Challenges of a hidden epidemic: HIV prevention among women in the United States

A systematic review of the use of atazanavir in women infected with HIV-1

BACKGROUND

Despite increasing numbers of women with HIV worldwide, females are under-represented in clinical trials of antiretrovirals and literature addressing gender differences in clinical outcomes, treatment discontinuation, adverse events and adherence are limited. Most recommendations specific to women in current guidelines relate to pregnant women or women wishing to become pregnant. The purpose of this systematic review is to provide clinicians with an overview of available literature regarding the use of ritonavir-boosted atazanavir (ATV/r) in women.

METHODS

The online databases PubMed and EMBASE, HIV-related conference abstracts and reference lists of relevant articles were searched according to predefined terms and limited to items published from 1 October 2007 to 1 October 2012. Updates to conference presentations were checked for substantive journal publication up to 28 November 2013.

RESULTS

Of the 294 initial citations retrieved, manual selection identified 19 relevant publications describing gender-based analyses of ATV/r. Publications describing gender-based differences in efficacy, safety, tolerability, pharmacokinetics, drug-drug interactions and adherence are critically evaluated.

CONCLUSIONS

As part of a combination antiretroviral therapy regimen, ATV/r appears to be a safe, effective and durable option for treatment-naive and early treatment-experienced patients with HIV-1 infection, including non-pregnant and pregnant women.

Active Drug-Using Women Use Female-Initiated Barrier Methods to Reduce HIV/STI Risk: Results from a Randomized Trial

Background. We tested an original, woman-focused intervention, based on body empowerment, and female-initiated barrier methods, including the female condom (FC) and cervical barriers. Methods. Eligible women were >= 18 years of age, HIV seronegative, and active drug users, reporting 30% or greater unprotected sex acts. Both controls (C) and intervention (I) participants received enhanced HIV/STI harm reduction counseling. I participants underwent 5 additional weekly group sessions. We compared change in frequency of unprotected vaginal intercourse across arms at 12 months. Results. Among 198 enrolled women, over 95% completed followup. Two-thirds were African-American; most of them used crack, had a primary partner, and reported sex exchange. In paired t-tests from baseline to followup, the frequency of unprotected vaginal sex dropped significantly for I (primary P < 0.00, nonprimary P < 0.002) and C (primary P < 0.008, nonprimary P < 0.000) arms with all partners. The difference in change across arms was of borderline significance for primary partner (P = 0.075); no difference was seen for nonprimary partner (P = 0.8). Use of male condom and FC increased with both partner types over time, but more consistently among I women. Conclusion: The “value-added” impact of the intervention was observed mainly with primary partners. Body knowledge with routine FC counseling should be incorporated into interventions for drug-using women.

Social justice and HIV vaccine research in the age of pre-exposure prophylaxis and treatment as prevention

The advent of pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) as means of HIV prevention raises issues of justice concerning how most fairly and equitably to apportion resources in support of the burgeoning variety of established HIV treatment and prevention measures and further HIV research, including HIV vaccine research. We apply contemporary approaches to social justice to assess the ethical justification for allocating resources in support of HIV vaccine research given competing priorities to support broad implementation of HIV treatment and prevention measures, including TasP and PrEP. We argue that there is prima facie reason to believe that a safe and effective preventive HIV vaccine would offer a distinct set of ethically significant benefits not provided by current HIV treatment or prevention methods. It is thereby possible to justify continued support for HIV vaccine research despite tension with priorities for treatment, prevention, and other research. We then consider a counter-argument to such a justification based on the uncertainty of successfully developing a safe and effective preventive HIV vaccine. Finally, we discuss how HIV vaccine research might now be ethically designed and conducted given the new preventive options of TasP and PrEP, focusing on the ethically appropriate standard of prevention for HIV vaccine trials.

Building social networks for health promotion: Shout-out Health, New Jersey, 2011

Background

Building social networks for health promotion in high-poverty areas may reduce health disparities. Community involvement provides a mechanism to reach at-risk people with culturally tailored health information. Shout-out Health was a feasibility project to provide opportunity and support for women at risk for or living with human immunodeficiency virus infection to carry out health promotion within their informal social networks.

