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1.  HIV pre-exposure prophylaxis for people who inject drugs: a review of current results and an agenda for future research 
Introduction
Studies examining the use of pre-exposure prophylaxis (PrEP) to prevent HIV transmission among people who inject drugs (PWIDs) have not been adequately summarized. Recently, the Bangkok Tenofovir Study has shown that PrEP may be effective at reducing new HIV infections among this high-risk group. This randomized controlled trial was the first study to specifically examine the efficacy of PrEP among PWIDs. In this review, we present the current state of evidence regarding the use of PrEP to prevent HIV infection in PWID populations, and set an agenda for future research to inform the most effective implementation of PrEP in the context of existing evidence-based HIV prevention strategies.
Discussion
Despite positive trial results confirming that PrEP may prevent HIV transmission among PWIDs, there remain many questions regarding the interpretation of these results, as well as obstacles to the implementation of PrEP regimens within highly diverse drug-using communities. Aside from the Bangkok Tenofovir Study, we identified only one other published study that has collected empirical data to inform the use of PrEP among PWIDs. The large gap in research regarding the use and implementation of PrEP for PWIDs signals the need for further research and attention.
Conclusions
We recommend that future research efforts focus on elucidating the generalizability of the Bangkok Tenofovir Study results in other injection drug–using populations, examining the willingness of PWIDs to use PrEP in diverse contexts, identifying barriers to adherence to PrEP regimens and determining the most effective ways to implement PrEP programmes within the context of existing evidence-based prevention strategies, including opioid substitution therapy and needle and syringe distribution programmes.
doi:10.7448/IAS.17.1.18899
PMCID: PMC3969508  PMID: 24679634
HIV; pre-exposure prophylaxis; injection drug use; people who inject drugs
2.  Ageing with HIV in South Africa 
AIDS (London, England)  2011;25(13):10.1097/QAD.0b013e32834982ea.
We used an established microsimulation model, quantified to a rural South African setting with a well-developed antiretroviral treatment program, to predict the impact of antiretroviral therapy on the HIV epidemic in the population aged 50+. We show that the HIV prevalence in patients aged 50+ will nearly double in the next 30 years, while the fraction of HIV infected patients aged over 50 will triple in the same period. This ageing epidemic has important consequences for the South African health-care system, as older HIV patients require specialized care.
doi:10.1097/QAD.0b013e32834982ea
PMCID: PMC3886337  PMID: 21681056
HIV; Antiretroviral therapy; Ageing; Mathematical model; Epidemiological trends
3.  The impact of antiretroviral treatment on the age composition of the HIV epidemic in sub-Saharan Africa 
AIDS (London, England)  2012;26(0 1):10.1097/QAD.0b013e3283558526.
Introduction
Antiretroviral treatment (ART) coverage is rapidly expanding in sub-Saharan Africa (SSA). Based on the effect of ART on survival of HIV-infected people and HIV transmission the age composition of the HIV epidemic in the region is expected to change in the coming decades. We quantify the change of the age composition of HIV-infected people in all countries in SSA.
Methods
We used STDSIM, a stochastic microsimulation model, and developed an approach to represent HIV prevalence and treatment coverage in 43 countries in SSA, using publicly available data. We predict future trends in HIV prevalence and total number of infections among the populations aged 15-49 and 50 years and older (50+) for different ART coverage levels.
Results
We show that, if treatment coverage continues to increase at present rates, the total number of HIV-infected patients aged 50+ will nearly triple over the coming years: from 3.1 million in 2011 to 9.1 million in 2040, dramatically changing the age composition of the HIV epidemic in SSA. In 2011, about 1 in 7 HIV-infected people was aged 50 years or older; in 2040, this ratio will be larger than 1 in 4.
Conclusion
The HIV epidemic in SSA is rapidly ageing, implying changing needs and demands in many social sectors, including health, social care, and old-age pension systems. Health policymakers need to anticipate the impact of the changing HIV age composition in their planning for future capacity in these systems.
doi:10.1097/QAD.0b013e3283558526
PMCID: PMC3886374  PMID: 22781175
HIV; Antiretroviral therapy; Ageing; Mathematical model; Epidemiological trends
4.  Concurrent Partnerships as a Driver of the HIV Epidemic in sub-Saharan Africa? The Evidence is Limited 
AIDS and behavior  2009;14(1):10.1007/s10461-009-9583-5.
doi:10.1007/s10461-009-9583-5
PMCID: PMC3819098  PMID: 19488848
5.  Sexual Behavior and Reproductive Health Among HIV-Infected Patients in Urban and Rural South Africa 
Journal of acquired immune deficiency syndromes (1999)  2008;47(4):10.1097/QAI.0b013e3181648de8.
