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Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.

Introduction Oral pre‐exposure prophylaxis (PrEP) provision is a priority intervention for high HIV prevalence settings and populations at substantial risk of HIV acquisition. This mathematical modelling analysis estimated the impact, cost and cost‐effectiveness of scaling up oral PrEP in 13 countries. Methods We projected the impact and cost‐effectiveness of oral PrEP between 2018 and 2030 using a combination of the Incidence Patterns Model and the Goals model. We created four PrEP rollout scenarios involving three priority populations—female sex workers (FSWs), serodiscordant couples (SDCs) and adolescent girls and young women (AGYW)—both with and without geographic prioritization. We applied the model to 13 countries (Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Mozambique, Namibia, Nigeria, Tanzania, Uganda, Zambia and Zimbabwe). The base case assumed achievement of the Joint United Nations Programme on HIV/AIDS 90‐90‐90 antiretroviral therapy targets, 90% male circumcision coverage by 2020 and 90% efficacy and adherence levels for oral PrEP. Results In the scenarios we examined, oral PrEP averted 3% to 8% of HIV infections across the 13 countries between 2018 and 2030. For all but three countries, more than 50% of the HIV infections averted by oral PrEP in the scenarios we examined could be obtained by rollout to FSWs and SDCs alone. For several countries, expanding oral PrEP to include medium‐risk AGYW in all regions greatly increased the impact. The efficiency and impact benefits of geographic prioritization of rollout to AGYW varied across countries. Variations in cost‐effectiveness across countries reflected differences in HIV incidence and expected variations in unit cost. For most countries, rolling out oral PrEP to FSWs, SDCs and geographically prioritized AGYW was not projected to have a substantial impact on the supply chain for antiretroviral drugs. Conclusions These modelling results can inform prioritization, target‐setting and other decisions related to oral PrEP scale‐up within combination prevention programmes. We caution against extensive use given limitations in cost data and implementation approaches. This analysis highlights some of the immediate challenges facing countries—for example, trade‐offs between overall impact and cost‐effectiveness—and emphasizes the need to improve data availability and risk assessment tools to help countries make informed decisions.

Introduction There are few data about the range of strategies used to prevent sexual HIV transmission within gay male serodiscordant couples. We examined HIV prevention strategies used by such couples and compared differences between countries. Methods Opposites Attract was a cohort study of male serodiscordant couples in Australia, Brazil and Thailand, from May 2014 (Australia) or May 2016 (Brazil/Thailand) to December 2016. At visits, HIV‐positive partners had viral load (VL) tested; HIV‐negative partners reported sexual behaviour and perceptions of their HIV‐positive partner's VL results. Within‐couple acts of condomless anal intercourse (CLAI) were categorized by strategy: condom‐protected, biomedically protected (undetectable VL and/or pre‐exposure prophylaxis [PrEP]), or not protected by either (HIV‐negative partners engaging in insertive CLAI, receptive CLAI with withdrawal, or receptive CLAI with ejaculation). Results A total of 343 couples were included in this analysis (153 in Australia, 93 in Brazil and 97 in Thailand). Three‐quarters of HIV‐positive partners were consistently virally suppressed (

Introduction Safer conception strategies minimize HIV risk during condomless sex to become pregnant. Gaps remain in understanding the acceptability, feasibility and choices HIV‐serodiscordant couples make when multiple safer conception options are available. Methods We conducted a pilot study of a comprehensive safer conception package for HIV‐serodiscordant couples with immediate fertility desires in Kenya from March 2016 to April 2018. The intervention package included antiretroviral therapy (ART) for HIV‐positive partners, oral pre‐exposure prophylaxis (PrEP) for HIV‐negative partners, daily fertility and sexual behaviour tracking via short message service (SMS) surveys, counselling on self‐insemination, and referrals for voluntary medical male circumcision and fertility care. Couples attended monthly visits until pregnancy with HIV testing for negative partners at each visit. We estimated the number of expected HIV seroconversions using a counterfactual cohort simulated from gender‐matched couples in the placebo arm of a previous PrEP clinical trial. We used bootstrap methods to compare expected and observed seroconversions. Results Of the 74 enrolled couples, 54% were HIV‐negative female/HIV‐positive male couples. The 6 and 12‐month cumulative pregnancy rates were 45.3% and 61.9% respectively. In the month preceding pregnancy, 80.9% of HIV‐positive partners were virally suppressed, 81.4% of HIV‐negative partners were highly adherent to PrEP, and SMS surveys indicated potential timing of condomless sex to peak fertility (median of sex acts = 10, interquartile range (IQR) 7 to 12; median condomless sex acts = 3.5, IQR 1 to 7). Most (95.7%) pregnancies were protected by ≥2 strategies: 57.4% were protected by high PrEP and ART adherence, male circumcision with or without timed condomless sex; 10 (21.3%) were protected by viral suppression in the HIV‐positive partner and male circumcision with or without timed condomless sex; 8 (17.0%) were protected by high PrEP adherence and male circumcision with or without timed condomless sex. We observed 0 HIV seroconversions (95% CI 0.0 to 6.0 per 100 person years), indicating a 100% reduction in HIV risk (p = 0.04). Conclusions The use of multiple safer conception strategies, primarily PrEP, ART, male circumcision and/or tracking fertility, was acceptable and feasible for African HIV‐serodiscordant couples and significantly reduced HIV transmission risk. It is important to increase the availability of and counselling about safer conception services in regions with HIV epidemics involving heterosexual transmission and high fertility.

