Biomedical HIV Prevention Technologies

IntroductionA vaginal ring containing dapivirine is effective for HIV prevention as pre‐exposure prophylaxis (PrEP). We evaluated the potential epidemiological impact and cost‐effectiveness of dapivirine vaginal ring PrEP among 22‐ to 45‐year‐old women in KwaZulu‐Natal, South Africa.MethodsUsing mathematical modelling, we studied dapivirine vaginal ring PrEP implementation, either unprioritized, or prioritized based on HIV incidence (≥3% per year), age (22 to 29 years) or female sex worker status, alongside the implementation of voluntary medical male circumcision and antiretroviral therapy scaled‐up to UNAIDS Fast‐Track targets. Outcomes over the intervention (2019 to 2030) and lifetime horizons included cumulative HIV infections, life‐years lived, costs and cost‐effectiveness. We assessed the incremental cost‐effectiveness ratios against the revealed willingness to pay ($500) and the standard (2017 per capita gross domestic product; $6161) cost‐effectiveness thresholds for South A...

Background: Adolescent sexual risky behaviours continue to be significant drivers of the HIV epidemic globally. The objective of this study was to determine factors associated with prior engagement in high-risk sexual behaviours among adolescents (10-19 years) in Karamoja sub-region, a pastoralist and post-conflict community in Northeastern Uganda. Methods: Between August and September 2016, we conducted a cross-sectional study among 1439 adolescents receiving primary healthcare services at nine public health facilities located in five of the seven districts that make up Karamoja sub-region. High-risk sexual behaviour was defined as engaging in sex with two or more (2+) sexual partners in the 6 months preceding the survey or exchanging sex for money or gifts with no or inconsistent use of condoms over the same period of time. Factors associated with prior engagement in high-risk sexual behaviours were analysed using a modified Poison regression model with log-link and Poisson-family via a generalized linear model. Results: Eighty-two percent (81.8%, n = 1177) of the respondents had ever tested for HIV while 62 % (61.5%, n = 885) had ever had sex. Of those that had ever had sex, 11.4% (n = 101) reported prior engagement in high-risk sexual behaviours. Prior engagement in high-risk sexual behaviours was lower among men than women (adjusted prevalence ratio (adj. PR) = 0.46; 95% Confidence Interval (95% CI): 0.33, 0.62) and those whose sex debut was above 14 years (adj.PR = 0.63; 95% CI: 0.57, 0.69). However, prior engagement in high-risk sexual behaviours was significantly higher in adolescents who were not aware of their recent sexual partner's HIV status (adj.PR = 2.43; 95% CI: 1.68, 3.52) and those who used illicit drugs (adj.PR = 2.76; 95% CI: 1.88, 4.05). Conclusion: Prior engagement in high-risk sexual behaviours was significantly associated with having sex with partners of unknown HIV sero-status and use of illicit drugs. These findings suggest a need for targeted interventions to improve mutual HIV status disclosure between sexual partners while minimizing their use of illicit drugs/substances.

Acronyms GBM gay and bisexual men HIV human immunodeficiency syndrome M mean (statistical average) NSW New South Wales QLD Queensland PEP post-exposure prophylaxis PrEP pre-exposure prophylaxis SD standard deviation US United States TasP treatment as prevention

The recent implementation of innovative biomedical preventive approaches to combat the continued high prevalence of HIV among certain populations, has refocused attention on the question of support in the management of treatment adherence. What distinguishes these approaches from classic research on similar themes is that the populations concerned are not HIV positive. The objective of this study was to assess participant and physician satisfaction with medical and community support provided in the ANRS-IPERGAY trial. As part of this trial, individual interviews were conducted with physicians and with HIV-negative participants involved in the trial. Collective interviews and focus groups were also conducted with the participants. A content thematic analysis was performed on the full two corpuses' data, with the aim of investigating discourse themes regarding the support offered as part of the trial. The discourse analysis of the HIV-negative participants and physicians underlined their satisfaction with many aspects of the medical and community support provided during the trial. The results were interpreted in link with news forms of patient education necessary of the medicalized prevention implementation.

The ANRS-IPERGAY trial consisted in providing sexual activity-based antiretroviral prophylaxis for HIV prevention (PrEP) with a package of prevention tools (counselling, condoms, HIV and sexually transmitted infections' screening) to highly exposed HIV-negative men who have sex with men (MSM). Few data exist concerning the patient-physician relationship in the particular context of PrEP, where physicians discuss sexual behaviours with MSM who are not classic patients, in that consultation is for prevention purposes, not for illness. This study took place during the open-label extension of ANRS-IPERGAY trial when all participants received PrEP. In this qualitative study, we examined how physicians perceived their relationship with participants in the ANRS-IPERGAY trial. Of all 30 physicians involved in the trial who were contacted by email to participate in an interview about their opinions and perceptions of ANRS-IPERGAY 18 volunteered to participate in the current sub-study. We...

