12 AUGUST 2011, VOLUME 12, ISSUE 32

AIDS is on the rise in many Muslim countries, driven by men having sex with other men in secret because of homophobia, religious intolerance and fear of being jailed or executed, according to a new study. The new report, released last week in the journal PLoS Medicine, was led by researchers from the Qatar branch of Weill Cornell Medical College who drew from dozens of smaller studies in Arabic, French and English. About 2 to 3 percent of men in the region have sex with other men, consistent with global averages, the study found. But condom use is low, gay and bisexual prostitution is common, and many married men hide their bisexuality and risk infecting their wives. In some countries, even male prostitutes often marry for appearances' sake. Truck drivers, prisoners and street children often have high rates of H.I.V. infection; in Pakistan, infection rates are rising rapidly among transgender prostitutes known as hijra. The lowest rates of condom use were reported in populous countries like Egypt and Pakistan, while they were highest in Sudan (above), Oman and Lebanon. To fight their nascent epidemics, some countries have adopted compulsory H.I.V. testing for marriage licenses and work visas. Because of religious taboos, accurate statistics on some aspects of health are hard to get from Middle Eastern governments. For example, international health authorities say that the world's highest rates of birth defects are in Muslim countries where cousins are encouraged to marry but that governments are reluctant to admit it.

Scientific research trials have theoretically proven that medical male circumcision can protect men from HIV infection by up to 60%. Now a study of a community of men who, over the last three years, have taken up medical circumcision, has shown the practical benefits of the intervention over a sustained period of time. The Bophelo Pele Medical Male Circumcision Centre in Orange Farm, run by the Centre for HIV and AIDS Prevention (CHAPS), is the first to run a public sector service offering medical male circumcision following research showing its benefits. Since its formation three years ago, the centre has been circumcising about 1,000 men between ages 15 and 49 per month on average. The review of the service shows that the intervention has dramatically reduced HIV acquisition among men in the Orange Farm area, south of Johannesburg.

"We found that the risk of them getting HIV after circumcision remains reduced in that about 76% of those people that we've circumcised, who were HIV-negative in 2007, still are HIV-negative today", says Dr Ntlotleng Mabena, Operations Manager for CHAPS. To arrive at the conclusion the study took into consideration factors including the risky sexual behaviour that the men still take. "We were actually trying to see if our counselling intervention also has an effect in terms of people reducing their risky behaviour. What the study found, unfortunately, is that men in this community are still not using condoms as optimally as they are supposed to use... People will use condoms with their not-so-frequent partners, but won't use condoms when they sleep with their frequent partners", Dr Mabena says. But this is a worrying trend which remains difficult to understand. "We put in a lot of effort in counselling people about risky behaviour and use of condoms. So, it's quite worrying to find that all these efforts are not really translated into actions by people who get this thorough counselling. There are a lot of arguments. We can speculate in trying to identify why people don't use condoms. But, ultimately, we really don't know what the reason is behind that", she says. Asked if some men think that because they are now circumcised that they are actually protected and, thus, using condoms is not really a priority, Dr Mabena said: "One big argument before the whole rollout of circumcision was that circumcision might encourage men to have indiscriminate sex without considering condoms and all those things. They may translate the message of reduction of HIV as a complete protection. What we found in this study is that there has not been a change in behaviour in terms of men engaging in risky sex. We compared a group of uncircumcised men to circumcised men. Both of them behaved the same. The circumcised men do not assume that the circumcision protects them better or completely. The behaviour is more or less the same".

Having said that, Dr Mabena is on a mission to encourage as many men as possible to circumcise. The Orange Farm Medical Male Circumcision Centre is a model on which the national Health Department has based the rollout of medical male circumcision across the nine provinces. "When an opportunity presents itself to action in order to reduce the risk of HIV infections, all responsible people should grab such opportunities with both hands", according to MEC for Health and Social Development in Gauteng province. MEC Mekgwe has set a massive target for medical male circumcision. She says by the end of 2012, about 125 000 men will have been circumcised in Gauteng. "(It's) because you can see the zeal, the will, but also the way our communities are responding to this particular issue. We have committed to bring the service closer to where people live", she says. But Mekgwe was also quick to state that the Abstain, Be faithful and Condomise message remains relevant as ever. She said being circumcised is not a license to have irresponsible sexual behaviour or too have multiple sexual partners.

Only six sub-Saharan African countries have failed to reduce the number of women dying in childbirth over the last two decades. High-spending South Africa is among them, with maternal mortality rates more than quadrupling since 1990. Human Rights Watch researcher Agnes Odhiambo says this is largely due to a lack of accountability. Maternal mortality rates in sub-Saharan Africa as a whole have been reduced by a quarter compared to 1990 levels. But the continent's most developed economy is moving in the opposite direction: South Africa's maternal mortality rate in 1990 was 150 per 100,000 live births; in its 2010 MDG progress report, the country reported this had risen to 625 per 100,000. "HIV is a big factor in maternal mortality in South Africa," says Odhiambo, adding that improved reporting means deaths that might have gone unrecorded in the past have also been added to the total. "But even with all that, the kind of negligence that is happening in our facilities... from what women were saying, substandard care is a big problem and that is an issue that we truly have to think about." ...

"Our health systems are challenged," says Marion Stevens, a midwife and member of Women in Sexual and Reproductive Rights and Health. She says the main factor in maternal deaths is HIV/AIDS, but argues that the national health department's focus on the pandemic is poorly executed. "Accountability is an important issue, because it asks the question why. With all the resources that are being spent on AIDS, why are we not looking also at women's health, and in particular at maternal mortality as a related issue?" The focus on AIDS, she says, has come at the cost of considering a continuum of health care. For example, women are told not to go for antenatal care until they are 20 weeks' pregnant because clinics are overwhelmed by other demands. "So for women who are ill when they're pregnant, if they want to get well, or if they are HIV-positive, or if they want to choose to have an abortion, then they essentially come in very very late, and that's problematic." Stevens says the health department has designed a powerful new strategy for sexual and reproductive health rights which provides for greater accountability and integrating issues of HIV and AIDS into a holistic view of women's health, but since it was completed in May, the document has been sitting on someone's desk...

