Structural approaches for prevention of sexually transmitted HIV in general populations: definitions and an operational approach

Introduction

Although biomedical HIV prevention efforts have seen a number of recent promising developments, behavioural interventions have often been described as failing. However, clear lessons have been identified from past efforts, including the need to address influential social, economic and legal structures; to tailor efforts to local contexts; and to address multiple influencing factors in combination. Despite these insights, there remains a pervasive strategy to try to achieve sexual behaviour change through single, decontextualized, interventions or sets of activities. With current calls for structural approaches to HIV as part of combination HIV prevention, though, there is a unique opportunity to define a structural approach to HIV prevention as one which moves beyond these past limitations and better incorporates our knowledge of the social world and the lessons from past efforts.

Discussion

A range of interlinked concepts require delineation and definition within the broad concept of a structural approach to HIV. This includes distinguishing between “structural factors,” which can be seen as any number of elements (other than knowledge) which influence risk and vulnerability, and “structural drivers,” which should be reserved for situations where an empirically established relationship to a target group is known. Operationalizing structural approaches similarly can take different paths, either working to alter structural drivers or alternatively working to build individual and community resilience to infection. A “structural diagnostic approach” is further defined as the process one undertakes to develop structural intervention strategies tailored to target groups.

Conclusions

For three decades, the HIV prevention community has struggled to reduce the spread of HIV through sexual risk behaviours with limited success, but equally with limited engagement with the lessons that have been learned about the social realities shaping patterns of sexual practices. Future HIV prevention efforts must address the multiple factors influencing risk and vulnerability, and they must do so in ways tailored to particular settings. Clarity on the concepts, terminology and approaches that can allow structural HIV prevention efforts to achieve this is therefore essential to improve the (social) science of HIV prevention.     

Women of Worth: the impact of a cash plus intervention to enhance attendance and reduce sexual health risks for young women in Cape Town,South Africa

IntroductionConditional cash transfers (CTs) augmented with other interventions are promising interventions for reducing HIV risk in adolescent girls and young women.MethodsA multi‐phase, quasi‐experimental study assessed the impact of a CT (ZAR300; $22) conditional on attending a skills building intervention, Women of Worth (WoW), designed to improve sexual and reproductive health (SRH) outcomes in Cape Town, South Africa from May 2017 to December 2019. The intervention entailed 12 sessions with encouragement to attend adolescent and youth‐friendly health services. Women aged 19–24 years were randomized 1:1 to receive the intervention with a CT (“cash + care” or C+C) or without a CT (“care”). The study included a pilot phase followed by a post‐modification phase with improved uptake and retention without changing programme content or CT. Self‐reported HIV prevalence and SRH/HIV vulnerability were assessed via a self‐administered questionnaire at baseline, after 11 sessions, and 6–30 months’ post‐intervention for a subset. Mixed effect logistic regression models were fitted to estimate within‐subject changes in outcomes.ResultsOf 5116 participants, 904 (452 participants per arm) were in the pilot and 4212 (2039 “care” participants and 2173 “C+C” participants) were in the post modified phase. There were 1867 (85.9%) and 135 (6,6%) participants in the “C+C” group and the “Care,” respectively, that were WoW completers (≥ 11 sessions/retention). During the pilot phase, 194 (42.9%) and 18 (4.0%) participants in “C+C” and the “care” groups were retained. Receiving a CT sustained participation nearly 60‐fold (OR 60.37; 95% CI: 17.32; 210.50, p <0.001). Three‐hundred and thirty women were followed for a median of 15.0 months [IQR: 13.3; 17.8] to assess the durability of impact. Self‐reported new employment status increased more than three‐fold (p <0.001) at WoW completion and was sustained to the longer time point. Intimate partner violence indicators were reduced immediately after WoW, but this was not durable.ConclusionsParticipants receiving CT had sustained participation in an SRH/HIV prevention skills building with improvement in employment and some SRH outcomes. Layered, “young woman centred” programmes to address HIV and SRH risk in young women may be enhanced with CT.     