Evidence from the past 40 years of HIV technology development and implementation indicates that the public health social contractwith its expectations of patient/citizen compliancehas hampered global disease control efforts. Despite the availability of a wide array of effective technologies, including antiretroviral drugs as treatment and prevention, voluntary medical male circumcision procedures, and newly developed intravaginal ring products, new infections among adults globally have not decreased significantly. In this paper, I describe a historical trend of limiting access to effective biomedical technologies to those deemed most deserving and compliant given concerns of misuse (non-adherence), product repurposing (not using the product for purposes originally intended), and the incitement of autonomy (increasing the risk of public exposure to diseases given personal protection from a specific disease). Examining the expectations of good citizenship (compliance, adherence, appropriate product use, and continued risk reduction) as it relates to human-technology interactions, reveals a continuing narrative of initially restricting access to newer technologies perceived fragile or costly based on an assessment of patient/citizen worth. In this, the conventional public health social contract continues to be an obstacle in the advancements of technologies to effectively reduce the global burden of HIV.

HIV pre-exposure prophylaxis (PrEP) is highly effective in men who have sex with men (MSM) at the individual level, but data on population-level impact are lacking. We examined whether rapid, targeted, and high-coverage roll-out of PrEP in an MSM epidemic would reduce HIV incidence in the cohort prescribed PrEP and state-wide in Australia's most populous state, New South Wales. The Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) study is an implementation cohort study of daily co-formulated tenofovir disoproxil fumarate and emtricitabine as HIV PrEP. We recruited high-risk gay men in a New South Wales-wide network of 21 clinics. We report protocol-specified co-primary outcomes at 12 months after recruitment of the first 3700 participants: within-cohort HIV incidence; and change in population HIV diagnoses in New South Wales between the 12-month periods before and after PrEP roll-out. The study is registered with ClinicalTrials.gov, number NCT02870790. We r...

Background: Adolescent sexual risky behaviours continue to be significant drivers of the HIV epidemic globally. The objective of this study was to determine factors associated with prior engagement in high-risk sexual behaviours among adolescents (10-19 years) in Karamoja sub-region, a pastoralist and post-conflict community in Northeastern Uganda. Methods: Between August and September 2016, we conducted a cross-sectional study among 1439 adolescents receiving primary healthcare services at nine public health facilities located in five of the seven districts that make up Karamoja sub-region. High-risk sexual behaviour was defined as engaging in sex with two or more (2+) sexual partners in the 6 months preceding the survey or exchanging sex for money or gifts with no or inconsistent use of condoms over the same period of time. Factors associated with prior engagement in high-risk sexual behaviours were analysed using a modified Poison regression model with log-link and Poisson-family via a generalized linear model. Results: Eighty-two percent (81.8%, n = 1177) of the respondents had ever tested for HIV while 62 % (61.5%, n = 885) had ever had sex. Of those that had ever had sex, 11.4% (n = 101) reported prior engagement in high-risk sexual behaviours. Prior engagement in high-risk sexual behaviours was lower among men than women (adjusted prevalence ratio (adj. PR) = 0.46; 95% Confidence Interval (95% CI): 0.33, 0.62) and those whose sex debut was above 14 years (adj.PR = 0.63; 95% CI: 0.57, 0.69). However, prior engagement in high-risk sexual behaviours was significantly higher in adolescents who were not aware of their recent sexual partner's HIV status (adj.PR = 2.43; 95% CI: 1.68, 3.52) and those who used illicit drugs (adj.PR = 2.76; 95% CI: 1.88, 4.05). Conclusion: Prior engagement in high-risk sexual behaviours was significantly associated with having sex with partners of unknown HIV sero-status and use of illicit drugs. These findings suggest a need for targeted interventions to improve mutual HIV status disclosure between sexual partners while minimizing their use of illicit drugs/substances.

Background Optimal strategies for pre-exposure prophylaxis (PrEP) engagement in generalised HIV epidemics are unknown. We aimed to assess PrEP uptake and engagement after population-level HIV testing and universal PrEP access to characterise gaps in the PrEP cascade in rural Kenya and Uganda. Methods We did a 72-week interim analysis of observational data from the ongoing SEARCH (Sustainable East Africa Research in Community Health) study. Following community sensitisation and PrEP education, we did HIV testing and offered PrEP at health fairs and facilities in 16 rural communities in western Kenya, eastern Uganda, and western Uganda. We provided enhanced PrEP counselling to individuals 15 years and older who were assessed as having an elevated HIV risk on the basis of serodifferent partnership or empirical risk score, or who otherwise self-identified as being at high risk but were not in serodifferent partnerships or identified by the risk score. PrEP follow-up visits were done at facilities, homes, or community locations. We assessed PrEP uptake within 90 days of HIV testing, programme engagement (follow-up visit attendance at week 4, week 12, and every 12 weeks thereafter), refills, self-reported adherence up to 72 weeks, and concentrations of tenofovir in hair samples from individuals reporting HIV risk and adherence during follow-up, and analysed factors associated with uptake and adherence. This study is registered with ClinicalTrials.gov, NCT01864603.

Pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) is now accepted as an efficacious approach to preventing HIV acquisition among people at high risk of HIV infection but, in most places, PrEP uptake to date has not been sufficient to have a large effect on HIV incidence. In this paper we consider several key elements of the effort to expand PrEP uptake for at-risk populations who would benefit most, such as increasing access to PrEP, integrating PrEP programs with other services, promoting PrEP persistence and developing systems for monitoring PrEP use. We used a PrEP Continuum framework to describe barriers to equitable uptake of PrEP, and to illustrate possible solutions to barriers. Access to PrEP includes regulatory issues and geographic proximity to PrEP providers. Integrating PrEP programs with other comprehensive sexual health services, through clinic-based programs or technology-based approaches, offers opportunities to identify P...

HIV continues to be a major health concern with approximately 2.1 million new infections occurring worldwide in 2015. In Central America, Guatemala had the highest incident number of HIV infections (3,700) in 2015. Antiretroviral pre-exposure prophylaxis (PrEP) was recently recommended by the World Health Organization (WHO) as an efficacious intervention to prevent HIV transmission. PrEP implementation efforts are underway in Guatemala and success will require providers that are knowledgeable and willing to prescribe PrEP. We sought to explore current PrEP awareness and prescribing attitudes among Guatemalan physicians in order to inform future PrEP implementation efforts. We conducted a cross-sectional survey of adult internal medicine physicians at the main teaching hospital in Guatemala City in March 2015. The survey included demographics, medical specialty, years of HIV patient care, PrEP awareness, willingness to prescribe PrEP, previous experience with post-exposure prophylaxi...

Introduction HIV continues to be a major health concern with approximately 2.1 million new infections occurring worldwide in 2015. In Central America, Guatemala had the highest incident number of HIV infections (3,700) in 2015. Antiretroviral pre-exposure prophylaxis (PrEP) was recently recommended by the World Health Organization (WHO) as an efficacious intervention to prevent HIV transmission. PrEP implementation efforts are underway in Guatemala and success will require providers that are knowledgeable and willing to prescribe PrEP. We sought to explore current PrEP awareness and prescribing attitudes among Guatemalan physicians in order to inform future PrEP implementation efforts. Methods We conducted a cross-sectional survey of adult internal medicine physicians at the main teaching hospital in Guatemala City in March 2015. The survey included demographics, medical specialty, years of HIV patient care, PrEP awareness, willingness to prescribe PrEP, previous experience with pos...

The introduction of effective combination antiretroviral therapy for HIV disease in 1996 was commonly narrated as a major event that transformed HIV from an inevitable death sentence into a ‘chronic manageable illness’ – at least for those populations in wealthier countries granted socially and economically affordable access to the new treatments, not to mention the relevant clinical infrastructures to monitor their effectiveness such as regular viral load testing. Sociologists cast this moment as the beginning of the normalization of responses to HIV/AIDS, in which activist engagements with HIV science on the part of affected communities resolved into the figure of the patient, or the passive consumer of medical goods (Rosenbrock et al. 2000). While the reframing of HIV as a chronic manageable illness can certainly be understood in terms of normalization, in this post I argue this narrative overlooks the sense in which the ‘Protease Moment’ (Rofes 2015) was predicated upon and instigated various forms of labour on the part of people living with HIV/AIDS that entailed experimentation with drugs and their diverse affordances.

The HIV epidemic in England is largely concentrated among heterosexuals who are predominately black African and men who have sex with men (MSM). We present for the first time trends in annual HIV incidence for adults attending sexual health clinics, where 80% of all HIV diagnoses are made. We identified newly diagnosed incident HIV using a recent infection testing algorithm (RITA) consisting of a biomarker (AxSYM assay, modified to determine antibody avidity), epidemiological and clinical information. We estimated HIV incidence using the WHO RITA formula for cross-sectional studies, with HIV testing data from sexual health clinics as the denominator. From 2009 to 2013, each year, between 9,700 and 26,000 black African heterosexuals (of between 161,000 and 231,000 heterosexuals overall) were included in analyses. For the same period, annually between 19,000 and 55,000 MSM were included. Estimates of HIV incidence among black Africans increased slightly (although non-significantly) fr...

