Increased HIV Transmission Research Articles

Male Circumcision and Risk of HIV Transmission from Male to Women

Male circumcision has proved to be protective for male to male HIV transmission. The effect of male circumcision on female partner's HIV status is still uncertain from previous studies. This systematic review aimed to assess whether circumcision status of an HIV-infected male changes the risk of HIV transmission to his female sexual partner. We analyzed findings from one randomized controlled trial and 4 cross sectional study and found no significant evidence in support of our hypothesis that male circumcision prevents HIV transmission in female. Due to high methodological and clinical heterogeneity, meta-analysis was not done. Qualitative synthesis revealed lack of existing good quality study to address this question. Four of five studies reported no association between male circumcision and HIV transmission. One cohort study reported protective effect of male circumcision on their female partner's HIV. Only one subpopulation of RCT (resume to sexual activity before wound healing) reported increased HIV transmission in female whose male partner is circumcised. Effect of male circumcision on HIV transmission is still blurred. Large scale randomized trial is needed to answer this question. Until then, the prevention programs should also emphasize other measures of HIV transmission.Medicine Today 2016 Vol.28(1): 22-26

Effects of patient load and travel distance on HIV transmission in a cohort of serodiscordant couples in rural China: a longitudinal analysis

BackgroundSustained viral suppression through antiretroviral therapy (ART) reduces the risk of sexual HIV transmission. However, it can require routine access to reliable and effective medical care, which can be difficult to obtain in resource-constrained areas. We investigated the effects of patient load and travel distance to an HIV care clinic on transmission risk in HIV serodiscordant couples in the Henan Province, China. MethodsThe study cohort arises from a population of HIV-infected individuals in central rural China where regional blood selling scandals in the 1990s led to mass HIV transmission of up to 30 000 people though unsanitary blood collection practices. Local disease control centres in our study prefecture followed up patients with HIV and their uninfected spouses to monitor transmission events since 2006. Eligible couples had to be registered residents living in the study prefecture, older than 16 years (the age of legal consent in China), in a stable marriage (no separation or divorce), one partner confirmed to be HIV seropositive and the other seronegative, and be willing to provide written or verbal informed consent. Cox proportional hazard models were used to compare events of HIV transmission between couples living near (<50 km), medium (≥50 km), or far (>100 km) distances from their assigned HIV care clinics, as well as between those attending clinics with high (>100 patients per clinician) versus low (≤100 patients per clinician) patient loads. Ethics approval for the analysis of these data for research purposes was provided by the Institutional Review Board of the National Center for AIDS/STD Control and Prevention (NCAIDS) at the Chinese Centers for Disease Control and Prevention. This analysis relied on an agreement between the Institutional Review Boards of NCAIDS and the University of North Carolina, Chapel Hill. Findings3611 HIV-serodiscordant couples contributed a total of 21 231 person-years. Index partners received HIV care at 159 different HIV care centres distributed over three tiers of care, including village clinics (40·8%) township health centres (56·6%), and county hospitals (2·5%). 2961 (82%) of the 3611 serodiscordant couples lived within 10 km of their assigned HIV clinic, and 2654 (73%) attended clinics with patient-to-provider ratios of at least 100:1. In adjusted Cox models, attending clinics in which clinicians bore average patient loads of 100 or more increased HIV transmission risk (adjusted hazard ratio [aHR] 1·50, 95% CI 1·00–4·84), an effect amplified in village tier clinics (1·55, 1·23–6·78). Travel distance was associated with HIV transmission only after stratification; travelling medium distances to village clinics increased transmission risk (1·83, 1·04–3·21), whereas travelling longer distances to township or county-level clinics lowered transmission risk (0·10, 0·01–0·75). InterpretationHigh patient loads at HIV clinics was strongly associated with increased risk of HIV transmission in our population, particularly at village-level clinics. Increased travel distance had divergent effects based on clinic tier, suggesting unique mechanisms operating across levels of resource availability. The resource availability of long-term HIV treatment might place substantial strains on small rural clinics, for which investments in additional support staff or time-saving tools such as point-of-care laboratory testing might bring about impactful change in treatment outcomes. FundingMinistry of Science and Technology, People's Republic of China, National Institutes of Health of the USA.

