Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team

Interaction of Depot Medroxyprogesterone Acetate and Tenofovir Disoproxil Fumarate/Emtricitabine on Peripheral Blood Mononuclear Cells and Cervical Tissue Susceptibility to HIV Infection and Pharmacokinetics

BACKGROUND

Depot medroxyprogesterone acetate (DMPA) is a widely used contraceptive method. HIV pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil fumarate (F/TDF) is highly effective in reducing HIV acquisition in women. We sought to determine the impact of DMPA on F/TDF pharmacokinetics and pharmacodynamics.

METHODS

Twelve healthy premenopausal cisgender women were enrolled and each completed 4 sequential conditions: (1) baseline, (2) steady-state F/TDF alone, (3) steady-state F/TDF + DMPA, and (4) DMPA alone. Assessments included clinical, pharmacokinetic, viral infectivity (ex vivo challenge of peripheral blood mononuclear cells by X4- and R5-tropic green fluorescent protein pseudoviruses and cervical tissue by HIV BaL ), endocrine, immune cell phenotyping, and renal function.

RESULTS

Compared with baseline, F/TDF (± DMPA) significantly decreased both %R5- and X4-infected CD4 T cells and F/TDF + DMPA decreased cervical explant p24 (all P < 0.05). The %R5- and X4-infected CD4 T cells were higher during DMPA alone than during F/TDF periods and lower than baseline (not statistically significant). Cervical explant p24 fell between baseline and F/TDF values (not statistically significant). There were neither statistically significant differences in F/TDF pharmacokinetics, including total or renal clearance of either antiviral drug, nor changes in glomerular filtration rate with the addition of DMPA. There were few immune cell phenotypic differences across conditions.

CONCLUSIONS

F/TDF decreased HIV infection in both challenge assays, whereas DMPA alone did not enhance HIV infection in either challenge assay. DMPA did not alter F/TDF pharmacokinetics or renal function.

Development and Validation of a Sociodemographic and Behavioral Characteristics-Based Risk-Score Algorithm for Targeting HIV Testing Among Adults in Kenya

To inform targeted HIV testing, we developed and externally validated a risk-score algorithm that incorporated behavioral characteristics. Outpatient data from five health facilities in western Kenya, comprising 19,458 adults ≥ 15 years tested for HIV from September 2017 to May 2018, were included in univariable and multivariable analyses used for algorithm development. Data for 11,330 adults attending one high-volume facility were used for validation. Using the final algorithm, patients were grouped into four risk-score categories: ≤ 9, 10-15, 16-29 and ≥ 30, with increasing HIV prevalence of 0.6% [95% confidence interval (CI) 0.46-0.75], 1.35% (95% CI 0.85-1.84), 2.65% (95% CI 1.8-3.51), and 15.15% (95% CI 9.03-21.27), respectively. The algorithm's discrimination performance was modest, with an area under the receiver-operating-curve of 0.69 (95% CI 0.53-0.84). In settings where universal testing is not feasible, a risk-score algorithm can identify sub-populations with higher HIV-risk to be prioritized for HIV testing.

Personal and Lifestyle Determinants of HIV Transmission Risk in Spanish University Students

The increase in human immunodeficiency virus (HIV) transmission cases poses a serious public health concern. Although several previous studies have been conducted with the aim of identifying the risk factors for HIV transmission, the number of cases has been increasing, especially in youth. The present study is aimed at the identification of personal and lifestyle determinants of HIV transmission risk in a sample of 335 Spanish university students selected by convenience sampling from a public university located in Alicante (Spain). Sociodemographic factors, lifestyles, and variables of HIV risk of transmission were evaluated. Group differences on risk of HIV transmission were evaluated between participants depending on their sociodemographic characteristics (age, sex, relationship status, employment status, economic status, and sexual orientation) and lifestyle (diet, physical exercise, smoking, alcohol consumption, and stress). Linear regression models were conducted in order to identify those personal and lifestyle variables related to HIV transmission risk. The obtained results indicate that, generally, being older, in a relationship, and employed were factors related to a high risk of HIV transmission. Regarding lifestyle, poor diet, lower intensity of physical exercise, higher alcohol intake, and smoking were fundamentally associated with a higher risk of HIV transmission, through lower use of condoms and higher frequency of risky sexual behaviors. Hence, participants who develop an unhealthy lifestyle exhibit twice the probability of being at a high risk of HIV transmission, especially regarding these previously indicated behaviors. The present study points out the relevance of sociodemographic characteristics and lifestyles of university students in their proneness to developing risky behaviors for HIV infection. Future studies should be developed with larger, randomized, and more representative samples, in order to obtain significant information for the development of effective preventive strategies oriented toward the increase in the adherence to healthy lifestyles and HIV prevention.

