Targeted and general population interventions for HIV prevention: towards a comprehensive approach

Mapping and size estimation of men who have sex with men in virtual platforms in Delhi, India

Introduction

In India, the HIV epidemic is concentrated among Key Populations (KPs), such as men who have sex with men (MSM), who bear a disproportionate burden of HIV disease. Conventional targeted interventions (TI) mitigate HIV transmission among MSM by focusing on physical hotspots. As increasingly, there is a shift within India’s MSM community to connect with sex partners online, novel approaches are needed to map virtual platforms where sexual networks are formed. The objective of this study was to estimate the number of MSM in Delhi using virtual platforms to connect for sex and to describe patterns of their use.

Methods

The study was conducted in the state of Delhi among MSM over 18 years of age who used virtual platforms to look for sexual partners. Virtual platforms were identified through community consultations. Size estimation was carried out by enumerating the number of online users, accounting for duplication across sites and time and based on interviews with 565 MSM.

Results

28,058 MSM (95% CI: range 26,455–29,817) use virtual sites to find sexual partners. We listed 14 MSM specific virtual sites, 14 general virtual sites, 19 social networking pages and 112 messenger groups, all used by MSM. Five virtual sites met feasibility criteria to be included in the virtual mapping. Of the MSM on these sites, 81% used them at night and 94% used them on Sundays, making these the peak time and day of use. Only 16% of users were aware of organizations providing HIV services and 7% were contacted by peer educators in the preceding three months. Two-fifths (42%) also visited a physical location to connect with sexual partners in the month prior to the study.

Discussion

TI programs that focus on physical hotspots do not reach the majority of MSM who use virtual sites. MSM active on virtual sites have a low awareness of HIV services. Virtual mapping and programmatic interventions to include them must be incorporated into current public health interventions to reach MSM at risk of HIV.

Identifying 'corridors of HIV transmission' in a severely affected rural South African population: a case for a shift toward targeted prevention strategies

Background

In the context of a severe generalized African HIV epidemic, the value of geographically targeted prevention interventions has only recently been given serious consideration. However, to date no study has performed a population-based analysis of the micro-geographical clustering of HIV incident infections, limiting the evidential support for such a strategy.

Methods

We followed 17 984 HIV-uninfected individuals aged 15–54 in a population-based cohort in rural KwaZulu-Natal, South Africa, and observed individual HIV sero-conversions between 2004 and 2014. We geo-located all individuals to an exact homestead of residence (accuracy <2 m). We then employed a two-dimensional Gaussian kernel of radius 3 km to produce robust estimates of HIV incidence which vary across continuous geographical space. We also applied Tango's flexibly shaped spatial scan statistic to identify irregularly shaped clusters of high HIV incidence.

Results

Between 2004 and 2014, we observed a total of 2 311 HIV sero-conversions over 70 534 person-years of observation, at an overall incidence of 3.3 [95% confidence interval (CI), 3.1-3.4] per 100 person-years. Three large irregularly-shaped clusters of new HIV infections (relative risk = 1.6, 1.7 and 2.3) were identified in two adjacent peri-urban communities near the National Road (P = 0.001, 0.015) as well as in a rural node bordering a recent coal mine development (P = 0.020), respectively. Together the clusters had a significantly higher age-sex standardized incidence of 5.1 (95% CI, 4.7-5.6) per 100 person-years compared with a standardized incidence of 3.0 per 100 person-years (95% CI, 2.9-3.2) in the remainder of the study area. Though these clusters comprise just 6.8% of the study area, they account for one out of every four sero-conversions observed over the study period.

Conclusions

Our study has revealed clear ‘corridors of transmission’ in this typical rural, hyper-endemic population. Even in a severely affected rural African population, an approach that seeks to provide preventive interventions to the most vulnerable geographies could be more effective and cost-effective in reducing the overall rate of new HIV infections. There is an urgent need to develop and test such interventions as part of an overall combination prevention approach.

