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WHAT'S NEW THIS TUESDAY: SIX ON HIV/AIDS TREATMENT AND PREVENTION

Monday, 30th of July 2012

• SIX ON HIV/AIDS TREATMENT AND PREVENTION

 

• PROJECTING THE BENEFITS OF ANTIRETROVIRAL THERAPY FOR HIV PREVENTION:  THE IMPACT OF POPULATION MOBILITY AND LINKAGE TO CARE

1.   Jason R. Andrews1, Robin Wood4, Linda-Gail Bekker4, Keren Middelkoop4 and

  Rochelle P. Walensky1,2,3

+ Author Affiliations

1.    ¹Division of Infectious Diseases, Massachusetts General Hospital 

2.    ²Division of General Medicine, Department of Medicine, Massachusetts General HospitalBoston 

3.    ³Harvard University Center for AIDS Research, Harvard Institute for Global Health CambridgeMassachusetts 

4.    ⁴Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Republic of South Africa

1.    Correspondence: Jason R. Andrews, MD, Division of Infectious Diseases, Massachusetts General Hospital, 50 Staniford St, 9th Fl, Boston, MA 02114 (jandrews6@partners.org).

Abstract below; full text available to JID subscribers

Background. Recent mathematical models suggested that frequent human immunodeficiency virus (HIV) testing with immediate initiation of antiretroviral therapy (ART) to individuals with a positive test result could profoundly curb transmission. The debate about ART as prevention has focused largely on parameter values. We aimed to evaluate structural assumptions regarding linkage to care and population mobility, which have received less attention.

Methods. We modified the linkage structure of published models of ART as prevention, such that individuals who decline initial testing or treatment do not link to care until late-stage HIV infection. We then added population mobility to the models. We populated the models with demographic, clinical, immigration, emigration, and linkage data from a South African township.

Results. In the refined linkage model, elimination of HIV transmission (defined as an incidence of <0.1%) did not occur by 30 years, even with optimistic assumptions about the linkage rate. Across a wide range of estimates, models were more sensitive to structural assumptions about linkage than to parameter values. Incorporating population mobility further attenuated the reduction in incidence conferred by ART as prevention.

Conclusions. Linkage to care and population mobility are critical features of ART-as-prevention models. Clinical trials should incorporate relevant data on linkage to care and migration to evaluate the impact of this strategy.

• HIV TREATMENT AS PREVENTION

       This introductory article forms part of a collection on this complex subject. Readers with further interests are advised to consult the homepage of www.plosmedicine.org

       Full text is at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001259

       Key Points

       It has been established that ART for those infected with HIV can prevent onward transmission of infection, but biological efficacy alone is not enough to confirm the impact that ART could have on the HIV epidemic, or to show how best to use ART to reduce incidence of HIV. This will be among the most important issues in the field of HIV prevention for the foreseeable future.

       Epidemiology, economics, demography, statistics, biology, and mathematical modelling will be central in framing key decisions in the optimal use of ART.

       The HIV Modelling Consortium aims to coordinate and promote research across these disciplines, and facilitate communication between researchers and policy-makers. At a collaborative meeting of this consortium in November 2011, several interlocking themes emerged that are discussed in this article and covered in more depth by other articles in this collection.

       Mathematical modelling is used to investigate the potential impact of treatment on HIV incidence. However, because of incomplete information on all the factors that could influence impact, substantial uncertainties will remain. Models should acknowledge those uncertainties and help prioritise data collection where this could strengthen model conclusions.

       The current economic constraints on HIV prevention bring to the fore the role of modelling to help assess the value and cost-effectiveness of ART. Understanding costs and integrating costing and epidemiological models will be key areas of ongoing and future research to help inform decision-making processes. Models are also being used to help design and interpret trials that test hypotheses about the impact of expanded access to treatment on the spread of HIV in communities.

       We hope that this article and others in the collection will provide a solid foundation upon which greater collaborations between disciplines will be formed, so as to better integrate the role of modelling into the wider scientific process and to more clearly articulate the strengths and weaknesses of particular modelling analyses. This approach will ultimately strengthen the support for evidence-based decision-making in HIV programmes.