Long seen as the ugly step-child of HIV prevention, the female condom seems to be gaining popularity through grassroots campaigns, according to a new report by the UN Population Fund (UNFPA). "For the fourth consecutive year, access to female condoms has increased dramatically, reaching a record number of 50 million... in 2009," the report states... The organization credits successful partnerships between governments and technical agencies for helping to increase access to female condoms. In 2005, UNFPA launched the Female Condom Initiative in 24 countries to ensure that female condom programming was integral to national AIDS policies and reproductive health programmes. "In a number of countries, governments... are applying highly creative approaches to educating the public about condoms and to overcoming the stigma and taboos sometimes associated with them," the report's authors said. "In the process, they are discovering that the female condom is a tool for women's empowerment, enabling women and adolescent girls to take the initiative to protect their own and their partners' health."...

Although not recommended for anal sex by the UN World Health Organization, some health authorities have opted to market it for use by MSM. In a 2002 US study, men reported more frequent problems with female condoms than male latex condoms, particularly slippage, discomfort and rectal bleeding; the authors recommended more research on the safety of female condoms for anal sex. Despite these gains, the female condom still lags behind the male condom in popularity; according to UNFPA... In Kenya, female condoms are part of the country's broader HIV and family planning programmes, but women have shown little interest. The country recently received three million female condoms from UNFPA and distributed them. "We do not have reliable data on acceptability but we know that among sex workers there is a high demand," said Peter Cherutich, head of HIV prevention at the National AIDS and Sexually transmitted infections Control Programme. "Overall, the demand is low mainly due to general unavailability and [lack of] information. "It is still more expensive [than the male condom] and we are yet to be confident that it is as widely popular as the male condom," he added. "Except for female sex workers and highly empowered women, most other women do not have the capacity to demand safe sex... the majority of women depend on their sexual partners to protect them."

The UNFPA report noted that female condoms can cost as much as US$1 each while male condoms are often distributed free of charge. In pharmacies in Nairobi, a pack of three male condoms costs from about $0.20 to just over $1. "In 2009, only one female condom was available for every 36 women worldwide," the report states... Conversations with other Nairobians reveal that ignorance about the female condom is still widespread... NASCOP's Cherutich said the Kenyan government would need to market the female condom in new ways to increase use. "We have not placed the female condom as a family planning tool, which if we had, would make FC less stigmatizing since family planning is now an accepted concept within family settings," he said.

...[Nine] countries, as well as the European Union, already forbid or restrict invasive research on great apes. Americans have to decide if the benefits to humans of research using chimpanzees outweigh the ethical, financial and scientific costs. The evidence is mounting that they do not. For one thing, many new techniques are cheaper, faster and more effective, including computer modeling and the testing of very small doses on human volunteers. In vitro methods now grow human cells and tissues for human biomedical studies, bypassing the need for whole animals. Such advances have led to a drop in primate research. Many federally owned chimpanzees were bred to support AIDS research, but later proved inferior to more modern technologies. As a result, most of the 500 federally owned chimpanzees are idling in warehouses. Ending chimpanzee research and retiring the animals to sanctuaries would save taxpayers about $30 million a year. We also know more about the consequences of invasive research on the animals themselves... Stories like these, as well as my understanding of the state of biomedical research, persuaded me to sponsor the Great Ape Protection and Cost Savings Act with Senator Maria Cantwell, Democrat of Washington. The bill would phase out invasive research on great apes and retire the 500 federally owned chimpanzees from laboratories to sanctuaries...

For nearly 20 years, New York City failed to require sex education in all public schools. Individual schools decided whether students were provided vital programs that could help them avoid disease and teenage pregnancy. This school year that patchwork system will finally change, replaced by a new sex education requirement for all students in public middle and high school. In middle schools, preteenage students will be taught about puberty, sexuality, the benefits of abstinence, teenage pregnancy and issues like sexual stereotyping. In high school, those lessons will be offered with more depth and detail, with an emphasis on preventing pregnancy and diseases, including H.I.V./AIDS. High school students can already get free condoms from school health resource rooms, but now teachers will be required to explain how to use them. The sex education push is part of an initiative by Mayor Michael Bloomberg to address the needs of young black and Latino men in the city. Dennis Walcott, the schools chancellor, said on Wednesday that new statistics helped to convince him and other officials that better sex education classes were necessary, especially in minority neighborhoods. Teenage pregnancy rates in those areas are far higher than in other parts of the city. And more than half of new H.I.V. cases in the city are in black and Hispanic men, Mr. Walcott said. Black and Hispanic youths have more sexual partners and are more susceptible to sexually transmitted diseases. Parents will have the option to refuse to allow their children to attend classes on birth control. But school officials should make certain that most of the new curriculum is available to all students. Some youngsters are having sex at age 11. To protect their health and futures, as Mr. Walcott said, "we cannot stick our heads in the sand."