Introduction Pre-exposure prophylaxis (PrEP) to prevent HIV infection is being rolled out in Africa. The uptake of PrEP to date has varied across populations and locations. We seek to understand the drivers of demand for PrEP through analysis of qualitative data collected in conjunction with a PrEP demonstration project involving East African HIV serodiscordant couples. Our goal was to inform demand creation by understanding what PrEP means - beyond HIV prevention - for the lives of users. Methods The Partners Demonstration Project evaluated an integrated strategy of PrEP and antiretroviral therapy (ART) delivery in which time-limited PrEP served as a "bridge" to long-term ART. Uninfected partners in HIV serodiscordant couples were offered PrEP at baseline and encouraged to discontinue once infected partners had taken ART for six months. We conducted 274 open-ended interviews with 93 couples at two Ugandan research sites. Interviews took place one month after enrolment and at later points in the follow-up period. Topics included are as follows: (1) discovery of serodiscordance; (2) decisions to accept/decline PrEP and/or ART; (3) PrEP and ART initiation; (4) experiences of using PrEP and ART; (5) PrEP discontinuation; (6) impact of PrEP and ART on the partnered relationship. Interviews were audio-recorded and transcribed. We used an inductive, content analytic approach to characterize meanings of PrEP stemming from its effectiveness for HIV prevention. Relevant content was represented as descriptive categories. Results Discovery of HIV serodiscordance resulted in fear of HIV transmission for couples, which led to loss of sexual intimacy in committed relationships, and to abandonment of plans for children. As a result, partners became alienated from each other. PrEP countered the threat to the relationship by reducing fear and reinstating hopes of having children together. Condom use worked against the re-establishment of intimacy and closeness. By increasing couples' sense of protection against HIV infection and raising the prospect of a return to "live sex" (sex without condoms), PrEP was perceived by couples as solving the problem of serodiscordance and preserving committed relationships. Conclusions The most effective demand creation strategies for PrEP may be those that address the everyday life priorities of potential users in addition to HIV prevention. Clinical trial number NCT02775929.

Introduction Oral pre‐exposure prophylaxis (PrEP) for HIV prevention has been proven to significantly reduce new HIV infections yet scale‐up has been slow. As contexts continue to adjust to make space for PrEP, it is crucial to understand the perspectives and experiences of potential end‐users. In order to inform PrEP and demand creation interventions, this paper examines personal perspectives on adopting and using PrEP among HIV at‐risk populations in sub‐Saharan Africa. Methods Using the principles of a scoping review in July 2018, we explored the extent, range, and nature of published literature regarding PrEP uptake and use among; men who have sex with men, HIV serodiscordant couples, adolescent girls and young women, pregnant and breastfeeding women, women partners of migrant workers; and people who use drugs. Steps included: identification of the research question; identification of relevant studies; study selection; charting the data; and collation – summarizing and reporting results. PubMed and PsycInfo were searched for papers relating to PrEP uptake and use in sub‐Saharan Africa. Resulting papers were reviewed with data extracted and compiled in Excel for analysis. A broad content analysis was conducted and organized into high‐level themes. Results and discussion Thirty‐five papers were included in this review. There was little opposition in general to oral PrEP; however, there were significant nuances in its broader acceptability, applicability, and usability. We identified five themes within which these are discussed. These relate to balancing complexities of personal empowerment and stigma; navigating complex risk environments; influences of relationships and partners; efficacy and side effects; and practicalities of use. This body of research suggests that while product attributes and the logistics of PrEP delivery and use are important topics, it is vital to consider stigma, the interactions of PrEP use with relationships, and the need for broader understanding of ARVs for prevention versus treatment. Conclusions Planning for, programming and promoting the adoption of oral PrEP necessitates a deeper understanding of end‐user priorities in order to ensure successful interventions. This review illustrates the nuances facilitating or deterring PrEP use that may affect the larger effort of PrEP scale‐up.

Introduction The chemokine receptor CCR5 is the main co-receptor for R5-tropic HIV-1 variants. We have previously described a novel 24-base pair deletion in the coding region of CCR5 among individuals from Rwanda. Here, we investigated the prevalence of hCCR5 Delta 24 in different cohorts and its impact on CCR5 expression and HIV-1 infection in vitro. Methods We screened hCCR5 Delta 24 in a total of 3232 individuals which were either HIV-1 uninfected, high-risk HIV-1 seronegative and seropositive partners from serodiscordant couples, Long-Term Survivors, or HIV-1 infected volunteers from Africa (Rwanda, Kenya, Guinea-Conakry) and Luxembourg, using a real-time PCR assay. The role of the 24-base pair deletion on CCR5 expression and HIV infection was assessed in cell lines and PBMC using mRNA quantification, confocal analysis, flow and imaging cytometry. Results and Discussion Among the 1661 patients from Rwanda, 12 individuals were heterozygous for hCCR5 Delta 24 but none were homozygous. Although heterozygosity for this allele may not confer complete resistance to HIV-1 infection, the prevalence of the mutation was 2.41% (95%CI: 0.43; 8.37) in 83 Long-Term Survivors (LTS) and 0.99% (95%CI: 0.45; 2.14) in 613 HIV-1 exposed seronegative members as compared with 0.35% (95% Cl: 0.06; 1.25) in 579 HIV-1 seropositive members. The prevalence of hCCR5 Delta 24 was 0.55% (95%CI: 0.15; 1.69) in 547 infants from Kenya but the mutation was not detected in 224 infants from Guinea-Conakry nor in 800 Caucasian individuals from Luxembourg. Expression of hCCR5 Delta 24 in cell lines and PBMC showed that the hCCR5 Delta 24 protein is stably expressed but is not transported to the plasma membrane due to a conformational change. Instead, the mutant receptor was retained intracellularly, colocalized with an endoplasmic reticulum marker and did not mediate HIV-1 infection. Co-transfection of hCCR5 Delta 24 and wtCCR5 did not indicate a transdominant negative effect of CCR5 Delta 24 on wtCCR5. Conclusions Our findings indicate that hCCR5 Delta 24 is not expressed at the cell surface. This could explain the higher prevalence of the heterozygous hCCR5 Delta 24 in LTS and HIV-1 exposed seronegative members from serodiscordant couples. Our data suggest an East-African localization of this deletion, which needs to be confirmed in larger cohorts from African and non-African countries.

