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HIV This Week: what scientific journals said
Welcome to the fifteenth issue of HIV This Week! In this issue you can learn more about economics (AIDS-impoverishment and the protective effects of money, the cost- effectiveness of ART and trimethoprim-sulfamethoxazole prophylaxis in resource- constrained settings), living with HIV (partnership characteristics linked to unprotected sex, why it’s worth it for people living with HIV to get vaccinated against influenza), sex work (the empowering impact of collectivisation strategies on safer sex practices in commercial sex), youth (our UNICEF colleagues place young people squarely at the centre of the HIV epidemic; effects of sex education in developing country schools), gender (whether men and women would purchase condoms more readily when placed near negative, neutral, or positive products; sex partner selection among inner-city African American youth), and universal access (a look back on key issues at the Toronto conference including treatment targets and HIV prevention trials – with an Editors’ note about plans at UNAIDS to improve trial conduct).
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. Economic causes and effects of AIDS in South African households. 2006;20:1861-67. Bachmann and Booysen investigated the magnitude and temporal directionality of associations between illness and death, and income and expenditure, in households affected by HIV. A cohort study with repeated measures was conducted in one rural and one urban area of South Africa among 405 households (1913 occupants) known to have HIV-infected occupants, and their neighbours. Interview surveys of household heads were conducted at baseline and five more times, semi-annually, providing information on household economics, illnesses and deaths. Regression analyses used marginal structural models and 'before-after' models to analyse changes. In marginal structural models, current or previous AIDS illness
was independently associated with 34% (95% CI 23-43%) lower monthly expenditure, and current or recent poverty was associated with 1.74 (95% CI 0.94-3.2) times higher odds of an AIDS death. In before-after models, each AIDS death was independently associated with a 23% (95% CI 11-34%) greater expenditure decline over 3 years. A US$100 higher monthly expenditure at baseline was associated with 0.31 (95% CI 0.13-0.74) times as many AIDS deaths and with 0.41 (95% CI 0.27-0.64) times as many AIDS illness episodes over 3 years. The authors conclude that AIDS deaths and illnesses predicted declining expenditure, and poverty predicted AIDS, suggesting that both welfare and effective treatment are needed. Editors’ note: This study demonstrates that AIDS itself is impoverishing but also that increased household resources can slow disease progression. This is likely due, in part, to the direct effect of adequate nutrition but may also involve other factors. It speaks for the importance of both nutritional support and micro-finance and other economic strategies to increase household resources. al. Cost-effectiveness of HIV treatment in resource-poor settings--the case of Cote d'Ivoire. 2006;355:1141-53.
As antiretroviral therapy is increasingly used in settings with limited resources, key questions about the timing of treatment and use of diagnostic tests to guide clinical decisions must be addressed. Goldie and colleagues assessed the cost-effectiveness of treatment strategies for a cohort of HIV-infected adults in Cote d'Ivoire (mean age 33 years; CD4 cell count 331 per cubic millimeter; HIV RNA level 5.3 log copies per milliliter). Using a computer-based simulation model that incorporates the CD4 cell count and HIV RNA level as predictors of disease progression, the authors compared the long-term clinical and economic outcomes associated with no treatment, trimethoprim-sulfamethoxazole prophylaxis alone, antiretroviral therapy alone, and trimethoprim-sulfamethoxazole prophylaxis with antiretroviral therapy. Compared with trimethoprim-sulfamethoxazole alone, life expectancy increased by 10.7 months with antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis initiated on the basis of clinical criteria and 45.9 months with antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis initiated on the basis of CD4 testing and clinical criteria. The incremental cost per year of life gained was US$240 for trimethoprim-sulfamethoxazole prophylaxis alone, US$620 for antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis without CD4 testing, and US$1180 for antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis with CD4 testing. None of the strategies that used antiretroviral therapy alone were as cost- effective as those that also used trimethoprim-sulfamethoxazole prophylaxis. Life expectancy was increased by 30% with use of a second line of antiretroviral therapy after failure of the first-line regimen. The authors conclude that a strategy of trimethoprim- sulfamethoxazole prophylaxis and antiretroviral therapy, with the use of clinical criteria alone or in combination with CD4 testing to guide the timing of treatment, is an economically attractive health investment in settings with limited resources. Editors’ note: This study provides unequivocal support from an economics perspective for the standard inclusion of trimethoprim-sulfamethoxazole prophylaxis in treatment regimes but it also highlights the survival advantage (close to 3 additional years) of adding CD4 testing to clinical criteria for treatment initiation. Successful efforts to reduce the cost, complexity and unavailability of CD4 testing would have tangible survival benefits. 