The recent implementation of innovative biomedical preventive approaches to combat the continued high prevalence of HIV among certain populations, has refocused attention on the question of support in the management of treatment adherence. What distinguishes these approaches from classic research on similar themes is that the populations concerned are not HIV positive. The objective of this study was to assess participant and physician satisfaction with medical and community support provided in the ANRS-IPERGAY trial. As part of this trial, individual interviews were conducted with physicians and with HIV-negative participants involved in the trial. Collective interviews and focus groups were also conducted with the participants. A content thematic analysis was performed on the full two corpuses’ data, with the aim of investigating discourse themes regarding the support offered as part of the trial. The discourse analysis of the HIV-negative participants and physicians underlined their satisfaction with many aspects of the medical and community support provided during the trial. The results were interpreted with respect to new forms of patient education necessary for the implementation of the medicalized prevention.

Can the history of AIDS ever be told without repeating dichotomies-medicine versus culture and politics-that were set up as the epidemic emerged and developed?-Engelmann 2018, p.217 Collective (self)-experimentation with bodies, pleasures, drugs, modes of intimacy and relations of care has been a critical element in the processes through which gay men and their communities' have grappled with the exigencies of HIV since the beginning of the epidemic. These experiments have been a significant feature, not only in the emergence of modern gay communities and the sexual ecologies within which the virus was first found to proliferate and rapidly spread, but also (and just as importantly) in the wide-ranging innovations in community mobilization, disease prevention, care practices, cultural intervention, clinical relations, patient advocacy, peer education and institutional rearrangements that have constituted this unprecedented response to a public health emergency (Race 2018, Papadopoulos 2018). In this paper I argue that the frame of collective experimentation is good for troubling familiar narratives that frame the recent biomedical turn in HIV prevention as a straightforward imposition of biomedical authority and technoscientific mandates on unwitting communities and populations (prevention 'from above'), and for drawing out the ways in which community mobilization, (sub)cultural innovation and collective self-fashioning have participated in the shaping and transformation of HIV ontologies.

Evidence from the past 40 years of HIV technology development and
implementation indicates that the public health social contract – with its
expectations of patient/citizen compliance – has hampered global
disease control efforts. Despite the availability of a wide array of
effective technologies, including antiretroviral drugs as treatment and
prevention, voluntary medical male circumcision procedures, and newly
developed intravaginal ring products, new infections among adults
globally have not decreased significantly. In this paper, I describe a
historical trend of limiting access to effective biomedical technologies to
those deemed most deserving and compliant given concerns of misuse
(non-adherence), product repurposing (not using the product for
purposes originally intended), and the incitement of autonomy
(increasing the risk of public exposure to diseases given personal
protection from a specific disease). Examining the expectations of good
citizenship (compliance, adherence, appropriate product use, and
continued risk reduction) as it relates to human-technology interactions,
reveals a continuing narrative of initially restricting access to newer
technologies perceived fragile or costly based on an assessment of
patient/citizen worth. In this, the conventional public health social
contract continues to be an obstacle in the advancements of
technologies to effectively reduce the global burden of HIV.

The Gay Science

Since the onset of the HIV epidemic, the behaviour of men who have sex with men has been subject to intense scrutiny on the part of the behavioural and sociomedical sciences. What happens when we consider the work of these sciences to be not merely descriptive, but also constitutive of the realities it describes? The Gay Science pays attention to lived experiences of sex, drugs and the scientific practices that make these experiences intelligible. Through a series of empirically and historically detailed case studies, the book examines how new technologies and scientific artifacts – such as antiretroviral therapy, digital hookup apps and research methods – mediate sexual encounters and shape the worlds and self-practices of men who have sex with men.

Rather than debunking scientific practices or minimizing their significance, The Gay Science approaches these practices as ways in which we ‘learn to be affected’ by HIV.  It explores what knowledge practices best engage us, move us and increase our powers and capacities for action. The book includes an historical analysis of drug use as a significant element in the formation of urban gay cultures; constructivist accounts of the emergence of barebacking and chemsex; a performative response to Pre-Exposure Prophylaxis and its uptake; and, a speculative analysis of ways of thinking and doing sexual community in the digital context.

Combining insights from queer theory, process philosophy and science and technology studies to develop an original approach to the analysis of sexuality, drug use, public health and digital practices, this book demonstrates the ontological consequences of different modes of attending to risk and pleasure. It is suitable for those interested in cultural studies, sociology, gender and sexuality studies, digital culture, public health and drug and alcohol studies.


Kane Race is Associate Professor of Gender and Cultural Studies at the University of Sydney, Australia. He is the convenor of the Queer Contingent of Unharm and the author of Pleasure Consuming Medicine: the queer politics of drugs (2009) and Plastic Water: the social and material life of bottled water (with Gay Hawkins and Emily Potter, 2015).