Weighing the gold in the gold standard: challenges in HIV prevention research

Community case management to accelerate access to healthcare in Mali: a realist process evaluation nested within a cluster randomized trial

The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.

Effectiveness of an intervention to improve ART adherence among men who have sex with men living with HIV: a randomized controlled trial in three public HIV clinics in Mexico

We conducted a parallel-group randomized controlled trial in three HIV clinics in Mexico to evaluate a user-centred habit-formation intervention to improve ART adherence among MSM living with HIV. We randomized 74 participants to the intervention group and 77 to the control group. We measured adherence at one, four, and ten months through medication possession ratio and self-reported adherence. Additionally, we measured viral load, CD4 cell count, major depression disorder symptoms, and alcohol and substance use disorder at baseline, fourth and tenth months. We found no statistically significant effect on adherence between groups. However, the intervention demonstrated positive results in major depression disorder symptoms (21% vs. 6%, p = 0.008) and substance use disorder (11% vs. 1%, p = 0.018) in the fourth month. The latter is relevant because, in addition to its direct benefit, it might also improve the chances of maintaining adequate adherence in the long term. This trial was retrospectively registered at ClinicalTrials.gov (trial number NCT03410680) on 8 January 2018.Trial registration: ClinicalTrials.gov identifier: NCT03410680.

Estimating HIV incidence over a decade in Zimbabwe: A comparison of the catalytic and Farrington models

Over the years, numerous modelling studies have been proposed to estimate HIV incidence. As a result, this study aimed to evaluate two alternative methods for predicting HIV incidence in Zimbabwe between 2005 and 2015. We estimated HIV incidence from seroprevalence data using the catalytic and Farrington-2-parameter models. Data were obtained from 2005-06, 2010-11, and 2015 Zimbabwe Demographic Health Survey (ZDHS). These models were validated at the micro and macro-level using community-based cohort incidence and empirical estimates from UNAIDS EPP/SPECTRUM, respectively. The HIV incidence for the catalytic model was 0.32% (CI: 0.28%, 0.36%), 0.36% (CI: 0.33%, 0.39%), and 0.28% (CI: 0.26%, 0.30%), for the years 2005-06, 2010-11, and 2015, respectively. The HIV incidence for the Farrington model was 0.21% (CI: 0.16%, 0.26%), 0.22% (CI: 0.20%, 0.25%), and 0.19% (CI: 0.16%, 0.22%), for the years 2005-06, 2010-11, and 2015, respectively. According to these findings, the catalytic model estimated a higher HIV incidence rate than the Farrington model. Compared to cohort estimates, the estimates were within the observed 95% confidence interval, with 88% and 75% agreement for the catalytic and Farrington models, respectively. The limits of agreement observed in the Bland-Altman plot were narrow for all plots, indicating that our model estimates were comparable to cohort estimates. Compared to UNAIDS estimates, the catalytic model predicted a progressive increase in HIV incidence for males throughout all survey years. Without a doubt, HIV incidence declined with each subsequent survey year for all models. To improve programmatic and policy decisions in the national HIV response, we recommend the triangulation of multiple methods for incidence estimation and interpretation of results. Multiple estimating approaches should be considered to reduce uncertainty in the estimations from various models.

HCV knowledge and attitudes among HIV-negative MSM and MSM living with HIV in China: results from a cross-sectional online survey

BACKGROUND

Men who have sex with men (MSM) are at high risk of hepatitis C virus (HCV) infection, especially for those living with human immunodeficiency virus (HIV). Learning about knowledge of and attitudes towards HCV is essential to inform health promotion interventions development. This is one of very limited studies to examine the level of knowledge and attitudes towards HCV and their determinants among HIV-negative MSM and MSM living with HIV in China.

METHODS

A cross-sectional survey was conducted across seven provinces in China from December 2021 to January 2022. All the MSM living with HIV were recruited offline, whereas the recruitment ratio for HIV-negative MSM was half online and half offline. Data on socio-demographic characteristics, sexual behaviors, knowledge about HCV, and attitude towards HCV from participants were collected through the online survey. Univariate and multivariable logistic regressions were used to determine the associated factors.

RESULTS

Only 39.3% (33/84) of HIV-negative men and 44.0% (37/84) of men living with HIV had a good level knowledge about HCV. Nearly one-third (32.1%, 27/84) of HIV-negative men and 41.7% (35/84) of men living with HIV reported a positive attitude towards HCV. For HIV-negative men, positive attitude towards HCV was associated with the multiple sexual partners (aOR: 5.8, 95%CI:1.9-18.1) and the use of recreational substances (aOR: 3.1, 95%CI: 1.0-9.4). For men living with HIV, knowledge about HCV was associated with disclosing sexual orientation to healthcare providers, family or friends (aOR: 7.0, 1.9-26.0), the multiple sexual partners (aOR: 0.2, 0.1-1.0), the use of recreational substances (aOR: 3.7, 95%CI: 1.1-13.1) and the HBV testing history (aOR: 7.3, 95%CI: 1.6-32.7); positive attitude towards HCV was associated with the use of recreational substances (aOR: 3.1, 95%CI: 1.1-9.0).

CONCLUSIONS

The majority of Chinese MSM showed an inadequate knowledge of and negative attitude towards HCV irrespective of HIV infection status. More tailored education campaigns and multicomponent interventions are required to be targeted on MSM, and more researches are also needed to inform how best to address the negative attitudes of this population towards HCV.

Sexually transmitted infection prevention behaviours: health impact, prevalence, correlates, and interventions

Sexually transmitted infections (STIs) remain a major public health threat, disproportionately affecting young people, and men who have sex with men. In this narrative review of the current state of behavioural science research on STI prevention, we consider the definition, health impacts, correlates and determinants, and interventions to promote STI prevention behaviour. Research on STI prevention behaviour has extended from a focus on abstinence, partner reduction and condom use, to also include novel preventive behaviours, notably treatment-as-prevention, pre-exposure prophylaxis (i.e., the preventive use of medicines by uninfected people), and vaccination for some STIs. Social-cognitive factors specified by, for instance the theory of planned behaviour, are critical proximal determinants of STI prevention behaviours, and related interventions can effectively promote STI prevention behaviours. Social-ecological perspectives highlight that individual-level determinants are embedded in more distal environmental influences, with social stigma especially affecting STI prevention behaviours and requiring effective intervention. Further to providing a major domain of application, STI prevention also poses critical challenges and opportunities for health psychology theory and research. We identify a need for health behaviour theory that addresses the processes linking multiple levels of influence on behaviour and provides practical guidance for multi-level behaviour change interventions adapted to specific contexts.

