HIV This Week

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.

Ncama BP. Acceptance and disclosure of HIV status through an integrated community/home-based care program in South Africa. Int Nurs Rev 2007;54(4):391-7.

This was a comparative study of acceptance and disclosure of the HIV status among people living with HIV (PLHIV) served by an integrated community/home-based care programme and those who are not in any home-based care programme. One of the major challenges in HIV care in developing countries is acceptance and disclosure of a positive HIV status by PLHIV. Denial and non-disclosure of HIV status hinders prevention efforts as well as access to treatment, care and support for these people. Quantitative data were collected in 2004 from a group of PLHIV served by the integrated community/home-based care programme and a group that was not receiving any community/home-based care. Data were compared between the two groups in terms of acceptance and disclosure of HIV status. The integrated community/home-based care programme was effective in improving acceptance and disclosure of the HIV-positive status by PLHIV. People living with HIV in the integrated community/home-based care programme did not find disclosure of their status difficult, and had disclosed their positive HIV status to more people than those who were not in any programme. PLHIV in the integrated community/home-based care programme not only disclosed their positive HIV status within their family network and households, but also disclosed to the community in general, sports group, religious groups and other social networks. Ncama and colleagues conclude that community/home-based care programmes can serve as catalysts for acceptance and disclosure of a positive HIV status by people living with HIV.

Editors’ note: Home-based care services such as this one can foster an individual’s acceptance of his/her HIV status. Disclosure of one’s HIV status, which is linked to acceptance of an HIV-positive diagnosis, is the first step in accessing family and community support. The more that people can come to terms with and disclose their HIV status, the more likely it is that their community’s awareness, openness, and understanding about HIV will increase, particularly in the context of access to care and treatment for those in need.

De Baets AJ, Sifovo S, Parsons R, Pazvakavambwa IE. HIV disclosure and discussions about grief with Shona children: A comparison between health care workers and community members in Eastern Zimbabwe. Soc Sci Med 2008; 66: 479-491.

Research in HIV-related counselling for African children has concentrated on urban tertiary hospitals, but most children have their first health care encounter at a rural primary health care centre. This study investigated perceptions about the acceptability of disclosing the parents’ or child’s HIV status to a child and talking about grief with children, as well as the preferred time, type, and setting for HIV disclosure. An anonymous survey was taken from 64 primary health care workers and 131 community members from rural Eastern Zimbabwe. The results expressed a high need and desire for such communications and should be interpreted against a background of high perceived confidence to talk about grief with adults and a high degree of familiarity with child bereavement and foster care. The participants preferred that partial disclosure occurs from the age of 10.8 (+/-4.2) years and full disclosure from the age of 14.4 (+/-4.5) years.  Compared to community members, health care workers were significantly more open to full disclosure and disclosure at a younger age but were slightly less open to discussing grief. The different preferred combinations of persons to initiate such communications included a health care worker in up to 56% of the responses and a family member in up to 52%. The most commonly preferred family members were father’s sister (up to 37%) and grandmother (up to 40%) rather than the partner (up to 15%). Southern African family dynamics may hinder a mother initiating HIV disclosure and discussions about grief, even though she is traditionally present during HIV diagnosis, counselling, and health education. A more culturally adapted approach than the standard Western ‘couple approach’ may thus be required.  Consequently, counselling training models may need to be adapted. Further research into empowering mothers to involve significant members from the extended family may be highly beneficial.

Editors’ note: The high acceptability of disclosure to children of their own and/or their parents’ serostatus and the perceived need for open communication about grief seen in this study contrasts with assumptions that there is great stigma in rural communities. Accommodating cultural sensitivities means that health care workers should ask the parents to bring the most appropriate family member to attend the child’s counselling sessions, unless parents prefer to initiate HIV disclosure and discussions about grief with their own children without any assistance – one third preferred this option in this study.

Brou H, Djohan G, Becquet R, Allou G, Ekouevi DK, Viho I, Leroy V, Desgrées-du-Loû A; ANRS 1201/1202/1253 Ditrame Plus Study Group. When do HIV-infected women disclose their HIV status to their male partner and why? A study in a PMTCT programme, Abidjan. PLoS Med. 2007 Dec;4(12):e342.

