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HIV/AIDS Nevirapine safe for HIV positive women for PMTCT: Zambia and Botswana studies The World Health Organization has reaffirmed its support for the use of nevirapine following a new Zambian study into the effects of the drug on HIV positive women. The study by the Zambian Centre for Infectious Disease Research examined 4,552 women receiving HIV/AIDS treatment, including 445 who had received a single dose of the drug to prevent mother-to-child HIV transmission. The researchers found that after one year those using nevirapine did not have worse clinical outcomes than those with no exposure to the drug. However, women with more advanced HIV would benefit from beginning a full regimen of ARV therapy before giving birth, which would limit resistance, increase survival rate and provide effective HIV protection for their babies. The research follows a 2004 Ugandan study which concluded that nevirapine is a safe and effective drug for preventing mother-to-child transmission, despite finding that a single dose could create a drug-resistant strain in some women and babies.1 The use of nevirapine in preventing motherto-child HIV transmission in Botswana was assessed in a study among 218 women randomly assigned to two groups receiving a single peripartum dose of nevirapine or a placebo. Those in the nevirapine group who began nervirapinebased antiretroviral treatment within six months of childbirth were at substantial risk of virologic failure (41.7% of the 60 women) compared to those in the placebo group (0 cases). However when antiretroviral treatment was initiated six months or more post-partum, no significant difference was found in the virological failure rate between the nevirapine and placebo groups.2 1. IRIN PlusNews, 13 September 2006. New Zambian research contradicts Ugandan study on nevirapine. At: bwww.plusnews.org/AIDSReport.ASP?ReportID=
6373&SelectRegion=East_Africa&Select Country=AFRICAN. 2. Lockman S, Shapiro RL, Smeaton LM, et al. Response to antiretroviral therapy after a single, peripartum dose of nevirapine [abstract]. New England Journal of Medicine 2007;356(2):135–47.
Reduction in perinatal transmission of HIV A new UNICEF report shows that only 9% of HIV positive pregnant women in low- and middleincome countries worldwide received antiretroviral drugs in 2005 that could prevent perinatal HIV transmission, an increase from 3% in 2003. The agreed global target is 80% by 2010. However, increases in some developing countries are greater. In Namibia, according to the report, access rates to drugs for pregnant women jumped from 6% to 29% from 2004 to 2005. In Rwanda it rose to 36% from 21%. In Swaziland, it rose to 34% from 4% and in South Africa to 30% from 22%. Only nine countries by 2005 were providing treatment to more than 40% of pregnant positive women: Argentina (87%), Belarus (60%), Brazil (48%), Botswana (54%), Jamaica (86%), Russian Federation (84%), Suriname (44%), Thailand (46%) and Ukraine (90%). A demonstrated political commitment, a decentralised approach to services and training and incorporation of care for the entire family were found to be the main factors in these countries.1 In Thailand, a register was kept of 2,200 children born at 84 public health hospitals in six provinces to HIV positive mothers from January 2001–December 2003, with follow-up of infection status. 95.7% of mother–infant pairs received some antiretroviral prophylaxis, the majority short-course zidovudine, with or without other antiretrovirals, usually nevirapine. Of 1,667 children where HIV status was determined, an overall transmission risk of 10.2% was estimated. Historically, the risk had been about 19–24%. The addition of nevirapine in 2004 with all deliveries may have improved effectiveness.2 197
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1. UNICEF, UNAIDS, WHO. Children and AIDS: A Stocktaking Report. New York: UNICEF, January, 2007. At: bwww.unicef.org/media/files/FINAL_ STOCKTAKING_REPORT.pdf N. 2. Plipat T, Naiwatanakul T, Rattanasuporn N, et al. Reduction in mother-to-child transmission of HIV in Thailand, 2001–2003: results from populationbased surveillance in six provinces. AIDS 2007; 21(2):145–51.
Breastfeeding does not contribute to mortality among HIV-positive women in Kenya A prospective cohort study comparing 198 HIV positive Kenyan women who breastfed and 98 who formula-fed found no increased risk of overall mortality after two years. But the breastfeeding women had faster CD4 and body mass index declines. In a previous randomised clinical trial breastfeeding mothers did have an increased risk of mortality compared to those who formula-fed. Then, four subsequent African cohort studies found no increased risk. The women in this latest study were not randomised. The women differed as regards education level, access to flush toilets and experience of HIVrelated illnesses. But they were similar in median age (25), were mostly married, and had similar viral loads and CD4 counts at baseline (32 weeks of pregnancy). Over the two-year follow-up, there were 12 deaths (6%) in breastfeeding women, eight related to HIV, and four (4%) in women who formula-fed. Risk of death was related to CD4 count but not feeding method.1 The preponderance of evidence is that HIV-positive women are not compromised by breastfeeding and as formula-fed infants are more likely to die of causes other than HIV, replacement feeding has not reduced the overall risk of infant mortality.2 1. Otieno PA, et al. HIV-1 disease progression in breastfeeding and formula-feeding mothers: a prospective 2-year comparison of T cell subsets, HIV-RNA levels, and mortality. Journal of Infectious Diseases 2007;195:220–29. 2. Wilfert CM, Fowler MG. Balancing maternal and infant benefits and the consequences of breastfeeding in the developing world during the era of HIV infection. Journal of Infectious Diseases 2007;195: 165–67. Summary of both articles by D Thaczuk,
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10 January 2007 at: bwww.aidsmap.com/en/news/ F2784693-8CA7-44F6-B490-78FOCC388254.aspN.
