Articles tagged as "Issue #60 - October 31, 2008"

December
12
2008

HIV This Week Issue #60

Welcome to the sixtieth issue of HIV This Week ! In this issue, we cover men who have sex with men (increasingly virtual gay communities must mean new HIV prevention strategies; is there a role for gay community in HIV prevention today?; rationale for a trial of male circumcision in men who have sex with men), country responses (human rights considerations in country strategic plans for universal access: glass half full or half empty?), stigma (fighting back: a conceptual framework for a multifaceted, multilevel strategy; Iranian high school girls have much to learn about people living with HIV), behaviour change (promising results from the Stepping Stones cluster randomised controlled trial in South Africa; effectiveness of skills building for sexual risk reduction in a trial among women in substance abuse treatment programs in the US), biomedical HIV prevention trials (why adherence in randomised controlled trials is so important; sexual risk behaviour in trials: does it improve or get worse?), treatment adherence (food supplementation improves adherence in Lusaka, Zambia; memory aids and social support are predictors of adherence in Southwest Ethiopia), diagnostics (data from South Africa call into question WHO clinical and CD4 count criteria for antiretroviral treatment failure; temperature stability of HIV RNA in plasma specimens), basic science (evidence from a paleovirological investigation reveals that HIV may have crossed to humans early in the 20th century; lessons to be learned when an AIDS patient and an elite suppressor handle the same virus differently), surveillance (how good and how bad is ‘know your epidemic’ in low- and middle-income countries; what do population-based surveys in sub-Saharan Africa contribute to HIV surveillance), women’s health (two-thirds of women living with HIV may have high risk human papillomavirus infections; women have better prognosis than men in an analysis of 23 seroconverter studies in high–income countries), and cultural determinants of risk (will sexual cleansing rituals in Western Kenya follow the road of other changes?).

 

To find out how you can access a majority of scientific journals free of charge, please click on the Journal Access tab above.

 

We want to be as helpful to you as we can, so please let us know what your interests are and what you think of HIV This Week by sending a comment to hivthisweek@unaids.org or by posting one on the HIV This Week website. If you would like to recommend an article for inclusion in HIV This Week or if you no longer wish to receive HIV This Week pdf issues by email, please contact us at hivthisweek@unaids.org. Don’t forget that you can find a wealth of information on the HIV epidemic and responses to it at www.unaids.org

For full PDF access to this issue:

HIV This Week Issue #60

Cate Hankins Nicolai Lohse Tania Lemay
Chief Scientific Adviser Research Officer Research Consultant

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Men who have sex with men

Simon Rosser BR, West W, Weinmeyer R. Are gay communities dying or just in transition? Results from an international consultation examining possible structural change in gay communities. AIDS Care. 2008 May;20(5):588-95.

This study sought to identify how urban gay communities are undergoing structural change, reasons for that change, and implications for HIV prevention planning. Key informants (N=29) at the AIDS Impact Conference from 17 cities in 14 countries completed surveys and participated in a facilitated structured dialog about whether gay communities are changing, and if so, how they are changing. In all cities, the virtual gay community was identified as currently larger than the offline physical community. Most cities identified that while the gay population in their cities appeared stable or growing, the gay community appeared in decline. Measures included greater integration of heterosexuals into historically gay-identified neighbourhoods and movement of gay persons into suburbs, decreased number of gay bars/clubs, less attendance at gay events, less volunteerism in gay or HIV/AIDS organizations, and the overall declining visibility of gay communities. Participants attributed structural change to multiple factors including gay neighbourhood gentrification, achievement of civil rights, less discrimination, a vibrant virtual community, and changes in drug use. Consistent with social assimilation, gay infrastructure, visibility, and community identification appears to be decreasing across cities. HIV prevention planning, interventions, treatment services, and policies need to be re-conceptualized for men who have sex with men in the future. Four recommendations for future HIV prevention and research are detailed.

