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UN Launches Innovative Plan To Significantly Cut New HIV Infections. 11/10/2017

Published by UN

Malawi teen, Martha, was born with HIV. Now a mother herself, she has defied the odds and her son, Rahim Idriss, is part of Malawis AIDS-free generation. In this picture, she awaits the results of Rahmins HIV test. After two months of waiting, she finds out the Rahmin, now 8-months old, is HIV negative. Photo: UNICEF/HIVA201500101/Schermbrucker

Despite a 50 per cent drop in AIDS-related deaths since the peak of the epidemic, new HIV infection declines among adults are lagging, prompting the United Nations to launch a 10-point plan that lays out immediate, concrete steps countries can take to accelerate progress.

As part of global efforts to end AIDS as a public health threat, the Joint UN Programme on HIV/AIDS (UNAIDS), the UN Population Fund (UNFPA) and other partners launched on Tuesday the HIV prevention 2020 road map at the first meeting of the Global HIV Prevention Coalition to reduce new HIV infections by 75 per cent by 2020.

“Scaling up treatment alone will not end AIDS,” said Michel Sidibé, Executive Director of UNAIDS, in a statement.

“We need more energy and action put into HIV prevention – stronger leadership, increased investment and community engagement to ensure that everyone, particularly people at higher risk of HIV, can protect themselves against the virus,” he added.

While new HIV infections among children have fallen by 47 per cent since 2010, new HIV infections among adults have declined by only 11 per cent.

In 2016, in the UN Political Declaration on Ending AIDS , countries committed to reduce new HIV infections by 75 per cent – from 2.2 million in 2010 to 500,000 in 2020. The new road map will fast-track countries to achieve this target.

“In many places, lack of access to education, lack of agency and lack of autonomy over their own bodies keep adolescent girls from claiming their human rights,” UNFPA Executive Director Dr. Natalia Kanem added.

“And the poorest girls have the least power to decide whether, when or whom to marry and whether, when or how often to become pregnant. This lack of power makes each one of these girls extremely vulnerable to HIV infection, sexually transmitted infections and unintended pregnancy,” underscored Dr. Kanem.

Ten-point plan for accelerating HIV prevention at the country level

 

The HIV prevention 2020 road map contains a 10-point action plan that lays out immediate, concrete steps for countries to accelerate progress, such as conducting up-to-date analysis to assess where maximum impact opportunities lie; developing guidance to identify gaps and actions for rapid scale-up; and addressing legal and policy barriers to reach the people most affected by HIV, including young people and key populations.

It identifies factors that have hindered progress, including political leadership gaps, punitive laws and a lack of HIV prevention services in humanitarian settings, and highlights the importance of community engagement to advocate for service delivery and accountability.

“UNAIDS is urging commitment and leadership for measurable results,” said Mr Sidibé. “Leadership to address sensitive political issues and leadership in mobilizing adequate funding of HIV prevention programmes.”

Cutting new infections by 75 per cent will require a focus on HIV prevention, combined with scaled-up HIV testing and treatment. A location-population-based method for efficient planning and programming along with a people-centred approach for those at higher HIV risk will be critical.

Concerted efforts will be needed, including to reach adolescent girls, young women and their male partners; to increase the availability and uptake of condoms; and to ensure that preventative medicines are available to people at higher risk of HIV.

The road map encourages countries to develop a 100-day plan for immediate actions, including setting national targets, reviewing progress made, reassessing national prevention programmes and taking immediate remedial action.

 

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UNAIDS Launches Coalition to Step Up Commitment to HIV Prevention. 10/10/2017

Published by AIDSALLIANCE

Today marks the launch of the UNAIDS Global HIV Prevention Coalition, demonstrating a renewed commitment to HIV prevention.

<p>Members of civil society organisations gather in Cape Town to discuss a renewed commitment to HIV prevention in advance of the Global HIV Prevention Coalition launch.</p>Members of civil society organisations gather in Cape Town to discuss the role of communities in HIV prevention, in advance of the Global HIV Prevention Coalition launch. © Alliance

The Alliance is an active member of and contributor to this Coalition, with civil society representatives including directors of two Alliance Linking Organisations – Rumah Cemara and Alliance for Public Health – attending the meeting.

Alongside them, we are proud that Nevala Kayando, who is a Y+ representative for Tanzania and member of READY+, will be speaking about 'Preventing HIV: Why education matters'.

The Coalition will launch a HIV Prevention 2020 Road Map [1] containing commitments and milestones, which will be reported on annually until 2020. The Road Map will form the basis of a country-led movement to scale up HIV prevention programmes as part of the commitment to end AIDS as a public health threat by 2030.

To ensure civil society representation from multiple countries in these plans, the Alliance held a meeting in August with members of civil society including Alliance Linking Organisations and partners to share and discuss their HIV prevention needs and goals. The outcomes of this meeting, as well as UNAIDS country consultations in 20 Fast Track countries were used to develop the Road Map.

The Alliance believes that a community-led response is integral to achieving the HIV prevention goal of reducing new infections by 75% (from 2010 figures) by 2020. Alongside this, we believe a person-centred approach to HIV programming, and a combination approach to HIV prevention is vital.

The Coalition launch in Geneva will generate discussions about how we can strengthen leadership and accountability for HIV prevention, as well as how we move from commitment to action, as set out in the Road Map. We champion this renewed commitment to prioritise prevention in the global HIV response.

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HIV Prevention 2020 Road Map — Accelerating HIV prevention to reduce new infections by 75%. 10/10/2017

Published by UNAIDS

The Road Map was prepared through a consultative process that brought together more than 40 countries and organizations, including civil society organizations, networks of people living with HIV, faith-based organizations, networks of key populations1 and international organizations and foundations, to chart the way forward to achieving global HIV prevention goals by 2020. Country assessments and national consultations were organized in participating countries towards reaffirming national leadership for HIV prevention, reviewing progress and discussing accelerated action for prevention. Thematic consultations and case study reviews were also conducted to develop key elements of the Road Map, most of which are also contained in a global results framework first proposed in a journal article in 2016.

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Reconsidering Primary Prevention of HIV: New Steps Forward in the Global Response. 4/10/2017

Published by GNP+

The world needs a new phase in the evolution of the HIV response—one that reinvigorates prevention by seamlessly combining the efficacy of upstream, midstream, and downstream interventions with the powerful effectiveness of community action.

Gay men and other men who have sex with men, people who inject drugs, sex workers, and transgender women are 24, 24, 13.5, and 49 times more likely to acquire HIV, respectively, than adults in the general population (15 years old and older). Globally, these “key populations” disproportionately bear the burden of new infections, as gay men and other men who have sex with men, people who inject drugs, sex workers, and transgender women accounted for 45% of all new HIV infections in 2015.

Key populations are rendered vulnerable to HIV by upstream factors like punitive and discriminatory laws and politically driven policies, creating stressors that exacerbate risk for acquisition. Moreover, the absence of protective laws and policies enable unchecked stigma and discrimination in healthcare settings. These barriers mean people delay or skip seeking the services they may need, making the problem of HIV even worse.

The persistence of revisionist characterizations of HIV has never and will never change the biology of acquisition:  HIV is primarily transmitted sexually and via blood through the sharing of injecting equipment. For primary prevention to stand a chance, the silence, denial, negativity, and moralism surrounding sex and drug use must end. Policy makers and donors, including governments, must shed their reluctance to openly and positively address sex and drug use in their public health discourse and responses to HIV.

Propelled by the introduction of powerful and life-saving antiretroviral medications, the increasingly bio-medicalized global HIV response challenges us to rigorously reimagine prevention. The prevention toolbox is getting bigger, but the application of the tools is getting smaller. Bio-medicalized interventions, which have been lauded as successes in the HIV response, must be strategically combined with other interventions and delivered by communities for which interventions are intended. Community-led prevention must be properly resourced.

Primary prevention remains seriously undermined by low funding levels that are grossly misaligned with the disproportionate impact HIV is having on key populations worldwide. For example, in the Global Fund to Fight AIDS, Tuberculosis, and Malaria’s 2014-2016 funding period, only $648 million of the $5.9 billion (or 12%) was specifically dedicated to programs intended for all key populations, and less than half of this was dedicated to the primary prevention of HIV.

The social shape of the HIV epidemic requires a return to a primary prevention strategy that is proactive, addresses upstream factors, re-centers communities most impacted by HIV, and properly resources combination approaches chosen and led by communities for which prevention efforts are intended. HIV and other sexual health services done with or led by community members for which the services are intended are more likely to result in earlier, comprehensive, and more frequent service engagement, and improved retention, yielding better health outcomes.

We the undersigned endorse the below core principles of practice to serve as broad guidelines for the design, implementation, and evaluation of primary prevention programs for gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people:

  • The imperative to reduce new sexually transmitted infections, including HIV, should not impinge on personal freedoms;
  • All people, including gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people, have the right to self-determination;
  • All people, including gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people, deserve the same level of support, health, access to services, and political rights as anyone else;
  • All people, including gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people, have the right to privacy and are entitled to a fulfilling and satisfying sex life;
  • Gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people, should be actively and meaningfully engaged at all stages and levels in research, program and policy development, implementation and evaluation—participatory processes should be utilized throughout;
  • Young people, including young gay men, young sex workers, young people who use drugs, and young transgender people should be directly engaged when planning HIV prevention programs, in a non-tokenistic way that recognizes unique factors like consent, emancipation, autonomy, and privacy laws;
  • The primary prevention of HIV should not be risk or deficit oriented—instead, successful HIV prevention efforts should leverage and be rooted in the strengths, resources, individuals and communities;
  • Pleasure, gender, satisfaction, intimacy, love, and desire are key concepts in a fuller understanding of sex and sexuality among gay men and other men who have sex with men, sex workers, transgender people, and of drug use among people who use drugs, and therefore in formulating more meaningful research, programmatic, and policy responses; and finally,
  • Researchers, prevention practitioners, healthcare professionals, and policymakers should consider structural, situational, and contextual factors in understanding HIV acquisition and transmission risk and in developing sexual health interventions tailored to the specific needs of gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people.

We therefore call upon advocates, healthcare providers, researchers, public health officials, and donors to:

  1. Stop chasing magic bullet solutions to HIV and end sloganeering about HIV drug coverage—instead, invest in carefully tailored combination approaches;
  2. Evolve primary prevention in a manner that seamlessly stitches together bio-medical, behavioral, community, and structural interventions, because these interventions lose their effectiveness without the others;
  3. Combine and tailor prevention approaches with consideration to acquisition and transmission dynamics that are specific to key populations—blanket approaches leave people behind;
  4. Imbue HIV primary prevention, care, and treatment with the power of community ownership and abandon top-down approaches;
  5. Remedy funding inequities by investing more substantively, strategically, and differentially in evidence-informed, rights-based, and community-led programs;
  6. Adopt a more nuanced understanding of gender that recognizes the complexity of identities and sexualities; and,
  7. Adopt community-endorsed, human rights-based principles of practice, starting with the Greater Involvement of People Living with AIDS/HIV (GIPA) principle.
Signed:

The Global Forum on MSM & HIV (MSMGF)
Global Action for Trans Equality (GATE)
IRGT: A Global Network of Transgender Women and HIV
The Global Advocacy Platform to Fast-track the HIV and Human Rights Responses with Gay and Bisexual Men (The Platform)
The Global Network of People Living with HIV (GNP+)
The Global Network of Sex Work Projects (NSWP)
The International Community of Women Living with HIV (ICW)
The International Network of People Who Use Drugs (INPUD)

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UNAIDS Must Prioritise Prevention In HIV Response. 28/7/2017

Published by AIDSALLIANCE

Shaun Mellors is the director of knowledge and influence at the International HIV/AIDS Alliance

A new report by UNAIDS highlights significant progress in the response to HIV globally, yet fails to emphasise the need to increase prevention work.

<p>Condom distribution through Link Up Uganda</p>Peer educator distributes condoms to youth in Naguru, Uganda © Peter Caton for International HIV/AIDS Alliance

The UNAIDS report (released 20 July) states that more than half of all people living with HIV worldwide are now receiving HIV treatment, and AIDS-related deaths have dropped by 36 percent since 2010. Collaborative efforts by all of us – communities, governments and multilateral agencies – have led to this changing reality for many people living with HIV.

Yet the number of new HIV infections remain unacceptably high. Despite the many achievements noted in the report, prevention is not on track. There were more than 1.8 million new infections in 2016 (down from 2.1 million in 2015), while the estimated numbers of new infections among key populations – such as sex workers, gay and other men who have sex with men, transgender people and people who inject drugs – continue to rise.

Lack of Global Leadership

More than 300,000 adolescent girls and young women, mostly in sub-Saharan Africa, were newly infected with HIV (UNAIDS). Globally agreed prevention targets are way off track because, often, HIV prevention services are still not targeting the right people in the right places.

There is a lack of political will to invest in systems that reach the populations who are most vulnerable and most stigmatised. Investment in HIV prevention programmes remains woefully inadequate and there is a visible lack of global leadership around HIV prevention.

If we are serious about achieving epidemic control and ending AIDS as a public health threat by 2030, we cannot afford to loosen our hold on any part of the global response, let alone one as important and underserved as preventing new infections.

People - Cntered Health Services

The World Health Organisation’s framework for integrated and people-centred health services offers the opportunity to shape combination HIV prevention services in a way that is centred around the person and their needs. As the primary custodians of their own health people need to be empowered to take effective decisions about their health, and communities to actively engage in the delivery of primary healthcare services.

A person-centred approach acknowledges that people’s prevention needs change over the course of their lives, and that those changes are due to a range of factors related to the individual (age, gender, lifestyle, economic situation) and to the surrounding environment (cultural norms, location, discriminatory laws, physical security).

A person-centred approach to delivering combination HIV prevention at scale means that planners and implementers must recognise:

  • people are best placed to decide which HIV prevention method is right for them when they are offered differentiated and integrated choices;
  • communities are effective partners in the delivery of prevention and care services, and can help alleviate overburdened health facilities;
  • strategic efforts to address the structural drivers of HIV transmission should be part of combination prevention packages.

Community - led Response

By directly providing combination HIV prevention packages at community level and using effective referral systems, communities can stimulate demand and increase people’s opportunities to access a broad range of services and remain healthy.

For prevention efforts to be effective it is critical to include people living with HIV. This will help strengthen community systems, enabling communities to partner more closely with formal health services and contribute to building resilient, equitable and sustainable systems for health. Those systems would be better equipped to tackle not only HIV, but sexual and reproductive health and rights, malaria, tuberculosis and non-communicable diseases.

In October, UNAIDS will launch the Global Prevention Coalition in Nairobi, Kenya. The Alliance is an active member and contributor to this coalition, and we call upon UNAIDS and civil society organisations to put prevention right at the core of our movement to end AIDS.

The coalition must be bold and visionary in its agenda. We believe that:

  • HIV prevention should apply a person-centered approach.
  • The roles of civil society and community organisations as valuable partners to HIV prevention services delivery need to be fully recognised and adequately resourced.
  • Resources should be available for the full set of combination HIV prevention interventions and measurable targets should be set for all programme components, including behavioural and structural interventions.
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People Living With Disabilities Are at Higher Risk. 14/6/2017

Published by WHATSUPHIV

THABO MOLELEKWA writes: People living with disabilities are often left out of HIV programs despite the fact that they are disproportionately at risk. Treatment Action Campaign activists say that, unless this is addressed, South Africa will struggle to reach the 90-90-90 target set by UNAids.
 
The idea is that by 2020, 90% of people who are HIV infected will be diagnosed; 90% of people who are diagnosed will be on antiretroviral treatment and 90% of those who receive antiretrovirals will be virally suppressed. 
 
Rosemary Brown is one of the researchers on the HPTN 071 (PopART)  study,  a randomized trial evaluating an HIV prevention package in 21 communities in Zambia and South Africa.
 
Brown told the SA Aids conference that the study had shown that people living with disabilities were at higher risk of acquiring HIV. The reason for this was that “few HIV programs sufficiently address the needs of people with disabilities.” 
 
Getting access to HIV testing and treatment services was often challenging for people with disabilities. “Scale up of HIV testing and treatment services for people with disabilities requires decentralisation through community based services,” she said.
 
TAC’s Portia Serote  revealed that children in informal settlements who lived with disabilities and were unable to attend school were also missing out on vaccination against the human papilloma virus, which can cause cervical cancer. This was because government was only carrying out vaccinations in school when girls were in Grade 4.
 
“Those children are at risk of being raped. They are therefore vulnerable to all kinds of diseases but they are always left out of HIV programs.” said Serote.
 
 “If the government continues to exclude the people living with disabilities, it is not likely that the country will reach the 90-90-90 goal,” she said.
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New Discussion Paper on HIV Prevention. 23/6/2017

Published by EANNASO

The Global Fund to Fight AIDS, Tuberculosis and Malaria is a major financier of national HIV responses and a vital source of prevention investments. By 2015, the Global Fund supported 3.6 million pregnant women to receive ARV prophylaxis to prevent transmission to their unborn children and distributed 5.3 billion condoms.

In its new strategy (2017-2022), the Global Fund has set ambitious new targets for HIV prevention. For example, the Fund aims to achieve a 38% reduction in new infections over the 2015-2022 period, including a 58% reduction in HIV incidence in adolescent girls and young women aged 15-24.

Investments in HIV prevention are particularly vital for key and vulnerable populations, who face a disproportionate burden of disease as well as disproportionate barriers to accessing services.

But is the Global Fund investing enough in HIV prevention to meet its targets?

The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that ending AIDS by 2030 will cost about $25 billion a year. About a quarter (26%) of this amount is required for HIV prevention.

ICASO and EANNASO examined funding requests and signed grant agreements from a sample of 25 African countries over the 2014-2016 funding cycle to determine how much the Global Fund is investing in HIV prevention interventions.

The aim of this discussion paper is to contribute to civil society and community groups’ advocacy efforts to increase Global Fund investments in HIV prevention interventions during the 2017-2019 funding cycle.

You can access the resource here

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The Rate of HIV Infection Remains Greater than the Number of People Initiating Treatment. 3/12/2016

Published by TIMESLIVE

This imbalance will stop the eradication of HIV/AIDS. It begs for increased investment into primary prevention.

Primary prevention caters to people who are HIV negative. It aims to reduce their chance of becoming infected. There are certain populations, now referred to as key populations, in whom the burden of infection is disproportionately high. These include men who have sex with men, sex workers, people who inject drugs, transgender people, and, in sub-Saharan Africa, adolescent girls and young women. Primary prevention should be tailored, and scaled up, for these groups.

Primary prevention can be provided in a number of ways. But the most exciting new innovation is pre-exposure prophylaxis (PrEP). PrEP is the use of anti-retrovirals by HIV-uninfected people to prevent HIV transmission. It is commonly given as a daily pill (sold as Truvada) to be taken orally in the same way that contraceptives are used to prevent pregnancy or antimalarial pills are taken before travelling to a high malaria risk area.

Numerous clinical trials and demonstration projects in diverse settings and populations have been conducted with PrEP all showing that it works. PrEP is easy to take. It is also largely side effect free and safe. There is one hitch: it has to be taken consistently at the time of HIV exposure. Adherence has been oral PrEP’s biggest stumbling block.

That’s why a huge effort is being made to find alternative ways to take PrEP. New formulations in the pipeline include long-acting injections, monthly vaginal rings, implants and topical gels, films and dissolving topical pills. The hope is that new formulations will make PrEP more accessible and convenient, particularly for adolescents and young people who may find a daily intervention cumbersome.

Adherence is PrEP’s Achilles’ heel

Adherence is key. To block HIV transmission PrEP must be “in the system” at the time of HIV exposure. Its effectiveness decreases rapidly when this “effective coverage” is inconsistent. Good adherence gives almost 100% HIV transmission prevention. Poor adherence results in little to no protection.

This is why, where possible, a daily dose during times of risk is recommended. But this may be difficult to achieve for some.

In PrEP trials the following reasons were given for poor adherence:

  • fear/experience of side effects,

  • fear of interactions with alcohol and other drugs,

  • forgetfulness,

  • dislike of pill-taking, and

  • fear of the discrimination associated with taking an anti-HIV pill.

Alternative dosing strategies using longer acting formulations and PrEP delivery methods may well be another way to increase PrEP effectiveness.

New PrEP frontiers

Topical gels, which can be applied pre and post sex to rectal and vaginal tissue, were the first alternative formulations to be tested. But the results in women have been inconsistent. This formulation still holds promise in men who have sex with men although efficacy trials haven’t yet been conducted.

An alternative strategy is a monthly vaginal ring, which in its current form contains slow-release dapivirine (another antiretroviral). Two large phase III clinical trials have demonstrated that the ring is effective and can reduce the chance of HIV infection by 27%-31%. In a sub analysis of different ages, older women once again fared better than young women.

The benefit of the vaginal ring is that there are less side effects because the drug is released locally and only a small amount enters the blood stream. The other huge plus is that women are encouraged to insert and forget, only changing the ring on a monthly basis. The obvious catch is that this is only suitable for women and vaginal intercourse.

The vaginal ring is undergoing further investigation.

Another tool that is being investigated and could overcome the need for a daily pill is a long-acting monthly injection. An injection of the antiretroviral cabotegravir (cabotegravir LA) has been shown to be very effective at lowering viral loads in people being treated for HIV when administered every two months.

Also being investigated are dissolving vaginal films – a bit like the breath fresheners that can be bought over the counter – as well as quick dissolving pills.

Perhaps most exciting of all is the prospect of an implant, a small rod which can be surgically placed just under the skin and will be able to slowly release antiviral protection over months.

Finally, new formulations are currently being investigated that will combine treatment for both contraception and preventing sexually transmitted infections. It is hoped that these multifunctional preventions may further encourage people to consistently use these products.

A new challenge to the field is how these new clinical trials can be efficiently designed. To qualify for first-line use of PrEP, new pills and products will need to have improved or equivalent efficacy compared to the current oral PrEP. And they would need to have reduced or equivalent side effects. All these formulations and delivery methods are still in the early stages of testing, but look to be out on the market within the next two to five years depending on their success.

PrEP for Africa

In sub-Saharan Africa, teenage girls and young women are most at risk of HIV infection. There are 2000 new infections in this group every week. These women are vulnerable because of the high prevalence of both gender-based violence and the commonality of age-disparate relationships and transactional sex. These conditions can make it difficult for women to negotiate safer sex practices. PrEP would enable these women to protect themselves in advance, without their partner’s knowledge or consent.

Kenya and South Africa are the only two African countries that have granted regulatory approval for PrEP. Neither have started to roll it out.

New interventions can only be useful if deployed and scaled up to the populations most in need. This raises questions of cost versus impact. It is hoped that new formulations and delivery systems will enhance choice, encourage use, and provide a platform from which PrEP roll out can be advocated.

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Closing the HIV Prevention Investment Gap. 28/11/2016

Published by UNAIDS

Despite the progress made against HIV over the past 15 years and the availability of proven prevention and treatment methods, the annual number of new HIV infections among adults has remained static, at an estimated 1.9 million a year since 2010. Moreover, there has been resurgence of new HIV infections among key populations in some parts of the world.

Inadequate investments in prevention and unfocused investments that do not reach the most affected populations and locations are among the reasons for the prevention gap. An analysis of four countries in different regions and with different types of epidemic found that the funding of effective and focused primary HIV prevention programmes was low—6% of total HIV investments in Brazil, 4% in Cameroon, 15% in Myanmar and 10% in South Africa. Country allocations for HIV primary prevention (excluding mother-to-child transmission of HIV and voluntary HIV testing and counselling) by the United States President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria have accounted for roughly 15% of total HIV expenditure.

With funding for prevention falling behind funding for treatment, fewer than one in five people at higher risk of HIV infection today have access to prevention programmes. UNAIDS modelling has shown that investing around a quarter of all the resources required for the AIDS response in HIV prevention services would be sufficient to make possible a range of prevention programmes, including condom programmes, pre-exposure prophylaxis, voluntary medical male circumcision, harm reduction, programmes to empower young women and girls, and mobilizing and providing essential service packages for and with key populations.

Investing more in prevention will also support treatment programmes to achieve their targets. Prevention programmes—including providing HIV information, condom distribution and outreach to young people and key populations—are often the first entry point for individuals to HIV testing and treatment. Community peer-led prevention programmes are also critical for reducing stigma and discrimination. Meanwhile, expanded access to treatment gives people at higher risk choices and encourages them to find out their HIV status; this, in turn, provides the opportunity to retain people who test negative in ongoing prevention programmes. Reducing the number of people who acquire HIV and will need treatment makes antiretroviral therapy programmes more sustainable.

In December 2015, the UNAIDS Executive Director, Michel Sidibé, called for investing a quarter for HIV prevention. In June 2016, United Nations Member States committed in the 2016 Political Declaration on Ending AIDS to ensuring that financial resources for prevention are adequate and constitute no less than a quarter of AIDS spending globally on average.

A number of countries have already taken action to increase their domestic funding for HIV prevention, including Namibia, which has committed to investing 30% of its HIV budget in preventing HIV among adults and children.

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Six Ways ARVs Can Help to End AIDS by 2030. 18/11/2016

Published by BHEKISISA

Science knows more than ever about how to use HIV treatment to prevent new infections but will it be enough to end Aids?

The HIV world today looks completely different than in 2004 when the South African government introduced free HIV treatment. The drugs are easier to take, have fewer side-effects and can also be used to prevent people from getting infected with HIV. Here's what we've got and how we can use antiretrovirals (ARVs) to help end Aids by 2030.

The three-in-one pill
The most commonly chosen regimen for treatment is an all-in-one-pill, or fixed dose combination, that contains the antiretroviral drugs tenofovir, emtricitabine and efavirenz. These pills suppress HIV in an infected person's body so well that they allow for the immune system to be restored. As a result, people with HIV fall sick less often and live for longer.

This three-in-one pill has predictable side effects that are usually minor. Because people only have to take one instead of three pills, they are also more likely to adhere to the treatment. The ARVs contained in the three-in-one pill also have few side effects – this also helps people to adhere to their treatment.

The new ARV 'kid' on the block
The latest ARV to watch is a drug called dolutegravir. It fits into a novel class of medications known as integrase inhibitors. They prevent HIV from integrating its genetic material into human cells, thus stopping HIV in its tracks. Dolutegravir may offer considerable advantages over current best-treatment. A 2016 study in The Lancet has shown dolutegravir to be even better than efavirenz, one of the ARVs in the three-in-one pill, at suppressing HIV. It also causes fewer side effects, is easy to take and should cost the same, or potentially even less, than other available ARVs. It is likely that the health department will incorporate dolutegravir into its treatment programme.

Test and treat
Until recently, people with HIV only started treatment when HIV had caused detectable immune system damage. This was measured by a CD4 count, which is an indication of how weak or strong someone's immune system is – the lower the count, the less well the immune system functions.

But two recent research studies, the Start and the Temprano trials, both of which were published in 2015 in the New England Journal of Medicine, have shown the best way to treat HIV infection is for someone to start on ARVs as soon as possible after being diagnosed, regardless of the person's CD4 count. Early treatment keeps positive people much healthier. In September, South Africa's health department started to offer everyone who tests HIV positive immediate, free access to ARVs.

ARVs can halt the transmission of HIV
It has now been proven that, because ARVs decrease the amount of virus in HIV-positive people's bodies, they make people far less likely to transmit the virus. In fact, 96% less likely, according to the HPTN 052 study, which was published in the New England Journal of Medicine this year. This is known as treatment as prevention, or Tasp, and is a massive step forward.

Previously, HIV prevention centred on preventing body fluids from being transferred during sex with the use of condoms or choosing not to have penetrative sex. Tasp has added one more very effective option to the prevention menu.

An HIV prevention pill
Pre-exposure prophylaxis, or PrEP, in the form of an HIV prevention pill, is one of the most exciting developments in the HIV prevention world. It has the potential to be an extremely powerful tool in turning the tide on the epidemic – if it's taken daily, it can reduce someone's chances of getting infected with HIV between 44% and more than 90%, depending on how well it's taken, studies have shown.

The HIV prevention tablet is a two-in-one pill: it consists of two ARVs, tenofovir and emtricitabine, which is taken daily by people who are HIV negative, but likely to be exposed to HIV. For example, PrEP could be used by an HIV-negative woman whose husband is HIV positive, but not yet on treatment. PrEP is of great benefit to groups in society who are at particularly high risk of contracting HIV: discordant couples, where one person is HIV positive and the other negative, sex workers, men who have sex with men and young women.

In June, the health department started to provide PrEP for free to 10 sex worker programmes. PrEP is also available for men who have sex with men at two state-sector clinics operated by the health department in partnership with the Anova Health Institute's Health4Men initiative. PrEP is also available in the private sector – a GP can prescribe it.

PrEP might have some drawbacks aside from the need for daily pill taking. A small number of people, about one in 10, develop gastric side effects, such as nausea or bloating, which usually self-resolves within a few weeks. In rare cases, PrEP can affect organs such as the kidneys. A few blood tests are therefore required to ensure that PrEP is being well tolerated by the body and is not causing any unexpected toxicity.

PrEP does not protect against any other sexually transmitted infection besides HIV. People who use PrEP in lieu of condoms might therefore be at risk of sexually transmitted infections, even though their risk of HIV is massively reduced. It is best to use PrEP together with condoms for maximum sexual protection.

An HIV emergency pill – but you have to take it for a month
Postexposure prophylaxis, or PEP, is not new. This is when HIV-negative people take ARVs after they think they've been exposed to HIV, for instance after a condom has broken or following a rape incident. PEP has been around for at least a decade, but knowledge and use of it remains unfortunately low.

PEP consists of a one-month course of three types of ARVs that can reduce the risk of HIV infection by about 80%, according to a 2016 study in the journal Clinical Infectious Diseases. It has to be taken within 72 hours after exposure to HIV – the sooner it's taken the more effective it is. It is available for free at state clinics to rape survivors and other people who have had a potentially high-risk exposure to HIV.

 

PEP is sometimes difficult to access as it is often required after the usual operating hours of daytime clinics or GP practices. This, together with a lack of knowledge among both potential PEP users and providers, creates a structural barrier to accessing PEP. The fact that PEP is sought after HIV exposure, in an emergency situation, is also a hindrance as anxiety and distress may affect people's motivation to seek PEP.

