[Show abstract][Hide abstract] ABSTRACT: To compare the potential impact of rectal (RMB), vaginal (VMB) and bi-compartment (RVMB) (applied vaginally and protective during vaginal and anal intercourse) microbicides to prevent HIV in various heterosexual populations. To understand when a RMB is as useful than a VMB for women practicing anal intercourse (AI).
Mathematical model was used to assess the population-level impact (cumulative fraction of new HIV infections prevented (CFP)) of the three different microbicides in various intervention scenarios and prevalence settings. We derived the break-even RMB efficacy required to reduce a female's cumulative risk of HIV infection by the same amount than a VMB.
Under optimistic coverage (fast roll-out, 100% uptake), a 50% efficacious VMB used in 75% of sex acts in population without AI may prevent ∼33% (27, 42%) new total (men and women combined) HIV infections over 25 years. The 25-year CFP reduces to ∼25% (20, 32%) and 17% (13, 23%) if uptake decreases to 75% and 50%, respectively. Similar loss of impact (by 25%-50%) is observed if the same VMB is introduced in populations with 5%-10% AI and for RR(RAI)=4-20. A RMB is as useful as a VMB (ie, break-even) in populations with 5% AI if RR(RAI)=20 and in populations with 15%-20% AI if RR(RAI)=4, independently of adherence as long as it is the same with both products. The 10-year CFP with a RVMB is twofold larger than for a VMB or RMB when AI=10% and RR(RAI)=10.
Even low AI frequency can compromise the impact of VMB interventions. RMB and RVMB will be important prevention tools for heterosexual populations.
[Show abstract][Hide abstract] ABSTRACT: Cash payments to improve health outcomes have been used for many years; however, their use for HIV prevention is new and the impact not yet well understood. We provide a brief background on the rationale behind using cash to improve health outcomes, review current studies completed or underway using cash for prevention of sexual transmission of HIV, and outline some key considerations on the use of cash payments to prevent HIV infections. We searched the literature for studies that implemented cash transfer programs and measured HIV or HIV-related outcomes. We identified 16 studies meeting our criteria; 10 are completed. The majority of studies have been conducted with adolescents in developing countries and payments are focused on addressing structural risk factors such as poverty. Most have seen reductions in sexual behavior and one large trial has documented a difference in HIV prevalence between young women getting cash transfers and those not. Cash transfer programs focused on changing risky sexual behaviors to reduce HIV risk suggest promise. The context in which programs are situated, the purpose of the cash transfer, and the population will all affect the impact of such programs; ongoing RCTs with HIV incidence endpoints will shed more light on the efficacy of cash payments as strategy for HIV prevention.
AIDS and Behavior 07/2012; 16(7):1729-38. DOI:10.1007/s10461-012-0240-z · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Law has played an important, but largely constitutive, role in the development of the public health enterprise. Thus, law has been central to setting up the institutions and offices of public health. The moral agenda has, however, been shaped to a much greater extent by bioethics. While social justice has been placed at the heart of this agenda, we argue that there has been little place within dominant conceptions of social justice for gender equity and women's interests which we see as crucial to a fully realised vision of social justice. We argue that, aside from particular interventions in the field of reproduction, public health practice tends to marginalise women-a claim we support by critically examining strategies to combat the HIV pandemic in sub-Saharan Africa. To counter the marginalisation of women's interests, this article argues that Amartya Sen's capabilities approach has much to contribute to the framing of public health law and policy. Sen's approach provides an evaluative and normative framework which recognises the importance of both gender and health equity to achieving social justice. We suggest that domestic law and international human rights provisions, in particular the emerging human right to health, offer mechanisms to promote capabilities, and foster a robust and inclusive conception of social justice.
Medical Law Review 11/2012; 21(2). DOI:10.1093/medlaw/fws036 · 0.73 Impact Factor
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