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1.  The Role of Viral Introductions in Sustaining Community-Based HIV Epidemics in Rural Uganda: Evidence from Spatial Clustering, Phylogenetics, and Egocentric Transmission Models 
PLoS Medicine  2014;11(3):e1001610.
Using different approaches to investigate HIV transmission patterns, Justin Lessler and colleagues find that extra-community HIV introductions are frequent and likely play a role in sustaining the epidemic in the Rakai community.
Please see later in the article for the Editors' Summary
Background
It is often assumed that local sexual networks play a dominant role in HIV spread in sub-Saharan Africa. The aim of this study was to determine the extent to which continued HIV transmission in rural communities—home to two-thirds of the African population—is driven by intra-community sexual networks versus viral introductions from outside of communities.
Methods and Findings
We analyzed the spatial dynamics of HIV transmission in rural Rakai District, Uganda, using data from a cohort of 14,594 individuals within 46 communities. We applied spatial clustering statistics, viral phylogenetics, and probabilistic transmission models to quantify the relative contribution of viral introductions into communities versus community- and household-based transmission to HIV incidence. Individuals living in households with HIV-incident (n = 189) or HIV-prevalent (n = 1,597) persons were 3.2 (95% CI: 2.7–3.7) times more likely to be HIV infected themselves compared to the population in general, but spatial clustering outside of households was relatively weak and was confined to distances <500 m. Phylogenetic analyses of gag and env genes suggest that chains of transmission frequently cross community boundaries. A total of 95 phylogenetic clusters were identified, of which 44% (42/95) were two individuals sharing a household. Among the remaining clusters, 72% (38/53) crossed community boundaries. Using the locations of self-reported sexual partners, we estimate that 39% (95% CI: 34%–42%) of new viral transmissions occur within stable household partnerships, and that among those infected by extra-household sexual partners, 62% (95% CI: 55%–70%) are infected by sexual partners from outside their community. These results rely on the representativeness of the sample and the quality of self-reported partnership data and may not reflect HIV transmission patterns outside of Rakai.
Conclusions
Our findings suggest that HIV introductions into communities are common and account for a significant proportion of new HIV infections acquired outside of households in rural Uganda, though the extent to which this is true elsewhere in Africa remains unknown. Our results also suggest that HIV prevention efforts should be implemented at spatial scales broader than the community and should target key populations likely responsible for introductions into communities.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
About 35 million people (25 million of whom live in sub-Saharan Africa) are currently infected with HIV, the virus that causes AIDS, and about 2.3 million people become newly infected every year. HIV destroys immune system cells, leaving infected individuals susceptible to other infections. HIV infection can be controlled by taking antiretroviral drugs (antiretroviral therapy, or ART) daily throughout life. Although originally available only to people living in wealthy countries, recent political efforts mean that 9.7 million people in low- and middle-income countries now have access to ART. However, ART does not cure HIV infection, so prevention of viral transmission remains extremely important. Because HIV is usually transmitted through unprotected sex with an infected partner, individuals can reduce their risk of infection by abstaining from sex, by having one or a few partners, and by using condoms. Male circumcision also reduces HIV transmission. In addition to reducing illness and death among HIV-positive people, ART also reduces HIV transmission.
Why Was This Study Done?
Effective HIV control requires an understanding of how HIV spreads through sexual networks. These networks include sexual partnerships between individuals in households, between community members in different households, and between individuals from different communities. Local sexual networks (household and intra-community sexual partnerships) are sometimes assumed to be the dominant driving force in HIV spread in sub-Saharan Africa, but are viral introductions from sexual partnerships with individuals outside the community also important? This question needs answering because the effectiveness of interventions such as ART as prevention partly depends on how many new infections in an intervention area are attributable to infection from partners residing in that area and how many are attributable to infection from partners living elsewhere. Here, the researchers use three analytical methods—spatial clustering statistics, viral phylogenetics, and egocentric transmission modeling—to ask whether HIV transmission in rural Uganda is driven predominantly by intra-community sexual networks. Spatial clustering analysis uses the geographical coordinates of households to measure the tendency of HIV-infected people to cluster spatially at scales consistent with community transmission. Viral phylogenetic analysis examines the genetic relatedness of viruses; if transmission is through local networks, viruses in newly infected individuals should more closely resemble viruses in other community members than those in people outside the community. Egocentric transmission modelling uses information on the locations of recent sexual partners to estimate the proportions of new transmissions from household, intra-community, and extra-community partners.
What Did the Researchers Do and Find?