Correlates of HIV seropositivity in young West and Central African women: A pooled analysis of 17 Demographic and Health Surveys

BACKGROUND

Young women in West and Central Africa have been described by the United Nations as being especially vulnerable to HIV/AIDS. Despite a consensus that increased efforts are necessary to address the needs of this particular demographic, correlates of HIV seropositivity in young West and Central African women have not been systematically described. This study fills this gap using a rich set of publicly available survey data.

METHODS

For this cross-sectional study, we combined HIV test results for young women (age 15-24 years) with information on demographic, cultural and socioeconomic correlates from 17 recent Demographic and Health Surveys (DHS) to estimate odds ratios (OR) from fixed effects logistic regression models accounting for potential individual, household-level and contextual risk factors of HIV seropositivity.

RESULTS

The prevalence of HIV seropositivity among young women is higher than for men of the same age in all included surveys, except for the Burkina Faso DHS. An important correlate of HIV seropositivity in young women is early sexual activity (OR = 1.510; 95% confidence interval (CI) = 1.100, 2.072), while higher education is associated with reduced odds of being HIV positive (OR = 0.215; 95% CI = 0.057, 0.820). No significant correlation has been found for individual HIV awareness, but HIV stigma is negatively associated with HIV seropositivity (OR = 0.495; 95% CI = 0.247, 0.990, in the fully adjusted model).

CONCLUSIONS

The results demonstrate the need to design effective policies addressing behavioral risks in young women. In particular, increasing HIV awareness alone is likely to be insufficient. Instead, information campaigns need to focus on transforming awareness into behavioral change. Moreover, fostering formal education may be an effective tool in the fight against HIV/AIDS.

Designing Evidence-Based Preventive Interventions That Reach More People, Faster, and with More Impact in Global Contexts

This article demonstrates the substantial similarities globally among preventive, evidence-based interventions (EBIs) designed to address HIV by providing four examples: an HIV family-focused intervention, the Community Popular Opinion Leader intervention, a South African maternal/child health program, and an EBI for sex workers in India. Each identified the key problems in the target population, utilized well-established social cognitive theories, created processes for engaging the target population, set standards for staff accountability, and included routine data collection to facilitate iterative program improvements over time. Building EBIs based on these common, robust features is an alternative design strategy to replication with fidelity. These components provide a road map for researchers, especially those using new technologies, and for local providers seeking to deliver EBIs that match their clients' and communities' needs. Technology platforms and community organizations may serve as resources for designers of the next generation of EBIs, offering an alternative to repeatedly validating the same interventions and replicating them with fidelity.

A Systematic Review of HIV Interventions for Young Women in Sub-Saharan Africa

Adolescent girls and young women (AGYW) ages (15-24 years old) in Southern and Eastern Africa account for nearly 30% of all new HIV infections. We conducted a systematic review of studies examining the effectiveness of behavioral, structural, and combined (behavioral + structural) interventions on HIV incidence and risky sexual behaviors among AGYW. Following PRISMA guidelines, we searched PubMed, CINAHL, Web of Science, and Global Health. Twenty-two studies met inclusion criteria conducted in Eastern and Southern Africa and comprised behavioral, structural, or combined (behavioral and structural) interventions. All findings are based on 22 studies. HIV incidence was significantly reduced by one structural intervention. All three types of interventions improved condom use among AGYW. Evidence suggests that structural interventions can reduce HIV incidence, while behavioral and combined interventions require further investigation.

How actors, processes, context and evidence influenced the development of Malawi's Health Sector Strategic Plan II

Health sector strategic plans are health policies outlining health service delivery in low- and middle- income countries, guiding health sectors to meet health needs while maximizing resources. However, little research has explored the formulation of these plans. This study utilized qualitative methods to explore the formulation of Malawi's Health Sector Strategic Plan II, including processes utilized, actors involved, important contextual factors and the use of evidence-based decision-making. Thirteen semi-structured key informant interviews with health policy actors were conducted to explore perceptions and experiences of formulating the policy. Data analysis used an inductive-deductive approach and interpretation of the data was guided by an adapted version of the Walt and Gilson Health Policy Triangle. Our results indicate that HSSP II formulation was complex and inclusive but that the Ministry of Health may have given up ownership of the formulation process to development partners to ensure their continued involvement. Disagreements between actors centered around inclusion of critical services in the Essential Health Package and selection of performance-based financing as purchasing strategy. Resource constraints and the Cashgate Scandal are critical contextual elements influencing the formulation and content of the policy. Evidence-based decision-making contributed to the plan's development despite respondents' divergent opinions regarding evidence availability, quality and the weight that evidence carried. The study raises questions regarding the roles of policy actors during health policy formulation, the inclusivity of health policy processes and their potential influence on government ownership of health policy, as well as the use of evidence in developing health sector strategic plans.

Comparison of HIV Risk Behaviors Between Clinical Trials and Observational Cohorts in Uganda

Many key populations have high-risk behaviors for HIV infection making them suitable for HIV vaccine efficacy trials. However, these behaviors may change when participants enroll into a trial. We used HIV simulated vaccine efficacy trials (SiVETs) nested within observational cohorts of fisherfolks and female sex workers in Uganda to evaluate this difference. We screened observational cohort participants for enrolment into SiVETs, until 572 were enrolled. Those not enrolled (n = 953) continued participation in the observational cohorts. We determined risk behaviors at baseline and at 1 year, assigned a numeric score to each behavior and defined composite score as the sum of reported behaviors. We compared changes in scores over 12 months. Both observational cohorts and SiVETs saw a significant decrease in score but greatest in the SiVETs. Investigators recruiting for trials from these populations should consider the likely effect of reduction in risk behaviors on incident HIV infection and trial statistical power.

The Gold Standard and the Pyrite Principle: Toward a Supplemental Frame of Reference

In medicine and social sciences, the phrase "gold standard" is often used to characterize an object or procedure described as unequivocally the best in its genre, against which all others should be compared. Examples of this usage are readily available in rigorously peer-reviewed publications, touted by test publishers, and appear in descriptions of methodologies by social science researchers. The phrase does not accurately describe commonly accepted measures, tests, and instruments. Instead, the descriptor can be ambiguous and misleading. This paper presents an overview of the history of the gold standard and its current applications to medicine and the social sciences. We question the use of the phrase "the gold standard" and suggest the additional operational use of a "pyrite principle" as a less presumptuous frame of reference. In thinking about validity and standards, the pyrite principle permits an understanding of standards as authoritative rather than fixed constructs in behavioral and health sciences.

