HIV This Week

Desai K, Boily MC, Garnett GP, Masse BR, Moses S, Bailey RC. The role of sexually transmitted infections in male circumcision effectiveness against HIV - Insights from clinical trial simulation. Emerg Themes Epidemiol 2006;3(1):19. http://www.ete-online.com/content/3/1/19

A landmark randomised trial of male circumcision in Orange Farm, South Africa recently showed a large and significant reduction in risk of HIV infection, reporting male circumcision effectiveness of 61% (95% CI 34-77%). Additionally, two further randomised trials of male circumcision in Kisumu, Kenya and Rakai, Uganda were recently stopped early reporting 53% and 48% effectiveness, respectively. Since male circumcision may protect against both HIV and certain sexually transmitted infections (STI), which are themselves cofactors of HIV infection, an important question is the extent to which this estimated effectiveness against HIV is mediated by the protective effect of circumcision against STI. The answer lies in the trial data if the appropriate statistical analyses can be identified to estimate the separate efficacies against HIV and STI, which combine to determine overall effectiveness. Focusing on the male circumcision trial in Kisumu, Desai and colleagues used a stochastic prevention trial simulator (1) to determine whether statistical analyses can validly estimate efficacy, (2) to determine whether male circumcision efficacy against STI alone can produce large effectiveness against HIV and (3) to estimate the fraction of all HIV infections prevented that are attributable to efficacy against STI when both efficacies combine. Valid estimation of separate efficacies against HIV and STI as well as male circumcision effectiveness is feasible with available STI and HIV trial data, under Kisumu trial conditions. Under their parameter assumptions, high overall effectiveness of male circumcision against HIV was observed only with a high male circumcision efficacy against HIV and was not possible on the basis of male circumcision efficacy against STI alone. The fraction of all HIV infections prevented which were attributable to male circumcision efficacy against STI was small, except when efficacy of male circumcision specifically against HIV was very low. In the three male circumcision trials which reported between 48% and 61% effectiveness, the fraction of HIV infections prevented in circumcised males which were attributable to STI was unlikely to be more than 10% to 20%. The authors conclude that estimation of the efficacy, attributable fraction and effectiveness leads to improved understanding of trial results, gives trial results greater external validity and is essential to determine the broader public health impact of circumcision to men and women.

Editors’ note: Now that these trials have been stopped it will be possible to examine the real data on incident STI and attempt to better tease out the contribution of STI prevention to the reduced incidence of HIV seen in men who underwent circumcision in the trials. WHO/UNAIDS are hosting a global consultation on the policy and programming implications of the three circumcision trial findings for countries in March 2007 which will take a closer look at all available data from the trials.

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Kahn JG, Marseille E, Auvert B. Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med 2006;3(12):e517. 10.1371/journal.pmed.0030517

Consistent with observational studies, a randomized controlled intervention trial of adult male circumcision conducted in the general population in Orange Farm (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. Kahn and colleagues present the first cost-effectiveness analysis of the use of male circumcision as an intervention to reduce the spread of HIV in sub-Saharan Africa. Cost-effectiveness was modelled for 1,000 male circumcisions done within a general adult male population. Intervention costs included performing male circumcision and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted, which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the Orange Farm trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and programme coverage. All results were discounted to the present at 3% per year. For Gauteng Province, assuming full coverage of the male circumcision intervention, with a 2005 adult male prevalence of 25.6%, 1000 circumcisions would avert an estimated 308 (80% CI 189-428) infections over 20 years. The cost is $US 181 (80% CI 117-306) per HIV infection averted, and net savings are $US 2.4 million (80% CI 1.3 million to 3.6 million). Cost-effectiveness is sensitive to the costs of male circumcision and of averted HIV treatment, the protective effect of male circumcision, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIV infection averted is $US 551 (80% CI 344-1071) and net savings are $US 753,000 (80% CI 0.3 million to 1.2 million). Cost-effectiveness improves by less than 10% when male circumcision intervention coverage is 50% of full coverage. The authors conclude that in settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult male circumcision is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. Male circumcision generates large net savings after adjustment for averted HIV medical costs.

Editors’ note: Cost per case of HIV infection averted will vary widely by setting and by the costs included in the analysis. It is important to include not just the immediate cost of the procedure and care of any adverse events (care provider, costs of equipment and supplies, facility time, etc.) but also in-service training costs, medical/clinical officer/nursing education costs, as well as individual counselling and public education on the benefits and limitations of male circumcision as an HIV prevention measure. The actual service delivery model also has implications for costs. For example, using an ‘eye camp’ service delivery model will incur quite different costs than a model which contextualises male circumcision within a programme addressing male sexual and reproductive health.