Introduction: HIV self-testing (HIVST) provides couples and individuals with a discreet, convenient and empowering testing option. As with all HIV testing, potential harms must be anticipated and mitigated to optimize individual and public health benefits. Here, we describe social harms (SHs) reported during HIVST implementation in Malawi, and propose a framework for grading and responding to harms, according to their severity. Methods: We report findings from six HIVST implementation studies in Malawi (2011 to 2017) that included substudies investigating SH reports. Qualitative methods included focus group discussions, in-depth interviews and critical incident interviews. Earlier studies used intensive quantitative methods (post-test questionnaires for intimate partner violence, household surveys, investigation of all deaths in HIVST communities). Later studies used post-marketing reporting with/without community engagement. Pharmacovigilance methodology (whereby potentially life-threatening/changing events are defined as “serious”) was used to grade SH severity, assuming more complete passive reporting for serious events. Results: During distribution of 175,683 HIVST kits, predominantly under passive SH reporting, 25 serious SHs were reported from 19 (0.011%) self-testers, including 15 partners in eight couples with newly identified HIV discordancy, and one perinatally infected adolescent. There were no deaths or suicides. Marriage break-up was the most commonly reported serious SH (sixteen individuals; eight couples), particularly among serodiscordant couples. Among new concordant HIV-positive couples, blame and frustration was common but rarely (one episode) led to serious SHs. Among concordant HIV-negative couples, increased trust and stronger relationships were reported. Coercion to test or disclose was generally considered “well-intentioned” within established couples. Women felt empowered and were assertive when offering HIVST test kits to their partners. Some women who persuaded their partner to test, however, did report SHs, including verbal or physical abuse and economic hardship. Conclusions: After more than six years of large-scale HIVST implementation and in-depth investigation of SHs in Malawi, we identified approximately one serious reported SH per 10,000 HIVST kits distributed, predominantly break-up of married serodiscordant couples. Both “active” and “passive” reporting systems identified serious SH events, although with more complete capture by “active” systems. As HIVST is scaled-up, efforts to support and further optimize community-led SH monitoring should be prioritized alongside HIVST distribution. Keywords: HIV/AIDS; HIV self-test; HIV testing; social harms; Malawi

Introduction Serodiscordant couples are a priority population for delivery of new HIV prevention interventions in Africa. An integrated strategy of delivering time‐limited, oral pre‐exposure prophylaxis (PrEP) to uninfected partners in serodiscordant couples as a bridge to long‐term antiretroviral treatment (ART) for infected partners has been implemented in East Africa, nearly eliminating new infections. We conducted a qualitative evaluation of the integrated strategy in Uganda, to better understand its success. Methods Data collection consisted of 274 in‐depth interviews with 93 participating couples, and 55 observations of clinical encounters between couples and healthcare providers. An inductive content analytic approach aimed at understanding and interpreting couples’ experiences of the integrated strategy was used to examine the data. Analysis sought to characterize: (1) key aspects of services provided; (2) what the services meant to recipients; and (3) how couples managed the integrated strategy. Themes were identified in each domain, and represented as descriptive categories. Categories were grouped inductively into more general propositions based on shared content. Propositions were linked and interpreted to explain “why the integrated strategy worked.” Results Couples found “couples‐focused” services provided through the integrated strategy strengthened partnered relationships threatened by the discovery of serodiscordance. They saw in services hope for “getting help” to stay together, turned joint visits to clinic into opportunities for mutual support, and experienced counselling as bringing them closer together. Couples adopted a “couples orientation” to the integrated strategy, considering the health of partners as they made decisions about initiating ART or accepting PrEP, and devising joint approaches to adherence. A couples orientation to services, grounded in strengthened partnerships, may have translated to greater success in using antiretrovirals to prevent HIV transmission. Conclusions Various strategies for delivering antiretrovirals for HIV prevention are being evaluated. Understanding how and why these strategies work will improve evaluation processes and strengthen implementation platforms. We highlight the role of service organization in shaping couples’ experiences of and responses to ART and PrEP in the context of the integrated strategy. Organizing services to promote positive care experiences will strengthen delivery and contribute to positive outcomes as antiretrovirals for prevention are rolled out.

Introduction: Adherence is essential for pre-exposure prophylaxis (PrEP) to protect against HIV acquisition, but PrEP use need not be life-long. PrEP is most efficient when its use is aligned with periods of risk – a concept termed prevention-effective adherence. The objective of this paper is to describe prevention-effective adherence and predictors of adherence within an open-label delivery project of integrated PrEP and antiretroviral therapy (ART) among HIV serodiscordant couples in Kenya and Uganda (the Partners Demonstration Project). Methods: We offered PrEP to HIV-uninfected participants until the partner living with HIV had taken ART for ≥6 months (a strategy known as “PrEP as a bridge to ART”). The level of adherence sufficient to protect against HIV was estimated in two ways: ≥4 and ≥6 doses/week (per electronic monitoring). Risk for HIV acquisition was considered high if the couple reported sex with 25 years, older male partners and desire for relationship success. Predictors of not achieving sufficient adherence were no longer being a couple, delayed PrEP initiation, >6 months of follow-up, ART use >6 months by the partner living with HIV and problem alcohol use. Conclusions: Over three-quarters of participant-visits by HIV-uninfected partners in serodiscordant couples achieved prevention-effective adherence with PrEP. Greater adherence was observed during months with HIV risk and the strongest predictor of achieving sufficient adherence was sexual activity.

Introduction: With increasing life expectancy, couples with at least one partner afflicted with HIV are more commonly pursuing the opportunity to have biologic offspring. Currently, there are no universally accepted recommendations regarding first line reproductive treatments for HIV serodiscordant couples lacking a history of infertility. We strongly believe that fertility care intervention should be the first line treatment, when affordably accessible, over natural conception for HIV serodiscordant couples to achieve pregnancy in a safe and efficacious manner. Discussion: In the era of highly active anti-retroviral therapy, in combination with timed intercourse and pre-exposure prophylaxis for the HIV negative partner, some members of the medical community are arguing in favour of natural conception as a means of achieving pregnancy in this patient population. In our opinion, laboratory assisted fertility methods, including intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection with semen washing should be the first line treatment recommendation for HIV serodiscordant couples desiring pregnancy for the following reasons: (1) abundance of evidence in the medical literature supporting the safety profile and efficacy of fertility care intervention in couples with HIV; paucity of data addressing safety of natural conception in comparison to fertility intervention techniques (2) unknown public health impact of promoting natural conception as a safe means of achieving pregnancy (3) ethical implications: patients should be offered the available and accessible treatment option posing the lowest possible known risk to the uninfected partner. Conclusions: We believe that physician assisted fertility care, when affordably accessible, should be the treatment of choice over natural conception. While the preliminary data on natural conception in couples using highly active anti-retroviral therapy/pre-exposure prophylaxis/timed intercourse appears promising, we believe that this approach should be limited to patients in resource poor settings where more sophisticated measures do not exist or for patients that simply cannot afford subspecialty care. There are likely to be unknown psychological and behavioural factors impacted by promoting natural conception and diminishing the importance of safe sex practices. Additionally, it is our moral obligation to patients to offer the affordably accessible treatment interventions that pose the least known risk when considering reproductive options.