Safety of formula-feeding for HIV uninfected infants: Coˆte d’Ivoire A study among infants of HIV-positive mothers in Abidjan, Coˆte d’Ivoire, looked at safety of infant feeding interventions aimed at reducing motherto-child HIV transmission in Africa (either formula feeding or shortened breastfeeding). At baseline, formula-feeding mothers were more educated and had better access to tap water and less shared housing than women who elected to breastfeed for a short duration. There was no evidence that formula-feeding mothers in this cohort had more advanced HIV disease than women who breastfed. Overall, at the end of two years, adverse events among HIV-uninfected infants were similar in both groups. Formula-fed infants had a significantly increased risk of diarrhoea and acute respiratory illnesses, while short-term breastfed infants tended to have a higher incidence of malnutrition. However, at two-year follow-up, the risk of hospitalisation and of mortality did not differ between the two feeding groups. In addition, when both groups of infants were compared to a historical cohort in which breastfeeding was prolonged, excellent two-year survival was found among HIV-uninfected children regardless of whether they breastfed long-term (95%) or breastfed for four months or never breastfed (96%). ‘‘Given appropriate nutritional counselling and care, access to clean water and a supply of breastmilk substitutes, these alternatives to prolonged breastfeeding can be safe interventions to prevent mother-to-child transmission of HIV in urban African settings.’’1 1. Becquet R, Bequet L, Ekouevi DK, et al. Two-year morbidity–mortality and alternatives to prolonged breast-feeding among children born to HIV-infected mothers in Coˆte d’Ivoire. PLoS Med 2007;4: e17–doi:10.1371/journal.pmed.0040017 doi. At: bhttp:// medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371%2Fjournal.pmed.0040030N. Accessed 29 January 2007.
Impact of HIV and highly active antiretroviral therapy on menstruation 1,635 HIV positive women and 595 HIV negative women in several US cities were recruited
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into a multicentre prospective cohort study to find out whether HIV and highly active antiretroviral therapy (HAART) increased the risk of changes in the menstrual cycle. The study ran from 1992 to 2002 and included interviews, medical tests and pelvic examinations every six months. The researchers focused on the following menstrual problems – amenorrhoea, oligomenorhoea, intermenstrual bleeding and menorrhagia. Prolonged use of HAART and higher CD4+ cell counts were both associated with a reduced risk of menstrual problems, due to the women’s better overall health. In general HIV positive women are not at increased risk of serious problems though severely ill HIV positive women with lower CD4+ cell counts may be at heightened risk of abnormal menstrual cycles.1 1. Massad LS, Evans CL, Minkoff H et al. Effects of HIV infection and its treatment on self-reported menstrual abnormalities in women. Journal of Women’s Health 2006;15(5):591–98.
Reduced fertility among HIV-positive women with high viral load, Uganda This study assessed whether HIV-1 viral load affects the likelihood of live birth among HIVpositive women in a nested case–control study of HIV positive women from a community cohort in Rakai District, Uganda. Cases were women who had a live birth (n=270), and controls were sexually active women who did not use contraception and did not become pregnant during follow-up (n=263). The data suggest that there may be considerable differences in the ability to produce a live birth among HIV positive women with high viral loads.1 1. Nguyen RHN, Gange SJ, Wabwire-Mangen F, et al. Reduced fertility among HIV-infected women associated with viral load in Rakai district, Uganda. International Journal of STD & AIDS 2006;17(12): 842–6.
Sexual dysfunction in men and women living with HIV: UK Men living with HIV who are on successful antiretroviral treatment expect to lead full lives, including in their sex lives, but may experience sexual dysfunction. This was a retrospective
study in 190 consecutive HIV positive men attending a sexual dysfunction service in an HIV clinic in London, UK. Men with sexual dysfunction commonly reported recreational drug use, co-infection with hepatitis B and C, anxiety and depressive illnesses, peripheral neuropathy and lipodystrophy. There was a significant relationship between complaints of retarded ejaculation and peripheral neuropathy. Sexual dysfunction related to use of medication in non-HIV settings is known to lead to poor adherence and may affect antiretroviral adherence if not addressed.1 Retrospective analysis of clinic notes of women with HIV attending the same HIV clinic in London found that about half the clinic’s cohort reported sexual problems, most commonly from contextual causes, or were not satisfied with sex in the preceding 12 months. A survey by letter of HIV clinical centres in the UK found that 60% had rarely or never asked women patients with HIV about sexual functioning.2 1. Richardson D, Lamba H, Goldmeier D, et al. Factors associated with sexual dysfunction in men with HIV infection [abstract]. International Journal of STD & AIDS 2006;17(11):764–67. 2. Bell C, Richardson D, Wall M, et al. HIV-associated female sexual dysfunction: clinical experience and literature review [abstract]. International Journal of STD & AIDS 2006;17(10):706-09.
Recurrence of cervical intraepithelial neoplasia in HIV-positive women A literature search of Medline and the Cochrane libraries found 15 articles on the rate of recurrence of cervical intraepithelial neoplasia (CIN) in HIV-positive women after excision of affected tissue and a margin of normal tissue. Of these 15 articles, five reported a recurrence rate of CIN in margin-negative patients ranging from 20–75%. This evidence suggests that standard excision for CIN in HIV positive women needs to be reconsidered to try to reduce recurrence rates and prevent invasive cervical cancer developing.1 1. Tebeu PM, Major AL, Mhawech P, et al. The recurrence of cervical intraepithelial neoplasia in HIV-positive women: a review of the literature [abstract]. International Journal of STD & AIDS 2006;17(8):507–11.
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Sexual networking patterns and HIV risk in four provinces of Viet Nam This is a study of patterns and determinants of HIV prevalence and risk behaviour characteristics in four population groups – female sex workers (n=2023), injecting drug users (n=1391), unmarried men aged 15–24 (n=1885) and different categories of mobile groups (n=1923) in four border provinces of Viet Nam during April–June 2002. Marked geographical contrasts in HIV prevalence were found, particularly among female sex workers (range 0–24%). HIV prevalence among injecting drug users varied at high levels in all provinces (range 4–36%), whereas lower prevalences were found among both unmarried young men (range 0–1.3%) and mobile groups (range 0–2.5%). All groups reported sex with female sex workers. Less than 40% of the female sex workers had used condoms consistently. An Giang province, which borders Cambodia, was the only province with high HIV rates among female sex workers. Sex with female sex workers and other non-regular sex partners appeared to be associated strongly with HIV infection among injecting drug users there (see Figure 1, reproduced from the article).