2.Living with HIV , , et al. Unprotected intercourse among people living with HIV/AIDS: the importance of partnership characteristics. 2006;18:801-7. Niccolai and colleagues determined the relative importance and interactive effects of partnership characteristics in unprotected intercourse among people living with HIV. They conducted an interview study among a convenience sample of people living with HIV in care. Of all the demographic, health status, risk history and behaviours and partnership covariates explored, only the partnership covariates were significantly associated with unprotected intercourse. Significant covariates included having a steady partner (OR 4.2, 95% CI 1.3- 13.5), an HIV-positive partner (OR 2.7, 95%CI 1.0-6.9 versus HIV-negative partner), or an unknown serostatus partner (OR 4.6, 95%CI 1.1-18.3 versus HIV-negative partner), and men who have sex with men partnerships (OR 3.0, 95%CI 1.2-7.3). Partnership covariates explained 23% of the variance in unprotected intercourse, but other groups of covariates did not significantly improve model fit. Significant interaction terms between reported partner HIV status, partnership type and sexual orientation revealed the greatest likelihood of unprotected intercourse in two groups of individuals: those in steady relationships with HIV- positive partners and men who have sex with men in relationships with partners of unknown serostatus. Prevention programming for people living with HIV should focus on partnership characteristics. Editors’ note: There are a variety of terms used to refer to such prevention programming, but a stronger message is conveyed about how best to design and implement effective programmes if we use the expression ‘for and by’ people living with HIV – it’s part of GIPA! , and clinical effectiveness of influenza vaccines in HIV-infected individuals: a meta-analysis. 2006;6:138.
Though influenza vaccines are the cornerstone of medical interventions aimed at protecting individuals against epidemic influenza, their effectiveness in HIV infected individuals is not certain. With the recent detection of influenza strains in countries with high HIV prevalence rates, Atashili and colleagues evaluated the current evidence on the efficacy and clinical effectiveness of influenza vaccines in HIV-infected individuals. The authors used electronic databases to identify studies assessing efficacy or effectiveness of influenza vaccines in HIV patients. They included studies that compared the incidence of culture- or serologically-confirmed influenza or clinical influenza-like illness in vaccinated to unvaccinated HIV infected individuals. Characteristics of study participants were independently abstracted and the risk difference (RD), the number needed to vaccinate to prevent one case of influenza (NNV), and the vaccine effectiveness (VE) computed. They identified six studies that assessed the incidence of influenza in vaccinated HIV-infected subjects. Four of these studies compared the incidence in vaccinated versus unvaccinated subjects. These involved a total of 646 HIV-infected subjects. In all the 4 studies, the incidence of influenza was lower in the vaccinated compared to unvaccinated subjects with RD ranging from -0.48 (95% CI -0.63 to -0.34) to -0.15 (95% CI -0.25 to 0.05); implying that 3 to 7 people would need to be vaccinated to prevent one case of influenza. Vaccine effectiveness ranged from 27% to 78%. A random effects model was used to obtain a summary RD of -0.27 (95%CI -0.42 to -0.11). There was no evidence of publication bias. The authors conclude that current evidence, though limited, suggests that influenza vaccines are moderately effective in reducing the
incidence of influenza in HIV-infected individuals. With the threat of a global influenza pandemic, there is an urgent need to evaluate the effectiveness of influenza vaccines in trials with a larger number of representative HIV-infected persons. Editors’ note: Ensuring that the sample size of people living with HIV within influenza vaccine trials will permit conclusions to be drawn about vaccine effects will be a challenge if these are carried out primarily in low HIV prevalence countries. 3.Sex work S prevention among female sex workers in Karnataka, India. 2006;18:739-49. Halli and colleagues evaluated the role of female sex worker collectives in the state of Karnataka, India, regarding their facilitating effect in increasing knowledge and promoting change towards safer sexual behaviour. In 2002 a state-wide survey of Female sex workers was administered to a stratified sample of 1,512 women. Following the survey, a collectivization index was developed to measure the degree of involvement of female sex workers in collective-related activities. The results indicate that a higher degree of collectivisation was associated with increased knowledge and higher reported condom use. Reported condom use was higher with commercial clients than with regular partners or husbands among all women and a gradient was observed in most outcome variables between women with low, medium and high collectivisation index scores. The authors conclude that collectivisation seems to have a positive impact in increasing knowledge and in empowering female sex workers in Karnataka to adopt safer sex practices, particularly with commercial clients. While these results are encouraging, they may be confounded by social desirability, selection and other biases. More longitudinal and qualitative studies are required to better understand the nature of sex worker collectives and the benefits that they can provide. 