No abstract available. Keywords: HIV; fertility care; antiretroviral; PrEP; infertility; IVF/ICSI; reproductive health; reproductive rights (Published: 8 March 2017) Citation: Narasimhan M et al. Journal of the International AIDS Society 2017, 20(Suppl 1):21829 http://www.jiasociety.org/index.php/jias/article/view/21829 | http://dx.doi.org/10.7448/IAS.20.2.21829

No abstract available. Keywords: HIV; HAART; serodiscordant couples; pregnancy; stigma (Published: 8 March 2017) Citation: Fransen-dos Santos R and Guarinieri M. Journal of the International AIDS Society 2017, 20(Suppl 1) :21749 http://www.jiasociety.org/index.php/jias/article/view/21749 | http://dx.doi.org/10.7448/IAS.20.2.21749

No abstract available. Keywords: HIV; women living with HIV; sexual and reproductive health; human rights; pregnancy; gender-based violence; anti-retroviral therapy; serodiscordant; serodifferent (Published: 8 March 2017) Citation: Orza L et al. Journal of the International AIDS Society 2017, 20(Suppl 1) :21469 http://www.jiasociety.org/index.php/jias/article/view/21469 | http://dx.doi.org/10.7448/IAS.20.2.21469

The recognition and fulfilment of the sexual and reproductive health and rights (SRHR) of all individuals and couples affected by HIV, including HIV-serodiscordant couples, requires intervention strategies aimed at achieving safe and healthy pregnancies and preventing undesired pregnancies. Reducing risk of horizontal and vertical transmission and addressing HIV-related infertility are key components of such interventions. In this commentary, we present challenges and opportunities for achieving safe pregnancies for serodiscordant couples through a social ecological lens. At the individual level, knowledge (e.g. of HIV status, assisted reproductive technologies) and skills (e.g. adhering to antiretroviral therapy or pre-exposure prophylaxis) are important. At the couple level, communication between partners around HIV status disclosure, fertility desires and safer pregnancy is required. Within the structural domain, social norms, stigma and discrimination from families, community and social networks influence individual and couple experiences. The availability and quality of safer conception and fertility support services within the healthcare system remains essential, including training for healthcare providers and strengthening integration of SRHR and HIV services. Policies, legislation and funding can improve access to SRHR services. A social ecological framework allows us to examine interactions between levels and how interventions at multiple levels can better support HIV-serodiscordant couples to achieve safe pregnancies. Strategies to achieve safer pregnancies should consider interrelated challenges at different levels of a social ecological framework. Interventions across multiple levels, implemented concurrently, have the potential to maximize impact and ensure the full SRHR of HIV-serodiscordant couples.

Introduction : For HIV serodiscordant couples in resource-limited settings, pregnancy is common despite the risk of sexual and/or perinatal HIV transmission. Some safer conception strategies to reduce HIV transmission during pregnancy attempts are available but often not used for reasons including knowledge, accessibility, preference and others. We sought to understand Kenyan health providers ’ and HIV serodiscordant couples ’ perspectives and experiences with safer conception. Methods : Between August 2015 and March 2016, we conducted key informant interviews (KIIs) with health providers from public and private HIV care and fertility clinics and in-depth interviews (IDIs) and focus group discussions (FGDs) with HIV serodiscordant couples participating in an open-label study of integrated pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for HIV prevention (the Partners Demonstration Project). An inductive analytic approach identified a number of themes related to experiences with and perceptions of safer conception strategies. Results : We conducted 20 KIIs with health providers, and 21 IDIs and 4 FGDs with HIV serodiscordant couples. HIV clinic providers frequently discussed timed condomless sex and antiretroviral medications while providers at private fertility care centres were more comfortable recommending medically assisted reproduction. Couples experienced with ART and PrEP reported that they were comfortable using these strategies to reduce HIV risk when attempting pregnancy. Timed condomless sex in conjunction with ART and PrEP was a preferred strategy, often owing to them being available for free in public and research clinics, as well as most widely known; however, couples often held inaccurate knowledge of how to identify days with peak fertility in the upcoming menstrual cycle. Conclusions : Antiretroviral-based HIV prevention is acceptable and accessible to meet the growing demand for safer conception services in Kenya, since medically assisted interventions are currently cost prohibitive. Cross-disciplinary training for health providers would expand confidence in all prevention options and foster the tailoring of counselling to couples ’ preferences. Keywords: HIV prevention; Kenya; pregnancy; safer conception; serodiscordant couples (Published: 8 March 2017) Citation: Ngure K et al. Journal of the International AIDS Society 2017, 20(Suppl 1) :21309 http://www.jiasociety.org/index.php/jias/article/view/21309 | http://dx.doi.org/10.7448/IAS.20.2.21309

Introduction: People living with HIV (PLHIV) have the right to exercise voluntary choices about their health, including their reproductive health. This commentary discusses the integral role that family planning (FP) plays in helping PLHIV, including those in serodiscordant relationships, achieve conception safely. The United States (US) President ’ s Emergency Plan for AIDS Relief (PEPFAR) is committed to meeting the reproductive health needs of PLHIV by improving their access to voluntary FP counselling and services, including prevention of unintended pregnancy and counselling for safer conception. Discussion: Inclusion of preconception care and counselling (PCC) as part of routine HIV services is critical to preventing unintended pregnancies and perinatal infections among PLHIV. PLHIV not desiring a current pregnancy should be provided with information and counselling on all available FP methods and then either given the method onsite or through a facilitated referral process. PLHIV, who desire children should be offered risk reduction counselling, support for HIV status disclosure and partner testing, information on safer conception options to reduce the risk of HIV transmission to the partner and the importance of adhering to antiretroviral treatment during pregnancy and breastfeeding to reduce the risk of vertical transmission to the infant. Integration of PCC, HIV and FP services at the same location is recommended to improve access to these services for PLHIV. Other considerations to be addressed include the social and structural context, the health system capacity to offer these services, and stigma and discrimination of providers. Conclusion: Evaluation of innovative service delivery models for delivering PCC services is needed, including provision in community-based settings. The US Government will continue to partner with local organizations, Ministries of Health, the private sector, civil society, multilateral and bilateral donors, and other key stakeholders to strengthen both the policy and programme environment to ensure that all PLHIV and serodiscordant couples have access to FP services, including prevention of unintended pregnancy and safer conception counselling. Keywords: Family planning; HIV; serodiscordant couples; safer pregnancy; United States Government; integration (Published: 8 March 2017) Citation: Mason J et al. Journal of the International AIDS Society 2017, 20 (Suppl 1) :21312 http://www.jiasociety.org/index.php/jias/article/view/21312 | http://dx.doi.org/10.7448/IAS.20.2.21312

