Lower HIV Incidence Research Articles

Comprehensive care with antiretroviral therapy for injecting‐drug users associates to low community viral load and restriction of HIV outbreak

An outbreak of HIV was detected amongst Finnish injecting‐drug users (IDUs) in 1998. The outbreak was caused by CRF01‐AE virus [1]. A comprehensive care programme including infectious diseases, addiction medicine, low threshold methadone program, needle exchange, accommodation and other social services started in December 2000. Funding was provided by municipalities. We have described earlier how the outbreak became geographically and socially restricted [2]. The data of newly diagnosed HIV infections in the hospital district of Helsinki and Uusimaa (Helsinki region) amongst IDUs and HIV‐1 subtypes were obtained from the Finnish national HIV registry. The Helsinki University Central Hospital (HUCH) registry was used to obtain the number of IDUs in HIV care, on antiretroviral therapy (ART), and plasma HIV‐1 RNA (VL) amongst IDUs. The HUCH registry also includes IDUs diagnosed with HIV infection in other Finnish regions, but currently living in Helsinki region. The highest number (n=65) of newly diagnosed HIV infections among IDUs in Helsinki region was observed in 1999 (Figure 1). Between 1998 and 2011, 249 IDUs were diagnosed with HIV infection. From 1998 to 2004 the subtype was CRF01‐AE in 187 (92%) cases, other subtypes in 5 (2%) cases and not subtyped in 11 (5%) cases. From 2005 to 2011 the subtype was CRF01‐AE in 25 (54%) cases, other subtypes in 15 (33%) cases and not subtyped in 6 (13%) cases. In 2011 there were 4 IDUs diagnosed with HIV, one of them with CRF01‐AE. In the Helsinki region out of 183 HIV‐infected IDUs in 2005, 100 (55%) had VL<50 copies/ml and out of 167 HIV‐infected IDUs in 2011, 133 (80%) had VL<50 copies/ml in 2011. We propose that from 2005 the low HIV‐1 RNA in plasma of IDUs has contributed to the low incidence of HIV among IDUs in Helsinki region. However, the incidence of HIV started to decline before the decline of VL in the cohort (Figure 1). This suggests that other factors besides ART may have decreased the risk of HIV infection among IDUs before ART coverage of the cohort became considerable. Other subtypes of HIV circulated among IDUs in the Helsinki region during the observation period, which emphasises the necessity of health promoting services (e.g. needle exchange) to be available to all IDUs.image

Interventions to reduce risky sexual behaviour for preventing HIV infection in workers in occupational settings

The workplace provides an important avenue to prevent HIV. To evaluate the effect of behavioral interventions for reducing HIV on high risk sexual behavior when delivered in an occupational setting. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO up until March 2011 and CINAHL, LILACS, DARE, OSH Update, and EPPI database up until October 2010. Randomised control trials (RCTs) in occupational settings or among workers at high risk for HIV that measured HIV, sexual transmitted diseases (STD), Voluntary Counseling and Testing (VCT), or risky sexual behaviour. Two reviewers independently selected studies for inclusion, extracted data and assessed risk of bias. We pooled studies that were similar. We found 8 RCTs with 11,164 participants but one study did not provide enough data. Studies compared VCT to no VCT and education to no intervention and to alternative education.VCT uptake increased to 51% when provided at the workplace compared to a voucher for VCT (RR=14.0 (95% CI 11.8 to16.7)). After VCT, self-reported STD decreased (RR = 0.10 (95% CI 0.01 to 0.73)) but HIV incidence (RR=1.4 (95% CI 0.7 to 2.7)) and unprotected sex (RR=0.71 (0.48 to 1.06)) did not decrease significantly. .Education reduced STDs (RR = 0.68 (95%CI 0.48 to 0.96)), unprotected sex (Standardised Mean Difference (SMD)= -0.17 (95% CI -0.29 to -0.05), sex with a commercial sex worker (RR = 0.88 (95% CI 0.81 to 0.96) but not multiple sexual partners (Mean Difference (MD) = -0.22 (95% CI -0.52 to 0.08) nor use of alcohol before sex (MD = -0.01 (95% CI of -0.11 to 0.08). Workplace interventions to prevent HIV are feasible. There is moderate quality evidence that VCT offered at the work site increases the uptake of testing. Even though this did no lower HIV-incidence, there was a decrease in self-reported sexual transmitted diseases and a decrease in risky sexual behaviour. There is low quality evidence that educational interventions decrease sexually transmitted diseases, unprotected sex and sex with commercial sex workers but not sex with multiple partners and the use of alcohol before sex.More and better randomised trials are needed directed at high risk groups such as truck drivers or workers in areas with a very high HIV prevalence such as Southern Africa. Risky sexual behaviour should be measured in a standardised way.