Evaluation of Sex Positive! A Video eHealth Intervention for Men Living with HIV

Sex Positive!^[+] is a two-arm, video-based web intervention aimed at reducing condomless anal sex (CAS) with partners of known and unknown serostatus that was delivered online to a racially and ethnically diverse sample of 830 gay, bisexual, and other men who have sex with men living with HIV. Men in each arm received 6 weekly videos after completing a baseline assessment and 4 weekly booster videos following a 6-month assessment. Follow-up assessments were conducted every 3 months for 1 year. At 3-month follow-up, men in the intervention arm reported significantly reduced risk of having unknown serodiscordant CAS partners than men in the control arm (RR 0.60, 95% CI 0.39-0.92), partially supporting study hypotheses. Aside from this finding, similar reductions in sexual risk behaviors were observed in both arms over the study period. There is much to be learned about video-based web interventions in terms of methodological development and intervention delivery, including frequency and duration of intervention components.

How Biomedical HIV Prevention Trials Incorporate Behavioral and Social Sciences Research: A Typology of Approaches

In the field of biomedical HIV prevention, researchers have meaningfully incorporated behavioral and social sciences research (BSSR) into numerous clinical trials, though the timing and degree of integration have been highly variable. The literature offers few frameworks that systematically characterize these collaborations. To fill this gap, we developed a typology of BSSR approaches within biomedical HIV prevention research. Focusing on trials that had safety and/or efficacy endpoints, we identified five approaches for combining BSSR and clinical research: formative, embedded, parallel, explanatory, and implications. We describe each approach and provide illustrative examples. By offering a shared vocabulary for distinguishing the timing and design of collaborative BSSR and clinical research, this typology can facilitate greater transparency in collaborators’ expectations and responsibilities, and help collaborators address challenges likely to be associated with such interdisciplinary research.

Impact of a structured HIV testing program in a hospital emergency department and a primary care center

Introduction

HIV testing guidelines are poorly implemented in most clinical settings. The best screening strategy and healthcare scenario are still unknown. The aim of our study is to evaluate the impact of a structured HIV testing intervention (DRIVE), compared to HIV testing as routinely performed in clinical practice, in two different clinical settings: a primary care center and an emergency department.

Methods

Prospective evaluation of an HIV testing strategy in two clinical settings from the same healthcare area. The DRIVE program included trained nurse practitioners to perform the screening, a questionnaire to assess the risk of exposure and HIV indicator conditions (RE&IC), and rapid HIV tests. The main variables between the DRIVE program and clinical practice were the absolute number of newly diagnosed HIV infections and testing coverage.

Results

The DRIVE program included 5,329 participants, of which 51.2% reported at least one positive answer in the questionnaire. The estimated HIV testing coverage was significantly higher in the DRIVE program than in the routine clinical practice (7.17% vs. 0.96%, p < 0.001), and was better in the primary care center than in the emergency department with the two strategies. Twenty-two HIV-positive people were identified, with a rate of 8.6‰ in the emergency department vs. 2.2‰ in the primary care center (p = 0.001). A higher rate of new HIV diagnoses was found in the DRIVE program compared to routine clinical practice (29.6 vs. 3.1 per 100,000 patients attended; p < 0.001).

Conclusions

An easy-to-implement, structured intervention increased the absolute number of new HIV diagnoses and HIV tests, compared to routine clinical practice.

FROM INDIVIDUAL HEALTH TO COMMUNITY HEALTH: TOWARDS MULTISCALE MODELING OF DIRECTLY TRANSMITTED INFECTIOUS DISEASE SYSTEMS

In this paper, we present a new method for developing a class of nested multiscale models for directly transmitted infectious disease systems that integrates within-host scale and between-host scale using community pathogen load (CPL) as a new public health measure of a community’s level of infectiousness and as an indicator of the effectiveness of health interventions. The approach develops a multiscale modeling science base for directly transmitted infectious disease systems (where the inside-host environment’s biological entities such as cells, tissues, organs, body fluids, whole body are the reservoir of infective pathogen in the community) that is comparable to an existing multiscale modeling science base for environmentally transmitted infectious diseases (where the outside-host geographical environment’s physical entities such as soil, air, formites/contact surfaces, food and water are the reservoir of infective pathogen in the community) where pathogen load in the environment is explicitly incorporated into the model. This is achieved by assuming that infected hosts in the community are homogeneous and unevenly distributed microbial habitats. We illustrate the utility of this multiscale modeling methodology by evaluating the comparative effectiveness of HIV/AIDS preventive and treatment interventions as a case study.

Simulated vaccine efficacy trials to estimate HIV incidence for actual vaccine clinical trials in key populations in Uganda

BACKGROUND

Fisherfolks (FF) and female sex workers (FSW) in Uganda could be suitable key populations for HIV vaccine efficacy trials because of the high HIV incidence and good retention in observational cohorts. However, the observed HIV incidence may differ in participants who enroll into a trial. We used simulated vaccine efficacy trials (SiVET) nested within observational cohorts in these populations to evaluate this difference.

METHODS

SiVETs were nested in two observational cohorts (Jul 2012-Apr 2014 in FF and Aug 2014-Apr 2017 in FSW). From Jan 2012 all observational cohort participants (aged 18-49 years) presenting for quarterly visits were screened for enrolment into SiVETs, until 572 were enrolled. Those not enrolled (screened-out or not screened) in SiVET continued participation in the observational cohorts. In addition to procedures in the observational cohorts (HIV testing & risk assessment), SiVET participants were given a licensed Hepatitis B vaccine mimicking a schedule of a possible HIV vaccine, and followed-up for 12 months.

FINDINGS

In total, 3989 participants were enrolled into observational cohorts (1575 FF prior to Jul 2012 and 2414 FSW prior to Aug 2014). Of these 3622 (90.8%) returned at least once, 672 (44.1%) were screened and 572 enrolled in the SiVETs. HIV incidence pre SIVETs was 4.5/100 person years-at-risk (pyar), 95%CI (3.8-5.5). HIV incidence in SiVET was 3.5/100 pyar, (2.2-5.6) and higher in those not enrolled in the SiVET, 5.9/100 pyar, (4.3-8.1). This difference was greatest among FF. In the 12 months post-SIVET period (FF, May 2014-Apr 2015 and FSW, May 2017-Apr 2018), the HIV incidence was 3.7/100 pyar, (2.5-5.8).

INTERPRETATION

HIV incidence was lower in SiVET participants compared to non-SiVET. This difference was different for the two populations. Researchers designing HIV efficacy trials using observational cohort data need to consider the potential for lower than expected HIV incidence following screening and enrolment.

