HIV This Week

Kruglov YV, Kobyshcha YV, Salyuk T, Varetska O, Shakarishvili A, Saldanha VP. The most severe HIV epidemic in Europe: Ukraine’s national HIV prevalence estimates for 2007. Sex Transm Infect. 2008 Aug;84 Suppl 1:i37-i41.

The objective of this study was to revise the national HIV estimates and quantify the magnitude of the HIV epidemic in Ukraine at the end of 2007. Internationally recommended methods – the Workbook and Spectrum – were employed to generate the estimates. This enables comparison of results with other countries using the same methodology. Estimation of the size of most at-risk populations nationally was performed using capture-recapture, multiplier and triangulation methods. HIV prevalence among most at-risk populations was estimated by linked HIV sentinel and behavioural surveillance among injecting drug users, and men who have sex with men, and unlinked sentinel surveillance among sex workers. The range of HIV prevalence and extrapolation for populations at lower risk were determined by consensus among national stakeholders. Results were reviewed by national stakeholders and endorsed by the government of Ukraine. At the end of 2007, an estimated 395 000 adults (range 230 000-573 000) aged 15-49 were living with HIV in Ukraine. Adult HIV prevalence was estimated at 1.63%, which represents the highest adult HIV prevalence of any country in Europe. The authors conclude that the HIV epidemic in Ukraine continues to grow at a record pace, concentrated among most at-risk populations, the majority of whom are unaware of their HIV status. The results emphasise the need to accelerate the coverage and quality of prevention programmes among most at-risk populations and their sexual partners.

Editors’ note: The process of developing these HIV estimates for Ukraine, the country with the highest HIV prevalence of any country in Europe, helped generate a national consensus that is key to the engagement of all stakeholders in designing, financing, staffing, and implementing a new national 5 year programme. A robust epidemiological baseline is marking a ‘know your epidemic’ line in the sand. Now, the response has to match it.

Sarker MS, Rahman M, Yirrell D, Campbell E, Rahman AS, Islam LN, Azim T. Molecular evidence for polyphyletic origin of human immunodeficiency virus type 1 subtype C in Bangladesh. Virus Res. 2008;135(1):89-94

HIV-1 positive blood samples were collected between 1999 and 2005 from population groups most at risk of HIV infection in Bangladesh through the national surveillance, from clients of the Voluntary Counselling and Testing (VCT) Unit for HIV at the International Centre for Diarrhoeal Diseases Research, Bangladesh, and a from survey of HIV in patients with tuberculosis. Partial sequences of the gag gene were used for subtyping the HIV strains by nested polymerase chain reaction using selective primers. Of the 198 HIV strains tested, subtype C (41.4%) was the commonest strain identified. Phylogenetic analysis of Bangladeshi subtype C strains showed that they clustered in polyphyletic branches representing HIV strains from different parts of the world. Most of the strains from injecting drug users clustered together and were similar to Indian strains. The VCT strains however were very heterogeneous and clustered with strains from India, Myanmar, Ethiopia and Zimbabwe. Data suggest that there have been few introductions into the injecting drug user population where the epidemic is driven by indigenous transmission. On the other hand there have been many and regular introductions of subtype C viruses through migrant workers in the VCT group. Very little overlap was observed in the strains obtained from injecting drug users and those from other population groups.

Editors´note: Injecting drug use transmission of subtype C virus in Bangladesh appears to be confined primarily to the community of people who inject drugs, with the strains being very similar. The majority of strains from the VCT clients were not subtype C and those that were subtype C were a very heterogeneous population, suggesting transmission from a variety of different geographical sources. None of the strains from the VCT clients clustered with isolates from the injecting drug users, suggesting little interaction between these two populations that could lead to HIV transmission. Studying HIV subtypes can provide a window on the dynamics of a country’s epidemic.

Gazi R, Mercer A, Wansom T, Kabir H, Saha NC, Azim T. An assessment of vulnerability to HIV infection of boatmen in Teknaf, Bangladesh. Confl Health. 2008;2(1):5

Mobile population groups are at high risk for contracting HIV infection. Many factors contribute to this risk, including high prevalence of risky behaviour and increased risk of violence due to conflict and war. The Naf River serves as the primary border crossing point between Teknaf, Bangladesh, and Mynamar [Burma] for both official and unofficial travel of people and goods. Little is known about the risk behaviour of boatmen who travel back and forth between Teknaf and Myanmar. However, Gazi and colleagues hypothesize that boatmen may act as a bridging population for HIV between the high-prevalence country of Myanmar and the low-prevalence country of Bangladesh. Methods included initial rapport building with community members, mapping of boatmen communities, and in-depth qualitative interviews with key informants and members from other vulnerable groups such as spouses of boatmen, female sex workers, and injecting drug users. Information from the first three stages was used to create a cross-sectional survey that was administered to 433 boatmen. Over 40% of the boatmen had visited Myanmar during the course of their work. 17% of these boatmen had sex with sex workers while abroad. There was a significant correlation found between the number of nights spent in Myanmar and sex with commercial sex workers. In the past year, 19% of all boatmen surveyed had sex with another man. Fourteen per cent of boatmen had participated in group sex, with groups ranging in size from three to fourteen people. Condom use was rare [0 to 4.7% during the last month], irrespective of types of sex partners. Regression analysis showed that boatmen who were 25 years and older were statistically less likely to have sexual intercourse with non- marital female partners in the last year compared to the boatmen aged less than 25 years. Similarly, deep sea fishing boatmen and non-fishing boatmen were statistically less likely to have sexual intercourse with non-marital female partners in the last year compared to the day-longfishing boatmen adjusting for all other variables. Boatmen’s knowledge regarding HIV transmission and personal risk perception for contracting HIV was low. Boatmen in Teknaf are an integral part of a high-risk sexual behaviour network between Myanmar and Bangladesh. They are at risk of obtaining HIV infection due to cross-border mobility and unsafe sexual practices. There is an urgent need for designing interventions targeting boatmen in Teknaf to combat an impending epidemic of HIV among this group. They could be included in the serological surveillance as a vulnerable group. Interventions need to address issues on both sides of the border, other vulnerable groups, and refugees. Strong political will and cross-border collaboration are mandatory for such interventions.

