HIV This Week Issue #83

Welcome to the 83rd issue of HIV This Week !  In this issue, we cover the following topics:

1. Microbicides

2. Pre-Exposure Prophylaxis

3. HIV Testing

4. Basic Science

5. Men who Have Sex with Men

6. Epidemiology

7. Gender

8. Paediatric Treatment

9. Sexually Transmitted Infections

10. Faith-based Responses

11. Male Circumcision

12. People who Inject Drugs—Risk Environment

13. Young People

14. Economics

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Don’t forget that you can find a wealth of information on the HIV epidemic and responses to it at www.unaids.org.

Cate Hankins,Chief Scientific Adviser to UNAIDS
Precious Lunga, Research officer
Tania Lemay, Research consultant
Gladys Tagi, Assistant

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Microbicides

Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women

Abdool Karim Q, Abdool Karim S, Frohlich JA, Grobler AC, Baxter C, Mansoor LE, Kharsany ABM, Sibeko S, Mlisana KP,Omar Z, Gengiah TN, Maarschalk S, Arulappan N, Mlotshwa M, Morris L,Taylor D, on behalf of the CAPRISA 004 Trial Group. Science. 2010; July [Epub ahead of print]

The CAPRISA 004 trial assessed effectiveness and safety of a 1% vaginal gel formulation of tenofovir, a nucleotide reverse transcriptase inhibitor, for the prevention of HIV acquisition in women. A double-blind, randomized controlled trial was conducted comparing tenofovir gel (n = 445) with placebo gel (n = 444) in sexually active, HIV uninfected 18 to 40 year-old women in urban and rural KwaZulu-Natal, South Africa. HIV serostatus, safety, sexual behaviour and gel and condom use were assessed at monthly follow-up visits for 30 months. HIV incidence in the tenofovir gel arm was 5.6 per 100 women-years, i.e. person time of study observation, (38/680.6 women-years) compared to 9.1 per 100 women-years (60/660.7 women-years) in the placebo gel arm (incidence rate ratio = 0.61; P = 0.017). In high adherers (gel adherence > 80%), HIV incidence was 54% lower (P = 0.025) in the tenofovir gel arm. In intermediate adherers (gel adherence 50 to 80%) and low adherers (gel adherence < 50%) the HIV incidence reduction was 38% and 28% respectively. Tenofovir gel reduced HIV acquisition by an estimated 39% overall, and by 54% in women with high gel adherence. No increase in the overall adverse event rates was observed. There were no changes in viral load and no tenofovir resistance in HIV seroconvertors. Tenofovir gel could potentially fill an important HIV prevention gap, especially for women unable to successfully negotiate mutual monogamy or condom use.

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Editors’ note: Following 20 years of research, including 11 effectiveness trials of 6 microbicide candidates that did not protect women from HIV, this groundbreaking study has responded to Zena Stein’s 1990 call for a women-controlled method for HIV prevention (Am J Pub Health 80, 460-462). The vaginal gel was inserted anytime in the 12 hours before anticipated sex and once in the 12 hours after sex. This dosing strategy was inspired by the effectiveness of antiretroviral prophylaxis at the time of exposure for preventing mother-to-child transmission. Whatever way the data are analysed, the results show effectiveness. Women who used the gel more consistently had more protection. WHO and UNAIDS are convening a meeting at the end of August 2010 at the invitation of the South African government to consider what further research is needed, what would be the regulatory pathway for tenofovir gel, and what programmatic issues would need to be addressed. An example of the latter would be the optimal frequency of HIV testing - having a test every month, as was done in the trial, would not be practical. When the results were presented in Vienna at IAS 2010 there was a standing ovation – an extremely rare event in science. You can download the slides and watch the presentation at: http://globalhealth.kff.org/AIDS2010/July-20/Safety-and-Effectiveness.aspx

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Pre-Exposure Prophylaxis

Sex frequency and sex planning among men who have sex with men in Bangkok, Thailand: implications for pre- and post-exposure prophylaxis against HIV infection.

van Griensven F, Thienkrua W, Sukwicha W, Wimonsate W, Chaikummao S, Varangrat A, Mock P. 2010. J Int AIDS Soc. 2010;13:13