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The strongest determinants of HIV infection among female sex workers were inconsistent condom use, history of injecting drug use and mobility, and among injecting drug users, sharing of injection equipment and sex with nonregular partners. HIV among injecting drug users can contribute to more generalised HIV spread in many settings. However, the effects of interventions to reduce sexual risk behaviour among injecting drug users have generally been modest. The study documents that in most places a substantial proportion of young unmarried men have multiple sex partners and low levels of consistent condom use. Documentation of risk behaviours among adult men is still limited.1 1. Nguyen AT, Fylkesnes K, Bui DT, et al. Human immunodeficiency virus (HIV) infection patterns and risk behaviours in different population groups and provinces in Viet Nam. Bulletin of World Health Organization 2007;85(1):35–41.
Brothel-based sexual health clinic for sex workers: South Africa Conventional health services often present barriers to sex workers seeking health care; sex
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workers fear that they will be refused services and may experience public humiliation by health workers. Brothel-based clinical services were established to provide sex workers in a suburb of Johannesburg, South Africa, with good quality sexual health services and HIV/ AIDS education and counselling, and treat STIs and other reproductive health problems. In a survey in that same neighbourhood in 1997, 45% of 247 sex workers had tested positive for HIV. The clinic services had a positive impact on perceptions of health and the need to prevent disease. The information sessions provided by the nurses also had a positive effect on condom use, and female condom use was successfully introduced. Brothel managers were supportive of the initiative due to improved health-seeking behaviour and the increased popularity of those brothels that were visited by the clinic. Applying this model more broadly, the National Roads Agency in South Africa, made up of truck-driver trade union and business interests, has collaborated with the national Department of Health to implement the ‘‘Trucking against AIDS’’ programme. Several permanent and temporary clinics were set up on major trucking routes to providing truckers with quality sexual health care services. Sex workers who base themselves at truck stops have started to utilise these clinics as well.1 1. Stadler J, Delany S. The ‘healthy brothel’: the context of clinical services for sex workers in Hillbrow, South Africa. Culture, Health & Sexuality 2006;8(5):451–63.
Sexual health of people with HIV: new UK STI guidelines There is a recognised synergy between STIs and HIV that may enhance transmission of both, and evidence that improved STI control, e.g. periodic presumptive treatment as well as syndromic management in sex workers,1 reduces HIV spread. Non-disclosure of HIV status is frequent and more common in casual and non-exclusive sexual relationships. In a UK community study of HIV positive gay men, 24% reported unprotected anal intercourse with more than one partner and 29% with partners of unknown or discordant HIV status in the previous year, while 41% reported an STI in the previous year. Celebration of unprotected sex by men who have sex with men
is becoming more vocal and ‘‘positive-only’’ sex venues have been created. HIV prevention campaigns have previously focused on those who are not known to have HIV even though people with HIV may not adopt or maintain safer sex practices. Now, sexual health care and positive prevention are being incorporated into HIV clinical care. These guidelines recommend that syphilis testing become a routine blood test and that a formal sexual health assessment (including annual cytology in women) and other appropriate tests be offered within a month of HIV diagnosis and at six-monthly intervals to patients under regular follow-up. Contact tracing and notification needs to consider both STIs and HIV. In people with HIV with significant immunosuppression, management of syphilis, genital herpes, genital warts and genital human papillomavirus may different significantly from that for other patients.2 1. See, for example, Vickerman P, Terris-Prestholt F, Delany S, et al. Are targeted HIV prevention activities cost-effective in high prevalence settings? Results from a STI treatment project for sex workers in Johannesburg, South Africa. Sexually Transmitted Diseases 2006;33(10/Supplement):S122–S132. 2. Nandwani R. 2006 UK National Guidelines on the Sexual Health of People with HIV: Sexually Transmitted Infections. International Journal of STD & AIDS 2006;17(9):594–606.
Partner violence and HIV risk behaviour among young men: South Africa Interviews with 1,275 sexually experienced young men aged 15–26 from 70 villages in the rural Eastern Cape, South Africa, found that 31.8% reported physical or sexual violence against female main partners. Violence was correlated with higher numbers of partners in the previous year and of lifetime sexual partners, substance abuse, sexual assault of non-partners and transactional sex. Men who reported violence also reported significantly higher levels of HIV risk behaviour. Interventions for HIV prevention must therefore explicitly address intimate partner violence.1 1. Dunkle KL, Jewkes RK, Nduna M, et al. Perpetration of partner violence and HIV risk behaviour among young men in rural Eastern Cape, South Africa. AIDS 2006;20(16):2107–14.
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Partner reduction vital in fight against HIV This commentary argues that it is time to call an armistice in the battle between condom promotion and abstinence for HIV prevention. Abstinence messages alone are not effective. However, condoms do not provide a total solution. Research from Kenya indicates that declining HIV incidence since the early to mid-1990s was accompanied by a substantial drop in multiple partners among men, reported in three Demographic and Health Surveys between 1993 and 2003. Thus, despite the reticence of health professionals to address sexual behaviour, the fear of AIDS means that many people are open to considering having fewer partners. Correct and consistent condom use should be promoted for self-protection, and discussion of abstinence, secondary abstinence or longer spacing between partners can all provide opportunities to promote self-efficacy, fidelity and partner limitation. New technologies such as male circumcision, vaccines, microbicides and antiretrovirals all have the potential to increase disinhibition and related risk-taking if they are not accompanied by an understanding that partner limitation is key to reversing generalised HIV epidemics.1 1. Shelton JD. Confessions of a condom lover. Lancet 2006;368:1947–49.