In Africa, women tested for HIV during antenatal care are counselled to share with their partner their HIV test result and to encourage partners to undertake HIV testing. Brou and colleagues investigate, among women tested for HIV within a prevention of mother-to-child transmission of HIV (PMTCT) programme, the key moments for disclosure of their own HIV status to their partner and the impact on partner HIV testing. Within the Ditrame Plus PMTCT project in Abidjan, 546 HIV-positive and 393 HIV-negative women were tested during pregnancy and followed-up for two years after delivery. Circumstances, frequency, and determinants of disclosure to the male partner were estimated according to HIV status. The determinants of partner HIV testing were identified according to women’s HIV status. During the two-year follow-up, disclosure to the partner was reported by 96.7% of the HIV-negative women, compared to 46.2% of HIV-positive women (chi(2) = 265.2, degrees of freedom [df] = 1, p < 0.001). Among HIV-infected women, privileged circumstances for disclosure were just before delivery, during early weaning (at 4 mo to prevent HIV postnatal transmission), or upon resumption of sexual activity. Formula feeding by HIV-infected women increased the probability of disclosure (adjusted odds ratio 1.54, 95% confidence interval 1.04-2.27, Wald test = 4.649, df = 1, p = 0.031), whereas household factors such as having a co-spouse or living with family reduced the probability of disclosure. The proportion of male partners tested for HIV was 23.1% among HIV-positive women and 14.8% among HIV-negative women (chi(2) = 10.04, df = 1, p = 0.002). Partners of HIV-positive women who were informed of their wife’s HIV status were more likely to undertake HIV testing than those not informed (37.7% versus 10.5%, chi(2) = 56.36, df = 1, p < 0.001). In PMTCT programmes, specific psychosocial counselling and support should be provided to women during the key moments of disclosure of HIV status to their partners (end of pregnancy, weaning, and resumption of sexual activity). This support could contribute to improving women’s adherence to the advice given to prevent postnatal and sexual HIV transmission.

Editors’ note: This study emphasises that there are “tellable” moments when HIV-positive women are more likely to disclose their status to their sexual partner – an essential step in obtaining understanding and moral support within the couple. Disclosure contributes to women’s capacity to adhere to advice to prevent postnatal and sexual HIV transmission. Furthermore, men who were informed of their partner’s HIV status, whether positive or negative, were much more likely to undertake HIV testing themselves.

Li L, Sun S, Wu Z, Wu S, Lin C, Yan Z. Disclosure of HIV status is a family matter: field notes from China. J Fam Psychol. 2007 Jun;21(2):307-14.

This study examines the role that family plays in disclosure of HIV in China. In-depth semistructured interviews were conducted with 30 individuals living with HIV infected through different routes. The vast majority of participants were between the ages of 20 and 39 years old (93.4%) and about a third (36.7%) were women. Two primary disclosure processes, involuntary and voluntary, are described. In both processes, family members other than the patient are usually the first to know HIV status. Positive impacts of disclosure include strengthening family relations and help with medical care and counselling, whereas negative impacts include fear, isolation, avoidance, and psychological burden. This study illustrates that family is an intricate part of the disclosure process in China and demonstrates the importance of including families in HIV interventions.

Editors’ note: This is the first systematic and in-depth description of HIV disclosure in China. Both voluntary and involuntary disclosure involve the family. In the former, HIV-positive people weigh the effect that disclosure would have on their families and when they decide to disclose it is often to a family member of the same generation (i.e. spouse or sibling) first. In the latter, parents are often chosen by a health care provider to bear the responsibility of informing the HIV-positive person. China is experiencing rapid social change and the practice of telling family members first may decline with the “Four Free One Care” national campaign. It provides four free services (medical assistance, anonymous HIV tests, education for orphans, and prenatal treatment for pregnant women) and one care service for elderly people who have lost children to AIDS.

Delvaux T, Nöstlinger C. Reproductive Choice for Women and Men Living with HIV: Contraception, Abortion and Fertility. Reprod Health Matters. 2007 May;15(29 Suppl):46-66.