Background
With the rollout of antiretroviral therapy in South Africa and its potential to prolong the lives of HIV-infected individuals, understanding the sexual behavior of HIV-positive people is essential to curbing secondary HIV transmission.
Methods
We surveyed 3819 HIV-positive patients during their first visit to an urban wellness clinic and a rural wellness clinic.
Results
Urban residents were more likely than rural residents to have current regular sex partners (75.1% vs. 46.0%; χ2 odds ratio [OR] = 3.531; P < 0.001), to have any current sexual partners (75.3% vs. 51.2%; χ2 OR = 2.908; P < 0.001), and to report consistent condom use with regular partners (78.4% vs. 48.3%; χ2 OR = 3.886; P < 0.001) and with casual partners (68.6% vs. 48.3%; χ2 OR = 2.337; P < 0.001). In multivariate analysis, independent predictors of consistent condom use with regular partners included across gender, urban residence, and higher education levels; for women, disclosure and younger age; and for men only, no history of alcohol consumption. Male and female participants with a casual sexual partner were less likely to use a condom consistently with regular partners. Additionally, urban residence and a CD4 count greater than 200 cells/mm3 as well as (for women only) a higher household income and a history of alcohol consumption were predictors of having a regular sexual partner.
Conclusions
HIV prevention programs in South Africa that emphasize the importance of condom use and disclosure and are tailored to the needs of their attending populations are critical given the potential for HIV-infected individuals to resume risky sexual behavior with improving health.
doi:10.1097/QAI.0b013e3181648de8
PMCID: PMC3811008  PMID: 18209685
condom use; HIV prevention; positive prevention; sexual behavior; South Africa; urban-rural
6.  Elimination of HIV in South Africa through Expanded Access to Antiretroviral Therapy: A Model Comparison Study 
PLoS Medicine  2013;10(10):e1001534.
Using nine structurally different models, Jan Hontelez and colleagues investigate timeframes for HIV elimination in South Africa using a universal test and treat strategy.
Please see later in the article for the Editors' Summary
Background
Expanded access to antiretroviral therapy (ART) using universal test and treat (UTT) has been suggested as a strategy to eliminate HIV in South Africa within 7 y based on an influential mathematical modeling study. However, the underlying deterministic model was criticized widely, and other modeling studies did not always confirm the study's finding. The objective of our study is to better understand the implications of different model structures and assumptions, so as to arrive at the best possible predictions of the long-term impact of UTT and the possibility of elimination of HIV.
Methods and Findings
We developed nine structurally different mathematical models of the South African HIV epidemic in a stepwise approach of increasing complexity and realism. The simplest model resembles the initial deterministic model, while the most comprehensive model is the stochastic microsimulation model STDSIM, which includes sexual networks and HIV stages with different degrees of infectiousness. We defined UTT as annual screening and immediate ART for all HIV-infected adults, starting at 13% in January 2012 and scaled up to 90% coverage by January 2019. All models predict elimination, yet those that capture more processes underlying the HIV transmission dynamics predict elimination at a later point in time, after 20 to 25 y. Importantly, the most comprehensive model predicts that the current strategy of ART at CD4 count ≤350 cells/µl will also lead to elimination, albeit 10 y later compared to UTT. Still, UTT remains cost-effective, as many additional life-years would be saved. The study's major limitations are that elimination was defined as incidence below 1/1,000 person-years rather than 0% prevalence, and drug resistance was not modeled.
Conclusions
Our results confirm previous predictions that the HIV epidemic in South Africa can be eliminated through universal testing and immediate treatment at 90% coverage. However, more realistic models show that elimination is likely to occur at a much later point in time than the initial model suggested. Also, UTT is a cost-effective intervention, but less cost-effective than previously predicted because the current South African ART treatment policy alone could already drive HIV into elimination.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
About 34 million people (mostly in low- and middle-income countries) are currently infected with HIV, the virus that causes AIDS, and every year another 2.5 million people become infected. HIV, which is usually transmitted through unprotected sex with an infected partner, gradually destroys CD4 lymphocytes and other immune system cells, leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, people infected with HIV often died within ten years of infection. Then, in 1996, antiretroviral therapy (ART) became available, and, for people living in affluent countries, HIV/AIDS became a chronic condition. However, ART was expensive, so HIV/AIDS remained a fatal condition for people living in resource-limited countries. In 2006, the international community set a target of achieving universal ART coverage by 2010, and ART programs were initiated in many resource-limited countries. Although universal ART coverage has still not been achieved in South Africa, where nearly 6 million people are HIV-positive, 80% of people in need of ART were receiving a World Health Organization–recommended ART regimen by October 2012.
