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Tracking the origin, early spread, and ignition of pandemic #HIV-1 through new approaches to phylogenetic analysis

17 Nov, 14 | by Leslie Goode, Blogmaster

“Distribution of HIV-1 subtypes in a population”, state Mumtaz & Raddad (STI) in a study of the HIV pandemic in the Middle East, “tracks the spread and evolution of the epidemic”.  Various studies covered in our previous blogs have attempted to read the history of the progress of the HIV epidemic through the evidence of the distribution of HIV genetic sub-types: Tatem & Salemi (STI/blogs) have investigated its spread throughout Africa; Zhao & Roca (STI/blogs) pass beyond the human epidemic to consider the genetic evidence for repeated transmission from chimpanzees to humans.

Now Faria & Lemey (F&L), in a paper recently appearing in Science, offer an account of the critical early phase of limited spread within Central Africa and the ignition of pandemic HIV-1 around 1960, bringing statistical approaches to bear to HIV-1 sequence data.  F&L produce a time-scaled phylogenetic “tree” of HIV-1 group M lineages, matching these up in each case with the geographical location of their earliest manifestation.

This approach points to the very strong likelihood (PP = 0.99) of an origin of the HIV1 epidemic in Kinshasa around 1920. Study of lineage migration shows comparatively early spread from Kinshasa to Brazzaville (Republic of Congo (RC)), and Mbuji-Mayi and Lubumbashi (southern Democratic Republic of Congo (DRC)) along the railway network, and its arrival around a decade later in Bwamanda and Kisangani (northern DRC).  The crucial period around 1960 (1952-1968) sees, for group M HIV-1, an exponential growth in levels of M-group transmission, while growth in group O transmission remains at previous levels.

But the most interesting aspect of the study relates to conditions around the sudden surge in group M HIV-1 transmission, as indicated by the accelerated ramification of viral lineages during the crucial period.  The authors consider the hypothesis that associates this ramification with the geographic dispersal of the epidemic, with the lineages emerging in the more widely distributed populations now being infected.  They reject this hypothesis, however, on the grounds that, when the epidemic history of lineages maintaining ancestry within Kinshasa is constructed, these turn out to exhibit phylo-genetic characteristics that are comparable to those of lineages in central Africa.

They conclude that the crucial explosion of pandemic HIV-1 transmission probably occurred in Kinshasa as a result of a historic contingency affecting a particular population subgroup.  Prime contenders are iatrogenic transmission as a result of the administration of unsterilized injections at STI clinics, and/or post-independence changes in sexual behaviour e.g. among commercial sex-workers.  The authors find support for the iatrogenic hypothesis in a study of the hepatitis C virus in the DRC which shows that it exhibits an age cohort effect, and in reports of an epidemic of hepatitis B in Kinshasa around 1951-2.

Failed PrEP trial (VOICE) participants give reasons for their poor adherence

13 Nov, 14 | by Leslie Goode, Blogmaster

Despite indications of the acceptability of Pre-Exposure Prophylaxis (PrEP) among certain populations (MSM in London (STI/Aghaizu & Nardone) 2013, and Australia (STI/Holt & De Wit) 2012), the extremely varied results that have emanated from large studies seeking to determine its efficacy and effectiveness as a preventative intervention remain a concern.  To name the most important examples, levels of risk-reduction were estimated as follows: CAPRISA 004 – 39%; iPrEX – 44%; CDC TDF2 – 62%; Partners-PrEP – 75%; FEM-PrEP – 0%; VOICE– 0%.  The reasons for this variation have been the topic of a number of contributions to this blog (especially: STI/blogs/Hendrix & Bumpus; STI/blogs/Haberer & Bangsberg), with consensus tending towards the poor adherence of study participants.

Last week in Cape Town results were briefly reported from a sub-study (VOICE D) of one of the less successful of these trials (VOICE). Microbicide Trials Network’s (MTN) VOICE study, discontinued in 2011, trialled daily tenofovir, in the form of vaginal gel or tablet, in 5,029 (mostly young) women from a representative range of sub-Saharan countries – S. Africa, Zimbabwe and Uganda. On the basis of self-reporting measures in the original VOICE trial, levels of adherence to the tenofovir regime had been estimated at 90%.  However, blood samples taken from participants found evidence of the drug in less of a third of the participants in the tablet arm, and less of a quarter of the participants in the gel arm, of the study.

