HIV Prevention Reduction Research Articles

Male Circumcision and Human Papillomavirus Infection in Men: A Systematic Review and Meta-Analysis

We systematically reviewed the evidence for an association between male circumcision and Human Papillomavirus (HPV) infection and genital warts in men. PubMed and Embase were searched to 15 September 2010. The measure of effect was the adjusted odds ratio (OR) or rate ratio (RR) when present and the crude estimate otherwise. Random effects meta-analyses were used to calculate summary measures of effect. We identified 23 papers about the association between circumcision and HPV DNA. Circumcised men were less likely to have prevalent genital HPV infection than uncircumcised men (summary OR, 0.57, 95% confidence interval [CI], 0.45-0.71) with between-study heterogeneity (P-heterogeneity = 0.006; I(2) = 50.5%; 19 studies). Similar summary associations were seen in clinical and methodological subgroups. The effect of circumcision was stronger at the glans/corona (OR, 0.47; 95% CI, 0.37-0.60) and urethra (OR, 0.35; 95% CI, 0.12-1.05) compared with sites more distal to the foreskin. There was weak evidence that circumcision was associated with decreased HPV incidence (summary RR, 0.75, 95% CI, 0.57-0.99; 3 studies) and increased HPV clearance (summary RR, 1.33; 95% CI, 0.89-1.98; 3 studies) but no evidence of an association with prevalent genital warts (OR, 0.93, 95% CI, 0.65-1.33; 15 studies). Several countries are expanding access to voluntary medical male circumcision to reduce HIV prevalence. This could provide additional benefit in reducing HPV prevalence.

Assessment of population-level effect of Avahan, an HIV-prevention initiative in India

The aim of Avahan, the India AIDS Initiative, was to reduce HIV transmission in the general population through large-scale prevention interventions focused on high-risk groups. It was launched in 2003 in six states with a total population of 300 million and a high HIV burden. We assessed the population-level effect of the first phase of Avahan (2003-08). Population prevalence was estimated by use of adjustment factors from the national HIV sentinel surveillance data obtained annually from antenatal clinics. A mixed-effects multilevel regression model was developed to estimate the association between intervention intensity and population HIV prevalence trends, taking into account differences in the underlying epidemic trends in states and other potential confounders, and to estimate the number of HIV infections averted with Avahan. 80 (61%) of 131 districts in the six Avahan states received funding from Avahan for HIV prevention, as the only or shared source. Greater intensity of Avahan, measured as amount of grant per HIV population (medians US$24-432 in the six states), was significantly associated with lower HIV prevalence in Andhra Pradesh (p=0·004), Karnataka (p=0·004), and Maharashtra (p=0·008) states; this association was not significant in Tamil Nadu (p=0·06), Manipur (p=0·62), and Nagaland (p=0·67). Overall, we estimated that 100,178 HIV infections (95% CI 25,897-207,713) were averted at the population level from 2003 up to 2008 as a result of Avahan. The results of our analysis suggest that Avahan had a beneficial effect in reducing HIV prevalence at the population level over 5 years of programme implementation in some of the states. With stagnating funding for HIV prevention globally, our findings support investment in well planned and managed HIV prevention programmes in low-income and middle-income countries. Bill & Melinda Gates Foundation.

Attempting to explain heterogeneous HIV epidemics in sub-Saharan Africa: potential role of historical changes in risk behaviour and male circumcision

BackgroundA key conclusion of the Four Cities Study, carried out to explore reasons for heterogeneity in the HIV epidemic between two cities in sub-Saharan Africa with relatively low prevalence (Cotonou...

O1-S09.01 Increased condom use and decreased HIV & STI prevalence among female sex workers following a targeted HIV prevention program in Karnataka, South India

BackgroundWe assessed the impact of a large-scale, targeted HIV prevention program among female sex workers (FSWs) in Karnataka state, south India.MethodsIn the context of an HIV prevention program involving 18...

O1-S11.02 Determinants of time trends in HIV prevalence in the young antenatal population of Karnataka districts

BackgroundIn 2003, the Bill & Melinda Gates Foundation initiated a focused HIV prevention program (India AIDS Initiative: Avahan) among high-risk and bridge groups. We studied determinants of time trends in...

P1-S2.38 A situational analysis of MSM and HIV at AAS's Centre Oasis in Burkina Faso

IntroductionIn Burkina Faso at the end of 2008, the AIDS pandemic was characterised by a drop in HIV prevalence rates during the preceding years. In contexts in which a reduction...