Incidence of HIV in Windhoek, Namibia: Demographic and Socio-Economic Associations

ObjectiveTo estimate HIV incidence and prevalence in Windhoek, Namibia and to analyze socio-economic factors related to HIV infection.MethodIn 2006/7, baseline surveys were performed with 1,753 private households living in the greater Windhoek area; follow-up visits took place in 2008 and 2009. Face-to-face socio-economic questionnaires were administrated by trained interviewers; biomedical markers were collected by nurses; GPS codes of household residences were recorded.ResultsThe HIV prevalence in the population (aged>12 years) was 11.8% in 2006/7 and 14.6% in 2009. HIV incidence between 2007 and 2009 was 2.4 per 100 person year (95%CI = 1.9–2.9). HIV incidence and prevalence were higher in female populations. HIV incidence appeared non-associated with any socioeconomic factor, indicating universal risk for the population. For women a positive trend was found between low per-capita consumption and HIV acquisition. A HIV knowledge score was strongly associated with HIV incidence for both men and women. High HIV prevalence and incidence was concentrated in the north-western part of the city, an area with lower HIV knowledge, higher HIV risk perception and lower per-capita consumption.DiscussionThe HIV incidence and prevalence figures do not suggest a declining epidemic in Windhoek. Higher vulnerability of women is recorded, most likely related to economic dependency and increasing transactional sex in Namibia. The lack of relation between HIV incidence and socio-economic factors confirms HIV risks for the overall urban community. Appropriate knowledge is strongly associated to lower HIV incidence and prevalence, underscoring the importance of continuous information and education activities for prevention of infection. Geographical areas were identified that would require prioritized HIV campaigning.

Adult male circumcision as an intervention against HIV: An operational study of uptake in a South African community (ANRS 12126)

BackgroundTo evaluate the knowledge, attitudes and beliefs about adult male circumcision (AMC), assess the association of AMC with HIV incidence and prevalence, and estimate AMC uptake in a Southern African community.MethodsA cross-sectional biomedical survey (ANRS-12126) conducted in 2007-2008 among a random sample of 1198 men aged 15 to 49 from Orange Farm (South Africa). Face-to-face interviews were conducted by structured questionnaire. Recent HIV infections were evaluated using the BED incidence assay. Circumcision status was self-reported and clinically assessed. Adjusted HIV incidence rate ratios (aIRR) and prevalence ratios (aPR) were calculated using Poisson regression.ResultsThe response rate was 73.9%. Most respondents agreed that circumcised men could become HIV infected and needed to use condoms, although 19.3% (95%CI: 17.1% to 21.6%) asserted that AMC protected fully against HIV. Among self-reported circumcised men, 44.9% (95%CI: 39.6% to 50.3%) had intact foreskins. Men without foreskins had lower HIV incidence and prevalence than men with foreskins (aIRR = 0.35; 95%CI: 0.14 to 0.88; aPR = 0.45, 95%CI: 0.26 to 0.79). No significant difference was found between self-reported circumcised men with foreskins and other uncircumcised men. Intention to undergo AMC was associated with ethnic group and partner and family support of AMC. Uptake of AMC was 58.8% (95%CI: 55.4% to 62.0%).ConclusionsAMC uptake in this community is high but communication and counseling should emphasize what clinical AMC is and its effect on HIV acquisition. These findings suggest that AMC roll-out is promising but requires careful implementation strategies to be successful against the African HIV epidemic.