After the closure of the VOICE study itself, the sub-study, VOICE D, engaged 127 former VOICE participants in in-depth interviews at which they were challenged with evidence of their poor adherence – with a view to stimulating frank discussion. When confronted with the evidence of blood tests, poor adherers initially expressed surprise and disbelief. Yet, according to the report, the aim of engaging frank discussion would seem to have been met.  The reason most frequently given was fear of the side effects of the drug, fuelled by peer participants and relatives and by the negative attitudes of community members.

Current trials of PrEP have re-evaluated and strengthened efforts to enhance adherence in the light of previous failures.  These include: the Follow-on African Consortium for Tenofovir Studies’ FACTS 001 (tenofovir gel before and after sex), the MTN’s ASPIRE and the International Microbial Partnership’s Ring Study (both the latter of vaginal ring releasing the ARV drug dapivirine) (MTN Trials). It is interesting that the Partners-PrEP study incorporated intensive “adherence interventions” for participants whose adherence levels fell below 80% (STI/blogs/Haberer & Bangsberg).

However, the VOICE D results may have implications for the usefulness of PrEP interventions more generally. At the very least, they discredit any idea that PrEP is able to offer a panacea. The value of PrEP, relative to other preventative interventions, is a contentious issue.  STI/Mukandavire & Vickerman (2013), for example, conclude that a scale-up of condom use is in most circumstances likely to be more effective than PrEP, but that PrEP could have a specific application in the case of female sex workers. STI/Verguet & Walsh (2012) see a future for PrEP in sub-Saharan countries with high HIV prevalence and without circumcision practice, such as S. Africa.  STI/Ying & Barnabas (2013) see targeted PrEP as a cost-effective addition to ARV.

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“Hispanic” label masks the specificity of the Puerto Rican #HIV problem in US Northeast

12 Nov, 14 | by Leslie Goode, Blogmaster

Interventions for HIV prevention should be informed by an understanding of the long-term source of infection, and not just by recent distribution (Mishra & Boily (STIs)).  Amongst recent studies that have sought to inform future interventions are investigations of known subgroups thought to be a potential bridge into the wider population – such as migrant workers, or sex workers (STI/Kissinger & Shedlin; STI/Faisel & Cleland).  There are other investigations that seek to refine on the definition of such groups (STIs/Davies & Tucker; STIs/Bayer & Coates).  But could there be instances where classifications established for the purposes of data collection actually mask the existence of the groups that could have epidemiological importance?

Puerto Ricans in the north-east of the US may be an interesting case in point.  A recent article (Deren & Santiago-Negron(D&S)) claims that the classification “Hispanic”, generally applied to Puerto Ricans for the purpose of data collection, may have obfuscated the distinctiveness of a Puerto Rican subgroup with its own specific risk profile, and considerable unmet medical health needs.   As though to illustrate the point, D&S assemble various data relating to strong correlations, for example: between AIDS diagnosis and being Hispanic; between residence in the North East of the US and IDU-associated HIV; between HIV incidence and being a Hispanic IDU.  Cumulatively – and taken along with the concentration of Puerto Ricans in the NE, and what is known of the high incidence of IDU-associated HIV in Puerto Rico itself – these data indicate the probability of a strong association, at least for the US North Eastern states, between Puerto Rican Hispanic identity and a high risk of drug-derived or heterosexually-transmitted HIV.  Furthermore, it is not only the subgroup of US Porto Ricans that have tended to slip under the net, according to D & J; high levels of IDU-transmitted HIV in the island of Puerto Rico itself have failed to attract due attention, on account of the peculiar status of Puerto Rico – which is a US territory, without being a US state.  As a result, Puerto Rico tends to figure neither in statistics for the Caribbean (as a US territory), nor in statistics for the US (since it is not a US state).

