HIV This Week

Trends in HIV Prevalence, Estimated HIV Incidence, and Risk Behaviour Among Men Who Have Sex With Men in Bangkok, Thailand, 2003-2007.

van Griensven F, Varangrat A, Wimonsate W, Tanpradech S, Kladsawad K, Chemnasiri T, Suksripanich O, Phanuphak P, Mock P, Kanggarnrua K, McNicholl J, Plipat T. J Acquir Immune Defic Syndr. 2009 No. [Epub ahead of print]

Men who have sex with men (MSM) continue to be at high risk for HIV infection. Here the authors evaluate trends in HIV prevalence, estimated HIV incidence, and risk behaviour among MSM in Bangkok, Thailand. Between 2003 and 2007, 3 biennial cross-sectional HIV prevalence assessments were conducted among men who have sex with men in Bangkok, Thailand, using venue-day-time sampling. Oral fluid was tested for HIV infection; demographic and behavioural data were self-collected using hand-held computers. Estimates of annual HIV incidence in young men who have sex with men were derived as follows: (number of HIV infections/sum of [current age-age at start of anal intercourse]) x 100). Logistic and Poisson regression was used to evaluate trends in HIV prevalence, estimated HIV incidence, and risk behaviour. The overall HIV prevalence increased from 17.3% in 2003 to 28.3% in 2005 to 30.8% in 2007 (P < 0.001 for trend). The estimated HIV incidence among young men who have sex with men increased from 4.1% in 2003 to 6.4% in 2005, to 7.7% in 2007 (P < 0.02 for trend). The increase in HIV prevalence from 2005 to 2007 was not statistically significant. The proportion of men reporting anal sex and casual or steady male sex partners in the past 3 months significantly decreased, whereas the proportion reporting drug use and drug use during sex significantly increased. No increase was observed in the proportion of men reporting consistent condom use. These data suggest that after a strong increase from 2003 to 2005, the HIV prevalence among men who have sex with men in Bangkok may have begun to stabilize. Given the continuing high levels of risk behaviour and the estimated high HIV incidence in young MSM, additional HIV preventive interventions are necessary.

Abstract: 1

Editors’ note: The high HIV prevalence in Bangkok among men who have sex with men is part of the global phenomenon of resurgent or newly described HIV epidemics among men who have sex with men around the world. The encouraging signs of a possible epidemic plateau should not distract from the need to intensify efforts towards universal access to services and prevention interventions for this key population. It is clear that current programmes are inadequate to reverse the epidemic among Thai men who have sex with men, unlike the 100 per cent condom campaign that led to the resounding success of the Royal Thai government in reversing the epidemic of heterosexual transmission in the mid-1990s.  

Anal Sexually Transmitted Infections and Risk of HIV Infection in Homosexual Men.

Jin F, Prestage GP, Imrie J, Kippax SC, Donovan B, Templeton DJ, Cunningham A, Mindel A, Cunningham PH, Kaldor JM, Grulich AE. J Acquir Immune Defic Syndr. 2009 Sep. [Epub ahead of print]

Jin et al examined a range of common bacterial and viral sexually transmitted infections as risk factors for HIV seroconversion in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. Detailed information about HIV risk behaviours was collected by interview twice yearly. Participants were tested annually for HIV, anal and urethral gonorrhoea and chlamydia, herpes simplex virus types 1 and 2, and syphilis. In addition, they reported annual diagnoses of these conditions and of genital and anal warts. Among 1427 enrolled participants, 53 HIV seroconverters were identified, giving an incidence of 0.78 per 100 person-years. After controlling for number of episodes of insertive and receptive nonseroconcordant unprotected anal intercourse, there were independent associations with anal gonorrhoea (adjusted hazard ratio = 7.12, 95% confidence interval: 2.05 to 24.79) and anal warts (hazard ratio = 3.63, 95% confidence interval: 1.62 to 8.14). Anal gonorrhoea and anal warts were independently associated with HIV acquisition. The added HIV prevention value of more frequent screening of the anus to allow early detection and treatment of anal sexually transmitted infections in homosexual men should be considered.

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Editor’s note: For the most part, the anal gonorrhoea diagnosed in this study of men who have sex with men was asymptomatic, suggesting that it was of relatively long standing. It may have caused a low-grade inflammation that would attract HIV target cells. Likewise, anal warts themselves and/or their treatment can disrupt natural defences, allowing HIV easier access to its prey. Given that these two infections were independently associated with HIV acquisition, it is important to assess the potential impact on HIV incidence in men who have sex with men of frequent sexual health screening and treatment of anal gonorrhoea and anal warts.

Improvement in Healing and Reduction in HIV Shedding with Episodic Acyclovir Therapy as Part of Syndromic Management among Men: A Randomized, Controlled Trial.

Paz-Bailey G, Sternberg M, Puren AJ, Markowitz LE, Ballard R, Delany S, Hawkes S, Nwanyanwu O, Ryan C, Lewis DA. J Infect Dis. 2009;200:1039-49.

It is uncertain whether episodic acyclovir will enhance ulcer healing if delivered at primary health care settings, because there is often a delay in treatment initiation. A double-blind, randomized, placebo-controlled trial of 5-day acyclovir (400 mg 3 times daily) was conducted among men with genital ulcers in South Africa. Participants received syndromic management; were tested for ulcer aetiology, human immunodeficiency virus (HIV), syphilis, and herpes simplex virus type 2 (HSV-2); and were seen over the course of a month to evaluate ulcer healing and HIV-1 RNA shedding. Outcomes were ulcer duration and HIV-1 RNA shedding, assessed on day 7 among HIV-1-seropositive participants with a herpetic ulcer. A total of 309 men received acyclovir, and 306 received placebo; 63% were HIV-1 positive. There were 295 HIV-1-positive participants with a herpetic ulcer. Acyclovir improved ulcer healing-61% of those receiving acyclovir healed by day 7, compared with 42% of those receiving placebo (adjusted relative risk, 1.4 [95% confidence interval, 1.1-1.8]). Acyclovir also improved healing by a median of 3 days and reduced HIV-1 ulcer shedding on day 7 (24% for acyclovir vs 37% for placebo). The authors report that addition of acyclovir to syndromic management will improve healing of genital ulcers and may potentially reduce HIV transmission in combination with other interventions.

