HIV This Week

Sebert Kuhlmann AK, Kraft JM, Galavotti C, Creek TL, Mooki M, Ntumy R. Radio role models for the prevention of mother-to-child transmission of HIV and HIV testing among pregnant women in Botswana. Health Promot Int. 2008 Apr 11 [Epub ahead of print]

Although Botswana supports a program for the prevention of mother-to-child-transmission of HIV (PMTCT), many women initially did not take advantage of the program. Using data from a 2003 survey of 504 pregnant and post-partum women, Sebert Kuhlmann and his colleagues assessed associations between exposure to a long-running radio serial drama that encourages use of the PMTCT program and HIV testing during pregnancy. Controlling for demographic, pregnancy and other variables, women who spontaneously named a PMTCT character in the serial drama as their favourite character were nearly twice as likely to test for HIV during pregnancy as those who did not. Additionally, multiparity, knowing a pregnant woman taking AZT, having a partner who tested, higher education and PMTCT knowledge were associated with HIV testing during pregnancy. Identification with characters in the radio serial drama is associated with testing during pregnancy. Coupled with other supporting elements, serial dramas could contribute to HIV prevention, treatment and care initiatives.

Editors’ note: This programme went further than public service announcements and counselling sessions to raise awareness of PMTCT services. It used two fundamental principles: modelling (showing people how to change) and reinforcement (supporting their efforts to change and to maintain healthy behaviours). The radio drama was the modelling component and may have helped some women to see HIV testing in pregnancy as a good choice supported by social norms. It is interesting to speculate whether this programme paved the way for broad acceptance of the introduction of a routine offer of antenatal testing in 2004.

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Wringe A, Isingo R, Urassa M, Maiseli G, Manyalla R, Changalucha J, Mngara J, Kalluvya S, Zaba B. Uptake of HIV voluntary counselling and testing services in rural Tanzania: implications for effective HIV prevention and equitable access to treatment. Trop Med Int Health. 2008;13(3):319-27.

Wringe and colleagues aimed to describe the associations between socio-demographic, behavioural and clinical characteristics and the use of HIV voluntary counselling and testing (VCT) services among residents in a rural ward in Tanzania. Eight thousand nine hundred and seventy participants from a community-based cohort were interviewed, provided blood for research HIV testing, and were offered VCT. Univariate and multivariate logistic regression was used to identify socio-demographic, clinical, and behavioural factors associated with VCT use. Although 31% (1246/3980) of men and 24% (1195/4990) of women expressed an interest in the service, only 12% of men and 7% of women subsequently completed VCT. Socio-demographic factors, such as marital status, area of residence, religion and ethnicity influenced VCT completion among males and females in different ways, while self-perceived risk of HIV, prior knowledge of VCT, and sex with a high-risk partner emerged as important predictors of VCT completion among both sexes. Among males only, those infected with HIV for 5 years or less tended to self-select for VCT compared to HIV-negatives (adjusted odds ratio = 1.43; 95% CI: 0.99-2.14). This contributed to a higher proportion of HIV-positive males knowing their status compared to HIV-positive females.  In this setting, a disproportionate number of HIV-positive women are failing to learn their status, which has implications for equitable access to onward referral for care and treatment services. Evidence that some high-risk behaviours may prompt VCT use is encouraging, although further interventions are required to improve knowledge about HIV risk and the benefits of VCT. Targeted interventions are also needed to promote VCT uptake among married women and rural residents.

Editors´note: Both the proportion of people interested in learning their HIV serostatus and the proportion of people who actually got tested are very low for a country with a sizeable HIV epidemic. It is likely that fear of stigma and discrimination had remained an important barrier to HIV testing during this study, since the Tanzanian government had already announced on radio and in newspapers that it intended to start providing free antiretroviral treatment though major hospitals.

Watts DH, Park JG, Cohn SE, Yu S, Hitti J, Stek A, Clax PA, Muderspach L, Lertora JJ. Safety and tolerability of depot medroxyprogesterone acetate among HIV-infected women on antiretroviral therapy: ACTG A5093. Contraception. 2008;77(2):84-90. Epub 2007 Dec 21.

Concomitant use of antiretroviral drugs and hormonal contraceptives may change the metabolism of each and the resulting safety profiles. We evaluated the safety and tolerability of depot medroxyprogesterone acetate among women on antiretroviral drugs. HIV-infected women on selected antiretroviral drug regimens or no antiretroviral drugs were administered medroxyprogesterone acetate 150 mg intramuscularly and evaluated for 12 weeks for adverse events, changes in CD4+ count and HIV RNA levels, and ovulation. Seventy evaluable subjects were included, 16 on nucleoside only or no antiretroviral drugs, 21 on nelfinavir-containing regimens, 17 on efavirenz-containing regimens and 16 on nevirapine-containing regimens. Nine Grade 3 or 4 adverse events occurred in seven subjects; none were judged related to medroxyprogesterone acetate. The most common findings possibly related to medroxyprogesterone acetate were abnormal vaginal bleeding (nine, 12.7%), headache (three, 4.2%), abdominal pain, mood changes, insomnia, anorexia and fatigue, each occurring in two (2.9%) subjects. No significant changes in CD4+ count or HIV RNA levels occurred with DMPA. No evidence of ovulation was detected, and no pregnancies occurred. In conclusion, the clinical profile associated with medroxyprogesterone acetate administration in HIV-infected women, most on antiretroviral drugs, appears similar to that seen in HIV-uninfected women. medroxyprogesterone acetate prevented ovulation and did not affect CD4+ counts or HIV RNA levels. In concert with previously published medroxyprogesterone acetate/antiretroviral drugs interaction data, these data suggest that medroxyprogesterone acetate can be used safely by HIV-infected women on the antiretroviral drugs studied.