Awareness and use of nonoccupational post-exposure prophylaxis among men who have sex with men in Vancouver, Canada.

Nonoccupational post-exposure prophylaxis (nPEP) is a strategy to reduce the risk of HIV infection in those with high-risk exposure. This study characterized nPEP awareness among gay, bisexual and other men who have sex with men (MSM) in Metro Vancouver, British Columbia, Canada after a pilot nPEP programme established in 2012. Momentum Health Study participants were MSM aged ≥16 years recruited via respondent-driven sampling (RDS) who completed a computer-assisted self-interview. Stratifying patients by HIV status, we used multivariable logistic regression with backward selection to identify factors associated with nPEP awareness. All analyses were RDS-adjusted. A total of 51.9% (112 of 173) of HIV-positive and 48.5% (272 of 500) of HIV-negative participants had heard of nPEP. Only 3% (five of 106) of HIV-negative participants who reported recent high-risk sex used nPEP. Generally, nPEP awareness was higher for participants who engaged in sexual activities with increased HIV transmission potential. Factors associated with greater awareness among HIV-negative participants included recent alcohol use, higher communal sexual altruism, previous sexually transmitted infection diagnosis, and greater perceived condom use self-efficacy. Other factors associated with greater awareness among HIV-negative participants included white race/ethnicity, gay sexual identity, more formal education, lower personal sexual altruism, and Vancouver residence. Greater nPEP awareness among HIV-positive participants was associated with greater perceived agency to ask sexual partners' HIV status and more frequently reporting doing so, a higher number of lifetime receptive sex partners, and greater access to condoms. Following implementation of an nPEP pilot programme, nPEP awareness among HIV-negative MSM was 51% and use was 3%. These data support the need to expand access to and actively promote nPEP services.

Heavy Alcohol Use Is Associated With Worse Retention in HIV Care.

Poor retention in HIV care is associated with worse clinical outcomes and increased HIV transmission. We examined the relationship between self-reported alcohol use, a potentially modifiable behavior, and retention. A total of 9694 people living with HIV from 7 participating US HIV clinical sites (the Centers for AIDS Research Network of Integrated Clinical Systems) contributed 23,225 observations from January 2011 to June 2014. The retention outcomes were (1) Institute of Medicine (IOM) retention: 2 visits within 1 year at least 90 days apart and (2) visit adherence [proportion of kept visits/(scheduled + kept visits)]. Alcohol use was measured with Alcohol Use Disorders Identification Test-C, generating drinking (never, moderate, and heavy) and binge frequency (never, monthly/less than monthly, weekly/daily) categories. Adjusted multivariable logistic models, accounting for repeat measures, were generated. Of our sample, 82% was men, 46% white, 35% black, and 14% Hispanic. At first assessment, 37% of participants reported never drinking, 38% moderate, and 25% heavy, and 89% of the patients were retained (IOM retention measure). Participants' mean (SD) visit adherence was 84% (25%). Heavy alcohol use was associated with inferior IOM-defined retention (adjusted odds ratio 0.78, 95% confidence interval: 0.69 to 0.88), and daily/weekly binge drinking was associated with lower visit adherence (adjusted odds ratio = 0.90, 95% confidence interval: 0.82 to 0.98). Both heavy drinking and frequent binge drinking were associated with worse retention in HIV care. Increased identification and treatment of heavy and binge drinking in HIV clinical care settings may improve retention in HIV care, with downstream effects of improved clinical outcomes and decreased HIV transmission.

Did we speciate on the Southern Coastal Plain of South Africa?