From a policy and programmatic point of view, this paper reviews the literature on the fertility-related needs of women and men living with HIV and how the entry points represented by family planning, sexually transmitted infection and HIV-related services can ensure access to contraception, abortion and fertility services for women and men living with HIV. Most contraceptive methods are safe and effective for HIV positive women and men. The existing range of contraceptive options should be available to people living with HIV, along with more information about and access to emergency contraception. Potential drug interactions must be considered between hormonal contraception and treatment for tuberculosis and certain antiretroviral drugs. Couples living with HIV who wish to use a permanent contraceptive method should have access to female sterilisation and vasectomy in an informed manner, free of coercion. How to promote condoms and dual protection and how to make them acceptable in long term-relationships remains a challenge. Both surgical and medical abortion are safe for women living with HIV. To reduce risk of vertical transmission of HIV and in cases of infertility, people with HIV should have access to sperm washing and other assisted conception methods, if these are available. Simple and cost-effective procedures to reduce risk of vertical transmission should be part of counselling for women and men living with HIV who intend to have children. Support for the reproductive rights of people with HIV is a priority. More operations research on best practices is needed.

Editors’ note: Sperm washing is expensive and not widely available. There are anecdotal reports of couples who want children minimising the risk of HIV transmission by having the HIV-negative woman take short course triple therapy as prophylaxis during unprotected sex with her HIV-positive male partner who has undetectable viral load levels. This makes theoretical sense even if success rates have not been documented.

Homelessness and unstable housing have been associated with HIV risk behaviour and poorer health among persons living with HIV (PLHIV), yet prior research has not tested causal associations. This paper describes the challenges, methods, and baseline sample of the Housing and Health Study, a longitudinal, multi-site, randomized controlled trial investigating the effects of providing immediate rental housing assistance to PLHIV who were homeless or at severe risk of homelessness. Primary outcomes included HIV disease progression, medical care access and utilization, treatment adherence, mental and physical health, and risks of transmitting HIV. Across three study sites, 630 participants completed baseline sessions and were randomized to receive either immediate rental housing assistance (treatment group) or assistance finding housing according to local standard practice (comparison group). Baseline sessions included a questionnaire, a two-session HIV risk-reduction counselling intervention, and blood sample collection to measure CD4 counts and viral load levels. Three follow-up visits occurred at 6, 12, and 18 months after baseline. Participants were mostly male, Black, unmarried, low-income, and nearly half were between 40 and 49 years old. At 18 months, 84% of the baseline sample was retained. The retention rates demonstrate the feasibility of conducting scientifically rigorous housing research, and the baseline results provide important information regarding characteristics of this understudied population that can inform future HIV prevention and treatment efforts.

Editors’ note: Whether addressing access to housing concerns among this population of people living with HIV more expeditiously will have positive effects on their risk behaviour and health status remains to be seen – unfortunately the sample size may be too small to detect differences over an 18 month period.

In many areas of the globe most HIV infection is transmitted sexually or in association with pregnancy, childbirth and breastfeeding, raising the need for sexual and reproductive health and AIDS initiatives to be mutually reinforcing. Many people with HIV, who are in good health, will want to have children, and highly active antiretroviral therapy provides women and men living with AIDS the possibility of envisaging new life projects such as parenthood, because of a return to health. However, there are still difficult choices to face concerning sexuality, parenthood desires and family life. Structural, social and cultural issues, as well as the lack of programmatic support, hinder the fulfilment of the right to quality sexual and reproductive health care and support for having a family. This paper addresses the continuum of care involved in parenthood for people living with HIV, from pregnancy to infant and child care, and provides evidence-based examples of policies and programmes that integrate sexual and reproductive health interventions with HIV-related care in order to support parenthood. Focusing on parenthood for people living with and affected by HIV, that is, focusing on the couple rather than the woman as the unit of care, the individual or the set of adults who are responsible for raising children, would be an innovative programmatic advance. Going beyond maternal and child health care to providing care and support for parents and others who are responsible for raising children is especially relevant for those living with HIV infection.

Editors’ note: In some settings the term ‘parent-to child transmission’ is gaining currency as the focus is increasingly on the couple and the parenting choices and capacities of both parents.

Shapiro K, Ray S. Sexual Health for People Living with HIV. Reprod Health Matters 2007;15:67-92 (supplement).

