HIV This Week

Suicide in HIV-Infected Individuals and the General Population in Switzerland, 1988-2008.

Keiser O, Spoerri A, Brinkhof MW, Hasse B, Gayet-Ageron A, Tissot F, Christen A, Battegay M, Schmid P, Bernasconi E, Egger M; for the Swiss HIV Cohort Study and the Swiss National Cohort. Am J Psychiatry. 2010. 167:143-150.

High rates of suicide have been described in HIV-infected patients, but it is unclear to what extent the introduction of antiretroviral therapy has affected suicide rates. The authors examined time trends and predictors of suicide in the pre-antiretroviral treatment (1988-1995) and antiretroviral treatment (1996-2008) eras in HIV-infected patients and the general population in Switzerland. The authors analyzed data from the Swiss HIV Cohort Study and the Swiss National Cohort, a longitudinal study of mortality in the Swiss general population. They calculated standardized mortality ratios comparing HIV-infected patients with the general population and used Poisson regression to identify risk factors for suicide. From 1988 to 2008, 15,275 patients were followed in the Swiss HIV Cohort Study for a median duration of 4.7 years. Of these, 150 died by suicide (rate 158.4 per 100,000 person-years). In men, standardized mortality ratios declined from 13.7 (95% CI=11.0-17.0) in the pre-antiretroviral treatment era to 3.5 (95% CI=2.5-4.8) in the late antiretroviral treatment era. In women, ratios declined from 11.6 (95% CI=6.4-20.9) to 5.7 (95% CI=3.2-10.3). In both periods, suicide rates tended to be higher in older patients, in men, in injection drug users, and in patients with advanced clinical stage of HIV illness. An increase in CD4 cell counts was associated with a reduced risk of suicide. Suicide rates decreased significantly with the introduction of antiretroviral treatment, but they remain above the rate observed in the general population, and risk factors for suicide remain similar.

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Editors’ note: The results of this study, revealing encouraging declines in the suicide rate among people living with HIV in Switzerland since the advent of antiretroviral treatment, need to be seen in context. Swiss suicide rates are in the top-third in Europe and the top quintile, i.e the top 20%, in the world. Declines in the suicide rate have occurred in the general population too but not to the extent seen in surrounding countries. Switzerland has no national suicide prevention programme to address this important public health problem and the suicide rate among people living with HIV, despite the important declines documented here, may be higher than in other European countries. They are certainly higher than in the general Swiss population and are higher than those in other patients with life-threatening conditions. Although 75% of people with HIV who committed suicide had a diagnosis of mental illness, it is unclear to what extent stigma, discrimination, social isolation, drug toxicity, and other factors are playing roles. Understanding what is influencing decisions to commit suicide is the first step to preventing such unnecessary deaths among people living with HIV.

Pandemic influenza: implications for programs controlling for HIV infection, tuberculosis, and chronic viral hepatitis.

Heffelfinger JD, Patel P, Brooks JT, Calvet H, Daley CL, Dean HD, Edlin BR, Gensheimer KF, Jereb J, Kent CK, Lennox JL, Louie JK, Lynfield R, Peters PJ, Pinckney L, Spradling P, Voetsch AC, Fiore A. Am J Public Health 2009; 99(S2)

Among vulnerable populations during an influenza pandemic are persons with or at risk for HIV infection, tuberculosis, or chronic viral hepatitis. HIV-infected persons have higher rates of hospitalization, prolonged illness, and increased mortality from influenza compared with the general population. Persons with tuberculosis and chronic viral hepatitis may also be at increased risk of morbidity and mortality from influenza because of altered immunity and chronic illness. These populations also face social and structural barriers that will be exacerbated by a pandemic. Existing infrastructure should be expanded and pandemic planning should include preparations to reduce the risks for these populations.

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Editors’ note: This article highlights the importance of pandemic influenza plans that include specific actions to reduce the risk of influenza among people living with HIV, tuberculosis or viral hepatitis and maintain continuity of care and prevention services. In the case of HIV, it is critical to prevent disruptions in the supply of antiretroviral drugs and to anticipate and mitigate personnel shortages to avoid the erratic dosing and sub therapeutic drug levels that can lead to disease progression and viral resistance. Improving rates of annual vaccination against seasonal influenza among people living with HIV, their caretakers, and health care providers is an obvious step. The higher risk of complications among young people with chronic medical conditions, in the case of the H1N1 influenza, underscores the importance of receiving the H1N1 vaccine if this description fits you.

Household impacts of AIDS: using a life course analysis to identify effective, poverty-reducing interventions for prevention, tratment, and care. Loewenson R, Whiteside A, Hadingham J. Aids Care. 2009; 21:1032-1041

A life course approach was used to assess household level impacts and inform interventions around HIV risk and AIDS vulnerability across seven major age-related stages of life. The focus was sub-Saharan Africa. The authors provided a qualitative review of evidence from published literature, particularly multicountry reviews on impacts of AIDS, on determinants of risk and vulnerability, and reports of large surveys. Areas of potential stress from birth to old age in households affected by AIDS, and interventions for dealing with these specific stresses were identified. While specific interventions for HIV are important at different stages, achieving survival and development outcomes demands a wider set of health, social security, and development interventions. One way to determine the priorities amongst these actions is to give weighting to interventions that address factors that have latent impacts later in life, which interrupt accumulating risk, or that change pathways to reduce the risk of both immediate and later stress. This qualitative review suggests that interventions, important for life cycle transitions in generalized epidemics where HIV risk and AIDS vulnerability are high, lie within and outside the health sector, and suggests examples of such interventions.

