Innovative HIV/AIDS program launched in Ottawa.

Collaboration among 31 social and health care agencies and the provincial government has resulted in an innovative program for Ottawa-area patients with HIV infection or AIDS. The target group is the homeless and people with "unstable" housing who live in the city''s downtown core, a group at high risk of contracting HIV. The education of family practitioners will be an important part of the program.     

The exotic and the mundane

The HIV/AIDS epidemic in Haiti has often been referred to as a “mystery,” and “striking similarities” between patterns of disease in Haiti and in sub-Saharan Africa are often underlined. The occurrence of AIDS in Haitians has also led to the postulation of a number of theories positing a Haitian origin for AIDS and linking the syndrome in Haitians to voodoo. A review of the epidemiological data gathered and published in the early years of the pandemic suggests that these “exotic” theories are not necessary to explain the Haitian epidemic, which is clearly linked not to Africa but to the United States. Patterns of risk identified among many of the first Haitians with AIDS are similar to risk factors identified in North America and Europe (same-sex contact with an HIV-infected individual and blood transfusion). The Haitian epidemicsubsequently came to resemble patterns seen in sub-Saharan Africa, where AIDS is predominantly a heterosexually transmitted disease. Similarly shifting patterns are described for several other Caribbean nations, underlining the importance of a historical analysis of the Caribbean pandemic as well as the necessity to link analysis of local epidemiology of AIDS/HIV to larger considerations of political economy.     

Is risk of Kaposi's sarcoma in AIDS patients in Britain increased if sexual partners came from United States or Africa?

OBJECTIVE--To determine whether the risk of Kaposi''s sarcoma in patients with AIDS is increased by sexual contact with groups from abroad with a high incidence of Kaposi''s sarcoma. DESIGN--Analysis of risk of Kaposi''s sarcoma in patients with AIDS, according to country of origin of their sexual partners. SETTING--United Kingdom. PATIENTS--2830 patients with AIDS reported to the Communicable Disease Surveillance Centre and the Communicable Disease (Scotland) Unit up to March 1990, of whom 566 had Kaposi''s sarcoma. MAIN OUTCOME MEASURES--Percentage of patients with AIDS who had Kaposi''s sarcoma. RESULTS--537 of 2291 homosexual or bisexual men (23%) with AIDS had Kaposi''s sarcoma; 10% (14/135) of the men and women who acquired HIV by heterosexual contact had Kaposi''s sarcoma. None of the 316 subjects who acquired HIV through non-sexual routes had Kaposi''s sarcoma. Kaposi''s sarcoma was more common among homosexual men whose likely source of infection included the United States (171/551, 31%) or Africa (9/34, 26%) than among those infected in the United Kingdom (119/625, 19%) (p less than 0.05). CONCLUSION--The data suggest that Kaposi''s sarcoma is caused by a sexually transmissible agent which was introduced into the British homosexual population mainly from the United States [corrected].     

Creating a new drug service in Edinburgh.

After one year Edinburgh''s Community Drug Problem Service has shown that if psychiatric services offer consultation and regular support for drug users many general practitioners will share the care of such patients and prescribe for them, under contract conditions, whether the key worker is a community psychiatric nurse or a drug worker from a voluntary agency. This seems to apply whether the prescribing is part of a "harm reduction" strategy over a long period or whether it is a short period of methadone substitution treatment. Given the 50% prevalence of HIV infection among drug users in the Edinburgh area and the fact that only half of them have been tested for seropositivity, the health and care of this demanding group of young people with a chaotic lifestyle are better shared among primary care, community based drug workers, and specialist community drugs team than treated exclusively by a centralised hospital drug dependency unit. As the progression to AIDS is predictable in a larger proportion of drug users who are positive for HIV, there is an even greater need for coordinated care between specialists and community agencies in the near future.     

Factors associated with HIV/AIDS diagnostic disclosure to HIV infected children receiving HAART: a multi-center study in Addis Ababa, Ethiopia

Background

Diagnostic disclosure of HIV/AIDS to a child is becoming an increasingly common issue in clinical practice. Nevertheless, some parents and health care professionals are reluctant to inform children about their HIV infection status. The objective of this study was to identify the proportion of children who have knowledge of their serostatus and factors associated with disclosure in HIV-infected children receiving HAART in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted in five hospitals in Addis Ababa from February 18, 2008–April 28, 2008. The study populations were parents/caretakers and children living with HIV/AIDS who were receiving Highly Active Antiretroviral Therapy (HAART) in selected hospitals in Addis Ababa. Univariate and multivariate logistic regression analysis were carried out using SPSS 12.0.1 statistical software.

Results

A total of 390 children/caretaker pairs were included in the study. Two hundred forty three children (62.3%) were between 6–9 years of age. HIV/AIDS status was known by 68 (17.4%) children, 93 (29%) caretakers reported knowing the child''s serostatus two years prior to our survey, 180 (46.2%) respondents said that the child should be told about his/her HIV/AIDS status when he/she is older than 14 years of age. Children less than 9 years of age and those living with educated caregivers are less likely to know their results than their counterparts. Children referred from hospital''s in-patient ward before attending the HIV clinic and private clinic were more likely to know their results than those from community clinic.

Conclusion

The proportion of disclosure of HIV/AIDS diagnosis to HIV-infected children is low. Strengthening referral linkage and health education tailored to educated caregivers are recommended to increase the rate of disclosure.     