PSA density improves the rate of prostate cancer detection in Chinese men with a PSA between 2.5–10.0 ng ml-1 and 10.1–20.0 ng ml-1: a multicenter study

Chinese men should have a higher prostate-specific antigen (PSA) “gray zone” than the traditional value of 2.5–10.0 ng ml⁻¹ since the incidence of prostate cancer (PCa) in Chinese men is relative low. We hypothesized that PSA density (PSAD) could improve the rate of PCa detection in Chinese men with a PSA higher than the traditional PSA “gray zone.” A total of 461 men with a PSA between 2.5 and 20.0 ng ml⁻¹, who had undergone prostatic biopsy at two Chinese centers were included in the analysis. The men were then further divided into groups with a PSA between 2.5–10.0 ng ml⁻¹ and 10.1–20.0 ng ml⁻¹. Receiver operating characteristic (ROC) curve was used to evaluate the efficacy of PSA and PSAD for the diagnosis of PCa. In men with a PSA of 2.5–10.0 ng ml⁻¹ or 10.1–20.0 ng ml⁻¹, the areas under the ROC curve were higher for PSAD than for PSA. This was consistent across both centers and the cohort overall. When the entire cohort was considered, the optimal PSAD cut-off for predicting PCa in men with a PSA of 2.5–10.0 ng ml⁻¹ was 0.15 ng ml⁻¹ ml⁻¹, with a sensitivity of 64.4% and specificity of 64.6%. The optimal cut-off for PSAD in men with a PSA of 10.1–20.0 ng ml⁻¹ was 0.33 ng ml⁻¹ ml⁻¹, with a sensitivity of 60.3% and specificity of 82.7%. PSAD can improve the effectiveness for PCa detection in Chinese men with a PSA of 2.5–10.0 ng ml⁻¹ (traditional Western PSA “gray zone”) and 10.1–20.0 ng ml⁻¹ (Chinese PSA “gray zone”).     

Meningitis in HIV-positive patients in sub-Saharan Africa: a review

Introduction

Meningitis is one of the leading causes of death among patients living with HIV in sub-Saharan Africa. There is no widespread tracking of the incidence rates of causative agents among patients living with HIV, yet the aetiologies of meningitis are different than those of the general population.

Methods

We reviewed the scientific literature published in PubMed to determine the incidence rates of meningitis among hospitalized people living with HIV in sub-Saharan Africa and report our findings from seven studies across sub-Saharan Africa.

Results

We found high rates of cryptococcal meningitis (19–68%). Tuberculous meningitis was lower (1–36%), although some centres included possible cases as “other” meningitis; therefore, this may not be a true representation of the total cases. Pyogenic meningitis ranged from 6 to 30% and “other” meningitis ranged from 7 to 28% of all reported cases of meningitis. Mortality rates ranged from 25 to 68%. This review describes the most common aetiologies and provides practical diagnostic, treatment and prevention considerations as they apply to the individual living with HIV in sub-Saharan Africa.

Conclusions

Diagnosis is often limited, and wider availability of accurate and low-cost laboratory diagnostics is desperately needed for prompt diagnosis and initiation of appropriate treatment. Wider acceptance and adoption of available preventative modalities can decrease the incidence of potentially fatal central nervous system infections in African patients living with HIV.     

Sexual risk after HIV diagnosis: a comparison of pre-ART individuals with CD4>500 cells/μl and ART-eligible individuals in a HIV treatment and care programme in rural KwaZulu-Natal,South Africa

Introduction

Little is known about people diagnosed as HIV-positive who access HIV care early in their disease. In pre-ART studies published to date, only a minority of the participants have CD4>500 cells/µl.

Methods

This cross-sectional study compared individuals presenting for HIV care with CD4>500 cells/µl, “pre-ART” (N=247), with individuals who had CD4<200 cells/µl or WHO Stage IV, “ART-eligible” (N=385). Baseline characteristics were contrasted between the two groups and logistic regression models used to explore group differences in: (a) being sexually active in the last month; (b) disclosure of HIV status to current partner; (c) knowing the HIV status of one''s current partner; and (d) condom use at last sex.

Results

Pre-ART and ART-eligible individuals were similar in terms of a wide range of socio-demographic characteristics. Controlling for gender, only current sexual behaviour and HIV-testing history were significantly different between ART groups. In multivariable models, participants in the pre-ART group were twice as likely to be sexually active in the last month, OR 2.06 95% CI (1.32, 3.21), and to know their partner''s status, OR 1.95 (1.18, 3.22) compared to those in the ART-eligible group. Self-reported disclosure of HIV status to current sexual partner (71%), condom use at last sex (61%) and HIV concordancy within relationships were not significantly different between the two ART groups. Overall, 39% of the study participants reported knowing that they were in concordant HIV-positive relationships. Fifty-five percent of all participants reported not knowing their partner''s HIV status, only half of whom reported using a condom at last sex. Pre-ART individuals were significantly less likely to have tested HIV-positive for the first time in the last year and to have tested for sickness-related reasons than the ART-eligible group.