Daily HIV anti-retroviral pre-exposure prophylaxis (PrEP) is being evaluated in clinical trials among men who have sex with men. However, daily PrEP may not be congruent with sexual exposure profiles of men who have sex with men. Here the authors investigate sex frequency and sex planning to identify and inform appropriate PrEP strategies for men who have sex with men. They evaluated sex frequency and sex planning in a cohort HIV-negative men who have sex with men in Bangkok, Thailand. Chi2 test was used to compare reports of sex on different weekdays; logistic regression was used to identify predictors of sex frequency and sex planning. Of 823 men who have sex with men (mean  age 28.3 yrs) 86% reported sex on 2 days per week or less and 65% reported their  last sex to have been planned. Sex on the weekend (~30%) was more often reported than sex on weekdays (~23%). In multivariate analysis, use of alcohol, erectile dysfunction drugs, group sex, sex with a foreigner, buying and selling sex and a  history of HIV testing were associated with having sex on 3 days per week or more; age 22 to 29 years, not identifying as homosexual, receptive anal intercourse and not engaging in group sex were associated with unplanned sex. Intermittently dosed PrEP (as opposed to daily) may be a feasible HIV prevention strategy and should be considered for evaluation in clinical trials. Predictors of sex frequency and sex planning may help to identify those in need for daily PrEP and those who may not be able to take a timely pre-exposure dose. 

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Editors’ note: In this study, planned sex meant ‘having made intentional arrangements to have sex, e.g. you went to the park, sauna, bar, or online to find a sex partners or you had made an appointment with another man to have sex’. Two-thirds of the men in this study had planned sex on the first encounter of the last day they had sex. Given the sex frequency reported in this study, it would be possible for many men who have sex with men in Bangkok to use intermittent pre-exposure prophylaxis (PrEP), if it proved to be effective. For others who are having sex more frequently or who are less able to plan when they will have sex, a daily antiretroviral dose would be more practical. There is a daily dose effectiveness trial underway among men who have sex with men in Peru, Ecuador, USA, South Africa, and Thailand - it will report results in the next 6 months. A safety and acceptability study of intermittent PrEP among men who have sex with men is underway in Kenya and Uganda and two further safety studies are planned. If daily PrEP provides protection and intermittent PrEP is safe, the question will be whether intermittent PrEP will be effective and for which men. Local studies such as this one eventually can inform the counselling that will help men to choose a tailored approach that will work best for them.

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HIV Testing

HIV-1 subtype C-infected individuals maintaining high viral load as potential targets for the "test-and-treat" approach to reduce HIV transmission.

Novitsky V, Wang R, Bussmann H, Lockman S, Baum M, Shapiro R, Thior I, Wester C,  Wester CW, Ogwu A, Asmelash A, Musonda R, Campa A, Moyo S, van Widenfelt E, Mine  M, Moffat C, Mmalane M, Makhema J, Marlink R, Gilbert P, Seage GR 3rd, DeGruttola V, Essex M.  PLoS One. 2010;5:e10148.

The first aim of the study is to assess the distribution of HIV-1 RNA levels in subtype C infection. Among 4,348 drug-naïve HIV-positive individuals participating in clinical studies in Botswana, the median baseline plasma HIV-1 RNA levels differed between the general population cohorts (4.1-4.2 log(10)) and  combination antiretroviral therapy-initiating cohorts (5.1-5.3 log(10)) by about one log(10). The proportion of individuals with high (> or = 50,000 (4.7 log(10)) copies/ml) HIV-1 RNA levels ranged from 24%-28% in the general HIV-positive population cohorts to 65%-83% in  combination antiretroviral therapy-initiating cohorts. The second aim is to estimate the proportion of individuals who maintain high HIV-1 RNA levels for an extended time and the duration of this period. For this analysis, the authors estimate the proportion of individuals who could be identified by repeated 6- vs. 12-month-interval HIV testing, as well as the potential reduction of HIV transmission time that can be achieved by testing and antiretroviral treatment. Longitudinal analysis of 42 seroconverters revealed that 33% (95% CI: 20%-50%) of individuals maintain high HIV-1 RNA levels for at least 180 days post seroconversion and the median duration of high viral load period was 350 (269; 428) days post seroconversion. They found that it would be possible to identify all HIV-infected individuals with viral load > or = 50,000 (4.7 log(10)) copies/ml using repeated six-month-interval HIV testing. Assuming individuals with high viral load initiate combination antiretroviral therapy after being identified, the period of high transmissibility due to high viral load can potentially be reduced by 77% (95% CI: 71%-82%). Therefore, if HIV-infected individuals maintaining high levels of plasma HIV-1 RNA for extended period of time contribute disproportionally to HIV transmission, a modified "test-and-treat" strategy targeting such individuals by repeated HIV testing (followed by initiation of combination antiretroviral therapy) might be a useful public health strategy for mitigating the HIV epidemic in some communities.