Critical evaluation of arguments opposing male circumcision: A systematic review

OBJECTIVE

To systematically evaluate evidence against male circumcision (MC).

METHODS

We searched PubMed, Google Scholar, EMBASE and Cochrane databases.

RESULTS

Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems.

CONCLUSIONS

Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.

Does Male Circumcision Reduce Women's Risk of Sexually Transmitted Infections, Cervical Cancer, and Associated Conditions?

Background: Male circumcision (MC) is proven to substantially reduce men's risk of a number of sexually transmitted infections (STIs). We conducted a detailed systematic review of the scientific literature to determine the relationship between MC and risk of STIs and associated conditions in women. Methods: Database searches by "circumcision women" and "circumcision female" identified 68 relevant articles for inclusion. Examination of bibliographies of these yielded 14 further publications. Each was rated for quality using a conventional rating system. Results: Evaluation of the data from the studies retrieved showed that MC is associated with a reduced risk in women of being infected by oncogenic human papillomavirus (HPV) genotypes and of contracting cervical cancer. Data from randomized controlled trials and other studies has confirmed that partner MC reduces women's risk not only of oncogenic HPV, but as well Trichomonas vaginalis, bacterial vaginosis and possibly genital ulcer disease. For herpes simplex virus type 2, Chlamydia trachomatis, Treponema pallidum, human immunodeficiency virus and candidiasis, the evidence is mixed. Male partner MC did not reduce risk of gonorrhea, Mycoplasma genitalium, dysuria or vaginal discharge in women. Conclusion: MC reduces risk of oncogenic HPV genotypes, cervical cancer, T. vaginalis, bacterial vaginosis and possibly genital ulcer disease in women. The reduction in risk of these STIs and cervical cancer adds to the data supporting global efforts to deploy MC as a health-promoting and life-saving public health measure and supplements other STI prevention strategies.

Association between male circumcision and women's biomedical health outcomes: a systematic review

BACKGROUND

Male circumcision reduces men's risk of acquiring HIV and some sexually transmitted infections from heterosexual exposure, and is essential for HIV prevention in sub-Saharan Africa. Studies have also investigated associations between male circumcision and risk of acquisition of HIV and sexually transmitted infections in women. We aimed to review all evidence on associations between male circumcision and women's health outcomes to benefit women's health programmes.

METHODS

In this systematic review we searched for peer-reviewed and grey literature publications reporting associations between male circumcision and women's health outcomes up to April 11, 2016. All biomedical (not psychological or social) outcomes in all study types were included. Searches were not restricted by year of publication, or to sub-Saharan Africa. Publications without primary data and not in English were excluded. We extracted data and assessed evidence on each outcome as high, medium, or low consistency on the basis of agreement between publications; outcomes found in fewer than three publications were indeterminate consistency.

FINDINGS

60 publications were included in our assessment. High-consistency evidence was found for five outcomes, with male circumcision protecting against cervical cancer, cervical dysplasia, herpes simplex virus type 2, chlamydia, and syphilis. Medium-consistency evidence was found for male circumcision protecting against human papillomavirus and low-risk human papillomavirus. Although the evidence shows a protective association with HIV, it was categorised as low consistency, because one trial showed an increased risk to female partners of HIV-infected men resuming sex early after male circumcision. Seven outcomes including HIV had low-consistency evidence and six were indeterminate.