• BATTLING THE VIRUS: A HUGE, STRANGE DRUG MARKET

Jun 2nd 2012 | NEW YORK | from the print edition of The Economist

Best viewed at http://www.economist.com/node/21556275?fb_ref=scn%2Ffb_ec%2Fbattling_the_virus&fb_source=timeline 

 

 

THE coming weeks may bring a victory in the long war against the human immunodeficiency virus (HIV), which causes AIDS. A drug called Truvada already treats the disease. By June 15th American regulators are expected to approve its use to prevent the transmission of HIV, too.

The past 30 years have produced several triumphs. A flood of money has helped scientists to invent new drugs and health workers to deliver them to those in need (see chart 1). These drugs have transformed a fatal disease into a chronic one. They have also made HIV a big business.

 

Sales of antiretroviral drugs in America and the five biggest European markets reached $13.3 billion in 2011, according to Datamonitor, a research outfit (see chart 2). The market is as unusual as it is large, both buoyed by government support and worryingly dependent on it. The past decade has brought fancier medicine in rich countries and copious aid for poor ones. But the war is far from won.

Publicly funded research has played a larger role in developing drugs for HIV than for other diseases. A study published last year in Health Affairs found that HIV drugs were three times as likely to involve a patent from the public sector. HIV also has special status among regulators. America’s Food and Drug Administration (FDA) created a faster way to review HIV drugs, allowing them on the market before the most expensive stage of clinical trials.

Convenient cocktails

In total, public and private investment has yielded more than two dozen HIV drugs. In 1987 Burroughs-Wellcome (now part of GlaxoSmithKline) introduced the first one, tackling an enzyme that helps the virus progress inside human cells. In 1995 Hoffmann-La Roche, a Swiss drug firm, launched the first protease inhibitor, which interrupts the virus at a later stage of replication. Today different medicines are combined to suppress resistance or reduce side-effects. The rise of combination therapy has brought a flurry of cross-licensing: companies strike deals to sell each other’s drugs in carefully calibrated cocktails.

One company stands out: Gilead, of California. A late entrant to the HIV race, Gilead quickly took the lead. Its strategy was simple: the more convenient the treatment, the better. In 2004 Gilead launched Truvada, a once-a-day, one-pill combination of two drugs. In 2006 it introduced Atripla, a once-a-day, one-pill combination of Truvada and another treatment. Atripla’s average wholesale price in America is nearly $25,000 per patient, per year. In 2011 its global sales reached $3.2 billion.

More good news for Gilead has come in recent weeks. An FDA panel recommended Truvada for preventive use: ie, to protect healthy people from contracting the virus. Another FDA panel endorsed Gilead’s new Quad pill, which is the simplest, most effective combination drug to date.

If the process for developing HIV drugs has been unusual, selling them has been even more so. America is the rich world’s biggest market, with 841,000 patients diagnosed—ten times as many as in Britain. More than 60% of HIV drugs in America are bought with public money. Insurers give HIV special treatment: patients are rarely pressed to buy the cheapest pills, as they might be if they had another disease.

Distributing drugs in poor countries is harder. A decade ago, hardly any poor people could afford them. At first, drugs firms handled this badly. In 1998, 39 big Western firms sued South Africa to protect their HIV patents. Global uproar ensued; the firms backed down in 2001.

Then two things changed. First, rich countries started donating vast sums to fight AIDS in poor ones. In 2000 there was less than $2 billion for HIV programmes each year; by 2010 there was $15 billion, thanks to the Global Fund to Fight AIDS, Tuberculosis and Malaria and George Bush junior’s President’s Emergency Plan for AIDS Relief (PEPFAR).

Second, the price of AIDS drugs plunged. In May 2000 a year’s “triple cocktail” therapy cost $10,000 or so. By 2011 the same pills sold for $62 in poor countries. PEPFAR cash buys generic versions of patented drugs, which may be supplied only to poor countries. Last year two drugmakers won most of PEPFAR’s contracts: Aurobindo, an Indian firm, and Matrix, an Indian firm acquired in 2007 by Mylan, an American one. PEPFAR’s bidding system keeps margins slim even by the standards of the generics industry, says Rajiv Malik, the president of Mylan. But volumes are huge.

Can treatment expand further? Despite the subsidies and the plunge in prices, less than half of those infected with HIV take HIV drugs. Those who do, however, live a long time, and they have to keep taking the pills. What’s more, new studies show that it helps to start treating patients early, so demand is sure to rise.