Prevalence and Factors of Concurrent Multiple Male Sex Partnership Among Men Who Have Sex With Men With Regular Sex Partners in Beijing, China

This study was to test whether the cognitive factors of the theory of planned behavior were associated with concurrent multiple male sex partnership (CMMSP) status (past three months) and intention to have CMMSP (next six months) among 251 men who have male regular sex partners in Beijing, China. The prevalence of having had CMMSP and intention to do so was 48.2% and 28.7%, respectively. Positive attitudes toward CMMSP, injunctive norm for not having CMMSP, and behavioral control for not having CMMSP were significantly associated with behavioral intention. Descriptive norm and perceived behavioral control were significant factors for CMMSP status.

HIV-Related Risk Behaviors Among Labor Migrants, Their Wives and the General Population in Nepal

Nepalese labor migrants and their wives are considered as at-risk populations for HIV infection. There may be a risk of HIV transmission from the labor migrant and their wives to the general population due to HIV-related risk behaviors, but so far empirical evidence to support this hypothesis is scarce. Therefore, this study was conducted to compare HIV-related risk behaviors between labor migrants, their wives, and males and females from the general population in the far-western region of Nepal. This was a cross-sectional study, in which structured face-to-face interviews were conducted with 261 male labor migrants, 262 wives of labor migrants, 123 males and 122 females from the general population. We found that the proportion of the labor migrants and their wives reporting having had extramarital sex in the previous year did not differ significantly with the males (11.9 vs. 13.4 %, p value 0.752) and females (2.0 vs. 1.7 %, p value 0.127) from the general population. However, the labor migrants compared with the males from the general population were 1.51 times and the wives of labor migrants compared with the females from the general population were 2.37 times more likely to have been tested for HIV. Both the males from the general population and the labor migrants are equally engaged in unprotected extramarital sex. Therefore, it is recommended that the prevention programs, including access to condoms and HIV testing, should be scaled up targeting a broader range of individuals in the far-western region of Nepal.

Acceptance of Treatment of Sexually Transmitted Infections for Stable Sexual Partners by Female Sex Workers in Kampala, Uganda

Background

The prevalence of sexually transmitted infections (STIs) among female sex workers (FSWs) in sub-Saharan Africa remains high. Providing treatment to the affected FSWs is a challenge, and more so to their stable sexual partners. There is scanty research information on acceptance of STI treatment for stable sexual partners by FSWs. We conducted a study to assess acceptance of STI treatment for stable sexual partners by FSWs, and to identify factors associated with acceptance.

Methods

We enrolled 241 FSWs in a cross sectional study; they were aged ≥ 18 years, had a stable sexual partner and a diagnosis of STI. Factors associated with acceptance of STI treatment for stable sexual partners were analysed in STATA (12) using Poisson regression. Mantel-Haenszel tests for interaction were performed.

Results

Acceptance of partner treatment was 50.6%. Majority (83.8%) of partners at the last sexual act were stable partners, and 32.4% of participants had asymptomatic STIs. Factors independently associated with acceptance were: earning ≤ $4 USD per sexual act (aPR 0.68; 95% CI: 0.49–0.94) and a clinical STI diagnosis (aPR 1.95; 95% CI: 1.30–2.92). The effect of low income on acceptance of partner treatment was seen in those with less education.

Conclusion

Acceptance of STI treatment for stable sexual partners was lower than that seen in other studies. Interventions to improve economic empowerment among FSWs may increase acceptance of partner treatment.

Maximising the effect of combination HIV prevention through prioritisation of the people and places in greatest need: a modelling study

BACKGROUND

Epidemiological data show substantial variation in the risk of HIV infection between communities within African countries. We hypothesised that focusing appropriate interventions on geographies and key populations at high risk of HIV infection could improve the effect of investments in the HIV response.