Introduction: Implementation of safer conception services for HIV-affected couples within primary healthcare clinics in resource-limited settings remains limited. We review service utilization and safer conception strategy uptake during the first three years of Sakh ’ umndeni , which is a safer conception clinic in South Africa. Methods: Sakh ’ umndeni is located at Witkoppen Health and Welfare Centre, a high-volume primary healthcare clinic in northern Johannesburg. Men and women desiring to conceive in less than or equal to six months and in relationships in which one or both partners are living with HIV are eligible for safer conception services. Clients receive a baseline health assessment and counselling around periconception HIV risk reduction strategies and choose which strategies they plan to use. Clients are followed-up monthly. We describe client service utilization and uptake and continuation of safer conception methods. Factors associated with male partner attendance are assessed using robust Poisson regression. Results: Overall 440 individuals utilized the service including 157 couples in which both partners attended (55%) and 126 unaccompanied female partners. Over half of the couples (55%) represented were in serodiscordant/unknown status relationships. Higher economic status and HIV-negative status of the women increased male partner involvement, while HIV-negative status of the men decreased male involvement. Regarding safer conception strategies, uptake of antiretroviral therapy initiation (90%), vaginal self-insemination among partnerships with HIV-negative men (75%) and timed condomless intercourse strategies (48%) were variable, but generally high. Overall uptake of pre-exposure prophylaxis (PrEP) was 23% and was lower among HIV-negative men than women (7% vs. 44%, p 60%. Conclusions: Safer conception strategies are generally used by clients per recommendations. High uptake of strategies suggests that the proposed combination prevention methods are acceptable to clients and appropriate for scale-up; however, low uptake of PrEP and MMC among HIV-negative men needs improvement. Targeted community-based efforts to reach men unlinked to safer conception services are needed, alongside streamlined approaches for service scale-up within existing HIV and non-HIV service delivery platforms. Keywords: HIV prevention; safer conception; serodiscordance; pre-exposure prophylaxis; self-insemination; timed condomless sex; implementation; sub-Saharan Africa (Published: 8 March 2017) Citation: Schwartz SR et al. Journal of the International AIDS Society 2017, 20(Suppl 1) :21291 http://www.jiasociety.org/index.php/jias/article/view/21291 | http://dx.doi.org/10.7448/IAS.20.2.21291

Introduction: With increasing life expectancy, couples with at least one partner afflicted with HIV are more commonly pursuing the opportunity to have biologic offspring. Currently, there are no universally accepted recommendations regarding first line reproductive treatments for HIV serodiscordant couples lacking a history of infertility. We strongly believe that fertility care intervention should be the first line treatment, when affordably accessible, over natural conception for HIV serodiscordant couples to achieve pregnancy in a safe and efficacious manner. Discussion: In the era of highly active anti-retroviral therapy, in combination with timed intercourse and pre-exposure prophylaxis for the HIV negative partner, some members of the medical community are arguing in favour of natural conception as a means of achieving pregnancy in this patient population. In our opinion, laboratory assisted fertility methods, including intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection with semen washing should be the first line treatment recommendation for HIV serodiscordant couples desiring pregnancy for the following reasons: (1) abundance of evidence in the medical literature supporting the safety profile and efficacy of fertility care intervention in couples with HIV; paucity of data addressing safety of natural conception in comparison to fertility intervention techniques (2) unknown public health impact of promoting natural conception as a safe means of achieving pregnancy (3) ethical implications: patients should be offered the available and accessible treatment option posing the lowest possible known risk to the uninfected partner. Conclusions: We believe that physician assisted fertility care, when affordably accessible, should be the treatment of choice over natural conception. While the preliminary data on natural conception in couples using highly active anti-retroviral therapy/pre-exposure prophylaxis/timed intercourse appears promising, we believe that this approach should be limited to patients in resource poor settings where more sophisticated measures do not exist or for patients that simply cannot afford subspecialty care. There are likely to be unknown psychological and behavioural factors impacted by promoting natural conception and diminishing the importance of safe sex practices. Additionally, it is our moral obligation to patients to offer the affordably accessible treatment interventions that pose the least known risk when considering reproductive options. Keywords: HIV; human immunodeficiency virus; fertility; serodiscordant; assisted reproduction; sperm washing; in vitro fertilization; natural conception (Published: 8 March 2017) Citation: Safier LZ and Sauer MV Journal of the International AIDS Society 2017, 20(Suppl 1):21294 http://www.jiasociety.org/index.php/jias/article/view/21294 | http://dx.doi.org/10.7448/IAS.20.2.21294

Introduction Better knowledge about fertility desires/intentions among HIV‐serodiscordant partners who face unique challenges when considering childbearing may be helpful in the development of targeted reproductive interventions. The aim of this systematic review was to synthesize the published literature regarding the prevalence of fertility desires/intentions and its associated factors among individuals in HIV‐serodiscordant relationships while distinguishing low‐ and middle‐income countries (LMIC) from high‐income countries (HIC). Methods A systematic search of all papers published prior to February 2017 was conducted in four electronic databases (PubMed/MEDLINE, PsycINFO, Web of Science and Cochrane Library). Empirical studies published in peer‐reviewed journals with individuals in HIV‐serodiscordant relationships assessing the prevalence of fertility desires/intentions and/or the associated factors were included in this systematic review. This review adhered to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Results and discussion After screening 1852 references, 29 studies were included, of which 21 were conducted in LMIC and eight in HIC. A great variability in the prevalence of fertility desires/intentions was observed in LMIC (8% to 84% (one member of the dyad included)). In HIC, the results showed a smaller discrepancy between in the prevalence (32% to 58% (one member of the dyad included)); the prevalence was higher when the couple was the unit of analysis (64% to 73%), which may be related to the fact that all these studies were conducted in the context of assisted reproduction. Few studies examined the factors associated with fertility desires/intentions, and all except one were conducted in LMIC. Individuals (e.g. number of children), couple‐level (e.g. belief that the partner wanted children) and structural factors (e.g. discussions with health workers) were found to be associated. Conclusions The results of this systematic review suggest that many individuals in HIV‐serodiscordant relationships have fertility desires/intentions, although the prevalence is particularly heterogeneous in LMIC in comparison to HIC. Well‐known factors such as younger age and a fewer number of living children were consistently associated with increased fertility desires/intentions. Different couple‐level factors emerged, reflecting the importance of considering both the individual and the couple. However, further studies that specifically focus on the dyad as the unit of analysis are warranted.

