PrEP as a feature in the optimal landscape of combination HIV prevention in sub-Saharan Africa

INTRODUCTION: The new WHO guidelines recommend offering pre-exposure prophylaxis (PrEP) to people who are at substantial risk of HIV infection. However, where PrEP should be prioritised, and for which population groups, remains an open question. The HIV landscape in sub-Saharan Africa features limited prevention resources, multiple options for achieving cost saving, and epidemic heterogeneity. This paper examines what role PrEP should play in optimal prevention in this complex and dynamic landscape. METHODS: We use a model that was previously developed to capture subnational HIV transmission in sub-Saharan Africa. With this model, we can consider how prevention funds could be distributed across and within countries throughout sub-Saharan Africa to enable optimal HIV prevention (that is, avert the greatest number of infections for the lowest cost). Here, we focus on PrEP to elucidate where, and to whom, it would optimally be offered in portfolios of interventions (alongside voluntary medical male circumcision, treatment as prevention, and behaviour change communication). Over a range of continental expenditure levels, we use our model to explore prevention patterns that incorporate PrEP, exclude PrEP, or implement PrEP according to a fixed incidence threshold. RESULTS: At low-to-moderate levels of total prevention expenditure, we find that the optimal intervention portfolios would include PrEP in only a few regions and primarily for female sex workers (FSW). Prioritisation of PrEP would expand with increasing total expenditure, such that the optimal prevention portfolios would offer PrEP in more subnational regions and increasingly for men who have sex with men (MSM) and the lower incidence general population. The marginal benefit of including PrEP among the available interventions increases with overall expenditure by up to 14% (relative to excluding PrEP). The minimum baseline incidence for the optimal offer of PrEP declines for all population groups as expenditure increases. We find that using a fixed incidence benchmark to guide PrEP decisions would incur considerable losses in impact (up to 7%) compared with an approach that uses PrEP more flexibly in light of prevailing budget conditions. CONCLUSIONS: Our findings suggest that, for an optimal distribution of prevention resources, choices of whether to implement PrEP in subnational regions should depend on the scope for impact of other possible interventions, local incidence in population groups, and total resources available. If prevention funding were to become restricted in the future, it may be suboptimal to use PrEP according to a fixed incidence benchmark, and other prevention modalities may be more cost-effective. In contrast, expansions in funding could permit PrEP to be used to its full potential in epidemiologically driven prevention portfolios and thereby enable a more cost-effective HIV response across Africa

Access to antiretroviral therapy and survival in eastern Europe and central Asia: a case study in Armenia

INTRODUCTION: Antiretroviral therapy (ART) substantially improves the health of people living with HIV and contributes to preventing new infections. While HIV incidence is decreasing in most regions, the epidemic in eastern Europe continues to rise, as new infections currently outnumber the rate of ART initiation. In this study, we assess ART use in Armenia and its impact on the number of AIDS diagnoses and mortality. METHODS: National surveillance data were obtained from the National Centre for AIDS Prevention, Armenia. Cox-proportional hazard models were used to determine the effect of demographic and clinical risk factors, including access to ART, on AIDS and mortality. RESULTS: Among people diagnosed with HIV since 2005, approximately 40% per year were diagnosed with CD4<200 cells per mL. Overall, 232 people (57.1%) with AIDS or a low CD4 count had not received ART by the end of 2010. Mortality was 34.1% among people living with HIV who did not initiate ART, and 0.3% among people who received ART. Among people diagnosed with HIV from 1996 to 2010, age at diagnosis, no use of ART, likely mode of transmission, likely place of transmission, low baseline CD4 count and no STI diagnosis at last contact are significantly associated with death. DISCUSSION: In Armenia, HIV is frequently diagnosed at a late stage of disease, indicating low testing rates. Of people diagnosed with HIV and in need of ART, a large proportion (approximately 60%) either do not provide consent for treatment, or are who migrants who cannot be located. CONCLUSIONS: Globally, the scale-up of ART has resulted in substantial reductions in mortality among individuals initiating therapy. However, in an era of momentum for treatment as prevention, treatment levels are not at adequate levels for preventing morbidities and mortality in some settings. Particular focus should be placed on key at-risk subgroups.Kylie‐Ann Mallitt, Samvel R Grigoryan, Arshak S Papoyan, Handan C Wand, David P Wilso

Twenty Years after Beijing: Can Promises be Turned into Progress?

Twenty years since the landmark women's conference at Beijing, and as the post?2015 agenda is concluded, it is clear that there has been a significant increase in rhetoric from governments and even some notable achievements in the field of women's equality and rights. But a failure to tackle underlying causes – particularly the persistent unequal power relations between women and men – has thwarted real, sustainable progress. A report by the Gender and Development Network has identified four areas in need of far greater political focus and resources: working with marginalised women to build their own agency; supporting women's collective action; promoting positive social norms; and reassessing macroeconomic policies and the role of the care economy

Multiple sex partner behavior in female undergraduate students in China: A multi-campus survey