For Puerto Ricans – with an AIDS fatality at six times the US average and rates of new IDU and heterosexual infection twice that of the US – the problems of their anomalous status do not end with inadequate reporting.   Budgets for syringe exchange programs (SEPs) are only a fifth of what they are in the US Northeast, while Puerto Rican IDUs are only a fifth as likely to be in treatment.  SEP schemes cannot be funded by the US federal government, while the local Puerto Rican response to the drugs problem has, until recently, been largely provided through faith-based programs, with addiction defined by the Mental Health Law (2000) as a spiritual and social problem rather than a mental disorder.  Relocation to the US Northeast for drug treatment has become a commonly recommended option, with 85% of Puerto Rican admission to drug treatment taking place in the US Northeast.

In view of all this, D&S recommend partnership between federal, local and private entities to develop a cross-regional approach to the Puerto-Rican epidemic.  They also point out the challenges posed for such an approach by the unique status of Puerto Rico as a territory, without the full representation available to states in the Northeast.

“Fast-tracking” the end of the HIV epidemic

8 Oct, 14 | by Leslie Goode, Blogmaster

At a high-level event on the margin of the UN General Assembly meeting in New York last month, convened with the support of UNAIDS, world leaders agreed that ending the AIDS epidemic as a global threat by 2030 was possible, and should be placed at the centre of health development goals.  The brochure, Fast Track (7 pages), sets out the agreed proposals.  The context of the agreement is the General Assembly’s discussion of 17 Sustainable Development Goals for 2015-2030 to replace the Millenium Development Goals that are due to expire in 2015 – and, more specifically, the formulation of targets to accompany the Sustainable Development Goal for health: “To ensure health lives and promote well-being for all at all ages”.  The week before the UN General Assembly saw the early online publication of a paper by 16 international experts (Norheim & Peto)  proposing as a “feasible goal” the overall reduction of pre-mature deaths by 40% – including, as an important element, a reduction by two-thirds of deaths due to HIV.

The proposals contained in Fast Track are in line with the most radical response scenario set out in pp.291-3 of the UNAIDS GAP report (July 2014), involving reduction of new adult infections to 500,000 by 2020, and 200,000 by 2030.  Also reminiscent of the earlier document is the sense of the tide of the epidemic having turned, and of its increasing concentration within the cities of 30 or so nations – and, more specifically, within fairly specific populations of those cities, such as sex workers, intravenous drug-users, etc..  This concentration represents both a challenge and an opportunity (STI/blogs/UNAIDS GAP report).  The new element in Fast Track is a three-fold target of 90%: for the proportion of those infected should know their HIV status, the proportion of those knowing their HIV status who receive anti-retroviral therapy, and the proportion of those on therapy who achieve undetectable levels of viral load – all by 2030.  A glance back at the GAP report itself reveals what a challenge this is likely to be (e.g. at present, 3 in 5 of HIV infected not receiving ART).

Also timed to coincide with the proposals (25th September) was the announcement of a scheme to expand access to viral load testing through an agreement affecting the pharmaceutical Roche’s COBAS® AmpliPrep/COBAS TaqMan HIV-1 Test version 2.0 (see STI/Hatzakis & Kantzanou).  Access to viral load testing is essential to monitoring of HIV-infected people (STI/Hill & Minton), and its high cost has been an obstacle to progress in low and middle income companies up until now.  The new agreement may smooth the way to the achievement of the ambitious targets set out in Fast Track.

Population-based evidence for the preventative efficacy of quadrivalent HPV in Australia

30 Sep, 14 | by Leslie Goode, Blogmaster

The HPV vaccination programmes introduced by many countries over the last few years (since 2007) reveal considerable diversity in the coverage they have achieved, the mode of access (i.e. school, public health, private clinics) and responsibility for cost (i.e. publically vv. privately funded) – even in Europe (see ECDC Guidance).  In the light of the known efficacy of the vaccine, implementation has seemed frustratingly slow – partly, in some cases, due to ungrounded negative public perceptions around safety (e.g. in Japan where the national programme was actually suspended) and the impact on sexual mores (e.g. in the US).  Early indicators of its positive health impacts in countries like Australia – where implementation was early (2007) and wholehearted – are therefore to be welcomed, as favouring the implementation of programmes in the future.  In the absence of evidence of the reduction of cervical and other cancers, evidence of the effectiveness of the quadrivalent vaccine against warts – from clinics (STI/Donovan & Fairley; STI/Garland & Jayasinghe; STI/Fairley & Bradshaw), or pharmacists (STI/Wilson & Baker) – or evidence for the reduction of cervical abnormalities (STI/blogs/Brogly & Yang) – may offer a proxy.