Editors’ note: A life course concept views people as passing though various transitions and stages in life with events at one stage having effects at later stages. Points of stress in the life cycle that HIV can affect offer opportunities to influence pathways of accumulating vulnerability. These can range from the obvious example of preventing mother-to-child transmission by antiretroviral prophylaxis to broader interventions, such as promoting more open communication within families. HIV influences the number and quality of ‘buffers’ available to deal with stress, including the buffers of social support, financial resources, and good health. Household and individual resilience to shocks experienced in generalised epidemics can be supported through broader systems approaches within and beyond the health sector that help people to manage the interacting socioeconomic and health challenges of HIV. Examples include explicit interventions to strengthen social networks, increase spending on public services and community safety nets, introduce law reform and enforcement, invest in training and support for family carers, and increase access to education and employment opportunities.

Nattabi B, Li J, Thompson SC, Orach CG, Earnest J. A Systematic Review of Factors Influencing Fertility Desires and Intentions Among People Living with HIV/AIDS: Implications for Policy and Service Delivery. AIDS Behav. 2009. DOI 10.1007/s10461-009-9537-y

With availability of antiretroviral treatments, HIV is increasingly recognised as a chronic disease people live with for many years. This paper critically reviews the current literature on fertility desires and reproductive intentions among people living with HIV and critiques the theoretical frameworks and methodologies used. A systematic review was conducted using electronic databases: ISI Web of Knowledge, Science Direct, Proquest, Jstor and CINAHL for articles published between 1990 and 2008. The search terms used were fertility desire, pregnancy, HIV, reproductive decision-making, reproductive intentions, motherhood, fatherhood and parenthood. Twenty-nine studies were reviewed. Fertility desires were influenced by a myriad of demographic, health, stigma-associated and psychosocial factors. Cultural factors were also important, particularly in Sub-Saharan Africa and Asia. Future research that examines fertility desires among people living with HIV should include cultural beliefs and practices in the theoretical framework in order to provide a holistic understanding and to enable development of services that meet the reproductive needs of people living with HIV.

Editors’ note: This interesting systematic review of studies of fertility desires and intentions reveals the importance of mixed methodologies (quantitative and qualitative) to contextualise findings and emphasises the use of theoretical frameworks relevant to cultural context to underpin study design and analyses. In most settings, people living with HIV are uncomfortable talking with health care providers about fertility issues, anticipating or experiencing biased information-giving and negative attitudes. Provision of services within a rights-based framework requires consideration of a risk-reduction approach to minimise vertical and horizontal HIV transmission through nonjudgmental care, treatment, and counselling.

Cooper D, Moodley J, Zweigenthal V, Bekker LG, Shah I, Myer L. Fertility Intentions and Reproductive Health Care Needs of People Living with HIV in Cape Town, South Africa: Implications for Integrating Reproductive Health and HIV Care Services. AIDS Behav. 2009;13:suppl1:38-46.

Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deficiency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on antiretroviral treatment strongly associated with women’s fertility intentions. Gender differences were also apparent in participants’ key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counselling and services that account for the diverse reproductive needs of these populations.

Editors’ note: This 2006 exploratory survey of fertility intentions among people living with HIV attending two public sector health centres in a high HIV prevalence residential area of Cape Town found that only 19% of women and 6% of men had consulted a doctor, nurse, or counsellor in HIV care about fertility intentions. Among women in HIV care, 11% had become pregnant since their HIV diagnosis, all unintentionally. Among women on antiretroviral treatment, 9% had become pregnant since starting treatment, with 30% of these pregnancies reportedly unintentional. On-site integration of sexual and reproductive health services into HIV care settings is urgently required in order to create space for discussions with women and men about their fertility intentions; to provide easy access to contraceptive measures for those who desire to postpone, prevent or discontinue pregnancies; and to provide timely antiretroviral prophylaxis to prevent mother-to-child transmission.

Deschamps MM, Noel F, Bonhomme J, Dévieux JG, Saint-Jean G, Zhu Y, Wright P, Pape JW, Malow RM. Prevention of mother-to-child transmission of HIV in Haiti. Rev Panam Salud Publica. 2009;25:24-30.

Deschamps and colleagues set out to describe the effectiveness of a program designed to reduce the rate of mother-to-child transmission of HIV at the primary HIV testing and treatment center in Haiti between 1999 and 2004. All pregnant, HIV-positive women who attended the major HIV testing and treatment clinic in Port-au-Prince, Haiti, between March 1999 and December 2004 were asked to participate in a mother-to-child transmission prevention program. Of the 650 women who participated, 73.3% received zidovudine (AZT), 2.9% received nevirapine (NVP), and 10.1% received triple-drug therapy when it became available in 2003 and if clinical/laboratory indications were met. Approximately 13.8% received no antiretroviral medication. All participants received cotrimoxazole prophylaxis and infant formula for their children. Kaplan-Meier survival analysis and the log rank test were used to evaluate program impact on child survival. Complete data were available for 348 mother-infant pairs who completed the program to prevent mother-to-child transmission of HIV. The rate of mother-to-child transmission in the study was 9.2% (95% CI:6.14-12.24), in contrast to the historical mother-to-child transmission rate of 27% in Haiti. HIV-positive infants were less likely to survive than HIV-negative infants at 18 months of follow-up (chi(2) = 19.06, P < .001, log rank test). Infant survival improved with early paediatric diagnosis and antiretroviral treatment. The mother-to-child transmission prevention program described proved to be feasible and effective in reducing vertical HIV transmission in Haiti. The authors emphasize the need to expand testing, extend services to rural areas, and implement early HIV diagnosis to reduce infant mortality.

