Canadian consensus statement on HIV and its transmission in the context of criminal law

INTRODUCTION:

A poor appreciation of the science related to HIV contributes to an overly broad use of the criminal law against individuals living with HIV in cases of HIV nondisclosure.

METHOD:

To promote an evidence-informed application of the law in Canada, a team of six Canadian medical experts on HIV and transmission led the development of a consensus statement on HIV sexual transmission, HIV transmission associated with biting and spitting, and the natural history of HIV infection. The statement is based on a literature review of the most recent and relevant scientific evidence (current as of December 2013) regarding HIV and its transmission. It has been endorsed by >70 additional Canadian HIV experts and the Association of Medical Microbiology and Infectious Disease Canada.

RESULTS:

Scientific and medical evidence clearly indicate that HIV is difficult to transmit during sex. For the purpose of informing the justice system, the per-act possibility of HIV transmission through sex, biting or spitting is described along a continuum from low possibility, to negligible possibility, to no possibility of transmission. This possibility takes into account the impact of factors such as the type of sexual acts, condom use, antiretroviral therapy and viral load. Dramatic advances in HIV therapy have transformed HIV infection into a chronic manageable condition.

DISCUSSION:

HIV physicians and scientists have a professional and ethical responsibility to assist those in the criminal justice system to understand and interpret the science regarding HIV. This is critical to prevent miscarriage of justice and to remove unnecessary barriers to evidence-based HIV prevention strategies.     

Hospital‐based routine HIV testing in high‐income countries: a systematic literature review

Objectives

To produce a summary of the published evidence of the barriers and facilitators for hospital‐based routine HIV testing in high‐income countries.

Methods

Electronic databases were searched for studies, which described the offer of HIV testing to adults attending emergency departments (EDs) and acute medical units (AMUs) in the UK and US, published between 2006 and 2015. Other high‐income countries were not included, as their guidelines do not recommend routine testing for HIV. The main outcomes of interest were HIV testing uptake, HIV testing coverage, factors facilitating HIV screening and barriers to HIV testing. Fourteen studies met the pre‐defined inclusion criteria and critically appraised using mixed methods appraisal tool (MMAT).

Results

HIV testing coverage ranged from 9.7% to 38.3% and 18.7% to 26% while uptake levels were high (70.1–84% and 53–75.4%) in the UK and US, respectively. Operational barriers such as lack of time, the need for training and concerns about giving results and follow‐up of HIV positive results, were reported. Patient‐specific factors including female sex, old age and low risk perception correlated with refusal of HIV testing. Factors that facilitated the offer of HIV testing were venous sampling (vs. point‐of‐care tests), commitment of medical staff to HIV testing policy and support from local HIV specialist providers.

Conclusions

There are several barriers to routine HIV testing in EDs and AMUs. Many of these stem from staff fears about offering HIV testing due to the perceived lack of knowledge about HIV. Our systematic review highlights areas which can be targeted to increase coverage of routine HIV testing.

     

National audit of perinatal HIV infections in the UK, 2006–2013: what lessons can be learnt?

Objectives

The aim of the study was to investigate circumstances surrounding perinatal transmissions of HIV (PHIVs) in the UK.

Methods

The National Study of HIV in Pregnancy and Childhood conducts comprehensive surveillance of all pregnancies in women diagnosed with HIV infection and their infants in the UK; reports of all HIV‐diagnosed children are also sought, regardless of country of birth. Children with PHIV born in 2006–2013 and reported by 2014 were included in an audit, with additional data collection via telephone interviews with clinicians involved in each case. Contributing factors for each transmission were identified, and cases described according to main likely contributing factor, by maternal diagnosis timing.

Results

A total of 108 PHIVs were identified. Of the 41 (38%) infants whose mothers were diagnosed before delivery, it is probable that most were infected in utero, around 20% intrapartum and 20% through breastfeeding. Timing of transmission was unknown for most children of undiagnosed mothers. For infants born to diagnosed women, the most common contributing factors for transmission were difficulties with engagement and/or antiretroviral therapy (ART) adherence in pregnancy (14 of 41) and late antenatal booking (nine of 41); for the 67 children with undiagnosed mothers, these were decline of HIV testing (28 of 67) and seroconversion (23 of 67). Adverse social circumstances around the time of pregnancy were reported for 53% of women, including uncertain immigration status, housing problems and intimate partner violence. Eight children died, all born to undiagnosed mothers.

