A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV

Factors affecting HIV concordancy in married couples in four African cities

OBJECTIVE

To determine risk factors for HIV transmission within married couples in four urban populations in sub-Saharan Africa.

METHODS

Data from a cross-sectional population-based study were used. Representative random samples approximating 1000 men and 1000 women in each of four cities of Kisumu (Kenya), Ndola (Zambia), Cotonou (Benin), and Yaoundé (Cameroon), were interviewed and tested for sexually transmitted infections (STI). Married couples were identified as concordant negative, discordant, or concordant positive for each STI. After excluding concordant HIV negative couples, analysis of behavioural and STI risk factors for HIV positive concordancy was undertaken across the four cities and in each city separately where sample size allowed.

RESULTS

Among 221 couples in which at least one member was HIV positive, we found that the only significant risk factor for positive HIV concordancy was herpes simplex type 2 (HSV-2) status. After adjusting for age and city of residence the odds ratio for HIV concordancy compared to couples with neither spouse HSV-2 positive was 3.4 (95% confidence interval, 0.62-18.4) for couples with one partner HSV-2 positive and 8.6 (95% confidence interval, 1.6-45.0) for couples with both partners HSV-2 positive. The same trends were seen in Kisumu and Ndola when they were analysed separately (numbers were small in the other cities).

CONCLUSIONS

Although cross-sectional studies are not ideal for delineating the sequence of transmission events, this study adds to the evidence that HSV-2 is a key risk factor in promoting HIV transmission.

Contraception choice for HIV positive women

UNAIDS/WHO estimates that 42 million people are living with HIV/AIDS worldwide and 50% of all adults with HIV infection are women predominantly infected via heterosexual transmission. Women with HIV infection, like other women, may wish to plan pregnancy, limit their family, or avoid pregnancy. Health professionals should enable these reproductive choices by counselling and appropriate contraception provision at the time of HIV diagnosis and during follow up. The aim of this article is to present a global overview of contraception choice for women living with HIV infection including effects on sexual transmission risk.

Incidence and risk factors for sexually transmitted infections among women in an Alabama HIV clinic

The objectives of this study were to assess the prevalence and incidence of curable sexually transmitted infections (STI), i.e., gonorrhea, chlamydial infection, or trichomoniasis, in a cohort of HIV-infected women. The study population was derived from women seeking primary care at an outpatient university HIV clinic who were participants in a women's natural history study. Enrollees (n = 225) were predominantly African-American, heterosexually infected, with mean age 35 years. Mean entry CD4+ T cell count was 405 cells/mm3. Over 6% were STI positive at initial screening. Subsequently, the combined curable STI incidence was 4.82/1000 woman-months over a median of 33 months of observation. Of 36 incident STIs, trichomoniasis was most common (n = 32). Predictors for acquisition of a curable STI included absenteeism at scheduled clinic appointments, RR = 1.99 (1.28, 3.08), and a higher CD4+ T cell count, RR = 1.15 (1.0028, 1.3115) for 100 cells. Interventions to prevent curable STI in HIV-infected women are warranted in primary care settings.

Contraceptive Use in HIV-Positive Women

The objective was to describe contraceptive use in women with HIV infection in France over the past decade. The study included 575 sexually active women of reproductive age, who knew the serologic status of their steady partners. It is part of a prospective observational study initiated in 1993 that was designed to investigate the gynecologic status of HIV-infected women. Women answered a standardized questionnaire about contraceptive use and sexual activity at each semiannual visit. Multivariate models were used to investigate parameters associated with the use of contraceptive methods. Contraceptive use was reported in 91% of the visits of women with an HIV-seronegative partner and 69% of women with an HIV-seropositive partner (P=0.0001). Consistent condom use was higher in serodiscordant couples than in seroconcordant couples (odds ratio [OR]=6.1, 95% CI=0.1-0.2, P<0.001). The use of oral contraception and intrauterine devices was higher in seroconcordant than in serodiscordant couples (OR=2.1, 95% CI=.5-2.9, P<0.001). Among women with an HIV-seronegative partner, the use of oral contraception and intrauterine devices decreased after the introduction of highly active antiretroviral therapy in 1998 (P=0.02) and was higher in couples with inconsistent condom use (OR=2.0, 95% CI=1.3-3.3). These data emphasize that contraception counseling should include a discussion on reproductive issues as well as transmission of HIV and other sexually transmitted infections, taking into account the partner's serostatus.

Inhibiting sexual transmission of HIV-1 infection

The worldwide infection rate for HIV-1 is estimated to be 14,000 per day, but only now, more than 20 years into the epidemic, are the immediate events between exposure to infectious virus and the establishment of infection becoming clear. Defining the mechanisms of HIV-1 transmission, the target cells involved and how the virus attaches to and fuses with these cells, could reveal ways to block the sexual spread of the virus. In this review, we will discuss how our increasing knowledge of the ways in which HIV-1 is transmitted is shaping the development of new, more sophisticated intervention strategies based on the application of vaginal or rectal microbicides.