The contribution of HIV-discordant relationships to new HIV infections in Rakai, Uganda

In their recent research letter entitled ‘The contribution of HIV-discordant relationships to new HIV infections in Rakai, Uganda’, Gray et al. [1] argue that targeting HIV testing and counseling efforts to HIV serodiscordant couples will have limited impact for HIV prevention. We disagree with this argument for several reasons. Gray et al. [1] underestimate the true contribution to overall HIV incidence from serodiscordant couples in two ways. First, they focus only on study participants identified as both married and serodiscordant. Yet approximately one-third of married couples had a partner of unknown HIV status (36 and 33% in the pre- and post-antiretroviral therapy (ART) intervals, respectively). It is likely that some of these couples were in fact HIV serodiscordant. Likewise, among those who were not currently married, some were likely in long-term serodiscordant relationships. Thus, the number of infections that occurred among serodiscordant couples is unknown but likely higher than could be reported with the available data. Second, although the authors state that acceptance of couples counseling has been low in their cohort, it is unclear from the letter what proportion of the couples identified as serodiscordant in the database were actually aware of their serodiscordant status or had received couples HIV testing and counseling (CHTC). Thus, the contribution of serodiscordant couples to new HIV infections may have been low because of mutual disclosure of HIV status or other effective interventions that reduce sexual risk behaviors and transmission [2–7]. In the current analysis, the authors report HIV incidence among discordant couples before and after ART availability (an ecologic measure). However, in a previous analysis of data from this cohort, they categorized discordant couples before and after ART initiation (a couple-level measure) [3]. If the authors had data on ART use among discordant couples, why not use these data in the research letter? This question is especially pertinent as data from the previous report showed that ART initiation was associated with both lower HIV incidence among discordant couples and with increased consistent condom use. Those data would support using CHTC as a way to identify additional discordant couples and link them to prevention and treatment services in order to reduce HIV transmission to the uninfected partner. Note that CHTC does not target discordant couples as stated by Gray and colleagues but rather seeks to identify discordant couples by providing HIV testing and counseling to persons in, or planning to be in, a sexual relationship, and allowing them to learn their HIV status together. In addition to reduced sexual risk behaviors among discordant couples, CHTC has benefits for preventing mother-to-child HIV transmission [8]. Nevertheless, CHTC is not a stand-alone intervention but instead is a first step in a continuum of effective prevention and treatment strategies. These strategies include linking HIV-positive individuals into care and treatment services; offering circumcision to HIV-negative men; and ensuring both partners have access to sexual risk reduction counseling and condoms [9,10], and prevention of mother-to-child HIV transmission services, including ART prophylaxis, family planning, and safer pregnancy counseling. Furthermore, if as Gray and colleagues suggest, a number of infections in discordant couples come from outside partners, these prevention interventions offer an opportunity to address this potential risk and discuss partner reduction and condom use with outside partners. In their conclusion, the authors state that there is merit to HIV testing and counseling, including of couples, but that prevention efforts need to address the broader population and embrace specific interventions. We agree. In combination with other proven interventions, CHTC has the potential to contribute to reductions in population-level HIV incidence in generalized epidemics and should be viewed as facilitating access to the continuum of effective prevention, care, and treatment strategies. Acknowledgements Conflicts of interest There are no conflicts of interest.

Prevalence and Incidence of HIV in a Rural Community-Based HIV Vaccine Preparedness Cohort in Masaka, Uganda

BackgroundLocal HIV epidemiology data are critical in determining the suitability of a population for HIV vaccine efficacy trials. The objective of this study was to estimate the prevalence and incidence of, and determine risk factors for HIV transmission in a rural community-based HIV vaccine preparedness cohort in Masaka, Uganda.MethodsBetween February and July 2004, we conducted a house-to-house HIV sero-prevalence survey among consenting individuals aged 18–60 years. Participants were interviewed, counseled and asked to provide blood for HIV testing. We then enrolled the HIV uninfected participants in a 2-year HIV sero-incidence study. Medical evaluations, HIV counseling and testing, and sample collection for laboratory analysis were done quarterly. Sexual risk behaviour data was collected every 6 months.ResultsThe HIV point prevalence was 11.2%, and was higher among women than men (12.9% vs. 8.6%, P = 0.007). Risk factors associated with prevalent HIV infection for men were age <25 years (aOR = 0.05, 95% CI 0.01–0.35) and reported genital ulcer disease in the past year (aOR = 2.17, 95% CI 1.23–3.83). Among women, being unmarried (aOR = 2.59, 95% CI 1.75–3.83) and reported genital ulcer disease in the past year (aOR = 2.40, 95% CI 1.64–3.51) were associated with prevalent HIV infection. Twenty-one seroconversions were recorded over 2025.8 person-years, an annual HIV incidence of 1.04% (95% CI: 0.68–1.59). The only significant risk factor for incident HIV infection was being unmarried (aRR = 3.44, 95% CI 1.43–8.28). Cohort retention after 2 years was 87%.ConclusionsWe found a high prevalence but low incidence of HIV in this cohort. HIV vaccine efficacy trials in this population may not be feasible due to the large sample sizes that would be required. HIV vaccine preparatory efforts in this setting should include identification of higher risk populations.

