Condom effectiveness in reducing heterosexual HIV transmission

Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections

BACKGROUND

Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs.

OBJECTIVES

To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs.

SELECTION CRITERIA

Randomized control trials (RCTs) featuring all of the following.1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.3. Trials that confirmed biological outcomes using laboratory testing.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values.

MAIN RESULTS

We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes.

AUTHORS' CONCLUSIONS

There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.

Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention

Large declines in HIV incidence have been reported since 2001, and scientific advances in HIV prevention provide strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public health approach to combination prevention that understands that risk is not evenly distributed and that effective interventions can vary by risk profile. Different countries have different microepidemics, with very different levels of transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies, people at highest risk for HIV, and the package of interventions that are most likely to have the largest effect in each different microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision, as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.

Lead screening for CXCR4 of the human HIV infection receptor inhibited by traditional Chinese medicine

The acquired immunodeficiency syndrome (AIDS) is a serious worldwide disease caused by the human immunodeficiency virus (HIV) infection. Recent research has pointed out that the G protein-coupled chemokine receptor CXCR4 and the coreceptor C-C chemokine receptor type 5 (CCR5) are important targets for HIV infection. The traditional Chinese medicine (TCM) database has been screened for candidate compounds by simulating molecular docking and molecular dynamics against HIV. Saussureamine C, 5-hydroxy-L-tryptophan, and diiodotyrosine are selected based on the highest docking score. The molecular dynamics is helpful in the analysis and detection of protein-ligand interactions. According to the analysis of docking poses, hydrophobic interactions, hydrogen bond variations, and the comparison of the effect on CXCR4 and CCR5, these results indicate Saussureamine C may have better effect on these two receptors. But for some considerations, diiodotyrosine could make the largest variation and may have some efficacy contrary to expectations.

Scaling up integrated prevention campaigns for global health: costs and cost-effectiveness in 70 countries

OBJECTIVE

This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases.

METHODS

We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer's perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted.

RESULTS

Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1692 and US$8340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness.

CONCLUSIONS

IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.

Estimating per-act HIV transmission risk: a systematic review

BACKGROUND

Effective HIV prevention programs rely on accurate estimates of the per-act risk of HIV acquisition from sexual and parenteral exposures. We updated the previous risk estimates of HIV acquisition from parenteral, vertical, and sexual exposures, and assessed the modifying effects of factors including condom use, male circumcision, and antiretroviral therapy.

METHODS

We conducted literature searches to identify new studies reporting data regarding per-act HIV transmission risk and modifying factors. Of the 7339 abstracts potentially related to per-act HIV transmission risk, three meta-analyses provided pooled per-act transmission risk probabilities and two studies provided data on modifying factors. Of the 8119 abstracts related to modifying factors, 15 relevant articles, including three meta-analyses, were included. We used fixed-effects inverse-variance models on the logarithmic scale to obtain updated estimates of certain transmission risks using data from primary studies, and employed Poisson regression to calculate relative risks with exact 95% confidence intervals for certain modifying factors.

RESULTS

Risk of HIV transmission was greatest for blood transfusion, followed by vertical exposure, sexual exposures, and other parenteral exposures. Sexual exposure risks ranged from low for oral sex to 138 infections per 10,000 exposures for receptive anal intercourse. Estimated risks of HIV acquisition from sexual exposure were attenuated by 99.2% with the dual use of condoms and antiretroviral treatment of the HIV-infected partner.

CONCLUSION

The risk of HIV acquisition varied widely, and the estimates for receptive anal intercourse increased compared with previous estimates. The risk associated with sexual intercourse was reduced most substantially by the combined use of condoms and antiretroviral treatment of HIV-infected partners.

HIV sexual transmission risk among serodiscordant couples: assessing the effects of combining prevention strategies

BACKGROUND

The number of strategies to prevent HIV transmission has increased following trials evaluating antiretroviral therapy (ART), preexposure prophylaxis (PrEP) and male circumcision. Serodiscordant couples need guidance on the effects of these strategies alone, and in combination with each other, on HIV transmission.

METHODS

We estimated the sexual risk of HIV transmission over 1-year and 10-year periods among male-male and male-female serodiscordant couples. We assumed the following reductions in transmission: 80% from consistent condom use; 54% from circumcision in the negative male partner of a heterosexual couple; 73% from circumcision in the negative partner of a male-male couple; 71% from PrEP in heterosexual couples; 44% from PrEP in male-male couples; and 96% from ART use by the HIV-infected partner.

FINDINGS

For couples using any single prevention strategy, a substantial cumulative risk of HIV transmission remained. For a male-female couple using only condoms, estimated risk over 10 years was 11%; for a male-male couple using only condoms, estimated risk was 76%. ART use by the HIV-infected partner was the most effective single strategy in reducing risk; among male-male couples, adding consistent condom use was necessary to keep the 10-year risk below 10%.

CONCLUSION

Focusing on 1-year and longer term transmission probabilities gives couples a better understanding of risk than those illustrated by data for a single sexual act. Long-term transmission probabilities to the negative partner in serodiscordant couples can be high, though these can be substantially reduced with the strategic use of preventive methods, especially those that include ART.

Insight into HIV of IFN-induced myxovirus resistance 2 (MX2) expressed by traditional Chinese medicine

Recently, an important topic of the acquired immunodeficiency syndrome (AIDS) had been published in 2013. In this report, the expression of the IFN-induced myxovirus resistance 2 (MX2) had been defined the function to kill the human immunodeficiency virus (HIV). The screening from the Traditional Chinese Medicine (TCM) database by simulating molecular docking and molecular dynamics could select candidate compounds, which may express MX2 against HIV. Saussureamine C, Crotalaburnine, and Precatorine are selected based on the highest docking score and other TCM compounds. The data from molecular dynamics are helpful in the analysis and detection of protein-ligand interactions. According to the docking poses, hydrophobic interactions, and hydrogen bond with structure variations, this research could assess the interaction between protein and ligand interaction. In addition to the detection of TCM compound efficacy, we suggest that Saussureamine C is better than the others in protein-ligand interaction and the structural variation to express MX2.

