Effectiveness of HIV prevention strategies in resource-poor countries: tailoring the intervention to the context

A Tale of Three Recent Pandemics: Influenza, HIV and SARS-CoV-2

Emerging infectious diseases are one of the main threats to public health, with the potential to cause a pandemic when the infectious agent manages to spread globally. The first major pandemic to appear in the 20th century was the influenza pandemic of 1918, caused by the influenza A H1N1 strain that is characterized by a high fatality rate. Another major pandemic was caused by the human immunodeficiency virus (HIV), that started early in the 20th century and remained undetected until 1981. The ongoing HIV pandemic demonstrated a high mortality and morbidity rate, with discrepant impacts in different regions around the globe. The most recent major pandemic event, is the ongoing pandemic of COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has caused over 5.7 million deaths since its emergence, 2 years ago. The aim of this work is to highlight the main determinants of the emergence, epidemic response and available countermeasures of these three pandemics, as we argue that such knowledge is paramount to prepare for the next pandemic. We analyse these pandemics’ historical and epidemiological contexts and the determinants of their emergence. Furthermore, we compare pharmaceutical and non-pharmaceutical interventions that have been used to slow down these three pandemics and zoom in on the technological advances that were made in the progress. Finally, we discuss the evolution of epidemiological modelling, that has become an essential tool to support public health policy making and discuss it in the context of these three pandemics. While these pandemics are caused by distinct viruses, that ignited in different time periods and in different regions of the globe, our work shows that many of the determinants of their emergence and countermeasures used to halt transmission were common. Therefore, it is important to further improve and optimize such approaches and adapt it to future threatening emerging infectious diseases.

Tailoring a sexual health curriculum to the sexual health challenges seen by midwifery, nursing and medical providers and students in Tanzania

BACKGROUND

 Tanzania is a country experiencing multiple sexual health challenges, but providers receive no formal training in sexual health.

AIM

 This study aimed to assess (1) what sexual health challenges are commonly seen in clinics in Tanzania, (2) which are raised by patients, (3) which are not addressed and (4) which topics to prioritise for a sexual health curriculum.

SETTING

 Healthcare settings in Tanzania.

METHODS

 Participants were 60 experienced and 61 student doctors, nurses and midwives working in Dar es Salaam. The authors conducted 18 focus groups stratified by profession (midwifery, nursing or medicine) and experience (practitioners vs. students).

RESULTS

 Providers identified six common sexual health concerns: (1) Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) and sexually transmissible infection (STI) (especially syphilis and gonorrhoea), (2) sexual violence (including intimate partner violence and female genital mutilation), (3) early and unwanted pregnancy (including early sexual debut and complications from abortion), (4) sexual dysfunctions, (5) key population concerns (e.g. lesbian, gay, bisexual, transgender (LGBT); sex work) and (6) non-procreative sexual behaviour (including pornography and masturbation in males and oral and anal sex practices in heterosexual couples). Across professions, few differences were observed. Homosexuality, sex work, masturbation and pornography were identified as taboo topics rarely discussed. Most participants (81%) wanted one comprehensive sexual health curriculum delivered across disciplines.

CONCLUSION

 A sexual health curriculum for health students in Tanzania needs to address the most common sexual health concerns of patients. In addition to teaching sexual science and clinical care, skills training in how to address taboo topics is recommended. Students endorsed almost all sexual health topics, which suggests that a comprehensive curriculum is appropriate.

Getting to zero HIV/AIDS in sub-Saharan Africa: Understanding perceptions of locals using the social determinants of health framework

This study explored a community perception of the facilitators and inhibitors of Getting to Zero (GTZ) in rural Zambia, sub-Saharan Africa. Data were collected in 2017. We use the Social Determinants of Health framework to guide organisation of key themes emerging from semistructured, focus group interviews with community members (N = 52). Data were analysed through an iterative descriptive/thematic approach which allowed for the highlighting of key themes. Emerging themes point to the significance of (a) individual, (b) sociocultural, (c) environmental and (d) economic factors, for example, treatment adherence, gender norms, food security and access to health care as important in GTZ. Implications for policy, practise and scholarship are suggested.

The Crisis of Sickle Cell Disease in Africa from Insights into Primary Prevention in Ghana and Nigeria: Notes from the Field

Sickle cell disease (SCD), an inherited blood disorder, impacts 2% of newborns in Nigeria and Ghana. Despite devastating health consequences, SCD prevention is not a priority in either country. This article describes our U.S. research team's feasibility assessment for adapting CHOICES, a computer-based SCD education program, for use in Ghana and Nigeria. We identified indigenous collaborators by reviewing published research and investigating advocacy organizations online. This led to a fact-finding trip to Africa to discuss SCD prevention with local boards of advisors. Three major recommendations emerged from the group discussions: design a culturally appropriate intervention; enlist community healthcare workers to deliver the CHOICES program; and collaborate with religious and community leaders and elders in public awareness campaigns. Based on extensive advisor input, we will modify the content and delivery of the CHOICES intervention to meet the needs of those impacted by SCD in Ghana and Nigeria.

Physical activity, social support and socio-economic status amongst persons living with HIV and AIDS: a review

Physical activity can be used for the effective and comprehensive management of HIV and AIDS. Social support and socio-economic status (SES) are two factors that shape physical activity behaviours. Individuals of low SES carry a disproportionate burden of the HIV and AIDS epidemic. In addition, limited resources constitute socio-ecological barriers predisposing such individuals to physical inactivity. The purpose of this narrative review is to examine the available literature on physical activity, social support and SES and to generate recommendations for designing and implementing physical activity interventions targeting people living with HIV and AIDS (PLWHA) of low SES. The review used literature from Google, Google Scholar and PubMed on physical activity of PLWHA, social support for physical activity, and SES and physical activity. Qualitative and quantitative studies in English were included from 1970 to 2016. The results show that social support plays a major role in promoting physical activity and counteracting the barriers to PA in PLWHA of low SES. The results on the role of social support and the influence of SES are integrated to help design appropriate physical activity interventions for PLWHA of low SES. Well-designed interventions should utilise social support and be contextualised for PLWHA of low SES, whose living conditions present multiple barriers to physical activity.

Sustained progress, but no room for complacency: Results of 2015 HIV estimations in India

Background & objectives:

Evidence-based planning has been the cornerstone of India's response to HIV/AIDS. Here we describe the process, method and tools used for generating the 2015 HIV estimates and provide a summary of the main results.