The researchers applied their three analytical methods to data collected from 14,594 individuals living in 46 communities (governmental administrative units) in Rakai District, Uganda. Spatial clustering analysis indicated that individuals who lived in households with individuals with incident HIV (newly diagnosed) or prevalent HIV (previously diagnosed) were 3.2 times more likely than the general population to be HIV-positive themselves. Spatial clustering outside households was relatively weak, however, and was confined to distances of less than half a kilometer. Viral phylogenetic analysis indicated that 44% of phylogenetic clusters (viruses with related genetic sequences found in more than one individual) were within households, but that 40% of clusters crossed community borders. Finally, analysis of the locations of self-reported sexual partners indicated that 39% of new viral transmissions occurred within stable household partnerships, but that among people newly infected by extra-household partners, nearly two-thirds were infected by partners from outside their community.
What Do These Findings Mean?
The results of all three analyses suggest that HIV introductions into communities are frequent and are likely to play an important role in sustaining HIV transmission in the Rakai District. Specifically, within this rural HIV-endemic region (a region where HIV infection is always present), viral introductions combined with intra-household transmission account for the majority of new infections, although community-based sexual networks also play a critical role in HIV transmission. These findings may not be generalizable to the broader Ugandan population or to other regions of Africa, and their accuracy is likely to be limited by the use of self-reported sexual partner data. Nevertheless, these findings indicate that the dynamics of HIV transmission in rural Uganda (and probably elsewhere) are complex. Consequently, to halt the spread of HIV, prevention efforts will need to be implemented at spatial scales broader than individual communities, and key populations that are likely to introduce HIV into communities will need to be targeted.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001610.
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and AIDS in Uganda and on HIV prevention strategies (in English and Spanish)
The UNAIDS Report on the Global AIDS Epidemic 2013 provides up-to-date information about the AIDS epidemic and efforts to halt it
The Center for AIDS Prevention Studies (University of California, San Francisco) has a fact sheet about sexual networks and HIV prevention
Wikipedia provides information on spatial clustering analysis (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
A PLOS Computational Biology Topic Page (a review article that is a published copy of record of a dynamic version of the article as found in Wikipedia) about viral phylodynamics is available
Personal stories about living with HIV/AIDS are available through Avert, NAM/aidsmap, and Healthtalkonline
doi:10.1371/journal.pmed.1001610
PMCID: PMC3942316  PMID: 24595023
2.  Epidemic Impacts of a Community Empowerment Intervention for HIV Prevention among Female Sex Workers in Generalized and Concentrated Epidemics 
PLoS ONE  2014;9(2):e88047.
Introduction
Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented.
Methods
We used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5–65% in Kenya and Ukraine; 10–70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 2012–2016 and, compared to status quo when all interventions are held constant.
Results
Optimistic but feasible coverage (65%–70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size.
Discussion
A community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.
doi:10.1371/journal.pone.0088047
PMCID: PMC3916392  PMID: 24516580
3.  Induced abortion, contraceptive use, and dual protection among female sex workers in Moscow, Russia 
Objective
To describe abortion history and current contraceptive use among female sex workers (FSWs) in Moscow, Russia.
Methods
A clinic-based survey was conducted among 147 FSWs in Moscow during an 8-month period in 2005.
Results
In total, 83 of 143 (58.0%) FSWs reported a history of abortion, with 45 of 143 (31.5%) indicating multiple abortions. Condoms were the primary form of contraception (145/146 [99.3%]); just 17 of 142 (12.0%) FSWs reported using non-barrier modern contraception. All women who reported using a non-barrier modern method also indicated condom use (i.e. dual protection). Non-barrier contraceptive use was associated with inconsistent condom use (odds ratio [OR] 3.10; 95% confidence interval [CI], 1.07–9.02) and multiple abortions (OR 4.71; 95% CI, 1.19–18.62).
Conclusion
The results illustrate substantial risk for unintended pregnancy among FSWs. Further research is needed regarding the dynamics of non-barrier contraception and condom use. Efforts to improve the health and wellbeing of FSWs should include access to safe and effective contraception, in addition to HIV prevention.
doi:10.1016/j.ijgo.2012.07.026
PMCID: PMC3529991  PMID: 23083495
Abortion; Condom use; Contraception; Dual protection; Female sex workers
4.  HIV now: why human rights matter more than ever 
doi:10.7448/IAS.16.1.18968
PMCID: PMC3860328  PMID: 24331755
5.  HIV among men who have sex with men in Malawi: elucidating HIV prevalence and correlates of infection to inform HIV prevention 
Journal of the International AIDS Society  2013;16(4Suppl 3):18742.
Introduction
There are limited data characterizing the burden of HIV among men who have sex with men (MSM) in Malawi. Epidemiologic research and access to HIV prevention, treatment and care services have been traditionally limited in Malawi by criminalization and stigmatization of same-sex practices. To inform the development of a comprehensive HIV prevention intervention for Malawian MSM, we conducted a community-led assessment of HIV prevalence and correlates of infection.
