Sexually transmitted co-infections increase HIV infectiousness through local inflammatory processes. The prevalence of STI among people living with HIV/AIDS has implications for containing the spread of HIV in general and the effectiveness of HIV treatments for prevention in particular.
A systematic review of studies examining STI co-infections in people living with HIV/AIDS. The review focuses on STI contracted after becoming HIV infected. Electronic database and manual searches located clinical and epidemiological studies of STI that increase HIV infectiousness.
Thirty seven studies of STI-HIV co-infection prevalence were located. Studies of adults living with HIV/AIDS from developed and developing countries reported STI rates for 46 different samples (33 samples had clinical/laboratory confirmed STI). The overall mean point-prevalence for confirmed STI was16.3% (SD = 16.4), and median 12.4% STI prevalence in people living with HIV/AIDS. The most common STI studied were Syphilis with median 9.5% prevalence, gonorrhea 9.5%, Chlamydia 5%, and Trichamoniasis 18.8% prevalence. STI prevalence was greatest at the time of HIV diagnosis, reflecting the role of STI in HIV transmission. Prevalence of STI among individuals receiving HIV treatment was not appreciably different from untreated persons.
The prevalence of STI in people infected with HIV suggests that STI co-infections could undermine efforts to use HIV treatments for prevention by increasing genital secretion infectiousness.
HIV STI co-infection; test and treat; HIV treatment for prevention; sexual health
Controlled studies show that HIV risk reduction counseling significantly increases condom use, reduces unprotected sex and prevents sexually transmitted infections. Nevertheless, without evidence of reducing HIV incidence, these interventions are generally discarded. One trial, the EXPLORE study, was designed to test whether 10 sessions of risk reduction counseling could impact HIV incidence among men who have sex with men in six US cities. Based on epidemiologic models to define effective HIV vaccines, a 35% reduction in HIV incidence was set a priori as the benchmark of success in this behavioral intervention trial. Results demonstrated a significant effect of the intervention, with more than a 35% reduction in HIV incidence observed during the initial 12 to 18 months following counseling. Over an unprecedented 48-month follow-up, however, the effect of counseling on HIV incidence declined to 18%. The current review examined how the scientific literature has thus far judged the outcomes of the EXPLORE study as well as the policy implications of these judgments. We identified 127 articles that cited The EXPLORE Study since its publication. Among articles that discuss the HIV incidence outcomes, 20% judged the intervention effective and 80% judged the intervention ineffective. The overwhelmingly negative interpretation of the EXPLORE study outcomes is reflected in public policies and prevention planning. We conclude that using a vaccine standard to define success led to a broad discrediting of the benefits of behavioral counseling and, ultimately, adversely impacted policies critical to the field of HIV prevention.
Antiretroviral therapies (ART) offer promising new avenues for HIV prevention. Unfortunately, people infected with HIV who have co-occurring sexually transmitted infections (STI) are more infectious than suggested by the amount of virus in their peripheral blood. We examined the history of STI co-infections in people living with HIV.
People living with HIV/AIDS completed confidential computerized interviews that assessed history of STI, sexual behaviors, and STI knowledge.
Among 414 men and 156 women currently receiving ART, 53% had been diagnosed with at least one STI since testing HIV positive; 24% women, 19% men, and 11% transgender persons had been diagnosed with an STI in the past year. History of STI was associated with younger age, greater STI knowledge, substance use, and ART non-adherence.
Aggressive strategies for detecting and treating STI in people receiving ART will be necessary to achieve protective benefits.
Substance use is a known predictor of poor adherence to antiretroviral therapies (ART) in people living with HIV/AIDS. Less studied is the association between substance use and treatment outcomes, namely suppression of HIV replication.
Adults living with HIV (N=183) who reported alcohol use in the previous week and receiving ART were observed over a 12-month period. Participants completed computer interviews, monthly-unannounced pill counts to monitor ART adherence, and daily cell-phone delivered interactive-text assessments for alcohol use. HIV viral load was collected at baseline and 12-month follow-up from medical records. Analyses compared participants who had undetectable HIV viral loads at baseline and follow-up (sustained viral suppression) to those with unsustained viral suppression. Analyses also compared participants who were adherent to their medications (> 85% pills taken) over the year of observation to those who were non-adherent.