METHODS

With use of Kenya as a case study, we developed a mathematical model that described the spatiotemporal evolution of the HIV epidemic and that incorporated the demographic, behavioural, and programmatic differences across subnational units. Modelled interventions (male circumcision, behaviour change communication, early antiretoviral therapy, and pre-exposure prophylaxis) could be provided to different population groups according to their risk behaviours or their location. For a given national budget, we compared the effect of a uniform intervention strategy, in which the same complement of interventions is provided across the country, with a focused strategy that tailors the set of interventions and amount of resources allocated to the local epidemiological conditions.

FINDINGS

A uniformly distributed combination of HIV prevention interventions could reduce the total number of new HIV infections by 40% during a 15-year period. With no additional spending, this effect could be increased by 14% during the 15 years-almost 100,000 extra infections, and result in 33% fewer new HIV infections occurring every year by the end of the period if the focused approach is used to tailor resource allocation to reflect patterns in local epidemiology. The cumulative difference in new infections during the 15-year projection period depends on total budget and costs of interventions, and could be as great as 150,000 (a cumulative difference as great as 22%) under different assumptions about the unit costs of intervention.

INTERPRETATION

The focused approach achieves greater effect than the uniform approach despite exactly the same investment. Through prioritisation of the people and locations at greatest risk of infection, and adaption of the interventions to reflect the local epidemiological context, the focused approach could substantially increase the efficiency and effectiveness of investments in HIV prevention.

FUNDING

The Bill & Melinda Gates Foundation and UNAIDS.

HIV-related stigma and NGO-isation in India: a historico-empirical analysis

In response to World Bank critiques in 2007, the Indian Ministry of Health and Family Welfare declared that human immunodeficiency virus (HIV)-related stigma was a barrier to the participation of non-governmental organisations (NGOs) in the implementation of HIV prevention targeted interventions. Taking a deeper view of HIV-related stigma as a historically inflected process of devaluation, this article details the history and transformation of NGO involvement in the HIV epidemic from 1986 through economic liberalisation in the 1990s up to the Second National AIDS Control Programme (NACP II 1999-2006). It additionally examines findings from interviews and participant observation of NGO workers (N = 24) from four targeted intervention NGOs in Delhi funded under NACP II. Analysis reveals that a second wave of HIV-related NGO involvement has mushroomed in the past two decades, affording NGO workers multiple pathways to credibility in the Indian response to the epidemic. Contradictions embedded in the overlap of these pathways produce stigma, reflecting 'adverse incorporation' of the NGO workers. Drawing upon noteworthy exceptions to this trend from the first wave of Indian HIV-related NGOs, the article calls for NGO participation as an explicitly political project of addressing the social inequalities that shape stigma as well as vulnerability to illness writ large.

Targeting strategies and behavior change to combat the HIV epidemic in southern Africa

Behavior change remains a cornerstone of effective HIV prevention, whether interventions aim to reduce primary HIV acquisition or in the context of ‘prevention for positives’, the likelihood of onward transmission. However, to optimize the growing number of biomedical interventions, both prevention and implementation science will need to take a broader view of what they consider to be behavior change, move away from a narrow focus on risk behaviors and give greater consideration to health-seeking behaviors, social practices, cultural and social norms. These have been largely excluded from primary prevention thinking in southern Africa. Exciting developments in other areas of HIV research science, for example viral genetics, molecular and spatial epidemiology, can also be part of this process as they are able to help us to identify sub-populations at greatest risk, even in severe generalized epidemics. A number of biomedical interventions are already being rolled out, and attempts to bring them to scale will peak in the next few years. Much needs to be done to support these efforts, but equally much can be learned from the challenges that can have wider value in other resource-poor contexts. With better understanding and more accurate targeting of sub-populations, communities and behaviors, it will be possible to strengthen biomedical intervention strategies and improve allocation of prevention resources.

A social marketing approach to building a behavioral intervention for congenital cytomegalovirus

Congenital cytomegalovirus (CMV) is the most common congenital infection in the United States, causing permanent disabilities in more than 5,500 children born each year. In the absence of a vaccine, a promising means of prevention is through a behavioral intervention that educates women about CMV and promotes adherence to hygiene guidelines during pregnancy. Although effective behavioral interventions have been identified for other infectious diseases with similar transmission modes, current research has not yet identified an effective intervention for CMV. One way to gather evidence and identify key elements of a successful CMV intervention is through a social marketing approach. This article describes a five-step process for applying social marketing principles to the research and development, implementation, and evaluation of a CMV behavioral intervention.