Social Capital and Women's Reduced Vulnerability to HIV Infection in Rural Zimbabwe

Social capital—especially through its “network” dimension (high levels of participation in local community groups)—is thought to be an important determinant of health in many contexts. We investigate its effect on HIV prevention, using prospective data from a general population cohort in eastern Zimbabwe spanning a period of extensive behavior change (1998–2003). Almost half of the initially uninfected women interviewed were members of at least one community group. In an analysis of 88 communities, individuals with higher levels of community group participation had lower incidence of new HIV infections and more of them had adopted safer behaviors, although these effects were largely accounted for by differences in socio-demographic composition. Individual women in community groups had lower HIV incidence and more extensive behavior change, even after controlling for confounding factors. Community group membership was not associated with lower HIV incidence in men, possibly refecting a propensity among men to participate in groups that allow them to develop and demonstrate their masculine identities—often at the expense of their health. Support for women's community groups could be an effective HIV prevention strategy in countries with large-scale HIV epidemics.

Did National HIV Prevention Programs Contribute to HIV Decline in Eastern Zimbabwe? Evidence From a Prospective Community Survey

To add to the evidence on the impact of national HIV prevention programs in reducing HIV risk in sub-Saharan African countries. Statistical analysis of prospective data on exposure to HIV prevention programs, relatives with AIDS and unemployment, and sexual behavior change and HIV incidence, in a population cohort of 4047 adults, collected over a period (1998-2003) when HIV prevalence and risk-behavior declined in eastern Zimbabwe. Exposure to HIV prevention programs and relatives with AIDS-but not unemployment-increased from 1998 to 2003. Men and women exposed to media campaigns and HIV/AIDS meetings had greater knowledge and self-efficacy, attributes that were concomitantly protective against HIV infection. Women attending community HIV/AIDS meetings before recruitment were more likely than other women to adopt lower-risk behavior (96.4% vs. 90.8%; adjusted odds ratio, 3.09; 95% confidence interval [CI], 1.27-7.49) and had lower HIV incidence (0.9% vs. 1.8%; adjusted incidence rate ratio, 0.63; 95% CI, 0.32-1.24) during the intersurvey period. Prior exposure to relatives with AIDS was not associated with differences in behavior change. More newly unemployed men as compared with employed men adopted lower-risk behavior (84.2% vs. 76.0%; adjusted odds ratio, 2.13; 95% CI, 0.98-4.59). Community-based HIV/AIDS meetings reduced risk-behavior amongst women who attended them, contributing to HIV decline in eastern Zimbabwe.

Infektionsepidemiologische Daten von Blutspendern in Deutschland 2007

The Robert Koch Institute collects and evaluates data on the prevalence and incidence of HIV, hepatitis C (HCV), hepatitis B (HBV), and syphilis infections among blood and plasma donors in Germany according to §22 of the Transfusion Act ("Transfusiongesetz"). The surveillance data permit an assessment of the occurrence of infections in the blood donor population and consequently the safety of the collected donations. This report includes data from all blood donation services in Germany for 2007. Due to the revision of the Transfusion Act in 2005, not only the number of donations but also the number of donors is now available for analysis. Nearly 550,000 donations or blood samples from new donors and more than 6.24 million donations collected from approximately 2.43 million repeat donors were tested for transfusion-relevant infections in 2007. The prevalence for HIV was 8.0/100,000, for HCV 70.0/100,000, for HBV 132.5/100,000, and for syphilis 36.8/100,000 donations. The proportion of seroconversions/100,000 donations was 0.6 for HIV, 1.1 for HCV, 0.6 for HBV, and 1.7 for syphilis. The analysis showed a very low incidence of HIV, HBV, and syphilis with marginal changes compared to previous years. The prevalence and incidence of HCV among blood donors was once again declining.

