HIV This Week

Acceptability of medical male circumcision in the traditionally circumcising communities in Northern Tanzania
Wambura M, Mwanga JR, Mosha JF, Mshana G, Mosha F, Changalucha J. BMC Public Health. 2011 May 23;11:373
Data from traditionally circumcising communities show that non-circumcised males and those circumcised in the medical settings are stigmatised. This is because traditional circumcision embodies local notions of bravery as anaesthetics are not used. This study was conducted to assess the acceptability of safe medical circumcision before the onset of sexual activity for HIV infection risk reduction in a traditionally circumcising community in Tanzania. A cross-sectional study was conducted among males and females aged 18-44 years in traditionally circumcising communities of Tarime District in Mara Region, North-eastern Tanzania. A face-to-face questionnaire was administered to females to collect information on the attitudes of women towards circumcision and the preferred age for circumcision. A similar questionnaire was administered to males to collect information on sociodemographic, preferred age for circumcision, factors influencing circumcision, client satisfaction, complications and beliefs surrounding the practice. Results were available for 170 males and 189 females. Of the males, 168 (98.8%) were circumcised and 61 (36.3%) of those circumcised had the procedure done in the medical setting. Of those interviewed, 165 (97.1%) males and 179 (94.7%) females supported medical male circumcision for their sons. Of these, 107 (64.8%) males and 130 (72.6%) females preferred prepubertal medical male circumcision (12 years or less). Preference for prepubertal circumcision was significantly associated with non-Kurya ethnic group, circumcision in the medical setting and residence in urban areas for males in the adjusted analysis. For females, preference for prepubertal circumcision was significantly associated with non-Kurya ethnic group and being born in urban areas in the adjusted analysis. There is a shift of preference from traditional male circumcision to medical male circumcision in this traditionally circumcising population. However, this preference has not changed the circumcision practices in the communities because of the community social pressure. The male circumcision national programme should take advantage of this preference for medical male circumcision by introducing safe and affordable circumcision services and mobilising communities in a culturally sensitive manner to take up circumcision services.

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Editor’s note: Given the numbers of male circumcisions that the 13 priority countries in sub-Saharan Africa are aiming to complete by 2015, many people believe that less attention should be given to communities that have high male circumcision prevalence already through traditional circumcising practices. This study suggests that these communities should not be left behind. Parents are concerned about bleeding, delays in wound healing, and adverse events. They also would prefer that the procedure
be done before sexual activity starts. Although 97% of men and 95% of women in this study supported voluntary medical male circumcision (VMMC) for their sons, 64% of men had been circumcised traditionally and uptake of VMMC is low due to social pressure and increased cost. If safe, affordable, and culturally sensitive VMMC services were made available, as they have been elsewhere in parts of Africa that practice traditional circumcision, it would not be long before parents and young people align
their actions with their preferences. There will be more on male circumcision in the next issue of HIV This Week, but in the meantime, do check out the Joint Strategic Action Framework on Voluntary Medical Male Circumcision that was launched by UNAIDS and PEPFAR on behalf of WHO and other partners last week at the International Conference on AIDS and Sexually Transmitted Infections in Africa held in Addis Ababa, Ethiopia. You can find it at: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspubl...

Towards an improved investment approach for an effective response to HIV/AIDS

Schwartländer B, Stover J, Hallett T, Atun R, Avila C, Gouws E, Bartos M, Ghys PD, Opuni M, Barr D, Alsallaq R, Bollinger L, de Freitas M, Garnett G, Holmes C, Legins K, Pillay Y, Stanciole AE, McClure C, Hirnschall G, Laga M, Padian N; Investment Framework Study Group - Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Lancet. 2011;377(9782):2031-41.

Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. Schwartländer and colleagues propose a strategic investment framework that is intended to support better management of national and international AIDS responses than exists with the present system. Their framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion. Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29.4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.

