 HIV-negative men had 1,184,343 episodes of anal sex with a condom and 117,133 anal sex acts without a condom with an HIV-positive partner. Of the 693 new HIV infections, 51% were through anal sex with a condom, 33% anal sex without a condom and 16% oral sex. For anal sex with a condom, the 95% confidence limits were 17% and 77%.

Conclusions

The proportion of HIV infections related to condom failure appears substantial and higher than previously thought. That 51% of transmissions occur despite condom use may be conservative (i.e. low) since we used a relatively high estimate (87.1%) for condom effectiveness. If condom effectiveness were closer to 70%, a value estimated from a recent CDC study, the number and proportion of HIV transmissions occurring despite condom use would be much higher. Therefore, while condom use should continue to be promoted and enhanced, this alone is unlikely to stem the tide of HIV infection among MSM.

WHO guidance grounded in a comprehensive approach to sexual and reproductive health and human rights: topical pre-exposure prophylaxis

Introduction

Two new microbicide products based on topical (vaginal) application of antiretroviral drugs – 1% tenofovir gel and the dapivirine ring – are currently in late-stage clinical testing, and results on their safety and effectiveness are expected to become available in early 2015. WHO guidelines on the use of topical pre-exposure prophylaxis (topical PrEP) are important in order to ensure that these new prevention products are optimally used.

Discussion

Given that these new topical PrEP products are designed to be woman initiated and will likely be delivered in reproductive health settings, it is important to ensure that the guidance be framed in the context of comprehensive sexual and reproductive health and human rights. In addition to the safety and effectiveness data resulting from clinical trials, and the regulatory approval required for new products, the WHO normative guidelines on the use of topical PrEP will be essential for rapid roll-out in countries.

Conclusions

Human rights standards and principles provide a framework for the provision of woman-initiated HIV prevention products. These include addressing issues related to the gender inequities which are linked to the provision of HIV-prevention, treatment and care for young girls and women. Effective programming for women and girls must therefore be based on understanding the local, social and community contexts of the AIDS epidemic in the country, and adapting HIV strategies and programmes accordingly. Such a framework therefore is needed not only to ensure optimal uptake of these new products by women and girls but also to address sociocultural barriers to women's and girls’ access to these products.

Use of Condoms among Human Immunodeficiency Virus Positive Women Attending Antenatal Clinic in Nnewi, South East Nigeria

BACKGROUND

Consistent use of condom provides protection from transmission of human immunodeficiency virus (HIV) infection in couples with sero-discordant HIV status. It also protects against acquiring other strains in HIV positive concordant couples.

AIM

This study evaluated the use of barrier method of contraception among HIV patients.

SUBJECTS AND METHODS

This was a descriptive cross-sectional study conducted among pregnant women in Nnamdi Azikiwe University Teaching Hospital Nnewi. An interviewer administered questionnaire was used to obtain relevant information from the subjects. Data was analyzed using SPSS software version 20.0 (Chicago, IL, USA, August 2011).

RESULT

A total of 126 HIV positive pregnant women participated in this study. The mean age of the women was 30.4 (5) years while the mean parity was 2.6 (1). All the patients had at least primary education with 63.5% (80/126) having secondary education as the highest educational attainment while 87.3% (110/126) were in monogamous marriage. The partner's HIV status showed that 41.3% (52/126) tested negative to HIV antibodies while 42.8% (54/126) tested positive to HIV antibodies and 15.9% (20/126) do not know partner's HIV status. Only 61.9% (78/126) of the couples use condom during sexual intercourse. Further analysis showed that 26.2% (33/126) use condom consistently except during timed intercourse for conception. There was significant association between type of relationship and use of barrier method of contraception. There was no significant association between sero-discordant couples and highest educational status with use of barrier method of conception.

CONCLUSION

Condom use among HIV positive couples is low and raises great concern on transmission of the virus to partners and babies born to positive mothers.