4.Youth . Young people: the centre of the HIV epidemic. 2006;938:15-41 Roland and Mary assessed whether young people have access to the information, skills and services required to reduce their vulnerability and whether there has been any reduction in HIV prevalence among 15-24 year olds. The authors reviewed the data on knowledge, behaviour, life skills, access to services and HIV prevalence among young people from nationally representative household surveys, antenatal care surveillance reports, behavioural surveillance surveys, a global coverage survey and other special studies. In countries where HIV is concentrated among sex workers, injecting drug users, or men who have sex with men, high-risk behaviour commences for most during adolescence, and large proportions of these high-risk populations are younger than 25 years. In countries with generalised epidemics, the epidemic is also driven by young people. Half of all new infections in sub-Saharan Africa occur among this group. Many young people do not have the basic knowledge and skills to prevent themselves from becoming infected with HIV. Young people continue to have insufficient access to information, counselling, testing, condoms, harm-reduction strategies, and treatment and care for sexually transmitted infections. Countries that have reported a decline in HIV prevalence have recorded the biggest changes in behaviour and prevalence among younger age groups. The authors conclude that the epidemic varies greatly in
different regions of the world, but in each of these epidemics young people are at the centre, both in terms of new infections and being the greatest potential force for change if they can be reached with the right programmes. effectiveness of sex education and HIV education interventions in schools in developing countries. 2006;938:103-50. Kirbi and colleagues conducted a systematic review to assess the impact of sex education and HIV education interventions in schools in developing countries on both risk behaviours for HIV and the psychosocial factors that affect them. They identified studies in developing countries that evaluated interventions using either experimental or strong quasi- experimental designs and measured the impact of the intervention on sexual risk behaviours. Each study was summarized and coded, and the results were tabulated by type of intervention. Twenty two intervention evaluations met the inclusion criteria: 17 were based on a curriculum and 5 were not, and 19 were implemented primarily by adults and 3 by peers. These 22 interventions significantly improved 21 out of 55 sexual behaviours measured. Only one of the interventions (a non-curriculum-based peer-led intervention) increased any measure of reported sexual intercourse; 7 interventions delayed the reported onset of sex; 3 reduced the reported number of sexual partners; and 1 reduced the reported frequency of sexual activity. Furthermore, 16 of the 22 interventions significantly delayed sex, reduced the frequency of sex, decreased the number of sexual partners, increased the use of condoms or contraceptives or reduced the incidence of unprotected sex. Of the 17 curriculum-based interventions, 13 had most of the characteristics believed to be important according to research in developed and developing countries and were taught by adults. Of these 13 studies, 11 significantly improved one or more reported sexual behaviours, and the remaining 2 showed non-significant improvements in reported sexual behaviour. Among these 13 studies, interventions led by both teachers and other adults had strong evidence of positive impact on reported behaviour. Of the 5 non-curriculum-based interventions, 2 of 4 adult-led and the 1 peer-led intervention improved one or more sexual behaviours. The authors conclude that a large majority of school-based sex education and HIV education interventions reduced reported risky sexual behaviours in developing countries. The curriculum-based interventions having the characteristics of effective interventions in the developed and developing world should be implemented more widely. All types of school-based interventions need additional rigorous evaluation, and more rigorous evaluations of peer-led and non-curriculum-based interventions are necessary before they can be widely recommended. Editors’ note: This systematic review strongly supports curriculum-based programmes for sex education and HIV education in schools in low- and middle-income countries, accompanied by rigorous evaluation to inform ongoing programme improvements. 5.Gender , dom purchasing: Effects of product positioning on reactions to condoms. 006 Sep 6; [Epub ahead of print].