Reliability and validity of the Ethiopian version of the hospital anxiety and depression scale (HADS) in HIV infected patients

Background

The hospital anxiety and depression scale (HADS) is a widely used instrument for evaluating psychological distress from anxiety and depression. HADS has not yet been validated in Ethiopia. The aim of this study was to evaluate the reliability and validity of the Amharic (Ethiopian language) version of HADs among HIV infected patients.

Methods

The translated scale was administered to 302 HIV/AIDS patients on follow up for and taking anti-retroviral treatment. Consistency assessment was conducted using Cronbach''s alpha, test-retest reliability using intra-class correlation coefficients (ICC). Construct validity was examined using principal components analysis (PCA). Parallel analysis, Kaiser''s criterion and the scree test were used for factor extraction.

Results

The internal consistency was 0.78 for the anxiety, 0.76 for depression subscales and 0.87 for the full scale of HADS. The intra-class correlation coefficient (ICC) was 80%, 86%, and 84% for the anxiety and depression subscales, and total score respectively. PCA revealed a one dimensional scale.

Conclusion

This preliminary validation study of the Ethiopian version of the HADs indicates that it has promising acceptability, reliability and validity. The adopted scale has a single underlying dimension as indicated by Razavi''s model. The HADS can be used to examine psychological distress in HIV infected patients. Findings are discussed and recommendations made.     

Sexual Healthcare Preferences among Gay and Bisexual Men: A Qualitative Study in San Francisco,California

Background

Research on gay and other men who have sex with men''s (G/MSM) preferences for sexual healthcare services focuses largely on HIV testing and to some extent on sexually transmitted infections (STI). This research illustrates the frequency and location of where G/MSM interface with the healthcare system, but it does not speak to why men seek care in those locations. As HIV and STI prevention strategies evolve, evidence about G/MSM''s motivations and decision-making can inform future plans to optimize models of HIV/STI prevention and primary care.

Methods

We conducted a phenomenological study of gay men''s sexual health seeking experiences, which included 32 in-depth interviews with gay and bisexual men. Interviews were transcribed verbatim and entered into Atlas.ti. We conducted a Framework Analysis.

Findings

We identified a continuum of sexual healthcare seeking practices and their associated drivers. Men differed in their preferences for separating sexual healthcare from other forms of healthcare (“fragmentation”) versus combining all care into one location (“consolidation”). Fragmentation drivers included: fear of being monitored by insurance companies, a desire to seek non-judgmental providers with expertise in sexual health, a desire for rapid HIV testing, perceiving sexual health services as more convenient than primary care services, and a lack of healthcare coverage. Consolidation drivers included: a comfortable and trusting relationship with a provider, a desire for one provider to oversee overall health and those with access to public or private health insurance.

Conclusions

Men in this study were likely to separate sexual healthcare from primary care. Based on this finding, we recommend placing new combination HIV/STI prevention interventions within sexual health clinics. Furthermore, given the evolution of the financing and delivery of healthcare services and in HIV prevention, policymakers and clinicians should consider including more primary care services within sexual healthcare settings.     

High Rates of HIV Seroconversion in Pregnant Women and Low Reported Levels of HIV Testing among Male Partners in Southern Mozambique: Results from a Mixed Methods Study

Introduction

Prevention of acute HIV infections in pregnancy is required to achieve elimination of pediatric HIV. Identification and support for HIV negative pregnant women and their partners, particularly serodiscordant couples, are critical. A mixed method study done in Southern Mozambique estimated HIV incidence during pregnancy, associated risk factors and factors influencing partner''s HIV testing.

Methods

Between April 2008 and November 2011, a prospective cohort of 1230 HIV negative pregnant women was followed during pregnancy. A structured questionnaire, HIV testing, and collection of dried blood spots were done at 2–3 scheduled visits. HIV incidence rates were calculated by repeat HIV testing and risk factors assessed by Poisson regression. A qualitative study including 37 individual interviews with men, women, and nurses and 11 focus group discussions (n = 94) with men, women and grandmothers explored motivators and barriers to uptake of male HIV testing.

Results

HIV incidence rate was estimated at 4.28/100 women-years (95%CI: 2.33–7.16). Significant risk factors for HIV acquisition were early sexual debut (RR 3.79, 95%CI: 1.04–13.78, p = 0.04) and living in Maputo Province (RR 4.35, 95%CI: 0.97–19.45, p = 0.05). Nineteen percent of women reported that their partner had tested for HIV (93% knew the result with 8/213 indicating an HIV positive partner), 56% said their partner had not tested and 19% did not know their partner test status. Of the 14 seroconversions, only one reported being in a serodiscordant relationship. Fear of discrimination or stigma was reported as a key barrier to male HIV testing, while knowing the importance of getting tested and receiving care was the main motivator.

Conclusions

HIV incidence during pregnancy is high in Southern Mozambique, but knowledge of partners'' HIV status remains low. Knowledge of both partners'' HIV status is critical for maximal effectiveness of prevention and treatment services to reach elimination of pediatric HIV/AIDS.     

Population-Level Scale-Up of Cervical Cancer Prevention Services in a Low-Resource Setting: Development,Implementation, and Evaluation of the Cervical Cancer Prevention Program in Zambia

Background

Very few efforts have been undertaken to scale-up low-cost approaches to cervical cancer prevention in low-resource countries.