Editors´note: These results are reassuring, particularly for women on efavirenz, a drug with potential teratogenic effects. However, the number of study participants was small and this was a 12-week study. Long-term DMPA use is associated with increases in weight and fat distribution, which may be exacerbated by some antiretroviral drugs.

Bock J, Johnson. Grandmothers’ Productivity and the HIV/AIDS Pandemic in sub-Saharan Africa. J Cross Cult Gerontol. 2008 Jan 8.

The human immunodeficiency virus (HIV) pandemic has left large numbers of orphans in sub-Saharan Africa. Botswana has an HIV prevalence rate of approximately 40% in adults. Morbidity and mortality are high, and in a population of a 1.3 million there are nearly 50,000 children who have lost one or both parents to HIV. The extended family, particularly grandparents, absorbs much of the childrearing responsibilities. This creates large amounts of additional work for grandmothers especially. The embodied capital model and the grandmother hypothesis are both derived from life history theory within evolutionary ecology, and both predict that one important factor in the evolution of the human extended family structure is that post-reproductive individuals such as grandmothers provide substantial support to their grandchildren’s survival. Data collected in the pre-pandemic context in a traditional multi-ethnic community in the Okavango Delta of Botswana are analyzed to calculate the amount of work effort provided to a household by women of different ages. Results show that the contributions of older and younger women to the household in term of both productivity and childrearing are qualitatively and quantitatively different. These results indicate that it is unrealistic to expect older women to be able to compensate for the loss of younger women’s contributions to the household, and that interventions be specifically designed to support older women based on the type of activities in which they engage that affect child survival, growth, and development.

Editors’ note: This study found that grandmothers are unable to substitute their labour for that of younger women lost to the family because of the energy intensity (strength and stamina) required for grain-processing. Further, the more time they allocate to food production, the less time they have for seeking and processing traditional wild foods that provide high levels of micronutrients and phytochemicals. They also can no longer produce traditional craft items such as the baskets, fishing implements, and tools essential to the productivity of all members of the household. Critically, their grandchildren have no means to acquire the skills and knowledge about traditional activities from them that are key to their long-term survival. Interventions to compensate for lost labour should support grandmothers in pursuing their traditional roles and activities.

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Larson BA, Fox MP, Rosen S, Bii M, Sigei C, Shaffer D, Sawe F, Wasunna M, Simon JL. Early effects of antiretroviral therapy on work performance: preliminary results from a cohort study of Kenyan agricultural workers. AIDS. 2008; 22(3):421-5.

This paper estimates the impact of antiretroviral therapy on days harvesting tea per month for tea-estate workers in Kenya. Such information is needed to assess the potential economic benefits of providing treatment to working adults. Data for this analysis come from company payroll records for 59 HIV-infected workers and a comparison group of all workers assigned to the same work teams (reference group, n = 1992) for a period covering 2 years before and 1 year after initiating antiretroviral therapy. Mean difference tests were used to obtain overall trends in days harvesting tea by month. A difference in difference approach was used to estimate the impact of HIV on days working in the pre-antiretroviral therapy period. Information on likely trends in the absence of the therapy was used to estimate the positive impacts on days harvesting tea over the initial 12 months on antiretroviral therapy. No significant difference existed in days plucking tea each month until the ninth month before initiating antiretroviral therapy, when workers worked -2.79 fewer days than references (15% less). This difference grew to 5.09 fewer days (27% less) in the final month before initiating antiretroviral therapy. After 12 months on antiretroviral therapy, Larson and colleagues conservatively estimate that workers worked at least twice as many days in the month than they would have in the absence of antiretroviral therapy. In conclusion treatment had a large, positive impact on the ability of workers to undertake their primary work activity, harvesting tea, in the first year on antiretroviral therapy.

Editors’ note: This study found that tea pluckers placed on antiretroviral treatment worked 7.5 to 9.5 days more harvesting tea in month 12 than they would have worked in the absence of antiretroviral treatment. A large cohort and a longer period of follow-up are required to determine the impact of antiretroviral treatment on work performance over the long term but these are promising initial findings.

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.

Hoffman RM, Umeh OC, Garris C, Givens N, Currier JS. Evaluation of Sex Differences of Fosamprenavir (With and Without Ritonavir) in HIV-Infected Men and Women. HIV Clin Trials. 2007; 8(6):371-80.

Recent studies focusing on HIV-1-infected women have suggested the existence of sex-related differences in natural history, antiretroviral pharmacokinetics, efficacy, and tolerability. This article analyzes three pivotal trials of the protease inhibitor (PI) fosamprenavir (FPV) with a view to providing a better understanding of potential sex differences in efficacy and safety. A post hoc, descriptive analysis was performed on data from 700 subjects (26% women) in three trials of FPV to evaluate sex differences with regard to efficacy, rates of discontinuation, and treatment-related adverse events. No major sex differences were found. Men and women had similarly good antiviral responses, with greater than 60% of treatment-naïve subjects achieving virologic suppression (<400 copies/mL) at 48 weeks. PI-experienced women in CONTEXT receiving once-daily FPV/r experienced the highest rates of discontinuations due to virologic failure (29% in women vs. 8% in men). Women generally had slightly lower rates of liver enzyme elevations and fewer abnormalities of total cholesterol and triglycerides. In conclusion, the absence of major sex differences provides reassurance, but the small number of women in these trials limited the ability to draw conclusions. Future trials should be specifically powered to detect sex differences in safety and efficacy.