Msisha WM, Kapiga SH, Earls FJ, Subramanian SV. Place matters: multilevel investigation of HIV distribution in Tanzania. AIDS. 2008;22(6):741-8.

Msisha and colleagues aimed to examine the extent to which the regional and neighborhood distribution of HIV in Tanzania is caused by the differential distribution of individual correlates and risk factors, using nationally representative, cross-sectional data on 12,522 women and men aged 15-49 years from the 2003-2004 Tanzanian AIDS Indicator Survey. Three-level multilevel binary logistic regression models were specified to estimate the relative contribution of regions and neighborhoods to the variation in HIV seroprevalence. Spatial distribution of individual correlates (and risk factors) of HIV do not explain the neighborhood and regional variation in HIV seroprevalence. Neighborhoods and regions accounted for approximately 14 and 6% of the total variation in HIV. HIV prevalence ranged from 1.8% (Kigoma) to 6.7% (Iringa) even after adjusting for the compositional make-up of these regions. An inverse association was observed between log odds of being HIV positive and neighborhood poverty [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.09-0.61] and regional poverty (OR 0.97, 95% CI 0.95-0.99). The study provides evidence for independent contextual variations in HIV, above and beyond that which can be ascribed to geographical variations in individual-level correlates and risk factors. The authors emphasize the need to adopt both a group-based and a place-based approach, as opposed to the dominant high-risk group approach, for understanding the epidemiology of HIV as well as for developing HIV intervention activities.

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da Silva ZJ, Oliveira I, Andersen A, Dias F, Rodrigues A, Holmgren B, Andersson S, Aaby P. Changes in prevalence and incidence of HIV-1, HIV-2 and dual infections in urban areas of Bissau, Guinea-Bissau: is HIV-2 disappearing? AIDS. 2008;22(10):1195-202.

Da Silva and colleagues aimed to assess the changes in HIV prevalence and incidence between 1996 and 2006 in urban areas of Bissau, using a cross-sectional survey of 384 randomly selected houses within a community-based follow-up study of HIV-1 and HIV-2. A total of 3242 individuals aged at least 15 years were eligible for inclusion. Participants were interviewed about behavioural and socio-economic factors and had a blood sample drawn. A total of 2548 individuals were tested for antibodies to HIV-1 and HIV-2, of whom 649 had taken part in a similar survey in 1996. With 0.5% HIV dual reactions included, the overall HIV-1 prevalence was 4.6% (118 out of 2548 ) and the HIV-2 prevalence was 4.4% (112 out of 2548). The prevalence of HIV-1 increased more for women than men especially in the 25-34-year age group. HIV-2 prevalence decreased below 45 years of age but not for individuals more than 45 years old. The incidence rate between 1996 and 2006 was 0.5 per 100 person-years for HIV-1 and 0.24 per 100 person-years for HIV-2. Compared with a previous period from 1987 to 1996, the incidence of HIV-2 is declining whereas no significant increase in the incidence of HIV-1 was observed. The present study shows an increasing prevalence of HIV-1 and a decreasing prevalence of HIV-2 in Guinea-Bissau. HIV is generally a bigger problem for women. Despite the general decline in prevalence, HIV-2 may continue as an infection in older people, especially women.

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Kyobutungi C, Ziraba AK, Ezeh A, Ye Y. The burden of disease profile of residents of Nairobi’s slums: Results from a Demographic Surveillance System. Popul Health Metr. 2008;6(1):1 [Epub ahead of print]

With increasing urbanization in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Slums are characteristically unplanned, underserved by social services, and their residents are largely underemployed and poor. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System. Data from the Nairobi Urban Health and Demographic Surveillance System collected between January 2003 and December 2005 were analysed. Core demographic events in the Nairobi Urban Health and Demographic Surveillance System including deaths are updated three times a year; cause of death is ascertained by verbal autopsy and cause of death is assigned according to the ICD 10 classification. Years of Life Lost due to premature mortality were calculated by multiplying deaths in each subcategory of sex, age group, and cause of death, by the Global Burden of Disease standard life expectancy at that age. The overall mortality burden per capita was 205 years of life lost /1,000 person years. Children under the age of five years had more than four times the mortality burden of the rest of the population, mostly due to pneumonia and diarrhoeal diseases. Among the population aged five years and above, HIV and tuberculosis accounted for about 50% of the mortality burden. Slum residents in Nairobi have a high mortality burden from preventable and treatable conditions. It is necessary to focus on these vulnerable populations since their health outcomes are comparable to or even worse than the health outcomes of rural dwellers who are often the focus of most interventions.

Hunter M. The changing political economy of sex in South Africa: the significance of unemployment and inequalities to the scale of the AIDS pandemic. Soc Sci Med. 2007;64(3):689-700.

