Integrating HIV Prevention into Services for Abused Women in South Africa

The relationship between intimate partner violence (IPV) and HIV risk is well documented, but few interventions jointly address these problems. We developed and examined the feasibility of an intervention to reduce HIV risk behaviors among 97 women seeking services for IPV from a community-based NGO in Johannesburg, South Africa. Two versions of the intervention (a 6-session group and a 1-day workshop) were implemented, both focusing on HIV prevention strategies integrated with issues of gender and power imbalance. Attendance was excellent in both intervention groups. Assessments were conducted at baseline, post-intervention and two-month follow-up to demonstrate the feasibility of an intervention trial. Women in both groups reported reductions in HIV misperceptions and trauma symptoms, and increases in HIV knowledge, risk reduction intentions, and condom use self-efficacy. The 6-session group showed greater improvements in HIV knowledge and decreases in HIV misperceptions in comparison to the 1-day workshop. The study demonstrated the feasibility and potential benefit of providing HIV prevention intervention to women seeking assistance for IPV.     

Prevention of mother-to-child transmission of HIV in Africa

HIV infection and mortality rates in African children are astoundingly high. Risk factors for mother-to-child transmission of HIV include maternal plasma viral load and breastfeeding. With regard to the latter, current data indicate that mixed feeding (breastfeeding with other oral foods and liquids) is associated with the greatest risk of transmission. Studies are under way to determine if exclusive breastfeeding with rapid early weaning can reduce transmission rates in the absence of exclusive formula feeding for all infants. Perinatal transmission rates have been dramatically reduced with the use of single-dose nevirapine, but this strategy protects only approximately 50% of infants, and more than 75% of women receiving nevirapine develop a major nevirapine resistance mutation. In developed areas of the world, antiretroviral therapy has reduced perinatal transmission by more than 90% compared with 1993 rates. Improved HIV-related care for HIV-infected women in Africa is needed to reduce rates of HIV infection in children and to prevent maternal mortality. This article summarizes a presentation by Sten H. Vermund, MD, PhD, at the International AIDS Society-USA course in Chicago in May 2004.     

Southern Africa: reports document legal responses to HIV/AIDS

A series of reports have been issued on the legal response to HIV/AIDS in eight member states of the Southern African Development Community (SADC). The states are Botswana, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe.     

Microbicides to prevent HIV transmission: overcoming obstacles to chemical barrier protection

BACKGROUND: Microbicides are topical compounds that could prevent sexually transmitted infections. Several compounds have demonstrated activity both in vitro and in animal models, but none has been approved for use in humans. METHODS: A review of >100 recent publications from MEDLINE (through October 2005) and abstracts presented at recent conferences was undertaken to describe the current status of microbicide research and to delineate why microbicides are not yet available. RESULTS: More than 15 candidate microbicides are currently being studied in clinical trials. Their mechanisms of action include disruption of the viral membrane by surfactants, maintenance of an acidic vaginal pH, binding to the viral envelope to block receptor binding, and blocking of receptors; they may also be combined with antiretroviral drugs. The development of safe and effective microbicides has been delayed by limitations in understanding the biological processes of human immunodeficiency virus (HIV) transmission, difficulties in extrapolation from animal models, lack of established correlates of protection, and the need to enroll and follow large cohorts of high-risk participants for several years in order to demonstrate efficacy. CONCLUSIONS: Safe and effective topical microbicides are biologically plausible. Several trials that are under way may demonstrate the ability of microbicides to protect against transmission of HIV, but multiple challenges remain.     