Why Was This Study Done?
ART is usually started when a person's CD4 count falls below 350 cells/µl blood, but it is thought that treatment of all HIV-positive individuals, regardless of their CD4 count, could reduce HIV transmission by reducing the infectiousness of HIV-positive individuals (“treatment as prevention”). Might it be possible, therefore, to eliminate HIV by screening everyone annually for infection and treating all HIV-positive individuals immediately? In 2009, a mathematical modeling study suggested that seven years of universal test and treat (UTT) could eliminate HIV in South Africa. The deterministic (nonrandom) model used in that study has been widely criticized, however, and some subsequent modeling studies have reached different conclusions, probably because of differences in the models' structures and in the assumptions built into them. A better understanding of the reasons for the discrepancies between models would help policy-makers decide whether to introduce UTT, so, here, the researchers developed several increasingly complex and realistic models of the South African HIV epidemic and used these models to predict the long-term impact of UTT in South Africa.
What Did the Researchers Do and Find?
The researchers developed nine structurally different mathematical models of the South African HIV epidemic based on the STDSIM framework, a stochastic microsimulation model that simulates the life course of individuals in a dynamic network of sexual contacts and in which events such as HIV infection are random processes. The simplest model, which resembled the original deterministic model, was extended by sequentially adding in factors such as different HIV transmission rates at different stages of HIV infection and up-to-date assumptions regarding the ability of ART to reduce HIV infectiousness. All the models replicated the prevalence of HIV in South Africa (the proportion of the population that was HIV-positive) between 1990 and 2010, and all predicted that UTT (defined as annual screening of individuals age 15+ years and immediate ART for all HIV-infected adults starting in 2012 and scaled up to 90% coverage by 2019) would result in HIV elimination (less than one new infection per 1,000 person-years). However, whereas the simplest model predicted that UTT would eliminate HIV after seven years, the more complex, realistic models predicted elimination at much later time points. Importantly, the most comprehensive model predicted that, although elimination would be reached after about 17 years of UTT, the current strategy of ART initiation for HIV-positive individuals at a CD4 cell count at or below 350 cells/µl would also lead to HIV elimination, albeit ten years later than UTT.
What Do These Findings Mean?
These findings confirm previous predictions that UTT could eliminate HIV in South Africa, but the development of more realistic models than those used in the past suggests that HIV elimination would occur substantially later than originally predicted. Importantly, the most comprehensive model suggests that HIV could be eliminated in South Africa using the current strategy for ART treatment alone. As with all modeling studies, the accuracy of these findings depends on the assumptions built into the models and on the structure of the models. Thus, although these findings support the use of UTT as an intervention to eliminate HIV, more research with comprehensive models that incorporate factors such as data from ongoing trials of treatment as prevention is needed to determine the population-level impact and overall cost-effectiveness of UTT.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001534.
This study is further discussed in a PLOS Medicine Perspective by Ford and Hirnschall
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 South Africa, on HIV treatment as prevention and the possibility of HIV elimination (in English and Spanish)
The 2012 UNAIDS World AIDS Day Report provides up-to-date information about the AIDS epidemic and efforts to halt it
The World Health Organization provides information about universal access to AIDS treatment (in several languages); its 2010 ART guidelines can be downloaded
The PLOS Medicine Collection Investigating the Impact of Treatment on New HIV Infections provides more information about HIV treatment as prevention
Personal stories about living with HIV/AIDS are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline
doi:10.1371/journal.pmed.1001534
PMCID: PMC3805487  PMID: 24167449
7.  Effects of Political Conflict Induced Treatment Interruptions on HIV Drug Resistance 
AIDS reviews  2013;15(1):15-24.
34 million people worldwide were living with the Human Immunodeficiency Virus (HIV) by the end of 2010. Despite significant advances in antiretroviral therapy (ART), drug resistance remains a major deterrent to successful, enduring treatment. Unplanned interruptions in ART have negative effects on HIV treatment outcomes including increased morbidity and mortality, as well as development of drug resistance. Treatment interruptions due to political conflicts, not infrequent in resource-limited settings, result in disruptions in health care, infrastructure, or treatment facilities and patient displacement. Such circumstances are ideal bases for ART resistance development, however there is limited awareness of and data available on the association between political conflicts and the development of HIV drug resistance. In this review we identify and discuss this association and review how varying ART half-lives, genetic barriers, different HIV subtypes, and archived resistance can lead to lack of medication effectiveness upon post-conflict resumption of care. Optimized ART stopping strategies as well as infrastructural concerns and stable HIV treatment systems to ensure continuity of care and rapid resumption of care must be addressed in order to mitigate risks of HIV drug resistance development during and after political conflicts. Increased awareness of such associations by clinicians as well as politicians and stakeholders is essential.