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New HIV Prevention Products Will Need Marketing and Effective Health Services to Reach the People Who Need Them. 24/10/2016

Published by AIDSMAP

There is a naivety among many HIV prevention researchers and advocates about the steps needed to introduce and implement new HIV prevention technologies such as oral pre-exposure prophylaxis (PrEP), vaginal rings and vaccines, according to speakers at the HIV Research for Prevention (HIVR4P 2016) conference in Chicago last week. Developing an effective prevention method is the easy part, they suggested – ensuring the product reaches end users can be more challenging.

Although conferences tend to pay little attention to well-established prevention interventions such as male circumcision, female condoms and programmes to prevent mother-to-child transmission (PMTCT), there are lessons to be learnt from their implementation, speakers said.

In each case, concerted efforts, marketing insights and functional health systems have been required to bring the interventions to scale. When these have been absent, coverage has been limited.

Examples from male circumcision

Karin Hatzold of Population Services International (PSI) described lessons learnt from the introduction of voluntary medical male circumcision in African countries. The procedure has been recommended by the World Health Organization and UNAIDS since 2007, but implementation has been patchy. While just under 12 million boys and men had been circumcised in 14 priority countries by the end of 2015, this was only 56% of the global target that had been set for completion by that time.

Focusing on Zimbabwe, she said that a 2013 survey showed that 68% of men were aware of circumcision as an HIV prevention method, 66% were interested in circumcision for themselves and 64% said they intended to get circumcised – but only 11% had actually been circumcised.

PSI used qualitative research and insights from marketing in order to examine why there was such a large gap between intention and action. Through this they developed a model to outline the path that men undertake on their journey to circumcision and to identify possible marketing interventions.

This highlighted that even after men had learnt about male circumcision and made an internal commitment to be circumcised, another stage followed in which men anticipated the procedure and the healing process. Men often experienced ‘cognitive dissonance’ between their belief in the long-term benefits of circumcision (protection from HIV and sexually transmitted infections [STIs]) and concern about its short-term consequences (pain during healing, abstinence from sex and time away from work). This dissonance is strongest in adult men and is less common among adolescents.

Quantitative surveys were used to segment the male population of Zimbabwe according to their needs, attitudes and behaviours in relation to male circumcision.

Twenty-one per cent of uncircumcised men were described as circumcision ‘enthusiasts’. They believe in the procedure’s benefits but still have some anxieties. This group has the greatest potential for interventions, as they are ready to go for circumcision, but need some additional support to overcome cognitive dissonance. They may be influenced by peers and social pressure.

Nineteen per cent of uncircumcised men are described as circumcision ‘neophytes’. They have not yet decided whether they want to be circumcised or not. They have a need for more information about circumcision and interventions to strengthen motivation.

Seventeen per cent are seen as ‘embarrassed rejecters’. They have mostly negative attitudes towards circumcision and minimal motivation. The attitudes of their peers could have the greatest influence on them.

Other population segments are ‘scared rejecters’ (16%) and the ‘highly resistant’ (22%). As there is less potential to convince these groups, they are a lower priority for interventions. There is also a group of men who have positive attitudes to circumcision like those of the ‘enthusiasts’ but who are less open to social pressure. As this is only 6% of uncircumcised men, they are also not a priority for interventions.

The research suggested interventions which can help Zimbabwean men move along the path towards circumcision. Outreach workers and marketing materials now provide honest and detailed information about the procedure and healing process, so as to more effectively deal with anxiety and cognitive dissonance.

In order to counteract short-term negative consequences, some more immediate benefits are now more clearly communicated. As well as better hygiene, there is also a focus on sexual appeal to female partners. Women may be more sexually satisfied, due to intercourse lasting for longer.

Enthusiastic clients who have already been circumcised are encouraged to act as advocates for the procedure, so as to tap into the influence of peers and to provide social support for men considering the intervention. Marketing materials have been created to help trigger these kind of conversations.

Bertran Auvert of the French National Institute of Health and Medical Research also outlined challenges and successes in promoting male circumcision. His example came from Orange Farm, a township near Johannesburg, South Africa, where the proportion of adult men circumcised rose from 13 to 55% in the three years from 2008, but then stopped rising. As in Zimbabwe, he said that the challenge was not to convince men of the benefits of circumcision, but to help men take the final step and attend a circumcision clinic.

An intervention he and his colleagues have recently piloted started with household visits, in which men were offered one-to-one discussions based on the motivational interviewing technique (a goal-orientated style of counselling, which aims to help clients overcome ambivalence). Men could have up to three sessions, but most decided to be circumcised after one motivational interview of around an hour.

Financial compensation of around USD$18 (equivalent to two or three days’ wages) was offered to compensate for the time the procedure and its recovery takes. This support was only offered during the nine-week period in which the pilot was run – the deadline also incited men to take action.

Prior to the intervention, 57% of men in a random household sample were circumcised. The intervention raised rates to 81%.

Among men who were circumcised, 83% said they wouldn’t have done it without the motivational interviewing and 40% wouldn’t have done it without the financial compensation. 

Examples from female condoms and the prevention of vertical transmission

Anne Philpott of the UK Department for International Development gave the example of the female condom, a product that was initially presented as a ‘magic bullet’ that would transform HIV prevention. Unrealistic expectations lead to disappointment, she suggested.

Globally, investment in female condom programming has been minimal, but there have been some success stories. Uptake of the female condom was initially low in Zimbabwe, so Population Services International redesigned their strategy. Hair salons became a key distribution point and hairdressers were given training in interpersonal communication skills, so that they could explain the benefits and demonstrate the use of the female condom. Currently, 1500 hair salons distribute 1.6 million female condoms each year.

She pointed out that while we often assume that we need to achieve something close to 100% uptake of an intervention, just having 5% or 10% of people consistently using an effective product can have a significant public health benefit.

Rangsima Lolekha of the Centers for Disease Control and Prevention in Thailand outlined the interventions that have succeeded in bringing down Thailand’s rate of vertical transmission from HIV-positive mothers from 24.2% in 1994 to 1.9% in 2015. As the science and international guidelines have progressed every few years, there has been a succession of policy changes. For them to be comprehensively implemented, it has been necessary to build consensus among local clinicians and local opinion leaders. Cost-effectiveness analyses and guidelines based on the Thai context have been crucial to this, she said.

During questions and answers, Chewe Luo of UNICEF noted that having Thai researchers centrally involved in the science of preventing mother to child transmission has been crucial to having buy-in within the country. But she asked whether enough was being done to ensure that the learning in one country is shared with its neighbours (for example, between Thailand and other south-east Asian countries). Strengthening networks to support south-to-south learning could help innovations be implemented throughout regions, rather than in just a few select locations, she suggested.

Timothy Mastro of FHI 360 praised the Thai example and pointed out that none of the potential prevention products discussed at the conference “will happen with any degree of coverage unless we have functional health systems”. International donors need to strengthen health systems that will be ready to deliver new interventions, rather than create new vertical systems for each innovation, he said.

Nomita Chandhiok of the Indian Council of Medical Research said that, within health systems, it was important for multipurpose technologies not to be seen as only being relevant to one issue. When female condoms have been rolled out as an HIV prevention tool, support and buy-in from family planning services has been limited. Similar issues may be faced by vaginal rings which provide HIV prevention, STI prevention and contraception.

Anne Philpott said that successful implementation required thinking about ‘the programme’ rather than just ‘the product’. Innovations should be provided through existing delivery platforms, building on existing experience. “Don’t be lured by the promise of the new,” she advised prevention researchers and advocates.

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Prevention Gap Report. 7/2016

Published by UNAIDS 

Remarkable scale up of antiretroviral therapy has put the world on track to reach the target on AIDS-related deaths. However, problems remain with HIV prevention. Declines in new HIV infections among adults have slowed, threatening further progress towards the end of the AIDS epidemic. Since 2010, the annual number of new infections among adults (15+) has remained static at an estimated 1.9 million. Efforts to reach fewer than 500,000 new HIV infections by 2020 are off track. This simple conclusion sits atop a complex and diverse global tapestry. Data from 146 countries show that some have achieved declines in new HIV infections among adults of 50% or more over the last 10 years, while many others have not made measurable progress, and yet others have experienced worrying increases in new HIV infections. 

Download report.

 

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Get ‘On Track’ with ‘Fast Track’ to Prevent HIV 04/04/2016

UNAIDS and the Alliance have produced an advocacy tool to support community-led organisations make the case for greater investment in HIV combination prevention at national, district and local levels.

The context is urgent. In less than 100 days, the 2016 United Nations General Assembly High-Level Meeting on Ending AIDS will take place in New York (6-10 June). The Outcome Document which will be agreed by governments will be of critical importance to accelerate the response to HIV over the next five years, and set the world on course to end the AIDS epidemic by 2030 as part of the Sustainable Development Goals. 

The time to act is now

Yet in the heart of our communities, among those people for whom life with HIV is their daily reality, the end of AIDS is still a distant hope. Whilst bold international targets have been set, meeting them requires a rapid acceleration in treatment and prevention programmes, rooted in human rights and gender equality and centred on people living with or affected by HIV.

Sadly, the numbers are not yet adding up. Despite an increasing array of prevention tools in recent years, there has only been a slow decline in new adult HIV infections. Progress in combating HIV has been very uneven. Young women in eastern and southern Africa continue to be highly vulnerable to HIV and across the world key populations have been inadequately reached by programmes to prevent and treat HIV. These gaps need to be acknowledged and urgently addressed.

According to Matteo Cassolato, the Alliance’s senior advisor on HIV prevention “We do not under-estimate how difficult it is for civil society to advocate for key population prevention programmes in countries where there is little to no political commitment and a lack of adequate financial resources.  But with the right information and clearer, evidence-based strategies, national governments can be pushed harder and community-led organisations can well placed to monitor how well they are doing.”

About the brief

That’s why we have collaborated with UNAIDS to produce a new brief to support community-led organisations advocate for combination HIV prevention and shape their country’s HIV programmes.

Advancing combination prevention follows on from the 2015 UNAIDS reference paper, Fast Tracking Combination Prevention.

It covers why it is important to act now, why a combination prevention approach is so vital, and gives the ‘A-B-C’ of what countries need to do – from calling on prevention programmes to be grounded in evidence, to advocating for national plans to achieve scale and coverage, and finally, demanding funds for HIV prevention, including for community-led responses. 

Four community-led case studies are included – focused on harm reduction in Kenya, work with girls and young women in Uganda, improving health services for MSM in Paraguay, and prevention among sex workers in India.

The brief is available to download and printed copies will be distributed at civil society led events over the coming months. This will ensure community-led organisations are in a position to hold governments to account following the commitments they make at the High-Level Meeting in June. 

Join the campaign

The new brief amplifies the UNAIDS campaign - Quarter for HIV Prevention (#quarter4HIVprevention) - which aims to recapture imagination and hope for HIV prevention. It calls for countries to examine how much they invest in HIV prevention. You can join the conversation on social media.

FACEBOOK: A Quarter for HIV Prevention Facebook Group

TWITTER: @QtrPrevention  #Qtr4HIVprevention

Our advocacy efforts at the UN High-Level Meeting on AIDS in June are supported through a new strategic partnership, between Aids Fonds/STOP AIDS NOW!, the International HIV/AIDS Alliance and the Dutch Ministry of Foreign Affairs who will work towards ending the AIDS epidemic in countries that are most affected by HIV. Together with local civil society organisations we will change policies and build institutional capacity to lobby and advocate beyond the 5-year life-cycle of the programme.

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Alvaro Bermejo: Linking prevention and treatment—the only way to stop HIV infections. 4/5/2015

Published at BMJ
Written by BMJ
29 April 2015


While new global HIV infection targets, including the recently adopted UNAIDS Fast Track targets—which aim for no more than 500 000 new infections among adults by 2020 and no more than 200 000 by 2030—have been well received, they are insufficient on their own to re-energize and guide country efforts in their national HIV response.

We have a set of agreed programming targets (90:90:90) to guide countries in their efforts to stop those infected with HIV from transmitting the virus to others and from dying of an AIDS related illness. Unfortunately, the same specificity has not yet been applied to the Fast Track targets to prevent new HIV infections. We need a new framing —and indicators to go with it—that links treatment and prevention in a way that makes sense, and which motivates countries to meet their targets.

Between 2010 and 2013, the number of new infections among adults only declined from 2.1 million to 1.9 million, 800 000 short of the 50% reduction that the world had committed itself to achieving by 2015.

Limited success in this area is largely owing to the fact that our current framing means we unavoidably end up contrasting HIV treatment with broader prevention. No formulation that pits preventing new infections against treatment will get traction, and it makes little scientific sense.

Understanding the dynamics of the HIV epidemic in the unique contexts of each country (down to the regional, district, and county level), and choosing the appropriate interventions for the right people in the right places, needs to remain the guiding principle. We need strategies that make sense of meeting the complex needs of people in the diversity of their daily lives.

A new framing that looks from the perspective of the person at risk, of each of us, might help unify and re-energise our approach. In some cultures this might explicitly mean each of us, as individuals, taking ownership and thinking through what actions we each need to take. In others, this might be more of a collective “me” that is based on shared actions among family or community groups.

A framing that links together prevention and treatment, and that truly starts from a self or collective notion of “me,” would call for each of us to:

Demand HIV services that will help stop me getting infected by HIV; or, if I am infected, from getting ill or further transmitting the virus; or, if I am ill, from dying of an AIDS related cause. We have not succeeded in mobilising demand for many proven interventions, whether condoms, circumcision, pre-exposure prophylaxis (PrEP), HIV testing, care, or early antiretroviral treatment. Stigma, violence, criminalisation, risk perception, gender inequality, and sex negative messaging in environments that lack a positive promotion of sexuality are key factors limiting demand—and they are common to HIV testing, treatment, and prevention. The interventions we need to turn this around are also common.

Access HIV services. Act on the knowledge of what and where services are available and access them. Where demand is strong, delivery barriers are getting in the way of access. We have made enormous progress in delivering HIV testing and antiretroviral therapy through clinical facilities; this has saved many lives. So too have innovations that have enabled those communities most vulnerable to contracting HIV to act as leaders and implementers in the provision of prevention and treatment services through peer outreach and support. Scaling services up to have treatment not just save lives, but stop new infections, will require a delivery model that reaches out into the community, where we have failed so far at delivering the quality HIV services that will stop new infections.

Use consistently. Consistent use (adherence) of whatever works for me to protect me from getting infected, from getting ill, or from infecting others. We have plenty of studies to show that adherence is as critical for PrEP, or to achieve viral suppression, as it is for condoms. Investments and mechanisms to strengthen consistent use—such as peer support and mobile technologies—will work across testing, treatment, and prevention.

The Global Fund, UNAIDS, and a number of other major global health players are currently all in the process of designing their post 2015 strategies. Framing both the narrative and the investments around mobilising demand, service provision, and adherence will drive optimum scale-up of interventions aimed at stopping new HIV infections, stopping AIDS related deaths, and stopping stigma and discrimination. These need to be linked. Tracks will continue to converge in the future as further treatment scale-up will require more patient centred, community delivery mechanisms and clinics will have a growing prevention agenda (PrEP and circumcision) to deliver. The sooner we recognise this, the more likely that our strategies will succeed.

Alvaro Bermejo is executive director of the International HIV/AIDS Alliance, a unique alliance of national civil society organisations dedicated to ending AIDS through community action.

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CAPRISA designated a Centre of Excellence for HIV prevention. 23/04/2015

Published at UNAIDS
16 April 2015


 

The Centre for the AIDS Programme of Research in South Africa (CAPRISA) at the University of KwaZulu-Natal has been designated as a National Research Foundation Centre of Excellence for HIV prevention by the South African Department of Science and Technology. The announcement was made on 14 April at the opening of the annual CAPRISA Scientific Advisory Board meeting, held in Durban, South Africa.

CAPRISA, a UNAIDS Collaborating Centre for HIV Research and Policy, has been recognized for its pioneering work in cutting-edge research as well as for its training programme for doctoral and medical students.

Speaking at the opening of the meeting, Luiz Loures, Deputy Executive Director of UNAIDS, emphasised the critical role CAPRISA plays in global efforts to end the AIDS epidemic by 2030.

The need to find new ways to prevent new HIV infections among young women and girls between the ages of 15 and 24 in South Africa emerged as a clear priority during the meeting, since they remain at a much higher risk of HIV infection than boys and young men of the same age group. The participants agreed that scientists have a key role to play in understanding and addressing the gender gap, in partnership with government and civil society. 

Established and emerging scientists from around South Africa presented innovations in HIV and tuberculosis-related science at the meeting that will provide a direction for current and future scientific research led by CAPRISA.

At a press conference, CAPRISA also announced that Nobel Laureate Françoise Barré-Sinoussi, was appointed to its Scientific Advisory Board for a three-year term. Along with fellow board members, she will guide and advise CAPRISA on research ideas and plans.

Quotes

“UNAIDS has outlined a critical Fast-Track strategy to end the AIDS epidemic as a public health threat by 2030. Countries will need powerful tools to maximize accountability and ensure that no one is left behind. South Africa is committed to support and conduct scientific research to make sure that we achieve our targets.”

Naledi Pandor, Minister of Science and Technology, South Africa

“We need a convergence of science, commitment, activism and funding to reduce new HIV infections among young women and girls. No country can work in isolation and we need to think on a global level to address this challenge.”

Salim Abdool Karim, Director of the Centre for the AIDS Programme of Research in South Africa

“The progress we made in the AIDS response undoubtedly brought hope to people. However, we need science to keep this hope alive. UNAIDS is proud to be working closely with CAPRISA. Together with UNAIDS, research institutes like the Centre for the AIDS Programme of Research in South Africa are critical to ensuring that science is working for and with people, especially those being left behind by the current AIDS response.”

Luiz Loures, UNAIDS Deputy Executive Director

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Community-Based HIV Prevention Spending Reaps Huge Savings. 17/07/2015

Published at AidsMeds
9 July 2015


Investing in community-based HIV prevention programs translates to a five-fold savings in avoided costs associated with treating the virus, according to a study of such programs in Ontario, Canada. Publishing their findings in AIDS and Behavior, researchers analyzed HIV infection rates and health care spending in Ontario between 1987 and 2011.

Community-based HIV prevention programs have prevented more than 16,000 HIV infections in Ontario over the past 25 years, saving the province’s health care system some 6.5 billion Canadian dollars. The estimated lifetime HIV treatment cost in Canada is about CA$287,000.

The researchers found that spending CA$1 on community-based prevention saves CA$5 in treatment costs.

To read a press release about the study, click here.

To read the study abstract, click here.

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High lifetime costs of treating HIV show importance of investing in prevention. 4/6/2015

Published at AIDSmap
Written by Michael Carter
27 May 2015


The lifetime cost for treating one HIV infection in the UK is almost £380,000, according to a model published in the online journal PLOS One. Switching to generic drugs once patents expired could reduce costs to just over £100,000. The investigators based their calculations on costs associated with treating a 30-year-old gay man infected in 2013 who lived to the age of 72 years. It was assumed that standards of HIV treatment and care were those specified in the 2012 edition of the guidelines of the British HIV Association (BHIVA).

“If 3,000 MSM [men who have sex with men] had been infected in 2013…and all were aged 30 years at infection then the future direct lifetime costs relating to HIV care amounts to approximately £1.1 billion,” write the authors. “Even with the future use of generics, the total sum remains in excess of £0.5 billion.” The authors believe these figures show the vital importance of investing in effective prevention strategies.

Thanks to improvements in HIV treatment and care, most patients with HIV in the UK and similar countries now have an excellent life expectancy. Researchers in the UK have calculated that, even after taking into consideration an increased risk of early death due to liver, kidney and heart disease and some cancers, a 30-year-old gay man with recent HIV infection would live until the age of 72 years.

As of 2013, there were 81,500 people accessing HIV care in the UK. The good life expectancy of people with HIV and continued high rates of new diagnoses – 6500 in 2013 – means that the number of people living with HIV in the UK is likely to increase significantly in coming years.

A team of investigators wanted to estimate the likely cost implications of the ongoing high rates of HIV infections in the UK. They hoped their findings would provide “valuable insights” for the evaluation of possible prevention initiatives.

They developed a model projecting the additional lifetime healthcare costs for gay and other MSM aged 30 years and infected with HIV in 2013. The model assumed no loss to follow-up and that standards and costs of healthcare remained as now. The first calculation was based on the use of patented drugs. The authors also estimated the impact of various strategies to reduce the cost of treatment and care – frequency of follow-up visits and CD4 cell monitoring; ritonavir-boosted protease inhibitor monotherapy for virologically suppressed patients; switching to generics after the patents on branded drugs expired. The authors performed 10,000 simulations.

The estimated mean lifetime cost of treating a single person was £360,800. With annual discounting of 3.5%, the cost was reduced to £185,000.

Reduced frequency of follow-up and monitoring all achieved cost savings, but the biggest price reduction was associated with switching to generic formulations – this reduced the estimated lifetime cost by half to £179,000, and with discounting the cost fell further to just over £100,000.

“In view of the high lifetime costs for HIV-positive individuals, there is large scope for preventative interventions to be cost-effective,” conclude the authors. “Our results show that for settings with good access to cART [combination antiretroviral therapy] and HIV care, it is imperative for investment into prevention programmes to be continued or scaled-up. Further reductions in drug prices by using generic antiretroviral drugs in place of patented drugs would reduce these costs considerably.”

Reference

Nakagawa F et al. Projected lifetime healthcare costs associated with HIV infection. PLOS One 10(4): e01205018, 2015.

 

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Scaling up cash transfers for HIV prevention among adolescent girls and young women. 26/01/2015

Published at UNAIDS
18 August 2014


 

Now a 19-year-old university student in South Africa, Noxolo Myeketsi started receiving a social welfare grant in 2005. Part of a state-run programme to assist poor households, the cash transfers allowed her to stay in school and her grandmother to buy food and pay their bills.

The grant changed Noxolo’s life for the better. Other girls turned to having sex, often with older men, in exchange for basic needs, and potentially exposed themselves to sexually transmitted infections and HIV.

“I believe that without the grant assistance, I would not have been able to make healthy decisions in my life. Maybe I would have ended up being a sugar daddy’s girl, like others from my area, or ended up contracting HIV,” Noxolo said.

Social protection schemes, including financial incentives, can make a difference in a number of ways. The World Bank reports that, globally, there is strong evidence that cash transfers improve the education, health and lifelong income of beneficiaries. 

“Cash transfer programmes work for HIV prevention and a host of other human development outcomes as well, and they are scalable,” said David Wilson, Director of the World Bank’s Global HIV/AIDS Program.

Studies conducted in South Africa show that small cash grants provided to poor households allow teenage girls to make safer sexual choices and can significantly reduce the number of new HIV infections. When psychosocial care and support are added to the cash, the results for girls are even better.

At the UNAIDS Programme Coordinating Board (PCB) meeting held in Geneva in July a thematic session was organized on addressing the social economic drivers of HIV through social protection, at which Noxolo spoke about the positive impact grants can have.

Following up on the PCB meeting, UNAIDS and the World Bank pledged to assist governments in the process of scaling up social protection programmes, including cash transfers, for HIV prevention in eastern and southern Africa, covering Botswana, Kenya, Lesotho, Malawi, South Africa, Swaziland, United Republic of Tanzania and Zambia.

“It is befitting that South Africa is the centre of the initiative because the country accounts for 23% of sub-Saharan Africa’s new HIV infections, 18% of the global HIV burden and has one of the world largest social protection programmes,” said Benjamin Ali, UNAIDS Country Director for South Africa.

Countries and partners will be urged to collaborate in a comprehensive review of social protection systems. Proposals to make such systems HIV sensitive include modifying age bands and other inclusion criteria to ensure that the groups most affected and at risk of HIV infection are covered, providing some cash directly to girls and young women and linking cash incentives to their adherence to HIV prevention and treatment programmes.

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Test-And-Treat Initiative Is A Means To Get Zambia And South Africa Closer To WHO’s HIV Treatment Targets. 23/03/2016

Published at POZ

16 March 2016


 

A study examining the effects of a household-based program offering HIV testing, linkage to medical care and immediate treatment for the virus has shown promise as a means of getting sub-Saharan African nations closer to the World Health Organization’s (WHO) targets for treatment and diagnosis, aidsmap reports. Researchers in the ongoing PopART (or HPTN 071) study examined the effects of such a home-based program in Zambia and Kwazulu Natal, South Africa.

 WHO has set an ambitious goal for nations to get, by 2020, 90 percent of their HIV population diagnosed, 90 percent of that group on treatment, and 90 percent of those on treatment virally suppressed. (In other words, 73 percent of all those living with HIV would have a fully suppressed viral load.)

Interim findings from the first round of the study, a pilot program in seven communities in which participants were recruited between November 2013 and mid-2015, were presented at the 2016 Conference on Retroviruses and Opportunistic Infections (CROI) in Boston.

The community-randomized trial is examining the effects of three methods: following the standards for HIV treatment according to national guidelines; an initiative that includes HIV prevention efforts and otherwise follows the national guidelines for HIV treatment; and an initiative that includes the same HIV prevention package and also offers treatment to individuals regardless of their CD4 levels.

In this first round of the study, the home-based testing program diagnosed 12,840 adults in Zambia and 3,300 adults in South Africa. About half of these individuals already knew they were HIV positive and were on treatment for the virus. After those who were not on treatment were referred to medical care, 58 percent of those in South Africa had begun taking antiretrovirals (ARVs) within 12 months, as had 53 percent of those in Zambia.

A combination effort that followed national treatment guidelines and made efforts to diagnose people with HIV, link them to care, and then immediately offer them ARVs, meant that 71 percent of the men and 72 percent of the women with HIV in Zambia, along with 58 percent of the men and 69 percent of the women with HIV in South Africa, were on treatment. The study’s interventions resulted in similar improvements in the proportion of those treated, cutting down by 43 percent the portion of the population that was diagnosed with HIV but not treated.

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The next wave of prevention: Ring-fencing HIV. 30/10/2014

Published by Health-E
Written by Kerry Cullinan
30 October 2014


A range of new products, including vaginal rings and antiretroviral (ARV) injections, may soon be on offer to prevent HIV.

Within a few years, women might be able to insert a vaginal ring that will both protect them from HIV infection and pregnancy.

Within a few years, women might be able to insert a vaginal ring that will both protect them from HIV infection and pregnancy.

Rings that slowly release ARV medicine into a woman’s vagina are in advanced clinical testing, with trial results expected next year. Researchers believe it will be easy to insert a contraceptive into the ring as well.

“About 92 percent of couples globally don’t use condoms, so it is important to develop other options,” said Sharon Hillier from the US University of Pittsburgh Medical School.

The ring will offer women a discreet way of preventing HIV undetected by their partners.

Some of the world’s top HIV researchers are in Cape Town this week attending the first global HIV Research for Prevention (HIVR4P) conference.

Using antiretroviral medication to prevent – not just treat – HIV is emerging as one of the most powerful weapons to contain the epidemic in the absence of a vaccine.

ARVs taken immediately after HIV exposure – in rape cases or when health workers are injured by needles while treating HIV positive patients – have been known to prevent HIV.

PrEP gets real?

More recently, the results of Dr Myron Cohen’s 10-year study of couples where one person was HIV positive and the other negative, were released. It found that if the HIV positive partner was on ARVs and their viral load was undetectable, their negative partner was 96 percent protected from HIV infection.

Researchers envisage people will be offered a “smorgasboard” of prevention methods – including condoms, ARVs and the possibility of a partially effective vaccine

A number of “treatment as prevention” studies have also shown that ARVs taken shortly before sex by people at high risk of HIV offer protection against HIV.

Truvada, a pill that combines the ARVs tenofovir and emtricitabine, reduced HIV transmission in gay men by 42 percent.

Long-acting injections containing ARVs that would only have to be given every two to three months are also in the pipeline, researchers said yesterday.

These would make it much easier for people to adhere to treatment and are also being tested to see whether they can protect HIV negative people form the virus.

Wits University’s Professor Helen Rees, who is a conference co-chair, said it was more realistic to control rather than eradicate the epidemic at this stage.

Dr Anthony Fauci, head of the US National Institute of Allergy and Infectious Diseases, told the 1300 delegates that comprehensive HIV prevention rested on the “synergy between vaccine and non-vaccine research”.

Researchers envisage that people can be offered a “smorgasboard” of prevention methods – including condoms, ARVs and the possibility of a partially effective vaccine.

Since 2009, when a vaccine trial in Thailand showed “modest” protection for around 30 percent of people after two years, researchers have been unraveling exactly how it worked. One of the key focus areas is how some of the Thai trialists were able to develop antibodies to partially protect themselves from HIV, and the quest for “broadly neutralising antibodies” is a cornerstone of vaccine research.

The Thai vaccine has been tested on South Africans over the past two years, and they showed the same antibody response. Within 18 months, South Africa could host a massive trial of a modified and improved version of the Thai vaccine involving 7000 people ad costing R1-billion, according to Medical Research Council President Dr Glenda Gray. – Health-e News Service.

 

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Changes In The Prescription Of Progestin Sub-dermal Implants (Implanon) In Women Who Are Taking Enzyme Inducing Drugs. 16/10/2014

Circular: Changes In The Prescription Of Progestin Sub-dermal Implants (Implanon) In Women Who Are Taking Enzyme Inducing Drugs Such As Efavirenz For HIV, Rifampicin For TBb, And Certain Drugs Used For Epilepsy (Carbamazepine, Phenytoin, and Phenobarbital). 16/10/2014

To all public health nurses, doctors and managers

New evidence has emerged that certain enzyme inducing drugs, such as Efavirenz for women who are HIV positive, Rifampicin for women who have TB, and Carbamazepine, Phenytoin, and Phenobarbital for women with epilepsy can interfere with the action and effectiveness of progestin subdermal implants.

It is therefore recommended:

1) Women who are on the enzyme inducing drugs listed above should not use Progestin subdermal implants (Implanon) but rather use another method, e.g. intrauterine devices or Depot Medro Xyprogesterone Acetate (DMPA). The effectiveness of combined oral contraceptives may be impaired by the enzyme inducing drugs, but could be used together with condoms if the women prefer this method.