Editors’ note: Over the period from 1999 to 2004 the annual number of women who agreed to undergo HIV testing at the GHESKIO clinic more than doubled and the number of HIV-positive women who enrolled in the prevention of mother-to-child transmission (PMTCT) programme quadrupled. Overall 43,173 women at higher risk of HIV exposure were tested (18.3% were HIV-positive) and 5270 were pregnant (12.3% HIV-positive). Of the 650 HIV-positive pregnant women, 28.7% did not participate in the PMTCT programme, primarily because they returned to rural areas, and only 14% were able to bring their partners in for HIV testing. After delivery, 73.9% of the women were using family planning services at 18-month follow-up compared to national uptake data of 23%. Despite persistent instability and violence in Haiti, this programme in Port-au-Prince has successfully reduced HIV transmission to infants to one-third of the historical rate. With a 2007 adult (15-49 years) HIV prevalence of 2.2% (1.9-2.5), in a league with the Bahamas, Guyana, Suriname, and Belize in the Americas, Haiti clearly needs a nationwide programme integrating family planning, voluntary counselling and testing, and HIV treatment services with good referral links between centres.

Cailhol J, Jourdain G, Coeur SL, Traisathit P, Boonrod K, Prommas S, Putiyanun C, Kanjanasing A, Lallemant M; for the Perinatal HIV Prevention Trial Group. Association of Low CD4 Cell Count and Intrauterine Growth Retardation in Thailand. J Acquir Immune Defic Syndr. 2009; 50:409-413.

Each year, intrauterine growth retardation affects 20-30 million neonates worldwide, mostly in resource-limited settings. Increased perinatal and infant mortality has been associated with intrauterine growth retardation. Some studies have suggested that HIV infection could increase the risk of intrauterine growth retardation. To confirm this hypothesis, Cailhol and colleagues examined the association between HIV-related factors and the risk of intrauterine growth retardation in Thailand. Data from a cohort of 1436 HIV-infected pregnant women enrolled in the « Perinatal HIV Prevention Trial-1 », a clinical trial conducted from 1997 to 1999 in Thailand, were analyzed using a logistic regression, adjusting for risk factors usually associated with intrauterine growth retardation. The rate of intrauterine growth retardation was 7.6%. Adjusting for a short maternal height, low body mass index, small weight gain during pregnancy, and infant female sex, a low maternal CD4 percentage was independently associated with intrauterine growth retardation (odds ratio 0.96, per 1% increment, 95% confidence interval 0.93 to 0.99, P = 0.03). The current World Health Organization recommendation to initiate combination antiretroviral therapy for immunocompromised women as early as possible during pregnancy for their own health and for the prevention of HIV mother-to-child transmission is likely to also decrease the incidence of intrauterine growth retardation. Encouraging immunocompromised HIV-infected women who plan to become pregnant to wait until immune restoration has been achieved may help to reduce the risk of intrauterine growth retardation.

Editors’ note: Intrauterine growth retardation (IUGR) is the second cause of perinatal mortality after prematurity. It is associated with higher susceptibility to various conditions in the neonatal period as well as with diseases in adulthood such as diabetes, obesity, and hypertension. This Thai study used the stringent definition of IUGR of ‘birth weight below the 10 th percentile of weight for the corresponding gestational age’, rather than the low birth weight cut-off of 2500 g which can indicate prematurity. Also it used CD4 percentage which is less variable than absolute CD4 count. The finding that CD4 percentage below the median contributed 28% of the risk of IUGR in this population gives added support to the recommendation to initiate antiretroviral treatment (as opposed to antiretroviral prophylaxis) in pregnancy for women with low CD4 counts.

Kimbrough LW, Fisher HH, Jones KT, Johnson WD, Thadiparthi S, Dooley S. Centers for Disease Control and Prevention. Accessing Social Networks With High Rates of Undiagnosed HIV Infection: The Social Networks Demonstration Project. Am J Public Health. 2009;99(6):1093-9.

Kimbrough and colleagues evaluated the use of social networks to reach persons with undiagnosed HIV infection in ethnic minority communities and link them to medical care and HIV prevention services. Nine community-based organizations in 7 cities received funding from the United States Centers for Disease Control and Prevention to enlist HIV-positive persons to refer others from their social, sexual, or drug-using networks for HIV testing; to provide HIV counselling, testing, and referral services; and to link HIV-positive and high-risk HIV-negative persons to appropriate medical care and prevention services. From October 1, 2003, to December 31, 2005, 422 recruiters referred 3172 of their peers for HIV services, of whom 177 were determined to be HIV positive; 63% of those who were HIV-positive were successfully linked to medical care and prevention services.  The HIV prevalence of 5.6% among those recruited in this project was significantly higher than the approximately 1% identified in other counselling, testing, and referral sites funded by the Centers for Disease Control and Prevention. This peer-driven approach is highly effective and can help programs identify persons with undiagnosed HIV infection in high-risk networks.

Editors’ note: HIV takes advantages of networks so why can’t HIV prevention and treatment take advantage of social networks? This peer-driven strategy though community-based organisations proved to be an efficient high-yield approach to accessing and providing HIV counselling, testing, and referral services to key populations at higher risk of HIV exposure that are difficult to reach with other more conventional strategies.