Fifty- two percent of participants had unsustained viral suppression; 47% were ART non-adherent. Overall results failed to demonstrate alcohol use as a correlate of sustained viral suppression or treatment adherence. However, alcohol use was associated with non-adherence among participants who did not have sustained viral suppression; non-adherence in unsustained viral suppression patients was related to drinking on fewer days of assessment, missing medications when drinking, and drinking socially.
Poor HIV treatment outcomes and non-adherence were prevalent among adults treated for HIV infection who drink alcohol. Drinking in relation to missed medications and drinking in social settings are targets for interventions among alcohol drinkers at greatest risk for poor treatment outcomes.
The success of antiretroviral therapy (ART) for treating HIV infection is now being turned toward HIV prevention. The Swiss Federal Commission for HIV/AIDS has declared that HIV positive persons who are treated with ART, have an undetectable viral load, and are free of co-occurring sexually transmitted infections (STI) should be considered non-infectious for sexual transmission of HIV. This study examined the implications of these assumptions in a sample of HIV positive individuals who drink alcohol.
People living with HIV/AIDS (N = 228) were recruited through community sampling and completed confidential computerized interviews, monthly unannounced pill counts for ART adherence, and HIV viral load obtained from medical records.
One hundred eighty five HIV positive drinkers were currently receiving ART and 43 were untreated. Among those receiving ART, one in three were not viral suppressed and one in five had recently been diagnosed with an STI. Adherence was generally suboptimal, including among those assumed less infectious. As many as one in four participants reported engaging in unprotected intercourse with an HIV uninfected partner in the past 4-months. There were few associations between assumed infectiousness and sexual practices.
Less than half of people who drink alcohol and take ART met the Swiss criteria for non-infectiousness. Poor adherence and prevalent STI threaten the long-term potential of using ART for prevention. In the absence of behavioral interventions, the realities of substance use and other barriers place doubt on the use of ART as prevention among alcohol drinkers.
Limited health literacy is a known barrier to medication adherence among people living with HIV. Adherence improvement interventions are urgently needed for this vulnerable population.
This study tested the efficacy of a pictograph-guided adherence skills building counseling intervention for limited literacy adults living with HIV.
Men and women living with HIV and receiving antiretroviral therapy (ART, N=446) who scored below 90% correct on a test of functional health literacy were partitioned into marginal and lower literacy groups and randomly allocated to one of three adherence-counseling conditions: (a) pictograph-guided adherence counseling, (b) standard adherence counseling, or (c) general health improvement counseling. Participants were followed for 9-months post-intervention with unannounced pill count adherence and blood plasma viral load as primary endpoints.
Preliminary analyses demonstrated the integrity of the trial and more than 90% of participants were retained. Generalized estimating equations showed significant interactions between counseling conditions and levels of participant health literacy across outcomes. Participants with marginal health literacy in the pictograph-guided and standard-counseling conditions demonstrated greater adherence and undetectable HIV viral loads compared to general health counseling. In contrast and contrary to hypotheses, participants with lower health literacy skills in the general health improvement counseling demonstrated greater adherence compared to the two adherence counseling conditions.
Patients with marginal literacy skills benefit from adherence counseling regardless of pictographic tailoring and patients with lower literacy skills may require more intensive or provider directed interventions.
HIV Treatment; Adherence Intervention; Health Literacy
This study examined the differential patterns of alcohol outcome expectancies in relation to drinking before sex and having sex partners who drink before sex among men (N = 614) and women (N = 158) sexually transmitted infections clinic patients in Cape Town South Africa. Hierarchical regressions, controlling for age, education, and alcohol use showed that men’s sexual enhancement alcohol expectancies were associated with drinking before sex and having sex partners who drank before sex. Behavioral disinhibition expectancies were inversely related to drinking before sex. For women, there were no associations between alcohol expectancies and drinking before sex, although sexual enhancement expectancies were related to having sex partners who drank before sex. We conclude that alcohol outcome expectancies, particularly expectancies that alcohol will enhance sexual experiences, are related to HIV transmission risks. Sexual risk reduction interventions for those at greatest risk for HIV/AIDS should directly address alcohol expectancies.