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Editors’ note: Viral load studies in sub-type B infection have shown that for most people the initial peak of viral load resolves to a steady-state setpoint in 4 to 6 months, with higher viral setpoint associated with an increased risk of disease progression and onward HIV transmission. Although we do not know what the threshold for HIV transmission is, it is assumed to be between 10,000 and 100,000 copies/ml, with 50,000 copies/ml used in most studies. This study of over 4000 people with sub-type C infection participating in 7 cohort studies in Botswana found that 24-28% of people in the general population studies and 65-83% in the populations staring on antiretroviral therapy had viral loads over 50,000. In the acute infection cohort, the mean and median duration of high viral load was about 12 months, with around 33% of people maintaining high viral loads. Modelling to determine the optimal testing frequency to identify these individuals and offer them immediate treatment revealed that more HIV transmission could be prevented (77%) with 6-monthly viral load testing than with an annual test. Clearly, people in need of life-prolonging treatment should be prioritised for access to therapy. Thereafter, strategies such as offering treatment to people who are not eligible for treatment based on CD4 count but who are most likely to transmit to others could be considered.

HIV testing
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HIV Testing

Couple-oriented prenatal HIV counseling for HIV primary prevention: an acceptability study.

Orne-Gliemann J, Tchendjou PT, Miric M, Gadgil M, Butsashvili M, Eboko F, Perez-Then E, Darak S, Kulkarni S, Kamkamidze G, Balestre E, Desgrees du Lou A, Dabis F. BMC Public Health. 2010;10:197.

A large proportion of the 2.5 million new adult HIV infections that occurred worldwide in 2007 were in stable couples. Feasible and acceptable strategies to improve HIV prevention in a conjugal context are scarce.  In the preparatory phase of the ANRS 12127 Prenahtest multi-site HIV prevention trial, the authors assessed the acceptability of couple-oriented post-test HIV counselling and men's involvement within prenatal care services, among pregnant women, male partners, and health care workers in Cameroon, Dominican Republic, Georgia, and India. Quantitative and qualitative research methods were used:  direct observations of health services; in-depth interviews with women, men, and health care workers; monitoring of the couple-oriented post-test HIV counselling intervention; and exit interviews with couple-oriented post-test HIV counselling participants. In-depth interviews conducted with 92 key informants across the four sites indicated that men rarely participated in antenatal care services, mainly because these are traditionally and programmatically a woman's domain. However men's involvement was reported to be acceptable and needed in order to improve antenatal care and HIV prevention services. Couple-oriented post-test HIV counselling was considered by the respondents to be a feasible and acceptable strategy to actively encourage  men to participate in prenatal HIV counselling and testing and overall in  reproductive health services. One of the keys to men's involvement within prenatal HIV counselling and testing is the better understanding of couple relationships, attitudes, and communication patterns between men and women, in terms of HIV and sexual and reproductive health; this conjugal context should be taken into account in the provision of quality prenatal HIV counselling, which aims at integrated prevention of mother-to-child transmission and primary prevention of HIV.

 

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Editors’ note: The Prenahtest trial assessing the impact of couple-oriented post-test counselling, underway in 4 low-to-medium HIV prevalence countries, will be completed in 2011. This preparatory study revealed support for the idea of increasing men’s involvement but identified a number of barriers that first must be overcome. These include making antenatal care services more physically and interpersonally receptive to male participation and challenging gender norms to address the social barriers to male involvement. This process can help change the paternalistic, unidirectional nature of relationships between most health care providers and patients which can reveal itself as lectures without opportunities for personalised prevention messages. Testing options for men are limited to sexually transmitted disease clinics, voluntary counselling and testing services, and male circumcision programmes. Couple counselling and testing in the context of pregnancy is an opportunity to increase the testing options for men while decreasing the likelihood of transmission to infants. It is an opportunity that should not to be missed – most men and women living in a serodiscordant couple do not know their status nor that of their partner.