INTERPRETATION

Scale-up of male circumcision in sub-Saharan Africa has public health implications for several outcomes in women. Evidence that female partners are at decreased risk of several diseases is highly consistent. Synergies between male circumcision and women's health programmes should be explored.

FUNDING

US Centers for Disease Control and Prevention and Jhpiego.

Could Circumcision of HIV-Positive Males Benefit Voluntary Medical Male Circumcision Programs in Africa? Mathematical Modeling Analysis

Background

The epidemiological and programmatic implications of inclusivity of HIV-positive males in voluntary medical male circumcision (VMMC) programs are uncertain. We modeled these implications using Zambia as an illustrative example.

Methods and Findings

We used the Age-Structured Mathematical (ASM) model to evaluate, over an intermediate horizon (2010–2025), the effectiveness (number of VMMCs needed to avert one HIV infection) of VMMC scale-up scenarios with varying proportions of HIV-positive males. The model was calibrated by fitting to HIV prevalence time trend data from 1990 to 2014. We assumed that inclusivity of HIV positive males may benefit VMMC programs by increasing VMMC uptake among higher risk males, or by circumcision reducing HIV male-to-female transmission risk. All analyses were generated assuming no further antiretroviral therapy (ART) scale-up.

The number of VMMCs needed to avert one HIV infection was projected to increase from 12.2 VMMCs per HIV infection averted, in a program that circumcises only HIV-negative males, to 14.0, in a program that includes HIV-positive males. The proportion of HIV-positive males was based on their representation in the population (e.g. 12.6% of those circumcised in 2010 would be HIV-positive based on HIV prevalence among males of 12.6% in 2010). However, if a program that only reaches out to HIV-negative males is associated with 20% lower uptake among higher-risk males, the effectiveness would be 13.2 VMMCs per infection averted. If improved inclusivity of HIV-positive males is associated with 20% higher uptake among higher-risk males, the effectiveness would be 12.4. As the assumed VMMC efficacy against male-to-female HIV transmission was increased from 0% to 20% and 46%, the effectiveness of circumcising regardless of HIV status improved from 14.0 to 11.5 and 9.1, respectively. The reduction in the HIV incidence rate among females increased accordingly, from 24.7% to 34.8% and 50.4%, respectively.

Conclusion

Improving inclusivity of males in VMMC programs regardless of HIV status increases VMMC effectiveness, if there is moderate increase in VMMC uptake among higher-risk males and/or if there is moderate efficacy for VMMC against male-to-female transmission. In these circumstances, VMMC programs can reduce the HIV incidence rate in males by nearly as much as expected by some ART programs, and additionally, females can benefit from the intervention nearly as much as males.

Tobacco Consumption Among HIV-Positive Respondents: Findings From the Third Round of the National Family Health Survey

INTRODUCTION

HIV-positive people are often more susceptible to illnesses associated with smoking, for example, cardiovascular disease, than those in the general population. The purpose of this article is to examine the association between tobacco use and HIV-status in India.

METHODS

This article analyzed data from the National Family Health Survey III, which provides a representative sample of the Indian population. Patterns in tobacco consumption among HIV-positive and negative respondents were assessed through logistic and ordinal regression models. Associations between smoking, asthma, and tuberculosis were examined through bivariate logistic regressions.

RESULTS

A greater percentage of male HIV-positive participants (68%) reported current tobacco use in comparison to male HIV-negative respondents (58%) and female HIV-positive (12%) and negative (11%) participants. Multivariable logistic regression analyses revealed that there was a positive correlation between male respondents' HIV-status and their propensity to use tobacco (odds ratio [OR] = 1.48, confidence interval [CI] = 1.05-2.1, P < .05) when controlled for extraneous variables. Results from ordinal regression analyses illustrated that male HIV-positive respondents had a twofold increased OR of smoking 20 or more cigarettes (OR = 2.1, CI = 1.4-3.2, P < .005). Finally, there was a positive association between being HIV-infected (adjusted odds ratio [AOR] = 4.6, CI = 2.02-10.6, P < .005), smoking 15-19 cigarettes (AOR = 2.11, CI = 1.1-4.1, P < .05) and male participants' TB-status.

