Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial

"The Cango Lyec Project - Healing the Elephant": HIV related vulnerabilities of post-conflict affected populations aged 13-49 years living in three Mid-Northern Uganda districts

BACKGROUND

The protracted war between the Government of Uganda and the Lord's Resistance Army in Northern Uganda (1996-2006) resulted in widespread atrocities, destruction of health infrastructure and services, weakening the social and economic fabric of the affected populations, internal displacement and death. Despite grave concerns that increased spread of HIV/AIDS may be devastating to post conflict Northern Uganda, empirical epidemiological data describing the legacy of the war on HIV infection are scarce.

METHODS

The 'Cango Lyec' Project is an open cohort study involving conflict-affected populations living in three districts of Gulu, Nwoya and Amuru in mid-northern Uganda. Between November 2011 and July 2012, 8 study communities randomly selected out of 32, were mapped and house-to-house census conducted to enumerate the entire community population. Consenting participants aged 13-49 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioural characteristics, in the local Luo language. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression was used to determine factors associated with HIV prevalence at baseline.

RESULTS

A total of 2954 participants were eligible, of whom 2449 were enrolled. Among 2388 participants with known HIV status, HIV prevalence was 12.2% (95%CI: 10.8-13.8), higher in females (14.6%) than males (8.5%, p < 0.001), higher in Gulu (15.2%) than Nwoya (11.6%, p < 0.001) and Amuru (7.5%, p = 0.006) districts. In this post-conflict period, HIV infection was significantly associated with war trauma experiences (Adj. OR = 2.50; 95%CI: 1.31-4.79), the psychiatric problems of PTSD (Adj. OR = 1.44; 95%CI: 1.06-1.96), Major Depressive Disorder (Adj. OR = 1.89; 95%CI: 1.28-2.80) and suicidal ideation (Adj. OR = 1.87; 95%CI: 1.34-2.61). Other HIV related vulnerabilities included older age, being married, separated, divorced or widowed, residing in an urban district, ulcerative sexually transmitted infections, and staying in a female headed household. There was no evidence in this study to suggest that people with a history of abduction were more likely to be HIV positive.

CONCLUSIONS

HIV prevalence in this post conflict-affected population is high and is significantly associated with age, trauma, depression, history of ulcerative STIs, and residing in more urban districts. Evidence-based HIV/STI prevention programs and culturally safe, gender and trauma-informed are urgently needed.

Genital inflammation, immune activation and risk of sexual HIV acquisition

PURPOSE OF REVIEW

Women who have genital inflammation are at increased risk of sexual HIV infection. The purpose of this review is to evaluate the mechanisms for this relationship, causes of genital inflammation, and strategies to manage this condition.

RECENT FINDINGS

We have recently shown in a cohort of South African women that HIV seroconversion was associated with persistently raised genital inflammatory cytokines (including MIP-1α, MIP-1β, and IP-10). Elevated inflammatory cytokine concentrations may facilitate HIV infection by recruiting and activating HIV target cells and disrupting the mucosal epithelial barrier. Bacterial vaginosis and sexually transmitted infections (STIs), which are predominantly asymptomatic in women, cause lower genital tract inflammation and increased HIV acquisition risk. In Africa, where syndromic management of STIs and bacterial vaginosis is standard-of-care, the substantial burden of asymptomatic infections has likely contributed to high-HIV incidence rates.

SUMMARY

A genital inflammatory profile contributes to the high risk of HIV acquisition in African women. STIs and bacterial vaginosis are poorly managed in Africa and other developing nations and as such remain major drivers of persistent genital inflammation and HIV acquisition among these women.

New Biomedical Technologies and Strategies for Prevention of HIV and Other Sexually Transmitted Infections

Sexually transmitted infections remain to be of public health concern in many developing countries. Their control is important, considering the high incidence of acute infections, complications and sequelae, and their socioeconomic impact. This article discusses the new biomedical technologies and strategies for the prevention of HIV and other sexually transmitted infections.

Evaluation of a demand-creation intervention for couples' HIV testing services among married or cohabiting individuals in Rakai, Uganda: a cluster-randomized intervention trial

BACKGROUND

Uptake of couples' HIV counseling and testing (couples' HCT) services remains largely low in most settings. We report the effect of a demand-creation intervention trial on couples' HCT uptake among married or cohabiting individuals who had never received couples' HCT.

METHODS

This was a cluster-randomized intervention trial implemented in three study regions with differing HIV prevalence levels (range: 9-43 %) in Rakai district, southwestern Uganda, between February and September 2014. We randomly assigned six clusters (1:1) to receive the intervention or serve as the comparison arm using computer-generated random numbers. In the intervention clusters, individuals attended small group, couple and male-focused interactive sessions, reinforced with testimonies from 'expert couples', and received invitation coupons to test together with their partners at designated health facilities. In the comparison clusters, participants attended general adult health education sessions but received no invitation coupons. The primary outcome was couples' HCT uptake, measured 12 months post-baseline. Baseline data were collected between November 2013 and February 2014 while follow-up data were collected between March and April 2015. We conducted intention-to-treat analysis using a mixed effects Poisson regression model to assess for differences in couples' HCT uptake between the intervention and comparison clusters. Data analysis was conducted using STATA statistical software, version 14.1.

RESULTS

Of 2135 married or cohabiting individuals interviewed at baseline, 42 % (n = 846) had ever received couples' HCT. Of those who had never received couples' HCT (n = 1,174), 697 were interviewed in the intervention clusters while 477 were interviewed in the comparison clusters. 73.6 % (n = 513) of those interviewed in the intervention and 82.6 % (n = 394) of those interviewed in the comparison cluster were interviewed at follow-up. Of those interviewed, 72.3 % (n = 371) in the intervention and 65.2 % (n = 257) in the comparison clusters received HCT. Couples' HCT uptake was higher in the intervention than in the comparison clusters (20.3 % versus 13.7 %; adjusted prevalence ratio (aPR) = 1.43, 95 % CI: 1.02, 2.01, P = 0.04).

CONCLUSION

Our findings show that a small group, couple and male-focused, demand-creation intervention reinforced with testimonies from 'expert couples', improved uptake of couples' HCT in this rural setting.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02492061 . Date of registration: June 14, 2015.

Evaluating HIV/STD Interventions in Developing Countries: Do Current Indicators Do Justice to Advances in Intervention Approaches?

HIV continues to spread unabated in many developing countries. Here we consider the interventions that are currently in place and critically discuss the methods that are being used to evaluate them as reported in the published literature. In recent years there has been a move away from highly individual-oriented interventions towards more participatory approaches that emphasise techniques such as community-led peer education and group discussions. However, this move towards more community orientated intervention techniques has not been matched by the development of evaluation methods with which to capture and explain the community and social changes which are often necessary preconditions for health-enhancing behaviour change. Evaluation research continues to rely on quantitative methodologies that fail to elucidate the complex changes that the newer interventions seek to promote within target communities. In addition, these methods of evaluation tend to rely on the use of highly individualistic and quantitative biomedical indicators such as HIV/STD rates, or knowledge, attitude, perception and behaviour (KAPB) survey questionnaires. We argue that such approaches are inadequate for the task of tracking and measuring important determinants of programme success such as psycho-social changes, features of the community-intervention interface and the degree of trust and identification with which members of target communities regard particular interventions. Rigorously conducted qualitative process evaluations taking account of the above factors could make a key contribution to the development of more successful HIV-prevention interventions.