In light of promising emerging data from recent studies indicating that a vaccine regimen under investigation for HIV may be more protective than expected, the National Institutes of Health is shifting the main goal of its own study of the vaccine to determining whether the vaccine prevents HIV infection and is expanding enrollment. Previously, the main goal of the study was to determine whether the vaccine decreased the amount of virus in the blood of vaccine recipients who later became infected with HIV, whereas prevention of the disease was a secondary goal. The study, conducted by the HIV Vaccine Trials Network (HVTN) and called HVTN 505, started at 12 US cities in June 2009 and is the largest ongoing HIV vaccine study in the world. As of July 5, 2011, more than 1173 volunteers were enrolled, and in response to the evidence, the National Institute of Allergy and Infectious Diseases (NIAID), which funds the HVTN, is expanding the study's enrollment from 1350 to 2200. The larger enrollment will allow scientists to determine whether the vaccine regimen is at least 50% effective at preventing HIV acquisition during the 18 months after immunization. Participants in the phase 2b placebo-controlled trial include 18- to 50-year-old circumcised men and transgender women who have sex with men and are HIV negative. Each participant will be monitored for 5 years. The vaccine consists of a 2-part regimen consisting of 1 recombinant DNA-based vaccine, delivered in a series of 3 immunizations during 8 weeks to prime the immune system, followed by a single recombinant vaccine at 24 weeks as a booster vaccine. The booster vaccine contains a weakened adenovirus type 5 to carry the vaccine contents and stimulate the immune system, according to the NIAID. In a press statement, the NIAID said studies that prompted the expansion of the HVTN 505 study included a major HIV vaccine trial in Thailand that involved 16,000 volunteers that showed for the first time, in 2009, that a vaccine can generate modest protection against HIV infection in humans...

While medical professionals and advocacy groups have begun to promote the research and development of pre-exposure prophylaxis (PrEP) as a method of HIV prevention for gay men, the AIDS Healthcare Foundation (AHF) has created a stir with its nationwide media campaign bent on stopping federal approval of PrEP. The campaign's primary target is the drug Truvada - manufactured by Gilead Sciences (a California-based company that creates antiretroviral drugs used for treatment of HIV-positive patients)... [AHF President Michael] Weinstein and other members of the campaign often invoke the 44 percent efficacy results of last year's iPrEx study (which enrolled 2,499 participants to test Truvada's ability to prevent seroconversion in at-risk, HIV-negative gay men), as well as low adherence rates and thoughts that no clinical PrEP research will translate into real world success for sexually active gay men... Some HIV researchers do not agree with the campaign, including Dr. Roy Gulick (the principal investigator for an upcoming PrEP study that will include the drugs Truvada and maraviroc) - who believes the organization misunderstands the nature of scientific research and, referring to the AHF, has stated that "the FDA is capable or judging the pros and cons of a drug without their help."...

HIV-positive civil servants in Malawi are unhappy with the government's announcement that it would stop providing a cash grant to help improve their diet. In June, the government said the scheme would be stopped and replaced with food packages. According to Mary Shawa, principal secretary in the office of the President and Cabinet responsible for HIV/AIDS and nutrition programmes, the cash grant programme "was grossly abused, with hundreds of workers claiming to have HIV in order to cash in on the payment". Shawa said most civil servants were not using the money for its intended purpose to buy extra food and improve nutrition: "Some people used the money to buy beers and go out with prostitutes, further spreading the virus." The cash grant was part of the civil service workplace programme aimed at improving nutrition among people living with HIV, most of whom receive a monthly salary of less than US$100.

Aston Chirwa, an office assistant in one of the government departments in the commercial capital Blantyre, told IRIN/PlusNews that the $35 monthly allowance had been a lifeline for him and his family, as his meagre income was barely enough to pay his daughter's high school fees. "The allowance was really making a big difference to my survival." Chirwa is among nearly 40,000 civil servants with HIV, out of about 170,000, who have been receiving the allowance since 2007. "The money was not only meant to buy food, I would use it for transportation to Chiradzulu District hospital where I receive ARVs," he added. AIDS activists have questioned the government's decision to introduce the food hamper, which is equivalent to the previous monthly allowance...

The FDA has approved a second once-daily tablet for HIV -- this one combining three medications: emtricitabine, rilpivirine, and tenofovir. The pill, manufactured by Gilead Sciences, combines that company's Truvada -- itself a combination of the two nucleoside reverse transcriptase inhibitors emtricitabine and tenofovir -- with rilpivirine (Edurant), a recently approved non-nucleoside reverse transcriptase inhibitor made by Tibotec Pharmaceuticals. The new pill will be called Complera... The first once-daily HIV pill, a combination of efavirenz, emtricitabine, and tenofovir (Atripla), was approved by the FDA in July 2006. Atripla is marketed by Gilead and Bristol-Myers Squibb. Complera's approval is based on data from two phase III trials, ECHO and THRIVE, which compared the safety and efficacy of rilpivirine with efavirenz. The studies included a background drug regimen, and most patients in the rilpivirine arms were also taking Truvada. A bioequivalence study conducted by Gilead demonstrated that the co-formulated single-tablet regimen achieved the same levels of medication in the blood as emtricitabine plus rilpivirine plus tenofovir, the company said, noting that Complera does not cure HIV-1 infection or help prevent the transmission of HIV to others. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogs, including tenofovir, one of Complera's ingredients, in combination with other antiretrovirals, the company noted... The most common side effects from rilpivirine included insomnia and headache; the most common adverse events with emtricitabine and tenofovir were diarrhea, nausea, fatigue, headache, dizziness, depression, insomnia, abnormal dreams, and rash.

AIDS advocates and researchers reacted with concern to CDC's Wednesday report on new HIV infections in the United States during 2006-09. While incidence overall plateaued, averaging 50,000 infections for each of the years, it increased among young men who have sex with men, particularly among young black/African-American MSM, who had a 48 percent increase in new infections. In the 1980s, HIV incidence peaked at 130,000 infections annually. "It means I don't see an AIDS policy, and I don't see anyone in charge," said Larry Kramer, veteran AIDS activist and playwright. "It's so dispiriting that it's hard to find something to say about it. How many times can you yell 'Help!' without ever getting anywhere?" The incidence data are "a great concern," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. But he and the director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Dr. Kevin Fenton, took issue with Kramer's interpretation. "The CDC is absolutely not resting," Fenton said. "It was a major accomplishment to drop infections from 130,000 to 50,000, and we're dealing with an epidemic that is dynamic." Incidence is at an "unacceptably high level," he said. However, given the growing number of people with HIV/AIDS, if current prevention efforts are not intensified, "we're likely to face an era of rising infections," Fenton said. Fauci and Fenton also pointed to new test-and-treat strategies to diagnose and treat HIV infections earlier, and thus to improve outcomes and drive down transmission rates. In a study, early treatment initiation made people with HIV at least 96 percent less likely to infect their heterosexual partners. Philip Alcabes, a public health epidemiologist at Hunter College in Manhattan, said, "It's not clear that prevention is a failure. The average adult's chances of encountering HIV infection - 0.02 percent a year - are rather low. It's not reasonable to expect that a sexually transmitted virus will disappear in America, or anywhere else. But I agree with Larry Kramer that there has been a dearth of new policy ideas."