CONCLUSIONS

Results in this article suggest HIV-positive men in India were not only significantly more likely to consume tobacco, but they also smoked a higher number of cigarettes compared to their HIV-negative counterparts. This is a cause for concern as our analyses revealed a possible association between the number of cigarettes smoked and TB-status.

IMPLICATIONS

This article contributes to knowledge on the intertwining epidemics of HIV and smoking through using cross-sectional data from the National Family Survey III to demonstrate that HIV-positive men in India display patterns of tobacco consumption which differs to that of HIV-negative men. These findings could have strong implications for long-term treatment of HIV-positive patients as smoking has been proven to increase the likelihood of contracting HIV-related illnesses.

Spatial analysis of HIV infection and associated individual characteristics in Burundi: indications for effective prevention

Background

Adequate resource allocation is critical in the battle against HIV/AIDS, especially in Africa. The determination of the location and nature of HIV services to implement must comply with the geographic, social and behavioral characteristics of patients. We therefore investigated the spatial heterogeneity of HIV prevalence in Burundi and then assessed the association of social and behavioral characteristics with HIV infection accounting for the spatial heterogeneity.

Methods

We used data from the 2010 Demographic and Health Survey. We analyzed these data with a geostatistical approach (which takes into account spatial autocorrelation) by i) interpolating HIV data using the kernel density estimation, ii) identifying the spatial clusters with high and low HIV prevalence using the Kulldorff spatial scan statistics, and then iii) performing a multivariate spatial logistic regression.

Results

Overall HIV prevalence was 1.4 %. The interpolated data showed the great spatial heterogeneity of HIV prevalence (from 0 to 10 %), independently of administrative boundaries. A cluster with high HIV prevalence was found in the capital city and adjacent areas (3.9 %; relative risk 3.7, p < 0.001) whereas a cluster with low prevalence straddled two southern provinces (0 %; p = 0.02). By multivariate spatial analysis, HIV infection was significantly associated with the female sex (posterior odds ratio [POR] 1.36, 95 % credible interval [CrI] 1.13-1.64), an older age (POR 1.97, 95 % CrI 1.26-3.08), the level of education (POR 1.50, 95 % CrI 1.22-1.84), the marital status (POR 1.86, 95 % CrI 1.23-2.80), a higher wealth index (POR 2.11, 95 % CrI 1.77-2.51), the sexual activity (POR 1.76, 95 % CrI 1.04-2.96), and a history of sexually transmitted infection (POR 2.03, 95 % CrI 1.56-2.64).

Conclusions

Our study, which shows where and towards which populations HIV resources should be allocated, could help national health policy makers develop an effective HIV intervention in Burundi. Our findings support the strategy of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for country-specific, in-depth analyses of HIV epidemics to tailor national prevention responses.

Circumcision Status and Risk of HIV Acquisition during Heterosexual Intercourse for Both Males and Females: A Meta-Analysis

In this study, we evaluated if male circumcision was associated with lower HIV acquisition for HIV (−) males and HIV (−) females during normal sexual behavior. We performed a systematic literature search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared HIV acquisition for the circumcised and uncircumcised groups. The reference lists of the included and excluded studies were also screened. Fifteen studies (4 RCTs and 11 prospective cohort studies) were included, and the related data were extracted and analyzed in a meta-analysis. Our study revealed strong evidence that male circumcision was associated with reduced HIV acquisition for HIV(−) males during sexual intercourse with females [pooled adjusted risk ratio (RR): 0.30, 95% CI 0.24 0.38, P < 0.00001] and provided a 70% protective effect. In contrast, no difference was detected in HIV acquisition for HIV (−) females between the circumcised and uncircumcised groups (pooled adjusted RR after sensitivity analysis: 0.68, 95%CI 0.40–1.15, P = 0.15). In conclusion, male circumcision could significantly protect males but not females from HIV acquisition at the population level. Male circumcision may serve as an additional approach toward HIV control, in conjunction with other strategies such as HIV counseling and testing, condom promotion, and so on.