Conclusions

Priority areas requiring improvement include reducing incident infections, improving ART adherence and facilitating better engagement in care, with attention to addressing the health inequalities and adverse social situations faced by these women.     

Reductions in HIV transmission risk behaviour following diagnosis of primary HIV infection: a cohort of high-risk men who have sex with men

Background

Risk‐reduction counselling is a standard preventive intervention, but behaviour change is difficult to sustain over the duration of HIV infection. However, primary HIV infection (PHI) is highly infectious and plays a key role in transmission – especially through dense sexual networks – but is short term, so even transient risk reduction can mitigate its high infectivity. Targeting behaviour‐change interventions at recently infected individuals may be highly effective, particularly in higher risk groups. We explored the potential impact on HIV transmission‐risk behaviour of PHI diagnosis in men who have sex with men (MSM).

Methods

MSM with PHI were interviewed at diagnosis and after 3 months of follow‐up about their sexual behaviour in the 12‐week periods before and after diagnosis and standard counselling.

Results

A total of 98 of 104 eligible MSM (94%) participated in the study, with 100% follow‐up. PHI was associated with high levels of recreational drug use, low levels of condom use, high numbers of sexual partners and a history of sex work. In the 12 weeks post‐diagnosis, 76% of participants eliminated risk of onward transmission entirely and, overall, there was a significant reduction in transmission‐risk behaviour, with patients reporting greater condom use and fewer sexual partners. Those with continued transmission‐risk behaviour were more likely to have another sexually transmitted infection (STI), use ketamine and have more sexual partners at baseline.

Conclusions

Most MSM recently diagnosed with PHI changed their behaviour to substantially reduce the risk of onward HIV transmission. Strategies are needed to (a) increase diagnoses of PHI to target prevention efforts effectively and (b) further reduce risk behaviours by targeting enhanced counselling to those most likely to continue with risk behaviours.

     

Assessment of mother-to-child HIV-1 and HIV-2 transmission: an AIDS reference laboratory collaborative study

Objective

A prospective study was carried out to assess HIV‐1 and HIV‐2 mother‐to‐child transmission (MTCT) rates in Portugal between 1999 and 2005 by analysing the proportion of diagnosed infected children born to HIV‐positive mothers.

Materials and methods

Serial blood samples were collected from 1315 children at risk of HIV‐1 infection, 131 children at risk of HIV‐2 infection and six children at risk of both HIV‐1 and HIV‐2 infections attending 25 Health Institutions. HIV proviral DNA was detected by nested polymerase chain reaction (PCR) and statistical analysis was performed using spss .

Results

DNA PCR using HIV‐1 and HIV‐2 long terminal repeat (LTR) primers amplified 92.5% and 75% of maternal HIV infections, respectively. Overall, MTCT occurred in 3.4% [95% confidence interval (CI) 2.5–4.6%] of HIV‐1 and 1.5% (95% CI 0.2–5.4%) of HIV‐2 mother–child pairs. A significant decrease in HIV‐1 MTCT was observed with time, from 7.0% (95% CI 2.6–14.6%) in 1999 to 0.5% (95% CI 0.0–2.5%) in 2005. HIV MTCT was associated with an absence of antiretroviral therapy in infected pregnant women (P<0.0001). Of the 48 infected children (46 with HIV‐1 and two with HIV‐2), the schedule of blood sample collection was followed for only 26 children. In 14 (53.8%) of those 26 children the infections were diagnosed in the first sample collected before they were 48 h old, suggesting in utero transmission. Despite the national recommendations for antenatal HIV testing, a high overall proportion (22.2% for HIV‐1 and 44.3% for HIV‐2) of mothers did not access any MTCT prevention measures, mostly because of late diagnosis in pregnancy. A small but significant proportion of HIV‐2 infection was found in mothers with no identifiable link with West Africa.

Conclusion

HIV‐2 transmission rates are low (1.5% in this study), and this may have led to a lower uptake of interventions, but in the absence of interventions transmission does occur. HIV‐1 transmission was also associated with a lack of intervention, mostly as a result of late presentation. Use of primers restricted to a single sequence led to false‐negative maternal results in a significant proportion of cases. In part this may have been attributable to very low HIV DNA loads as well as primer template mismatches. HIV infection was not documented in children born to mothers with negative HIV DNA PCR results.     