Conservation en paillettes des gamètes et embryons humains : sécurité vis-à-vis du virus de type 1 de l'immunodéficience humaine

OBJECTIVE

The possibility of offering assisted reproductive technologies (ART) to HIV-positive couples has revived questions concerning the safety of the gametes and embryos cryopreservation in liquid nitrogen tanks.

PATIENTS AND METHODS

We evaluated the safety of three types of straws - polyvinyl chloride (PVC), polyethylene terephthalate glycol (PETG) and so-called 'high-security' ionomeric resin (IR) - containing HIV-1 under standard conditions of cryopreservation. Potential HIV contamination was assessed by RT-PCR and then nested PCR.

RESULTS

Under cryopreservation conditions, the sealed open ends of PVC and PETG straws were not safe. The ultrasound sealing system seems to be the weak link in obtaining total imperviousness of the straws. In contrast, both ends of the IR straws were safe for HIV in the framework of their use for ART.

CONCLUSION

Sealing cryopreservation straws ultrasonically could incur the risk of not assuring their impermeability. Under standard cryopreservation conditions thermosealing of IR straws appears to be safe for HIV.

Canadian Contraception Consensus

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Disruption of the upper female reproductive tract epithelium by nonoxynol-9

Spermicides containing nonoxynol-9 (N-9) may increase HIV transmission. In women, intravaginal N-9 is found in the uterus shortly after its insertion. Exposure of the female upper reproductive tract to N-9 may alter epithelial integrity, thereby increasing HIV transmission risk. Our goal was to characterize the histological effects of N-9 on uterine epithelium in an animal model. Female mice were exposed to intravaginal or intrauterine Advantage-S (N-9), Replens, K-Y(R) jelly or water. After various exposure times, mice were sacrificed and stained uterine tissue sections were analyzed by a pathologist blinded to treatment.Intravaginal and intrauterine N-9 administration resulted in disruption of uterine epithelium compared to Replens, K-Y jelly or water. N-9 caused rapid (within 10 min), focal, uterine epithelial sloughing and complete epithelial loss within 24 h. Epithelial regeneration began 48 h after exposure N-9 and was completely restored within 72 h; the new epithelial layer, however, was composed of cuboidal cells instead of normally present columnar cells. In addition, hemorrhage and necrosis were present are all time points examined. Our results demonstrate for the first time that N-9 has a deleterious effect on uterine epithelium. Although these results were observed in a mouse model, similar disruption of the upper reproductive tract epithelium in women by N-9 may facilitate HIV infection and serve as an unrecognized portal of human HIV transmission.

Comparison of Sexually Transmitted Disease Prevalence by Reported Level of Condom Use Among Patients Attending an Urban Sexually Transmitted Disease Clinic

BACKGROUND

There is controversy as to the protective effect of condoms in preventing various sexually transmitted diseases (STDs).

GOAL

The goal of this study was to assess the association of various levels of condom use with a variety of STD.

STUDY DESIGN

We conducted a cross-sectional study of female and heterosexual male visits to an urban STD clinic between 1990 and 2001.

METHODS

Prevalence rates were calculated for gonorrhea, chlamydia, trichomonas, recent-onset genital warts, first-episode herpes, and molluscum contagiosum by reported level of condom use over the past 4 months, with adjusted odds ratios (AOR) calculated by logistic regression.

RESULTS

Among 126,220 patient visits (39% women and 61% men), condom use over the past 4 months was reported by 54%, with 38% reporting inconsistent use and 16% consistent use. Condom users reported greater sexual risk in the past 4 months than nonusers (ie, new sex partners: 63% vs. 41%, P <0.001; multiple sex partners: 60% vs. 36%, P <0.001). When all condom users were compared with nonusers, there was limited evidence of protection against specific STD. However, when the analysis was restricted to condom users, infection rates were significantly lower in consistent than inconsistent users for both men and women for gonorrhea (AOR, 0.87 and 0.71, respectfully) and chlamydia (AOR, 0.66 and 0.74, respectfully), for trichomonas in women (AOR, 0.87), and for genital herpes in men (AOR, 0.73).

CONCLUSIONS

Comparisons of STD between condom users and nonusers are confounded by greater sexual risk in users. Comparing consistent with inconsistent users reduces this confounding, revealing protection for both men and women for nonviral STD and for genital herpes for men.

Evaluation of the condom distribution program in New South Wales Prisons, Australia

Male to male unprotected anal sex is the main route of HIV transmission in Australia. The Australian Study of Health and Relationships, a large, representative population survey of sexual health behaviors, found that six percent of males in the general population have engaged in homosexual activity. These findings were consistent with studies in Europeand North America. Condoms have been shown to reduce the transmission of HIV in the community. Barriers to the use of condoms include access,stigma,and cost? Nevertheless, increased condom use has been reported among homosexual males, sex workers and injecting drug users although recent declines in condom use among homosexuals has presented new challenges in HIV prevention.

The prevalence of male to male sexual activity may be higher in prison than in the general population. Sexual activity in prison can be consensual and non-consensual involving both homosexual / bisexual and heterosexual men.