The role of acute and early HIV infection in the spread of HIV and implications for transmission prevention strategies in Lilongwe, Malawi: a modelling study

HIV transmission risk is higher during acute and early HIV infection than it is during chronic infection, but the contribution of early infection to the spread of HIV is controversial. We estimated the contribution of early infection to HIV incidence in Lilongwe, Malawi, and predict the future effect of hypothetical prevention interventions targeted at early infection only, chronic infection only, or both stages. We developed a deterministic mathematical model describing heterosexual HIV transmission, informed by detailed behavioural and viral-load data collected in Lilongwe. We included sexual contact within and outside of steady pairs and divided the infectious period into intervals to allow for changes in transmissibility by infection stage. We used a Bayesian melding approach to fit the model to HIV prevalence data collected between 1987 and 2005 at Lilongwe antenatal clinics. We assessed interventions that reduced the per-contact transmission probability to 0.00003 in people receiving them, and varied the proportion of individuals receiving the intervention in each stage. We estimated that 38.4% (95% credible interval 18.6-52.3) of HIV transmissions in Lilongwe are attributable to sexual contact with individuals with early infection. Interventions targeted at only early infection substantially reduced HIV prevalence, but did not lead to elimination, even with 100% coverage. Interventions targeted at only chronic infections also reduced HIV prevalence, but coverage levels of 95-99% were needed for the elimination of HIV. In scenarios with less than 95% coverage of interventions targeted at chronic infections, additional interventions reaching 25-75% of individuals with early infection reduced HIV prevalence substantially. Our results suggest that early infection plays an important part in HIV transmission in this sub-Saharan African setting. Without near-complete coverage, interventions during chronic infection will probably have incomplete effectiveness unless complemented by strategies targeting individuals with early HIV infection. National Institutes of Health, University of North Carolina Center for AIDS Research.

Abstinence and harm reduction: Can they work together?

Studies published by Zule and colleagues have suggested that use of low dead-space syringes (LDSS) instead of high dead-space syringes (HDSS) by injecting drug users (IDUs) could dramatically reduce HIV transmission. However, evidence is limited because experiments have considered a small range of syringe types and have been unable to reliably estimate the efficacy of using LDSS for reducing HIV transmission. We critically appraise available evidence to determine whether using LDSS is likely to dramatically reduce HIV transmission.We systematically review the literature on the dead-space volume of syringes and estimate the factor difference in blood volume transferred from sharing LDSS or HDSS. Existing data on the relationship between host viral load and HIV transmission risk is used to evaluate the likely efficacy of using LDSS instead of HDSS. An HIV transmission model is used to make conservative impact projections for switching to using LDSS, and explore the implications of heterogeneity in IDU transmission risk and syringe preferences.Although highly variable, reviewed studies suggest that HDSS have on average 10 times the dead-space volume of LDSS and could result in 6/54/489 times more blood being transferred after 0/1/2 water rinses. Assuming a conservative 2-fold increase in HIV transmission risk per 10-fold increase in infected blood inoculum, HDSS use could be associated with a mean 1.7/3.6/6.5-fold increase in transmission risk compared to LDSS for 0/1/2 rinses. However, even for a low efficacy estimate, modelling suggests that partially transferring to LDSS use from using HDSS could dramatically reduce HIV prevalence (generally >33% if LDSS use is 50%), but impact will depend on IDU behavioural heterogeneity and syringe preference.Indirect evidence suggests that encouraging HDSS users to use LDSS could be a powerful HIV prevention strategy. There is an urgent need to evaluate the real life effectiveness of this strategy.

Evidence for changes in behaviour leading to reductions in HIV prevalence in urban Malawi

BackgroundAt the epicentre of the HIV epidemic in Eastern Africa, HIV prevalence has appeared to stabilise in most countries. However, there are indications that the HIV epidemic in Malawi has...

P01-100 - Spiritual enhanced drug addiction rehabilitation (SEDAR) program: An innovative strategy for increase coverage of methadone program in Malaysia

