HIV This Week

Socio-demographic characteristics and behavioural risk factors of female sex workers in sub-Saharan Africa: a systematic review

Scorgie F, Chersich MF, Ntaganira I, Gerbase A, Lule F, Lo YR.  AIDS Behav. 2011 Jul 13.

Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioural underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers in this region, their occupational contexts and key behavioural risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. Female sex workers commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalisation, high mobility and hazardous alcohol use. These, in turn, predict behaviours such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviours such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of female sex workers, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Tailored services at sufficiently high coverage, taking into account the behavioural and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by female sex workers on the continent.

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Editor’s note: This exhaustive review examines the structural and occupational contexts that shape sex worker vulnerability to HIV exposure in sub-Saharan Africa. It distinguishes between sex work and more ‘socially accepted’ transactional sex (exchanges of material goods¾such as food, cosmetics, transport, school fees, items for children, or a place to sleep for sex). Sex work is defined using the 2000 UNAIDS definition as ‘any agreement between two or more persons in which the objective is exclusively limited to the sexual act and ends with that and which involves preliminary negotiations for a price’. Sex work in sub-Saharan Africa is not typically based in large-scale brothels, as are found in Asia, and does not commonly involve intermediaries, although there are pimps in some settings and middlemen on the highways. The settings for solicitation are at the place of sex, e.g. outdoors in some settings, or different from the place of sex, e.g. sex may be negotiated in a drinking venue but take place at the sex worker’s home. As virtually everywhere worldwide, sex in the man’s space, e.g. his car or room, entails increased risk of violence and forced unprotected sex. Overall, clients come from all corners of society. Although mobility, employment in seasonal agriculture or the military, and separation of workers from family are factors that predict purchase of sexual services, frequently men residing in surrounding communities are also clients. Condom use, anal and oral sex practices, alcohol and other substance use, harmful legislation, human rights violations, coercion, stigma, and poor access to services¾you will find them all mentioned in this review. The challenge is to move from epidemiological studies that treat sex workers as a ‘core group’ to implementation of rights-based, evidence-informed initiatives that are designed for and by sex workers to reduce vulnerability by improving sex work conditions and contexts. This would be greatly facilitated by structural interventions to decriminalise sex work, as Senegal has done.

Cost-efficacy analysis of the MONET trial using UK antiretroviral drug prices

Gazzard B, Hill A, Anceau A. Appl Health Econ Health Policy. 2011 Jul 1;9(4):217-23.

In virologically suppressed patients, switching to darunavir/ritonavir (DRV/r) monotherapy maintains HIV RNA suppression, and could also lower treatment costs. The purpose of this analysis was to calculate the potential cost savings from the use of DRV/r monotherapy in the United Kingdom (UK). In the MONET trial, 256 patients with HIV RNA <50 copies/mL on current highly active antiretroviral therapy for over 24 weeks (non-nucleoside reverse-transcriptase inhibitor [NNRTI] based [43%] or protease inhibitor [PI] based [57%]), switched to DRV/r 800/100 mg once daily, either as monotherapy (n = 127) or with two NRTIs (n = 129). The UK costs per patient with HIV RNA <50 copies/mL at week 48 (responders) were calculated using a 'switch included' analysis to account for additional antiretrovirals taken after initial treatment failure. By this analysis, efficacy was 93.5% versus 95.1% in the DRV/r monotherapy and triple therapy arms, respectively. British National Formulary 2009 values were used. Before the trial, the mean annual cost of antiretrovirals was £6906 for patients receiving NNRTI-based highly active antiretroviral therapy, and £8348 for patients receiving PI-based highly active antiretroviral therapy. During the MONET trial, the mean annual per-patient cost of antiretrovirals was £8642 in the triple therapy arm, of which 55% was from NRTIs and 45% from PIs. The mean per-patient cost in the monotherapy arm was £4126, a saving of 52% versus triple therapy. The mean cost per responder was £9085 in the triple therapy arm versus £4413 in the DRV/r monotherapy arm.Based on the MONET results, the lower cost of DRV/r monotherapy versus triple therapy in the UK would allow more patients to be treated for fixed budgets, while maintaining HIV RNA suppression at <50 copies/mL. If all patients meeting the inclusion criteria of the MONET trial in the UK were switched to DRV/r monotherapy, there is the potential to save up to £60 million in antiretroviral drug costs from the UK NHS budget.

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Editor’s note: Standard of care antiretroviral therapy involves three drugs: 2 nucleoside analogues and either an NNRTI (non-nucleoside reverse-transcriptase inhibitor) or PI (protease inhibitor). Monotherapy with the use of the protease inhibitor boosted darunavir (DRV/r) is an option in the European treatment guidelines but is not included in the International AIDS Society guidelines. However, both sets of guidelines recommend starting antiretroviral therapy at 350-500 cells/uL. Increasing survival, steady HIV incidence, and changes in treatment eligibility all are increasing treatment demand and costs at a time of significant pressure on health care budgets. The MONET trial, a 144-week controlled phase 3b open-label trial in 11 European countries, Russia, and Israel has recruited patients with viral loads below 50 copies/mL and with no history of virological failure since starting antiretroviral therapy. The trial results at 48 weeks showed that virological suppression is maintained with DRV/r monotherapy (Arrabas et al AIDS 2010; 24:223-30). Although these results cannot be extrapolated to treatment-naïve populations or those on treatment with detectable viral loads and more frequent monitoring may be required when on DRV/r monotherapy, there remains the potential for significant cost savings, as shown in this analysis specific to the UK setting.