Recommendations for incorporating human immunodeficiency virus (HIV) prevention into the medical care of persons living with HIV

The estimated number of annual new human immunodeficiency virus (HIV) infections in the United States has remained at 40,000 for >10 years. Reducing the rate of transmission will require new strategies, including emphasis on prevention of transmission by HIV-infected persons. Medical care providers can affect HIV transmission by screening HIV-infected patients for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors, reinforcing changes to safer behavior, referring patients for services such as substance abuse treatment, facilitating partner counseling and referral, and identifying and treating other sexually transmitted diseases. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop evidence-based recommendations for incorporating HIV prevention into the medical care of persons living with HIV. This article summarizes key aspects of the recommendations.

Gynecologic issues in the HIV-infected woman

Science has made great strides in understanding the management of the many gynecologic conditions that affect HIV-positive women with an increased frequency. As HIV-infected women's life expectancy continues to lengthen, new treatments are necessary for recurring conditions, such as lower genital tract neoplasias. The medical field has much to learn about the interaction between sex steroids, HIV-infection, and the immune system. As knowledge grows, clinicians will be better equipped to counsel women about contraceptive issues, pregnancy, and menopause.

Who infects whom? HIV-1 concordance and discordance among migrant and non-migrant couples in South Africa

OBJECTIVES

To measure HIV-1 discordance among migrant and non-migrant men and their rural partners, and to estimate the relative risk of infection from inside versus outside primary relationships.

DESIGN

A cross-sectional behavioural and HIV-1 seroprevalence survey among 168 couples in which the male partner either a migrant, or not.

METHODS

A detailed questionnaire was administered and blood was collected for laboratory analysis. A mathematical model was developed to estimate the relative risk of infection from inside versus from outside regular relationships.

RESULTS

A total of 70% (117 of 168) of couples were negatively concordant for HIV, 9% (16 of 168) were positively concordant and 21% (35 of 168) were discordant. Migrant couples were more likely than non-migrant couples to have one or both partners infected [35 versus 19%; P = 0.026; odds ratio (OR) = 2.28] and to be HIV-1 discordant (27 versus 15%; P = 0.066; OR = 2.06). In 71.4% of discordant couples, the male was the infected partner; this did not differ by migration status. In the mathematical model, migrant men were 26 times more likely to be infected from outside their regular relationships than from inside [relative risk (RR) = 26.3; P = 0.000]; non-migrant men were 10 times more likely to be infected from outside their regular relationships than inside (RR = 10.5; P = 0.00003).

CONCLUSIONS

Migration continues to play an important role in the spread of HIV-1 in South Africa. The direction of spread of the epidemic is not only from returning migrant men to their rural partners, but also from women to their migrant partners. Prevention efforts will need to target both migrant men and women who remain at home.

Reproduction in couples who are affected by human immunodeficiency virus: Medical, ethical, and legal considerations

There has been a transformation in the treatment of human immunodeficiency virus from the treatment of complications that define acquired immune deficiency syndrome to the maintenance of long-term health, with an expanding number of antiretroviral medications. Because human immunodeficiency virus infection now is considered to be a chronic disease, couples will be seen in greater numbers for preconception counseling. The ethical and legal implications, including the relevance of the Americans with Disability Act, are complex but support the assistance with reproduction of couples who are affected by human immunodeficiency virus in many instances. All couples who are affected by human immunodeficiency virus, whether fertile or infertile, who want to have genetically related offspring should be seen preconceptionally for counseling and testing. Intensive education involves a multidisciplinary approach to ensure that a couple is fully informed. Determination of whether to offer treatment should be based on the same criteria that are applied to couples who are affected by other chronic diseases. Medical treatment is dependent on the unique circumstances of each couple. In general, the affected partner(s) should be treated aggressively with antiretrovirals and then serum; if applicable, semen testing is required to document undetectable concentrations of human immunodeficiency virus (<50-100 copies/mL).

HIV risk in relation to marriage in areas with high prevalence of HIV infection

In sub-Saharan Africa, the prevalence of HIV infection among young women is much higher than that among young men. Many women enter marriage HIV-infected, suggesting that men may be predominantly infected by their wives. Using data from cross-sectional surveys in Kisumu, Kenya, and Ndola, Zambia, in 1997, the prevalence of HIV infection at marriage was estimated from age at marriage and age- and sex-specific prevalence of HIV infection among unmarried individuals. Using a deterministic model, this prevalence was compared with measured concordance of HIV infection among recently married couples to estimate transmission probabilities within marriage and extramarital incidence of HIV infection. Over a wide range of assumptions, we estimated that at least one quarter of cases of HIV infection in recently married men were acquired from extramarital partnerships, and for both men and women, less than one half of cases of HIV infection were acquired from their spouse. In these sites, many infections in married men, even in those with HIV-infected wives, may be acquired from outside the marriage.

The efficacy of a relationship-based HIV/STD prevention program for heterosexual couples

OBJECTIVES

This study examined the efficacy of a relationship-based HIV/sexually transmitted disease prevention program for heterosexual couples and whether it is more effective when delivered to the couple or to the woman alone.