Smith & Canfell (S&C), recently published in Journal of Infectious Diseases, claim to provide the first whole population analysis of the impact on genital warts of a national HPV vaccination programme – and this may be the best predictor of the longer-term, and more important, cancer prevention benefits to be seen in future years.  It is no surprise it derives from Australia, the first (2007) country to introduce routine school-based vaccination of 12-13 yr girls, plus catch-up through to 2009 for girls 13-17 yrs in schools, and young women 18-26 yrs in primary care. Earlier studies in Australia largely relied on data from sexual health clinics; this study is based on national data of all hospital episodes 1999-2011 involving a diagnosis of genital warts.

The findings of S&C show a decline of 89.9% in admissions involving warts from 2006/7 to 2010/11 for girls aged 12-17 yrs, a decline of 72.7% for women aged 18-26, and a decline of 38% for men aged 18-14 (the indirect effect of female vaccination).  The decline of cases in the 18-28 age group occurs from mid-2008. Other age groups do not show the same sharp decline, nor do MSM – to judge from the fact that the decline exclusively concerns warts in non-anal location.

An issue of particular concern to Australia, and one that consequently receives considerable attention in this study, is the impact on the indigenous population, where incidence and mortality rates for cervical cancer are, respectively, 2.8 and 4.7 times higher for the indigenous as for the non-indigenous population.  Reductions for indigenous and non-indigenous females appear to be similar (86.7% and 76.1% respectively) – which is curious, given that data for two Australian states indicate lower rates of course completion (3 doses) by indigenous females.  If the same tendency in uptake were replicated in the other Australian states (which we don’t know) this might suggest the efficacy of ≤2 dose courses of therapy.  Such a result would corroborate the findings of a recent study covered in this blog (STI/blogs/”Catch up” and incomplete HPV vaccination), which investigates the efficacy of ≤2 dose courses of therapy also in the context of socially disadvantaged groups.

 

Missed HPV vaccination opportunities: a consequence of avoiding awkward conversations

15 Sep, 14 | by Leslie Goode, Blogmaster

In the US, routine administration of quadrivalent HPV vaccine is recommended for girls and boys at 11-12 yrs, with catch-up vaccination recommended up to 26 yrs for girls, and 21 yrs for boys.  The difficulty has been in the implementation of the recommendation: overall rates of initiating and completion among US teenage girls currently stand at 57% and 35% respectively, according to data from NIS-Teen (CDC/MMWR 25.7.14).  This is of particular of concern, since there is evidence both from the US and from the UK that those most at risk (e.g. ethnic minorities) happen also to be those who are most likely to miss out on vaccination (STI/Niccola & Hadler; STI/Sacks & Robinson; STI/Liddon & Hadler). What is the reason for this poor uptake?  NIS-Teen, on the basis of recent survey evidence, claim that the lack of strong provider recommendation may often lead to missed vaccination opportunities (STI/blogs/”catch-up”).  (Kepka & Seraya (STIs) discuss the difficulty of ensuring the conformity of providers with HPV guidelines).  Yet, how, in practice, do these missed vaccination opportunities occur between well intentioned parents and providers who wish to protect adolescents from developing cancer as adults?

A recent qualitative study (Perkins & Pierre-Joseph), based on interviews with 124 parents/guardians and 37 providers in one large public clinic and three smaller private ones, offers an illuminating insight into the conversational moves characterizing the kind of real-life discussions between provider and parent that lead to missed opportunities – most often through the decision to delay the initiation of HPV vaccination.  The report analyzes these in considerable detail.  Typically, however, it is a question of a “complicity” between the conversational partners in respect to broaching the topic of the daughter’s sexual behaviour, taking the form of a tacit agreement to postpone the discussion about vaccination until a more appropriate time.  The script generally runs: “My doctor asked me if I thought if she was sexually active and I said no and then she said that there was plenty of time”.