Stringer EM, Levy J, Sinkala M, Chi BH, Matongo I, Chintu N, Stringer JS. HIV disease progression by hormonal contraceptive method: secondary analysis of a randomized trial. AIDS. 2009 ;23(11):1377-82 14.

HIV-infected women need access to safe contraception. Stringer and colleagues hypothesized that women using depomedroxyprogesterone acetate (DMPA) contraception would have faster HIV disease progression than women using oral contraceptive pills and nonhormonal methods. In a previously reported trial, the authors randomized 599 HIV-infected women to the intrauterine device (IUD) or hormonal contraception. Women randomized to hormonal contraception chose between oral contraceptive pills and DMPA. This analysis investigates the relationship between exposure to hormonal contraception and HIV disease progression [ defined as death, becoming eligible for antiretroviral therapy, or both]. Of the 595 women not on antiretroviral therapy at the time of randomization, 302 were allocated to hormonal contraception, of whom 190 (63%) initiated DMPA and 112 (37%) initiated oral contraceptive pills. Women starting IUD, oral contraceptive pills, or DMPA were similar at baseline. Compared with women using the IUD, the adjusted hazard of death was not significantly increased among women using oral contraceptive pills [1.24; 95% confidence interval (CI) 0.42-3.63] or DMPA (1.83; 95% CI 0.82-4.08). However, women using oral contraceptive pills (adjusted hazard ratio (AHR) 1.69; 95% CI 1.09-2.64) or DMPA (AHR 1.56; 95% CI 1.08-2.26) trended toward an increased likelihood of becoming eligible for antiretroviral therapy. Women exposed to oral contraceptive pills (AHR 1.67; 95% CI 1.10-2.51) and DMPA (AHR 1.62; 95% CI 1.16-2.28) also had an increased hazard of meeting this study’s composite disease progression outcome (death or becoming antiretroviral therapy eligible) than women using the IUD. In this secondary analysis, exposure to oral contraceptive pills or DMPA was associated with HIV disease progression among women not yet on antiretroviral therapy. This finding, if confirmed elsewhere, would have global implications and requires urgent further investigation.

Editors’ note: The relationship between hormonal contraception and disease progression was not an a priori hypothesis of this trial and 47% of the participants switched contraceptive methods, withdrew from the study, or were lost to follow-up. The researchers addressed the switching by treating contraceptive method as a time-varying exposure but the fact that women assigned to the contraceptive arm could choose either DMPA or oral contraceptives could have introduced confounding. Given that the risk of maternal mortality increases with each subsequent pregnancy, with a women’s lifetime risk of dying in pregnancy as high as one in 22 in sub-Saharan Africa, women need safe and effective contraception when they want it. These results are by no mean definitive but they support the urgent call for a trial evaluating the potential relationship between HIV disease progression and hormonal contraception.

Van der Borght SF, Clevenbergh P, Rijckborst H, Nsalou P, Onyia N, Lange JM, de Wit TF, Van der Loeff MF. Mortality and morbidity among HIV type-1-infected patients during the first 5 years of a multicountry HIV workplace programme in Africa. Antivir Ther. 2009;14(1):63-74.

Van der Borght and colleagues aimed to evaluate the effectiveness of an HIV workplace programme in sub-Saharan Africa. The international brewing company, Heineken, introduced an HIV workplace programme in its African subsidiaries in 2001. Beneficiaries from 16 sites in 5 countries were eligible. HIV type-1 (HIV-1)-infected individuals were assessed clinically and immunologically, and started highly active antiretroviral therapy if they had AIDS or had a CD4+ T-cell count <300 cells/microl. In this cohort, study patients were followed-up for vital status, new AIDS events, CD4+ T-cell count, and haemoglobin. Over the first 5 years of the programme, 431 adults were found to be HIV-1-infected. The mortality rate among those not yet taking highly active antiretroviral therapy was 2.6 per 100 person-years of observation. By October 2006, 249 patients had started highly active antiretroviral therapy at a median CD4+ T-cell count of 170 cells/microl; 59 (23.7%) patients were in CDC stage C. Among patients on highly active antiretroviral therapy, 25 died and 7 were lost to follow-up. The mortality rate was 3.7 per 100 person-years of observation overall, 14 per 100 person-years of observation in the first 16 weeks and 2.5 per 100 person-years of observation thereafter (P < 0.0001). At 4 years after start of treatment, 89% of patients were known to be alive. The CD4+ T-cell count increased by a median of 153 and 238 cells/microl after 1 and 4 years of highly active antiretroviral therapy, respectively. In this HIV workplace programme in sub-Saharan Africa, long-term high survival was achieved.

Editors’ note: Leading the way forward for private sector engagement in HIV in Africa, this private sector company began implementing an HIV workplace programme in May 2001 in Nigeria, Rwanda, Burundi, Republic of Congo, and Democratic Republic of Congo. Not only its own direct staff but also the African staffs of its subsidiaries, their spouses, and their children are entitled to free healthcare by the company. With voluntary and confidential HIV testing, assessment for treatment initiation, no drug stock-outs, and good treatment durability with low loss to follow-up, this small but well-managed and adequately funded programme achieved excellent treatment outcomes over 5 years. This is a good example of corporate social responsibility in action – cheers!

Winskell K, Enger D. A new way of perceiving the pandemic: the findings from a participatory research process on young Africans’ stories about HIV/AIDS. Cult Health Sex. 2009 May;11(4):453-67.