Alas, aid dipped in 2009 and 2010, thanks to the financial crisis. To make matters more complicated, there is a trade-off between more drugs and better ones. Most patients in poor countries get outdated pills, according to Médecins Sans Frontières. Allowing generics firms to copy yet more patented drugs might help. Since 2006 Gilead has licensed drugs to generics firms for 5% royalties. Last year it went further, agreeing to license drugs to a “patent pool” to centralise royalty deals for a range of firms. So far, however, Gilead is the only Western company to join.

Even in rich countries, public willingness to pay for the best drugs may be waning. Express Scripts manages drug costs for American employers. With Gilead’s expensive Quad poised to enter the market, employers have started asking Steve Miller, the chief medical officer, to contain HIV costs, possibly by nudging patients towards cheaper drugs.

There are two distinct HIV markets. In rich countries, many good treatments jostle for market share. The best will generate fat profits, since patients have to take their pills every day. But Datamonitor predicts that growth will slow after 2017, as many drugs lose patent protection and prices crash. In poor countries, by contrast, Big Pharma makes very little money but the most efficient copycats thrive. Meanwhile, the world still waits for a cure.

• USE OF DEVICES FOR ADULT MALE CIRCUMCISION IN PUBLIC

HEALTH HIV PREVENTION PROGRAMMES

        

Conclusions of the WHO Technical Advisory Group on Innovations

in Male Circumcision

 

Executive summary

World Health Organization, HIV Department

February 2012

 

Background

The WHO Global Health Sector Strategy on HIV/AIDS, 2011–2015, strives to reduce new HIV infections. This goal will be achieved only by implementing existing effective prevention technologies with sufficient intensity and scale. In March 2007 WHO and UNAIDS recommended male circumcision as an efficacious intervention for the prevention of heterosexually acquired HIV infection in men. It is recommended that countries with generalized HIV epidemics and a low prevalence of male circumcision progressively expand access to safe voluntary medical male circumcision services.

 

i. As countries have begun implementing this intervention, several challenges have become evident, including uncertain client demand and limited human and material resources. Specifically, the number of physicians and surgeons available to perform the procedure is low, and the time and equipment required for the currently recommended standard surgical methods are substantial. Therefore, research is underway to identify innovative methods that are simpler, less resource intensive, usable by non-physician providers, acceptable to clients and providers, and as safe as standard surgical male circumcision. Research on specific devices for adult male circumcision as alternative methods to standard surgical male circumcision has evolved over the past year, and member states and supporting partners have requested guidance regarding use of the new devices.

 

WHO, through expert consultations, has defined a pathway for the clinical evaluation of male circumcision devices for use in public health programmes for HIV prevention.

 

ii. The pathway includes an initial efficacy and safety study in the country of intended use, followed by a series of clinical studies consisting of a comparative study and a field study. For WHO global recommendations on use of devices as alternative methods for male circumcision, two series of clinical studies from different countries are required. By the end of 2011, a series of clinical studies was completed in one low-resource country, Rwanda, on one device that causes necrosis of the foreskin over one week through controlled radial compression with an elastic ring after which the device is removed. Safety and efficacy, and comparative studies had been completed on another device that achieves haemostasis by compression of the foreskin between two nonelastic locking rings. The foreskin can be excised immediately after the device has been placed correctly and the device remains in place for one week. Field studies with this device are underway in 2012.

ii

Objectives, target audience and development of conclusions and

recommendations

This Executive Summary is from a report on the conclusions and recommendations of the WHO Technical Advisory Group on Innovations in Male Circumcision (TAG) on use of a device as an alternative method to standard adult surgical procedures. The full report will be available soon. The TAG met in January 2012 and the report was developed to advise Member States implementing voluntary medical male circumcision as a HIV prevention intervention in national programmes and supporting partners. Given the data available, the conclusions and recommendations focus on an elastic ring controlled radial compression device.

As noted, data on this device were available from one series of clinical studies conducted in Rwanda.

Additional data on at least this device and another type of device are expected within the year. The report on the TA G conclusions also identifies additional information needed to guide further research to inform decision-makers and the development of guidance. The exact timing of guidance depends on availability of evidence from studies still in progress.