Investigation of potent lead for acquired immunodeficiency syndrome from traditional Chinese medicine

Acquired immunodeficiency syndrome (AIDS), caused by human immunodeficiency virus (HIV), has become, because of the rapid spread of the disease, a serious global problem and cannot be treated. Recent studies indicate that VIF is a protein of HIV to prevent all of human immunity to attack HIV. Molecular compounds of traditional Chinese medicine (TCM) database filtered through molecular docking and molecular dynamics simulations to inhibit VIF can protect against HIV. Glutamic acid, plantagoguanidinic acid, and Aurantiamide acetate based docking score higher with other TCM compounds selected. Molecular dynamics are useful for analysis and detection ligand interactions. According to the docking position, hydrophobic interactions, hydrogen bonding changes, and structure variation, the study try to select the efficacy of traditional Chinese medicine compound Aurantiamide acetate is better than the other for protein-ligand interactions to maintain the protein composition, based on changes in the structure.

Lead screening for HIV-1 integrase (IN) inhibited by traditional Chinese medicine

Human immunodeficiency virus causes the acquired immunodeficiency syndrome (AIDS) and becomes a serious world-wide problem because of this disease's rapid propagation and incurability. Integrase strand transfer inhibitors (INSTIs) supports HIV have rapid drug resistance for antitreatment. Screening the traditional Chinese medicine (TCM) database by simulating molecular docking and molecular dynamics may select molecular compounds to inhibit INSTIs against HIV drug resistance. (S)-cathinone and (1S,2S)-norpseudoephedrine are selected based on structure and ligand-based drugs are designed and then get higher bioactivity predicted score from SVM than Raltegravir and other TCM compounds. The molecular dynamics are helpful in the analysis and detection of protein-ligand interactions. According to the docking poses, hydrophobic interactions and hydrogen bond variations define the main regions of important amino acids in integrase. In addition to the detection of TCM compound efficacy, we suggest (1S,2S)-norpseudoephedrine is better than the others based on the analysis of interaction and the effect on the structural variation.

Canadian consensus statement on HIV and its transmission in the context of criminal law

INTRODUCTION

A poor appreciation of the science related to HIV contributes to an overly broad use of the criminal law against individuals living with HIV in cases of HIV nondisclosure.

METHOD

To promote an evidence-informed application of the law in Canada, a team of six Canadian medical experts on HIV and transmission led the development of a consensus statement on HIV sexual transmission, HIV transmission associated with biting and spitting, and the natural history of HIV infection. The statement is based on a literature review of the most recent and relevant scientific evidence (current as of December 2013) regarding HIV and its transmission. It has been endorsed by >70 additional Canadian HIV experts and the Association of Medical Microbiology and Infectious Disease Canada.

RESULTS

Scientific and medical evidence clearly indicate that HIV is difficult to transmit during sex. For the purpose of informing the justice system, the per-act possibility of HIV transmission through sex, biting or spitting is described along a continuum from low possibility, to negligible possibility, to no possibility of transmission. This possibility takes into account the impact of factors such as the type of sexual acts, condom use, antiretroviral therapy and viral load. Dramatic advances in HIV therapy have transformed HIV infection into a chronic manageable condition.

DISCUSSION

HIV physicians and scientists have a professional and ethical responsibility to assist those in the criminal justice system to understand and interpret the science regarding HIV. This is critical to prevent miscarriage of justice and to remove unnecessary barriers to evidence-based HIV prevention strategies.

Perceived behavioural control, subjective norms, attitudes and intention to use condom: a longitudinal cross-lagged design

Based on the Theory of Planned Behaviour (TPB), the purpose of this investigation was to examine the directionality of the association among condom use, intention, attitudes, subjective norms and perceived behavioural control. The present study investigated the nature of these relationships using a longitudinal cross-lagged design applied to data from a cohort of 958 randomly selected Italian adults. Using structural equation modelling, two cross-lagged panel analyses revealed reciprocal relationships between intention and attitudes and between intention and condom use. Contrary to expectations, baseline subjective norms and perceived behavioural control did not predict subsequent intention to use condom when controlled for the autoregressive effect of intention at T1 on the same variable at T2. Also, perceived behavioural control at T1 did not influence condom use at T2 after controlling for the effect of baseline intention. The possibility of reciprocity was also tested for all relations and significant results were found. The moderation effect of perceived behavioural control on the relationship between intention and condom use was not significant. The differences in age, gender and partnership status were taken into account in the analyses.

Factors Associated With Forensic Nurses Offering HIV nPEP Status Post Sexual Assault

Nonoccupational, postexposure prophylaxis (nPEP) for human immunodeficiency virus (HIV) is offered inconsistently to patients who have been sexually assaulted. This may be due to Forensic Nurse Examiner (FNE) programs utilizing diverse nPEP protocols and HIV risk assessment algorithms. This study examines factors associated with FNEs offering nPEP to patients following sexual assault at two FNE programs in urban settings. Offering nPEP is mostly driven by site-specific protocol. At Site 1, in addition to open anal or open genital wounds, the presence of injury to the head or face was associated with FNEs offering nPEP (adjusted odds ratio [AOR] 64.15, 95% confidence interval [CI] = [2.12, 1942.37]). At Site 2, patients assaulted by someone of Other race/ethnicity (non-White, non-African American) were 86% less likely to be offered nPEP (AOR 0.14, 95% CI = [.03, .72]) than patients assaulted by Whites. In addition to following site-specific protocols, future research should further explore the mechanisms influencing clinician decision making.

HIV prevalence trends, risky behaviours, and governmental and community responses to the epidemic among men who have sex with men in China

Purpose of Review. Numerous studies reported the rapid spread of HIV/AIDS epidemic among men who have sex with men (MSM) in China. This paper aims to investigate the overall epidemic trend and associated high-risk behaviours among Chinese MSM and to explore the governmental and community responses to the epidemic. Recent Findings. HIV prevalence among Chinese MSM increased rapidly in all Chinese regions in the past decade and disproportionally affected the Southwest China. In addition to the high-risk homosexual behaviours, overlapping bisexual, commercial, and drug use behaviours are commonly observed among Chinese MSM. The Chinese government has significantly expanded the surveillance efforts among MSM over the past decade. Community responses against HIV have been substantially strengthened with the support of international aid. However, lack of enabling legal and financial environment undermines the role of community-based organisations (CBOs) in HIV surveillance and prevention. Conclusion. HIV continues to spread rapidly among MSM in China. The hidden nature of MSM and the overlapping homosexual, bisexual, and commercial behaviours remain a challenge for HIV prevention among MSM. Strong collaboration between the government and CBOs and innovative intervention approaches are essential for effective HIV surveillance and prevention among MSM in China.