Editors’ note: This retrospective analysis attempts to pull together data from three trials to overcome the low numbers of participating women. Finding no sex-based differences does not mean that these do not exist when studies are not designed to be able to detect them. The December 2007 Geneva consultation ‘Making HIV trials work for women and adolescent girls’ concluded that for clinical trials to include a scientifically meaningful number of women, a new norm in clinical trial conduct would need to be fostered.

van Leeuwen E, Wit FW, Repping S, Eeftinck Schattenkerk JK, Reiss P, van der Veen F, Prins JM. Effects of antiretroviral therapy on semen quality. AIDS. 2008; 22(5):637-42.

Van Leeuwen and colleagues aimed to evaluate the effect of combination antiretroviral therapy on semen quality in a longitudinal cohort study from the HIV outpatient clinic of the Academic Medical Centre in Amsterdam, the Netherlands. A cohort of 34 male patients with different estimated duration of HIV-1 infection, who were about to start various combinations of combination antiretroviral therapy, were included. Blood and semen were analyzed before the start of combination antiretroviral therapy and 4, 12, 24, 36 and 48 weeks thereafter. The authors examined the effect of combination antiretroviral therapy on semen parameters by a repeated measurements procedure using a mixed-effects model. The median period of follow up was 48 weeks (interquartile range 33-52 weeks). Five patients used thymidine analogue-containing combination antiretroviral therapy, 23 used tenofovir-based combination antiretroviral therapy, six used other regimens. At all timepoints the percentage of progressively motile spermatozoa was low according to WHO criteria, and it decreased significantly from 28 to 17% during follow-up (P = 0.02). All other semen parameters were in the normal range and remained stable. In conclusion, combination antiretroviral therapy negatively affected the percentage of progressively motile spermatozoa. Whether this reduced motility affects the chances of fathering a child or leads to an increased need for artificial reproductive techniques is at present unknown.

Editors’ note: This longitudinal study was short in duration but had the advantage that each man starting on antiretroviral treatment served as his own before/after control. All semen parameters remained normal with the exception of reduced spermatozoa motility. This may be mediated by mitochondrial dysfunction causing mitochondrial depletion or by some other mechanism linked to one or more drug classes. Whether this effect persists over time and whether it has an effect on fertility remain unknown and deserve more study.

Allen S, Stephenson R, Weiss H, Karita E, Priddy F, Fuller L, Declercq A. Pregnancy, hormonal contraceptive use, and HIV-related death in Rwanda. J Womens Health (Larchmt) 2007; 16:1017-27.

Few studies have examined the influence of pregnancy and hormonal contraception on HIV-related deaths in African women. Rwanda is a country with high fertility, high HIV prevalence, and frequent use of hormonal contraception in urban areas. Data from a prospective cohort study of 460 urban childbearing (18-35 years) women living with HIV followed at 6-monthly intervals for 6 years in Kigali, Rwanda, were analyzed. The relationship of time-dependent measures of pregnancy and hormonal contraceptive use to death from HIV disease was assessed with multivariate models. Incident pregnancy was not associated with elevated risk of death among women living with HIV. Oral and injectable hormonal contraceptive use had borderline protective effects associated with reduced mortality (HR 0.40, 95% CI 0.15-1.07 and HR 0.48, 95% CI 0.21-1.08 for mortality, respectively) in a multivariate model including time-dependent measures. In conclusion, the results point to the benefits of integrating family planning and HIV services. In a highly pronatalist society, such as Rwanda, which is experiencing high HIV prevalence, service integration affords an opportunity to provide HIV testing to women at risk of pregnancy and to promote family planning among women living with HIV.

Editors’ note: Women (and men for that matter) when diagnosed HIV-positive, and when starting on antiretroviral therapy, should be asked about their fertility intentions and counselled concerning their options. More attention is needed urgently to integrate reproductive health and HIV services to ensure that unplanned pregnancies are avoided and HIV transmission risk during pregnancy, childbirth, and breastfeeding is minimised.

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Macphail C, Pettifor AE, Pascoe S, Rees HV. Contraception use and pregnancy among 15-24 year old South African women: a nationally representative cross-sectional survey. BMC Med 2007; 5:31.

Adolescent reproductive health has not continued to receive the attention it deserves since the start of the HIV epidemic. In South Africa, high numbers of adolescent women report pregnancies that are unwanted and yet few have accessed available termination of pregnancy services. Enabling contraception use is vital for meeting the goals of HIV prevention. A nationally representative survey of South African 15-24 year olds was undertaken. Participants completed a questionnaire on sexual behaviour and provided an oral fluid sample for HIV testing. Analysis of the data was restricted to women (n = 6 217), particularly those who reported being sexual active in the last 12 months (n = 3 618 ) and was conducted using methods allowing for sample strata, primary sampling units and population weights in the program STATA 8.0. Univariate and multivariate analyses were conducted to explore factors associated with contraceptive use. Two thirds of all women reported having ever been sexually active and among these 87% were sexually active in the past 12 months. Among women who reported currently being sexually active, 52.2% reported using contraceptives. There was evidence of association between contraceptive use and being employed or a student (vs unemployed); fewer sex partners; type of last sex partner; having talked to last partner about condom use, and having ever been pregnant. The authors conclude that specific emphasis must be placed on encouraging young women to use contraceptive methods that offer protection against pregnancy and STIs/HIV. The consistent finding of a relationship between discussing condom use with partners and condom use indicates the importance of involvement of male partners in women’s contraceptive decisions.

Editors’ note: Male partners are more likely to get involved and young women are more likely to involve them in both HIV prevention and contraception decision making if they develop communication skills in sexual relationships. Behaviours that result in unwanted pregnancy are also those that lead to HIV transmission. Breaking the silence to talk about protection must become the social norm among young, sexually active people everywhere.

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Smith DJ, Mbakwem BC. Life projects and therapeutic itineraries: marriage, fertility, and antiretroviral therapy in Nigeria. AIDS. 2007;21 Suppl 5:S37-41.

