HIV This Week

Menzies N, Abang B, Wanyenze R, Nuwaha F, Mugisha B, Coutinho A, Bunnell R, Mermin J, Blandford JM. The costs and effectiveness of four HIV counselling and testing strategies in Uganda. AIDS. 2009;23(3):395-401.

HIV counselling and testing is a key intervention for HIV control, and new strategies have been developed for expanding coverage in developing countries. Menzies and colleagues compared costs and outcomes of four HIV counselling and testing strategies in Uganda. A retrospective cohort of 84 323 individuals received HIV counselling and testing at one of four Ugandan HIV counselling and testing programmes between June 2003 and September 2005. Strategies assessed were stand-alone; hospital-based; household-member; and door-to-door. The authors collected data on client volume, demographics, prior testing and HIV diagnosis from project monitoring systems, and cost data from project accounts and personnel interviews. Strategies were compared in terms of costs and effectiveness at reaching key population groups. Household-member and door-to-door HIV counselling and testing strategies reached the largest proportion of previously untested individuals (>90% of all clients). Hospital-based HIV counselling and testing diagnosed the greatest proportion of HIV-infected individuals (27% prevalence), followed by stand-alone HIV counselling and testing (19%). Household-member HIV counselling and testing identified the highest percentage of discordant couples; however, this was a small fraction of total clients (<4%). Costs per client (2007 USD) were $19.26 for stand-alone, $11.68 for hospital-based, $13.85 for household-member, and $8.29 for door-to-door- HIV counselling and testing. All testing strategies had relatively low per client costs. Hospital-based HIV counselling and testing most readily identified HIV-infected individuals eligible for treatment, whereas home-based strategies more efficiently reached populations with low rates of prior testing and HIV-infected people with higher CD4 cell counts. Multiple HIV counselling and testing strategies with different costs and efficiencies can be used to meet the UNAIDS/WHO call for universal HIV counselling and testing access by 2010.

Editors’ note: This useful cost-effectiveness study of four different HIV counselling and testing strategies that a national HIV programme might consider demonstrates the value of each in a generalized epidemic. More than 30 per cent (range 30.7-48.1 per cent) of all people found HIV-positive had advanced immunosuppression (CD4+ count <200 cells/μl) regardless of testing strategy. Door-to-door strategies reached previously untested people cheaply in this country where in 2007 less than a quarter of people had ever been tested. These data indicate that a variety of testing strategies, providing choices for individuals, couples, and communities, can work in complementary fashion to accomplish the goals of increasing knowledge of serostatus and facilitating earlier treatment initiation.

Li Q, Estes JD, Schlievert PM, Duan L, Brosnahan AJ, Southern PJ, Reilly CS, Peterson ML, Schultz-Darken N, Brunner KG, Nephew KR, Pambuccian S, Lifson JD, Carlis JV & Haase AT. Glycerol monolaurate prevents mucosal SIV transmission. Nature 2009 [Epub ahead of print] doi:10.1038/nature07831

Although there has been great progress in treating human immunodeficiency virus 1 (HIV-1) infection, preventing transmission has thus far proven an elusive goal. Indeed, recent trials of a candidate vaccine and microbicide have been disappointing, both for want of efficacy and concerns about increased rates of transmission. Nonetheless, studies of vaginal transmission in the simian immunodeficiency virus (SIV)–rhesus macaque (Macacca mulatta) model point to opportunities at the earliest stages of infection in which a vaccine or microbicide might be protective, by limiting the expansion of infected founder populations at the portal of entry. Here Li and colleagues show in this SIV–macaque model, that an outside-in endocervical mucosal signalling system, involving MIP-3 (also known as CCL20), plasmacytoid dendritic cells and CCR5 cell-attracting chemokines produced by these cells, in combination with the innate immune and inflammatory responses to infection in both cervix and vagina, recruits CD4 1 T cells to fuel this obligate expansion . They then show that glycerol monolaurate—a widely used antimicrobial compound with inhibitory activity against the production of MIP-3a and other proinflammatory cytokines— can inhibit mucosal signalling and the innate and inflammatory response to HIV-1 and SIV in vitro, and in vivo it can protect rhesus macaques from acute infection despite repeated intra-vaginal exposure to high doses of SIV. This new approach, plausibly linked to interfering with innate host responses that recruit the target cells necessary to establish systemic infection, opens a promising new avenue for the development of effective interventions to block HIV-1 mucosal transmission.