Editors’ note: Applying an ecological model of health behaviour (intra-individual, interpersonal, institutional/organisational, community, structural) to understanding the resurgent HIV epidemic among gay men living primarily in the global north reveals that many ingredients of successful early HIV prevention (community activism, community-appropriate interventions, and a sense of solidarity against the virus) are ill adapted to current realities of increasingly virtual gay communities. Structural changes in gay communities have reduced the effectiveness of HIV prevention making it high time to take stock, rethink, and tailor effective strategies to reduce HIV incidence among men who have sex with men.

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Men who have sex with men

Rowe MS, Dowsett GW. Sex, love, friendship, belonging and place: Is there a role for ‘Gay Community’ in HIV prevention today? Cult Health Sex. 2008 May; 10(4):329-44.

The decade since highly active anti-retroviral therapy arrived has been a time of change for gay men in the West. HIV incidence rates have been levelling off-and in some cities, increasing markedly-for the first time since the early years of the pandemic. New sexual subcultures have found expression, including Internet chat rooms, ‘poz-only’ sex parties, ‘barebacking’ and crystal methamphetamine use. These circumstances force a re-evaluation of HIV prevention targeting gay communities. Rowe and Dowsett examine the antecedents of current HIV-prevention dilemmas in findings from a qualitative study of gay men who were personally and professionally engaged in HIV in Sydney, Australia, in 1997-1998, immediately after the ‘protease moment’. The men’s lives were characterized by constant and difficult negotiation of gay subjectivities. They did not find a place of uniform belonging in the gay community; rather, ambivalence-toward the gay community and HIV prevention-and fragmentation emerged as themes. The authors’ findings suggest that by the late 1990s, the ethos of safe sex developed in the early HIV period was no longer a unifying cultural value. They explore the conditions that led to this shift and the implications for HIV prevention in the 21st century.

Editors’ note: These Australian findings from 1997-98 suggest that the advent of effective combination treatment constituted a turning point in gay history from which the logic of the safe sex culture as a unifying and enduring cultural value began to falter. With potential resonance for HIV prevention programmes elsewhere, this underscores the need to recognise that much of what gay men experience as gay community lies outside what are traditionally understood to be a community’s geographic, social, and conceptual boundaries.

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Men who have sex with men

Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA. 2008 Oct 8;300(14):1674-84.

Randomized controlled trials and meta-analyses have demonstrated that male circumcision reduces men's risk of contracting human immunodeficiency virus (HIV) infection during heterosexual intercourse. Less is known about whether male circumcision provides protection against HIV infection among men who have sex with men. Millett et al set out to quantitatively summarize the strength of the association between male circumcision and HIV infection and other sexually transmitted infections (STIs) across observational studies of men who have sex with men. They undertake a comprehensive search of databases, including MEDLINE, EMBASE, ERIC, Sociofile, PsycINFO, Web of Science, and Google Scholar, and correspondence with researchers, to find published articles, conference proceedings, and unpublished reports through February 2008. Of 18 studies that quantitatively examined the association between male circumcision and HIV sexually transmitted infection among men who have sex with men, 15 (83%) met the selection criteria for the meta-analysis. Independent abstraction was conducted by pairs of reviewers using a standardized abstraction form. Study quality was assessed using the Newcastle-Ottawa Scale. A total of 53,567 men who have sex with men (52% circumcised) were included in the meta-analysis. The odds of being HIV-positive were nonsignificantly lower among men who have sex with men who were circumcised than uncircumcised (odds ratio, 0.86; 95% confidence interval, 0.65-1.13; number of independent effect sizes [k] = 15). Higher study quality was associated with a reduced odds of HIV infection among circumcised men who have sex with men (beta, -0.415; P = .01). Among men who have sex with men who primarily engaged in insertive anal sex, the association between male circumcision and HIV was protective but not statistically significant (odds ratio, 0.71; 95% confidence interval, 0.23-2.22; k = 4). Male circumcision had a protective association with HIV in studies of men who have sex with men conducted before the introduction of highly active antiretroviral therapy ( odds ratio, 0.47; 95% confidence interval, 0.32-0.69; k = 3). Neither the association between male circumcision and other sexually transmitted infections (odds ratio, 1.02; 95% confidence interval, 0.83-1.26; k = 8), nor its relationship with study quality was statistically significant (beta, 0.265; P = .47). The authors conclude that pooled analyses of available observational studies of men who have sex with men revealed insufficient evidence that male circumcision protects against HIV infection or other sexually transmitted infections. However, the comparable protective effect of male circumcision in men who have sex with men studies of men who have sex with men conducted before the era of highly active antiretroviral therapy, as in the recent male circumcision trials of heterosexual African men, supports further investigation of male circumcision for HIV prevention among men who have sex with men.