Defining high HIV incidence subgroups of Australian homosexual men: implications for conducting HIV prevention trials in low HIV prevalence settings

Objectives

The aim of the study was to assess whether subpopulations with sufficiently high HIV incidences for HIV prevention trials can be identified in low HIV incidence settings such as Australia.

Methods

In a community‐based cohort study of HIV‐negative homosexually active men in Sydney, Australia, potential risk factors associated with an annual HIV incidence of ≥2 per 100 person‐years (PY) were identified. A stepwise procedure ranked these factors according to HIV incidence, to create a ‘high‐incidence’ subgroup of participants. Willingness to participate in HIV prevention trials was assessed.

Results

Although the incidence in the cohort overall was only 0.78 per 100 PY, nine risk variables were associated with an HIV incidence of 2 per 100 PY or greater. Stepwise inclusion of these variables revealed a ‘high‐incidence’ subgroup of men representing 24% of the total follow‐up time with a combined HIV incidence of 2.71 per 100 PY, who reported at least one of three risk factors in the past 6 months. These men were more willing than others to participate in vaccine and antiretroviral therapy HIV prevention trials.

Conclusions

These findings demonstrate that it is possible to identify high HIV incidence subpopulations in low‐incidence settings such as Australia, and these men are of above average willingness to participate in HIV prevention trials.     

HIV prevalence among first‐presentation psychotic patients

Objectives

First‐episode psychosis is a frequent emergency department (ED) presentation that may potentially be secondary to an underlying life‐threatening HIV‐related condition. The aim of this study was to determine the prevalence of HIV infection in patients presenting with a first episode of psychosis.

Methods

Medical records of 159 consecutive African, Asian, White and mixed ethnicity patients presenting to a tertiary academic hospital ED with a first episode of psychotic features were prospectively reviewed.

Results

Of the 159 subjects, 63 (39.6%) were HIV positive. An underlying medical condition was the most common aetiology of psychosis in both HIV‐positive (84.2%) and HIV‐negative (35.4%) subjects, but was significantly more common in HIV‐positive individuals (P < 0.001). Substance‐induced psychotic disorders and other primary psychiatric disorders were significantly more common in subjects without HIV infection (P < 0.001 and P < 0.001, respectively). While there were more men in the HIV‐negative group (66.7%), gender distribution was almost equal in the HIV‐infected group (49.2% male). Overall, as well as in both groups, most subjects were of African race, were unemployed and had not completed high school.

Conclusions

Co‐occurrence of HIV infection was a frequent finding in first‐episode psychotic individuals residing in a high‐prevalence HIV setting. These individuals are more likely to have an underlying medical condition precipitating the onset of psychosis, not to have been initiated on antiretroviral therapy and to present with a low CD4 cell count and high HIV viral load.

     

High prevalence of unintended pregnancies in HIV-positive women of reproductive age in Ontario, Canada: a retrospective study

Objectives

There is speculation, but there are few data, on the high rates of unintended pregnancies in HIV‐positive women. We investigated rates and correlates of unintended pregnancies among HIV‐positive women of reproductive age.

Methods

A cross‐sectional study was conducted with recruitment stratified to match the geographical distribution of HIV‐positive women of reproductive age (18–52 years) living in Ontario, Canada. Women, recruited from 38 sites between October 2007 and April 2009, were invited to complete a 189‐item self‐administered survey. This analysis focused on questions relating to pregnancy and whether the last pregnancy was intended. Logistic regression models were fitted to calculate unadjusted and adjusted odds ratios of correlates of unintended pregnancies occurring after HIV diagnosis. Happiness with unintended pregnancies was also assessed.

Results

The median age at the time of the survey of the 416 participating HIV‐positive women who were previously pregnant (53% before and 47% after HIV diagnosis) was 38 years [interquartile range (IQR) 33–44 years] and their last pregnancy was a median of 8 years (IQR 3–14 years) prior to the survey (n=283). Fifty‐nine per cent were born outside Canada and 47% were of African ethnicity. Of the 416, 56% [95% confidence interval (CI) 51–61%] identified that their last pregnancy was unintended (57% before and 54% after HIV diagnosis). In the multivariable model, significant correlates of unintended pregnancy after HIV diagnosis were: marital status (P=0.01) and never having given birth (P=0.01). Women were less happy if their pregnancy was unintended (P<0.01).