In releasing new HIV incidence data on Wednesday, CDC stated that the "alarming increase among young black gay and bisexual men requires urgent action." The statistics show that blacks represent just 14 percent of the US population but accounted for 44 percent of new HIV infections in 2009. Among young black men who have sex with men, new HIV infections rose by 48 percent from 2006 to 2009. "That is an outrage," said Phill Wilson, president and CEO of the Black AIDS Institute. "That number is completely unacceptable. Especially now when the prevention toolbox is literally exploding with new options." The release of the data came one year after the publication of the Obama administration's National HIV/AIDS Strategy. "We now have the tools that could dramatically drive down new infections," Wilson said. "We have a roadmap to victory. We understand that people must be tested and know their status. We understand that linking 'poz' people to care right away saves lives. And we know that providing antiretrovirals to healthy people can also save lives. "They're calling this 'alarming,' but it's clearly past that point," Wilson said. "Our house is on fire." Jonathan Mermin, MD, director of CDC's Division of HIV/AIDS Prevention, said, "We are deeply concerned by the alarming rise in new HIV infections in young, black gay and bisexual men and the continued impact of HIV among young gay and bisexual men of all races. We cannot allow the health of a new generation of gay men to be lost to a preventable disease. "It's time to renew the focus on HIV among gay men and confront the homophobia and stigma that all too often accompany this disease," Mermin said.

The National Health Service could save millions of pounds if it switched from using the Cervarix human papillomavirus vaccine to Gardasil, suggests a new study by the Health Protection Agency (HPA). NHS in 2008 launched its HPV vaccine program for schoolgirls, opting to use UK-based GlaxoSmithKline's Cervarix. At the time, many sexual health doctors were perplexed. While both Cervarix and US-based Merck & Co.'s Gardasil protect against the same two HPV strains that cause most cervical cancer cases, Gardasil additionally targets two other HPV types linked to most genital wart cases. The government refused to reveal the price Glaxo offered for Cervarix during the contracting process. However, to be as cost-effective as Gardasil, Cervarix would have to be £13-21 (US $21-$34) less per dose, determined an HPA study published in 2008. The new HPA study estimates that genital warts cost NHS about 17 million pounds (US $27.7 million) a year. In 2008, about 149,000 cases were seen in general practice surgeries, sexual health clinics and hospitals. The average cost to NHS per genital wart case was 113 pounds (US $184). Genital warts "exert a considerable impact on health services, a large proportion of which could be prevented" by using Gardasil, wrote HPA's Dr. Kate Solden and colleagues. One year after Gardasil's 2007 introduction in Australia, genital wart diagnoses declined 25 percent among young women, they noted. The government's three-year contract for Cervarix is coming up for renewal, so the new study could stimulate further debate over the vaccines' relative advantages.

As funding for HIV programs has declined, speculation of a merger between Stop AIDS Project and San Francisco AIDS Foundation has heated up. The boards of directors are seriously considering a combination, with an agreement possibly as early as this month, according to Bay Area Reporter sources. SFAF and Stop AIDS officials contacted by BAR neither confirmed nor denied a pending merger. Stop AIDS is "looking at a number of options," including merging with another agency, Executive Director Kyreill Noon said in March. Since then, the agency's finances have stabilized, though several staff members had to be laid off and a satellite office on Sanchez St. near Market closed. "We are still in conversation about it," Noon said of an SFAF/Stop AIDS merger agreement. "The talks haven't stopped; that is all I should say right now." The agencies have already teamed up to provide services to black men who have sex with men under a new contract for a program beginning this fall. The lead agency is SFAF. SFAF is also the lead agency for two pending city contracts: one to distribute clean needles to injection drug users and a second to provide HIV testing to MSM, transgendered persons and IDUs. "All I can say is just that we collaborate with a lot of community partners regularly and engage in merger discussions with other agencies in the community," said Ryan McKeel, SFAF spokesperson. "Stop AIDS is one of those agencies we have held merger talks with." In 2007, SFAF absorbed both Magnet, the MSM health clinic in the Castro, and Stonewall Project, which provided harm reduction services to transgender people and MSM.

A new government study has found that more than half of workers in Swaziland's garment industry are living with HIV, and officials are realizing that the once-hailed promise of manufacturing employment has become a financial and medical nightmare for tens of thousands of Swazi women... About 30,000 Swazis, mostly women, are employed in garment factories financed by Taiwanese investors and operated by managers from mainland China. The survey also found that most factory workers were well informed about HIV/AIDS, and 90 percent of workers interviewed were aware of the female condom and other methods of preventing HIV. Government officials will now begin investigating the gap between knowledge of HIV/AIDS prevention and workers' susceptibility to HIV. The prevalence rate for textile industry employees is significantly higher than the 26 percent rate among sexually active adult Swazis. "Women comprise the largest number of workers at the garment industry plants. They work long hours at wages so low some of them are known to turn to prostitution to support themselves and their families," said Alicia Simelane, an HIV testing and counselling officer at the Matsapha Industrial Estate, where Swaziland's industry is concentrated outside the commercial hub of Manzini.