Methods

In a public sector cervical cancer prevention program in Zambia, nurses provided visual-inspection with acetic acid (VIA) and cryotherapy in clinics co-housed with HIV/AIDS programs, and referred women with complex lesions for histopathologic evaluation. Low-cost technological adaptations were deployed for improving VIA detection, facilitating expert physician opinion, and ensuring quality assurance. Key process and outcome indicators were derived by analyzing electronic medical records to evaluate program expansion efforts.

Findings

Between 2006-2013, screening services were expanded from 2 to 12 clinics in Lusaka, the most-populous province in Zambia, through which 102,942 women were screened. The majority (71.7%) were in the target age-range of 25–49 years; 28% were HIV-positive. Out of 101,867 with evaluable data, 20,419 (20%) were VIA positive, of whom 11,508 (56.4%) were treated with cryotherapy, and 8,911 (43.6%) were referred for histopathologic evaluation. Most women (87%, 86,301 of 98,961 evaluable) received same-day services (including 5% undergoing same-visit cryotherapy and 82% screening VIA-negative). The proportion of women with cervical intraepithelial neoplasia grade 2 and worse (CIN2+) among those referred for histopathologic evaluation was 44.1% (1,735/3,938 with histopathology results). Detection rates for CIN2+ and invasive cervical cancer were 17 and 7 per 1,000 women screened, respectively. Women with HIV were more likely to screen positive, to be referred for histopathologic evaluation, and to have cervical precancer and cancer than HIV-negative women.

Interpretation

We creatively disrupted the ''no screening'' status quo prevailing in Zambia and addressed the heavy burden of cervical disease among previously unscreened women by establishing and scaling-up public-sector screening and treatment services at a population level. Key determinants for successful expansion included leveraging HIV/AIDS program investments, and context-specific information technology applications for quality assurance and filling human resource gaps.     

Rationale,Design and Methods of the Ecological Study of Sexual Behaviors and HIV/STI among African American Men Who Have Sex with Men in the Southeastern United States (The MARI Study)

Background

This paper describes the rationale, design, and methodology of the Ecological Study of Sexual Behaviors and HIV/STI among African American Men Who Have Sex with Men (MSM) in the Southeastern United States (U.S.; known locally simply as the MARI Study).

Methods

Participants are African American MSM aged 18 years and older residing in the deep South.

Results

Between 2013 and 2015, 800 African American MSM recruited from two study sites (Jackson, MS and Atlanta, GA) will undergo a 1.5-hour examination to obtain anthropometric and blood pressure measures as well as to undergo testing for sexually transmitted infections (STI), including HIV. Intrapersonal, interpersonal, and environmental factors are assessed by audio computer-assisted self-interview survey. Primary outcomes include sexual risk behaviors (e.g., condomless anal sex) and prevalent STIs (HIV, syphilis, gonorrhea, and Chlamydia).

Conclusion

The MARI Study will typify the HIV environmental ''riskscape'' and provide empirical evidence into novel ecological correlates of HIV risk among African American MSM in the deep South, a population most heavily impacted by HIV. The study''s anticipated findings will be of interest to a broad audience and lead to more informed prevention efforts, including effective policies and interventions, that achieve the goals of the updated 2020 U.S. National HIV/AIDS Strategy.     

A CMA position. Acquired immunodeficiency syndrome.

The following general principles serve as guidelines for various bodies, health care professionals and the general public. Specific aspects of infection with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) that relate to physicians'' ethical responsibilities as well as society''s moral obligations are discussed. Such matters include the need for education, research and treatment resources; the patient''s right to investigation and treatment and to refusal of either; the need to obtain the patient''s informed consent; the right to privacy and confidentiality; the importance of infection control; and the right to financial compensation in the case of occupational exposure to HIV.     

The HIV epidemic among men who have sex with men—behaviour beats science

More than three decades after the emergence of HIV/AIDS, more than 30 million people worldwide still live with the disease. In the West, those most at risk are men who have sex with men owing to a combination of social factors and, ironically, improved healthcare.The acquired immune deficiency syndrome (AIDS) pandemic that started more than 30 years ago remains one of the greatest public-health concerns worldwide: in 2009, it was estimated that 33.3 million individuals were infected with human immunodeficiency virus (HIV), with 2.6 million new infections globally (see graphic; [1]). Even in the affluent countries of North America, Australia, New Zealand and Western and Central Europe, the numbers of people infected with HIV have grown over the past two decades. Although the availability of efficient diagnostics and highly active antiretroviral therapy (HAART) have drastically improved life expectancy and quality of life—at least in those parts of the world where both are available and affordable—HAART does not cure the disease. Moreover, despite massive research efforts, there is no efficient vaccine on the market to protect against infection with HIV.Given the lack of either a vaccine or a cure, the main public-health intervention to halt the pandemic is to prevent viral transmission in the first placeGiven the lack of either a vaccine or a cure, the main public-health intervention to halt the pandemic is to prevent viral transmission in the first place. In fact, the transmission of HIV is not as efficient as other, more resistant blood-borne viruses such as hepatitis B and hepatitis C viruses (HBV and HCV), and it requires direct contact of blood or semen from an infected person with the blood system of the exposed person. This feature puts certain groups at greater risk of transmission: heterosexuals with many sexual partners, including sex workers, men who have sex with men (MSM—a technical term used by health professionals to avoid forcing individuals to define themselves in a specific sexuality), people who inject drugs, newborns of HIV-infected mothers, blood recipients and healthcare workers. Yet, the risk of infection differs for each of these groups. There is also a geographical dimension to the risk, as different parts of the world have unique epidemiological characteristics, reflecting biological, behavioural and socio-economic factors. In many parts of Africa and Asia, for example, the most susceptible groups are heterosexuals and sex workers; in Eastern Europe, people who inject drugs are mainly affected; and in western countries, the most vulnerable population are MSM, followed by heterosexual migrants from areas where HIV is endemic [2].