'Yummy or crummy?' The multisensory components of medicines-taking among HIV-positive youth

The global rollout of Antiretroviral Treatment (ART) has revealed an urgent need to understand the medicines-taking practices of HIV-positive adolescents. In the last decade, the literature on the social determinants of health has broadened the evidence-base on ART adherence. Interdisciplinary studies have expanded conceptions of medicines-taking beyond clinical or health systems frameworks, recognising the importance of socio-structural conditions and of patients' beliefs and experiences. Participatory research techniques which foreground the perspectives of adolescents provide greater insights still into their adherence. This article explores the use of participatory methods within a broader study on the social determinants of ART adherence among HIV-positive adolescents in South Africa. We describe how participatory methods were incorporated into this study (n = 1,059 in the quantitative baseline). We focus on an exercise, 'Yummy or crummy?', that explored the multisensory dimensions of medicines-taking, including their colour, smell, shape, and delivery mechanism. We describe two principal findings: first, adolescents' preference for greater understanding of the chemical workings of medicines, manifested in their preferences for colour, taste and shape of medicines; and second, the vital relationship between sensory preferences and the social imperatives of discretion and confidentiality regarding HIV-status.

Occurrence of HIV eradication for preexposure prophylaxis treatment with a deterministic HIV model

The authors examine the human immunodeficiency virus (HIV) eradication in this study using a mathematical model and analyse the occurrence of virus eradication during the early stage of infection. To this end they use a deterministic HIV-infection model, modify it to describe the pharmacological dynamics of antiretroviral HIV drugs, and consider the clinical experimental results of preexposure prophylaxis HIV treatment. They also use numerical simulation to model the experimental scenario, thereby supporting the clinical results with a model-based explanation. The study results indicate that the protocol employed in the experiment can eradicate HIV in infected patients at the early stage of the infection.

Evidence for sample selection effect and Hawthorne effect in behavioural HIV prevention trial among young women in a rural South African community

OBJECTIVES

We examined the potential influence of both sample selection effects and Hawthorne effects in the behavioural HIV Prevention Trial Network 068 study, designed to examine whether cash transfers conditional on school attendance reduce HIV acquisition in young South African women. We explored whether school enrolment among study participants differed from the underlying population, and whether differences existed at baseline (sample selection effect) or arose during study participation (Hawthorne effect).

METHODS

We constructed a cohort of 3889 young women aged 11-20 years using data from the Agincourt Health and socio-Demographic Surveillance System. We compared school enrolment in 2011 (trial start) and 2015 (trial end) between those who did (n=1720) and did not (n=2169) enrol in the trial. To isolate the Hawthorne effect, we restricted the cohort to those enrolled in school in 2011.

RESULTS

In 2011, trial participants were already more likely to be enrolled in school (99%) compared with non-participants (93%). However, this association was attenuated with covariate adjustment (adjusted risk difference (aRD) (95% CI): 2.9 (- 0.7 to 6.5)). Restricting to those enrolled in school in 2011, trial participants were also more likely to be enrolled in school in 2015 (aRD (95% CI): 4.9 (1.5 to 8.3)). The strength of associations increased with age.

CONCLUSIONS

Trial participants across both study arms were more likely to be enrolled in school than non-participants. Our findings suggest that both sample selection and Hawthorne effects may have diminished the differences in school enrolment between study arms, a plausible explanation for the null trial findings. The Hawthorne-specific findings generate hypotheses for how to structure school retention interventions to prevent HIV.

Examining effectiveness of tailorable computer-assisted therapy programmes for substance misuse: Programme usage and clinical outcomes data from Breaking Free Online

RATIONALE

When evaluating complex, tailorable digital behavioural interventions, additional approaches may be required alongside established methodologies such as randomised controlled trials (RCTs). Research evaluating a computer-assisted therapy (CAT) programme for substance misuse, Breaking Free Online (BFO), is informed by Medical Research Council (MRC) guidance recommending examination of 'mechanisms of action' of individual intervention strategies, which is relevant when evaluating digital interventions with content that may evolve over time.

AIMS

To report findings from examination of mechanisms of action of tailoring advice within the BFO programme and outcomes from specific intervention strategies.

METHODOLOGY

Analysis of covariance and linear regressions were used to assess intervention completion data, and psychometric and clinical outcomes, for 2311 service users accessing drug and alcohol treatment services across the UK.

RESULTS

Tailoring advice provided to users appeared to prompt them to prioritise completion of intervention strategies associated with their areas of highest biopsychosocial impairment. Completion of specific intervention strategies within BFO were associated with specific clinical outcomes, with a dose response also being found. Mechanisms of action analyses revealed the primacy of cognitions, with cognitive restructuring strategies being associated with improvements in mental health, severity of substance dependence, quality of life and global biopsychosocial functioning.

CONCLUSIONS

The MRC framework provides an evolved research paradigm within the field of digital behavioural change. By assessing baseline profiles of need, BFO can target the most appropriate clinical content for individual users. Mechanisms of action research can be used to inform modifications to BFO to continually update clinical content and the technology platform.

Betting on the fastest horse: Using computer simulation to design a combination HIV intervention for future projects in Maharashtra, India

Objective

To inform the design of a combination intervention strategy targeting HIV-infected unhealthy alcohol users in Maharashtra, India, that could be tested in future randomized control trials.

Methods

Using probabilistic compartmental simulation modeling we compared intervention strategies targeting HIV-infected unhealthy alcohol users on antiretroviral therapy (ART) in Maharashtra, India. We tested interventions targeting four behaviors (unhealthy alcohol consumption, risky sexual behavior, depression and antiretroviral adherence), in three formats (individual, group based, community) and two durations (shorter versus longer). A total of 5,386 possible intervention combinations were tested across the population for a 20-year time horizon and intervention bundles were narrowed down based on incremental cost-effectiveness analysis using a two-step probabilistic uncertainty analysis approach.

Results

Taking into account uncertainty in transmission variables and intervention cost and effectiveness values, we were able to reduce the number of possible intervention combinations to be used in a randomized control trial from over 5,000 to less than 5. The most robust intervention bundle identified was a combination of three interventions: long individual alcohol counseling; weekly Short Message Service (SMS) adherence counseling; and brief sex risk group counseling.

Conclusions

In addition to guiding policy design, simulation modeling of HIV transmission can be used as a preparatory step to trial design, offering a method for intervention pre-selection at a reduced cost.

Feasibility of a UK community-based, eTherapy mental health service in Greater Manchester: repeated-measures and between-groups study of 'Living Life to the Full Interactive', 'Sleepio' and 'Breaking Free Online' at 'Self Help Services'

OBJECTIVES

There is increasing evidence to support the effectiveness of eTherapies for mental health, although limited data have been reported from community-based services. Therefore, this service evaluation reports on feasibility and outcomes from an eTherapy mental health service.

SETTING

'Self Help Services', an Increasing Access to Psychological Therapies (IAPT) eTherapy service in Greater Manchester.

PARTICIPANTS

1068 service users referred to the service for secondary care for their mental health difficulties.

INTERVENTIONS

Participants were triaged into one of three eTherapy programmes: 'Living Life to the Full Interactive' for low mood, stress and anxiety; 'Sleepio' for insomnia; and 'Breaking Free Online' for substance misuse, depending on clinical need.