Localized spatial clustering of HIV infections in a widely disseminated rural South African epidemic

BACKGROUND

South Africa contains more than one in seven of the world's HIV-positive population. Knowledge of local variation in levels of HIV infection is important for prioritization of areas for intervention. We apply two spatial analytical techniques to investigate the micro-geographical patterns and clustering of HIV infections in a high prevalence, rural population in KwaZulu-Natal, South Africa.

METHODS

All 12,221 participants who consented to an HIV test in a population under continuous demographical surveillance were linked to their homesteads and geo-located in a geographical information system (accuracy of <2 m). We then used a two-dimensional Gaussian kernel of radius 3 km to produce robust estimates of HIV prevalence that vary across continuous geographical space. We also applied a Kulldorff spatial scan statistic (Bernoulli model) to formally identify clusters of infections (P < 0.05).

RESULTS

The results reveal considerable geographical variation in local HIV prevalence (range = 6-36%) within this relatively homogenous population and provide clear empirical evidence for the localized clustering of HIV infections. Three high-risk, overlapping spatial clusters [Relative Risk (RR) = 1.34-1.62] were identified by the Kulldorff statistic along the National Road (P < or = 0.01), whereas three low risk clusters (RR = 0.2-0.38) were identified elsewhere in the study area (P < or = 0.017).

CONCLUSIONS

The findings show the existence of several localized HIV epidemics of varying intensity that are partly contained within geographically defined communities. Despite the overall high prevalence of HIV in many rural South African settings, the results support the need for interventions that target socio-geographic spaces (communities) at greatest risk to supplement measures aimed at the general population.

Mitigating risky sexual behaviors among Russian narcology hospital patients: the PREVENT (Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment) randomized controlled trial

AIM

To assess the effectiveness of a sexual risk reduction intervention in the Russian narcology hospital setting.

DESIGN, SETTING AND PARTICIPANTS

This was a randomized controlled trial from October 2004 to December 2005 among patients with alcohol and/or heroin dependence from two narcology hospitals in St Petersburg, Russia.

INTERVENTION

Intervention subjects received two personalized sexual behavior counseling sessions plus three telephone booster sessions. Control subjects received usual addiction treatment, which did not include sexual behavior counseling. All received a research assessment and condoms at baseline.

MEASUREMENTS

Primary outcomes were percentage of safe sex episodes (number of times condoms were used / by number of sexual episodes) and no unprotected sex (100% condom use or abstinence) during the previous 3 months, assessed at 6 months.

FINDINGS

Intervention subjects reported higher median percentage of safe sex episodes (unadjusted median difference 12.7%; P = 0.01; adjusted median difference 23%, P = 0.07); a significant difference was not detected for the outcome no unprotected sex in the past 3 months [unadjusted odds ratio (OR) 1.6, 95% confidence interval (CI) 0.8-3.1; adjusted OR 1.5, 95% CI 0.7-3.3].

CONCLUSIONS

Among Russian substance-dependent individuals, sexual behavior counseling during addiction treatment should be considered as one potential component of efforts to decrease risky sexual behaviors in this HIV at-risk population.

Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges

Sexually transmitted infections (STIs) constitute a huge health and economic burden for developing countries: 75-85% of the estimated 340 million annual new cases of curable STIs occur in these countries, and STIs account for 17% economic losses because of ill health. The importance of STIs has been more widely recognised since the advent of the HIV/AIDS epidemic, and there is good evidence that the control of STIs can reduce HIV transmission. The main interventions which could reduce the incidence and prevalence of STIs include primary prevention (information, education and communication campaigns, condom promotion, use of safe microbicides, and vaccines), screening and case finding among vulnerable groups (for example, pregnant women), STI case management using the syndromic approach, targeted interventions for populations at high risk (for example, sex workers), and in some circumstances (targeted) periodic mass treatment. The challenge is not just to develop new interventions, but to identify barriers to the implementation of existing tools, and to devise strategies for ensuring that effective STI control programmes are implemented in the future.

