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HIV This Week: what scientific journals said
Welcome to the fifteenth issue of HIV This Week! In this issue you can learn more about
economics (AIDS-impoverishment and the protective effects of money, the cost-
effectiveness of ART and trimethoprim-sulfamethoxazole prophylaxis in resource-
constrained settings), living with HIV (partnership characteristics linked to unprotected
sex, why it’s worth it for people living with HIV to get vaccinated against influenza), sex
(the empowering impact of collectivisation strategies on safer sex practices in
commercial sex), youth (our UNICEF colleagues place young people squarely at the centre of
the HIV epidemic; effects of sex education in developing country schools), gender (whether
men and women would purchase condoms more readily when placed near negative, neutral, or
positive products; sex partner selection among inner-city African American youth), and
universal access (a look back on key issues at the Toronto conference including treatment
targets and HIV prevention trials – with an Editors’ note about plans at UNAIDS to improve
trial conduct).
To find out how you can access a majority of scientific journals free of charge, please see
the last page of this issue or check the HIV This Week blog on the UNAIDS website at
We want to be as helpful to you as we can, so please let us know what your interests are and
what you think of HIV This Week by sending a commenby
posting one on the HIV This Week blog. If you would like to recommend an article for
inclusion in HIV This Week, please let us know.
Don’t forget that you can find a wealth of information on the HIV epidemic and responses to it at . 1. Economics
. Economic causes and effects of AIDS in South African households.
Bachmann and Booysen investigated the magnitude and temporal directionality of
associations between illness and death, and income and expenditure, in households affected
by HIV. A cohort study with repeated measures was conducted in one rural and one urban
area of South Africa among 405 households (1913 occupants) known to have HIV-infected
occupants, and their neighbours. Interview surveys of household heads were conducted at
baseline and five more times, semi-annually, providing information on household economics,
illnesses and deaths. Regression analyses used marginal structural models and 'before-after'
models to analyse changes. In marginal structural models, current or previous AIDS illness
was independently associated with 34% (95% CI 23-43%) lower monthly expenditure, and
current or recent poverty was associated with 1.74 (95% CI 0.94-3.2) times higher odds of
an AIDS death. In before-after models, each AIDS death was independently associated with
a 23% (95% CI 11-34%) greater expenditure decline over 3 years. A US$100 higher monthly
expenditure at baseline was associated with 0.31 (95% CI 0.13-0.74) times as many AIDS
deaths and with 0.41 (95% CI 0.27-0.64) times as many AIDS illness episodes over 3 years.
The authors conclude that AIDS deaths and illnesses predicted declining expenditure, and
poverty predicted AIDS, suggesting that both welfare and effective treatment are needed.
Editors’ note: This study demonstrates that AIDS itself is impoverishing but also that
increased household resources can slow disease progression. This is likely due, in part,
to the direct effect of adequate nutrition but may also involve other factors. It speaks
for the importance of both nutritional support and micro-finance and other economic
strategies to increase household resources.

al. Cost-effectiveness of HIV treatment in resource-poor
settings--the case of Cote d'Ivoire.

As antiretroviral therapy is increasingly used in settings with limited resources, key
questions about the timing of treatment and use of diagnostic tests to guide clinical
decisions must be addressed. Goldie and colleagues assessed the cost-effectiveness of
treatment strategies for a cohort of HIV-infected adults in Cote d'Ivoire (mean age 33
years; CD4 cell count 331 per cubic millimeter; HIV RNA level 5.3 log copies per milliliter).
Using a computer-based simulation model that incorporates the CD4 cell count and HIV RNA
level as predictors of disease progression, the authors compared the long-term clinical and
economic outcomes associated with no treatment, trimethoprim-sulfamethoxazole
prophylaxis alone, antiretroviral therapy alone, and trimethoprim-sulfamethoxazole
prophylaxis with antiretroviral therapy. Compared with trimethoprim-sulfamethoxazole
alone, life expectancy increased by 10.7 months with antiretroviral therapy and
trimethoprim-sulfamethoxazole prophylaxis initiated on the basis of clinical criteria and 45.9
months with antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis initiated
on the basis of CD4 testing and clinical criteria. The incremental cost per year of life gained
was US$240 for trimethoprim-sulfamethoxazole prophylaxis alone, US$620 for
antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis without CD4 testing,
and US$1180 for antiretroviral therapy and trimethoprim-sulfamethoxazole prophylaxis with
CD4 testing. None of the strategies that used antiretroviral therapy alone were as cost-
effective as those that also used trimethoprim-sulfamethoxazole prophylaxis. Life
expectancy was increased by 30% with use of a second line of antiretroviral therapy after
failure of the first-line regimen. The authors conclude that a strategy of trimethoprim-
sulfamethoxazole prophylaxis and antiretroviral therapy, with the use of clinical criteria
alone or in combination with CD4 testing to guide the timing of treatment, is an economically
attractive health investment in settings with limited resources. Editors’ note: This study
provides unequivocal support from an economics perspective for the standard inclusion of
trimethoprim-sulfamethoxazole prophylaxis in treatment regimes but it also highlights
the survival advantage (close to 3 additional years) of adding CD4 testing to clinical
criteria for treatment initiation. Successful efforts to reduce the cost, complexity and
unavailability of CD4 testing would have tangible survival benefits.