IntroductionIn Malaysia, national methadone maintenance therapy program was started by the goverment in October 2005 as part of harm reduction approach in reducing HIV prevalence among drug users along with needles and Syringes exchange(NSEP) program. However, slow coverage of MMT treatment occurs due to limited resources in existing health facilities and lack of participation from general practioners(Gps). There is a need for another paltform to increase coverage and participation of GPs in national MMT program.ObjectivesTo compare the retention rate and other outcomes measures between SEDAR program and Standard MMT treatment in hospital.AimsTo determine the feasability of MMT program in mosque environment.MethodsThe pilot MMT program known as SEDAR program was conducted in Ar-Rahman mosque involving 30 clients. Brief spiritual intervention(BSI) was given by mosque staffs on top of standard MMT treatment counseling. BSI include washing body parts with water or “wuduk”, praying in the mosque or “tahiyatul masjid” and recite “doa” in the mosque environment prior to direct observed therapy of methadone in the mosque by the pharmacist. The retention rate, % of urine drugs negative over time period, drug use and HIV risk behavior, quality of live and spiritual progress were measure using specific tools: OTI, WHO Qol, SF36, HIR96.ResultsWe expect the SEDAR group in Mosque has better outcomes or comparable with standard MMT treatment in hospital setting.ConclusionsThe SEDAR program is feasable to increase coverage of MMT program in Malaysia.

Monitoring trends in HIV prevalence among young people, aged 15 to 24 years, in Manicaland, Zimbabwe

BackgroundIn June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. We assessed progress toward this target in Manicaland, Zimbabwe, using repeated household-based population serosurvey data. We also validated the representativeness of surveillance data from young pregnant women, aged 15 to 24 years, attending antenatal care (ANC) clinics, which UNAIDS recommends for monitoring population HIV prevalence trends in this age group. Changes in socio-demographic characteristics and reported sexual behaviour are investigated.MethodsProgress towards the UNGASS target was measured by calculating the proportional change in HIV prevalence among youth and young ANC attendees over three survey periods (round 1: 1998-2000; round 2: 2001-2003; and round 3: 2003-2005). The Z-score test was used to compare differences in trends between the two data sources. Characteristics of participants and trends in sexual risk behaviour were analyzed using Student's and two-tailed Z-score tests.ResultsHIV prevalence among youth in the general population declined by 50.7% (from 12.2% to 6.0%) from round 1 to 3. Intermediary trends showed a large decline from round 1 to 2 of 60.9% (from 12.2% to 4.8%), offset by an increase from round 2 to 3 of 26.0% (from 4.8% to 6.0%). Among young ANC attendees, the proportional decline in prevalence of 43.5% (from 17.9% to 10.1%) was similar to that in the population (test for differences in trend: p value = 0.488) although ANC data significantly underestimated the population prevalence decline from round 1 to 2 (test for difference in trend: p value = 0.003) and underestimated the increase from round 2 to 3 (test for difference in trend: p value = 0.012). Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines.ConclusionsIn Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends.

Trends in HIV prevalence and sexual behaviour among young people aged 15–24 years in countries most affected by HIV

ObjectivesIn 2001 the United Nations (UN) Declaration of Commitment was signed by 189 countries with a goal to reduce HIV prevalence among young people by 25% by 2010. Progress towards...

Does Governance Matter in the Fight Against HIV/AIDS Epidemic? Evidence from Cross-Country Analysis

In this paper I attempt to investigate the role of governance - as measured by government effectiveness, control of corruption, and rule of law - on the HIV prevalence. Thus, the paper argues that countries whose governments are highly ranked according to these various induces of the quality of institutions tend to do better in reducing HIV prevalence. In an empirical analysis of cross-section data of 90 countries, I find that different aspects of the quality of institutions from a country (corruption, law, government effectiveness) are always significant regardless of the other control variables that are used in the least square, quantile, and instrumental estimation. These effects are more important in sub-Saharan Africa which is the epicenter of the epidemic. The paper highlights the importance of good governance for the effectiveness of HIV/AIDS programs in the fight against the epidemic.

HIV Prevalence and Related Behaviors Among Sex Workers in Jamaica

The aims of the study were to estimate HIV prevalence among sex workers (SWs) in Jamaica and to identify risk factors associated with HIV infection. Face to face interviews and HIV testing of 450 SWs across Jamaica were conducted in 2005. Participants were identified by key informants. About 9% of SWs were HIV-positive. HIV-positive SWs tended to be older, less educated, have a history of crack/cocaine use, and were less likely to be aware of the Ministry of Health's prevention programme. More than 90% of SWs reported having easy access to condoms and using condoms at last sex with local and tourist clients. However, 30% of SWs used condoms with nonpaying partners. Knowledge of HIV prevention methods was high but only 38.6% of SWs appropriately rejected myths about HIV transmission by mosquito bites and meal sharing. Prevention programmes targeting SWs must emphasize the risk associated with both paying and nonpaying sexual partners while providing knowledge about HIV prevention. Increased access to prevention programmes is likely to reduce HIV prevalence among this population.