PMCID: PMC3774601  PMID: 23449225
Treatment Interruption; Unplanned; Resistance; Political Crises; NNRTI Tail
8.  HIV-1 Sero-Prevalence and Awareness of Mother-to-Child Transmission Issues Among Women Seeking Antenatal Care in Tamil Nadu, India 
Background
Despite increasing availability of HIV-1 testing, education, and methods to prevent transmission, Indian women and their children remain at risk of acquiring HIV. We assessed the sero-prevalence and awareness about HIV among pregnant women presenting to a private tertiary care hospital in South India.
Methods
Sero-prevalence was determined via enzyme-linked immunosorbent assay (ELISA) testing, and questionnaires were analyzed using chi-square statistics and odds ratios to look for factors associated with HIV positivity.
Results
A total of 7956 women who presented for antenatal care were interviewed. Fifty-one women of the 7235 women who underwent HIV testing (0.7%) were found to be HIV positive. Awareness of mother-to-child transmission (MTCT) of HIV (64%), HIV transmission through breast milk (42%), and prevention of MTCT (13%) was low.
Conclusions
There is a need to educate South Indian women about HIV to give them information and the means to protect themselves and their unborn children from acquiring HIV.
doi:10.1177/1545109710371132
PMCID: PMC3652013  PMID: 20530464
HIV; sero-prevalence; awareness; pregnancy; antenatal; India
9.  A Cross-Sectional Study to Assess HPV Knowledge and HPV Vaccine Acceptability in Mali 
PLoS ONE  2013;8(2):e56402.
Despite a high prevalence of oncogenic human papilloma virus (HPV) infection and cervical cancer mortality, HPV vaccination is not currently available in Mali. Knowledge of HPV and cervical cancer in Mali, and thereby vaccine readiness, may be limited. Research staff visited homes in a radial pattern from a central location to recruit adolescent females and males aged 12–17 years and men and women aged ≥18 years (N = 51) in a peri-urban village of Bamako, Mali. Participants took part in structured interviews assessing knowledge, attitudes, and practices related to HPV, cervical cancer, and HPV vaccination. We found low levels of HPV and cervical cancer knowledge. While only 2.0% of respondents knew that HPV is a sexually transmitted infection (STI), 100% said they would be willing to receive HPV vaccination and would like the HPV vaccine to be available in Mali. Moreover, 74.5% said they would vaccinate their child(ren) against HPV. Men were found to have significantly greater autonomy in the decision to vaccinate themselves than women and adolescents (p = 0.005), a potential barrier to be addressed by immunization campaigns. HPV vaccination would be highly acceptable if the vaccine became widely available in Bamako, Mali. This study demonstrates the need for a significant investment in health education if truly informed consent is to be obtained for HPV vaccination. Potential HPV vaccination campaigns should provide more information about HPV and the vaccine. Barriers to vaccination, including the significantly lower ability of the majority of the target population to autonomously decide to get vaccinated, must also be addressed in future HPV vaccine campaigns.
doi:10.1371/journal.pone.0056402
PMCID: PMC3576405  PMID: 23431375
10.  Sexual Risk Behaviors Among HIV-Infected South African Men and Women with Their Partners in a Primary Care Program: Implications for Couples-Based Prevention 
AIDS and Behavior  2012;16(1):139-150.
We studied 1163 sexually-active HIV-infected South African men and women in an urban primary care program to understand patterns of sexual behaviors and whether these behaviors differed by partner HIV status. Overall, 40% reported a HIV-positive partner and 60% a HIV-negative or status unknown partner; and 17.5% reported >2 sex acts in the last 2 weeks, 16.4% unprotected sex in the last 6 months, and 3.7% >1 sex partner in the last 6 months. Antiretroviral therapy (ART) was consistently associated with decreased sexual risk behaviors, as well as with reporting a HIV-negative or status unknown partner. The odds of sexual risk behaviors differed by sex; and were generally higher among participants reporting a HIV-positive partner, but continued among those with a HIV-negative or status unknown partner. These data support ART as a means of HIV prevention. Engaging in sexual risk behaviors primarily with HIV-positive partners was not widely practiced in this setting, emphasizing the need for couples-based prevention.
doi:10.1007/s10461-011-9941-y
PMCID: PMC3184366  PMID: 21476005
HIV; AIDS; South Africa; Sexual risk behavior; ART
11.  The potential impact of RV144-like vaccines in rural South Africa: a study using the STDSIM microsimulation model 
Vaccine  2011;29(36):6100-6106.