Sexual health is defined in terms of well-being, but is challenged by the social, cultural and economic realities faced by women and men with HIV. A sexual rights approach puts women and men with HIV in charge of their sexual health. Accurate, accessible information to make informed choices and safe, pleasurable sexual relationships possible is best delivered through peer education and health professionals trained in empathetic approaches to sensitive issues. Young people with HIV especially need appropriate sex education and support for dealing with sexuality and self-identity with HIV. Women and men with HIV need condoms, appropriate services for sexually transmitted infections, sexual dysfunction and management of cervical and anogenital cancers. Interventions based on positive prevention, that combine protection of personal health with avoiding HIV/STI transmission to partners, are recommended. HIV counselling following a positive test has increased condom use and decreased coercive sex and outside sexual contacts among discordant couples. HIV treatment and care have reduced stigma and increased uptake of HIV testing and disclosure of positive status to partners. High adherence to antiretroviral therapy and safer sexual behaviour must go hand-in-hand. Sexual health services have worked with peer educators and volunteer groups to reach those at higher risk, such as sex workers. Technological advances in diagnosis of STIs, microbicide development and screening and vaccination for human papillomavirus must be available in developing countries and for those with the highest need globally.

Editors’ note: The sexual health of people living with HIV may be poorly addressed by care providers who are uncomfortable with sexuality in general, let alone the sexuality of people living with HIV, despite the individual and community benefits of sexual health and positive prevention. Training is needed to ensure that education on condom use and appropriate medical care are provided in a context that acknowledges and promotes safe and enjoyable sexual relationships for people living with HIV.

Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med 2007 Mar 1; [Epub ahead of print]

AIDS stigmas interfere with HIV prevention, diagnosis, and treatment and can become internalized by people living with HIV. However, the effects of internalized AIDS stigmas have not been investigated in Africa, home to two-thirds of the more than 40 million people living with HIV in the world. The current study examined the prevalence of discrimination experiences and internalized stigmas among 420 HIV-positive men and 643 HIV-positive women recruited from AIDS services in Cape Town, South Africa. The anonymous surveys found that 40% of persons with HIV had experienced discrimination resulting from having HIV infection and one in five had lost a place to stay or a job because of their HIV status. More than one in three participants indicated feeling dirty, ashamed, or guilty because of their HIV status. A hierarchical regression model that included demographic characteristics, health and treatment status, social support, substance use, and internalized stigma significantly predicted cognitive-affective depression. Internalized stigma accounted for 4.8% of the variance in cognitive-affective depression scores over and above the other variables. These results indicate an urgent need for social reform to reduce AIDS stigmas and the design of interventions to assist people living with HIV to adjust and adapt to the social conditions of AIDS in South Africa.

Editors’ note: Addressing stigma effectively requires social change. The isolation of people living with HIV and the extent to which they are judged to be the “other” can be reduced by familiarisation and solidarity building activities in communities. Addressing internalized stigma requires social environment change, individual counselling and peer support.

Miller AN, Rubin DL. Motivations and methods for self-disclosure of HIV seropositivity in Nairobi, Kenya. AIDS Behav 2007 Feb 13; [Epub ahead of print]

This study employed structured interviews with 307 people living with HIV in Nairobi, Kenya to investigate their serostatus disclosure with respect to four types of relationships in their lives: partners, friends, family members, and religious leaders/clergy. Regarding motivations for disclosure, it was found that a sense of duty and seeking material support motivated disclosure to family and partners, fear of loss of confidentiality inhibited disclosure to friends, and the need for advice encouraged disclosure to religious leaders. The method of disclosure most frequently mentioned was direct, with males less likely than females to use direct methods when disclosing to spouses or partners. Intermediated disclosure was common in partner/spouse relationships with around one-third of partners preferring to disclose through a third party. Methods used to disclose as well as reasons for doing so varied by relationship type.

 Editors’ note: It is often said that disclosure should be on a need-to-know basis – but this report highlights that in some relationships there is a need to have it be known. Disclosure counselling which focuses on decision making about who needs to know, what mechanisms to use for disclosure and what assistance may be available can help people negotiate through these waters safely and effectively.

Graham SM, Holte SE, Peshu NM, Richardson BA, Panteleeff DD, Jaoko WG, Ndinya-Achola JO, Mandaliya KN, Overbaugh JM, McClelland RS. Initiation of antiretroviral therapy leads to a rapid decline in cervical and vaginal HIV-1 shedding. AIDS 2007;21:501-507.