Science & Society Series on Sex and Science

Sex is the greatest invention of all time: not only has sexual reproduction facilitated the evolution of higher life forms, it has had a profound influence on human history, culture and society. This series explores our attempts to understand the influence of sex in the natural world, and the biological, medical and cultural aspects of sexual reproduction, gender and sexual pleasure.Public-health programmes intended to prevent the transmission of HIV therefore have to address these groups individually. Such measures require education and the involvement of at-risk populations, and recommendations must be based on a thorough understanding of the social, economic and other factors that determine disease risk among certain groups of people. For instance, one of the most efficient measures to decrease the risk of HIV infection among people who inject drugs is to offer clean syringes and needles,and safe places to use them. One of the most efficient ways to prevent HIV transmission during sexual intercourse is the use of condoms. But, the answers are not always as simple; human behaviour is complex and even irrational at times. This paper outlines the main causes of the HIV epidemic among MSM in western countries, highlights specific behavioural factors that increase exposure to HIV and discusses how these can be addressed in public-health programmes.AIDS was first identified and described in the USA in June 1981 [3]. Following reports from Los Angeles and New York City about clusters of otherwise healthy Caucasian MSM who developed Kaposi''s sarcoma and fatal Pneumocystis carinii (jirovecii) pneumonia, the US Centers for Disease Control and Prevention (CDC) conducted an epidemiological investigation and identified a man they referred to as ‘patient zero'': a flight attendant working for Air Canada named Gaëtan Dugas, who had numerous male sexual partners in North America. Dugas might not have been the first person who was infected with HIV, but the first one who was identified with the disease.​disease.Open in a separate windowSee full size illustration: http://staging-www.nature.com/embor/journal/v13/n11/full/embor2012152i1.htmlIt was a combination of a general liberal attitude towards sex that was prevalent among MSM, unprotected anal sex and having multiple sexual partners that allowed HIV to spread quickly among the gay community in the early 1980s. Owing to the overwhelming impact on MSM in the early years of the AIDS epidemic—when many MSM saw close friends, partners and lovers die—gay communities adopted a range of practices to reduce the risk of infection successfully by changing sexual behaviours. Regretfully, these achievements did not last; many other developed countries also recorded a resurgence in the number of MSM newly diagnosed with HIV/AIDS since the mid-1990s [4]. The main reason for the re-emergence of the disease was the come-back of risky sexual behaviours, triggered by wider social and cultural changes, greater social acceptance for gay men and, somehow unpredictably, the introduction of more efficient drugs [5].The most important risk factor for exposure to HIV among MSM remains sexual practices. As the rectal mucosa is more fragile than the vaginal or oral, anal sex increases the risk for transmitting HIV and other sexually transmitted infections (STIs). The frequency of risky sexual practices between MSM seems to be increasing [6], which would go some way to explaining the resurgence of AIDS.Another main factor for the resurgence of AIDS among the gay communities in western countries is, ironically, the efficiency of HAARTIn addition, gay communities have a relatively liberal attitude towards sex and partnership. The way they form partnerships may differ from many heterosexuals: the sexual contact is more instantaneous and spontaneous, and sexual intercourse may take place early in a relationship [7]. Relationships between some MSM may be more flexible, and concurrent sex with casual partners during a relationship is generally more tolerable [8,9]. Concomitancy and age-mixing of sexual partners has a strong influence on the dynamic of HIV transmission if an infected man is unaware of his infection owing to the asymptomatic nature during the first years of HIV infection, or because he has not been tested for HIV [10]. Early sexual debut is another reason for greater exposure to HIV, as MSM would have more partners during their lifetime.Social changes have also played a role in increasing the HIV transmission rate among MSM. Since the 1990s, homosexuality and gay lifestyle have become much more accepted in many western societies. This increasing tolerance and acceptance has enabled many MSM ‘to get out of the closet'', that is to disclose their sexual orientation and have fulfilling lives. It has also encouraged entrepreneurs to tap into this customer base by offering services and establishments specifically for MSM including cafés, bars, clubs, restaurants, hotels and bath houses, all specifically intended for the purpose of meeting other men. This sexually liberal climate, along with the venues to meet other gay men, has amplified the risk of having sex with an HIV-infected partner.Similarly, the rise of internet-dating sites has increased the ease with which new partners can be found. New sexual practices and behavioural norms are quickly diffused between cultures, with possible international importing of HIV and other STIs. The internet, which is affordable, immediate and discrete, has become the most popular way of searching for other MSM. Most gay-related internet sites are free and guarantee anonymity until participants find the preferred fit and disclose their personal details or picture. The discrete nature of the web also allows MSM who are still ‘in the closet'' or ‘on the down low'' to search for sexual partners. This electronic meeting place might modify the sexual risk, as it exposes users to a diverse pool of men and increases their ability to search and negotiate for sexual practices [11]. The anonymity also allows MSM to search explicitly for unprotected anal sex [12]. MSM who originate from low-resource countries and migrate to developed countries might not be familiar with the risk of unprotected sex and may also be excited about the sizeable and versatile MSM community in the hosting country [12]. A combination of insufficient knowledge about HIV/AIDS, coupled with their interest in experiencing gay life, may increase the risk for those migrants to become infected with HIV.