The link between "sweatshop" wages and the risk of HIV has been known for years, but the statistical impact of the risk is only becoming apparent now. The garment factories began renting government-built factory shells in the late 1990s and early 2000s to take advantage of Swaziland's trade agreement with the United States, which under the African Growth and Opportunities Act (AGOA) allows textile goods made in the country to enter the US without import taxes. According to the US Department of Commerce, the value of Swaziland's AGOA exports increased nearly threefold, from US$65 million in 2001 to a peak of $199 million in 2005. Now the country's fortunes have declined: by 2007 Swaziland's AGOA exports were only $141 million, and by 2009 had almost halved to $101 million. A strengthening of the local currency - the Lilangeni, which is pegged to the South African rand - combined with the global economic slowdown, resulted in a steep decline in orders. Factories, some of which were built at government expense and rented at very low cost to encourage businesses to set up in the country, have closed. Matsapha-based garment factories contacted by IRIN/PlusNews would not comment on the record, but indicated that they complied with health and safety standards. "The activity that causes AIDS is not done at the workplace. We are not responsible for the private lives of our employees," said the manager of one firm.

Although initiatives are under way in the UK to diagnose HIV infection early, late presentation is still a major issue and often results in serious health complications for the individual and has implications for society, including high costs and increased rates of transmission. Intervention strategies in the UK have aimed at increasing testing opportunities but still a significant proportion of those with HIV infection either decline testing or continue to test late. The main objective of this study is to identify ideas and themes as to why testing was not carried out earlier in men who have sex with men (MSM) who presented with late HIV infection. Semi-structured interviews were carried out with MSM presenting late with a CD4 cell count of <200. A structured framework approach was used to analyse the data collected and generate ideas as to why they did not seek testing earlier. Seventeen MSM were interviewed and four main themes were identified: psychological barriers, including fear of illness and dying, stigma surrounding testing for HIV and in living with a positive diagnosis, perceived low risk for contracting HIV despite participants reporting having a good understanding of HIV and its transmission and strong views that a more active approach by healthcare services, including general practice, is necessary if the uptake of HIV testing is to increase. Late presentation with HIV infection continues to be a problem in the UK despite government initiatives to expand opportunities for testing. Recurring themes for late testing were a low perceived risk for HIV infection and a fear of HIV and a positive diagnosis. Population-targeted health promotion alongside a more proactive approach by healthcare professionals and making HIV testing more convenient and accessible may result in earlier testing.

Abstract
Objective: Receptive anal intercourse in both men and women is associated with the highest probability for sexual acquisition of HIV infection. As part of a strategy to develop an effective rectal microbicide we performed an ex vivo preclinical evaluation to determine the efficacy and limit of multiple combinations of reverse transcriptase inhibitors.

Design: A nucleotide, PMPA (tenofovir), and a nucleoside, FTC (emtricitabine), reverse transcriptase inhibitors, and two non-nucleoside reverse transcriptase inhibitors: UC781 and TMC120 (dapivirine), were used in double, triple and quadruple combinations against a panel of CCR5- and CXCR4-using clade B HIV-1 isolates and against reverse transcriptase inhibitor-escape variants.

Methods: Indicator cells and colorectal tissue explants were used to assess antiviral activity of drug combinations.

Results: All combinations inhibited the isolates tested in a cellular model and in colorectal explants, and produced, for at least one of the compounds, a change in the dose response curve. Double and triple combinations incrementally augmented activity, even against RTI escape mutants, whereas quadruple combinations conferred little further advantage.

Conclusions: The colorectal explant model may be used to identify the best candidate molecules and their combinations at the preclinical stage. Furthermore, this study demonstrates that combinations based on RTIs with different HIV-1 inhibitory mechanisms have potential as colorectal microbicides.

"Kaposi's sarcoma-associated herpesvirus (KSHV) is the etiological agent of Kaposi's sarcoma (KS), the most common cancer in individuals with untreated HIV/AIDS. Host control of KSHV infection and KS oncogenesis by CD8 T cells remains underexplored," investigators in London, United Kingdom report. "Although KSHV CD8 epitopes have been identified, the responses they elicit are weak and little is known about their relative importance. We sought to make a direct comparison of the recognition of a selection of the best-described known epitopes by a cohort of KSHV-seropositive, HIV-co-infected individuals, in order to assess the relative dominance of these epitopes. We further sought to identify novel epitopes from within a candidate immunogenic protein encoded by KSHV ORF28. MHC binding and denaturation assays identified putative novel A*0201-restricted epitopes from within the late-lytic glycoprotein ORF28. Recognition of these candidate epitopes was tested in a cohort of KSHV-seropositive, HIV-1-seropositive, A*0201-positive individuals by ex vivo ELISPOT, and compared with recognition of nine previously described epitopes. One novel late-lytic epitope from ORF28 was recognized by 7.1% of individuals, and was used for further investigation of KSHV-specific T cells using multimer technology. One known late-lytic epitope from the glycoprotein-encoding K8.1 was recognized by 71.4% of individuals, and represented an immunodominant KSHV epitope, but was too hydrophobic for multimer synthesis," wrote R.C. Robey and colleagues, University of London.

Abstract
Background: The Centers for Disease Control and Prevention recommended an "opt-out" human immunodeficiency virus (HIV) testing strategy in 2006 for all persons aged 13 to 64 years at healthcare settings. We conducted this study to identify individual, health, and policy factors that may be associated with HIV testing in US adults.

Methods: The 2008 Behavioral Risk Factors Surveillance System data were utilized. Individuals' residency states were classified into 4 categories based on the legislation status to HIV testing laws in 2007 and HIV/acquired immune deficiency syndrome morbidity. A multivariate logistic regression adjusting for survey designs was performed to examine factors associated with HIV testing.