BACKGROUND
The only successful HIV vaccine trial to date is the RV144 trial of the ALVAC/AIDSVAX vaccine in Thailand, which showed an overall incidence reduction of 31%. Most cases were prevented in the first year, suggesting a rapidly waning efficacy. Here, we predict the population level impact and cost-effectiveness of practical implementation of such a vaccine in a setting of a generalised epidemic with high HIV prevalence and incidence.
METHODS
We used STDSIM, an established individual-based microsimulation model, tailored to a rural South African area with a well-functioning HIV treatment and care programme. We estimated the impact of a single round of mass vaccination for everybody aged 15–49, as well as 5-year and 2-year revaccination strategies for young adults (aged 15–29). We calculated proportion of new infections prevented, cost-effectiveness indicators, and budget impact estimates of combined ART and vaccination programmes.
RESULTS
A single round of mass vaccination with a RV144-like vaccine will have a limited impact, preventing only 9% or 5% of new infections after 10 years at 60% and 30% coverage levels, respectively. Revaccination strategies are highly cost-effective if vaccine prices can be kept below 150 US$/vaccine for 2-year revaccination strategies, and below 200 US$/vaccine for 5-year revaccination strategies. Net cost-savings through reduced need for HIV treatment and care occur when vaccine prices are kept below 75 US$/vaccine. These results are sensitive to alternative assumptions on the underlying sexual network, background prevention interventions, and individual’s propensity and consistency to participate in the vaccination campaign.
DISCUSSION
A modestly effective vaccine can be a cost-effective intervention in highly endemic settings. To predict the impact of vaccination strategies in other endemic situations, sufficient knowledge of the underlying sexual network, prevention and treatment interventions, and individual propensity and consistency to participate, is key. These issues are all best addressed in an individual-based microsimulation model.
doi:10.1016/j.vaccine.2011.06.059
PMCID: PMC3157643  PMID: 21703321
HIV vaccine; Mathematical model; Microsimulation model; South Africa; Cost-effectiveness
12.  Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery 
AIDS care  2011;23(6):722-733.
The current study examines sexual behaviors among HIV-infected Indians in primary care, where access to highly active antiretroviral therapy (HAART) has recently increased. Between January to April 2008, we assessed the sexual behaviors of 247 HIV-infected South Indians in care. Multivariable logistic regression models were used to determine predictors of being in a HIV-seroconcordant primary relationship, being sexually active, and reporting unprotected sex. Over three-fourths (80%) of participants were HAART-experienced. Among the 58% of participants who were currently in a seroconcordant relationship, one-third were serodiscordant when first tested for HIV. Approximately two-thirds (63.2%) of participants were sexually active; 9.0% reported unprotected sex. In the multivariable analyses, participants who were in a seroconcordant primary relationship were more likely to have children, use alcohol, report unprotected sex, and have been enrolled in care for >12 months. Sexually active participants were more likely to be on HAART, have a prior tuberculosis diagnosis, test Herpes simplex type 2 antibody seropositive, and have low general health perceptions. Participants who reported unprotected sex were more likely to be in a seroconcordant relationship, be childless, want to have a child, and use alcohol. We did not document an association between HAART and unprotected sex. Among HIV-infected Indians in primary care, predictors of unprotected sex included alcohol use and desire for children. Prevention interventions for Indian couples should integrate reproductive health and alcohol use counseling at entry into care.
doi:10.1080/09540121.2010.525616
PMCID: PMC3095699  PMID: 21293990
HIV; AIDS; sexual behavior; HAART; India
13.  Morbidity and Mortality among Infants Born to HIV-Infected Women in South Africa: Implications for Child Health in Resource-Limited Settings 
Journal of Tropical Pediatrics  2010;57(2):109-119.
Background: We examined correlates of infant morbidity and mortality within the first 3 months of life among HIV-exposed infants receiving post-exposure antiretroviral prophylaxis in South Africa. Methods: We conducted a prospective cohort study of 848 mother–child dyads. Multivariable Cox proportional hazards models were used. Results: The main causes of infant morbidity were gastrointestinal and respiratory infections. Morbidity was higher with infant HIV infection (HR: 2.61; 95% CI: 1.40–4.85; p = 0.002) and maternal plasma viral load (PVL) >100 000 copies ml−1 (HR: 1.87; 95% CI: 1.01–3.48; p = 0.048), and lower with maternal age <20 years (HR: 0.25; 95% CI: 0.07–0.88; p = 0.031). Mortality was higher with infant HIV infection (HR: 4.10; 95% CI: 1.18–14.31; p = 0.027) and maternal PVL >100 000 copies ml−1 (HR: 6.93; 95% CI: 1.64–29.26; p = 0.008). Infant feeding status did not influence the risk of morbidity nor mortality. Conclusions: Future interventions that minimize pediatric HIV infection and reduce maternal viremia, which are the main predictors of child health soon after birth, will impact positively on infant health outcomes.