The authors’ recommendations, based on the strategy of providers achieving rates of ≥ 80%, are: co-adminstration with tetanus and meningococcal vaccine, focussing on cancer prevention benefits and vaccine safety, and expressing a strong recommendation (i.e. “expecting a yes”) – in short, routinizing and normalizing HPV vaccination.

Not the least interesting aspect of their findings was the very considerably greater success of the ethnically diverse public clinic as against the majority white private clinics in initiating vaccination (77% vv. 54%, according to the electronic medical record).  More can be less, it would seem, when it comes to certain public health interventions.

 

“Catch-up” and incomplete HPV vaccination better than nothing

26 Aug, 14 | by Leslie Goode, Blogmaster

Quadrivalent HPV vaccine (HPV4) has been shown to protect against HPV types 16 & 18, which cause 70% of cervical cancers, and HPV types 6 & 11, which cause 90% of genital warts.  Health authorities in the US and elsewhere have therefore recommended routine vaccination of girls (and more recently boys) at ages 11 & 12, and “catch-up” vaccination for women aged 13 to 26. Vaccination programmes in New Zealand (STIs/Read & Fairley) and Australia (STIs/Fairley and Bradshaw) have indicated what can be achieved, given adequate coverage.

For the US and elsewhere there remains a problem of ensuring coverage.  Recent figures from the US Centers for Disease Control and Prevention National Immunization Survey-Teen (NIS-Teen) for 13-17 year-olds ≥1 dose quadrivalent or bivalent vaccine, CDC/MMWR 25.7.14, show levels that remain obstinately low despite year on year improvement, rising from 53.8% to 57.3% (girls), and from 20.8% to 34.6% (boys) between 2012 and 2013.  By comparison, UK uptake on the first 3 years of its programme was 66% (STIs/Sacks & Robinson).  The low US rate is of particular concern because there is considerable evidence from the US and UK that it is often those who are most at risk, such as racial and ethnic minorities, who are most likely to miss out on vaccination (STIs/Niccola & Hadler; STIs/Sacks & Robinson; STIs/Liddon & Hadler).  Tantalizingly, the Report estimates at 91.3% the coverage for ≥1 dose by age 13, if HPV vaccine had been administered to adolescent girls born in 2000 during health care visits when they received another vaccine.

This, of course, raises the question why this opportunity is being missed.  The authors cite the disquieting datum that, when NIS-Teen asked parents to identify reasons for non-vaccination, one third of parents of girls and over half of parents of boys reported that their child’s clinician had not recommended  that their child receive an HPV vaccination.  They therefore point to the need to address gaps in clinician knowledge and communication skills as well as parental knowledge.  A discussion of apparent difficulty of ensuring the conformity of providers to HPV guidelines has already been discussed by STIs/Kepka & Seraya.

 

Given poor levels of uptake at age 11-12, especially among some of the needier populations, it becomes important to know the effectiveness of catch-up vaccination and incomplete vaccination.  This is made very evident in a recent US cross-sectional study, Brogly & Shi Yang (B&Y), of the relation of cervical abnormalities to HPV vaccination status amongst 235 minority women undergoing routine cervical cytology testing.  Only 54% of these had initiated, and only 33% completed, vaccination – and of those vaccinated, only 3% had received the vaccination before sexual debut.  Their results appear to show that even a tardy, and frequently incomplete, HPV vaccination confers significant benefits on individual women.  Abnormalities (ASCUS, LSIL or HSIL) proved to be considerably reduced amongst the vaccinated group, even where participants had not completed the full course of three injections – RR 0.35 for ≥1 dose as against no vaccination; RR 0.45 for 1-2 doses as against no vaccination; RR 0.26 for completed vaccine as against no vaccination.  If corroborated in further studies, these findings could reinforce argument in favour of the effectiveness of HPV catch-up against those have placed this in doubt (STs/Chesson & Markowitz).