Improving contraceptive delivery to women with HIV: Kenya 319 pregnant women with HIV participating in a perinatal HIV transmission study were referred to local clinics for contraceptive counselling and management and followed prospectively. Median time to sexual activity post-partum was two months. 72% (231) initiated hormonal contraceptive use at about three months post-partum (range 1–11 months) and used it for at least two months during follow-up. This included 44% Depo Provera, 31% oral contraception and 25% who switched methods during follow-up. Partner notification, infant mortality and condom use were similar between contraceptive users and non-users.1 1. Balkus J, Bosire R, John-Stewart G, et al. High uptake of postpartum hormonal contraception among HIV-1 seropositive women in Kenya [abstract]. Sexually Transmitted Diseases 2007;34(1):25–29.
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Hormonal contraception and risk of HIV acquisition: Uganda and Zimbabwe This study among 6,109 HIV-negative women recruited from family planning clinics who were using either Depo Provera or combined oral contraception in Uganda and Zimbabwe tested the women quarterly for HIV over 15–24 months. 213 women became HIV positive during the study. Neither hormonal contraceptive method was associated with risk of HIV acquisition overall, including among women with cervical or vaginal infections.1 1. Morrison CS, Richardson BA, Mmiro F, et al for the Hormonal Contraception and the Risk of HIV Acquisition Study Group. Hormonal contraception and the risk of HIV acquisition [abstract]. AIDS 2007;21(1):85–95.
Treatment of herpes simplex virus reduces genital shedding of HIV Epidemiologic and biologic data support a strong association between herpes simplex virus type 2 (HSV-2) and infection with human immunodeficiency virus type 1 (HIV-1). A recent metaanalysis of prospective observational studies showed that patients who were seropositive for HSV-2 had three times the risk of acquiring HIV-1, as compared with those who were seronegative for HSV-2. A randomised, double-blind, placebo-controlled trial was conducted of HSV suppressive therapy with valacyclovir (at a dose of 500 mg twice daily) in Burkina Faso among women who were seropositive for HIV-1 and HSV-2. All of them were ineligible for highly active antiretroviral therapy. The women were followed for 24 weeks (12 weeks before and 12 weeks after randomisation). A total of 140 women were randomly assigned to treatment groups; 136 were included in the analyses. Daily treatment with valacyclovir for three months significantly diminished the shedding of HIV-1 RNA, reduced plasma HIV-1 RNA levels, and reduced genital HIV-1 RNA levels when shedding was present in women dually infected with HIV-1 and HSV-2. This effect steadily increased over time, which suggested that a longer duration of treatment might have led to an even greater reduction in HIV-1 RNA levels. These findings should be verified through clinical trials of longer duration. Although our trial had no HIV clinical
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outcomes, its results may be relevant to HIV-1 prevention and management.1 1. Nagot N, Oue´draogo A, Foulongne V, et al. Reduction of HIV-1 RNA levels with therapy to suppress herpes simplex virus. New England Journal of Medicine 2007;356(8):790–99.
HIV/STI prevention for men who have sex with men, Kenya The stigmatisation and denial of homosexual behaviour in Africa can mean that vulnerable populations are overlooked in HIV/STI prevention programmes. Researchers sought to understand the extent to which men who have sex with men in Kenya are at risk of HIV and other STIs, identify the factors associated with risk behaviours and determine their sexual health needs in order to develop appropriate interventions. They began by gathering quantative data from 500 men in Nairobi over age 18 who have had sexual intercourse with one or more male partners. A sample of these men and those who interact with them participated in in-depth interviews and observation was carried out in social settings where the men meet. The men were identified through snowball sampling. They came from diverse socio-economic backgrounds, many had also had sex with a woman and many remain sexually active with a woman. 23% identified themselves as bisexual. 63% of respondents reported stigma and discrimination to be a major problem in their lives, with many – especially sex workers – reporting an incident of stigma and violence in the previous year. Knowledge of condoms for protection against HIV/STIs was high, though condom use varied, with those reporting a single partner and those who had experienced violence in the previous 12 months least likely to use condoms. Most of the survey sample used oil-based lubricants and were unaware of the damage these can cause to condoms. Half of respondents had ever had an STI and this was significantly more likely for those practising oral sex. 57% had taken an HIV test (compared to 27% of all men in the Nairobi area). Confidentiality was a major concern for those seeking treatment, and the stigma around sex between men means that even where
symptoms are obviously linked to sexual behaviour, health providers, even in HIV testing and STI services, are not discussing this explicitly with their patients or with fellow health providers. Peer education also has an important role in disseminating information about multiple partners, unprotected sex and incorrect use of lubrication and empowering and supporting this vulnerable population to adopt HIV/STI protective behaviours.1 1. Understanding the HIV/STI prevention needs of men who have sex with men in Kenya [Research summary]. Population Council/Horizons. Available at: bwww. popcouncil.org/pdfs/horizons/msmkenya.pdfN.
Cellulose sulfate microbicide trial stopped A Phase III study of the candidate microbicide cellulose sulfate to prevent HIV transmission in women has been stopped prematurely because of a high number of HIV infections in the active as compared with the placebo group. This is a disappointing and unexpected setback in the search for a safe and effective microbicide that can be used by women for protection against HIV infection. Cellulose sulfate was one of four compounds being evaluated in large-scale studies of effectiveness among women at high risk of HIV infection. The Carraguard study is nearing completion in three sites in South Africa, with results expected by the end of 2007. PRO2000 is being tested in one study with five sites and another with seven sites, all in southern African countries, with results expected in 2009 and 2008 respectively. In the second study BufferGel, a vaginal defence enhancer, is also being tested. All the other products mentioned are called HIV entry inhibitors and block HIV infection. There is as yet no explanation as to why cellulose sulfate was associated with a higher risk of HIV infection than the placebo. A statement from CONRAD, who conducted the cellulose sulfate trial, can be found at bwww. conrad.orgN.1 1. Excerpted from a statement by the World Health Organization and UNAIDS, 31 January 2007. Full text at: bwww.who.int/mediacentre/news/ statements/2007N.