Alcohol is related to HIV risk behaviors in southern Africa and these behaviors are correlated with sensation seeking personality and alcohol outcome expectancies. Here we report for the first time the associations among sensation seeking, substance use, and sexual risks in a prospective study in Africa. Sexually transmitted infection clinic patients in Cape Town South Africa (157 men and 64 women) completed (a) baseline measures of sensation seeking, sexual enhancement alcohol outcome expectancies, alcohol use in sexual contexts, and unprotected sexual behaviors and (b) 6-month follow-up measures of alcohol use in sexual contexts and unprotected sexual acts. Results confirmed that sensation seeking predicts HIV risk behavior and sensation seeking is related to alcohol outcome expectancies which in turn predict alcohol use in sexual contexts. HIV prevention counseling that addresses drinking in relation to sex is urgently needed in southern Africa.
South Africa has the highest prevalence of HIV in the world. Because living with HIV is stressful and because alcohol consumption is often used to cope with stress, we examined whether stress mediates the association between HIV status and alcohol use among adults residing in South African townships. Field workers approached pedestrians or patrons of informal alcohol-serving venues (i.e., shebeens) and invited their participation in a survey. Of the 1,717 participants (98% Black, 34% women, mean age = 31), 82% were HIV-negative, 9% were HIV-positive, and 9% did not know their test result. Participants living with HIV reported greater perceived life stress compared to participants whose HIV status was negative or unknown. Perceived stress was associated with increased alcohol use (frequency of drinking days, frequency of intoxication, and frequency of drinking in shebeens/taverns). Subsequent analyses showed that stress mediated the association between HIV status and alcohol use. These findings indicate that greater frequency of drinking days, perceived intoxication, and drinking at shebeens was associated with elevated stress levels among participants who were HIV-positive. Perceived life stress mediates the association between HIV status and alcohol use. Programs to enhance stress management among HIV-positive South Africans may help to reduce alcohol consumption which may, in turn, lead to reduced rates of HIV transmission.
alcohol; stress; HIV; South Africa; mediation
Health disparities in access to antiretroviral therapy (ART) as well as the demands of long-term medication adherence have meant the full benefits of HIV treatment are often not realized. In particular, food insecurity has emerged as a robust predictor of ART non-adherence. However, research is limited in determining whether food insecurity uniquely impedes HIV treatment or if food insecurity is merely a marker for poverty that interferes more broadly with treatment. This study examined indicators of poverty at multiple levels in a sample of 364 men and 157 women living with HIV recruited through an offering of a free holiday food basket. Results showed that 61% (N = 321) of participants had experienced at least one indicator of food insecurity in the previous month. Multivariate analyses showed that food insecurity was closely tied to lack of transportation. In addition, food insecurity was associated with lacking access to ART and poor ART adherence after adjusting for neighbourhood poverty, living in an area without a supermarket (food desert), education, stable housing, and reliable transportation. Results therefore affirm previous research that has suggested food insecurity is uniquely associated with poor ART adherence and calls for structural interventions that address basic survival needs among people living with HIV, especially food security.
Southern Africa's catastrophic HIV epidemic is exacerbated by co-occurring sexually transmitted infections (STI). Understanding HIV transmission risks of STI patients who test HIV positive may inform prevention interventions.
To examine behavioral risks and behavior changes associated with testing HIV positive among STI patients.
A cohort study of 29 STI patients who tested HIV positive during one year of observation and 77 patients who persistently tested HIV negative. Computerized behavioral interviews were collected at baseline and one year later, and STI clinic charts were abstracted over the same one year period.
STI patients who reported genital bleeding during sex at the baseline were significantly more likely to test HIV positive. Reductions in number of sex partners and rates of unprotected intercourse occurred for all STI clinic patients regardless of whether they tested HIV positive.