Methods:

Spectrum software supported by the UNAIDS was used to produce HIV estimates for India as a whole and its States/Union Territories. This tool takes into consideration the size and HIV prevalence of defined population groups and programme data to estimate HIV prevalence, incidence and mortality over time as well as treatment needs.

Results:

India's national adult prevalence of HIV was 0.26 per cent in 2015. Of the 2.1 million people living with HIV/AIDS, the largest numbers were in Andhra Pradesh, Maharashtra and Karnataka. New HIV infections were an estimated 86,000 in 2015, reflecting a decline by around 32 per cent from 2007. The declining trend in incidence was mirrored in most States, though an increasing trend was detected in Assam, Chandigarh, Chhattisgarh, Gujarat, Sikkim, Tripura and Uttar Pradesh. AIDS-related deaths were estimated to be 67,600 in 2015, reflecting a 54 per cent decline from 2007. There were variations in the rate and trend of decline across India for this indicator also.

Interpretation & conclusions:

While key indicators measured through Spectrum modelling confirm success of the National AIDS Control Programme, there is no room for complacency as rising incidence trends in some geographical areas and population pockets remain the cause of concern. Progress achieved so far in responding to HIV/AIDS needs to be sustained to end the HIV epidemic.

Virological and immunological failure of HAART and associated risk factors among adults and adolescents in the Tigray region of Northern Ethiopia

Background

Human immunodeficiency virus/Acquired immunodeficiency syndrome associated morbidity and mortality has reduced significantly since the introduction of highly active antiretroviral therapy. As a result of increasing access to highly active antiretroviral therapy, the survival and quality of life of the patients has significantly improved globally. Despite this promising result, regular monitoring of people on antiretroviral therapy is recommended to ensure whether there is an effective treatment response or not. This study was designed to assess virological and immunological failure of highly active antiretroviral therapy users among adults and adolescents in the Tigray region of Northern Ethiopia, where scanty data are available.

Methods

A retrospective follow up study was conducted from September 1 to December 30, 2016 to assess the magnitude and factors associated with virological and immunological failure among 260 adults and adolescents highly active antiretroviral therapy users who started first line ART between January 1, 2008 to March 1, 2016. A standardized questionnaire was used to collect socio-demographic and clinical data. SPSS Version21 statistical software was used for analysis. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated to virological and immunological failure. Statistical association was declared significant if p-value was ≤ 0.05.

Result

A total of 30 (11.5%) and 17 (6.5%) participants experienced virological and immunological failure respectively in a median time of 36 months of highly active antiretroviral therapy. Virological failure was associated with non-adherence to medications, aged < 40 years old, having CD4⁺ T-cells count < 250 cells/μL and male gender. Similarly, immunological failure was associated with non-adherence, tuberculosis co-infection and Human immunodeficiency virus RNA ≥1000 copies/mL.

Conclusions

The current result shows that immunological and virological failure is a problem in a setting where highly active antiretroviral therapy has been largely scale up. The problem is more in patients with poor adherence. This will in turn affect the global targets of 90% viral suppression by 2020. This may indicate the need for more investment and commitment to improving patient adherence in the study area.

Scaling up family planning in Sierra Leone: A prospective cost-benefit analysis

Family planning is commonly regarded as a highly cost-effective health intervention with wider social and economic benefits. Yet use of family planning services in Sierra Leone is currently low and 25.0% of married women have an unmet need for contraception. This study aims to estimate the costs and benefits of scaling up family planning in Sierra Leone. Using the OneHealth Tool, two scenarios of scaling up family planning coverage to currently married women in Sierra Leone over 2013-2035 were assessed and compared to a 'no-change' counterfactual. Our costing included direct costs of drugs, supplies and personnel time, programme costs and a share of health facility overhead costs. To monetise the benefits, we projected the cost savings of the government providing five essential social services - primary education, child immunisation, malaria prevention, maternal health services and improved drinking water - in the scale-up scenarios compared to the counterfactual. The total population, estimated at 6.1 million in 2013, is projected to reach 8.3 million by 2035 in the high scenario compared to a counterfactual of 9.6 million. We estimate that by 2035, there will be 1400 fewer maternal deaths and 700 fewer infant deaths in the high scenario compared to the counterfactual. Our modelling suggests that total costs of the family planning programme in Sierra Leone will increase from US$4.2 million in 2013 to US$10.6 million a year by 2035 in the high scenario. For every dollar spent on family planning, Sierra Leone is estimated to save US$2.10 in expenditure on the five selected social sector services over the period. There is a strong investment case for scaling up family planning services in Sierra Leone. The ambitious scale-up scenarios have historical precedent in other sub-Saharan African countries, but the extent to which they will be achieved depends on a commitment from both the government and donors to strengthening Sierra Leone's health system post-Ebola.

The Relationship of Repeated Technical Assistance Support Visits to the Delivery of Positive Health, Dignity, and Prevention (PHDP) Messages by Healthcare Providers in Mozambique: A Longitudinal Multilevel Analysis

BACKGROUND

Positive health, dignity, and prevention (PHDP) is Mozambique's strategy to engage clinicians in the delivery of prevention messages to their HIV-positive clients. This national implementation strategy uses provider trainings on offering key messages and focuses on intervening on 9 evidence-based risk reduction areas. We investigated the impact of longitudinal technical assistance (TA) as an addition to this basic training.

METHODS

We followed 153 healthcare providers in 5 Mozambican provinces over 6 months to evaluate the impact of on-site, observation-based TA on PHDP implementation. Longitudinal multilevel models were estimated to model change in PHDP message delivery over time among individual providers.

RESULTS

With each additional TA visit, providers delivered about 1 additional PHDP message ( P < .001); clinicians and nonclinicians started at about the same baseline level, but clinicians improved more quickly ( P = .004). Message delivery varied by practice sector; maternal and child health sectors outperformed other sectors.

CONCLUSION

Longitudinal TA helped reach the programmatic goals of the PHDP program in Mozambique.