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HIV/AIDS Nevirapine safe for HIV positive women for PMTCT: Zambia and Botswana studies The World Health Organization has reaffirmed its support for the use of nevirapine following a new Zambian study into the effects of the drug on HIV positive women. The study by the Zambian Centre for Infectious Disease Research examined 4,552 women receiving HIV/AIDS treatment, including 445 who had received a single dose of the drug to prevent mother-to-child HIV transmission. The researchers found that after one year those using nevirapine did not have worse clinical outcomes than those with no exposure to the drug. However, women with more advanced HIV would benefit from beginning a full regimen of ARV therapy before giving birth, which would limit resistance, increase survival rate and provide effective HIV protection for their babies. The research follows a 2004 Ugandan study which concluded that nevirapine is a safe and effective drug for preventing mother-to-child transmission, despite finding that a single dose could create a drug-resistant strain in some women and babies.1 The use of nevirapine in preventing motherto-child HIV transmission in Botswana was assessed in a study among 218 women randomly assigned to two groups receiving a single peripartum dose of nevirapine or a placebo. Those in the nevirapine group who began nervirapinebased antiretroviral treatment within six months of childbirth were at substantial risk of virologic failure (41.7% of the 60 women) compared to those in the placebo group (0 cases). However when antiretroviral treatment was initiated six months or more post-partum, no significant difference was found in the virological failure rate between the nevirapine and placebo groups.2 1. IRIN PlusNews, 13 September 2006. New Zambian research contradicts Ugandan study on nevirapine. At: bwww.plusnews.org/AIDSReport.ASP?ReportID=
6373&SelectRegion=East_Africa&Select Country=AFRICAN. 2. Lockman S, Shapiro RL, Smeaton LM, et al. Response to antiretroviral therapy after a single, peripartum dose of nevirapine [abstract]. New England Journal of Medicine 2007;356(2):135–47.
Reduction in perinatal transmission of HIV A new UNICEF report shows that only 9% of HIV positive pregnant women in low- and middleincome countries worldwide received antiretroviral drugs in 2005 that could prevent perinatal HIV transmission, an increase from 3% in 2003. The agreed global target is 80% by 2010. However, increases in some developing countries are greater. In Namibia, according to the report, access rates to drugs for pregnant women jumped from 6% to 29% from 2004 to 2005. In Rwanda it rose to 36% from 21%. In Swaziland, it rose to 34% from 4% and in South Africa to 30% from 22%. Only nine countries by 2005 were providing treatment to more than 40% of pregnant positive women: Argentina (87%), Belarus (60%), Brazil (48%), Botswana (54%), Jamaica (86%), Russian Federation (84%), Suriname (44%), Thailand (46%) and Ukraine (90%). A demonstrated political commitment, a decentralised approach to services and training and incorporation of care for the entire family were found to be the main factors in these countries.1 In Thailand, a register was kept of 2,200 children born at 84 public health hospitals in six provinces to HIV positive mothers from January 2001–December 2003, with follow-up of infection status. 95.7% of mother–infant pairs received some antiretroviral prophylaxis, the majority short-course zidovudine, with or without other antiretrovirals, usually nevirapine. Of 1,667 children where HIV status was determined, an overall transmission risk of 10.2% was estimated. Historically, the risk had been about 19–24%. The addition of nevirapine in 2004 with all deliveries may have improved effectiveness.2 197
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1. UNICEF, UNAIDS, WHO. Children and AIDS: A Stocktaking Report. New York: UNICEF, January, 2007. At: bwww.unicef.org/media/files/FINAL_ STOCKTAKING_REPORT.pdf N. 2. Plipat T, Naiwatanakul T, Rattanasuporn N, et al. Reduction in mother-to-child transmission of HIV in Thailand, 2001–2003: results from populationbased surveillance in six provinces. AIDS 2007; 21(2):145–51.
Breastfeeding does not contribute to mortality among HIV-positive women in Kenya A prospective cohort study comparing 198 HIV positive Kenyan women who breastfed and 98 who formula-fed found no increased risk of overall mortality after two years. But the breastfeeding women had faster CD4 and body mass index declines. In a previous randomised clinical trial breastfeeding mothers did have an increased risk of mortality compared to those who formula-fed. Then, four subsequent African cohort studies found no increased risk. The women in this latest study were not randomised. The women differed as regards education level, access to flush toilets and experience of HIVrelated illnesses. But they were similar in median age (25), were mostly married, and had similar viral loads and CD4 counts at baseline (32 weeks of pregnancy). Over the two-year follow-up, there were 12 deaths (6%) in breastfeeding women, eight related to HIV, and four (4%) in women who formula-fed. Risk of death was related to CD4 count but not feeding method.1 The preponderance of evidence is that HIV-positive women are not compromised by breastfeeding and as formula-fed infants are more likely to die of causes other than HIV, replacement feeding has not reduced the overall risk of infant mortality.2 1. Otieno PA, et al. HIV-1 disease progression in breastfeeding and formula-feeding mothers: a prospective 2-year comparison of T cell subsets, HIV-RNA levels, and mortality. Journal of Infectious Diseases 2007;195:220–29. 2. Wilfert CM, Fowler MG. Balancing maternal and infant benefits and the consequences of breastfeeding in the developing world during the era of HIV infection. Journal of Infectious Diseases 2007;195: 165–67. Summary of both articles by D Thaczuk,
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10 January 2007 at: bwww.aidsmap.com/en/news/ F2784693-8CA7-44F6-B490-78FOCC388254.aspN.