Oral pre-exposure prophylaxis (PrEP) for prevention of HIV in serodiscordant heterosexual couples in the United States: opportunities and challenges

Oral HIV pre-exposure prophylaxis (PrEP) is a promising new biomedical prevention approach in which HIV-negative individuals are provided with daily oral antiretroviral medication for the primary prevention of HIV-1. Several clinical trials have demonstrated efficacy of oral PrEP for HIV prevention among groups at high risk for HIV, with adherence closely associated with level of risk reduction. In the United States (US), three groups have been prioritized for initial implementation of PrEP-injection drug users, men who have sex with men at substantial risk for HIV, and HIV-negative partners within serodiscordant heterosexual couples. Numerous demonstration projects involving PrEP implementation among MSM are underway, but relatively little research has been devoted to study PrEP implementation in HIV-serodiscordant heterosexual couples in the US. Such couples face a unique set of challenges to PrEP implementation at the individual, couple, and provider level with regard to PrEP uptake and maintenance, adherence, safety and toxicity, clinical monitoring, and sexual risk behavior. Oral PrEP also provides new opportunities for serodiscordant couples and healthcare providers for primary prevention and reproductive health. This article provides a review of the critical issues, challenges, and opportunities involved in the implementation of oral PrEP among HIV-serodiscordant heterosexual couples in the US.

Impact of antiretroviral therapy on health-related quality of life among South African women in the CAPRISA 002 acute infection study

Concerns are often raised regarding potentially adverse effects of antiretroviral therapy (ART) on health-related quality of life (HRQoL), but there is limited longitudinal data to prove this. Building on our prior investigation, we examined the impact of ART on HRQoL among HIV-infected South African women with extensive follow-up in the CAPRISA 002 Acute Infection Cohort Study. Overall HRQoL and five sub-domains [physical well-being (PWB), emotional well-being (EWB), functional and global well-being (FGWB), social well-being (SWB) and cognitive functioning (CF)] were assessed using the Functional Assessment of HIV Infection (FAHI) instrument. Our analyses comparing FAHI scores between pre-ART (established infection) and ART phases using paired Wilcoxon signed-rank tests and adjusted mixed-effects regression models revealed improvements on ART in overall HRQoL, and in PWB, EWB, and SWB, but not in FGWB and CF. No long-term adverse impact of ART on HRQoL was detected, providing additional non-biomedical support to early treatment strategies.

Replacing clinic-based tests with home-use tests may increase HIV prevalence among Seattle men who have sex with men: evidence from a mathematical model

BACKGROUND

Home-use tests have potential to increase HIV testing but may increase the rate of false-negative tests and decrease linkage to HIV care. We sought to estimate the impact of replacing clinic-based testing with home-use tests on HIV prevalence among men who have sex with men (MSM) in Seattle, Washington.

METHODS

We adapted a deterministic, continuous-time model of HIV transmission dynamics parameterized using a 2003 random digit dial study of Seattle MSM. Test performance was based on the OraQuick In-Home HIV Test (OraSure Technologies, Inc, Bethlehem, PA) for home-use tests and, on an average, of antigen-antibody combination assays and nucleic acid amplification tests for clinic-based testing.

RESULTS

Based on observed levels of clinic-based testing, our baseline model predicted an equilibrium HIV prevalence of 18.6%. If all men replaced clinic-based testing with home-use tests, prevalence increased to 27.5% if home-use testing did not impact testing frequency and to 22.4% if home-use testing increased testing frequency 3-fold. Regardless of how much home-use testing increased testing frequency, any replacement of clinic-based testing with home-use testing increased prevalence. These increases in HIV prevalence were mostly caused by the relatively long window period of the currently approved test. If the window period of a home-use test were 2 months instead of 3 months, prevalence would decrease if all MSM replaced clinic-based testing with home-use tests and tested more than 2.6 times more frequently.

CONCLUSIONS

Our model suggests that if home-use HIV tests replace supplement clinic-based testing, HIV prevalence may increase among Seattle MSM, even if home-use tests result in increased testing.