HIV testing
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Basic Science

Effects of thymic selection of the T-cell repertoire on HLA class I-associated control of HIV infection.

Kosmrlj A, Read EL, Qi Y, Allen TM, Altfeld M, Deeks SG, Pereyra F, Carrington M, Walker BD, Chakraborty AK. Nature. 2010;465:350-4

Without therapy, most people infected with human immunodeficiency virus (HIV) ultimately progress to AIDS. Rare individuals ('elite controllers') maintain very low levels of HIV RNA without therapy, thereby making disease progression and transmission unlikely. Certain HLA class I alleles are markedly enriched in elite controllers, with the highest association observed for HLA-B57. Because HLA molecules present viral peptides that activate CD8(+) T cells, an immune-mediated mechanism is probably responsible for superior control of HIV. Here the authors describe how the peptide-binding characteristics of HLA-B57 molecules affect thymic development such that, compared to other HLA-restricted T cells, a larger fraction of the naive repertoire of B57-restricted clones recognizes a viral epitope, and these T cells are more cross-reactive to mutants of targeted epitopes. Their calculations predict that such a T-cell repertoire imposes strong immune pressure on immunodominant HIV epitopes and emergent mutants, thereby promoting efficient control of the virus. Supporting these predictions, in a large cohort of HLA-typed individuals, Kosmrlj and colleagues’ experiments show that the relative ability of HLA-B alleles to control HIV correlates with their peptide-binding characteristics that affect thymic development. These results provide a conceptual framework that unifies diverse empirical observations, and have implications for vaccination strategies.

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Editors’ note:  The human leukocyte antigen (HLA) system is composed of a large number of genes related to immune system function in humans. It was first recognised as a result of reactions to organ transplantation. Organ transplants are less likely to be rejected if the donor and recipient have similar HLA profiles. People expressing HLA-B8 have a rapid progression to HIV disease while those expressing HLA-B57 tend to have a lower HIV viral setpoint and a slower HIV disease progression. This research suggests that this difference is related to the diversity of peptides presented in the thymus during T-cell development. Individuals with HLA-B57 tend to have a more cross-reactive repertoire because their T-cells encounter fewer self-peptides during development – this also makes such individuals more likely to have autoimmune diseases and hypersensitivity reactions. Although rarer, cross-reactive T-cells are found in people with other HLA alleles so the challenge for a T-cell vaccine will be to activate these cells in everyone to enable robust immune responses.

Basic science
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Men Who have Sex with Men

Bisexual concurrency, bisexual partnerships, and HIV among Southern African men who have sex with men.

Beyrer C, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, Baral S. Sex Transm Infect. 2010. [Epub ahead of print]

The sexual behaviour of men who have sex with men in southern Africa has been little studied. Beyrer et al present here the first data on bisexual partnerships and bisexual concurrency among men who have sex with men in Malawi, Namibia and Botswana. The authors conducted a cross-sectional probe of a convenience sample of 537 men who have ever reported anal sex with another man using a structured survey instrument and rapid-kit HIV screening. 34.1% of men who have sex with men were married or had a stable female partner, and 53.7% reported both male and female sexual partners in the past 6 months. Bisexual concurrency was common, with 16.6% of men who have sex with men having concurrent relationships with both a man and a woman. In bivariate analyses, any bisexual partnerships were associated with lower education (OR 1.6, 95% CI 1.1 to 2.3), higher condom use (OR 6.6, 95% CI 3.2 to 13.9), less likelihood of having ever     tested for HIV (OR 1.6, 95% CI 1.1 to 2.3), less likelihood of having disclosed sexual orientation to family (OR 0.47, 95% CI 0.32 to 0.67) and being more likely to have received money for casual sex (OR 1.9, 95% CI 1.3 to 2.7). Bisexual concurrency was associated with a higher self-reported condom use (OR 1.7, 95% CI 1.0 to 3.1), being employed (OR 1.8, 95% CI 1.2 to 2.9), lower likelihood of disclosure of sexual orientation to family (OR 0.37, 95% CI 0.22 to 0.65) and having paid for sex with men (OR 2.0, 95% CI 1.2 to 3.2).The majority of men who have sex with men in this study report some bisexual partnerships in the previous 6 months. Concurrency with sexual partners of both genders is common. Encouragingly, men reporting any concurrent bisexual activity were more likely to report condom use with sexual partners, and these men were not more likely to have HIV infection than men reporting only male partners. HIV-prevention programmes focussing on decreasing concurrent sexual partners in the African context should also target bisexual concurrency among men who have sex with men. Decriminalisation of same-sex practices will potentiate evidence-based HIV-prevention programmes targeting men who have sex with men.