This paper presents the findings, shares the methodology, and outlines the benefits of a multi-country participatory research process on a unique data source: stories about HIV and AIDS written by young Africans. Between 1997 and 2005, more than 105,000 young people from 37 countries participated in competitions inviting them to think up storylines for short fiction films to educate their communities about HIV as part of the ‘ Scenarios from Africa’ communication process. The winning stories were selected by juries made up of people living with HIV and other local specialists in prevention, treatment and care; former contest winners and other young people; and communication specialists, including the top African directors, who went on to transform the ideas into short films. In 2005, over 200 jurors selected 30 winners from the 22,894 stories submitted that year by 63,327 contest participants. After reading around 200 stories each and participating in the selection process, jurors compiled their observations and recommendations. The jurors’ findings reveal notable persistent shortcomings in existing communication efforts and identify key emerging needs. In some areas, they show remarkable consistency across the continent. Jurors view this as a powerful needs assessment, networking, and capacity building process that motivates action.

Editors’ note: Between 1997 and 2005 the Scenarios in Africa participatory communication initiative ran four contest cycles for storylines for short fiction films, producing an average of three films a year by Africa’s most celebrated filmmakers (viewable at www.globaldialogues.org) to trigger discussion about the epidemic in communities across West Africa. Analysis of 2005 submissions revealed a high level of understanding of basic facts, most marked among younger contestants. The most common recommendation made by the jurors was for destigmatisation to counter moralisation of the epidemic and to humanise people living with HIV. Jurors placed primary emphasis on fostering the life skills of young people so they can enact HIV prevention. Mobilised to submit stories by more than 1000 local organisations, the participating young people communicated rich insight into their contextualised understanding of the epidemic, information from the front lines of youth prevention in Africa with direct relevance for creating more enabling environments for HIV prevention.

Dolan Looby SE, Collins M, Lee H, Grinspoon S. Effects of long-term testosterone administration in HIV-infected women: a randomized, placebo-controlled trial. AIDS. 2009 Mar 12. [Epub ahead of print]

Androgen deficiency is common in HIV-infected women. Dolan Looby and colleagues investigated the long-term effects of transdermal testosterone on body composition, bone mineral density, quality of life, and safety. Twenty-five HIV-infected women with free testosterone below the median (</=3 pg/ml) of the female normal range were randomized to receive transdermal testosterone (300 mug twice weekly) or identical placebo over 18 months. Women demonstrated low androgen levels (1.3 +/- 0.1 pg/ml) with relatively low weight (22.8 +/- 0.6 kg/m) and low bone mineral density (-0.61 +/- 0.17 SD hip T score) at baseline. No statistically significant differences were seen between the groups at baseline. The discontinuation rate was 16% and did not differ between treatment groups (P = 0.24). Free testosterone by equilibrium dialysis increased over 18 months (7.9 +/- 1.8 vs. 0.3 +/- 0.4 pg/ml; P = 0.002, testosterone vs. placebo). Testosterone was well tolerated and did not affect lipids, liver, or safety indices. Lean mass (1.8 +/- 0.5 vs. 0.8 +/- 0.9 kg; P = 0.04) and BMI (1.6 +/- 0.4 vs. 0.8 +/- 0.6 kg/m; P = 0.03, testosterone vs. placebo) increased in response to testosterone, whereas fat mass remained unchanged. Testosterone increased bone mineral density at the hip (0.01 +/- 0.01 vs. -0.01 +/- 0.01 g/cm; P = 0.02) and trochanter (0.01 +/- 0.01 vs. -0.02 +/- 0.01 g/cm; P = 0.01, testosterone vs. placebo). Testosterone significantly improved depression indices (-6.8 +/- 2.2 vs. -1.9 +/-3.1; P = 0.02) and problems affecting sexual function (-1.8 +/- 0.8 vs. 0.5 +/-0.5; P = 0.01, testosterone vs. placebo). Long-term testosterone administration was well tolerated in HIV-infected women and resulted in significant improvements in body composition, bone mineral density, and quality of life indices. Further evaluation of the safety and efficacy of testosterone use among HIV-infected women is warranted.

Editors’ note: Androgen deficiency is highly prevalent among women living with HIV and is associated with reduced lean body mass, bone mineral density, and quality of life. Whereas treatment is routine in HIV-positive men with low testosterone levels, no treatment strategies exist for women with similar problems. This is the first long-term (18 months) randomised controlled trial in HIV-positive women of the effects of testosterone administered via a transdermal patch versus a control patch. Because it reveals very encouraging effects on bone mineral density, body composition, and quality of life without signs of virilisation, further studies of long-term treatment with testosterone for women living with HIV should proceed to see if these encouraging findings are confirmed.

Franco-Paredes C, Hidron A, Tellez I, Lesesne J, Del Rio C. HIV Infection and Travel: Pretravel Recommendations and Health-Related Risks. Top HIV Med. 2009;17(1):2-11.

In the current era of globalization and ease of air travel combined with the increased survival attained since the advent of potent antiretroviral therapy, HIV-infected individuals are travelling to remote and resource-limited areas of the world. Travel-related health risks in a patient with HIV depend on the patient’s immune status, destination, travel itinerary, and type of travel. HIV-infected patients with a CD4+ count of 200 cells/mm3 or lower, particularly those who are treatment-naive and newly diagnosed, are at increased risk of complications when travelling to resource-poor settings. These increased risks include those of acquiring gastrointestinal, respiratory, and endemic tropical infectious diseases. Individuals with a CD4+ count higher than 200 cells/mm3 (whether receiving antiretroviral treatment or not) are considered to have limited immune deficiency for the purpose of travel-related recommendations; in general, they may safely receive most recommended and required vaccines. Pretravel consultation before departure is crucial to address strategies to protect against vaccine-preventable diseases (routine, recommended, and required vaccinations); vector-borne diseases, particularly malaria; gastrointestinal infections; and sexually transmitted diseases. HIV-infected travellers who are ill, particularly those with fever, should undergo an immediate medical evaluation to rule out the possibility of a life-threatening infectious disease such as malaria.