A community randomized controlled trial to investigate impact of improved STD management and behavioural interventions on HIV incidence in rural Masaka, Uganda: trial design, methods and baseline findings

OBJECTIVE

To describe study design, methods and baseline findings of a behavioural intervention alone and in combination with improved management of sexually transmitted diseases (STDs) aimed at reducing HIV incidence and other STDs.

DESIGN

A three-arm community randomized controlled trial (RCT) of 18 rural communities (approximately 96 000 adults) in SW Uganda. A standardized behavioural intervention was implemented in 12 communities (arms A and B) through community-based education, meetings and information leaflets. Six of these communities in addition received improved STD management through government and private health units (arm B). Arm C communities received routine government health services. Impact assessment was through three questionnaire and serological surveys of 750-1000 adults in each community at 18-24-month intervals. The primary outcome measure was HIV incidence and secondary measures were syphilis and herpes simplex virus type 2 incidence, prevalence of Neisseria gonorrhoea and Chlamydia trachomatis and sexual behaviour changes.

RESULTS

Approximately 15 000 adults (72% of eligible population) were enrolled at baseline. HIV baseline prevalence rates were 9-10% in all arms and demographic and behavioural characteristics and STD prevalence were also similar. In intervention communities, there were 391 995 attendance at 81 502 activities (6.1 per target adult), 164 063 leaflets distributed (2.6 per person) and 1 586 270 condoms (16.5 condoms per adult). In the STD communities a total of 12 239 STD cases (65% women) were seen over a 5-year period (7.7 per 100 adults/year).

CONCLUSION

This is the first community RCT of its type with a behavioural component. There is fair baseline comparability between study arms and process data suggest that interventions were adequately implemented.

Can antiretroviral therapy be used to prevent sexual transmission of human immunodeficiency virus type 1?

Approximately 5 million people annually are newly infected with human immunodeficiency virus (HIV). Although education, behavior modification, and promotion of condom use are effective transmission-prevention measures, the severity of the pandemic demands that all possible prevention strategies be explored. Antiretroviral therapy has the potential to decrease sexual transmission of HIV type 1 by reducing levels of HIV RNA and thus decreasing the risk that infected persons will transmit the disease or by its use as preexposure or postexposure prophylaxis. In this article, we explore the rationale for using antiretroviral therapy to prevent sexual transmission of HIV, as well as the limitations of this approach.

Enhancing primary care HIV prevention: a comprehensive clinical intervention

CONTEXT

Human immunodeficiency virus (HIV) and sexually transmitted disease (STD) risk assessment and counseling are recommended for a large proportion of the population, yet measured rates of such counseling remain low.

OBJECTIVE

Use a comprehensive intervention to improve and sustain rates of HIV/STD risk assessment and counseling by providers.

DESIGN

Patient telephone survey using a one-group pre- and post-intervention design with measurements over a 62-week period.

SETTING AND PARTICIPANTS

Patients (N=1042) from two outpatient clinics at a health maintenance organization (HMO) presenting for either of two types of index visit: symptomatic (n=210), or routine physical examination or birth control (n=832) visits.

MAIN OUTCOME MEASURES

Telephone survey performed within 3 weeks of the index visit. Patients' recall of a general discussion of HIV/STDs and specific discussion of sexual behaviors/risk factors.

RESULTS

The intervention was associated with increased patient recall of providers: discussing HIV/STD in general (OR 1.6; 95% CI, 1.12-2.22), asking about sexual behaviors/risk factors (OR 1.7; 95% CI, 1.2-2.6), discussing HIV prevention generally (OR 2.4; 95% CI, 1.4-4.0), and discussing personal risk reduction (OR 2.6; 95% CI, 1.6-4.3). Provision of written materials concerning HIV/STD also increased significantly (OR 2.8; 95% CI, 1.3-4.3). A clear-cut pattern of improved provider effort was seen, with the most pronounced improvements in high-risk patients. Results were stable over a 38-week follow-up period.