Adding fuel to the fire: alcohol's effect on the HIV epidemic in sub-Saharan Africa

Hahn JA, Woolf-King SE, Muyindike W. Curr HIV/AIDS Rep. 2011 Jun 29. [Epub ahead of print]

Alcohol consumption adds fuel to the HIV epidemic in sub-Saharan Africa, which has the highest prevalence of HIV infection and heavy episodic drinking in the world. Alcohol consumption is associated with behaviours such as unprotected sex and poor medication adherence, and biological factors such as increased susceptibility to infection, comorbid conditions, and infectiousness, which may synergistically increase HIV acquisition and onward transmission. Few interventions to decrease alcohol consumption and alcohol-related sexual risk behaviours have been developed or implemented in sub-Saharan Africa, and few HIV or health policies or services in sub-Saharan Africa address alcohol consumption. Structural interventions, such as regulating the availability, price, and advertising of alcohol, are challenging to implement due to the preponderance of homemade alcohol and beverage industry resistance. This article reviews the current knowledge on how alcohol influences the HIV epidemic in sub-Saharan Africa, summarises current interventions and policies, and identifies areas for increased research and development.

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Editor’s note: This makes for sobering reading. Fully 4% of deaths worldwide are attributed to alcohol consumption. The prevalence of heavy episodic alcohol drinking among drinkers is the highest in sub-Saharan Africa where 31% of alcohol consumption is from unrecorded alcohol that is brewed, fermented, or distilled from locally grown grains or fruits. Heavy alcohol consumption is associated with sexual risk-taking and decreased self-care behaviours such as poor adherence to medications but for those not on antiretroviral therapy, it is associated with lower CD4 counts and shorter time to CD4 counts under 200 cells/uL. Integration of brief interventions into HIV testing programmes to reduce alcohol consumption shows promise but structural interventions to regulate alcohol are needed to change the risk environment (taxes on alcohol, drunk driving laws, national awareness campaigns, etc.). Governments need to overcome resistance by the alcohol beverage industry and devise ways to regulate sales of home-made alcohol if they are to make headway in addressing the multi-factorial effects of alcohol on HIV epidemics in sub-Saharan Africa.

It's not just who you are but where you live: an exploration of community influences on individual HIV status in rural Malawi

Feldacker C, Ennett ST, Speizer I. Soc Sci Med. 2011;72(5):717-25.

Approximately 1 million people are infected with Human Immunodeficiency Virus (HIV) in Malawi. Despite efforts aimed at changing individual risk behaviours, HIV prevalence continues to rise among rural populations. Both previous research and the Political Economy of Health framework suggest that community-based socio-economic factors and accessibility may influence HIV transmission; however, these community factors have received little empirical investigation. To fill this gap, this research uses data from a nationally representative probability sample of rural Malawians combined with small area estimates of community socio-economic and accessibility data in logistic regression models to: 1) reveal relationships between community factors and individual HIV status; 2) determine whether these relationships operate through individual HIV risk behaviours; and 3) explore whether these associations vary by gender. Community socio-economic factors include relative and absolute poverty; community accessibility factors include distance to roads, cities, and public health facilities. Individual HIV risk behaviours include reported condom use, sexually transmitted infections, multiple partnerships, and paid sex. Results show that higher community income inequality, community proximity to a major road, and community proximity to a public health clinic are associated with increased odds of HIV for women. For men, community proximity to a major road and community proximity to a public health clinic are associated with increased odds of HIV infection. These direct relationships between community factors and individual HIV status are not mediated by individual HIV risk behaviours. The Political Economy of Health frames the discussion. This study provides evidence for expanding HIV prevention efforts beyond individual risk behaviours to consideration of community factors that may drive the HIV epidemic in rural Malawi.

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Editor’s note: In this interesting analysis of whether and how community socio-economic and accessibility factors influence HIV status in rural Malawi, community was census-defined as approximately 500 households. Demographic and health survey data from 2004, community poverty and road data from the last Malawi census (1998), and 2002 data on the location of health centres were used to create the following variables: income inequality (Gini index), absolute economic deprivation (poverty headcount or % below the poverty line), distance to a major urban area, distance to a major road, distance to a public health facility, self-reported HIV risk behaviour (sex partner type and numbers, condom use with last 3 partners, previous sexually transmitted infection, and payment for sex ever) and HIV status (fingerprick filter paper specimen). The findings are thought provoking. Rural residence seems protective, for both women and men, perhaps because greater distance and cost may prohibit travel to commercial centres where extramarital sex may occur. Higher HIV risk with closer proximity to health centres is puzzling; however, health posts are often located in small commercial centres that are themselves associated with increased sexual risk taking. As well, people with HIV infection may move to be closer to health centres for improved access to care. The most striking finding is that income inequality, as opposed to absolute poverty, is associated with increased HIV in women. Why would this be so? High levels of income inequality may foster decreased trust, fewer social ties, and risk environments that facilitate HIV exposure. Women may be forced to choose between short-term survival strategies and long-term consequences (HIV infection). As integrated microfinance and HIV prevention programmes are introduced to address gendered economic disparities and food insecurity, it is important to anticipate and prevent possible secondary effects of increased income on HIV sexual risk.