METHODS

Couples (n = 217) were recruited and randomized to (1) 6 sessions provided to couples together (n = 81), (2) the same intervention provided to the woman alone (n = 73), or (3) a 1-session control condition provided to the woman alone (n = 63).

RESULTS

The intervention was effective in reducing the proportion of unprotected and increasing the proportion of protected sexual acts. No significant differences in effects were observed between couples receiving the intervention together and those in which the woman received it alone.

CONCLUSIONS

This study demonstrates the efficacy of a relationship-based prevention program for couples at risk for HIV infection.

The contribution of steady and casual partnerships to the incidence of HIV infection among homosexual men in Amsterdam

OBJECTIVE

To assess the relative contribution of steady and casual partnerships to the incidence of HIV infection among homosexual men in Amsterdam, and to determine the effect of increasing sexually risky behaviours among both types of partners in the era of highly active antiretroviral therapy (HAART).

METHODS

A mathematical model was developed for the spread of HIV infection among young homosexual men in Amsterdam after the introduction of HAART. The model describes the formation of both steady and casual partnerships. Behavioural parameters were estimated separately for steady and casual partners from the Amsterdam Cohort Study among young homosexual men. HIV incidence and the fraction of new infections attributed to casual contacts were calculated from the model, allowing for uncertainty in the increases in risky behaviour, the effect of HAART, and levels of HIV testing and HAART administration.

RESULTS

Currently, 86% (range 74-90%) of new HIV infections occur within steady partnerships. A reduction of 75-99% in infectivity caused by HAART will be counterbalanced by increases of 50% (range 30-80%) in risky behaviour with steady partners, but not by increases of up to 100% with casual partners. If HIV testing is increased from 42 to 80% and HAART administration from 70 to 85%, then even an increase of 100% in risk-taking with steady partners will not outweigh the effect of HAART.

CONCLUSION

Most new HIV infections among homosexual men in Amsterdam occur within steady relationships. Prevention measures should address risky behaviour, specifically with steady partners, and the promotion of HIV testing.

Sexual behavior of HIV discordant couples after HIV counseling and testing

BACKGROUND AND OBJECTIVES

Sexual behavior following voluntary HIV counseling and testing (VCT) is described in 963 cohabiting heterosexual couples with one HIV positive and one HIV negative partner ('discordant couples'). Biological markers were used to assess the validity of self-report.

METHODS

Couples were recruited from a same-day VCT center in Lusaka, Zambia. Sexual exposures with and without condoms were recorded at 3-monthly intervals. Sperm detected on vaginal smears, pregnancy, and sexually transmitted diseases (STD) including HIV, gonorrhea, syphilis, and Trichomonas vaginalis were assessed.

RESULTS

Less than 3% of couples reported current condom use prior to VCT. In the year after VCT, > 80% of reported acts of intercourse in discordant couples included condom use. Reporting 100% condom use was associated with 39-70% reductions in biological markers; however most intervals with reported unprotected sex were negative for all biological markers. Under-reporting was common: 50% of sperm and 32% of pregnancies and HIV transmissions were detected when couples had reported always using condoms. Positive laboratory tests for STD and reported extramarital sex were relatively infrequent. DNA sequencing confirmed that 87% of new HIV infections were acquired from the spouse.

CONCLUSIONS

Joint VCT prompted sustained but imperfect condom use in HIV discordant couples. Biological markers were insensitive but provided evidence for a significant under-reporting of unprotected sex. Strategies that encourage truthful reporting of sexual behavior and sensitive biological markers of exposure are urgently needed. The impact of prevention programs should be assessed with both behavioral and biological measures.

Norms, social networks, and HIV-related risk behaviors among urban disadvantaged drug users

Altering norms may be an important approach to introducing and sustaining health protective behavior change. This study sought to examine the relationship between condom use, condom norms, and social network characteristics among a sample of economically impoverished individuals at risk for acquiring and transmitting HIV. Participants were 1051 individuals from a drug-using community in the USA. Eighty percent were current drug users; 17% were HIV seropositive. Reported condom use was strongly associated with peer norms about condom use (friends talking about condoms, encouraging condom use, and using condoms). Women were less likely than men to report that their friends used condoms. Injection drug use was negatively associated with peer norms about condom use, while church attendance and network characteristics were positively associated with condom-promoting norms. The size of the health advice and the financial support networks was most positively related to condom norms. Network methodology may aid in the identification of specific ties that promote condom use norms in a population. The findings of this study may have implications for norm change interventions among disadvantaged communities at high risk for HIV/AIDS.

Safety of cryopreservation straws for human gametes or embryos: a study with human immunodeficiency virus-1 under cryopreservation conditions

BACKGROUND

The possibility of assisted reproductive technology (ART) for couples carrying viruses, especially HIV-1, necessitates consideration of the safety of cryopreserving human gametes or embryos in liquid nitrogen tanks. Following our evaluation of the safety of three kinds of straws containing HIV-1 at 37 degrees C, we have now examined the HIV-1 imperviousness of the same straws under cryopreservation conditions.