Editors’ note: This excellent review should be required reading for all UN staff living with HIV who travel internationally or who live in resource-constrained settings. It compiles current knowledge on the use of live attenuated and inactivated vaccines by CD4+ count and provides practical advice. This includes delaying travel until 3 months after starting antiretroviral treatment to avoid immune reconstitution syndromes during travel, keeping medication with its official documentation in hand luggage with a back-up supply in checked luggage, hand hygiene with water and soap or alcohol-based solutions, knowing about potential protease inhibitor drug interactions with malaria treatment, careful attention to water and food safety to avoid enteric infections, adherence to safer sex strategies, and the importance of prompt evaluation of fever while travelling or on return .

Willard S, Holzemer WL, Wantland DJ, Cuca YP, Kirksey KM, Portillo CJ, Corless IB, Rivero-Méndez M, Rosa ME, Nicholas PK, Hamilton MJ, Sefcik E, Kemppainen J, Canaval G, Robinson L, Moezzi S, Human S, Arudo J, Eller LS, Bunch E, Dole PJ, Coleman C, Nokes K, Reynolds NR, Tsai YF, Maryland M, Voss J, Lindgren T. Does “asymptomatic” mean without symptoms for those living with HIV infection? AIDS Care. 2009;21(3):322-8.

Throughout the history of the HIV epidemic, HIV-positive patients with relatively high CD4 counts and no clinical features of opportunistic infections have been classified as “asymptomatic” by definition and treatment guidelines. This classification, however, does not take into consideration the array of symptoms that an HIV-positive person can experience long before progressing to AIDS. This short report describes two international multi-site studies conducted in 2003-2005 and 2005-2007. The results from the studies show that HIV-positive people may experience symptoms throughout the trajectory of their disease, regardless of CD4 count or classification. Providers should discuss symptoms and symptom management with their clients at all stages of the disease.

Editors’ note: Both physical and psychological symptoms were reported by ‘asymptomatic’ people living with HIV regardless of CD4 count category or whether they were on antiretroviral medications. The twenty most frequently reported symptoms in the 33 to 60% range included fatigue (57-60%), depression, muscle aches, weakness, thirst, worry, difficulty concentrating, memory loss, dry mouth, insomnia, joint pain, diarrhoea, shortness of breath with activity, night sweats, gas/bloating, headaches, abdominal pain, and numbness/tingling of hands/fingers or feet/toes or legs (33 to 37%). Recognising both the broad variation in how patients perceive and rate their symptom experience and that many of these symptoms in HIV-positive individuals can be addressed by specific measures just as they can be in HIV-negative people, clinicians need to carefully interview their ‘asymptomatic’ patients for the presence of symptoms and address symptom management to improve quality of life.

Madec Y, Szumilin E, Genevier C, Ferradini L, Balkan S, Pujades M, Fontanet A. Weight gain at 3 months of antiretroviral therapy is strongly associated with survival: evidence from two developing countries. AIDS. 2009;27(7):853-61.

In developing countries, access to laboratory tests remains limited, and the use of simple tools such as weight to monitor HIV-infected patients treated with antiretroviral therapy should be evaluated. Madec and colleagues conducted a cohort study of 2451 Cambodian and 2618 Kenyan adults who initiated antiretroviral therapy between 2001 and 2007. The prognostic value of weight gain at 3 months of antiretroviral therapy on 3-6 months mortality, and at 6 months on 6-12 months mortality, was investigated using Poisson regression. Mortality rates [95% confidence interval (CI)] between 3 and 6 months of antiretroviral therapy were 9.9 (7.6-12.7) and 13.5 (11.0-16.7) per 100 person-years in Cambodia and Kenya, respectively. At 3 months, among patients with initial body mass index less than or equal to 18.5 kg/m (43% of the study population), mortality rate ratios (95% CI) were 6.3 (3.0-13.1) and 3.4 (1.4-8.3) for those with weight gain less than or equal to 5 and 5-10%, respectively, compared with those with weight gain of more than 10%. At 6 months, weight gain was also predictive of subsequent mortality: mortality rate ratio (95% CI) was 7.3 (4.0-13.3) for those with weight gain less than or equal to 5% compared with those with weight gain of more than 10%. Weight gain at 3 months is strongly associated with survival. Poor compliance or undiagnosed opportunistic infections should be investigated in patients with initial body mass index less than or equal to 18.5 and achieving weight gain less than or equal to 10%.

Editors’ note: While CD4+ count and viral load remain the gold standards for monitoring patients on antiretroviral treatment, simple tools such as weight gain at 3 months can alert providers to the need to assess adherence, the presence of an opportunistic infection such as tuberculosis, or poor nutritional intake. Whereas overall programme performance can be measured by the proportion of patients achieving at least 10% weight gain at 6 months, the 3-month point is more critical for patient evaluation. As this study of over 5000 Cambodians and Kenyans initiating antiretroviral treatment shows, there was a 6-fold increase in risk of dying for patients with less than or equal to 5% weight gain compared to those with more than 10% weight gain at 3 months. CD4 count at treatment initiation was no longer predictive of mortality between 3 and 6 months once weight gain at 3 months was taken into account. Until antiretroviral treatment is more widely available so that patients initiate treatment at an earlier stage of infection, simple, low-cost weight monitoring will be particularly relevant.