Increased HIV transmission in persons who inject drugs (PWIDs) has led to subepidemics and outbreaks in several countries in Europe, including Bulgaria. In this study in Bulgaria, we investigate the origin and spatiotemporal evolutionary history of HIV-1 infections in PWIDs and the distribution of antiretroviral resistance mutations and hepatitis co-infections in these populations. We analyzed HIV-1 polymerase sequences available from 117 of 359 PWIDs diagnosed with HIV/AIDS from 1999 to 2011. Of these, 50 (42.7%) were classified as CRF02_AG, 41 (35.0%) CRF01_AE, 12 (10.3%) URFs, ten (8.5%) subtype B, two (1.7%) subtype F1 and two (1.7%) CRF14_BG. Most recent common ancestor dating suggests that CRF01_AE was likely first introduced from Southeast Asia into persons reporting heterosexual infection in Bulgaria in 1992 and spread subsequently to PWIDs in the capital city of Sofia around 2003. Conversely, CRF02_AG in Bulgaria was likely first introduced into PWID from Germany in 2000 and later entered heterosexual populations around 2009. The overall prevalence of resistance mutations was 6.8% (8/117), of which 5.1% (5/117) was observed in patients on antiretroviral therapy and 1.7% (2/117) was from transmitted drug resistance mutations in drug-naïve individuals. 189/204 (92.6%) PWIDs were also co-infected with hepatitis C (HCV) and 31/183 (16.9%) were co-infected with hepatitis B (HBV). Our study provides valuable molecular epidemiological information on the introduction and distribution of the main HIV-1 subtypes, resistance mutations and hepatitis co-infections among PWIDs with HIV-1 in Bulgaria which can be used to target prevention efforts.

Origin and spread of HIV-1 in persons who inject drugs in Bulgaria

Increased HIV transmission in persons who inject drugs (PWIDs) has led to subepidemics and outbreaks in several countries in Europe, including Bulgaria. In this study in Bulgaria, we investigate the origin and spatiotemporal evolutionary history of HIV-1 infections in PWIDs and the distribution of antiretroviral resistance mutations and hepatitis co-infections in these populations. We analyzed HIV-1 polymerase sequences available from 117 of 359 PWIDs diagnosed with HIV/AIDS from 1999 to 2011. Of these, 50 (42.7%) were classified as CRF02_AG, 41 (35.0%) CRF01_AE, 12 (10.3%) URFs, ten (8.5%) subtype B, two (1.7%) subtype F1 and two (1.7%) CRF14_BG. Most recent common ancestor dating suggests that CRF01_AE was likely first introduced from Southeast Asia into persons reporting heterosexual infection in Bulgaria in 1992 and spread subsequently to PWIDs in the capital city of Sofia around 2003. Conversely, CRF02_AG in Bulgaria was likely first introduced into PWID from Germany in 2000 and later entered heterosexual populations around 2009. The overall prevalence of resistance mutations was 6.8% (8/117), of which 5.1% (5/117) was observed in patients on antiretroviral therapy and 1.7% (2/117) was from transmitted drug resistance mutations in drug-naïve individuals. 189/204 (92.6%) PWIDs were also co-infected with hepatitis C (HCV) and 31/183 (16.9%) were co-infected with hepatitis B (HBV). Our study provides valuable molecular epidemiological information on the introduction and distribution of the main HIV-1 subtypes, resistance mutations and hepatitis co-infections among PWIDs with HIV-1 in Bulgaria which can be used to target prevention efforts.

Heroin Use and Injection Risk Behaviors in Colombia: Implications for HIV/AIDS Prevention

ABSTRACTBackground: Heroin production in Colombia has increased dramatically in recent decades, and some studies point to an increase in local heroin use since the mid-1990s. Despite this rapid increase, little is known about the effects of these activities on heroin injection within Colombia. One of the biggest concerns surrounding heroin injection is the potential spread of HIV through drug user networks. Objectives: This article examines injection risk behaviors among heroin injectors in the Colombian cities of Medellín and Pereira to explore the implications for possible increased HIV transmission within this group. Methods: A cross-sectional study used respondent-driving sampling to recruit a sample of 540 people who inject drugs (PWID) over 18 years of age (Medellín: n = 242, Pereira: n = 298). Structured interviews with each participant were conducted using the World Health Organization Drug Injection Study Phase II Survey. An HIV test was also administered. Results: Information regarding the socio-demographics, injection drug use, HIV risk and transmission behaviors, injection risk management, and HIV knowledge and prevalence of participants are reported. The study identified many young, newly initiated injectors who engage in risky injection practices. The study also found that HIV prevalence is fairly low among participants (2.7%). Conclusions/Importance: Findings indicate a potential risk for the spread of HIV among PWID in Colombia given their widespread sharing practices, high rate of new injector initiation, and unsafe syringe cleaning practices. Colombia has a possibly time-limited opportunity to prevent an HIV epidemic by implementing harm reduction interventions among young, newly initiated PWID.