Conclusions

Reported sexual risk behaviours by pre-ART individuals with CD4>500 cells/µl suggest a continued risk of onward HIV transmission. There is a need for positive prevention efforts to target this group given that current treatment guidelines do not provide them with ART. Strengthening support regarding disclosure, partner HIV testing and consistent condom use, and further promotion of HIV testing in the community to assist earlier diagnosis are urgently required.     

Invasive and non-invasive brain stimulation for treatment of neuropathic pain in patients with spinal cord injury: A review

Context

Past evidence has shown that invasive and non-invasive brain stimulation may be effective for relieving central pain.

Objective

To perform a topical review of the literature on brain neurostimulation techniques in patients with chronic neuropathic pain due to traumatic spinal cord injury (SCI) and to assess the current evidence for their therapeutic efficacy.

Methods

A MEDLINE search was performed using following terms: “Spinal cord injury”, “Neuropathic pain”, “Brain stimulation”, “Deep brain stimulation” (DBS), “Motor cortex stimulation” (MCS), “Transcranial magnetic stimulation” (TMS), “Transcranial direct current stimulation” (tDCS), “Cranial electrotherapy stimulation” (CES).

Results

Invasive neurostimulation therapies, in particular DBS and epidural MCS, have shown promise as treatments for neuropathic and phantom limb pain. However, the long-term efficacy of DBS is low, while MCS has a relatively higher potential with lesser complications that DBS. Among the non-invasive techniques, there is accumulating evidence that repetitive TMS can produce analgesic effects in healthy subjects undergoing laboratory-induced pain and in chronic pain conditions of various etiologies, at least partially and transiently. Another very safe technique of non-invasive brain stimulation – tDCS – applied over the sensory-motor cortex has been reported to decrease pain sensation and increase pain threshold in healthy subjects. CES has also proved to be effective in managing some types of pain, including neuropathic pain in subjects with SCI.

Conclusion

A number of studies have begun to use non-invasive neuromodulatory techniques therapeutically to relieve neuropathic pain and phantom phenomena in patients with SCI. However, further studies are warranted to corroborate the early findings and confirm different targets and stimulation paradigms. The utility of these protocols in combination with pharmacological approaches should also be explored.     

Towards elimination of mother-to-child transmission of HIV: performance of different models of care for initiating lifelong antiretroviral therapy for pregnant women in Malawi (Option B+)

Introduction

Malawi introduced a new strategy to improve the effectiveness of prevention of mother-to-child HIV transmission (PMTCT), the Option B+ strategy. We aimed to (i) describe how Option B+ is provided in health facilities in the South East Zone in Malawi, identifying the diverse approaches to service organization (the “model of care”) and (ii) explore associations between the “model of care” and health facility–level uptake and retention rates for pregnant women identified as HIV-positive at antenatal (ANC) clinics.

Methods

A health facility survey was conducted in all facilities providing PMTCT/antiretroviral therapy (ART) services in six of Malawi''s 28 districts to describe and compare Option B+ service delivery models. Associations of identified models with program performance were explored using facility cohort reports.

Results

Among 141 health facilities, four “models of care” were identified: A) facilities where newly identified HIV-positive women are initiated and followed on ART at the ANC clinic until delivery; B) facilities where newly identified HIV-positive women receive only the first dose of ART at the ANC clinic, and are referred to the ART clinic for follow-up; C) facilities where newly identified HIV-positive women are referred from ANC to the ART clinic for initiation and follow-up of ART; and D) facilities serving as ART referral sites (not providing ANC). The proportion of women tested for HIV during ANC was highest in facilities applying Model A and lowest in facilities applying Model B. The highest retention rates were reported in Model C and D facilities and lowest in Model B facilities. In multivariable analyses, health facility factors independently associated with uptake of HIV testing and counselling (HTC) in ANC were number of women per HTC counsellor, HIV test kit availability, and the “model of care” applied; factors independently associated with ART retention were district location, patient volume and the “model of care” applied.