Community Context

The Shout-out Health project was designed by an academic–community agency team. During 3 months, health promotion topics were chosen, developed, and delivered to community members within informal social networks by participants living in Paterson and Jersey City, New Jersey.

Methods

We recruited women from our community agency partner’s clients; 57 women participated in in-person or online meetings facilitated by our team. The participants identified and developed the health topics, and we discussed each topic and checked it for message accuracy before the participants provided health promotion within their informal social networks. The primary outcome for evaluating feasibility included the women’s feedback about their experiences and the number of times they provided health promotion in the community. Other data collection included participant questionnaires and community-recipient evaluations.

Outcome

More than half of the participants reported substantial life challenges, such as unemployment and housing problems, yet with technical support and a modest stipend, women in both groups successfully provided health promotion to 5,861 people within their informal social networks.

Interpretation

Shout-out Health was feasible and has implications for building social networks to disseminate health information and reduce health disparities in communities.

Efficacy of an HIV intervention in reducing high-risk human papillomavirus, nonviral sexually transmitted infections, and concurrency among African American women: a randomized-controlled trial

OBJECTIVE

This trial evaluated the efficacy of an HIV-intervention condition, relative to a health-promotion condition, in reducing incidence of nonviral sexually transmitted infections (STIs; Chlamydia, gonorrhea, and trichomoniasis), oncogenic human papillomavirus (HPV) subtypes 16 and 18, sexual concurrency, and other HIV-associated behaviors over a 12-month period.

DESIGN

Randomized-controlled trial. Data analysts blinded to treatment allocation.

SETTING

Kaiser Permanente, GA.

SUBJECTS

A random sample of 848 African American women.

INTERVENTION

The two 4-hour HIV intervention sessions were based on Social Cognitive Theory and the Theory of Gender and Power. The intervention was designed to enhance participants' self-sufficiency and attitudes and skills associated with condom use. The HIV intervention also encouraged STI testing and treatment of male sex partners and reducing vaginal douching and individual and male partner concurrency.

MAIN OUTCOME MEASURE

Incident nonviral STIs.

RESULTS

In generalized estimating equations' analyses, over the 12-month follow-up, participants in the HIV intervention, relative to the comparison, were less likely to have nonviral incident STIs (odds ratio [OR] = 0.62; 95% confidence interval [CI]: 0.40 to 0.96; P = 0.033) and incident high-risk HPV infection (OR = 0.37; 95% CI: 0.18 to 0.77; P = 0.008) or concurrent male sex partners (OR = 0.55; 95% CI: 0.37 to 0.83; P = 0.005). In addition, intervention participants were less likely to report multiple male sex partners, more likely to use condoms during oral sex, more likely to inform their main partner of their STI test results, encourage their main partner to seek STI testing, report that their main partner was treated for STIs, and report not douching.

CONCLUSIONS

This is the first trial to demonstrate that an HIV intervention can achieve reductions in nonviral STIs, high-risk HPV, and individual concurrency.

Relationship between menopause symptoms and HIV risk among midlife women in methadone treatment: a pilot study

This pilot study explores somatic, psychological, and urogenital menopause symptoms associated with HIV drug and sexual risk among midlife women with substance abuse histories in methadone maintenance treatment. The Menopause Rating Scale (MRS) assessed menopause symptoms and severity. The Risk Behavior Assessment assessed demographic characteristics, drug, and sexual risk behaviors. Menopause symptom associations of HIV drug and sexual risk findings indicated that high school graduates and women not having sex with a regular partner scored significantly higher on the MRS somatic symptom subscale. HIV negative women had higher total MRS scores compared with HIV positive women. Forty-six percent of the sample was sexually active with almost half engaged in unprotected sex. Significant associations with sexual risk were high MRS somatic subscale scores with inconsistent condom use for vaginal sex, HIV negative with inconsistent protected vaginal sex, heroin use with having sex while high with HIV negative status. Preliminary data provide a basis for further exploration and designing intervention approaches to reduce HIV risk and further transmission among midlife women in methadone treatment.