The report is intended for national public health officials in countries implementing male circumcision for HIV prevention and for policy- and decision-makers, including funders, interested in the potential use of devices as additional methods for male circumcision in resource-limited settings. It may also be of interest to health workers and non-governmental organizations.

To review the data and develop the conclusions, WHO applied the GRA DE approach for the development and review of recommendations

 

iii. The approach, in brief, includes stating clear questions to be answered and specifying primary outcomes of interest, reviewing the literature, and grading the quality of the evidence for each question and outcome

 

iv. Moving “from evidence to recommendation” for each question required consideration of the quality of evidence, the balance of benefits and harms, values and preferences, resource use and feasibility. A separate document with the GRA DE tables and evidence summaries will be made available once the study data are in the public domain.

Each participant of the TA G and consultants submitted a Declaration of Interests to the WHO Secretariat.

No significant conflicts or potential conflicts of interests were identified that required any invited participant not to attend. One participant had been involved as a clinical researcher on the initial safety research of the device studied in Rwanda. As requested by the Secretariat, he did not contribute to discussions on the implications of the evidence or the formulation of recommendations, but he did provide technical information on the study.

iii

Key conclusions from the January 2012 meeting of the Technical

Advisory Group

The key recommendations of the WHO TA G cover the use of a device as an alternative to standard adult surgical methods and its use by specific types of providers for voluntary male circumcision in public health HIV prevention programmes. Further remarks and information needs are described in the full report.

 

I. Use of an elastic ring controlled radial compression device for adult

male circumcision

1.1 The elastic ring controlled radial compression device for which data were available from one safety, one comparative, and one field study in one country (Rwanda) by the end of 2011 can be used in that same country (Rwanda), subject to approval/endorsement by the national programme, for phased implementation among men 18 years and older with rigorous monitoring for adverseevents and side-effects.

 

It was recommended that the phased implementation include:

a) active surveillance of the first 1000 clients to identify and record all adverse events and side-effects based on standardized definitions. The active surveillance may change to passive surveillance after the first 1000 clients, if the incidence of events is reassuringly low, as determined by independent review.

b) appropriate counselling on sexual abstinence and condom use1 after male circumcision and before complete healing is always crucial, but it is particularly crucial with use of this device because the healing time is at least one week longer than with standard surgery.

c) that, as approximately 10–15% of adult men were not clinically eligible for this device (due to phimosis or narrow opening of the foreskin), access is assured to standard surgical circumcision services. Alternative acceptable and efficient service delivery models for men who are not eligible for this device method should be identified and these models should be pilot-tested for feasibility.

1.2 The controlled radial elastic compression ring device for which data were available from one safety, one comparative, and one field study in one country (Rwanda) in 2011 is not yet recommended for use as an alternative method for male circumcision in national programmes outside the country where the first series of studies was conducted.

II. Use of the elastic ring controlled radial compression device by midlevel

Providers

In Rwanda where a field study with this device has been completed, physicians and mid-level providers (nurses) who are appropriately trained and deemed competent can perform the placement and removal of the device for men 18 years and older, with careful monitoring during phased implementation in actual practice, and in different types of settings, with active surveillance of the first 1000 clients as indicated above.

 

1 Condom use is also advised after healing since male circumcision only partially reduces the risk of sexual transmission of HIV from women to men. Male circumcision should be considered as part of a combination prevention package.

iv

Information gaps

Since the device has not been evaluated in men under age 18 years bridging studies must be conducted to establish its performance and safety in younger populations. In addition no systematic follow-up of clients has been done beyond nine weeks and longer-term follow-up of selected clients must be completed to document wound healing and final cosmetic result one year after the procedure. Since there are limited data in men with HIV infection or those with other immuno-compromising co-morbidities such as diabetes, the performance and safety of the device in such clients must be documented. Service delivery models will need to be tested to identify efficient approaches to delivering the entire minimum service package and ensuring access to male circumcision for those men excluded for device-specific contraindications.

 

Data from independent studies in countries other than Rwanda are necessary before a recommendation can be generalized beyond the country where the initial three studies were conducted. A comparative and a field study to assess the safety, efficacy and acceptability of the device in another country are underway. The TAG encourages the studies to be completed so results would be available during 2012.