…the chances that an HIV-negative MSM finds himself engaged in sexual contact with an HIV-infected partner are higher than 15 years agoCorresponding with the increased number of sexual partners and the greater risk during sexual intercourse, MSM are also exposed to other STIs, especially if they are already infected with HIV. Increasing incidence of syphilis, as well as outbreaks of primary and secondary syphilis among MSM, has been reported during the past decade from developed countries [13,14]. Primary syphilis might manifest in a ‘chancer''—a sore—which is a possible port of entry for HIV. Additionally, the immunological reaction to STIs includes the migration of macrophages and lymphocytes to the affected organs. These cells are also the target of HIV, and thus one STI increases the chances of infection with further STIs or HIV. Over the past years, several outbreaks of lymphogranuloma venereum (an uncommon STI), presenting proctitis (inflammation of the rectum), and genital ulcers with inguinal adenopathy (inflammation of the lymph nodes in the groin) have been reported [15]. The asymptomatic nature of some STIs, along with the limited success of the risk-reduction strategies practiced by MSM, might explain the increased incidence of STIs among gay men [16,17]. Among HIV-infected individuals, genital infections with common STI pathogens have been associated with increased HIV viral load in semen, thus negating the benefit of HAART [18].Another important factor for the resurgence of AIDS among the gay communities in western countries is, ironically, the efficiency of HAART, which has converted AIDS from a death sentence into a manageable chronic medical condition. As the perceived threat of HIV/AIDS diminishes and direct experience with death disappears, some MSM may be more inclined to take higher risks. Before the introduction of HAART in the mid-1990s, most MSM had direct experience of the devastating effects of HIV/AIDS on friends and loved ones. It is important to note that HAART reduces the viral load in HIV-infected persons to undetectable levels in the blood and thereby decreases the risk of infecting partners. However, studies have documented the persistence of HIV virions and infected cells in semen of HIV-infected MSM treated with HAART [19]. Most physicians, therefore, do not recommend unprotected sex for HAART-treated HIV/AIDS patients, although the risk of HIV transmission has been significantly reduced.…public-health measures to reduce the prevalence of HIV among MSM should focus on the behavioural and psychosocial factors that increase the risk of infectionAs such, HAART has profoundly changed the impact of HIV/AIDS: people who live with HIV/AIDS who adhere to their drug regimen are usually asymptomatic and seem healthy. The non-fatal prognosis for AIDS, the large communities of HIV-infected MSM who live apparently healthy lives and the greater social acceptability of the disease have together reduced the perceived threat of HIV/AIDS.The success of HAART has affected sexual behaviour, a phenomenon called ‘AIDS optimism''. First, as HIV-infected MSM feel healthy and their sex-drive is preserved, they have a normal sex life and seek sexual partners, similarly to HIV-negative MSM. Second, before HAART and during its introduction in the 1990s, people living with HIV/AIDS could be recognized either by their cachectic posture or by the lipodystrophic features of their cheekbones and limbs due to loss of subdermal fat—a side-effect of the first generation of protease inhibitors. HIV-negative MSM could therefore decline sexual contact or insist on safer sex practices. However, modern HAART has diminished side-effects and HIV-infected men are usually unrecognizable. MSM may wrongly consider their sexual partners to be HIV-negative and might have unprotected sex. Third, some MSM may be aware of the availability of post-exposure prophylaxis as an additional use of ART, and might have unprotected sex then request the treatment, which is available up to 72 hours after sex [20]. These men may not be aware that post-exposure treatment has not been proven to be efficient in humans in randomized clinical trials. Finally, young MSM, who have not witnessed the devastation of AIDS, may no longer feel threatened by the disease and might engage in unprotected sex. The advanced manageability of HIV, as portrayed in the media and advertisements sponsored by the pharmaceutical industry, may further disinhibit their sexual behaviour.Moreover, the success of HAART and decades of public-health recommendations to practice safe sex may have led to ‘AIDS fatigue''. Some MSM may become desensitized to safe-sex messages and might develop a negative emotional response to HIV issues. As the number of newly diagnosed HIV-positive MSM is increasing, some will also remain unaware of their infection and may ignore safe-sex practices. Thus, the chances that an HIV-negative MSM finds himself engaged in sexual contact with an HIV-infected partner are higher than 15 years ago. Some public-health professionals argue that the uptake of HIV tests among MSM has more to do with the increased acceptance of their lifestyle than an increasing infection rate; thus the high HIV rates recorded are no more than epidemiological fallacy. However, even if this assumption is true, it neither explains the rapid dynamic of HIV transmission among MSM communities, nor the increased syphilis infection rates. Additionally, ART-resistant strains of HIV have emerged, which complicates treatment and prolongs the transmission period. The prevalence of primary or transmitted drug-resistant HIV strains in North America and Western Europe is as high as 26% [21].…it crucially requires the involvement and engagement of the gay community themselves to maintain effective and acceptable interventionsDrug abuse is another relevant risk factor. Even if the percentage of intravenous drug users among MSM may not differ compared with the percentage among heterosexuals, it creates a twofold risk of acquiring HIV: by blood-to-blood transmission when sharing needles and syringes, and by semen-to-blood exposure when having sex. Some males who inject drugs may also engage in sex with other males, although they are heterosexuals, to finance their addiction.MSM are generally aware of their risk of acquiring HIV and of the importance of condom use. Yet, they have developed alternative strategies to prevent possible HIV exposure that involve evaluating their partners and the environment in which they meet more carefully, and then taking calculated risks [22]. One such strategy used is called ‘negotiated safety'', in which both men disclose to each other their HIV status before they have sexual intercourse and may decide to perform unprotected anal sex if they are both negative. The efficacy of this strategy depends on the time at which they were tested, their honesty and being safe if performing sex outside the primary sexual relationship. The second strategy is ‘sero-sorting'', when MSM restrict unprotected anal intercourse only to partners they believe to be concordant [23]. MSM negotiate and try to identify signs that might indicate that a partner could be HIV-positive, such as special physical features—being cachectic or lypodystrophic—the venue and context in which they meet, and when visiting the home of a partner, taking a quick look in their drawers or in the bathroom closet to search for HAART tablets (‘sero-guessing''). Another strategy is called ‘strategic positioning'', which is the use of sero-status to determine sexual roles in which MSM may perform only oral sex or take the active role in anal sex. However, these risk reduction strategies, widely used by MSM, offer only limited protection from HIV [24].The recommended use of condoms during anal sex can fall by the wayside after recreational drug use. Drugs such as alcohol and methamphetamine, which are commonly used at clubs, discos and other venues, lower social barriers and increase sociability. MSM using such drugs are therefore more