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Editors’ note: The results of this acyclovir trial for the 63% of participants who were HIV-positive are encouraging – acyclovir healed herpes simplex-2 (HSV-2) ulcers more quickly (median of 3 days) and reduced HIV shedding from the ulcers. The latter could be due in part to the direct effect of acyclovir itself on HIV replication. WHO recommends that countries in which HSV-2 accounts for more that 30% of genital ulcer disease add antiherpetic treatment to syndromic management algorithms for genital ulcer disease. Why this is not uniformly done is unclear – the cost of treatment has been much reduced by generic acyclovir. Even though trials to date have not found that acyclovir reduces ongoing HIV transmission, it provides symptom relief and reduces herpes shedding. Given that the ulcer is often what may have brought the patient in for care, providers should take advantage of the opportunity while prescribing acyclovir to initiate discussions about HIV testing and counselling with all patients presenting with genital ulcer disease – the majority are unlikely unaware of their HIV status and are not accessing HIV prevention and treatment services.

 Prevalence of unprotected anal intercourse among HIV-diagnosed MSM who have sex with men in the United States: a meta-analysis.

Crepaz N, Marks G, Liau A, Mullins MM, Aupont LW, Marshall KJ, Jacobs ED, Wolitski RJ; for the HIV/AIDS Prevention Research Synthesis (PRS) Team, USA. AIDS. 2009; 23:1617-29

Crepaz and colleagues set out to integrate the empirical findings on the prevalence of unprotected anal intercourse among HIV-diagnosed men who have sex with men in the United States by comprehensively searching MEDLINE, EMBASE, PsycINFO (2000-2007), hand searching bibliographic lists, and contacting researchers. Thirty US studies (n = 18 121) met selection criteria. Analyses were conducted using random-effects models and meta-regression. The prevalence of unprotected anal intercourse was considerably higher with HIV-seropositive partners (30%; 95% confidence interval 25-36) than with serostatus unknown (16%; 95% confidence interval 13-21) or HIV-seronegative partners (13%; 95% confidence interval 10-16). The prevalence of unprotected anal intercourse with either a serostatus unknown or HIV-seronegative partner was 26%. The unprotected anal intercourse prevalence did not differ by the length of the behavioural recall window but did vary by the type of anal intercourse (insertive vs. receptive). Studies with the following features had a lower unprotected anal intercourse prevalence: recruiting participants before 2000, men who have sex with men of colour being the majority of study sample, recruiting participants from medical settings, using random or systematic sampling methods, and having interviewers administer the questionnaire. Being on antiretroviral therapy, having an undetectable viral load, and reporting more than 90% medication adherence were not associated with unprotected anal intercourse. Most HIV-diagnosed men who have sex with men protect partners during sexual activity, but a sizeable percentage continues to engage in sexual behaviours that place others at risk for HIV infection and place themselves at risk for other sexually transmitted infections. Prevention with positives programs continues to be urgently needed for men who have sex with men in the United States.

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Editors’ note: Men who have sex with men who know their HIV-positive status may practice harm reduction approaches such as serosorting (only engaging in unprotected sex with seropositive partners) and strategic positioning (selectively engaging in unprotected receptive, rather than unprotected insertive anal intercourse because the per-act risk of transmission is lower. This meta-analysis quantitatively synthesized US literature, excluding studies recruiting male sex workers, methamphetamine users, and men with clinically diagnosed alcohol dependency, as well as those that recruited entirely from high-risk settings (gay brothels, sex parties, and barebacking websites). With the behavioural recall window ranging from last sex to the past 12 months (median 3 months), the study found no support for the hypothesis that clinical variables (treatment status, medication adherence, and viral load) were associated with unprotected anal intercourse. Rather, serosorting and strategic positioning appear to be intentional and deliberate HIV-related harm-reduction behaviours chosen by some HIV-positive men, The relative safety of such strategies deserves urgent investigation given that there was a 26% increase in estimated male HIV cases among American men who have sex with men over the period 2004 to 2007. In 2007, 72% of male HIV cases from 38 US areas were attributed to male-to-male sexual activity.

High HIV Prevalence Among Men Who have Sex with Men in Soweto, South Africa: Results from the Soweto Men’s Study.

Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, McIntyre J. AIDS Behav. 2009 Aug. [Epub ahead of print]

The Soweto Men’s Study assessed HIV prevalence and associated risk factors among men who have sex with men in Soweto, South Africa. Using respondent driven sampling recruitment methods, Lane and colleagues recruited 378 men who have sex with men (including 15 seeds) over 30 weeks in 2008. All results were adjusted for respondent driven sampling sampling design. Overall HIV prevalence was estimated at 13.2% (95% confidence interval 12.4-13.9%), with 33.9% among gay-identified men, 6.4% among bisexual-identified men, and 10.1% among straight-identified men who have sex with men. In multivariable analysis, HIV infection was associated with being older than 25 (adjusted odds ratio (AOR) 3.8, 95% CI 3.2-4.6), gay self-identification (AOR 2.3, 95% CI 1.8-3.0), monthly income less than ZAR500 (AOR 1.4, 95% CI 1.2-1.7), purchasing alcohol or drugs in exchange for sex with another man (AOR 3.9, 95% CI 3.2-4.7), reporting any URAI (AOR 4.4, 95% CI 3.5-5.7), reporting between six and nine partners in the prior 6 months (AOR 5.7, 95% CI 4.0-8.2), circumcision, (AOR 0.2, 95% CI 0.1-0.2), a regular female partner (AOR 0.2, 95% CI 0.2-0.3), smoking marijuana in the last 6 months (AOR 0.6, 95% CI 0.5-0.8), unprotected vaginal intercourse in the last 6 months (AOR 0.5, 95% CI 0.4-0.6), and STI symptoms in the last year (AOR 0.7, 95% CI 0.5-0.8). The results of the Soweto Men’s Study confirm that men who have sex with men are at high risk for HIV infection, with gay men at highest risk. HIV prevention and treatment for men who have sex with men are urgently needed.