doi:10.1093/tropej/fmq061
PMCID: PMC3107462  PMID: 20601692
South Africa; mother-to-child transmission; breast-feeding; infant HIV-1 infection; mortality; morbidity
14.  Who gets tested for HIV in a South African urban township? Implications for test and treat and gender-based prevention interventions 
Background
With increasing calls for linking HIV-infected individuals to treatment and care via expanded testing, we examined socio-demographic and behavioral characteristics associated with HIV testing among men and women in Soweto, South Africa.
Methods
We conducted a cross-sectional household survey involving 1539 men and 1877 women as part of the community-randomized prevention trial Project ACCEPT/HPTN043 between July 2007-October 2007. Multivariable logistic regression models, stratified by sex, assessed factors associated with HIV testing, and then repeated testing.
Results
Most women (64.8%) and 28.9% of men reported ever having been tested for HIV, among whom 57.9% reported repeated HIV testing. In multivariable analyses, youth and students had a lower odds of HIV testing. Men and women who had conversations about HIV/AIDS with increasing frequency and who had heard about antiretroviral therapy were more likely to report HIV testing, as well as repeated testing. Men who had ≥12 years of education and who were of high socio-economic status; and women who were married, who were of low socio-economic status, and who had children under their care had a higher odds of HIV testing. Women, older individuals, those with higher levels of education, married individuals, and those with children under their care had a higher odds of reporting repeated HIV testing. Uptake of HIV testing was not associated with condom use, having multiple sex partners, and HIV-related stigma.
Conclusions
Given the low uptake of HIV testing among men and youth, further targeted interventions could facilitate a test and treat strategy among urban South Africans.
doi:10.1097/QAI.0b013e318202c82c
PMCID: PMC3137901  PMID: 21084993
HIV; AIDS; VCT; testing; Africa
15.  Decreased sexual risk behavior in the era of HAART among HIV-infected urban and rural South Africans attending primary care clinics 
AIDS (London, England)  2010;24(17):2687-2696.
Objective
In light of increasing access to highly active antiretroviral treatment (HAART) in sub-Saharan Africa, we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIV-infected South Africans in urban and rural primary care clinics.
Design
Prospective observational cohort study.
Methods
We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003–2010, representing 19703 clinic visits. The primary outcomes were being sexually active, unprotected sex, and >1 sex partner and were evaluated at six monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors.
Results
Among 6263 HIV-infected men and women, over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up, visits while receiving HAART were associated with a decrease in those reporting being sexually active (AOR: 0.86 [95% CI: 0.78–0.95]). Unprotected sex and having >1 sex partner were reduced at visits following HAART initiation compared to pre-HAART visits (AOR: 0.40 [95% CI: 0.34–0.46] and AOR: 0.20 [95% CI: 0.14–0.29], respectively).
Conclusions
Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.
doi:10.1097/QAD.0b013e32833e78d4
PMCID: PMC3130627  PMID: 20808202
South Africa; HAART; antiretroviral therapy; sexual behavior; HIV transmission; AIDS; HIV
16.  The Impact of the New WHO Antiretroviral Treatment Guidelines on HIV Epidemic Dynamics and Cost in South Africa 
PLoS ONE  2011;6(7):e21919.
Background
Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of ≤350 cells/µl rather than ≤200 cells/µl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs.
Methods and Finding
We used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at ≤200 cells/µl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years.
Conclusions
Our study strengthens the WHO recommendation of starting ART at ≤350 cells/µl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.
doi:10.1371/journal.pone.0021919
PMCID: PMC3140490  PMID: 21799755
17.  Age-gaps in sexual partnerships: seeing beyond ‘sugar daddies’ 
AIDS (London, England)  2011;25(6):861-863.
We examine for the first time age-mixing in sexual relationships in a population with very high HIV incidence and prevalence in rural South Africa. The highest levels of age assortativity (the pairing of like with like) were casual partnerships reported by men, the lowest levels were spousal relationships reported by women. Given the age–sex distribution of HIV prevalence in this population, interventions to decrease age-gaps in spousal relationships may be effective in reducing HIV incidence.
doi:10.1097/QAD.0b013e32834344c9
PMCID: PMC3117250  PMID: 21358377
18.  How HIV treatment could result in effective prevention 
Future virology  2010;5(4):405-415.