 

The TAG recommended that national programmes interested in exploring the potential of devices within voluntary medical male circumcision for HIV prevention public health programmes, in advance of a global recommendation, should not conduct additional comparative studies but prepare in a stepwise manner for possible implementation, including discussing with key stakeholders and conducting preliminary research on acceptability and feasibility.

 

·       HOW TIMES HAVE CHANGED – HIV AND AIDS IN SOUTH AFRICA IN 2011

South African Medical Journal, Vol 102, No 2 (2012), editorial

At the International AIDS Conference in 2006, the UN envoy on AIDS, Stephen Lewis, described the South African government as ‘Obtuse, dilatory and negligent about rolling out treatment’, and its AIDS policy as ‘more worthy of a lunatic fringe than of a concerned and compassionate state … [and] wrong, immoral [and] indefensible … The government has a lot to atone for. I’m of the opinion that they can never achieve redemption.’1 During this period, the media accused the government, under former President Mbeki, of being denialist and nicknamed the late Minister of Health, Manto Tshabalala-Msimang, ‘Dr No’ and ‘Dr Beetroot’ because of her antipathy towards antiretroviral therapy and for advocating the virtues of nutrition.2 , 3

Despite Lewis’ pessimism, South Africa is now well on its way to redemption! In October 2009, President Zuma gave a speech described by the Treatment Action Campaign (TAC) as an historic comment on AIDS, which banished AIDS denialism and ushered in a new health era in South Africa.4 He acknowledged that South Africa had a large HIV and AIDS problem, and after citing the impact of HIV and AIDS on individuals, families and South African society said: ‘Let me emphasise that although we have a comprehensive strategy to tackle HIV and AIDS that has been acknowledged internationally, and though we have the largest antiretroviral programme in the world, we are not yet winning this battle.’5 What policy changes did government endorse, and what are their effects?

On World AIDS Day 1 December 2009, President Zuma announced significant changes to the national AIDS prevention and treatment policies. Pregnant women would be eligible for antiretroviral therapy (ART) at 14 weeks rather than 24 weeks, all HIV-positive children under 1 year of age would be eligible for ART irrespective of CD4 count, and TB/HIV co-infected patients and multidrug-resistant TB patients with a CD4 count of ≤350 cells/µl would be eligible for ARVs. To increase access further, President Zuma launched a national HIV counselling and testing (HCT) campaign to test 15 million people and screen them for TB by June 2011. This news made headlines the world over, signalling a new beginning and a break with the past.6 , 7

On 12 August 2011, the Minister of Health announced the results of the HCT campaign, and the Deputy President announced that all HIV-positive patients with a CD4 count ≤350 are eligible for ARVs, so that South Africa now fully complies with WHO ART guidelines.8 Truly an achievement!

The HCT scale-up policy required changes in the way health services were provided. In 2009, the Department of Health (DoH) planned to prepare an additional 500 public ART facilities per quarter and to initiate 500 000 new patients on ART between April 2010 and June 2011. To decrease waiting times at facilities, the DoH introduced provider-initiated counselling and testing (PICT) and nurse-initiated and managed ARV treatment (NIMART). In contrast to voluntary counselling and testing (VCT), PICT requires that every person accessing care at a public facility be offered an HIV test by their healthcare provider (and be screened for TB), regardless of the health service sought, while NIMART allows nurses to initiate adults and children onto ART. In April 2010, 3% of patients in facilities were offered HIV tests and 390 nurses were trained in NIMART. To improve on this baseline, targets were set for provinces, districts and facilities to improve their HCT and NIMART performances. By June 2011, the DoH increased the percentage of clients being offered HIV tests in facilities to 8% and has trained 7 492 professional nurses in diagnosing and prescribing for HIV and AIDS.

During the campaign, the private sector performed over 315 000 HIV tests; the public health sector performed 13.3 million HIV tests and 8 million TB screenings and initiated 429 530 patients onto treatment. With 2 million HIV-positive tests reported during the campaign and more than 1.4 million cumulatively initiated on treatment since 2004 – up from less than 100 000 in 2005 – it became clear that an equally strong effort was needed to ensure good-quality ART data and to support good clinical management.