2) Women who are HIV infected and on Efavirenz, or who are epileptic and on Carbamazepine, Phenytoin, or Phenobarbital, and already have the Progestin sub-dermal implants (Implanon) inserted should be covered with another non-hormonal contraceptive method (intrauterine devices or condoms). They should be given the option of having the Progestin sub-dermal implants (Implanon) removed and replaced with an alternative method as in 1) above.

3) Women who are infected with TB and on Rifampicin and already have the Progestin sub-dermal implants (Implanon) inserted should be covered with another non-hormonal contraceptive method (intrauterine devices or condoms) for the duration of their TB treatment.

For more information please contact Dr Pearl Holele on Holelp@health.gov.za or 012 395 9736 or Dr Zuki Pinini on PininZ@health.gov.za or 012 395 9157 in the National Department of Health.

DR Y PILLAY
DEPUTY DIRECTOR-GENERAL: HIV/AIDS, TB and MCWH
 

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The South African HIV scientist who gave girls back control of their bodies. 28/10/2014

Published at the Guardian
Written by Linda Nordling
Subtitle: Quarraisha Abdool Karim has won a top science prize for her work protecting women from HIV in South Africa
28 October 2014


Quarraisha Abdool Karim

Last weekend Quarraisha Abdool Karim, one of South Africa’s top HIV researchers, became the first woman to receive a US$100,000 (£62,000) prize for developing world scientists. The prize is a welcome recognition for the 54-year-old epidemiologist.

Abdool Karim has devoted her career to developing tools that African women can use to protect themselves against HIV. She is involved in developing a battery of new methods, including anti-HIV gels and long-term injectables.

One of the main challenges has been how to prevent HIV infection of young women, who in South Africa have the greatest risk of contracting HIV. Most HIV prevention methods, such as condoms, faithfulness or abstinence, are difficult for women to control. In rural areas, where farming is falling out of fashion, women often don’t earn money, and sex frequently becomes a form of currency.

In 1990 Abdool Karim led South Africa’s first community-based survey of HIV infection in the KwaZulu-Natal province on the country’s east coast. At the time, HIV was a silent epidemic in South Africa, with few carriers showing symptoms. Deaths from Aids only became commonplace in the late 90s, nearly 20 years after the disease was first discovered in the US.

The HIV prevalence in South Africa was low back then (around 1%) compared to current rates (over 12% nationwide in 2012). But Abdool Karim found that HIV infection rates shot up quickly in girls aged 15-19 years old, while the prevalence among boys only started climbing in their late 20s. Why did the girls have HIV but not the boys?

“It could only be that the younger girls were having sex with men from the older age group,” says Abdool Karim. It was one of the first descriptions of what became known as the “age-sex” difference in HIV acquisition in sub-Saharan Africa. Other studies found that older men sleeping with teenage girls was key driver of the HIV epidemic in Africa.

The age-sex gap has proven tricky to address. Abdool Karim found in her studies of the epidemic that even when girls and women knew the risks involved, HIV wasn’t an overriding fear. “Aids six or seven years down the line was less of a priority than survival today,” she says.

Working with sex workers, Abdool Karim had the idea of a HIV barrier gel that women could use to prevent themselves from HIV. She’d heard about microbicides – compounds that can be put inside the vagina or rectum to protect against sexually transmitted infections. The first one she tested, a spermicide called Nonoxynol-9, didn’t stop HIV. Nor did the second one, a gel containing a drug known as PRO2000.

However, on 20 July 2010, South African researchers led by Quarraisha and her husband, Salim Abdool Karim, unveiled the first global results showing that a microbicide could protect against HIV. In clinical trials of a gel containing the anti-retroviral drug Tenofovir, the women using the gel reported a 39% reduction in HIV infections, compared with those using a placebo gel.

The study also found that among women who were high-adherers (who used the gel over 80% of the time before and after intercourse) HIV infections dropped by 54%. A confirmatory trial of the Tenofovir gel is underway, and if successful the vaginal gel could fill a gap in HIV prevention for women who may not be able to insist on condoms or faithfulness from their partners.

Other tools being tested by Abdool Karim and her colleagues might have higher rates of protection. One is a ring that is fitted around the cervix containing a powerful anti-retroviral called Dapivirine. Abdool Karim is part of an international trial of the product managed by the International Partnership on Microbicides and the Microbicide Trials Network. Another is a three-monthly injection for HIV prevention.

There are also long-term plans to evaluate therapies combining HIV prevention with other medical technologies, for instance birth control. Successful outcomes from these studies could give women a variety of options for protecting themselves against HIV, Abdool Karim says. Options are important, she adds, as what works for one woman may not be suitable for another.

Prevention remains the key to curbing HIV in South Africa. Anti-retroviral rollout in South Africa has changed HIV from a death sentence to a chronic but manageable disease. But rates of new HIV infections exceed treatment rates. The HIV prevalence has remained at about 30% despite the fact that the numbers on treatment increased from about 48,000 in 2003 to close to 2.6 million Aids patients on treatment in 2012. “We can’t treat our way out of the epidemic,” says Abdool Karim.

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New UNDP Report Highlights the Role That Cash Transfers Can Play in Preventing HIV. 22/10/2-14

Published by allAfrica.com

NEW YORK CITY, 22 October 2014 (UNDP) - Today, on the International Day for the Eradication of Poverty, UNDP has released a new report on cash transfers and HIV prevention. Cash transfers are a major tool in the fight against poverty in its many forms.

Since their introduction in Brazil, Mexico and Bangladesh in the early 1990s, cash transfers have grown in popularity worldwide. Recent evidence points convincingly to a new benefit of cash transfers: HIV prevention. UNDP believes that cash transfers are just one example of how development approaches can be brought to bear on the HIV epidemic, highlighting a path toward ending poverty and ending AIDS in our lifetime.

"We've known for years that cash transfers can reduce poverty, improve access to education and health services, and tackle other broader development objectives.

That cash transfers are now showing serious potential to prevent HIV at the same time is a huge 'win-win', with possible implications for how sectors of government design and finance mutually beneficial programmes," says Dr. Mandeep Dhaliwal, Director of UNDP's HIV, Health and Development Group, which produced the report.

UNDP's report emphasizes that it is precisely cash transfers' impacts on underlying drivers of the epidemic that make them so effective for reducing HIV risk. The report recognizes HIV as an issue of inequalities, one propagated in particular by overlapping gender and economic inequalities. Cash transfers can most usefully prevent HIV where they help reduce these inequalities.

That addressing inequality is central to this story makes the work immediately relevant to UNDP's new Strategic Plan, 2014-2017.

"Our new Strategic Plan prioritizes reducing poverty and addressing inequalities, including economic and gender inequalities. It emphasizes inclusive social protection and the importance of co-benefit analysis and planning. All of these areas can serve as possible entry points for cash transfers work. Not surprisingly, effective cash transfer programmes will also play an important role in the fight against Ebola," adds Dr. Dhaliwal.

UNDP's report offers a comprehensive set of strategies for moving forward in terms of policy and programmes as well as research. These recommendations are anchored in an important fact: that cash transfers already reach over one billion people in the developing world.

"Given the scope and popularity of cash transfer programmes, which are and will continue to be implemented for broader development objectives, the greatest opportunities may not be in scaling up pilot studies focused exclusively on HIV prevention," comments Brian Lutz, UNDP Policy Specialist and one of the report's co-authors. "Rather, the immediate opportunity is in making cash transfers and other forms of social protection HIV-sensitive - in other words, maximizing the positive impacts on HIV while minimizing the negative ones."

According to the report, making cash transfers HIV-sensitive can be accomplished by first considering key contextual factors that drive the epidemic in a given area, and then adjusting various programme elements to ensure coverage and access by those most vulnerable.

Much of the available evidence on cash transfers and HIV prevention centres on girls and young women, who bear significant HIV burdens, particularly in sub-Saharan Africa, and often have less control over their sexual choices than do men. UNDP's report recommends that cash transfers also be explored for their potential to prevent HIV among key populations, such as men who have sex with men, transgender people, sex workers, and people who inject drugs.

Investment approaches to AIDS and the Global Fund's new funding model have placed a premium on interventions that are high-impact, cost-effective and sustainable. UNDP's report notes that cash transfers' potential to impact HIV alongside poverty and other development objectives makes them a particularly appealing investment opportunity.

Previous work by UNDP and the STRIVE consortium at the London School of Hygiene & Tropical Medicine shows how cross-sectoral financing of cash transfers can make them cost-effective investments of scarce resources. The report suggests that, where relevant, cash transfers could be integrated into Global Fund concept notes, which are anchored in comprehensive national plans.

"Comprehensive national strategic plans create opportunities to identify links across sectors of government, such as those embodied by cash transfers for HIV prevention. At the same time, HIV-sensitive cash transfers might qualify for extra resources, beyond regular country allocations, that the Global Fund has set aside to finance evidence-based, high-impact innovations," says Mr. Lutz.

UNDP cautions that specific attention must be paid to ethical and human rights considerations. It advises against making receipt of cash transfers contingent on HIV status or maintenance of HIV status.

Nor should cash transfers be linked to irreversible or invasive procedures, such as medical male circumcision or microbicide use, regardless of the potential for efficacy in these areas. Instead, the report recommends that efforts be made to reduce financial and non-financial demand-side barriers, such as user fees and transport costs, to help people who wish to access these and similar services that are critical components of comprehensive HIV responses.

UNDP's report on cash transfers and HIV prevention builds upon the HIV, Health and Development Group's ongoing work, particularly its work helping countries to embed HIV and health into action on gender, poverty and broader efforts to accelerate and sustain progress on the Millennium Development Goals (MDGs). Fighting poverty and HIV are at the core of the MDGs and are expected to remain central within the post-2015 development agenda.

UNDP's Discussion Paper on Cash Transfers and HIV Prevention is available here.

About UNDP's HIV, Health and Development Group

UNDP is a founding cosponsor of the Joint UN Programme on HIV/AIDS (UNAIDS), a partner of the Global Fund to Fight AIDS, Tuberculosis and Malaria, and a cosponsor of several other international health partnerships.

UNDP's work on HIV, health and development leverages the organization's core strengths and mandates in human development, governance and capacity development to complement the efforts of specialist health agencies of the United Nations system.

Contact Information

Ludo Bok - ludo.bok@undp.org

Roy Small - roy.small@undp.org

Online at: http://allafrica.com/stories/201410201031.html

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Learning about additional HIV prevention methods doesn’t undermine gay men’s intentions to use condoms. 15/9/2014

Published by AIDSMap

Roger Pebody

Health promotion interventions can combine information about condoms and alternative biomedical prevention methods without undermining attitudes and intentions to use condoms, according to an experimental study published in the September issue of AIDS & Behavior.

“Our results are inconsistent with risk compensation theory, which posits that use of a biomedical prevention approach will lead to less positive attitudes, intentions, and use of condoms,” comment the authors.

Typically, health education messages encourage individuals to take a single course of action, without considering alternative options. However a ‘combination prevention’ approach may involve advocacy of more than one possible course of action. There has been little previous research on how receiving multiple prevention messages affects attitudes and intentions to use condoms. Condoms remain a particularly cheap and effective way of preventing HIV transmission in those who are happy to use them.

The researchers therefore conducted an experiment in which HIV-negative gay men would watch information videos about different prevention topics. Four HIV-prevention videos were developed, each one focusing solely on either condoms, PrEP (pre-exposure prophylaxis), PEP (post-exposure prophylaxis) or rectal microbicides. Each video had a similar style, delivering a similar range of factual information about the method’s financial cost, effectiveness at preventing infection, mode of operation, side-effects and impact on sexual pleasure.

Study participants were randomised to see either a single video, a combination of two videos, or all four videos together.

Afterwards, the researchers asked men about their likelihood of using the prevention method(s) they had just been given information about. In addition, the respondents were asked about the advantages and disadvantages of sex with and without condoms.

A sample of 803 HIV-negative gay men was recruited through targeted Facebook advertising in the United States. Of note, men in this sample reported relatively high rates of condom use – four in five said they had always used condoms with casual partners in the past year.

The researchers wanted to check that hearing about alternative prevention options wouldn’t make people feel less favourably towards condoms. The results were very reassuring – there were no significant differences in participants’ intention of using condoms, or their assessment of condoms’ costs and benefits, according to the videos that had been seen.

This was also the case for intentions to use PEP, PrEP or rectal microbicides. Seeing information about additional options either made no difference to men’s intention to use a specific method (e.g. a microbicide), or it was associated with a greater intention to use them (PEP, PrEP).

The results were consistent for men who reported unprotected sex with casual partners, and men who did not.

 “In summary, our results suggest no differences in attitudes and intentions towards condom use or unprotected sex when MSM [men who have sex with men] received brief messages about condoms and multiple biomedical prevention approaches,” the researchers conclude. The results should encourage those who plan to disseminate information about biomedical prevention options, they comment.

Reference

Mustanski B et al. Effects of Messaging About Multiple Biomedical and Behavioral HIV Prevention Methods on Intentions to use Among US MSM: Results of an Experimental Messaging Study. AIDS and Behavior 18: 1651-1660, 2014.

This news report is also available in Portuguese.

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HIV Prevention Tops the News at AIDS 2014. 27/7/2014

Published by The Body Pro, By Liz Highleyman 

Chris Beyrer (Credit: Liz Highleyman)

Chris Beyrer (Credit: Liz Highleyman)

Biomedical prevention has garnered more headlines than HIV treatment in recent years, and the news coming out of the 20th International AIDS Conference last week in Melbourne was no exception.

 

WHO PrEP Guidelines

Before the start of the conference, the World Health Organization (WHO) released new guidelines for HIV prevention, diagnosis, treatment, and care for key populations. The biggest story was its recommendation that gay and bisexual men who are at risk for HIV infection consider using antiretroviral drugs for pre-exposure prophylaxis, or PrEP, with some news outlets reporting that WHO had advised all men who have sex with men to start Truvada (tenofovir/emtricitabine).

The Food and Drug Administration's 2012 approval of Truvada for PrEP was based in part on data from the international iPrEx trial, which showed that once-daily Truvada reduced the risk of HIV infection for gay and bisexual men and transgender women by 44% overall, rising to more than 90% among participants with blood drug levels indicating regular use.

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"These recommendations highlight how HIV uninfected people can play an important role in getting to zero transmissions," iPrEx protocol chair and San Francisco AIDS Foundation medical director Robert Grant from the Gladstone Institutes told BETA. "These medications have a proven record of safety and effectiveness for treatment and prevention."

Presenting the guidelines at AIDS 2014, Fabio Mesquita, Brazil's HIV and STI health director, stressed that "evidence is the strongest that PrEP clearly can work" for gay men. There has only been one study of PrEP using tenofovir alone for people who inject drugs (the Bangkok Tenofovir Study), and demonstration projects are still warranted for sex workers and other populations.

Addressing the exaggerated media reports at a press briefing, International AIDS Society incoming president Chris Beyrer emphasized that the WHO guidelines state that PrEP is "an additional prevention option for men who want it" as part of a comprehensive set of services that would also include condoms, counseling, screening and treatment for other sexually transmitted infections, and addressing legal and policy barriers that impede access to services. Like birth control options for women, he explained, PrEP is just one option, and choices can change over a lifetime.

This excerpt was cross-posted with the permission of BETAblog.org. Read the full article.

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AIDS 2014: PrEP is a beginning with new prevention technologies in the works.23/7/2014

Published in ScienceSpeak by o

AIDS2014postScience Speaks is live-blogging from AIDS 2014 in Melbourne, Australia through the week, with updates on research, policy and insights from the 20th International AIDS Conference.

MELBOURNE, AUSTRALIA –  Dr. Kenneth Mayer of the Fenway Institute and the Harvard School of Public Health offered a comprehensive look at HIV prevention technologies at the opening plenary today while emphasizing critical behavioral underpinnings associated with making those technologies effective. The significant prevention impact of treatment expansion, alone is not sufficient, Mayer said, with modelling data  showing that even with full implementation of the 2013 World Health Organization treatment guidelines expanding treatment to an additional 10 million people, half a million people would still become infected with HIV each year.

But, he showed, prevention options have increased, and new ones in development are promising. Reminding his audience that adherence is the major predictor of effectiveness for pre-exposure prophylaxis, or PrEP, and that sexually transmitted infections and sexual violence also matter, Mayer outlined a number of studies that aim to optimize delivery of antiretrovirals for prevention and to make them easier to use, user-initiated, longer-acting, and multi-purpose.

The FACTS001 trial is testing the use of tenofovir gel used before and after sexual intercourse to prevent acquisition of both HIV and the herpes simplex virus in South Africa. With results expected next year, this could be the first approved topical gel PrEP product. Other studies are looking at other antiretroviral drugs in gels for vaginal and rectal use, and in microbicide rings with hopes that the rings could be effective for 3 months and might also be fitted with birth control compounds. The hope is that these rings will be easy to use, comfortable, not require insertion by a healthcare provider, and will be suitable for the developing world. Work also is underway on a contraceptive barrier, a silicone diaphragm for the over-the-counter distribution.

Long-acting injectable antiretroviral drugs are also in trials for prevention, as well as for treatment,   and would potentially provide protection from HIV for a 3-month period, Mayer said. He also highlighted the potential of VRC01, a monoclonal antibody isolated from a person with HIV who is a long-term non-progressor. It will be evaluated as post-exposure prophylaxis in infants and adults, could potentially be developed into a topical film, and may inform development of an effective vaccine.

Mayer flagged two controversies associated with PrEP—the cost and who should provide it. He cited a Massachusetts study that found that HIV providers thought PrEP use should be managed by primary care providers since their focus was patients with established HIV infection while primary care providers said they didn’t have the expertise to manage antiretroviral use. The cost of PrEP also has sparked debate, and Mayer shared data demonstrating that PrEP becomes increasingly cost-effective when targeted to individuals and groups at high risk for HIV acquisition. Moreover, Mayer noted that many conditions have already called for treating large numbers of people to prevent a relatively small number of adverse health events, including statin drugs to reduce cardiovascular events associated with high cholesterol.

Mayer also highlighted medical circumcision as a high impact prevention technology, and noted that new devices and task-shifting hold promise for continued scale-up. People who inject drugs were identified by Mayer as a group with a clear need for harm reduction services in addition to other prevention interventions and he cited a study showing that the combination of antiretroviral therapy and buprenorphine in HIV primary care settings led to more viral suppression.

Mayer reminded his audience that prevention technologies operate in a web of social issues at the individual, community and policy level, requiring attention to resources and human rights. He pointed to a website, www.hivresourcetracking.org, that provides information that includes expenditures by intervention.

Finally, Mayer honored the memory of his colleague Joep Lange, who he said “as a treatment expert recognized very early on the potential prevention benefit of antiretroviral drugs.”

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Child Support Grant Keeps Sugar Daddies Away. 26/11/2013

Health-e

By Laura Lopez Gonzalez

Child support grant may help protect young women from contracting HIV by keeping sugar daddies away, according to a new study released today.

As part of the study, researchers interviewed 3 515 young people between the ages of ten and 18 years in two urban and two rural health districts in the Western Cape and Mpumalanga, and followed them up a year later.

The research found that, while around 15 percent of teenagers were engaging in a risky sexual behaviour such as unprotected sex, multiple partners or sex while under the influence of drugs or alcohol, girls from families that received government’s R300 child support grant were less likely to have sex with older men, or “sugar daddies.”

The study also found that girls who said they slept with older men were also more likely to report having sex in exchange for money, school fees or transport.

These girls were also more likely to report having multiple partners, unprotected sex and having sex while drunk or high, according the research conducted by Oxford University in partnership with the universities of the Witwatersrand and KwaZulu-Natal.

“Child support grants do not make teenagers more sensible when it comes to safer sex,” said Mark Orkin, professor with the University of the Witwatersrand’s School of Public and Development Management and study co-author. “What they can do is promote enough financial security for girls that they do not have to choose their sexual partners through economic necessity.”

By allowing women to avoid relationships based on economic need with older men, South Africa’s child grant may be preventing new HIV infections, according to the study’s lead author Dr Lucie Cluver from the UK’s Oxford University.

“The study’s main message is very clear,” she said. “If we give child support grants or other cash transfers to families then we can reduce HIV risk among girls in those families.”

Sex between younger women and older men is one of the main drivers of HIV in South Africa, where HIV prevalence among girls between the ages of 15 and 19 is five times higher than that among their male peers, according to the latest Human Sciences Research Council household survey.

Cluver added the study, published in the international medical journal The Lancet Global Health, is a powerful reminder of young women’s vulnerability.

“There have been loads of stories in the media about sugar daddies and about how girls are choosing to do this…that it’s a kind of life style choice,” she told Health-e. “This data really suggests the opposite because it says that even if you give a relatively tiny amount of money to the family to put them just above the level of survival, then girls are choosing not to have sugar daddies.”

The study comes on the heels of a 2012 joint assessment of the child grant by government and the United Nations Children’s Fund that found that children receiving the grant were more likely have better early nutrition, complete more years of schooling and score higher in maths.

“We should be very proud of our child and foster child care support grants,” Cluver said. “They cost a lot of money but this study is really saying that the money is worth it when you consider what we are protecting teenagers and young people against.”

She added that with the child grant’s proven benefits, more needs to be done to reach the roughly 30 percent of children who need, but are not receiving the grant. – Health-e News Service.

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Cultural Factors in the Fight against HIV, 29/10/2013

By Dr. Cesar Chelala

Pravda.ru

Cultural factors in the fight against HIV. 51423.jpeg

The latest UNAIDS report on HIV informs that approximately 35.3 million people are HIV-infected worldwide, but deaths from AIDS are falling and the number of people receiving treatment is going up. Also, the number of people newly infected with the disease dropped from 2.5 million in 2011 to 2.3 million in 2012.

One of the cultural factors that has proven to be significant in increasing the risks of HIV-infection is cross-generational relationships - in which at least a 10-year age difference exists between partners. In the "sugar daddy" phenomenon, as it is called, young women take older men as sexual partners.

For the young women, this is a sign of prestige among their peers and a way for them to pay for luxuries (or sometimes for education) that they otherwise could not afford. In some cases, poor families even encourage young girls to enter into these relationships in the belief that they will improve the family's overall economic situation.

Older men, for their part, are attracted to younger women because it is a sign of status among an older man's friends to have one or more young girlfriends. Older men believe that younger women are virgins and therefore less likely to be infected and pass the infection to them.  

This phenomenon clearly illustrates the powerful link between women's health and their lack of empowerment, since young women are frequently unable to negotiate a safe sexual relationship with older, more powerful men. For example, in traditional African societies, because of the respect shown to elders, it is difficult for young women to reject advances by older men. This places young women at a disadvantage in demanding the use of condoms. 

The reluctance by men, both young and old, to use condoms is one of the primary catalysts of the HIV/AIDS epidemic. It has been demonstrated that the older the man is with regard to his female companion and the more money he gives her, the less likely he is to use a condom. Studies have also shown that the greater the age difference between partners, the more frequent is the practice of unsafe sexual behavior.

Another dangerous social practice is the use of some specific sexual techniques that make women vulnerable to the infection. One of those techniques is the act of having sex without the natural lubrication of the vagina. In addition, to increase men's pleasure, some women, particularly in some African countries, apply cosmetic powder or alum into the vagina to make it drier. However, as a result of this increased friction, abrasions or lesions to the lining of the vagina may occur which increase the possibility of transmission of the HIV.

In regions of some countries such as in Kenya, practices such as "wife inheritance" and "widow cleansing" can be significant contributing factors to the spread of the disease. In wife inheritance, the brother of a deceased man "inherits" his brother's wife, even if he died from AIDS. Since his sister-in-law will probably be infected, the surviving brother will probably acquire the infection from her.  Custom also determines that because a widow is "unclean", she is obliged to undergo a cleansing ritual by having sex with another man immediately after her husbands' death, even if he died from AIDS.

In addition to those factors, alcoholism and drug abuse are also risks factors for increased transmission of HIV. Since it is known that in those cases judgment is impaired, adolescent boys and girls may feel more tempted to engage in risky sexual behavior.

Women's lower status, the social stigma still surrounding the infection and poverty are all important contributing factors to the more rapid spread of the infection. Since women's lower status is usually associated with low or no personal income, many activities are now being conducted across Africa aimed at empowering young women by providing them with life skills, micro-credit loans and vocational training.

Among the many examples of how poverty may affect the HIV/AIDS epidemic is the case of the poor farmers in Henan Province in China. It is estimated that, in central Henan Province alone, more than one million people contracted HIV from selling their blood in unsanitary collection stations. Although Henan constitutes the best-known case, 22 other provinces have also what is known as "AIDS villages" where the infection is most widespread.

However, there should be increased cooperation between the ministries of health and education to improve health curricula in schools and to sensitize lawmakers to pass enforceable legislation that addresses the seduction of minors and cultural risk factors for HIV. Although many countries have legislation, it is seldom enforced. 

To continue those advances in the fight against HIV/AIDS, increased emphasis should be placed on prevention efforts, particularly with regard to social and cultural factors that affect its growth rate. Unless these factors are properly addressed, they will continue to have significant social and demographic consequences in the regions most affected: Sub-Saharan countries, the Caribbean and South East Asia, among others. 

Dr. Cesar Chelala, an international public health consultant, is the author of "AIDS: A Modern Epidemic," a publication of the Pan American Health Organization

Дмитрий Судаков

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MIV/vigs Kan 14% Daal as Hulle Weet 17/05/2013

Beeld: Fanie van Rooyen

Om ’n hele gemeenskap behoorlik oor MIV/vigs in te lig en te verseker dat lede van die gemeenskap maklik toegang tot MIV-toetse en -berading het, kan die voorkoms van MIV in so ’n gemeenskap met tot 14% laat daal.

Dit is bevind in ’n drie jaar lange internasionale navorsingsprojek. Wetenskaplikes van die Raad op Geesteswetenskaplike Navorsing (RGN) het die bevindings gister amptelik bekend gestel.

Die Accept-navorsingsprojek het ’n kombinasie van sosiale, gedrags- en strukturele benaderings tot MIV/vigs-voorkoming in 48 gemeenskappe in Suid-Afrika, Tanzanië, Kenia en Thailand getoets.

In Suid-Afrika is die proeflopie in gemeenskappe in Soweto en die Vulindlela-distrik in KwaZulu-Natal uitgevoer.

“Hierdie is die eerste grootskaalse, langtermyn- internasionale studie wat aangepak is om vas te stel of ’n gemeenskap se kennis van MIV/vigs en hul toegang tot toetse en berading die vigsepidemie kan help stuit,” het prof. Linda Richter, hoofondersoeker van Accept, by die bekendstelling gesê.

“Die proeflopie het drie jaar geduur, maar die idee vir die projek het al sowat 15 jaar tevore ontstaan.”

Dr. Heidi van Rooyen, direkteur van die projek, het gesê die 48 gemeenskappe is volgens sosiaal-ekonomiese faktore in pare van twee soortgelyke gemeenskappe verdeel.

“In elk van die pare het ons dan in een van die gemeenskappe ’n veldtog begin om die gemeenskap teen MIV/vigs te mobiliseer, om vrywillige toetsing aan te moedig en vryelik beskikbaar te stel, om berading so toeganklik moontlik te maak, om opleiding oor MIV/vigs aan te bied en om die siekte te destigmatiseer,” het Van Rooyen gesê.

In die ander gemeenskap van elke paar is só ’n veldtog nie begin nie. Dié gemeenskappe het as kontrolegroepe gedien.

“Ons het bevind ons ingrypingstrategie het die getal nuwe infeksies in die betrokke gemeenskappe met 14% laat daal,” het Van Rooyen gesê.

 

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HIV/AIDS: The HIV Prevention Agenda. 13/12/2012

Getting – and keeping – people on treatment

JOHANNESBURG, 13 December 2012 (PlusNews) - If the world scales-up HIV treatment and prevention in the next two years, a critical tipping point - in which those on treatment outnumber those newly infected with the virus - could be reached, according to the global HIV prevention advocacy organization AVAC.

On the heels of AVAC's annual African Partners Forum, which was held in early December, IRIN/PlusNews breaks down the issues likely to top the HIV prevention agenda in the coming year.

1. End confusion over "combination prevention". It may have been the catch phrase of 2012, but “combination prevention” - the use of complementary behavioural, biomedical and other prevention strategies - remains poorly defined. AVAC is urging activists to help guide focused discussions about combination prevention and how donors, policy makers and implementers can best develop combination prevention packages tailored to individual countries’ needs.

2. Start - and keep - people on antiretroviral (ARV) therapy. While the latest UNAIDS report charts increasing access to ARVs over the past decade, only about half of those who need ARVs are receiving them. Meanwhile, more health officials are starting to shift their focus away from treatment numbers and towards treatment quality to ensure that people who begin treatment stay on it, and to make sure this treatment is working. According to AVAC, more innovative strategies are needed to improve uptake and retention in treatment programmes.

Such strategies will be especially important in “treatment as prevention” programmes. In most treatment protocols, only people living with HIV who have relatively low CD4 counts - indicating weaker immune strength - are put on ARVs. With treatment as prevention, even HIV-positive people with higher CD4 counts will take ARVs in order to decrease the likelihood of transmitting the virus to their partners. “Treatment as prevention” has also been used to describe the use of ARVs by people who are HIV-negative but at a high risk of contracting the virus.

Although there are treatment as prevention pilot projects underway among high-risk populations, policymakers remain unsure how treatment as prevention will work in contexts of generalized risk.

3. Prepare for the next wave of non-surgical medical male circumcision (MMC) devices. South African activists continue to protest the use of the controversial, unapproved Tara Klamp, a non-surgical device used to perform MMC. Even so, the first non-surgical MMC devices are expected to receive UN World Health Organization (WHO) prequalification in 2013, according to AVAC. Prequalification allows 14 prioritized African countries, including Swaziland, Ethiopia and South Africa, to use the devices,
which could offer MMC in areas where surgical options are not safely available.