Dworkin SL, Beckford ST, Ehrhardt AA. Sexual scripts of women: A longitudinal analysis of participants in a gender-specific HIV/STD prevention intervention. Arch Sex Behav 2006 Dec 21 [Epub ahead of print].

Project FIO (The Future Is Ours) was a three arm randomized controlled HIV prevention intervention trial carried out with heterosexually-active women in a high seroprevalence area of New York City. The trial was effective and women in the eight-session intervention arm were significantly more likely to report decreased unsafe sex or no unsafe sex compared to controls at one month and one year post-intervention. Dworkin and colleagues conducted a qualitative analysis of women's sexual scripts at baseline and one year follow-up for a randomly selected sub-sample of participants in Project FIO. The authors examined the domains of sexual initiation, pace setting, sexual decision-making, communication about sexual needs, and the timing of condom introductions in the experimental and control arms at baseline and one year follow-up. At one year follow-up, among both the experimental and control arms, results showed changes away from male-dominated and toward female-dominated sexual initiation and sexual decision-making. Among both the experimental and control arms, results also showed that trial participants shifted from a late condom introduction (right before intercourse) toward much earlier mention of condoms (e.g. during a date). The authors conclude that the fact that shifts in sexual scripts at one year follow-up occurred in both groups is likely reflective of the degree to which a lengthy assessment interview facilitated comfort with discussing and imagining new sexual behaviours, even for control group participants who did not receive the intervention. The value of empirically assessing sexual scripts in HIV prevention and doing so longitudinally is assessed in light of the goals of HIV prevention interventions.

Editors’ note: Randomised controlled trials, such as this one, of non-biomedical interventions help determine what works and what does not in HIV prevention – and what should be scaled up for maximum effect.

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Rea MF, Santos RG, Sanchez-Moreno CC. Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements. Acta Paediatr 2007;96:94-99.

Rea and colleagues assessed the information and counselling on infant feeding in HIV+ mothers in a cross-sectional study, based on 118 structured observations of mothers' visits to health professionals (5-8/professional) in 15 purposively selected HIV healthcare units in Sao Paulo, Brazil. The general quality of communication and counselling skills was good: for example, professionals responded to all mothers' questions (98%); kept eye-to-eye contact (82%); and encouraged the mother to talk (77.1%). However, the information provided to mothers aimed to help their choices concerning infant feeding was of very poor quality. No mother, for example, was informed about alternatives to formula feeding and the danger of mixed feeding. None was offered the option of using banked breast milk. Only around 20% of mothers were informed about the safe preparation of formula feeding. When counselled by a nutritionist (compared with a paediatrician) more mothers were informed about the correct way to prepare bottle-feeds. No mention was made of cup feeding. The authors conclude that although health workers have good communication skills, the information provided to HIV+ mothers is insufficient. Recommending against breast-feeding and providing infant formula may not be enough to achieve safer infant-feeding practices.

Editors’ note: This study has important implications for an in-service training focus on the content of counselling on infant feeding and an appropriate division of labour.

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Hovey JD, Booker V, Seligman LD. Using theatrical presentations as a means of disseminating knowledge of HIV/AIDS risk factors to migrant farm workers: An evaluation of the effectiveness of the Informate program. J Immigr Minor Health 2006 Dec 21[Epub ahead of print].

Previous research has suggested that Mexican migrant farm workers are at elevated risk for contracting HIV and that they are in need of receiving HIV-related education. Hovey and colleagues evaluated the impact of the Informate adolescent theatre programme on HIV knowledge and attitudes among farm worker audience members of various ages. Audience members from 7 migrant farm worker camps completed a self-administered questionnaire before and after they observed the Informate performance. Paired-samples t-tests and McNemar tests indicated an increase in knowledge in "modes of HIV transmission," "body fluids that can transmit HIV," and items assessing HIV "myths." In addition, a greater percentage of farm workers at post-test reported that they believed that condoms should always be used during sex. The authors conclude that overall findings from this study suggest that theatre can be an effective medium for increasing HIV-related knowledge among migrant farm workers. However, they suggest that, because some farm workers held false beliefs regarding modes of HIV transmission after viewing the theatre programme, theatre used in combination with other prevention activities may provide for a more comprehensive educational experience.

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Rietmeijer CA, Lloyd LV, McLean C. Discussing HIV serostatus with prospective sex partners: A potential HIV prevention strategy among high-risk men who have sex with men. Sex Transm Dis 2006 Dec 12 [Epub ahead of print].