Smith and colleagues aimed to examine and understand the marital and fertility aspirations and behaviours of individuals receiving antiretroviral therapy in Nigeria and evaluate the effects on sexual behaviour, disclosure, and adherence. The study used ethnographic methods of participant observation and in-depth interviews of individuals receiving antiretroviral therapy through a government-supported programme in southeastern Nigeria. Interviews and observations of individuals on treatment demonstrate that marriage and childbearing are paramount desires for people whose health is restored by antiretroviral therapy. The concept of life projects is introduced and combined with the established idea of therapeutic itineraries to show how participation in and adherence to treatment, disclosure of HIV status, and decisions about sexual behaviour cannot be understood in purely biomedical terms. Marital and reproductive aspirations routinely impinge on and often trump clinical and public health priorities. Emblematic case studies are provided to illustrate the social dynamics that motivate and explain behaviour seemingly inimical to individual and public health. In conclusion effective antiretroviral programme design and therapy management will require acknowledging and often enabling rather than discouraging the marital and reproductive goals of individuals if issues of disclosure, adherence, and prevention are to be realistically addressed.

Editors’ note: Antiretroviral treatment can lead to the restoration of life projects that may have been abandoned, such as developing long-term partnerships and having children. Enabling people to navigate these new horizons with joy and satisfaction in ways that are safe for themselves and others is a welcome challenge.

Frye V, Latka MH, Wu Y, Valverde EE, Knowlton AR, Knight KR, Arnsten JH, O’Leary A; INSPIRE Study Team. Intimate partner violence perpetration against main female partners among HIV-positive male injection drug users. J Acquir Immune Defic Syndr. 2007;46 Suppl 2:S101-9.

Intimate partner violence against women is a serious public health and social problem and is associated with a host of adverse health outcomes and behaviours, HIV risk behaviours included, among women who are victimized. Historically, research has focused on correlates of intimate partner violence victimization among women; thus, there is less information on the role of men in perpetrating intimate partner violence, particularly among men at risk for transmitting HIV to their female partners. Frye and colleagues assessed the self-reported prevalence and correlates of perpetration and threat of perpetration of physical and/or sexual intimate partner violence against a main female partner among 317 men with HIV who were current injection drug users. More than 40% of men reported perpetrating physical (39%) and/or sexual (4%) violence against their main female partners in the past year. Multivariate analyses revealed that low education, homelessness, psychologic distress, and unprotected sex with main and non-main HIV-negative female partners were positively associated with intimate partner violence perpetration against main female partners. These findings reveal that intimate partner violence perpetration is prevalent among HIV-positive male injecting drug users and associated with sexual HIV transmission risk behaviours. Intimate partner violence assessment and treatment among HIV-positive men in HIV care is recommended as a way to prevent intimate partner violence perpetration andvictimization and to reduce potential HIV transmission.

Editors’ note: Although more research is needed to better understand how HIV and drug involvement influence the natural history of intimate partner violence across the life span, programmes are needed now to address the dynamics of abusive relationships, reduce the violence, and prevent HIV transmission. HIV care services need to integrate the assessment and treatment of both violence experience and violence perpetration.

Maganja RK, Maman S, Groues A, Mbwambo JK. Skinning the goat and pulling the load: transactional sex among youth in Dar es Salaam, Tanzania. AIDS Care. 2007;19:974-81.

Transactional sex has been associated with risk of HIV infection in a number of studies throughout sub-Saharan Africa. Urban young women are economically vulnerable and at heightened risk of HIV infection in Tanzania; yet there are few studies that have explored relationship dynamics, including transactional sex, in this setting. This paper sheds light on the broader context of sexual relationships among youth at risk for HIV, how transactional sex plays out in these relationships, and how the transactional nature of relationships affects women’s risk for HIV. Maganja and colleagues conducted 60 in-depth interviews and 14 focus group discussions with young men and women, 16-24 years old, in Dar es Salaam, Tanzania. These data guided the development of a community-based HIV and violence prevention intervention for young men. Youth described the exchange of sex for money or other material goods in all types of sexual relationships. While the exchange was explicit in casual relationships, young women voiced material and monetary expectations from their committed partners as well. Young men described their pursuit of multiple partners as sexually motivated, while women sought multiple partners for economic reasons. Young men were aware of the expectations of material support from partners, and acknowledged that their ability to provide for a partner affected both the longevity and exclusivity of their relationships. Youth described a deep mistrust of the motivations and commitment of their sexual partners. Furthermore, young women’s financial dependence on men affected their ability to negotiate safe sexual behaviours in both casual and committed relationships. Programmes designed to reduce HIV risk among Tanzanian youth need to take into account the transactional component of sexual relationships and how such exchanges differ according to partner type.

Editors’ note: Giving and receiving gifts from sexual partners is a worldwide phenomenon. When the strategy is ‘skinning the goat’ ( Tanzania), ‘detoothing’ ( Uganda), or extracting resources from male partners, women are less likely to negotiate safer sex and both sexes may mistrust and disrespect each other. Prevention programmes that overlook these dynamics influencing risk and safety are missing the boat. The challenge is to find ways to shift gender imbalances in access to resources, engage young men to change attitudes to power and control in relationships, and encourage alternative ways of expressing love and respect by both sexes.

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Poulin M. Sex, money, and premarital partnerships in southern Malawi. Soc Sci Med. 2007;65(11):2383-93.