But AVAC cautions this new technology might not suit all countries and that policy makers need to be prepared to decide whether they’ll stick with the surgical “snip” or move towards new devices that allow lower cadre health workers to perform circumcisions, AVAC says.

4. Define and launch a core package of pre-exposure prophylaxis (PrEP) demonstration projects. Although the WHO issued guidance on the use of PrEP in July 2012, AVAC says that many global health agencies and national HIV programmes are hesitant to adopt the strategy of giving HIV-negative people at high risk of contracting the virus ARVs to prevent infection without first conducting more pilot programmes.

According to AVAC, the PrEP agenda will hinge on defining just what kinds of pilot projects or studies policymakers need in order to be convinced.

5. Safeguard HIV-prevention research funding. Finally, AVAC says research funding for new prevention methods - like vaccines or ARV-based microbicides - needs to sustained. Luckily, the US President's Emergency Plan for AIDS Relief (PEPFAR) will likely continue to support research not only into vaccines but also into point-of-care HIV technology, according to its latest blueprint.

Meanwhile, South Africa has taken a keen interest in supporting its own national research into a microbicide using the ARV tenofovir.

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AVAC urges HIV prevention research "reality check" in new report. 9/12/12

Cape Town, South Africa, December 9, 2013 AVAC – In a report released today, AVAC calls on funders and researchers to capitalize on lessons learned from a range of recent HIV prevention trials with better problem solving, more critical thinking and coordinated action around large-scale human trials, faster roll out of proven options and ongoing research for new advances that women and men will want to use.

This year’s AVAC Report, entitled Research and Reality, pays particular attention to the needs of women and girls. Citing recent trials that failed to provide conclusive answers due to low use of products in the studies, the report lays out a broad and ambitious development agenda for female-initiated prevention options including vaginal gels, rings and other emerging biomedical strategies.

The new report also urges researchers, donors and implementers to step up plans for large-scale delivery of recently proven methods for women and men, including pre-exposure prophylaxis (PrEP) and non-surgical male circumcision devices. While pilot studies of these options are in progress, a lack of longer-range plans for program scale-up and roll out means that valuable time, and lives, could be lost.

“Prevention research has had both rough times and revolutionary breakthroughs in the past few years. It’s time to apply lessons from these experiences to work faster and smarter going forward,” said Mitchell Warren, AVAC executive director. “As advocates, we’re looking to make sure that new HIV prevention developments are turned into action—whether that’s delivering new options that work to the people who need them, or revising past assumptions based on trials that didn’t go as planned.”

“We need to keep focused on HIV prevention that’s effective, available and meets the needs of men and women throughout their lives,” Warren said.

Refocusing the Search for New Methods for Women

Research and Reality, released at the 17th International Conference on AIDS and STIs in Africa (ICASA), takes an in-depth, critical look at prevention research for women. There has been a positive, proof of concept finding that a vaginal gel can reduce women’s risk of HIV, as well as positive data on daily oral tenofovir-based PrEP in women. However, there have also been two trials in which participants did not actually use the options being tested regularly enough to answer the study questions.

In the report, AVAC offers recommendations and analysis to move beyond competing interpretations of these data. This is the first advocacy document to provide a full picture of what the trials do and do not reveal about the future of female-initiated prevention. It identifies clear steps to take to address issues from past trials and a core set of questions that need to be answered through strategic research going forward.

“It would be completely unacceptable to throw up our hands and say we don’t know what women want,” said Warren. “With women representing half of the global HIV epidemic, it’s both a practical and a moral imperative to keep up the search for new methods that women can control and want to use.”

“Recent trial results may be puzzling, but one thing we know for sure is that many women at risk want and need new ways to protect themselves from HIV,” said Nono Eland, chairperson of the Women’s Sector of the South African National AIDS Council (SANAC). “The prevention revolution continues. Earlier this year, participants at the SANAC Women's Sector biennial summit called for better investment in prevention for women. We called for women to be meaningfully involved at all stages—from planning to distribution of HIV prevention products that are developed for us and reiterated the need for prevention research literacy for communities.”

To help resolve questions and challenges about women’s prevention options, Research and Reality recommends that researchers and trial sponsors:

  • Continue to explore and measure methods to improve adherence.
  • Conduct additional qualitative research to better understand women’s reasons for enrolling in a trial and using (or not using) a study product.
  • Use innovative trial designs that would select trial participants who are most likely to adhere to a product regimen so efficacy can be determined – if the trial shows efficacy, bridging studies should be designed to examine how the strategy might work among more diverse populations

“When conventional approaches to science are not working, it’s time to break with convention,” said Dr. Helen Rees, Executive Director of the Wits Reproductive Health and HIV Institute in South Africa and a member of AVAC’s board of directors. “We urgently need to identify a range of prevention options that can work for women – and then we need to know which options will work best for which women.”

Research and Reality also provides four overarching recommendations on issues that lie at the intersection of research goals and real-world conditions.

  • Launch complex trials to answer complex questions – Clinical trials remain the only way to answer the most important scientific questions in HIV prevention. Researchers and funders must continue to launch new trials despite the challenges, complexities and costs. This is especially true for AIDS vaccines, as well as to clarify the effect of hormonal contraception on HIV risk, where research is critical and must proceed.
  • Plan for roll out beyond pilot projects – Pilot projects are an important first step toward ensuring that promising research results translate into real impact on people’s lives, but pilot projects alone will not end the AIDS epidemic. To realize their full potential, interventions such as daily oral PrEP and non-surgical devices for voluntary medical male circumcision need to be adequately resourced, ramped up, and included in national HIV/AIDS implementation plans.
  • Invest and innovate in virologic suppression – In addition to the life-saving benefits of antiretroviral therapy as treatment for people living with HIV, research shows that ARV treatment can dramatically reduce the risk of HIV transmission to others. But treatment works in this way only when it effectively suppresses virus in the body to very low levels. To achieve and sustain HIV suppression and realize the full preventive potential of treatment, it is critical to invest in treatment adherence programs, new antiretroviral therapies, therapeutic vaccines and a cure.
  • Align programs, models and funding to stay on track to end AIDS – Countries are developing HIV prevention plans and targets based on modeling that does not fully account for realities on the ground. Models are essential, but they need to be designed with built-in feedback loops – pulling in surveillance data and other information about the impact of prevention programs, so that results can be improved quickly over time.

The new Research and Reality recommendations build on the AVAC Playbook, a long-term agenda for global HIV prevention efforts first issued in 2011. AVAC assesses and reports on the most critical next steps for the development and delivery of new prevention options each year.

###

About AVAC: Founded in 1995, AVAC is a non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic. The full report, AVAC Report 2013: Research and Reality, is available at www.avac.org/report2013.

Contact:
Mitchell Warren, mitchell@avac.org, +1-914-661-1536
Kay Marshall, kay@avac.org, +1-347-249-6375

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Anova-GALA Partnership Develops Innovative HIV Awareness Resource for Deaf South Africans. 3/12/12

MEDIA ADVISORY: Anova Health Institute and Gay and Lesbian Memory in Action (GALA) have collaborated to produce a first-of-its-kind resource that promotes HIV awareness among Deaf South Africans.

Anova Health

Under the banner of the See it! Sign it! Know it! Share it! initiative, the Deaf digital stories project aims to promote HIV awareness among Deaf people in a creative  and accessible way.

According to Deaf Project Officer Cherae Halley, the Deaf community is at increased risk of HIV infection for a number of reasons.

“Low levels of knowledge around HIV because of failures in Deaf education and a healthcare system that does not cater to the unique needs of the Deaf community are some of the major stumbling blocks to HIV prevention and treatment among the Deaf public,” said Halley.

Halley says little has been done to address HIV as it affects Deaf South Africans, despite HIV prevalence among people with disabilities being alarmingly high at 14.1 per cent. Such statistics support the overwhelming need for targeted interventions such as the Deaf digital stories project.

The digital stories manual and DVD pack is a tool for facilitating workshops in which Deaf people can easily access accurate information on HIV, sexuality and human rights.

The personal stories of eight Deaf peer educators captured on the DVD are used in conjunction with the manual to tackle a variety of topics, including educational and information barriers, HIV-related stigma, gender, sexuality, drug and alcohol abuse, and communication difficulties.

Anova Health Institute’s Chief Operating Officer Helen Struthers agrees that this resource is an important first step in addressing knowledge gaps within the Deaf community.  

“Anova is excited to be partnering with GALA to pioneer desperately needed HIV awareness and education materials, which are tailored to this vulnerable group,” she said.

For information about GALA’s Deaf HIV/AIDS awareness project, please contact Cherae Halley on +27 11 717 4239 or deafhivproject@gmail.com.

For general media enquiries, please contact John Marnell on +27 11 717 4239 or john.marnell@wits.ac.za.

To order See it! Sign it! Know it! Share it! Email: deafhivproject@gmail.com.

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Hormonal Contraception Advice not Reaching Women. 1/3/12

WHO has advised women on injectable hormonal birth control to use condoms to prevent HIV infection in light of possible HIV risks associated with "the shot"

1 March 2012

Johannesburg - The World Health Organization (WHO) has advised women on injectable hormonal birth control to use condoms to prevent HIV infection in light of possible HIV risks associated with "the shot", but HIV organizations and activists say this has not been effectively communicated to women.

In October 2011, a study published in the medical journal, The Lancet, suggested hormonal contraception doubled the risk of a woman contracting HIV - and of HIV-positive women transmitting the virus to their partners.

The study prompted WHO expert consultations to review available research on the topic in early 2012. On 16 February the WHO largely affirmed existing guidelines allowing all women to use hormonal contraception.

However, because the UN agency was unable to definitively rule out the possibility that progesterone-only birth-control shots like Depo-Provera posed no HIV risk, it is now strongly advising women at risk of or living with HIV to use condoms concurrently to prevent HIV infection or transmission.

Criticism

HIV organizations, researchers and activists have criticized the WHO and UNAIDS for not clearly communicating the document's message to African women, who remain the most affected by the continent's high HIV prevalence rates.

Lillian Mworeko, regional coordinator for the International Community of Women Living with HIV Eastern Africa (ICWEA) was the only African civil society representative invited to speak at the WHO consultations on behalf of the continent’s HIV-positive women.

"It's important for us to know the information [in the WHO statement] is being received in different ways by different people with clear communication that is going to get down to service providers and to women," Mworeko told IRIN/PlusNews. "When I look at the statement, I understand it because I attended the meeting but for someone who wasn't at the meeting, I'm not sure they will.

"We are at a point where we need to move very fast," she added. "As a woman who sat in on that meeting, I feel we are moving very slowly [to communicate this] and this is unacceptable."

Those in the HIV and family planning fields must find a way to translate the statement's nuanced messaging to women - communicating possible risks without turning women off from much needed services, noted Helen Rees, executive director of the Wits Reproductive Health and HIV Institute at the University of the Witwatersrand in Johannesburg, South Africa.

In the past two decades, Depo-Provera has topped the list of state-provided birth control in Africa. Countries such as South Africa, Uganda and Kenya all depend on family planning services to help reduce high rates of maternal and infant mortality by preventing unwanted pregnancies.

WHO response

According to Mary Lyn Gaffield, a WHO epidemiologist who coordinated the recent meetings, the WHO has already begun translating the 16 February statement into multiple languages, and is developing tools for family planning and HIV service providers that will incorporate the need to caution women using progesterone-only contraception on possible HIV risks.

UNAIDS has already begun training its staff on the WHO's new advice.

Even with such UN guidance, putting the WHO's advice into practice will be difficult for health workers and women in high HIV prevalence countries, Rees said.

In South Africa, about 18 percent of adults are living with HIV. Every woman in South Africa is at risk of HIV - and many still cannot negotiate condom use, she told IRIN/PlusNews.

"Family planning programmes are going to have to rapidly re-look at the methods that are available and what we are [asking] health workers to promote," Rees said during a teleconference question and answer session hosted by the HIV prevention organization, AVAC. "Access to the female condom - it's an old [topic] that we've been talking about for a long time but it becomes imperative now."

South Africa is already moving towards lower dose hormonal contraception in new national guidelines, which will identify the potential HIV risk associated with hormonal contraception. According to Rees, more health workers are already being trained on lower dose, hormonal IUDs.

Studies unfunded

UNAIDS science adviser Cate Hankins also confirmed that UNAIDS would be advocating for more studies on the potential HIV risks associated with hormonal contraception.

No clinical trial has specifically looked at the issue. Researchers have relied on data gathered as part of other trials instead. For instance, the 2011 study used data obtained as part of two trials looking at the effects of herpes treatment on HIV transmission.

International health organizations like FHI360, formerly Family Health International, are already planning such trials, according to Charles Morrison, senior director of clinical sciences.

"The idea would be to take women who wished to be put on highly effective, long-acting contraception methods and randomize," he said during the teleconference. "The big issues are whether women would be willing to be randomized [or assigned a birth control method]; how well they'd adhere to one method and whether they would switch mid-trial."

However, these planned trials remain unfunded and - if funded - would take about five years to produce results, Morrison told IRIN/PlusNews.

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Prevention Revolution. 11/10/11

The world is at the “hot edge” of developing groundbreaking HIV prevention interventions and on many fronts South Africa is in the thick of things

Health-e

By Anso Thom
11 October 2011

The world is at the “hot edge” of developing groundbreaking HIV prevention interventions and on many fronts South Africa is in the thick of things, according to a leading clinical researcher.

“We are truly seeing a prevention revolution,” Professor Linda-Gail Bekker, principal investigator at the Desmond Tutu HIV Centre at the University of Cape Town told a media gathering in Cape Town yesterday (Monday).

Considered one of the world’s foremost HIV and tuberculosis researchers, Bekker said there was a “nice range of armaments (against HIV infection) coming through”.

Results from a range of large studies looking at among others microbicides for women, rectal gels primarily for men who have sex with men, as well as the use of oral antiretrovirals as a prevention prophylaxis were expected from next year.

Statistics are varied, but the international numbers indicate that a staggering 7 400 new HIV infections occur daily, making targeted prevention interventions even more critical. “We need to close the tap,” said Bekker.

She said there was a need to target the “at risk” groups which include pregnant women, young women, men who have sex with men (MSM), intravenous drug users, commercial sex workers, prisoners, migrant workers and orphans and vulnerable children.

She said that in terms of the prevention of HIV transmission from mother to child “we need to move in and shut it down”.

“We have just got to go and do it,” she said, adding that 60 000 babies were infected with HIV every year in South Africa, while it was possible to eliminate paediatric HIV and remove the burden of caring for HIV positive patients for a lifetime.

It is widely believed that a critical intervention is a prevention method placed in the hands of women. Microbicides are vaginal and rectal products containing antiretroviral drugs already used to treat HIV/AIDS and which are now being tested as a method to prevent HIV infection.

Last year, one clinical study in South Africa (Caprisa 004) showed that a vaginal microbicide gel containing the ARV Tenofovir can offer women a 38% protection from heterosexual transmission of HIV, and that it also reduces transmission of genital herpes.

Although it was a major scientific breakthrough which provided hope and encouragement, the sample size was small and is now being confirmed in a much bigger trial (FACTS 001) involving over 3 000 participants.

A number of clinical studies testing microbicide products are currently underway or about to begin in South Africa and a few other African countries.

In addition, other formulations of vaginal microbicides, rectal microbicides and antiretroviral drugs taken orally are also being tested as prevention options for men and for discordant couples (those where one partner is infected with HIV and the other is not).

Bekker said they were hoping that the VOICE study and its four-arm HIV prevention trial in women would provide even more answers.

Two arms of the trial involve taking a placebo and compared to one arm taking a daily oral dose of tenofovir and FTC and another arm using a daily 1% tenofovir vaginal gel.

The trial is scheduled to conclude in 2012 with data available early in 2013.

A rectal microbicide containing Tenofovir will undergo safety tests in South Africa, Peru, Thailand and the United States early next year.

A vaginal ring containing an antiretroviral Dapirivine, not currently used in treatment of HIV/AIDS, is also in the development pipeline.

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Expert Panel Picks 'Best Buys' for HIV Prevention. 29/9/11

Money to be spent on HIV prevention, best buys: vaccine research, mass infant circumcision, preventing mother to child transmission, safer blood supplies and a scale up of antiretroviral treatment

AIDSMap

By Keith Alcorn
29 September 2011

If $10 billion of new money can be spent on HIV prevention over the next five years, the priorities should be more investment in vaccine research, mass infant circumcision, preventing mother to child transmission, safer blood supplies and a scale up of antiretroviral treatment, according to a panel of five of the world’s most distinguished economists.

Their recommendations, released on 28 September, are the product of a review process managed by the Copenhagen Consensus Center, a think-tank funded by the Danish government to evaluate the most effective solutions to global development problems.

Investing in vaccine research and development

Overall, the panel found this to be the most compelling investment. “It is likely that spending an extra $100 million a year on vaccine research will meaningfully shorten the time in which a vaccine is developed,” the panel noted.

Although a vaccine is found to be highly cost-effective in itself, it is the speeding up of vaccine research by spending a relatively small amount over the next five years that makes it the panel’s `best buy`. Having a vaccine in 2030 rather than 2040 would save around $100 billion according to the most conservative calculation, which doesn’t factor in the gains in productivity that could be achieved by infections averted.

Introduce medical infant male circumcision

Circumcising all male infants in countries with a high HIV burden, at a cost of $3.15 billion over five years, would be a better investment than campaigns for adult male circumcision. This is partly because the panel feared that circumcision campaigns will lead men to have more unprotected sex in the long run because they feel less vulnerable to infection. It is worth noting that five-year follow-up of men who took part in the first major randomised trial of circumcision for HIV prevention found no evidence of an increase in risky sex.

Prevention of mother-to-child transmission

A scale-up of interventions to prevent mother-to-child transmission would be highly cost-effective, but also remarkably cheap – just $140 million over five years to avert an estimated 265,000 infections. The potential costs averted could be as high as $32 billion. The challenge in making this investment lies in improving access to services and reducing the stigma of HIV diagnosis, noted Lori Bollinger of the Futures Institute in a paper analysing the cost-effectiveness of interventions to prevent non-sexual HIV transmission.

Improving safety of the blood supply

The cheapest and most cost-effective intervention recommended by the panel is making blood transfusions safer by ensuring that all countries have a high-quality system for screening blood donations. An investment of $2 million over 5 years could avert around 150,000 new infections and would benefit nearly half a billion people who live in countries with unsound screening systems.

Maximising treatment coverage in people with low CD4 counts

The panel concluded that maximising treatment coverage for people with low CD4 counts by spending an extra $6.2 billion over five years would have the biggest impact on new infections, but only if it was accompanied by comprehensive prevention activities. Mead Over and Professor Geoff Garnett of Imperial College, London, who carried out the modelling on treatment, said that neither treatment nor prevention alone would have sufficient impact on new infections.

They say that their modelling suggests that economic growth after 2020 will allow many more African countries to follow the lead of South Africa and Botswana in taking responsibility for their HIV treatment costs, suggesting that an early investment could reap long-term rewards.

Other measures

Measures which proved less attractive to the panel, but which are still cost-effective, include:

Cash transfers to keep girls in school: although a sound policy choice, the HIV-related benefit of this expenditure would be quite limited.

Reducing risky drug injecting behaviours: although cost-effective, the impact is likely to be limited in sub-Saharan Africa in comparison to investments in blood safety or prevention of mother-to-child transmission.

Further information

Detailed research papers and further information on the Rethink HIV project is available at the Rethink HIV website.

 

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HIV/AIDS and Chronic Diseases - Learning from Each Other. 20/9/11

Health officials in sub-Saharan Africa are finally focusing on non-communicable diseases (NCDs)

20 September 2011

 

Johannesburg - Health officials in sub-Saharan Africa are finally focusing on non-communicable diseases (NCDs) such as cancer, diabetes and chronic lung disease, having spent much of the past decade concentrating on HIV/AIDS and malaria.

The growth of NCDs in developing countries has gone almost unnoticed, having been largely perceived as a problem affecting affluent countries. But NCDs have overtaken infectious diseases as the leading cause of death worldwide, with nearly 80 percent of these deaths occurring in low- and middle-income countries, according to the World Health Organization (WHO).

The UN High-level Meeting on NCDs on 19-20 September sought to identify concrete actions to tackle the issue. The last time the UN held such a meeting on a disease was 10 years ago for HIV/AIDS and the similarities do not end there.

Countries grappling with HIV prevalence are now faced with rising epidemics of chronic diseases. UNAIDS has warned that diabetes cases, for example, will rise by 50 percent globally and by 100 percent in sub-Saharan Africa between 2010 and 2030.

As more HIV-positive people access antiretrovirals and live longer, their risks of contracting illnesses such as diabetes and heart disease are growing. In South Africa, the fourth most common cause of death in people living with HIV is hypertension, while diabetes comes in at number six.

Great resource

According to Miriam Rabkin, director for health systems strategies at Columbia University's International Center for AIDS Care and Treatment Programs (ICAP), HIV and NCDs are often seen as completely separate challenges.

"In fact, HIV and NCD departments are often siloed and separated at every level of the health system, from the health facility to the Ministry of Health, up to the WHO. But from a health systems perspective, HIV, a chronic communicable disease, and NCDs, chronic non-communicable diseases, actually have a great deal in common and it is important for us to learn from each other," she told IRIN/PlusNews.

"In many countries, HIV programmes are actually the first large-scale chronic disease programme, and can be a great resource... it's important to avoid 'reinventing the wheel'," Rabkin noted.

The responses to HIV and NCDs can take similar approaches, including appointment and medication reminders, transport support, and counselling to support adherence and ongoing behaviour change.

In 2010, Columbia University and the Ethiopian Diabetes Association conducted a study looking at whether the tools and approaches used for HIV could be applied to the care of adults with diabetes. "It was a small study, but we did show that the quality of care for diabetes improved quite rapidly over a period of six months," said Rabkin.

However, Catherine Hankins, scientific adviser for UNAIDS, suggested more could be done to integrate the treatment of chronic diseases into the health sector. "Pregnant women who get gestational diabetes - what happens to them? You may have an antenatal system that has worked really well now for HIV. You know to put them on antiretroviral treatment, but then maybe there is no referral set-up for diabetes because there is no diabetes care," Hankins told IRIN/PlusNews on the sidelines of the recent AIDS Vaccine conference.

Countries are slowly beginning to combine HIV services with chronic disease care. According to Shanthi Mendis, coordinator of WHO's Chronic Disease Prevention and Management, HIV services and cervical cancer screening have been integrated in some settings. Kenya's Ministry of Health and the Kenya Cardiac Association have begun to screen people tested for HIV for hypertension, and to refer them to the appropriate care and treatment services.

Funding gap

Funding, or lack thereof, however, remains a problem for both HIV/AIDS and NCDs - more so for chronic diseases that lack the high-profile activist campaigns and celebrities found in the AIDS sector.

The US Centre for Global Development estimates that less than 3 percent (US$503 million) of the almost $22 billion spent in 2007 on global development assistance for health was spent on NCDs.

"We can be efficient and creative; we can avoid redundancies and build on the lessons of HIV scale-up. But the idea that because we have invested so heavily in HIV we can somehow treat NCDs for free is a dangerous illusion," Rabkin cautioned.

Mendis admitted that social and community mobilization for chronic diseases will "require more advocacy and will take more time", unlike AIDS, which had had a "devastating impact" on families and societies and galvanized communities quicker. "NCDs impact on families but... the impact is more prolonged... People with HIV provide a powerful image of sickness. NCDs, on the other hand, are silent killers and most of the time do not even cause symptoms."

 

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Pregnancy Doubled Risk of Female-to-male HIV Transmission in Partners in Prevention Study. 5/8/11

Pregnancy increased the risks of female-to-male HIV transmission twofold among over 3300 serodiscordant couples

AIDSMap

By Carole Leach-lemmens
5 August 2011

Pregnancy increased the risks of female-to-male HIV transmission twofold among over 3300 serodiscordant couples from seven African countries, Nelly R Mugo and colleagues reported in a prospective study published in the advance online edition of AIDS.

The risks of becoming infected with HIV during pregnancy increased at the same rate. However, this was partly explained by other factors, including unprotected sex.

Women now account for 60% of HIV infections in adults in sub-Saharan Africa. Many African countries with high HIV prevalence also have high fertility rates and often women are pregnant for a considerable proportion of their adult lives.

Pregnancy brings biological and behavioural changes that may make a woman more susceptible to getting HIV, as well as making her more infectious, so increasing the risks of transmission.

To date, limited prospective studies have found inconsistent results, showing either an increased risk or no elevated risk of acquiring HIV during pregnancy. However, evidence shows that women infected during their pregnancy have a high rate of HIV transmission to their infants.

The authors note one study which showed increased HIV shedding in genital secretions during pregnancy, suggesting increased infectiousness, yet no prospective study has looked specifically at pregnancy as a risk factor for female-to-male transmission.

The authors chose to look at the association between pregnancy and the risks of getting HIV, as well as the risks of transmitting HIV from females to males, in a secondary analysis of a prospective study of African HIV serodiscordant couples.

From November 2004 to April 2007, 3408 HIV serodiscordant couples from Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia were enrolled in the Partners in Prevention HSV-2/HIV transmission study, a randomised, placebo-controlled, clinical trial of aciclovir as herpes simplex virus-2 (HSV-2) suppressive therapy for the prevention of HIV transmission. Aciclovir did not decrease HIV transmission risk within the couples.

Of the 3321 couples in the analysis, about a third (1085) included an HIV-positive male partner and the remaining two-thirds (2236) included an HIV-positive female partner. Eligibility included being over 18 years of age, having three or more episodes of vaginal intercourse in the three months before screening, and having the intention of remaining a couple.

HIV-positive partners were positive for HSV-2, had CD4 cell counts over 250 cells/mm3 and were not taking antiretrovirals. HIV-positive women pregnant at the time of screening were excluded from the study. Women who became pregnant stopped the study medication until the end of pregnancy. Pregnant HIV-negative women were included, as were those who became pregnant during follow-up.

HIV-positive partners were seen monthly, and HIV-negative partners were seen every three months. Sexual behaviour data including condom use was recorded at each visit, as was contraceptive use.

Comprehensive prevention services included individual and couple HIV-risk-reduction counselling, quarterly syndromic management of sexually transmitted infections, STI treatment and free condoms.

The majority were married and living together. Median CD4 cell count was 461 cells/mm3. The couples were followed for up to 24 months; median time for HIV-negative and HIV-positive partners was 20.9 months (IQR: 15.6-24.1) and 19.9 months (IQR: 14.3-23.9), respectively.

Of the 61 HIV seroconversions among women, close to 30% (17) happened during pregnancy. HIV incidence during pregnancy was 7.35 per 100 person years compared to 3.01 per 100 person years during non-pregnant periods,  (HR: 2.34, 95% CI: 1.33-4.09, p=0.003). Risk was high during both early and late pregnancy. However, in multivariate analysis after controlling for age, contraceptive use and unprotected sex, the effect of pregnancy on HIV risk was not statistically significant.

Of the 58 HIV transmissions to men, 12 (20.7%) happened during pregnancy. The incidence of female-to-male transmission was 3.46 per 100 person-years during pregnancy, compared to 1.58 per 100 person-years when the female partner was not pregnant. This was statistically significant  (HR  2.31, p=0.01) and remained significant after adjusting for confounding factors (HR.2.47, p=0.01).

The authors underscore the public health importance of these new findings showing pregnancy increases the risk of female-to-male transmission twofold. New strategies, they add, are needed “to strengthen family planning and maternal health services for women with and at risk for HIV in order to reduce unwanted pregnancies and avert HIV transmission to pregnant women and from pregnant women to their infants and partners”.

Strengths of the study include a large sample size and multinational cohort. The study also established a genetic viral linkage of transmitted HIV within partnerships, so minimising the potential for misclassification of female-to-male transmission.

The authors note their findings can be generalised; all participants were co-infected with HSV-2, as are over 80% of all HIV-positive adults in sub-Saharan Africa.

The authors conclude increased risk for HIV female-to-male transmission during pregnancy requires “further studies to understand the possible biologic mechanisms that may explain this finding”. They add: “Prenatal couples' HIV counselling and testing, implementation of repeat HIV testing in pregnancy, and earlier initiation of combination ART should become part of routine antenatal care to protect mothers, infants and male partners from HIV.”

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Survey Reveals Gaps in HIV Programming for MSM. 14/7/11

Survey reveals a marginalized group of people with little access to basic HIV prevention tools such as condoms and few means to learn about HIV.

14 July 2011

Nairobi - A new global survey of more than 5,000 men who have sex with men (MSM) reveals a marginalized group of people with little access to basic HIV prevention tools such as condoms and few means to learn about HIV.

Conducted by the Global Forum on MSM & HIV between 24 June and 17 August 2010, the survey sought to highlight key gaps in global efforts to provide MSM with evidence-informed HIV prevention services. More than 1,000 of the study participants - drawn from all over the world - were health workers; 22 percent reported being HIV-positive.

The authors recommend expanding access to HIV prevention services for MSM across the globe, more focus on promoting awareness of emerging HIV prevention interventions and more robust and sustained stigma-reduction efforts. Some of the major findings of the survey include:

Access to health services - Fifty-three percent of participants said they could easily access testing for sexually transmitted infections, while 51 percent said they had easy access to HIV counselling; 47 percent found STI treatment easily accessible.

Just 36 percent of MSM surveyed reported having easy access to HIV treatment, while 27 percent said it was available but difficult to access, was not available or had never heard of HIV treatment.

Access to HIV prevention - Free condoms were easily accessible only to 44 percent of participants, while just 29 percent could obtain lubricant.

 Just 30 percent of participants reported easy access to each of the basic HIV prevention services, including behavioural HIV/AIDS interventions, HIV education materials, mental health services, free or low-cost medical care, media campaigns focused on reducing HIV, and laws/policies to ensure access to HIV prevention.

Just 25 percent said they had access to sex education.

Stigma - Africa reported the highest levels of stigma and external homophobia, followed by the Middle East, Asia-Pacific, Central/South America and the Caribbean, which all reported similar levels of stigma. Australia and New Zealand reported the lowest levels of stigma and external homophobia.

MSM from Africa and the Asia-Pacific region reported the highest levels of internalized homophobia.

