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Hardee K.,FutuResearch Group | Gay J.,J. Gay Consultants LLC | Croce-Galis M.,Artemis | Peltz A.,United States Agency for International Development
Journal of the International AIDS Society | Year: 2014

There is growing interest in expanding public health approaches that address social and structural drivers that affect the environment in which behaviour occurs. Half of those living with HIV infection are women. The sociocultural and political environment in which women live can enable or inhibit their ability to protect themselves from acquiring HIV. This paper examines the evidence related to six key social and structural drivers of HIV for women: transforming gender norms; addressing violence against women; transforming legal norms to empower women; promoting women's employment, income and livelihood opportunities; advancing education for girls and reducing stigma and discrimination. The paper reviews the evidence for successful and promising social and structural interventions related to each driver. This analysis contains peer-reviewed published research and study reports with clear and transparent data on the effectiveness of interventions. Structural interventions to address these key social and structural drivers have led to increasing HIV-protective behaviours, creating more gender-equitable relationships and decreasing violence, improving services for women, increasing widows' ability to cope with HIV and reducing behaviour that increases HIV risk, particularly among young people. © 2014 Hardee K et al; licensee International AIDS Society.

Polis C.B.,United States Agency for International Development | Phillips S.J.,World Health Organization | Curtis K.M.,Centers for Disease Control and Prevention
AIDS | Year: 2013

OBJECTIVE: To systematically review epidemiologic evidence assessing whether hormonal contraception alters the risk of HIV transmission from an HIV-positive woman to an HIV-negative male partner. DESIGN: Systematic review. METHODS: We included articles published or in press through December 15, 2011. We assessed studies with direct evidence on hormonal contraception use and HIV transmission, and summarized studies with indirect evidence related to genital or plasma viral load. RESULTS: One study provided direct evidence on oral contraceptive pills (OCPs) or injectable contraception and female-to-male HIV transmission; both injectables [Cox-adjusted hazard ratio (adjHR) 1.95, 95% confidence interval (CI) 1.06-3.58; marginal structural model (MSM) adjusted odds ratio (adjOR) 3.01, 95% CI 1.47-6.16] and OCPs (Cox adjHR 2.09, 95% CI 0.75-5.84; MSM adjOR 2.35, 95% CI 0.79-6.95) generated elevated point estimates, but only estimates for injectables were significant. Findings from 11 indirect studies assessing various hormonal contraception methods and viral genital shedding or setpoint were mixed, and seven of eight studies indicated no adverse effect of various hormonal contraception methods on plasma viral load. CONCLUSION: The only direct study on OCPs or injectable contraception and female-to-male HIV transmission suggests increased risk with the use of injectables. Given the potential for confounding in observational data, the paucity of direct evidence on this subject, and mixed indirect evidence, additional evidence is needed. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Polis C.B.,United States Agency for International Development | Curtis K.M.,Centers for Disease Control and Prevention
The Lancet Infectious Diseases | Year: 2013

Whether or not the use of hormonal contraception affects risk of HIV acquisition is an important question for public health. We did a systematic review, searching PubMed and Embase, aiming to explore the possibility of an association between various forms of hormonal contraception and risk of HIV acquisition. We identified 20 relevant prospective studies, eight of which met our minimum quality criteria. Of these eight, all reported findings for progestin-only injectables, and seven also reported findings for oral contraceptive pills. Most of the studies that assessed the use of oral contraceptive pills showed no significant association with HIV acquisition. None of the three studies that assessed the use of injectable norethisterone enanthate showed a significant association with HIV acquisition. Studies that assessed the use of depot-medroxyprogesterone acetate (DMPA) or non-specified injectable contraceptives had heterogeneous methods and mixed results, with some investigators noting a 1·5-2·2 times increased risk of HIV acquisition, and others reporting no association. Thus, some, but not all, observational data raise concern about a potential association between use of DMPA and risk of HIV acquisition. More definitive evidence for the existence and size of any potential effect could inform appropriate counselling and policy responses in countries with varied profiles of HIV risk, maternal mortality, and access to contraceptive services. © 2013 Elsevier Ltd.

Wolf R.C.,United States Agency for International Development
Journal of the International AIDS Society | Year: 2013

While still an understudied area, there is a growing body of studies highlighting epidemiologic data on men who have sex with men (MSM) in sub-Saharan Africa (SSA) which challenge the attitudes of complacency and irrelevancy among donors and country governments that are uncomfortable in addressing key populations (KPs). While some of the past inaction may be explained by ignorance, new data document highly elevated and sustained HIV prevalence that is seemingly isolated from recent overall declines in prevalence. The articles in this series highlight new studies which focus on the stark epidemiologic burden in countries from concentrated, mixed and generalized epidemic settings. The issue includes research from West, Central, East and Southern Africa and explores the pervasive impact of stigma and discrimination as critical barriers to confronting the HIV epidemic among MSM and the intersecting stigma and marginalization found between living with HIV and sexual minority status. Interventions to remove barriers to service access, including those aimed at training providers and mobilizing communities even within stigmatized peri-urban settings, are featured in this issue, which further demonstrates the immediate need for comprehensive action to address HIV among MSM in all countries in the region, regardless of epidemic classification.

Sgaier S.K.,Bill and Melinda Gates Foundation | Sgaier S.K.,University of Washington | Reed J.B.,Office of the U.S. Global AIDS Coordinator | Thomas A.,Naval Health Research Center | Njeuhmeli E.,United States Agency for International Development
PLoS Medicine | Year: 2014

Voluntary medical male circumcision (VMMC) is capable of reducing the risk of sexual transmission of HIV from females to males by approximately 60%. In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended making VMMC part of a comprehensive HIV prevention package in countries with a generalized HIV epidemic and low rates of male circumcision. Modeling studies undertaken in 2009-2011 estimated that circumcising 80% of adult males in 14 priority countries in Eastern and Southern Africa within five years, and sustaining coverage levels thereafter, could avert 3.4 million HIV infections within 15 years and save US$16.5 billion in treatment costs. In response, WHO/UNAIDS launched the Joint Strategic Action Framework for accelerating the scale-up of VMMC for HIV prevention in Southern and Eastern Africa, calling for 80% coverage of adult male circumcision by 2016. While VMMC programs have grown dramatically since inception, they appear unlikely to reach this goal. This review provides an overview of findings from the PLOS Collection "Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up." The use of devices for VMMC is also explored. We propose emphasizing management solutions to help VMMC programs in the priority countries achieve the desired impact of averting the greatest possible number of HIV infections. Our recommendations include advocating for prioritization and funding of VMMC, increasing strategic targeting to achieve the goal of reducing HIV incidence, focusing on programmatic efficiency, exploring the role of new technologies, rethinking demand creation, strengthening data use for decision-making, improving governments' program management capacity, strategizing for sustainability, and maintaining a flexible scale-up strategy informed by a strong monitoring, learning, and evaluation platform.

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