Defining high HIV incidence subgroups of Australian homosexual men: implications for conducting HIV prevention trials in low HIV prevalence settings

The aim of the study was to assess whether subpopulations with sufficiently high HIV incidences for HIV prevention trials can be identified in low HIV incidence settings such as Australia. In a community-based cohort study of HIV-negative homosexually active men in Sydney, Australia, potential risk factors associated with an annual HIV incidence of ≥2 per 100 person-years (PY) were identified. A stepwise procedure ranked these factors according to HIV incidence, to create a 'high-incidence' subgroup of participants. Willingness to participate in HIV prevention trials was assessed. Although the incidence in the cohort overall was only 0.78 per 100 PY, nine risk variables were associated with an HIV incidence of 2 per 100 PY or greater. Stepwise inclusion of these variables revealed a 'high-incidence' subgroup of men representing 24% of the total follow-up time with a combined HIV incidence of 2.71 per 100 PY, who reported at least one of three risk factors in the past 6 months. These men were more willing than others to participate in vaccine and antiretroviral therapy HIV prevention trials. These findings demonstrate that it is possible to identify high HIV incidence subpopulations in low-incidence settings such as Australia, and these men are of above average willingness to participate in HIV prevention trials.

Reply to Black et al. High HIV incidence or poor test performance?

We note the concern of Black et al. [1] in the implications of our findings on mother-to-child transmission (MTCT) of HIV and our recommendations related to prevention of MTCT programmes [1,2]. They also acknowledge that despite the availability of antiretroviral prophylaxis a significant proportion of perinatal HIV infections could be attributed to ‘incident maternal HIV infections’ (recent HIV infections during pregnancy). However, their main concern with our findings lies in the possible effect of an unreliable testing methodology on the reported seroincidence. We agree with Black et al. [1] that rapid tests with varying performance and more importantly poor sensitivity at the initial visit could contribute to false ‘seroconversions’ at the subsequent visit. Hence, Black et al. [1] imply that the HIV incidence in the study population is considerably lower than that reported. We confirm that the Abbott Determine HIV Rapid test (Abbott Laboratories, Abbott Park, Illinois, USA), known for its high sensitivity, and the serial testing algorithms were used at both time points, with user variability at the different times. It is likely that the sensitivity of tests was compromised at the first visit by unsupervised nonstudy staff, although this could not be determined in the absence of laboratory confirmations of these initial results [3]. Direct virological testing was not performed in this study. Hence, if HIV infections were missed at the initial visit and subsequently incorrectly interpreted as a new infection at the repeat visit by the same test, we would not have been able to confirm whether this was due to the infection being missed as a result of a ‘window period’ or poor technical performance of the rapid test. If we are to implicate the lack of sensitivity of the rapid tests as a contributory factor to the potentially large proportion of 72 cases of ‘false seroconversions’, this could most certainly contribute to an overestimate of HIV incidence. However, a similar application of the above explanation regarding the lack of sensitivity at a subsequent testing opportunity would logically provide us with an underestimate of incident HIV infections (false-negative results) at the repeat visit. We also agree with Black et al. [1] that varying testing algorithms do make interstudy comparisons difficult, and for the purpose of measuring true HIV incidence in a population, one needs to use more superior tests and testing algorithms. We would like to add that varying study designs, target populations and measures of seroincidence could also make interstudy comparisons difficult. Our study [2] reported both an incidence risk of 3% and an incidence rate of 10.7 per 100 woman-years. Our incidence risk is lower than that reported by Rehle et al. [4] in their cross-sectional survey; however, the 5.2% could also be attributed to a different testing method used. Furthermore, the antenatal HIV prevalence in Rehle et al.'s [4] study population and our study [2] population was 37 and 28%, respectively. The much lower HIV incidence (0%) reported in the Western Cape population is probably expected with the associated lowest antenatal HIV prevalence (12.6%) in South Africa [5,6]. The variable HIV incidence risks reported in the different studies are therefore plausible if one considers the related antenatal HIV prevalence in these populations. We strongly disagree with Black et al. [1] that retesting of pregnant women should be postponed until a more reliable testing algorithm is used in studies. We concur with the opinion of Karim [7] that the availability of incidence data, however inaccurate they may be in the absence of more reliable testing algorithms, remains useful information in understanding of the HIV epidemic in settings with high antenatal HIV prevalences. Furthermore, the multiple prenatal clinic visits by pregnant women provide greater opportunities for HIV testing using rapid tests in a resource-limited setting, hence it would be prudent to offer a retest at a subsequent visit if the likelihood of false-negative results range between 1.4 and 5% at the initial visit. Nonetheless, repeat testing has been demonstrated to be cost-effective and provides added opportunities to prevent perinatal HIV infection through the use of PMTCT prophylaxis, modified obstetric practice and safe infant-feeding practice [8,9].

