What Works for Women and Girls

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viral load below 400 copies/ml but data were compatible with one transmission per 79person-years. In ten studies with HIV-positive people not receiving antiretroviral therapywith 9,998 person years of follow-up, the overall HIV transmission rate, irrespectiveof viral load category and sexually transmitted diseases, the transmission rate was 5.64per 100 person years. The largest number of serodiscordant couples was reported infive studies from sub-Saharan Africa. “There was insufficient data to allow estimationof summary rates of transmission through sexual intercourse without condoms, or toseparate female-male and male-female transmission” (Attia et al., 2009: 1399). “Thissystematic review did not identify any study from which the risk of HIV transmissionper act of unprotected sexual intercourse among persons with suppressed viremiafollowing ART could be quantified directly. The available studies found no episodesof HIV transmission in discordant heterosexual couples If the HIV-infected partnerwas treated with ART and had a viral load below 400 copies/ml…The comparison ofoverall rates in patients on ART and not on ART nevertheless indicated that heterosexualtransmission was reduced by 92%” (Attia et al., 2009: 1401). (Gray V) (treatment,sex behavior, Sub-Saharan Africa)“The Commission of Experts of Clinical HIV/AIDS Therapy of the Federal Office ofPublic Health of Switzerland concluded that an HIV-positive person who does not havean STI and is on HAART, with undetectable viral load under 40 copies per ml cannottransmit HIV sexually, as long as the person is completely adherent; viral load is undetectablefor at least six months; and has no other STIs. It is estimated that in the caseof complete suppression of viral load, the risk to transmit HIV through sexual intercoursewithout using condoms is less than 1 in 100,000. The Commission cautionedthat this should apply only to patients who are highly motivated to be adherent, are in astable relationship, are regularly followed by a physician, have no STIs, are in a mutuallymonogamous relationship and the HIV-negative partner is counseled and agreesto not use condoms. The HIV-negative partner must be the one to decide, since if theydo acquire HIV, the consequences are most significant for the HIV-negative partner.Both partners must be counseled jointly (Vernazza et al., 2008). However, ability todetect viral load below 40 copies ml, regular physician monitoring and partner counselingas described in Switzerland in Vernazza et al., 2008 has not been described in adeveloping country context. Others have argued that treatment alone is not reliable, aswomen receiving antiretroviral therapy shed HIV (Cohen et al, 2009). (Gray V) (treatment,condoms, Switzerland)Data from 3,408 heterosexual HIV serodiscordant couples from seven African countries(Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, and Zambia) wasanalyzed and found that ART use was associated with substantially lower risk for HIVtransmission. Of 103 couples, only one transmission occurred when the HIV-positivecouple had initiated treatment. Couples were followed for up to 24 months, with HIVtesting of uninfected partners every three months. None of the HIV-positive partnerswho initiated treatment met national eligibility criteria for ARV treatment initiation180 CHAPTER 7 TREATMENT
(Donnell et al., 2010). (Abstract) (treatment, Botswana, Kenya, Rwanda, South Africa,Tanzania, Uganda, Zambia)Gaps in Programming—Reducing Transmission1. Intensified efforts are needed to increase condom use and reduce multiple partnershipsby people who know their HIV-positive status or who are on ARV treatment, includingyoung people.1. Intensified efforts are needed to increase condom use and reduce multiple partnerships bypeople who know their HIV-positive status or who are on ARV treatment, including youngpeople. Studies found that consistent condom use between discordant couples was lowand, among those on treatment, decreased over time.Gap noted, for example in South Africa (Almeleh, 2008); Uganda (Birungi et al.,2009a,b,c, Kirungi et al., 2008b, Bajunirwe et al., 2008, Asiimwe et al., 2008, Bunnellet al., 2005); Thailand (Tunthanathip et al., 2009); Ethiopia (Deribe et al., 2008); Zambiaand Rwanda (Dunkle et al., 2008); Cameroon (Dia et al., 2008); and Cameroon, Kenya,Tanzania, Burkina Faso and Ghana (De Walque, 2007).WHAT WORKS FOR WOMEN AND GIRLS181
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WHAT WORKSFOR WOMEN AND GIRLSEviden
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Authors:Jill Gay, MAKaren Hardee, P
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Jose Esparza, MD, Ph.D.Senior Advis
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Shyam Kottilil, MD, Ph.D.Staff Clin
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Larry Slutsker, MD, MPHChief, Malar
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Table of ContentsList of Abbreviati
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List of Abbreviations3TCACTAHIANCAP
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PEPPHAPHRPIDPLHAPMTCTPPEPPTPRPTPRBP
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MethodologyMeasuring “what works
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2. Hormonal contraception is safe f
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outcomes has been more difficult to
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2. Promoting contraceptives and fam
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International Political Commitments
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established national action plans o
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Organization of the DocumentThis do
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Table 1.1Countries included in What
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understanding the epidemic in any g
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girls in school, for example. The c
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Within each intervention, studies a
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Chapter 3.Prevention for WomenA. Ma
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Special Risks for WomenStill, despi
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AIDS cases reported from 1982 to 20
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experience observed in clinical tri
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Female Condoms Are the Only Female-
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condom if it gives them more pleasu
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Correct use of the female condom ha