Conclusions

The prevalence of unintended pregnancy was high in this cohort. Pregnancy planning programmes are needed for this population to decrease fetal and maternal complications and reduce vertical and horizontal transmission.     

The effects of the attributable fraction and the duration of symptoms on burden estimates of influenza‐associated respiratory illnesses in a high HIV prevalence setting,South Africa, 2013‐2015

Background

The attributable fraction of influenza virus detection to illness (INF‐AF) and the duration of symptoms as a surveillance inclusion criterion could potentially have substantial effects on influenza disease burden estimates.

Methods

We estimated rates of influenza‐associated influenza‐like illness (ILI) and severe acute (SARI‐10) or chronic (SCRI‐10) respiratory illness (using a symptom duration cutoff of ≤10 days) among HIV‐infected and HIV‐uninfected patients attending 3 hospitals and 2 affiliated clinics in South Africa during 2013‐2015. We calculated the unadjusted and INF‐AF‐adjusted rates and relative risk (RR) due to HIV infection. Rates were expressed per 100 000 population.

Results

The estimated mean annual unadjusted rates of influenza‐associated illness were 1467.7, 50.3, and 27.4 among patients with ILI, SARI‐10, and SCRI‐10, respectively. After adjusting for the INF‐AF, the percent reduction in the estimated rates was 8.9% (rate: 1336.9), 11.0% (rate: 44.8), and 16.3% (rate: 22.9) among patients with ILI, SARI‐10, and SCRI‐10, respectively. HIV‐infected compared to HIV‐uninfected individuals experienced a 2.3 (95% CI: 2.2‐2.4)‐, 9.7 (95% CI: 8.0‐11.8)‐, and 10.0 (95% CI: 7.9‐12.7)‐fold increased risk of influenza‐associated illness among patients with ILI, SARI‐10, and SCRI‐10, respectively. Overall 34% of the estimated influenza‐associated hospitalizations had symptom duration of >10 days; 8% and 44% among individuals aged <5 and ≥5 years, respectively.

Conclusion

The marginal differences between unadjusted and INF‐AF‐adjusted rates are unlikely to affect policies on prioritization of interventions. HIV‐infected individuals experienced an increased risk of influenza‐associated illness and may benefit more from annual influenza immunization. The use of a symptom duration cutoff of ≤10 days may underestimate influenza‐associated disease burden, especially in older individuals.     

The changing face of the HIV epidemic in sub‐Saharan Africa

The widespread roll‐out of antiretroviral therapy (ART) has substantially changed the face of human immunodeficiency virus (HIV). Timely initiation of ART in HIV‐infected individuals dramatically reduces mortality and improves employment rates to levels prior to HIV infection. Recent findings from several studies have shown that ART reduces HIV transmission risk even with modest ART coverage of the HIV‐infected population and imperfect ART adherence. While condoms are highly effective in the prevention of HIV acquisition, they are compromised by low and inconsistent usage; male medical circumcision substantially reduces HIV transmission but uptake remains relatively low; ART during pregnancy, delivery and breastfeeding can virtually eliminate mother‐to‐child transmission but implementation is challenging, especially in resource‐limited settings. The current HIV prevention recommendations focus on a combination of preventions approach, including ART as treatment or pre‐ or post‐exposure prophylaxis together with condoms, circumcision and sexual behaviour modification. Improved survival in HIV‐infected individuals and reduced HIV transmission risk is beginning to result in limited HIV incidence decline at population level and substantial increases in HIV prevalence. However, achievements in HIV treatment and prevention are threatened by the challenges of lifelong adherence to preventive and therapeutic methods and by the ageing of the HIV‐infected cohorts potentially complicating HIV management. Although current thinking suggests prevention of HIV transmission through early detection of infection immediately followed by ART could eventually result in elimination of the HIV epidemic, controversies remain as to whether we can treat our way out of the HIV epidemic.     