In this paper, Poulin argues two main points. First, in premarital, sexual partnerships in rural Malawi, the purpose of money exchange extends beyond the alleviation of female partners’ economic constraints. Second, by clarifying this broader purpose, it becomes possible to recognize where women exert control over their own sexual selves. These findings come from field observations and a rich set of in-depth interviews (N=54), bolstered on occasion by survey data, conducted with young women and men, aged 15-24 years, in the Balaka district in the southern region of the country. This research demonstrates that, contrary to typical expectations, money and gift transfers in sexual partnerships are part and parcel of the courting practices of young Malawian women and men. Transfers are as much about the expression of love and commitment as they are about meeting the financial needs of women or the acquisition of sex for men. Using narrative information to shed light on the semiotics of the sex-money link, these findings from Malawi offer a new perspective that broadens usual interpretations of transactional sex, the understanding of which is critical in a responding to AIDS.

Editors’ note: For young people in this rural Malawi district, money gifts mark commitment, love, and movement towards marriage. Girls interpret them as loving gestures and boys intend for them to be interpreted that way. Many young women appear to have decision-making power over partner choice, condom use, and acting on sexual desire – challenging typical notions of ‘transactional sex’ and encouraging us to be more nuanced in our understanding.

Ng’andwe C, Lowe JJ, Richards PJ, Hause L, Wood C, Angeletti PC. The distribution of sexually transmitted Human Papillomaviruses in HIV positive and negative patients in Zambia, Africa. BMC Infect Dis 2007;7:77. http://www.biomedcentral.com/content/pdf/1471-2334-7-77.pdf.

Human Papillomaviruses (HPV) are double-stranded DNA viruses, considered to be the primary etiological agents in cervical intraepithelial neoplasias and cancers. Approximately 15-20 of the 40 mucosal HPVs confer a high-risk of progression of lesions to invasive cancer. In this study, Ng’anwe and colleagues investigated the prevalence of sexually transmitted HPVs in Human Immunodeficiency Virus (HIV) positive and negative patients in Zambia, Africa. The rate of high-risk HPV genotypes worldwide varies within each country. Thus, we sought to investigate the rates of HPV infection in sub-Saharan Africa and the potential role of HIV in affecting the HPV genotype distribution. This retrospective cross-sectional study reports findings on the association and effects of HIV on HPV infections in an existing cohort of patients at University Teaching Hospital (UTH) Lusaka, Zambia. The objective of this study was to assess HPV prevalence, genotype distribution and to identify co-factors that influence HPV infection. Polymerase chain reaction (PCR) with two standard consensus primer sets (CpI/II and GP5+/6+) was used to test for the presence of HPV DNA. Primers specific for b-actin were used to monitor DNA quality. Vaginal lavage samples collected between 1998-1999 from total of 70 women from a larger cohort that were analyzed for HIV and human herpesvirus infection. Seventy of the samples yielded usable DNA. HIV status was determined by two rapid assays, Capillus and Determine. The incidence of HIV and HPV infections and HPV genotype distributions were calculated and statistical significance was determined by Chi-Squared test. Ng’andwe and colleagues determined that most common HPV genotypes detected among these Zambian patients were types 16 and 18 (21.6% each), which is approximately three-fold greater than the rates for HPV16, and ten-fold greater than the rates for HPV18 in the United States. The worldwide prevalence of HPV16 is approximately 14% and HPV18 is 5%. The overall ratio of high-risk  to low-risk  HPVs in the patient cohort was 69% and 31% respectively; essentially identical to that for the HR and LR distributions worldwide. However, we discovered that HIV positive patients were two-times as likely to have an high risk HPV as HIV negative individuals, while the distribution of low risk HPVs was unaffected by HIV status. Interestingly, we observed a nine-fold increase in HPV18 infection frequency in HIV positive versus HIV negative individuals. The rate of oncogenic HPVs (type 16 and 18) in Zambia was much higher than in the U.S., potentially providing an explanation for the high-rates of cervical cancer in Zambia. Surprisingly, we discovered a strong association between positive HIV status and the prevalence of high risk HPVs, and specifically HPV18.

Editors’ note: Although the sample size is small, the findings are striking and provide justification for the introduction of a public health HPV vaccine programme in Zambia where the immunosuppressive effects of HIV infection may be contributing to the surprising levels of high risk HPV 16 and 18. Public sector prices for low-and middle- income countries for the quadrivalent recombinant vaccine against HPV 6, 11, 16, 18 (Merck’s GARDASIL) and the bivalent recombinant vaccine against HPV 16, 18 (Glaxo Smith Kline’s CERVARIX) are urgently needed. For example, GARDASIL, which is being rolled out in some industrial countries now, costs an estimated $360 for the three dose series.

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Franceschi S, Jaffe H. Cervical cancer screening of women living with HIV infection: a must in the era of antiretroviral therapy. Clin Infect Dis 2007;45:510-3.

Women living with human immunodeficiency virus (HIV) infection have a much higher risk of human papillomavirus infection and cervical cancer than do HIV-negative women. Before the introduction of antiretroviral therapy, the lack of cervical cancer screening among HIV-positive women probably had little influence on their life expectancies because of the high competing mortality associated with other causes, but the situation is changing rapidly everywhere. In sub-Saharan Africa, for instance, approximately 400,000 HIV-positive women were receiving antiretroviral therapy in 2005. Funds given to antiretroviral therapy programs in low-resource countries not only support the purchase of drugs, but they also support the development of clinical infrastructures and laboratories. Because women who receive antiretroviral therapy are observed regularly, they can also receive the continuity of care needed for cervical screening. Therefore, the real opportunity to prevent cervical cancer in HIV-positive women in low-resource countries should not be missed, especially as new, inexpensive screening methods (e.g., rapid human papillomavirus tests) are under evaluation.

Editors’ note: Until universal HPV vaccination strategies are in place, preventing avoidable deaths due to cervical cancer relies on early diagnosis. Comprehensive care for women living with HIV includes regular cervical screening to detect and treat the HPV-induced cervical lesions that can lead to carcinoma of the cervix, an AIDS-defining disease.