Women's land ownership and risk of HIV infection in Kenya

Theory predicts that land ownership empowers women to avoid HIV acquisition by reducing their reliance on risky survival sex and enhancing their ability to negotiate safer sex. However, this prediction has not been tested empirically. Using a sample of 5511 women working in the agricultural sector from the 1998, 2003 and 2008-09 Kenya Demographic and Health Surveys, we examined the relationship between women's land ownership and participation in transactional sex, multiple sexual partnerships and unprotected sex, and HIV infection status. We controlled for demographic characteristics and household wealth, using negative binomial and logistic regression models. Women's land ownership was associated with fewer sexual partners in the past year (incidence rate ratio, 0.98; 95% confidence interval [CI], 0.95-1.00) and lower likelihood of engaging in transactional sex (odds ratio [OR], 0.67; 95% CI: 0.46-0.99), indicators of reduced survival sex, but was not associated with unprotected sex with casual partners (OR, 0.64; 95% CI, 0.35-1.18) or with unprotected sex with any partner among women with high self-perceived HIV risk (OR, 1.02; 95% CI, 0.57-1.84), indicating no difference in safer sex negotiation. Land ownership was also associated with reduced HIV infection among women most likely to engage in survival sex, i.e., women not under the household headship of a husband (OR, 0.40; 95% CI, 0.18-0.89), but not among women living in husband-headed households, for whom increased negotiation for safer sex would be more relevant (OR, 1.74; 95% CI, 0.92-3.29). These findings suggest that reinforcing women's land rights may reduce reliance on survival sex and serve as a viable structural approach to HIV prevention, particularly for women not in a husband's household, including unmarried women and female household heads.

Having Multiple Sexual Partners among Iranian Intra-Venous Drug Users

BACKGROUND

Transmission of HIV from intra-venous drug users (IDUs) to the community occurs predominantly through high-risk sexual behaviors. Limited information exists regarding the high-risk sexual behaviors of IDUs in Iran.

AIM

The aim of this study was to determine the prevalence and factors associated with having multiple sexual partners among Iranian IDUs.

METHODS

This is a national survey on drug-dependent adults. Participants were sampled from medical centers, prisons, and streets of capitals of 29 provinces in Iran between May 2007 and February 2008. We analyzed data of 1416 current IDUs. Socio-demographics and drug use characteristics were entered into a binary logistic regression model to determine predictors of having multiple sexual partners.

RESULTS

Having multiple sexual partners in the past or at the time of survey was reported by 56.4% of Iranian IDUs. Multivariate analysis showed that the likelihood of having multiple sexual partners in IDUs decreased by being married [odds ratio (OR), 0.38; P < 0.001] and increased by female gender (OR, 13.44; P = 0.02), having illegal income (OR, 1.72; P = 0.003), higher monthly family income (OR, 1.01; P = 0.003), pleasure, curiosity, and recreation as cause of first drug use (OR, 1.37; P = 0.04), ruins as usual place for injection (OR, 1.89; P = 0.001) and history of syringe sharing (OR, 1.50; P = 0.02).

CONCLUSION

Having multiple sexual partners was reported by majority of Iranian IDUs, and this was linked to socio-demographics, initiation data, and other risk behaviors. This information should be considered in prevention efforts to reduce sexual transmission of HIV infection in Iran.

Factors affecting the HIV/AIDS epidemic: an ecological analysis of global data

BACKGROUND

All over the world the prevalence of Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) has became a stumbling stone in progress of human civilization and is a huge concern for people worldwide.

OBJECTIVES

To determine the social and health factors which contribute to increase the size of HIV epidemic globally.

METHODS

The country level indicators of HIV prevalence rates, are contraceptive prevalence rate, physicians density, proportion of Muslim populations, adolescent fertility rate, and mean year of schooling were compiled of 187 countries from the United Nations (UN) agencies. To extract the major factors from those indicators of the later five categories, backward multiple regression analysis was used as the statistical tool.