Between 1990 and 2005, HIV prevalence rates in South Africa jumped from less than 1% to around 29%. Important scholarship has demonstrated how racialized structures entrenched by colonialism and apartheid set the scene for the rapid unfolding of the AIDS pandemic, like other causes of ill-health before it. Of particular relevance is the legacy of circular male-migration, an institution that for much of the 20th century helped to propel the transmission of sexually transmitted infections among black South Africans denied permanent urban residence. But while the deep-rooted antecedents of AIDS have been noted, less attention has been given to more recent changes in the political economy of sex, including those resulting from the post-apartheid government’s adoption of broadly neo-liberal policies. As an unintentional consequence, male migration and apartheid can be seen as almost inevitably resulting in AIDS, a view that can disconnect the pandemic from contemporary social and economic debates. Combining ethnographic, historical, and demographic approaches, and focusing on sexuality in the late apartheid and early post-apartheid periods, this article outlines three interlinked dynamics critical to understanding the scale of the AIDS pandemic: (1) rising unemployment and social inequalities that leave some groups, especially poor women, extremely vulnerable; (2) greatly reduced marital rates and the subsequent increase of one person households; and (3) rising levels of women’s migration, especially through circular movements between rural areas and informal settlements/urban areas. As a window into these changes, the article gives primary attention to the country’s burgeoning informal settlements–spaces in which HIV rates are reported to be twice the national average–and to connections between poverty and money/sex exchanges.

Editors´note: Political economy analyses help conceptualise HIV as a symptom of ‘structural violence’ with sex as a mode of transmission. Housing, employment, and social equality are clearly linked to HIV, both historically and contemporarily, and help explain the striking scale of the South African epidemic. This article, which suggests ways to reconfigure the response to AIDS around a more politically enabling agenda, makes for thought-provoking reading.

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Kang M, Dunbar M, Laver S, Padian N. University of California Programme in Women’s Health, University of California-San Francisco, 50 Beale Street, San Francisco, CA 94105, USA. Maternal versus paternal orphans and HIV/STI risk among adolescent girls in Zimbabwe. AIDS Care. 2008;20(2):214-7.

The AIDS epidemic has contributed to a drastic increase in the number of orphans in Zimbabwe. Orphans (whether orphaned by AIDS or other causes) have been shown to have economic and educational disadvantages as well as poor reproductive health outcomes. Kang and colleagues recruited a convenience sample of 200 girls in a peri-urban area of Zimbabwe to examine the impact of orphan status (compared to non-orphans) on household composition, education, risk behaviour, pregnancy and prevalent HIV and HSV-2 infection. In the study population, maternal orphans were more likely to be in households headed by themselves or a sibling, to be sexually active, to have had a sexually transmitted infection, to have been pregnant and to be infected with HIV. Paternal orphans were more likely to have ever been homeless and to be out of school. The findings suggest that maternal care and support is important for HIV prevention. This finding corroborates previous research in Zimbabwe and has implications for intervention strategies among orphan girls.

Editors´note: Because of recruitment methodology, these results are not generalizable, however they do provide food for thought. Although paternal orphanhood had more of an impact on household financial stability and orphaned girls’ educational attainment, the loss of a mother affected behavioural risk and biological outcomes (HIV, HSV-2). Keeping mothers alive helps reduce sexual risk in adolescent girls. How would orphaned adolescent girls in Zimbabwe benefit from support and mentoring by women in their communities?

Hargrove, John. Migration, mines and mores: the HIV epidemic in southern Africa. South Afr J Sci. 2008: Volume 104, Issue 1 & 2:53-61.

The seriousness of the HIV epidemic in southern and eastern Africa has its roots in the 19th century - in the employment practices instituted on mines, farms and in cities, where millions of men have, ever since, lived apart from their families for the greater part of each year. This destruction of the family unit was a sociological disaster waiting for the arrival of HIV and is the source of many other social ills - not least the increasingly violent nature of South African society. In the short term we can promote HIV prevention measures such as male circumcision and condom use. In the medium term, we can hope that the many billions already spent on microbicide and vaccine research begin to pay dividends. In the long term, we need to change fundamentally the way that people live.

Editors’ note: Hargrove cogently argues that it is “Rhodes not roads”, i.e. that it was the colonial migratory labour practices that fragmented families and severely compromised family coherence that were the critical determinants at the heart of the southern Africa epidemic. His unavoidable conclusion is that, in addition to intensifying HIV prevention and treatment, we must urgently rebuild family structures in southern and eastern Africa if the HIV epidemic and many other problems having similar sociological determinants are to be dealt with effectively.

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Hladik W, Musinguzi J, Kirungi W, Opio A, Stover J, Kaharuza F, Bunnell R, Kafuko J, Mermin J. The estimated burden of HIV/AIDS in Uganda, 2005-2010. AIDS. 2008; 19; 22(4):503-10.

Hladik and colleagues amied to estimate the burden of HIV disease in Uganda and the effect of HIV control programmes to mitigate it. The authors performed mathematical modelling and projecting using surveillance and census data. Using antenatal clinic surveillance (1986-2002) and a recent population-based survey (2004-2005) data, they modelled the adult national HIV prevalence over time (1981-2004), and kept prevalence constant at 6.4% for the years 2004-2010. Using Spectrum software and census data, they estimated the national burden of HIV disease and the effect of selected HIV-related prevention and treatment programmes. In 2005, they estimated that there were 135,300 new HIV infections (adult HIV incidence 0.96%), 691,900 asymptomatic prevalent infections, 88 100 AIDS cases, and 76 400 AIDS deaths. An estimated 647,000 (80%) HIV-infected adults were unaware of their infection; one third of all adult deaths were HIV related. As a result of population growth, by 2008 a similar number of people will be HIV infected (1.1 million) as during the peak of the epidemic in 1994. Although antiretroviral therapy coverage is expected to rise from 67,000 (2005) to 160,000 (2010), the number of persons needing but not receiving antiretroviral therapy will decrease only slightly from 127,600 (2005) to 111,100 (2010). The use of single-dose in 2005 nevirapine probably averted only 4% of the estimated 20 400 vertical infections. In conclusion, HIV continues to be a leading cause of adult disease and death in Uganda. Universal antiretroviral therapy access is probably unachievable. With the absolute burden of HIV disease approaching the historic peak in the early 1990s, more effective prevention programmes are of paramount importance.