Civic educating rural pregnant mothers to take full nevaripine dose a tool to reducing HIV prevalence in Malawi

Background It is estimated that 600,000 women get pregnant every year in Malawi. Primary health care plays a vital role. Prevention to Child Transmission of HIV education is important in a country like Malawi where prevalence of HIV positive mothers exceeds 20% than normal country prevalence of 12%. In the ultra-partum period Nevaripine has proved to be an effective drug in reducing transmission from mother to Child. Accessibility of essential medicine like nevaripine drug to women and neonates is especially a problem to rural areas where many women deliver at home due to difficulties in accessing health facilities. Objectives This civic education intervention aimed to increase rural HIV+ pregnant mothers uptake of Nevarapine tablets and syrup for infants’ dose for Prevention of mother to child transmission of HIV and to promote hospital delivery. Methods Global Hope Mobilization is providing education and counselling to women in rural setting to access basic medicines such as nevaripine, as well as to promote hospital delivery in Lilongwe district rural setting. Households with pregnant women were included through a random sample and a total of 700 pregnant women were included in a programme to provide civic education materials, including leaflets; local meetings, counselling sessions, and home visits. Nevaripine tablets and syrup were also administered, ANC data were collected and used from the nearest health facility. The intervention was assessed through one to one interviews, focus group discussion, and questionnaires. Results 100% of the pregnant women were sensitized on taking nevaripine, counselled and referred for HIV testing. To date 98% of women have attended pre and post VCT counselling testing and ANC at health facilities and at private clinics referred to. Of these women 66% were found to be HIV positive. Nevaripine tablets and instructions were issued to them when they reached 32 to 34 weeks of gestation. 60% Infants received Nevaripine syrup within 3 days after birth. Of these 6% are not known to have taken syrup and were lost to follow up, while 60% returned for post counselling. The major barriers of the intervention were home delivery, traditional beliefs and lack of knowledge of HIV status and on the course of nevaripine. Discussion

Minimal impact of circumcision on HIV acquisition in men who have sex with men

Men who have sex with men (MSM) are disproportionately affected by HIV. The proven efficacy of circumcision in reducing the risk of HIV acquisition among African heterosexual males has raised the question of whether this protective effect may extend to MSM populations. We examined the potential impact of circumcision on an HIV epidemic within a population of MSM. A mathematical model was developed to simulate HIV transmission in an MSM population. The model incorporated both circumcision and seropositioning, and was used to predict the reduction in HIV prevalence and incidence as a result of the two interventions. Estimates for the time required to achieve these gains were also calculated. We derive simple formulae for the decrease in HIV prevalence with increased circumcision. Our model predicts that if an initially uncircumcised MSM population in a developed country with a baseline HIV prevalence of 10% underwent universal circumcision, HIV incidence would only be reduced to 95% of pre-intervention levels and HIV prevalence to 9.6% after 20 years. In the longer term, our model predicts that prevalence would only decrease from 10% to 6%, but this would take several generations to achieve. The effectiveness of circumcision increases marginally with higher degrees of seropositioning. The results of these calculations suggest that circumcision as a public health intervention will not produce a substantial decrease in HIV prevalence or incidence among MSM in the near future, and only modest reductions are achievable in the long-term.

Behavioral Mechanisms in HIV Epidemiology and Prevention: Past, Present, and Future Roles

In the 1980s, behavioral variations across geographically and socially defined populations were the central focus of AIDS research, and behavior change was seen as the primary means of controlling HIV epidemics. Today, biological mechanisms--especially other sexually transmitted infections, antiretroviral therapy, and male circumcision--predominate in HIV epidemiology and prevention. We describe several reasons for this shift in emphasis. Although the shift is understandable, we argue for a sustained focus on behavioral mechanisms in HIV research in order to realize the theoretical promise of interventions targeting the biological aspects of HIV risk. We also provide evidence to suggest that large reductions in HIV prevalence may be accomplished by small changes in behavior. Moreover, we contend that behavioral mechanisms will find their proper place in HIV epidemiology and prevention only when investigators adopt a conceptual model that treats prevalence as a determinant as well as an outcome of behavior and that explicitly recognizes the dynamic interdependence between behavior and other epidemiological and demographic parameters.