HIV prevention interventions to reduce sexual risk for African Americans: the influence of community-level stigma and psychological processes

Interventions to improve public health may benefit from consideration of how environmental contexts can facilitate or hinder their success. We examined the extent to which efficacy of interventions to improve African Americans' condom use practices was moderated by two indicators of structural stigma-Whites' attitudes toward African Americans and residential segregation in the communities where interventions occurred. A previously published meta-analytic database was re-analyzed to examine the interplay of community-level stigma with the psychological processes implied by intervention content in influencing intervention efficacy. All studies were conducted in the United States and included samples that were at least 50% African American. Whites' attitudes were drawn from the American National Election Studies, which collects data from nationally representative samples. Residential segregation was drawn from published reports. Results showed independent effects of Whites' attitudes and residential segregation on condom use effect sizes. Interventions were most successful when Whites' attitudes were more positive or when residential segregation was low. These two structural factors interacted: Interventions improved condom use only when communities had both relatively positive attitudes toward African Americans and lower levels of segregation. The effect of Whites' attitudes was more pronounced at longer follow-up intervals and for younger samples and those samples with more African Americans. Tailoring content to participants' values and needs, which may reduce African Americans' mistrust of intervention providers, buffered against the negative influence of Whites' attitudes on condom use. The structural factors uniquely accounted for variance in condom use effect sizes over and above intervention-level features and community-level education and poverty. Results highlight the interplay of social identity and environment in perpetuating intergroup disparities. Potential mechanisms for these effects are discussed along with public health implications.

Screening and prevention of sexually transmitted infections

Sexually transmitted infections (STIs) are common and costly, in part because they are asymptomatic and result in serious complications. Primary care clinicians can easily diagnose and effectively treat most STIs. Clinicians should screen patients for STIs based on high-risk behaviors, and consult with local public health officials to adapt national screening guidelines to local epidemiology. Clinical encounters involving STI screening are opportunities to counsel patients on risk behaviors, and vaccinate against human papillomavirus and hepatitis B. Electronic health records and mobile phone apps show promise for improving the clinical care of STIs.

Sources of HIV incidence among stable couples in sub-Saharan Africa

Introduction

The recent availability of efficacious prevention interventions among stable couples offers new opportunities for reducing HIV incidence in sub-Saharan Africa. Understanding the dynamics of HIV incidence among stable couples is critical to inform HIV prevention strategy across sub-Saharan Africa.

Methods

We quantified the sources of HIV incidence arising among stable couples in sub-Saharan Africa using a cohort-type mathematical model parameterized by nationally representative data. Uncertainty and sensitivity analyses were incorporated.

Results

HIV incidence arising among stable concordant HIV-negative couples contribute each year, on average, 29.4% of total HIV incidence; of those, 22.5% (range: 11.1%–39.8%) are infections acquired by one of the partners from sources external to the couple, less than 1% are infections acquired by both partners from external sources within a year and 6.8% (range: 3.6%–11.6%) are transmissions to the uninfected partner in the couple in less than a year after the other partner acquired the infection from an external source. The mean contribution of stable HIV sero-discordant couples to total HIV incidence is 30.4%, with most of those, 29.7% (range: 9.1%–47.9%), being due to HIV transmissions from the infected to the uninfected partner within the couple. The remaining incidence, 40.2% (range: 23.7%–64.6%), occurs among persons not in stable couples.

Conclusions

Close to two-thirds of total HIV incidence in sub-Saharan Africa occur among stable couples; however, only half of this incidence is attributed to HIV transmissions from the infected to the uninfected partner in the couple. The remaining incidence is acquired through extra-partner sex. Substantial reductions in HIV incidence can be achieved only through a prevention approach that targets all modes of HIV exposure among stable couples and among individuals not in stable couples.

Family planning knowledge and practice among people living with HIV in Nepal

Unsafe sexual behavior is common among the HIV infected. This exposes them to the risks of unintended pregnancy, HIV transmission to uninfected partners and super-infection. Studies on the use of family planning measures among People Living with HIV (PLHIV) are scarce in Nepal. The aim of this study was to explore the knowledge and practice of family planning (FP) in PLHIV. A cross sectional survey was conducted during July-December 2012 in Kaski district of Nepal. A total of 120 PLHIVs were recruited using snowball sampling from three HIV clinics within the Pokhara sub-metropolitan city area. This study found that nine in ten PLHIV had heard about family planning. Two thirds of respondents were using at least one FP method. The majority (65.8%) used condoms and had received FP counseling (67.5%). Less than one percent used condoms in addition to another contraceptive. Being single, being female and having received the counselling sessions were associated with the use of FP. The individuals who received FP counseling were more likely [OR 4.522; 95% CI (1.410-14.504)] to use FP. Females were more likely [OR 4.808; 95% CI (1.396-16.556)] to use FP than males. The individuals who were single/de-facto widowed were more likely [OR 7.330; 95% CI (2.064-26.028)] to use FP than the married individuals. Our findings suggest that there is a need to focus on FP counseling if the HIV prevention program is to increase FP use among the PLHIV population. Use of dual contraceptives need to be promoted through counseling sessions and other health promotion programs focusing in HIV prevention.

The long-term effectiveness of methadone maintenance treatment in prevention of hepatitis C virus among illicit drug users: a modeling study

Background:

Chronic infection with hepatitis C virus (HCV) is increasingly recognized as a major global health problem. Illicit injection drug use is an important risk factor for the rising hepatitis C virus (HCV) prevalence in IR Iran.

Objectives:

The objective of this study was to determine the long-term effectiveness (total quality adjusted life years (QALYs) gained) of methadone maintenance treatment (MMT program) in prevention of HCV infection among injecting drug users (IDUs).

Materials and Methods:

A number of Markov models were developed to model morbidity and mortality among IDUs. The input data used in modeling were collected by a self-reported method from 259 IDUs before registration and one year after MMT and also from previous studies. One way and probabilistic sensitivity analyses were done to show the effects of uncertainty in parameters on number of life years and QALYs saved. The expected consequences were estimated using a life-time time horizon for the two strategies including implementation and not implementation of the MMT program.

Results:

Our model estimated that total number of discounted life years lived per IDU with and without the MMT program would be 5.15 (5.05 - 5.25) and 4.63 (4.42 - 4.81), respectively. The model also estimated that total number of discounted QALYs lived per IDU with and without the MMT program would be 4.11 (3.86 - 4.41) and 2.45 (2.17 - 2.84). Simulation results indicated that all differences in life years and QALYs lived between the two strategies were statistically significant (p < 0.001). Based on our model, total discounted life years and QALYs saved in a cohort of 1000 IDUs were 1790 (1520 - 2090) and 1590 (1090- 2090), respectively.