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Editors’ note:  Historical and current labour migration patterns in southern Africa are thought to be major contributors to sexual concurrency, most often defined as men having two or more female sexual partners and women having two or more male partners at the same time. This is the first study of bisexual concurrency among men who have sex with men, defined as being in an ongoing sexual relationship with both a male and a female partner. Bisexuality was defined as sex with at least one man and one woman in the previous 6 months. The study population in Botswana, Namibia, and Malawi was urban and more likely to be gay-identified because the men were recruited through local human rights organisations with links to these communities of men. All three countries criminalise same sex behaviour. Although the findings cannot be generalised to the entire population of men who have sex with men, they are nonetheless thought provoking. Overall, more than half were sexually active with both men and women, one third were married to women, and one in six was in a stable relationship with a man and a woman. Men were more likely to identify as bisexual and report bisexual concurrency in settings where the social pressure to marry women was strong, such as Malawi. HIV infection prevalence was about twice as high as national estimates of HIV prevalence for men of reproductive age; however, condom use with regular and casual sex partners was higher among those in concurrent bisexual partnerships. Further research is needed to better understand the contribution of bisexuality and bisexual concurrency to African epidemics but the capacity to undertake such research and design tailored prevention programmes will depend on how quickly these countries move to decriminalise homosexuality.

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Epidemiology

HIV decline in Zimbabwe due to reductions in risky sex? Evidence from a comprehensive epidemiological review.

 

Gregson S, Gonese E, Hallett TB, Taruberekera N, Hargrove JW, Lopman B, Corbett EL, Dorrington R, Dube S, Dehne K, Mugurungi O. Int J Epidemiol. 2010. [Epub ahead of print]

Recent data from antenatal clinic surveillance and general population surveys suggest substantial declines in human immunodeficiency virus  (HIV) prevalence in Zimbabwe. The authors assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence. Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985-2007 was conducted. HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000.   Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15-24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007. These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis level.

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Editors’ note: Trying to determine the factors that have contributed to the most convincing decline in countrywide HIV prevalence in southern Africa was challenging. The first step was to assemble all available evidence from sources such as population surveys, vital registration, antenatal surveillance, incidence studies, censuses, and behavioural and other studies. After their results were assessed for quality, potential biases, and plausibility, estimates of HIV prevalence and incidence were calculated and modelling conducted to assess the possible impact on HIV prevalence of out-migration from Zimbabwe. The overall findings are striking. Condom use with non-regular partners was already high by the late 1990s and had contributed to bringing the decline in HIV incidence to a tipping point where the net reproductive number was less than one. Further risk reduction in the form of substantial reductions in reported non-regular sexual partners from 1999 to 2004 hastened the fall in incidence. Mortality affected HIV prevalence but out-migration likely had small effects. Zimbabwe has an HIV treatment burden that will last for decades but it has made a major contribution to our understanding of HIV epidemic dynamics. There are critically important lessons still to be learned about what prompted behaviour change in Zimbabwe.

Epidemiology
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Epidemiology

HIV Transmission Rates in Thailand: Evidence of HIV Prevention and Transmission Decline. Siraprapasiri T, Peerapatanapokin W, Manne J, Niccolai L, Kunanusont C. J Acquir Immune Defic Syndr. 2010; 54:430-6