Conclusions

A large variety exists in the way health facilities have integrated PMTCT Option B+ care into routine service delivery. This study showed that the “model of care” chosen is associated with uptake of HIV testing in ANC and retention in care on ART. Further patient-level research is needed to guide policy recommendations.     

Cross‐sectional trends in HIV prevalence among pregnant women in Botswana: an opportunity for PrEP?

IntroductionYoung women in sub‐Saharan Africa are at particularly high risk of HIV acquisition. Recent shifts towards “test and treat” strategies have potential to reduce transmission in this age group but have not been widely studied outside of clinical trials. Using data from nationwide surveillance among pregnant women in Botswana, where a “test and treat” program was implemented in 2016, we describe trends in HIV prevalence over time and highlight opportunities for targeted prevention.MethodsThe Tsepamo study abstracted data from obstetric records of all women delivering at eight government hospitals in Botswana between 2015 and 2019, accounting for 45% of all births in the country (n = 120,755). We used a stratified analysis to identify prevalence trends and evaluated decreases in HIV prevalence over time using the Cochrane–Armitage test for linear trend. A multivariable logistic regression analysis was also performed to identify factors associated with declines in HIV prevalence.ResultsOverall HIV prevalence was 24.1% among 120,755 women who delivered during the study period. Prevalence differed by site of delivery, ranging from 16.1% to 28.2%, and increased markedly with age. Lower educational attainment (adjusted odds ratio [aOR] = 3.28; 95% confidence interval [CI] 3.07–3.50) and being unmarried (aOR = 1.98; 95% CI 1.88–2.08) were associated with HIV infection. HIV prevalence was 10.0% with a first pregnancy, 21.0% with a second and 39.2% with a third or greater (aOR = 2.20; for any prior pregnancy; 95% CI 2.10–2.29). The same age‐adjusted trends were seen when data were limited to women aged 15–24, with a two‐ to three‐fold increase in HIV prevalence between a first and third pregnancy. Prevalence decreased linearly during the 5‐year study period from 25.8% to 22.7% (p <0.001). Among age‐specific strata, the greatest absolute decline occurred in those aged 35–39, with an 8.7% absolute decrease in HIV prevalence from 2015 to 2019. Minimal declines were seen in those 15–24, with a decrease of only 1.5% over the same period.ConclusionsWhile overall trends in Botswana show HIV prevalence declining among pregnant women, prevalence among the youngest age group has remained stagnant. Preventative interventions utilizing pre‐exposure prophylaxis should be prioritized during the high‐risk period surrounding a woman''s first pregnancy.     

Changes in Health-Related Quality of Life (HRQOL) of a Specific Group of Adolescent Idiopathic Scoliosis (AIS) Patients Who Came Across Both Bracing and Surgery

Background/Purpose of the StudyChanges in health-related quality of life (HRQOL) of AIS patients coming across both bracing and surgery have not yet reported. These patients received two major clinical interventions and their HRQOL might be different from previous articles. The aim of this study is to evaluate the changes of HRQOL of a specific group of AIS patients who experienced both bracing and surgery.MethodsOne hundred and twenty-eight patients requiring surgery with prior bracing treatment were identified from the electronic record. SRS-22 questionnaire was completed at 7 time points crossing both interventions (namely “Before”, “Bracing ≤ 1 year”, “Bracing > 1 year”, “Pre-op”, “Post-op”, “Post-op ≤ 1 year, and “Post-op 1-2 years”).ResultsSRS-22 “Function”, “Pain” and “Self-image” scores were decreased from “Before” to “Bracing ≤ 1 year” when started bracing and raised at “Bracing > 1 year”. The 3 scores were dropped from “Bracing > 1 year” to “Pre-op”, particularly on “Self-image”. “Function” and “Pain” were significantly dropped from “Pre-op” to “Post-op” and kept raising until “Post-op 1–2 years”. “Self-image” was improving after “Pre-op”. “Mental” was relatively stable along the timeline.ConclusionThis study described the changes in HRQOL of a specific group of AIS patients. Scores were dropped after the two major clinical interventions and recovered afterwards. Medical professionals were able to plan and provide appropriate supports on the expected changes in HRQOL, especially on function, pain and mental.     