Measuring the Potential Impact of Combination HIV Prevention in Sub-Saharan Africa

A public health approach to combination HIV prevention is advocated to contain the epidemic in sub-Saharan Africa. We explore the implications of universal access to treatment along with HIV education scale-up in the region. We develop an HIV transmission model to investigate the impacts of universal access to treatment, as well as an analytical framework to estimate the effects of HIV education scale-up on the epidemic. We calibrate the model with data from South Africa and simulate the impacts of universal access to treatment along with HIV education scale-up on prevalence, incidence, and HIV-related deaths over a course of 15 years. Our results show that the impact of combined interventions is significantly larger than the summation of individual intervention impacts (super-additive property). The combined strategy of universal access to treatment and HIV education scale-up decreases the incidence rate by 74% over the course of 15 years, whereas universal access to treatment and HIV education scale up will separately decrease that by 43% and 8%, respectively. Combination HIV prevention could be notably effective in transforming HIV epidemic to a low-level endemicity. Our results suggest that in designing effective combination prevention in sub-Saharan Africa, priorities should be given to achieving universal access to treatment as quickly as possible and improving compliance to condom use.     

Factors Determining Prenatal HIV Testing for Prevention of Mother to Child Transmission of HIV in Mpumalanga,South Africa

This study assessed factors associated with participation in HIV counseling and testing and reported reasons for not taking part in Voluntary HIV Counseling and Testing among 930 pregnant women attending clinics for antenatal care in South Africa. Results indicate that from 930 clients interviewed 87% had agreed to participate in individual pre-test HIV counseling and 81.2% had received their test results in post-test counseling. Fear for taking the test, lack of confidentiality and knowing one’s HIV status were the main reasons why women refused to test. In multivariable analysis trust of HCT provider was associated with participation in HIV pre-test counseling and no risky drinking was associated with participation in HIV post-test counseling. These findings suggest mistrust towards HCT providers should be reduced and screening and brief intervention for alcohol problems provided.     

Microbicides to prevent heterosexual transmission of HIV: ten years down the road

The development of topical microbicides for HIV prevention originated in response to the unabated spread of HIV despite the availability of an effective HIV prevention tool (condoms), as well as the lack of an effective HIV vaccine. Initially, hopes were pinned on existing over-the-counter spermicides containing nonoxynol-9. Concern about the toxicity of nonoxynol-9 with frequent use, and its small or nonexistent protective effect against HIV and other sexually transmitted infections (STIs), has spurred the development of new microbicides with a number of novel mechanisms of action. Significant progress has been made in the last decade. The microbicides pipeline currently contains approximately 34 products in preclinical development, 15 in Phase I safety trials, four in Phase II expanded safety and preliminary effectiveness trials, and three in Phase II/III or Phase III effectiveness trials. Laboratory and clinical research has been complemented by a growing body of research and literature on microbicide acceptability, harm reduction and dual protection strategies, and potential markets. However, many challenges remain, including the need for a significant increase in investment to accelerate product development and complementary research, and to plan for availability and access once effective microbicides are available.     

HIV type 1 subtype C gag and nef diversity in Southern Africa

Several HIV-1 subtype C-specific gag- and/or nef-based vaccines are currently intended for clinical trial in southern Africa. Here we provide sequences of 64 gag and 45 nef genes sampled in Malawi, Zambia, Zimbabwe, and South Africa and assess the degree of southern African HIV-1 diversity that will confront these vaccines. Whereas reasonable phylogenetic evidence exists for geographical clustering of subtype C gag and nef sequences from various other parts of the world, there is little evidence of similar population founder effects in the southern African epidemic. The entire breadth of subtype C diversity is represented in the southern African genes suggesting there may be no advantage in producing region- or country-specific subtype C vaccines. We do not, however, find much evidence of intersubtype recombination in the Southern African genes, implying that the likelihood of vaccine failure due to the emergence of intersubtype recombinants is probably low.     