CONCLUSION

A sustained improvement in HIV/STD risk assessment and counseling can be achieved in an outpatient HMO setting using a relatively non-intensive systematized intervention.

Interventions against sexually transmitted infections (STI) to prevent HIV infection

STIs have taken on a more important role with the advent of the HIV/AIDS epidemic, and there is good evidence that their control can reduce HIV transmission. The challenge is not just to develop new interventions, but to identify barriers to the effective implementation of existing tools, and to devise ways to overcome these barriers. This 'scaling-up' of effective strategies will require an international and a multisectoral approach. It will require the formation of new partnerships between the private and public sectors and between governments and the communities they represent.

A community-level HIV prevention intervention for inner-city women: results of the women and infants demonstration projects

OBJECTIVES

This study examined the effects of a multisite community-level HIV prevention intervention on women's condom-use behaviors.

METHODS

The theory-based behavioral intervention was implemented with low-income, primarily African American women in 4 urban communities. It was evaluated with data from pre- and postintervention cross-sectional surveys in matched intervention and comparison communities.

RESULTS

At baseline, 68% of the women had no intention of using condoms with their main partners and 70% were not using condoms consistently with other partners. After 2 years of intervention activities, increases in rates of talking with main partners about condoms were significantly larger in intervention communities than in comparison communities (P = .03). Intervention communities also had significant increases in the proportion of women who had tried to get their main partners to use condoms (P = .01). The trends for condom use with other partners were similar but nonsignificant.

CONCLUSIONS

Many women at risk for HIV infection are still not using condoms. Community-level interventions may be an effective way to reach large numbers of women and change their condom-use behaviors, particularly their behaviors with regard to communication with main sex partners.

Women and the prevention of HIV infection: an integrative review of the literature

In the United States, recent epidemiological evidence suggests that the epidemic of AIDS is growing rapidly among women. However, the theories used to guide research in the area of prevention of HIV infection often do not account for gender. As a result, research with women has been limited and the development of interventions to reduce risk behaviors impeded. This review examines research with women and HIV related to prevention and identifies the gaps and strengths in this body of work. Content analysis was used to evaluate 40 published papers meeting the following criteria: title or abstract indicating a report of research with women and HIV/AIDS, refereed journal as source, English language, and implications for prevention of HIV among women. Findings suggest a growing awareness of women's risk of HIV, but basic research pertaining to the behavior of women related to their vulnerability to HIV infection is scant. Prevention research and evaluation of interventions are also in their infancy. This review calls attention to the need for continued research that specifically addresses women's needs in the prevention of HIV.

Temporal trends in HIV risk behaviors of out-of-treatment injection drug users and injection drug users who smoke crack

This study compared the baseline sociodemographic characteristics and HIV risk behaviors of two groups of out-of-treatment injection drug users (IDUs): 366 who concurrently smoked crack (smoking IDUs) and 212 who did not smoke crack (IDUs) in the past 30 days. Temporal trends in recent risk behaviors were also assessed for each drug user group over an 18-month period, January 1992 through June 1994. Baseline data were collected in South Philadelphia before the implementation of a multisite HIV intervention research project funded by the National Institute on Drug Abuse. For the temporal trend analysis, the sample was grouped into four intake periods based on the date of the baseline interview. The results indicated that although both groups were economically disadvantaged and at high risk of HIV infection and transmission, smoking injectors had fewer economic resources and were at a moderately greater risk because of higher levels of sexual risk behaviors. Analysis of temporal trends revealed few reductions in drug risk behaviors and none in sexual risk behaviors. This study points to the need for examining differences between types of drug users, developing appropriate multidrug treatment programs and assessing the characteristics of communities so that theory-based interventions can be tailored for maximum effectiveness.