Correct and consistent condom use has been promoted as a method to prevent sexually transmitted infections including HIV. Yet research has repeatedly shown that people fail to use condoms consistently. One influence on the pervasive lack of condom use that has
received relatively little attention is the context in which consumers are exposed to condoms (i.e., how condoms are displayed in retail settings). The authors present two studies which explored variations in condom shelf placement and its effects on people's condom attitudes and acquisition. Study 1 explored the shelf placement of condoms in 59 retail outlets in Connecticut, USA and found that condoms were typically located in areas of high visibility (e.g., next to the pharmacy counter) and on shelves adjacent to feminine hygiene and disease treatment products. In Study 2,120 heterosexual undergraduate students at the University of Connecticut were randomly assigned to evaluate condoms adjacent to sensual, positive, neutral, or negative products and found that overall men reported more positive attitudes and acquired more condoms when exposed to condoms in a sensual context compared to women in the same condition. Among women, condom attitudes were more positive in the context of neutral products; condom acquisition was strongest for women exposed to condoms in the positive aisles (that is, shelves containing “positive” health products such as vitamins, nutrition bars, and fitness or wellness magazines). The authors discuss the implications of these studies for HIV prevention, public health, and condom marketing strategies, and conclude that the results of this study suggest a gender-specific approach to condom promotion. Editors’ note: For effective marketing of condoms to both women and men in shops and pharmacies, a rapid assessment using key informants and focus groups followed by close monitoring of sales to assess impact would be ideal. Failing that, placing condoms in both high visibility and positive health product areas would likely catch both retail markets. .Understanding sex partner selection from the perspective of inner-city black adolescents. 2006;38:132-8. Black adolescents in inner-city settings in the United Sates are at increased risk for HIV and other STDs. Sex partner characteristics, as well as individual behaviour, influence individuals' STD risk, yet little is known about the process of sex partner selection for adolescents in this setting. Andrinopoulos and colleagues conducted semistructured in-depth interviews during the summer and fall of 2002 with 50 inner-city black adolescents (26 females and 24 males) who had been purposively recruited from an STD clinic in the eastern region of Baltimore, Maryland. Content analysis was used to study interview texts. They found that young women desire a monogamous romantic partner, rather than a casual sex partner; however, to fulfil their desire for emotional intimacy, they often accept a relationship with a non-monogamous partner. Young men seek both physical and emotional benefits from being in a relationship; having a partner helps them to feel wanted, and they gain social status among their peers when they have multiple partners. For men, these benefits may help compensate for an inability to obtain jobs that would improve their financial and, as a result, social status. Both young women and young men assess partners' STD risk on the basis of appearance. The authors conclude that HIV and other STD prevention initiatives must go beyond the scope of traditional messages aimed at behaviour change and address the need for social support and socioeconomic opportunities among at- risk, inner-city adolescents. Editors’ note: Seeking status through sexual partner choice is age-old but now may carry the risk of HIV and STD in many settings around the world in which young people have limited educational and economic opportunities. It is widely accepted as part of the risk context for girls and young women but the fact that boys and young men are similarly affected in low resource settings should not be forgotten. 6.Universal access AIDS treatment and prevention. 2006;355:1In this perspective article, Robert Steinbrook looked back on the Toronto AIDS conference arguing that the growth of the pandemic continues to outpace the broad and expanding efforts to control it. Since HAART became available a decade ago, the treatment of HIV infection has been streamlined — for example, from 10 pills daily taken in three doses with food restrictions to as little as 1 pill once a day. Many presentations at the conference showed that treating HIV is feasible in all countries. The best price for a first-line regimen of generic antiretroviral drugs in low-income countries is now about US$130 a year for adults (down from US$285 in April 2004) and less than US$200 a year for children. In 2005, there were an estimated 4.1 million people newly infected with HIV and 2.8 million AIDS-related deaths. The author reviews resource needs and estimates of actual funding, coverage of specific prevention programmes, and