Editors’ note: Although HIV prevalence has declined significantly since the mid-1990s in Uganda, a country with one of the oldest epidemics in the world, the burden of HIV remains high. An important majority of people living with HIV are unaware of their HIV status and therefore are not being evaluated for treatment initiation. New HIV infections that continue to outpace AIDS deaths mean that the total number of people living with HIV this year will reach the 1994 historic peak of 1.1 million people living with HIV, all of whom will eventually need treatment. This is no time for Uganda, and other countries reporting declines in HIV transmission in specific populations, to rest on its laurels. Continued treatment scale-up accompanied by intensified, evidence-informed prevention are urgently needed.

Hargreaves JR, Bonell CP, Boler T, Boccia D, Birdthistle I, Fletcher A, Pronyk PM, Glynn JR. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS. 2008; 30; 22(3):403-14.

Hargreaves and colleagues amied to assess the evidence that the association between educational attainment and risk of HIV infection is changing over time in sub-Saharan Africa. The authors conducted a systematic review of published peer-reviewed articles. Articles were identified that reported original data comparing individually measured educational attainment and HIV status among at least 300 individuals representative of the general population of countries or regions of sub-Saharan Africa. Statistical analyses were required to adjust for potential confounders but not over-adjust for variables on the causal pathway. Approximately 4000 abstracts and 1200 full papers were reviewed. Thirty-six articles were included in the study, containing data on 72 discrete populations from 11 countries between 1987 and 2003, representing over 200,000 individuals. Studies on data collected prior to 1996 generally found either no association or the highest risk of HIV infection among the most educated. Studies conducted from 1996 onwards were more likely to find a lower risk of HIV infection among the most educated. Where data over time were available, HIV prevalence fell more consistently among highly educated groups than among less educated groups, in whom HIV prevalence sometimes rose while overall population prevalence was falling. In several populations, associations suggesting greater HIV risk in the more educated at earlier time points were replaced by weaker associations later. HIV infections appear to be shifting towards higher prevalence among the least educated in sub-Saharan Africa, reversing previous patterns. Policy responses that ensure HIV-prevention measures reach all strata of society and increase education levels are urgently needed.

Editors’ note: Although data were available from only 11 countries, the findings are supported by evidence of behaviour change as well as theoretical plausibility. The ‘diffusion of innovations’ model would predict information seeking and adoption of new practices, such as condom use, by more-educated, more-empowered members of a population. This strongly suggests that larger reductions in HIV incidence can be achieved by improving school enrolment, such as through abolition of primary school fees (as has been done in Kenya, Malawi, Tanzania, and Uganda), and tailoring HIV prevention programmes for socially vulnerable groups, while creating positive social environments which reinforce safer HIV prevention behavioural norms across the population.

Jahn A, Floyd S, Crampin AC, Mwaungulu F, Mvula H, Munthali F, McGrath N, Mwafilaso J, Mwinuka V, Mangongo B, Fine PE, Zaba B, Glynn JR. Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. Lancet. 2008;371(9624):1603-11.

Malawi, which has about 80,000 deaths from AIDS every year, made free antiretroviral therapy available to more than 80 000 patients between 2004 and 2006. Jahn and colleagues aimed to investigate mortality in a population before and after the introduction of free antiretroviral therapy, and therefore to assess the effects of such programmes on survival at the population level. The authors used a demographic surveillance system to measure mortality in a population of 32,000 in northern Malawi, from August, 2002, when free antiretroviral therapy was not available in the study district, until February, 2006, 8 months after a clinic opened. Causes of death were established through verbal autopsies (retrospective interviews). Patients who registered for antiretroviral therapy at the clinic were identified and linked to the population under surveillance. Trends in mortality were analysed by age, sex, cause of death, and zone of residence. Before antiretroviral therapy became available in June, 2005, mortality in adults (aged 15-59 years) was 9.8 deaths for 1000 person-years of observation (95% CI 8.9-10.9). The probability of dying between the ages of 15 and 60 years was 43% (39-49) for men and 43% (38-47) for women; 229 of 352 deaths (65.1%) were attributed to AIDS. 8 months after the clinic that provided antiretroviral therapy opened, 107 adults from the study population had accessed treatment, out of an estimated 334 in need of treatment. Overall mortality in adults had decreased by 10% from 10.2 to 8.7 deaths for 1000 person-years of observation (adjusted rate ratio 0.90, 95% CI 0.70-1.14). Mortality was reduced by 35% (adjusted rate ratio 0.65, 0.46-0.92) in adults near the main road, where mortality before antiretroviral therapy was highest (from 13.2 to 8.5 deaths per 1000 person-years of observation before and after antiretroviral therapy). Mortality in adults aged 60 years or older did not change. The findings of a reduction in mortality in adults aged between 15 and 59 years, with no change in those older than 60 years, suggests that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy in rural Malawi, which led to a decline in adult mortality that was detectable at the population level.

Editors’ note: With no vital registration system in place or reliable mortality statistics reported from health services, this study established a continuous registration demographic surveillance system after completing a household census in Karonga district (pop. 32,000). A child born into this population before the introduction of antiretroviral therapy had a 37% lifetime risk of dying from AIDS. This surveillance system demonstrated that by 8 months after the free antiretroviral treatment programme began, overall mortality in adults aged 15-59 had decreased by 10%. Only a third of adults in need of treatment had been started on antiretroviral treatment so population mortality should continue to fall as access to treatment is decentralized and scaled up.