An October 2010 review found over 40 patient management systems and various non-standard non-networked monitoring systems in the public sector for monitoring ART data. To address this challenge, in May 2010 the National Health Council (NHC, comprising Ministers and health MECs) adopted a standardised register and clinical stationery to assist with capturing and tracking patient information at health facilities. The paper register adopted by the NDoH was a modified version of a register used in the Western Cape that had been implemented since the start of the ART programme. This paper register formed the first tier of a three-tier monitoring system approved by the NHC in December 2010.

A non-networked electronic register and a networked electronic medical record comprise tiers 2 and 3. The tiered approach provides the tools to standardise ART monitoring with a system that best suits the varied needs of facilities with a goal to facilitate standardised reporting. The system and supports information management as well as patient management throughout the provinces and nationally. The NDoH plans to have the electronic register working in at least one facility per district by March 2012.

South Africa has moved from pariah status to a country acclaimed for its progressive HIV policies. This is clearly the result of the right leadership at the right time! The implementation of these policies is already beginning to show dividends, as illustrated by the recently released Statistics South Africa estimates of decreasing infant and under-5 mortality rates as well as increased life expectancy rates – which they attribute largely to increased access to ARVs.

This editorial has tried to illustrate the gains that have been made in combating HIV. Clearly this summary does not do justice to a highly complex set of interventions and continuing challenges or to the role played by researchers, academics, public sector managers, front-line health workers and our development partners. However, to eliminate the scourge of HIV and AIDS and its terrible twin TB, much more needs to be done – strengthening the health system based on the primary health care approach is but one strategy that is required to achieve all of the Millennium Development Goals.

Y Pillay, National Department of Health, Pretoria

C White
N McCormick, Clinton Health Access Initiative,Pretoria

Corresponding author: Y Pillay (ypillay@intekom.co.za)

Note: all authors write in their personal capacities.

References

1. British Broadcasting Company. South African AIDS policy attacked. 19 August 2006. http://news.bbc.co.uk/2/hi/5265432.stm (accessed 1 September 2011).

1. British Broadcasting Company. South African AIDS policy attacked. 19 August 2006. http://news.bbc.co.uk/2/hi/5265432.stm (accessed 1 September 2011).

2. Journ-AIDS. Manto Tshababala-Msimang. http://www.journaids.org/index.php/essential_information/hivaids_key_people/manto_tshabalala-msimang/ (accessed 29 August 2011).

2. Journ-AIDS. Manto Tshababala-Msimang. http://www.journaids.org/index.php/essential_information/hivaids_key_people/manto_tshabalala-msimang/ (accessed 29 August 2011).

3. Webber B. Manto Tshabalala-Msimang: South African who oversaw discredited AIDS policy, dies at 69. New York Times website, 2009. http://www.nytimes.com/2009/12/17/world/africa/17manto.html (accessed 29 August 2009).

3. Webber B. Manto Tshabalala-Msimang: South African who oversaw discredited AIDS policy, dies at 69. New York Times website, 2009. http://www.nytimes.com/2009/12/17/world/africa/17manto.html (accessed 29 August 2009).

4. South African Press Association. TAC praises Zuma for Aids speech. 2009. http://www.iol.co.za/news/politics/tac-praises-zuma-for-aids-speech-1.463197 (accessed 1 September 2011).

4. South African Press Association. TAC praises Zuma for Aids speech. 2009. http://www.iol.co.za/news/politics/tac-praises-zuma-for-aids-speech-1.463197 (accessed 1 September 2011).

5. Zuma J. Address by the President of the Republic of South Africa, HE Mr Jacob Zuma, to the National Council of Provinces (NCOP), NCOP Chamber, Cape Town, 2009. South African Government website, 2009. http://www.info.gov.za/speech/DynamicAction?pageid=461&sid=5322&tid=5467 (accessed 1 September 2009).

5. Zuma J. Address by the President of the Republic of South Africa, HE Mr Jacob Zuma, to the National Council of Provinces (NCOP), NCOP Chamber, Cape Town, 2009. South African Government website, 2009. http://www.info.gov.za/speech/DynamicAction?pageid=461&sid=5322&tid=5467 (accessed 1 September 2009).

6. The Lancet. HIV/AIDS: A new South Africa takes responsibility. 2009. http://download.thelancet.com/flatcontentassets/pdfs/S0140673609620651.pdf (accessed 25 September 2009).