The value of population campaigns offering free-of-charge HIV-testing: Observational study in a town in Cameroon

Background: HIV testing is encouraged, but in many countries testing is rarely free of charge except during campaign periods. Aim: To study experiences from four years of campaign week for HIVtesting in the town of Ngaoundere, Cameroon. Data have been collected and recorded from handwritten protocols in 2001, from pre- and post-counselling sheets in 2002, and from laboratory protocols in 2003-4. Results: Seropositivity tended to increase with increasing age, female sex, number of sexpartners last five years and with low educational level. Different dimensions of knowledge about HIV was associated with less seropositivity. One of five persons tested never came back to know their result, but seropositivity in this group was not higher than for those who returned. Overall HIV prevalence during the last three years of campaign testing was 9.0%, a little higher than WHO national figures for Cameroon. Conclusions: HIV campaigns including testing may stimulate interest and knowledge about HIV, which is important to lower HIV incidence. The HIV vulnerability of females was confirmed. Campaigns did not easily attract less educated persons, and campaign testing prevalence therefore could be expected to be lower than HIV prevalence in the local population. On the other hand, people with high risk behaviour may be over-represented, increasing campaign testing prevalence. Most symptomatic persons receiving a positive test did not come back for medical follow-up.

Comparison of Projected and Actual Outcomes of the HIV/AIDS Epidemic in Malawi, 1990–2000

BackgroundIn 1992 Liomba et al used HIV-AIDS prevalence data from 1980 to 1990 and projected the adult HIV prevalence and the impact of AIDS for the years 1991 to 2000, under high and low HIV incidence scenarios, using EpiModel, DemProj and the AIDS Impact Model. This report compares the actual outcomes of the HIV-AIDS epidemic in Malawi from 1991 to 2000 with projections made by Liomba et al.Methods and FindingsDue to the lack of data on rural HIV prevalence in 1992, the prevalence estimates for the years 1980 to 1990 used by Liomba et al were higher than the now published prevalence. We re-estimated the projections for 1991 to 2000 based on more recent estimates of 1980 to 1990 HIV-AIDS prevalence using the Spectrum modeling software, and compared the old and new projections with the actual epidemic figures reported by NAC. The original projections made by Liomba et al and the adjusted projections made in this report are both very similar to the observed course of the AIDS epidemic reported by National AIDS Commission. Unfortunately for Malawi the epidemic seems to have followed the high scenario of HIV incidence.ConclusionThe course of the epidemic in Malawi and the social and economic devastation caused by it, despite the presence of reasonably good projections and prevention recommendations by Liomba et al, highlights the need for better co-ordination between research and practice. It also emphasizes the need to examine the difficulties faced by countries like Malawi to act more rapidly and implement effective prevention measures in the face of an epidemic.

Running in Place: Implications of HIV Incidence Estimates among Urban Men Who Have Sex with Men in the United States and Other Industrialized Countries

Attempts to document changing HIV incidence rates among MSM are compromised by issues of generalizability and statistical power. To address these issues, this paper reports annualized mean HIV incidence rates from the entire published incidence literature on MSM from Europe, North America and Australia for the period 1995-2005. Publications that met the entry criteria were coded for region of the world, sampling method and year of study. From these reports, we calculated a mean incidence rate with confidence intervals for these variables. Although no differences in mean incidence rates were found for MSM from 1995 to 2005, HIV incidence rates are lower in Australia than either North America or Europe. We calculated a mean incidence rate of 2.39% for MSM in the United States, which if sustained within a cohort of MSM, would yield HIV prevalence rate of approximately 40% at age 40. These extrapolations overlap published HIV prevalence rates for MSM younger than age 40 in the United States. HIV incidence rates in the 2-3% range will adversely affect the health of gay male communities for decades to come. This analysis suggests that greater attention should be devoted to the question of how best to design prevention interventions that will lower HIV incidence rates among gay men.