2. Living with HIV
, , et al. Unprotected intercourse among people living with HIV/AIDS:
the importance of partnership characteristics.
Niccolai and colleagues determined the relative importance and interactive effects of
partnership characteristics in unprotected intercourse among people living with HIV. They
conducted an interview study among a convenience sample of people living with HIV in care.
Of all the demographic, health status, risk history and behaviours and partnership covariates
explored, only the partnership covariates were significantly associated with unprotected
intercourse. Significant covariates included having a steady partner (OR 4.2, 95% CI 1.3-
13.5), an HIV-positive partner (OR 2.7, 95%CI 1.0-6.9 versus HIV-negative partner), or an
unknown serostatus partner (OR 4.6, 95%CI 1.1-18.3 versus HIV-negative partner), and men
who have sex with men partnerships (OR 3.0, 95%CI 1.2-7.3). Partnership covariates
explained 23% of the variance in unprotected intercourse, but other groups of covariates did
not significantly improve model fit. Significant interaction terms between reported partner
HIV status, partnership type and sexual orientation revealed the greatest likelihood of
unprotected intercourse in two groups of individuals: those in steady relationships with HIV-
positive partners and men who have sex with men in relationships with partners of unknown
serostatus. Prevention programming for people living with HIV should focus on partnership
characteristics. Editors’ note: There are a variety of terms used to refer to such
prevention programming, but a stronger message is conveyed about how best to design
and implement effective programmes if we use the expression ‘for and by’ people living
with HIV – it’s part of GIPA!
, and clinical effectiveness of influenza vaccines in
HIV-infected individuals: a meta-analysis.

Though influenza vaccines are the cornerstone of medical interventions aimed at protecting individuals against epidemic influenza, their effectiveness in HIV infected individuals is not certain. With the recent detection of influenza strains in countries with high HIV prevalence rates, Atashili and colleagues evaluated the current evidence on the efficacy and clinical effectiveness of influenza vaccines in HIV-infected individuals. The authors used electronic databases to identify studies assessing efficacy or effectiveness of influenza vaccines in HIV patients. They included studies that compared the incidence of culture- or serologically-confirmed influenza or clinical influenza-like illness in vaccinated to unvaccinated HIV infected individuals. Characteristics of study participants were independently abstracted and the risk difference (RD), the number needed to vaccinate to prevent one case of influenza (NNV), and the vaccine effectiveness (VE) computed. They identified six studies that assessed the incidence of influenza in vaccinated HIV-infected subjects. Four of these studies compared the incidence in vaccinated versus unvaccinated subjects. These involved a total of 646 HIV-infected subjects. In all the 4 studies, the incidence of influenza was lower in the vaccinated compared to unvaccinated subjects with RD ranging from -0.48 (95% CI -0.63 to -0.34) to -0.15 (95% CI -0.25 to 0.05); implying that 3 to 7 people would need to be vaccinated to prevent one case of influenza. Vaccine effectiveness ranged from 27% to 78%. A random effects model was used to obtain a summary RD of -0.27 (95%CI -0.42 to -0.11). There was no evidence of publication bias. The authors conclude that current evidence, though limited, suggests that influenza vaccines are moderately effective in reducing the incidence of influenza in HIV-infected individuals. With the threat of a global influenza
pandemic, there is an urgent need to evaluate the effectiveness of influenza vaccines in
trials with a larger number of representative HIV-infected persons. Editors’ note: Ensuring
that the sample size of people living with HIV within influenza vaccine trials will permit
conclusions to be drawn about vaccine effects will be a challenge if these are carried
out primarily in low HIV prevalence countries.

