HIV This Week

Lindenburg CE, Krol A, et al. Decline in HIV incidence and injecting, but not in sexual risk behaviour, seen in drug users in Amsterdam: a 19-year prospective cohort study. AIDS 2006;20:1771-75.

Lindenburg and colleagues studied temporal changes in HIV incidence, HIV transmission routes, and both injecting and sexual risk behaviour in the open Amsterdam Cohort Study among drug users. Initiated in 1985, the Amsterdam Cohort Study enabled the authors to study changes in trends since HAART became widespread in 1996. Person-time techniques were used to study the trend in HIV incidence among HIV-negative drug users. HIV transmission routes were determined using detailed standardised questionnaires. Trends in injecting and sexual risk behaviours were evaluated with a logistic regression model adjusted for correlations between visits of the same individual. The 1315 HIV-negative individuals, of whom 93 seroconverted for HIV, yielded 6970 HIV-negative person-years of follow-up. The HIV incidence was 7 per 100 person-years in 1986 and fell so that after 1999 it varied between 0 and 0.5 per 100 person-years. The odds ratio was 15.6 (95% CI 2.6-94.6) for HIV transmission through unprotected heterosexual contact versus injecting after 1996 compared with the period before. Reports of both injecting and borrowing needles significantly declined over the period 1985-2004. Reports of sexual risk behaviour and sexually transmitted infections at follow-up visits decreased before, but not after, 1996. The authors conclude that the HIV incidence among drug users in the Amsterdam Cohort Study has declined since 1985. Accompanied by a reduction in injecting drug use and needle sharing, this decline occurred despite continued sexual risk behaviour. At present, new HIV seroconversions are related mainly to unprotected heterosexual contacts. Therefore, HIV prevention programmes for drug users should pay specific attention to the importance of safer sex practices.

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Hoffmann O, Boler T, Dick B. Achieving the global goals on HIV among young people most at risk in developing countries: young sex workers, injecting drug users and men who have sex with men. World Health Organ Tech Rep Ser 2006;938:287-315.Hoffmann and colleagues undertook a systematic literature review to identify programmes in low- and middle-income countries for young people in the three selected groups most at risk from HIV: young sex workers, injecting drug users, and men who have sex with men. The authors also identified programmes directed at young people in developed countries as well as programmes in low- and middle-income countries for these three population groups that did not differentiate between young people and adults. Young people 10 to 24 years of age represent a large proportion of the population most at risk of becoming infected with HIV in low- and middle-income countries. Despite this fact, well documented evaluations of programmes for these groups are scarce. However, there is evidence of effectiveness for programmes that are facility-based and use outreach to provide information and services to at-risk young people. The authors conclude that there is growing evidence from low- and middle-income countries of successful initiatives for groups most at risk from HIV, and these programmes should be widely implemented provided that they are carefully planned and monitored and have a strong evaluation component. However, there is an urgent need to disaggregate data by age in order to determine how effective these programmes are in reaching young people and to better understand the specific needs of at-risk young people as opposed to older age groups.

Sinanovic E, Kumaranayake L. Sharing the burden of TB/HIV? Costs and financing of public-private partnerships for tuberculosis treatment in South Africa. Trop Med Int Health 2006;11:1466-74. http://www.blackwell-synergy.com/doi/full/10.1111/j.1365-3156.2006.01686.x

Sinanovic and Kumaranayake explored the economic costs and sources of financing for different public-private partnership (PPP) arrangements for tuberculosis (TB) service provision involving both workplace and non-profit private providers in South Africa. The financing required for the different models from the perspective of the provincial TB programme, provider, and the patient were considered. Two models of TB provider partnerships were evaluated, relative to sole public provision: public-private workplace (PWP) and public-private non-government (PNP). The cost analysis was undertaken from a societal perspective. Costs were collected retrospectively to consider both the financial and economic costs. Patient costs were estimated using a retrospective structured patient interview. Expansion of PPPs could potentially lead to reduced government sector financing requirements for new patients: government financing would require $609-690 per new patient treated in the purely public model, in contrast to PNP sites which would only need to $130-139 per patient and $36-46 with the PWP model. Moreover, there are no patient costs associated with the treatment in the employer-based facilities and the cost to the patient supervised in the community is, on average, three times lower than in public sector facilities. The results suggest that there is a strong economic case for expanding PPP involvement in TB treatment in the process of scaling up. The cost to the government per new patient treated could be reduced by enhanced partnership between the private and public sectors.