METHODS

Polyvinyl chloride (PVC), polyethylene terephthalate glycol (PETG) and high-security ionomeric resin (IR) straws (24 each) were tested. Each straw was filled with 100 microl of HIV-1-containing supernatant [reverse transcriptase (RT) activity: 15 000 c.p.m./50 microl]. Then PVC and PETG straws were sealed ultrasonically only at their free-end, and IR straws were thermosoldered at both ends. Each straw was put in a 15 ml Falcon tube which was capped and submerged in a liquid-nitrogen tank for 7 days. After bleach decontamination or not, the outside of each end of the straw was rinsed with RPMI medium (1 ml) before cryopreservation and after thawing. Viral RNA was extracted from the medium and then amplified by RT-polymerase chain reaction (PCR) followed by nested-PCR using HIV-1 protease-specific primers.

RESULTS

HIV-1 RNA was detected in some PVC and PETG rinse media, probably resulting from splashing during ultrasonic sealing, but not in the rinse media of thermosoldered IR straws.

CONCLUSION

Under cryopreservation conditions, IR straws would appear to be safe for HIV-1 storage in ART. For PVC and PETG straws, as highlighted in this study, the ultrasonic sealing could be the weak safety link.

Relationship power, condom use and HIV risk among women in the USA

Women's ability to negotiate safer sexual practices, particularly condom use, is a vital component of HIV/STD prevention strategies. Gender-based power imbalances may constrain women's negotiation ability, yet few empirical studies have tested the hypothesis that sexual relationship power constitutes a key factor in condom use negotiation. In this investigation, a new measure - the Sexual Relationship Power Scale (SRPS) - was applied. Data were collected from 388, mostly Latina, women at an urban community health centre in Massachusetts. Women with high levels of relationship power were five times as likely as women with low levels to report consistent condom use, after controlling for sociodemographic and psychosocial variables (p < 0.05). Population attributable risk estimates indicate that 52% of the lack of consistent condom use among women can be attributed to low sexual relationship power. The strong association between the Sexual Relationship Power Scale and consistent condom use supports the hypothesis that relationship power plays a key role in safer sex decision making. These findings underscore the importance of including the issue of relationship power in the design and implementation of programmes that promote sexual and reproductive health, as well as research investigating condom use and HIV risk.

Microbicides: a new approach to preventing HIV and other sexually transmitted infections

Many chemical agents can block human immunodeficiency virus (HIV) infection in the laboratory. Scientists are investigating which of these, used intravaginally by women, will safely prevent the sexual transmission of HIV in humans. Several such products - microbicides - will soon be tested in populations at high risk for HIV, and others are waiting in the wings. Microbicides will provide a low-cost method, controlled by women, for protection against HIV, other sexually transmitted pathogens and unwanted pregnancy, and will therefore have global public-health benefits.

Do condoms prevent genital HPV infection, external genital warts, or cervical neoplasia? A meta-analysis

BACKGROUND

Although condoms most likely prevent HIV infection, evidence of their effectiveness against other sexually transmitted diseases is mixed.

GOAL

The goal of the study was to determine whether condom use prevents genital human papillomavirus (HPV) infection and HPV-related conditions.

STUDY DESIGN

We conducted a literature review and meta-analysis of the effect of condom use on the prevention of genital warts, subclinical HPV infection, cervical intraepithelial neoplasia (CIN), and invasive cervical cancer (ICC).

RESULTS

Among 27 estimates from 20 studies, there was no consistent evidence that condom use reduces the risk of becoming HPV DNA-positive. However, risk for genital warts, CIN of grade II or III (CIN II or III), and ICC was somewhat reduced.

CONCLUSIONS

Available data are too inconsistent to provide precise estimates. However, they suggest that while condoms may not prevent HPV infection, they may protect against genital warts, CIN II or III, and ICC.

HIV infection and pregnancy status among adults attending voluntary counseling and testing in 2 developing countries

OBJECTIVES

This study investigated the impact of HIV voluntary counseling and testing (VCT) on reproduction planning among 1634 adults in 2 sub-Saharan countries.

METHODS

Data were obtained from a multisite randomized controlled trial.

RESULTS

At 6 months post-VCT, the women more likely to be pregnant were younger (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.0, 6.5), not using contraceptives (OR = 0.1; 95% CI = 0.1, 0.3), and HIV infected (OR = 3.0; 95% CI = 1.3, 7.0). An interaction emerged linking pregnancy intention at baseline and HIV serostatus with pregnancy at follow-up (OR = 0.1; 95% CI =.0, 0.4) Partner pregnancy rates did not differ by HIV serostatus among men.

CONCLUSIONS

HIV diagnosis may influence reproduction planning for women but not for men.

Evaluating the risk of HIV transmission through unprotected orogenital sex

We analysed a cohort of heterosexual HIV- serodiscordant couples with the aim of evaluating the risk of transmission ascribed to unprotected orogenital intercourse. A total of 135 seronegative individuals (110 women and 25 men), whose only risk exposure to HIV was unprotected orogenital sex with their infected partner, registered 210 person-years of follow-up. After an estimated total of over 19,000 unprotected orogenital exposures with the infected partner not a single HIV seroconversion occurred.