3. Sex work
S prevention among
female sex workers in Karnataka, India.
Halli and colleagues evaluated the role of female sex worker collectives in the state of
Karnataka, India, regarding their facilitating effect in increasing knowledge and promoting
change towards safer sexual behaviour. In 2002 a state-wide survey of Female sex workers
was administered to a stratified sample of 1,512 women. Following the survey, a
collectivization index was developed to measure the degree of involvement of female sex
workers in collective-related activities. The results indicate that a higher degree of
collectivisation was associated with increased knowledge and higher reported condom use.
Reported condom use was higher with commercial clients than with regular partners or
husbands among all women and a gradient was observed in most outcome variables between
women with low, medium and high collectivisation index scores. The authors conclude that
collectivisation seems to have a positive impact in increasing knowledge and in empowering
female sex workers in Karnataka to adopt safer sex practices, particularly with commercial
clients. While these results are encouraging, they may be confounded by social desirability,
selection and other biases. More longitudinal and qualitative studies are required to better
understand the nature of sex worker collectives and the benefits that they can provide.
4. Youth
. Young people: the centre of the HIV epidemic.
Roland and Mary assessed whether young people have access to the information, skills and
services required to reduce their vulnerability and whether there has been any reduction in
HIV prevalence among 15-24 year olds. The authors reviewed the data on knowledge,
behaviour, life skills, access to services and HIV prevalence among young people from
nationally representative household surveys, antenatal care surveillance reports, behavioural
surveillance surveys, a global coverage survey and other special studies. In countries where
HIV is concentrated among sex workers, injecting drug users, or men who have sex with men,
high-risk behaviour commences for most during adolescence, and large proportions of these
high-risk populations are younger than 25 years. In countries with generalised epidemics, the
epidemic is also driven by young people. Half of all new infections in sub-Saharan Africa
occur among this group. Many young people do not have the basic knowledge and skills to
prevent themselves from becoming infected with HIV. Young people continue to have
insufficient access to information, counselling, testing, condoms, harm-reduction strategies,
and treatment and care for sexually transmitted infections. Countries that have reported a
decline in HIV prevalence have recorded the biggest changes in behaviour and prevalence
among younger age groups. The authors conclude that the epidemic varies greatly in
different regions of the world, but in each of these epidemics young people are at the
centre, both in terms of new infections and being the greatest potential force for change if
they can be reached with the right programmes.
effectiveness of sex education and HIV education interventions
in schools in developing countries.
Kirbi and colleagues conducted a systematic review to assess the impact of sex education and
HIV education interventions in schools in developing countries on both risk behaviours for
HIV and the psychosocial factors that affect them. They identified studies in developing
countries that evaluated interventions using either experimental or strong quasi-
experimental designs and measured the impact of the intervention on sexual risk behaviours.
Each study was summarized and coded, and the results were tabulated by type of
intervention. Twenty two intervention evaluations met the inclusion criteria: 17 were based
on a curriculum and 5 were not, and 19 were implemented primarily by adults and 3 by peers.
These 22 interventions significantly improved 21 out of 55 sexual behaviours measured. Only
one of the interventions (a non-curriculum-based peer-led intervention) increased any
measure of reported sexual intercourse; 7 interventions delayed the reported onset of sex;
3 reduced the reported number of sexual partners; and 1 reduced the reported frequency of
sexual activity. Furthermore, 16 of the 22 interventions significantly delayed sex, reduced
the frequency of sex, decreased the number of sexual partners, increased the use of
condoms or contraceptives or reduced the incidence of unprotected sex. Of the 17
curriculum-based interventions, 13 had most of the characteristics believed to be important
according to research in developed and developing countries and were taught by adults. Of
these 13 studies, 11 significantly improved one or more reported sexual behaviours, and the
remaining 2 showed non-significant improvements in reported sexual behaviour. Among these
13 studies, interventions led by both teachers and other adults had strong evidence of
positive impact on reported behaviour. Of the 5 non-curriculum-based interventions, 2 of 4
adult-led and the 1 peer-led intervention improved one or more sexual behaviours. The
authors conclude that a large majority of school-based sex education and HIV education
interventions reduced reported risky sexual behaviours in developing countries. The
curriculum-based interventions having the characteristics of effective interventions in the
developed and developing world should be implemented more widely. All types of school-based
interventions need additional rigorous evaluation, and more rigorous evaluations of peer-led
and non-curriculum-based interventions are necessary before they can be widely
recommended. Editors’ note: This systematic review strongly supports curriculum-based
programmes for sex education and HIV education in schools in low- and middle-income
countries, accompanied by rigorous evaluation to inform ongoing programme