Risk factors for incident diabetes mellitus among HIV-infected patients receiving combination antiretroviral therapy in Taiwan: a case–control study

Objectives

Recent studies suggest that patients with HIV infection are at increased risk for incident diabetes mellitus (DM). We investigated the incidence and risk factors of DM among HIV‐infected patients receiving combination antiretroviral therapy (CART) in Taiwan.

Methods

Incident cases of DM were identified among HIV‐infected patients at the National Taiwan University Hospital between 1993 and 2006. A retrospective case–control study was conducted after matching cases with controls for sex, age at HIV diagnosis, year of HIV diagnosis, mode of HIV transmission and baseline CD4 lymphocyte count. A multivariate analysis was performed to identify risk factors for incident DM among HIV‐infected patients.

Results

In 824 HIV‐infected patients eligible for analysis, 50 cases of incident DM were diagnosed, resulting in an incidence of 13.1 cases per 1000 person‐years of follow‐up. In total, 100 matched controls were identified. Risk factors for incident DM were a family history of DM [odds ratio (OR) 2.656; 95% confidence interval (CI) 1.209–5.834], exposure to zidovudine (OR 3.168; 95% CI 1.159–8.661) and current use of protease inhibitors (OR 2.528; 95% CI 1.186–5.389).

Conclusions

Incident DM was associated with a family history of DM, exposure to zidovudine and current use of protease inhibitors in HIV‐infected patients receiving CART in Taiwan.     

Male circumcision for the prevention of heterosexually acquired HIV infection: a meta-analysis of randomized trials involving 11,050 men

Objectives

Observational studies and a small collection of randomized controlled trials (RCTs) suggest that male circumcision may significantly reduce HIV transmission between sero‐discordant contacts. The Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization have recently announced recommendations to scale up male circumcision in countries with generalized epidemics and low levels of male circumcision. However, no meta‐analysis has been conducted to determine the effectiveness of this intervention.

Methods

We conducted a systematic review of medical literature, and included any RCTs assessing male circumcision to prevent heterosexually acquired HIV infection among males. We used the DerSimonian–Laird random effects method to pool study outcomes. We calculated the relative risk (RR), risk difference, number needed to treat (NNT) and I², all with 95% confidence intervals (CIs).

Results

We identified three RCTs that met our inclusion criteria, involving a total of 11 050 men. The pooled RR was 0.44 (95% CI 0.33–0.60, P<0.0001, I²=0%, 95% CI 0–35%). The risk difference was 0.014 (95% CI 0.07–0.21), yielding a NNT of 72 (95% CI 50–143).

Conclusions

Male circumcision is an effective strategy for reducing new male HIV infections. Its impact on a population level will require consistently safe sexual practices to maintain the protective benefit.     

High risk for occupational exposure to HIV and utilization of post-exposure prophylaxis in a teaching hospital in Pune,India

Background  

The risk for occupational exposure to HIV has been well characterized in the developed world, but limited information is available about this transmission risk in resource-constrained settings facing the largest burden of HIV infection. In addition, the feasibility and utilization of post-exposure prophylaxis (PEP) programs in these settings are unclear. Therefore, we examined the rate and characteristics of occupational exposure to HIV and the utilization of PEP among health care workers (HCW) in a large, urban government teaching hospital in Pune, India.     

Pregnancy and HIV transmission among HIV-discordant couples in a clinical trial in Kisumu, Kenya

Objectives

A large proportion of new HIV infections in sub‐Saharan Africa occur in stable HIV‐discordant partnerships. In some couples, the strong desire to conceive a child may lead to risky behaviour despite knowledge of discordant serostatus. Our objective was to compare HIV transmission between discordant couples who did and did not conceive during participation in a clinical trial.

Methods

Five hundred and thirty‐two HIV‐discordant couples were followed for up to 2 years in Kisumu, Kenya as part of the Partners in Prevention HSV/HIV Transmission Study. Quarterly HIV‐1 antibody and urine pregnancy test results were analysed.

Results

Forty‐one HIV‐1 seroconversions occurred over 888 person‐years of follow‐up, resulting in an annual incidence of 4.6/100 person‐years. Twenty seroconversions occurred among 186 HIV‐1‐uninfected individuals in partnerships in which pregnancy occurred (10.8% of HIV‐1‐negative partners in this group seroconverted), in comparison to 21 seroconversions among 353 uninfected individuals in partnerships in which pregnancy did not occur (5.9% of HIV‐1‐negative partners seroconverted), resulting in a relative risk of 1.8 [95% confidence interval (CI) 1.01–3.26; P<0.05].