Introduction : Studies in heterosexual HIV serodiscordant couples have provided critical evidence on the role of HIV treatments in reducing HIV transmission risk. However, there are limited data regarding the effect of treatment on HIV transmission in homosexual male couples. We examined features of male homosexual HIV serodiscordant relationships that may impact upon the design of HIV treatment and transmission studies. Methods : Data were from a prospective cohort study of HIV-negative homosexual men in Sydney, Australia. Men were followed up with six-monthly interviews and annual testing for HIV. Characteristics of men in HIV serodiscordant and seroconcordant relationships at baseline were compared, and a longitudinal analysis performed of rate of relationship break-up and of HIV incidence. Results : At baseline, 5.5% of participants ( n =79) had an HIV-positive partner. Most (80.8%) of these relationships were non-monogamous, and 36.7% of men reported recent unprotected anal intercourse (UAI) with casual partners. The rate of relationship break-up was 29.5 per 100 person-years. Half of men in serodiscordant relationships (49.4%) reported recent UAI with their regular partners. HIV incidence was 2.2 per 100 person-years. It was substantially higher in relationships of less than one year’s duration (6.1 per 100 person-years) and in men who reported unprotected receptive anal intercourse with ejaculation with their regular partners (15.5 per 100 person-years). Conclusions : Levels of HIV transmission risk and incidence were high, particularly in early relationships. Rates of relationship break-up were high. These data suggest that studies of HIV treatments and transmission in homosexual serodiscordant couples should focus on early relationships so as not to underestimate risk, and sample sizes must allow for high rates of relationship break-up. Keywords: HIV treatment as prevention; men who have sex with men; homosexual men; serodiscordant couples; HIV viral load; HIV transmission. (Published: 25 May 2015) Citation: Bavinton BR et al. Journal of the International AIDS Society 2015, 18 :19884 http://www.jiasociety.org/index.php/jias/article/view/19884 | http://dx.doi.org/10.7448/IAS.18.1.19884

Introduction: Despite scale-up of antiretroviral therapy (ART) for treating HIV-positive persons, HIV incidence remains elevated among those at high risk such as persons in serodiscordant partnerships. Antiretrovirals taken by HIV-negative persons as pre- exposure prophylaxis (PrEP) has the potential to avert infections in individuals in serodiscordant partnerships. Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV- positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation. Methods: To estimate the real world delivery costs of PrEP, we conducted micro-costing and time and motion analyses in an open-label prospective study of PrEP and ART delivery targeted to high-risk serodiscordant couples in Uganda (the Partners Demonstration Project). The cost (in USD, in 2012) of PrEP and ART for serodiscordant couples was assessed, with and without research components, in the study setting. Using Ministry of Health costs, the cost of PrEP and ART provision within a government programme was estimated, as was the cost of providing PrEP in addition to ART. We parameterized an HIV transmission model to estimate the health and economic impacts of 1) PrEP and ART targeted to high-risk serodiscordant couples in the context of current ARTuse and 2) increasing ARTcoverage to 55% of HIV-positive persons with CD4 5500 cells/mL without PrEP. The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years. Results: The annual cost of PrEP and ARTdelivery for serodiscordant couples was $1058 per couple in the study setting and $453 in the government setting. The portion of the programme cost due to PrEP was $408 and $92 per couple per year in the study and government settings, respectively. Over 10 years, a programme of PrEP and ART for high-risk serodiscordant couples was projected to avert 43% of HIV infections compared to current practice with an ICER of $1340 per infection averted. This was comparable to ART expansion alone, which would avert 37% of infections with an ICER of $1452. Conclusions: Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings.The annual cost of PrEP in this programme is less than $100 per serodiscordant couple if implemented in public clinics.

Introduction : Increased life expectancy of HIV-positive individuals during recent years has drawn attention to their quality of life, which includes fulfilment of fertility desires. In particular, heterosexual HIV serodiscordant couples constitute a special group for whom the balance between desired pregnancy and the risk of viral transmission should be carefully considered and optimized. Although advanced assisted reproductive technologies are available, such treatments are expensive and are often unavailable. Moreover, standard viral load testing and antiretroviral therapy may not be accessible due to structural or individual barriers. To reduce the risk of HIV transmission, a lower cost alternative is timed condomless sex combined with other risk-reduction strategies. However, timed condomless sex requires specific knowledge of how to accurately predict the fertile window in a menstrual cycle. The aim of this study was to summarize inexpensive fertility awareness methods (FAMs) that predict the fertile window and may be useful for counselling HIV-positive couples on lower cost options to conceive. Methods : Original English-language research articles were identified by a detailed Medline and Embase search in July 2014. Relevant citations in the included articles were also retrieved. Results and discussion : Calendar method, basal body temperature and cervicovaginal mucus secretions are the most accessible and sensitive FAMs, although poor specificity precludes their independent use in ovulation detection. In contrast, urinary luteinizing hormone testing is highly specific but less sensitive, and more expensive. To maximize the chance of conception per cycle, the likelihood of natural conception needs to be assessed with a basic fertility evaluation of both partners and a combination of FAMs should be offered. Adherence to other risk-reduction strategies should also be advised, and timely referral to reproductive medicine specialists is necessary when sub/infertility is suspected. Conclusions : FAMs provide effective, economical and accessible options for HIV serodiscordant couples to conceive while minimizing unnecessary viral exposure. It is important for health care providers to initiate conversations about fertility desires in HIV-positive couples and to educate identified couples on safer conception strategies. Keywords: HIV; serodiscordant couples; conception; timed intercourse; fertility awareness; fertility evaluation. (Published: 9 January 2015) Citation: Liao C et al. Journal of the International AIDS Society 2015, 18 :19447 http://www.jiasociety.org/index.php/jias/article/view/19447 | http://dx.doi.org/10.7448/IAS.18.1.19447