<p>Abstract</p> <p>Background</p> <p>China is realizing increases in women engaged in premarital sex and multiple sex partner behavior. Our aim was to examine prevalence and determinants of multiple sex partner behavior among female undergraduates in China.</p> <p>Methods</p> <p>Anonymously completed questionnaires were received from 4,769 unmarried female undergraduates, recruited using randomized cluster sampling by type of university and students' major and grade. Items captured demographic, family, peer and work influence, and student factors (major, academic performance, and sex-related knowledge and attitudes). To examine risk factors for sexual behaviors, we used multi-level logistic regression, yielding odds ratios (OR) and 95% confidence intervals (95% CI).</p> <p>Results</p> <p>Of 4,769 female students, 863 (18.10%) reported ever having sexual intercourse, and 5.31% reported having multiple sex partners (29.32% of all women having sexual intercourse). Several demographic, family, peer and work influences, and student factors (including major, performance, knowledge, and attitude toward sex) were risk factors for ever having sex. However, risk factors for multiple sex partners only included working in a place of entertainment, having current close friends that were living with boyfriends, poor academic performance, and positive attitudes toward multiple partners. These women also were more likely to practice masturbation, start having sex at a younger age, have sex with married men and/or men not their "boyfriends" at first coitus, and not use condoms consistently.</p> <p>Conclusion</p> <p>A small but important subset of Chinese female undergraduates is engaged in unprotected sex with multiple sex partners. Interventions need to target at risk women, stressing the importance of consistent condom use.</p

Perspectives on Intergenerational Vulnerability for Adolescents Affected by HIV: An Argument for Voice and Visibility

The authors address the dynamic role of adolescents affected by HIV and AIDS. They analyse evidence for how intergenerational dynamics interact with HIV?related vulnerability, through the likely influence of being AIDS?affected on vulnerability to HIV infection, and through intergenerational reproductions of structural disadvantages and social determinants of HIV vulnerability. They review evidence of AIDS' impacts on children and of contextual influences on their vulnerability to infection, linked to orphaning, inequality and lack of education. They point to the paucity of longitudinal research into this area and challenges in uncovering structural determinants of vulnerability. Pressure for generalised ‘hard’ evidence in global policy fails to capture context?specific dynamics. Focus shifts from the notion of children as passive ‘objects’ of study to one that includes ‘agency’ as central to adolescents maturing and interacting with multiple challenges. The authors argue for new approaches to research and policy, giving children voice and visibility in these debates

Sexual attitudes, pattern of communication, and sexual behavior among unmarried out-of-school youth in China

<p>Abstract</p> <p>Background</p> <p>In recent years, more adolescents are engaging in premarital sex in China. However, only a limited number of studies have explored out-of-school youth's sexual attitudes and behaviors, critical for prevention intervention development.</p> <p>Methods</p> <p>Using data from the baseline survey of a comprehensive sex education program that was conducted in a suburb of Shanghai in 2000–2002, this study describes sexual attitudes, patterns of communication on sexual matters, and premarital sexual behavior among 1,304 out-of-school youth. Multivariate logistic regression analysis was conducted to examine the factors associated with youth's premarital sexual intercourse.</p> <p>Results</p> <p>The majority (60%) of out-of-school youth held favorable attitudes towards premarital sex. Males were more likely to have favorable attitudes compared with females. Male youth generally did not communicate with either parent about sex, while one-third of female youth talked to their mothers about sexual matters. Both males and females chose their friends as the person with whom they were most likely to talk about sexual matters. About 18% of the youth reported having engaged in sexual intercourse. One-fifth of sexually active youth had always used a contraceptive method, and one-quarter had been pregnant (or had impregnated a partner). There were no gender differences in rate of premarital sex or frequency of contraceptive use. Multivariate analysis revealed that age, education, family structure, parent's discipline, attitudes towards premarital sex, pattern of communication and dating were significantly associated with youth premarital sex.</p> <p>Conclusion</p> <p>A substantial proportion of out-of-school youth engage in risky sexual behaviors. Prevention programs that empower communication and sexual negotiation skills, and promote condom use should be implemented for this vulnerable group.</p

Women experience a better long-term immune recovery and a better survival on HAART in Lao People's Democratic Republic.

<p>Abstract</p> <p>Background</p> <p>In April 2003, Médecins Sans Frontières launched an HIV/AIDS programme to provide free HAART to HIV-infected patients in Laos. Although HIV prevalence is estimated as low in this country, it has been increasing in the last years. This work reports the first results of an observational cohort study and it aims to identify the principal determinants of the CD4 cells evolution and to assess mortality among patients on HAART.</p> <p>Methods</p> <p>We performed a retrospective database analysis on patients initiated on HAART between 2003 and 2009 (CD4<200cells/μL or WHO stage 4). We excluded from the analysis patients who were less than 16 years old and pregnant women. To explore the determinants of the CD4 reconstitution, a linear mixed model was adjusted. To identify typical trajectories of the CD4 cells, a latent trajectory analysis was carried out. Finally, a Cox proportional-hazards model was used to reveal predictors of mortality on HAART including appointment delay greater than 1 day.</p> <p>Results</p> <p>A total of 1365 patients entered the programme and 913 (66.9%) received an HAART with a median CD4 of 49 cells/μL [IQR 15–148]. High baseline CD4 cell count and female gender were associated with a higher CD4 level over time. In addition, this gender difference increased over time. Two typical latent CD4 trajectories were revealed showing that 31% of women against 22% of men followed a high CD4 trajectory. In the long-term, women were more likely to attend appointments without delay. Mortality reached 6.2% (95% CI 4.8-8.0%) at 4 months and 9.1% (95% CI 7.3-11.3%) at 1 year. Female gender (HR=0.17, 95% CI 0.07-0.44) and high CD4 trajectory (HR=0.19, 95% CI 0.08-0.47) were independently associated with a lower death rate.</p> <p>Conclusions</p> <p>Patients who initiated HAART were severely immunocompromised yielding to a high early mortality. In the long-term on HAART, women achieved a better CD4 cells reconstitution than men and were less likely to die. This study highlights important differences between men and women regarding response to HAART and medical care, and questions men’s compliance to treatment.</p