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Editors’ note: This is the first study of men who have sex with men in Africa to use respondent driven sampling (RDS) methodology to assess both HIV prevalence and risk factors. Intriguingly, the multivariate analysis revealed that the strongest adjusted odds ratio for associations with decreased risk of HIV infection was for being circumcised. Insertive anal intercourse was reported more commonly than receptive anal intercourse (85.2% ever versus 20.6% ever) and HIV prevalence among gay-identified men was more than 3 times that of bisexual and straight-identified men who have sex with men. Since the latter groups have to date been more likely to report the exclusive practice of insertive anal intercourse with male partners, this study may be providing the hypothesis-generating evidence that would support a trial of male circumcision for HIV prevention among primarily insertive men who have sex with men. On the more immediately practical side, rapid research is needed to find out whether current messages about male circumcision for HIV prevention are reaching bisexual and straight-identified men in South Africa and other high HIV prevalence settings.

HIV prevention while the bulldozers roll: Exploring the effect of the demolition of Goa’s red-light area.

Shahmanesh M, Wayal S, Andrew G, Patel V, Cowan FM, Hart G. Soc Sci Med. 2009; 69:604-12.

Interventions targeting sex-workers are pivotal to HIV prevention in India. Community mobilisation is considered by the National AIDS Control Programme to be an integral component of this strategy. Nevertheless societal factors, and specifically policy and legislation around sex-work, are potential barriers to widespread collectivisation and empowerment of sex-workers. Between November 2003 and December 2005 Shahmanesh and colleagues conducted participatory observation and rapid ethnographic mapping with several hundred brief informant interviews, in addition to 34 semi-structured interviews with key-informants, 16 in-depth interviews with female sex-workers, and 3 focus-group-discussions with clients and mediators. This article provides a detailed examination of the demolition of Baina, one of India’s large red-light areas, in 2004, and one of the first accounts of the effect of dismantling the red-light area on the organisation of sex-work and sex-workers’ sexual risk. The results suggest that the concentrated and homogeneous brothel-based sex-work environment rapidly evolved into heterogeneous, clandestine and dispersed modes of operation. The social context of sex-work that emerged from the dust of the demolition was higher risk and less conducive to HIV prevention. The demolition acted as a negative structural intervention; a catastrophic event that fragmented sex-workers’ collective identity and agency and rendered them voiceless and marginalised. The findings suggest that an abolitionist approach to sex-work and legislation or policy that either criminalises this large group of women, or renders them as invisible victims, will increase the stigma and exclusion they experience. For the targeted HIV prevention approaches advocated by the National AIDS Control Programme to be effective, there is a need for legislation and policy that supports sex-workers’ agency and self-organisation and enables them to create a safer working environment for themselves.

For Abstract click here: 1

Editors’ note: The authors of this thoughtful analysis were engaged in a study developing a participatory evidence-based HIV prevention intervention when the demolition of Baina started following a high court judgement. Because the dispersion and marginalisation of women following eviction would make the study impossible the researchers began documenting unfolding events and their effects on the community, as well as on the evolving relationship between the researchers and the community. This rich description helps understand how abolitionist discourses, whether religious or social reformist, converge to strip women who are sex workers of any agency, either by stigmatising them or by depicting them as victims by conflating sex work with trafficking, If you have wondered what a negative structural intervention is and does, and if you ever worked with communities, this is an article that you won’t be able to stop reading.

Early Coital Debut and Associated HIV Risk Factors Among Young Women and Men in South Africa.

Pettifor A, O’Brien K, Macphail C, Miller WC, Rees H. Int Perspect Sex Reprod Health. 2009;35:82-90.

Young people in South Africa are at high risk of HIV infection. Because first sexual experiences may influence a young person’s HIV risk, a better understanding of coital debut is needed. Data from a nationally representative survey that included 7,692 sexually active South African youth aged 15-24 were used to assess characteristics related to sexual debut and to respondents’ first sexual partner. Poisson regression analyses were conducted to identify relationships among these characteristics and partner age differences, early coital debut (i.e., before age 15), forced sex with one’s first partner and nonuse of condoms at first sex. Eighteen percent of young men and 8% of young women reported early coital debut. The likelihood of early debut was elevated among females and males who had had an older first partner (adjusted prevalence ratio, 1.1 per year) and among females who had had forced sex (2.5). Lack of condom use at first sex was associated with early coital debut (1.5) and forced sex (1.6) for males. Among females, the likelihood of nonuse was elevated for respondents who had had an early debut but had not had forced sex (1.3), and among those who had had both a later debut and forced sex (1.4). Early coital debut is associated with factors that may increase a young person’s risk for HIV infection, such as forced sex and having older partners. Intervention efforts should encourage youth to delay coital debut and promote strategies to make young people’s first sexual experience safer.

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Editors’ note: The majority of young people in this nationally representative survey did not report early coital debut and comparison with previous studies in the same age-group in South Africa suggests that age at sexual debut has not changed significantly during the past decade. Because HIV prevalence is so high in South Africa, young people should be encouraged to delay the onset of first penetrative sex. Concerted efforts are required to address the contractual and structural factors that can make young people’s first sexual experiences safer in high HIV prevalence contexts.

Men who have sex with men and HIV/AIDS in sub-Saharan Africa. Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaffe H. Lancet. 2009;374: 416-422.