Methods
From April 2011 to March 2012, 338 MSM were enrolled in a cross-sectional study in Blantyre, Malawi. Participants were recruited by respondent-driven sampling methods (RDS), reaching 19 waves. Trained staff administered the socio-behavioural survey and HIV and syphilis voluntary counselling and testing.
Results
Crude HIV and syphilis prevalence estimates were 15.4% (RDS-weighted 12.5%, 95% confidence interval (CI): 7.3–17.8) and 5.3% (RDS-weighted 4.4%, 95% CI: 3.1–7.6), respectively. Ninety per cent (90.4%, unweighted) of HIV infections were reported as being previously undiagnosed. Participants were predominantly gay-identified (60.8%) or bisexually identified (36.3%); 50.7% reported recent concurrent relationships. Approximately half reported consistent condom use (always or almost always) with casual male partners, and proportions were relatively uniform across partner types and genders. The prevalence of perceived and experienced stigma exceeded 20% for almost all variables, 11.4% ever experienced physical violence and 7% were ever raped. Current age >25 years (RDS-weighted adjusted odds ratio (AOR) 3.9, 95% CI: 1.2–12.7), single marital status (RDS-weighted AOR: 0.3; 95% CI: 0.1–0.8) and age of first sex with a man <16 years (RDS-weighted AOR: 4.3, 95% CI: 1.2–15.0) were independently associated with HIV infection.
Conclusions
Results demonstrate that MSM represent an underserved, at-risk population for HIV services in Malawi and merit comprehensive HIV prevention services. Results provide a number of priorities for research and prevention programmes for MSM, including providing access to and encouraging regular confidential HIV testing and counselling, and risk reduction counselling related to anal intercourse. Other targets include the provision of condoms and compatible lubricants, HIV prevention information, and HIV and sexually transmitted infection treatment and adherence support. Addressing multiple levels of HIV risk, including structural factors, may help to ensure that programmes have sufficient coverage to impact this HIV epidemic among MSM.
doi:10.7448/IAS.16.4.18742
PMCID: PMC3852128  PMID: 24321110
HIV; men who have sex with men (MSM); behavioural risks; stigma; Malawi; prevention
6.  A pilot cohort study to assess the feasibility of HIV prevention science research among men who have sex with men in Dakar, Senegal 
Journal of the International AIDS Society  2013;16(4Suppl 3):18753.
Introduction
Men who have sex with men (MSM) are disproportionately burdened by HIV in Senegal, across sub-Saharan Africa and throughout the world. This is driven in part by stigma, and limits health achievements and social capital among these populations. To date, there is a limited understanding of the feasibility of prospective HIV prevention studies among MSM in Senegal, including HIV incidence and cohort retention rates.
Methods
One hundred and nineteen men who reported having anal sex with another man in the past 12 months were randomly selected from a sampling frame of 450 unique members of community groups serving MSM in Dakar. These men were enrolled in a 15-month pilot cohort study implemented by a community-based partner. The study included a structured survey instrument and biological testing for HIV, syphilis and hepatitis B virus at two time points.
Results
Baseline HIV prevalence was 36.0% (43/114), with cumulative HIV prevalence at study end being 47.2% (51/108). The annualized incidence rate was 16% (8/40 at risk for seroconversion over 15 months of follow-up, 95% confidence interval 4.6–27.4%). Thirty-seven men were lost to follow up, including at least four deaths. Men who were able to confide in someone about health, emotional distress and sex were less likely to be HIV positive (OR 0.36, p < 0.05, 95% CI 0.13, 0.97).
Conclusions
High HIV prevalence and incidence, as well as mortality in this young population of Senegalese MSM indicate a public health emergency. Moreover, given the high burden of HIV and rate of incident HIV infections, this population appears to be appropriate for the evaluation of novel HIV prevention, treatment and care approaches. Using a study implemented by community-based organizations, there appears to be feasibility in implementing interventions addressing the multiple levels of HIV risk among MSM in this setting. However, low retention across arms of this pilot intervention, and in the cohort, will need to be addressed for larger-scale efficacy trials to be feasible.
doi:10.7448/IAS.16.4.18753
PMCID: PMC3852354  PMID: 24321115
HIV; socio-economic status; men who have sex with men; Africa; prevention
7.  The HIV epidemic and human rights violations in Brazil 
doi:10.7448/IAS.16.1.18817
PMCID: PMC3827457  PMID: 24225350
8.  The potential uses of preexposure prophylaxis for HIV prevention among people who inject drugs 
Current opinion in HIV and AIDS  2012;7(6):10.1097/COH.0b013e328358e49e.