Editors’ note: The observational data on HIV risk and circumcision status among men who have sex with men, even those who primarily engage in insertive sex, do not suggest the strong protective effect seen for men who have sex with women. In fact, the findings are at best a non-significant trend and at worse a chance finding. However, male circumcision was significantly protective for men having sex with men before the advent of antiretroviral treatment. The feasibility of a randomised controlled clinical trial to resolve the question of whether male circumcision confers a significant level of partial protection to men who have sex with men in the era of antiretroviral treatment is being assessed in Peru where overenrolment of primarily insertive men would increase the statistical power of a trial.

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Country responses

Gruskin S, Tarantola D. Universal Access to HIV prevention, treatment and care: assessing the inclusion of human rights in international and national strategic plans. AIDS. 2008 Aug;22 Suppl 2:S123-32.

Rhetorical acknowledgment of the value of human rights for the AIDS response continues, yet practical application of human rights principles to national efforts appears to be increasingly deficient. We assess the ways in which international and national strategic plans and other core documents take into account the commitments made by countries to uphold human rights in their efforts towards achieving Universal Access. Key documents from the Joint United Nations Programme on HIV and AIDS (UNAIDS), the World Health Organization (WHO), the World Bank, the Global Fund to Fight AIDS, TB and Malaria (GFATM) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) were reviewed along with 14 national HIV strategic plans chosen for their illustration of the diversity of HIV epidemic patterns, levels of income and geographical location. Whereas human rights concepts overwhelmingly appeared in both international and national strategic documents, their translation into actionable terms or monitoring frameworks was weak, unspecific or absent. Future work should analyse strategic plans, plans of operation, budgets and actual implementation so that full advantage can be taken, not only of the moral and legal value of human rights, but also their instrumental value for achieving Universal Access.

Editors’ note: This review is a mini-primer on human rights, presenting definitions of key human rights terms relevant to universal access, including ‘duty bearers’, rights holders’, and the 3AQ (availability, accessibility, acceptability and quality). It finds that in most countries assessed, universal access remains primarily equated with treatment, underscoring the need to emphasise prevention as the mainstay of universal access. As well, law reform, ensuring confidentiality protection, preventing violence against women, and other strategies beyond traditional health sector approaches essential to an effective response receive little attention. Important strides have been made in the recognition of marginalised communities but much more is needed to operationalise human rights in national HIV strategic plans.

National responses
No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Stigma

Mahajan AP, Sayles JN, Patel VA, Remien RH, Sawires SR, Ortiz DJ, Szekeres G, Coates TJ. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS. 2008 Aug;22 Suppl 2:S67-79.

Although stigma is considered a major barrier to effective responses to the AIDS epidemic, stigma reduction efforts are relegated to the bottom of AIDS programme priorities. The complexity of HIV-related stigma is often cited as a primary reason for the limited response to this pervasive phenomenon. In this paper, Mahajan et al systematically review the scientific literature on HIV-related stigma to document the current state of research, identify gaps in the available evidence and highlight promising strategies to address stigma. They focus on the following key challenges: defining, measuring and reducing HIV-related stigma as well as assessing the impact of stigma on the effectiveness of HIV prevention and treatment programmes. Based on the literature, the authors conclude by offering a set of recommendations that may represent important next steps in a multifaceted response to stigma in the AIDS epidemic.

Editors’ note: Stigma may be defined as a mark of disgrace, an attribute that is deeply discrediting, or a difference that taints and discounts a person. The conceptual framework presented here starts with the foundation of inequalities in social, political, and economic power that promulgate labelling, stereotyping, separation/status loss, and discrimination. Moving toward consensus on how best to define, measure, and diminish stigma is the first step. One component would be community organising among people living with HIV and their sympathetic supporters to ‘unleash the power of resistance on the part of the stigmatised’ but stigma will only be effectively reduced through an overarching multifaceted, multilevel approach.