inclined to have sex with an unknown partner and might not use a condom, as their judgment is impaired. This risky combination of drug use during sexual contact is called ‘party and play'' on internet sites for MSM who are searching for a partner [25].The result is that in the post-HAART era, MSM still remain the group most at risk of acquiring HIV, with substantial evidence for continuing HIV transmission. It has been estimated that more than 40% of HIV-positive young MSM are involved in risky sexual behaviour, despite their awareness of their infection [26,27]. Behavioural, emotional, psychological, environmental and epidemiological factors all act synergistically to increase risk-taking when it comes to sexual practices, thus exacerbating HIV incidence in MSM. These factors might be even more dominant among HIV-positive MSM, driving them to perform unprotected anal sex. They face specific psychosocial factors such as the need to be loved and cared for, a different meaning of sex as an emotional connection and a decreased desire for intimacy after their diagnosis, owing to mixed feelings of shame and guilt [24].By contrast, HIV-infected MSM who receive HAART and achieve undetectable viral load in their blood usually reduce the risk of transmitting the virus to their sexual contacts, and probably engage less in risky sexual behaviour than those who are not on ART [28]. One explanation is that they frequent HIV clinics more often and are therefore more aware of the need to use condoms, and receive positive self-care advice. Some studies have shown that many HIV-positive men are also engaged in both sero-sorting and strategic positioning, probably to avoid HIV transmission to members of their social and sexual networks [29].…the success of HAART and decades of public-health recommendations to practice safe sex might have led to ‘AIDS fatigue''Some HIV-infected MSM therefore prefer to contact sero-concordant HIV-positive partners to experience unprotected anal intercourse, free from the worry of infecting a negative partner, or the embarrassment of having to disclose their HIV status to a negative partner, exposing themselves to the stigma attached to HIV. These perceived benefits seem to outweigh the perceived risks of contracting another strain of HIV, potentially drug-resistant, or STIs.Lacking an efficient vaccine or cure for AIDS, public-health measures to reduce the prevalence of HIV among MSM should focus on the behavioural and psychosocial factors that increase the risk of infection. Effectively, this means educational and outreach campaigns to address risky sexual behaviour and to promote the use of condoms and other protective strategies. These interventions should involve all relevant parties: non-governmental and governmental organizations, health providers, public-health experts and gay-related agencies. The message about the continuing risks and dangers of HIV/AIDS should go through multiple routes to address as many men as possible through the internet, media, clubs, bars and public spaces, to reinforce consistent condom use and other risk-reduction strategies, and to promote early diagnosis and treatment.Such campaigns should address both HIV-negative and HIV-positive men, but with a different focus on the needs of each. HIV-negative MSM should be informed about the possible routes of HIV transmission, the importance of using condoms, improving negotiation skills and other risk-reduction strategies to protect themselves and their partners. Innovative interventions could also attempt to associate the strong motivation of MSM for masculinity with the use of condoms. Additionally, frequent HIV testing in MSM-friendly clinics and community settings should be encouraged to detect new infections as early as possible. HIV-infected MSM should be instructed with safe-sex recommendations and prescribed HAART to reduce seminal viral load. Intervention in this group should address the unique psychological, social and medical status of each patient. As pointed out above, it crucially requires the involvement and engagement of the gay community themselves to maintain effective and acceptable interventions.Health educators must also respect the needs, wishes and behaviour of MSM when addressing them about the risk of HIV/AIDS, and making recommendations about safe-sex practices. Although condoms are indeed efficient at preventing HIV transmission, they might nonetheless be the ‘incorrect'' instrument in the ‘wrong'' place for many people. Condom use breaks the intimacy and spontaneity of sex and reduces the pleasure. Although we hope that we can convince a young, HIV-positive MSM to use condoms, this might not be a realistic goal. As such, addressing the risks requires a sensitive, ‘down-to-earth'' approach that respects gay culture and the dynamic of finding partners, as well as training physicians to provide counselling for MSM in a friendly and confident way.Reducing the use of illicit drugs in both HIV-infected and uninfected MSM is another priority, although in some cases drugs are used to cope with the stress related to living with HIV. Appropriate interventions for HIV-infected MSM must therefore include stress-reduction techniques, psychological services and counselling about the negative effects of substance use. Another public-health priority is to promote the disclosure of HIV status as part of the ethics related to using gay-dating sites. As the perceived threat of HIV has diminished owing to the success of ART and the non-fatal medical prognosis of HIV/AIDS, noticeable messages should be more positive and reflect contemporary gay life, using gay-related and non-gay-related venues frequented by MSM, such as gyms, airports, shops or tourist resorts.To address the problem and slow or halt the pandemic requires focused, evidence-based measures that respect biological, emotional and social aspects in a holistic approach…In conclusion, HIV prevalence among MSM remains high and, given the increase in survival of HIV-infected individuals and the high rate of new infections, this hyper-endemic state is likely to be sustained in developed countries [14]. To address the problem and slow or halt the pandemic requires focused, evidence-based measures that respect biological, emotional and social aspects in a holistic approach [24], taking into account psychological stressors, drug habits, discrimination and the quest for intimacy. It is also important to increase the sensitivity of health providers towards the special needs of MSM, to conduct open and non-judgemental discussions with their patients. A supportive medical environment can encourage MSM to adhere to periodical HIV testing, HBV and hepatitis A virus immunizations and, possibly, to comply with condom use [19]. Finally, due to the similarities in MSM behaviours in industrialized countries, a closer collaboration is required between researchers from countries that have large MSM communities. We are entering the fourth decade of the AIDS epidemic, and despite awareness among MSM of their greater vulnerability to HIV and the introduction of new medical interventions, the rate of new infections continues to rise disproportionately. It is time for new interventions.? Open in a separate windowZohar MorOpen in a separate windowMichael Dan     