Editors’ note: This study reveals that the endocervix, the inner surface of the cervix linking the vagina with the uterus or womb, is the predominant site for initial infected cell clusters. There are not enough target cells there for SIV infection to take hold but the inflammatory response of the innate mucosal immune system calls more target cells to this site, expanding the infected founder cell population which then allows establishment of self-propagating infection in lymph tissues. In this encouraging report, inexpensive and safe glycerol monolaurate brakes this vicious cycle of signalling and inflammatory response to prevent acute SIV infection in several repeatedly exposed animals. Longer-term and well-powered studies with larger numbers of animals are clearly warranted.

Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22 Suppl 4:S17-25.

Leclerc-Madlala reviews the current state of knowledge on age-disparate sexual relationships in the context of the southern African HIV hyperepidemic. Disproportionately high HIV infection rates among young women aged 15-24 years have been attributed to their greater involvement in relationships with older-aged partners. Whereas early studies emphasized economic concerns in the context of poverty as driving girls to accept or seek the attentions of older employed men, close-grained studies reveal a complex interplay of meanings and motives that prompt both men and women across socioeconomic strata to engage in intergenerational sex. Studies have revealed that age-disparate relationships are meaningful and perceived as beneficial at a number of levels, including social, physical, psychological, as well as economic and symbolic. In the context of growing economic inequalities and cultural expectations for men to give and women to receive a compensation for sex, relationships with older men are a common and readily available way through which young women gain materially, affirm self-worth, achieve social goals, increase longer-term life chances, or otherwise add value and enjoyment to life. Awareness of HIV risks in these relationships remains low. HIV prevention policies and programmes need to start from an understanding of how those engaged in risky behaviour perceive their sexual relationships and conceptualize the choices they make and the strategies they use. A more comprehensive policy on women and girls with better integration of communities in assessing and addressing issues, and an expansion of campaigns and programmes on the role of men as protectors and supporters of women are recommended.

Editors’ note: This excellent review describes the facilitating social factors in both rural and urban settings that may motivate younger women to value age-disparate sexual relationships for their potential to provide access to social, emotional, symbolic, and financial capital. While young women often hold positive perceptions toward age-disparate relationships, they are aware of the dangers of dependency and unsafe sex leading to pregnancy and sexually transmitted infections including HIV. Although they may be pushed into sexual liaisons with older men for survival reasons, many young women do not perceive themselves as victims. Acknowledging the implicit transactional and reciprocal elements of age-disparate sex and the wider realities of women’s lives in southern Africa is fundamental to a two-pronged approach that focuses on empowering women while working to change men’s behaviours and attitudes. In communities most at risk, creative ways need to be found to support male champions for HIV prevention who represent a masculinity that protects self and others from HIV. This article appeared in a journal supplement of papers drawn from a UNAIDS-convened consultation on the vulnerability of young women in southern Africa. The entire supplement can be downloaded free of charge, if you are among the first 5000 people interested, at https://articleworks.cadmus.com/doc/926318.

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Ntaganira J, Muula AS, Masaisa F, Dusabeyezu F, Siziya S, Rudatsikira E. Intimate partner violence among pregnant women in Rwanda. BMC Womens Health. 2008;8:17.

Intimate partner violence, defined as actual or threatened physical, sexual, psychological, and emotional abuse by current or former partners is a global public health concern. The prevalence and determinants of intimate partner violence against pregnant women has not been described in Rwanda. A study was conducted to identify variables associated with intimate partner violence among Rwandan pregnant women. A convenient sample of 600 pregnant women attending antenatal clinics were administered a questionnaire which included items on demographics, HIV status, intimate partner violence, and alcohol use by the male partner. Mean age and proportions of intimate partner violence in different groups were assessed. Odds of intimate partner violence were estimated using logistic regression analysis. Of the 600 respondents, 35.1% reported intimate partner violence in the last 12 months. HIV-positive pregnant women had higher rates of all forms of intimate partner violence than HIV-negative pregnant women: pulling hair (44.3% vs. 20.3%), slapping (32.0% vs. 15.3%), kicking with fists (36.3% vs. 19.7%), throwing to the ground and kicking with feet (23.3% vs. 12.7%), and burning with hot liquid (4.1% vs. 3.5%). HIV-positive participants were more than twice likely to report physical intimate partner violence than those who were HIV-negative (OR = 2.38; 95% CI [1.59, 3.57]). Other factors positively associated with physical intimate partner violence included sexual abuse before the age of 14 years (OR = 2.69; 95% CI [1.69, 4.29]), having an alcohol drinking male partner (OR = 4.10; 95% CI [2.48, 6.77] for occasional drinkers and OR = 3.37; 95% CI [2.05, 5.54] for heavy drinkers), and having a male partner with other sexual partners (OR = 1.53; 95% CI [1.15, 2.20]. Education was negatively associated with lifetime intimate partner violence. In reporting on prevalence of intimate partner violence among pregnant women attending antenatal care in Rwanda, Central Africa, the authors advocate that screening for intimate partner violence be an integral part of HIV care, as well as routine antenatal care. Services for battered women should also be made available.