Globally, men who have sex with men continue to bear a high burden of HIV infection. In sub-Saharan Africa, same-sex behaviours have been largely neglected by HIV research up to now. The results from recent studies, however, indicate the widespread existence of groups of men who have sex with men across Africa, and high rates of HIV infection, HIV risk behaviour, and evidence of behavioural links between men who have sex with men and heterosexual networks have been reported. Yet most African men who have sex with men have no safe access to relevant HIV information and services, and many African states have not begun to recognise or address the needs of these men in the context of national HIV prevention and control programmes. The HIV community now has considerable challenges in clarifying and addressing the needs of men who have sex with men in sub-Saharan Africa; homosexuality is illegal in most countries, and political and social hostility are endemic. An effective response to HIV requires improved strategic information about all risk groups, including men who have sex with men. The belated response to men who have sex with men with HIV infection needs rapid and sustained national and international commitment to the development of appropriate interventions and action to reduce structural and social barriers to make these accessible.

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 Editors’ note: Major barriers exist in access to effective HIV prevention, treatment, and care and support for men who have sex with men in sub-Saharan Africa. Not the least of these is the need for African political commitment to legal reforms and social protection for sexual minorities and those who work with them. It is not surprising that HIV subtypes in African men who have sex with men are similar to those occurring in the general population given that a high proportion of them report recent female sexual partners and many are married. What is surprising is how little is known about them. Only 17 of 52 African countries reported any information about risk knowledge and behaviour, HIV prevalence, and access to care among men who have sex with men in their 2008 reports of progress on the 2001 Declaration of Commitment. The silence must be broken to start to reverse the inaction that is so harmful to men who have sex with men, and to everyone else in Africa.

Role of widows in the heterosexual transmission of HIV in Manicaland, Zimbabwe, 1998-2003. Lopman BA, Nyamukapa C, Hallett TB, Mushati P, Spark-du Preez N, Kurwa F, Wambe M, Gregson S. Sex Transm Infect. 2009 85 Suppl 1:i41-8.

AIDS is the main driver of young widowhood in southern Africa. The demographic characteristics of widows, their reported risk behaviours, and the prevalence of HIV were examined by analysing a longitudinal population-based cohort of men and women aged 15-54 years in Manicaland, eastern Zimbabwe. The results from statistical analyses were used to construct a mathematical simulation model with the aim of estimating the contribution of widow behaviour to heterosexual HIV transmission. 413 (11.4%) sexually experienced women and 31 (1.2%) sexually experienced men were reported to be widowed at the time of follow-up. The prevalence of HIV was exceptionally high among both widows (61%) and widowers (male widows) (54%). Widows were more likely to have high rates of partner change and engage in a pattern of transactional sex than married women. Widowers took partners who were a median of 10 years younger than themselves. Mathematical model simulations of different scenarios of sexual behaviour of widows suggested that the sexual activity of widow(er)s may underlie 8-17% of new HIV infections over a 20-year period. This combined statistical analysis and model simulation suggest that widowhood plays an important role in the transmission of HIV in this rural Zimbabwean population. High-risk partnerships may be formed when widowed men and women reconnect to the sexual network.

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Editors’ note : The practice of widows marrying the brother of their deceased spouse, known as the ‘levirate’, appears to have declined in Zimbabwe, along with traditional practices discouraging widows from taking another partner for one year after the death of their spouse. Widows’ rights to inheritance are better protected, although less so for those married under customary law. Nevertheless, this modelling study in a rural area suggests that widows and widowers in this high prevalence setting are more likely to enter into high risk partnerships when they reconnect to the sexual network. Many of them likely need support and knowledge to make safe sexual choices after the death of a spouse. Widows in particular need legal advice and increased financial independence through employment opportunities to reduce their need for economic support from a new partner.

Birungi H, Mugisha JF, Obare F, Nyombi JK. Sexual behaviour and desires among adolescents perinatally infected with human immunodeficiency virus in Uganda: implications for programming. J Adolesc Health. 2009;44:184-7.

Counselling programs for adolescents living with human immunodeficiency virus (HIV) encourage abstinence from sex and relationships. This Uganda study, however, found that many of these adolescents are sexually active or desire to be in relationships but engage in poor preventive practices. Programmes for HIV therefore need to strengthen preventive services to this group.

Editors’ note: In this study, 732 adolescents aged 15 to 19 years living with HIV in 4 districts in Uganda were interviewed, 48 participated in focus group discussions, and 12 underwent in-depth interviews for ethnographic case stories. One-third was sexually active and of these 38% had disclosed their HIV status to their current partners. Overall 51% feared disclosing their status to their friends. At first sex, 37% had used condoms and much of current condom use was for pregnancy prevention. Clearly, the sexual and reproductive needs of this unique and growing population of perinatally infected young people are not being adequately met by current service approaches.

Schmiege SJ, Broaddus MR, Levin M, Bryan AD. Randomized trial of group interventions to reduce HIV/STD risk and change theoretical mediators among detained adolescents. JConsult Clin Psychol. 2009;77:38-50.

Criminally involved adolescents engage in high levels of risky sexual behaviour and alcohol use, and alcohol use may contribute to lack of condom use. Detained adolescents (n = 484) were randomized to (1) a theory-based sexual risk reduction intervention (GPI), (2) the GPI condition with a group-based alcohol risk reduction motivational enhancement therapy component (GPI + GMET), or (3) an information-only control (INFO). All interventions were presented in same-sex groups in single sessions lasting from 2 to 4 hr. Changes to putative theoretical mediators ( attitudes, perceived norms, self-efficacy, and intentions) were measured immediately following intervention administration. The primary outcomes were risky sexual behaviour and sexual behaviour while drinking measured 3 months later (65.1% retention). The GPI + GMET intervention demonstrated superiority over both other conditions in influencing theoretical mediators and over the INFO control in reducing risky sexual behaviour. Self-efficacy and intentions were significant mediators between condition and later risky sexual behaviour. This study contributes to an understanding of harm reduction among high-risk adolescents and has implications for understanding circumstances in which the inclusion of group-based alcohol risk reduction motivational enhancement therapy components may be effective.