Mamlin J, Kimaiyo S, Lewis S, Tadayo H, Jerop FK, Gichunge C, Petersen T, Yih Y, Braitstein P, Einterz R. Integrating Nutrition Support for Food-Insecure Patients and Their Dependents Into an HIV Care and Treatment Program in Western Kenya. Am J Public Health. 2009;99(2):215-21.

The Academic Model Providing Access to Healthcare (AMPATH) is a partnership between Moi Teaching and Referral Hospital, Moi University School of Medicine, and a consortium of universities led by Indiana University. AMPATH has over 50000 patients in active care in 17 main clinics around western Kenya. Despite antiretroviral therapy, many patients were not recovering their health because of food insecurity. AMPATH therefore established partnerships with the World Food Program and United States Agency for International Development and began high production farms to complement food support. Today, nutritionists assess all AMPATH patients and dependents for food security and refer those in need to the food program. Mamlin and colleagues describe the implementation, challenges, and successes of this program.

Editors’ note: This comprehensive programme combines HIV treatment initiation with extensive nutritional support for food-insecure patients (one-third) and their dependents for the 6 months needed to get them back to a productive life. Sustained through a combination of food production, food donation, and an effective food distribution infrastructure, including a computerized nutrition information system, this trailblazing programme aims to enhance income security for those patients who still need nutritional support after 6 months, rather than fostering dependency. They are referred to a family preservation initiative where they may benefit from, for example, microenterprise training, with or without microfinance, or participation in cooperatives with other patients to grow high value produce. It is time for domestic governments and international donors to step forward to replicate similar food security programmes for selected patients on antiretroviral treatment.

Swaans K, Broerse J, Meincke M, Mudhara M, Bunders J. Promoting food security and well-being among poor and HIV/AIDS affected households: Lessons from an interactive and integrated approach. Eval Program Plann. 2009;32(1):31-42

Participatory and interdisciplinary approaches have been suggested to develop appropriate agricultural innovations as an alternative strategy to improve food security and well-being among HIV affected households. However, sustainable implementation of such interactive approaches is far from easy and straight forward. This study reports of the Interactive Learning and Action approach, a methodology for agricultural innovation which has been adapted to the context of HIV. Role players in agriculture and health were brought together to stimulate and sustain innovation among three support groups for poor and affected households in a rural high HIV prevalence area in South Africa. The effectiveness of the approach was evaluated using both outcome and process criteria. The results indicate that an interactive approach in which service providers/researchers engage themselves as actors to explore the livelihood system and develop appropriate solutions in joint collaboration with resource users has potential. However, it also revealed that cooperation among participants and stakeholders at the interface of agriculture and HIV is complicated and sensitive to erosion. Of particular concern was the difficulty of mobilizing members from poor and affected households to participate and to overcome stigma and discrimination. Lessons and potential applications for the further development of interactive approaches are discussed.

Editors’ note: Interactive approaches build a close collaboration between relevant stakeholders to share knowledge, insights, experiences, needs, and creativity and to generate required involvement and ownership. The Interactive Learning Approach is characterised by enhancement of trust relationships, mutual learning, and knowledge integration between relevant stakeholders in a carefully guided process that is both interactive and iterative, around a shared vision. Adapting it to HIV clearly has some pitfalls, not the least of which are HIV illness and death, on the one hand, and stigma and discrimination on the other.

Nilmanat K, Street AF. Karmic quest: Thai family caregivers promoting a peaceful death for people with AIDS. Contemp Nurse. 2007;27(2):94-103.

Nilmanat and colleagues report the constructions of karma by four Thai family caregivers living with a dying person with AIDS in southern Thailand. These four families form a subset of a larger ethnographic case study exploring the experiences of families living with a relative with AIDS. Serial interviews, observations, and field journals were used as data collection methods with the four families. The findings indicated that the karmic quest is a dominant theme in the narratives of these families caring for their loved ones dying with AIDS.  The ‘calm and peaceful’ death that is described in the palliative care literature equated with their desire for the Buddhist philosophy of a harmonious death. The families used the law of karma and reincarnation as their main frame of reference and mobilised their religious resources to create meaning and purpose. Karmic healing activities were aimed at ending suffering, promoting a peaceful and calm death and ensuring a better life in the next one. The findings are important for the development of palliative nursing practice in Thailand by acknowledging religious and cultural values to promote peaceful death.

Editors´note: Palliative care aims to provide the best quality of life and relieve the suffering of people living with an incurable illness while offering comfort and support to their families and carers. It is a holistic approach which takes account of emotional, psychological, and spiritual needs as well as physical ones. In southern Thailand, Buddhist philosophy and karmic healing activities provide just such a holistic approach.

Ridge D, Williams I, Anderson J, Elford J. Like a prayer: the role of spirituality and religion for people living with HIV in the UK. Sociol Health Illn. 2008;30(3):413-28.