Purpose of review
Oral preexposure prophylaxis (PrEP) has shown HIV preventive efficacy for several key populations at risk for HIV infection including MSM and heterosexual men and women in HIV serodiscordant relationships. An efficacy trial of daily oral tenofovir among people who inject drugs (IDU) is underway in Thailand.
Recent findings
Although efficacy data is pending, there is emerging biological and public health plausibility data suggesting the utility of PrEP as an effective component of combination HIV prevention for IDU. Drawing from studies characterizing adherence to antiretroviral therapy for IDU, there are a range of scientific and operational considerations for the potential use of PrEP for IDU. We review here the available literature on the potential use of PrEP for IDU, barriers to uptake and adherence, and potential implementation science questions, which could address, and potently increase, the effectiveness of this intervention.
Summary
IDU remain the most underserved population in the HIV response worldwide, and have a marked gap in prevention services, making PrEP a potentially promising addition to the prevention toolkit for people who use drugs and, for those already living with HIV infection, for their spouses and other sexual partners.
doi:10.1097/COH.0b013e328358e49e
PMCID: PMC3819201  PMID: 23076122
HIV; injecting drug user; preexposure prophylaxis; prevention
9.  The Highest Attainable Standard of Evidence (HASTE) for HIV/AIDS Interventions: Toward a Public Health Approach to Defining Evidence 
Public Health Reports  2012;127(6):572-584.
SYNOPSIS
Objectives
Evidence-driven decisions have become a standard for health interventions, policy, and programs. While randomized controlled trials (RCTs) are encouraged for public health interventions, there are limitations with RCTs as the gold standard of evidence for HIV interventions. We developed a novel system of evaluating evidence for assessing HIV preventive interventions termed the Highest Attainable Standard of Evidence (HASTE).
Methods
The HASTE system focuses on triangulation of three distinct categories of evidence: efficacy data, implementation data, and plausibility. We conducted systematic reviews, including experimental and observational data, to assess all available interventions for men who have sex with men (MSM). We collected implementation and programmatic data using a global electronic consultation, Internet searches, and in-person consultations. We assessed plausibility with expert analyses of both biological and public health evidence.
Results
HASTE includes four grades of evidence: Strong (Grade 1), Conditional (Grade 2), Insufficient (Grade 3), and Inappropriate (Grade 4). We used the HASTE system to evaluate the evidence for HIV interventions for MSM in low- and middle-income countries. Several differences emerged in the strength of recommendation with the use of the HASTE system, including strong recommendations for voluntary counseling and testing and for structural interventions.
Conclusions
The HASTE system addresses a need for an evidence evaluation tool that is specific for HIV interventions and facilitates an evaluation of biomedical, behavioral, and structural approaches using the highest standard of attainable evidence. HASTE represents a tool that balances scientific integrity and practicality in assessing the quality of evidence of preventive interventions targeting the most-at-risk populations for HIV.
PMCID: PMC3461350  PMID: 23115382
10.  Global epidemiology of HIV infection in men who have sex with men 
Lancet  2012;380(9839):367-377.
Epidemics of HIV in men who have sex with men (MSM) continue to expand in most countries. We sought to understand the epidemiological drivers of the global epidemic in MSM and why it continues unabated. We did a comprehensive review of available data for HIV prevalence, incidence, risk factors, and the molecular epidemiology of HIV in MSM from 2007 to 2011, and modelled the dynamics of HIV transmission with an agent-based simulation. Our findings show that the high probability of transmission per act through receptive anal intercourse has a central role in explaining the disproportionate disease burden in MSM. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiological data show substantial clustering of HIV infections in MSM networks, and higher rates of dual-variant and multiple-variant HIV infection in MSM than in heterosexual people in the same populations. Prevention strategies that lower biological transmission and acquisition risks, such as approaches based on antiretrovirals, offer promise for controlling the expanding epidemic in MSM, but their potential effectiveness is limited by structural factors that contribute to low health-seeking behaviours in populations of MSM in many parts of the world.
doi:10.1016/S0140-6736(12)60821-6
PMCID: PMC3805037  PMID: 22819660
11.  From personal survival to public health: community leadership by men who have sex with men in the response to HIV 
Lancet  2012;380(9839):400-410.
Community leadership and participation by gay men and men who have sex with men (MSM) have been central to the response to HIV since the beginning of the epidemic. Through a wide array of actions, engagement of MSM has been important in the protection of communities. The connection between personal and community health as drivers of health advocacy continue to be a powerful element. The passion and urgency brought by MSM communities have led to the targeting and expansion of HIV and AIDS research and programming, and have improved the synergy of health and human rights, sustainability, accountability, and health outcomes for all people affected by HIV. MSM are, however, frequently excluded from the evidence-based services that they helped to develop, despite them generally being the most effective actors in challenging environments. Without MSM community involvement, government-run health programmes might have little chance of effectively reaching communities or scaling up interventions to lessen, and ultimately end, the HIV pandemic.
doi:10.1016/S0140-6736(12)60834-4
PMCID: PMC3805044  PMID: 22819662
12.  A call to action for comprehensive HIV services for men who have sex with men 
Lancet  2012;380(9839):424-438.
Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments. Condom and lubricant access for MSM globally is highly cost effective. Antiretroviral-based prevention, and antiretroviral access for MSM globally, would also be cost effective, but would probably require substantial reductions in drug costs in high-income countries to be feasible. To address HIV in MSM will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done.
doi:10.1016/S0140-6736(12)61022-8
PMCID: PMC3805059  PMID: 22819663
13.  Acceptability of Pre-Exposure Prophylaxis among Men Who Have Sex with Men and Transgender Women in Northern Thailand 
PLoS ONE  2013;8(10):e76650.
Background
Northern Thailand has a high burden HIV epidemic among MSM and TG. Oral pre-exposure prophylaxis (PrEP) with tenofovir-emtricitabine has demonstrated efficacy in preventing HIV among MSM and TG in Chiang Mai, Thailand. Determinants of PrEP acceptability are needed to gauge the potential uptake of this prevention strategy.
Methods
From January to February 2012, 238 MSM and TG participants, who self-reported as HIV-uninfected or of unknown status, completed a self-administered survey on hand-held computers. Participants were recruited by venue-day-time sampling and asked to rate their likelihood of using oral PrEP for HIV prevention with an efficacy of 50%. PrEP acceptability was defined as being “very likely” to use PrEP. Odds ratios and 95% CIs were calculated to identify correlates of acceptability.
Results
131 MSM and 107 TG responded, with mean ages of 23.7 and 21.8, respectively. 24% of MSM engaged primarily in receptive anal sex vs. 74% of TG. 21% of MSM and 44% of TG reported regular medication use. Prior awareness of PrEP was high at 66% among both MSM and TG respondents. 41% of MSM and 37% of TG were "very likely" to use PrEP. Among MSM, factors associated with PrEP acceptability included a prior history of STIs (AOR 4.6; 95%CIs 1.7-12.6), previous HIV testing (AOR 2.4 95%CIs 1.1-5.3), regularly planned sex (AOR 2.8 95%CIs 1.1-7.2), and infrequent sex (AOR 2.9 95%CIs 1.3-6.3). Among TG, factors associated with acceptability included prior awareness of PrEP (AOR 3.3; 95%CIs 1.2-9.0) and having private insurance (AOR 5.0; 95%CIs 1.3-19.0).
Conclusion
MSM and TG in Northern Thailand are distinct groups in terms of sexual behaviors, patterns of medication use, and correlates of PrEP acceptability. Efforts to maximize PrEP uptake should include expanded HIV testing services and the provision of financial subsidies to reduce the cost of PrEP.
doi:10.1371/journal.pone.0076650
PMCID: PMC3792988  PMID: 24116132
14.  The Feasibility of HIV Vaccine Efficacy Trials among Russian Injection Drug Users 
Vaccine  2007;25(41):7014-7016.
Summary
IDU exposure remains a primary driver of the Russian HIV epidemic, and recent incidence data provide little evidence that this epidemic is slowing. While there are multiple important challenges that need to be further explored before starting vaccine trials, most importantly access to evidence-based drug treatment services for trial participants, the current context of high HIV incidence and low genetic diversity of HIV strains, suggests the need for intensified prevention strategies and supports the feasibility of mounting efficacy trials of HIV vaccines among IDUs in the Russian Federation.
doi:10.1016/j.vaccine.2007.07.028
PMCID: PMC3747029  PMID: 17707960
HIV; Injection Drug use; St. Petersburg; Molecular Epidemiology; Vaccines
15.  Time to act: a call for comprehensive responses to HIV in people who use drugs 
Lancet  2010;376(9740):551-563.
The published work on HIV in people who use drugs shows that the global burden of HIV infection in this group can be reduced. Concerted action by governments, multilateral organisations, health systems, and individuals could lead to enormous benefits for families, communities, and societies. We review the evidence and identify synergies between biomedical science, public health, and human rights. Cost-effective interventions, including needle and syringe exchange programmes, opioid substitution therapy, and expanded access to HIV treatment and care, are supported on public health and human rights grounds; however, only around 10% of people who use drugs worldwide are being reached, and far too many are imprisoned for minor offences or detained without trial. To change this situation will take commitment, advocacy, and political courage to advance the action agenda. Failure to do so will exacerbate the spread of HIV infection, undermine treatment programmes, and continue to expand prison populations with patients in need of care.
doi:10.1016/S0140-6736(10)60928-2
PMCID: PMC3682471  PMID: 20650515
16.  Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics 
BMC Public Health  2013;13:482.