Antiretroviral therapy (ART) may decrease HIV-1 infectivity in women by reducing genital HIV-1 shedding. Graham and colleagues aimed to evaluate the time course and magnitude of decay in cervical and vaginal HIV-1 shedding as women initiate ART. This prospective, observational study of 20 antiretroviral-naive women initiating ART with stavudine, lamivudine, and nevirapine measured HIV-1 RNA in plasma, cervical secretions, and vaginal secretions. Qualitative polymerase chain reaction estimated HIV-1 DNA in cervical and vaginal samples. Perelson’s two-phase viral decay model and non-linear random effects were used to compare RNA decay rates. Decreases in proviral DNA were evaluated using logistic regression and generalized estimating equations. Significant decreases in the quantity of HIV-1 RNA were observed by day 2 in plasma (P < 0.001), day 2 in cervical secretions (P = 0.001), and day 4 in vaginal secretions (P < 0.001). Modeled initial and subsequent RNA decay rates in plasma, cervical secretions, and vaginal secretions were 0.6, 0.8, and 1.2 log10 virions/day, and 0.04, 0.05, and 0.06 log10 virions/day, respectively. The initial decay rate for vaginal HIV-1 RNA was more rapid than for plasma RNA (P = 0.02). Detection of HIV-1 DNA decreased significantly in vaginal secretions during the first week (P < 0.001). At day 28, 10 women had detectable HIV-1 RNA or proviral DNA in genital secretions. Genital HIV-1 shedding decreased rapidly after ART initiation, consistent with a rapid decrease in infectivity. However, incomplete viral suppression in half of these women may indicate an ongoing risk of transmission.

Editors’ note: These are encouraging findings suggesting possibly reduced infectiousness as a result of reduced HIV shedding during antiretroviral treatment initiation but it should be remembered that some studies have shown variable correlations between plasma viral load and viral load in genital secretions, including cervical and vaginal secretions as well as seminal fluid. While the need for safer sex precautions remains, these results do give added weight to the importance of antiretroviral cover during labour and delivery to prevent mother-to-child transmission.

Although highly active antiretroviral therapy (HAART) has lowered the incidence of various opportunistic diseases, its impact on cervical squamous intraepithelial lesions (SILs) is unclear. Heard and colleagues seek to compare the incidence of SILs in HIV-infected women receiving HAART versus those not receiving HAART and to determine the role of risk factors including immunosuppression in the pathogenesis of SIL. A total of 298 HIV-infected women with normal Papanicolaou (Pap) smear and normal colposcopic findings at enrollment were followed-up until incident SIL or last follow-up visit. Cox regression modelling was used to assess risks factors for incident SIL. Eighty-eight women developed SILs, including 75 low-grade lesions, during a median follow-up of 28 months (16-52; incidence of 8.7 cases per 100 person-years). No invasive cervical cancers were identified. Incidence decreased from 10.7 to 6.5 per 100 person-years in non-receiving versus receiving HAART women (relative risk [RR]: 0.7; 95% confidence interval [CI]: 0.4-1.2, P=0.15, from the adjusted Cox model). Incident SIL was not associated to low CD4+ T-cell count (P=0.54). In multivariate analysis, the only significant risk factor for incident lesion was the age between 30-39 compared with over 40 (RR: 3.5; 95% CI: 1.4-8.9; P=0.02). The authors conclude that no impact in the development of SIL was evidenced for CD4+ T-cell counts, but they cannot exclude a modest impact of HAART. All HIV-positive women should be offered to participate in cervical cancer screening programmes whether or not they receive effective antiretroviral therapy.

Editors’ note: HPV and HIV are both sexually transmitted diseases and bad bed partners. Invasive cervical cancer was added to the list of AIDS-defining illnesses in 1993 in recognition of the effects of HIV-related immune suppression on cervical cancer progression. Women living with HIV should have regular Papanicolaou (Pap) tests and be followed closely for signs of cervical dysplasia.