Analysis of HIV transmission rates has provided insight into the impacts of HIV-related prevention programming and policies in the United States by providing timely information beyond incidence or prevalence alone. The purpose of this analysis is to use transmission rates to assess past prevention efforts and explore trends of the epidemic in subpopulations within Thailand. Asian Epidemic Model HIV incidence and prevalence were used to calculate transmission rates over time nationally and among high-risk populations. A national HIV program implemented in Thailand in the 1990s that targeted sex workers   and the general population was correlated with a decrease in new cases despite high prevalence. The turning point of the epidemic was in 1991 when the national transmission rate was 32%. By the late 1990s, the rate dropped to less than 4%. All subpopulations experienced a rate decline; however, sex workers still experienced higher transmission rates. The declining trend in HIV transmission rates despite ever-growing prevalence indicates prevention success correlated with the national HIV program. Data from subgroup analyses provide stronger evidence of prevention success than incidence alone, as this measure demonstrates the effect of efforts and accounts for the burden of disease in the population.

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Editors’ note: This paper defines the HIV transmission rate as the new cases of HIV divided by the existing number of persons living with HIV for a specified time. It provides a measure that considers the spread of HIV by accounting for the number of people capable of transmitting HIV. How accurate the transmission rate calculated in this manner will be clearly depends on how good are the HIV incidence and prevalence estimates. Nevertheless, Thailand has clearly met the Millennium Development Goal 6 ‘to halt and reverse the spread of HIV by 2015’ through sustained reductions in HIV incidence. This resulted from the swift action that provoked dramatic changes in HIV incidence from a peak in 1991 and concerted prevention programming thereafter. These included mobilisation of non-governmental organisations, the 100% condom use campaign that went national in 1992, blood screening programmes, and active surveillance. It is unclear how accurate transmission rates calculated this way are for key populations such as men who have sex with men, people who inject drugs, and couples in which one person has HIV infection, but the need to engage these people in the design of effective tailored prevention programming and better surveillance is clear.

Epidemiology
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Gender

Transactional sex amongst young people in rural northern Tanzania: an ethnography of young women's motivations and negotiation.

Wamoyi J, Wight D, Plummer M, Mshana GH, Ross D. Reprod Health. 2010;7:2.

Material exchange for sex (transactional sex) may be important to sexual relationships and health in certain cultures, yet the motivations for transactional sex, its scale and consequences are still little   understood. The aim of this paper is to examine young women's motivations to exchange sex for gifts or money, the way in which they negotiate transactional sex throughout their relationships, and the implications of these negotiations for the HIV epidemic. An ethnographic research design was used, with   information collected primarily using participant observation and in-depth   interviews in a rural community in North Western Tanzania. The qualitative approach was complemented by an innovative assisted self-completion   questionnaire. Transactional sex underlays most non-marital relationships and was not, per se, perceived as immoral. However, women's   motivations varied, for instance: escaping intense poverty, seeking beauty   products or accumulating business capital. There was also strong pressure from peers to engage in transactional sex, in particular to consume like others and avoid ridicule for inadequate remuneration. Macro-level factors shaping transactional sex (e.g. economic, kinship and normative factors) overwhelmingly benefited men, but at a micro-level there were different dimensions of power,   stemming from individual attributes and immediate circumstances, some of which   benefited women. Young women actively used their sexuality as an economic resource, often entering into relationships primarily for economic gain. Transactional sex is likely to increase the risk of HIV by providing    a dynamic for partner change, making more affluent, higher risk men more desirable, and creating further barriers to condom use. Behavioural interventions should directly address how embedded transactional sex is in sexual culture.   

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Editors’ note: If you want to learn more about ethnographic methodologies, this fascinating paper is an excellent read. Its explicit descriptions of data gathering by participant observation in 9 villages over 3 years give added weight to its dismissal of any Western-centric assumption that assumes poverty is what links sex with material gain. Sexual relationships are complex phenomena influenced by macro-social, micro-social, psychological, and physiological factors in all societies. This study focuses on the social factors that shape sexual relationships in rural northwest Tanzania where material exchange for sex underlies most non-marital relationships, along with physical pleasure, reproduction, self-esteem, and love or other non-material motives. The findings resonate with data from other settings, reinforcing the notion that for HIV prevention strategies to be effective, they must acknowledge the economic importance of sex for young women. While income-generating schemes would be a good start, transactional sex is deeply rooted in this and other cultures, requiring profound cultural change. In the meantime, generation of economic opportunities for girls and young women will increase their bargaining power, while education and communication skills building will increase their negotiating skills for postponement of sex and for male and female condom use. 

Gender
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