Reduced production of sulfated glycosaminoglycans occurs in Zambian children with kwashiorkor but not marasmus

Background:Kwashiorkor, a form of severe malnutrition with high mortality, is characterized by edema and systemic abnormalities. Although extremely common, its pathophysiology remains poorly understood, and its characteristic physical signs are unexplained.Objective: Because kwashiorkor can develop in protein-losing enteropathy, which is caused by a loss of enterocyte heparan sulfate proteoglycan (HSPG), and previous observations suggest abnormal sulfated glycosaminoglycan (GAG) metabolism, we examined whether intestinal GAG and HSPG are abnormal in children with kwashiorkor.Design: Duodenal biopsy samples collected from Zambian children with marasmus (n = 18), marasmic kwashiorkor (n = 8), and kwashiorkor (n = 15) were examined for expression of HSPG, GAGs, and immunologic markers and compared against reference samples from healthy UK control children. GAG and HSPG expression density and inflammatory cell populations were quantitated by computerized analysis.Results: The kwashiorkor group was less wasted and had a lower HIV incidence than did the other groups. All duodenal biopsy samples showed inflammation compared with the histologically uninflamed control samples. Biopsy samples from marasmic children had greater inflammation and greater CD3+ and HLA-DR (human leukocyte antigen DR)–positive cell densities than did samples from children with kwashiorkor. Expression of both HSPG and GAGs was similar between marasmic and well-nourished UK children but was markedly lower in children with kwashiorkor in both the epithelium and lamina propria. Although underglycosylated and undersulfated, epithelial syndecan-1 protein was normally expressed in kwashiorkor, which confirmed that abnormalities arise after core protein synthesis.Conclusions: Intestinal HSPG loss occurs in kwashiorkor, which may precipitate protein-losing enteropathy to cause edema. If occurring systemically, impaired HSPG expression could cause several previously unexplained features of kwashiorkor. We speculate that a genetic predisposition to reduced HSPG biosynthesis may offer a contrasting selective advantage, by both diminishing protein catabolism during transient undernutrition and protecting against specific infectious diseases.

Low HIV Seroincidence Among Female Commercial Sex Workers: A Barrier for Measuring HIV Vaccine Efficacy

To the Editor: We thank Barroso et al for providing a summary of their pilot study to evaluate methods and barriers to recruitment of commercial sex workers (CSWs) in Rio de Janeiro, Brazil. As they note, HIV efficacy trials require enrollment of large and diverse cohorts of participants that reflect the demographics of high-risk individuals. This may ensure that summary measures of efficacy are most applicable to populations in greatest need of HIV vaccines.1 Because vaccine effects could differ between female and male populations, as has been suggested from herpes vaccine trials,2,3 and because interpretation of surrogate endpoints (eg, viral load set point) may be influenced by gender,4,5 HIV vaccines should be evaluated in both populations, when possible. In their study, Barroso et al report that despite extensive outreach, only 7.8% of CSWs visited the vaccine trial site and less than 1% actually enrolled in the Phase IIB trial. Several of the social and cultural barriers that they enumerate (eg, lack of understanding of rationale for vaccine trials, transportation, clinic hours, and lack of reliable contact information) are barriers that can be addressed through ongoing work within high-risk communities and innovative logistical solutions (eg, extended clinic hours, providing cell phone time and/or voicemail boxes, and use of community outreach workers). Such strategies often require long-standing relationships with communities at risk, ongoing community education, and sufficient resources to staff outreach and flexible clinic hours. When these strategies are implemented, female CSW populations can be successfully recruited and retained, as noted in our vaccine feasibility study6 and in the subsequent Phase IIB vaccine trial.7 However, one of the most important challenges remaining is to recruit female populations with high HIV incidence in the United States. One reason for low HIV incidence rates in these trials is likely due to the fact that all participants receive extensive risk reduction counseling and linkage to local prevention services, with resultant substantial declines in HIV risk.6,8 Another reason may be low HIV prevalence in male partners. In Brazil, for example, where a simultaneous focus on ensuring access to prevention and treatment services has helped keep the epidemic stable, national adult HIV prevalence has remained stable at 0.5% since 2000.9 In fact, a limited number of studies on HIV seroincidence estimates among CSWs in South America have acknowledged rates as low as 0%.10-13 Efforts are currently underway to develop and test novel strategies to recruit high-incidence cohorts of women into trials through 2 National Institutes of Health-funded clinical trials networks: the HIV Vaccine Trials Network and the HIV Prevention Trials Network. These efforts build upon the efforts of investigators like our Brazilian colleagues, and investigators in the previously reported HIV Vaccine Trials Network 903 study, to ensure that future HIV vaccine trials are able to fully evaluate vaccine effects in women. Gaston Djomand, MD, MPH* Chris Beyrer, MD, MPH† Susan Buchbinder, MD‡ *HIV Vaccine Trials Network Seattle, WA †Johns Hopkins Bloomberg School of Public Health Baltimore, MD ‡Department of Public Health HIV Research Section San Francisco, CA