Floridia and colleagues used data from a large national surveillance study to describe antiretroviral regimens in pregnant women with HIV, with particular reference to the presence at conception of antiretroviral treatments contraindicated in pregnancy. Therapeutic changes during pregnancy were also analysed. Among 334 women on antiretroviral treatment at conception, less than half (42.4%) reported current pregnancy as planned. A large number of different regimens (80) was observed. All the regimens included at least one nucleoside or nucleotide reverse transcriptase inhibitor. Non-nucleoside reverse transcriptase inhibitors and protease inhibitors were present in similar proportions (39.2% and 40.7%, respectively). The most commonly used drugs were lamivudine (83.2% of regimens), zidovudine (50.0%), stavudine (d4T; 38.0%), nevirapine (25.7%), didanosine (ddl; 17.7%) and nelfinavir (17.7%). Treament with efavirenz (13.5% of regimens) and ddl+d4T (9.6%) was markedly frequent. Use of efavirenz at conception was associated with a subsequent treatment change during pregnancy (odds ratio [OR]: 13.2.; 95% confidence interval [CI]: 3.2-53.8, P < 0.001). A similar but less strong association was found for ddl (OR: 1.8; 95% CI:1.03-3.25, P = 0.033), whereas being on nevirapine was associated with a lower risk (OR: 0.58; 95% CI: 0.38-0.81, P = 0.013). These data show that treatment at conception frequently represents the regimen previously selected for the treatment of the non-pregnant woman. The observed rates of exposure to contraindicated treatment should lead prescribing physicians to consider in HIV-positive women therapeutic choices that take into account the likelihood of an unplanned pregnancy. Such an approach is likely to reduce not only unintended exposures to contraindicated drugs, but also therapeutic changes during pregnancy.

Editors’ note: In choosing antiretroviral treatment in women of child bearing age it is important to keep in mind the risk of pregnancy, the safety of the chosen antiretroviral treatment in pregnancy and the likelihood of having to change treatment during the pregnancy.

Bazant ES, Boulay M. Factors associated with religious congregation members’ support to people living with HIV/AIDS in Kumasi, Ghana. AIDS Behav 2007 Jan 6[Epub ahead of print].

Physical, social and economic constraints often limit the ability of people living with HIV to meet their basic needs. Community members are a valuable source of support for people living with HIV, although little is known about the types of support they provide or how to mobilise this support. Bazant and Boulay examined this issue by conducting a survey of 1200 members of 6 religious congregations in Kumasi, Ghana. A fifth of congregation members reported providing some support to people with HIV in the last 6 months, mostly through prayer, financial support, and counselling. Factors associated with providing support include having heard a congregation or tribal chief speaking about HIV, collective efficacy related to HIV, and perceived risk of becoming infected with HIV. The authors conclude that to enhance support to people with HIV, programmes should involve community leaders and encourage dialogue on ways to address the epidemic.

Williams AL. Perspectives on spirituality at the end of life: a meta-summary. Palliat Support Care 2006;4:407-17.

Williams undertook a meta-summary of the qualitative literature on spiritual perspectives of adults who are at the end of life to summarily analyze the research to date and identify areas for future research on the relationship of spirituality with physical, functional, and psychosocial outcomes in the health care setting. Included were all English language reports from 1966 to the present catalogued in PubMed, Medline, PsycInfo, and CINAHL, identifiable as qualitative investigations of the spiritual perspectives of adults at the end of life. The final sample included 11 articles, collectively representing data from 217 adults. The preponderance of participants had a diagnosis of cancer, those with AIDS, cardiovascular disease, and ALS were also represented. Approximately half the studies were conducted in the United States; others were performed in Australia, Finland, Scotland, and Taiwan. Following a process of theme extraction and abstraction, thematic patterns emerged and effect sizes were calculated. A spectrum of spirituality at the end of life encompassing spiritual despair (alienation, loss of self, dissonance), spiritual work (forgiveness, self-exploration, search for balance), and spiritual well-being (connection, self-actualization, consonance) emerged. The authors conclude that the findings from this meta-summary confirm the fundamental importance of spirituality at the end of life and highlight the shifts in spiritual health that are possible when a terminally ill person is able to do the necessary spiritual work. Existing end-of-life frameworks neglect spiritual work and consequently may be deficient in guiding research. The area of spiritual work is fertile ground for further investigation, especially interventions aimed at improving spiritual health and general quality of life among the dying.

Editors’ note: These results from an international study stimulate a desire for much more information on approaches that are effective in improving wellbeing and quality of life among those who are dying.

Ndinda C, Chimbwete C, McGrath N, Pool R, Mdp Group. Community attitudes towards individuals living with HIV in rural KwaZulu-Natal, South Africa. AIDS Care 2007;19:92-101.