MSM-specific services - Some 52 percent of respondents reported that MSM health facilities were not available or unknown.

Media campaigns to reduce homophobia were rare, with 30 percent of the survey's participants reporting that anti-homophobia campaigns were not available and another 20 percent saying they were "unheard of".

Knowledge of and access to emerging HIV prevention strategies - Fifty percent of respondents said medical male circumcision was easily accessible and just 10 percent had not heard of circumcision as a biomedical strategy for HIV prevention.

Post-exposure prophylaxis (PEP) was described as easily accessible by only 18 percent of respondents, with 35 percent reporting that they had never heard of PEP.

Thirty-nine percent of participants had never heard of pre-exposure prophylaxis for HIV prevention, while 44 percent of MSM had never heard of topical microbicides.

 

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Large Gaps in the HIV Prevention Evidence Base. 9/6/11

Evidence-based approaches are needed in HIV prevention, large areas of interest are under-researched.

AIDSMap

By Roger Pebody
9 june 2011

An analysis of research that is relevant to HIV prevention in the United Kingdom has identified several important topics on which little research is done. Writing in the journal BMC Public Health, the authors point to the lack of studies into combination prevention packages, individuals with undiagnosed infection, the impact of social policy and the implementation of interventions that have been successful in other countries. It is rare for the impact of mass media campaigns to be evaluated.

The authors say that although innovative, evidence-based approaches are needed in HIV prevention, large areas of interest are under-researched.

The analysis was conducted by the National Institute of Health Research Evaluation Trials and Studies Coordinating Centre, whose staff searched databases for studies conducted between 2006 and 2009 in the UK, United States, Canada, Australia and New Zealand. (Studies conducted in European countries were excluded).

They identified 868 relevant systematic reviews, randomised controlled trials, cohort studies, case-control studies and surveys. They then categorised them both in terms of the activities or topics they dealt with, and the social groups studied.

The most widely studied areas were:

-Intervention technologies, such as circumcision, pre-exposure prophylaxis, condoms, the use of HIV treatment to reduce infectivity and needle exchange (216 studies).

-The investigation of sexual or risk-taking behaviour and studies of interventions which aim to change behaviour (206 studies).

-Descriptive epidemiology: studies seeking to understand the distribution of disease in populations and the association of infection with age, socio-economic groups and sexual activities (162 studies).

Nonetheless the authors didn’t look in detail at the studies or attempt to assess their quality. They say that even when there are a significant number of publications on a topic, this “does not necessarily equate to high quality, robust research or provide evidence that translates to effective prevention.”

Moreover a number of under-researched areas were identified:

- Undiagnosed infection: better understanding of the characteristics of people with undiagnosed infection, interventions which aim to reach these individuals and understanding of the barriers to HIV testing. Only four papers were identified which covered this area, mostly conducted with gay men.

- Research which tests the ability of an intervention that has been successful in one place to be repeated, translated or adapted in a new setting. Only three studies were found. However the authors note that since most HIV prevention research comes from the United States, we need to know if approaches developed there are as effective in other contexts.

- Studies on policies, laws or ethical issues which impact on HIV prevention. This would include prosecutions of HIV transmission, but despite this having become a key issue in recent years, only three studies were identified.

- Combination prevention: when more than one prevention intervention is provided in combination, for example when sexually transmitted infection screening is provided together with an educational intervention. Ten studies were categorised as addressing this issue, but only two actually evaluated the added value of putting interventions together.

- Studies covering social factors that impact on HIV (e.g. education or housing), structural interventions which address social factors, and research into stigma and discrimination. A total of 26 studies were identified.

- Educational interventions, including campaigns, social marketing, leaflets, videos and school-based work. The researchers expected to find more than 28 studies in this area; they were particularly surprised to identify only two studies of the impact of mass-media campaigns.

In terms of the risk groups most often researched, these were people with diagnosed HIV, drug and alcohol users, men who have sex with men, and young people.

Less research is conducted specifically with older people, transgender people, sex workers, heterosexuals (especially heterosexual men), non-black ethnic groups and people who are socially excluded.

The authors say that they would welcome suggestions for research that would help fill the gaps in the evidence base.

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AIDS: No Time for Complacency. 29/4/11

HIV prevention, the mainstay of the response to the HIV epidemic, is in danger of falling off the global agenda

29 April 2011

HIV prevention, the mainstay of the response to the HIV epidemic, is in danger of falling off the global agenda. It seems that the rate of new HIV infections has passed its peak -- the past decade has seen it fall by 20%. But every day still brings more than 7 000 new HIV infections across the globe. Two-fifths of these are in young people.

How do we capture, in Martin Luther King Junior's memorable phrase, "the fierce urgency of now" to insist that that is 7 000 infections too many?

Next week the High Level Commission on HIV Prevention, formed by United Nations Programme on HIV/Aids (UNAids) executive director Michel Sidibé convenes on Robben Island to foster new urgency and commitment to HIV prevention. This highly charged venue was proposed by renowned Brazilian marketer Nizan Guanaes: what could better symbolise a long struggle and the power of perseverance to prevail -- elements so pertinent to the Aids response?

Prevention remains the surest and most immediate way of halting the Aids epidemic and accelerated HIV-prevention success also makes more feasible the vital task of ensuring that all those who have become infected are able to get life-saving HIV treatment when they need it.

Preventing HIV works, but flagging interest requires a new, determined surge in leadership and commitment at every level of government and society to transform the response -- putting the interests of those at risk above politics and ideology. It requires us to learn from and support people vulnerable to HIV, not blame them.

The UNAids commission has joined the call for an HIV-prevention revolution. A revolution in which we are all called upon to do our part: insisting that leaders and policymakers understand and act on the dynamics of their specific epidemics and expanding the practical protection of human rights to overcome the inequities that drive the spread of HIV.

The young people who overwhelmingly led the popular uprising that tore down Egypt's corrupt and morally bankrupt regime are a global inspiration. Their spirit and their mastery of new forms of cellphone- and internet-accelerated social movements are part of the agenda we must harness for an HIV-prevention revolution.

This is our collective responsibility, but our legacy will, above all, be how much we can inspire and create the space for a new generation of young leaders to take over the vanguard of this revolution.

The centrepiece of our deliberations on Robben Island will be to hear the demands of young people themselves for a renewed Aids response and the practical commitments that leaders from business, politics, diplomacy and the media can make to further those demands.

The next global milestone in the Aids response will come in June, when the United Nations General Assembly comes together to review progress and chart the future course of the global Aids response. Our hope is that the spirit of struggle and renewal will inspire that gathering to sweep away any vestige of complacency in the Aids response.

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HIV Battle Targets Truck Drivers as Infections Soar. 19/4/11

Kenya Aids Strategic Plan 2009-2013 identified long distance truck drivers as one group facing the highest risk of acquiring and transmitting HIV.

AllAfrica

By George Murage
19 April 2011

Kenya is recording 100,000 new HIV infections every year according to statistics from the Ministry of Public Health.

The government and development partners are consequently working to put in place to reduce the rate of infection.

Head of disease prevention and control Dr Willis Akhwale said there are two new HIV infections for every one person who is on antiretroviral therapy.

"Currently, the cost of antiretroviral drugs is about Sh8 billion for about 450,000 patients," Akhwale said.

He said the Kenya Aids Strategic Plan 2009-2013 identified long distance truck drivers as one group facing the highest risk of acquiring and transmitting HIV.

The doctor said various studies have reported HIV prevalence ranging between 14-20 per cent among this group, which is more than double the prevalence among the general population.

"The long distance truck drivers play a central role in the spread of HIV along the transport corridors," he said.

Akhwale was speaking in Maai Mahiu, Naivasha during the launch of one of the Roadside Wellness Centres set up on the highways.

He said truckers had one of the most challenging jobs and some of them engage in unprotected sex with prostitutes.

The head of the National Aids and STI control programme Dr Nicholas Muraguri said truck drivers contribute to 30 per cent of HIV infections.

"We are committed to fighting HIV/ Aids and this centre will address the issue by targeting truck drivers and commercial sex workers," he said.

Japan deputy chief of mission Yoichiro Yamada said his country will continue supporting Kenya and the roadside centre was one of country's projects.

He said since 1990, Japan has given Sh880m in funding to NGOs, CBOs, schools and health centres to improve the lives of Kenyans.

Yoichiro said through JICA - Japan's International development arm - they will partner with Kenya to train customs officers and establish the 'one-stop border post' in the East African region.

He said the post will enable speedy and efficient custom clearance and enhance the flow of goods and services among East African countries.

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Challenges to HIV and AIDS Prevention. 3/11

We need to look at some of the initial mistakes in the early sensitizations on HIV and AIDS in the late eighties and nineties.

AfriComNet

By S. Beny Sam
March 2011

In the 70s and the 80s some of us had so much admiration for some of the countries in the Eastern and Southern Africa mainly for what we referred to as political maturity and general development. We saw them then as great producers of great politicians and academics.

Well, that was then…things have changed so much over the years that we are at a loss as to whether the whole continent was not on the verge of collectively going to the dogs.
In the early 90s, if you went to a place like Nairobi. If you were blindfolded in the airplane and placed in the center of that city and your blindfold removed, you will swear by your poor mother’s breast that you were in a Western city. You see Kenya had all one could admire.

Yes the structures could still be there, but that political mess in 2007 happened to have changed a whole lot of things. In Uganda, in the early 90s, it dawned on one that that country was carved out as an HIV zone. But you see although you could say that the people in the rural areas were kind of backward, the sensitization on HIV and AIDS sank into everyone and they were all alert and ready to fight it how admirable! In fact at the time Ugandans were overcareful not to help spread the virus. They served every drink, even beer and stout with straws and you opened your own drink, so that the bar tender does not touch your drink. They were so afraid of HIV and AIDS that they had all sorts of wrong notions as to how to contract it.
You could literally see small kids along the streets of their towns encouraging visitors or foreigners to have condom. They used to call HIV Slim. When you entered your hotel room, you will find condoms all over the place, so much so that you seem compelled to use them if you had to tangle. There will be condoms on the study table, under your pillows, in the wardrobe, in the bathroom and on the wall by the bed. Today Uganda is indeed a success story when it comes to political and citizen will to consciously fight the epidemic. So much for Uganda and their AIDS fight.

A couple of days ago I was listening to DJ Base Nightline which featured some discussion on HIV and AIDS and it was so amazing how little people still knew about the pandemic from the questions or comments they raised. But really what got me mad was a BBC interview last week where some youths said they wash and reuse the condoms because of scarcity. Others even said that they use plastic bags as improvisation for condoms. These were Kenyan youths, can you imagine! The fact that the youth have good intensions to protect themselves could be excused, but definitely, wrapping plastic bag round your penis and tie it up at the balls is incredible in 21st century Africa. Do you see why it is good to be small? Kenya is too big for authorities to get condoms to every nook and cranny.

Over here in Sierra Leone, I think we have enough condoms for those who care to use it. Aren’t we so blessed….tell me aren’t we? In the Nightline program on SLBC I mentioned earlier there were some of our compatriots who are still at the denial state. They claimed not to have seen anybody living with AIDS. For them it does not exist! Even when somebody living with AIDS called and spoke on the program, some people still had their doubts. Well one cannot be surprised since these days there are a lot of doubting Thomas’s in our country. I really loved the high knowledge level of the panelists on that program. One important issue is the distinction between HIV and AIDS. At first the two were separated by a slash, thereby giving the erroneous idea that they were one and the same. No…HIV is the virus and AIDS is the disease.

We need to look at some of the initial mistakes in the early sensitizations on HIV and AIDS in the late eighties and nineties. One major blunder was the scare messages that proved counter productive. In these days people will tell you that the moment you contract AIDS you will die, since there was no cure. The disease was thus synonymous with death. This to a large extent scared people to the extent that they did not see the need to even bother about attempting to protect themselves. Most of them gave up to fatalism and then started the campaign that in fact it did not exist.

Of course a big blunder initially was the efforts to trace the origins of the disease. People in the early periods spent so much time on tracing the history and played the blame game. All the talk of Green monkeys and all that only succeeded in distracting from the real issues at stake. Of course these could be part of the people living in denial that AIDS does not exist. What is still a problem is getting the right messages across. Most of the recorded songs on HIV and AIDS still have scare messages that are quite alarmist. Today messages should actually stress the fact that with the use of antiretroviral drugs, people living with the disease can live several years thereafter. One good slogan is There is life after AIDS. You do not give up on life simply because you have tested positive. You can actually continue living.

What is critical is that the drugs cannot be taken on empty stomach. So the issue of nutrition comes in. There is some irony about the challenges faced by those working on HIV and AIDS programs. Formerly a lot of people opted not to cooperate with agencies because they said they did not know people suffering from AIDS. Many agencies threw the challenge that if people living with the disease declare their status openly, they will be supported. This happened after 2003 when a national organization was launched in Freetown called Network of HIV Infected Persons (NETHIPS). Thereafter many other networks were formed at Regional and District Levels. This has really helped the Advocacy work since the people who were living with the disease are part of the campaign. A major shortfall however in some cases has been the area of care and support for those who have come out in the open to say they are positive. Care and support has been lagging behind the demands. The main reason has been that a lot of agencies had been working on the preventive aspect and not the care and support.

This development that is people coming into the open to say they are living with HIV and AIDS has helped a little bit to reduce stigma and discrimination. With the antiretroviral drugs, people living with HIV and AIDS look good and much confident in life. This is not to say that still some portion of our society still stigmatize and discriminate. See, like people say we are all vulnerable to diseases and it makes sense if we support those who are infected. You may not be infected but surely you can be affected

There are the poverty and development angles of the effects of HIV and AIDS. Since the disease reduces people’s ability to exhibit their potentials to the fullest, it undermines the community’s development and consequently makes people less able to reduce poverty.

Now we have other challenges. I must hasten to say that we should not exclusively concentrate on taking care of the sexual causes and forget the other seemingly silent and invisible causes. You can use condoms for sex, but what happens in the beauty salon? Many do not wear gloves and use razor blades one per person. With the skin head so much in vogue today, vulnerability is increased.

One other critical area is the transfusion of tested blood. We all know many Districts do not have the facility of blood banks and this leaves a dilemma of whether to transfuse untested blood just to save a life. Isn’t this a difficult situation? Do you start to see that there is more to it than the sensitization? Of course in scenes of accidents, first aiders without gloves may be at risk. As they say, better to have a wise enemy than a foolish friend. The good thing is that the test for HIV is free. And do not tell me you do not know where to get your free condoms. There is this argument that it is better to strengthen the fight against malaria since HIV and AIDS has had so much attention. Well I think Malaria is easier to prevent, since its mode of transmission is one and can be easier tackled. In any case HIV and AIDS aggravate other illnesses.

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Opportunity for HIV Prevention that Works. 11/3/11

South Africa is making progress, but we need to maintain the status of those that are HIV negative

Health-e

By Joanne Brink
11 March 2011

OPINION: South Africa’s HIV/AIDS National Strategic Plan for health has two objectives – reducing the incidence of new HIV infections by half and placing 80% of those in need onto anti-retroviral treatment. As a country, we are making some progress in scaling up our national HIV treatment programmes, but concurrently we need to maintain the status of those that are HIV negative. By Joanne Brink.

Over 95% of grade 8 to 12 learners are HIV negative.  Although not preventative, testing for HIV in secondary schools presents a significant opportunity for establishing a culture of knowing your status, allowing for the enforcement of a healthy lifestyle. Yes, there are many concerns, but let us focus on addressing the concerns by involving learners and their parents in the design and implementation of any school health and HIV testing programme, rather than lose this opportunity. By instilling healthy habits and regular HIV testing amongst our teens of today and at an early age, we have a better chance of reducing new HIV infections amongst our adults of the future.   

And make no mistake, many of our teens are having sex and are very much at risk of contracting HIV. A recent study conducted in Tshwane Municipality by The Foundation for Professional Development (FPD), a private institute of higher education, found that 40% of grade 8 to 12 learners are engaging in sexual activity, half of them with more than one sexual partner. However only 22% of these sexually active teens had been tested for HIV or thought they were at risk of contracting the disease. Yet, the vast majority reported that HIV was a topic discussed in their school at least once a month. This suggests that our current classroom model of delivering HIV prevention programmes to our learners is excelling on a theoretical manner, while the reactive behaviour that should stem from such knowledge is not evident.  

Focus groups conducted through FPD’s HIV management courses for schools, have provided some insight into the reasons that HIV prevention is not working in our schools and how to improve on the current approach. Discussions in the grade 8 to 12 learner focus groups confirmed an extensive factual knowledge of HIV – learners were able to quote statistics and recite the majority of HIV transmission and prevention methods. Yet they did not see themselves at risk of contracting HIV, even though the majority reported to be sexually active.

The critical insight here is that learners are not able to relate to or internalise the meaning behind these “HIV facts” that they are being taught at school. According to them, the current HIV prevention messages are delivered through didactic classroom lectures - often emphasising abstinence - whereas they would prefer to engage in the open and have direct conversations about the reality of their lifestyles and sexual health, as young adults, rather than focusing on HIV only. They advised that we should not be “coming in saying HIV HIV”, but make the campaign part of a wider focus about looking after their overall health. “Talk to us about what has been happening in our lives and [then] compare it to HIV and AIDS – helping us to differentiate between the lives that we are living and the lives that we need to lead” – female Grade 12 learner.

A school based health screening and HIV testing campaign will give learners a chance to engage with counsellors and health workers, whether they choose to test for HIV or not. For many, this will be their first open conversation with an adult about sexual health and lifestyle choices. Broadening the school based HCT campaign from an exclusively HIV screening focus to an integrated health programme, as proposed by the departments of health and education, will help to make HIV testing routine amongst our teens.  The pre- and post-test counselling experience will provide learners with the opportunity to ask direct questions and reflect on their own lifestyle and behavioural choices.

Furthermore, learners shared that their most trusted and valued source of information was their parents or caregivers. Yet their parents were unwilling and uncomfortable discussing sexual health matters or HIV with their children. The majority of parents believed that their role would be fulfilled once the “birds and bees” had been discussed once, whereas their teens craved regular conversations starting at a much younger age. Parents were however accused by their kids of being relatively uninformed about HIV and its effects. “They only know to tell us to use condoms to prevent HIV and that’s it. It would be nice to have parents who are informed about HIV. And if we could do something to inform our parents”- male Grade 12 learner. Although talking about sex to their parents would initially be awkward, learners yearned to do so and wanted to find a way to make the conversation easier for their parents.  

A school health and HIV screening campaign is an opportunity for parents to become better informed and thereby help to open the conversation between parents and their teens. Parents should be encouraged to accompany their children for health and HIV screening at the school, not only for their own wellbeing, but so that they can better understand the emotions and questions that their children will face during an HIV test and can better provide ongoing support and compassion post-testing.  

Grade 8 to 12 learners were born after the years when South Africa started responding to HIV and have grown up knowing about HIV and anti-retroviral treatment. This implying, that the messages to this group should be different to those of other generations.

School based HIV counselling and testing, integrated with a general health screening programme, is a chance for us to get HIV prevention right amongst our adults of the future. What is clear is that our teens have a lot of good advice to offer about how to improve HIV programmes that target youth. Involving them in the design of any school based health and HIV screening programme is critical to ensuring its success.

 Joanne Brink works for Foundation for Professional Development (FPD) -  The Foundation for Professional Development’s (FPD) vision is to build a better society through education and development, and the best place to start is with the foundation of society – our teachers – developing their ability to manage classrooms and inspiring them with the latest international teaching methodologies.

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Lessons in HIV Prevention. 11/2/11

The key is to triangulate HIV data with behaviour data . .  ask people very specifically: 'What's going on in your community'.

11 February 2011

African countries struggling to contain HIV epidemics can learn a thing or two about HIV prevention from Zimbabwe, say the authors of a new study which found that a reduction in sexual partners drove a decrease in new HIV infections there.

Zimbabwe's HIV prevalence fell by 13 percent between 1997 and 2007, a decline too steep to be attributed solely to HIV's natural progression and a hint that something else was forming a crucial part of the HIV reduction equation, said lead author and Harvard University Public Health lecturer Daniel Halperin.

"The modelling showed it couldn't just be the natural curve [of the epidemic]; the decline was too dramatic," he told IRIN/PlusNews. "The modelling suggested it was also due to behaviour change and behavioural data also suggested a change, but what was missing was the all important 'why'."

According to Halperin, Zimbabwe's success story points to the power of social change and the need for more detailed analyses of HIV success stories in Africa. He compared it to the role of partner reduction in the fight against HIV in Uganda, which promoted a reduction in multiple partnerships as the key focus of its HIV prevention campaigns in the late 1980s and early 1990s.

While many countries in sub-Saharan Africa, such as Ethiopia and Kenya, have seen recent reductions in HIV prevalence, it remains difficult to understand exactly what has driven these drops.

Low pay and fear

To find the reasons behind Zimbabwe's steep decline, researchers drew on almost a decade of HIV data, including mathematical models, large-scale HIV prevention trials and national surveys. Researchers supplemented this research with in-depth expert interviews and focus group discussions with 200 participants nationwide.

From 1990 to 2000, AIDS-related deaths rose by 30 percent in Zimbabwe, and according to researchers, focus groups revealed that this spike in AIDS-related mortality scared many into behaviour change.

"In the focus groups, men said things like: 'Oh I used to have a lot of girl friends. I used to have lots of fun, then my uncle died of AIDS’," Halperin said. "A lot of these men said, 'I can't leave my kids orphaned'."

According to the paper, focus group discussions also reported that societal norms shifted during this time and that increasing stigma was attached to factors associated with HIV risk such as paying for sex, having sexually transmitted infections (STIs) and multiple concurrent partnerships (MCPs).

Data from an HIV research site in Zimbabwe's Manicaland province showed that men who reported having MCPs fell by 40 percent between about 1998 and 2003 - roughly the same time period in which the number of new HIV infections was falling rapidly and salaries in the country fell by about 90 percent.

While men in focus groups said this decline in earnings made them less able to afford to pay for sex or sustain multiple sexual relationships, Halperin cautioned that economics probably only played a secondary role in reducing HIV, as new infections had began to decrease years before the effects of the recession were widely felt in about 2003.

The bigger picture for Africa

Halperin noted that when compared to other countries with well-funded HIV prevention programmes - such as Botswana - which have not charted such large gains in HIV prevention, Zimbabwe's success story may highlight that grass roots, social change is not necessarily a result of big spending.

"I think the donor-funded HIV programmes were probably useful in bringing down HIV prevalence but I think this shows you just can't pump money into a country, that things are only going to turn around once the communities get mobilized," he said. "[In Zimbabwe] the community sort of 'got it'; there was a change in norms and that became a part of popular culture."

"Many guys in focus groups said that if you got STIs in the early 1990s, you were called a 'hero', then universally around 1999, you never heard that again. Something happened in societal norms and I don't think there was some donor-funded programme that told people that STIs were shameful," Halperin added.

"I think a lot of credit goes to the Zimbabwean people themselves."

As more success stories emerge, Halperin said that more detailed analyses that looked at behaviour; epidemiology and programme coverage would be needed to explain successes, and failures.

"MCPs were the answer here but they may not be the answer everywhere; we need to do this kind of study in different countries, different situations," he said. "The key is to triangulate HIV data with behaviour data, but we also need qualitative data... We need to ask people very specifically: 'What's going on in your community'."

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UNAIDS Unveils Plan on Global HIV/AIDS Response. 22/1/11

Revolution in prevention politics, policies and practices is critically needed

AllAfrica

By Yinka Shokunbi
22 January 2011

As the world enters into the 30th year of the AIDS epidemic, the Joint Action Committee on HIV/AIDS (UNAIDS) is working to reposition its global response to the epidemic focusing on new environmental commitments.

Ten years after, the United Nations Special Session on HIV/AIDS and the landmark adoption of the Declaration of Commitment on HIV/AIDS, member states are equally preparing for the 2011 High Level Meeting on AIDS to review and renew future commitments for the AIDS response.

Towards achieving the objective of the new strategies, UNAIDS has launched a new five-year strategic plan (2011-2015) which aims to advance global progress in achieving country set targets for universal access to HIV prevention, treatment, care and support and to halt and reverse the spread of HIV and contribute to the achievement of the Millennium Development Goals (MDGs) by 2015.

According to the executive director of UNAIDS, Michel Sidibe, "This strategy was developed through a highly inclusive and open process-reflecting the needs and opportunities ahead of us and it is about fundamentally transforming the global AIDS response."

The chief aim of the new strategy is to get to a zero level of infection in the world.

The global commitments include achieving universal access to HIV prevention, treatment, care and support; to halt and reverse the spread of HIV and contribute to the achievement of the MDGs.

Strategic directions to be advanced by UNAIDS include revolutionising HIV prevention. The vision of this strategy is to get to Zero New Infections by 2015.

According to the UN organ, more than 7000 people are newly infected with HIV every day. And a revolution in prevention politics, policies and practices is critically needed. This can be achieved by fostering political incentives for commitment and catalysing transformative social movements regarding sexuality, drug use and HIV education for all, led by people living with HIV and affected communities, women and young people.

It is also critical to target epidemic hot spots, particularly in megacities, and to ensure equitable access to high-quality, cost-effective HIV prevention programmes that include rapid adoption of scientific breakthroughs.

The body also intends to catalyse the next phase of treatment, care and support. The goal is to get to Zero AIDS-related Deaths by 2015.

It recorded that a total of 1.8 million people died from AIDS-related causes in 2009 and it is imperative that there should be access to treatment for all who need it and this can come about through simpler, more affordable and more effective drug regimens and delivery systems.

UNAIDS noted also that greater links between antiretroviral therapy services and primary health, maternal and child health, TB and sexual and reproductive health services will further reduce costs and contribute to greater efficiencies.

That enhanced capacity for rapid registration will increase access to medicines, as will countries' abilities to make use of TRIPS flexibilities.

Likewise, nutritional support and social protection services must be strengthened for people living with and affected by HIV, including orphans and vulnerable children, through the use of social and cash transfers and the expansion of social insurance schemes.

The body aims to advance human rights and gender equality for the HIV Response with the vision to get to get to Zero Discrimination by 2015.

It is concerned that social and legal environments that fail to protect against stigma and discrimination or to facilitate access to HIV programmes continue to block universal access. Therefore, it advocates that countries must make greater efforts: to realise and protect HIV-related human rights, including the rights of women and girls; to implement protective legal environments for people living with HIV and populations at higher risk of HIV infection; and to ensure HIV coverage for the most underserved and vulnerable communities. People living with and at higher risk of HIV should know their HIV-related rights and be supported to mobilise around them. Much greater investment should be made to address the intersections between HIV vulnerability, gender inequality and violence against women and girls.

Adopted by the Programme Committee Board in December 2010, the strategy will also serve as reference in the lead up to the UN High Level Meeting on AIDS.

"The High Level Meeting will be a major milestone in the history of the AIDS response. Only by working together to set our future course can we accelerate greater results for people," noted Sidibé.

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How Bananas and Herbs may Prevent the Transmission of HIV. 11/1/11

Ban Lec, a highly concentrated lectin agent, may eventually prove beneficial in inhibiting HIV transmission.

FoxNews

By Chris Kilham
11 January 2011

There has been some buzz lately in the medical/science community about an article published in last year's issue of the Journal of Biological Chemistry, which announced findings that novel lectins found in bananas may help to prevent the transmission and spread of HIV. 

The study, originating from the University of Michigan, suggests that eventually many lives may be saved as a result of the development of Ban Lec, a concentrated extract of banana lectins. Lectins are proteins that bind to sugars. The HIV virus is contained in an “envelope” containing the sugar mannose. In laboratory studies, Ban Lec attached itself to the envelope of HIV, prohibiting its replication. Does this mean that eating bananas can help to prevent the transmission of HIV? Absolutely not. There is no evidence of any kind to suggest that eating bananas is any sort of a preventive factor in HIV infection. What this suggests is that Ban Lec, a highly concentrated lectin agent, may eventually prove beneficial in inhibiting HIV transmission.

According to UN AIDS Epidemic Update statistics, approximately 2.6 million people became infected with HIV in 2009. Among them, approximately 375,000 were children. HIV spreads through sexual transmission and through the use of shared needles, as well as by being born to infected parents, and is controlled by avoiding IV needle use, engaging in sex with partners tested free of HIV and wearing a condom. Even then, there is risk. HIV is considered a pandemic, claiming millions of lives globally. Sub-Saharan Africa has been especially hard hit by HIV, with an estimated 22.5 million people infected. In 2009 alone, an estimated 1.3 million Africans died of AIDS-related illnesses. The end of this is nowhere in sight.

Against this backdrop of horror and fatality, many thousands of researchers are investigating possible anti-HIV agents. Some of these are herbal. In one reported HIV study, a polysaccharide from the common herb hyssop inhibited the replication of the virus. The same compound also demonstrated significant protective activity on infected cells. While these findings are encouraging, they do not mean that hyssop prevents HIV.

In another study, a high lignin extract of pine cone seeds demonstrated anti-HIV activity, and helped to reverse the cellular destruction caused by HIV-infected white blood cells. Still other research shows that plant sterols, which are similar to cholesterol, may help to inhibit the invasion of cells by HIV. In mice and monkeys, an extract of pokeweed inhibited HIV significantly. At least three North American prairie plants have demonstrated significant enough anti-HIV activity that they are being studied further.

Does this science mean that a cure for HIV is close at hand? No, it does not. Does this mean that herbs can prevent or cure HIV? At this point we have no reason to believe that this is so. HIV remains a scourge that is ripping its way through the human population with no end in sight.

Of the various botanicals used in cases of HIV, cannabis appears to be the most beneficial. Though cannabis does not inhibit HIV infection or stop the virus from replicating, it does prove highly valuable in cases of HIV wasting syndrome and in cases of HIV-related neuropathy. In HIV wasting syndrome, infected people can experience tremendous difficulty eating or maintaining weight. The use of cannabis stimulates appetite in this population, enabling HIV infected people to eat, and to maintain weight. In cases of HIV-related neuropathy, infected persons experience pain in the longer nerves of the body, especially pain in the soles of the feet. But by smoking or eating cannabis, this pain can be managed enough to greatly reduce or even eliminate this pain. The virus remains, but the pain is managed.