Conclusions

Pregnancy was associated with an increased risk of HIV seroconversion in discordant couples. These data suggest that the intention to conceive among HIV discordant couples may be contributing to the epidemic.     

Major but differential decline in the incidence of Staphylococcus aureus bacteraemia in HIV-infected individuals from 1995 to 2007: a nationwide cohort study*

Objectives

Incidence rates (IRs) of Staphylococcus aureus bacteraemia (SAB) are known to be higher in HIV‐infected individuals than in the general population, but have not been assessed in the era of highly active antiretroviral therapy.

Methods

From 1 January 1995 to 31 December 2007, all Danish HIV‐infected individuals (n=4871) and population controls (n=92 116) matched on age and sex were enrolled in a cohort and all cases of SAB were registered. IRs and risk factors were estimated using time‐updated Poisson regression analysis.

Results

We identified 329 cases of SAB in 284 individuals, of whom 132 individuals were infected with HIV and 152 were not [crude IR ratio (IRR) 24.2; 95% confidence interval (CI) 19.5–30.0, for HIV‐infected vs. non‐HIV‐infected individuals]. Over time, IR declined for HIV‐infected individuals (IRR 0.40). Injecting drug users (IDUs) had the highest incidence and the smallest decline in IR, while men who have sex with men (MSM) had the largest decline over time. Among HIV‐infected individuals, a latest CD4 count <100 cells/μL was the strongest independent predictor of SAB (IRR 10.2). Additionally, HIV transmission group was associated with risk of SAB. MSM were more likely to have hospital‐acquired SAB, a low CD4 cell count and AIDS at the time of HIV acquisition compared with IDUs.

Conclusions

We found that the incidence of SAB among HIV‐infected individuals declined during the study period, but remained higher than that among HIV‐uninfected individuals. There was an unevenly distributed burden of SAB among HIV transmission groups (IDU>MSM). Low CD4 cell count and IDU were strong predictors of SAB among HIV‐infected individuals.     

A primary care level algorithm for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission

Objective To present an algorithm for primary‐care health workers for identifying HIV‐infected adolescents in populations at high risk through mother‐to‐child transmission. Methods Five hundred and six adolescent (10–18 years) attendees to two primary care clinics in Harare, Zimbabwe, were recruited. A randomly extracted ‘training’ data set (n = 251) was used to generate an algorithm using variables identified as associated with HIV through multivariable logistic regression. Performance characteristics of the algorithm were evaluated in the remaining (‘test’) records (n = 255) at different HIV prevalence rates. Results HIV prevalence was 17%, and infection was independently associated with client‐reported orphanhood, past hospitalization, skin problems, presenting with sexually transmitted infection and poor functional ability. Classifying adolescents as requiring HIV testing if they reported >1 of these five criteria had 74% sensitivity and 80% specificity for HIV, with the algorithm correctly predicting the HIV status of 79% of participants. In low‐HIV‐prevalence settings (<2%), the algorithm would have a high negative predictive value (≥99.5%) and result in an estimated 60% decrease in the number of people needing to test to identify one HIV‐infected individual, compared with universal testing. Conclusions Our simple algorithm can identify which individuals are likely to be HIV infected with sufficient accuracy to provide a screening tool for use in settings not already implementing universal testing policies among this age‐group, for example immigrants to low‐HIV‐prevalence countries.     

Pre‐exposure prophylaxis: awareness,acceptability and risk compensation behaviour among men who have sex with men and the transgender population

Objectives

This exploratory study examined the facilitators of and barriers to acceptance of pre‐exposure prophylaxis (PrEP) and potential risk compensation behaviour emerging from its use among men who have sex with men (MSM) and transgender individuals (TGs) in India.

Methods

A questionnaire was administered to 400 individuals registered with a targeted intervention programme. Logistic regression models were used to identify facilitators of and barriers to PrEP acceptance.