PRIMARY OUTCOMES MEASURES

Standardised psychometric assessments of depression, anxiety and social functioning, collected as part of the IAPT Minimum Data Set, were conducted at baseline and post-treatment.

RESULTS

Data indicated baseline differences, with the Breaking Free Online group having higher scores for depression and anxiety than the Living Life to the Full Interactive (depression CI 1.27 to 3.21, p<0.0001; anxiety CI 077 to 1.72, p<0.0001) and Sleepio (depression CI 1.19 to 4.52, p<0.0001; anxiety CI 2.16 to 5.23, p<0.0001) groups. Promising improvements in mental health scores were found within all three groups (all p<0.0001), as were significant reductions in numbers of service users reaching clinical threshold scores for mental health difficulties (p<0.0001). Number of days of engagement was not related to change from baseline for the Living Life to the Full or Sleepio programmes but was associated with degree of change for Breaking Free Online.

CONCLUSION

Data presented provide evidence for feasibility of this eTherapy delivery model in supporting service users with a range of mental health difficulties and suggest that eTherapies may be a useful addition to treatment offering in community-based services.

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

BACKGROUND

Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade.

METHODS

We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence.

FINDINGS

From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories.

INTERPRETATION

There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods.

FUNDING

Bill & Melinda Gates Foundation.

Gender-Specific Combination HIV Prevention for Youth in High-Burden Settings: The MP3 Youth Observational Pilot Study Protocol

Background

Nearly three decades into the epidemic, sub-Saharan Africa (SSA) remains the region most heavily affected by human immunodeficiency virus (HIV), with nearly 70% of the 34 million people living with HIV globally residing in the region. In SSA, female and male youth (15 to 24 years) are at a disproportionately high risk of HIV infection compared to adults. As such, there is a need to target HIV prevention strategies to youth and to tailor them to a gender-specific context. This protocol describes the process for the multi-staged approach in the design of the MP3 Youth pilot study, a gender-specific, combination, HIV prevention intervention for youth in Kenya.

Objective

The objective of this multi-method protocol is to outline a rigorous and replicable methodology for a gender-specific combination HIV prevention pilot study for youth in high-burden settings, illustrating the triangulated methods undertaken to ensure that age, sex, and context are integral in the design of the intervention.

Methods

The mixed-methods, cross-sectional, longitudinal cohort pilot study protocol was developed by first conducting a systematic review of the literature, which shaped focus group discussions around prevention package and delivery options, and that also informed age- and sex- stratified mathematical modeling. The review, qualitative data, and mathematical modeling created a triangulated evidence base of interventions to be included in the pilot study protocol. To design the pilot study protocol, we convened an expert panel to select HIV prevention interventions effective for youth in SSA, which will be offered in a mobile health setting. The goal of the pilot study implementation and evaluation is to apply lessons learned to more effective HIV prevention evidence and programming.

Results

The combination HIV prevention package in this protocol includes (1) offering HIV testing and counseling for all youth; (2) voluntary medical circumcision and condoms for males; (3) pre-exposure prophylaxis (PrEP), conditional cash transfer (CCT), and contraceptives for females; and (4) referrals for HIV care among those identified as HIV-positive. The combination package platform selected is mobile health teams in an integrated services delivery model. A cross-sectional analysis will be conducted to determine the uptake of the interventions. To determine long-term impact, the protocol outlines enrolling selected participants in mutually exclusive longitudinal cohorts (HIV-positive, PrEP, CCT, and HIV-negative) followed by using mobile phone text messages (short message service, SMS) and in-person surveys to prospectively assess prevention method uptake, adherence, and risk compensation behaviors. Cross-sectional and sub-cohort analyses will be conducted to determine intervention packages uptake.

Conclusions

The literature review, focus groups, and modeling indicate that offering age- and gender- specific combination HIV prevention interventions that include biomedical, behavioral, and structural interventions can have an impact on HIV risk reduction. Implementing this protocol will show the feasibility of delivering these services at scale. The MP3 Youth study is one of the few combination HIV prevention intervention protocols incorporating youth- and gender-specific interventions in one delivery setting. Lessons learned from the design of the protocol can be incorporated into the national guidance for combination HIV prevention for youth in Kenya and other high-burden SSA settings.

Trial Registration

ClinicalTrials.gov NCT01571128; http://clinicaltrials.gov/ct2/show/NCT01571128?term=MP3+youth&rank=1 (Archived by WebCite at http://www.webcitation.org/6nmioPd54)

HIV/Sexually Transmitted Infection Prevention Messaging: Targeting Root Causes of Sexual Risk Behavior

INTRODUCTION

Sexual risk behaviors (SRBs) often lead to sexually transmitted infections (STI), yet little is known about what drives SRB and whether this differs by sex.

METHOD

Participants (n = 920; 75% white) were drawn from the Raising Healthy Children study, enrolled in 1993 and 1994 in grades 1 to 2, and followed up through age 24/25 years. Lifetime STI diagnosis was defined by self-report or seropositivity for Chlamydia trachomatis or herpes simplex virus 2. Multivariable models assessed individual (social skills, behavioral disinhibition) and environmental factors (family involvement, school bonding, antisocial friends) predictive of STI diagnosis as mediated by 3 proximal SRB (sex under the influence of drugs or alcohol, condom use, lifetime number of sex partners).

RESULTS

Twenty-five percent of participants had ever had an STI. All SRBs differed by sex (P < 0.001), and female participants were more likely to have had an STI (P < 0.001). Behavioral disinhibition and antisocial friends in adolescence were associated with more SRB for both sexes, whereas social skills were associated with less SRB in female but more in male participants. Considering SRB and individual and environmental factors together, lifetime number of sex partners (adjusted relative risk [ARR], 1.04per partner; 95% confidence interval [CI], 1.03-1.05) and inconsistent condom use (ARR, 1.10per year; 95% CI, 1.04-1.16) were associated with increased risk of STI, whereas social skills were associated with decreased risk of STI (ARR, 0.84; 95% CI, 0.75-0.93). Behavioral disinhibition seemed to drive SRB, but family involvement mitigated this in several cases.

CONCLUSIONS

Adolescent environmental influences and individual characteristics drive some SRB and may be more effective targets for STI/HIV prevention interventions than proximal risk behaviors.

The use of cash transfers for HIV prevention--are we there yet?