Conclusions:

Considering the high prevalence of illicit injecting drug use in Iran and MMT effectiveness in prevention of HCV infection, it is necessary to develop MMT centers at regional and national levels.

HIV pre-exposure prophylaxis interest among female sex workers in Guangxi, China

OBJECTIVES

Acceptability of pre-exposure prophylaxis (PrEP) and willingness to participate in a clinical trial for both safety and efficacy of PrEP were investigated among female sex workers (FSWs) in Guangxi, China.

METHODS

A cross-sectional study was performed in three cities in Guangxi. Structured, self-administered questionnaires were used to assess the acceptability of PrEP and the willingness to participate in a clinical trial. Multivariable logistic regression models were fitted to identify predictors.

RESULTS

Among 405 participants, 15.1% had heard of PrEP. If PrEP was deemed to be effective, safe and provided for free, 85.9% reported that they would accept it, and 54.3% of those who accepted PrEP said that they would participate in a clinical trial. The increased acceptability of PrEP was associated with working in male dominated venues, higher income, a poor family relationship, better HIV/AIDS knowledge, not realizing HIV risk from unfamiliar clients, not being forced to use condoms by the gatekeepers, consistent use of condoms, and use of drugs to prevent STD infection. The increased willingness to participate in a clinical trial was associated with a poor family relationship, better HIV/AIDS knowledge, not realizing HIV risk from unfamiliar clients, a willingness to adhere to daily PreP use, and not being concerned about discrimination by others. The main reason for rejecting PrEP or participating in a clinical trial was the concern about the side effects of PrEP.

CONCLUSIONS

Acceptability of PrEP among Guangxi FSWs is relatively high, indicating that PrEP intervention programs may be feasible for Chinese FSWs. Given the fact that most of the participants had never heard of PrEP before, and that family, gatekeepers, and social discrimination could significantly affect its acceptability, a comprehensive mix of multiple interventions is necessary for the successful implementation of a PrEP program among this population in Guangxi.

Cost-effectiveness of Methadone Maintenance Treatment in Prevention of HIV Among Drug Users in Shiraz, South of Iran

Background:

The increase in high-risk injections and unsafe sexual behaviors has led to increased HIV infection prevalence among Intravenous Drug Users (IDUs). The high costs of HIV/AIDS care and low financial resources necessitate an economic evaluation to make the best decision for the control of HIV/AIDS.

Objectives:

This study was conducted to determine the cost-effectiveness of Methadone Maintenance Treatment (MMT) centers in HIV infection prevention among drug users.

Materials and Methods:

In this interventional study, we included all the seven MMT centers and the drug users registered there (n = 694). We calculated all the costs imposed on the government, i.e. Provider of case. Mathematical models were used to estimate the number of HIV cases averted from high-risk behaviors. Sensitivity analyses were performed to show the effects of uncertainty in parameters on the number of HIV cases averted and also Incremental Cost-Effectiveness Ratio (ICER).

Results:

Based on the averted models, the selected MMT centers could prevent 128 HIV cases during 1 year. The total cost was $ 547423 and that of HIV/AIDS care in the no intervention scenario was estimated $ 14171816. ICER was $ 106382 per HIV case averted. The results of the sensitivity analysis indicated that MMT intervention was cost-effective even in the worst scenario and ICER varied from $ 39149 to $ 290004 per HIV case averted.

Conclusions:

With regard to the high prevalence of drug injection among drug users and considering the high effectiveness and cost-effectiveness of MMT centers in preventing HIV infection, establishment of MMT centers in regional and national levels seems reasonable.

HIV among men who have sex with men in Malawi: elucidating HIV prevalence and correlates of infection to inform HIV prevention

Introduction

There are limited data characterizing the burden of HIV among men who have sex with men (MSM) in Malawi. Epidemiologic research and access to HIV prevention, treatment and care services have been traditionally limited in Malawi by criminalization and stigmatization of same-sex practices. To inform the development of a comprehensive HIV prevention intervention for Malawian MSM, we conducted a community-led assessment of HIV prevalence and correlates of infection.

Methods

From April 2011 to March 2012, 338 MSM were enrolled in a cross-sectional study in Blantyre, Malawi. Participants were recruited by respondent-driven sampling methods (RDS), reaching 19 waves. Trained staff administered the socio-behavioural survey and HIV and syphilis voluntary counselling and testing.

Results

Crude HIV and syphilis prevalence estimates were 15.4% (RDS-weighted 12.5%, 95% confidence interval (CI): 7.3–17.8) and 5.3% (RDS-weighted 4.4%, 95% CI: 3.1–7.6), respectively. Ninety per cent (90.4%, unweighted) of HIV infections were reported as being previously undiagnosed. Participants were predominantly gay-identified (60.8%) or bisexually identified (36.3%); 50.7% reported recent concurrent relationships. Approximately half reported consistent condom use (always or almost always) with casual male partners, and proportions were relatively uniform across partner types and genders. The prevalence of perceived and experienced stigma exceeded 20% for almost all variables, 11.4% ever experienced physical violence and 7% were ever raped. Current age >25 years (RDS-weighted adjusted odds ratio (AOR) 3.9, 95% CI: 1.2–12.7), single marital status (RDS-weighted AOR: 0.3; 95% CI: 0.1–0.8) and age of first sex with a man <16 years (RDS-weighted AOR: 4.3, 95% CI: 1.2–15.0) were independently associated with HIV infection.

Conclusions

Results demonstrate that MSM represent an underserved, at-risk population for HIV services in Malawi and merit comprehensive HIV prevention services. Results provide a number of priorities for research and prevention programmes for MSM, including providing access to and encouraging regular confidential HIV testing and counselling, and risk reduction counselling related to anal intercourse. Other targets include the provision of condoms and compatible lubricants, HIV prevention information, and HIV and sexually transmitted infection treatment and adherence support. Addressing multiple levels of HIV risk, including structural factors, may help to ensure that programmes have sufficient coverage to impact this HIV epidemic among MSM.

Sexually transmitted and anorectal infectious diseases

Sexually transmitted diseases (STDs) are common and they can involve the anus and rectum in both men and women. In this article, the main bacterial and viral STDs that affect the anus and rectum are discussed, including their prevalence, presentation, and treatment.