Introduction : HIV testing is key to the delivery of pre-exposure prophylaxis (PrEP): testing HIV-uninfected at-risk persons is the first step for PrEP initiation and ongoing HIV testing is an essential part of PrEP delivery. Thus, novel and cost-effective HIV-testing approaches to streamline delivery of PrEP are urgently needed. Within a demonstration project of PrEP for HIV prevention among high-risk HIV serodiscordant couples in Kenya (the Partners Demonstration Project), we conducted a pilot evaluation of HIV self-testing. Methods : Clinic visits were scheduled quarterly and included in-clinic HIV testing using fingerstick rapid HIV tests and refills of PrEP prescriptions. HIV oral fluid self-test kits were provided for participants to use in the two-month interval between scheduled quarterly clinic visits. Acceptability of HIV self-testing was assessed using both quantitative and qualitative methods. Results : We found that 222 of 226 (98%) HIV-uninfected persons who were offered accepted self-testing. Nearly all (96.8%) reported that using the self-testing kit was easy. More than half (54.5%) reportedly did not share the HIV results from self-testing with anyone and almost all (98.7%) the participants did not share the HIV self-testing kits with anyone. Many participants reported that HIV self-testing was empowering and reduced anxiety associated with waiting between clinic HIV tests. Conclusions : HIV self-testing was highly acceptable and may therefore be a feasible strategy to efficiently permit routine HIV testing between PrEP refills. Keywords: Feasibility; acceptability; HIV; self-testing; PrEP; Kenya (Published: 10 February 2017) Ngure K et al. Journal of the International AIDS Society 2017, 20 :21234 www.jiasociety.org/index.php/jias/article/view/21234 | http://dx.doi.org/10.7448/IAS.20.1.21234

Introduction: Stakeholders continue to discuss the appropriateness of antiretroviral-based pre-exposure prophylaxis (PrEP) for HIV prevention among sub-Saharan African and other women. In particular, women need formulations they can adhere to given that effectiveness has been found to correlate with adherence. Evidence from family planning shows that contraceptive use, continuation and adherence may be increased by expanding choices. To explore the potential role of choice in women's use of HIV prevention methods, we conducted a secondary analysis of research with female sex workers (FSWs) and men and women in serodiscordant couples (SDCs) in Kenya, and adolescent and young women in South Africa. Our objective here is to present their interest in and preferences for PrEP formulations pills, gel and injectable. Methods: In this qualitative study, in Kenya we conducted three focus groups with FSWs, and three with SDCs. In South Africa, we conducted two focus groups with adolescent girls, and two with young women. All focus groups were audio-recorded, transcribed and translated into English as needed. We structurally and thematically coded transcripts using a codebook and QSR NVivo 9.0; generated code reports; and conducted inductive thematic analysis to identify major trends and themes. Results: All groups expressed strong interest in PrEP products. In Kenya, FSWs said the products might help them earn more money, because they would feel safer accepting more clients or having sex without condoms for a higher price. SDCs said the products might replace condoms and reanimate couples' sex lives. Most sex workers and SDCs preferred an injectable because it would last longer, required little intervention and was private. In South Africa, adolescent girls believed it would be possible to obtain the products more privately than condoms. Young women were excited about PrEP but concerned about interactions with alcohol and drug use, which often precede sex. Adolescents did not prefer a particular formulation but noted benefits and limitations of each; young women's preferences also varied. Conclusions: The circumstances and preferences of sub-Saharan African women are likely to vary within and across groups and to change over time, highlighting the importance of choice in HIV prevention methods.

We are living in an extraordinary moment in the HIV response. Advances in science, implementation, community engagement and political support have led to unprecedented optimism and measurable declines in new forms of HIV infections in many communities, populations and affected countries. There is growing realization that through strategic use of the prevention, treatment and care advances we now have in hand, the fourth decade of the AIDS pandemic could be where we finally achieve meaningful and sustained reductions in new HIV infections, close to full life expectancy for those living with the virus, and integration of HIV into health services, which could be beneficial to both HIV programmes and strapped health systems. We are learning how to use the powerful insight that effective early HIV treatment is a potent HIV-preventive intervention for serodiscordant couples and may have preventive impacts at community and population levels. And we have new and combined prevention tools and technologies (and more in the research and development pipeline), which could markedly increase prevention choices and offer real promise in protecting those most in need of prevention. (Published: 10 December 2013) Citation: Beyrer C. Journal of the International AIDS Society 2013, 16 :18968 http://www.jiasociety.org/index.php/jias/article/view/18968 | http://dx.doi.org/10.7448/IAS.16.1.18968

Introduction : Safer conception interventions should ideally involve both members of an HIV-affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa. Methods : We conducted six semistructured individual interviews per site (a total of 12 interviews) as well as a focus group discussion at each clinic site (a total of 13 additional participants). All interviews were coded in Atlas.ti using a grounded theory approach to develop codes and to identify core themes and subthemes in the data. Results : Managing the clinical and relationship complexities related to serodiscordant couples wishing to conceive was flagged as a concern by all categories of health providers. Providers added that, in the HIV clinical setting, they often found it difficult to balance their professional priorities, to maintain the health of their clients, and to ensure that partners were not exposed to unnecessary risk, while still supporting their clients’ desires to have a child. Many providers expressed concern over issues related to disclosure of HIV status between partners, particularly when managing couples where one partner was not aware of the other’s status and expressed the desire for a child. Provider experiences were that female clients most often sought out care, and it was difficult to reach the male partner to include him in the consultation. Conclusions : Providers require support in dealing with HIV disclosure issues and in becoming more confident in dealing with couples and serodiscordance. Prior to implementing safer conception programmes, focused training is needed for healthcare professionals to address some of the ethical and relationship issues that are critical in the context of safer conception care. Keywords: safer conception; couples; serodiscordance; healthcare providers. (Published 12 March 2014) Citation: Crankshaw TL et al. Journal of the International AIDS Society 2014, 17 :18832 http://www.jiasociety.org/index.php/jias/article/view/18832 | http://dx.doi.org/10.7448/IAS.17.1.18832