We observed 5% of HIV negative STI clinic patients subsequently testing HIV positive over one year. Behavioral risk reduction interventions are urgently needed for men and women STI clinic patients.
HIV prevalence in Botswana is among the highest in the world and sexual networking patterns represent an important dimension to understanding the spread of HIV/AIDS.
To examine risk behaviour associated with recent multiple sexual partnerships among people living with HIV/AIDS in Botswana.
Confidential brief interviews were administered to 209 HIV positive men and 291 HIV positive women recruited conveniently from HIV/AIDS support groups and antiretroviral clinics. Measures included demographics, duration of HIV diagnosis, sexual partnerships, condom use, and HIV status disclosure.
The response rate was 63% and 309 (62%) participants were currently sexually active, of whom 247 (80%) reported only one sex partner in the previous 3 months and 62 (20%) reported two or more partners during that time. Condom use exceeded 80% across partner types and regardless of multiple partnerships. Steady sex partners of participants with multiple partnerships were significantly less likely to be protected by condoms than steady partners of individuals with only one sex partner. Individuals with multiple sex partners were also significantly less likely to have disclosed their HIV status.
Multiple sexual partnerships, many of which are probably concurrent, are not uncommon among sexually active people living with HIV in Botswana. HIV prevention is needed for all individuals who are at risk and assistance should be provided to HIV infected people who continue to practise unprotected sex with uninfected partners or partners of unknown HIV status.
HIV/AIDS prevention; multiple concurrent sex partners; HIV positive sex risks; positive prevention
Evidence based, single-session, behavioral interventions that can be used in public health settings are urgently needed for preventing the spread of HIV and other sexually transmitted infections (STI). Brief interventions are particularly promising given the relatively low burden they place on financially limited service providers.
To estimate the efficacy of single-session, behavioral interventions for STI prevention.
MEDLINE (PubMed), PsycINFO, CINAHL, ERIC, Proquest, all international sub-databases in the WHO's Global Health Library were searched through May 2011.
Data from 29 single-session interventions (20 studies; N = 52,465) with an STI outcome were coded and analyzed.
The odds of participants being infected with an STI in the intervention group were reduced by 35% (OR = .65, 95% CI=.55–.77) relative to control group participants. Interventions were compared to active controls and follow-up periods averaged 58 weeks. As such, single-session interventions lead to considerable benefit in terms of disease prevention and create minimal burden for both the patient and the provider.
Single-session interventions were most often implemented during routine health care services by clinic staff. Use of these procedures make these interventions a reasonable option for currently existing health care infrastructure. Brief and effective STI prevention interventions are a valuable tool for disease prevention and can be readily adapted to bolster the benefits of partially effective biomedical STI/HIV prevention technologies.
This study explored narratives of drinking as a coping strategy among female drinkers in a South African township. In 2010–11, we conducted qualitative in-depth interviews with 54 women recruited from 12 alcohol-serving venues. Most women drank heavily and linked their drinking to stressors. They were motivated to use drinking to manage their emotions, facilitate social engagement, and achieve a sense of empowerment, even while recognizing the limitations of this strategy. This study helps to contextualize heavy drinking behavior among women in this setting. Multifaceted interventions that help female drinkers to more effectively manage stressors may aid in reducing hazardous drinking.
South Africa; Stressors; Coping; Drinking; Alcohol; Women; Qualitative
Male circumcision (MC) can prevent female to male HIV transmission and has the potential to significantly alter HIV epidemics. The ultimate impact of MC on HIV prevention will be determined, in part, by behavioral factors. In order to fully realize the protective benefits of MC, factors related to acceptability and sexual risk must be considered. Research shows that acceptability of MC among uncircumcised men is high and suggests that free and safe circumcision may be taken up in high-HIV prevalence places. Perceptions of adverse effects of MC may however limit uptake. Furthermore, considerable risk reduction counseling provided by MC trials limits our ability to understand the impact MC may have on behavior. There is also no evidence that MC protects women with HIV positive partners or that it offers protection during anal intercourse. Research is urgently needed to better understand and manage the behavioral implications of MC for HIV prevention.