Critical Review: Mechanisms of HIV Transmission in Depo-Provera Users: The Likely Role of Hypoestrogenism.

Almost half of new HIV infections worldwide occur in women, and vaginal intercourse is the most common mode of transmission. Accumulating evidence suggests that depot medroxyprogesterone acetate may increase HIV transmission, but little is known about the underlying mechanisms. We propose that hypoestrogenism in depot medroxyprogesterone acetate may contribute to increased HIV transmission. We present supportive evidence and propose potential interventions to prevent or treat vaginal hypoestrogenism using vaginal estrogens.

HIV Exceptionalism: Development through Disease in Sierra Leone by Adia Benton

Adia Benton, HIVExceptionalism: Development through Disease in Sierra Leone. Minneapolis: University of Minnesota Press, 2015. 192 pp.Among many books written about HIV epidemic in Africa over past few decades, book-length anthropological studies remain a rarity. Adia Benton's new book, HIV Exceptionalism-Development through Disease in Sierra Leone, helps to fill that gap. Through fine-grained accounts describing how individuals navigated new structures, new relationships, and new expectations that came along with being beneficiaries of global HIV funding, Benton reveals jagged edges and uncomfortable truths about broader global-local health encounters. This book tells a compelling story about an entire society adapting to a sudden infusion of donor money for a disease that, in this particular context, barely existed.The book is about HIV in Sierra Leone, but issue of local responses to global health initiatives has relevance beyond HIV or any particular country context. What makes this particular disease in this particular country an interesting case for ethnographic study is fact that HIV rates here have been historically very low, both before and after 1991-2002 civil war, and yet country received a large infusion of foreign aid money specifically for HIV/AIDS prevention and care programs. HIV services were initially introduced on a pilot basis in 2004, and by 2007 Global Fund had secured enough funding to open a network of treatment centers that offered anti-AIDS treatment free of charge. By 2012, country had spent more than $12 million USD on HIV/AIDS services, and all while HIV prevalence rates remained essentially no different than pre-war figure of 1.5 percent. How did country and its war-ravaged health systems adapt to absorb those funds? How did people adjust their behavior to become models of positive living? How were hierarchies of power established between transnational donors, local health officials, NGOs, AIDS activists, and expert patients? What made HIV so exceptional in comparison to all other challenges confronting country at time? All these questions are explored in Benton's anthropological project to hold lived experience in focus while mapping networks, institutions, beliefs, and conceptions that emerged with flood of post-war HIV/AIDS money.Sierra Leone's civil war was winding down just as international HIV/ AIDS was revving up. With 2001 launch of PEPFAR program (President's Emergency Program for AIDS Relief) by US President George W. Bush, a multi-billion dollar fund to address global HIV/AIDS epidemic became available. What some had called the AIDS industry roared into action at that time and search was on for worthy projects and countries to target for assistance. The newly launched PEPFAR program with its billions of dollars was actively searching for worthy projects and countries to target for HIV assistance. Expert consensus then was that war and HIV always conspired against affected populations and constituted a double emergency. When it was found that HIV prevalence in conflict-affected Sierra Leone was lower than anticipated, experts argued that normalization in post-conflict period would lead to increased HIV transmission. While this never happened, it did not stop international funders or Sierra Leonean officials from making a case to secure attractive emergency HIV/AIDS funds. And why not? With those funds, nearly $80 million allocated over a five-year period, came a wide-range of services-medical care, support groups, income generation projects, education, food supplements, and skills training, among others. All of these were welcomed in dire social and economic circumstances of postwar Sierra Leone. But HIV was, and remains, exceptional among diseases, and exceptionalism created what Benton refers to as an economy of suffering, whereby those who had AIDS could claim unique hardship in a context where daily suffering was norm. …

Chronic distress and the vulnerable host: a new target for HIV treatment and prevention?