Lingappa JR, Lambdin B, Bukusi EA, Ngure K, Kavuma L, Inambao M, Kanweka W, Allen S, Kiarie JN, Makhema J, Were E, Manongi R, Coetzee D, de Bruyn G,Delany-Moretlwe S, Magaret A, Mugo N, Mujugira A, Ndase P, Celum C; for the Partners in Prevention HSV-2/HIV Transmission Study Group. Regional Differences in Prevalence of HIV-1 Discordance in Africa and Enrollment of HIV-1 Discordant Couples into an HIV-1 Prevention Trial. PLoS ONE. 2008; 3(1):e1411.

Most HIV-1 transmission in Africa occurs among HIV-1-discordant couples (one partner HIV-1 infected and one uninfected) who are unaware of their discordant HIV-1 serostatus. Given the high HIV-1 incidence among HIV-1 discordant couples and to assess efficacy of interventions for reducing HIV-1 transmission, HIV-1 discordant couples represent a critical target population for HIV-1 prevention interventions and prevention trials. Substantial regional differences exist in HIV-1 prevalence in Africa, but regional differences in HIV-1 discordance among African couples, has not previously been reported. The Partners in Prevention herpes simplex virus type 2 (HSV-2)/HIV-1 Transmission Trial (”Partners HSV-2 Study”), the first large HIV-1 prevention trial in Africa involving HIV-1 discordant couples, completed enrolment in May 2007. Partners HSV-2 Study recruitment data from 12 sites from East and Southern Africa were used to assess HIV-1 discordance among couples accessing couples HIV-1 counselling and testing, and to correlate with enrolment of HIV-1 discordant couples. HIV-1 discordance at Partners HSV-2 Study sites ranged from 8-31% of couples tested from the community. Across all study sites and, among all couples with one HIV-1 infected partner, almost half (49%) of couples were HIV-1 discordant. Site-specific monthly enrolment of HIV-1 discordant couples into the clinical trial was not directly associated with prevalence of HIV-1 discordance, but was modestly correlated with national HIV-1 counselling and testing rates and access to palliative care/basic health care (r = 0.74, p = 0.09). In conclusion, HIV-1 discordant couples are a critical target for HIV-1 prevention in Africa. In addition to community prevalence of HIV-1 discordance, national infrastructure for HIV-1 testing and healthcare delivery and effective community outreach strategies impact recruitment of HIV-1 discordant couples into HIV-1 prevention trials.

Editors’ note: In the screening phase for a large trial assessing the impact of herpes simplex-2 (HSV-2) suppression with acyclovir in co-infected (HIV-1, HSV-2) partners of HIV-negative, HSV-2 negative people, 51,900 couples were tested. Among all the couples tested in which HIV infection was found, 36 to 85% of them, depending on the study site, were discordant with an overall rate of 49%. Because discordant couples are such an important population for HIV prevention (in reality, HIV prevalence is 50% in the couple’s bed), community mobilisation to encourage couples to be tested as couples, rather than as individuals, and to provide social support to couples who learn their discordant or positive concordant status is an urgent public health priority.

Hallett TB, Singh K, Smith JA, White RG, Abu-Raddad LJ, Garnett GP. Understanding the impact of male circumcision interventions on the spread of HIV in Southern Africa. PLoS ONE. 2008; 3(5):e2212. Three randomised controlled trials have clearly shown that circumcision of adult men reduces the chance that they acquire HIV infection. However, the potential impact of circumcision programmes–either alone or in combination with other established approaches–is not known and no further field trials are planned. Hallett and colleagues have used a mathematical model, parameterised using existing trial findings, to understand and predict the impact of circumcision programmes at the population level. The results indicate that circumcision will lead to reductions in incidence for women and uncircumcised men, as well as those circumcised, but that even the most effective intervention is unlikely to completely stem the spread of the virus. Without additional interventions, HIV incidence could eventually be reduced by 25-35%, depending on the level of coverage achieved and whether onward transmission from circumcised men is also reduced. However, circumcision interventions can act synergistically with other types of prevention programmes, and if efforts to change behaviour are increased in parallel with the scale-up of circumcision services, then dramatic reductions in HIV incidence could be achieved. In the long-term, this could lead to reduced AIDS deaths and less need for anti-retroviral therapy. Any increases in risk behaviours following circumcision, i.e. ‘risk compensation’, could offset some of the potential benefit of the intervention, especially for women, but only very large increases would lead to more infections overall. Circumcision will not be the silver bullet to prevent HIV transmission, but interventions could help to substantially protect men and women from infection, especially in combination with other approaches.

Editors’ note: As this modelling study confirms, male circumcision can not and should not be a standalone HIV prevention strategy but rather part of a combination prevention strategy that increases choices for people. Since all methods, other than sexual abstinence, are partially protective, people should aim to combine methods for increased protection. This modelling study also estimates the potential impact for women, the subject of an important consultation being convened by WHO, UNAIDS, UNICEF, and UNFPA in Mombasa, Kenya, June 24-25 2008.

Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N; for the HIV/AIDS Prevention Research Synthesis Team. Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review. AIDS Behav 2007 ; 12(1):1-17.