Human immunodeficiency virus type 1 incidence among blood donors in France, 1992 through 2006: use of an immunoassay to identify recent infections

In France, blood donations found to be positive for the presence of human immunodeficiency virus type 1 (HIV-1) are further tested to detect recent infections (< or =180 days) using an enzyme immunoassay (EIA-RI) developed in 2002. The characteristics of recently infected donors, estimates of HIV-1 incidence, and the residual risk of transfusion-transmitted HIV-1 are presented, in both first-time and repeat donors. Of the 1027 donations found to be HIV-1-positive between 1992 and 2006, a total of 459 could be retrospectively tested with the EIA-RI. Multivariate analysis was performed to determine the donor characteristics associated with recent infection. Incidence rates and residual risk obtained with the EIA-RI were compared to classical cohort estimates derived from repeat donor histories. Of the 459 HIV-1-positive donors studied, 105 (22.9%; 95% confidence interval [CI], 19.2-27.0) were identified as recently infected. Factors independently associated with recent infection were repeat donor status (adjusted odds ratio [AOR], 4.0; 95% CI, 2.4-6.9) and non-B subtypes (AOR, 2.0; 95% CI, 1.2-3.6). Incidence decreased from 4.3 (95% CI, 1.9-9.4) in 1992 through 1994 to 1.3 (95% CI, 0.6-2.8) per 10(5) in 2004 through 2006 in first-time donors and from 3.2 (95% CI, 2.0-5.0) to 0.8 (95% CI, 0.4-1.4) per 10(5) in repeat donors. Incidence and residual risk estimates were similar to those obtained with the classical cohort method. This study suggests that the EIA-RI can be used to estimate HIV-1 incidence in a population with low HIV incidence. The estimated HIV-1 incidence in the blood donor population confirms the extremely low risk (1 in 3,350,000 donations) of HIV-infected blood donations entering the blood supply in France.

Cross-sectional research design and relatively low HIV incidence, rather than blood exposures, explain the peripheral location of HIV cases within the sexual networks observed on Likoma

Cross-sectional research design and relatively low HIV incidence, rather than blood exposures, explain the peripheral location of HIV cases within the sexual networks observed on Likoma

Does Raising Awareness of HIV Serostatus Lower HIV Incidence

Previous studies have shown that people tend to reduce their high-risk sexual behavior when they learn that they are HIV infected (ACC Sep 14 2005).

The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa.

Knowledge of the effect of socioeconomic status on HIV infection in Africa stems largely from cross-sectional studies. Cross-sectional studies suffer from two important limitations: two-way causality between socioeconomic status and HIV serostatus and simultaneous effects of socioeconomic status on HIV incidence and HIV-positive survival time. Both problems are avoided in longitudinal cohort studies. We used data from a longitudinal HIV surveillance and a linked demographic surveillance in a poor rural community in KwaZulu-Natal, South Africa, to investigate the effect of three measures of socioeconomic status on HIV incidence: educational attainment, household wealth categories (based on a ranking of households on an assets index scale) and per capita household expenditure. Our sample comprised of 3325 individuals who tested HIV-negative at baseline and either HIV-negative or -positive on a second test (on average 1.3 years later). In multivariable survival analysis, one additional year of education reduced the hazard of acquiring HIV by 7% (P = 0.017) net of sex, age, wealth, household expenditure, rural vs. urban/periurban residence, migration status and partnership status. Holding other factors equal, members of households that fell into the middle 40% of relative wealth had a 72% higher hazard of HIV acquisition than members of the 40% poorest households (P = 0.012). Per capita household expenditure did not significantly affect HIV incidence (P = 0.669). Although poverty reduction is important for obvious reasons, it may not be as effective as anticipated in reducing the spread of HIV in rural South Africa. In contrast, our results suggest that increasing educational attainment in the general population may lower HIV incidence.