Epidemiological impact of a syphilis vaccine: a simulation study

Despite the availability of inexpensive antimicrobial treatment, syphilis remains prevalent worldwide, affecting millions of individuals. Furthermore, syphilis infection is suspected of increasing both susceptibility to, and tendency to transmit, HIV. Development of a syphilis vaccine would be a potentially promising step towards control, but the value of dedicating resources to vaccine development should be evaluated in the context of the anticipated benefits. Here, we use a detailed mathematical model to explore the potential impact of rolling out a hypothetical syphilis vaccine on morbidity from both syphilis and HIV and compare it to the impact of expanded ‘screen and treat’ programmes using existing treatments. Our results suggest that an efficacious vaccine has the potential to sharply reduce syphilis prevalence under a wide range of scenarios, while expanded treatment interventions are likely to be substantially less effective. Our modelled interventions in our simulated study populations are expected to have little effect on HIV, and in some scenarios lead to small increases in HIV incidence, suggesting that interventions against syphilis should be accompanied with interventions against other sexually transmitted infections to prevent the possibility that lower morbidity or lower perceived risk from syphilis could lead to increases in other sexually transmitted diseases.

Evaluating Public Health Interventions: 2. Stepping Up to Routine Public Health Evaluation With the Stepped Wedge Design

In a stepped wedge design (SWD), an intervention is rolled out in a staggered manner over time, in groups of experimental units, so that by the end, all units experience the intervention. For example, in the MaxART study, the date at which to offer universal antiretroviral therapy to otherwise ineligible clients is being randomly assigned in nine "steps" of four months duration so that after three years, all 14 facilities in northern and central Swaziland will be offering early treatment. In the common alternative, the cluster randomized trial (CRT), experimental units are randomly allocated on a single common start date to the interventions to be compared. Often, the SWD is more feasible than the CRT, both for practical and ethical reasons, but takes longer to complete. The SWD permits both within- and between- unit comparisons, while the CRT only allows between-unit comparisons. Thus, confounding bias with respect to time-invariant factors tends to be lower in an SWD than a CRT, but the SWD cannot as readily control for confounding by time-varying factors. SWDs have generally more statistical power than CRTs, especially as the intraunit correlation and the number of participants within unit increases. Software for both designs are available, although for a more limited set of SWD scenarios.

Meta-analyses involving cluster randomization trials: a review of published literature in health care

Throughout the 1980s and 1990s cluster randomization trials have been increasingly used to evaluate effectivenessof health care intervention. Such trials have raised several methodologic challenges in analysis. Meta-analyses involving cluster randomization trials are becoming common in the area of health care intervention. However, as yet there has been no empirical evidence of current practice in the meta-analyses. Thus a review was performed to identify and examine synthesis approaches of meta-analyses involving cluster randomization trials in the published literature. Electronic databases were searched for meta-analyses involving cluster randomization trials from the earliest date available to 2000. Once a meta-analysis was identified, papers on the relevant cluster randomization trials included were also requested. Each of the original papers of cluster randomization trials included was examined for its randomized design and unit, and adjustment for clustering effect in analysis. Each of the selected meta-analyses was then evaluated as to its synthesis concerning clustering effect. In total, 25 eligible meta-analyses were reviewed. Of these, 15 meta-analyses reported simple conventional methods of the fixed-effect model as method of analysis, while six did not incorporate the cluster randomization trial results in the synthesis methods but described the trial results individually. Three meta-analyses attempted to account for the clustering effect in the synthesis methods but approaches were in arbitrary. Fifteen meta-analyses included more than one cluster randomization trial, each of which included cluster randomization trials with a mixture of randomized designs and units, and units of analysis. These mixture situations might increase heterogeneity, but have not been considered in any meta-analysis. Some methods dealing with a binary outcome for some specific situations have been discussed. In conclusion, some difficulties in the quantitative synthesis procedures were found in the meta-analyses involving cluster randomization trials. Recommendations in the applications of approaches to some specific situations in a binary outcome variable have also been provided. There are still, however, several methodologic issues of the meta-analyses involving cluster randomization trials that need to be investigated further.

Does HIV Exploit the Inflammatory Milieu of the Male Genital Tract for Successful Infection?

In many parts of the World, medical male circumcision (MMC) is used as standard prevention of care against HIV infection. This is based on seminal reports made over 10 years ago that removal of the foreskin provides up to 60% protection against HIV infection in males and seems currently the best antiretroviral-free prevention strategy yet against the global epidemic. We explore the potential mechanisms by which MMC protects against HIV-1 acquisition and that one of the oldest, albeit re-invented, rituals of removing a foreskin underscores the exploitative nature of HIV on the anatomy and tissue of the uncircumcised penis. Furthermore, foreskin removal also reveals how males acquire HIV, and in reality, the underlying mechanisms of MMC are not known. We argue that the normal sequelae of inflammation in the male genital tract (MGT) for protection from sexually transmitted infections (STI)-induced pathology represents a perfect immune and microbial ecosystem for HIV acquisition. The accumulation of HIV-1 target cells in foreskin tissue and within the urethra in response to STIs, both during and after resolution of infection, suggests that acquisition of HIV-1, through sexual contact, makes use of the natural immune milieu of the MGT. Understanding immunity in the MGT, the movement of HIV-1 target cells to the urethra and foreskin tissue upon encounter with microbial signals would provide more insight into viral acquisition and lay the foundation for further prevention strategies in males that would be critical to curb the epidemic in all sexual partners at risk of infection. The global female-centric focus of HIV-1 transmission and acquisition research has tended to leave gaps in our knowledge of what determines HIV-1 acquisition in men and such understanding would provide a more balanced and complete view of viral acquisition.

Economic Evaluation of Community-Based HIV Prevention Programs in Ontario: Evidence of Effectiveness in Reducing HIV Infections and Health Care Costs

Investments in community-based HIV prevention programs in Ontario over the past two and a half decades are assumed to have had an impact on the HIV epidemic, but they have never been systematically evaluated. To help close this knowledge gap, we conducted a macro-level evaluation of investment in Ontario HIV prevention programs from the payer perspective. Our results showed that, from 1987 to 2011, province-wide community-based programs helped to avert a total of 16,672 HIV infections, saving Ontario's health care system approximately $6.5 billion Canadian dollars (range 4.8-7.5B). We also showed that these community-based HIV programs were cost-saving: from 2005 to 2011, every dollar invested in these programs saved about $5. This study is an important first step in understanding the impact of investing in community-based HIV prevention programs in Ontario and recognizing the impact that these programs have had in reducing HIV infections and health care costs.

Prevalence and Correlates of Chlamydia trachomatis and Neisseria gonorrhoeae by Anatomic Site Among Urban Thai Men Who Have Sex With Men

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection are prevalent among men who have sex with men (MSM) and may infect multiple anatomic sites. We measured site-specific prevalence and correlates of CT and NG infection among Bangkok MSM Cohort Study participants.

METHODS

In April 2006 to November 2010, 1744 men enrolled in the Bangkok MSM Cohort Study. Participants provided historical information and underwent physical examination. Rectal, urethral, and pharyngeal CT and NG screening were performed by nucleic acid amplification and/or culture. Logistic regression was used to identify correlates of site-specific CT, NG, and coinfection.