Poverty and social inequality are significant drivers of the HIV epidemic and are risk factors for acquiring HIV. As such, many individuals worldwide are at risk for new HIV infection, especially young women in East and Southern Africa. By addressing these drivers, social protection programmes may mitigate the impact of poverty and social inequality on HIV risk. There is reason to believe that social protection can be used successfully for HIV prevention; social protection programmes, including cash transfers, have led to positive health outcomes and behaviour in other contexts, and they have been used successfully to promote education and increased income and employment opportunities. Furthermore, cash transfers have influenced sexual behaviour of young women and girls, thereby decreasing sexual risk factors for HIV infection. When HIV outcomes have been measured, several randomised controlled trials have shown that indirectly, cash transfers have led to reduced HIV prevalence and incidence. In these studies, school attendance and safer sexual health were directly incentivised through the cash transfer, yet there was a positive effect on HIV outcomes. In this review, we discuss the growth of social protection programmes, their benefits and impact on health, education and economic potential, and how these outcomes may affect HIV risk. We also review the studies that have shown that cash transfers can lead to reduced HIV infection, including study limitations and what questions still remain with regard to using cash transfers for HIV prevention.

Does HIV Exploit the Inflammatory Milieu of the Male Genital Tract for Successful Infection?

In many parts of the World, medical male circumcision (MMC) is used as standard prevention of care against HIV infection. This is based on seminal reports made over 10 years ago that removal of the foreskin provides up to 60% protection against HIV infection in males and seems currently the best antiretroviral-free prevention strategy yet against the global epidemic. We explore the potential mechanisms by which MMC protects against HIV-1 acquisition and that one of the oldest, albeit re-invented, rituals of removing a foreskin underscores the exploitative nature of HIV on the anatomy and tissue of the uncircumcised penis. Furthermore, foreskin removal also reveals how males acquire HIV, and in reality, the underlying mechanisms of MMC are not known. We argue that the normal sequelae of inflammation in the male genital tract (MGT) for protection from sexually transmitted infections (STI)-induced pathology represents a perfect immune and microbial ecosystem for HIV acquisition. The accumulation of HIV-1 target cells in foreskin tissue and within the urethra in response to STIs, both during and after resolution of infection, suggests that acquisition of HIV-1, through sexual contact, makes use of the natural immune milieu of the MGT. Understanding immunity in the MGT, the movement of HIV-1 target cells to the urethra and foreskin tissue upon encounter with microbial signals would provide more insight into viral acquisition and lay the foundation for further prevention strategies in males that would be critical to curb the epidemic in all sexual partners at risk of infection. The global female-centric focus of HIV-1 transmission and acquisition research has tended to leave gaps in our knowledge of what determines HIV-1 acquisition in men and such understanding would provide a more balanced and complete view of viral acquisition.

Comparison of HIV incidence estimated in clinical trial and observational cohort settings in a high risk fishing population in Uganda: Implications for sample size estimates

BACKGROUND

Clinical trial participants may differ from the source population due to the demands of trial participation and self-selection, inadvertent selection of a lower-risk group, or both. We investigated the HIV risk status of volunteers in a Simulated Vaccine Efficacy Trial (SiVET) nested within a prospective observational cohort of fisher folks in South Western Uganda.

METHODS

Volunteers aged 18-49 years, at high risk for HIV from fishing communities in Masaka district were recruited into an observational cohort and followed quarterly. High risk was defined as a self-report, of at least one of the following in the past three months; sexually transmitted infections, unprotected sex with >1 partner or a new sexual partner, use of recreational drugs, weekly alcohol use, and/or frequent travel. Volunteers who had at least three months of follow-up in the observational cohort were consecutively enrolled in SiVET, administered Hepatitis B vaccine at months (0, 1, 6) and followed-up three days post vaccinations to mimic a vaccine trial schedule. HIV incidence over the next 12 months was compared between SiVET and the observational cohort studies.

RESULTS

Between January 2012 and February 2013, 575 individuals were enrolled in the observational cohort, of whom 282 were enrolled in SiVET between July 2012 and February 2013. Despite similar pattern of reported risk behaviour in both studies, HIV incidence was higher in observational cohort, 11.4 cases/100 PYO [95% CI: 7.4-17.7] compared to 3.8 [95% CI: 2.0-7.0] in SiVET (p<0.01). SiVET volunteers tended to be men, having some education and longer-term residents, all factors that are also associated with lower HIV risk.

CONCLUSION

We observed a lower HIV incidence in SiVET than in the observational cohort. The two populations differed significantly in demographics but not in reported risk. HIV incidence estimates from observational cohorts must be used with caution to estimate the trial study size.

Conducting experimental research in marginalised populations: clinical and methodological implications from a mixed-methods randomised controlled trial in Kenya

Experimental studies to test interventions for people living with HIV in low- and middle-income countries are essential to ensure appropriate and effective clinical care. The implications of study participation on outcome data in such populations have been discussed theoretically, but rarely empirically examined. We aimed to explore the effects of participating in a randomised controlled trial conducted in an HIV clinic in Mombasa, Kenya. We report qualitative data from the Treatment Outcomes in Palliative Care trial, which evaluated the impact of a nurse-led palliative care intervention for HIV positive adults on antiretroviral therapy compared to standard care. Participants in both arms attended five monthly quantitative data collection appointments. Post-trial exit, 10 control and 20 intervention patients participated in semi-structured qualitative interviews, analysed using thematic analysis. We found benefit attributed to the compassion of the research team, social support, communication, completion of patient reported outcome measures (PROMs) and material support (transport reimbursement). Being treated with compassion and receiving social support enabled participants to build positive relationships with the research team, which improved mental health and well-being. Open and non-judgmental communication made participants feel accepted. Participants described how repeated completion of the PROMs was a prompt for reflection, through which they began to help themselves and self-care. Participant reimbursements relieved financial hardship and enabled them to fulfil their social responsibilities, enhancing self-worth. These findings emphasise the importance of compassion, support and effective communication in the clinical encounter, particularly in stigmatised and isolated populations, and the potential of the integration of simple PROMs to improve patient outcomes. Participation in research has unexpected positive benefits for participants, which should be taken into account when designing research in similar populations. Researchers should be aware of the effects of financial reimbursement and contact with researchers in isolated and impoverished communities.

ART influences HIV persistence in the female reproductive tract and cervicovaginal secretions

The recently completed HIV prevention trials network study 052 is a landmark collaboration demonstrating that HIV transmission in discordant couples can be dramatically reduced by treating the infected individual with antiretroviral therapy (ART). However, the cellular and virological events that occur in the female reproductive tract (FRT) during ART that result in such a drastic decrease in transmission were not studied and remain unknown. Here, we implemented an in vivo model of ART in BM/liver/thymus (BLT) humanized mice in order to better understand the ability of ART to prevent secondary HIV transmission. We demonstrated that the entire FRT of BLT mice is reconstituted with human CD4+ cells that are shed into cervicovaginal secretions (CVS). A high percentage of the CD4+ T cells in the FRT and CVS expressed CCR5 and therefore are potential HIV target cells. Infection with HIV increased the numbers of CD4+ and CD8+ T cells in CVS of BLT mice. Furthermore, HIV was present in CVS during infection. Finally, we evaluated the effect of ART on HIV levels in the FRT and CVS and demonstrated that ART can efficiently suppress cell-free HIV-RNA in CVS, despite residual levels of HIV-RNA+ cells in both the FRT and CVS.