Rietmeijer and colleagues assessed factors associated with HIV serostatus discussions among men who have sex with men (MSM). The authors conducted a cross-sectional survey among MSM visiting an urban sexually transmitted infection (STI) clinic. MSM were asked about sex partner recruitment, serostatus of partners, condom use, drugs use, and HIV serostatus discussions with sex partners. Among 1,400 MSM reporting occasional sex partners, serostatus discussion with 100% of partners was reported by 509 (36.3%), with 50-99% of partners by 263 (18.8%), and with <50% of partners by 628 (44.9%). Factors associated with serostatus discussion included lower number of sex partners, anal sex with an occasional partner, and sex partner recruitment through the internet. Partner recruitment in bathhouses and having sex with both men and women were negatively associated. The authors conclude that discussion of HIV serostatus was common among MSM studied. Although this strategy has limitations, interventions should address HIV status discussions. Because the internet may facilitate these discussions, web-based interventions should be evaluated.

Editors’ note: Here is yet another study suggesting that prevention activities could use the internet for maximum effect among some men who have sex with men. Challenges include designing effective programmes and convincing internet providers that they have a social responsibility to facilitate their implementation.

Tyndall MW, Wood E, Zhang R, Lai C, Montaner JS, Kerr T. HIV seroprevalence among participants at a medically supervised injection facility in Vancouver, Canada: implications for prevention, care and treatment. Harm Reduct J 2006;3:36.http://www.harmreductionjournal.com/content/3/1/36

North America’s first government sanctioned medically supervised injection facility was opened during September 2003 in Vancouver, Canada. This was in response to a large open public drug scene, high rates of HIV and hepatitis C transmission, fatal drug overdoses, and poor health outcomes among the city’s injection drug users. Between December 2003 and April 2005, a representative sample of 1,035 supervised injection facility participants were enrolled in a prospective cohort that required completing an interviewer-administered questionnaire and providing a blood sample for HIV testing. HIV infection was detected in 170/1007 (17%) participants and was associated with Aboriginal ethnicity (OR 2.70, 95% CI 1.84-3.97), a history of borrowing used needles/syringes (OR 2.0, 95% CI 1.37-2.93), previous incarceration (OR 1.87, 95% CI 1.11-3.14), and daily injection cocaine use (OR 1.42, 95% CI 1.00-2.03). The supervised injection facility has attracted a large number of marginalized injection drug users and presents an excellent opportunity to enhance HIV prevention through education, the provision of sterile injecting equipment, and a supervised environment to self-inject. In addition, the supervised injection facility is an important point of contact for HIV positive individuals who may not be participating in HIV care and treatment.

Editors’ note: This supervised injecting facility is attracting a clientele which often has poor contact with health and social services. Increased safer injecting, lowered morbidity and mortality and lower HIV incidence are the end results to be achieved and documented, as they have in been in Switzerland.

Yap L, Butler T, Richters J, Kirkwood K, Grant L, Saxby M, Ropp F, Donovan B. Do condoms cause rape and mayhem? The long-term effects of condoms in New South Wales' prisons. Sex Transm Infect. 2006 Dec 19; [Epub ahead of print]

Concerns raised by opponents to condom provision in prisons have not been objectively examined and the issue continues to be debated. Yap and colleagues examined the long-term effects of the introduction of condoms and dental dams into New South Wales prisons in 1996, focusing on particular concerns raised by politicians, prison officers, prison nurses, and prisoners. These groups were worried that: (a) condoms would encourage prisoners to have sex, (b) condoms would lead to an increase in sexual assaults in prisons, (c) prisoners would use condoms to hide and store drugs and other contraband, and (d) prisoners would use condoms as weapons. Data sources included the New South Wales Inmate Health Surveys in 1996 and 2001 and official reports from the New South Wales Department of Corrective Services. The 1996 IHS involved 657 men and 132 women randomly selected from all prisons with a 90% response rate. The 2001 survey involved 747 men and 167 women inmates with an 85% response rate. There was a decrease in reports of both consensual male-to-male sex and male sexual assaults 5 years after the introduction of condoms into prisons in 1996. Condoms were often used for concealing contraband items and other purposes but this was not associated with an increase in drug injecting in prison. Only three incidents of a condom being used in assaults on prison officers were recorded between 1996 and 2005; none were serious. The authors conclude that they found no evidence of serious adverse consequences of distributing condoms and dental dams to prisoners in New South Wales. Condoms are an important public health measure in the fight against HIV and sexually transmitted diseases; they should be made freely available to prisoners as they are to other high- risk groups in the community.

Editors’ note: Condoms have been available in Canadian penitentiaries since 1994 and in prisons in New South Wales since 1996 but the vast majority of prisons worldwide do not make condoms available to inmates with dire results. Results such as these can be used to influence correctional system leadership, particularly when national laws invest them with responsibility for detainee health on their watch.