Background
Social and structural factors are now well accepted as determinants of HIV vulnerabilities. These factors are representative of social, economic, organizational and political inequities. Associated with an improved understanding of multiple levels of HIV risk has been the recognition of the need to implement multi-level HIV prevention strategies. Prevention sciences research and programming aiming to decrease HIV incidence requires epidemiologic studies to collect data on multiple levels of risk to inform combination HIV prevention packages.
Discussion
Proximal individual-level risks, such as sharing injection devices and unprotected penile-vaginal or penile-anal sex, are necessary in mediating HIV acquisition and transmission. However, higher order social and structural-level risks can facilitate or reduce HIV transmission on population levels. Data characterizing these risks is often far more actionable than characterizing individual-level risks. We propose a modified social ecological model (MSEM) to help visualize multi-level domains of HIV infection risks and guide the development of epidemiologic HIV studies. Such a model may inform research in epidemiology and prevention sciences, particularly for key populations including men who have sex with men (MSM), people who inject drugs (PID), and sex workers. The MSEM builds on existing frameworks by examining multi-level risk contexts for HIV infection and situating individual HIV infection risks within wider network, community, and public policy contexts as well as epidemic stage. The utility of the MSEM is demonstrated with case studies of HIV risk among PID and MSM.
Summary
The MSEM is a flexible model for guiding epidemiologic studies among key populations at risk for HIV in diverse sociocultural contexts. Successful HIV prevention strategies for key populations require effective integration of evidence-based biomedical, behavioral, and structural interventions. While the focus of epidemiologic studies has traditionally been on describing individual-level risk factors, the future necessitates comprehensive epidemiologic data characterizing multiple levels of HIV risk.
doi:10.1186/1471-2458-13-482
PMCID: PMC3674938  PMID: 23679953
17.  Injection Drug Use, Sexual Risk, Violence, and STI/HIV among Moscow FSWs 
Sexually transmitted infections  2012;88(4):278-283.
Background/objectives
The HIV prevalence in Eastern Europe and Central Asia continues to increase. While injection drug use (IDU) is leading factor, heterosexual transmission is on the rise. Little is known about female sex workers (FSWs) in the region despite the central role of commercial sex in heterosexual STI/HIV transmission globally. We evaluated the prevalence of STI/HIV among Moscow-based FSWs, and potential risk factors including IDU, sexual risks, and violence victimization.
Methods
Moscow-based FSWs (n=147) completed a clinic-based survey and STI/HIV testing over an eight month period in 2005.
Results
HIV prevalence was 4.8%, and 31.3% were infected with at least one STI including HIV. Sexual behaviors significantly associated with STI/HIV included anal sex (AOR 3.48), high client volume (three or more clients daily, AOR 2.71), recent subbotnik (sex demanded by police; AOR 2.50), and regularly being presented with more clients than initially agreed to (AOR 2.45). Past year experiences of physical violence from clients and threats of violence from pimps were associated with STI/HIV (AOR 3.14; AOR 3.65 respectively). IDU was not significantly associated with STI/HIV. Anal sex and high client volume partially mediated the associations of abuse with STI/HIV.
Conclusion
Findings illustrate substantial potential for heterosexual STI/HIV transmission in a setting better known for IDU-related risk. Many of the STI/HIV risks observed are not modifiable by FSWs alone. STI/HIV prevention efforts for this vulnerable population will benefit from reducing coercion and abuse perpetrated by pimps and clients.
doi:10.1136/sextrans-2011-050171
PMCID: PMC3628729  PMID: 22287530
18.  Immuno-virologic outcomes and immuno-virologic discordance among adults alive and on anti-retroviral therapy at 12 months in Nigeria 
BMC Infectious Diseases  2013;13:113.
Background
Predictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs.
Methods
The HACART study was a multi-center observational clinic-based cohort study of 2585 adults who started HAART between April 2008 and February 2009. A total of 628 patients were randomly selected at 12 months for immuno-virologic analyses.
Results
Virologic suppression rate (<400 copies/ml) was 76.7%, immunologic recovery rate (CD4 change from baseline ≥50 cells/mm3) was 77.4% and immuno-virologic discordance rate was 33%. In multivariate logistic regression, virologic failure was associated with age <30 years (OR 1.79; 95% CI: 1.17-2.67, p=0.03), anemia (Hemoglobin < 10 g/dl) (OR 1.71; 95% CI: 1.22-2.61, p=0.03), poor adherence (OR 3.82; 95% CI: 2.17-5.97, p=0.001), and post-secondary education (OR 0.60; 95% CI: 0.30-0.86, p=0.02). Immunologic failure was associated with male gender (OR 1.46; 95% CI: 1.04-2.45, p=0.04), and age <30 years (OR 1.50; 95% CI: 1.11-2.39, p=0.03). Virologic failure with immunologic success (VL-/CD4+) was associated with anemia (OR 1.80; 95% CI: 1.13-2.88, p=0.03), poor adherence (OR 3.90; 95% CI: 1.92-8.24, p=0.001), and post-secondary education (OR 0.40; 95% CI: 0.22-0.68, p=0.005).