Results: A total of 281,826 adults aged 18 to 64 years answered HIV testing questions in 2008. The proportions of US adults who had ever been tested for HIV increased from 35.9% in 2006 to 39.9% in 2008. HIV testing varied across the individual's characteristics including sociodemographics, access to regular health care, and risk for HIV infection. Compared with residents of "high morbidity-opt out" states, those living in "high morbidity-opt in" states with legislative restrictions for HIV testing had a slightly lower odds of being tested for HIV (adjusted odds ratio=0.96; 95% confidence interval=0.92, 1.01). Adults living in "low morbidity" states were significantly less likely to be tested for HIV, regardless of legislative status.

Conclusions: To implement routine HIV testing in the general population, the role of public health resources should be emphasized and legislative barriers should be further reduced. Strategies need to be developed to reach people who do not have regular access to health care.

Abstract
Background: Herpes simplex virus type 2 (HSV-2) is an important cause of genital ulcers and can increase the risk for human immunodeficiency virus type 1 (HIV-1) transmission. Our objective was to determine the incidence and correlates of HSV-2 infection in HIV-1-seronegative Kenyan men reporting high-risk sexual behavior, compared with high-risk HIV-1-seronegative women in the same community.

Methods: Cohort participants were screened for prevalent HIV-1 infection. HIV-1-uninfected participants had regularly scheduled follow-up visits, with HIV counseling and testing and collection of demographic and behavioral data. Archived blood samples were tested for HSV-2.

Results: HSV-2 prevalence was 22.0% in men and 50.8% in women (P < 0.001). HSV-2 incidence in men was 9.0 per 100 person-years, and was associated with incident HIV-1 infection (adjusted incidence rate ratio [aIRR], 3.9; 95% confidence interval [CI], 1.3-12.4). Use of soap for genital washing was protective (aIRR, 0.3; 95% CI, 0.1-0.8). Receptive anal intercourse had a borderline association with HSV-2 acquisition in men (aIRR, 2.0; 95% CI, 1.0-4.1; P = 0.057), and weakened the association with incident HIV-1. Among women, HSV-2 incidence was 22.1 per 100 person-years (P < 0.001 compared with incidence in men), and was associated with incident HIV-1 infection (aIRR, 8.9; 95% CI, 3.6-21.8) and vaginal washing with soap (aIRR, 1.9; 95% CI, 1.0-3.4).

Conclusions: HSV-2 incidence in these men and women is among the highest reported, and is associated with HIV-1 acquisition. Although vaginal washing with soap may increase HSV-2 risk in women, genital hygiene may be protective in men.

Abstract
Background and Method: Multiple studies reported a fast-spreading human immunodeficiency virus (HIV) epidemic among men who have sex with men (MSM) in China. This study aimed to estimate the magnitude and time trends of HIV prevalence among MSM in different geographical regions of China through a systemic review and meta-analysis.

Results: A total of 94 articles were identified (25 in English and 69 in Chinese) and analyzed. National HIV prevalence among Chinese MSM has increased over this period, from 1.4% (95% confidence interval [CI]: 0.8%-2.4%) in 2001 to 5.3% (95% CI: 4.8%-5.8%) in 2009. MSM in Southwest China have the highest HIV prevalence, of 11.4% (95% CI: 9.6%-13.5%) in comparison with other regions, which range 3.5% to 4.8%.

Conclusions: Significant increases in HIV prevalence among MSM were consistently observed across all Chinese regions. There is an urgent need for implementation of effective public health interventions to curb the spread of HIV infection among MSM across China, especially in the Southwest.

Abstract
Background: Episodic acyclovir therapy has been added to genital ulcer disease (GUD) syndromic management guidelines in several sub-Saharan African countries with human immunodeficiency virus (HIV) epidemics. We examined the correlates of health care seeking in men with GUD and its relationship to HIV-1 and herpes simplex virus type 2 outcomes.

Methods: Men with GUD (n = 615) were recruited from primary health care clinics in Gauteng province, South Africa for a randomized controlled trial of episodic acyclovir therapy. We used baseline survey and sexually transmitted infection/HIV-testing data to examine delay in health care seeking (defined as time from ulcer recognition to baseline study visit).

Results: Median delay in health care seeking for GUD was 5 days, and one-quarter of men had previously sought care for the current ulcer. Previous care seekers were older, had more episodes of ulceration in the past year, and were more likely to test seropositive for HIV-1 and HSV-2. Delay in health care seeking was significantly associated with age, education level, and sex during the ulceration episode. Delays in care seeking were related to poorer HIV-1 outcomes; these findings were valid after controlling for advanced HIV.

Conclusions: Interventions to help shorten the duration between ulcer recognition and health care seeking for men with GUD are needed.

Abstract
Background: Genital herpes (GH) is widespread, and detrimental to patients' quality of life. It is not always adequately treated, however, with potential consequences for patients' well-being and healthcare costs. Involving patients in treatment decisions can increase their satisfaction and adherence. We investigated patients' preferences for different GH treatments.

Methods: A discrete choice experiment was administered to 154 subjects with GH. Subjects chose between different treatment options: episodic, suppressive, or no treatment, described according to: chance of GH recurrence; chance of transmitting the GH virus to a partner; chance of becoming infected with HIV; number of tablets to be taken every day and during an outbreak; and out-of-pocket cost. Subjects' willingness to pay and probability of treatment uptake were estimated.

Results: Subjects preferred antiviral treatment to no treatment, and subjects receiving suppressive treatment preferred this treatment to no treatment. Effect of treatment on GH recurrence and HIV infection rates was a significant influence on subject's choice, as were the number of tablets taken daily and during an outbreak and out-of pocket treatment cost. Subjects were willing to pay between $15.50 and $73.41 for treatment. Subjects' willingness to pay depends on the type of treatment and their current treatment.

Conclusions: Subjects' preferences are influenced by both the treatment they follow and attributes of treatment including cost. Knowledge of patients' preferences, together with their clinical status, could help decision-makers to optimize therapy uptake and success.