As the number of HIV infections continues to surpass treatment capacity, new HIV prevention strategies are imperative. Beyond individual clinical benefits, by rendering an individual less infectious, expanding access to highly active antiretroviral therapy (HAART) could also have a larger public health impact of curbing new HIV infections. Recent guidelines have moved towards initiating HAART at higher CD4 cell counts, thus increasing the number of individuals in need of treatment. A new treatment strategy is wanting that can simultaneously curb the epidemic and provide necessary treatment to those most in need. A recent debate has centered on whether an expansion of free and universal treatment, regardless of CD4 cell count, could be a means of HIV prevention. In light of the growing access to HAART in resource-limited settings and increasing evidence suggesting the clinical and prevention benefits of initiating treatment at higher CD4 cell counts, it is conceivable that, in the future, HAART will be an integral part of both individual-level clinical treatment programs as well as public health-based HIV prevention interventions.
doi:10.2217/fvl.10.38
PMCID: PMC2929800  PMID: 20814447
AIDS; antiretrovirals; highly active antiretroviral therapy; HIV; prevention; treatment
20.  Disclosure of HIV status: Experiences of Patients Enrolled in an Integrated TB and HAART Pilot Programme in South Africa 
The convergence between the tuberculosis (TB) and HIV epidemics has led to studies investigating strategies for integrated HIV and TB care. We present the experiences of a cohort of 17 patients enrolled in the first integrated TB and HIV treatment pilot programme, conducted in Durban, South Africa, as a precursor to a pivotal trial to answer the question of when to start antiretroviral treatment (ART) in patients co-infected with HIV and TB. Patients’ experiences with integrated TB and HIV care can provide insight about the problems or benefits of introducing HIV treatment into existing TB care in resource-constrained settings, where stigma and discrimination are often pervasive and determining factors influencing treatment uptake and coverage. Individual interviews, focus group discussions, and observations were used to understand patients’ experiences with integrated TB and HIV treatment. The patients described incorporating highly active antiretroviral therapy (HAART) into their daily routine as ‘easy’; however, the patients experienced difficulties with disclosing their HIV status. Non-disclosure to sexual partners may jeopardise safer-sex practices and enhance HIV transmission. Being on TB treatment created a safe space for all patients to conceal their HIV status from those to whom they did not wish to disclose. The data suggest that the context of directly observed therapy (DOT) for TB may have the added benefit of creating a safe space for introducing ART to patients who would benefit most from treatment initiation but who are not ready or prepared to disclose their HIV status to others.
doi:10.2989/AJAR.2009.8.1.1.714
PMCID: PMC2856961  PMID: 20411037
antiretroviral therapy; co-infection; directly observed therapy; qualitative research; resource-poor settings; sexual behaviour; South Africa; treatment issues; tuberculosis
21.  Patterns of sexual behaviour of male patients before testing HIV-positive in a Cambodian hospital, Phnom Penh 
Sexual health  2008;5(4):353-358.
Background
Sexual behaviours among HIV-positive male patients in Cambodia have not been fully evaluated.
Objectives
The patterns of sexual behaviours and social factors were compared between married and single men.
Methods
A retrospective cross-sectional survey of 174 male HIV patients was undertaken during March 1999–June 2000 in Phnom Penh.
Results
Many participants (61%) reported that they were unaware that their sexual behaviours may have put them at risk of HIV infection. Sexual behaviours included having sex with a sex worker (90%), multiple sexual partners (41%), and both of these behaviours (37%). Two-thirds (69%) reported using a condom when having sex with a sex worker. Condom use with multiple sexual partners was low (24%). A history of condom use with a sex worker was less likely to be reported among married men than single men (P = 0.008). Always using condoms with a sex worker did not differ between married men and single men. Social factors that influenced visiting a sex worker included invitation by a friend (88%), alcohol consumption (74%), and having extra spending money (72%). Multivariate analysis suggests that alcohol consumption (P = 0.008) and having extra spending money (P = 0.02) were strongly associated with visiting a sex worker.
Conclusions
In Cambodia, HIV-infected men frequently reported a history of using sex workers. Having multiple sex partners or using a sex worker and multiple sexual partners were not rare. Interventions should target men in settings where alcohol is consumed and to encourage married men to use condoms.
PMCID: PMC2853752  PMID: 19061555
HIV; men; social factors
22.  Bisexuality, Sexual Risk Taking, and HIV Prevalence Among Men Who Have Sex With Men Accessing Voluntary Counseling and Testing Services in Mumbai, India 
Objectives
To describe sociodemographics, sexual risk behavior, and estimate HIV and sexually transmitted infection (STI) prevalence among men who have sex with men (MSM) in Mumbai, India.