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Barreiro P, Castilla JA, Labarga P, Soriano V. Is natural conception a valid option for HIV-serodiscordant couples? Hum Reprod 2007 Sep;22(9):2353-8.

The remarkable reduction in HIV-related morbidity and mortality as a consequence of the widespread use of highly active antiretroviral therapy (HAART) has led to a growing number of HIV-positive persons and their partners requesting counselling regarding the chances of reproduction. A thoughtful medical evaluation of the couple, which should entail HIV status, screening for genital infections and fertile potential, is needed before considering any reproductive attempt. Given that both sexual and perinatal transmission of HIV is directly correlated with the level of viral replication, being almost negligible in patients with undetectable viremia, HAART should be given to the infected partner to minimize the risk of transmission. Assisted reproduction after ’sperm washing’ may further reduce the chances of infection, although this is not within reach or desire for a significant number of HIV-serodiscordant couples. From our perspective, natural conception could now be considered a possible alternative for HIV-serodiscordant couples, as long as complete suppression of viremia with HAART is achieved in the HIV-positive partner. The objective of this paper is to propose a protocol that may minimize risks in HIV-discordant couples that have opted for natural conception.

Editors’ note: Reproductive counselling of male-positive, female-negative sero-discordant couples desiring a pregnancy focuses on ways of reducing the risk of sexual transmission while fulfilling personal reproductive goals. Although not mentioned by this Spanish team, some HIV-negative women are using antiretroviral prophylaxis in the hopes of reducing risk even further, although the safety and efficacy of doing so is unknown.

Brijnath B. It’s about TIME: engendering AIDS in Africa. Cult Health Sex. 2007 Jul-Aug;9(4):371-86.

This paper analyses how TIME magazine represents sub-Saharan African women in its coverage of HIV. As rates of infection escalate across the continent, researchers are increasingly emphasising the need to understand the socioeconomic and cultural contexts that make women particularly vulnerable to infection. Yet popular media representations of AIDS continue to rely on older colonial imageries of Africa as the feminised, diseased ‘dark continent’. This article identifies three major themes in TIME’s representation of sub-Saharan African women and HIV: the metaphor of Africa as a woman in crisis, the construction of women as the means of transmission, and the engendered nature of the debate about the impact of international development policies. It is argued that the reliance on familiar cultural narratives often obscures the epidemiological, economic, and cultural realities within which sub-Saharan women live. Not merely a consequence of unprotected sex, AIDS in sub-Saharan Africa is also the result of global economics and politics, reflecting the inequities between the West and Africa, male and female, white and black. The paper concludes with a call for further research on the role of representations of HIV and its actual routes of transmission.

Editors’ note: Western media influence the discourse on AIDS at many levels. TIME magazine, which has a circulation of 28 million people, has taken a special interest in AIDS in sub-Saharan Africa. This article underscores the difference between the magazine’s conceptual framework and the lived experience for many women which is rooted in the structural violence of poverty and women’s limited choices which determine with whom they will have sex and under what conditions.

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Seeley J, Grellier R, Barnett T. Gender and HIV/AIDS impact mitigation in sub-Saharan Africa–recognising the constraints. SAHARA J 2004;1:87-98.

In discussions of gender and HIV, attention has focused on prevention. This is a vital area. However, Seeley and colleagues argue that there is also a need to focus more attention on the resulting impact of the epidemic, because inequalities that promote the spread of infection are also hampering containment and impact mitigation. The authors propose a framework highlighting the gendered constraints exacerbated by the epidemic. These constraints are reviewed under the following headings: Gender-specific constraints: stemming from the specific nature of gender relations themselves, such as the availability of labour in agriculture, business and for household tasks, as well as access to services and markets, and the incidence of gendered violence. Gender-intensified disadvantages: stemming from the uneven and often inequitable distribution of resources between men and women, including cultural/religious conventions, and the social rules and norms that regulate property rights, inheritance practices and resource endowments. Gender-imposed constraints: resulting from biases and partialities of those individuals who have the authority and power to allocate resources. These include provision of credit, information, agricultural extension and health care. The differential involvement of men and women in development programmes affects access to resources, as does political participation, including involvement in the formulation of policies aimed at poverty reduction. These constraints take us beyond gender relations and sexual behaviour. But women’s lives will not change in the short term. The challenges they face in mitigating the impact of HIV will not be addressed by focusing only on their specific vulnerability to HIV infection. Unequal gender relations and the nature of ‘development’ need to be changed too.

Editors’ note: This conceptual framework is helpful in understanding vulnerability to HIV and its impacts. Gender inequality and the inequitable distribution of resources are constraining both prevention and impact mitigation. Denial by governments and donors of the entrenched nature of these disparities and of the need for sustained social changes stands in the way of addressing women’s lack of access to information, skills, assets, credit, and technology.

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Strebel A, Crawford M, Shefer T, Cloete A, Henda N, Kaufman M, Simbayi L, Magome K, Kalichman S. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa. SAHARA J. 2006 Nov;3(3):516-28.

The links between gender roles, gender-based violence, and HIV risk are complex and culturally specific. In this qualitative study Strebel and colleagues investigated how women and men in two black communities in the Western Cape, South Africa, constructed their gender identities and roles, how they understood gender-based violence, and what they believed about the links between gender relations and HIV risk. First the authors conducted 16 key informant interviews with members of relevant stakeholder organisations. Then they held eight focus group discussions with community members in single-sex groups. Key findings included the perception that although traditional gender roles were still very much in evidence, shifts in power between men and women were occurring. Also, gender-based violence was regarded as a major problem throughout communities, and was seen to be fuelled by unemployment, poverty and alcohol abuse. HIV was regarded as particularly a problem of African communities, with strong themes of stigma, discrimination, and especially ‘othering’ evident. Developing effective HIV interventions in these communities will require tackling the overlapping as well as divergent constructions of gender, gender violence, and HIV which emerged in the study.