Suitability of FIFA’s “The 11” Training Programme for Young Football Players – Impact on Physical Performance

There is a paucity of evidence regarding the use of injury prevention programmes for preadolescents participating in sport. “The 11 ”injury prevention programme was developed by FIFA’s medical research centre (F-MARC) to help reduce the risk of injury in football players aged 14 years and over. The aim of this study was to determine the suitability and effectiveness of “The 11 ”for younger football players. Twenty-four [12 experimental (EXP), 12 control (CON)] young football players (age 10.4 ± 1.4 yr) participated. The EXP group followed “The 11 ”training programme 5 days per week, for 6 weeks, completing all but one of the 10 exercises. Prior to, and after the intervention, both EXP and CON groups performed a battery of football-specific physical tests. Changes in performance scores within each group were compared using independent t-tests (p ≤ 0.05). Feedback was also gathered on the young players’ perceptions of “The 11”. No injuries occurred during the study in either group. Compliance to the intervention was 72%. Measures of leg power (3 step jump and counter-movement jump) increased significantly (3.4 and 6.0% respectively, p < 0.05). Speed over 20 m improved by 2% (p < 0.05). Most players considered “The 11 ”beneficial but not enjoyable in the prescribed format. Given the observed improvements in the physical abilities and the perceived benefits of “The 11”, it would appear that a modified version of the programme is appropriate and should be included in the training of young football players, for both physical development and potential injury prevention purposes, as well as to promote fair play. To further engage young football players in such a programme, some modification to “The 11 ”should be considered.

Key points

• Children who participate in recreational and competitive sports, especially football, are susceptible to injury.
• There is a need for the design and assessment of injury prevention programmes for children.
• The 11 ”improves essential physical performance characteristics and has the potential to reduce the risk of injury.
• It may be prudent to implement a ‘child-friendly’ version of “The 11”, to enhance long-term programme adherence and to ensure progressive physical development of players.

Key words: Injury, football, soccer, children, prevention, FIFA     

Closing the gap: did delivery approaches complementary to home‐based testing reach men with HIV testing services during and after the HPTN 071 (PopART) trial in Zambia?

IntroductionThe HPTN 071 (PopART) trial demonstrated that universal HIV testing‐and‐treatment reduced community‐level HIV incidence. Door‐to‐door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men.MethodsBetween 2013 and 2017, three intervention rounds (IRs) of door‐to‐door HTS delivery were conducted in eight PopART communities in Zambia. Additional strategies implemented in parallel, included: community‐wide “Man‐up” campaigns (IR1), smaller HTS campaigns at work/social places (IR2) and revisits to households with the option of HIV self‐testing (HIVST) (IR3). In 2018, community “hubs” offering HTS were implemented for 7 months in all eight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods.ResultsBy the end of the three IRs, 65–75% of men were reached with HTS, primarily through door‐to‐door service delivery. In IR1 and IR2, “Man‐up” and work/social place campaigns accounted for ∼1 percentage point each and in IR3, revisits with the option of self‐testing for ∼15 percentage points of this total coverage per IR. The yield of newly diagnosed HIV‐positive men ranged from 2.2% for HIVST revisits to 9.9% in work/social places. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that ∼36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion.ConclusionsAchieving high coverage of HTS among men requires universal, home‐based service delivery combined with an option of HIVST and delivery of HTS through community‐based hubs. When men are reached, they are willing to test for HIV. Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men''s needs.Clinical Trial Number{"type":"clinical-trial","attrs":{"text":"NCT01900977","term_id":"NCT01900977"}}NCT01900977     

Risky behaviours among young people living with HIV attending care and treatment clinics in Dar Es Salaam,Tanzania: implications for prevention with a positive approach

Introduction

Prevention with a positive approach has been advocated as one of the main strategies to reduce new instances of HIV infection. Risky sexual behaviours among people living with HIV/AIDS are the cornerstone for this approach. Understanding the extent to which infected individuals practice risky behaviours is fundamental in designing appropriate population-specific interventions. With the HIV infection transmission rates remaining high among young people in sub-Saharan Africa, continued prevention among them remains a priority. This study therefore seeks to describe the magnitude and determinants of risky sexual behaviours among young people living with HIV.

Methods

A cross-sectional study was conducted between June and July 2010 in selected Care and Treatment Clinics (CTCs) in Dar Es Salaam, Tanzania. A total of 282 HIV-positive patients aged 15–24 were interviewed about their sexual behaviours using a questionnaire.