Additionally, HIV infected people often use extracts of immune-enhancing mushrooms, especially the mushroom Reishi (Ganoderma lucidum) to bolster overall immune function. Many mushrooms contain polysacchardies that enhance immune function, and some of these funguses may prove helpful in long-term strategies to maintain better health in case of HIV infection. This form of treatment is popular among proponents of Traditional Chinese Medicine.

Despite encouraging science and the occasional positive news story, there is no known cure for HIV. And even though various studies of herbs suggest that some may eventually prove useful as complementary therapies for managing HIV, that day is down the road. And bananas? Don’t hold out too much hope there. Bananas are good foods, and their lectins may demonstrate anti-HIV properties, but there is a great deal of science yet to be performed to determine the actual worth of this approach in a human population.

While nature often holds a cure for life-threatening diseases, in the case of HIV, we have yet to find such a cure. In the meantime, all the basics apply. Be responsible in your sexual activity, avoid high-risk behaviors such as having sex with strangers and prostitutes and sharing needles, use a condom to reduce the risk of infection, and do not assume that eating any particular thing gives you protection against the virus. It doesn’t.

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Migrant Workers' Wives Talk Sex. 10/12/10

The government estimates that 80 percent of HIV-positive people do not know they have the virus.

1 December 2010

Nepalganj - It was only after her husband died that Tika Thapa discovered he was HIV-positive. That was eight years ago. When her husband returned from working in the Indian state of Gujarat, he was severely ill. He told her it was probably tuberculosis (TB); they continued to have unprotected sex.

"I didn't know anything about HIV then, so I never asked him to get tested," she told IRIN. Now, 38 and HIV positive, she is telling others in Nepalganj, a city in Nepal that borders India, to be more vigilant.

As a worker with a grassroots group affiliated with the government's National AIDS and STD (sexually transmitted diseases) Research Centre (NCASC), she said she had spoken to almost 500 people this year about how HIV spreads and measures that can be taken to avoid contracting it.

"When I share my experience with the wives of migrant workers, they tell me that I've opened their eyes and that they want to get their blood checked [for HIV]."

NCASC estimates that 0.49 percent of the population, or some 70,000 people, are living with HIV - a relatively low prevalence, but very few people in Nepal get tested.

The government estimates that 80 percent of HIV-positive people do not know they have the virus.

Most confirmed cases, 62.5 percent, are migrant workers and their wives, 41 percent and 21.5 percent, respectively, according to NCASC.

Migrating to work

Per capita GDP in Nepal is US$467, according to the Ministry of Finance, and the woes of the country's job market - low pay, high unemployment - have been exacerbated by years of political turmoil.

These conditions push some 1.5 million Nepalis every year to seek seasonal work abroad, mostly in neighbouring India but, increasingly, in other countries in Asia and in the Gulf, according to the Nepali government's Central Bureau of Statistics.

Away from their wives for long periods, some male migrant workers turn to brothels. This is how Thapa believes her husband became infected.

And the trend is showing no sign of letting up. Nearly half of all new HIV cases are recorded among people living in highway districts, which are home to high numbers of migratory workers, according to the 2010 UN General Assembly Special Session on HIV AIDS (UNGASS) report on Nepal.

Breaking taboos

Knowing the HIV risks faced by male migrant workers while abroad, Prativa Nepali, 22, decided to be unusually candid in discussing sex with her husband, who is working in Malaysia.

"I told him that that if you need a sexual partner while you're there, that's okay but be careful [use condoms]," she said.

Such frank discussions are much more difficult to navigate for Aayesa Seheba, 24, who lives down the road in Nepalganj's Pragatisil community and whose husband is also working in Malaysia.

She is Muslim and she says her religion is strict in discouraging discussion about sexually transmitted diseases.

"When I brought up the issue with my husband, he said testing wasn't necessary since he hadn't done anything wrong," she said. "And, in Islamic culture, this is something that's very difficult to discuss."

Trained by the Nagarjun Development Committee, a local NGO providing HIV/AIDS awareness and free anti-retroviral treatment, Chandra Kala Gurung works to broach such communication barriers between husband and wife.

Gurung said local attitudes towards discussing sexual health have relaxed somewhat in the 10 years she has been door-stopping men and women in the Pragatisil neighbourhood.

Resistance does not easily deter her. "If they don't listen the first time, I go two, three, four or five times - however many times it takes," she said.

"The first time I go I don't ask direct questions. First, I just want them to know me. I try to make jokes. Later, I try to ask more: if they use condoms, if they have been tested for HIV."

"If they get angry, I just laugh."

She said the lives she can save are worth the awkward encounters

 

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Call for Increased Prevention. Living with AIDS # 460. 9/12/10

HIV prevalence in the country has remained constant over the last three years

Health-e

By Khopotso Bodibe
9 December 2010

As local and international studies show that new HIV infections have remained static over the last 10 years, dealing with the epidemic now requires the world to give HIV prevention efforts the same attention as treatment to bring down new infections.

The 2009 national antenatal survey shows that HIV prevalence in the country has remained constant over the last three years at around 29%. The Joint United Nations’ Programme on HIV/AIDS (UNAIDS) report, which shows the level of HIV infection around the world, also shows that South Africa has reduced new HIV infections by 25% over the last decade. But the war on AIDS is not over yet. While infection levels in the general population remain unchanged, certain groups such as women older than 30, men who have sex with men and injecting drug users still remain at greater risk of HIV infection.    

“Urban data, for example in Zambia, suggest that 50% of people who are newly infected through heterosexual transmission actually acquired it within marriage or cohabitation and, indeed, in a whole lot of other countries we are seeing statistics of 60%, 55% where it’s among people who are cohabiting. Evidence also indicates that paid sex work, sex between men and use of contaminated needles by intravenous drug users are significant factors in the HIV epidemic in a number of countries – even those with generalized epidemics. We still have pockets of key populations that need to be taken care of when it comes to access to treatment, care, prevention and support services”, says Professor Shelia Tlou, Director of the Joint United Nations’ Programme on HIV/AIDS (UNAIDS).

Tlou also pointed out that many people still do not know their HIV status. This lack of knowledge poses a risk factor for HIV acquisition and transmission in relationships where partners don’t know of each other’s HIV status.

“The prevalence of sero-discordant (couples), that is, couples where one is positive, the other is negative is actually high in our region – as high as 35% to 85% - hence, there is a need for couples’ counseling and testing. We have a large proportion of people who are in long-term relationships. We need to make sure that we have couples’ counseling and testing to ensure that they access services – prevention, treatment, care and support”, she said.

The discovery of new technologies, such as microbicides, is crucial to prevent HIV infection in women, added the Treatment Action Campaign’s Nonkosi Khumalo.     

“It’s one thing to be looking forward to as women because it puts power in our own hands. Availability of female condoms is still very, very low. Women still rely largely on whether their male counterparts want to use the male condoms that are largely available”, said Khumalo.        

Deputy Health Minister, Dr Gwen Ramokgopa, urged South Africans to test for HIV. Currently, the government is running a massive campaign which began in April and will end in June next year to test about 15 million citizens.  

“We believe that knowing one’s status is the beginning of a sustainable prevention as well as treatment programme”.

But as gains in HIV prevention and treatment programmes now start showing, concern abounds over AIDS funding.  Governments in Africa are not spending enough to deal with the challenge of AIDS, despite promises to increase their spending on health. For too long they have relied on donors, who are now holding their purses very tight.

UNAIDS’s Professor Sheila Tlou said: “The AIDS response is fragile. It needs to be kept alive. It needs to be kept alive with funding. Domestic funding is still very low. A lot of our countries had said that they would devote, at least, 15% of their budgets to health and HIV/AIDS and very few countries in Africa have done so. However, we need to ensure that that investment is there. AIDS programmes can be made sustainable and affordable. We need to rely less on international donors. Right now we are estimating that $15. 5 billion was available for the AIDS response in 2009, but this was $10 billion short of what was needed. We need international funding, but we also need domestic funding”.

The last decade has been characterised by the fight for access to AIDS treatment in poor countries. Now more than five million people are receiving life-saving antiretrovirals as a result. The fight these coming years should rightly focus on more access to treatment, but also on strengthening HIV prevention efforts. This will need money and our governments need to come to the party to continue the gains achieved in the response to AIDS.  

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Swedish Law behind Rise in HIV Cases: Experts. 1/12/10

The law against infectious diseases should undergo a thorough overhaul

1 December 2010

"Today, when there is effective treatment, HIV is no longer a fatal disease. There is no study that shows that punishment for HIV transmission reduces the spread of the virus," wrote Inger Forsgren, Anders Karlsson, Åsa Regnér and Per Ole Träskman in a opinion piece published in the Dagens Nyheter daily on Wednesday.

Forsgren is the chairperson of HIV-Sweden, Karlsson the head doctor of Södersjukhuset's Venhälsan, Regnér the general secretary of the Swedish Association for Sexuality Education (Riksförbundet för Sexuell Upplysning, RFSU) and Träskman a criminal law professor at Lund University.

"The law against infectious diseases should undergo a thorough overhaul, the duty to inform abolished and only those who deliberately transmit HIV prosecuted," they added.

Agneta Holmström, the head of the infectious diseases unit at the National Board of Health and Welfare (Socialstyrelsen), said that she does not know if the duty of disclosure, which requires all those thought to be infected with a sexually transmitted disease to come forward for testing in order to track the spread, has resulted in a spike in HIV cases.

"That's something for the government department to look into if they decide to look over this act. But our agency, we will continue to look into this and talk to the Swedish Institute of Infectious Disease Control (Smittskyddsinstitutet - SMI) to do a study," she told The Local on Wednesday.

She added that occasionally, it may involve a misunderstanding when it comes to ordering people to test for STDs, such as having the wrong address on file for the individual.

Among all STDs, Holmström said the one that poses the greatest concern in Sweden remains chlamydia because the general population are "very much aware" of the risks involved with the other diseases, saying that HIV is stable in Sweden aside from occasion outbreaks among drug users.

"They don't think chlamydia is a serious disease, it's not life-threatening, they don't think they have to go and get tested. There has been an explosion in the last few years since 2007. It is very difficult to find the people you have relations with," she said.

Sweden's first HIV case was diagnosed in 1982, before AIDS was properly diagnosed by the US Centers for Disease Control. Slightly more than 5,000 people in Sweden currently live with AIDS, said Viveca Urwitz, the former head of the SMI's HIV prevention unit.

Up until December 2009, a total of 8,935 HIV infection cases had been reported in Sweden, of which 30 percent involved women and 2,310 were diagnosed as AIDS. A total of 486 new cases were reported last year.

Slightly more than 50 percent of the new cases were reported in Stockholm, 14 percent in Västra Götaland and Skåne and the remainder across the country.

Urwitz revealed that more than half of all new diagnosed HIV cases in Sweden every year are among new migrants from high-risk countries, with Thailand and Ethiopia the two most common.

"A lot of them don't know, some do and some don't," Urwitz told The Local regarding HIV-infected migrants to Sweden.

She emphasised that these migrants are not refugees, but those who come to Sweden for family or work purposes.

Overall, the number of people living with HIV in Sweden is slowly growing, particularly among high-risk groups such as men who have sex with other men, intravenous drug users and people who buy and sell sex.

Both Holmström and Urwitz believe that the government's measures to combat HIV and AIDS are effective, but Urwitz pointed out health care and education, the main drivers behind prevention, are decentralised in Sweden, so it is difficult to ensure the same treatment across the country.

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Anti-nausea Drug has Anti-HIV Effect Too. 4/11/10

Strongest anti-HIV effect of any neurokinin-1 receptor antagonist.

AIDSMap

By Keith Alcorn
4 November 2010

A drug used to quell nausea caused by chemotherapy has a strong anti-HIV effect in the test-tube, and this effect is intensified if the HIV protease inhibitors saquinavir or ritonavir are also present.

The drug, aprepitant (Emend, manufactured by Merck & Co), also returns the favour by intensifying the antiretroviral effect of ritonavir and saquinavir, and blood levels of aprepitant are boosted by ritonavir.

The findings, reported in an advance online publication of the journal AIDS, have resulted in a clinical trial that is now testing the safety and pharmacokinetics of aprepitant in HIV-positive people.

Aprepitant is one of a class of neurokinin-1 receptor antagonists that block the neuropeptide substance P, which is involved in interactions between the nervous system and the immune system.

The interaction between substance P and the neurokinin-1 receptor is critical for viral infection of a cell, and HIV is no exception.

Previous experiments have shown that a substance P antagonist – a chemical that can block its normal receptor on human cells – reduces HIV infection of macrophages by reducing the display of CCR5 receptors on these cells. Most types of HIV require the CCR5 receptor in order to gain access to CD4 cells and other immune system cells.

Aprepitant is licensed for the prevention and treatment of nausea due to cancer chemotherapy. It was selected for this experiment after the discovery that it could prevent HIV infection of macrophages.

Further tests showed that it had the strongest anti-HIV effect of any neurokinin-1 receptor antagonist.

In this study the drug was incubated alone and in combination with a number of antiretroviral drugs from different classes: ritonavir and saquinavir (protease inhibitors); nevirapine (non-nucleoside reverse transcriptase inhibitor) T-20 (entry inhibitor) and AZT, ddI and 3TC (nucleoside analogues).

The researchers looked at the synergistic effect of the drugs in peripheral blood mononuclear cells infected with a wide range of HIV isolates representing all global sub-types and major recombinant forms, and viruses adapted to use the CCR5 and CXCR4 receptors.

The researchers found that the antiviral effect of aprepitant used together with the two protease inhibitors was greater than would be expected from adding up the antiviral effect of each drug alone, in other words, synergistic. Use of aprepitant with a protease inhibitor resulted in double the expected antiviral effect. A smaller synergistic effect was observed with 3TC and AZT. No synergy was observed with other drugs.

The researchers found no difference in activity according to viral subtype or receptor usage.

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Behaviour Change Programmes have had Little Impact on HIV Incidence Amongst Girls and Women in Poorer Countries. 19/5/10

Behavioural change interventions to prevent sexual transmission of HIV among women and girls in resource-limited settings have had limited success,

AIDSMap

By Michael Carter
19 May 2010

Behavioural change interventions to prevent sexual transmission of HIV among women and girls in resource-limited settings have had limited success, according to a systematic review published in the online edition of AIDS and Behavior.

Only eight randomised controlled trials or prospective studies with a control arm could be identified by the investigators. Moreover, only two of these programmes reduced HIV incidence. Three other interventions had an impact on HIV risk behaviours or the incidence of sexually transmitted infections.

Approximately 50% of worldwide HIV infections are in women and girls. However, the impact of HIV on women in the countries hardest hit by HIV has been more severe, with 60% of HIV infections in sub-Saharan Africa being in girls or women.

The development of female-controlled biomedical methods of HIV prevention, such as microbicides, has been slow and disappointing. Therefore HIV prevention for women and girls is reliant upon behaviour change – for example, delayed sexual debut, a reduction in the number of partners, and condom use. These methods of prevention are largely controlled by male partners, and in many cases women and girls are unable to insist on behaviour that could protect their sexual and reproductive health.

Mindful of these circumstances, an international team of investigators conducted a systematic review of behaviour change interventions to see if they reduced either HIV incidence or HIV risk behaviours.

Randomised controlled trials or prospective studies with a control arm conducted after 1990 was eligible for inclusion.

After an exhaustive literature search, the investigators were only able to identify eight studies (reported in eleven research papers) that met their inclusion criteria.

Six of the studies were conducted in Africa, one was carried out in India, and one in Mexico.

A total of 42,000 women or girls were included in these studies, and these people were followed for an average of 2.6 years.

The type of intervention varied from a single counselling session to more extensive and long-term support.

Only two interventions had an impact on HIV incidence.

The first of these was a six-month programme of group education and motivational sessions for female sex workers and brothel madams in Mumbai, India.

The intervention for the sex workers consisted of the use of motivational literature and videos, group discussions, and the use of pictorial resources focusing on HIV and condom use. The women were instructed how to use condoms correctly, and encouraged to educate their clients about condom use.

Brothel madams were educated about the economic benefits and importance of maintaining the good health of their sex workers.

HIV incidence was reduced by 67% in the intervention arm compared to the control arm. However, the investigators noted that condoms and lubricant were only provided to women in the intervention arm, and were not given to the sex workers in the control group.

This intervention was also shown to reduce the incidence of both syphilis and hepatitis B.

The second study was conducted in Uganda, and this showed that attendance at an HIV study event in the previous year reduced HIV incidence by up to 59%. Incidence of herpes simplex type-2 (HSV-2) was also reduced by 45%.

Three other interventions were successfully reduced the incidence of sexually transmitted infections, but not HIV. Condom use higher in the intervention arm in the Mexican study than in the controls (27 vs 18%, p < 0.01).

“This review has highlighted the reality that current behavior change interventions, by themselves, have been limited in their ability to control HIV infection in women and girls in low- and middle-income countries,” comment the investigators.

The investigators highlight that women and girls often have little control over their sexual and reproductive health and in many cases are unable to insist on condom use.

A “combination” approach to prevention is advocated by the study’s authors, one that addresses both behavioural and biomedical risk factors.

They write, “the diminishing hope that a single behavioral or biomedical prevention intervention will be sufficient to address the growing HIV pandemic has heralded a programmatic shift towards combination HIV prevention programming.”

Reference
McCoy SI et al. Behavior change interventions to prevent HIV infection among women living in low and middle income countries: a systematic review. AIDS Behav, online edition, DOI 10. 1007/s10461-009-9644-9, 2010.

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Bill Gates Maps the Way to More Effective HIV Prevention 21/7/2010

Bill Gates maps the way to more effective HIV prevention

Published: 21 July 2010

The world lacks the means to treat its way out of HIV, Microsoft founder and billionaire philanthropist Bill Gates told the Eighteenth International AIDS Conference in Vienna on Monday.

However, he presented models that showed that we could cut current epidemics by 40% with the efficient and targeted use of simple prevention resources we have already. Adding in microbicides and pre-exposure prophylaxis (PrEP), which may be available in five years, could cut them by 60%.

Gates said: “If we push for a new focus of efficiency in both treatment and prevention and continue to innovate new tools we can start writing the story of the end of AIDS.”

We should be launching concerted drives to increase the provision of treatment to prevent mother-to-child transmission, and to roll out male circumcision programmes, he added.

“These are potentially so cheap and easy to supply it’s actually more expensive not to implement them.”

Gates admitted he had been sceptical about the potential impact of circumcision.

“I agreed it was effective, but I didn’t think lots of men would come forward for it. I was wrong: many young men are coming forward,” he said, pausing his presentation to show a short film about a 19-year-old in Swaziland who had done just that.

And yet male circumcision was not reaching nearly enough men: just 150,000 so far out of over 40 million who might benefit from it.

In the case of treatment to prevent mother-to-child transmission, he said: “I really don’t understand why only 45% of mothers have access to it; we should have it above 90%. We should go to each of the countries involved and we need to get political leaders to set tough goals. I’d like to see even in the next year a big change on this.”

He added that politicians should also be pressurised to provide for prevention programmes targeting the communities where they would make the biggest difference. In Kenya 10% of infections are due to sex between men, yet few districts have provision for men who have sex with men (MSM). In districts in Russia where clean needles had been provided, the rise in HIV prevalence last decade was a tenth of the rise in districts where they had not.

“The problem is not lack of data,” he said. “The problem is that countries are not using the data to make funding decisions. Instead politicians are making decisions based on fear and stigma.”

Correctly targeted interventions, including behavioural interventions that are properly focused and researched, might cut the global epidemic in half, Gates said.

“That would be good news but not good enough. Thankfully in the future we may have more tools.”

He referred to a mathematical model from the team at Imperial College in London, which showed that in a country with a generalised epidemic – the example being rural Zimbabwe – using properly-targeted prevention tools would cut the projected prevalence in the year 2031 by 38%. Adding in microbicides and pre-exposure prophylaxis would cut it by 53%.

In a country that still has a focused epidemic, like Benin, the impact would be larger: the model predicts that currently available prevention, efficiently targeted, would cut the 2031 prevalence by 46%, and adding in microbicides and PrEP would cut it by 64%.

However, he added, “We have to face that expanding our prevention efforts won’t start driving down the number of deaths and the number of people we have to treat for a decade. The only way we will reduce this now is to expand treatment.”

When funding is limited, he said, both the cost of the drugs and the cost of delivering them needed to go down.  Like Bill Clinton (see aidsmap article: Clinton: 'it's the end of the beginning' of the AIDS epidemic), he felt that the cost of first-line regimens was unlikely to go down a lot further, although there needed to be continued price pressure on the cost of both tenofovir and of second-line regimens, which now represented 25% of drug costs. Like Clinton, he thought the best savings would come from making economies of scale in distribution schemes and in task-shifting health personnel so that non-specialist help and drug delivery were provided by healthcare assistants.

“If we could get the total cost down to about $300 a year we could treat twice as many people,” he said.

Gates commented: “Other countries might need different interventions to achieve results, but the control of HIV would stand alongside the eradication of smallpox as one of the great medical interventions in history.”

Watch Bill Gates's speech on the Kaiser Family Foundation website

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Cash Payments can Reduce HIV/Sexually Transmitted Infections in Africa - New Bank Studies. 18/7/10

Two new studies show how young women and men in Malawi and Tanzania who were given cash payments had significantly lower HIV and other STI rates

18 July 2010

Vienna/Washington - On the eve of a global AIDS summit in Vienna, the World Bank today released two new studies that show how young women and men in Malawi and Tanzania who were given cash payments had significantly lower HIV and other sexually transmitted infection (STI) rates than other groups in their communities.

The two studies―‘Schooling, Income, and HIV Risk (SIHR) Malawi,’ and ‘The RESPECT Study: Evaluating Conditional Transfers for HIV/STI Prevention in Tanzania’―are modeled on ‘conditional cash transfer’ programs, like the ‘Oportunidades’ program in Mexico, which use cash payments to encourage children and adults in poor households to improve their education and healthcare.

“The world desperately needs new HIV prevention strategies because for every two people who receive life-saving AIDS treatment, another five become newly infected, which is an impossible situation for many poor countries and their communities,” says Dr. David Wilson, the World Bank’s newly appointed Director for its Global HIV/AIDS Program.

An international authority on HIV prevention, Wilson will head the Bank team at the International AIDS Society summit in Vienna, July 18-23. “These two studies show the potential for using cash payments to prevent people, especially women and girls, from engaging in unsafe sex while also ensuring that they stay in school and get the full benefit of an education,” Wilson says. “They can also boost incomes for poor families and help them escape poverty.”

Schooling, Income, and HIV Risk (SIHR) Malawi

This cash transfer study, which ran for two years between 2008-09, randomly enrolled 3,796 adolescent girls and young women between the ages of 13 and 22 from Zomba, a district in Malawi with high HIV rates and school dropout rates among adolescent girls.

The only condition for receiving cash payments every month was that the girls enrolled in the program had to attend school regularly. As part of the program, their parents received cash payments as well. The girls’ school attendance was checked every month and payment for the following month was withheld for any student whose attendance rate was below 75 percent in the previous month.

Although the cash payments were made purely on the basis of school attendance, the money also made the girls less vulnerable to contracting HIV and other STIs. Eighteen months after the program began, HIV infections among girls in the program were 60-percent lower than those who were part of a control group and did not receive payments. Also significantly, HSV-2 infections (herpes simplex virus – type 2, the most common cause of genital herpes) among girls in the program were 75-percent lower than in the control group.

Girls who received payments not only had less sex, but when they did, they tended to choose younger, safer partners.

The new study suggests that the cash transfers may have led to a drop in so-called ‘transactional sex.’ At the beginning of the study, a quarter of sexually active participants said they started relationships because they ‘needed his assistance’ or ‘wanted gifts/money.’ Meanwhile, among the sexually-active schoolgirls in the control group, 90 percent said that they received an average of US$6.50 a month in gifts or cash from their partners. Given that the country’s per capital yearly GDP in 2008 was US$287.5, the girls considered these gifts very valuable.

After a year, schoolgirls receiving payments from the cash-transfer program seemed to avoid older men, who tend to be wealthier and are much more likely to be HIV positive than schoolboys. The sexual partners were two years older on average than the girls, compared with three years for the control group. More strikingly, less than 2 percent of the sexual partners were 25 or older, compared with 21 percent for the control group.

Conditional cash transfer programs, which immediately boost income among poor families while investing in better health and education prospects for children, have not typically been part of HIV prevention strategies among adolescent girls and young women. Such programs, perhaps designed with an added focus on adolescent girls, could become an important part of effective HIV-prevention strategies at a small marginal cost, complementing interventions that explicitly target ‘behavior change.’

“Programs like these could become an important missing part of effective HIV-prevention strategies,” says Berk Özler, a Senior Economist with the World Bank’s Development Research Group, who conducted the study with researchers from George Washington University and the University of California, San Diego. “These findings suggest that empowering girls financially can also lead to reduced risk—not just by reducing their sexual activity or practicingsafer sex, but also by enabling them to choose partners who are less likely to be infected with HIV in the first place.”

The RESPECT Study: Evaluating Conditional Transfers for HIV/STI Prevention in Tanzania

This $1.8 million study in Tanzania was designed to give cash payments to adults to avoid unsafe sex and prevent STIs such as chlamydia, gonorrhea, trichomonas, mycoplasma genitalium, and syphilis, each of which is preventable and curable. The study enrolled 2,399 participants, males and females between the ages of 18 and 30 in 10 villages, in the Kilombero and Ulanga districts of Southwest Tanzania, located 100 kilometers south of the major highway linking Dar Es Salaam with Zambia and Malawi.

All participants have been monitored on a regular basis (every four months during a 12-month period) for common STIs transmitted through unprotected sexual contact and which therefore serve as a proxy for risky sexual behavior and vulnerability to HIV infection.

Medical teams were sent to each village every four months to conduct STI testing. Individual pre-test and post-test counseling was provided to study enrollees at each testing interval, and monthly group counseling sessions were also made available to all study participants to assist them in their efforts to reduce risky sexual behaviors..

After 12 months of rewarding people for testing negative for STIs, the program recorded a 25-percent drop in the numbers of STIs compared to people in control groups who were not paid to stay STI-free. All participants received free treatment when testing STI positive. But only those who tested negative in the cash group received payments. Cash payments were not tied to HIV status. Those who tested positive first, but negative after four months, also received cash payments.

The cash, up to US$60 per person over 12 months, made a difference in many households. The country’s gross national income per capita was US$496.4 in 2008, and on average, the annual earnings of study participants were half of that amount.

“Using cash payments to reduce STIs by 25 percent over the course of 12 months is encouraging and means that we should further test this idea in other settings and maybe on a larger scale.,” says Damien de Walque, a Senior Economist in the World Bank’s Development Research Group, who carried out the study with researchers from the University of California in Berkeley and the Ifakara Health Institute in Tanzania.”Existing prevention strategies have had limited success so we have to look for creative new approaches to help people change their behavior and finally stop and then reverse the HIV/AIDS epidemic.”

World Bank and HIV/AIDS

The World Bank continues to recognize AIDS as a serious development challenge that has inflicted widespread human tragedy as well as robbed countries of their productive citizens and workers, causing serious economic loss. To date, the Bank has provided US$4.5 billion for HIV prevention, treatment, care and support programs in developing countries. Since 2006, 4.3 million people have received counseling and testing through Bank-supported projects focused on HIV prevention. During the past year alone, the Bank provided US$630 million in funding disbursements and new commitments for HIV and AIDS programs, helping poor countries fill critical gaps in AIDS prevention, treatment, and mitigation.

To make sure that HIV/AIDS programs are more effective and sustainable over the coming years, Global AIDS Director, David Wilson says that the World Bank must continue to integrate its HIV work with its broader mission to help developing countries strengthen their overall health systems to improve the state of people’s health.

“We have to move AIDS treatment away from a purely emergency response towards a sustainable long-term future by folding AIDS prevention, treatment and other health-related HIV services into stronger national health systems that make health and development dollars work reciprocally together for maximum effect,” Wilson says. “The Bank’s record lending for health in FY10—roughly $4 billion, up from $2.9 billion the previous year—reflects a strong demand from countries for Bank support.”

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Effort 'Badly Targeted'. 09/05/08

Mark Henderson, Science Editor

May 9, 2008

The fight against the Aids epidemic in Africa is founded on ineffective strategies and should focus on male circumcision and reducing promiscuity, according to leading scientists in the field.

HIV containment is generally based on the "three pillars" - promotion and provision of condoms, HIV status testing and treatment of other sexually transmitted infections (STIs) that can increase the risk of becoming infected. There is little evidence, however, that any of these methods works well in sub-Saharan Africa, where two thirds of the 33.2 million people who carry the virus live, a review for the journal Science has found. It was published in a special issue to mark the 25th anniversary of the discovery of the HIV virus that causes Aids. 

Its authors said that only two approaches - male circumcision and campaigns to persuade people to take fewer sexual partners - have been shown to reduce HIV transmission significantly in the world's worst affected region. 

International resources need to focus on these unfashionable policies, which receive minimal funding, to make them the cornerstones of HIV prevention, the scientists from Harvard School of Public Health and the University of California, Berkeley, said. 

Related Links

The unspoken truths about Aids

Circumcise men to cut Aids, says UN  

"Despite relatively large investments in Aids prevention efforts for some years, including sizeable spending in some of the most heavily affected countries (such as South Africa and Botswana), it's clear that we need to do a better job of reducing the rate of new HIV infections," said Daniel Halperin, of Harvard, who led the research team. 

"We need a fairly dramatic shift in priorities, not just a minor tweaking. The vast majority of donor investments in HIV prevention in the generalised epidemics of Africa continue to go to approaches for which the evidence of actual impact is increasingly unclear. 

"Many of these approaches, such as HIV testing and treating other sexually transmitted infections, do have important public health benefits, and should be continued, but not because we believe they will definitely have a major impact on reducing HIV infections. 

"Meanwhile, there is still some foot dragging on more fully implementing those approaches for which the evidence is much stronger, namely to scale up safe, voluntary male circumcision services, and to more assertively promote partner reduction." 