Editors’ note: Knowledge and understanding of the specific social context of communities, including social constructions of gender and masculinities as well as shifting gender dynamics, is key to the design and implementation of effective prevention programmes addressing HIV and gender-based violence.

Baeten JM, Lavreys L, Overbaugh J. The influence of hormonal contraceptive use on HIV-1 transmission and disease progression. Clin Infect Dis. 2007 Aug 1;45(3):360-9.

Women account for nearly one-half of new human immunodeficiency virus type 1 (HIV-1) infections worldwide, including the majority of infections in Africa. Biological and epidemiological studies suggest that hormonal contraceptive use could influence susceptibility to HIV-1, as well as infectivity and disease progression for those who become infected. However, not all studies have shown this relationship, and many questions remain. Safe and effective contraceptive choices are essential for women with and at risk for HIV-1 infection. Thus, understanding the effect, if any, of hormonal contraception on HIV-1 disease among women is a public health priority.

Editors’ note: Epidemiological and laboratory data suggest biologically plausible effects of hormonal contraception on HIV susceptibility, infectiousness, and disease progression but the findings are inconsistent. What is clear now is that hormonal contraception offers no protection against HIV. This underscores the importance of dual protection with condoms, greater involvement of men in reproductive health, and integrated sexual and reproductive health programming.

Dunkle KL, Jewkes R, Nduna M, Jama N, Levin J, Sikweyiya Y, Koss MP. Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: Prevalence, predictors, and associations with gender-based violence. Soc Sci Med. 2007;65(6):1235-48.

Dunkle and co-authors explored the prevalence and predictors of transactional sex with casual partners and main girlfriends among 1288 men aged 15-26 from 70 villages in the rural Eastern Cape province of South Africa. Data were collected through face-to-face interviews with young men enrolling in the Stepping Stones HIV prevention trial. A total of 17.7% of participants reported giving material resources or money to casual sex partners and 6.6% received resources from a casual partner. Transactionally motivated relationships with main girlfriends were more balanced between giving (14.9%) and getting (14.3%). The authors constructed multivariable models to identify the predictors for giving and for getting material resources in casual and in main relationships. Each model resulted in remarkably similar predictors. All four types of exchange were associated with higher socio-economic status, more adverse childhood experiences, more lifetime sexual partners, and alcohol use. Men who were more resistant to peer pressure to have sex were less likely to report transactional sex with casual partners, and men who reported more equitable gender attitudes were less likely to report main partnerships underpinned by exchange. The most consistent predictors of all four types of transaction were perpetration of intimate partner violence and rape against women other than a main partner. The strong and consistent association between perpetration of gender-based violence and both giving and getting material goods from female partners suggests that transactional sex in both main and casual relationships should be viewed within a broader continuum of men’s exercise of gendered power and control. HIV prevention interventions need to explicitly address transactional sex in the context of ideas about masculinity, which place a high emphasis on heterosexual success with, and control of, women.

Editors’ note: Giving and receiving material goods in unequal sexual relationships can be manipulative, reinforcing power imbalances. The association with intimate partner violence seen in this study provides further food for thought for the design of HIV prevention programmes addressing transactional sex.

Gielen AC, Ghandour RM, Burke JG, Mahoney P, McDonnell KA, O’Campo P. HIV/AIDS and intimate partner violence: intersecting women’s health issues in the United States. Trauma Violence Abuse 2007;8:178-98.

This article reviews 35 United States studies on the intersection of HIV and adult intimate partner violence (IPV). Most studies describe rates of IPV among women at risk or living with HIV and identify correlates, using multiple types of convenience samples (e.g., women in methadone treatment, women in shelters or clinics), cross-sectional designs, and self-reported risk behaviours. HIV-positive women appear to experience any IPV at rates comparable to HIV-negative women from the same underlying populations; however, their abuse seems to be more frequent and more severe. The authors found only four relevant interventions and none addressed sexually transmitted HIV and partner violence risk reduction simultaneously. There is a critical need for research on (a) causal pathways and cumulative effects of the syndemic issues of violence, HIV, and substance abuse and (b) interventions that target IPV victims at risk for HIV, as well as HIV-positive women who may be experiencing IPV.

Editors’ note: This work highlights important interactions between HIV risk, HIV serostatus and violence. Gender-based violence or intimate partner violence is a human rights violation in all settings which calls for sustained, effective prevention strategies – supporting men and boys to redefine masculinity to exclude it is an essential start. Legislation that is enforced backs up the message.

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Parikh SA. The political economy of marriage and HIV: the ABC approach, “safe” infidelity, and managing moral risk in Uganda. Am J Public Health 2007;97:1198-208.

Research has shown that married women’s greatest risk for HIV infection is their husbands’ extramarital sexual activities. Using 6 months of ethnographic research in south-eastern Uganda, Parikh examined how the social and economic contexts surrounding men’s extramarital sexuality and the dynamics of marriage put men and women at risk for HIV infection. The author found that Uganda’s HIV prevention messages may be inadvertently contributing to increased difficulty in acknowledging HIV risk and to newer forms of sexual secrecy and that structural determinants, including persistent poverty, intersect with gender inequalities to shape marital risk. After examining a community effort to regulate men’s sexuality, the author suggests that HIV prevention strategies should focus more on endogenous forms of risk reduction while simultaneously addressing structural factors that facilitate opportunities for men’s extramarital sex.

Editors’ note: Serodiscordance among stable couples in Uganda can be in either direction with some studies finding the woman as the HIV positive partner in as many as 38% of couples. Marital risk may be more shaped by couples not knowing their serostatus rather than either partner having sexual partners outside the relationship. Secrecy about previous HIV risk can be as dangerous to one’s partner as secrecy about current risk. HIV prevention strategies for stable couples should assist people to acknowledge risk, take an HIV test and break the silence.