Methods
Eight hundred thirty-one MSM attending voluntary counseling and testing (VCT) services at the Humsafar Trust, answered a behavioral questionnaire and consented for Venereal Disease Research Laboratory and HIV testing from January 2003 through December 2004. Multivariate logistic regression was performed for sociodemographics, sexual risk behavior, and STIs with HIV result as an outcome.
Results
HIV prevalence among MSM was 12.5%. MSM who were illiterate [adjusted odds ratio (AOR) 2.28; 95% confidence interval (CI): 1.08 to 4.84], married (AOR 2.70; 95% CI: 1,56 to 4.76), preferred male partners (AOR 4.68; 95% CI: 1.90 to 11.51), had partners of both genders (AOR 2.73; 95% CI: 1.03 to 7.23), presented with an STI (AOR 3.31; 95% CI: 1.96 to 5.61); or presented with a reactive venereal disease research laboratory test (AOR 4.92; 95% CI: 2.55 to 9.53) at their VCT visit were more likely to be HIV infected.
Conclusions
MSM accessing VCT services in Mumbai have a high risk of STI and HIV acquisition. Culturally appropriate interventions that focus on sexual risk behavior and promote condom use among MSM, particularly the bridge population of bisexual men, are needed to slow the urban Indian AIDS epidemic.
doi:10.1097/QAI.0b013e3181c354d8
PMCID: PMC2844633  PMID: 19934765
bisexual; homosexual; India; men who have sex with men; Mumbai; voluntary counseling and testing
23.  The failure of routine rapid HIV testing: a case study of improving low sensitivity in the field 
Background
The rapid HIV antibody test is the diagnostic tool of choice in low and middle-income countries. Previous evidence suggests that rapid HIV diagnostic tests may underperform in the field, failing to detect a substantial number of infections. A research study inadvertently discovered that a clinic rapid HIV testing process was failing to detect cases of established (high antibody titer) infection, exhibiting an estimated 68.7% sensitivity (95% CI [41.3%-89.0%]) over the course of the first three weeks of observation. The setting is a public service clinic that provides STI diagnosis and treatment in an impoverished, peri-urban community outside of Cape Town, South Africa.
Methods
The researchers and local health administrators collaborated to investigate the cause of the poor test performance and make necessary corrections. The clinic changed the brand of rapid test being used and later introduced quality improvement measures. Observations were made of the clinic staff as they administered rapid HIV tests to real patients. Estimated testing sensitivity was calculated as the number of rapid HIV test positive individuals detected by the clinic divided by this number plus the number of PCR positive, highly reactive 3rd generation ELISA patients identified among those who were rapid test negative at the clinic.
Results
In the period of five months after the clinic made the switch of rapid HIV tests, estimated sensitivity improved to 93.5% (95% CI [86.5%-97.6%]), during which time observations of counselors administering tests at the clinic found poor adherence to the recommended testing protocol. Quality improvement measures were implemented and estimated sensitivity rose to 95.1% (95% CI [83.5%-99.4%]) during the final two months of full observation.
Conclusions
Poor testing procedure in the field can lead to exceedingly low levels of rapid HIV test sensitivity, making it imperative that stringent quality control measures are implemented where they do not already exist. Certain brands of rapid-testing kits may perform better than others when faced with sub-optimal use.
doi:10.1186/1472-6963-10-73
PMCID: PMC2851712  PMID: 20307310
24.  The production of consumption: addressing the impact of mineral mining on tuberculosis in southern Africa 
Background
Miners in southern Africa experience incident rates of tuberculosis up to ten times greater than the general population. Migration to and from mines may be amplifying tuberculosis epidemics in the general population.
Discussion
Migration to and from mineral mines contributes to HIV risks and associated tuberculosis incidence. Health and safety conditions within mines also promote the risk of silicosis (a tuberculosis risk factor) and transmission of tuberculosis bacilli in close quarters. In the context of migration, current tuberculosis prevention and treatment strategies often fail to provide sufficient continuity of care to ensure appropriate tuberculosis detection and treatment. Reports from Lesotho and South Africa suggest that miners pose transmission risks to other household or community members as they travel home undetected or inadequately treated, particularly with drug-resistant forms of tuberculosis. Reducing risky exposures on the mines, enhancing the continuity of primary care services, and improving the enforcement of occupational health codes may mitigate the harmful association between mineral mining activities and tuberculosis incidence among affected communities.
Summary
Tuberculosis incidence appears to be amplified by mineral mining operations in southern Africa. A number of immediately-available measures to improve continuity of care for miners, change recruitment and compensation practices, and reduce the primary risk of infection may critically mitigate the negative association between mineral mining and tuberculosis.
doi:10.1186/1744-8603-5-11
PMCID: PMC2770998  PMID: 19785769

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