Spatial clustering of "measured" and "unmeasured" risk factors for HIV infections in hyper-endemic communities in KwaZulu-Natal, South Africa: results from geoadditive models

Sub-Saharan Africa contains more than 60% of all HIV infections worldwide. HIV prevalence was currently estimated to be at least 15% in KwaZulu-Natal and the epidemic is described as hyper-endemic. Knowledge of spatial clustering of risk factors which are linked to new HIV infections is important for prioritizing areas to change the trajectory of the epidemic. Geoadditive models were used to investigate spatial characteristics of the risk factors from two clinical trial units (Umkomaas and Botha's Hill) in the province of KwaZulu-Natal, South Africa. Study population was a cohort of women who screened and enrolled in an HIV prevention biomedical intervention trial. The results suggest high HIV incidence rates (5.8 and 8 per 100 person-year). Considerable spatial variations in behavioural factors within a relatively small geographical region, low level of education, early age at sexual debut, higher number of sexual partners, not being married/cohabitating with a sexual partner and sexual activity in exchange for money, gift and drugs were all determined to be clustered in certain regions; they were accounted for 25% (Umkomaas) and 65% (Botha's Hill) of the excess new HIV infections in two clinical trial units. Results from our study highlighted existence of significant spatial heterogeneity in "measured" and "unmeasured" risk factors in a relatively small region. As the HIV funding has been declining, identifying, targeting and reaching the most-at-risk individuals will likely play a significant role in developing the most efficient and cost-effective prevention programmes and subsequently will change the trajectory of the epidemic.

Spatial Distributions of HIV Infection in an Endemic Area of Western Kenya: Guiding Information for Localized HIV Control and Prevention

HIV is still a major health problem in developing countries. Even though high HIV-risk-taking behaviors have been reported in African fishing villages, local distribution patterns of HIV infection in the communities surrounding these villages have not been thoroughly analyzed. The objective of this study was to investigate the geographical distribution patterns of HIV infection in communities surrounding African fishing villages. In 2011, we applied age- and sex-stratified random sampling to collect 1,957 blood samples from 42,617 individuals registered in the Health and Demographic Surveillance System in Mbita, which is located on the shore of Lake Victoria in western Kenya. We used these samples to evaluate existing antibody detection assays for several infectious diseases, including HIV antibody titers. Based on the results of the assays, we evaluated the prevalence of HIV infection according to sex, age, and altitude of participating households. We also used Kulldorff’s spatial scan statistic to test for HIV clustering in the study area. The prevalence of HIV at our study site was 25.3%. Compared with the younger age group (15–19 years), adults aged 30–34 years were 6.71 times more likely to be HIV-positive, and the estimated HIV-positive population among women was 1.43 times larger than among men. Kulldorff’s spatial scan statistic detected one marginally significant (P = 0.055) HIV-positive and one significant HIV-negative cluster (P = 0.047) in the study area. These results suggest a homogeneous HIV distribution in the communities surrounding fishing villages. In addition to individual behavior, more complex and diverse factors related to the social and cultural environment can contribute to a homogeneous distribution pattern of HIV infection outside of African fishing villages. To reduce rates of transmission in HIV-endemic areas, HIV prevention and control programs optimized for the local environment need to be developed.

Sociocognitive Predictors of Condom Use and Intentions Among Adolescents in Three Sub-Saharan Sites

Many HIV intervention programs in sub-Saharan Africa have applied social cognitive theories such as the theory of planned behavior. However, a recent sub-Saharan African review was unable to show increased effectiveness for theory-based interventions. This study assessed whether the predictive value of attitudes, subjective norms, self-efficacy, and intention was similar to studies in Europe and the U.S., and whether there were differences between three sub-Saharan sites. Longitudinal multigroup structural equation modeling was used to assess whether attitudes, subjective norms, and self-efficacy predicted condom use intentions and condom use (after 6 months) among adolescents in three sites, namely Cape Town (South Africa; N = 625), Dar es Salaam (Tanzania; N = 271), and Mankweng (South Africa; N = 404). Condom use intentions were predicted by subjective norms and self-efficacy in all three sites. Attitudes were not related to intentions in Dar es Salaam and were moderately related to intentions in Cape Town and Mankweng. The proportions of explained variance in intentions and behavior were decent (37-52 and 9-19%, respectively). Although significant differences in predictive value were found between sites and in comparison to European and U.S. studies, intentions could adequately be explained by attitudes, subjective norms, and self-efficacy. However, the limited proportions of variance in behavior explained by intentions could signify the importance of contextual and environmental factors. Future studies are recommended to use an integrative approach that takes into account both individual and contextual factors, as well as social and environmental differences.

Voluntary medical male circumcision scale-up in Nyanza, Kenya: evaluating technical efficiency and productivity of service delivery

Background

Voluntary medical male circumcision (VMMC) service delivery is complex and resource-intensive. In Kenya’s context there is still paucity of information on resource use vis-à-vis outputs as programs scale up. Knowledge of technical efficiency, productivity and potential sources of constraints is desirable to improve decision-making.

Objective

To evaluate technical efficiency and productivity of VMMC service delivery in Nyanza in 2011/2012 using data envelopment analysis.

Design

Comparative process evaluation of facilities providing VMMC in Nyanza in 2011/2012 using output orientated data envelopment analysis.

Results

Twenty one facilities were evaluated. Only 1 of 7 variables considered (total elapsed operation time) significantly improved from 32.8 minutes (SD 8.8) in 2011 to 30 minutes (SD 6.6) in 2012 (95%CI = 0.0350–5.2488; p = 0.047). Mean scale technical efficiency significantly improved from 91% (SD 19.8) in 2011 to 99% (SD 4.0) in 2012 particularly among outreach compared to fixed service delivery facilities (CI -31.47959–4.698508; p = 0.005). Increase in mean VRS technical efficiency from 84% (SD 25.3) in 2011 and 89% (SD 25.1) in 2012 was not statistically significant. Benchmark facilities were #119 and #125 in 2011 and #103 in 2012. Malmquist Productivity Index (MPI) at fixed facilities declined by 2.5% but gained by 4.9% at outreach ones by 2012. Total factor productivity improved by 83% (p = 0.032) in 2012, largely due to progress in technological efficiency by 79% (p = 0.008).

Conclusions

Significant improvement in scale technical efficiency among outreach facilities in 2012 was attributable to accelerated activities. However, ongoing pure technical inefficiency requires concerted attention. Technological progress was the key driver of service productivity growth in Nyanza. Incorporating service-quality dimensions and using stepwise-multiple criteria in performance evaluation enhances comprehensiveness and validity. These findings highlight site-level resource use and sources of variations in VMMC service productivity, which are important for program planning.