Muula AS, Ngulube TJ, Siziya S, Makupe CM, Umar E, Prozesky HW, Wiysonge CS, Mataya RH. Gender distribution of adult patients on highly active antiretroviral therapy (HAART) in Southern Africa: a systematic review. BMC Public Health 2007;7:63

HIV and AIDS are significant and growing public health concerns in southern Africa. The majority of countries in the region have national adult HIV prevalence estimates exceeding 10 percent. The increasing availability of highly active antiretroviral therapy (HAART) has potential to mitigate the situation. There is however concern that women may experience more barriers in accessing treatment programs than men. A systematic review of the literature was carried out to describe the gender distribution of patients accessing highly active antiretroviral therapy (HAART) in Southern Africa. Data on number of patients on treatment, their mean or median age and gender were obtained and compared across studies and reports. The median or mean age of patients in the studies ranged from 33 to 39 years. While female to male HIV infection prevalence ratios in the southern African countries ranged from 1.2:1 to 1.6:1, female to male ratios on HAART ranged from 0.8: 1 to 2.3: 1. The majority of the reports had a female: male ratio in treatment exceeding 1.6. Overall, there were more females on HAART than there were males and this was not solely explained by the higher HIV prevalence among females compared to males. In most Southern African countries, proportionally more females are on HIV antiretroviral treatment than men, even when the higher HIV infection prevalence in females is accounted for. There is need to identify the factors that are facilitating women’s accessibility to HIV treatment. As more patients access HAART in the region, it will be important to continue assessing the gender distribution of patients on HAART.

Editors’ note: These results showing that women are accessing antiretroviral treatment proportionately more than men are not surprising in view of women’s overall higher utilization of health services compared to men. They do suggest that significant financial barriers are being overcome for many women. Continued close monitoring of the comparative treatment access of men and women remains important from the perspective of equity.

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Chi BH, Sinkala M, Stringer EM, Cantrell RA, Mtonga V, Bulterys M, Zulu I, Kankasa C, Wilfert C, Weidle PJ, Vermund SH, Stringer JS. Early clinical and immune response to NNRTI-based antiretroviral therapy among women with prior exposure to single-dose nevirapine. AIDS 2007;21:957-964.

Chi and colleagues’ objective was to determine whether prior exposure to single-dose nevirapine (NVP) for prevention of mother-to-child HIV transmission (PMTCT) is associated with attenuated CD4 cell response, death, or clinical treatment failure in women starting antiretroviral therapy (ART) containing non-nucleoside reverse transcriptase inhibitors (NNRTI). The method used was an open cohort evaluation of outcomes for women in program sites across Zambia. HIV treatment was provided according to Zambian/World Health Organization guidelines. Peripartum NVP exposure status was known for 6740 women initiating NNRTI-containing ART, of whom 751 (11%) reported prior use of NVP for PMTCT. There was no significant difference in mean CD4 cell change between those exposed or unexposed to NVP at 6 (+202 versus +182 cells/mul; P = 0.20) or 12 (+201 versus +211 cells/mul; P = 0.60) months. Multivariable analyses showed no significant differences in mortality [adjusted hazard ratio (HR), 1.2; 95% confidence interval (CI), 0.8-1.8] or clinical treatment failure (adjusted HR, 1.1; 95% CI, 0.8-1.5). Comparison of recent NVP exposure with remote exposure suggested a less favourable CD4 cell response at 6 (+150 versus +219 cells/mul; P = 0.06) and 12 (+149 versus +215 cells/mul; P = 0.39) months. Women with recent NVP exposure also had a trend towards elevated risk for clinical treatment failure (adjusted HR, 1.6; 95% CI, 0.9-2.7). The authors conclude that exposure to maternal single-dose NVP was not associated with substantially different short-term treatment outcomes. However, evidence was suggestive that exposure within 6 months of ART initiation may be a risk factor for poor treatment outcomes, highlighting the importance of ART screening and initiation early in pregnancy.

Editors’ note: This encouraging report suggests that even when women develop nevirapine resistance following a single dose of nevirapine it will not affect their own treatment prospects, particularly if treatment is not required for at least 6 months after delivering. However, the potential deleterious effects for women who do require early treatment are a concern. CD4 count testing for HIV-positive pregnant women and antiretroviral treatment combination regimes for those who are treatment eligible would accomplish both goals: preventing mother-to-child transmission and preserving the life of mothers.

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Mendenhall E, Muzizi L, Stephenson R, Chomba E, Ahmed Y, Haworth A, Allen S. Property grabbing and will writing in Lusaka, Zambia: an examination of wills of HIV-infected cohabiting couples. AIDS Care 2007;19:369-74.

High rates of HIV and poverty place women in a precarious economic situation in Lusaka, Zambia. Mortality from HIV infection is high, leaving many households single headed and creating almost a half a million orphans. One of the most prevalent forms of gender violence that creates poverty in women is when the male’s family claims the property of the deceased from the widow and the children. The Zambia-Emory HIV Research Project collected 184 wills from individuals in monogamous unions where one or both of the individuals were HIV-positive. Despite the fact that many wills specifically stated that their extended family was not allowed to tamper with their possessions in the event of death, property grabbing proved to be a prevalent and difficult issue in Lusaka. In order to improve the lives of widowed women in Lusaka, the government and other civic and non-governmental organisations must inform women of their rights to own and protect their land and other assets in the event of their husbands’ death, an issue of increasing importance in the area of HIV/AIDS.

Editors’ note: Informing women of their property and inheritance rights is a good first step but without legal redress to ensure those rights are upheld, wills are but pieces of paper.