Results

The respondents consisted of 68% MSM and 32% TGs. Risk behaviour categorization identified 40% as low risk, 41% as medium risk and, 19% as high risk for HIV infection. About 93% of the respondents were unaware of PrEP, but once informed about it, 99% were willing to use PrEP. The facilitators of PrEP acceptance were some schooling [odds ratio (OR) 2.16; P = 0.51], being married or in a live‐in relationship (OR 2.08; P = 0.46), having a high calculated risk (OR 3.12; P = 0.33), and having a high self‐perceived risk (OR 1.8; P = 0.35). Increasing age (OR 2.12; P = 0.04) was a significant barrier. TGs had higher odds of acceptance of PrEP under conditions of additional cost (OR 2.12; P = 0.02) and once‐daily pill (OR 2.85; P = 0.04). Individuals identified as low risk for HIV infection showed lower odds of potential risk compensation, defined as more sexual partners (OR 0.8; P = 0.35), unsafe sex with new partners (OR 0.71; P = 0.16), and decreased condom use with regular partners (OR 0.95; P = 0.84), as compared with medium‐risk individuals. The associations, although not statistically significant, are nevertheless important for public health action given the limited scientific evidence on PrEP use among MSM and TGs in India.

Conclusions

With high acceptability and a low likelihood of risk compensation behaviour, PrEP can be considered as an effective prevention strategy for HIV infection among MSM and TGs in India.

     

High acceptability of HIV voluntary counselling and testing among female sex workers: impact of individual and social factors

Objectives

Voluntary counselling and testing (VCT) for HIV infection is an important tool for prevention of HIV infection and AIDS in high‐risk groups. Our goal was to describe the acceptability and consequences of VCT among a stigmatized and vulnerable group, female sex workers (FSWs), in Conakry, Guinea.

Methods

Acceptance of the test and return for test results at baseline and consequences of testing 1 year later were described. The perceived risk of HIV infection and perceived benefits and barriers to testing were examined using quantitative and qualitative methods.

Results

All 421 FSW participants agreed to undergo VCT and most participants (92%) returned for their results. The main reason cited for VCT acceptance was the wish to know their HIV status. However, some managers of FSW worksites urged FSWs to be tested, curtailing FSWs' free decision‐making. One year later, status disclosure was common (90% of the 198 individuals who knew their results among those who participated in the follow‐up part of the study). Positive consequences of testing were far more frequently reported than negative consequences (98% vs. 2%, respectively). Negative life events included banishment from the worksite (one case) and verbal abuse (two cases).

Conclusion

Acceptability of VCT appears high in the FSW population in Conakry as a consequence of both perceptions of high individual risk and social pressures.     

Use of neonatal post-exposure prophylaxis for prevention of mother-to-child HIV transmission in the UK and Ireland, 2001-2008

Objectives

To investigate changing clinical practice with regard to antiretroviral post‐exposure prophylaxis (PEP) and factors associated with the use of combination prophylaxis in infants born to HIV‐infected women in the UK and Ireland.

Methods

Surveillance of obstetric and paediatric HIV infection in the UK and Ireland is conducted through the National Study of HIV in Pregnancy and Childhood. Infants born to HIV‐infected women between 2001 and 2008 were included in the study.

Results

Ninety‐nine per cent of infants (8155 of 8205) received antiretroviral prophylaxis; 86% of those with information on type of prophylaxis (n=8050) received single, 3% dual and 11% triple drug prophylaxis. Among those who received prophylaxis, use of triple prophylaxis increased significantly between 2001–2004 and 2005–2008, from 9% (297 of 3243) to 13% (624 of 4807) overall (P<0.001); from 43% (41 of 95) to 71% (45 of 63) in infants born to untreated women; and from 13% (114 of 883) to 32% (344 of 1088) where mothers were viraemic despite highly active antiretroviral therapy (HAART) in pregnancy. In multivariable analysis, factors associated with receipt of triple prophylaxis included later time period, shorter duration or lack of antenatal antiretroviral therapy, receipt of antiretroviral drugs during labour, detectable maternal viral load, CD4 count<200 cells/μL in pregnancy, preterm delivery (<37 weeks) and unplanned (emergency caesarean or vaginal) delivery.

Conclusion

Between 2001 and 2008, almost all infants born to HIV‐infected women in the UK and Ireland received antiretroviral PEP, mostly with one drug. Use of triple PEP increased over time, particularly for infants whose mothers were untreated or viraemic despite HAART, in line with current guidelines.