Safety of formula-feeding for HIV uninfected infants: Coˆte d’Ivoire A study among infants of HIV-positive mothers in Abidjan, Coˆte d’Ivoire, looked at safety of infant feeding interventions aimed at reducing motherto-child HIV transmission in Africa (either formula feeding or shortened breastfeeding). At baseline, formula-feeding mothers were more educated and had better access to tap water and less shared housing than women who elected to breastfeed for a short duration. There was no evidence that formula-feeding mothers in this cohort had more advanced HIV disease than women who breastfed. Overall, at the end of two years, adverse events among HIV-uninfected infants were similar in both groups. Formula-fed infants had a significantly increased risk of diarrhoea and acute respiratory illnesses, while short-term breastfed infants tended to have a higher incidence of malnutrition. However, at two-year follow-up, the risk of hospitalisation and of mortality did not differ between the two feeding groups. In addition, when both groups of infants were compared to a historical cohort in which breastfeeding was prolonged, excellent two-year survival was found among HIV-uninfected children regardless of whether they breastfed long-term (95%) or breastfed for four months or never breastfed (96%). ‘‘Given appropriate nutritional counselling and care, access to clean water and a supply of breastmilk substitutes, these alternatives to prolonged breastfeeding can be safe interventions to prevent mother-to-child transmission of HIV in urban African settings.’’1 1. Becquet R, Bequet L, Ekouevi DK, et al. Two-year morbidity–mortality and alternatives to prolonged breast-feeding among children born to HIV-infected mothers in Coˆte d’Ivoire. PLoS Med 2007;4: e17–doi:10.1371/journal.pmed.0040017 doi. At: bhttp:// medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371%2Fjournal.pmed.0040030N. Accessed 29 January 2007.
Impact of HIV and highly active antiretroviral therapy on menstruation 1,635 HIV positive women and 595 HIV negative women in several US cities were recruited
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into a multicentre prospective cohort study to find out whether HIV and highly active antiretroviral therapy (HAART) increased the risk of changes in the menstrual cycle. The study ran from 1992 to 2002 and included interviews, medical tests and pelvic examinations every six months. The researchers focused on the following menstrual problems – amenorrhoea, oligomenorhoea, intermenstrual bleeding and menorrhagia. Prolonged use of HAART and higher CD4+ cell counts were both associated with a reduced risk of menstrual problems, due to the women’s better overall health. In general HIV positive women are not at increased risk of serious problems though severely ill HIV positive women with lower CD4+ cell counts may be at heightened risk of abnormal menstrual cycles.1 1. Massad LS, Evans CL, Minkoff H et al. Effects of HIV infection and its treatment on self-reported menstrual abnormalities in women. Journal of Women’s Health 2006;15(5):591–98.
Reduced fertility among HIV-positive women with high viral load, Uganda This study assessed whether HIV-1 viral load affects the likelihood of live birth among HIVpositive women in a nested case–control study of HIV positive women from a community cohort in Rakai District, Uganda. Cases were women who had a live birth (n=270), and controls were sexually active women who did not use contraception and did not become pregnant during follow-up (n=263). The data suggest that there may be considerable differences in the ability to produce a live birth among HIV positive women with high viral loads.1 1. Nguyen RHN, Gange SJ, Wabwire-Mangen F, et al. Reduced fertility among HIV-infected women associated with viral load in Rakai district, Uganda. International Journal of STD & AIDS 2006;17(12): 842–6.
Sexual dysfunction in men and women living with HIV: UK Men living with HIV who are on successful antiretroviral treatment expect to lead full lives, including in their sex lives, but may experience sexual dysfunction. This was a retrospective
study in 190 consecutive HIV positive men attending a sexual dysfunction service in an HIV clinic in London, UK. Men with sexual dysfunction commonly reported recreational drug use, co-infection with hepatitis B and C, anxiety and depressive illnesses, peripheral neuropathy and lipodystrophy. There was a significant relationship between complaints of retarded ejaculation and peripheral neuropathy. Sexual dysfunction related to use of medication in non-HIV settings is known to lead to poor adherence and may affect antiretroviral adherence if not addressed.1 Retrospective analysis of clinic notes of women with HIV attending the same HIV clinic in London found that about half the clinic’s cohort reported sexual problems, most commonly from contextual causes, or were not satisfied with sex in the preceding 12 months. A survey by letter of HIV clinical centres in the UK found that 60% had rarely or never asked women patients with HIV about sexual functioning.2 1. Richardson D, Lamba H, Goldmeier D, et al. Factors associated with sexual dysfunction in men with HIV infection [abstract]. International Journal of STD & AIDS 2006;17(11):764–67. 2. Bell C, Richardson D, Wall M, et al. HIV-associated female sexual dysfunction: clinical experience and literature review [abstract]. International Journal of STD & AIDS 2006;17(10):706-09.
Recurrence of cervical intraepithelial neoplasia in HIV-positive women A literature search of Medline and the Cochrane libraries found 15 articles on the rate of recurrence of cervical intraepithelial neoplasia (CIN) in HIV-positive women after excision of affected tissue and a margin of normal tissue. Of these 15 articles, five reported a recurrence rate of CIN in margin-negative patients ranging from 20–75%. This evidence suggests that standard excision for CIN in HIV positive women needs to be reconsidered to try to reduce recurrence rates and prevent invasive cervical cancer developing.1 1. Tebeu PM, Major AL, Mhawech P, et al. The recurrence of cervical intraepithelial neoplasia in HIV-positive women: a review of the literature [abstract]. International Journal of STD & AIDS 2006;17(8):507–11.
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Sexual networking patterns and HIV risk in four provinces of Viet Nam This is a study of patterns and determinants of HIV prevalence and risk behaviour characteristics in four population groups – female sex workers (n=2023), injecting drug users (n=1391), unmarried men aged 15–24 (n=1885) and different categories of mobile groups (n=1923) in four border provinces of Viet Nam during April–June 2002. Marked geographical contrasts in HIV prevalence were found, particularly among female sex workers (range 0–24%). HIV prevalence among injecting drug users varied at high levels in all provinces (range 4–36%), whereas lower prevalences were found among both unmarried young men (range 0–1.3%) and mobile groups (range 0–2.5%). All groups reported sex with female sex workers. Less than 40% of the female sex workers had used condoms consistently. An Giang province, which borders Cambodia, was the only province with high HIV rates among female sex workers. Sex with female sex workers and other non-regular sex partners appeared to be associated strongly with HIV infection among injecting drug users there (see Figure 1, reproduced from the article).