6. The Lancet. HIV/AIDS: A new South Africa takes responsibility. 2009. http://download.thelancet.com/flatcontentassets/pdfs/S0140673609620651.pdf (accessed 25 September 2009).

7. Dugger CW. Breaking with past, South Africa issues broad AIDS policy. New York Times website, 2009. http://www.nytimes.com/2009/12/02/world/africa/02safrica.html (accessed 25 August 2011).

7. Dugger CW. Breaking with past, South Africa issues broad AIDS policy. New York Times website, 2009. http://www.nytimes.com/2009/12/02/world/africa/02safrica.html (accessed 25 August 2011).

8. South African Press Association. ARV program open to all now. 2011. http://www.sundaytribune.co.za/arv-program-open-to-all-now-1.1116850 (accessed 1 September 2011).

8. South African Press Association. ARV program open to all now. 2011. http://www.sundaytribune.co.za/arv-program-open-to-all-now-1.1116850 (accessed 1 September 2011).

 

• DECREASE OF HIV PREVALENCE OVER TIME AMONG THE MALE POPULATION OF ORANGE FARM, SOUTH AFRICA, FOLLOWING A CIRCUMCISION ROLL-OUT

Abstract, also at http://pag.aids2012.org/abstracts.aspx?aid=3903

Presented by Bertran Auvert (France).

B. Auvert¹, D. Taljaard², R. Sitta³, D. Reach², P. Lissouba³, J. Bouscaillou³, B. Singh⁴, D. Shabangu², C. Nhlapo⁵, J. Otchere- Darko², T. Mashigo², R. Taljaard⁶, G. Phatedi², M. Tsepe², M. Chakela², A. Mkhwanazi², P. Ntshangase², G. Peytavin⁷, S. Billy⁵, A. Puren⁴, D. Lewis<sup>4

1</sup>University of Versailles, Versailles, France, ²CHAPS, Johannesburg, South Africa, ³Inserm U1018-CESP, Villejuif, France, ⁴NICD-NHLS, Johannesburg, South Africa, ⁵SFH, Johannesburg, South Africa, ⁶Progressus, Johannesburg, South Africa, ⁷Hopital Bichat - Claude-Bernard, Paris, France

 

Background: The effect of the roll-out of voluntary medical male circumcision (VMMC) in Southern and Eastern Africa on HIV prevalence is unknown. Three years after the beginning of the Orange Farm (South Africa) VMMC roll-out (ANRS-12126), the project´s impact on HIV prevalence over time was assessed.

Methods: Two cross-sectional surveys were conducted, one in 2007-2008 (n=1971), before the beginning of the roll-out, and one in 2010-2011 (n=3268). The response rates exceeded 80%. Male residents aged 15 to 49 were randomly sampled, interviewed, assessed for circumcision status, counselled and tested for HIV. Blood samples were tested for HIV and for recent HIV infection using the BED assay. Prevalence ratios (PR) were calculated using multivariate (aPR) and propensity score weighted (wPR) Poisson regression models to assess the association of HIV prevalence and recent HIV infections with time and circumcision status. Covariates comprised age group, ethnic group, religion, having children, alcohol consumption, education level, age at first sexual intercourse, marital status and occupation.

Results: In three years, male circumcision prevalence standardized on age increased from 17.0% to 53.9%. In the 2007-2008 and 2010-2011 surveys, the propensity weighted effect of circumcision status on HIV prevalence was wPR=0.37 (95%CI: 0.19−0.58) and wPR=0.48 (95%CI: 0.35−0.65), respectively. HIV prevalence standardized on age decreased from 12.5% to 9.3%, aPR= 0.74 (95%CI: 0.60−0.91), among participants aged 15 to 49, and from 6.2% to 4.2%, aPR= 0.64 (95%CI: 0.49−0.85), among participants aged 15 to 29. Propensity analyses showed that the intervention avoided 536 (95%CI: 135 −1318) HIV infections in 2011 among the 52,000 adult men living in Orange Farm.

Conclusions: This study shows for the first time that the roll-out of VMMC in Africa can, if successfully promoted, lead to a decrease of HIV prevalence over time, detectable three years after its onset.

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