Preconception care: preventing and treating infections

Introduction

Infections can impact the reproductive health of women and hence may influence pregnancy related outcomes for both the mother and the child. These infections range from sexually transmitted infections (STIs) to TORCHS infections to periodontal disease to systemic infections and may be transmitted to the fetus during pregnancy, labor, delivery or breastfeeding.

Methods

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

Results

Preconception behavioral interventions significantly declines re-infection or new STI rates by 35% (95% CI: 20-47%). Further, condom use has been shown to be the most effective way to prevent HIV infection (85% protection in prospective studies) through sexual intercourse. Intervention trials showed that preconception vaccination against tetanus averted a significant number of neonatal deaths (including those specifically due to tetanus) when compared to placebo in women receiving more than 1 dose of the vaccine (OR 0.28; 95% CI: 0.15-0.52); (OR 0.02; 95% CI: 0.00-0.28) respectively.

Conclusion

Preconception counseling should be offered to women of reproductive age as soon as they test HIV-positive, and conversely women of reproductive age should be screened with their partners before pregnancy. Risk assessment, screening, and treatment for specific infections should be a component of preconception care because there is convincing evidence that treatment of these infections before pregnancy prevents neonatal infections.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Using mixed-method assessment to advance adolescent HIV prevention

This two-phase, community-based pilot study examined the impact of an innovative calendar-based assessment on HIV risk perception and risk reduction planning with racially diverse youth aged 14 to 21 at a public health clinic. Participants (N = 232) completed a Sexual Health History Calendar (SHHC) assessing behaviors over the previous 12 months, risk self-appraisals, and future behavioral intentions. Youths' narratives included negative self-appraisals (36%), named a risk-related critical incident (13%) or regret (9%), or expressed increased risk awareness (9%) and need for behavior change (18%). A minority were positive (28%) or reflected improvement (7%). All Phase 2 participants (n = 122) identified at least one specific risky behavior they intended to change. These data and the SHHC's visual cues facilitated risk-reduction intervention tailored to the unique circumstances in which each youth's risk taking occurred. For nurses and other providers in clinical settings, the SHHC can offer a critical link between assessment and intervention.

Changes in sexual behaviors among HIV-infected individuals after their HIV diagnosis in a rural prefecture of Eastern China

OBJECTIVE

To describe changes in sexual behaviors among HIV-infected individuals after their HIV diagnosis.

METHODS

All HIV-infected individuals diagnosed by the end of 2009 in Taizhou Prefecture were invited to participate in this 12-month prospective study. Assessments including the total number and types of sexual contacts, and condom use details for up to their most familiar eight sexual contacts were collected both at enrollment and 12-month follow-up.

RESULTS

262 HIV-infected individuals were eligible for analysis. The total number of sexual contacts reported by participants was 4,017, 1,496 and 356 during the 12- month period prior to HIV diagnosis (T1), the 12-month period prior to the baseline survey (T2), and the 12-month follow-up period (T3), respectively. The difference in the number of sexual contacts between T2 and T1 was -5 in median (IQR -1, -14), and the difference between T3 and T2 was 0 in median (IQR: 0, -6). A larger proportion of spousal or long-term heterosexual contact was reported from T1(27.7%) to T2(42.5%) to T3(76.1%), whereas a smaller proportion of commercial heterosexual contacts was reported from T1 (48.6%) to T2 (33.2%) to T3 (7.0%) as well as a smaller proportion of non-commercial casual homosexual contacts was reported from T2 (8.4%) to T3 (3.8%).The proportion of consistent condom use increased significantly from T1 (9.3%) to T2 (35.3%) to T3 (91.5%).

CONCLUSION

Sexual behaviors did not change in a uniform manner for the participants in our study. Sexual behaviors and sexual networks vis-à-vis HIV diagnosis and follow-up were associated with the participant's characteristics and HIV infection and treatment status. The overall lesson is that individuals who are unaware of their HIV infection are the main drivers of secondary transmission. Early identification of HIV infection and access to antiretroviral therapy (ART) are both key strategies to the control and prevention.

Efficient and equitable HIV prevention: A case study of male circumcision in South Africa

Background

We determine efficient, equitable and mixed efficient-equitable allocations of a male circumcision (MC) intervention reducing female to male HIV transmission in South Africa (SA), as a case study of an efficiency-equity framework for resource allocation in HIV prevention.

Methods

We present a mathematical model developed with epidemiological and cost data from the nine provinces of SA. The hypothetical one-year-long MC intervention with a budget of US$ 10 million targeted adult men 15–49 years of age in SA. The intervention was evaluated according to two criteria: an efficiency criterion, which focused on maximizing the number of HIV infections averted by the intervention, and an equity criterion (defined geographically), which focused on maximizing the chance that each male adult individual had access to the intervention regardless of his province.

Results

A purely efficient intervention would prevent 4,008 HIV infections over a year. In the meantime, a purely equitable intervention would avert 3,198 infections, which represents a 20% reduction in infection outcome as compared to the purely efficient scenario. A half efficient-half equitable scenario would prevent 3,749 infections, that is, a 6% reduction in infection outcome as compared to the purely efficient scenario.

Conclusions

This paper provides a framework for resource allocation in the health sector which incorporates a simple equity metric in addition to efficiency. In the specific context of SA with a MC intervention for the prevention of HIV, incorporation of geographical equity only slightly reduces the overall efficiency of the intervention.

Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: evaluating findings from Project Accept (HPTN 043)

Background

Study-based global health interventions, especially those that are conducted on an international or multi-site basis, frequently require site-specific adaptations in order to (1) respond to socio-cultural differences in risk determinants, (2) to make interventions more relevant to target population needs, and (3) in recognition of ‘global health diplomacy' issues. We report on the adaptations development, approval and implementation process from the Project Accept voluntary counseling and testing, community mobilization and post-test support services intervention.

Methods

We reviewed all relevant documentation collected during the study intervention period (e.g. monthly progress reports; bi-annual steering committee presentations) and conducted a series of semi-structured interviews with project directors and between 12 and 23 field staff at each study site in South Africa, Zimbabwe, Thailand and Tanzania during 2009. Respondents were asked to describe (1) the adaptations development and approval process and (2) the most successful site-specific adaptations from the perspective of facilitating intervention implementation.