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Stigma

Ghabili K, Shoja MM, Kamran P. The Iranian female high school students’ attitude towards people with HIV/AIDS: a cross-sectional study. AIDS Res Ther. 2008 Jul 22;5:15.

Acquired Immunodeficiency Syndrome (AIDS) has become an important public health hazard in Iran. It is believed that AIDS-related knowledge does not necessarily translate into behaviour modification. Hence, it has been suggested that culturally appropriate educational campaigns should be implemented to obtain satisfactory outcomes. Here, Ghabili et al evaluated the female high school students’ attitude towards HIV in Tabriz, Iran to assess the cultural needs for the related educational programs and to discover sources of information about AIDS. Anonymous, self-administered questionnaires were filled by the young female students. Among 300 students, 91% agreed that being an HIV carrier should not be an obstacle to obtaining education and employment. Moreover, 72.5% of the students declared that the community should be informed of HIV-positive people. In addition, one-tenth declared that they would feel extremely uncomfortable towards their HIV infected classmate. In addition, only 16% of the students stated that they would continue to shop at HIV infected grocer’s store. The mass media and the experts were the major source and the most reliable source of information about AIDS, respectively. Tabrizian female students have overall negative attitudes towards HIV. HIV-related educational campaigns should target the students, society, and the families with emphasizing the leading roles of health staff.

Editors’ note: Among the striking negative attitudes among Iranian high school girls are the views that children who are HIV carriers should be send to special schools/classes (41%), special hospitals should be created for AIDS patients (86%), and most AIDS patients do not care if they infect other people too (66%). Clearly, school-based education programmes need to anchored in society-wide educational campaigns, using credible information and spokespeople to create new community and family understandings about HIV.

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Behaviour change

Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, Duvvury N. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial. BMJ. 2008 Aug 7;337:a506. doi: 10.1136/bmj.a506

Jewkes et al aimed to assess the impact of Stepping Stones, a HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour. Cluster randomised controlled trial was conducted in 70 villages (clusters) in the Eastern Cape province of South Africa. Participants were 1360 men and 1416 women aged 15-26 years, who were mostly attending schools. Stepping Stones, a 50 hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2. The primary outcome measure was HIV incidence. Other outcomes being incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse. The authors found that there was no evidence that Stepping Stones lowered the incidence of HIV (adjusted incidence rate ratio 0.95, 95% confidence interval 0.67 to 1.35). The programme was associated with a reduction of about 33% in the incidence of HSV-2 (0.67, 0.46 to 0.97; P=0.036)-that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1000 people exposed. Stepping Stones significantly improved a number of reported risk behaviours in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women desired behaviour changes were not reported and those in the Stepping Stones programme reported more transactional sex at 12 months. The authors concluded that Stepping Stones did not reduce incidence of HIV but had an impact on several risk factors for HIV-notably, HSV-2 and perpetration of intimate partner violence. TRIAL REGISTRATION: Clinical Trials NCT00332878.

Editors’ note: Stepping Stones is a participatory HIV prevention programme that aims to be gender transformative, improving sexual health through building stronger, more gender equitable relationships. Developed for use in Uganda in 1995, it has been adapted for 17 settings, used in over 40 countries, translated into 13 languages, used with hundreds of thousands of individuals, but never has been evaluated using a randomised controlled trial design with biological outcomes. Although no impact on HIV was found, possibly due to sample size limitations, the reduced incidence of herpes simplex type 2 is significant and although women did not show much behaviour change, men reported significant behaviour change that likely reflects changing ideas of masculinity.

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Behaviour change

Tross S, Campbell AN, Cohen LR, Calsyn D, Pavlicova M, Miele GM, Hu MC, Haynes L, Nugent N, Gan W, Hatch-Maillette M, Mandler R, McLaughlin P, El-Bassel N, Crits-Christoph P, Nunes EV. Effectiveness of HIV/STD sexual risk reduction groups for women in substance abuse treatment programs: results of NIDA Clinical Trials Network Trial. J Acquir Immune Defic Syndr. 2008 Aug 15;48(5):581-9.