Editors’ note: Criminally involved adolescents in detention present challenges to effective HIV prevention on several levels but this is, after all, a ‘teachable moment’ when they may more easily contemplate the negative aspects of a behaviour as well as avenues of behaviour change. Most of the 14 to 17 year olds (82.7% male) in this study were sexually active (92.7%) with a median age at first intercourse of 13.02 years. Of these, 82% reported alcohol use during a sexual encounter. In the full group, 90.9% had used alcohol in the past year with the average number of drinks at one time being 4.7. This randomised controlled trial found that incorporating an alcohol-related sexual risk reduction component that was non-confrontational and supportive into a more traditional sexual risk reduction intervention resulted in increased condom use self-efficacy and intentions to use condoms. Retention at 3 months was low but nonetheless these promising findings deserve further study and practical application.

Shinde S, Setia MS, Row-Kavi A, Anand V, Jerajani H. Male sex workers: are we ignoring a risk group in Mumbai, India? Indian J Dermatol Venereol Leprol. 2009;75:41-6.

Male sex workers have recently been recognized as an important risk group for sexually transmitted infections including human immunodeficiency virus infection. Although there are global studies on male sex workers, few such studies describe the behavioural patterns and sexually transmitted infections among this population in India. Male sex workers were evaluated at the Humsafar trust, a community based organization situated in suburban Mumbai, India. Shinde and colleagues report on the demographics, sexual behaviours, and sexually transmitted infections including HIV of these sex workers. Of the 75 male sex workers, 24 were men and 51 were transgenders. The mean age of the group was 23.3 (+ 4.9) years. About 15% were married or lived with a permanent partner. Of these individuals, 85% reported sex work as a main source of income and 15% as an additional source. All the individuals reported anal sex (87% anal receptive sex and 13% anal insertive sex). About 13% of male sex workers had never used a condom. The HIV prevalence was 33% (17% in men vs 41% in transgenders, P = 0.04). The sexually transmitted infection prevalence was 60% (58% in men vs 61% in transgenders, P = 0.8). Syphilis was the most common sexually transmitted infection (28%) in these male sex workers. HIV was associated with being a transgender (41 vs 17%, P = 0.04), age > 26 years (57 vs 28%, P = 0.04), more than one year of sex work (38 vs 8%, P = 0.05), and income P = 0.02). These male sex workers have high-risk behaviours, low consistent condom use, and high prevalence of sexually transmitted infections and HIV infections. These groups should be the focus of intensive public health interventions aimed at reduction of risky sexual practices, and prevention and care for both HIV and sexually transmitted infections.

Editors’ note: This study did not recruit any male sex workers involved solely in the heterosexual sex trade possibly because such men are less likely to attend this clinic treating sexually transmitted infections (STI). Among the sex worker participants were kothis, effeminate men who have sex with men but may also have sex with women, and hijras, male-to-female transgendered people who are primarily the receptive partners because of their female gender identity. Overall, only one-third reported always using condoms, with the most common reasons for non-use being non-availability (43%) and refusal of condom use by the partner (20%). Social marginalization of sex workers in India, as elsewhere, hampers the development of effective programmes to help them avoid HIV infection and obtain treatment for STI and HIV. They appear to be considerably more at risk of acquiring HIV infection than do women who sell sexual services and are particularly likely to benefit from improved access to condoms and skills training to enhance condom negotiation.

Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW. Structural and Environmental Barriers to Condom Use Negotiation With Clients Among Female Sex Workers: Implications for HIV-Prevention Strategies and Policy. Am J Public Health. 2009;99:659-665.

Shannon and colleagues investigated the relationship between environmental-structural factors and condom-use negotiation between female sex workers and clients. They used baseline data from a 2006 Vancouver, British Columbia, community-based cohort of female sex workers, to map the clustering of hot spots for being pressured into unprotected sexual intercourse by a client and assess sexual HIV. The authors then used multivariate logistic modelling to estimate the relationship between environmental-structural factors and being pressured by a client into unprotected intercourse. In multivariate analyses, being pressured to have unprotected sexual intercourse was independently associated with having an individual zoning restriction (odds ratio [OR]=3.39; 95% confidence interval [CI]=1.00, 9.36), working away from main streets because of policing (OR=3.01; 95% CI=1.39, 7.44), borrowing a used crack pipe (OR=2.51; 95% CI=1.06, 2.49), client-perpetrated violence (OR=2.08; 95% CI=1.06, 4.49), and servicing clients in cars or in public spaces (OR=2.00; 95% CI=1.65, 5.73). Given growing global concern surrounding the failings of prohibitive sex-work legislation on sex workers’ health, there is urgent need for environmental-structural HIV-prevention efforts that facilitate sex workers’ ability to negotiate condom use in safer sex-work environments and criminalize abuse by clients and third parties.

Editors’ note: The buying and selling of sexual services has never been illegal in Canada, however it is illegal to communicate in public spaces for the purposes of sexual transaction and the law prohibits ‘keeping or transporting a person to a common bawdy-house”, thus restricting legal indoor sex work. This study used the risk environment framework as its theoretical base, hypothesising that macro- and meso-level factors outside the individual affect negotiation of individual risk. Trained peer researchers, who were former or current sex workers, interviewed 205 sex workers participating in the Maka Project cohort. They were recruited at sex work strolls at staggered times and spaces along these strolls. The analysis of the effects of enforcement of Canada’s prohibitive sex-work policies reveals the need for legal and policy reforms to create safer work environments in which exploitation by clients and third parties is effectively criminalised and condom use is readily and consistently negotiated.