Results

Across sites, proposed adaptations were identified by field staff and submitted to project directors for review on a formally planned basis. The cross-site intervention sub-committee then ensured fidelity to the study protocol before approval. Successfully-implemented adaptations included: intervention delivery adaptations (e.g. development of tailored counseling messages for immigrant labour groups in South Africa) political, environmental and infrastructural adaptations (e.g. use of local community centers as VCT venues in Zimbabwe); religious adaptations (e.g. dividing clients by gender in Muslim areas of Tanzania); economic adaptations (e.g. co-provision of income generating skills classes in Zimbabwe); epidemiological adaptations (e.g. provision of ‘youth-friendly’ services in South Africa, Zimbabwe and Tanzania), and social adaptations (e.g. modification of terminology to local dialects in Thailand: and adjustment of service delivery schedules to suit seasonal and daily work schedules across sites).

Conclusions

Adaptation selection, development and approval during multi-site global health research studies should be a planned process that maintains fidelity to the study protocol. The successful implementation of appropriate site-specific adaptations may have important implications for intervention implementation, from both a service uptake and a global health diplomacy perspective.

Worldwide application of prevention science in adolescent health

The burden of morbidity and mortality from non-communicable disease has risen worldwide and is accelerating in low-income and middle-income countries, whereas the burden from infectious diseases has declined. Since this transition, the prevention of non-communicable disease as well as communicable disease causes of adolescent mortality has risen in importance. Problem behaviours that increase the short-term or long-term likelihood of morbidity and mortality, including alcohol, tobacco, and other drug misuse, mental health problems, unsafe sex, risky and unsafe driving, and violence are largely preventable. In the past 30 years new discoveries have led to prevention science being established as a discipline designed to mitigate these problem behaviours. Longitudinal studies have provided an understanding of risk and protective factors across the life course for many of these problem behaviours. Risks cluster across development to produce early accumulation of risk in childhood and more pervasive risk in adolescence. This understanding has led to the construction of developmentally appropriate prevention policies and programmes that have shown short-term and long-term reductions in these adolescent problem behaviours. We describe the principles of prevention science, provide examples of efficacious preventive interventions, describe challenges and potential solutions to take efficacious prevention policies and programmes to scale, and conclude with recommendations to reduce the burden of adolescent mortality and morbidity worldwide through preventive intervention.

Scaling up circumcision programs in Southern Africa: the potential impact of gender disparities and changes in condom use behaviors on heterosexual HIV transmission

Circumcision significantly reduces female-to-male transmission of HIV infection, but changes in behavior may influence the overall impact on transmission. We sought to explore these effects, particularly for societies where women have less power to negotiate safe sex. We developed a compartmental epidemic model to simulate the population-level impact of various circumcision programs on heterosexual HIV transmission in Soweto. We incorporated gender-specific negotiation of condom use in sexual partnerships and explored post-circumcision changes in condom use. A 5-year prevention program in which only an additional 10% of uncircumcised males undergo circumcision each year, for example, would prevent 13% of the expected new HIV infections over 20 years. Outcomes were sensitive to potential changes in behavior and differed by gender. For Southern Africa, even modest programs offering circumcision would result in significant benefits. Because decreases in male condom use could diminish these benefits, particularly for women, circumcision programs should emphasize risk-reduction counseling.

Acute HIV-1 infection is highly prevalent in Ugandan adults with suspected malaria

OBJECTIVES

Acute febrile illnesses consistent with malaria are the most common presentation at health clinics in sub-Saharan Africa, accounting for 30-50% of outpatient visits. The symptoms of acute HIV infection can mimic acute malaria. We investigated whether acute HIV infections could be identified among adults with suspected malaria at rural health centers in Uganda.

DESIGN

A cross-sectional study of 1000 consecutive patients referred for malaria blood smears at each of seven government health centers, of which 2893 (41%) were 13 years or older and tested for HIV.

METHODS

HIV enzyme immunoassay antibody testing was performed on dried blood spots and confirmed by western blot. Enzyme immunoassay-nonreactive and enzyme immunoassay-reactive, western blot-unconfirmed samples were pooled (10/pool) and tested for HIV RNA by nucleic acid amplification testing. We defined acute HIV infection as HIV-1 RNA positive with a negative or indeterminate HIV-1 western blot pattern and early HIV infection as HIV-1 RNA positive with a positive western blot pattern, but with a BED-corrected optical density of below 0.8.

RESULTS

Of 2893 patients evaluated, 324 (11%) had test results indicating HIV infection. Overall, 30 patients (1.0%) had acute HIV infection, 56 (1.8%) had early HIV infection, and 238 (8%) had established HIV infection. Acute HIV infections were more prevalent at sites with higher HIV prevalence and lower malaria endemicity.

CONCLUSION

At multiple sites in Uganda, 1-3% of adults with suspected malaria had acute or early HIV infection. These findings highlight a major opportunity for expanding recognition of acute and early HIV infection in Africa.

An effective, low-cost approach to implementing HIV/AIDS education programs in low literacy populations: an example from rural Haiti

The HIV/AIDS pandemic disproportionately afflicts regions of the world that have minimal access to formal schooling and low literacy rates. Health educational interventions are difficult to evaluate efficiently in these settings because standard approaches such as written questionnaires cannot easily be employed. Here, we describe a novel method of rapidly assessing health interventions among large groups that does not require the ability to read or write. We tested this evaluation tool within the context of a community-based HIV/AIDS drama education program in a low-literate region of rural Haiti. The evaluation was simple, easy to use, and confirmed substantial improvements in knowledge after the intervention. The tool also provided information that helped alter the intervention to improve educational outcomes in subsequent productions of the drama. This evaluation method can be utilized for very little cost, and may be replicated in resource-poor, non-literate settings throughout the developing world.

HIV prevention for South African youth: which interventions work? A systematic review of current evidence

BACKGROUND

In South Africa, HIV prevalence among youth aged 15-24 is among the world's highest. Given the urgent need to identify effective HIV prevention approaches, this review assesses the evidence base for youth HIV prevention in South Africa.

METHODS

Systematic, analytical review of HIV prevention interventions targeting youth in South Africa since 2000. Critical assessment of interventions in 4 domains: 1) study design and outcomes, 2) intervention design (content, curriculum, theory, adaptation process), 3) thematic focus and HIV causal pathways, 4) intervention delivery (duration, intensity, who, how, where).