Heterosexual risk behaviors in at-risk young men from early adolescence to young adulthood: prevalence, prediction, and association with STD contraction

Health-compromising lifestyles involve stable patterns of behavior and are associated with high-risk social environments and accelerated developmental trajectories. Developmentally, antisocial behavior is associated with such lifestyles. Mediational models predicting a measure of lifetime average sexual risk behavior assessed over a 10-year period (from ages 13-14 to 22-23 years) were examined for a sample of at-risk young men. The measure included years of abstinence from intercourse as well as levels of 3 key heterosexual indicators of risk: frequency of intercourse, number of intercourse partners, and condom use. Predictors included lifetime average measures of contextual, family, and peer process variables and individual behaviors. In addition, similar models for prediction of STD contraction were assessed. A younger age of onset of intercourse was associated with higher numbers of intercourse partners after onset. As hypothesized, findings indicated mediational associations of socioeconomic status, parental monitoring, deviant-peer association, antisocial behavior, and substance use in the prediction of sexual risk behavior. Lower condom use also predicted STD contraction.

Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania

OBJECTIVE

To describe the dynamics of HIV transmission in stable sexual partnerships in rural Tanzania.

DESIGN

Retrospective cohort study nested within community-randomized trial to investigate the impact of a sexually transmitted disease treatment program.

METHODS

A cohort of 1802 couples was followed up for 2 years, with the HIV status of each couple assessed at baseline and follow-up.

RESULTS

At baseline, 96.7% of couples were concordant-negative, 0.9% were concordant-positive, 1.2% were discordant with the male partner being HIV-positive, and 1.2% were discordant with the female partner being HIV-positive. Individuals living with an HIV-positive partner were more likely to be HIV-positive at baseline (women: odds ratio [OR] = 75.7, 95% confidence interval [CI]: 33.4-172; men: OR = 62.4, CI: 28.5-137). Seroincidence rates in discordant couples were 10 per 100 person-years (py) and 5 per 100 py for women and men, respectively (rate ratio [RR] = 2.0, CI: 0.28-22.1). In concordant-negative couples, seroincidence rates were 0.17 per 100 py in women and 0.45 per 100 py in men (RR = 0.38, CI: 0.12-1.04). Individuals living in discordant couples were at a greatly increased risk of infection compared with individuals in concordant-negative couples (RR = 57.9, CI: 12.0-244 for women; RR = 11.0, CI: 1.2-47.5 for men).

CONCLUSION

Men were more likely than women to introduce HIV infection in concordant-negative partnerships. In discordant couples, incidence in HIV-negative women was twice as high as in men. HIV-negative individuals in discordant partnerships are at high risk of infection, and preventive interventions targeted at such individuals are urgently needed.

Reproductive choices for couples with haemophilia

: Summary. The impact of having a child with an inherited bleeding disorder such as haemophilia can have a far-reaching effect on the individual as well as other close family members. This situation is further complicated in the case of human immunodeficiency (HIV) serodiscordant couples, where the haemophilic man is affected with HIV through infected blood products whilst his partner is seronegative and wanting to have children. It is essential that information on the effects of haemophilia, its inheritance, the possibilities of antenatal diagnosis, the consideration of selective abortion and the new reproductive opportunities available to these couples are made accessible so that an informed decision about proceeding with having a family can be made. Couples may wish to have a family through nonreproductive methods such as fostering or adoption. Alternatively, they may wish to remain childless. In this paper, the terms 'having children' and 'having a family' will refer to conception through biological reproduction. Pre-implantation genetic diagnosis (PGD) offers families at risk of having a child with certain inherited genetic disorders the opportunity to give birth to an unaffected child. It may be considered as an option for couples who would not wish to have prenatal diagnosis leading to possible termination of a pregnancy. Assisted conception techniques, such as 'sperm washing' or the use of 'donor sperm', offer serodiscordant couples affected by HIV a risk-reduced or risk-free opportunity, respectively, to have a child without infecting the mother, who could in turn infect the fetus by vertical transmission. This article, in addition to outlining the inheritance of haemophilia and the more common prenatal screening and diagnostic tests, discusses in more detail the latest reproductive opportunities available for families affected by haemophilia and considering having a family.

Concordance between HIV source partner identification and molecular confirmation in acute retroviral syndrome

Most HIV-1 transmission studies use self-reported history to define the source contact. To evaluate the reliability of epidemiologic source partner reporting, heteroduplex mobility assays (HMAs) were performed comparing the different viral strains present in the partners. Partners were typed for human leukocyte antigen (HLA) to evaluate the degree of shared alleles. Of 11 couples evaluated, HMA analysis confirmed nine transmissions (including 1 oral-genital transmission), indicated probable transmission in 1 couple, and suggested an alternative source partner in another. Nine source partners transmitted a major variant. Four source partners knew their HIV status. Previous HIV monitoring was reported by 5 of the 6 confirmed source partners who were unaware of their HIV status at the time of transmission. We also evaluated potential "sharing of HLA alleles" as a risk factor for HIV-1 acquisition; partners were not found to have a higher degree of shared HLA alleles. Lack of awareness about infection status as a consequence of infrequent testing plays a major role in the secondary transmission of HIV. These findings re-emphasize the importance of using safe sex practices at all times.