Pathologic stress (distress) disturbs immune, cardiovascular, metabolic, and behavioral homeostasis. Individuals living with HIV and those at risk are vulnerable to stress disorders. Corticotropin-releasing hormone (CRH) is critical in neuroendocrine immune regulation. CRH, a neuropeptide, is distributed in the central and peripheral nervous systems and acts principally on CRH receptor type 1 (CRHR1). CRH in the brain modulates neuropsychiatric disorders. CRH and stress modulation of immunity is two-pronged; there is a direct action on hypothalamic-pituitary-adrenal secretion of glucocorticoids and through immune organ sympathetic innervation. CRH is a central and systemic proinflammatory cytokine. Glucocorticoids and their receptors have gene regulatory actions on viral replication and cause central and systemic immune suppression. CRH and stress activation contributes to central nervous system (CNS) viral entry important in HIV-associated neurocognitive disorders and HIV-associated dementia. CNS CRH overproduction short-circuits reward, executive, and emotional control, leading to addiction, cognitive impairment, and psychiatric comorbidity. CRHR1 is an important therapeutic target for medication development. CRHR1 antagonist clinical trials have focused on psychiatric disorders with little attention paid to neuroendocrine immune disorders. Studies of those with HIV and those at risk show that concurrent stress-related disorders contribute to higher morbidity and mortality; stress-related conditions, addiction, immune dysfunction, and comorbid psychiatric illness all increase HIV transmission. Neuropsychiatric disease, chronic inflammation, and substance abuse are endemic, and chronic distress is a pathologic factor. It is being understood that stress and CRH are fundamental to neuroendocrine immunity; therapeutic interventions with existing and novel agents hold promise for restoring homeostasis, reducing morbidity and mortality for those with HIV and possibly reducing future disease transmission.

Strategic information is everyone's business: perspectives from an international stakeholder meeting to enhance strategic information data along the HIV Cascade for people who inject drugs.

People who inject drugs (PWID) are at increased HIV transmission risk because of unsafe injecting practices and a host of other individual, network, and structural factors. Thus, PWID have a great need for services within the Cascade of HIV prevention, diagnosis, care, and treatment (HIV Cascade). Yet the systems that monitor their progress through the Cascade are often lacking. Subsequently, fewer reliable data are available to guide programs targeting this key population (KP). Programmatic data, which are helpful in tracking PWID through the Cascade, also are limited because not all countries have harm reduction programming from which to estimate Cascade indicators. Also, due to stigma and the illegal nature of drug use, PWID may not disclose their drug use behavior or HIV status when accessing services. Consequently, PWID appear to have low HIV testing rates and, for those living with HIV, lower access to health services and lower viral suppression rates than do other KP groups. This commentary, based on outcomes from an international stakeholder meeting, identifies data gaps and proposes solutions to strengthen strategic information (SI), the systematic collection, analysis, and dissemination of information, to optimize HIV prevention, care, and treatment programming for PWID.

P09.10 The potential impact of vaccination on the prevalence of gonorrhoea

Introduction Gonorrhoea, one of the most common sexually transmitted infections worldwide, can lead to serious sequelae, including infertility and increased HIV transmission. Recently, untreatable, multidrug-resistant Neisseria gonorrhoeae strains have been reported. In the absence of new antibiotics, and given the speed with which resistance has emerged to all previously used antibiotics, development of a vaccine would be the ideal solution to this public health emergency. Understanding the desired characteristics, target population, and expected impact of an anti-gonococcal vaccine is essential to facilitate vaccine design, assessment, and implementation. The modelling presented herein aims to fill these conceptual gaps and inform future gonococcal vaccine development. Methods Using an individual-based, epidemiological simulation model, gonococcal prevalence was simulated in a heterosexual population of 100, 000 individuals (with a ~1.7% prevalence rate) after the introduction of vaccines with varied efficacy (10–100%) and duration of protection (2.5–20 years). Results Model simulations predicted that gonococcal prevalence could be reduced by; at least, 90% after 20 years, if all 13-year-olds were given a vaccine with 50% efficacy that does not wane. A comparable reduction in prevalence could be achieved by a vaccine with 100% efficacy that wanes after 7.5 years. A 40% reduction in prevalence would be achieved with a non-waning vaccine of just 20% efficacy. Conclusion A vaccine of moderate efficacy and duration could have a substantive impact on gonococcal prevalence and disease sequelae, if coverage is high and protection lasts over the highest risk period (i.e. most sexual partner change) among youths. Disclosure of interest statement This work was funded by the Australian National Health and Medical Research Council, The Australian Government Department of Health, and the National Institutes of Health USA. No pharmaceutical grants were received in the development of this study.