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Editor’s note: The three categories of investment in this proposed framework are programmatic activities, critical enablers, and catalytic HIV funding to achieve synergies within broader health and development. The first category includes 1) procurement, distribution, and marketing of male and female condoms; 2) prevention of vertical transmission programmes; 3) voluntary medical male circumcision; 4) programmes for populations that are key to the epidemic and key to the response, such as people who inject drugs, men who have sex with men, and sex workers; 5) social and behaviour change programmes; and 6) antiretroviral therapy. The critical enablers include social enablers that create conducive environments for the HIV response (e.g. stigma reduction, advocacy for human rights, HIV testing/treatment literacy) and programme enablers (e.g. capacity building, programme linkages, adherence support). With an eye to creating synergies across development sectors, alignment of national AIDS responses to country development objectives, combined with use of catalytic HIV funding to address issues such as gender-based violence and social protection, can help ensure that the response to HIV contributes to strengthening social, legal, and health systems. As countries undertake ‘know your epidemic, tailor your response’ initiatives, this makes for good background reading. Funders at all levels will find this a useful conceptual framework for orienting their investment strategies to support efficient AIDS responses.

Effectiveness and cost effectiveness of expanding harm reduction and antiretroviral therapy in a mixed HIV epidemic: a modelling analysis for Ukraine

Alistar SS, Owens DK, Brandeau ML. PLoS Med. 2011;8(3):e1000423.

Injection drug use and heterosexual virus transmission both contribute to the growing mixed HIV epidemics in Eastern Europe and Central Asia. In Ukraine—chosen in this study as a representative country—injection drug use-related risk behaviours cause half of new infections, but few people who inject drugs receive methadone substitution therapy. Only 10% of eligible individuals receive antiretroviral therapy. The appropriate resource allocation between these programmes has not been studied. Alistar and colleagues estimated the effectiveness and cost-effectiveness of strategies for expanding methadone substitution therapy programmes and antiretroviral therapy in mixed HIV epidemics, using Ukraine as a case study. They developed a dynamic compartmental model of the HIV epidemic in a population of non-injectors, people who inject opiates, and people who inject drugs who are on methadone substitution therapy, stratified by HIV status, and populated it with data from the Ukraine. The authors considered programmes expanding methadone substitution therapy, increasing access to antiretroviral therapy, or both. They measured health care costs, quality-adjusted life years (QALYs), HIV prevalence, infections averted, and incremental cost-effectiveness. Without incremental interventions, HIV prevalence reached 67.2% (people who inject drugs) and 0.88% (non-injectors) after 20 years. Offering methadone substitution therapy to 25% of people who inject drugs reduced prevalence most effectively (to 53.1% injection drug users, 0.80% non- injection drug users, and was most cost-effective, averting 4,700 infections and adding 76,000 QALYs compared with no intervention at US$530/QALY gained. Expanding both antiretroviral therapy (80% coverage of those eligible for antiretroviral therapy according to WHO criteria) and methadone substitution therapy (25% coverage) was the next most cost-effective strategy, adding 105,000 QALYs at US$1120/QALY gained versus the methadone substitution therapy-only strategy and averting 8300 infections versus no intervention. Expanding only antiretroviral therapy (80% coverage) added 38,000 QALYs at US$2240/QALY gained versus the methadone substitution therapy-only strategy, and averted 4080 infections versus no intervention. Offering antiretroviral therapy to 80% of non-injectors eligible for treatment by WHO criteria, but only 10% of people who inject drugs, averted only 1800 infections versus no intervention and was not cost effective. Methadone substitution therapy is a highly cost-effective option for the growing mixed HIV epidemic in Ukraine. A strategy that expands both methadone substitution therapy and antiretroviral treatment to high levels is the most effective intervention, and is very cost effective by WHO criteria. When expanding antiretroviral therapy, access to methadone substitution therapy provides additional benefit in infections averted. These findings are potentially relevant to other settings with mixed HIV epidemics.