South Africa has one of the highest rates of fetal alcohol spectrum disorder (FASD) in the world; however, little is known about what men and women, who attend alcohol serving establishments, believe about alcohol use during pregnancy and how these beliefs may be related to alcohol use.
To understand FASD beliefs and related behaviors among men and women attending alcohol-serving establishments.
We surveyed 1,047 men (n=565) and women (n=482) -including pregnant women and men with pregnant partners- attending alcohol serving establishments in a township located in Cape Town, South Africa. RESULTS: Among both pregnant (n=53) and non-pregnant (n=429) women, 54% reported drinking alcohol at least 2–4 times per month, and 57% reported having at least 3–4 alcohol drinks during a typical drinking session. Pregnant women were less likely to believe that they should not drink alcohol and that alcohol can harm a fetus when compared to non-pregnant women. Similar findings were observed between men with pregnant partners compared to men without pregnant partners. Among women, beliefs about how much alcohol pregnant women can safely drink were associated with self-reported alcohol use.
Efforts to address FASD need to focus on understanding how men and women perceive alcohol use during pregnancy and situational factors that contribute to alcohol consumption among pregnant women attending alcohol serving establishments. Structural and individual-level interventions targeting women at alcohol serving establishments should be prioritized to mitigate alcohol use during pregnancy.
Psychiatric symptoms including depression are common among people living with HIV/AIDS (PLWHA), and antidepressant medications have been shown to reduce depressive symptoms and also enhance antiretroviral (ARV) adherence in this population.
Because these benefits have not been studied among PLWHA using other psychotropic (PSY) medications in addition to antidepressants, we examined the impact of adherence to a diverse range of PSY medications (including antidepressants, mood stabilizers, and anti-psychotic medications) on depressive symptoms and ARV adherence in PLWA.
Participants for this cohort study were recruited through physician outpatient clinics. Depressive symptoms were assessed monthly using a 10-item version of the Center for Epidemiological Studies – Depression (CES-D) scale; PSY and ARV medication adherence were assessed using monthly unannounced telephone pill count assessments across a three-month period.
A general community-based, healthcare setting was utilized for the study.
Of the 353 PLWHA we identified on stable ARV medications, we were able to maintain contact with 324 (92%) across a 3-month period (227 men; 97 women). Mean age of this convenience sample was 45 years and 90% were African-American.
Main Outcome Measure
Mean ARV adherence across a 3-month study period.
The results showed that greater depressive symptoms were associated with lower ARV adherence among our sample of PLWHA. Greater adherence to PSY medications regardless of medication class was positively related to higher ARV adherence. We also found that greater adherence to PSY medications significantly reduced the negative association between depressive symptoms and ARV medication adherence among PLWHA.
The results of this study point to the need for screening and treatment of depressive symptoms and also further study of the impact of multiple PSY medications regimens on health outcomes among PLWHA.
Housing for people living with HIV/AIDS has been linked to a number of positive physical and mental health outcomes, in addition to decreased sexual and drug-related risk behavior. The current study identified service priorities for people living with HIV/AIDS, services provided by HIV/AIDS housing agencies, and unmet service needs for people living with HIV/AIDS through a nationwide telephone survey of HIV/AIDS housing agencies in the United States. Housing, alcohol/drug treatment, and mental health services were identified as the three highest priorities for people living with HIV/AIDS and assistance finding employment, dental care, vocational assistance, and mental health services were the top needs not being met. Differences by geographical region were also examined. Findings indicate that while housing affords people living with HIV/AIDS access to services, there are still areas (e.g., mental health services) where gaps in linkages to care exist.