Antenatal sero-prevalence rates of 30% and more have been reported in KwaZulu-Natal since 1998 and over 50% of all adult deaths in 2000 were due to AIDS. Understanding the changing social and cultural attitudes to AIDS is important in providing contextual information to aid the design of interventions. Ndinda and colleagues examined community attitudes towards individuals living with HIV. Eleven focus groups were conducted with men and women. Participants were asked to discuss how people living with HIV were treated within the family and community. The discussions were recorded and transcribed in isiZulu and then translated into English. These were coded using Nudist-6 software to identify key themes and sub-themes using content analysis. Gender and area differences were investigated. Generally participants expressed positive attitudes to the treatment of AIDS patients and felt that people living with HIV were being cared for within families. However, they reported more negative attitudes to those living with HIV by the general community and suggested these attitudes and acts of discrimination influenced disclosure. Discrimination included physical isolation and symbolism such as referring to them using a ‘three finger’ gesture. Participants also reported mixed responses to known HIV-positive individuals, ranging from sympathy to a lack of care, on the grounds that the person is certain to die. There are gender differences in terms of the attitudes towards people living with HIV. Compassion and hopelessness seem to be more common among women than men.

Editors’ note: It is important for communities to build on findings like these to constructively address negative attitudes and foster nurturing, positive attitudes.

Zachariah R, Fitzgerald M, Massaquoi M, Pasulani O, Arnould L, Makombe S, Harries AD. Risk factors for high early mortality in patients on antiretroviral treatment in a rural district of Malawi. AIDS 2006;20:2355-60.

Zacchariah and colleagues determined the cumulative proportion of deaths that occur within 3 and 6 months of starting ART, and identified risk factors that may be associated with such mortality, among adults started on ART in a rural district hospital in Thyolo, Malawi. Over a 2-year period (April 2003 to April 2005), the authors examined the mortality within the first 3 and 6 months of starting ART. A total of 1507 individuals (517 men and 990 women), whose median age was 35 years were included in the study. There were a total of 190 (12.6%) deaths on ART of which 116 (61%) occurred within the first 3 months (very early mortality) and 150 (79%) during the first 6 months of initiating ART. Significant risk factors associated with such mortality included WHO stage IV disease, a baseline CD4 cell count under 50 cells/mul and increasing grades of malnutrition. A linear trend in mortality was observed with increasing grades of malnutrition (P=0.001) and decreasing CD4 cell counts (P=0.001). Individuals who were severely malnourished (that is, body mass index less than 16.0 kg/m²) had a six times higher risk of dying in the first 3 months than those with a normal nutritional status. The authors conclude that among individuals starting ART, the body mass index and clinical staging could be important screening tools for use to identify and target individuals who, despite ART, are still at a high risk of early death.

Editors’ note: That severe malnourishment increased the risk of early mortality six-fold in patients starting antiretroviral treatment underlines strongly the importance of nutritional supplementation as a critical component of treatment programmes. In a number of countries, the World Food Programme is helping vulnerable individuals and their families to smooth the transition onto drug treatment, enable adherence to antiretroviral treatment regimens and improve survival.

Clifford GM, Goncalves MA, Franceschi S; for the HPV and HIV Study Group. Human papillomavirus types among women infected with HIV: a meta-analysis. AIDS 2006;20(18):2337-44.

HIV-positive women have a high prevalence of human papillomavirus (HPV) infection and are infected with a broader range of HPV types than HIV-negative women. However, it is not known to what extent these different types are associated with high-grade squamous intraepithelial lesions (HSIL) and cancer. Clifford and colleagues conducted a meta-analysis of HPV type-specific prevalence among HIV-positive women, stratified by geographical region and by cervical cytology: normal, atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesions (ASCUS/LSIL) or HSIL. In 20 studies, 5578 HIV-positive women were identified, largely from North America but also Africa, Asia, Europe and South/Central America. For 3230 women with no cytological abnormalities, prevalence was 36.3% for any HPV and 11.9% for multiple HPV types. The six most common high-risk HPV types were 16 (4.5%), 58 (3.6%), 18 (3.1%), 52 (2.8%), 31 (2.0%) and 33 (2.0%). HPV16 was also the most common type in 2053 HIV-positive women with ASCUS/LSIL and 295 with HSIL. Those with HSIL were significantly less likely to be infected with HPV16 (OR 0.6, 95%CI 0.4-0.7) than the general female population with HSIL. In contrast, HIV-positive women with HSIL were significantly more likely to be infected with HPV types 11, 18, 33, 51, 52, 53, 58 and 61, and with multiple HPV types. The authors conclude that the proportion of HIV-positive women with HPV16 rose with increasing severity of cervical lesions. Nevertheless, HPV16 remained underrepresented in HIV-positive women with HSIL, who showed a higher proportion of other HPV types and multiple types compared with the general female population with HSIL.