includes a chart which compares coverage of antiretroviral treatment by country. Countries with less than 35% of those in need on treatment include Trinidad and Tobago, Burkina Faso, Zambia, Chad, Benin, Cameroon, South Africa, Kenya, Burundi, China, Malawi, and Ethiopia. He then summarises biomedical approaches to prevention currently being evaluated, often in large controlled trials. These include cervical barriers, such as the diaphragm; therapy to suppress herpes simplex virus type 2, the primary cause of genital herpes (a risk factor for acquiring and transmitting HIV); microbicides that could be applied to the vagina or rectum; male circumcision; pre-exposure prophylaxis with antiretroviral drugs; and expanded treatment of infected persons not only for their own health but also to prevent HIV transmission. He then highlights the consensus view that providing antiretroviral therapy to subjects who acquire HIV infection during the course of a study is an indispensable part of the agreement between trial sponsors and trial participants. He suggests that there is disagreement, however, about the obligation to people whose infection is detected when they are screened for trial eligibility, as well as about who should assume the long-term financial costs and manage the complexity of treatment – trial sponsors, the country where the trial is conducted, an international fund, or someone else. Although trial participants are unlikely to need treatment until years after they become infected, they will eventually need it for life. Editors’ note: UNAIDS is following up on the recommendations of an international consultation on creating effective partnerships for HIV prevention trials in 2005. The whole process, which included three regional consultations, was initiated as a result of the suspension of the tenofovir trials in Cambodia and Cameroon. We are planning three meetings over the coming months to address three specific recommendations: to develop Good Community Practice Guidelines which outline processes, procedures, and minimum requirements for community engagement in HIV prevention research; to identify programmatic and financing approaches for providing care and treatment to people who develop intercurrent infections (or who are screened out at recruitment for HIV prevention trials because they are found to be HIV-positive); and to revise and update the 2000 UNAIDS guidance document on ethical considerations in HIV preventive vaccine research (to be expanded to apply to all HIV prevention trials).
That was HIV This Week, signing off. Editors’ notes on journal access
For readers in all countries: All abstracts in HIV This Week are freely available on the Web. You can access a majority of scientific journals free of charge no matter where you are located, but for some journals you do need a subscription to access the full text of an article. Some journals are free to readers in all countries either through ScienceDirect or through the journal’s own website. For articles available through ScienceDirect, you should follow the link to the ScienceDirect website. Then, type in the title of the journal for which you are searching. Some journals are open access, available to readers in all countries: American Medical Association journals (ican Society of Clinical Oncology (2 journals), Australian Medical Association (1 journal), BioMed Central journals
), BMJ journals (), Canadian Medical Association (1 journal), Nature Publishing GroupPublic Library of Scien) and Science (1 journal).
Other journals offer free access to full-text articles after a certain period of time (see lists at High Wire Press and PubMed Central
For residents of low- and middle-income countries: the Health InterNetwork Access to Research Initiative (HINARI) HINARI, set up by the World Health Organisation (WHO) and major publishers, enables readers in low- and middle-income countries to gain access to one of the world's largest collections of biomedical and health literature. Over 3400 journal titles are now available to health institutions in 113 countries, benefiting many thousands of health workers and researchers, and in turn, contributing to improved world health. More information on the
HINARI programme and eligible countries is available at mail: . Local, not-for-profit institutions in low- and middle- income countries may register for access to the journals through HINARI. Institutions in countries with GNP per capita below $1000 are eligible for free access. Institutions in countries with GNP per capita $1000- $3000 pay a fee of $1000 per year/institution. For employees of UNAIDS or WHO: If you work for WHO or UNAIDS, you can access a number of journals by going to the WHO library. You can also see the full list of journals you can access freely on the web (including usernames and passwords) by going to the WHO Library website, accessible through the home page of WHO inmation Resources. If you work for UNAIDS, HIV This Week is also available on the intranet at the link .
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