Condom use, risk perception, and HIV knowledge: a comparison across sexes in Nigeria

Background

This paper analyzes how different types of Human immunodeficiency virus (HIV) knowledge influences condom use across the sexes.

Methods

The empirical work was based on a household survey conducted among 1979 households of a representative group of stallholders in Lagos, Nigeria in 2008. Condom use during last sexual intercourse was analyzed using a multivariate model corrected for clustering effects. The data included questions on socioeconomic characteristics, knowledge of the existence of HIV, HIV prevention, HIV stigma, intended pregnancy, and risk perceptions of engaging in unprotected sex.

Results

A large HIV knowledge gap between males and females was observed. Across the sexes, different types of knowledge are important in condom use. Low-risk perceptions of engaging in unprotected sex and not knowing that condoms prevent HIV infection appear to be the best predictors for risky sexual behavior among men. For females, stigma leads to lower condom use. Obviously, lack of knowledge on where condoms are available (9.4% and 29.1% of male and female respondents, respectively) reduced condom use in both males and females.

Conclusion

The results call for programmatic approaches to differentiate between males and females in the focus of HIV prevention campaigns. Moreover, the high predictive power of high-risk perceptions of engaging in unprotected sex (while correcting for other HIV knowledge indicators) calls for further exploration on how to influence these risk perceptions in HIV prevention programs.

Pregnancy incidence and risk factors among women participating in vaginal microbicide trials for HIV prevention: systematic review and meta-analysis

Introduction

Pregnancy is contraindicated in vaginal microbicide trials for the prevention of HIV infection in women due to the unknown maternal and fetal safety of the microbicides. Women who become pregnant are taken off the microbicide during pregnancy period but this result in reduction of the power of the trials. Strategies to reduce the pregnancy rates require an understanding of the incidence and associated risk factors of pregnancy in microbicide trials. This systematic review estimates the overall incidence rate of pregnancy in microbicide trials and describes the associated risk factors.

Methods

A comprehensive literature search was carried out to identify eligible studies from electronic databases and other sources. Two review authors independently selected studies and extracted relevant data from included studies. Meta-analysis of incidence rates of pregnancy was carried out and risk factors of pregnancy were reported narratively.

Results

Fifteen studies reporting data from 10 microbicide trials (N=27,384 participants) were included. A total of 4,107 participants (15.0%) fell pregnant and a meta-analysis of incidence rates of pregnancy from 8 microbicide trials (N=25,551) yielded an overall incidence rate of 23.37 (95%CI: 17.78 to 28.96) pregnancies per 100 woman-years. However, significant heterogeneity was detected. Hormonal injectable, intra-uterine device (IUD) or implants or sterilization, older age, more years of education and condom use were associated with lower pregnancy. On the other hand, living with a man, history of pregnancy, self and partner desire for future baby, oral contraceptive use, increased number of unprotected sexual acts and inconsistent use of condoms were associated with higher pregnancy.

Conclusions

The incidence rate of pregnancy in microbicide trials is high and strategies for its reduction are urgently required in order to improve the sample size and power of these trials.

Condom use and concurrent partnering among heterosexually active, African American men: a qualitative report

African Americans are overrepresented among heterosexual cases of HIV/AIDS in the USA. Inconsistent condom use and concurrent partnering are two sexual behaviors driving the heterosexual HIV epidemic in the African American community. To inform the development of an HIV prevention behavioral intervention to decrease concurrent partnering and increase condom use among African American heterosexual men, we conducted formative research, including 61 structured interviews, 5 focus groups with 25 men, and 30 in-depth qualitative interviews between July and December 2009. We used a grounded theoretical approach and categorizing strategies to code and analyze the qualitative data. Results around condom use confirmed earlier findings among heterosexual men in general: condoms diminish pleasure, interfere with erection, and symbolize infidelity. Although valued by some as a form of disease prevention and pregnancy prevention, condoms are often used only with specific types of female partners, such as new or casual partners, or due to visual risk assessment. Sex partner concurrency was described as normative and ascribed to men's "natural" desire to engage in a variety of sexual activities or their high sex drive, with little recognition of the role it plays in the heterosexual HIV epidemic. Fatherhood emerged among many men as a crucial life event and compelling motivation for reducing sexual risk behavior. Based on these results, we conclude that existing HIV prevention efforts to improve attitudes towards and motivate use of condoms either have not reached or have not been successful with African American heterosexual men. In designing behavioral interventions to decrease concurrent partnering and increase condom use, addressing negative attitudes towards condoms and partner risk assessment is critical, as is integrating novel motivational approaches related to identity as fathers and men in the African American community.

Sexual behaviour in a rural high HIV prevalence South African community: time trends in the antiretroviral treatment era

Objectives:

Data from generalized epidemic settings have consistently found that patients on antiretroviral therapy (ART) reduce sexual risk behaviours, but how sexual behaviour changes in the general population in response to ART availability, including amongst HIV-uninfected and undiagnosed adults, has not been characterized in these settings.

Design:

General population open cohort.

Methods:

We report trends in sexual behaviour indicators for men aged 17–54 years and women aged 17–49 years in rural KwaZulu-Natal province, based on annual sexual behaviour surveys during ART scale-up from 2005 to 2011. Estimates are adjusted for survey nonparticipation and nonresponse to individual survey items using inverse probability weighting and multiple imputation. Trends are presented by HIV status, knowledge of status, age and marital status.

Results:

Reports of condom use at last sex with a regular partner increased by 2.6% points per year [95% confidence interval (CI) 1.5%, 3.7%] for men and 4.1% per year (3.0%, 5.3%) for women. Condom use at last sex with a casual partner was high and did not change significantly over the period for both sexes. There were statistically significant declines in the percentage reporting multiple partnerships in the last year and the point prevalence of concurrency. Trends within subgroups were generally consistent with overall estimates.

Conclusion:

We find no evidence of increased sexual risk-taking following ART availability and protective changes in some behaviours, suggesting that general trends in sexual behaviour are not counter-acting preventive effects of HIV treatment. Continued monitoring of population-level sexual behaviour indicators will be essential to interpret the success of combination-prevention programmes.