Results

Prevalence of unprotected sex was 40.0% among young males and 37.5% among young females (p<0.001). Multiple sexual partnerships were reported by 10.6% of males and 15.9% of females (p<0.005). More than 50% of the participants did not know about the HIV status of their sexual partners. A large proportion of participants had minimal knowledge of transmission (46.7% males vs. 60.4% females) and prevention (65.3% males vs. 73.4% females) of sexually transmitted infections (STIs). Independent predictors of condom use included non-use of alcohol [adjusted odds ratio (AOR), 0.40 95% confidence interval (CI); 0.17–0.84] and younger age (15–19 years) (AOR, 2.76, 95% CI: 1.05–7.27). Being on antiretroviral therapy (AOR, 0.38, 95% CI: 0.17–0.85) and not knowing partners’ HIV sero-status (AOR, 2.62, 95% CI: 1.14–5.10) predicted the practice of multiple sexual partnership.

Conclusions

Unprotected sex and multiple sexual partnerships were prevalent among young people living with HIV. Less knowledge on STI and lack of HIV disclosure increased the vulnerability and risk for HIV transmission among young people. Specific intervention measures addressing alcohol consumption, risky sexual behaviours, and STI transmission and prevention knowledge should be integrated in the routine HIV/AIDS care and treatment offered to this age group.     

Communication between HIV-infected children and their caregivers about HIV medicines: a cross-sectional study in Jinja district,Uganda

Introduction

Knowledge of antiretroviral therapy (ART) among children with HIV depends on open communication with them about their health and medicines. Guidelines assign responsibility for communication to children''s home caregivers. Other research suggests that communication is poor and knowledge about ART is low among children on treatment in low-income countries. This study sought to describe communication about medicine for HIV in quantitative terms from the perspectives of both children and caregivers. Thereafter, it established the factors associated with this communication and with children''s knowledge about their HIV medicines.

Methods

We undertook a cross-sectional survey of a random sample of 394 children with HIV on treatment and their caregivers at nine health facilities in Jinja District, Uganda. We assessed reported frequency and content of communication regarding their medicines as well as knowledge of what the medicines were for. Logistic regression analysis was used to determine the factors associated with communication patterns and children''s knowledge of HIV medicines.

Results

Although 79.6% of the caregivers reported that they explained to the children about the medicines, only half (50.8%) of the children said they knew that they were taking medicines for HIV. Older children aged 15–17 years were less likely to communicate with a caregiver about the HIV medicines in the preceding month (OR 0.5, 95% CI 0.3–0.7, p=0.002). Children aged 11–14 years (OR 6.1, 95% CI 2.8–13.7, p<0.001) and 15–17 years (OR 12.6, 95% CI 4.6–34.3, p<0.001) were more likely to know they were taking medicines for HIV compared to the younger ones. The least common reported topic of discussion between children and caregivers was “what the medicines are for” while “the time to take medicines” was by far the most mentioned by children.

Conclusions

Communication about, and knowledge of, HIV medicines among children with HIV is low. Young age (less than 15 years) was associated with more frequent communication. Caregivers should be supported to communicate diagnosis and treatment to children with HIV. Age-sensitive guidelines about the nature and content of communication should be developed.     

Gay and bisexual men's awareness and knowledge of treatment as prevention: findings from the Momentum Health Study in Vancouver,Canada

Introduction

Awareness and knowledge of treatment as prevention (TasP) was assessed among HIV-positive and HIV-negative gay, bisexual and other men who have sex with men (GBMSM) in Vancouver, Canada.

Methods

Baseline cross-sectional survey data were analyzed for GBMSM enrolled, via respondent-driven sampling (RDS), in the Momentum Health Study. TasP awareness was defined as ever versus never heard of the term “TasP.” Multivariable logistic regression identified covariates of TasP awareness. Among those aware of TasP, men''s level of knowledge of TasP was explored through an examination of self-perceived knowledge levels, risk perceptions and short-answer definitions of TasP which were coded as “complete” if three TasP-related components were identified (i.e. HIV treatment, viral suppression and prevention of transmission). Information source was also assessed. Analyses were stratified by HIV status and RDS adjusted.