Quantitative assessment of the role of male circumcision in HIV epidemiology at the population level

ObjectiveThree recent randomized trials have shown that male circumcision (circumcision) reduces HIV incidence in heterosexual men by about 60%. Mathematical models are needed to assess the historical role of circumcision in the observed disparate levels of prevalence in sub-Saharan Africa and to translate these findings into estimates of the population-level impact of circumcision on HIV prevalence. Methods and findingsA deterministic compartmental model of HIV dynamics with circumcision was parameterized by empirical data from the Rakai, Masaka, and Four-City studies. Circumcision was found to account for about two-thirds of the differential HIV prevalence between West Africa and East and Southern Africa. We found that in Kisumu, Kenya, and in Rakai, Uganda, universal circumcision implemented in 2008 would reduce HIV prevalence by 19% and 14%, respectively, by 2020. In Kisumu, a setting with high HIV prevalence, about 6 circumcisions would be needed for each infection averted while in Rakai, 11 circumcisions would be needed. Females will also benefit from circumcision with a substantial reduction in prevalence of about 8% in Kisumu and 4% in Rakai within a few years of universal circumcision. The beneficial impact of circumcision for both males and females will not be undermined by risk behavior compensation unless the increase in risk behavior is in excess of 30%. The effectiveness of circumcision as an intervention is maximized by universal circumcision within 2–3 years. ConclusionsIn West Africa, circumcision may have “quarantined” the spread of HIV by limiting sustainable transmission to within high risk groups and bridge populations. Our findings indicate that circumcision is an effective intervention in both high and intermediate HIV prevalence settings. Circumcision coverage should be expanded as soon as possible to optimize the epidemiological impact.

Male circumcision and risk of HIV infection among heterosexual African American men attending Baltimore sexually transmitted disease clinics.

Male circumcision has received international attention as an intervention for reducing HIV infection among high-risk heterosexual men; however, few US studies have evaluated its association with the risk of HIV infection. We analyzed visit records for heterosexual African American men who underwent HIV testing while attending sexually transmitted disease (STD) clinics in Baltimore, Maryland, from 1993 to 2000. We used multivariable binomial regression to evaluate associations between circumcision and the risk of HIV infection among visits by patients with known and unknown HIV exposure. Overall, 1096 (2.7%) of 40,571 clinic visits yielded positive HIV test results. Among 394 visits by patients with known HIV exposure, circumcision was significantly associated with lower HIV prevalence (10.2% vs. 22.0%; adjusted prevalence rate ratio [PRR], 0.49 [95% confidence interval [CI], 0.26-0.93]). Conversely, among 40,177 visits by patients with unknown HIV exposure, circumcision was not associated with reduced HIV prevalence (2.5% vs. 3.3%; adjusted PRR, 1.00 [95% CI, 0.86-1.15]), and age >or=25 years old and diagnosis of ulcerative STD were associated with increased prevalence. Circumcision was associated with substantially reduced HIV risk in patients with known HIV exposure, suggesting that results of other studies demonstrating reduced HIV risk for circumcision among heterosexual men likely can be generalized to the US context.

Heroin in brown, black and white: Structural factors and medical consequences in the US heroin market

Background Heroin coming into the United States historically comes from three widely dispersed geographical regions: Southwest Asia, Southeast Asia and Mexico. A fourth source of US-bound heroin, from Colombia, originated in the early 1990s. The fact that the four heroin sources produce differing morphologies and qualities of heroin has not been critically examined. In addition, it is not well established how the contemporary competing dynamics of interdiction, or restriction of heroin flows across international boundaries, and neoliberal, e.g., global expansion of free trade, policies are affecting heroin markets. This paper will highlight changes in the US heroin market, including source trends, the political economy of the now dominant source and the resultant effects on the heroin risk environment by US region. Methods Using a structural and historical framework this paper examines two decades of secondary data sources, including government and drug control agency documents, on heroin flows together with published work on the political and economic dynamics in Latin America. Results Co-occurring neoliberal economic reforms may have contributed to paradoxical effects of US/Colombian interdiction efforts. Since entering the US market, heroin from Colombia has been distributed at a much higher quality and lower retail price. An increasingly exclusive market has developed with Mexican and Colombian heroin gaining market share and displacing Asian heroin. These trends have had dramatic effects on the risk environment for heroin consumers. An intriguing factor is that different global sources of heroin produce substantially different products. Plausible associations exist between heroin source/form and drug use behaviours and harms. For example, cold water-soluble powdered heroin (sources: Asia, Colombia) may be associated with higher HIV prevalence in the US, while low-solubility “black tar” heroin (BTH; source: Mexico) is historically used in areas with reduced HIV prevalence. BTH is associated with soft tissue infections caused by Clostridium bacteria. Conclusion Source and type of heroin are structural factors in the risk environment of heroin users: source dictates distribution and type predicts practice. How specific types of heroin are used and with what risk is therefore distributed geographically. Continued flux in the heroin market and its effects on the risk environment for drug users deserves further attention.