RESULTS

Eight youth HIV prevention interventions were included; all were similar in HIV prevention content and objectives, but varied in thematic focus, hypothesised causal pathways, theoretical basis, delivery method, intensity and duration. Interventions were school- (5) or group-based (3), involving in- and out-of-school youth. Primary outcomes included HIV incidence (2), reported sexual risk behavior alone (4), or with alcohol use (2). Interventions led to reductions in STI incidence (1), and reported sexual or alcohol risk behaviours (5), although effect size varied. All but one targeted at least one structural factor associated with HIV infection: gender and sexual coercion (3), alcohol/substance use (2), or economic factors (2). Delivery methods and formats varied, and included teachers (5), peer educators (5), and older mentors (1). School-based interventions experienced frequent implementation challenges.

CONCLUSIONS

Key recommendations include: address HIV social risk factors, such as gender, poverty and alcohol; target the structural and institutional context; work to change social norms; and engage schools in new ways, including participatory learning.

Rethinking the role of the local community in HIV epidemic spread in sub-Saharan Africa: a proximate-determinants approach

The spread of HIV in sub-Saharan Africa continues largely unabated. To improve prevention interventions, a better understanding of the determinants of HIV infection is required. Conceptual frameworks can guide epidemiological investigation and prevent a misguided focus on single risk factors in isolation. Existing frameworks of HIV infection focus on transmission. However, the transmitting individual is rarely known. By contrast, data on individual HIV acquisition are available from longitudinal studies and tests for recent HIV infection. From the perspective of individuals susceptible to HIV, it is important to distinguish between factors determining the individual's biological disposition and sexual behavior and community-level factors, which can affect both HIV acquisition and the likelihood that a sex partner chosen from a community will be infected with HIV and transmit the infection. We propose a framework that takes the susceptible individual as a starting point and links distal, proximate and biological determinants of HIV infection at both the individual and the community level. We describe three necessary ingredients for the use of the framework (identification of the relevant community, multilevel analysis and methods for causal inference).

Sustained release of microbicides by newly engineered vaginal rings

OBJECTIVE

An effective vaginal microbicide against sexual HIV transmission remains elusive, with requirements for adherence to appropriate application of effective, nontoxic products being a major deterrent. We explored methods to enable sustained release of combinations of antiretroviral microbicides, utilizing intravaginal rings composed of biosoluble Acacia gum or nonbiodegradable hydrogel of 2-hydroxyethyl methacrylate and sodium methacrylate, materials approved for use by the US Food and Drug Administration.

DESIGN AND METHODS

The reverse transcriptase inhibitors TMC120, PMPA, 3'-azido-3'-deoxythymidine, and a newly characterized anti-HIV agent, Boc-lysinated betulonic acid, were incorporated into vaginal rings with different combinations. Daily and cumulative release rates of these inhibitors in ring eluates were determined by high-performance liquid chromatography, gas chromatography, or immunoassay. Anti-HIV effects were measured by assessment of p24 Gag antigen in T-cell cultures exposed to HIV-1 isolates.

RESULTS

Drug release rates were sustained at concentrations higher than the minimum effective dose for HIV inhibition. The release was maintained for no less than 15 and 28 days from the Acacia gum and 2-hydroxyethyl methacrylate and sodium methacrylate rings, respectively. Boc-lysinated betulonic acid showed more than 90% inhibition of HIV-1 infection in H9 cells, with little toxicity to normal cells.

CONCLUSION

The intravaginal rings described here are capable of efficacious drug delivery. Incorporation of several antiretroviral agents, including betulinol derivatives, which act at multiple levels of the HIV life cycle, may provide a synergistic effect to achieve higher efficacy on the inhibition of HIV infection.

Localized spatial clustering of HIV infections in a widely disseminated rural South African epidemic

BACKGROUND

South Africa contains more than one in seven of the world's HIV-positive population. Knowledge of local variation in levels of HIV infection is important for prioritization of areas for intervention. We apply two spatial analytical techniques to investigate the micro-geographical patterns and clustering of HIV infections in a high prevalence, rural population in KwaZulu-Natal, South Africa.

METHODS

All 12,221 participants who consented to an HIV test in a population under continuous demographical surveillance were linked to their homesteads and geo-located in a geographical information system (accuracy of <2 m). We then used a two-dimensional Gaussian kernel of radius 3 km to produce robust estimates of HIV prevalence that vary across continuous geographical space. We also applied a Kulldorff spatial scan statistic (Bernoulli model) to formally identify clusters of infections (P < 0.05).

RESULTS

The results reveal considerable geographical variation in local HIV prevalence (range = 6-36%) within this relatively homogenous population and provide clear empirical evidence for the localized clustering of HIV infections. Three high-risk, overlapping spatial clusters [Relative Risk (RR) = 1.34-1.62] were identified by the Kulldorff statistic along the National Road (P < or = 0.01), whereas three low risk clusters (RR = 0.2-0.38) were identified elsewhere in the study area (P < or = 0.017).

CONCLUSIONS

The findings show the existence of several localized HIV epidemics of varying intensity that are partly contained within geographically defined communities. Despite the overall high prevalence of HIV in many rural South African settings, the results support the need for interventions that target socio-geographic spaces (communities) at greatest risk to supplement measures aimed at the general population.

Moving beyond the alphabet soup of HIV prevention

The 'ABCs' of prevention (abstinence, be faithful, use a condom) continue to be the subject of intense debate in the international dialogue on HIV/AIDS prevention policy. The authors argue that the ABC terminology infantilizes the prevention discussion by excluding essential interventions and oversimplifying the prevention challenge facing countries. The dialogue that is needed is less about the relative merits of one intervention over another, but rather how to promote comprehensive national prevention programmes that have a measurable impact on HIV incidence. Accountability is key to advancing HIV prevention on the national and international levels. Governments, donors and global agencies must be held accountable for prevention programming that is tailored to the specific characteristics of national epidemics, brings quality interventions to a scale, addresses environmental factors in vulnerability, and links prevention and treatment services. Whereas each national prevention response must remain unique, policy makers, donors and advocates can assess a country's prevention programming by the degree to which it is designed, scaled and implemented to make impact over time.

How can we calculate the "E" in "CEA"?