Results

Of 719 participants, 23% were HIV-positive, 68% Caucasian and median age was 33 (Interquartile range (IQR) 26,47). Overall, 46% heard of TasP with differences by HIV status [69% HIV-positive vs. 41% HIV-negative GBMSM (p<0.0001)]. In adjusted models: HIV-positive GBMSM were more likely to have heard of TasP if they were Canadian born, unemployed, not using party drugs and had higher CD4 counts; HIV-negative GBMSM were more likely to have heard of TasP if they were Caucasian (vs. Aboriginal), students, had higher education, a regular partner and multiple sexual partners. Among those aware of TasP 91% of HIV-positive and 69% of HIV-negative GBMSM (p<0.0001) felt they knew “a lot” or “a bit in general” about TasP; 64 and 41% (p=0.002) felt HIV treatment made the risk of transmission “a lot lower”; and 21 and 13% (p<0.0001) demonstrated “complete” TasP definitions. The leading information source was doctors (44%) for HIV-positive GBMSM and community agencies (38%) for HIV-negative GBMSM, followed by gay media for both populations (34%).

Conclusions

Nearly half of GBMSM in this study reported having heard of TasP, yet only 14% demonstrated complete understanding of the concept. Variations in TasP awareness and knowledge by HIV status, and key socio-demographic, behavioural and clinical factors, highlight a need for health communication strategies relevant to diverse communities of GBMSM in order to advance overall TasP health literacy.     

Ending overly broad HIV criminalization: Canadian scientists and clinicians stand for justice

In Canada, people living with HIV who do not disclose their HIV status prior to sexual acts risk prosecution for aggravated sexual assault even if they have sex with a condom or while having a low (or undetectable) viral load, they had no intent to transmit HIV, and no transmission occurred. In 2013, six distinguished Canadian HIV scientists and clinicians took ground-breaking action to advance justice by co-authoring the “Canadian consensus statement on HIV and its transmission in the context of the criminal law.” This effort was born out of the belief that the application of criminal law to HIV non-disclosure was being driven by a poor appreciation of the science of HIV. More than 75 HIV scientists and clinicians Canada-wide have now endorsed the statement, agreeing that “[they] have a professional and ethical responsibility to assist those in the criminal justice system to understand and interpret current medical and scientific evidence regarding HIV.” As some 61 countries have adopted laws that specifically allow for HIV criminalization, and prosecutions for HIV non-disclosure, exposure and transmission have been reported in at least 49 countries, the authors hope that others around the world will take similar action.     

Test-retest reliability of the Valsalva maneuver in spinal cord injury

Objective: To determine the test-retest reliability of quantitative and qualitative baroreflex sensitivity (BRS) parameters derived from the Valsalva maneuver (VM) in individuals with traumatic cervical SCI.Design: Test-retest reliability.Setting: Tertiary rehabilitation center.Participants: Fourteen participants with cervical SCI (ranging from C3-C8 neurological level).Outcome Measurements: Beat-to-beat systolic blood pressure (SBP) traces (finger photoplethysmography) were obtained during a 15-second forced expiration at two time points (7.6 ± 2.9 days between sessions) to assess VM reliability. Test-retest reliability of BRS metrics from derived from the VM (Valsalva ratio; VR, pressure recovery time; PRT, vagal baroreflex sensitivity; BRSv, adrenergic baroreflex sensitivity; BRSa₁, and total recovery; TR) were assessed by intra-class correlation coefficient (ICC, with 95% confidence interval; CI) and by qualitative reproducibility (V, N, or M pattern).Results: ICCs for quantitative parameters were (CI): VR = 0.894 (0.703–0.965), TR = 0.927 (0.789–0.976), BRSa₁ = 0.561 (0.149–0.911), PRT = 0.728 (0.343–0.904), BRSv = 0.243 (−0.309–0.673). Qualitatively, 12 subjects (85.7%) demonstrated reproducible VM patterns at both time points (3 “M” pattern, 8 “V” pattern and one “N” pattern).Conclusion: VR (a measure of cardiovagal function) and TR (a measure of sympathetic adrenergic function) are reliable quantitative parameters that can be derived from SBP response to VM in participants with SCI. Qualitative waveform analysis was reproducible in 12/14 participants. This provides the foundational evidence required to pursue further validity testing to establish a role for VM in the assessment of autonomic functions in SCI.