RESULTS

The national HIV prevalence rate was significantly correlated with almost all the predictors. Backward multiple linear regression analysis identified the proportion of Muslims, physicians density, and adolescent fertility rate are as the three most prominent factors linked with the national HIV epidemic.

CONCLUSION

The findings support the hypotheses that a higher adolescent fertility rate in the population is the adverse effect of premarital and extramarital sex that leads to longer period of sexual activity which increases the risk of HIV infection. On the hand, and cultural restrictions of Muslims and sufficient physicians will decelerate the spread of HIV infections in the society.

Heterosexual anal intercourse: a neglected risk factor for HIV?

Heterosexual anal intercourse confers a much greater risk of HIV transmission than vaginal intercourse, yet its contribution to heterosexual HIV epidemics has been under-researched. In this article we review the current state of knowledge of heterosexual anal intercourse practice worldwide and identify the information required to assess its role in HIV transmission within heterosexual populations, including input measures required to inform mathematical models. We then discuss the evidence relating anal intercourse and HIV with sexual violence.

Is early sexual debut a risk factor for HIV infection among women in sub-Saharan Africa? A systematic review

PROBLEM

In Africa, adolescent girls have high HIV risk. Early sexual debut may be a risk factor, although evidence has not been systematically compiled.

METHODS

A systematic review was conducted. Quantitative studies from sub-Saharan Africa with biologically confirmed HIV infection measures were included.

RESULTS

A total of 128 full texts were screened. Twenty-five met the inclusion criteria, most cross-sectional. Half of studies, and all with large sample sizes, reported significant bivariate associations. These remained significant in all three studies controlling for socio-demographic factors; both studies controlling for sexual activity duration and four of eight studies controlling for subsequent risk behaviour.

CONCLUSIONS

Higher-quality studies consistently find significant bivariate associations between early sexual debut and HIV. In some studies, the increase in women's HIV infection risk seems to result from women's later engagement in risky sexual behaviours, rather than being directly related to early onset of sexual debut. In other studies, the increase in risk did not seem to be due to specific behavioural risk characteristics of the respondents or their sexual partners, suggesting that the risk may relate more to the potential for biological factors, for example, genital trauma, or other factors that have not been captured by the studies in this review.

Placental malaria and mother-to-child transmission of human immunodeficiency virus-1 in rural Rwanda

We conducted a nested case-control study of placental malaria (PM) and mother-to-child transmission (MTCT) of human immunodeficiency virus-1 (HIV-1) within a prospective cohort of 627 mother-infant pairs followed from October 1989 until April 1994 in rural Rwanda. Sixty stored placentas were examined for PM and other placental pathology, comparing 20 HIV-infected mother-infant (perinatal transmitter) pairs, 20 HIV-uninfected pairs, and 20 HIV-infected mothers who did not transmit to their infant perinatally. Of 60 placentas examined, 45% showed evidence of PM. Placental malaria was associated with increased risk of MTCT of HIV-1 (adjusted odds ratio [aOR] = 6.3; 95% confidence interval [CI] = 1.4-29.1), especially among primigravidae (aOR = 12.0; 95% CI = 1.0-150; P < 0.05). Before antiretroviral therapy or prophylaxis, PM was associated with early infant HIV infection among rural Rwandan women living in a hyper-endemic malaria region. Primigravidae, among whom malaria tends to be most severe, may be at higher risk.

Spousal intimate partner violence is associated with HIV and Other STIs among married Rwandan women

HIV is a health problem in Rwanda, where the adult HIV prevalence is 3.1% (WHO 2008 in Online database of HIV/AIDS epidemiological data, found at: http://www.who.int/globalatlas ); the majority of those infected are women (UNAIDS 2008 in http://data.unaids.org/pub/Report/2008/rwanda_2008_country_progress_report_en.pdf ). Prior studies indicate that intimate partner violence is frequently associated with increased HIV risk in women, often because men who abuse their wives also exhibit riskier sexual behaviors (Silverman et al. in JAMA 300:703-710 2008. Population-based data from the 2005 Rwanda Demographic and Health Survey indicate that women with few, if any, other sexual risk factors who have experienced sexual, physical, or emotional abuse within their marriages are 1.61-3.46 times as likely to test positive for HIV, and 2.14-4.11 times more likely to report another STI. These findings confirm prior clinical studies that indicate that intimate partner violence is a correlate of HIV/STIs in Rwanda. Further research is needed to determine whether Rwandan men that abuse their wives have higher baseline rates of HIV/STI infection.