Because drug-involved women are among the fastest growing groups with AIDS, sexual risk reduction intervention for them is a public health imperative. The objective was to test effectiveness of HIV/STD safer sex skills building (SSB) groups for women in community drug treatment. This was a randomized trial of SSB versus standard HIV/STD Education (HE); assessments at baseline, 3 and 6 months. The participants were women recruited from 12 methadone or psychosocial treatment programs in Clinical Trials Network of National Institute on Drug Abuse. Five hundred fifteen women with >or=1 unprotected vaginal or anal sex occasion (USO) with a male partner in the past 6 months were randomized. In SSB, five 90-minute groups used problem solving and skills rehearsal to increase HIV/STD risk awareness, condom use, and partner negotiation skills. In HE, one 60-minute group covered HIV/STD disease, testing, treatment, and prevention information. There were a number of USOs at follow-up. A significant difference in mean USOs was obtained between SSB and HE over time (F = 67.2, P < 0.0001). At 3 months, significant decrements were observed in both conditions. At 6 months, SSB maintained the decrease and HE returned to baseline (P < 0.0377). Women in SSB had 29% fewer USOs than those in HE. The authors concluded that skills building interventions can produce ongoing sexual risk reduction in women in community drug treatment.

Editors’ note: Introducing a new acronym – USO or unprotected sex occasion – this randomised controlled trial found sustained sexual risk reduction 6 months later in women on drug treatment who received a brief, gender-specific, skills-oriented risk reduction intervention delivered by drug treatment staff at community-based clinics. The control group received one health education session compared to the five skills building sessions received by the experimental group, a design that does not permit definitive attribution because of difference in does. Nonetheless, these are impressive results for women who are at high risk for heterosexual acquisition of HIV during drug treatment, as they are often in primary sexual relationships with male drug users and their own substance use may continue, influencing sexual risk.

Your rating: None Average: 3 (1 vote)
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.
December
11
2008

Biomedical HIV prevention tools

Weiss HA, Wasserheit JN, Barnabas RV, Hayes RJ, Abu-Raddad LJ. Persisting with prevention: The importance of adherence for HIV prevention. Emerg Themes Epidemiol. 2008 Jul 11;5:8.

Only four out of 31 completed randomised controlled trials of HIV prevention strategies against sexual transmission have shown significant efficacy. Poor adherence may have contributed to the lack of effect in some of these trials. In this paper Weiss et al explore the impact of various levels of adherence on measured efficacy within a randomized controlled trial. They used simple quantitative methods to illustrate the impact of various levels of adherence on measured efficacy by assuming a uniform population in terms of sexual behaviour and the binomial model for the transmission probability per partnership. At 100% adherence the measured efficacy within a randomised controlled trial is a reasonable approximation of the true biological efficacy. However, as adherence levels fall, the efficacy measured within a trial substantially under-estimates the true biological efficacy. For example, at 60% adherence, the measured efficacy can be less than half of the true biological efficacy. The authors conclude that poor adherence during a trial can substantially reduce the power to detect an effect, and improved methods of achieving and maintaining high adherence within trials are needed. There are currently 12 ongoing HIV prevention trials, all but one of which require ongoing user-adherence. Attention must be given to methods of maximizing adherence when piloting and designing randomised controlled trials RCTs and HIV prevention programmes.

Editors’ note: Anticipated levels of adherence to prevention measures, which are likely to be lower than those achieved with antiretroviral treatment, must be taken into account when designing trials. Trials need to be powered to detect a smaller efficacy than a true biological efficacy that would result from 100% adherence. Otherwise it is not clear whether a null result, as has been seen in several trials, reflects a truly ineffective intervention; low study power due to factors such as underestimates of HIV incidence, effective intervention in the control arm, and higher than expected loss to follow-up; or poor adherence. Methods to achieve and maintain high adherence in a trial are key to successful trial conduct but also to eventual application of any prevention method that does prove efficacious.

No votes yet
  • Share this!
No comment Add a comment
The content of this field is kept private and will not be shown publicly.
By submitting this form, you accept the Mollom privacy policy.