Conclusions
Although favorable immuno-virologic outcomes could be achieved in this large ART program, immuno-virologic discordance was observed in a third of the patients. Focusing on intensified treatment preparation and adherence, young patients, males, persons with low educational status and most importantly baseline anemia assessment and management may help address predictors of poor immuno-virologic outcomes, and improve overall HIV program impact. Viral load testing in addition to the CD4 testing should be considered to identify, characterize and address negative immuno-virologic outcomes and discordance.
doi:10.1186/1471-2334-13-113
PMCID: PMC3599241  PMID: 23452915
Immuno-virologic outcomes; Immuno-virologic discordance; Anemia; Treatment failure; Sub-Saharan Africa; Nigeria; PEPFAR; Anti-retroviral therapy; Viral load testing
19.  Human Rights Research and Ethics Review: Protecting Individuals or Protecting the State? 
PLoS Medicine  2012;9(10):e1001325.
Joseph Amon and colleagues discuss the challenges of conducting human rights research in settings where local research ethics committees may favor the interests of the state over the interests of research participants.
doi:10.1371/journal.pmed.1001325
PMCID: PMC3472977  PMID: 23091422
20.  Molecular surveillance for drug-resistant Plasmodium falciparum in clinical and subclinical populations from three border regions of Burma/Myanmar: cross-sectional data and a systematic review of resistance studies 
Malaria Journal  2012;11:333.
Background
Confirmation of artemisinin-delayed parasite clearance in Plasmodium falciparum along the Thai-Myanmar border has inspired a global response to contain and monitor drug resistance to avert the disastrous consequences of a potential spread to Africa. However, resistance data from Myanmar are sparse, particularly from high-risk areas where limited health services and decades of displacement create conditions for resistance to spread. Subclinical infections may represent an important reservoir for resistance genes that confer a fitness disadvantage relative to wild-type alleles. This study estimates the prevalence of resistance genotypes in three previously unstudied remote populations in Myanmar and tests the a priori hypothesis that resistance gene prevalence would be higher among isolates collected from subclinical infections than isolates collected from febrile clinical patients. A systematic review of resistance studies is provided for context.
Methods
Community health workers in Karen and Kachin States and an area spanning the Indo-Myanmar border collected dried blood spots from 988 febrile clinical patients and 4,591 villagers with subclinical infection participating in routine prevalence surveys. Samples positive for P. falciparum 18 s ribosomal RNA by real-time PCR were genotyped for P. falciparum multidrug resistance protein (pfmdr1) copy number and the pfcrt K76T polymorphism using multiplex real-time PCR.
Results
Pfmdr1 copy number increase and the pfcrt K76 polymorphism were determined for 173 and 269 isolates, respectively. Mean pfmdr1 copy number was 1.2 (range: 0.7 to 3.7). Pfmdr1 copy number increase was present in 17.5%, 9.6% and 11.1% of isolates from Karen and Kachin States and the Indo-Myanmar border, respectively. Pfmdr1 amplification was more prevalent in subclinical isolates (20.3%) than clinical isolates (6.4%, odds ratio 3.7, 95% confidence interval 1.1 - 12.5). Pfcrt K76T prevalence ranged from 90-100%.
Conclusions
Community health workers can contribute to molecular surveillance of drug resistance in remote areas of Myanmar. Marginal and displaced populations under-represented among previous resistance investigations can and should be included in resistance surveillance efforts, particularly once genetic markers of artemisinin-delayed parasite clearance are identified. Subclinical infections may contribute to the epidemiology of drug resistance, but determination of gene amplification from desiccated filter samples requires further validation when DNA concentration is low.
doi:10.1186/1475-2875-11-333
PMCID: PMC3518194  PMID: 22992214
Malaria; Plasmodium falciparum; Artemisinin resistance; Genetic; Subclinical infection; Conflict; Myanmar
21.  Risk Factors for HIV and Unprotected Anal Intercourse among Men Who Have Sex with Men (MSM) in Almaty, Kazakhstan 
PLoS ONE  2012;7(8):e43071.