The study also aimed to examine the relationship between vaccination status and HPV genotype, but the sample size was too small to establish anything very conclusive.  STIs/Nielsen & Kjaer claim to demonstrate, with a far larger Danish sample, that low-risk types are frequent in ASCUS lesions, but scarcely ever occur in isolation from high-risk HPV types, where the lesions are more severe.

UNAIDS Gap Report: “The beginning of the end of the AIDS epidemic

20 Aug, 14 | by Leslie Goode, Blogmaster

In advance of the 20th International AIDS Conference in Melbourne 20th-24th July, UNAIDS has published its Report entitled The Gap.  This offers a panoramic survey of progress and challenges to date, graphically presented.

The general sense of a tide having at last turned in the global battle against HIV is borne out by the Report’s account of the increased concentration of the epidemic on certain key fronts where the struggle will henceforth need to be carried on.  Overall, it points to a global decline – and a swiftly accelerating decline – in HIV incidence and AIDS related mortality globally.  New infections have fallen 38% from 2001, 13% over the last three years; mortality has declined 35% since 2005, 19% over the last three years.  The Middle East and North Africa (see STIs/blog;  STIs/Saba & Abu-Raddad; Abu-Raddad & Riedner), and Eastern Europe and Russia constitute the sole exceptions to this pattern (with increases in mortality of 66%, and 5% respectively).

The “flip-side” is an increasingly visible concentration of the epidemic.  Fifteen countries (with Nigeria and S. Africa generally topping the list) account for 75% of the global HIV burden, 76% of last year’s (2013) new infections, and 74% of last year’s AIDS-related mortality.  In view of this, it is no surprise that the major part of the Gap report consists in a series of profiles: first, of the principal world regions, and second key populations (prisoners, transgender etc.).  These recurrently pose the question: “Why am I being left behind?”

Three aspects of the situation as described by the report strike this reader as particularly telling:

–          the proportion of those living with HIV who are still not accessing ART: three in every five.  In Nigeria 80% have no access to treatment.

–          the vulnerability of adult women in sub-Saharan Africa, who alone account for 80% of the 16 million women aged 15 yrs and older who live with HIV.

–          the appallingly low proportion of children living with HIV who receive ART: a mere 24%.

Does risk compensation behaviour neutralize the benefits of voluntary medical male circumcision?

18 Aug, 14 | by Leslie Goode, Blogmaster

The effectiveness and feasibility of voluntary medical male circumcision (VMMC) as a preventative intervention against HIV has been demonstrated in a variety of non-circumcising African communities.  The WHO has designated 14 countries in southern and eastern Africa as priority areas for VMMC scale-up.  Attempts to model the progress of the epidemic have long sought to factor in the potential contribution of VMMC (STIs/Hallett & Abu-Raddad).  However, the possibility of risk-compensation remains an ongoing concern (i.e. that the known preventative effects of VMMC will lead to increased sexual risk-taking).  Current evidence has been largely limited to behavioural evaluations and extended follow-up in populations where RCTs of VMMC were being conducted (e.g. Rakai, Uganda; Orange Farm, South Africa; Kisumu, Kenya).  The evidence has been reassuring, by and large.  Yet it is also inconclusive – for two reasons: first, on account of the rigorous risk reduction counselling invariably provided by these trials, which is far in excess of what would be offered in operational settings; second, due to the lack of certainty as to the preventative effectiveness of VMMC that prevailed at the time when these RCTs were being conducted.  These are precisely the issues that bedevil studies seeking to evaluate risk compensation in the context of pre-exposure prophylaxis (PrEP): see STIs/blog/Marcus & Grant; STIs/blogs/Mugwanya & Baeten.

A recent prospective, longitudinal study conducted in Nyanza Province, Kenya (Westercamp & Bailey) claims to mark an important step forward towards understanding the relation between VMMC and sexual risk-taking in everyday operational settings.  Participants in the study were not exposed to unrealistic levels of risk reduction counselling, and the preventative efficacy of VMMC had already been well established prior to commencement of the study.  Participants were followed up, at six monthly intervals over a two year period, having assigned themselves either to a circumcision (1,5888) or a control (1,599) group, using (as far as possible) audio computer-assisted self-interview questionnaires to investigate sexual behaviour.