RESULTS

Among 1743 participants, 19.2% were infected with CT and/or NG. CT, NG, and CT-NG coinfection were detected in 11.6%, 4.6%, and 2.9%, of participants, respectively. Rectal, urethral, and pharyngeal CT infections were detected in 9.5%, 4.5%, and 3.6% of cases. N. gonorrhoeae was present at these sites in 6.1%, 1.8%, and 0.5% of cases. Most infections were asymptomatic (CT: 95.3%, NG: 83.2%). Rectal CT and NG infections were mutually associated (CT: adjusted odds ratio [AOR], 5.4; 95% confidence interval [CI], 3.4-8.7; NG: AOR, 2.4; 95% CI, 1.1-5.2) and independently associated with HIV infection (CT: AOR, 1.6, 95% CI, 1.0-2.4; NG: AOR, 2.0, 95% CI, 1.3-3.1). Numerous behavioral correlates of infection were observed.

CONCLUSIONS

CT and NG infections are highly prevalent among MSM in Bangkok, most frequently affect the rectum, and are most often asymptomatic. Routine screening of asymptomatic MSM for CT and NG infection should include rectal sampling and focus on men with HIV and a history of other sexually transmitted infections.

HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities

Global trends in HIV infection demonstrate an overall increase in HIV prevalence and substantial declines in AIDS related deaths largely attributable to the survival benefits of antiretroviral treatment. Sub-Saharan Africa carries a disproportionate burden of HIV, accounting for more than 70% of the global burden of infection. Success in HIV prevention in sub-Saharan Africa has the potential to impact on the global burden of HIV. Notwithstanding substantial progress in scaling up antiretroviral therapy (ART), sub-Saharan Africa accounted for 74% of the 1.5 million AIDS related deaths in 2013. Of the estimated 6000 new infections that occur globally each day, two out of three are in sub-Saharan Africa with young women continuing to bear a disproportionate burden. Adolescent girls and young women aged 15-24 years have up to eight fold higher rates of HIV infection compared to their male peers. There remains a gap in women initiated HIV prevention technologies especially for women who are unable to negotiate the current HIV prevention options of abstinence, behavior change, condoms and medical male circumcision or early treatment initiation in their relationships. The possibility of an AIDS free generation cannot be realized unless we are able to prevent HIV infection in young women. This review will focus on the epidemiology of HIV infection in sub-Saharan Africa, key drivers of the continued high incidence, mortality rates and priorities for altering current epidemic trajectory in the region. Strategies for optimizing the use of existing and increasingly limited resources are included.

Strong Country Level Correlation between Syphilis and HSV-2 Prevalence

Background. Syphilis is curable but Herpes Simplex Virus-2 (HSV-2) is not. As a result, the prevalence of syphilis but not HSV-2 may be influenced by the efficacy of national STI screening and treatment capacity. If the prevalence of syphilis and HSV-2 is found to be correlated, then this makes it more likely that something other than differential STI treatment is responsible for variations in the prevalence of both HSV-2 and syphilis. Methods. Simple linear regression was used to evaluate the relationship between national antenatal syphilis prevalence and HSV-2 prevalence in women in two time periods: 1990–1999 and 2008. Adjustments were performed for the laboratory syphilis testing algorithm used and the prevalence of circumcision. Results. The prevalence of syphilis was positively correlated with that of HSV-2 for both time periods (adjusted correlations, 20–24-year-olds: 1990–99: R² = 0.54, P < 0.001; 2008: R² = 0.41, P < 0.001 and 40–44-year-olds: 1990–99: R² = 0.42, P < 0.001; 2008: R² = 0.49, P < 0.001). Conclusion. The prevalence of syphilis and HSV-2 is positively correlated. This could be due to a common set of risk factors underpinning both STIs.

Low HIV testing uptake following diagnosis of a sexually transmitted infection in Spain: implications for the implementation of efficient strategies to reduce the undiagnosed HIV epidemic

Sexually transmitted infections (STIs) are recognized as one of the conditions in which HIV testing is most clearly indicated. We analyse whether people diagnosed with an STI are being tested for HIV according to the experience of participants in an outreach rapid testing programme in Spain. Between 2008 and 2010, 6293 individuals underwent rapid testing and completed a self-administered questionnaire. We calculated the percentage of individuals that were diagnosed with an STI in the last 5 years and identified the setting where the last episode occurred. We then determined the percentage not receiving an HIV test after the last STI diagnosis and estimated the associated factors. Overall, 17.3% (N = 959) of participants reported an STI diagnosis in the last 5 years, of which 81.5% occurred in general medical settings. Sixty-one percent reported not undergoing HIV testing after their last STI diagnosis, 2.2% of whom reported they had refused the test. Not receiving an HIV test after the last STI diagnosis was independently associated with not being a man who has sex with men (MSM), having had fewer sexual partners, being diagnosed in general medical settings and having received a diagnosis other than syphilis. An unacceptably large percentage of people diagnosed with STI are not being tested for HIV because healthcare providers frequently fail to offer the test. Offering routine HIV testing at general medical settings, regardless of the type of STI diagnosed and population group, should be a high priority and is probably a more efficient strategy than universal screening in general healthcare settings.

Prevalence of reproductive tract infections and the predictive value of girls' symptom-based reporting: findings from a cross-sectional survey in rural western Kenya

Objectives

Reproductive tract infections (RTIs), including sexually acquired, among adolescent girls is a public health concern, but few studies have measured prevalence in low-middle-income countries. The objective of this study was to examine prevalence in rural schoolgirls in Kenya against their reported symptoms.

Methods

In 2013, a survey was conducted in 542 adolescent schoolgirls aged 14–17 years who were enrolled in a menstrual feasibility study. Vaginal self-swabbing was conducted after girls were interviewed face-to-face by trained nurses on symptoms. The prevalence of girls with symptoms and laboratory-confirmed infections, and the sensitivity, specificity, positive and negative predictive values of symptoms compared with laboratory results, were calculated.

Results

Of 515 girls agreeing to self-swab, 510 answered symptom questions. A quarter (24%) reported one or more symptoms; most commonly vaginal discharge (11%), pain (9%) or itching (4%). Laboratory tests confirmed 28% of girls had one or more RTI. Prevalence rose with age; among girls aged 16–17 years, 33% had infections. Bacterial vaginosis was the most common (18%), followed by Candida albicans (9%), Chlamydia trachomatis (3%), Trichomonas vaginalis (3%) and Neisseria gonorrhoeae (1%). Reported symptoms had a low sensitivity and positive predictive value. Three-quarters of girls with bacterial vaginosis and C. albicans, and 50% with T. vaginalis were asymptomatic.

Conclusions

There is a high prevalence of adolescent schoolgirls with RTI in rural Kenya. Public efforts are required to identify and treat infections among girls to reduce longer-term sequelae but poor reliability of symptom reporting minimises utility of symptom-based diagnosis in this population.

Trial registration number

ISRCTN17486946.

Impact of Contextual Factors on the Effect of Interventions to Improve Health Worker Performance in Sub-Saharan Africa: Review of Randomised Clinical Trials

BACKGROUND

Africa bears 24% of the global burden of disease but has only 3% of the world's health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness.

METHODS AND FINDINGS

A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions' components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover.

CONCLUSIONS

Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.

Barriers to access reproductive health care for pregnant adolescent girls: a qualitative study in Tanzania

AIMS

In Tanzania, approximately 25% of adolescents give birth and 50% more become sexually active during adolescence. We hypothesised that reproductive health education and services for adolescent girls are inaccessible and conducted this study to gain insights into their perceptions of sexually transmitted infections (STIs) and barriers to reproductive health service utilisation in rural Mwanza, Tanzania.

METHODS

We conducted nine focus groups among pregnant adolescents aged 15-20 years. Data were transcribed, translated and coded for relevant themes using NVivo10 software for qualitative data analysis.