Todd J, Cremin I, McGrath N, Bwanika JB, Wringe A, Marston M, Kasamba I, Mushati P, Lutalo T, Hosegood V, Zaba B. Reported number of sexual partners: comparison of data from four African longitudinal studies. Sex Transm Infect. 2009 Apr;85 Suppl 1:i72-80.

Todd et al set out to compare reported numbers of sexual partners in Eastern and Southern Africa. Sexual partnership data from four longitudinal population-based surveys (1998-2007) in Zimbabwe, Uganda and South Africa were aggregated and overall proportions reporting more than one lifetime sexual partner calculated. A lexis-style table was used to illustrate the average lifetime sexual partners by site, sex, age group and birth cohort. The male-to-female ratio of mean number of partnerships in the last 12 months was calculated by site and survey. For each single year of age, the proportion sexually active in the past year, the mean number of partners in the past year and the proportion with more than one partner in the past year were calculated. Over 90% of men and women between 25 and 45 years of age reported being sexually active during the past 12 months, with most reporting at least one sexual partner. Overall, men reported higher numbers of lifetime sexual partners and partners in the last year than women. The male-to-female ratio of mean partnerships in the last year ranged from 1.41 to 1.86. In southern African cohorts, individuals in later birth cohorts reported fewer sexual partners and a lower proportion reported multiple partnerships compared with earlier birth cohorts, whereas these behavioural changes were not observed in the Ugandan cohorts. Across the four sites, reports of sexual partnerships followed a similar pattern for each sex. The longitudinal results show that reductions in the number of partnerships were more evident in southern Africa than in Uganda.

Editors’ note: This interesting analysis compares sexual behaviour trends over time in four sites in East and Southern Africa, finding decreased numbers of lifetime sexual partners reported by later birth cohorts. The exception is Uganda, where this change has been described as occurring in the 1990s before the period considered in this paper. Despite different levels of HIV prevalence, the reported number of sexual partners is similar across these four sites. Qualitative research would help interpret these findings and explore the suggestion that differences in partner types and partnership duration may help explain the observed discrepancies in HIV prevalence.

Kalichman S, Simbayi L, Cain D, Jooste S. Heterosexual Anal Intercourse among Community and Clinical Settings in Cape Town, South Africa. Sex Transm Infect. 2009 May 7. [Epub ahead of print]

Anal intercourse is an efficient mode of HIV transmission and may play a role in heterosexual HIV epidemics of southern Africa. However, little information is available on the anal sex practices of heterosexuals in South Africa. Kalichman and colleagues set out to examine the occurrence of anal intercourse in samples drawn from community and clinic settings. Using anonymous surveys collected from convenience samples of 2593 men and 1818 women in two townships and one large city sexually transmitted infections’ clinic in Cape Town, the authors examined measures including demographics, HIV risk history, substance use, and three month retrospective sexual behaviour. A total of 14% (n = 360) men and 10% (n = 172) women reported engaging in anal intercourse in the past three months. Men used condoms during 67% and women 50% of anal intercourse occasions. Anal intercourse was associated with younger age, being unmarried, having a history of sexually transmitted infections, exchanging sex, using substances, having been tested for HIV, and testing HIV positive. Anal intercourse is reported relatively less frequently than unprotected vaginal intercourse among heterosexuals. The low prevalence of anal intercourse among heterosexuals may be offset by its greater efficiency for transmitting HIV. Anal sex should be discussed in heterosexual HIV prevention programming.

Editors’ note: Most research to date has suggested that heterosexual anal intercourse in South Africa is relatively rare. After removing from the dataset the 6% of men who reported same-sex partners in the previous 3 months, this study found that 14% of men and 10% of women reported anal sex over that period. Although heterosexual anal sex was reported more frequently among STI clinic patients than township community members, no differences were found in the proportions of anal intercourse acts protected by condoms. Clearly, a focus on this sexual behaviour that carries a higher risk of HIV acquisition for women should be integrated into HIV prevention programmes aimed at fostering condom-use skills and sexual communication skills.

Exner TM, Mantell JE, Adeokun LA, Udoh IA, Ladipo OA, Delano GE, Faleye J, Akinpelu K. Mobilizing men as partners: the results of an intervention to increase dual protection among Nigerian men. Health Educ Res. 2009 Apr 9. [Epub ahead of print]

This quasi-experimental, proof-of-concept study evaluated the effects of an intervention designed to help Nigerian men decrease risk for HIV, sexually transmitted infections, and unintended pregnancy. The intervention was delivered in groups during two 5-hour workshops, with a monthly 2-hour check-in session. A comparison condition consisted of a group-based half-day didactic workshop. Based on recruitment area, 149 men were assigned to the intervention and 132 to the comparison. Men were evaluated at baseline and 3-month post-intervention. At follow-up, men assigned to the intervention were almost four times more likely than comparison men to report condom use at last intercourse (P < 0.001) and to report fewer unprotected vaginal sex occasions, greater self-efficacy for negotiation, a more egalitarian power dynamic in their primary relationship, more positive expectations for condom use, and greater intention for future consistent condom use (all P values < 0.05). Findings suggest that this intervention is both feasible and effective.

Editors’ note: In addition to reducing HIV-related stigmatizing beliefs, this group-based cognitive-behavioural ‘mobilising men as partners’ intervention, tailored to the needs and culture of Nigerian men, resulted in significantly higher safer-sex self-efficacy and yet significantly less male-dominated power dynamics in primary relationships. Whether the results seen at 3 months would be sustained over time, whether there was community level influence supporting the positive changes (the intervention men were from different communities than the control men), and whether their female partners would corroborate the findings are all questions deserving further investigation.