The scientists found that the "three pillars" have been effective at reducing transmission of HIV in countries such as Thailand, where the epidemic is spread mainly by gay men, intravenous drug users and sex workers. 

In sub-Saharan Africa, however, the virus is commonly passed on through heterosexual relationships, particularly when people have multiple partners. This makes each of the usual approaches less effective. Regular condom use, for instance, is hard to promote for long-term relationships. 

Studies in Africa have also shown that neither HIV testing nor treating other STIs has a lasting impact. Male circumcision, by contrast, has been shown to be highly effective, reducing the risk of infection by at least 60 per cent in three recent randomised controlled trials run in Africa. Yet it receives only about 1 per cent funding distributed by the UN Aids Programme.

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Families Can Be Protective Force Against HIV, Says Senior UN Official. 28/01/10

Imprtant role in prevention and care confirmed.

UN News Centre

HIV and AIDS place greater burdens on families, who can sometimes be torn apart by the epidemic, but they are also a major force in prevention education as well as care and support, according to the head of the United Nations agency dealing with the issue.

“Family support can improve adherence to treatment, provide sustaining care and offer the first line of defence against stigma and isolation. And in the largest sense, strong families contribute to community – and by extension national – stability,” Michel Sidibé, Executive Director of the Joint UN Programme on HIV/AIDS (UNAIDS), said yesterday in his keynote address to a colloquium in Doha, Qatar, where scholars gathered to discuss issues affecting the family.

Mr. Sidibé noted that communities with higher burdens struggle to shield their children from infection and to care for those who have lost parents to the disease. “Yes, families can be, and are, torn apart by AIDS,” he stated.

“But let’s look at this another way: Families can also be highly protective, inoculating members against the worst outcomes of AIDS. They offer a dependable means of prevention education and the clout to keep children in school, on track and out of risk,” he added.

He highlighted recent findings from the two-year research project of the Joint Learning Initiative on Children and HIV/AIDS, which showed that families take on approximately 90 per cent of the financial cost of caring for infected and affected children. Many of these families are already living in extreme poverty, yet few receive any support from sources outside their communities.

“Maintaining and strengthening families is not very expensive,” said Mr. Sidibé. “Any developing country, no matter how poor, can afford a social protection package for children affected by HIV and AIDS and extreme poverty.”

The International Labour Organization (ILO), he said, estimates that for low-income African countries, such a package could cost less than 4.5 per cent of gross domestic product (GDP), and could include a small universal old-age pension, universal primary education, free primary health care, and a child benefit of 25 cents per day.

The UNAIDS chief cited as another key concern the freedom of movement for people living with HIV, particularly migrant workers and their families.

According to the agency, Qatar – like many others in the Middle East and North African region – imposes restriction on entry, stay and residence based on HIV status. Such restrictions are widely considered discriminatory and serve no public health benefit, it noted.

UNAIDS also pointed out that the HIV epidemic is steadily growing in the Middle East and North Africa. In 2008 there were an estimated 310,000 people living with HIV, up from 200,000 in 2001. In that same year, approximately 35,000 people became newly infected with HIV in the region.

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Fauci, Other HIV Experts Discuss Way Forward in HIV Prevention & Treatment. 14/12/09

 

December 14, 2009

Leave it to Anthony Fauci to cut right to the chase when it comes to delineating the right path forward at this critical juncture in HIV treatment and prevention.

At a forum today on “The Future of Global HIV Treatment and Prevention,” Fauci, head of the National Institute of Allergy and Infectious Diseases, summed up the current dilemma facing AIDS experts and policymakers this way: “If you have increased global HIV prevalence and more individuals requiring antiretroviral therapy, is this an insurmountable challenge or are we going to have to rise occasion to address this?”

His answer was unequivocal: “It is not insurmountable,” Fauci said at the event, hosted by the Center for Strategic and International Studies.

Fauci took the audience on a historical journey, through the “dark ages” of the HIV epidemic, when “everyone I treated died” because physicians and scientists did not know what they were dealing with, to today, when the average life expectancy of a 20-year-old HIV-positive patient in the U.S. is 69 years.

In a warning against complacency, Fauci said, “We have much, much more to do than what we’ve accomplished.” With 7,400 new infections every day, including 1,200 among children and about half among women, the HIV virus is attacking “the fruit of the youth of the world,” he said.

The way forward, he said, is an aggressive search for new biomedical prevention tools and strategies, including microbicides, PrEP, and a vaccine. He touched on today’s “discouraging news” that researchers did not find any evidence that PRO 2000, a microbicide, was effective in reducing the risk of HIV infection among women. Noting that PRO 2000 did not include an ARV, Fauci reiterated his commitment to microbicide research and said he “feels confident” that other candidates will yield more promising results. 

One audience member asked Fauci whether, in light of the WHO’s new treatment guidelines calling for earlier initiation of ARVs, countries should move to treat the sickest people, with CD4 counts under 200, or the “not-so-sick” who are newly eligible for HIV therapy.

“I can’t give you a Sophie’s choice answer,” Fauci said. “You obviously can’t stop therapy with someone you’ve started,” but each country will have to make their own decisions about how to proceed in light of the new guidelines. What is really needed, he added, is a more robust response to the AIDS pandemic from countries besides those in the G-8.

During a panel discussion after Fauci’s remarks, other experts also weighed on in the current dilemma, in which more people are eligible for and in need of ARV treatment, but funding remains level and the US appears to be shifting its attention to other diseases and health threats.

Dr. Diane Havlir, professor of medicine at the University of California, San Francisco, and a member of the Center for Global Health Policy’s Scientific Advisory Committee, said scientists and other advocates need to better communicate the significant side benefits of PEPFAR on other disease interventions, such as tuberculosis.

 “One of the things we’ve gotten with ARV roll-out is reduction in TB rates,” she said. “There are so many examples of interventions that are cross-cutting.”

Dr. Havlir also noted that the field of HIV is very dynamic, and new tools could dramatically change the treatment and prevention paradigm. “I’m not saying we won’t have to make hard choices, but let’s be smart about the data we have before us as we got into this,” she said.

She said the decision of the International AIDS Society to hold its 2012 conference in Washington presents “a tremendous opportunity” to showcase the benefits of AIDS programs as well as the importance of the US contribution to fighting the epidemic.  

Elly Katabira, president-elect of IAS, said HIV treatment success stories need to be told more clearly because they make for a compelling case for additional investments. Treatment shortages may grab headlines, he said, but a more gripping story might, for example, showcase the number of teachers who have been able to access treatment and the societal contributions they’ve been able to make as a result.

The most pointed message at the CSIS forum was delivered at the end by Julio Montaner, current IAS president. “It’s almost like we are punishing success,” he said of the flagging international commitment to HIV/AIDS despite great success and growing need. HIV experts deserve some of the blame, he said, for failing to adequately connect the dots, at least in the public arena, between HIV programs and resulting societal gains, from decreased mortality to fewer AIDS orphans.

Whatever the reason, he said, the situation needs to be placed squarely on the agenda of the international community, including his native Canada.

 

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Gates Calls for Scale-Up of Evidence-Based Prevention. 19/7/10

Bill Gates told a packed audience at IAS 2010 that his Foundation is committed to AIDS for the long haul

19 July 2010

Vienna – Bill Gates told a packed audience at IAS 2010 that his Foundation is committed to AIDS for the long haul, while highlighting the need to maximize resources by scaling up the prevention strategies we can count on; male circumcision, prevention of mother to child transmission (PMTCT) and HIV treatment as prevention.

Gates characterized PMTCT and male circumcision as interventions that are more expensive not to do, noting that the $1.4 million spent in Kenya to circumcise 36,000 men would translate into a treatment cost ten times as much if those men became HIV infected. He called the 45 percent coverage of PMTCT a “disgrace” given the low cost of the intervention and the human cost of HIV-infected children.  He also challenged the audience to press for interventions targeted to populations most at risk including MSM, injection drug users and commercial sex workers.  He worried that some countries are not targeting their prevention funds because of stigma and offered Russia’s shifting of resources from drug users to the general population as a decision that “wastes money which costs lives.”

Notably, Gates highlighted antiretroviral therapy (ART) as prevention and suggested it was especially important to ensure treatment of individuals who have CD4 counts less than 200, because their higher viral load makes them more likely to transmit the virus to others.  Underscoring the need to maximize treatment resources, he said simplifying treatment and minimizing personnel costs was imperative and was more likely than decreases in drug costs.

Referring to soon-to-be-released clinical trial data on microbicides and a partially effective vaccine trial last year, Gates expressed optimism about the evolving tools to fight the epidemic.  He cited a modeling study showing that implementing current evidence-based prevention tools could reduce HIV incidence by 38 percent. Moreover, the addition of pre-exposure prophylaxis (PrEP) and a partially effective vaccine could trigger a 90 percent reduction in cases of HIV infection.

Acknowledging that fighting AIDS was a huge challenge, Gates noted that HIV was likely to remain the largest part of the Bill & Melinda Gates Foundation’s global health portfolio for another decade, ensuring the audience of his continuing commitment to the cause.

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HIV & AIDS – the Imperative of Prevention. 17/10/10

The most important concern in the HIV & AIDS field is the task of prevention.

Consultancy Africa Intelligence

By Joana Finkelstein Veras
17 October 2010

The most important concern in the HIV & AIDS field is the task of prevention. The epidemiological measures of prevalence and incidence illustrate the imperative to invest in this area.

Prevalence refers to the total number of infected people within a population at a certain point in time. HIV prevalence can be affected by variation in incidence levels (the number of new infections), the deaths of infected people (which lowers overall prevalence),  and by treatment adherence (which, even at low levels of incidence, contributes to an increase in prevalence over time). HIV incidence varies according to the measurement period and methods used (whether household or antenatal clinic surveys, for example).

Both prevalence and incidence differ across regions and age groups, and across gender cohorts as well. The control of both depends mostly on the adoption of preventive interventions that reduce new infections. Therefore, decreases in incidence and thereby in prevalence depend on effective preventative interventions.  This CAI discussion paper delves into the issues that characterise the imperative of prevention, weighing the benefits and challenges associated with each.

Treatment as prevention

One preventative intervention involves treatment employed as part of prevention. In this case, prevention and treatment cannot be considered separately. Effective treatment can prevent some new infections – as in the case of vertical transmission from mother to child, where it significantly reduces the risk of transmission to the baby due to the decrease in the viral load of the mother. However, treatment intervention does not carry the same kind of preventative effect with regard to transmission via sexual intercourse or drug injection. In these later cases, HIV incidence and prevalence can be lowered more effectively through the adoption of measures that empower people to access and control their health care.

There are two key issues to consider regarding prevention:

The first aspect to consider to carry out effective prevention is related to the accessibility to preventive tools such as educational campaigns run via radio and TV; to places where the prevention can take place, for instance in schools, health centres or urban environments; to products such as free male and female condoms or eventually the recently unveiled tenofovir microbicide gel (not yet on the market); and to diagnostics such as the HIV antibody test accompanied by counselling, for instance. However, usually not everyone within a targeted population has access to them. Moreover, some populations have not been even targeted or face the consequences of a late response to the HIV&AIDS reality.

The situation in Lesotho serves as an example illustrating the lack of access to prevention and treatment. Although the first AIDS cases there were reported in the late 1980s, leading to the instigation of a National Prevention Programme, it was only after the year 2000 that a structured Governmental strategy was put in place with the aim of increasing condom use alongside provision of care for the infected population. The late response was influenced by poor finances and infrastructure combined with extreme social discrimination against women in a male-dominated society. Traditionally, women lacked political, financial and social rights. Statistics indicate that, in 2008, women made up 56% of the infected adult population.

HIV prevalence did not rise significantly between 2000 and 2003; however, the goal of reducing HIV prevalence by 5% by 2003 was not achieved. Then in 2003 HIV & AIDS was declared a national disaster. Only in 2006 did Lesotho pass the Legal Capacity of Married Persons Act, which grants equal status to married women.

Lesotho's AIDS effort is now guided by the National AIDS Policy and Strategic Plan for 2006-2011. The Government is focusing on HIV prevention through condom promotion, prevention of mother-to-child transmission, and providing anti-retroviral treatment for the infected population.

The second prevention issue involves developing appropriate models for corresponding prevention interventions:

Some models aim to instigate behaviour change by adopting a strong informative approach. These models have proven to be effective to some extent, especially in educating people about the risks of infection, means of transmission, the nature of the HIV virus and its relation to AIDS, as well as warning them about the consequences of living with HIV & AIDS. However, this approach is weak in answering the question: why is it that well-informed people expose themselves to HIV? Sometimes, people seem to ignore information that had been learnt, tune it out. Why do we act in ways that also endanger health?

Alternative models focus on a relational approach, aiming to achieve structural attitude changes towards the way people deal not just with HIV & AIDS, but also with relationships, care for oneself and others, sexuality, losses, choices and death. All these challenges are to some extent feared by human beings, though not necessarily at a conscious level. One of the key focuses of this approach is the issue of acceptance of one's natural fears and vulnerability to danger, which experience and studies have shown to be greatly denied. Where denial occurs, adoption of a distant attitude towards the reality of HIV & AIDS is observed.

Africa offers numerous examples of planned mass-media interventions that have been successful for over a decade as preventive tools. These interventions are part of a model that combines entertainment with education, known as 'edutainment.' The soap opera, Soul City, launched in 1994, which initially targeted disadvantaged South Africans, now airs on prime time TV and attracts a huge and diverse audience.

The show strongly emphasises the HIV & AIDS issue bringing to life through the characters' experiences situations in which people are faced with the challenging demand of making choices that would prevent them or not from infection and would also determine the course of their relationships. In 2002 a TV programme for young children, Takalani Sesame, introduced an HIV-positive character whose mother had died of AIDS. In different ways, these shows aim at addressing social issues like exclusion, HIV & AIDS and violence, and are based on the reality and demands of their own region. Takalani Sesame is an adaptation to the African reality of the original North American puppet animation, Sesame Street.

These programmes are good examples of interventions that consider personal background and local culture as important aspects in the implementation of prevention strategies. Models strongly based on behaviour change rather than on  aspects related to subjective instances, like the history of peoples' relationships, have shown limited reach in more structural changes. An example of this is the approach to the African ABC strategy also launched in the 1990s, based on the premises of 'abstinence,' 'be faithful' and 'condomise.' There is no doubt that the informative dimension should always be presented when talking about HIV & AIDS, but would it not be more effective to broaden the scenario in which the information is given?

Brazil offers an alternative to what seems to be a more traditional approach to preventive interventions of HIV & AIDS. The South American country was one of the first in the world to stop associating AIDS with death in its mass media campaigns, emphasising aspects like human rights and the incentive of self-esteem. Moreover, a variety of groups, like men who have sex with men or women that have sex with women, as well as taboo subjects, like women that are ashamed of buying condoms, have been targeted in mass campaigns. These broader approaches illustrate ways through which HIV & AIDS can be dealt with as an issue related to life experiences, choices and relationships.

Preventative measures are not limited to mass-media programmes. Group works within institutions like schools, churches, health services, and test centres, amongst others, are also part of the wide range of possible interventions. Furthermore, HIV&AIDS-related concerns do not necessarily have to be dealt with as an issue in itself. They can be included in regular school courses or in workshops related to sexuality, relationships and life planning, for example. Playful and informal (personal) approaches combined with clear information creates an understanding and intimate atmosphere that make the service users more confident in sharing information and confronting their own fear of taking the serological test. This approach can transform the socio-political demand of engaging people in taking the HIV test into a personal demand. Regarding implemented strategies, interventions based on the training of multiplication agents for the prevention of HIV that pass on their knowledge and experience to other member of the community have been successful in Brazil, for example.

Conclusion

The most efficient way of achieving the target of prevention is through the adoption of a relational approach. Information is not enough and can be easily forgotten or denied. In order to think about personal sexual behaviour, people need to be touched: touched by a sense of vulnerability, and by the need of caring for others. Furthermore, it can be useless to insist on a pure informative approach towards well-informed people.

Trained personnel are needed to deal with such an approach. Financial investment, social and political engagement and appropriate strategic planning need to continue taking place in order for people to respond effectively to the HIV & AIDS pandemic. Participation of community leaders or other community members in the development of prevention programmes is crucial in order to help health and business professionals to see and listen to community demands form a closer angle and define strategies realistically.

In addition, it is generally acknowledged that prevention is more cost-effective than treatment and the development of new medications and technology to deal with HIV & AIDS itself. Finally, it is crucial to consider, design and implement interventions that target local communities within African countries, since continental interventions have been successful to some extent but have not seemed to be able to cover regional specificities.

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HIV Prevention In Africa: A Complex Interplay Between Religion, Culture, Tradition And Science 4/09

From Consultancy Africa Intelligence - HIV & AIDS Newsletter:

"A perfect example, and undeniably pertinent to the topic of this newsletter, is the recent statement by Pope Benedict XVI. The Roman Catholic Church has continued to promote an abstinence and faithfulness-only approach to HIV prevention in Africa, despite the evidence that confirms that this strategy cannot work within such a context. The African continent is the fastest growing region for the Roman Catholic Church, and is therefore significantly influenced by the position of the Church on matters such as HIV & AIDS. At the same time, the continent is also desperate for progress in the area of HIV prevention, which can only be achieved through the large-scale implementation of proven-to-work strategies."
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Hope: An Overlooked Tool In The Battle Against HIV/AIDS. 08/08/08

Economic and Social Research Council (ESRC)

The links between HIV transmission and the degree to which people are able to adopt realistic plans to achieve future projects, in other words, hope, have been overlooked in policies to tackle HIV/AIDS. New research funded by the Economic and Social Research Council (ESRC) argues that hope is a powerful tool in the battle to stop the spread of HIV/AIDS. 

Almost 30 years into the AIDS epidemic a medical vaccine for the disease remains elusive. Efforts to control the spread of HIV have been fairly successful in Western countries but have met little success in Africa. For example, life expectancy at birth is now estimated to be 36 years in Botswana, instead of 71 years without AIDS. It is expected to drop towards 30 within the next ten years. 

ESRC Professorial Fellow, Tony Barnett, from the London School of Economics, argues: "Current policies to tackle HIV/AIDS in Africa emphasise individual behaviour such as the ABC approach to prevention: Abstain, Be faithful, Condomise. However, these measures require that people have hope for the future and goals to aim for. And if wider economic and social circumstances are so poor that people lack hope for the future, then these current policies will have limited success." 

People with hope for the future are less likely to engage in activities in the present that put them at risk of illness in the future. Those without hope for the future, by contrast, place a low value on the future. For example, men who lack hope for the future may be unwilling to surrender immediate pleasure in return for a far-off future benefit by wearing a condom. 

Increasing evidence shows that policies to combat AIDS that focus exclusively on individual behaviour are flawed if they dissociate behavioural change from the social, economic and cultural contexts. Security, stability, expectations of seeing the birth of grandchildren and their coming to adulthood, expectations of seeing a small enterprise grow bigger or a tree crop plantation come to maturity - these are all signs and indicators of hope that can have vital impacts on decisions and behaviours. 

In contrast HIV/AIDS can destroy hope, resulting in vicious spirals that damage societies and lead to further HIV infections. When life prospects are so poor, people have little incentive to save for the future and to educate children. AIDS has also led to a growing number of orphans in Africa. Without financial, educational and emotional support for the future, a growing number of young people in Africa are less prepared for life and more vulnerable to HIV/AIDS. 

"Hope is quite straightforward to measure via questionnaires and surveys can help to identify high risk environments," concludes Professor Barnett. "Although there is not a great deal of experience in developing programmes to increase hope, policies such as cash support for children, microfinance for small businesses, women's education, reduced discriminations against sexual minorities and health system reform will improve the wider environment. And with more to live for, interventions to encourage individuals to change their behaviour are more likely to succeed." 

For further information, contact:

Professor Tony Barnett (Tel: 01263 587136, e-mail: a.s.barnett@lse.ac.uk)

ESRC Press Office: Kelly Barnett (Tel: 01793 413032, e-mail: kelly.barnett@esrc.ac.uk)Danielle Moore (Tel: 01793 413312; e-mail: danielle.moore@esrc.ac.uk)

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How HIV Prevention Has to Change. 14/10/10

HIV prevention can be effective

AMFAR

By Chris Collins
14 October 2010

Tom Frieden, director of the Centers for Disease Control and Prevention (CDC), has included the domestic HIV/AIDS epidemic on his short list of "winnable battles" in public health. We could dramatically reduce the number of new HIV infections in America below the current annual rate of 56,000.  But without important changes in the way our country addresses HIV/AIDS, in five years there may well be more new infections each year, not fewer. 

Any discussion of HIV prevention should start with the good news.  Numerous research studies have demonstrated that HIV prevention can be effective.  Community-driven and publicly funded HIV prevention helped bring the HIV infection rate down dramatically from its peak in the mid-1980s, and prevention programs averted more than 350,000 new infections between 1991 and 2006.1   And yet the HIV infection rate has not fallen in over a decade and is likely creeping upward.  HIV continues to have a devastating impact on the hardest hit communities, including gay men, African Americans, and Latinos.

President Obama’s National HIV/AIDS Strategy, released in July, sets the worthy goal of reducing HIV infection by 25% over five years.  It pledges reforms in the U.S. approach to AIDS, including improved coordination, accountability, and targeted use of resources for populations most at risk.  These are all critically important measures, but alone are not sufficient to reach the President’s Strategy goals.  To do that we’ll need systemic change in HIV prevention.  Here are some of the priorities:

First, increase and make better use of resources.  Domestic HIV prevention receives only about 3% of total federal HIV spending.  A new analysis from David Holtgrave at Johns Hopkins University suggests that increased investments in HIV prevention now will yield savings down the road.2   Funding also needs to be used more wisely, and hard choices need to be made about deploying resources where they can have greatest impact at the Federal, state and local level.  

What is needed: In his FY 2012 budget proposal, the President should make the resource increases necessary to accomplish Strategy goals.

Second, make lower incidence the primary focus.  It sounds obvious, but the goal of HIV prevention should be to bring down the HIV infection rate, also called HIV incidence.  Yet too many publicly funded prevention programs operate on a small scale and do not reach many of those at elevated risk. Four out of five gay and bisexual men report not being reached with individual or group prevention programs in the prior year.3

In one recent CDC survey of gay men sampled in 21 urban centers a shocking 71% of young Black gay men living with HIV were not aware of their status.  

What is needed: Operational plans now being drawn up by federal agencies to implement the National Strategy must detail a process for identifying prevention services associated with reducing HIV incidence and not just HIV risk behavior, as well as for bringing the most effective prevention services to the scale necessary for making a measurable impact on the hardest hit communities. 

Third, address the context of vulnerability.  We have to deliver prevention messages that can help people modify their behavior, along with condoms, syringe exchange, and other proven prevention approaches.  But reducing HIV incidence will also require increasing the reach of comprehensive services including AIDS treatment, frequent voluntary HIV testing, prevention programming for people living with HIV, and supportive services such as housing. 

A person’s risk behavior is very different from their likelihood of becoming infected with HIV.  For example, African-American gay men do not practice riskier sexual behavior than their white counterparts, and have lower risk profiles in some respects.  But an African-American gay man is at far greater risk of becoming HIV positive.  This is due to several factors outlined by Greg Millett and colleagues,4 including higher rates of sexually transmitted infections (STIs) and lower rates of both AIDS treatment and knowledge of HIV status. 

Antiretroviral therapy lowers HIV viral load and evidence suggests it may reduce the likelihood of infecting others, so identifying people living with HIV and giving them the opportunity to receive appropriate care should be a top prevention priority. Yet one out of three people living with HIV/AIDS in America is not in care.5  Greater uptake of treatment and other services depends on innovative approaches to overcoming social barriers to health care utilization, including stigma, racism, and homophobia. 

What is needed: National Strategy operational plans must address HIV prevention as part of a coordinated effort to expand voluntary HIV testing and delivery of AIDS treatment and STI services.  Federal contracts should reflect the critical role of all HIV service providers in linking people with appropriate treatment and prevention interventions, and helping people living with HIV stay in care.  Community prevention providers will continue to have a critical role in prevention services, though in some cases their work would broaden to include helping people access and stay in care, and delivering services on a wider scale. 

HHS has announced a plan to work across its agencies to expand integrated services in areas with high HIV incidence.  It’s an excellent approach that can be the leading edge of a successful Strategy if the program has the necessary resources, brings services to scale, and reaches those who have thus far not received the services they need.

Finally, get the answers we need to have greater impact.  Ultimately a cure and a vaccine are necessary to bring the HIV epidemic to an end, and there is new hope on both these fronts that justifies increased research investments.  But for the near term, we must make better use of the interventions at hand.  Research efforts across the US government need to tell us more about how to expand the reach of comprehensive programming, provide people with services they feel safe and comfortable using, and address the social and structural factors driving vulnerability to HIV infection.  As Tom Coates and colleagues6 have observed, HIV prevention research has paid woefully insufficient attention to assessing programs that can be delivered broadly enough to impact overall incidence, including scaled up individual and small group interventions, and other approaches.  

What is needed: National Strategy operational plans should reinforce the critical coordination and planning role of the Office of AIDS Research (OAR) at the National Institutes of Health and outline specifically what research is needed short and long term to accomplish Strategy goals on time.  

We have the tools to dramatically reduce HIV infection rates, and in fact prevention experts from the CDC and Johns Hopkins University estimate7 that HIV incidence could be reduced by 40% or more in five to ten years.  Now we need the leadership to put these tools to work in a reinvigorated, strategic, and adequately resourced national effort.

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How Sexual Agreements Affect HIV Risk, Relationship Satisfaction. 13/7/10

Agreements - rules about whether sex with outside partners is allowed

13 July 2010

A new study examining the relationship dynamics of gay male couples finds that couples make "sexual agreements" -- rules about whether sex with outside partners is allowed -- primarily because they want to strengthen and improve their relationship rather than for protection against HIV. Published in the journal AIDS Care, the study explores how sexual agreements affect both HIV risk and a relationship's satisfaction and quality, and contains insights for HIV prevention.

Gay couples' top reasons for establishing sexual agreements were to build trust in the relationship, promote honesty between partners and to protect the relationship, according to the study, led by Colleen Hoff, professor of sexuality studies at San Francisco State University.

"We found that gay couples are interested in building healthy, satisfying and loving relationships," Hoff said. "These desires, when nurtured, can lead to strong relationships. Yet the reality is that a broken sexual agreement, or one that isn't clear to either partner, can make both partners vulnerable to HIV."

Widespread among gay couples, sexual agreements can include conditions limiting when, where, how often and with whom outside sex is permitted and whether safe sex is practiced.

Hoff and colleagues surveyed 566 gay male couples in the San Francisco Bay Area and found that 99 percent had sexual agreements. Specifically, 45 percent had monogamous agreements, 47 percent had open agreements and 8 percent of couples had discrepant agreements where partners reported a different understanding of whether they have an open or monogamous agreement.

"Discrepant couples were particularly concerning in terms of HIV risk," Hoff said. "When there isn't consensus on what the agreement is, one partner could be involved in risky behavior outside of the relationship and the other partner may be unaware of the resulting risk of unprotected sex within the relationship."

The study suggests that knowing what motivates gay couples to make sexual agreements could help HIV prevention programs tailor their efforts to be relevant to the whole relationship. "HIV prevention needs to take a more holistic approach that goes beyond messages about safe sex," Hoff said. "Helping gay couples learn how to negotiate robust sexual agreements and how to disclose and deal with a break in an agreement could be an effective approach to HIV prevention."

Participants in the study responded to a series of statements assessing their satisfaction with their relationship and various relationship characteristics, such as trust and intimacy. The study found no significant difference in relationship satisfaction between men in open or discrepant relationships and those in monogamous relationships. For relationship characteristics, participants' responses did vary significantly depending on the type of sexual agreement they had (open, discrepant or monogamous). Men in monogamous relationships reported greater levels of intimacy with their partner, more trust, commitment and attachment toward their partner and greater equality in the relationship.

Funded by the National Institute of Mental Health, this study is part of a five-year longitudinal study following the relationship dynamics of 566 gay couples in the context of HIV prevention.

"Relationship characteristics and motivations behind agreements among gay male couples: differences by agreement type and couple serostatus" was published in the July 2010 issue of the journal AIDS Care. In addition to Hoff, co-authors include Sean C. Beougher, Deepalika Chakravarty, Lynae A. Darbes and Torsten B. Neilands.

Colleen Hoff is professor of sexuality studies at San Francisco State University and director of the University's Center for Research on Gender and Sexuality.

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How to Transform HIV Prevention. 2010

HIV/AIDS and the transgender community

The Body

Raquel Sapién and Robert Valadéz
Summer 2010

Introduction

From the onset of the epidemic, HIV has greatly affected the world's most vulnerable populations, and among those most affected are women and gay and bisexual men. There is little information available, however, about how HIV has affected transgender women and men, despite evidence suggesting that they may be at high risk. With rates of new infections on the rise among gay and bisexual men, public health officials are beginning to scratch their heads over what may be occurring among transgender people. We must understand how HIV prevention and treatment can be tailored to meet the needs of this highly misunderstood population.

What Does "Transgender" Mean?

Transgender men and women are generally defined as people whose gender identity, expression, or behavior differs from their biological sex. Contrary to popular belief, not all transgender people choose to undergo sex reassignment surgery. Many do take hormones, however, to change their appearance to match the gender with which they identify.

From the "hijra" in India to the "twospirit" of Native American tribes, transgender people have been recognized in many civilizations and in many different regions of the world. Sadly, their history has been riddled with misconceptions, intolerance, and perhaps most troubling, neglect. All of these factors have contributed to disparities that leave transgender people vulnerable to a host of health issues, including HIV. Despite building political momentum in recent years by working in solidarity with the larger gay, lesbian, and bisexual movement, transgender people are often still invisible or ignored in discussions ranging from education to health care.