Requests approaching 50,000 annually for emergency drug release program.

Health Canada''s Emergency Drug Release Program, which allows physicians to acquire nonmarketed drugs to treat people with HIV infection, AIDS and other illnesses, handles about 44 000 requests annually. The executive director of the Drugs Directorate says the program''s name is a misnomer, since few of the requests involve medical emergencies. Dr. Philip Berger, who uses the program for his AIDS patients, complains that the amount of paperwork required is oppressive. A government spokesperson says changes may be made to make the program less labour intensive.     

Voluntary medical male circumcision: logistics, commodities, and waste management requirements for scale-up of services

Background

The global HIV prevention community is implementing voluntary medical male circumcision (VMMC) programs across eastern and southern Africa, with a goal of reaching 80% coverage in adult males by 2015. Successful implementation will depend on the accessibility of commodities essential for VMMC programming and the appropriate allocation of resources to support the VMMC supply chain. For this, the United States President’s Emergency Plan for AIDS Relief, in collaboration with the World Health Organization and the Joint United Nations Programme on HIV/AIDS, has developed a standard list of commodities for VMMC programs.

Methods and Findings

This list of commodities was used to inform program planning for a 1-y program to circumcise 152,000 adult men in Swaziland. During this process, additional key commodities were identified, expanding the standard list to include commodities for waste management, HIV counseling and testing, and the treatment of sexually transmitted infections.The approximate costs for the procurement of commodities, management of a supply chain, and waste disposal, were determined for the VMMC program in Swaziland using current market prices of goods and services.Previous costing studies of VMMC programs did not capture supply chain costs, nor the full range of commodities needed for VMMC program implementation or waste management. Our calculations indicate that depending upon the volume of services provided, supply chain and waste management, including commodities and associated labor, contribute between US$58.92 and US$73.57 to the cost of performing one adult male circumcision in Swaziland.

Conclusions

Experience with the VMMC program in Swaziland indicates that supply chain and waste management add approximately US$60 per circumcision, nearly doubling the total per procedure cost estimated previously; these additional costs are used to inform the estimate of per procedure costs modeled by Njeuhmeli et al. in “Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa.” Program planners and policy makers should consider the significant contribution of supply chain and waste management to VMMC program costs as they determine future resource needs for VMMC programs. Please see later in the article for the Editors'' Summary     

A Comprehensive Mapping of HIV-1 Genotypes in Various Risk Groups and Regions across China Based on a Nationwide Molecular Epidemiologic Survey

Background

China is experiencing a dynamic HIV/AIDS epidemic. While serology based surveillance systems have reported the spread of HIV/AIDS, detailed tracking of its transmission in populations and regions is not possible without mapping it at the molecular level. We therefore conducted a nationwide molecular epidemiology survey across the country.

Methods

HIV-1 genotypes were determined from 1,408 HIV-positive persons newly diagnosed in 2006. The prevalence of each genotype was estimated by weighting the genotype’s prevalence from each province- and risk-specific subpopulation with the number of reported cases in the corresponding subgroups in that year.

Results

CRF07_BC (35.5%), CRF01_AE (27.6%), CRF08_BC (20.1%), and subtype B'' (9.6%) were the four main HIV-1 strains in China. CRF07_BC and CRF08_BC were the primary drivers of infection among injecting drug users in northeastern and southeastern China, respectively, and subtype B'' remained dominant among former plasma donors in central China. In contrast, all four strains occurred in significant proportions among heterosexuals nationwide, pointing to an expansion of the HIV-1 epidemic from high-risk populations into the general population. CRF01_AE also replaced subtype B as the principal driver of infection among men-who-have-sex-with-men.

Conclusions

Our study provides the first comprehensive baseline data on the diversity and characteristics of HIV/AIDS epidemic in China, reflecting unique region- and risk group-specific transmission dynamics. The results provide information critical for designing effective prevention measures against HIV transmission.     