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Editor’s note: This model showing that methadone substitution provides the biggest ‘bang for the buck’, i.e. is a highly cost-effective option, produces Ukraine-specific findings that should be of interest to all the countries in Eastern Europe and Central Asia, the region in which the HIV epidemic continues to expand. Comparing the effectiveness, total expenditures, and efficiency of three strategies: scaling up methadone, scaling up antiretroviral therapy, and scaling up both methadone and antiretroviral therapy, the model predicts that combining scaled-up opioid substitution with scaled up antiretroviral therapy meets WHO guidelines for cost-effectiveness, i.e. costs less than the per capita Gross Domestic Product (GDP). Policy makers need to prioritise based on available resources—implementation of high levels of methadone substitution and antiretroviral therapy over 20 years costs an estimated USD 150 million and averts 8300 infections while methadone substitution alone would cost USD 50 million and avert 4700 infections. Best would be to do both but it would be unwise to jeopardise the scale-up of methadone maintenance—it has a cost-effectiveness edge in averting infections and preventing future treatment costs. Plus methadone maintenance has the added benefit of improving antiretroviral treatment adherence among people who inject drugs.

Short message service reminder intervention doubles sexually transmitted infection/HIV re-testing rates among men who have sex with men

Bourne C, Knight V, Guy R, Wand H, Lu H, McNulty A. Sex Transm Infect. 2011 Apr;87(3):229-31.

The objective of this study was to evaluate the impact of a short message service (SMS) reminder system on HIV/sexually transmitted infection (STI) re-testing rates among men who have sex with men. The SMS reminder programme started in late 2008 at a large Australian sexual health clinic. SMS reminders were recommended 3-6 times monthly for men who have sex with men considered high-risk based on self-reported sexual behaviour. The evaluation compared HIV negative men who have sex with men who had a HIV/STI test between 1 January and 31 August 2010 and received a SMS reminder (SMS group) with those tested in the same time period (comparison group) and pre-SMS period (pre-SMS group, 1 January 2008 and 31 August 2008) who did not receive the SMS. HIV/STI re-testing rates were measured within 9 months for each group. Baseline characteristics were compared between study groups and multivariate logistic regression used to assess the association between SMS and re-testing and control for any imbalances in the study groups. There were 714 HIV negative men who have sex with men in the SMS group, 1084 in the comparison group and 1753 in the pre-SMS group. In the SMS group, 64% were re-tested within 9 months compared to 30% in the comparison group (p<0.001) and 31% in the pre-SMS group (p<0.001). After adjusting for baseline differences, re-testing was 4.4 times more likely (95% CI 3.5 to 5.5) in the SMS group than the comparison group and 3.1 times more likely (95% CI 2.5 to 3.8) than the pre-SMS group. SMS reminders increased HIV/STI re-testing among HIV negative men who have sex with men. SMS offers a cheap, efficient system to increase HIV/STI re-testing in a busy clinical setting.

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Editors’ note: Australian HIV testing guidelines recommend annual testing for men who have sex with men and 3-6 monthly testing from men who have sex with men who are considered to be at higher risk of HIV exposure. Only a quarter of men in the latter category are actually having two or more HIV tests a year. In this study, short message service (SMS) reminders were tailored to risk behaviour. The SMS template was added to the patient electronic database, enabling clinicians to record the reminder date for a message stating ‘You are due for your next screening. Please call xxxxxx to make an appointment.’ Overall 93% of men provided a cell phone number. In this first reported study of SMS texting reminders for HIV testing among men who have sex with men, re-testing for HIV and sexually transmitted infections was 3 to 4 times higher in men who received SMS reminders. The programme allowed large numbers of messages to be sent automatically with minimal labour requirements and at low cost (5 cents each), comparing very favourably to telephone calls or postal reminders. The next step in this clinic will be SMS reminders to clinicians reminding them to offer the reminders!