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The strongest determinants of HIV infection among female sex workers were inconsistent condom use, history of injecting drug use and mobility, and among injecting drug users, sharing of injection equipment and sex with nonregular partners. HIV among injecting drug users can contribute to more generalised HIV spread in many settings. However, the effects of interventions to reduce sexual risk behaviour among injecting drug users have generally been modest. The study documents that in most places a substantial proportion of young unmarried men have multiple sex partners and low levels of consistent condom use. Documentation of risk behaviours among adult men is still limited.1 1. Nguyen AT, Fylkesnes K, Bui DT, et al. Human immunodeficiency virus (HIV) infection patterns and risk behaviours in different population groups and provinces in Viet Nam. Bulletin of World Health Organization 2007;85(1):35–41.
Brothel-based sexual health clinic for sex workers: South Africa Conventional health services often present barriers to sex workers seeking health care; sex
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workers fear that they will be refused services and may experience public humiliation by health workers. Brothel-based clinical services were established to provide sex workers in a suburb of Johannesburg, South Africa, with good quality sexual health services and HIV/ AIDS education and counselling, and treat STIs and other reproductive health problems. In a survey in that same neighbourhood in 1997, 45% of 247 sex workers had tested positive for HIV. The clinic services had a positive impact on perceptions of health and the need to prevent disease. The information sessions provided by the nurses also had a positive effect on condom use, and female condom use was successfully introduced. Brothel managers were supportive of the initiative due to improved health-seeking behaviour and the increased popularity of those brothels that were visited by the clinic. Applying this model more broadly, the National Roads Agency in South Africa, made up of truck-driver trade union and business interests, has collaborated with the national Department of Health to implement the ‘‘Trucking against AIDS’’ programme. Several permanent and temporary clinics were set up on major trucking routes to providing truckers with quality sexual health care services. Sex workers who base themselves at truck stops have started to utilise these clinics as well.1 1. Stadler J, Delany S. The ‘healthy brothel’: the context of clinical services for sex workers in Hillbrow, South Africa. Culture, Health & Sexuality 2006;8(5):451–63.
Sexual health of people with HIV: new UK STI guidelines There is a recognised synergy between STIs and HIV that may enhance transmission of both, and evidence that improved STI control, e.g. periodic presumptive treatment as well as syndromic management in sex workers,1 reduces HIV spread. Non-disclosure of HIV status is frequent and more common in casual and non-exclusive sexual relationships. In a UK community study of HIV positive gay men, 24% reported unprotected anal intercourse with more than one partner and 29% with partners of unknown or discordant HIV status in the previous year, while 41% reported an STI in the previous year. Celebration of unprotected sex by men who have sex with men
is becoming more vocal and ‘‘positive-only’’ sex venues have been created. HIV prevention campaigns have previously focused on those who are not known to have HIV even though people with HIV may not adopt or maintain safer sex practices. Now, sexual health care and positive prevention are being incorporated into HIV clinical care. These guidelines recommend that syphilis testing become a routine blood test and that a formal sexual health assessment (including annual cytology in women) and other appropriate tests be offered within a month of HIV diagnosis and at six-monthly intervals to patients under regular follow-up. Contact tracing and notification needs to consider both STIs and HIV. In people with HIV with significant immunosuppression, management of syphilis, genital herpes, genital warts and genital human papillomavirus may different significantly from that for other patients.2 1. See, for example, Vickerman P, Terris-Prestholt F, Delany S, et al. Are targeted HIV prevention activities cost-effective in high prevalence settings? Results from a STI treatment project for sex workers in Johannesburg, South Africa. Sexually Transmitted Diseases 2006;33(10/Supplement):S122–S132. 2. Nandwani R. 2006 UK National Guidelines on the Sexual Health of People with HIV: Sexually Transmitted Infections. International Journal of STD & AIDS 2006;17(9):594–606.
Partner violence and HIV risk behaviour among young men: South Africa Interviews with 1,275 sexually experienced young men aged 15–26 from 70 villages in the rural Eastern Cape, South Africa, found that 31.8% reported physical or sexual violence against female main partners. Violence was correlated with higher numbers of partners in the previous year and of lifetime sexual partners, substance abuse, sexual assault of non-partners and transactional sex. Men who reported violence also reported significantly higher levels of HIV risk behaviour. Interventions for HIV prevention must therefore explicitly address intimate partner violence.1 1. Dunkle KL, Jewkes RK, Nduna M, et al. Perpetration of partner violence and HIV risk behaviour among young men in rural Eastern Cape, South Africa. AIDS 2006;20(16):2107–14.
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Partner reduction vital in fight against HIV This commentary argues that it is time to call an armistice in the battle between condom promotion and abstinence for HIV prevention. Abstinence messages alone are not effective. However, condoms do not provide a total solution. Research from Kenya indicates that declining HIV incidence since the early to mid-1990s was accompanied by a substantial drop in multiple partners among men, reported in three Demographic and Health Surveys between 1993 and 2003. Thus, despite the reticence of health professionals to address sexual behaviour, the fear of AIDS means that many people are open to considering having fewer partners. Correct and consistent condom use should be promoted for self-protection, and discussion of abstinence, secondary abstinence or longer spacing between partners can all provide opportunities to promote self-efficacy, fidelity and partner limitation. New technologies such as male circumcision, vaccines, microbicides and antiretrovirals all have the potential to increase disinhibition and related risk-taking if they are not accompanied by an understanding that partner limitation is key to reversing generalised HIV epidemics.1 1. Shelton JD. Confessions of a condom lover. Lancet 2006;368:1947–49.