Kalichman SC, Simbayi LC, Cloete A, Clayford M, Arnolds W, Mxoli M, Smith G, Cherry C, Shefer T, Crawford M, Kalichman MO. Integrated Gender-Based Violence and HIV Risk Reduction Intervention for South African Men: Results of a Quasi-Experimental Field Trial. Prev Sci. 2009 Apr 8. [Epub ahead of print]

South Africa is in the midst of one of the world’s most devastating HIV epidemics and there is a well-documented association between violence against women and HIV transmission. Interventions that target men and integrate HIV prevention with gender-based violence prevention may demonstrate synergistic effects. A quasi-experimental field intervention trial was conducted with two communities randomly assigned to receive either: (a) a five session integrated intervention designed to simultaneously reduce gender-based violence and HIV risk behaviours (N = 242) or (b) a single 3-hour alcohol and HIV risk reduction session (N = 233). Men were followed for 1-, 3-, and 6-months post intervention with 90% retention. Results indicated that the gender-based violence/HIV intervention reduced negative attitudes toward women in the short term and reduced violence against women in the longer term. Men in the gender-based violence/HIV intervention also increased their talking with sex partners about condoms and were more likely to have been tested for HIV at the follow-ups. There were few differences between conditions on any HIV transmission risk reduction behavioural outcomes. Further research is needed to examine the potential synergistic effects of alcohol use, gender violence, and HIV prevention interventions.

Editors’ note: Negative attitudes toward women in South Africa and societal acceptance of violence against women impede men from acting responsibly to reduce HIV risks for themselves and their partners. More than half of the men in this study reported a history of physically assaulting a sex partner and one in five had been detained for domestic violence. Although the study had an inherently weak study design (randomising two communities but examining individual level behaviour change), was conducted in one cultural group only (Xhosa), and 89% of the participants were unemployed and able to attend lengthy workshops, the findings are intriguing. The gender-based violence prevention group reported a number of positive changes in attitudes and behaviours toward women, but the alcohol prevention group appears to have offered greater potential for sexual risk reduction. A three-component programme of HIV sexual risk reduction, alcohol reduction, and gender violence prevention may achieve greater impact. However, until South Africa and other countries worldwide intervene effectively to penalise gender-based violence and create new social norms of respect and gender equality, counting on individual behaviour change alone is like swimming upstream against powerful currents.

Attia S, Egger M, Müller M, Zwahlen M, Low N. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009 Apr 17. [Epub ahead of print]

Attia and colleagues aimed to synthesize the evidence on the risk of HIV transmission through unprotected sexual intercourse according to viral load and treatment with combination antiretroviral therapy. They conducted a systematic review and meta-analysis, searching Medline, Embase, and conference abstracts from 1996-2009. The authors included longitudinal studies of serodiscordant couples reporting on HIV transmission according to plasma viral load or use of antiretroviral therapy and used random-effects Poisson regression models to obtain summary transmission rates [with 95% confidence intervals, (CI)]. If there were no transmission events they estimated an upper 97.5% confidence limit. They identified 11 cohorts reporting on 5021 heterosexual couples and 461 HIV-transmission events. The rate of transmission overall from antiretroviral therapy-treated patients was 0.46 (95% CI 0.19-1.09) per 100 person-years, based on five events. The transmission rate from a seropositive partner with viral load below 400 copies/ml on antiretroviral therapy, based on two studies, was zero with an upper 97.5% confidence limit of 1.27 per 100 person-years, and 0.16 (95% CI 0.02-1.13) per 100 person-years if not on antiretroviral therapy , based on five studies and one event. There were insufficient data to calculate rates according to the presence or absence of sexually transmitted infections, condom use, or vaginal or anal intercourse. Studies of heterosexual discordant couples observed no transmission in patients treated with antiretroviral therapy and with viral load below 400 copies/ml, but data were compatible with one transmission per 79 person-years. Further studies are needed to better define the risk of HIV transmission from patients on antiretroviral therapy.

Editors’ note: This study underscores the considerable uncertainty about the risk of HIV transmission under ‘Swiss Commission’ conditions, that is, viral load below 40 copies/ml, no other sexually transmitted infection, and consistent adherence to antiretroviral treatment. The Commission stated ‘much lower than one per 100,000 acts of sexual intercourse’ whereas this systematic review and meta-analysis of existing data found them compatible with one new infection for every 79 person-years of follow-up (or 7900 acts of sexual intercourse, if the yearly average is 100 contacts). Further studies are needed to quantify HIV transmission risk in different populations, including men who have sex with men for whom there are no comparable published data. In the meantime, since the Swiss Commission statement January 2008 UNAIDS has continued to reassert the importance of correct and consistent condom use – a key part of positive prevention and a cornerstone of HIV prevention for people without HIV.

Wood E, Kerr T, Marshall BD, Li K, Zhang R, Hogg RS, Harrigan PR, Montaner JS. Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study. BMJ. 2009 Apr 30;338:b1649.

To examine the relation between plasma HIV-1 RNA concentrations in the community and HIV incidence among injecting drug users, Wood and colleagues conducted a prospective cohort study in an inner city community in Vancouver, Canada. Injecting drug users, with and without HIV, were followed up every six months between 1 May 1996 and 30 June 2007. The main outcome measures were estimated community plasma HIV-1 RNA in the six months before each HIV-negative participant’s follow-up visit and associated HIV incidence. Among 622 injecting drug users with HIV, 12 435 measurements of plasma HIV-1 RNA were obtained. Among 1429 injecting drug users without HIV, there were 155 HIV seroconversions, resulting in an incidence density of 2.49 (95% confidence interval 2.09 to 2.88) per 100 person years. In a Cox model that adjusted for unsafe sexual behaviours and using nonsterile syringes, the estimated community plasma HIV-1 RNA concentration remained independently associated with the time to HIV seroconversion (hazard ratio 3.32 (1.82 to 6.08, P<0.001), per log(10) increase). When the follow-up period was limited to observations after 1 January 1998 (when the median plasma HIV RNA concentration was <20 000 copies/ml), the median viral load was no longer statistically associated with HIV incidence (1.70 (0.79 to 3.67, P=0.175), per log(10) increase). The authors concluded that a longitudinal measure of community plasma HIV-1 RNA concentration was correlated with the community HIV incidence rate and predicted HIV incidence independent of unsafe sexual behaviours and sharing used syringes. If these findings are confirmed, they could help to inform both HIV prevention and treatment interventions.