Transgender populations in the United States have been affected by the HIV epidemic. This systematic review estimates the prevalence of HIV infection and risk behaviours of transgender persons. Comprehensive searches of the US-based HIV behavioural prevention literature identified 29 studies focusing on male-to-female transgender women; five of these studies also reported data on female-to-male transgender men. Using meta-analytic approaches, prevalence rates were estimated by synthesizing weighted means. Meta-analytic findings indicated that 27.7% (95% confidence interval [CI], 24.8-30.6%) of male-to-female transgender women tested positive for HIV infection (four studies), while 11.8% (95% CI, 10.5-13.2%) of male-to-female transgender women self-reported being HIV-seropositive (18 studies). Higher HIV infection rates were found among African-American male-to-female transgender women regardless of assessment method (56.3% test result; 30.8% self-report). Large percentages of male-to-female transgender women (range, 27-48%) reported engaging in risky behaviours (e.g., unprotected receptive anal intercourse, multiple casual partners, sex work). HIV prevalence and risk behaviours were low among female-to-male transgender men. Contextual factors potentially related to increased HIV risk include mental health concerns, physical abuse, social isolation, economic marginalization, and unmet transgender-specific healthcare needs. Additional research is needed to explain the causes of HIV risk behaviour of transgender persons. These findings should be considered when developing and adapting prevention interventions for transgender populations.

Editors’ note: This systematic review highlights marked differences in HIV prevalence by self-report versus actual HIV testing and in HIV prevalence and risk behaviour between male-to-female transgender women and female-to-male transgender men. In the four studies that included HIV testing, HIV prevalence in transgender women exceeded that of men who have sex with men in 5 US cities and was highest among African-American transgender women. Prevention programmes encouraging transgender persons to practice safer sex behaviours within different types of sexual relationships risk failure if they do not address the individual, interpersonal, and structural/societal contexts influencing their sexual and injecting behaviour.

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Myer L, Rebe K, Morroni C. Missed opportunities to address reproductive health care needs among HIV-infected women in antiretroviral therapy programmes. Trop Med Int Health. 2007; 12(12):1484-9.

Myer and colleagues investigate the delivery of reproductive health care services in an antiretroviral therapy programme in Cape Town, South Africa. A cross-sectional survey was conducted among 227 consecutive women attending a hospital-based antiretroviral therapy outpatient service who had been on antiretroviral therapy for at least one month. Semi-structured interviews investigating reproductive health issues and services received were conducted in participants’ home language by a trained interviewer. Sixty-seven per cent of the women were younger than 30 years and 75% were sexually active. The use of both condoms (70%) and hormonal contraceptives (31%) decreased with age, while the prevalence of sterilization (13%) increased with age. Few women knew about emergency contraception (7%) or termination of pregnancy (13%). Approximately 45% of women had had a Papanicolau smear, and this was constant across all age groups. One in 10 women had experienced verbal or physical abuse by an intimate partner since their HIV diagnosis. More than 80% of women had discussed the use of condoms and other forms of contraception with a health care provider since their HIV diagnosis, but less than 5% had discussed emergency contraception or termination of pregnancy, and no woman had discussed issues of partner violence. These data delineate the large unmet need for reproductive health services among HIV-infected women receiving antiretroviral therapy in this setting. While issues related to condom and contraceptive use are relatively well addressed, reproductive health services related to unintended pregnancy and partner violence appear to be neglected. The integration of a broad range of reproductive health services into antiretroviral therapy programmes requires urgent attention in both research and policy-making circles.

Editors’ note: Systematic investigations of the reproductive health needs of women on antiretroviral treatment in sub-Saharan Africa are rare. Most antiretroviral programmes focus on condoms and sexual risk reduction counselling to prevent ongoing sexual transmission and on contraception to prevent unwanted pregnancies and danger to the foetus posed by some antiretroviral drugs. Often they do not address comprehensive reproductive health care needs including emergency contraception, termination of pregnancy, gender-based violence, and screening to prevent cervical cancer, which is itself an AIDS-defining condition. Creating one-stop services by integrating reproductive health fully into antiretroviral programmes supports the sexual and reproductive health and rights of women living with HIV. Such integration is urgently needed both in urban settings where it may be easier to accomplish and in rural settings across sub-Saharan Africa.

Zungu-Dirwayi N, Shisana O, Louw J, Dana P. Social determinants for HIV prevalence among South African educators. AIDS Care. 2007; 19(10):1296-303.

HIV prevalence among women in South Africa continues to be high despite the availability of a comprehensive plan for the control of HIV and a plethora of prevention programmes. Any explanation for the ongoing high HIV prevalence continues to be elusive. The objective of this study was to understand the relationship between HIV, gender, race, and socioeconomic status among South African public sector educators in order to inform prevention programmes. A cross-sectional survey involving a probability sample of 1,766 schools out of 26,713 in the Department of Education Register of School Needs was selected. A sample of 24,200 respondents out of 356,749 public sector educators participated in the study. Nurses registered with the South African Nursing Council were recruited, trained to conduct interviews and to collect specimens for HIV testing. The study found an association between HIV, gender, race, and socioeconomic status among educators. African educators showed a higher HIV prevalence than other race groups. Among females, the highest HIV prevalence was among educators aged 25-35 years and in males aged 36-49 years. Further, educators with a high income and educational qualifications had a lower HIV prevalence compared to educators with low income and low educational qualifications, regardless of sex. Migration and marital factors were also found to play a role in HIV infection. The results suggest that HIV prevention needs to take into account critical issues around empowerment of vulnerable groups such as women and certain race groups to be able to implement safe sexual practices and therefore reduce HIV infections.

Editors’ note: Nearly 13% of all educators were HIV-positive in this study, a tremendous toll for any educational system. HIV prevalence in women who began teaching being married (14.7%) or engaged (11.4%) was lower than that among those who began their career being single (25.4%). Prevention programmes for young, single, female educators who are mobile are urgently needed. Educators of both sexes who were placed away from their families on completion of their studies had a significantly higher HIV prevalence. School boards need to consider the advantages of keeping teachers’ families with them to preserve mid-to-long term teaching capacity.