The potential impact of vaccination on the prevalence of gonorrhea

Gonorrhea, one of the most common sexually transmitted infections worldwide, can lead to serious sequelae, including infertility and increased HIV transmission. Recently, untreatable, multidrug-resistant Neisseria gonorrhoeae strains have been reported. In the absence of new antibiotics, and given the speed with which resistance has emerged to all previously used antibiotics, development of a vaccine would be the ideal solution to this public health emergency. Understanding the desired characteristics, target population, and expected impact of an anti-gonococcal vaccine is essential to facilitate vaccine design, assessment and implementation. The modeling presented herein aims to fill these conceptual gaps, and inform future gonococcal vaccine development. Using an individual-based, epidemiological simulation model, gonococcal prevalence was simulated in a heterosexual population of 100,000 individuals after the introduction of vaccines with varied efficacy (10–100%) and duration of protection (2.5–20 years). Model simulations predict that gonococcal prevalence could be reduced by at least 90% after 20 years, if all 13-year-olds were given a non-waning vaccine with 50% efficacy, or a vaccine with 100% efficacy that wanes after 7.5 years. A 40% reduction in prevalence is achievable with a non-waning vaccine of only 20% efficacy. We conclude that a vaccine of moderate efficacy and duration could have a substantive impact on gonococcal prevalence, and disease sequelae, if coverage is high and protection lasts over the highest risk period (i.e., most sexual partner change) among young people.

Seasonal PrEP for partners of migrant miners in southern Mozambique: a highly focused PrEP intervention.

IntroductionTo be used most effectively, pre-exposure prophylaxis (PrEP) should be prioritized to those at high risk of acquisition and would ideally be aligned with time periods of increased exposure. Identifying such time periods is not always straightforward, however. Gaza Province in southern Mozambique is characterized by high levels of HIV transmission and circular labour migration to mines in South Africa. A strong seasonal pattern in births is observable, reflecting an increase in conception in December. Given the potential for increased HIV transmission between miners returning in December and their partners in Gaza Province, PrEP use by the latter would be a useful means of HIV prevention, especially for couples who wish to conceive.MethodsA mathematical model was used to represent population-level adult heterosexual HIV transmission in Gaza Province. Increased HIV acquisition among partners of miners in December, coinciding with the miners’ return from South Africa, is represented. In addition to a PrEP intervention, the scale-up of treatment and recent scale-up of male circumcision that have occurred in Gaza are represented.ResultsProviding time-limited PrEP to the partners of migrant miners, as opposed to providing PrEP all year, would improve the cost per infection averted by 7.5-fold. For the cost per infection averted to be below US$3000, at least 85% of PrEP users would need to be good adherers and PrEP would need to be cheaper than US$115 per person per year. Uncertainty regarding incidence of HIV transmission among partners of miners each year in December has a strong influence on estimates of cost per infection averted.ConclusionsProviding time-limited PrEP to partners of migrant miners in Gaza Province during periods of increased exposure would be a novel strategy for providing PrEP. This strategy would allow for a better prioritized intervention, with the potential to improve the efficiency of a PrEP intervention considerably, as well as providing important reproductive health benefits.

Drug Treatment as HIV Prevention Among Women and Girls Who Inject Drugs From a Global Perspective: Progress, Gaps, and Future Directions.

Although there have been significant reductions in the number of new HIV infections globally from 2009 to 2013, incidence remains unacceptably high for persons who use drugs. In many settings, women and girls who inject drugs (WWID) with HIV/AIDS experience poor treatment access, including evidence-based practices like antiretroviral therapy and drug treatment. Medication-assisted therapies (MAT) for substance use disorders are especially inaccessible, which in their absence, increases HIV transmission risk. Irrespective of setting or culture, drug treatment using MAT is not only effective but also cost-effective at reducing opioid use and linked injection and sexual risks. Data presented here for WWID address their access to MAT for opioid addiction and to treatments being developed that address the relationship, family, and vocational needs of this group. The most glaring finding is that globally, WWID frequently are excluded in surveys or studies with an impressive lack of disaggregated data by gender when surveying access to MAT—even in wealthy countries. Despite this, there have been some striking improvements in implementing drug treatment as prevention, notably in Iran and China. Still, real barriers remain for women and girls to accessing drug treatment, other harm reduction services, and antiretroviral therapy. Development and/or implementation of interventions that facilitate women and girls engaging in drug treatment that address their roles within society, work, and family/relationships, and outcome evaluation of these interventions are crucial.

