Articles tagged as "Issue #62 - 13 December, 2008"

December
15
2008

HIV This Week #62

Welcome to the 62nd issue of HIV This Week ! In this issue, we cover behaviour change (multiple sources of evidence reveal what actually did happen in Uganda ), prevention (four windows of opportunity for HIV prevention; insights from mathematical modelling on treatment as prevention), microeconomics (out-of-pocket costs gulf the effects of free antiretroviral drugs in China; hungry kids in affected households in Cambodia), tuberculosis (progress in diagnostics; BCG vaccine-induced complications in kids starting antiretroviral treatment ), intimate partner violence(childhood exposures to violence among South African men associated with perpetration of violence; news from the morgue in the Republic of Congo reveals murder of HIV-positive women); treatment (drug resistance after first-line highly active antiretroviral therapy; what factors increase regimen durability), HIV testing (rapid testing makes no inroads in a rural South African community), injecting drug use (increases in the number of people who inject drugs and HIV prevalence among them), epidemiology (mature epidemics in 5 African countries: what role does commercial sex play?), faith-based organisations(time for real change in Malawi), pathogenesis(news from the SMART trial on inflammation and mortality; why we need to know more about HIV immunopathogenesis), microbicides(intravaginal rings find favour in Kenya, what we know and don’t know about mucosal HIV transmission), prevention trial conduct (improving recruitment and retention in virtual world HIV prevention trials), and youth (urban adolescent school girls have much to learn in India).

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 HIV This Week #62

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

 

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December
15
2008

Behaviour change

Kirby D. Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence. Sex Transm Infect. 2008;84 Suppl 2:ii35-41.

Kirby set out to identify the changes in sexual behaviour that led to the dramatic reduction in the prevalence of HIV in Uganda in the early 1990s. Seven different types of evidence were examined: (1) models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; (2) reports of behaviour change in the primary newspaper in Uganda; (3) surveys with questions about perceptions of personal behaviour change; (4) large demographic and health surveys (DHS) collected in 1988/9 and 1995 and large Global Program on AIDS (GPA) surveys in 1989 and 1995 with questions about reported sexual behaviour; (5) smaller less representative surveys of reported sexual behaviour collected in other years; (6) reports of numbers of condoms shipped to Uganda; and (7) historical documents describing the implementation of HIV prevention programmes in Uganda. All seven types of data produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners. Consistent with basic theories about transmission of sexually transmitted infections, first reducing the number of sexual partners and breaking up sexual networks and then reducing the chances of HIV transmission with remaining casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalised epidemics.

Editors’ note: HIV incidence in Uganda began declining from a peak in 1987-88 and then declined more rapidly after 1992-93. Although each of the seven types of evidence presented here has limitations, together they paint a convincing picture that people restricted their sexual activity outside long-term marital and cohabiting relationships and then increased condom use with casual sexual partners when condom availability improved with the arrival in the early 1990s of large shipments of condoms. The debates about ‘the one thing’ that led to Uganda’s historical fall in HIV prevalence are put to rest by this article highlighting the importance of combination prevention, including a good dose of political leadership, in stimulating and sustaining incidence declines.

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December
15
2008

Prevention

Cohen MS, Kaleebu P, Coates T. Prevention of the sexual transmission of HIV-1: preparing for success. J Int AIDS Soc. 2008;11(1):4.  

There are four opportunities for HIV prevention: before exposure, at the moment of exposure, immediately after exposure, and as secondary prevention focused on infected subjects. Until recently, most resources have been directed toward behavioural strategies aimed at preventing exposure entirely. Recognizing that these strategies are not enough to contain the epidemic, investigators are turning their attention to post-exposure prevention opportunities. There is increasing focus on the use of antiretroviral treatment-either systemic or topical (microbicides)- to prevent infection at the moment of exposure. Likewise, there is growing evidence that antiretroviral treatment of infected people could serve as prevention as well. A number of ongoing clinical trials will shed some light on the potential of these approaches. Above all, prevention of HIV requires decision-makers to focus resources on strategies that are most effective. Finally, treatment of HIV and prevention of HIV must be considered and deployed together.