RESULTS

Most participants were aware of the dangers of STIs to themselves and their unborn babies, but did not perceive themselves as at risk of acquiring STIs. They viewed condoms as ineffective for preventing STIs and pregnancies and unnecessary for those in committed relationships. Stigma, long waiting times, and lack of privacy in the clinics discouraged adolescent girls from seeking reproductive health care.

CONCLUSION

Reproductive health care for adolescent girls who are not pregnant is practically nonexistent in Tanzania. Healthcare access for pregnant young women is also limited. Targeted changes to increase clinic accessibility and to provide reproductive health education to all rather than only pregnant women have the potential to address these gaps.

The Art of HIV Elimination: Past and Present Science

INTRODUCTION

Remarkable strides have been made in controlling the HIV epidemic, although not enough to achieve epidemic control. More recently, interest in biomedical HIV control approaches has increased, but substantial challenges with the HIV cascade of care hinder successful implementation. We summarise all available HIV prevention methods and make recommendations on how to address current challenges.

DISCUSSION

In the early days of the epidemic, behavioural approaches to control the HIV dominated, and the few available evidence-based interventions demonstrated to reduce HIV transmission were applied independently from one another. More recently, it has become clear that combination prevention strategies targeted to high transmission geographies and people at most risk of infections are required to achieve epidemic control. Biomedical strategies such as male medical circumcision and antiretroviral therapy for treatment in HIV-positive individuals and as pre-exposure prophylaxis in HIV-negative individuals provide immense promise for the future of HIV control. In resource-rich settings, the threat of HIV treatment optimism resulting in increased sexual risk taking has been observed and there are concerns that as ART roll-out matures in resource-poor settings and the benefits of ART become clearly visible, behavioural disinhibition may also become a challenge in those settings. Unfortunately, an efficacious vaccine, a strategy which could potentially halt the HIV epidemic, remains elusive.

CONCLUSION

Combination HIV prevention offers a logical approach to HIV control, although what and how the available options should be combined is contextual. Therefore, knowledge of the local or national drivers of HIV infection is paramount. Problems with the HIV care continuum remain of concern, hindering progress towards the UNAIDS target of 90-90-90 by 2020. Research is needed on combination interventions that address all the steps of the cascade as the steps are not independent of each other. Until these issues are addressed, HIV elimination may remain an unattainable goal.

Bacterial Vaginosis and Subclinical Markers of Genital Tract Inflammation and Mucosal Immunity

Bacterial vaginosis (BV) has been linked to an increased risk of human immunodeficiency virus (HIV) acquisition and transmission in observational studies, but the underlying biological mechanisms are unknown. We measured biomarkers of subclinical vaginal inflammation, endogenous antimicrobial activity, and vaginal flora in women with BV and repeated sampling 1 week and 1 month after completion of metronidazole therapy. We also compared this cohort of women with BV to a healthy control cohort without BV. A longitudinal, open label study of 33 women with a Nugent score of 4 or higher was conducted. All women had genital swabs, cervicovaginal lavage (CVL) fluid, and cervicovaginal biopsies obtained at enrollment and received 7 days of metronidazole treatment. Repeat sampling was performed approximately 1 week and 1 month after completion of therapy. Participant's baseline samples were compared to a healthy, racially matched control group (n=13) without BV. The CVL from women with resolved BV (Nugent 0-3) had significantly higher anti-HIV activity, secretory leukocyte protease inhibitor (SLPI), and growth-related oncogene alpha (GRO-α) levels and their ectocervical tissues had significantly more CD8 cells in the epithelium. Women with persistent BV after treatment had significantly higher levels of interleukin-1β, tumor necrosis factor alpha (TNF-α), and intercellular adhesion molecule 1 (ICAM-1) in the CVL. At study entry, participants had significantly greater numbers of CCR5(+) immune cells and a higher CD4/CD8 ratio in ectocervical tissues prior to metronidazole treatment, compared to a racially matched cohort of women with a Nugent score of 0-3. These data indicate that BV is associated with changes in select soluble immune mediators, an increase in HIV target cells, and a reduction in endogenous antimicrobial activity, which may contribute to the increased risk of HIV acquisition.

Education, HIV, and Early Fertility: Experimental Evidence from Kenya

A seven-year randomized evaluation suggests education subsidies reduce adolescent girls' dropout, pregnancy, and marriage but not sexually transmitted infection (STI). The government's HIV curriculum, which stresses abstinence until marriage, does not reduce pregnancy or STI. Both programs combined reduce STI more, but cut dropout and pregnancy less, than education subsidies alone. These results are inconsistent with a model of schooling and sexual behavior in which both pregnancy and STI are determined by one factor (unprotected sex), but consistent with a two-factor model in which choices between committed and casual relationships also affect these outcomes.

Measuring the Potential Impact of Combination HIV Prevention in Sub-Saharan Africa

A public health approach to combination HIV prevention is advocated to contain the epidemic in sub-Saharan Africa. We explore the implications of universal access to treatment along with HIV education scale-up in the region. We develop an HIV transmission model to investigate the impacts of universal access to treatment, as well as an analytical framework to estimate the effects of HIV education scale-up on the epidemic. We calibrate the model with data from South Africa and simulate the impacts of universal access to treatment along with HIV education scale-up on prevalence, incidence, and HIV-related deaths over a course of 15 years. Our results show that the impact of combined interventions is significantly larger than the summation of individual intervention impacts (super-additive property). The combined strategy of universal access to treatment and HIV education scale-up decreases the incidence rate by 74% over the course of 15 years, whereas universal access to treatment and HIV education scale up will separately decrease that by 43% and 8%, respectively. Combination HIV prevention could be notably effective in transforming HIV epidemic to a low-level endemicity. Our results suggest that in designing effective combination prevention in sub-Saharan Africa, priorities should be given to achieving universal access to treatment as quickly as possible and improving compliance to condom use.

HIV and sexually transmitted diseases

While STDs have an important impact on HIV transmission, experimental intervention studies demonstrating that STD control reduces HIV incidence have had mixed results. STDs can impact the clinical management of patients infected with HIV by increasing both viral load and HIV infectiousness. The clinical management of STDs is a dynamic field that has seen the advent of new diagnostic assays as well as changes in susceptibility to and availability of antimicrobial agents. As a result, excellence in HIV medical care requires physicians to be current in STD medicine. Physicians who care for patients with HIV infection should be familiar with recent guidelines recommending routine risk assessment and STD screening in these patients.

Changes in the contribution of genital tract infections to HIV acquisition among Kenyan high-risk women from 1993 to 2012

OBJECTIVE

The objective of this study was to understand temporal trends in the contribution of different genital tract infections to HIV incidence over 20 years of follow-up in a cohort of high-risk women.

DESIGN

A prospective cohort study.

METHODS

We performed monthly evaluations for HIV, vaginal yeast, bacterial vaginosis, Trichomonas vaginalis, Neisseria gonorrhoeae, nonspecific cervicitis, herpes simplex virus type two (HSV-2), genital ulcer disease (GUD) and genital warts. We used Cox regression to evaluate the association between sexually transmitted infections (STIs) and HIV acquisition over four time periods (1993-1997, 1998-2002, 2003-2007, 2008-2012). Models were adjusted for age, workplace, sexual risk behaviour, hormonal contraceptive use and other STIs. The resulting hazard ratios were used to calculate population attributable risk percentage (PAR%).

