Wrapping up CROI 2013, Part 2: Saving babies, reaching young women, and men who have sex with men making a difference

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Science Speaks spent March 3 – 6 at the Conference on Retroviruses and Opportunistic Infections, covering breaking research news and discussions. Today we will wrap up with a look at how the President’s Emergency Plan For AIDS Relief affects infant mortality, what combination prevention means to young South African women, and where men who have sex with men fit in.

Is HIV Development Assistance Reducing Child Mortality in Sub-Saharan Africa?: In the first study to quantitatively measure the effect of the President’s Emergency Plan For AIDS Relief on child mortality, Eran Bendavid of Stanford University looked at rates of death in children under five years old, among children of HIV-infected parents, and children whose parents did not have the virus, and compared what happened in countries with and without PEPFAR programs. Death rates of children with HIV-infected parents dropped in PEPFAR supported countries, while death rates among children with HIV-infected parents continued to rise in non-PEPFAR countries. Rates of death among children whose parents did not have HIV stayed the same in both settings. At the press conference where he presented his findings, Bendavid was asked whether the impact of sequestration and the further budget tightening to follow would affect the programs that had made this difference. “Foreign aid is always vulnerable,” he said. As are the lives of small children in the midst of an epidemic.

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When Worlds Collide
: “Knowledge is a right and a precursor to behavior change, but is insufficient in itself,” Dr. Sinead Delany-Moretlwe from the University of Witwatersrand in Johannesburg said March 5 at CROI.
Offering context and commentary on the high rate of HIV infection among young South African women and the challenges of HIV prevention among this group, she noted that most interventions have focused on behavior change with very little evidence that they work or hold benefits for young women

With infections rates that are 10-fold higher in women than in young men—the highest of any demographic group in the country, effective interventions are urgently needed, she said.

She pointed to the dismal results of the VOICE trial released at this meeting and highlighted the finding that adherence in the trial was associated with being older than 25. While many young women were enrolled in FemPrEP and VOICE, the trial findings show that these women did not perceive themselves to be at risk, which coupled with the poor rates of actually taking the drug, raises the question of whether daily PrEP is suitable for this group.

HIV testing among young women is low and in many countries laws restrict access to testing among young people. Even in South Africa where there are no legal barriers, parents and communities may not be supportive of young women seeking an HIV test.

HIV prevention is influenced by population and place, argued Delany-Moretlwe. There are biological vulnerabilities during adolescence in the genital tract and neurocognitive changes that make this a time of immense transition from dependence to independence. Those are factors that may account for more sexual risk behavior and less condom use and the selection of older men for the economic benefits they may receive.

“Context matters,” said Delany-Moretlwe, as she noted that for many of these women that context includes alcohol and violence. Rapid urbanization leads to a concentration of infections in cities and a concentration in urban informal settlements when opportunities for education and for work elude these women. Under 40 percent of girls complete secondary school and the lack of education and job opportunities are a major driver of transactional sex and sex work among young women.

Delany-Moretlwe argued that the health of these young women is socially determined and therefore we should move beyond individual factors to influence health. She referenced a prevention program in Malawi that pays girls to stay in school and demonstrated that cash payments can reduce HIV risk in generalized epidemics. She suggested that young women need combination prevention that includes biomedical interventions as well as strategies to alter the social and economic contexts in which risks occur—reducing risk “in context.” She pointed out that the HIV budget should not have to pay for all of these interventions, given the broader benefits to the community and the real challenge of expanding coverage of these structural interventions as essential ingredients to combination prevention at the population level. Young women will need to be at the center of the partnerships that must be formed to implement successful HIV prevention for this group, according to Delany-Moretlwe.

In response to a question from the audience about the role of treatment as prevention, Delany-Moretlwe said that treatment will only be a prevention strategy for young women if men get tested and treated.

***

Which brings us too . . .

“The health of men is actually a huge challenge in the world. Men do worse than women,” Kevin DeCock of the Centers for Disease Control and Prevention commented during a CROI session March 6. He was speaking during the question answer session at the end of a themed discussion, MSM in the Developing World March 5 at CROI. “Men are a vulnerable population,” De Cock added, stressing that he was “not trying to make a joke.”

He had a question at the end of this session that addressed HIV prevalence and risk factors among men who have sex with men in Cote d’Ivoire, Ghana, Vietnam and Thailand. Among the challenges:

  • A study in Ghana found less than 10 percent of HIV-infected men who have sex with men knew their status;
  • In Vietnam a study showed that the greater the number of “syndemic conditions” including alcohol and amphetamine use, suicide risk, post-traumatic stress, childhood sexual abuse, the greater the risk of unprotected anal intercourse;
  • In a Thailand study, while men reported that their rates of drug use and unprotected anal intercourse dropped, their HIV incidence did not;

“We’ve made progress,” De Cock said, but he added, “It seems we’re not making it, with men who have sex with men.”

He concluded with his question: “Can we leave with optimism?”

Session convener Chris Beyrer answered slowly. Men are presenting later, with more advanced disease, he said. More data is slowly becoming available about HIV rates among men who have sex with men, but it is showing more incidence. But small changes can have impact — relatively modest increases in condom use make a big difference.

And in the first decade of the epidemic, the community led response was powerful.

“We know that gay men can do this,” he said. “We’ve done it before. And I think it’s before all of us to work on the resilience and engagement of this community.”

 

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