Male viral load and heterosexual transmission of HIV-1 subtype E in northern Thailand

We evaluated the association between HIV-1 RNA copies/mL in men and heterosexual transmission to their female partners among 493 couples in Thailand. Husbands were identified as HIV-positive when they were screened as blood donors; nearly all were infected with HIV subtype E. Wives had no known risks for HIV infection other than sex with their husbands. In multivariate analysis, each log10 increment of HIV RNA in the man was associated with an 81% increased rate of HIV transmission to his wife (odds ratio = 1.81, 95% confidence interval: 1.33-2.48). No transmission occurred at viral loads below 1094 copies/mL, and a dose-response effect was seen with increasing viral load in the man. In multivariate analysis, a history of a sexually transmitted disease in the man or woman, longer duration of hormonal contraceptive use, and the woman's onset of sexual activity at less than 20 years of age were also associated with increased seropositivity of the wife.

Correlates of nontransmission in US women at high risk of human immunodeficiency virus type 1 infection through sexual exposure

Seventeen women who were persistently uninfected by human immunodeficiency virus type 1 (HIV-1), despite repeated sexual exposure, and 12 of their HIV-positive male partners were studied for antiviral correlates of non-transmission. Thirteen women had > or = 1 immune response in the form of CD8 cell noncytotoxic HIV-1 suppressive activity, proliferative CD4 cell response to HIV antigens, CD8 cell production of macrophage inflammatory protein-1 beta, or ELISPOT assay for HIV-1-specific interferon-gamma secretion. The male HIV-positive partners without AIDS had extremely high CD8 cell counts. All 8 male partners evaluated showed CD8 cell-related cytotoxic HIV suppressive activity. Reduced CD4 cell susceptibility to infection, neutralizing antibody, single-cell cytokine production, and local antibody in the women played no apparent protective role. These observations suggest that the primary protective factor is CD8 cell activity in both the HIV-positive donor and the HIV-negative partner. These findings have substantial implications for vaccine development.

The effects of antiretroviral therapy on HIV-1 RNA loads in seminal plasma in HIV-positive patients with and without urethritis

BACKGROUND

High seminal plasma HIV-1 RNA loads (SVL) have been reported during gonococcal, non-gonococcal and chlamydial urethritis in patients not taking antiretroviral therapy.

OBJECTIVE

To examine if urethritis leads to increased SVL in HIV-positive patients taking antiretroviral therapy.

METHODS

Men who had been taking therapy for at least 3 months were recruited: 24 had urethitis (PWU) and 16 were without urethritis (controls). At three visits, 1 week apart, blood plasma viral load (BVL) and SVL were assayed by quantitative polymerase chain reaction or the NASBA assay.

RESULTS

Most subjects had undetectable SVL (18 PWU, 13 controls). Among those with undetectable BVL prior to first study visit, virus was undetectable in semen in 5/5 episodes of chlamydial urethritis, 6/7 episodes of non-gonococcal urethritis and 4/5 cases of gonococcal urethritis. Two PWU with undetectable BVL just prior to the first study visit had low to moderate SVL, which became undetectable by visit 2 following treatment. Of nine subjects with detectable SVL, eight had detectable BVL (3/3 controls and 5/6 PWU). Of these, 1/3 controls and 4/5 PWU (all with gonococcal urethritis) had poorly controlled BVL just prior to the first study visit. These four PWU had high SVL and one had higher levels in semen than in blood. This patient's SVL was reduced more than 20-fold following treatment for gonococcal urethritis.

CONCLUSIONS

Effective antiretroviral therapy appeared to limit the effect of urethritis on SVL. When BVL was poorly controlled by antiretroviral therapy, high SVL occurred during gonococcal urethritis, increasing the potential risk of transmitting both wild type and drug resistant strains of HIV-1.

Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use

BACKGROUND

Sexual acquisition of HIV is influenced by choice of partner, sex act, and condom use. However, current risk-reduction strategies focus mainly on condom use.

GOAL

To estimate the contribution of choice of partner, sex act, and condom use on the per-act relative and absolute risks for HIV infection.

STUDY DESIGN

Per-act relative risk for HIV infection was calculated with use of estimates of HIV prevalence, risk of condom failure, HIV test accuracy, and per-act risk of HIV transmission for different sex acts. Absolute risks were calculated on the basis of these relative risk estimates.

RESULTS

Choosing a partner who tested negative instead of an untested partner reduced the relative risk of HIV infection 47-fold; using condoms, 20-fold; and choosing insertive fellatio rather than insertive anal sex, 13-fold. Choosing one risk-reduction behavior substantially reduces absolute risk of HIV infection for heterosexuals but not for men who have sex with men.

CONCLUSION

Clarifying the magnitude of risk associated with different choices may help people make effective and sustainable changes in behavior.