Because full funding for HIV/AIDS prevention interventions is unlikely to occur in the near future, it is essential that the resources available are spent in the most effective way possible. This paper presents a matrix of effectiveness coefficients for HIV/AIDS-related prevention interventions that can be used as an integral part of the coordinated strategic planning process currently underway by the World Bank and UNAIDS, as the interventions in the matrix are harmonized with the interventions in that process. Coefficients for four types of sexual behavior change (condom use, partner reduction, sexually transmitted infection treatment-seeking behavior, age at first sex) across three different risk groups (high, medium, low) are presented, along with their interquartile ranges. Results indicate that: (1) impacts seem greater when an intervention includes interpersonal contact, rather than targeting a more general audience; (2) although significant impacts are observed in the columns measuring changing condom use, other impacts are lower, and sometimes are actually (measured) zero; and (3) additional studies have evaluations of the number of sexual partners and have found a greater impact than previous studies. Although progress has been made in increasing the number of evaluation studies that can be utilized in this impact matrix, particularly in the area of youth interventions, there are still empty cells in which no studies report impacts. Finally, it is important to note that issues such as quality differences and synergies between programmes could have an effect on the impacts calculated for a particular strategic plan.

Preventing HIV with young people: a case study from Zambia

The US President's Emergency Plan for AIDS Relief (PEPFAR) is funding thousands of community-based organisations, international NGOs and government services in high HIV prevalence countries to persuade young people to abstain from sex until marriage (Abstinence, Behaviour Change, Youth--ABY). This paper describes how this strategy is being implemented in Zambia, and community responses to it. It is derived from published information and observations and discussions in the Eastern Province in 2005-2006. A few NGOs have challenged the strategy, but many took the funds and are paying large numbers of peer educators to promote abstinence only. Messages are rife that condoms have holes or don't work sufficiently well to make them worth using. Condom promotion materials have been replaced. Service providers refuse to give condoms to young people. Young people who had attended sexuality and life skills programmes that gave them accurate information are rejecting inaccurate messages and demanding condoms. Without this education, however, inaccurate messages will spread quickly. It is not possible to promote condoms only for high risk people without stigmatising both the people and condoms, and it also jeopardises promoting condom use for contraception. Everything possible must be done to reduce negative messages about condoms. Everyone involved in HIV/AIDS needs to reflect on their own work in relation to this new climate and ensure that all prevention options are widely available, correct information is given and condoms are available for everyone who needs them.

The spread, treatment, and prevention of HIV-1: evolution of a global pandemic

The most up-to-date estimates demonstrate very heterogeneous spread of HIV-1, and more than 30 million people are now living with HIV-1 infection, most of them in sub-Saharan Africa. The efficiency of transmission of HIV-1 depends primarily on the concentration of the virus in the infectious host. Although treatment with antiviral agents has proven a very effective way to improve the health and survival of infected individuals, as we discuss here, the epidemic will continue to grow unless greatly improved prevention strategies can be developed and implemented. No prophylactic vaccine is on the horizon. However, several behavioral and structural strategies have made a difference--male circumcision provides substantial protection from sexually transmitted diseases, including HIV-1, and the application of antiretroviral agents for prevention holds great promise.

Promoting child and adolescent mental health in the context of the HIV/AIDS pandemic with a focus on sub-Saharan Africa

BACKGROUND

The pandemic of HIV/AIDS is actually a composite of many regional and national-level epidemics. The progress made in many parts of the developed and developing world is tempered by the continued devastating consequences of HIV infection in sub-Saharan Africa (SSA). This review focuses on the ways in which children and adolescents are impacted by the epidemic, giving particular attention to their mental health.

METHODS

A health promotion framework is adopted to guide analysis. Three issues are covered: prevention of HIV infection, care and treatment of children infected with HIV, and care of children whose caregivers are ill or have died of AIDS. Existing reviews and literature search engines were used to review the scientific literature, focusing on the past five years.

RESULTS

Preventive interventions continue to manifest limited benefits in behavioral changes. More complex causal models and improved behavioral measures are needed. In the African context, the time has come to view pediatric AIDS as a chronic disease in which the mental health of caregivers and children influences important aspects of disease prevention and management. Increasingly sophisticated studies support earlier findings that social and psychological functioning, educational achievement and economic well-being of children who lose parents to AIDS are worse than that of other children.

CONCLUSIONS

Important changes are taking place in SSA in increased access to HIV testing and antiretroviral therapies. To be effective in promoting mental health of children and adolescents, interventions require a more fundamental understanding of how to build HIV competence at personal and community levels. A key recommendation calls for the design and execution of population-based studies that include both multilevel and longitudinal features. Such rigorous conceptual and empirical investigations that assess the capacities of children are required to mobilize children, families and communities in comprehensive actions plans for prevention, treatment and care in response to the enduring HIV/AIDS pandemic.

Individual, social, and environmental influences associated with HIV infection among injection drug users in Tijuana, Mexico

OBJECTIVE

We examined correlates of HIV infection among injection drug users (IDUs) in Tijuana, Mexico, a city bordering the United States, which is situated on major migration and drug trafficking routes.

METHODS

IDUs aged > or =18 years were recruited using respondent-driven sampling. Participants underwent antibody testing for HIV and syphilis and structured interviews. Weighted logistic regression identified correlates of HIV infection.

RESULTS

Of 1056 IDUs, the median age was 37 years, 86% were male, and 76% were migrants. HIV prevalence was higher in female participants than in male participants (8% vs. 3%; P = 0.01). Most IDUs testing HIV-positive were previously unaware of their serostatus (93%). IDUs reported injecting with a median of 2 people in the prior 6 months and had been arrested for having injection stigmata (ie, "track-marks") a median of 3 times. Factors independently associated with HIV infection were being female, syphilis titers consistent with active infection, larger numbers of recent injection partners, living in Tijuana for a shorter duration, and being arrested for having track-marks.

CONCLUSIONS

Individual, social, and environmental factors were independently associated with HIV infection among IDUs in Tijuana. These findings suggest the need to intervene not solely on individual risk behaviors but on social processes that drive these behaviors, including problematic policing practices.

High HIV incidence in a community with high HIV prevalence in rural South Africa: findings from a prospective population-based study

OBJECTIVES

To measure HIV incidence in a rural area of South Africa with high HIV prevalence and to analyze risk factors for acquisition of HIV using a prospective population-based cohort study.

METHODS

Data from two rounds (2003-2005) of a large prospective population-based HIV survey in rural KwaZulu-Natal were used to calculate HIV incidence by sex and 5-year age group. Multiple imputations (MI) were used to adjust for selection effects and risk factors for acquiring HIV were examined in Weibull multiple regression.