Editors’ note: HPV infection is the most common sexually transmitted infection in the world. This study found that HPV16 was the most common detectable HPV type in women with HIV infection, as it is in women without HIV infection, when the cervix was healthy or when cervical changes were at most low grade. The fact that women with high grade lesions had more of other HPV types and more multiple types may be due to the effects of immune deficiency. Correlating CD4 count with the predominance of certain HPV types and with cervical pathology will assist in predicting the potential impact of the new HPV vaccines for women with HIV infection or who subsequently acquire HIV infection.

Wolitski RJ, Flores SA, O’leary A, Bimbi DS, Gomez CA. Beliefs about personal and partner responsibility among HIV-seropositive men who have sex with men: measurement and association with transmission risk behaviour. AIDS Behav 2006 Nov 14 [Epub ahead of print].

Beliefs of people living with HIV about their own responsibility for preventing HIV transmission (personal responsibility) and their sex partners’ responsibility for protecting themselves (partner responsibility) are poorly understood. A sample of 1163 HIV-seropositive men who have sex with men (55% men of colour) completed an A-CASI assessment of sexual behaviour and psychosocial measures. A two-dimensional model that represents four orientations toward responsibility was tested: (1) self-high personal and low partner responsibility, (2) other-low personal and high partner responsibility, (3) shared-high personal and high partner responsibility, and (4) diminished-low personal and low partner responsibility. The self-responsibility group demonstrated the lowest risk of HIV transmission and the other responsibility group had the highest risk. Intermediate risk was observed in the shared and diminished responsibility groups.

Editors’ note: Building on beliefs about responsibility (and also self-efficacy) to develop effective programming is a significant challenge but these are key elements in decision making and in behaviour within dyads, sexual or not, and literature outside the HIV field may throw some light on this.

Cotton S, Tsevat J, Szaflarski M, Kudel I, Sherman SN, Feinberg J, Leonard AC, Holmes WC. Changes in religiousness and spirituality attributed to HIV: are there sex and race differences? J Gen Intern Med 2006;21 Suppl 5:S14-20.

Having a serious illness such as HIV raises existential issues, which are potentially manifested as changes in religiousness and spirituality. Cotton and colleagues described changes in religiousness and spirituality of people with HIV, and determines if these changes differed by sex and race. Three-hundred and forty-seven adults with HIV from 4 sites were asked demographic, clinical, and religious/spiritual questions. Six religious/spiritual questions assessed personal and social domains of religiousness and spirituality. Eighty-eight participants (25%) reported being “more religious” and 142 (41%) reported being “more spiritual” since being diagnosed with HIV. Approximately 1 in 4 participants also reported that they felt more alienated by a religious group since their HIV diagnosis and approximately 1 in 10 reported changing their place of religious worship because of HIV. A total of 174 participants (50%) believed that their religiousness/spirituality helped them live longer. Fewer Caucasians than African Americans reported becoming more spiritual since their HIV diagnosis (37% versus 52%, P<0.015), more Caucasians than African Americans felt alienated from religious communities (44% versus 21%, P<.001), and fewer Caucasians than African Americans believed that their religiousness/spirituality helped them live longer (41% vs 68%, P<.001). There were no significantly different reported changes in religious and spiritual experiences by sex. In conclusion, many participants report having become more spiritual or religious since contracting HIV, though many have felt alienated by a religious group-some to the point of changing their place of worship. The authors conclude that clinicians conducting spiritual assessments should be aware that changes in religious and spiritual experiences attributed to HIV might differ between Caucasian and African Americans.

Editors’ note: These findings from the United States may also find resonance in other cultures.