Simple but powerful health messages for increasing condom use in young adults

In a large longitudinal study involving young adults, we conducted an eight-hour STD educational intervention and examined the impact of the intervention on the efficacy of a message for promoting condom use. The message was framed in positive or negative terms and was presented visually or in numbers (percentages or frequencies). Results indicated that the numerical positive-framed message increased condom use among young adults who did not receive the intervention, whereas the numerical negative-framed message did not. Attitudes toward condom use along with changes in intentions to use condoms mediated this framing effect. In contrast, the positive-framed and negative-framed messages were equally and highly effective for promoting condom use when the messages were presented visually or when young adults received the STD educational intervention before reading the message, suggesting that the simple brochures featuring visual aids were as effective in changing attitudes and behavioral intentions as the extensive intervention. These findings add to a growing body of evidence detailing the mechanisms that allow well-constructed visual aids to be among the most effective, transparent, memorable, and ethically desirable means of risk communication. Clinical and public health implications are discussed.

The potential impact of expanding antiretroviral therapy and combination prevention in Vietnam: towards elimination of HIV transmission

BACKGROUND

Few studies have assessed the effects of antiretroviral therapy (ART) to prevent HIV transmission in Asian HIV epidemics. Vietnam has a concentrated HIV epidemic with the highest prevalence among people who inject drugs. We investigated the impact of expanded HIV testing and counseling (HTC) and early ART, combined with other prevention interventions on HIV transmission.

METHODS

A deterministic mathematical model was developed using HIV prevalence trends in Can Tho province, Vietnam. Scenarios included offering periodic HTC and immediate ART with and without targeting subpopulations and examining combined strategies with methadone maintenance therapy and condom use.

RESULTS

From 2011 to 2050, maintaining current interventions will incur an estimated 18,115 new HIV infections and will cost US $22.1 million (reference scenario). Annual HTC and immediate treatment, if offered to all adults, will reduce new HIV infections by 14,513 (80%) and will cost US $76.9 million. Annual HTC and immediate treatment offered only to people who inject drugs will reduce new infections by 13,578 (75%) and will cost only US $23.6 million. Annual HTC and immediate treatment for key populations, combined with scale-up of methadone maintenance therapy and condom use, will reduce new infections by 14,723 (81%) with similar costs (US $22.7 million). This combination prevention scenario will reduce the incidence to less than 1 per 100,000 in 14 years and will result in a relative cost saving after 19 years.

CONCLUSIONS

Targeted periodic HTC and immediate ART combined with other interventions is cost-effective and could lead to potential elimination of HIV in Can Tho.

Sex role segregation and mixing among men who have sex with men: implications for biomedical HIV prevention interventions

OBJECTIVE

Men who have sex with men (MSM) practice role segregation - insertive or receptive only sex positions instead of a versatile role - in several international settings where candidate biomedical HIV prevention interventions (e.g., circumcision, anal microbicide) will be tested. The effects of these position-specific interventions on HIV incidence are modeled.

MATERIALS AND METHODS

We developed a deterministic compartmental model to predict HIV incidence among Indian MSM using data from 2003-2010. The model's sex mixing matrix was derived from network data of Indian MSM (n=4604). Our model captures changing distribution of sex roles over time. We modeled microbicide and circumcision efficacy on trials with heterosexuals.

RESULTS

Increasing numbers of versatile MSM resulted in little change in HIV incidence over 20 years. Anal microbicides and circumcision would decrease the HIV prevalence at 10 years from 15.6% to 12.9% and 12.7% respectively. Anal microbicides would provide similar protection to circumcision at the population level despite lower modeled efficacy (54% and 60% risk reduction, respectively). Combination of the interventions were additive: in 5 years, the reduction in HIV prevalence of the combination (-3.2%) is almost the sum of their individual reductions in HIV prevalence (-1.8% and -1.7%).

CONCLUSIONS

MSM sex role segregation and mixing, unlike changes in the sex role distribution, may be important for evaluating HIV prevention interventions in international settings. Synergies between some position-specific prevention interventions such as circumcision and anal microbicides warrant further study.

Translation of biomedical prevention strategies for HIV: prospects and pitfalls

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.

Determinants of risky sexual behavior among injecting drug users (IDUs) in Georgia

Injection risk practices and risky sexual behaviors place injection drug users (IDUs) and their sexual partners particularly vulnerable to HIV. The purpose of the study was to describe and understand determinants of high-risk sexual behavior among IDUs in Georgia. A cross-sectional, anonymous survey assessed knowledge, behavior and HIV status in IDUs in five Georgian cities (Tbilisi, Gori, Telavi, Zugdidi, Batumi) in 2009. The study enrolled in total 1,127 (1,112 males, 15 females) IDUs. Results indicate that occasional sexual relationships are common among male IDUs, including married ones. A subsample of 661 male IDUs who reported having occasional and paid sex partners during the last 12 months was analyzed. Multivariate analysis shows that not having a regular partner in the last 12 month (adjusted odds ratio (aOR) 1.57, 95 % CI 1.04 2.37), and using previously used needles/syringes at last injecting (aOR 2.37, 95 % I 1.10-5.11) are independent correlates of inconsistent condom use with occasional and paid sexual partners among IDUs. Buprenorphine injectors have lower odds of inconsistent condom use with occasional and paid sexual partners compared to heroin injectors (aOR 0.47, 95 % CI 0.27-0.80), and IDUs who live in Telavi are twice more likely to engage in such risky sexual behavior than capital city residents (aOR 2.55, 95 % CI 1.46-4.48). More effective programs focused on sexual risk behavior reduction strategies should be designed and implemented.

Clinician and patient recognition of anogenital herpes disease in HIV positive men who have sex with men

Anogenital ulcers caused by herpes simplex virus type 2 (HSV-2) are associated with an increased risk of human immunodeficiency virus (HIV) transmission. When compared with clinician examination, HIV/HSV-2 coinfected men who have sex with men are frequently unaware of anogenital ulcers. These data highlight the importance of condom use and the need for new HSV-2 prevention strategies.

HIV due to female sex work: regional and global estimates

INTRODUCTION

Female sex workers (FSWs) are at high risk of HIV infection. Our objective was to determine the proportion of HIV prevalence in the general female adult population that is attributable to the occupational exposure of female sex work, due to unprotected sexual intercourse.

METHODS

Population attributable fractions of HIV prevalence due to female sex work were estimated for 2011. A systematic search was conducted to retrieve required input data from available sources. Data gaps of HIV prevalence in FSWs for 2011 were filled using multilevel modeling and multivariate linear regression. The fraction of HIV attributable to female sex work was estimated as the excess HIV burden in FSWs deducting the HIV burden in FSWs due to injecting drug use.