Abstract
Background: Human immunodeficiency virus (HIV)/sexually transmitted disease (STD)-related interventions rely on self-reported risk behavioral data, which are biased toward social desirability. It is warranted to develop methods for data triangulation.

Methods: Some questions on HIV/STD-related behaviors that were asked in 5 face-to-face (FTF) surveys were repeated at the end of the surveys, using the newly developed bean method (BM), which requested participants to transfer a bean of a particular color from a large jar to a smaller one, depending on whether the answer was affirmative (yellow, white, green, or red) or not (black); both jars contained 500 mixed-up colored beans. At the end of each day, the number of beans for each color was counted and was compared with the results of the FTF interviews. Participants were ensured that the researchers would not trace their responses.

Results: Among female sex workers who were noninjecting drug users, the BM as compared with the FTF interviews, reported higher prevalence of inconsistent condom use in the last 6 months, unprotected sex with the last client, and STD in the last 6 months. Among men who have sex with men in Hong Kong, the BM as compared to the FTF interviews, reported higher prevalence of unprotected sex with another man and having >3 sex partners in the last 12 months. No statistically significant between-method differences were reported among injecting drug users.

Conclusions: Results of HIV/STD-related behaviors are dependent on mode of data collection. The simple BM can be used regularly to triangulate self-reported HIV-related behavioral data obtained from FTF interviews.

Abstract
Objectives: To examine methamphetamine use and its association with sexual behavior among young men who have sex with men.

Design: Cross-sectional observational analysis.

Setting: Eight US cities.

Participants: As part of the Adolescent Trials Network for HIV/AIDS Interventions, adolescent boys and young men who have sex with men, aged 12 to 24 years, were recruited from social venues (eg, clubs, parks, and street corners) between January 3, 2005, and August 21, 2006, to complete a study survey.

Main Outcome Measures: Reported methamphetamine use in the past 90 days and reported sexual risk behavior compared with individuals reporting no hard drug use and individuals reporting hard drug use in the past 90 days.

Results: Among 595 adolescent boys and young men, 64 reported recent methamphetamine use, and 444 reported no recent hard drug use (87 reported use of hard drugs other than methamphetamine). Recent methamphetamine use was associated with a history of sexually transmitted diseases (51.6%), 2 or more sex partners in the past 90 days (85.7%), sex with an injection drug user (51.6%), and sex with someone who has human immunodeficiency virus (32.8%) compared with individuals reporting no recent hard drug use (21.1%, 63.1%, 10.7%, and 11.1%, respectively; P < .05 for all [n = 441]). Recent users of methamphetamine were more likely to have a history of homelessness (71.9%) and were less likely to be currently attending school (35.9%) compared with individuals reporting no recent hard drug use (28.4% and 60.4%, respectively; P < .001 for both).

Conclusions: Adolescent boys and young men who have sex with men and use methamphetamine seem to be at high risk for human immunodeficiency virus. Prevention programs among this age group should address issues like housing, polydrug use, and educational needs.

Population sequencing was performed for persons identified with persistent low-level viremia in 2 clinical trials. Persistent low-level viremia (defined as plasma HIV-1 RNA level >50 and <1000 copies/mL in at least 2 determinations over a 24-week period, after at least 24 weeks of antiretroviral therapy) was observed in 65 (5.6%) of 1158 patients at risk. New resistance mutations were detected during persistent low-level viremia in 37% of the 54 evaluable cases. The most common mutations were M184I/V (14 cases), K103N (9), and M230L (3). Detection of new mutations was associated with higher HIV-1 RNA levels during persistent low-level viremia.

In what represents an important step toward curing HIV, a USC scientist has created a virus that hunts down HIV-infected cells. Dr. Pin Wang's lentiviral vector latches onto HIV-infected cells, flagging them with what is called "suicide gene therapy" -- allowing drugs to later target and destroy them. "If you deplete all of the HIV-infected cells, you can at least partially solve the problem," said Wang, chemical engineering professor with the USC Viterbi School of Engineering. The process is analogous to the military practice of "buddy lasing" -- that is, having a soldier on the ground illuminate a target with a laser to guide a precision bombing strike from an aircraft. Like a precision bombing raid, the lentiviral vector approach to targeting HIV has the advantage of avoiding collateral damage, keeping cells that are not infected by HIV out of harm's way. Such accuracy has not been achieved by using drugs alone, Wang said. So far, the lentiviral vector has only been tested in culture dishes and has resulted in the destruction of about 35 percent of existing HIV cells. While that may not sound like a large percentage, if this treatment were to be used in humans, it would likely be repeated several times to maximize effectiveness. Among the next steps will be to test the procedure in mice. While this is an important breakthrough, it is not yet a cure, Wang said. "This is an early stage of research, but certainly it is one of the options in that direction," he said. Wang's research, which was funded by the National Institutes of Health, appears in the July 23 issue of Virus Research.

Journal Reference:
Lee C-L, Dang J, Joo K-I, Wang P. Engineered lentiviral vectors pseudotyped with a CD4 receptor and a fusogenic protein can target cells expressing HIV-1 envelope proteins. Virus Research, 2011

Special Issue on Innate Immunity. Edited by William A. Paxton and Teunis B.H. Geijtenbeek

Innate immune factors associated with HIV-1 transmission
Pollakis G; Stax MJ; Paxton WA

Innate signaling in HIV-1 infection of dendritic cells
van der Vlist M; van der Aar AMG; Gringhuis SI; Geijtenbeek TBH

Innate immunity in acute HIV-1 infection
Borrow P

Natural killer cells, dendritic cells, and the alarming high-mobility group box 1 protein: a dangerous trio in HIV-1 infection?
Gougeon ML; Bras M

HIV-1 infection and induction of interferon alpha in plasmacytoid dendritic cells
Benlahrech A; Patterson S