RESULTS

Between 1993 and 2012, 1964 women contributed 6135 person-years of follow-up. The overall PAR% for each infection was prevalent HSV-2 (48.3%), incident HSV-2 (4.5%), bacterial vaginosis (15.1%), intermediate microbiota (7.5%), vaginal yeast (6.4%), T. vaginalis (1.1%), N. gonorrhoeae (0.9%), nonspecific cervicitis (0.7%), GUD (0.8%) and genital warts (-0.2%). Across the four time periods, the PAR% for prevalent HSV-2 (40.4%, 61.8%, 58.4%, 48.3%) and bacterial vaginosis (17.1%, 19.5%, 14.7%, 17.1%) remained relatively high and had no significant trend for change over time. The PAR% for trichomoniasis, gonorrhoea, GUD and genital warts remained less than 3% across the four periods.

CONCLUSION

Bacterial vaginosis and HSV-2 have consistently been the largest contributors to HIV acquisition risk in the Mombasa Cohort over the past 20 years. Interventions that prevent these conditions would benefit women's health and could reduce their risk of becoming infected with HIV.

Rush to judgment: the STI-treatment trials and HIV in sub-Saharan Africa

INTRODUCTION

The extraordinarily high incidence of HIV in sub-Saharan Africa led to the search for cofactor infections that could explain the high rates of transmission in the region. Genital inflammation and lesions caused by sexually transmitted infections (STIs) were a probable mechanism, and numerous observational studies indicated several STI cofactors. Nine out of the ten randomized controlled trials (RCTs), however, failed to demonstrate that treating STIs could lower HIV incidence. We evaluate all 10 trials to determine if their design permits the conclusion, widely believed, that STI treatment is ineffective in reducing HIV incidence.

DISCUSSION

Examination of the trials reveals critical methodological problems sufficient to account for statistically insignificant outcomes in nine of the ten trials. Shortcomings of the trials include weak exposure contrast, confounding, non-differential misclassification, contamination and effect modification, all of which consistently bias the results toward the null. In any future STI-HIV trial, ethical considerations will again require weak exposure contrast. The complexity posed by HIV transmission in the genital microbial environment means that any future STI-HIV trial will face confounding, non-differential misclassification and effect modification. As a result, it is unlikely that additional trials would be able to answer the question of whether STI control reduces HIV incidence.

CONCLUSIONS

Shortcomings in published RCTs render invalid the conclusion that treating STIs and other cofactor infections is ineffective in HIV prevention. Meta-analyses of observational studies conclude that STIs can raise HIV transmission efficiency two- to fourfold. Health policy is always implemented under uncertainty. Given the known benefits of STI control, the irreparable harm from not treating STIs and the likely decline in HIV incidence resulting from STI control, it is appropriate to expand STI control programmes and to use funds earmarked for HIV prevention to finance those programmes.

Prevalence of sexually transmitted infections in female clinic attendees in Honiara, Solomon Islands

OBJECTIVES

This study sought to determine the prevalence of common bacterial sexually transmitted infections, including Chlamydia trachomatis and Neisseria gonorrhoeae, in women attending clinics in the Solomon Islands.

METHODS

We conducted a sexual health survey among women attending three nurse-led community outpatient clinics in August 2014, to establish the prevalence of bacterial sexually transmitted infections in female clinic attenders in Honiara, Solomon Islands. Vaginal swab samples were tested for infection with C. trachomatis and N. gonorrhoeae using a commercial strand displacement amplification assay. Serum samples were tested for syphilis.

RESULTS

We enrolled 296 women, aged 16-49, attending three clinics. Knowledge of safe sexual practices was high but reported condom usage was low. The prevalence of infection with C. trachomatis was 20%. The prevalence of infection with N. gonorrhoeae and syphilis were 5.1% and 4.1%, respectively.

CONCLUSIONS

Bacterial sexually transmitted infections are a major health problem in the Solomon Islands. Interventions are urgently needed.

High HIV, HPV, and STI prevalence among young Western Cape, South African women: EVRI HIV prevention preparedness trial

BACKGROUND

This study sought to assess the feasibility of conducting a phase III HIV prevention trial using a multivalent human papillomavirus (HPV) vaccine (Gardasil; Merck, Whitehouse Station, NJ).

METHODS

A total of 479 sexually active women aged 16-24 years in the Western Cape, South Africa, were enrolled in the Efficacy of HPV Vaccine to Reduce HIV Infection (EVRI) Trial. Of these, 402 were HIV negative, nonpregnant, and randomized 1:1 to receive Gardasil or a saline placebo vaccine. Vaccine doses were administered at enrollment, month 2, and month 6, and participants were followed for 1 month after the third dose. Enrollment HIV, HPV, other sexually transmitted infections (STIs), and cervical cytology were evaluated. Rates of accrual, vaccine compliance, and adherence to protocol were monitored.

RESULTS

High rates of accrual of eligible females to study (93%) and completion of the 3-dose vaccine series (91%) were noted, with few protocol violations. Ineligibility due to reported HIV positivity was 19%, and another 12% of those enrolled tested HIV positive. STI prevalence was high, with 6.2%, 10.9%, and 32.8% testing positive for syphilis, gonorrhea, and chlamydia, respectively. Cervical prevalence of ≥1 of 37 HPV types was 71%. STI and HPV prevalence was highest among the youngest women (<19 years).

CONCLUSIONS

Feasibility (successful accrual, retention, and vaccination) of conducting randomized placebo-controlled trials of HPV vaccines among HIV high-risk women in South Africa was demonstrated. This work demonstrates that phase III HIV prevention trials need to intervene at young ages and screen and treat multiple STIs concurrently to have a measurable impact on HIV acquisition.

Adaptive pair-matching in randomized trials with unbiased and efficient effect estimation

In randomized trials, pair-matching is an intuitive design strategy to protect study validity and to potentially increase study power. In a common design, candidate units are identified, and their baseline characteristics used to create the best n/2 matched pairs. Within the resulting pairs, the intervention is randomized, and the outcomes measured at the end of follow-up. We consider this design to be adaptive, because the construction of the matched pairs depends on the baseline covariates of all candidate units. As a consequence, the observed data cannot be considered as n/2 independent, identically distributed pairs of units, as common practice assumes. Instead, the observed data consist of n dependent units. This paper explores the consequences of adaptive pair-matching in randomized trials for estimation of the average treatment effect, conditional the baseline covariates of the n study units. By avoiding estimation of the covariate distribution, estimators of this conditional effect will often be more precise than estimators of the marginal effect. We contrast the unadjusted estimator with targeted minimum loss based estimation and show substantial efficiency gains from matching and further gains with adjustment. This work is motivated by the Sustainable East Africa Research in Community Health study, an ongoing community randomized trial to evaluate the impact of immediate and streamlined antiretroviral therapy on HIV incidence in rural East Africa.

Challenges of cluster randomized trials

Cluster randomized trials are trials that randomize clusters of people, rather than individuals. They are becoming increasingly common. A number of innovations have been developed recently, particularly in the calculation of the required size of a cluster trial, the handling of missing data, designs to minimize recruitment bias, the ethics of cluster randomized trials and the stepped wedge design. This article will highlight and illustrate these developments. It will also discuss issues with regards to the reporting of cluster randomized trials.

The road ahead: working towards effective clinical translation of biomedical HIV prevention strategies

ABSTRACT 

Emerging evidence from several randomized controlled trials show that antiretroviral-based biomedical HIV prevention interventions are efficacious in preventing HIV if they are taken as directed, and could potentially reduce the number of new HIV infections globally. Strategies such as treatment as prevention and use of oral pre-exposure prophylaxis for HIV prevention have shown great promise, yet have raised important implementation concerns around awareness and acceptance, delivery, adherence, side effects, risk compensation, cost–effectiveness and drug resistance. In order to address these issues, a number of treatment as prevention and pre-exposure prophylaxis demonstration projects have been initiated to assess the feasibility of introducing these interventions in ‘real-world’ settings. These projects will be instrumental in determining best practices for optimal delivery and sustainability of these HIV prevention interventions. The road to effective translation to clinical setting is promising, but comes with challenges which are not insurmountable.