Editors’ note: This ecological study estimated community plasma viral load from the viral loads of injecting drug users on treatment in this urban community which has a centralised antiretroviral dispensation programme and HIV laboratory. The proportion of patients on 3 or more antiretroviral drugs increased from 8.4% in 1996 to 98.8% in 2007 while both median estimated community plasma HIV-1 RNA concentrations and HIV incidence fell. The likelihood that an HIV-negative injecting drug user had seroconverted since the last clinic visit was correlated with the median estimated community viral load during the prior 6 months. It is not possible to conclude from these data that the association was causal but the fact that the highest rates of HIV seroconversion occurred in the year after the highest community plasma HIV-2 concentration support this hypothesis. These findings no doubt influenced the provincial government to fund an innovative programme to expand access to treatment for street-involved people living in Vancouver’s downtown eastside and downtown Prince George, British Columbia.

Tobian AAR, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, Charvat B,* Ssempijja V, Riedesel M, Oliver AE, Nowak RG, Moulton LH, Chen MZ, Reynolds SJ, Wawer MJ and Gray RH. Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis. N Engl J Med. 2009;360:1298-309.

Male circumcision significantly reduced the incidence of human immunodeficiency virus (HIV) infection among men in three clinical trials. Tobian and colleagues assessed the efficacy of male circumcision for the prevention of herpes simplex virus type 2 (HSV-2) and human papillomavirus (HPV) infections and syphilis in HIV-negative adolescent boys and men. They enrolled 5534 HIV-negative, uncircumcised male subjects between the ages of 15 and 49 years in two trials of male circumcision for the prevention of HIV and other sexually transmitted infections. Of these subjects, 3393 (61.3%) were HSV-2– seronegative at enrolment. Of the seronegative subjects, 1684 had been randomly assigned to undergo immediate circumcision (intervention group) and 1709 to undergo circumcision after 24 months (control group). At baseline and at 6, 12, and 24 months, the authors tested subjects for HSV-2 and HIV infection and syphilis, along with performing physical examinations and conducting interviews. In addition, they evaluated a subgroup of subjects for HPV infection at baseline and at 24 months. At 24 months, the cumulative probability of HSV-2 seroconversion was 7.8% in the intervention group and 10.3% in the control group (adjusted hazard ratio in the intervention group, 0.72; 95% confidence interval [CI], 0.56 to 0.92; P = 0.008). The prevalence of high-risk HPV genotypes was 18.0% in the intervention group and 27.9% in the control group (adjusted risk ratio, 0.65; 95% CI, 0.46 to 0.90; P = 0.009). However, no significant difference between the two study groups was observed in the incidence of syphilis (adjusted hazard ratio, 1.10; 95% CI, 0.75 to 1.65; P = 0.44). In addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection, findings that underscore the potential public health benefits of the procedure.

Editors’ note: To date, limited statistical power, confounding by sexual practices correlated with a high risk of transmission, and determination of circumcision status only by self-report have plagued observational studies on male circumcision and sexually transmitted infections. This randomised, controlled trial in rural Uganda demonstrates that male circumcision in adolescent boys and men significantly reduces the incidence of herpes simplex virus-2 (HSV-2) infection and the prevalence of human papilloma virus (HPV) infection. Whether the latter is due to decreased HPV acquisition or increased HPV clearance is unclear but it does explain the lower risk of cervical cancer experienced by women whose partners are circumcised. The adjusted efficacy of male circumcision was 28% for the prevention of HSV-2, an infection thought to be a cofactor in HIV acquisition. This may explain in part the incontrovertible partial protection from HIV afforded by male circumcision.

Delany-Moretlwe S, Lingappa JR and Celum C. New Insights on Interactions Between HIV-1 and HSV-2. Curr Infect Dis Rep. 2009;11(2):135-42.

Herpes simplex type 2 (HSV-2) infection is common and frequently asymptomatic. Concerns exist about the high prevalence of HSV-2, particularly in areas of high HIV prevalence, because of observations that HSV-2 is associated with an increased risk of HIV acquisition, transmission, and disease progression. Several randomized trials have tested or are testing whether HSV-2 treatment can limit the spread of HIV, with mixed results. Although treatment with acyclovir, 400 mg twice daily, does not reduce HIV incidence, suppressive acyclovir and valacyclovir reduce HIV levels in plasma and in the genital tract. Ongoing trials are evaluating whether HSV suppression will reduce HIV transmission and disease progression. Until a protective HSV-2 or HIV vaccine is available, effective interventions that reduce the effect of HSV-2 on HIV transmission are critically needed.

Editors’ note: This excellent summary of what is known about the complex and bidirectional interactions between HIV-1 and herpes simplex virus–2 (HSV-2) was published before the May 8 th release of results from the multi-centre Partners in Prevention Study of 3408 discordant couples conducted in Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia. To test whether HSV-2 daily suppressive therapy would reduce HIV transmission, HIV/HSV-2 co-infected partners were randomised to receive acyclovir 400 mg twice daily or matching placebo for 2 years while the uninfected partner was followed-up for HIV-1 seroconversion. Although acyclovir reduced the frequency of genital ulcers by 73% and HIV viral load by 40%, no significant difference was found in the rate of HIV transmission. A 17% reduction in HIV disease progression produced by low cost acyclovir was an intriguing result worthy of further study. With more than half a billion people infected with HSV-2, including up to 90% of people living with HIV, developing an HSV-2 vaccine continues to be a very high priority.