5. Gender
, dom purchasing: Effects of product
positioning on reactions to condoms.
006 Sep 6; [Epub ahead of print].

Correct and consistent condom use has been promoted as a method to prevent sexually
transmitted infections including HIV. Yet research has repeatedly shown that people fail to
use condoms consistently. One influence on the pervasive lack of condom use that has
received relatively little attention is the context in which consumers are exposed to condoms
(i.e., how condoms are displayed in retail settings). The authors present two studies which
explored variations in condom shelf placement and its effects on people's condom attitudes
and acquisition. Study 1 explored the shelf placement of condoms in 59 retail outlets in
Connecticut, USA and found that condoms were typically located in areas of high visibility
(e.g., next to the pharmacy counter) and on shelves adjacent to feminine hygiene and disease
treatment products. In Study 2,120 heterosexual undergraduate students at the University
of Connecticut were randomly assigned to evaluate condoms adjacent to sensual, positive,
neutral, or negative products and found that overall men reported more positive attitudes
and acquired more condoms when exposed to condoms in a sensual context compared to
women in the same condition. Among women, condom attitudes were more positive in the
context of neutral products; condom acquisition was strongest for women exposed to
condoms in the positive aisles (that is, shelves containing “positive” health products such as
vitamins, nutrition bars, and fitness or wellness magazines). The authors discuss the
implications of these studies for HIV prevention, public health, and condom marketing
strategies, and conclude that the results of this study suggest a gender-specific approach to
condom promotion. Editors’ note: For effective marketing of condoms to both women and
men in shops and pharmacies, a rapid assessment using key informants and focus groups
followed by close monitoring of sales to assess impact would be ideal. Failing that,
placing condoms in both high visibility and positive health product areas would likely
catch both retail markets.
.Understanding sex partner selection from the perspective
of inner-city black adolescents.
Black adolescents in inner-city settings in the United Sates are at increased risk for HIV
and other STDs. Sex partner characteristics, as well as individual behaviour, influence
individuals' STD risk, yet little is known about the process of sex partner selection for
adolescents in this setting. Andrinopoulos and colleagues conducted semistructured in-depth
interviews during the summer and fall of 2002 with 50 inner-city black adolescents (26
females and 24 males) who had been purposively recruited from an STD clinic in the eastern
region of Baltimore, Maryland. Content analysis was used to study interview texts. They
found that young women desire a monogamous romantic partner, rather than a casual sex
partner; however, to fulfil their desire for emotional intimacy, they often accept a
relationship with a non-monogamous partner. Young men seek both physical and emotional
benefits from being in a relationship; having a partner helps them to feel wanted, and they
gain social status among their peers when they have multiple partners. For men, these
benefits may help compensate for an inability to obtain jobs that would improve their
financial and, as a result, social status. Both young women and young men assess partners'
STD risk on the basis of appearance. The authors conclude that HIV and other STD
prevention initiatives must go beyond the scope of traditional messages aimed at behaviour
change and address the need for social support and socioeconomic opportunities among at-
risk, inner-city adolescents. Editors’ note: Seeking status through sexual partner choice
is age-old but now may carry the risk of HIV and STD in many settings around the
world in which young people have limited educational and economic opportunities. It is
widely accepted as part of the risk context for girls and young women but the fact that