Knowledge and skills for management of sexually transmitted infections among rural medical practitioners in Bangladesh

Sexually transmitted infection (STI) management is considered rudimentary among rural medical practitioners (RMPs) in Bangladesh. We sought to understand the level of knowledge and skills in STI management and to assess the impact of a two-day training orientation among RMPs in Tangail district. Data were collected through a baseline survey of 225 practicing RMPs in the study area and a three-month follow-up survey of 99 RMPs who participated in a two-day STI/HIV orientation training. The level of formal training among RMPs ranged from none (22.7%), to paramedical training (14.7%) and local medical assistant training (62.6%). The baseline survey revealed a low level of STI/HIV knowledge and misconceptions about the transmission of STI/HIV among RMPs. RMPs mostly prescribed first line antibiotics for treatment of common reproductive tract infections (RTIs) including STIs, but they rarely prescribed the correct dosages according to the national RTI/STI management guidelines. Only 3% of RMPs were able to correctly answer all four HIV transmission (unprotected sexual intercourse, blood transfusion, needle sharing and mother to child transmission) questions at baseline, while 94.9% of RMPs answered all four correctly at three months following the training (p=0.001). Only 10% of RMPs reported suggesting the recommended drug (azithromycin) and only 2% mentioned about the recommended dosage (2gm single dose) for the treatment of urethritis/cervicitis; compared to 49.5% suggested azithromycin at follow-up with 39.4% mentioned the recommended 2gm single dose (p=0.001). Our study found low level of knowledge and poor practices related RTI/STI management among RMPs. Short orientation training and education intervention shown promise to increase knowledge and management skills for RTIs/STIs.

Uptake and population-level impact of expedited partner therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: the Washington State community-level randomized trial of EPT

BACKGROUND

Expedited partner therapy (EPT), the practice of treating the sex partners of persons with sexually transmitted infections without their medical evaluation, increases partner treatment and decreases gonorrhea and chlamydia reinfection rates. We conducted a stepped-wedge, community-level randomized trial to determine whether a public health intervention promoting EPT could increase its use and decrease chlamydia test positivity and gonorrhea incidence in women.

METHODS AND FINDINGS

The trial randomly assigned local health jurisdictions (LHJs) in Washington State, US, into four study waves. Waves instituted the intervention in randomly assigned order at intervals of 6-8 mo. Of the state's 25 LHJs, 24 were eligible and 23 participated. Heterosexual individuals with gonorrhea or chlamydial infection were eligible for the intervention. The study made free patient-delivered partner therapy (PDPT) available to clinicians, and provided public health partner services based on clinician referral. The main study outcomes were chlamydia test positivity among women ages 14-25 y in 219 sentinel clinics, and incidence of reported gonorrhea in women, both measured at the community level. Receipt of PDPT from clinicians was evaluated among randomly selected patients. 23 and 22 LHJs provided data on gonorrhea and chlamydia outcomes, respectively. The intervention increased the percentage of persons receiving PDPT from clinicians (from 18% to 34%, p < 0.001) and the percentage receiving partner services (from 25% to 45%, p < 0.001). Chlamydia test positivity and gonorrhea incidence in women decreased over the study period, from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000, respectively. After adjusting for temporal trends, the intervention was associated with an approximately 10% reduction in both chlamydia positivity and gonorrhea incidence, though the confidence bounds on these outcomes both crossed one (chlamydia positivity prevalence ratio = 0.89, 95% CI 0.77-1.04, p = 0.15; gonorrhea incidence rate ratio = 0.91, 95% CI .71-1.16, p = 0.45). Study findings were potentially limited by inadequate statistical power, by the institution of some aspects of the study intervention outside of the research randomization sequence, and by the fact that LHJs did not constitute truly isolated sexual networks.

CONCLUSIONS

A public health intervention promoting the use of free PDPT substantially increased its use and may have resulted in decreased chlamydial and gonococcal infections at the population level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01665690.

The role of dendritic cells in driving genital tract inflammation and HIV transmission risk: are there opportunities to intervene?

Effective prevention of new HIV infections will require an understanding of the mechanisms involved in HIV acquisition. HIV transmission across the female genital tract is the major mode of new HIV infections in sub-Saharan Africa and involves complex processes, including cell activation, inflammation and recruitment of HIV target cells. Activated CD4(+) T-cells, dendritic cells (DC) and macrophages have been described as targets for HIV at the genital mucosa. Activation of these cells may occur in the presence of sexually-transmitted infections, disturbances of commensal flora and other inflammatory processes. In this review, we discuss causes and consequences of inflammation in the female genital tract, with a focus on DC. We describe the central role these cells may play in facilitating or preventing HIV transmission across the genital mucosa, and in the initial recognition of HIV and other pathogens, allowing activation of an adaptive immune response to infection. We discuss studies that investigate interventions to limit DC activation, inflammation and HIV transmission. This knowledge is essential in the development of novel strategies for effective HIV control, including microbicides and pre-exposure prophylaxis.

Improved knowledge and reported practice regarding sexually transmitted infections among healthcare providers in rural Vietnam: a cluster randomised controlled educational intervention

BACKGROUND

Healthcare providers (HCPs) play a critical role in controlling the spread of sexually transmitted infections (STI) through early and accurate diagnosis, appropriate treatment and prevention counselling. This study aimed to assess the effectiveness of an educational intervention about STI on knowledge and reported practice among HCPs and to explore which determinants may influence the intervention's effects.

METHODS

A cluster randomized controlled educational intervention was carried out in a rural district, Vietnam. 32 communes of the district were randomized into two arms, with 160 HCPs in an STI intervention arm and 144 in a control arm. The STI intervention comprised interactive training with basic STI knowledge, case scenarios, and poster distribution. Questionnaires to evaluate knowledge and reported practice were completed three times: before, during and after the intervention. Correct answer was scored as 1; "do not know", incorrect answer was scored as 0. Univariate and multilevel multivariate analyses were applied.

RESULTS

Of the maximum 56 points, the mean knowledge score increased significantly in the STI intervention arm and in the control arm post-intervention (37.2 to 48.4, and 32.7 to 41.7, respectively). In multivariate regression analysis, knowledge improvement in the intervention arm was significantly higher than that in the control arm (regression coefficient = 2.97, p = 0.008). Other factors which positively influenced the increase in knowledge were being between 35 and 50 years old, having intermediate professional training, being a pharmacist or working at a village level (regression coefficient: 2.81, 4.43, 5.53 and 7.91, respectively). Post-intervention, the mean reported practice score increased significantly in the STI intervention arm (from 17.6 to 21.8) and insignificantly in the control arm (maximum 36 points). Factors which positively influenced the increase in reported practice were being between 35 and 50 years old, having intermediate professional training, or working at a pharmacy/drugstore (regression coefficient: 2.15, 3.33 and 3.22, respectively).

CONCLUSIONS

This study indicates that an educational intervention including interactive training and multi-faceted interventions may be effective in improving STI knowledge and reported practice of HCPs at grassroots level, particularly among pharmacists, HCPs who work in villages or pharmacies/drugstores, and who initially have low STI knowledge.