Editors’ note: Intimate partner violence affects 25-43% of women globally at some point in their lifetime. That over one-third of pregnant women and almost one-half of HIV-positive pregnant women in this Rwandan study had experienced such violence in the past 12 months is striking. In addition to the significant mental and physical health consequences for women, physical violence increases the risk of low birth weight infants, pre-term delivery and neonatal death, and negatively affects breast feeding post partum. Prenatal care providers should have a high degree of suspicion of intimate partner violence among pregnant women with HIV infection and make a concerted effort to provide necessary social, treatment, and legal support for these women.

Kim J, Pronyk P, Barnett T, Watts C. Exploring the role of economic empowerment in HIV prevention. AIDS. 2008;22 Suppl 4:S57-71.

It has been argued that women’s economic vulnerability and dependence on men increases their vulnerability to HIV by constraining their ability to negotiate the conditions, including sexual abstinence, condom use and multiple partnerships, which shape their risk of infection. In the face of escalating infection rates among women, and particularly young women, many have pointed to the potential importance of economic empowerment strategies for HIV prevention responses. Global evidence suggests that the relationship between poverty and HIV risk is complex, and that poverty on its own cannot be viewed simplistically as a driver of the HIV epidemic. Rather, its role appears to be multidimensional and to interact with a range of other factors, including mobility, social and economic inequalities and social capital, which converge in a particularly potent way for young women living in southern Africa. To date, there have been few interventions that have explicitly attempted to combine economic empowerment with the goal of HIV prevention, and even fewer that have been rigorously evaluated. This paper explores how programmes such as microfinance, livelihood training and efforts to safeguard women’s food security and access to property have begun to incorporate an HIV prevention focus. Although such circumscribed interventions, by themselves, are unlikely to lead to significant impacts on a national or regional scale, they are useful for testing cross-sectoral partnership models, generating practical lessons and providing a metaphor for what might be possible in promoting women’s economic empowerment more broadly. Despite numerous calls to ‘mainstream AIDS’ in economic development, cross-sectoral responses have not been widely taken up by government or other stakeholders. Kim and colleagues suggest potential reasons for limited progress to date and conclude by presenting programme and policy recommendations for further exploring and harnessing linkages between economic empowerment and HIV prevention in Southern Africa.

Editors’ note: This powerful article in a journal supplement of papers drawn from a UNAIDS-convened consultation on the vulnerability of young women in southern Africa uses the World Bank definition of empowerment: ‘the process of increasing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes’. It presents the evidence on microfinance, livelihood training, improving food security, and securing women’s property and inheritance rights, as well as recommendations for policy and programming on economic empowerment for HIV prevention. The entire supplement can be downloaded free of charge, if you are among the first 5000 people interested, at https://articleworks.cadmus.com/doc/926318

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Reid T, van Engelgem I, Telfer B, Manzi M. Providing HIV care in the aftermath of Kenya’s post-election violence Medecins Sans Frontieres’ lessons learned January - March 2008. Confl Health. 2008;2:15.

Kenya’s post-election violence in early 2008 created considerable problems for health services, and in particular, those providing HIV care. It was feared that the disruptions in services would lead to widespread treatment interruption. Medecins sans Frontières had been working in the Kibera slum for 10 years and was providing antiretroviral therapy to almost 2000 patients when the violence broke out. Medecins sans Frontières responded to the crisis in a number of ways and managed to keep HIV services going. Treatment interruption was less than expected, and Medecins sans Frontières profited by a number of « lessons learned » that could be applied to similar contexts where a stable situation suddenly deteriorates.

Editors’ note: When an apparently stable situation deteriorates rapidly, clinic staff cannot get to work safely and patients cut off from health care services cannot access their medical records detailing their treatment regimens. Furthermore, acute trauma cases change workloads dramatically in clinics where the caseload is normally a mixture of primary health care problems and a comprehensive HIV programme. An updated Emergency Preparedness Plan, close communication ties with the community for daily situation assessments, emergency data management systems, and high levels of treatment literary motivating patients to seek creative solutions, can reduce the risk of antiretroviral treatment interruptions.