RESULTS

During 5253 person-years at risk, 170 individuals became seropositive. The crude HIV incidence rate per 100 person-years was 3.8 [95% confidence interval (CI), 3.2-4.6] in women aged 15-49 years and 2.3 (95% CI, 1.8-3.1) in men aged 15-54 years. MI significantly increased the HIV incidence rates both in women and men [7.9/100 person-years (95% CI, 7.4-8.4) and 5.1/100 person-years (95% CI 4.1-6.2), respectively]. When holding other factors constant in Weibull multiple regression, the hazard of HIV seroconversion was approximately twice as high in people who were currently unmarried but had a partner than among people who were currently married (P < 0.001) and increased with increasing distance from a government health clinic (P = 0.051) and decreasing distance from a primary road (P = 0.002).

CONCLUSION

In this high HIV prevalence community in rural South Africa HIV incidence is very high. The present focus on antiretroviral treatment needs to be balanced with a renewed emphasis on HIV prevention for both sexes.

A systematic review of published evidence on intervention impact on condom use in sub-Saharan Africa and Asia

OBJECTIVE

There has been much debate about the value of condoms in HIV/STI programming. This should be informed by evidence about intervention impact on condom use, but there is limited compiled literature. This review aims to quantify intervention impact on condom use in sub-Saharan Africa and Asia, in different types of partnership.

METHODS

A systematic review was conducted of papers published between 1998 and 2006 presenting evaluations of interventions involving condom promotion in sub-Saharan Africa and Asia. Data on reported postintervention levels of condom use, and various measures of changes in condom use, by partnership type, were compiled.

RESULTS

A total of 1374 abstracts were identified. Sixty-two met the inclusion criteria (42 reporting significant increases in condom use): 44 from sub-Saharan Africa and 18 from Asia. Many (19) reported on condom use in commercial sex (15 significant), six on use with casual partners (three significant), 11 on use in marital/steady partnerships (nine significant), 14 on use by youths (eight significant) and 20 combined partnership types (11 significant). There is substantial evidence of interventions targeted at sex workers and clients achieving large increases in condom use. Far less evidence exists of intervention impact on condom use in casual relationships. In primary partnerships, postintervention condom use was low unless one partner was knowingly HIV-infected or at high-risk, or avoiding pregnancy. Evaluations of interventions targeting youths recorded limited increases in condom use.

CONCLUSIONS

The findings illustrate the range of evidence about postintervention condom use in different partnerships, and how patterns of use are influenced by partnership type and perceptions of risk. Where possible, intervention studies should also assess biological endpoints, since prevention of infection is the measure of most interest in the evaluation of condom promotion interventions.

Potential impact of antiretroviral chemoprophylaxis on HIV-1 transmission in resource-limited settings

Background

The potential impact of pre-exposure chemoprophylaxis (PrEP) on heterosexual transmission of HIV-1 infection in resource-limited settings is uncertain.

Methodology/Principle Findings

A deterministic mathematical model was used to simulate the effects of antiretroviral PrEP on an HIV-1 epidemic in sub-Saharan Africa under different scenarios (optimistic, neutral and pessimistic) both with and without sexual disinhibition. Sensitivity analyses were used to evaluate the effect of uncertainty in input parameters on model output and included calculation of partial rank correlations and standardized rank regressions. In the scenario without sexual disinhibition after PrEP initiation, key parameters influencing infections prevented were effectiveness of PrEP (partial rank correlation coefficient (PRCC) = 0.94), PrEP discontinuation rate (PRCC = −0.94), level of coverage (PRCC = 0.92), and time to achieve target coverage (PRCC = −0.82). In the scenario with sexual disinhibition, PrEP effectiveness and the extent of sexual disinhibition had the greatest impact on prevention. An optimistic scenario of PrEP with 90% effectiveness and 75% coverage of the general population predicted a 74% decline in cumulative HIV-1 infections after 10 years, and a 28.8% decline with PrEP targeted to the highest risk groups (16% of the population). Even with a 100% increase in at-risk behavior from sexual disinhibition, a beneficial effect (23.4%–62.7% decrease in infections) was seen with 90% effective PrEP across a broad range of coverage (25%–75%). Similar disinhibition led to a rise in infections with lower effectiveness of PrEP (≤50%).

Conclusions/Significance

Mathematical modeling supports the potential public health benefit of PrEP. Approximately 2.7 to 3.2 million new HIV-1 infections could be averted in southern sub-Saharan Africa over 10 years by targeting PrEP (having 90% effectiveness) to those at highest behavioral risk and by preventing sexual disinhibition. This benefit could be lost, however, by sexual disinhibition and by high PrEP discontinuation, especially with lower PrEP effectiveness (≤50%).

Supporting Positive Living and Sexual Health (SPLASH): a clinician and behavioral counselor risk-reduction intervention in a university-based HIV clinic

Effective HIV prevention interventions with HIV-positive persons are paramount to stemming the rate of new infections. This paper describes an HIV-clinic-based demonstration project aimed at decreasing patient HIV-transmission risk behaviors and sexually transmitted infections. Systematic, computer-assisted assessment of patient risk aided primary care providers in delivering prevention messages. Patients at greater risk were referred to an HIV Prevention Specialist for behavioral counseling. Patients completed a computerized behavioral staging assessment to self-identify risk behaviors and readiness to change behaviors and counseling messages were individually tailored based on computer assessment. Challenges to project implementation: primary care provider buy-in, patient privacy concerns during risk assessment, and low participation in behavioral counseling. Forty-six percent of persons completing a risk assessment (2,124) were at risk for HIV transmission. Of 121 patients who scheduled counseling appointments, 42% completed at least one session. Despite challenges, successful implementation of a clinic-based prevention intervention is feasible, particularly with attention to patient and provider concerns.

The future of HIV prevention: control of sexually transmitted infections and circumcision interventions

Prevention and control of sexually transmitted infections (STIs) has proven effective in reducing HIV infection when treatment is available promptly for symptomatic persons in conditions of an emerging epidemic. Biologically, it is assumed that reduced genital tract inflammation reduces infectiousness for HIV as well as reducing susceptibility in HIV-uninfected persons. Male circumcision has been demonstrated effective in reducing risk for HIV infection in three separate trials from South Africa, Kenya, and Uganda. Global expansion of STI treatment and male circumcision programs are vital tools for control of HIV infection; current evidence is reviewed and research priorities are presented.