RESULTS

An estimated fifteen percent of HIV in the general female adult population is attributable to (unsafe) female sex work. The region with the highest attributable fraction is Sub Saharan Africa, but the burden is also substantial for the Caribbean, Latin America and South and Southeast Asia. We estimate 106,000 deaths from HIV are a result of female sex work globally, 98,000 of which occur in Sub-Saharan Africa. If HIV prevalence in other population groups originating from sexual contact with FSWs had been considered, the overall attributable burden would probably be much larger.

DISCUSSION

Female sex work is an important contributor to HIV transmission and the global HIV burden. Effective HIV prevention measures exist and have been successfully targeted at key populations in many settings. These must be scaled up.

CONCLUSION

FSWs suffer from high HIV burden and are a crucial core population for HIV transmission. Surveillance, prevention and treatment of HIV in FSWs should benefit both this often neglected vulnerable group and the general population.

Dual use of long-acting reversible contraceptives and condoms among adolescents

Unintended pregnancy and sexually transmitted infections (STI) continue to be significant public health problems, and adolescents are disproportionately affected by both. With national attention and funding directed toward adolescent pregnancy prevention, promotion of long-acting reversible contraceptive (LARC) use among adolescents is both timely and relevant. However, LARCs provide no protection against STIs, requiring dual-method use of both LARC and barrier methods, most commonly the male latex condom, to address these issues simultaneously. Rates of both LARC and dual-method contraception are low in the United States, but have increased in recent years. Dual-method contraception is highest among younger women and adolescents with multiple or new sex partners. Consistent condom use remains a major barrier to dual-method use, as it necessitates admission of STI risk by both partners, and use is dependent upon two decision-makers rather than a single contraceptive user. Promoting the initiation and maintenance of LARC and condom use across multiple partnered sexual encounters requires understanding of individual, dyadic, and social influences. Successful maintenance of contraceptive and STI prevention behaviors requires individualized, longitudinal reinforcement, and social supports, but can ultimately reduce the burden of unintended pregnancy and STI among adolescents.

Antiretrovirals and safer conception for HIV-serodiscordant couples

PURPOSE OF REVIEW

Many men and women living with HIV and their uninfected partners attempt to conceive children. HIV-prevention science can be applied to reduce sexual transmission risk while respecting couples' reproductive goals. Here we discuss antiretrovirals as prevention in the context of safer conception for HIV-serodiscordant couples.

RECENT FINDINGS

Antiretroviral therapy (ART) for the infected partner and pre-exposure prophylaxis (PrEP) for the uninfected partner reduce the risk of heterosexual HIV transmission. Several demonstration projects suggest the feasibility and acceptability of antiretroviral (ARV)s as periconception HIV-prevention for HIV-serodiscordant couples. The application of ARVs to periconception risk reduction may be limited by adherence.

SUMMARY

For male-infected (M+F-) couples who cannot access sperm processing and female-infected (F+M-) couples unwilling to carry out insemination without intercourse, ART for the infected partner, PrEP for the uninfected partner, combined with treatment for sexually transmitted infections, sex limited to peak fertility, and medical male circumcision (for F+M couples) provide excellent, well tolerated options for reducing the risk of periconception HIV sexual transmission.

Estimating the impact of state budget cuts and redirection of prevention resources on the HIV epidemic in 59 California local health departments

BACKGROUND

In the wake of a national economic downturn, the state of California, in 2009-2010, implemented budget cuts that eliminated state funding of HIV prevention and testing. To mitigate the effect of these cuts remaining federal funds were redirected. This analysis estimates the impact of these budget cuts and reallocation of resources on HIV transmission and associated HIV treatment costs.

METHODS AND FINDINGS

We estimated the effect of the budget cuts and reallocation for California county health departments (excluding Los Angeles and San Francisco) on the number of individuals living with or at-risk for HIV who received HIV prevention services. We used a Bernoulli model to estimate the number of new infections that would occur each year as a result of the changes, and assigned lifetime treatment costs to those new infections. We explored the effect of redirecting federal funds to more cost-effective programs, as well as the potential effect of allocating funds proportionately by transmission category. We estimated that cutting HIV prevention resulted in 55 new infections that were associated with $20 million in lifetime treatment costs. The redirection of federal funds to more cost-effective programs averted 15 HIV infections. If HIV prevention funding were allocated proportionately to transmission categories, we estimated that HIV infections could be reduced below the number that occurred annually before the state budget cuts.

CONCLUSIONS

Reducing funding for HIV prevention may result in short-term savings at the expense of additional HIV infections and increased HIV treatment costs. Existing HIV prevention funds would likely have a greater impact on the epidemic if they were allocated to the more cost-effective programs and the populations most likely to acquire and transmit the infection.

High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa

The landmark HIV Prevention Trials Network (HPTN) 052 trial in HIV-discordant couples demonstrated unequivocally that treatment with antiretroviral therapy (ART) substantially lowers the probability of HIV transmission to the HIV-uninfected partner. However, it has been vigorously debated whether substantial population-level reductions in the rate of new HIV infections could be achieved in "real-world" sub-Saharan African settings where stable, cohabiting couples are often not the norm and where considerable operational challenges exist to the successful and sustainable delivery of treatment and care to large numbers of patients. We used data from one of Africa's largest population-based prospective cohort studies (in rural KwaZulu-Natal, South Africa) to follow up a total of 16,667 individuals who were HIV-uninfected at baseline, observing individual HIV seroconversions over the period 2004 to 2011. Holding other key HIV risk factors constant, individual HIV acquisition risk declined significantly with increasing ART coverage in the surrounding local community. For example, an HIV-uninfected individual living in a community with high ART coverage (30 to 40% of all HIV-infected individuals on ART) was 38% less likely to acquire HIV than someone living in a community where ART coverage was low (<10% of all HIV-infected individuals on ART).

The impact of syphilis screening among female sex workers in China: a modelling study

BACKGROUND

In China, female sex workers (FSWs) are at high risk of syphilis infection, but are hard to reach for interventions. Point-of-care testing introduces opportunities for expanding syphilis control measures. Modelling is used to estimate the impact of using rapid tests to screen FSWs for syphilis. In other settings, modelling has predicted large rebounds in infectious syphilis following screening, which may undermine any impact achieved.

METHODS

A deterministic syphilis transmission model among FSWs and clients was fitted to data from Yunnan Province (FSW syphilis prevalence = 7.5%), and used to estimate the impact of rapid syphilis testing and treatment for FSWs. Impact projections were compared for different model structures that included risk heterogeneity amongst FSWs, incoming syphilis infections amongst new FSWs and clients and re-infection from FSWs' regular non-commercial partners. The rebound in syphilis prevalence after screening ceased was explored.