Effects of integrated interventions on transmission risk and care continuum outcomes in persons living with HIV: meta-analysis, 1996-2014

BACKGROUND

Reducing HIV infection and improving outcomes along the continuum of HIV care are high priorities of the US National HIV/AIDS strategy. Interventions that target multiple problem behaviors simultaneously in an integrated approach (referred to as integrated interventions) may improve prevention and care outcomes of persons living with HIV (PLWH). This systematic review and meta-analysis examines the effects of integrated interventions.

METHODS

A systematic review, including both electronic and hand searches, was conducted to identify randomized controlled trials (RCTs) published between 1996 and 2014 that were designed to target at least two of the following behaviors among PLWH: HIV transmission risk behaviors, HIV care engagement, and medication adherence. Effect sizes were meta-analyzed using random-effects models.

RESULTS

Fifteen RCTs met the inclusion criteria. Integrated interventions significantly reduced sex without condoms [odds ratio (OR) = 0.74, 95% confidence interval (CI) = 0.59, 0.94, P = 0.013, 13 effect sizes] and had marginally significant effects on improving medication adherence behaviors (OR = 1.35, 95% CI = 0.98, 1.85, P = 0.063, 12 effect sizes) and undetectable viral load (OR = 1.46, 95% CI = 0.93, 2.27, P = 0.098, seven effect sizes). Significant intervention effects on at least two outcomes were seen in RCTs tailored to individual needs, delivered one on one, or in settings wherein PLWH received services or care.

CONCLUSION

Integrated interventions produced some favorable prevention and care continuum outcomes in PLWH. How to incorporate integrated interventions with other combination HIV prevention strategies to reach the optimal impact requires further research.

What Works Well in HIV Prevention Among Spanish Young People? An Analysis of Differential Effectiveness Among Six Intervention Techniques

The AIDS epidemic remains a concern of public health among young people and adolescents. Prevention programs have revealed diverse deficiencies to attain their main goal: preventing risky behaviors. This experimental study evaluates the differential effectiveness of six intervention techniques for preventing HIV/AIDS based on informational-motivational-behavioral Model (talk, website, attitudinal discussion, participation of a seropositive person, fear induction and role play). 239 Spanish young people took part in an experimental design to evaluate six intervention techniques and a non-intervention condition, through changes in their knowledge, attitudes and protective sex behavior. Our findings support a general effectiveness of preventive intervention techniques comparing non-intervention. In particular, the motivational techniques reveal more effectiveness for these Spanish young people. Therefore, it is required identifying a differential impact of the intervention techniques when implementing HIV behavioral interventions.

Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies

By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits.

Comparing Psychosocial Correlates of Condomless Anal Sex in HIV-Diagnosed and HIV-Nondiagnosed Men Who Have Sex with Men: A Series of Meta-Analyses of Studies from 1993-2013

PURPOSE

Men who have sex with men (MSM) continue to be overrepresented in rates of incidence and prevalence of human immunodeficiency virus (HIV). Both HIV-diagnosed (HIV-D) and HIV-nondiagnosed (HIV-N) MSM report a variety of reasons for intentional and unintentional nonuse of condoms. Elucidating and comparing reasons for continued engagement in condomless anal sex specific to both HIV-D and HIV-N MSM likely is important to identifying effective prevention.

METHODS

This study employed meta-analytic methods to evaluate and compare correlates to condomless anal sex in both HIV-D and HIV-N MSM from primary studies from 1993 to February 2013.

RESULTS

Of the 19 individual correlates assessed within the subgroup of HIV-D MSM, variables that achieved significant effect were alcohol, mind-altering substance use, sexual-enhancement medication, intentional condom nonuse, self-efficacy, attitudes toward condom use, social support, gay identity, compulsivity, trading sex, and number of sex partners. Those that were statistically non-significant were intention to use a condom, perceived risk, perceived norms, perceived responsibility, HIV medical management, treatment optimism, mental health, and setting. Of the 12 correlates assessed within the subgroup of HIV-N MSM, variables that achieved significant effect were alcohol, mind-altering substance use, intentional condom nonuse, attitudes toward condom use, perceived risk, and setting. Those observed as statistically non-significant were perceived norms, social support, gay identity, mental health, trading sex, and number of sex partners.

CONCLUSION

Study results have clinical implications that may guide future prevention research and practice by highlighting risk variables shared between HIV-N and HIV-D MSM, as well as variables observed to be unique to each group that may warrant more tailored intervention. Further investigation is recommended to elucidate the relationships among these variables such that optimal intervention can be determined.

Changes in the contribution of genital tract infections to HIV acquisition among Kenyan high-risk women from 1993 to 2012

OBJECTIVE

The objective of this study was to understand temporal trends in the contribution of different genital tract infections to HIV incidence over 20 years of follow-up in a cohort of high-risk women.

DESIGN

A prospective cohort study.

METHODS

We performed monthly evaluations for HIV, vaginal yeast, bacterial vaginosis, Trichomonas vaginalis, Neisseria gonorrhoeae, nonspecific cervicitis, herpes simplex virus type two (HSV-2), genital ulcer disease (GUD) and genital warts. We used Cox regression to evaluate the association between sexually transmitted infections (STIs) and HIV acquisition over four time periods (1993-1997, 1998-2002, 2003-2007, 2008-2012). Models were adjusted for age, workplace, sexual risk behaviour, hormonal contraceptive use and other STIs. The resulting hazard ratios were used to calculate population attributable risk percentage (PAR%).

RESULTS

Between 1993 and 2012, 1964 women contributed 6135 person-years of follow-up. The overall PAR% for each infection was prevalent HSV-2 (48.3%), incident HSV-2 (4.5%), bacterial vaginosis (15.1%), intermediate microbiota (7.5%), vaginal yeast (6.4%), T. vaginalis (1.1%), N. gonorrhoeae (0.9%), nonspecific cervicitis (0.7%), GUD (0.8%) and genital warts (-0.2%). Across the four time periods, the PAR% for prevalent HSV-2 (40.4%, 61.8%, 58.4%, 48.3%) and bacterial vaginosis (17.1%, 19.5%, 14.7%, 17.1%) remained relatively high and had no significant trend for change over time. The PAR% for trichomoniasis, gonorrhoea, GUD and genital warts remained less than 3% across the four periods.