Voluntary counseling and testing for couples: a high-leverage intervention for HIV/AIDS prevention in sub-Saharan Africa

Most HIV infections in sub-Saharan Africa occur during heterosexual intercourse between persons in couple relationships. Women who are infected by HIV seropositive partners risk infecting their infants in turn. Despite their salience as social contexts for sexual activity and HIV infection, couple relationships have not been given adequate attention by social/behavioral research in sub-Saharan Africa. Increasingly studies point to the value of voluntary HIV counseling and testing (VCT) as a HIV prevention tool. Studies in Africa frequently report that VCT is associated with reduced risk behaviors and lower rates of seroconversion among HIV serodiscordant couples. Many of these studies point out that VCT has considerable potential for HIV prevention among other heterosexual couples, and recommend that VCT for couples be practiced more widely in Africa. However, follow-up in the area of VCT for couples has been extremely limited. Thus, current understandings from social/behavioral research on how couples in sub-Saharan Africa manage HIV risks as well as HIV prevention interventions to support couples' HIV prevention efforts have remained underdeveloped. It appears that important opportunities are being missed for preventing HIV infection, be it by heterosexual transmission or mother-to-child HIV transmission by mothers who have been infected by their partners. Based on an overview of documentation on VCT in sub-Saharan Africa, this paper proposes that increased attention to couples-focused VCT provides a high-leverage HIV prevention intervention for African countries. The second half of the paper indicates areas where VCT needs to be strengthened, particularly with respect to couples. It also identifies areas where applied social/behavioral research is needed to improve knowledge about how couples in sub-Saharan Africa deal with the risks of HIV infection.

Using intervention theory to model factors influencing behavior change. Project RESPECT

Project RESPECT was a multisite randomized trial comparing three clinic-based interventions' ability to increase condom use and prevent infection with HIV and sexually transmitted diseases. Because Project RESPECT had guiding concepts that determined the content of the sessions, the authors investigated how the intervention operated using these theoretical variables. Growth curve analysis and structural equation modeling estimated the correlation between intentions toward condom use and self-reports of condom use and isolated the treatment effects on mediating variables--attitudes, self-efficacy, and social norms--that predict intentions. The correlations between intentions and behavior exceeded .70 for both genders, justifying the emphasis on intentions. Project RESPECT was effective through changing attitudes and self-efficacy for females in both counseling interventions. For males, only enhanced counseling had significant effects on these two mediator variables.

HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda

OBJECTIVE

Evidence of condom effectiveness for HIV and sexually transmitted disease (STD) prevention is based primarily on high-risk populations. We examined condom effectiveness in a general population with high HIV prevalence in rural Africa.

METHODS

Data were from a randomized community trial in Rakai, Uganda. Condom usage information was obtained prospectively from 17,264 sexually active individuals aged 15-59 years over a period of 30 months. HIV incidence and STD prevalence was determined for consistent and irregular condom users, compared to non-users. Adjusted rate ratios (RR) of HIV acquisition were estimated by Poisson multivariate regression, and odds ratios of STDs estimated by logistic regression.

RESULTS

Only 4.4% reported consistent condom use and 16.5% reported inconsistent use during the prior year. Condom use was higher among males, and younger, unmarried and better educated individuals, and those reporting multiple sex partners or extramarital relationships. Consistent condom use significantly reduced HIV incidence [RR, 0.37; 95% confidence interval (CI), 0.15-0.88], syphilis [odds ratio (OR), 0.71; 95% CI, 0.53-0.94] and gonorrhea/Chlamydia (OR, 0.50; 95% CI, 0.25-0.97) after adjustment for socio-demographic and behavioral characteristics. Irregular condom use was not protective against HIV or STD and was associated with increased gonorrhea/Chlamydia risk (OR, 1.44; 95% CI, 1.06-1.99). The population attributable fraction of consistent use for prevention of HIV was -4.5% (95% CI, -8.3 to 0.0), due to the low prevalence of consistent use in the population.

CONCLUSIONS

Consistent condom use provides protection from HIV and STDs, whereas inconsistent use is not protective. Programs must emphasize consistent condom use for HIV and STD prevention.

Sociodemographic, behavioral, and clinical correlates of inconsistent condom use in HIV-serodiscordant heterosexual couples

We examined sociodemographic, behavioral, and clinical characteristics associated with inconsistent condom use in a cross-sectional analysis of 145 sexually active HIV-serodiscordant heterosexual couples who participated in the California Partners Study II. All couples were aware of their HIV-serodiscordant status. Forty-five percent of couples reported having had unprotected vaginal or anal sex in the previous 6 months. In the multivariate couple-level analyses, factors independently associated with inconsistent (i.e., <100%) condom use in the previous 6 months included lower educational level, unemployment, African-American ethnicity, and practice of anal sex by the couple. Injection drug use was associated with inconsistent condom use among couples with younger HIV-infected partners. In addition, couples with HIV-infected partners who had higher CD4 cell counts and couples in which the HIV-infected male partner ever had sex with a man were more likely to use condoms inconsistently. Consistency of condom use did not depend on the gender of the HIV-infected partner or duration of sexual relationship. The findings suggest that many HIV-serodiscordant heterosexual couples remain at high risk of HIV transmission and may benefit not only from behavioral interventions but also from structural interventions aimed at improving their social and economic conditions.