RESULTS

All model structures suggest yearly syphilis screening could substantially reduce (by 72-88%) syphilis prevalence amongst FSWs in this setting over five years. However, incoming syphilis infections amongst new FSWs and clients or re-infections from regular non-commercial partners of FSWs can considerably reduce (>30%) the proportion of infections averted. Including heterogeneity in risk amongst FSWs had little effect upon the proportion of infections averted. In this setting, the rebound in syphilis prevalence after screening ceased is predicted to be slight, but it could be large in high prevalence settings.

CONCLUSIONS

Rapid test screening could dramatically reduce syphilis prevalence amongst hard-to-reach groups, but strategies to reduce re-infection from regular non-commercial partners are needed to maximise impact.

[Sexuality and risk for sexual transmission of HIV among serodiscordant couples in Ouagadougou, Burkina Faso]

This article is a contribution to improve the management of serodiscordant couples in Ouagadougou. The aim of the study was to explore sexuality and the risk for sexual transmission of HIV among serodiscordant couples followed-up in CHU-YO. The study consisted of a descriptive cross-sectional study conducted over 6 months, from 1 January 2010 to 30 June 2010. A total of 80 heterosexual serodiscordant couples participated. Women were infected with HIV in most cases (75%). The mean age was 37.5 years for HIV partners and 40 years for seronegatives. Men were significantly older than women (p = 0.01). The couples weremarried (83.7%) or cohabiting (16.3%). The average of serodiscordance duration was 4 years. Seventy-four couples (92.5%) engaged in sexual intercourses, mostly vaginal intercourses. Both partners were satisfied only in 9 couples (12.2%). Although most couples (97.5%) knew the use of condoms for HIV prevention, 59.5% did not use it consistently, particularly when women were the seropositive partners (p = 0.01). The lack of privacy (37.5%) and desire of childbearing (26.25%) were the main reasons for not consistently using condoms among couples. Sexual dysfunction was a concern with 97.5% of the couples. The decrease in libido was most common (37.2%). Sexual intercourses with an outside partner were reported in 20 couples (25%), mostly regarding men (p = 0.03). Specific management could improve the quality of sexual life for couples in the light of the difficulties they face and reduce the risk for HIV transmission to negative partners.

Combination implementation for HIV prevention: moving from clinical trial evidence to population-level effects

The promise of combination HIV prevention-the application of multiple HIV prevention interventions to maximise population-level effects-has never been greater. However, to succeed in achieving significant reductions in HIV incidence, an additional concept needs to be considered: combination implementation. Combination implementation for HIV prevention is the pragmatic, localised application of evidence-based strategies to enable high sustained uptake and quality of interventions for prevention of HIV. In this Review, we explore diverse implementation strategies including HIV testing and counselling models, task shifting, linkage to and retention in care, antiretroviral therapy support, behaviour change, demand creation, and structural interventions, and discusses how they could be used to complement HIV prevention efforts such as medical male circumcision and treatment as prevention. HIV prevention and treatment have arrived at a pivotal moment when combination efforts might result in substantial enough population-level effects to reverse the epidemic and drive towards elimination of HIV. Only through careful consideration of how to implement and operationalise HIV prevention interventions will the HIV community be able to move from clinical trial evidence to population-level effects.

Inconsistent Condom Use among Iranian Male Drug Injectors

OBJECTIVES

The aim of this study was to determine the prevalence and associated factors of inconsistent condom use among Iranian male injecting drug users (IDUs).

MATERIALS AND METHODS

Data came from the national Iranian behavioral survey of drug dependence, which sampled 7743 individuals with drug dependence, from medical centers, prisons, and streets in 29 provinces in Iran, in 2007. This study included all individuals who were male, IDUs, and were sexually active (n = 1131). The main outcome was inconsistent condom use which was assessed using a single item. A logistic regression was used to determine the association between socio-economic data, drug use data, and high risk injection behaviors with inconsistent condom use.

RESULT

83.3% of sexually active IDUs (n = 965) reported inconsistent condom use. Based on the logistic regression, likelihood of inconsistent condom use was higher among those with a history of syringe sharing [Odds Ratio (OR); 1.63, 95% Confidence Interval (CI); 1.13-2.34], but lower among those with higher education levels (OR; 0.34, 95% CI; 0.14-0.82), those who mostly inject at home (OR; 0.09, 95% CI; 0.02-0.47), and those with a history of treatment (OR; 0.54, 95% CI; 0.31-0.94).

CONCLUSION

Because of the link between unsafe sex and risky injecting behaviors among Iranian IDUs, combined programs targeting both sexual and injection behavior may be more appropriate than programs that target sexual or injection behavior. The efficacy of combined programs should be, however, compared with traditional programs that only target sexual or injection behavior of IDUs.

Biomedical Strategies for Human Immunodeficiency Virus (HIV) Prevention? A New Paradigm

Introduction: This article presents recent developments in biomedical interventions for prevention of sexual transmission of the human immunodeficiency virus (HIV) infection. Materials and Methods: A review of results from randomised clinical trials on the use of antiretroviral (ARV) medications and other biomedical methods to prevent the transmission and acquisition of HIV infection. Results: Pre-exposure prophylaxis (PrEP) refers to the provision of ARV medications to uninfected persons at high risk of HIV infection either in the form of topical agents, e.g. vaginal microbicide gels, or orally administered tablets. The Caprissa study demonstrated the efficacy of vaginal microbicides, the Vaginal and Oral Interventions to Control the Epidemic (VOICE) study however was not able to confirm these results. Oral PrEP was found to be efficacious in the iPrEx study on men who have sex with men (MSM), and among heterosexual couples in the Partners-PrEP and the TDF2 studies in Africa. The HPTN 052 trial demonstrated that the provision of early ARV treatment was able to prevent transmission of HIV by 92% compared with delayed treatment. This has led to enthusiasm to roll out treatment as prevention (TasP) programmes. Encouraging results from studies on male circumcision to prevent HIV acquisition have resulted in several implementation projects in Africa. Another encouraging result has been the success, albeit modest, of the prime-boost combination RV144 vaccine trial in Thailand. Conclusion: New advances in prevention strategies are urgently needed to slow down the HIV pandemic. Recent developments particularly in the form of PrEP and TasP have given new hope that we will be able to achieve this goal. Key words: Biomedical, HIV infection, Prevention