Myeloid dendritic cells in HIV-1 infection
Derby N; Martinelli E; Robbiani M

Macrophages and HIV-1
Cobos-Jimenez V; Booiman T; Hamann J; Kootstra NA

A look at HIV journey: from dendritic cells to infection spread in CD4+ T cells
Blanchet F; Moris A; Mitchell JP; Piguet V

Induction of innate immunity in control of mucosal transmission of HIV
Wang Y; Lehner T

Dendritic cells at the interface of innate and adaptive immunity to HIV-1
Smed-Sorensen A; Lore K

Generalized immune activation and innate immune responses in simian immunodeficiency virus infection
Bosinger SE; Sodora DL; Silvestri G

Emerging role for complement in HIV infection
Huber G; Banki Z; Lengauer S; Stoiber H

Host genetic polymorphisms associated with innate immune factors and HIV-1
Sobieszczyk ME; Lingappa JR; McElrath MJ

Targeting HIV-1 innate immune responses therapeutically
Ellegard R; Shankar EM; Larsson M

Effective sexually transmitted infection (STIs)/HIV prevention programs are urgently needed, but translating evidence-based methods of STI/HIV prevention into sustainable programs has been difficult. Social influences are critical for establishing condom use norms. This study systematically reviewed social network-based interventions focused on condom promotion. Social networks were defined as groups who self-identified prior to the research study. Eleven eligible research studies were identified and included in this review. Only three studies measured biological endpoints and five studies used validated measures of condom use. Among the nine studies with control groups, eight showed significant improvements in at least one measure of condom use. There were large differences in how social network members were identified and involved in the interventions. This systematic review highlights the potential utility of social network-based condom promotion programs. More research is needed to show how these promising studies can be expanded.

Abstract
Background: HIV prevention programs targeting youth often emphasize the role of peers, and assume that youths will model their behavior after their peers'. We challenge this view; we argue that adopting a given behavior requires social approval, and that youths do not necessarily turn to peers for such approval. This study analyzes survey data on youths in urban Cameroon to 1) identify which type of persons youths look to for social approval, and 2) establish how important social approval by these persons is for condom use among youths.

Methods: HIV prevention programs targeting youth often emphasize the role of peers, and assume that youths will model their behavior after their peers'. We challenge this view; we argue that adopting a given behavior requires social approval, and that youths do not necessarily turn to peers for such approval. This study analyzes survey data on youths in urban Cameroon to 1) identify which type of persons youths look to for social approval, and 2) establish how important social approval by these persons is for condom use among youths.

Results: The data show that only 3% of youths named their friends as people whose opinion they valued, while 93% mentioned family members. The perceived approval of condom use by these persons had a significant positive effect on the frequency of condom use among youths. The frequency of condom use was also affected by the respondents' attitudes toward condom use, the range of persons with whom they discussed reproductive health matters, whether they were enrolled in school, socioeconomic status, their self-efficacy, perceived severity of AIDS, risk perception and sexual risk behavior. The perceived social approval of condom use and the respondents' own condom attitudes were correlated.

Conclusions: Our analysis demonstrates that perceived social approval facilitates the adoption of condom use among urban Cameroonian youth. However, youths tend to value the opinions of family members much more than the opinions of their peers. These results suggest that interventions targeting youths should not focus exclusively on peers but should also include other groups, such as parents and community leaders.

HIV vaccine development has been slow and difficult. Although a priority from the moment HIV was discovered to be the cause of AIDS in 1986, only three products have completed efficacy testing in a series of five clinical efficacy trials. Of these, only one, RV 144, the Thai efficacy trial of a canarypox prime and envelope subunit boost, demonstrated modest efficacy to protect against infection. However, that result was transforming and spurred fundamental changes in the HIV vaccine development field. The last three efficacy trials have yielded entirely unexpected results and emphasize the critical importance of human clinical trials. The notion that a vaccine could protect from HIV infection had been questioned and we still do not know what is needed to afford protective immunity. However, advances in nonhuman primate models, neutralizing antibody design and an appreciation for the urgent need to conduct more clinical efficacy trials to evaluate conceptually distinct products has brought new hope and vigor to the vaccine development enterprise.

There are strongly held divergent opinions among people working in the HIV vaccine field regarding the relative merits of stimulating different arms of the immune system with an HIV vaccine, and there have been rapid shifts in this paradigm as the results of the first human vaccine trials have unfolded over the last decade. The first two human efficacy HIV vaccine trials, Vax003 and Vax004, tested gp120 Env protein vaccines with the hope that they would elicit protective neutralizing antibodies (NAbs). Neither vaccine conferred protection from infection. Since this inauspicious beginning, our collective mood swings have been chronicled by the astute observer of HIV research and researchers, Jon Cohen. The failure of the first antibody-based vaccines led to a heightened interest in vaccines that elicited T-cell responses. The next efficacy trial was the STEP trial, designed to test T-cell responses using adenovirus 5 (Ad5) vectors to express HIV Gag, Pol and Nef. The hope for this vaccine was not that it would prevent infection, but that it might improve the control of HIV upon infection, and slow disease progression. Initial optimism gave way to 'devastation' when we learned that the vaccine-induced T cells failed to help control the virus in newly infected vaccinees; this was compounded by the concern that pre-existing Ad5 immunity may have enhanced infection rates. Meanwhile, the RV144 vaccine trial in Thailand was underway, using an ALVAC vector prime, protein-boost combination. The widely held skepticism regarding this approach gave way to a collective 'Wow' when a modest but statistically significant protection from infection was observed. The immune responses targeted in failed trials should not be tarnished by association, nor viewed as conceptual failures. Rather, they should serve as benchmarks; we must do better in terms of breadth and potency of the responses. RV144, with its promising protective effect, provides the first opportunity to define correlates of protective immunity, but still the vaccine effect was marginal. Thus a more critical goal than repeating RV144 is improving upon it, and RV144 also serves as a benchmark.