Integrating HIV Care into Primary Care Services: Quantifying Progress of an Intervention in South Africa

Background

Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated.

Methods

A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach''s alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial.

Results

Cronbach''s alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score.

Conclusion

The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.     

Are general practitioners ready to prevent the spread of HIV?

General practitioners are excellently placed to assess a person''s risk of being infected with the human immunodeficiency virus (HIV) and to give advice on reducing that risk. Their attitudes to the acquired immune deficiency syndrome (AIDS) and infection with HIV are, however, unknown. A questionnaire survey of 196 general practitioners in East Berkshire Health District was used to assess general practitioners'' readiness to undertake opportunistic health education to prevent the spread of infection with HIV. Altogether 132 replied. Sixty four of them expressed little interest in health education about HIV, and one in six would not dissent from the notion that AIDS could be controlled only by criminalising homosexuality. Only 75 of them had initiated discussions about HIV with patients. Moreover, many underestimated the risks from heterosexual sex while exaggerating the risks from non-sexual contact.Advice from general practitioners if given extensively might reduce the spread of infection with HIV. How best this may be achieved needs to be considered urgently.     

A Model for the Roll-Out of Comprehensive Adult Male Circumcision Services in African Low-Income Settings of High HIV Incidence: The ANRS 12126 Bophelo Pele Project

Background

World Health Organization (WHO)/Joint United Nations Programme on AIDS (UNAIDS) has recommended adult male circumcision (AMC) for the prevention of heterosexually acquired HIV infection in men from communities where HIV is hyperendemic and AMC prevalence is low. The objective of this study was to investigate the feasibility of the roll-out of medicalized AMC according to UNAIDS/WHO operational guidelines in a targeted African setting.

Methods and Findings

The ANRS 12126 “Bophelo Pele” project was implemented in 2008 in the township of Orange Farm (South Africa). It became functional in 5 mo once local and ethical authorizations were obtained. Project activities involved community mobilization and outreach, as well as communication approaches aimed at both men and women incorporating broader HIV prevention strategies and promoting sexual health. Free medicalized AMC was offered to male residents aged 15 y and over at the project''s main center, which had been designed for low-income settings. Through the establishment of an innovative surgical organization, up to 150 AMCs under local anesthesia, with sterilized circumcision disposable kits and electrocautery, could be performed per day by three task-sharing teams of one medical circumciser and five nurses. Community support for the project was high. As of November 2009, 14,011 men had been circumcised, averaging 740 per month in the past 12 mo, and 27.5% of project participants agreed to be tested for HIV. The rate of adverse events, none of which resulted in permanent damage or death, was 1.8%. Most of the men surveyed (92%) rated the services provided positively. An estimated 39.1% of adult uncircumcised male residents have undergone surgery and uptake is steadily increasing.

Conclusion

This study demonstrates that a quality AMC roll-out adapted to African low-income settings is feasible and can be implemented quickly and safely according to international guidelines. The project can be a model for the scale-up of comprehensive AMC services, which could be tailored for other rural and urban communities of high HIV prevalence and low AMC rates in Eastern and Southern Africa. Please see later in the article for the Editors'' Summary     

Wording effects and the factor structure of the Hospital Anxiety & Depression Scale in HIV/AIDS patients on antiretroviral treatment in South Africa

Background

Given the immense burden of HIV/AIDS on health systems in sub-Saharan Africa and the intricate link between HIV/AIDS and mental health problems, health care providers need a valid and reliable instrument to assess mental health rapidly. The Hospital Anxiety and Depression Scale (HADS) may constitute such an instrument. The aims of this study were to: (1) examine the factor structure of the HADS in a population of South African HIV/AIDS patients on antiretroviral treatment (ART); and (2) identify and control the disturbing influence of systematic wording effects in vulnerable respondent groups.

Methodology/Principal Findings

The translated scale was administered to 716 HIV/AIDS patients enrolled in the public sector ART program in South Africa. A combined confirmatory factor analysis and correlated-traits-correlated-methods framework was used to determine the preferred factor structure of the HADS, while controlling for the disturbing influence of systematic wording effects. When assessing the structure without a negative wording factor, all three factor structures displayed an acceptable fit to the data. The three-factor solution best fitted the data. Addition of a method factor significantly improved the fit of all three factor solutions. Using χ² difference testing, Razavi''s one-factor solution displayed a superior fit compared to the other two factor solutions.

Conclusions

The study outcomes support the use of the HADS as a valid and reliable means to screen for mental health problems in HIV/AIDS patients enrolled in a public-sector ART program in a resource-limited context. The results demonstrate the importance of evaluating and correcting for wording effects when examining the factor structure of the screening instrument in vulnerable patient groups. In light of the inter-relationships between HIV/AIDS and mental health problems and the scarcity of adequate screening tools, additional studies on this topic are required.     

The Role of NGOs in HIV/AIDS Prevention in Nigeria

The HIV/AIDS pandemic data in Nigeria indicates that 3.5 million Nigerians have HIV/AIDS. The Obasanjo administrations National Action Committee on AIDS is uncoordinated and lacks commitment as indicated by the shortage of antiretroviral drugs, corruption and administration of expired drugs. NGOs combating the spread of HIV in Nigeria attempt to reach many community groups, religious, womens, youth and mens organizations. The increased awareness about HIV/AIDS through promotion of public discourse has helped people to take positive action toward prevention of HIV infection.