CONCLUSION

Bacterial vaginosis and HSV-2 have consistently been the largest contributors to HIV acquisition risk in the Mombasa Cohort over the past 20 years. Interventions that prevent these conditions would benefit women's health and could reduce their risk of becoming infected with HIV.

Clinical Trial Design for HIV Prevention Research: Determining Standards of Prevention

This article seeks to advance ethical dialogue on choosing standards of prevention in clinical trials testing improved biomedical prevention methods for HIV. The stakes in this area of research are high, given the continued high rates of infection in many countries and the budget limitations that have constrained efforts to expand treatment for all who are currently HIV-infected. New prevention methods are still needed; at the same time, some existing prevention and treatment interventions have been proven effective but are not yet widely available in the countries where they most urgently needed. The ethical tensions in this field of clinical research are well known and have been the subject of extensive debate. There is no single clinical trial design that can optimize all the ethically important goals and commitments involved in research. Several recent articles have described the current ethical difficulties in designing HIV prevention trials, especially in resource limited settings; however, there is no consensus on how to handle clinical trial design decisions, and existing international ethical guidelines offer conflicting advice. This article acknowledges these deep ethical dilemmas and moves beyond a simple descriptive approach to advance an organized method for considering what clinical trial designs will be ethically acceptable for HIV prevention trials, balancing the relevant criteria and providing justification for specific design decisions.

Rush to judgment: the STI-treatment trials and HIV in sub-Saharan Africa

INTRODUCTION

The extraordinarily high incidence of HIV in sub-Saharan Africa led to the search for cofactor infections that could explain the high rates of transmission in the region. Genital inflammation and lesions caused by sexually transmitted infections (STIs) were a probable mechanism, and numerous observational studies indicated several STI cofactors. Nine out of the ten randomized controlled trials (RCTs), however, failed to demonstrate that treating STIs could lower HIV incidence. We evaluate all 10 trials to determine if their design permits the conclusion, widely believed, that STI treatment is ineffective in reducing HIV incidence.

DISCUSSION

Examination of the trials reveals critical methodological problems sufficient to account for statistically insignificant outcomes in nine of the ten trials. Shortcomings of the trials include weak exposure contrast, confounding, non-differential misclassification, contamination and effect modification, all of which consistently bias the results toward the null. In any future STI-HIV trial, ethical considerations will again require weak exposure contrast. The complexity posed by HIV transmission in the genital microbial environment means that any future STI-HIV trial will face confounding, non-differential misclassification and effect modification. As a result, it is unlikely that additional trials would be able to answer the question of whether STI control reduces HIV incidence.

CONCLUSIONS

Shortcomings in published RCTs render invalid the conclusion that treating STIs and other cofactor infections is ineffective in HIV prevention. Meta-analyses of observational studies conclude that STIs can raise HIV transmission efficiency two- to fourfold. Health policy is always implemented under uncertainty. Given the known benefits of STI control, the irreparable harm from not treating STIs and the likely decline in HIV incidence resulting from STI control, it is appropriate to expand STI control programmes and to use funds earmarked for HIV prevention to finance those programmes.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

Combination HIV prevention for female sex workers: what is the evidence?

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

The Flawed Reliance on Randomized Controlled Trials in Studies of HIV Behavioral Prevention Interventions for People Who Inject Drugs and Other Populations

This article discusses ways in which randomized controlled trials do not accurately measure the impact of HIV behavioral interventions. This is because: 1. Such trials measure the wrong outcomes. Behavior change may have little to do with changes in HIV incidence since behavior change in events between HIV-concordant people have no impact on incidence. Even more important, the comparison of HIV incidence rates between study arms of individual-level RCTs does not measure the true outcome of interest-whether or not the intervention reduces HIV transmission at the community level. This is because this comparison cannot measure the extent to which the intervention stops transmission by HIV-infected people in the study to those outside it. (And this is made even worse if HIV-infected are excluded from the evaluation of the intervention.) 2. There are potential harms implicit in most cognitively oriented behavioral interventions that are not measured in current practice and may not be measurable using RCTs. Intervention trials often reinforce norms and values of individual self-protection. They rarely if ever measure whether doing this reduces community trust, solidarity, cohesion, organization, or activism in ways that might facilitate HIV transmission. 3. Many interventions are not best conceived of as interventions with individuals but rather with networks, cultures of risks, or communities. As such, randomizing individuals leads to effective interventions that diffuse protection through a community; but these are evaluated as ineffective because the changes diffuse to the control arm, which leads to systematic and erroneous reductions in the evaluated effectiveness as RCTs measure it. The paper ends by discussing research designs that are superior to individual-level RCTs at measuring whether an intervention reduces or increases new HIV transmission.

The impact of community mobilisation on HIV prevention in middle and low income countries: a systematic review and critique

While community mobilisation (CM) is increasingly advocated for HIV prevention, its impact on measurable outcomes has not been established. We performed a systematic review of the impact of CM within HIV prevention interventions (N = 20), on biomedical, behavioural and social outcomes. Among most at risk groups (particularly sex workers), the evidence is somewhat consistent, indicating a tendency for positive impact, with stronger results for behavioural and social outcomes than for biomedical ones. Among youth and general communities, the evidence remains inconclusive. Success appears to be enhanced by engaging groups with a strong collective identity and by simultaneously addressing the socio-political context. We suggest that the inconclusiveness of the findings reflects problems with the evidence, rather than indicating that CM is ineffective. We discuss weaknesses in the operationalization of CM, neglect of social context, and incompatibility between context-specific CM processes and the aspiration of review methodologies to provide simple, context-transcending answers.

Modelling in concentrated epidemics: informing epidemic trajectories and assessing prevention approaches

PURPOSE OF THE REVIEW

This review summarizes recent mathematical modelling studies conducted among key populations including MSM, people who inject drugs (PWID), and female sex workers (FSWs) in low prevalence settings used as a marker of concentrated epidemics.

RECENT FINDINGS

Most recent studies focused on MSM, Asian settings or high-income countries, studied the transmission dynamics or modelled pre-exposure prophylaxis, treatment as prevention or behavioural interventions specific to each key population (e.g., needle exchange programme or use of low-dead space syringes for PWID). Biological interventions were deemed effective and cost-effective, though still expensive, and often deemed unlikely to result in HIV elimination if used alone. Targeting high-risk individuals even within key populations improved efficiency. Some studies made innovative use of models to formally evaluate HIV prevention programmes, to interpret genetic or co-infection data, and to address methodological questions and validate epidemiological tools.

CONCLUSION

More work is needed to optimize combination prevention focusing on key populations in different settings. The gaps identified include the limited number of studies modelling drug resistance, structural interventions, treatment as prevention among FSWs, and estimating the contribution of key populations to overall transmission in different settings.

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.