Despite major advances in HIV therapy, the number of new HIV infections remains very high, even in high-income countries where resurgence among men who have sex with men (MSM) has been witnessed. New prevention strategies have therefore to be assessed in order to curb the incidence of HIV infection. Recent studies have explored the effectiveness of antiretroviral therapy (ART) for HIV prevention and have generally yielded encouraging results. ART has been used successfully to prevent mother-to-child transmission of HIV, HIV acquisition following occupational or sexual exposure to HIV (post-exposure prophylaxis), and more recently, to reduce the risk of HIV transmission within a serodiscordant couple by treating the HIVpositive partner (HPTN 052 study). Another possible use of ART in prevention is pre-exposure prophylaxis, where ART is taken by an HIV-seronegative individual before HIV exposure. This PrEP strategy has been validated in animal models and more recently assessed in clinical trials in humans. The results of six large efficacy trials of PrEP are now available, but results have been inconsistent. The use of tenofovir gel in women at higher risk in Sub-Saharan Africa has shown efficacy when given before and after sex in the Caprisa 004 study (reduction of 39% of the incidence of HIV), whereas no efficacy was shown with daily use in the VOICE trial. Similarly, daily oral PrEP with tenofovir or tenofovir and emtricitabine has proved effective in the Iprex trial in MSM (reduction of 42% of HIV incidence), in the Partners PrEP study (reduction of 67 to 75% in HIV incidence) and in the TDF-2 trial (reduction of 63% in HIV incidence), but not in the Fem-PrEP or the VOICE trials in women. There are many potential explanations for these apparently conflicting results, such as the populations in which these strategies have been assessed, the differential pharmacokinetics of ART in the male and female genital tracts and most likely the high level of adherence which is required to confer protection against HIV acquisition. These results have also generated a lot of controversy about the implementation of PrEP. Some think that the data are good enough to rollout PrEP in key populations at higher risk. Others think more research is needed before PrEP is implemented because of concerns around safety, emerging resistance, cost and change in sexual behaviour that might offset the benefit of PrEP. Safety is indeed a major concern in healthy individuals. New studies are underway to address these issues and are assessing PrEP regimens in open-label studies (Iprex-OLE in MSM), intermittent PrEP regimens to try to improve adherence, new ART classes and new modalities of drug delivery. PrEP is therefore a promising biomedical intervention that might be used in the near future in addition to current prevention methods to prevent HIV infection and help control the spread of this infection. (Published: 11 November 2012) Citation: Abstracts of the Eleventh International Congress on Drug Therapy in HIV Infection Molina JM. Journal of the International AIDS Society 2012, 15 (Suppl 4):18069 http://www.jiasociety.org/index.php/jias/article/view/18069 | http://dx.doi.org/10.7448/IAS.15.6.18069

Background : The current HIV epidemic in Thailand is primarily driven by new cases among men who have sex with men (MSM). HPTN052 study demonstrated 96% efficacy of immediate antiretroviral therapy (ART) to reduce HIV transmission among serodiscordant heterosexual couples. As a result, universal HIV testing and immediate ART has emerged as a strategy to reduce HIV transmission in certain at-risk populations. The acceptability of this strategy, however, is unknown in MSM. Methods: From August 2011-March 2012, we conducted a cross-sectional study using self-administered questionnaires to assess attitudes towards universal HIV testing and immediate ART among MSM VCT clients in Bangkok. Participants were asked to complete the questionnaires prior to and after knowing their HIV status. The study was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. Results: Of 342 MSM, the median age (IQR) was 26 (22-31) years, and 34.2% had bachelor's degree or higher. Previous HIV testing was reported by 69.9%, 35.2% of which had HIV testing annually. The most common reasons for previous HIV testing included perceived risk behaviors (63.6%), annual health checkup (26.4%), and partner's request (13.8%). Prior to receiving pre-test counseling, 74.4% expressed interest to get regular HIV testing. Health benefits from testing (59.6%), free testing (36.5%), and speedy service (35.7%) were the most common persuasive reasons to come for regular HIV testing. Longevity (73.1%) and prevention of HIV transmission to others (58.4%) were reasons for interest in immediate ART (if tested positive) program while costs (37.0%) and life-long burden (36.7%) were cited as main barriers. Among MSM who tested HIV-positive (n=45, 13.2%), the interest to participate in immediate ART program was very high both before and after knowing their HIV status (86.7% vs 93.3%, p=0.371). Among HIV-negative MSM, the interest to participate in regular HIV testing program significantly increased after knowing HIV status (83.4% vs 77.0%, p

The 2013 World Health Organization's (WHO) Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection provide more than 50 new recommendations across the continuum of HIV care, including recommendations on HIV testing, using antiretroviral drugs for prevention, linking individuals to HIV care and treatment services, initiating and maintaining antiretroviral therapy (ART) and monitoring treatment. Guidance is provided across all age groups and populations of adults, pregnant and breastfeeding women, adolescents and key populations. The guidelines are based on a public health approach to expanding the use of ARV drugs for HIV treatment and prevention, with a particular focus on resource-limited settings. The most important new clinical recommendations include: treating adults, adolescents and older children earlier - starting ART in all individuals with a CD4 cell count of 500 cells/mm(3) or less (but giving priority to those with advanced clinical disease or a CD4 cell count less than 350 cells/mm(3)); starting ART at any CD4 cell count in certain populations, including those with active TB (existing recommendation), Hepatitis B infection and severe chronic liver disease, HIV-positive partners in serodiscordant couples (existing recommendation), pregnant and breastfeeding women, and children younger than 5 years of age; a preferred first-line ART regimen of Tenofovir+3TC or FTC+ Efavirenz as a once-daily fixed-dose combination for adults, pregnant women, and children aged 3 years and older; and the use of viral load testing as the preferred approach to monitoring the response to ART and to diagnose treatment failure. Guidance is also provided on enhancing the efficiency and effectiveness of HIV services, including strategies to improve retention in care, and adherence to ART; task-shifting to address human resource gaps; decentralizing delivery of ART to primary health care, and integrating ART services within maternal and child health, TB or drug dependency clinics. There is additional guidance for programme managers on how to plan HIV programmes and use resources most efficiently.

The question of whether to initiate ART at higher CD4+ cell counts than currently recommended by World Health Organization (WHO) treatment guidelines received much attention at the XVII International AIDS Conference (AIDS 2008). If studies presented at the conference ultimately lead to a revision of WHO treatment guidance, the estimated number of people who will need ART globally will increase substantially. Task-shifting is emerging as an important strategy for dealing with the acute shortage of health care workers in many high-burden countries, and several studies presented at AIDS 2008 demonstrated the impressive health system efficiencies garnered by using nurses or other health care providers to deliver HIV care and treatment. Other key presentations and discussion at the conference focused on the optimal time to start TB treatment in HIV-infected patients, the growing risk of resistance in high-burden countries, including its impact on future treatment options, and several large cohort trials testing optimal drug regimens in resource-limited settings. Biomedical prevention research continues to confirm the long-term, protective benefits of circumcision. Several studies involving HIV serodiscordant heterosexual couples have produced data suggesting a strong protective effect of ART for HIV-negative partners. Disappointing results from recent vaccine and non-ARV based microbicides trials are nevertheless providing important data to this field, and the expanding number of pre-exposure prophylaxis (PrEP) trials and ARV-based microbicides appear to provide the best hope for a new, efficacious biomedical prevention intervention.