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A two month prospective study from
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A study of trends from Demographic
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8. Peer education for women can inc
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3B. Prevention for Women: Partner R
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matic focus on partner reduction, y
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of HIV acquisition, but were either
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four visits, each participant was i
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What Works—Prevention for Women:
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vention immediately following the b
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Chapter 4.Prevention for Key Affect
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2010). Transgender men and women al
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confidentiality—violate human rig
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there were major socio-demographic
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and post-intervention were used to
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tent condom use and 1.5 times more
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to their peers, distribute condoms
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Gaps in Programming—Female Sex Wo
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of a sexual relationship with a pri
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than were naltrexone or placebo. HI
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attributed to …swift introduction
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Promising Strategies:5. Sex-segrega
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9. Programming to prevent initiatio
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D’Ivoire, Cuba, Estonia, Indonesi
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Gaps in Programming—Women Prisone
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EVIDENCEPromising Strategies:1. Vol
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In fact, as of September 2008, 66 o
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Transgender women and men are often
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2009). “The invisibility and marg
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especially young women, have their
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negotiation skills and other critic
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to be reached with sex and HIV educ
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What Works—Prevention for Young P
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44% and 100% of participants (Kirby
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tudes, self-efficacy, intentions, a
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as young people in this area had li
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ical validity of the findings that
Page 132 and 133: study reported having received info
Page 134 and 135: nancy. Almost 87% of men and 89% of
Page 136 and 137: last sex, having ever used a condom
Page 138 and 139: Gap noted, for example, in South Af
Page 140 and 141: Disaggregated Data Is NeededEffecti
Page 142 and 143: were also effective in increasing u
Page 145 and 146: Chapter 6.HIV Testing and Counselin
Page 147 and 148: Equitable Access to Testing and Cou
Page 149 and 150: they would come for HIV testing, re
Page 151 and 152: their jobs (Human Rights Watch, 200
Page 153 and 154: What Works—HIV Testing and Counse
Page 155 and 156: women. Of all married HIV-positive
Page 157 and 158: A study in Ethiopia found that inco
Page 159 and 160: At a provincial hospital in Mombasa
Page 161 and 162: Between June and December 2007, mob
Page 163 and 164: Promising Strategies:6. Encouraging
Page 165 and 166: 10. Counseling may reduce risk beha
Page 167 and 168: women learned violence prevention s
Page 169 and 170: Chapter 7.TreatmentA. Provision and
Page 171 and 172: Treatment Has Been Successfully Adm
Page 173 and 174: HIV Prevention Is Needed as well as
Page 175 and 176: Gaps in Programming—Provision and
Page 177 and 178: These practices and tools are usefu
Page 179 and 180: Non-judgmental, non-stigmatizing in
Page 181: percent among ART-experienced patie
Page 186 and 187: The sexual health of women is an im
Page 188 and 189: [ for women living with HIV]: impro
Page 190 and 191: Available GuidelinesA number of sex
Page 192 and 193: advantages of dual method use, alon
Page 194 and 195: contraception: 57% used hormonal co
Page 196 and 197: different; and progression to WHO c
Page 198 and 199: HIV-related behavioral or biologic
Page 200 and 201: use was positively associated with
Page 202 and 203: Gaps in Programming—Meeting the S
Page 204 and 205: Interactions between ARVs and oral
Page 207 and 208: Chapter 9.Safe Motherhood and Preve
Page 209 and 210: Pillar 1: Preventing Primary HIV In
Page 211 and 212: mission of HIV. HIV testing and cou
Page 213 and 214: EVIDENCE1. Preventing unintended pr
Page 215 and 216: Gaps in Programming—Reducing Unin
Page 217 and 218: 9B. Safe Motherhood and Preventiono
Page 219 and 220: EVIDENCEPromising Strategies:1. Dis
Page 221 and 222: Gaps in Programming—Pre-Conceptio
Page 223 and 224: 9C-1. Safe Motherhood and Preventio
Page 225 and 226: tion (Kershaw et al., 2006). “…
Page 227 and 228: outine tests. Fifty percent of the
Page 229 and 230: An evaluation of UNICEF-funded PMTC
Page 231 and 232: and syphilis (by rapid plasma regai
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2. Additional efforts are needed to
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for their own disease” (ITPC, 200
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own health needs has never been eva
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dine and lamivudine during pregnanc
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chose elective cesarean section to
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their current pregnancy or a past p
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Promising Strategies:5. Integrating
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Gaps in Programming—Treatment1. I
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cesarean, and 221 were non-elective
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3. Efforts are needed to ensure tha
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“There is no doubt that there are
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formula feeding increases the risk