Improving contraceptive delivery to women with HIV: Kenya 319 pregnant women with HIV participating in a perinatal HIV transmission study were referred to local clinics for contraceptive counselling and management and followed prospectively. Median time to sexual activity post-partum was two months. 72% (231) initiated hormonal contraceptive use at about three months post-partum (range 1–11 months) and used it for at least two months during follow-up. This included 44% Depo Provera, 31% oral contraception and 25% who switched methods during follow-up. Partner notification, infant mortality and condom use were similar between contraceptive users and non-users.1 1. Balkus J, Bosire R, John-Stewart G, et al. High uptake of postpartum hormonal contraception among HIV-1 seropositive women in Kenya [abstract]. Sexually Transmitted Diseases 2007;34(1):25–29.
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Hormonal contraception and risk of HIV acquisition: Uganda and Zimbabwe This study among 6,109 HIV-negative women recruited from family planning clinics who were using either Depo Provera or combined oral contraception in Uganda and Zimbabwe tested the women quarterly for HIV over 15–24 months. 213 women became HIV positive during the study. Neither hormonal contraceptive method was associated with risk of HIV acquisition overall, including among women with cervical or vaginal infections.1 1. Morrison CS, Richardson BA, Mmiro F, et al for the Hormonal Contraception and the Risk of HIV Acquisition Study Group. Hormonal contraception and the risk of HIV acquisition [abstract]. AIDS 2007;21(1):85–95.
Treatment of herpes simplex virus reduces genital shedding of HIV Epidemiologic and biologic data support a strong association between herpes simplex virus type 2 (HSV-2) and infection with human immunodeficiency virus type 1 (HIV-1). A recent metaanalysis of prospective observational studies showed that patients who were seropositive for HSV-2 had three times the risk of acquiring HIV-1, as compared with those who were seronegative for HSV-2. A randomised, double-blind, placebo-controlled trial was conducted of HSV suppressive therapy with valacyclovir (at a dose of 500 mg twice daily) in Burkina Faso among women who were seropositive for HIV-1 and HSV-2. All of them were ineligible for highly active antiretroviral therapy. The women were followed for 24 weeks (12 weeks before and 12 weeks after randomisation). A total of 140 women were randomly assigned to treatment groups; 136 were included in the analyses. Daily treatment with valacyclovir for three months significantly diminished the shedding of HIV-1 RNA, reduced plasma HIV-1 RNA levels, and reduced genital HIV-1 RNA levels when shedding was present in women dually infected with HIV-1 and HSV-2. This effect steadily increased over time, which suggested that a longer duration of treatment might have led to an even greater reduction in HIV-1 RNA levels. These findings should be verified through clinical trials of longer duration. Although our trial had no HIV clinical
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outcomes, its results may be relevant to HIV-1 prevention and management.1 1. Nagot N, Oue´draogo A, Foulongne V, et al. Reduction of HIV-1 RNA levels with therapy to suppress herpes simplex virus. New England Journal of Medicine 2007;356(8):790–99.
HIV/STI prevention for men who have sex with men, Kenya The stigmatisation and denial of homosexual behaviour in Africa can mean that vulnerable populations are overlooked in HIV/STI prevention programmes. Researchers sought to understand the extent to which men who have sex with men in Kenya are at risk of HIV and other STIs, identify the factors associated with risk behaviours and determine their sexual health needs in order to develop appropriate interventions. They began by gathering quantative data from 500 men in Nairobi over age 18 who have had sexual intercourse with one or more male partners. A sample of these men and those who interact with them participated in in-depth interviews and observation was carried out in social settings where the men meet. The men were identified through snowball sampling. They came from diverse socio-economic backgrounds, many had also had sex with a woman and many remain sexually active with a woman. 23% identified themselves as bisexual. 63% of respondents reported stigma and discrimination to be a major problem in their lives, with many – especially sex workers – reporting an incident of stigma and violence in the previous year. Knowledge of condoms for protection against HIV/STIs was high, though condom use varied, with those reporting a single partner and those who had experienced violence in the previous 12 months least likely to use condoms. Most of the survey sample used oil-based lubricants and were unaware of the damage these can cause to condoms. Half of respondents had ever had an STI and this was significantly more likely for those practising oral sex. 57% had taken an HIV test (compared to 27% of all men in the Nairobi area). Confidentiality was a major concern for those seeking treatment, and the stigma around sex between men means that even where
symptoms are obviously linked to sexual behaviour, health providers, even in HIV testing and STI services, are not discussing this explicitly with their patients or with fellow health providers. Peer education also has an important role in disseminating information about multiple partners, unprotected sex and incorrect use of lubrication and empowering and supporting this vulnerable population to adopt HIV/STI protective behaviours.1 1. Understanding the HIV/STI prevention needs of men who have sex with men in Kenya [Research summary]. Population Council/Horizons. Available at: bwww. popcouncil.org/pdfs/horizons/msmkenya.pdfN.
Cellulose sulfate microbicide trial stopped A Phase III study of the candidate microbicide cellulose sulfate to prevent HIV transmission in women has been stopped prematurely because of a high number of HIV infections in the active as compared with the placebo group. This is a disappointing and unexpected setback in the search for a safe and effective microbicide that can be used by women for protection against HIV infection. Cellulose sulfate was one of four compounds being evaluated in large-scale studies of effectiveness among women at high risk of HIV infection. The Carraguard study is nearing completion in three sites in South Africa, with results expected by the end of 2007. PRO2000 is being tested in one study with five sites and another with seven sites, all in southern African countries, with results expected in 2009 and 2008 respectively. In the second study BufferGel, a vaginal defence enhancer, is also being tested. All the other products mentioned are called HIV entry inhibitors and block HIV infection. There is as yet no explanation as to why cellulose sulfate was associated with a higher risk of HIV infection than the placebo. A statement from CONRAD, who conducted the cellulose sulfate trial, can be found at bwww. conrad.orgN.1 1. Excerpted from a statement by the World Health Organization and UNAIDS, 31 January 2007. Full text at: bwww.who.int/mediacentre/news/ statements/2007N.
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