Parameters for sample size estimation from a group-randomized HIV prevention trial in HIV clinics in sub-Saharan Africa

Sample size calculations for a group-randomized trial (GRT) require an estimate of the expected intraclass correlation coefficient (ICC). However, few ICC estimates from GRTs in HIV/AIDS research have been published, leaving investigators with little data on which to base expectations. We used data from a multi-country study to estimate ICCs for variables related to physical and mental health and HIV risk behaviors. ICCs for perceptions of physical and mental health tended to be higher than those for HIV risk behavior variables, which were higher than ICCs for CD4 count. Covariate adjustment for country and socio-demographic variables reduced most ICC estimates. For risk behavior variables, adjustment for country and socio-demographic variables reduced ICC estimates by as much as 84 %. Variability in ICC estimates has important implications for study design, as a larger ICC reduces power. ICC estimates presented in this analysis will allow more precise sample size estimates for future GRTs.

Current perspectives in HIV post-exposure prophylaxis

The incidence of human immunodeficiency virus (HIV) infection continues to rise among core groups and efforts to reduce the numbers of new infections are being redoubled. Post-exposure prophylaxis (PEP) is the use of short-term antiretroviral therapy (ART) to reduce the risk of acquisition of HIV infection following exposure. Current guidelines recommend a 28-day course of ART within 36-72 hours of exposure to HIV. As long as individuals continue to be exposed to HIV there will be a role for PEP in the foreseeable future. Nonoccupational PEP, the vast majority of which is for sexual exposure (PEPSE), has a significant role to play in HIV prevention efforts. Awareness of PEP and its availability for both clinicians and those who are eligible to receive it are crucial to ensure that PEP is used to its full potential in any HIV prevention strategy. In this review, we provide current evidence for the use of PEPSE, assessment of the risk of HIV transmission, indications for PEP, drug regimens, and management of patients started on PEP. We summarize national and international guidelines for the use of PEPSE. We explore the place of PEP within the wider strategy of reducing HIV incidence rates in the era of treatment as prevention and pre-exposure prophylaxis. We also consider the implications of recent data from interventional and observational studies demonstrating significant reductions in the risk of HIV transmission within a serodiscordant relationship if the HIV-positive partner is taking effective ART upon PEP guidelines.

The need for multipurpose prevention technologies in sub-Saharan Africa

Women bear a disproportionate burden of the HIV epidemic in sub-Saharan Africa and account for about 60% of all adults living with HIV in that region. Young women, including adolescent girls, unable to negotiate mutual faithfulness and/or condom use with their male partners are particularly vulnerable. In addition to the high HIV burden, women in Africa also experience high rates of other sexually transmitted infections and unwanted pregnancies. The development of technologies that can simultaneously meet these multiple sexual reproductive health needs would therefore be extremely beneficial in the African setting.

Preconception care: preventing and treating infections

Introduction

Infections can impact the reproductive health of women and hence may influence pregnancy related outcomes for both the mother and the child. These infections range from sexually transmitted infections (STIs) to TORCHS infections to periodontal disease to systemic infections and may be transmitted to the fetus during pregnancy, labor, delivery or breastfeeding.

Methods

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

Results

Preconception behavioral interventions significantly declines re-infection or new STI rates by 35% (95% CI: 20-47%). Further, condom use has been shown to be the most effective way to prevent HIV infection (85% protection in prospective studies) through sexual intercourse. Intervention trials showed that preconception vaccination against tetanus averted a significant number of neonatal deaths (including those specifically due to tetanus) when compared to placebo in women receiving more than 1 dose of the vaccine (OR 0.28; 95% CI: 0.15-0.52); (OR 0.02; 95% CI: 0.00-0.28) respectively.

Conclusion

Preconception counseling should be offered to women of reproductive age as soon as they test HIV-positive, and conversely women of reproductive age should be screened with their partners before pregnancy. Risk assessment, screening, and treatment for specific infections should be a component of preconception care because there is convincing evidence that treatment of these infections before pregnancy prevents neonatal infections.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Prevalence of Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae and human papillomavirus in a sexual health clinic setting in urban Sri Lanka

The prevalences of Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, and human papillomavirus (HPV) in Sri Lanka are not well reported; the objective of this study is to describe the prevalences of these four sexually transmitted infections among attendees of sexual health clinic in an urban setting. Vaginal swabs were collected from consenting women attending a sexual health clinic and tested for the presence of the above sexually transmitted infections using nucleic acid amplification techniques. Basic demographic details were sought from each participant (483 women of age range 14-61, median 30 years, IQR 12 years) via a research assistant-administered questionnaire. Overall, a prevalence of T. vaginalis, C. trachomatis, N. gonorrhoeae and HPV was 2.3%, (95% CI: 1.2-4.1%), 8.2% (95% CI: 5.6-11.4%), 7.6% (95% CI: 5.2-10.8%), and 44.4% (95% CI: 39.8-49.1%), respectively. Among the 197 positive for HPV, HPV6 accounted for 23.1%, HPV16 (12.5%), then HPV11, HPV66 and HPV58 were the commonest. Vaccine-related types (6/11/16/18) were detected in 59.9% of cases (95%CI: 52.7-66.8%). The high prevalence of sexually transmitted infections (45.2%) is a potential risk factor for an increase in HIV infections in the country and the high carriage of HPV supports the need for cervical cancer screening and prevention programmes.

Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda

BACKGROUND

Intimate partner violence (IPV) and HIV are important and interconnected public health concerns. While it is recognized that they share common social drivers, there is limited evidence surrounding the potential of community interventions to reduce violence and HIV risk at the community level. The SASA! study assessed the community-level impact of SASA!, a community mobilization intervention to prevent violence and reduce HIV-risk behaviors.

METHODS

From 2007 to 2012 a pair-matched cluster randomized controlled trial (CRT) was conducted in eight communities (four intervention and four control) in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, 18- to 49-years old, were undertaken at baseline (n = 1,583) and four years post intervention implementation (n = 2,532). Six violence and HIV-related primary outcomes were defined a priori. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up.

RESULTS

The intervention was associated with significantly lower social acceptance of IPV among women (adjusted risk ratio 0.54, 95% confidence interval (CI) 0.38 to 0.79) and lower acceptance among men (0.13, 95% CI 0.01 to 1.15); significantly greater acceptance that a woman can refuse sex among women (1.28, 95% CI 1.07 to 1.52) and men (1.31, 95% CI 1.00 to 1.70); 52% lower past year experience of physical IPV among women (0.48, 95% CI 0.16 to 1.39); and lower levels of past year experience of sexual IPV (0.76, 95% CI 0.33 to 1.72). Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities (0.57, 95% CI 0.36 to 0.91).

CONCLUSIONS

This is the first CRT in sub-Saharan Africa to assess the community impact of a mobilization program on the social acceptability of IPV, the past year prevalence of IPV and levels of sexual concurrency. SASA! achieved important community impacts, and is now being delivered in control communities and replicated in 15 countries.

TRIAL REGISTRATION

ClinicalTrials.gov #NCT00790959.

Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections

BACKGROUND

Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs.

OBJECTIVES

To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs.

SELECTION CRITERIA

Randomized control trials (RCTs) featuring all of the following.1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.3. Trials that confirmed biological outcomes using laboratory testing.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values.

MAIN RESULTS

We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes.

AUTHORS' CONCLUSIONS

There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.