The impact of social context on self-management in women living with HIV

HIV self-management is central to the health of people living with HIV and is comprised of the daily tasks individuals employ to manage their illness. Women living with HIV are confronted with social context vulnerabilities that impede their ability to conduct HIV self-management behaviors, including demanding social roles, poverty, homelessness, decreased social capital, and limited access to health care. We examined the relationship between these vulnerabilities and HIV self-management in a cross-sectional secondary analysis of 260 women living with HIV from two U.S. sites. All social context variables were assessed using validated self-report scales. HIV Self-Management was assessed using the HIV Self-Management Scale that measures daily health practices, HIV social support, and the chronic nature of HIV. Data were analyzed using appropriate descriptive statistics and multivariable regression. Mean age was 46 years and 65% of participants were African-American. Results indicated that social context variables, particularly social capital, significantly predicted all domains of HIV self-management including daily health practices (F = 5.40, adjusted R(2) = 0.27, p < 0.01), HIV social support (F = 4.50, adjusted R(2) = 0.22, p < 0.01), and accepting the chronic nature of HIV (F = 5.57, adjusted R(2) = 0.27, p < 0.01). We found evidence to support the influence of the traditional social roles of mother and employee on the daily health practices and the chronic nature of HIV domains of HIV self-management. Our data support the idea that women's social context influences their HIV self-management behavior. While social context has been previously identified as important, our data provide new evidence on which aspects of social context might be important targets of self-management interventions for women living with HIV. Working to improve social capital and to incorporate social roles into the daily health practices of women living with HIV may improve the health of this population.

HIV acquisition among women from selected areas of the United States: a cohort study

BACKGROUND

Women account for 23% of newly diagnosed HIV infections in the United States, but there are few recent, well-characterized cohorts of U.S. women in whom behavior characteristics and HIV acquisition have been well-described.

OBJECTIVE

To evaluate HIV incidence and describe behaviors among U.S. women residing in areas of high HIV prevalence.

DESIGN

Multisite, longitudinal cohort of women who had HIV rapid testing and audio computer-assisted self-interviews at baseline and every 6 months for up to 12 months. (ClinicalTrials.gov: NCT00995176)

SETTING

10 urban and periurban communities with high HIV prevalence and poverty rates, located in the northeastern and southeastern United States.

PATIENTS

Venue-based sampling was used to recruit women aged 18 to 44 years who recently had unprotected sex and had 1 or more additional personal or partner risk factors and no self-reported previous HIV diagnosis.

MEASUREMENTS

HIV prevalence and incidence, frequency of HIV risk behaviors, and health status perceptions.

RESULTS

Among 2099 high-risk women (85.9% black and 11.7% of Hispanic ethnicity), 32 (1.5%) were diagnosed with HIV infection at enrollment. Annual HIV incidence was 0.32% (95% CI, 0.14% to 0.74%). Older age, substance use, and knowing a partner had HIV were associated with HIV prevalence. Ten women died during the study (0.61% per year).

LIMITATIONS

Longitudinal assessment of risk behaviors was limited to a maximum of 12 months. There were few incident HIV infections, precluding identification of characteristics predictive of HIV acquisition.

CONCLUSION

This study enrolled a cohort of women with HIV incidence substantially higher than the Centers for Disease Control and Prevention national estimate in the general population of U.S. black women. Concerted efforts to improve preventive health care strategies for HIV and overall health status are needed for similar populations.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Preventing HIV in U.S. women and girls: a call for social action

Successes in HIV prevention efforts in the U.S. have resulted in drastic reductions in the number of new infections in the U.S. among white gay men and injection drug users, a stabilization in overall annual rates of new HIV infections, and near eradication of mother-to child transmission of HIV. Despite this remarkable progress, the proportion of AIDS cases in women has slowly, quietly, and steadily increased from 7% in 1985 to 25% in 2008. The fact the prevention efforts have not reduced HIV spread among women suggests that targeting the individual behaviors of women to prevent HIV acquisition is not a sufficiently effective public health strategy. Interventions that more broadly address the needs of women and their families, and address the contextual factors in which HIV risk occurs are more likely to lead to measurable and sustainable progress. Over the past 30 years, we have seen the U.S. HIV epidemic in women become similar to patterns of HIV risk among women in the developing world. In 2009, 85% of women who acquired HIV became infected through sex with a man and the majority (83%) of them were non-white women. Efforts to understand these immense disparities and create gender-responsive strategies must be a priority within our National HIV/AIDS Strategy.