Editors’ note: This excellent review of the prevention of sexual HIV transmission focuses on a menu of options driven by scientific results rather than ideology. Condoms and male circumcision have not reached their full prevention potential and the ecological evidence on the population-level benefits of antiretroviral treatment is mixed. Further, the very short time between HIV exposure, infection, and viral replication with seeding of reservoirs poses a major challenge for vaccine development. Pre-exposure prophylaxis gets antiretroviral protection on board before exposure to prevent infection at the time of exposure – it works for mother-to-child transmission so there are high hopes that it will enter the scientifically-validated combination prevention armamentarium for sexual transmission in coming years. Watch this space.  

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December
15
2008

Prevention

Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2008 Nov 26. [Epub ahead of print].  

Roughly 3 million people worldwide were receiving antiretroviral therapy at the end of 2007, but an estimated 6·7 million were still in need of treatment and a further 2·7 million became infected with HIV in 2007. Prevention efforts might reduce HIV incidence but are unlikely to eliminate this disease. Granich and colleagues investigated a theoretical strategy of universal voluntary HIV testing and immediate treatment with ART, and examined the conditions under which the HIV epidemic could be driven towards elimination. They used mathematical models to explore the effect on the case reproduction number (stochastic model) and long-term dynamics of the HIV epidemic (deterministic transmission model) of testing all people in their test-case community (aged 15 years and older) for HIV every year and starting people on antiretroviral treatment immediately after they are diagnosed HIV positive. They used data from South Africa as the test case for a generalised epidemic, and assumed that all HIV transmission was heterosexual. The studied strategy could greatly accelerate the transition from the present endemic phase, in which most adults living with HIV are not receiving antiretroviral treatment, to an elimination phase, in which most are on antiretroviral treatment, within 5 years. It could reduce HIV incidence and mortality to less than one case per 1000 people per year by 2016, or within 10 years of full implementation of the strategy, and reduce the prevalence of HIV to less than 1% within 50 years. The authors estimate that in 2032, the yearly cost of the present strategy and the theoretical strategy would both be US$1·7 billion; however, after this time, the cost of the present strategy would continue to increase whereas that of the theoretical strategy would decrease. They conclude that universal voluntary HIV testing and immediate antiretroviral treatment, combined with present prevention approaches, could have a major effect on severe generalised HIV epidemics. This approach merits further mathematical modelling, research, and broad consultation.

Editors’ note: This mathematical modelling of universal voluntary testing and antiretroviral treatment at HIV diagnosis regardless of CD4 count in a southern Africa-like epidemic setting is provoking lively debate. Two accompanying commentaries highlight the pros and cons of such a theoretical strategy. Information on the clinical benefits of early treatment for individuals is urgently needed as it unclear whether people would start medication for public health benefit alone. The idea of antiretroviral drugs for prevention is not new. Antiretroviral pre-exposure prophylaxis of mother-to-child transmission and post-exposure prophylaxis for accidental HIV exposure are standard practices while trials of both oral and topical antiretroviral pre-exposure prophylaxis are currently underway in diverse populations. The HPTN 052 trial assessing the effect of index partner treatment on sexual transmission will also provide needed data on the benefits of early versus delayed antiretroviral therapy. In the meantime, given that antiretroviral drugs already play a role in HIV prevention, they are part of combination prevention. Thoughtful messaging to ensure good comprehension of their relative contribution to combination HIV prevention can help minimise harmful behavioural risk compensation, provide a degree of reassurance to many on effective treatment, and reinforce the smart idea of combining methods for better prevention of sexual transmission.