HIV infection: epidemiology, pathogenesis, treatment, and prevention

HIV prevalence is increasing worldwide because people on antiretroviral therapy are living longer, although new infections decreased from 3.3 million in 2002, to 2.3 million in 2012. Global AIDS-related deaths peaked at 2.3 million in 2005, and decreased to 1.6 million by 2012. An estimated 9.7 million people in low-income and middle-income countries had started antiretroviral therapy by 2012. New insights into the mechanisms of latent infection and the importance of reservoirs of infection might eventually lead to a cure. The role of immune activation in the pathogenesis of non-AIDS clinical events (major causes of morbidity and mortality in people on antiretroviral therapy) is receiving increased recognition. Breakthroughs in the prevention of HIV important to public health include male medical circumcision, antiretrovirals to prevent mother-to-child transmission, antiretroviral therapy in people with HIV to prevent transmission, and antiretrovirals for pre-exposure prophylaxis. Research into other prevention interventions, notably vaccines and vaginal microbicides, is in progress.

Women's beliefs about male circumcision, HIV prevention, and sexual behaviors in Kisumu, Kenya

It is important to understand how women's sexual practices may be influenced by male circumcision (MC) as an HIV prevention effort. Women's beliefs about MC and sexual behaviour will likely influence the scale-up and uptake of medical MC. We conducted qualitative interviews with 30 sexually active women in Kisumu, Kenya. Women discussed MC related to perceived health benefits, condom use, sexual behaviour, knowledge of susceptibility to HIV and sexually transmitted infections (STIs), circumcision preference, and influence on circumcision uptake. Respondents had a good understanding of the partial protection of MC for acquisition of HIV for men. Women perceived circumcised men as cleaner, carrying fewer diseases, and taking more time to reach ejaculation. Male's circumcision status is a salient factor for women's sexual decision making, including partner choice, and condom use. It will be important that educational information affirms that MC provides only partial protection against female to male transmission of HIV and some STIs; that other HIV and STI prevention methods such as condoms need to be used in conjunction with MC; that MC does not preclude a man from having HIV; and that couples should develop plans for not having sex while the man is healing.

Working with men to prevent intimate partner violence in a conflict-affected setting: a pilot cluster randomized controlled trial in rural Côte d'Ivoire

BACKGROUND

Evidence from armed conflict settings points to high levels of intimate partner violence (IPV) against women. Current knowledge on how to prevent IPV is limited-especially within war-affected settings. To inform prevention programming on gender-based violence in settings affected by conflict, we evaluated the impact of adding a targeted men's intervention to a community-based prevention programme in Côte d'Ivoire.

METHODS

We conducted a two-armed, non-blinded cluster randomized trial in Côte d'Ivoire among 12 pair-matched communities spanning government-controlled, UN buffer, and rebel-controlled zones. The intervention communities received a 16-week IPV prevention intervention using a men's discussion group format. All communities received community-based prevention programmes. Baseline data were collected from couples in September 2010 (pre-intervention) and follow-up in March 2012 (one year post-intervention). The primary trial outcome was women's reported experiences of physical and/or sexual IPV in the last 12 months. We also assessed men's reported intention to use physical IPV, attitudes towards sexual IPV, use of hostility and conflict management skills, and participation in gendered household tasks. An adjusted cluster-level intention to treat analysis was used to compare outcomes between intervention and control communities at follow-up.

RESULTS

At follow-up, reported levels of physical and/or sexual IPV in the intervention arm had decreased compared to the control arm (ARR 0.52, 95% CI 0.18-1.51, not significant). Men participating in the intervention reported decreased intentions to use physical IPV (ARR 0.83, 95% CI 0.66-1.06) and improved attitudes toward sexual IPV (ARR 1.21, 95% CI 0.77-1.91). Significant differences were found between men in the intervention and control arms' reported ability to control their hostility and manage conflict (ARR 1.3, 95% CI 1.06-1.58), and participation in gendered household tasks (ARR 2.47, 95% CI 1.24-4.90).

CONCLUSIONS

This trial points to the value of adding interventions working with men alongside community activities to reduce levels of IPV in conflict-affected settings. The intervention significantly influenced men's reported behaviours related to hostility and conflict management and gender equitable behaviours. The decreased mean level of IPV and the differences between intervention and control arms, while not statistically significant, suggest that IPV in conflict-affected areas can be reduced through concerted efforts to include men directly in violence prevention programming. A larger-scale trial is needed to replicate these findings and further understand the mechanisms of change.

TRIAL REGISTRATION

clinicaltrials.gov NCT01803932.

HIV prevention services and testing utilization behaviors among men who have sex with men at elevated risk for HIV in Chongqing, China

Objective. To investigate barriers and correlates of the use of HIV prevention services and HIV testing behaviors among men who have sex with men in Chongqing. Methods. Three consecutive cross-sectional surveys provided demographic, sexual behavior, HIV/syphilis infection, HIV prevention service, and testing behavior data. Results. Of 1239 participants, 15.4% were infected with HIV, incidence was 12.3 per 100 persons/year (95% CI: 9.2–15.3), 38% of the participants reported ever having unprotected insertive anal sex, 40% ever received free condom/lubricants in the past year, and 27.7% ever obtained free sexually transmitted infection examination/treatment in the past year. Multivariable logistic regression revealed that lower levels of HIV/AIDS related stigmatizing/discriminatory attitudes, full-time jobs, and sex debut with men at a younger age were independently associated with use of free condom/lubricants. Large social networks, higher incomes, and sexual debut with men at a younger age were associated with use of any HIV prevention and HIV testing services. Lower levels of stigmatizing/discriminatory attitudes were also associated with HIV testing. Fearing needles and being unaware of the venues for testing were top barriers for testing service utilization. Conclusion. It is imperative to address HIV/AIDS related stigmatizing/discriminatory attitudes and other barriers while delivering intervention and testing services.

Genital schistosomiasis and its unacknowledged role on HIV transmission in the STD intervention studies

Treatment of sexually transmitted infections (STIs) has been hypothesised to decrease HIV transmission. Although observational studies show an association between STIs and HIV, only one prospective randomised controlled trial (RCT) has confirmed this. Female genital schistosomiasis can cause genital lesions, accompanied by bloody discharge, ulcers or malodorous discharge. Genital schistosomiasis is common, starts before puberty and symptoms can be mistaken for STIs. Three observational studies have found an association between schistosomiasis and HIV. Genital lesions that develop in childhood are chronic. This paper sought to explore the possible effects of schistosomiasis on the RCTs of STI treatment for HIV prevention.

In the study sites, schistosomiasis was a likely cause of genital lesions. The studies recruited women that may have had genital schistosomal lesions established in childhood. Schistosomiasis endemic areas with different prevalence levels may have influenced HIV incidence in intervention and control sites differently, and some control group interventions may have influenced the impact of schistosomiasis on the study results. Schistosomiasis is a neglected cause of genital tract disease. It may have been an independent cause of HIV incidence in the RCTs of STI treatment for HIV prevention and may have obscured the findings of these trials.

Acceptability of Condoms, Circumcision and PrEP among Young Black Men Who Have Sex with Men: A Descriptive Study Based on Effectiveness and Cost

The current study examined and compared the willingness of young Black men who have sex with men (YBMSM) to accept pre-exposure prophylaxis (PrEP), adult male circumcision, and condoms for reducing their risk of HIV acquisition. The majority (67%) reported unprotected receptive anal sex in the last six months. About three-quarters (71%) would accept using PrEP if it was 100% effective. Cost influenced PrEP acceptance with 19% indicating acceptance at $100 per month co-pay. Of those not circumcised, 50% indicated willingness if circumcision was 100% effective. Acceptance of circumcision decreased markedly to 17% with co-pays of $100. About 73% of men were willing to use condoms if they were 100% effective and 50% indicated a willingness at the cost of $10 per month. The findings suggest that condom use promotion strategies should remain at the forefront of public health efforts to control HIV incidence among YBMSM.