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Oyefara JL. Food insecurity, HIV/AIDS pandemic and sexual behaviour of female commercial sex workers in Lagos metropolis, Nigeria. SAHARA J. 2007; 4(2):626-35.

This study examined the role of hunger and food insecurity in the sexual behaviour of female sex workers in Lagos metropolis, Nigeria within the context of HIV. In addition, the study investigated the prevalence of sexually transmitted infections and induced abortion among the respondents. Cross-sectional survey and in-depth interview research methods were adopted to generate both quantitative and qualitative data from the respondents. The study showed that 35.0% of the respondents joined the sex industry because of poverty and lack of other means of getting daily food. While all the respondents had knowledge about the existence of HIV and AIDS, 82.0% of them identified sexual intercourse as a major route of HIV transmission. There was a significant relationship between poverty, food insecurity, and consistent use of condoms by female sex workers at P<0.01. Specifically, only 24.7% of the respondents used condoms regularly in every sexual act. Consequently, 51.6% had previous cases of sexually transmitted infections. The most prevalent sexually transmitted infection among the respondents was gonorrhoea, with 76.4% prevalence among ever infected female sex workers. This was followed by syphilis with a prevalence of 21.1%. In addition, 59.1% of the sample had become pregnant while on the job and 93.1% of these pregnancies were aborted through induced abortion. In conclusion, hunger and malnutrition were the factors that pushed young women into prostitution in Nigeria and these same factors hindered them from practicing safe sex within the sex industry. Thus, it is recommended that the Nigerian government should develop programmes that will reduce hunger and food insecurity, in order to reduce rapid transmission of HIV infection in the country.

Editors’ note: The links between hunger, food insecurity, and vulnerability to HIV described by this article are brought into sharp relief by the current global food crisis. Improving local food production to meet basic food needs not only helps reduce poverty levels; it pulls the rug out from under food insecurity as a driver of the HIV epidemic.

Salemi M, de Oliveira T, Ciccozzi M, Rezza G, Goodenow MM. High-Resolution Molecular Epidemiology and Evolutionary History of HIV-1 Subtypes in Albania. PLoS ONE. 2008 Jan 2;3(1):e1390.

The HIV-1 epidemic in Western Europe is largely due to subtype B. Little is known about the HIV-1 in Eastern Europe, but a few studies have shown that non-B subtypes are quite common. In Albania, where a recent study estimated a ten-fold increase of AIDS incidence during the last six years, subtype A and B account for 90% of the known infections. Salemi and colleagues investigated the demographic history of HIV-1 subtype A and B in Albania by using a statistical framework based on coalescent theory and phylogeography. High-resolution phylogenetic and molecular clock analysis showed a limited introduction to the Balkan country of subtype A during the late 1980s followed by an epidemic outburst in the early 1990s. In contrast, subtype B was apparently introduced multiple times between the mid-1970s and mid-1980s. Both subtypes are growing exponentially, although the HIV-1A epidemic displays a faster growth rate, and a significantly higher basic reproductive number R(0). HIV-1A gene flow occurs primarily from the capital Tirane, in the center of the country, to the periphery, while HIV-1B flow is characterized by a balanced exchange between center and periphery. Finally, the authors calculated that the actual number of infections in Albania is at least two orders of magnitude higher than previously thought. The analysis demonstrates the power of recently developed computational tools to investigate molecular epidemiology of pathogens, and emphasize the complex factors involved in the establishment of HIV-1 epidemics. The authors suggest that a significant correlation exists between HIV-1 exponential spread and the socio-political changes occurred during the Balkan wars. The fast growth of a relatively new non-B epidemic in the Balkans may have significant consequences for the evolution of HIV-1 epidemiology in neighboring countries in Eastern and Western Europe.

Editors’ note: Phylogenies reconstructed from randomly sampled viral gene sequences can give insight into population-level changes and epidemic dynamics. This study of treatment-naïve subjects who had no major mutations associated with drug resistance was able to describe the quite different trajectories of both subtype A and subtype B during a time of socio-political turmoil in the region. It has implications for further epidemic monitoring and for intensified prevention programmes.

Lewis F, Hughes GJ, Rambaut A, Pozniak A, Leigh Brown AJ. Episodic sexual transmission of HIV revealed by molecular phylodynamics. PLoS Med. 2008;5(3):e50.

The structure of sexual contact networks plays a key role in the epidemiology of sexually transmitted infections, and their reconstruction from interview data has provided valuable insights into the spread of infection. For HIV, the long period of infectivity has made the interpretation of contact networks more difficult, and major discrepancies have been observed between the contact network and the transmission network revealed by viral phylogenetics. The high rate of HIV evolution in principle allows for detailed reconstruction of links between virus from different individuals, but often sampling has been too sparse to describe the structure of the transmission network. The aim of this study was to analyze a high-density sample of an HIV-infected population using recently developed techniques in phylogenetics to infer the short-term dynamics of the epidemic among men who have sex with men. Sequences of the protease and reverse transcriptase coding regions from 2,126 patients, predominantly men who have sex with men , from London were compared: 402 of these showed a close match to at least one other subtype B sequence. Nine large clusters were identified on the basis of genetic distance; all were confirmed by Bayesian Monte Carlo Markov chain phylogenetic analysis. Overall, 25% of individuals with a close match with one sequence are linked to 10 or more others. Dated phylogenies of the clusters using a relaxed clock indicated that 65% of the transmissions within clusters took place between 1995 and 2000, and 25% occurred within 6 months after infection. The likelihood that not all members of the clusters have been identified renders the latter observation conservative. In conclusion, reconstruction of the HIV transmission network using a dated phylogeny approach has revealed the HIV epidemic among men who have sex with men in London to have been episodic, with evidence of multiple clusters of transmissions dating to the late 1990s, a period when HIV prevalence is known to have doubled in this population. The quantitative description of the transmission dynamics among men who have sex with men will be important for parameterization of epidemiological models and in designing intervention strategies.