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December
15
2008

Micro-economics

Moon S, Van Leemput L, Durier N, Jambert E, Dahmane A, Jie Y, Wu G, Philips M, Hu Y, Saranchuk P. Out-of-pocket costs of AIDS care in China: are free antiretroviral drugs enough? AIDS Care. 2008;20(8):984-94.

Financial access to HIV care and treatment can be difficult for many people in China, where the government provides free antiretroviral drugs but does not cover the cost of other medically necessary components, such as lab tests and drugs for opportunistic infections. This article estimates out-of-pocket costs for treatment and care that a person living with HIV in China might face over the course of one year. Data comes from two treatment projects run by Médecins Sans Frontières in Nanning, Guangxi Province and Xiangfan, Hubei Province. Based on the national treatment guidelines, Moon and colleagues estimated costs for seven different patient profiles ranging from WHO Clinical Stages I through IV. They found that patients face significant financial barriers to even qualify for the free antiretroviral treatment program. For those who do, HIV care and treatment can be a catastrophic health expenditure, with cumulative patient contributions ranging from approximately US$200-3939/year in Nanning and US$13-1179/year in Xiangfan, depending on the patient’s clinical stage of HIV infection. In Nanning, these expenses translate as up to 340% of an urban resident’s annual income or 1200% for rural residents; in Xiangfan, expenses rise to 116% of annual income for city dwellers and 295% in rural areas. While providing antiretroviral drugs free of charge is an important step, the costs of other components of care constitute important financial barriers that may exclude patients from accessing appropriate care. Such barriers can also lead to undesirable outcomes in the future, such as impoverishment of AIDS-affected households, higher antiretroviral drug-resistance rates and greater need for complex, expensive second-line antiretroviral drugs.

Editors’ note: Using data demonstrating that, for many people on HIV treatment in China, out-of-pocket expenditures reach ‘catastrophic’ health expenditure levels, the authors urge policy makers to consider both patient health and long-term treatment programme viability in designing strategies to prevent widespread resistance. Out-of-pocket expenditures create serious impediments for people who need antiretroviral therapy to access treatment, attend clinic regularly, and achieve high adherence levels. There are cogent economic arguments in favour of a free minimum package of HIV care that goes beyond antiretroviral drugs to include HIV tests, consultations, laboratory testing, hospitalisation, prophylaxis, and treatment of common opportunistic infections.

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December
15
2008

Micro-economics

Alkenbrack Batteh SE, Forsythe S, Martin G, Chettra T. Confirming the impact of HIV/AIDS epidemics on household vulnerability in Asia: the case of Cambodia. AIDS. 2008;22 Suppl 1:S103-11.

This study explores the effects of HIV on household economics and the social wellbeing of children in HIV-affected families in Cambodia. A purposive sample of parents living with HIV and their children was selected from networks of people living with HIV. ‘Nearest-neighbour’ households served as the comparison group. Interviews were conducted with the parent and at least one child or adolescent in each household between October 2003 and January 2004. The urban/rural sample included 1000 households, 1000 adults, and 1443 children aged 6-17 years, inclusive, and was drawn from Phnom Penh, Battambang and Takeo provinces. Despite similar overall expenditures, HIV-affected households incurred proportionately larger expenditures on medical care and funerals. Income among case households was lower than comparison households. HIV-affected households were more likely to sell off assets, borrow from family members, take out loans, and ration medical care and food for children. Children in HIV-affected households reported eating fewer meals in a day, increased frequency of hunger, and increased household and employment responsibilities compared with comparison children. School enrollment rates were similar between pairs of households. The results add to growing evidence that HIV contributes to increased vulnerability to poverty and increased burdens on families and children. This study corroborates findings from previous studies in Asia, while providing country-specific information to stakeholders in Cambodia. At this stage in the epidemic, policy makers should focus on implementing and evaluating mitigation interventions.