Editors’ note: As TB continues to rise in sub-Saharan Africa and reports of the virtually untreatable XDR-TB (extremely drug resistant TB) surface worldwide the need for creative cost-effective service delivery models is ever more evident. These models would mean lower costs for both governments and patients.

Bolding G, Davis M, et al. Heterosexual men and women who seek sex through the Internet. Int J STD AIDS 2006;17:530-4.

Heterosexual women (n=330), heterosexual men (n=319) and gay men (n=331) attending a London HIV-testing clinic in 2002-2003 completed a confidential self-administered questionnaire concerning their sexual behaviour and use of the internet for seeking sexual partners (response rate 70%). One-in-twenty (5%) heterosexual women and one-in-ten (10%) heterosexual men had used the internet to look for sexual partners in the previous 12 months compared with nearly half (43%) the gay men (P<0.001). Rates of high-risk sexual behaviour with a casual partner were elevated among those who used the internet to look for sex (compared with those who did not). However, people who looked for sex through the internet were just as likely to meet their high-risk casual partners offline as online. The authors conclude that the findings suggest high-risk heterosexual women and men are selectively using the internet to look for sex rather than the internet per se leading to riskier sexual behaviour.

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Carballo-Dieguez A, Miner M, et al. Sexual negotiation, HIV-status disclosure, and sexual risk behaviour among Latino men who use the internet to seek sex with other Men. Arch Sex Behav 2006 Aug 25; [Epub ahead of print]

As part of a wider study of internet-using Latino men who have sex with men (MSM), Carballo-Dieguez and colleagues studied the likelihood that HIV-negative (n=200) and HIV-positive (n=50) Latino MSM would engage in sexual negotiations and disclosure of their HIV status prior to their first sexual encounters with men met over the Internet. They also analyzed the sexual behaviours that followed online encounters. The results showed that both HIV-negative and positive men were significantly more likely to engage in sexual negotiation and serostatus disclosure on the internet than in person. Those who engaged in sexual negotiations were also more likely to use condoms for anal intercourse. Compared to HIV-negative MSM, HIV-positive MSM were significantly less likely to disclose their serostatus, and 41% of them acknowledged having misrepresented their serostatus to a prospective sexual partner met over the internet. Although similar proportions of HIV-positive and negative men had condom-less anal intercourse, HIV-positive MSM were more likely to report lack of intention to use condoms. Pleasure was the reason most frequently cited for lack of condom use. Cybersex was reported by only one-fifth of the sample. The authors conclude that the internet, an understudied milieu of sexual networking, may present new possibilities for the implementation of risk reduction strategies, such as the promotion of sexual negotiation prior to first in-person encounter and serostatus disclosure.

Orne-Gliemann J, Mukotekwa T, et al. Community-based assessment of infant feeding practices within a programme for prevention of mother-to-child HIV transmission in rural Zimbabwe. Public Health Nutr 2006;9:563-69.

Orne-Gliemann and colleagues describe the infant feeding practices and attitudes of women who used prevention of mother-to-child transmission of HIV (PMTCT) services in rural Zimbabwe. They conducted a cross-sectional study including structured interviews and focus group discussions between June 2003 and February 2004 in Murambinda Mission Hospital (Buhera District, Manicaland Province), the first site offering PMTCT services in rural Zimbabwe. The interviews targeted HIV-infected and HIV-negative women who received prenatal HIV counselling and testing and minimal infant feeding counselling, and who delivered between 15 August 2001 and 15 February 2003. Focus groups were conducted among young and elderly men and women. Overall, 71 HIV-infected and 93 HIV-negative mothers were interviewed in clinics or at home. Most infants (97%) had ever been breast-fed. HIV-negative mothers introduced fluids/foods other than breast milk significantly sooner than HIV-infected mothers (median 4.0 vs. 6.0 months, P=0.005). Infants born to HIV-negative mothers were weaned significantly later than HIV-exposed infants (median 19.0 vs. 6.0 months, P<0.0001). More than 90% of mothers reported that breast-feeding their infant was a personal decision, a third of whom also mentioned having taken into account health workers' messages. The authors conclude that the HIV-infected mothers interviewed were gradually implementing infant feeding practices recommended in the context of HIV. Increased infant feeding support capacity in resource-limited rural populations is required, i.e. training of counselling staff, decentralised follow-up and weaning support.