When taken without interruption, antiretroviral therapies (ART) effectively treat HIV infection. Alcohol is a well-known direct and indirect influence on ART adherence. Believing that drinking is harmful while taking ART (interactive toxicity beliefs) is also associated with poor adherence. The current study included 333 people living with HIV who were taking ART and actively using alcohol. Participants were recruited from health care providers and social services in a major southern U.S. city. Results showed that 52% of persons found non-adherent to ART stated that they stopped taking their medications when they were drinking. Multivariate analyses showed that interrupting treatment when drinking was related to current non-adherence, over and above several common correlates of non-adherence including frequency of alcohol use itself. These results confirm and extend past research, indicating an urgent need for medication adherence interventions designed for people living with HIV who drink.
alcohol; antiretroviral therapy; beliefs; HIV treatment adherence
Black men who have sex with men (BMSM) are severely affected by the HIV epidemic, yet research on the relationship between HIV stigma and status disclosure is relatively limited among this population. Within this epidemic, internalized HIV stigma, the extent to which people living with HIV/AIDS (PLWHA) endorse the negative beliefs associated with HIV as true of themselves, can negatively shape interpersonal outcomes and have important implications for psychological and physical health. In a sample of HIV-positive BMSM (N = 156), the current study examined the effect of internalized stigma on HIV status disclosure to sexual partners, which can inform sexual decision-making in serodiscordant couples, and HIV status disclosure to family members, which can be beneficial in minimizing the psychological distress associated with HIV. Results revealed that greater internalized stigma was associated with less HIV status disclosure to participants’ last sexual partner and to family members. Findings from this study provide evidence that internalized negative beliefs about one’s HIV status are linked to adverse interpersonal consequences. Implications of these findings are discussed with regard to prevention and intervention efforts to reduce HIV stigmatization.
HIV; internalized stigma; Black; men who have sex with men; disclosure
The current study was conducted to examine the impact of mixing genders in HIV prevention intervention groups targeted toward HIV positive men and women.
Men (N=310) and women (N=126) participated in a randomized clinical trial testing a behavioral risk reduction/ medication adherence intervention versus a general health control condition administered to small mixed gender groups. Gender composition of groups was examined in relation to participant group attendance and group satisfaction measures through correlations and logistic regression.
Significant regression models were found for men in the risk reduction condition and for women in the general health condition, however, regression models were not significant for women in the risk reduction condition and men in the general health condition.
The findings indicate that mixing genders in risk reduction interventions for men and women living with HIV/AIDS has no negative impact on women’s group satisfaction and may positively impact men’s group satisfaction. This calls into question the assumption that gender sensitive material will always make individuals uncomfortable within mixed gender groups.
Implications for practice and policy
In practice, mixed gender intervention groups can be a helpful option for delivering programs to diverse populations especially when resources are limited within community-based services providers and AIDS service organizations.
Although more thorough investigation is needed about the consequences and possible benefits of mixing genders within HIV prevention intervention groups, this study supports the idea that mixing genders may be a viable option, in practice, without sacrificing the integrity of the intervention.
HIV/AIDS; risk reduction; medication adherence
Affordable and effective antiretroviral therapy (ART) adherence interventions are needed for many patients to promote positive treatment outcomes and prevent viral resistance. We conducted a two-arm randomized trial (n = 40 men and women receiving and less than 95% adherent to ART) to test a single office session followed by four biweekly cell phone counseling sessions that were grounded in behavioral self-management model of medication adherence using data from phone-based unannounced pill counts to provide feedback-guided adherence strategies. The control condition received usual care and matched office and cell phone/pill count contacts. Participants were baseline assessed and followed with biweekly unannounced pill counts and 4-month from baseline computerized interviews (39/40 retained). Results showed that the self-regulation counseling delivered by cell phone demonstrated significant improvements in adherence compared to the control condition; adherence improved from 87% of pills taken at baseline to 94% adherence 4 months after baseline, p < 0.01. The observed effect sizes ranged from moderate (d = 0.45) to large (d = 0.80). Gains in adherence were paralleled with increased self-efficacy (p < 0.05) and use of behavioral strategies for ART adherence (p < 0.05). We conclude that the outcomes from this test of concept trial warrant further research on cell phone-delivered self-regulation counseling in a larger and more rigorous trial.