Introduction
Men who have sex with men (MSM) are at high risk for HIV infection. MSM in Central Asia, however, are not adequately studied to assess their risk of HIV transmission. Methods: This study used respondent driven sampling methods to recruit 400 MSM in Almaty, the largest city in Kazakhstan, into a cross-sectional study. Participation involved a one-time interviewer-administered questionnaire and rapid HIV screening test. Prevalence data were adjusted for respondent network size and recruitment patterns. Multivariate logistic regression was used to investigate the association between HIV and selected risk factors, and unprotected anal intercourse (UAI) and selected risk factors.
Results
After respondent driven sampling (RDS) weighted analysis, 20.2% of MSM were HIV-positive, and 69.0% had unprotected sex with at least one male partner in the last 12 months. Regression analysis showed that HIV infection was associated with unprotected receptive anal sex (AOR: 2.00; 95% CI: 1.04–3.84). Having unprotected anal intercourse with male partners, a measure of HIV risk behaviors, was associated with being single (AOR: 0.38; 95% CI: 0.23–0.64); very difficult access to lubricants (AOR: 11.08; 95% CI: 4.93–24.91); STI symptoms (AOR: 3.45; 95% CI: 1.42–8.40); transactional sex (AOR: 3.21; 95% CI: 1.66–6.22); and non-injection drug use (AOR: 3.10; 95% CI: 1.51–6.36).
Conclusions
This study found a high HIV prevalence among MSM in Almaty, and a population of MSM engaging in multiple high-risk behavior in Almaty. Greater access to HIV education and prevention interventions is needed to limit the HIV epidemic among MSM in Almaty.
doi:10.1371/journal.pone.0043071
PMCID: PMC3427329  PMID: 22937013
22.  Expanding the Space: Inclusion of Most-at-Risk Populations in HIV Prevention, Treatment, and Care Services 
The provision of appropriate HIV prevention, treatment, and care services for most-at-risk populations (MARP) will challenge many health care systems. For people who sell sex (SW) or inject drugs (IDU) and for men who have sex with men (MSM), stigma, discrimination, and criminalization can limit access to care, inhibit service uptake, and reduce the disclosure of risks. Several models for provision of HIV services to MARP may address these issues. We discuss integrated models, stand-alone services, and hybrid models, which may be appropriate for some MARP in some settings. Both public health and human rights frameworks concur that those at greatest risk should have expanded access to services.
doi:10.1097/QAI.0b013e31821db944
PMCID: PMC3164959  PMID: 21857306
most-at-risk populations (MARP); HIV; health systems; stigma; discrimination; models of care
23.  Afterword: Police, policing, and HIV: new partnerships and paradigms 
doi:10.1186/1477-7517-9-32
PMCID: PMC3413548  PMID: 22770379
24.  Human Rights Abuses and Suicidal Ideation among Male Injecting Drug Users in Delhi, India 
Background
Human rights abuses, denial of care, police surveillance, and violence directed at IDUs have been found to impact HIV prevention efforts due to decreased attendance in harm reduction programs. The association of mental health status with rights abuses has not been examined extensively among drug users. In India, drug control laws are often in conflict with harm reduction policies, thus increasing the likelihood of rights abuses against IDUs. The purpose of this study was to describe human rights abuses occurring among IDUs in Delhi and examine their association with suicidal ideation.
Methods
343 IDUs were recruited in two research sites in Delhi through respondent driven sampling and were interviewed with a cross sectional survey questionnaire that included items on human rights and socio demographics.
Results
IDUs in the study experienced many human rights abuses. Notably among these were denial of admission into hospital (38.5%), denial of needles and syringes (20%), police arrests for carrying needles and using drugs (85%), verbal abuse (95%) and physical abuse (88%). Several human rights abuses were associated with suicidal ideation. These include being denied needles and syringes (OR: 7.28, 95% CI: 3.03- 17.49); being arrested by police for carrying needles and using drugs (OR: 2.53, 95% CI: 1.06- 6.03), and being physically abused (OR: 1.66, 95% CI: 1.05- 2.23). The likelihood of suicidal ideation is also strongly related to the cumulative number of abuses.
Conclusions
These findings demonstrate that there is a high prevalence of human rights abuses among IDUs in Delhi. Given the alarming rate of suicidal ideation and its close relationship with human rights abuses it is essential that IDU interventions are executed within a rights-based framework.
doi:10.1016/j.drugpo.2010.09.011
PMCID: PMC3070048  PMID: 21439808
Human rights; IDU; India; Suicide; HIV/AIDS
25.  Engaging Men in Prevention and Care for HIV/AIDS in Africa 
PLoS Medicine  2012;9(2):e1001167.
Ed Mills and colleagues argue that a more balanced approach to gender is needed so that both men and women are involved in HIV treatment and prevention.
doi:10.1371/journal.pmed.1001167
PMCID: PMC3274499  PMID: 22346735

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