Over 40,000 people are now living with diagnosed HIV in the United Kingdom (UK). There is, however, uncertainty about how people with HIV use religion or spirituality to cope with their infection. Adopting a modified grounded theory approach, Ridge and colleagues analysed individual and group interviews with the people most affected by HIV in the UK: black African heterosexual men and women and gay men (mostly white). For the majority of black African heterosexual men and women in our study, religion was extremely important. The authors found that gay men in the study were less religious than black Africans, although many were spiritual in some way. Black African individuals constructed their spiritual narratives as largely Christian or collective, while gay men described more individualistic or ‘New Age’ approaches.  The authors developed a six-level heuristic device to examine the ways in which prayer and meditation were deployed in narratives to modulate subjective wellbeing. These were: (i) creating a dialogue with an absent counsellor; (ii) constructing a compassionate ‘life scheme’; (iii) interrupting rumination; (iv) establishing mindfulness; (v) promoting positive thinking, and (vi) getting results. That people with HIV report specific subjective benefits from prayer or meditation presents a challenge to secular healthcare professionals and sociologists.

Editors´note: Open-ended in-depth interviews and focus groups revealed that most black Africans in this study were deeply spiritual in their approach to living with HIV and despite high stigma levels in their place of worship they relied heavily on their religion for support. Although some gay men had deep misgivings about religion and its wounding hostility to gay sexuality, they sought meaning in life, were striving to live in harmony and balance, and saw earth as a stepping-stone to another existence. In both groups, whether it was secular, spiritual, or religious in nature, prayer helped interrupt negative rumination and promoted mindfulness.

Kristin L Dunkle, Rob Stephenson, Etienne Karita, Elwyn Chomba, Kayitesi Kayitenkore, Cheswa Vwalika, Lauren Greenberg, Susan Allen. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Lancet. 2008;371(9631):2183-91.

Sub-Saharan Africa has a high rate of HIV infection, most of which is attributable to heterosexual transmission. Few attempts have been made to assess the extent of HIV transmission within marriages, and HIV prevention efforts remain focused on abstinence and non-marital sex. Dunkle and colleagues aimed to estimate the proportion of heterosexual transmission of HIV which occurs within married or cohabiting couples in urban Zambia and Rwanda each year. The authors used population-based data from Demographic and Health Surveys (DHS) on heterosexual behaviour in Zambia in 2001–02 and in Rwanda in 2005, as well as used data on the HIV serostatus of married or cohabiting couples and non-cohabiting couples that was collected through a voluntary counselling and testing service for urban couples in Lusaka, in Zambia, and Kigali, in Rwanda. They estimated the probability that an individual would acquire an incident HIV infection from a cohabiting or non-cohabiting sexual partner, and then the proportion of total heterosexual HIV transmission which occurs within married or cohabiting couples in these settings each year. DHS data from 1739 Zambian women, 540 Zambian men, 1176 Rwandan women, and 606 Rwandan men was analyzed. Under the base model, the authors estimated that 55·1% to 92·7% of new heterosexually acquired HIV infections among adults in urban Zambia and Rwanda occurred within serodiscordant marital or cohabiting relationships, depending on the sex of the index partner and on location. Under the extended model, which incorporated the higher rates of reported condom use that were found with non-cohabiting partners, the authors estimated that 60·3% to 94·2% of new heterosexually acquired infections occurred within marriage or cohabitation. An intervention for couples which reduced transmission in serodiscordant urban cohabiting couples from 20% to 7% every year could avert 35·7% to 60·3% of heterosexually transmitted HIV infections that would otherwise occur. Since most heterosexual HIV transmission for both men and women in urban Zambia and Rwanda takes place within marriage or cohabitation, voluntary counselling and testing for couples should be promoted, as should other evidence-based interventions that target heterosexual couples.

Editors´note: With three-quarters of HIV-infected adults in sub-Saharan Africa unaware of their HIV status and high levels of marital serodiscordance, marriage or cohabitation poses a risk for both men and women. Promoting fidelity for couples without accompanying HIV testing can result in a 20% annual transmission rate. Scale-up of couple-based counselling and testing accompanied by support for marital disclosure and plans for risk reduction, antiretroviral treatment and preventive care for the infected partner, and male circumcision for HIV-negative men is urgently needed.

Curioso WH, Kurth AE. Access, use and perceptions regarding Internet, cell phones and PDAs as a means for health promotion for people living with HIV in Peru. BMC Med Inform Decis Mak 2007;7:24.

Internet tools, cell phones, and other information and communication technologies are being used by HIV-positive people on their own initiative. Little is known about the perceptions of HIV-positive people towards these technologies in Peru. The purpose of this paper is to report on perceptions towards use of information and communication technologies as a means to support antiretroviral medication adherence and HIV transmission risk reduction. Curioso and Kurth conducted a qualitative study (in-depth interviews) among adult people living with HIV in two community-based clinics in Peru. 31 HIV-positive individuals in Lima were interviewed (n = 28 men, 3 women). They found that people living with HIV in Peru are using tools such as cell phones, and the internet (via e-mail, chat, list-serves) to support their HIV care and to make social and sexual connections. In general, they have positive perceptions about using the Internet, cell phones, and PDA for HIV health promotion interventions. The authors conclude that health promotion interventions using information and communication technology tools among people living with HIV in resource-constrained settings may be acceptable and feasible, and can build on existing patterns of use.

Editors’ note: Cell phone communication infrastructure is already in place in most low-and-middle-income countries so determining whether cell phone delivered behavioural support would be effective in improving adherence to treatment and HIV risk reduction makes sense. The first step is determining whether using cell phone technology for health promotion is acceptable and culturally relevant. This seems to be the case in Lima, Peru, despite the small sample size in this study.