boys and young men are similarly affected in low resource settings should not be

6. Universal access
AIDS treatment and prevention.
In this perspective article, Robert Steinbrook looked back on the Toronto AIDS
conference arguing that the growth of the pandemic continues to outpace the broad
and expanding efforts to control it. Since HAART became available a decade ago, the
treatment of HIV infection has been streamlined — for example, from 10 pills daily
taken in three doses with food restrictions to as little as 1 pill once a day. Many
presentations at the conference showed that treating HIV is feasible in all countries.
The best price for a first-line regimen of generic antiretroviral drugs in low-income
countries is now about US$130 a year for adults (down from US$285 in April 2004)
and less than US$200 a year for children. In 2005, there were an estimated 4.1
million people newly infected with HIV and 2.8 million AIDS-related deaths. The
author reviews resource needs and estimates of actual funding, coverage of specific
prevention programmes, and includes a chart which compares coverage of
antiretroviral treatment by country. Countries with less than 35% of those in need on
treatment include Trinidad and Tobago, Burkina Faso, Zambia, Chad, Benin, Cameroon,
South Africa, Kenya, Burundi, China, Malawi, and Ethiopia. He then summarises
biomedical approaches to prevention currently being evaluated, often in large
controlled trials. These include cervical barriers, such as the diaphragm; therapy to
suppress herpes simplex virus type 2, the primary cause of genital herpes (a risk
factor for acquiring and transmitting HIV); microbicides that could be applied to the
vagina or rectum; male circumcision; pre-exposure prophylaxis with antiretroviral
drugs; and expanded treatment of infected persons not only for their own health but
also to prevent HIV transmission. He then highlights the consensus view that
providing antiretroviral therapy to subjects who acquire HIV infection during the
course of a study is an indispensable part of the agreement between trial sponsors
and trial participants. He suggests that there is disagreement, however, about the
obligation to people whose infection is detected when they are screened for trial
eligibility, as well as about who should assume the long-term financial costs and
manage the complexity of treatment – trial sponsors, the country where the trial is
conducted, an international fund, or someone else. Although trial participants are
unlikely to need treatment until years after they become infected, they will
eventually need it for life. Editors’ note: UNAIDS is following up on the
recommendations of an international consultation on creating effective
partnerships for HIV prevention trials in 2005. The whole process, which
included three regional consultations, was initiated as a result of the suspension
of the tenofovir trials in Cambodia and Cameroon. We are planning three
meetings over the coming months to address three specific recommendations: to

develop Good Community Practice Guidelines which outline processes, procedures,
and minimum requirements for community engagement in HIV prevention
research; to identify programmatic and financing approaches for providing care
and treatment to people who develop intercurrent infections (or who are
screened out at recruitment for HIV prevention trials because they are found to
be HIV-positive); and to revise and update the 2000 UNAIDS guidance
document on ethical considerations in HIV preventive vaccine research (to be
expanded to apply to all HIV prevention trials).

That was HIV This Week, signing off.

Editors’ notes on journal access

For readers in all countries:
All abstracts in HIV This Week are freely available on the Web.
You can access a majority of scientific journals free of charge no matter where you are
located, but for some journals you do need a subscription to access the full text of an
article. Some journals are free to readers in all countries either through ScienceDirect or
through the journal’s own website.
For articles available through ScienceDirect, you should follow the link
to the ScienceDirect website. Then, type in the title of the
journal for which you are searching.
Some journals are open access, available to readers in all countries: American Medical
Association journals (ican Society of Clinical Oncology (2
journals), Australian Medical Association (1 journal), BioMed Central journals
), BMJ journals (), Canadian Medical Association (1 journal), Nature Publishing GroupPublic Library of Scien) and Science (1 journal). Other journals offer free access to full-text articles after a certain period of time (see
lists at High Wire Press and PubMed Central

For residents of low- and middle-income countries: the Health InterNetwork Access to
Research Initiative (HINARI)
HINARI, set up by the World Health Organisation (WHO) and major publishers, enables
readers in low- and middle-income countries to gain access to one of the world's largest
collections of biomedical and health literature. Over 3400 journal titles are now available to
health institutions in 113 countries, benefiting many thousands of health workers and
researchers, and in turn, contributing to improved world health. More information on the
HINARI programme and eligible countries is available at mail: .
Local, not-for-profit institutions in low- and middle- income countries may register for
access to the journals through HINARI. Institutions in countries with GNP per capita below
$1000 are eligible for free access. Institutions in countries with GNP per capita $1000-
$3000 pay a fee of $1000 per year/institution.
For employees of UNAIDS or WHO:
If you work for WHO or UNAIDS, you can access a number of journals by going to the WHO
library. You can also see the full list of journals you can access freely on the web (including
usernames and passwords) by going to the WHO Library website, accessible through the
home page of WHO inmation Resources. If you
work for UNAIDS, HIV This Week is also available on the intranet at the link

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