Recognising and managing increased HIV transmission risk in newborns.

Prevention of mother-to-child transmission (PMTCT) programmes have improved maternal health outcomes and reduced the incidence of paediatric HIV, resulting in improved child health and survival. Nevertheless, high-risk vertical exposures remain common and are responsible for a high proportion of transmissions. In the absence of antiretrovirals (ARVs), an 8- to 12-hour labour has approximately the same 15% risk of transmission as 18 months of mixed feeding. The intensity of transmission risk is highest during labour and delivery; however, the brevity of this intra-partum period lends itself to post-exposure interventions to reduce such risk. There is good evidence that infant post-exposure prophylaxis (PEP) reduces intra-partum transmission even in the absence of maternal prophylaxis. Recent reports suggest that infant combination ARV prophylaxis (cARP) is more efficient at reducing intra-partum transmission than a single agent in situations of minimal pre-labour prophylaxis. Guidelines from the developed world have incorporated infant cARP for increased-risk scenarios. In contrast, recent guidelines for low-resource settings have rightfully focused on reducing postnatal transmission to preserve the benefits of breastfeeding, but have largely ignored the potential of augmented infant PEP for reducing intra-partum transmissions. Minimal pre-labour prophylaxis, poor adherence in the month prior to delivery, elevated maternal viral load at delivery, spontaneous preterm labour with prolonged rupture of membranes and chorioamnionitis are simple clinical criteria that identify increased intra-partum transmission risk. In these increased-risk scenarios, transmission frequency may be halved by combining nevirapine and zidovudine as a form of boosted infant PEP. This strategy may be important to reduce intra-partum transmissions when PMTCT is suboptimal.

Increasing prevalence of HIV infection among first time clients in Italian drug treatment services - is it sexual transmission?

BackgroundOver the last two decades, the proportion of people who inject drugs among newly reported HIV cases in Italy has been continuously declining. This trend is reflected in the prevalence of HIV infection among problem drug users followed in drug treatment services. We report nationwide trends in the prevalence of HIV and HCV among tested clients in charge to drug addiction services from 2005 to 2011.MethodsData on the prevalence of HIV and HCV among drug users from public drug treatment services across Italy were collected and analyzed for the period from 2005 to 2011. Prevalence of HIV and HCV were compared between clients returning to treatment and those entering treatment for the first time, and by gender. Due to the high percentage of missing data, the “inverse probability weight” method was used. Trends in testing uptake were also analysed.ResultsA significant decrease of HIV and HCV prevalence is observed among all PDUs entering treatment (from 14.7% to 11.1% and from 61.6% to 50%, respectively, in 2005–2011). By contrast, among those entering the services for the first time, after an initial decline the prevalence of HIV infection steadily increased in both sexes, from 2.2% in 2009 to 5.3% in 2011. Self-reported injecting rates in this group decreased over time, and in 2011 the proportion reporting drug injecting was lower among new clients than in people returning to services (14.5 vs. 34.4%). We also observed a progressive and significant reduction in HIV and HCV testing in drug treatment services.ConclusionsChanges in injection practice and type of drugs used, coupled with a concurrent reduction in HCV prevalence, do not support drug injection as the main explanation for an increased HIV transmission in people entering drug treatment services for the first time. While reductions in testing rates raise concerns over data quality, the possibility of increased sexual transmission needs to be considered.

HIV shedding from male circumcision wounds in HIV-infected men: a prospective cohort study.