Editors’ note: This first report of the application of phylodynamics to HIV-sequence data-mining reveals discrete outbreaks among men who have sex with men in London over a 5 year period in the late 1990s fuelled by efficient transmission during acute infection. As pointed out in the accompanying editorial by Pilcher et al in this open access journal, this suggests the need for stronger emphasis on outbreak detection and network intervention strategies. This may be increasingly possible as more newly diagnosed patients have resistance testing performed but ensuring the confidentiality and security of data will be key in balancing individual privacy rights with scientific and public health objectives.

Hargrove JW, Humphrey JH, Mutasa K, Parekh BS, McDougal JS, Ntozini R, Chidawanyika H, Moulton LH, Ward B, Nathoo K, Iliff PJ, Kopp E. Improved HIV-1 incidence estimates using the BED capture enzyme immunoassay. AIDS. 2008;22(4):511-8.

Hargrove and colleagues aimed to validate the BED capture enzyme immunoassay for HIV-1 subtype C and to derive adjustments facilitating estimation of HIV-1 incidence from cross-sectional surveys. Laboratory analysis of archived plasma samples collected in Zimbabwe were performed. Serial plasma samples from 85 women who seroconverted to HIV-1 during the postpartum year were assayed by BED and used to estimate the window period between seroconversion and the attainment of a specified BED absorbance. HIV-1 incidences for the year prior to recruitment and for the postpartum year were calculated by applying the BED technique to HIV-1-positive samples collected at baseline and at 12 months. The mean window for an absorbance cut-off of 0.8 was 187 days. Among women who were HIV-1 positive at baseline and retested at 12 months, a proportion (epsilon) 5.2% (142/2749) had a BED absorbance < 0.8 at 12 months and were falsely identified as recent seroconverters. Consequently, the estimated BED annual incidence at 12 months postpartum (7.6%) was 2.2 times the contemporary prospective estimate. BED incidence adjusted for epsilon was 3.5% [95% confidence interval (CI), 2.6-4.5], close to the 3.4% estimated prospectively. Adjusted BED incidence at baseline was 6.0% (95% CI, 5.2-6.9) and, like the prospective estimates, declined with maternal age. Unadjusted BED incidence estimates were largely independent of age; the pooled estimate was 58% higher than adjusted incidence. The authors conclude that the BED method can be used in an African setting, but further estimates of epsilon and of the window period are required, using large samples in a variety of circumstances, before its general utility can be gauged.

Editors’ note: In December 2005, UNAIDS recommended against the use of the BED technique during routine HIV surveillance for estimating absolute HIV incidence or monitoring trends. This was because of the high number of false positive results for HIV incidence, i.e. people who had been living with HIV infection for a long time appeared to be recent seroconverters. The compensatory procedure identified here for sub-type C epidemics is promising but requires estimates of ‘epsilon’ in large samples from a variety of circumstances. Ideally, these should be obtained by comparing BED estimates with HIV incidence figures from other sources, as was done here.

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Chen XS, Yin YP, Tucker JD, Gao X, Cheng F, Wang TF, Wang HC, Huang PY, Cohen MS. Detection of Acute and Established HIV Infections in Sexually Transmitted Disease Clinics in Guangxi, China: Implications for Screening and Prevention of HIV Infection. J Infect Dis. 2007;196:1654-61.

Human immunodeficiency virus (HIV) has spread throughout China and to some degree has penetrated the general heterosexual population in some regions. A cross-sectional survey of 11,461 sexually transmitted disease (STD) clinic attendees in 8 cities in Guangxi, China, was conducted for syphilis and for acute and established HIV infections. The prevalence of HIV was 1.2% among the participants. Five acute (pre-seroconversion) HIV infections were detected. Multivariate analysis showed that HIV infection was independently related to unmarried status (odds ratio [OR], 1.73 [95% confidence interval {CI}, 1.00-2.99), less education (OR for less than primary school, 4.21 [90% CI, 1.21-14.58]), residence in city A (OR, 11.48 [95% CI, 2.05-64.31]) or city B (OR, 7.93 [95% CI, 1.75-35.91]), working in the entertainment industry (OR, 3.98 [95% CI, 1.14-13.88]), injection drug use (OR, 25.09 [95% CI, 10.43-60.39]), no condom use during most recent sexual intercourse (OR, 4.97 [95% CI, 1.38-17.88]), and syphilitic infection (OR, 1.91 [95% CI, 1.03-3.56]). Chen and colleagues conclude that the HIV prevalence in STD clinics is significantly greater than that in the general population, and subjects were identified who would be missed by conventional surveillance. China’s nationwide system of public STD clinics, which reach down to the township level, should be used for HIV control programs.

Editors’ note: With nearly half of new HIV infections in China in 2006 a result of heterosexual transmission, China needs to rapidly move on this front to increase the low condom use rates, particularly in the context of sex work. Large numbers of migrant labourers are on the move and sex with a sex worker in the previous year was reported by 9% of men in a population-based survey. In addition, China’s imbalanced sex ratios have created a population of young, poor, unmarried men of low education who are at higher sexual risk of HIV infection, Changing the conditions of sex work to 100% condom use and introducing provider-initiated HIV testing in STD clinics under conditions of the 3 Cs (consent, confidentiality, and counselling) are critical actions in what is clearly a shifting epidemic.