Recommendations of the IOM clinical preventive services for women committee: implications for obstetricians and gynecologists

PURPOSE OF REVIEW

In July 2011, in response to language in the Affordable Care Act (ACA) the Office of the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services (HHS) tasked the Institute of Medicine (IOM) to develop a report on the clinical preventive services necessary for women. The committee proposed eight new clinical preventive service recommendations aimed at closing significant gaps in preventive healthcare. This article reviews the process, findings, and the implications for obstetrician gynecologists and other primary care clinicians. Obstetricians and gynecologists play a major role in delivering primary care to women and many of the services recommended by the Committee are part of the core set of obstetrics and gynecology services.

RECENT FINDINGS

The women's health amendment to the ACA (Federal Register, 2010) requires that new private health plans cover - with no cost-sharing requirements - preventive healthcare services for women. Congress requested that a review be conducted to ascertain whether there were any additional needed preventive services specific to women's health that should be included.

SUMMARY

The IOM Committee on Preventive Services for Women recommended eight clinical measures specific to women's health that should be considered for coverage without co-payment. The US Department of HHS reviewed and adopted these recommendations, and, as a result, new health plans will need to include these services as part of insurance policies with plan years beginning on or after 1 August 2012. The authors discuss the implications of the IOM recommendations on practicing clinicians and on their potential impact on women's health and well being.

From racial discrimination to risky sex: prospective relations involving peers and parents

This study investigated how early experience with racial discrimination affected the subsequent risky sexual behaviors of a diverse sample of African American youths (N = 745). The analyses focused on 3 risk-promoting factors thought to mediate the hypothesized discrimination → risky sex relation: negative affect, affiliation with deviant peers, and favorable attitudes toward risky sex. In addition, attentive parenting was examined as a protective factor. Analyses using structural equation modeling revealed that youths who perceived more racial discrimination at age 10 or 11 were engaging in more sexual risk taking at age 18 or 19. This relation was mediated by the hypothesized risk-promoting factors via pathways that were consistent with our conceptual model. Results also indicated a prospective reciprocal relation between parenting and children's deviant affiliations: deviant peer affiliations at age 10 or 11 predicted more attentive parenting behaviors by the parents; this response from the parents, in turn, predicted relatively fewer deviant affiliations when the youths were 15 or 16. Study findings are discussed in terms of their relevance to the disproportionately high rates of sexually transmitted infections among African Americans.

Experience in international clinical research: the HIV Prevention Trials Network

The HIV Prevention Trials Network (HPTN) is supported by the NIH to conduct randomized clinical trials to assess the efficacy of HIV prevention strategies and technologies to reduce HIV transmission between adults. A special focus of attention is on the use of antiretroviral drugs to prevent HIV transmission, both by reducing infectiousness among HIV-infected persons taking combination antiretroviral therapy (cART) and also by reducing susceptibility among HIV-uninfected persons taking antiretrovirals for pre-exposure prophylaxis. Studies may be developmental in nature to assess novel ideas for interventions or for assessing trial feasibility. However, pivotal efficacy trials to test HIV-specific prevention strategies and technologies are the main HPTN priority. Examples include a major protocol investigating the impact of expanded testing and linkage to care on HIV surveillance indicators in the USA (HPTN 065). Another protocol is addressing similar issues while also investigating how combinations of prevention approaches are best deployed to make a community-level impact in southern Africa (HPTN 071). HPTN 068 is evaluating a novel conditional cash transfer structural intervention to increase school completion rates in young girls and thereby reduce their HIV risk. Studies outside the US address the epidemic in most at-risk populations and include an assessment of opiate agonist therapy to reduce risk of HIV seroconversion among injection drug users (HTPN 058), methods to increase HIV testing rates (HTPN 043), as well as methods for reducing high-risk behaviors, and increasing adherence to cART in HIV-infected individuals (HPTN 062 and HPTN 063, respectively). The recent HPTN 052 study demonstrated that a 96% reduction in HIV transmission could be achieved between serodiscordant sexual partners by providing the infected partners with cART at a CD4(+) cell count (350-550/µl) above the level that would usually qualify them for therapy in low- and middle-income countries. The immediate relevance to public health policy showcased in these trials is a paradigm for the HPTN: design and conduct of clinical trials using available licensed tools that can be rapidly translated for implementation ('Prevention NOW!').