BackgroundA randomized trial of voluntary medical male circumcision (MC) of HIV—infected men reported increased HIV transmission to female partners among men who resumed sexual intercourse prior to wound healing. We conducted a prospective observational study to assess penile HIV shedding after MC.Methods and FindingsHIV shedding was evaluated among 223 HIV—infected men (183 self—reported not receiving antiretroviral therapy [ART], 11 self—reported receiving ART and had a detectable plasma viral load [VL], and 29 self—reported receiving ART and had an undetectable plasma VL [<400 copies/ml]) in Rakai, Uganda, between June 2009 and April 2012. Preoperative and weekly penile lavages collected for 6 wk and then at 12 wk were tested for HIV shedding and VL using a real—time quantitative PCR assay. Unadjusted prevalence risk ratios (PRRs) and adjusted PRRs (adjPRRs) of HIV shedding were estimated using modified Poisson regression with robust variance. HIV shedding was detected in 9.3% (17/183) of men not on ART prior to surgery and 39.3% (72/183) of these men during the entire study. Relative to baseline, the proportion shedding was significantly increased after MC at 1 wk (PRR = 1.87, 95% CI = 1.12–3.14, p = 0.012), 2 wk (PRR = 3.16, 95% CI = 1.94–5.13, p < 0.001), and 3 wk (PRR = 1.98, 95% CI = 1.19–3.28, p = 0.008) after MC. However, compared to baseline, HIV shedding was decreased by 6 wk after MC (PRR = 0.27, 95% CI = 0.09–0.83, p = 0.023) and remained suppressed at 12 wk after MC (PRR = 0.19, 95% CI = 0.06–0.64, p = 0.008). Detectable HIV shedding from MC wounds occurred in more study visits among men with an HIV plasma VL > 50,000 copies/ml than among those with an HIV plasma VL < 400 copies/ml (adjPRR = 10.3, 95% CI = 4.25–24.90, p < 0.001). Detectable HIV shedding was less common in visits from men with healed MC wounds compared to visits from men without healed wounds (adjPRR = 0.12, 95% CI = 0.07–0.23, p < 0.001) and in visits from men on ART with undetectable plasma VL compared to men not on ART (PRR = 0.15, 95% CI = 0.05–0.43, p = 0.001). Among men with detectable penile HIV shedding, the median log10 HIV copies/milliliter of lavage fluid was significantly lower in men with ART—induced undetectable plasma VL (1.93, interquartile range [IQR] = 1.83–2.14) than in men not on ART (2.63, IQR = 2.28–3.22, p < 0.001). Limitations of this observational study include significant differences in baseline covariates, lack of confirmed receipt of ART for individuals who reported ART use, and lack of information on potential ART initiation during follow—up for those who were not on ART at enrollment.ConclusionPenile HIV shedding is significantly reduced after healing of MC wounds. Lower plasma VL is associated with decreased frequency and quantity of HIV shedding from MC wounds. Starting ART prior to MC should be considered to reduce male-to-female HIV transmission risk. Research is needed to assess the time on ART required to decrease shedding, and the acceptability and feasibility of initiating ART at the time of MC.

Recognising and managing increased HIV transmission risk in newborns

Recognising and managing increased HIV transmission risk in newborns

Transmission clustering among newly diagnosed HIV patients in Chicago, 2008 to 2011: using phylogenetics to expand knowledge of regional HIV transmission patterns.

HIV transmission cluster analyses can inform HIV prevention efforts. We describe the first such assessment for transmission clustering among HIV patients in Chicago. We performed transmission cluster analyses using HIV pol sequences from newly diagnosed patients presenting to Chicago's largest HIV clinic between 2008 and 2011. We compared sequences through progressive pairwise alignment, using neighbor joining to construct an unrooted phylogenetic tree. We defined clusters as >2 sequences among which each sequence had at least 1 partner within a genetic distance of ≤1.5%. We used multivariable regression to examine factors associated with clustering and used geospatial analysis to assess geographic proximity of phylogenetically clustered patients. We compared sequences from 920 patients, median age of 35 years, 75% male, 67% black, 23% Hispanic, and 8% had a rapid plasma reagin titer ≥1:16 concurrent with their HIV diagnosis. We had HIV transmission risk data for 54%; 43% identified as men who have sex with men (MSM). Phylogenetic analysis demonstrated 123 patients (13%) grouped into 26 clusters, the largest having 20 members. In multivariable regression, age <25, black race, MSM status, male gender, higher HIV viral load, and rapid plasma reagin ≥1:16 associated with clustering. We did not observe geographic grouping of genetically clustered patients. Our results demonstrate high rates of HIV transmission clustering, without local geographic foci, among young black MSM in Chicago. Applied prospectively, phylogenetic analyses could guide prevention efforts and help break the cycle of transmission.