The result?  No risk-compensation, apparently.  In fact, the findings show an increase of 30%/6% in condom use at last sex (for the circumcised/control group), and a broadly comparable decline for both groups across a range of indicators, including transactional sex in the last six months (26-12%), most recent sex with a casual partner (20-12%), and having multiple partners in the last six months (26-16%).  The only adverse finding was an increase in sexual activity for both groups among the younger participants – but this seems to be largely explained by transition to married status.

The decline might be due to some limited exposure to HIV education through participation, or reflect “cognitive dissonance” – i.e. the re-evaluation of behaviours in the light of the personal investment involved in getting circumcised.  But there is evidence it might be part and parcel of a decrease in sexual risk-taking in the community at large due to the implementation of the VMMC programme over the period of the study 2008-2011.  A curious finding was the greatly reduced perception of high HIV risk among the “cross-over group” of those 20% of the control group who subsequently chose to be circumcised, as against the perceptions of those who initially assigned themselves to the circumcision group.  This, according to the authors, suggests that men motivated to early adoption of VMMC may represent a higher risk group.  When this finding is taken together with recent evidence of high (90%) acceptance of VTC services among men undergoing circumcision, the case stacks up for ensuring the provision of high-quality counselling as a priority throughout the commencement and rapid initial sale up of VMMC services.

Should bisexuals be considered a population with specific sexual health needs?

28 Jul, 14 | by Leslie Goode, Blogmaster

Across many cultural contexts, men who have sex with both men and women (MSMW) have levels of STIs/HIV comparable to those we find in men who have sex only with men (MSM); but MSMW have often proved particularly hard for health services to access.  Mercer & Cassell (M&C) (UK) and STIs/Beyrer & Baral (B&B) (South Africa) refer to poor rates of HIV testing as compared to MSM (RR 0.31 and 0.62 respectively). Both studies stress the need to find ways of targeting safe-sex messages for MSMW who do not identify as gay.

In an intriguingly entitled reivew of the literature on MSMW sexual health in the US 2008-2013 (“Beyond the bisexual bridge”)  Jeffries  corroborates this general picture of high STI risk and poor accessibility.  But he seeks to get beyond what he considers an obsession on the part of researchers with the role of MSMW as a “bridging” population with women.  He claims this “characterization” is not justified by the research – at least where the US is concerned (Chu & Curran; Satcher & Dean; Kahn & Catania).  He also views it as ultimately detrimental to the sexual health of MSMW, which needs to be founded on the “recognition of MSMW’s unique sexual and social experiences”.

The article reviews both the sexual health, and socio-cultural challenges to MSMW’s health.  Sexual health challenges include: levels of STIs other than HIV equalling and exceeding MSM levels, alongside levels of HIV lower than MSM, yet higher than MSW (as in the UK (see M&C)); also enormously higher levels of injection drug use, sex in exchange for money or drugs, and drug and alcohol use during sex than in MSM; also sex within female networks (as well as male) that imperil sexual health, with a high proportion of female partners having injected drugs, being under influence of drugs during sex, and having concurrent partners.  Socio-cultural challenges include biphobia in society at large, and fairly extreme socio-economic marginalization, as indicated by lack of education, poverty, homelessness and incarceration.

Some corroboration of the role that Jeffries attributes to settled identities in moderating at risk behaviour is provided by the success of a number of ongoing initiatives aimed at black or Latino MSMW.  These all appear to address MSMW’s masculinity concerns and heterosexual identities in a non-judgmental and culturally sensitive manner.  Men of African American Legacy Empowering Self (MAALES) has been evaluated in a RCT discussed in an earlier blog (STI/blog/Are bisexuals well served by interventions that assume gay identity?).  Jeffries also mentions: Hombres Sanos; the Bruthas Project; the Enhanced Sexual health Intervention for Men (ES-HIM).

A puzzle remains in the lower susceptibility of MSMW, as against MSM, to HIV – alongside equivalent or higher susceptibility to other STIs .  Jeffries discusses this, but offers no explanation.  Could the less than expected levels of HIV in MSMW be the result of an association between MSM identity and sexual networks that carry particular risk of HIV transmission?

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