Editors’ note: Using a ‘nearest neighbour’ comparison group to try to disentangle risk from impact (HIV and poverty are known to influence each other with HIV exacerbating poverty and poverty increasing HIV exposure risk), this large study confirms the dissaving associated with HIV-related illnesses. Economic survival strategies come at the expense of longer-term investments in the household affecting future generations. Children in HIV-affected households are significantly disadvantaged compared to their neighbouring peers despite the food assistance provided to 81% of the case households. Implementation and evaluation of comprehensive mitigation strategies are urgently needed to inform policymaking and minimise the long-term impacts of HIV on low-income countries such as Cambodia.

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December
15
2008

Tuberculosis

Grandjean L, Moore DA Tuberculosis in the developing world: recent advances in diagnosis with special consideration of extensively drug-resistant tuberculosis. Curr Opin Infect Dis. 2008;21(5):454-61.

 

Globally tuberculosis is mainly diagnosed by sputum smear microscopy, which fails to detect half of all cases and fails to identify drug resistance. Inadequate global tuberculosis control through the directly observed therapy short course strategy alone and the growing threat of multidrug-resistant and extensively drug-resistant tuberculosis has driven recent development of new commercial and noncommercial tests, which are most desperately needed in resource-limited, high-burden settings. This review outlines the range of options currently available, highlighting particularly those recent developments with greatest potential for addressing the growing multidrug-resistant and extensively drug-resistant disaster as it affects those communities least technically and financially capable of controlling it. Simplification of molecular-diagnostic techniques, rapid-liquid culture and the use of colorimetric indicators have improved the sensitivity, speed and reliability of tuberculosis and multidrug-resistant tuberculosis detection, while decreasing cost and bringing diagnosis closer towards (though still some way from) the point-of-care. Global tuberculosis control in 2008 demands the use of new tools for more sensitive and rapid detection of active disease and of drug resistance. Improved technologies are available for reference laboratories but for settings where resources and technical capacity are limited there is little ready for field implementation. The pipeline is promising, but in the interim wider use of liquid culture and manual or colorimetric drug susceptibility testing should be promoted.

Editors’ note: In high-disease burden resource-constrained settings, sustainable human resources, sample transport, biosafety, and laboratory maintenance are as important as having a good test. In this era of MDRTB and XDRTB (multi- and extensively- drug-resistant TB), rational decision-making on implementation and long-term feasibility requires conducting formal evaluations of the cost-effectiveness of new and existing tests, including century-old sputum microscopy.

Comorbidity
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December
15
2008

Tuberculosis

Nuttall JJ, Davies MA, Hussey GD, Eley BS. Bacillus Calmette-Guérin (BCG) vaccine-induced complications in children treated with highly active antiretroviral therapy. Int J Infect Dis. 2008;12(6):e99-e105

 

Nuttall and colleagues aimed to describe the frequency, risk factors, and clinical features of bacillus Calmette-Guérin (BCG) complications in HIV-infected children treated with highly active antiretroviral therapy (HAART). A retrospective study of children started on HAART between August 2002 and November 2004 was completed. Six percent (21/352; 95% CI 3.7-8.0%) developed BCG complications. All developed ipsilateral axillary lymphadenitis; one child had suspected disseminated BCG infection. There were 14 females; median age at start of HAART was 5 months. BCG disease developed a median of 34 days after starting HAART. At baseline and 6 months into HAART, the median CD4 percentage and log(10) viral load were 12.3/6.1 and 23.9/4.5, respectively. Seventeen (81%) of the patients were treated with either zidovudine or stavudine combined with lamivudine and ritonavir. Young age and high baseline viral load were independent risk factors for development of BCG complications. Mycobacterium bovis BCG was isolated in 70% of patients who underwent incision and drainage of abscesses at the vaccination site or regional lymph nodes. This study identified a high prevalence of BCG complications in children on HAART. A clinical case definition of BCG immune reconstitution syndrome independent of laboratory parameters for use in resource-limited settings should be developed.