The lack of a national monitoring system that gathers data on transgender people results in a great deal of missing information. The U.S. Census does not include an option for people to indicate a transgender identity. This is extremely problematic, as the Census largely determines the funding of government programs aimed at populations with the greatest need. In the Census's current form, transgender people do not exist. Thus public health officials are left to speculate on their exact number, their average annual income, and how many are raising children, among other things. This creates a huge challenge for transgender advocates to obtain the necessary funding for programs aimed at advancing their well-being, as there are little to no data to identify their needs and support strategies to meet them.

What Do We Know About HIV and the Transgender Community?

Recently, California has begun formally documenting health trends among its transgender residents. As of 2002, the state began recording "male-to-female" and "female-to-male" as gender reporting options in publicly funded HIV counseling sites. In 2003, the California Department of Health Services released data that revealed that transgender clients had much higher rates of HIV diagnoses (6.3%) than clients of other high-risk categories. This includes men who have sex with men (4.2%) and partners of people with HIV (4.8%).

The California data provided muchneeded insight into the relationship between HIV and the transgender population, proving that the issue needs greater attention. Still, while California is the most populous state in the U.S., it does not provide a complete picture of the HIV epidemic among transgender people across the U.S.

In 2007, the CDC conducted a metaanalysis of 29 studies focusing on transgender women and five studies focusing on transgender men, to estimate the prevalence of HIV. This meta-analysis reported findings similar to those in previous literature: transgender people are disproportionately affected by HIV. Specifically, it revealed that 28% of transgender women studied tested positive for HIV.

Even more alarming are the rates of HIV among transgender people of color. The 2003 California data showed that HIV diagnoses among African-American transgender clients, at 29%, were significantly higher than among all other racial groups. The CDC's meta-analysis echoed these data, reporting that among transgender African-American women, 56% tested positive for HIV. This was dramatically higher than the rate of HIV-positive white transgender women (17%) .

Studies highlighting rates of HIV among transgender men are even more rare, but what research does exist points to low rates of HIV among this population. Because there is no reliable estimate of the size of the transgender population, however, it may be that the actual rate of HIV infection among both transgender men and women may be even higher than reported.

Why Are Transgender People at Higher Risk for HIV?

Discrimination plays a big role in the challenges transgender people face, which in turn makes them highly vulnerable to HIV over the course of their lives. Many transgender people experience discrimination early in life, within their families. Violence, emotional abuse, and rejection from family members leave them without the emotional and financial support that often help young people establish stability in adulthood.

A 2007 CDC study reported that 42% of transgender women participated in sex work. Of these women, 39% engaged in unprotected receptive anal intercourse.

Various studies point to transphobia and homophobia as barriers to transgender people successfully obtaining education, employment, social services, and housing. Lack of family and institutional support pushes transgender people to the margins of the formal economy. This is particularly burdensome to transgender people of color, who face additional discrimination based on their race or ethnicity. As a consequence, they often are exposed to stressful environments, experience social isolation, and participate in behavior that places their health and safety at risk.

Limited employment options may force transgender people to turn to the street as a source of income. Many turn to "survival crimes" such as sex work, drug sales, and theft. The 2007 CDC study reported that 42% of transgender women participated in sex work. Of these women, 39% engaged in unprotected receptive anal intercourse. This rate was even higher among all transgender women in the study (44%). Further, 39% of transgender women in the study reported sex while drunk or high.

Since health care is strongly tied to employment in the U.S., many transgender people have difficulty obtaining hormone treatments through legitimate health care facilities, with the CDC reporting that half of transgender people lack health insurance. As a result, many turn to the street for hormones, with 34% reporting nonmedical sources for hormones. Additionally, 25% reported injecting silicone. The high rate of transgender people injecting hormones and silicone raises serious concerns about their exposure to HIV through the use of nonsterilized injection equipment.

How Do HIV Medications Interact With Hormone Therapy?

Despite the high numbers of transgender people using hormone therapy, both through medical and nonmedical sources, little is known about the interactions and potential toxicities of hormones and HIV medications. There have been no major studies of the interaction between the two, and what is known about people with HIV taking hormone therapy and HIV medications at the same time has come from studies of menopausal women taking hormone replacement therapy to minimize the effects of menopause.

Studies show that some HIV drugs can decrease or increase the levels of hormones in the blood. Further, estrogen can cause reduced levels of some HIV drugs and put one at risk for viral rebound or drug resistance. Further research is necessary to observe any potentially harmful interactions among transgender people, as well as any side effects from long-term use of both hormone therapy and HIV medications.

Where to Go From Here?

Currently, there is no evidence-based HIV intervention tailored for transgender people. There is an urgent need to better understand the social and behavioral factors underlying their risk behaviors if we are to prevent more HIV infections in this population. Special efforts must be made to ensure that transgender people are involved in the design of HIV prevention efforts, to ensure a comprehensive and effective strategy.

HIV clinical trials should include transgender people in order to understand the effects of new medications on hormone therapies. These trials should also include transgender youth and seniors.

Lastly, public health agencies should advocate for education on transgender issues to minimize the physical and mental health disparities they face. This includes encouraging schools and families to foster positive identities among transgender youth.

 

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Kenya's Smart Solution to AIDS Awareness: Game On! 26/10/10

Action-packed computer game that’s fun to play, yet contains strong social messages

The Daily Maverick

By Mandy de Waal
26 October 2010

How do you teach young people in Africa about safe sex in a way that’s not patronising, alienating or obstructive? Meet Mark Kaigwa, a young Kenyan who was part of a Nairobi-based Warner Bros initiative to create an action-packed computer game that’s fun to play, yet contains strong social messages

You’re in a taxi, riding through the middle of Nairobi, carrying something that is more precious to you than anything else in the world. Catastrophe strikes when the taxi is hijacked. But the real story begins when you join forces with four other strangers in the vehicle get out of the situation alive and find your stolen bounty.

That’s the compelling story line for an exciting computer game created by Warner Bros in conjunction with a 22-year-old Kenyan writer Mark Kaigwa. What’s remarkable about the game is that it is steeped in Kenyan culture and engages local youth in a gripping multiplayer format while educating them on HIV, Aids and safe sex.

Expertly made with brilliant graphics, “Pamoja Mtaani” includes hip-hop music from local greats like Jua Cali, Redsan, Prezzo and Amaniscript. The PC game shows that collaborations between Hollywood and Africa can yield innovative, meaningful solutions, and how private sector and NGO partnerships can deliver results in areas where many government initiatives have failed. Developed by Virtual Heroes Inc and Warner Bros Entertainment Interactive, “Pamoja Mtaani” was sponsored by the US President's Emergency Plan for Aids Relief (Pepfar).

The problem with a lot of HIV and Aids education is that it is, exactly that, education. Droll, parochial safe-sex messages aimed at youth who are at a stage in their lives when they want to embrace risk and experiment is likely to alienate or switch young people off.

What’s cool about “Pamoja Mtaani” (which means “Together in the ‘hood”), is that like World of Warcraft or Battlefield, people want to play it. There’s high drama, action, the entire storyline is locally relevant and set in Kenya.

“This was a mind-blowing opportunity because one of the things about the game that is fascinating is that all the action takes place in Sheng, which is a slang spoken in Kenya,” says Kaigwa. Sheng is primarily based on Swahili, English and a few other vernacular languages. “Sheng is a dynamic language that changes so often that there are probably places I could go right now where they would speak a Sheng that I almost would not be able to understand.”

The game was developed by Warner Bros, and Kaigwa was a principal writer, along with Cajetan Boy, an accomplished screen writer and director from Kenya. Also part of the project was a behavioural change expert who ensured the story and the game would elicit a shift in thinking from the people who played it.

“In terms of process, we would write in English, get approval and then translate everything back into Sheng so that people who experience the game can see how genuine and realistic it is. It was a huge creative challenge which I am so glad we met because the positive feedback we’ve been getting on the game has been incredible,” said Kaigwa speaking to The Daily Maverick from Kenya. “I am glad we could represent the city of Nairobi, where the game is based, in a way people felt was authentic. That the game is seen as accurate in terms of everyday life in the city.”

More important to Kaigwa is the fact that the social messaging in the game is subtle and doesn’t interfere with the gaming experience, but is strong enough to make a difference to people’s lives. “The game works on a couple of levels. Woven into the story is very, very subtle behaviour change messaging and that’s what has led to the game receiving such widespread acclaim and recognition. People are realising this is a very different way to approaching a social problem that is always addressed in a very specific way.” Here Kaigwa is talking about your typical safe sex education. Another important aspect of the game is that it collects data from the youths who play the game, and enables social scientists to learn more about prevailing behaviours and attitudes towards HIV, Aids and safe sex. This in turn can enable the creation of better initiatives and programmes to tackle the problem.

 

“In the game there are different messages geared to youth who have disparate social positions or outlooks on life. Because this is a role-playing game you make decisions on behalf of the character and you act out the consequences of those decisions through the character.” The characters include a carefree and sensual musician called Lady D, a superstitious football-loving guy called Lefty, an übergeek called Sean, a hot-headed guy Georgie who preys on girls and Judy, a smart medical student.

The game is available as a free-to-play initiative in Nairobi, where it can be found in youth centres or at gaming arcades alongside the city’s slums. “About a thousand or so kids play the game each week, and thanks to the research Warner Bros is able to compile concrete research statistics about the effect the game is having. As the game is played the research helps determine how the game engages you and at what risk level it engages you. Then there are game masters who act as peer councillors in the game, and they make a strong impression because of the mentoring and guiding role they play in a very relevant context.

“You can’t sit younger audiences down and tell them about the dangers of HIV/Aids, you need to engage them. This game makes them part of an exciting adventure they invest in, and that’s why it is working to change behaviour and getting such a positive response,” says Kaigwa.

A writer who by his own admission is involved in more projects than is good for him, Kaigwa’s next effort is a short film called “Dawa” and is a story about a couple of swindlers. “The film is a story about a grandfather and his grandson who are both con-artists in the big city, and are at their wits’ end. They move back to their home village to pull off their biggest con yet and get a lot more than they bargained for.” When Kaigwa’s not writing scripts, developing games or involved with social initiatives, he’s busy with a number of start-ups and entrepreneurial online businesses.

Kaigwa describes himself as an innovator, and you’ll understand why this is apt when you hear how he’s marketing his short film. “I am busy creating a Web comic that details the prequel of the film, and I am also busy with a mobile game that covers what happens after the film. Basically what I am doing is creating a bigger experience, or offering depth to the experience of the story outside of just the film. What I’m doing is creating a culture or an immersion, and trying to find a viable way to sustain this.”

A graduate of East Africa’s Maisha Film Lab which has been a training ground for many great film-makers in Kenya, Kaigwa is experimenting with an innovative blend of gaming, filmmaking, mobile and digital experiences to businesses for the social good that also make money. “The innovation economy is the best place for me. For the first time in history Africa is not behind. Africa is teaching things to the West and there is no better time to be in Africa than now. I want to innovate in the fields of writing, film, digital and mobile for myself, for other individuals, for companies and for the collective good of a country that I am passionate about.”

Given much of the work Kaigwa is doing changes attitudes and behaviours on significant social issues, let’s hope he succeeds.

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Popular Opinion Leaders Add No Benefit to Intensive HIV Prevention. 7/4/10

HIV prevention using ‘popular opinion leaders’ is no more effective at reducing risky sexual behaviour and the incidence of sexually transmitted infections than prevention consisting of counselling, treating sexually transmitted infections, and condom provision

AIDSMap

Michael Carter
7 April 2010

HIV prevention using ‘popular opinion leaders’ is no more effective at reducing risky sexual behaviour and the incidence of sexually transmitted infections than prevention consisting of counselling, treating sexually transmitted infections, and condom provision, investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

The prospective study was conducted in five countries with a high prevalence of HIV. The study’s findings were “contrary to expectations”, but the investigators believe that this was because of the intensive prevention offered to individuals in the control arm.

They note that such a level of prevention is often unaffordable in many resource-limited settings outside the context of clinical trials. By contrast, prevention programmes using popular opinion leaders have been shown to be highly cost-effective.

Peer education, involving the training and engagement of individuals from communities with a high risk of HIV to endorse prevention messages personally, has been shown to be help reduce risky sexual behaviour in some populations.

However, there is little information about the use of peer educators, or popular opinion leaders, in resource-limited settings.

Therefore, between 2002 and 2007, investigators from the US conducted a study in five countries with a high HIV prevalence to “evaluate rigorously” the use of such a prevention initiative.

Venues were selected in China, India, Peru, Russia and Zimbabwe. At all sites, screening and treatment for sexually transmitted infections were available, as were free or low-cost condoms. Half the sites were randomised to also provide a popular opinion leader intervention.

Follow-up lasted 24 months. At baseline, and then again after twelve and 24 months, all of the 18,147 individuals enrolled in the study were screened for HIV and other sexually transmitted infections, received extensive post-test counselling on each occasion and also underwent a 45-minute interview by a trained interviewer on sexual risk behaviour, alcohol and drug use, and symptoms of illness at each of the three follow-up visits.

Those randomised to the Community Popular Opinion Leader group of the study also received an intervention designed to mobilise the influence of local popular opinion leaders, who had undergone training in how to promote safer sex in everyday life amongst their usual contacts, tailored according to country and culture.

Interventions in the opnion leader arm took place in different settings according to country: trade school dormitories (Russia); urban wine shops (India); markets (China); barrios (Peru); villages (Zimbabwe). Venues within each country were randomised to the control arm or the intervention arm after matching for incidence of sexually transmitted infections.

The investigators compared reported rates of unprotected sex and new diagnoses of sexually transmitted infections (inclduing HIV) between the two arms of the study.

At the end of the two years of the study, the proportion of individuals reporting unprotected sex had fallen by 33% in both study arms. Although the level of reduction varied between countries (11 to 64%), the use of popular opinion leaders was not shown to have an additional benefit in any of the settings.

Similarly, incidence of sexually transmitted infections fell by a comparable amount between the two arms of the study (approximately 20%).

However, closer analysis of the results showed that rates of genital herpes were lower in the popular opinion leader arm in both China (p = 0.012) and Russia (p = 0.016).

“Contrary to expectations, the community popular opinion leader intervention and its comparison condition produced similar, significant, and clinically relevant reductions in both STD incidence and self-reported extramarital unprotected sexual acts”, comment the investigators.

The investigators stress that the individuals in the comparison group had received intensive HIV and sexual health prevention services. It is important to note that the control arm did not represent the standard of care in existence in each country at that time. In China for example treatment for sexually transmitted infections is typically given in the form of Chinese herbal treatment dispensed by pharmacists, not antibiotic treatment.

Since the completion of the study, many of the components of the comprehensive prevention services available at the study sites have disappeared due to lack of funding. The investigators note that the ethics have been questioned of offering a comparison arm (in this case intensive counselling, testing and treatment) that cannot be sustained after the trial closes.

The investigators note that peer education programmes in the US have been shown to be highly cost-efficient. In the US, preventing any one HIV infection is estimated to have cost $40.

They suggest, “it is more likely to be feasible for a resource-poor community to sustain the community popular opinion leader intervention than the intensive AIDS comparison conditions.”

However, since this study did not compare intensive counselling and testing with the popular leader intervention alone, the potential impact of the latter intrevention alone is unknown.

Reference

The NIMH Collaborative HIV/STD Prevention Trial Group. Results of the NIMH collaborative HIV sexually transmitted disease prevention trial of a community popular opinion leader intervention. J Acquir Immune Defic Syndr (advance online publication), 2010.

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Prevention Efforts And Infection Patterns Mismatched 27/5/09

JOHANNESBURG, 27 May (PLUSNEWS) - In at least five African countries, scarce resources are being spent on national HIV prevention campaigns that do not reach the people most at risk of infection, new research has found.

  Between 2007 and 2008, UNAIDS and the World Bank partnered with the national AIDS authorities of Kenya, Lesotho, Swaziland, Uganda and Mozambique to find out how and where most HIV infections were occurring in each country, and whether existing prevention efforts and expenditure matched these findings.
  The recently released reports reveal that few prevention programmes are based on existing evidence of what drives HIV/AIDS epidemics in the five countries surveyed.
  In Lesotho, where nearly one in four are living with HIV, an analysis of national prevalence and behavioural data found that most new infections were occurring because people had more than one partner at a time, both before and during marriage. But Lesotho has no prevention strategies to address the problem of concurrent partnerships, or target couples who are married or in long-term relationships.
  An evaluation of Mozambique's prevention response found that an estimated 19 percent of new HIV infections resulted from sex work, 3 percent from injecting drug use, and 5 percent from men who have sex with men (MSM), yet there are very few programmes targeting sex workers, and none aimed at drug users and MSM.
  The research also found that spending on HIV prevention was often simply too low: Lesotho spent just 13 percent of its national AIDS budget on prevention, whereas Uganda spent 34 percent, despite having an HIV infection rate of only 5.4 percent.
  Debrework Zewdie, director of the World Bank's Global HIV/AIDS Unit, noted that the current global economic downturn made it more important than ever to get the most impact out of investments in HIV prevention. "These syntheses use the growing amounts of data and information available to better understand each country's epidemic and response, and identify how prevention might be more effective."
  The reports made recommendations on how the countries could move towards more evidence-based prevention strategies to make more efficient use of limited resources.
  Lesotho was advised to revise the content of its prevention messages to address multiple concurrent partnerships and integrate partner reduction into all future policies. One of the recommendations to Mozambique was that condom promotion programmes be focused on high-risk groups such as sex workers.
  The five-country project also aimed to build capacity to enable these nations to undertake similar studies in future, as part of their ongoing efforts to evaluate and plan HIV responses.
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Scientists at AIDS Meeting Urge HIV Prevention for Long-Term Couples in Africa. 18/02/10

HIV continues to spread among couples in long-term relationships in sub-Saharan Africa because health authorities focus instead on the risks posed by casual sexual encounters, especially in young people. As a result, few HIV-prevention strategies have been devised for this overlooked population.

The Washington Post

SAN FRANCISCO -- HIV continues to spread among couples in long-term relationships in sub-Saharan Africa because health authorities focus instead on the risks posed by casual sexual encounters, especially in young people. As a result, few HIV-prevention strategies have been devised for this overlooked population.

Those are among the conclusions reached by scientists presenting research at the 17th Conference on Retroviruses and Opportunistic Infections, the annual mid-winter AIDS meeting in the United States. The failure to recognize how much HIV-transmission has occurred over decades in seemingly low-risk couples is "tragic," said epidemiologist Rebecca Bunnell of the Centers for Disease Control and Prevention, who worked in Uganda and Kenya for 14 years.

"It undoubtedly has resulted in millions of deaths and has produced millions of orphans," she told the more than 4,000 researchers gathered here.

Only as HIV testing has become more common in Africa in the past few years have health authorities come to appreciate the vast number of "discordant couples," in which one partner is HIV-positive and the other isn't.

For example, in the East African nation of Kenya, about 1 in 10 couples is affected by HIV. In 40 percent of those couples, both partners are infected. But in 60 percent -- about 340,000 couples -- only one partner is.

The likelihood that an infected person will pass the virus to a partner depends on many things. The risk decreases if the man is circumcised. Female-to-male transmission is less likely than male to female. In many cases, the infected partner in a discordant couple became infected before the current relationship or marriage began, and many HIV-affected couples remain discordant for years.

The problem is that most people do not know their HIV status. In particular, many people in stable relationships have never gone for testing because they perceive themselves to be at low risk for becoming infected.

A 2007 study that tested the blood of a representative sample of 16,000 Kenyans between the ages of 15 and 64 found that only 15 percent of infected people knew they had the virus. The fraction of HIV-affected couples in which partners know each other's status is even lower -- only 9 percent. In co-habiting couples, use of condoms, which could greatly lower the risk of transmitting the virus, is very low -- about 5 percent.

The consequence is that many of the continent's new infections occur among long-standing couples (albeit sometimes with the virus being introduced through an outside liaison). In Uganda, 65 percent of recent infections occur in married people. Furthermore, when one partner in an HIV-affected couple dies, that often opens new chances that the virus will be passed to others. In Zimbabwe, 8 to 17 percent of new HIV infections are attributed to the sexual activity of widows or widowers.

Prevention campaigns that focus on couples and partner testing -- with a counselor present when the status of each is revealed -- are one strategy for addressing this problem. But that, in turn, could become a new impediment to testing, some experts say.

"The message has to be very carefully crafted," said Wafaa El-Sadr, an AIDS researcher at Columbia University who helps run prevention programs in 14 African countries. "You want to encourage people to come as couples, but you never want to turn anybody away just because they come alone."

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Time For Prevention That Works. 2/12/09

JOHANNESBURG, 2 December (PLUSNEWS) - An array of interventions aimed at slowing the rate of new HIV infections in Africa has been tried over the last two decades. Some were tested to see if they actually worked, but many were not.

 In southern Africa "we were hit very quickly and very hard [by HIV/AIDS]," said Prof Geoff Setswe, chief research specialist in the Social Aspects of HIV/AIDS and Health at South Africa's Human Sciences Research Council (HSRC).

 Prevention initiatives were developed and rolled out rapidly and often haphazardly. "We started doing anything we thought would help and said, 'We'll see later', so there was a lot of hit and miss."

 Setswe was addressing delegates at the Social Aspects of HIV/AIDS Research Alliance (SAHARA) conference on 1 December in Johannesburg, South Africa, on the question of what constitutes evidence in the field of HIV prevention.

 With the global economic crisis squeezing AIDS budgets, and a frustrating lack of progress in significantly reducing new HIV infections, donors and governments are under more pressure than ever to concentrate resources on prevention strategies that are known to work.

 In science, the gold standard for demonstrating efficacy is randomized controlled clinical trials, with compared outcomes between one group that received an intervention and another that received a placebo. Such trials have been successfully used to provide strong evidence for bio-medical prevention strategies such as male circumcision and treatment to prevent mother-to-child transmission (PMTCT).

 But clinical trials are not always appropriate for testing behavioural and social interventions, such as the ABC (Abstain, Be Faithful, Condomise) approach, or efforts to reduce multiple concurrent sexual partnerships.

 Perhaps for this reason, no behavioural or social intervention has so far met the criteria for "best evidence", which Setswe defined as at least 80 percent effectiveness.

 Counselling people living with HIV has been found to be 68 percent effective in reducing high-risk sexual behaviours, classified as "good evidence" by Setswe.

 Other seemingly promising interventions, such as a microfinance programme in rural Limpopo Province that included raising awareness of gender-based violence and HIV education, failed to reduce new HIV infections.

 Dr Olive Shisana, CEO of the HSRC, pointed out that even prevention strategies with a strong evidence base were not always implemented; funding and capacity limitations often created obstacles, as did social, cultural and political factors.

 Despite compelling evidence that male circumcision reduces HIV infections among men, for example, South Africa has lagged behind other countries in the region in implementing a mass circumcision programme. "There are still people among us who say, 'We shouldn't implement because it's against our culture'," Shisana said.

 Donors also often do not base decisions to fund prevention efforts on successful outcomes: the United States, guided by a conservative religious ideology, funded many abstinence-only initiatives without any evidence that they reduced infection rates.

 Meanwhile, programme managers are often forced to chase donor money rather than the evidence. As a result, said one delegate reacting to Setswe's presentation, programmes were sometimes changed to accommodate donor whims, creating a lack of consistency.

 Dr Innocent Ntanganira, the World Health Organization's regional adviser on HIV prevention, commented that the time for small-scale, piecemeal interventions with little impact was over, and called for evidence-based, cost-effective interventions to be scaled up. "We know what works," he said. "We need to go to scale with national prevention programmes."

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UNAIDS Expert: Prevention Needs Full Funding. 26/01/10

January 26, 2010 by davidbryden

Evaristo Marowa, UNAIDS Country Coordinator for Botswana, said today that major opportunities to prevent HIV, and save billions of dollars in the long run, will be missed if the US and the international community fail to increase AIDS funding for Botswana and other countries in southern and eastern Africa. 

He made his comments in a presentation at the Global Health Council, where he also provided a powerpoint:  Botswana HIV epi and responses.  Dr. Marowa’s presentation comes as global AIDS advocates anxiously await next week’s release of President Obama’s budget proposal.  His urgent warning about the danger of donors adopting a flat or near-flat funding approach provided an interesting counterpoint to last week’s CSIS publication on HIV prevention, which did not mention the need to increase funding in its recommendations to the US government.

Dr. Marowa is a physician with a specialty in dermatology and sexually transmitted infections (STIs). He trained at Universities in Harare, Kinshasa, Liverpool and London.  Since September 2006, he has been the UNAIDS country coordinator in Botswana, and previously he worked in Tanzania, Zimbabwe, and Bangladesh.

HIV prevalence in Botswana has fallen in recent years from 38% to 24%, with declines seen particularly in young people. The country has had strong leadership on the issue at the highest levels, which Marowa called “visionary and committed.” Prevention of mother-to-child transmission has been “an astounding success,” with a transmission rate of about 4%.  A large proportion of people have been tested for HIV, about 60 to 70%, and access to antiretroviral medications is also high at about 85%.  PEPFAR has been a major support to these programs, providing about $90 million a year.

However, he said that a high degree of internal mobility in the population, multiple concurrent partnerships, low rates of male circumcision, low condom use, and high rates of gender-based violence, which form the basis for an ongoing HIV/AIDS crisis.  Marowa also cited alcohol abuse as a contributing factor, an issue on which he said the current president was very active.

To get ahead of the epidemic, Dr. Marowa emphasized the need to expand prevention services, including male circumcision.  Circumcision has been shown to reduce the chance of a male acquiring HIV infection from a female by about 60%.  It also has been found to provide several other health benefits, including reducing the risk of contracting herpes simplex virus type 2 (HSV-2), human papillomavirus (HPV), invasive penile cancer, urinary tract infections, syphilis, chancroid and cancer of the cervix in female partners. 

He said that about 10% of men in Botswana have been circumcised, but he said this is probably an overestimate.  Marowa said the procedure is widely accepted among men, and in fact there is a long waiting list for the procedure.  The country’s leadership is on board with ramping up circumcision campaigns, yet, he said, a key limiting factor is the lack of resources for personnel and other costs.

Botswana has a plan in place called Vision 2016, which commits the country to reducing HIV prevalence by 50% by 2016.  This plan includes, in addition to circumcision, the reduction of concurrent sexual partners.  Marowa said that PSI is a key partner in Botswana taking this work forward, and he said it needed more funding.  He said a significantly scaled-up prevention effort in the region would save billions of dollars by averting the need for ARV treatment.

He cited collaboration with PEPFAR on issues affecting refugees and migrants (who are not eligible for the government’s free ARV treatment), as well as preparation of the PEPFAR partnership framework. UNAIDS is on the steering committee for the preparation of the partnership framework, which is now in draft form.

Botswana has historically not been a major Global Fund recipient. He said UNAIDS is also working with PEPFAR to strengthen the Country Coordinating Mechanism, which prepares the applications for Global Fund resources.

UNAIDS in Botswana is also working to improve measures of new HIV infections (HIV incidence), which has been a challenge, and it is in the process of finalizing a Know Your Epidemic Study.

Another major challenge, he said, is the lack of data on HIV prevalence among men who have sex with men, sex workers and prison inmates.  He said UNAIDS was working closely with the US Centers for Disease Control to improve disease surveillance. 

He said the needs of MSM are included in the national framework that guides the AIDS response, yet there have been problems getting legal registration of civil society groups that represent MSM.

 

 

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`No Sex` Months Proposed as Fire-Break for HIV in Worst-Affected Countries. 30/06/10

National month of sex abstinence could slow the spread of HIV

AIDSMap

Keith Alcorn
30 June 2010

Two leading HIV researchers say that countries worst affected by HIV should test whether promoting a national month of sex abstinence could slow the spread of HIV, by interrupting the chain of transmission during the primary, highly infectious stage of HIV infection.

Professor Alan Whiteside of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of Kwazulu-Natal and Dr Justin Parkhurst of the London School of Hygiene and Tropical Medicine (LSHTM) say that if mathematical modelling shows the idea to have possibilities, national campaigns to test the hypothesis should follow.

Swaziland is already considering the idea, Professor Whiteside says.

HIV levels are highest in the month to six weeks after infection, before immune responses begin to control the virus. Individuals in this phase of infection may account for anywhere from 10-45% of new HIV infections.

Stopping large numbers of recently infected people from passing on the virus for a month could act as a `fire break`, in the same way that trees are chopped down in a forest fire to break the progress of the fire.

Prof. Whitseside and Dr Parkhurst speculate that in addition to universal male circumcision, one reason why Muslim nations have much lower HIV prevalence is because during the fasting month of Ramadan observant Muslims are expected to abstain from sex during daylight hours.

But, while converting people to a religion is not a practical public health strategy, the authors highlight the World Health Organisation’s ‘tobacco-free’ days and suggest that campaigns – even temporary – can reduce risk behaviour across a population.

“Witnessing the national pride and unity shared among citizens in South Africa during the World Cup, I believe community mobilisations can work. This can be a way forward in some of the worst hit communities. This kind of initiative could provide hyper-endemic countries with a one-off, short-term adaptation that is cost-effective, easy to monitor, and does not create additional stigma,” said Alan Whiteside.

“It is difficult to change people’s behavior permanently, but when communities are mobilised to act together, it is not impossible to imagine regular periods of behaviour change shared by whole communities, or even whole countries.

Evidence shows that if all people could do this simultaneously, it would have a greater protective effect than if people try to do it independently. Of course any such effort would need to be designed to suit local contexts and cultures, but this provides another potential strategy in the fight against HIV,” said Justin Parkhurst.

The authors point out that a month of ‘safe sex/no sex’ can also produce easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign.

“In light of the continuing high incidence rates across southern Africa, we may find that this kind of novel idea to address the epidemic presents a real opportunity for prevention,” added Whiteside.

They suggest the idea could be adapted for different populations, depending on what is driving the epidemic. Among miners in South Africa, for example, a `no commercial sex` month may be most appropriate. In other contexts, promoting a `safe sex only` month might be worth trying.

“Permanent monogamy may be a challenging long-term goal for some, but a `month of monogamy` might be a useful starting point…In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic,” they conclude.

Reference

Parkhurst J, Whiteside A. Innovative responses for preventing HIV transmission: the protective value of population-wide interruptions of risk activity. Southern African Journal of HIV Medicine, 19-21, April 2010.

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