Anal Douche Practices and Willingness to Use a Rectal Microbicide Enema for HIV Prevention and Associated Factors Among an Internet Sample of HIV-Negative and HIV-Discordant Male Couples in the US

A significant proportion of MSM acquire HIV from their primary relationship partners. Rectal microbicides are currently being studied to determine their efficacy for HIV prevention, yet willingness to use rectal microbicides among male couples is largely unknown. Dyadic data from 333 HIV-negative and HIV-discordant male couples, representing 631 HIV-negative men, were used to assess anal douching practices and willingness to use a rectal microbicide for HIV prevention. 17 % of men douched 100 % of the time before having anal sex within their primary partner. Among those who had sex outside of their relationship, 36 % had douched 100 % of the time before having anal sex with a casual MSM partner. Most men (63 %) indicated a willingness to use a theoretically effective rectal microbicide prior to anal sex for HIV prevention. If found effective, rectal microbicides delivered as an anal douche may be an acceptable format for HIV prevention to some MSM who already engage in anal douching. Understanding current douching practices will be important in successfully promoting the uptake of rectal microbicides.     

Transmitted HIV type 1 drug resistance among individuals with recent HIV infection in East and Southern Africa

To characterize WHO-defined transmitted HIV drug resistance mutation (TDRM) data from recently HIV-infected African volunteers, we sequenced HIV (pol) and evaluated for TDRM the earliest available specimens from ARV-naive volunteers diagnosed within 1 year of their estimated date of infection at eight research centers in sub-Saharan Africa. TDRMs were detected in 19/408 (5%) volunteers. The prevalence of TDRMs varied by research center, from 5/26 (19%) in Entebbe, 6/78 (8%) in Kigali, 2/49 (4%) in Kilifi, to 3/106 (3%) in Lusaka. One of five volunteers from Cape Town (20%) had TDRMs. Despite small numbers, our data suggest an increase in DRMs by year of infection in Zambia (p?=?0.004). The prevalence observed in Entebbe was high across the entire study. ARV history data from 12 (63%) HIV-infected sexual partners were available; 3 reported ARV use prior to transmission. Among four partners with sequence data available, transmission linkage was confirmed and two had the same TDRMs as the newly infected volunteer (both K103N). As ARV therapy continues to increase in availability throughout Africa, monitoring incident virus strains for the presence of TDRMs should be a priority. Early HIV infection cohorts provide an excellent and important platform to monitor the development of TDRMs to inform treatment guidelines, drug choices, and strategies for secondary prevention of TDRM transmission.     

Willingness to participate in a national seroprevalence study of HIV infection

This paper examines the impact of the social dimension of AIDS on a person's willingness to participate in a hypothetical national seroprevalence study of HIV infection. Data from the AIDS supplement of the 1987 National Health Interview Survey provided information about the sociodemographic characteristics and AIDS-related variables and the expressed willingness to participate in a national serosurvey. A multivariate logistic regression model was used to evaluate simultaneously associations between the sociodemographic variables and AIDS-related variables with willingness to participate. Results show that those with sociodemographic characteristics most dissimilar from reported AIDS cases were least willing to participate while those with a high knowledge about AIDS, experience of the HIV test or tested people, and higher perceptions of risk were more willing to participate. We found two exceptions to this general result. First, respondents with no knowledge about AIDS, but a higher level of education, were less willing to participate than those with no knowledge and a lower level of education. Second, respondents with a higher perception of risk and a higher level of education were also less willing than those with high perception of risk and less education.     

Willingness to Use HIV Pre-Exposure Prophylaxis Among Opiate Users

Few studies of pre-exposure prophylaxis (PrEP) to prevent HIV infection have focused on drug users. Between February to September 2013, we asked 351 opiate injectors entering detoxification treatment about HIV risk, knowledge about PrEP, and willingness to use a once daily PrEP pill under one of two randomly assigned effectiveness scenarios—40 % (low) or 90 % (high) effective in reducing HIV risk. Participants were 70 % male and 87 % non-Hispanic White. Only 7 % had heard of a drug to reduce HIV risk, yet once informed, 47 % would be willing to take such a pill [35 % of those in the low effectiveness scenario and 58 % in the high group (p < 0.001)]. Higher perceived HIV risk was associated with greater willingness to take medication. Increasing knowledge of PrEP and the rate of HIV reduction-effectiveness promised will influence its use among targeted high-risk drug users.