Editors’ note: This South African study suggests that infants and children with HIV infection who have received the bacillus Calmette-Guerin (BCG) vaccine, a routine immunisation at birth in high TB-burden settings, should be monitored closely for BCG complications during the first 3 to 6 months of antiretroviral treatment. These complications seem to be manifestations of immune reconstitution inflammatory syndrome (IRIS) provoked by restoration of pathogen-specific immune responses as the immune system begins to recover following treatment initiation. In light of the risk of IRIS, BCG vaccine should be withheld when the mother’s HIV-positive status is known, until the HIV-negative status of the infant has been established.

Comorbidity
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December
15
2008

Intimate partner violence

Gupta J, Silverman JG, Hemenway D, Acevedo-Garcia D, Stein DJ, Williams DR. Physical violence against intimate partners and related exposures to violence among South African men. CMAJ. 2008;179(6):535-41.

Despite high rates of intimate partner violence in South Africa, there have been no national studies of men’s perpetration of violence against female partners. Gupta and colleagues analyzed data from the South Africa Stress and Health Study, a cross-sectional, nationally representative study, specifically examining data for men who had ever been married or had ever cohabited with a female partner. They calculated the prevalence of physical violence against intimate female partners and used logistic regression to examine associations with physical abuse during childhood and exposure to parental and community violence. A total of 834 male participants in the South Africa Stress and Health Study met the study criteria. Of these, 27.5% reported using physical violence against their current or most recent female partner during their current or most recent marriage or cohabiting relationship. Crude odds ratios (ORs) and 95% confidence intervals (CIs) indicated significant associations between perpetration of violence against an intimate partner and witnessing parental violence (OR 3.91, 95% CI 2.66-5.73) or experiencing physical abuse during childhood (OR 3.24, 95% CI 2.27-4.63), but not exposure to community violence (OR 1.29, 95% CI 0.88-1.88). The 2 significant associations persisted in adjusted analyses: OR 3.22 (95% CI 1.94-5.33) for witnessing parental violence and OR 1.73 (95% CI 1.07-2.79) for experiencing physical abuse during childhood. The authors concluded that they had found a high prevalence of physical violence perpetrated by men against their intimate partners. Men who experienced physical abuse during childhood or were exposed to parental violence were at the greatest risk.

Editors’ note: More than a quarter of men in this nationally representative study reported having perpetrated physical violence against their most recent partner. The estimate would likely have been higher if the question had been about lifetime perpetration of violence against all intimate partners. This behaviour was more prevalent in men who were abused themselves as children or who had witnessed parental violence. In both cases, this may have led them to view such behaviour as normative. Intimate partner violence, sexually risky behaviours, and HIV infection are interlinked making condemnation of intimate partner violence both an HIV prevention and human rights imperative.

Gender
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December
15
2008

Intimate partner violence

Le Coeur S, Khlat M, Halembokaka G. Increased HIV infection rate among violent deaths: a mortuary study in the Republic of Congo. AIDS. 2008;22(13):1675-6.  

There is no evidence to suggest an association between violent deaths and HIV in Africa. Le Cœur and colleagues report the results of a study performed in Pointe-Noire, Congo, where post-mortem HIV serologies were performed among all deaths referred to the morgue. The HIV prevalence among violent deaths was 37%, significantly higher than 10% among accidental deaths, with an adjusted odds ratio of 6 (P = 0.03). Prevention of domestic violence and fight against stigmatization should be parts of HIV programmes in Africa.

Editors’ note: To obtain a death certificate for burial in Pointe-Noire, the bodies of all deceased persons must be taken to the city morgue, making for a relatively complete denominator. Of the 1309 deaths registered during the study period, 14 were homicides and 5 suicides. More than a third of these people were HIV-positive at the time of death. Of the 4 HIV-positive homicides, 3 were women who had been slaughtered by a family member. These small but striking numbers highlight the importance of fighting stigma and preventing domestic violence .

Gender
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