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of age. For breastfed infants, the
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weeks of gestation and continued un
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A study in Côte d’Ivoire with 54
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during breastfeeding compared with
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3 times higher for infants who were
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counseling tools are needed. Studie
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Chapter 10.Preventing, Detecting an
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latent infection. Some immunocompro
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concurrent active TB and HIV infect
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mortality of HIV-positive people re
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in a 65% decline in mortality and t
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1. Efforts are needed to reduce TB-
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al., 2004 cited in Slutsker and Mar
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stillbirths by 33%. Three cluster-r
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Gaps in Programming—Malaria1. Fur
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dose global coverage was just 27% i
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Chapter 11.Strengthening the Enabli
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combining microfinance and training
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pants meeting once per week for thr
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the men believed that they should n
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in the intervention village were si
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positive impacts. The quasi-experim
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Samoa, Serbia and Montenegro, Thail
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factor associated with sexual assau
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What Works—Strengthening the Enab
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worked with women’s groups, radio
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of school in addressing gender-base
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11C. Strengthening the Enabling Env
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also widely used worldwide and part
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ecognize women’s property rights
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Promising Strategies:2. Community o
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11D. Strengthening the Enabling Env
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more likely to report having used a
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likely than illiterate women to kno
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of the women surveyed were HIV-posi
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countries extending the fee aboliti
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families and separated from their c
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used the resource “Understanding
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6. Support groups for people living
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11G. Strengthening the Enabling Env
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EVIDENCEPromising Strategies:1. Inv
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Chapter 12.Care and SupportA. Women
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ical care provided by family member
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dealing with their sorrow, grief, a
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What Works—Care and Support: Wome
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2. Peer support groups can be highl
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discriminated unjustly against them
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6. Home-based antiretroviral therap
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12B. Care and Support: Orphans and
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(Thurman et al., 2007). As of 2008,
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care and services were provided, wh
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for treatment can be safely monitor
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A study done in Kenya (year not giv
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ather than a narrowly defined HIV/A
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7. Further interventions to provide
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ning providers, antenatal care and
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What Works—Structuring Health Ser
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counts available at primary health
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Pregnant women reported feeling out
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Before implementation of the PMTCT
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accessing PMTCT. An evaluation of 3
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A mathematical model based on TB tr
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1. Improved integration is needed b
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15. Additional efforts are needed t
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Community-based Care is holistic ca
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Microfinance is often defined as fi
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Sexuality is a central aspect of be
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References 1Aaron, E. and S. Crinit
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Akabaysh, H. and G. Psacharopoulos.
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Andia, I., A. Kaida, M. Maier, D. G
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Barker, P., C. McCanno, N. Mehta, C
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Berer, M. 2008b. “Male Circumcisi
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Bong, C-N., S. Chen, Y-J. Jong, T-S
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Campbell, L. and M. Lambey. 2002.
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Coovadia, H. 2004. “Antiretrovira
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Druce, N. and A. Nolan. 2007. “Se
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“What Works compiles a wealth of
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