The convergence of the global smoking, COPD, tuberculosis, HIV, and respiratory infection epidemics

At the beginning of the 21st century, we are facing the convergence of several epidemics. These include tobacco smoking, tuberculosis, HIV infection, influenza, and chronic obstructive pulmonary disease. These epidemics interact by way of increasing disease susceptibility and worsening outcomes. To control these interacting epidemics, we need to better understand each infection and how it influences the others. Multifaceted approaches will be necessary to reduce the impact on those in developing nations most likely to be affected by the convergence of all epidemics.

Assessing Local Model Adequacy in Bayesian Hierarchical Models Using the Partitioned Deviance Information Criterion

Many diagnostic tools and goodness-of-fit measures, such as the Akaike information criterion (AIC) and the Bayesian deviance information criterion (DIC), are available to evaluate the overall adequacy of linear regression models. In addition, visually assessing adequacy in models has become an essential part of any regression analysis. In this paper, we focus on a spatial consideration of the local DIC measure for model selection and goodness-of-fit evaluation. We use a partitioning of the DIC into the local DIC, leverage, and deviance residuals to assess local model fit and influence for both individual observations and groups of observations in a Bayesian framework. We use visualization of the local DIC and differences in local DIC between models to assist in model selection and to visualize the global and local impacts of adding covariates or model parameters. We demonstrate the utility of the local DIC in assessing model adequacy using HIV prevalence data from pregnant women in the Butare province of Rwanda during 1989-1993 using a range of linear model specifications, from global effects only to spatially varying coefficient models, and a set of covariates related to sexual behavior. Results of applying the diagnostic visualization approach include more refined model selection and greater understanding of the models as applied to the data.

Global lung health: the colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD

Tuberculosis (TB), smoking, HIV and chronic obstructive pulmonary disease (COPD) are burgeoning epidemics in developing countries. The link between TB and HIV is well established. Less well recognised is the strong relationship between tobacco smoking and the development and natural history of TB. These associations are of considerable relevance to public health and disease outcomes in individuals with TB. Moreover, tobacco smoking, a modifiable risk factor, is associated with poorer outcomes in HIV-associated opportunistic infections, of which TB is the commonest in developing countries. It is now also becoming clear that TB, like tobacco smoke, besides its known consequences of bronchiectasis and other pulmonary morbidity, is also a significant risk factor for the development of COPD. Thus, there is a deleterious and synergistic interaction between TB, HIV, tobacco smoking and COPD in a large proportion of the world's population. Further work, specifically mechanistic and epidemiological studies, is required to clarify the role of tobacco smoke on the progression of TB and HIV infection, and to assess the impact of smoking cessation interventions. These interactions deserve urgent attention and have major implications for coordinated public health planning and policy recommendations in the developing world.

Sex steroid hormones, hormonal contraception, and the immunobiology of human immunodeficiency virus-1 infection

Worldwide, an increasing number of women use oral or injectable hormonal contraceptives. However, inadequate information is available to aid women and health care professionals in weighing the potential risks of hormonal contraceptive use in individuals living with HIV-1 or at high risk of infection. Numerous epidemiological studies and challenge studies in a rhesus macaque model suggest that progesterone-based contraceptives increase the risk of HIV-1 infection in humans and simian immunodeficiency virus (SIV) infection in macaques, accelerate disease progression, and increase viral shedding in the genital tract. However, because several other studies in humans have not observed any effect of exogenously administered progesterone on HIV-1 acquisition and disease progression, the issue continues to be a topic of intense research and ongoing discussion. In contrast to progesterone, systemic or intravaginal treatment with estrogen efficiently protects female rhesus macaques against the transmission of SIV, likely by enhancing the natural protective properties of the lower genital tract mucosal tissue. Although the molecular and cellular mechanisms underlying the effect of sex steroid hormones on HIV-1 and SIV acquisition and disease progression are not well understood, progesterone and estrogen are known to regulate a number of immune mechanisms that may exert an effect on retroviral infection. This review summarizes current knowledge of the effects of various types of sex steroid hormones on immune processes involved in the biology of HIV-1 infection.

Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis

Male circumcision provides long-term indirect protection to women by reducing the risk of heterosexual men becoming infected with HIV. In this Review, we summarise the evidence for a direct effect of male circumcision on the risk of women becoming infected with HIV. We identified 19 epidemiological analyses, from 11 study populations, of the association of male circumcision and HIV risk in women. A random-effects meta-analysis of data from the one randomised controlled trial and six longitudinal analyses showed little evidence that male circumcision directly reduces risk of HIV in women (summary relative risk 0.80, 95% CI 0.53-1.36). Definitive data would come from a further randomised controlled trial of circumcision among men infected with HIV in serodiscordant heterosexual relationships, but this would involve enrolling about 10 000 couples and is likely to be logistically unfeasible. As circumcision services for HIV prevention are scaled-up in high HIV prevalence settings, rapid integration with existing prevention strategies would maximise benefits for both men and women. Rigorous monitoring is essential to ensure that any adverse effects on women are detected and minimised.

The history and challenge of HIV prevention

The HIV/AIDS pandemic has become part of the contemporary global landscape. Few predicted its effect on mortality and morbidity or its devastating social and economic consequences, particularly in sub-Saharan Africa. Successful responses have addressed sensitive social factors surrounding HIV prevention, such as sexual behaviour, drug use, and gender equalities, countered stigma and discrimination, and mobilised affected communities; but such responses have been few and far between. Only in recent years has the international response to HIV prevention gathered momentum, mainly due to the availability of treatment with antiretroviral drugs, the recognition that the pandemic has both development and security implications, and a substantial increase in financial resources brought about by new funders and funding mechanisms. We now require an urgent and revitalised global movement for HIV prevention that supports a combination of behavioural, structural, and biomedical approaches and is based on scientifically derived evidence and the wisdom and ownership of communities.

Explaining continued high HIV prevalence in South Africa: socioeconomic factors, HIV incidence and sexual behaviour change among a rural cohort, 2001-2004

OBJECTIVES

To estimate HIV incidence and explore evidence for changing sexual behaviour over time among men and women belonging to different socioeconomic groups in rural South Africa.

DESIGN AND METHODS

A cohort study conducted between 2001 and 2004; 3881 individuals aged 14-35 years enumerated in eight villages were eligible. At least three household visits were made to contact each eligible respondent at both timepoints. Sexual behaviour data were collected in structured, respondent-focused interviews. HIV serostatus was assessed using an oral fluid enzyme-linked immunosorbent assay at each timepoint.

RESULTS

Data on sexual behaviour were available from 1967 individuals at both timepoints. A total of 1286 HIV-negative individuals at baseline contributed to the analysis of incidence. HIV incidence was 2.2/100 person-years among men and 4.9/100 person-years in women, among whom it was highest in the least educated group. Median age at first sex was lower among later birth cohorts. A higher number of previously sexually active individuals reported having multiple partners in the past year in 2004 than 2001. Condom use with non-spousal partners increased from 2001 to 2004. Migrant men more often reported multiple partners. Migrant and more educated individuals of both sexes and women from wealthier households reported higher levels of condom use.

DISCUSSION

HIV incidence is high in rural South Africa, particularly among women of low education. Some risky sexual behaviours (early sexual debut, having multiple sexual partners) are becoming more common over time. Condom use is increasing. Existing HIV prevention strategies have only been partly effective in generating population-level behavioural change.

Sexual risk factors for HIV infection in early and advanced HIV epidemics in sub-Saharan Africa: systematic overview of 68 epidemiological studies

Background

It is commonly assumed that sexual risk factors for heterosexual HIV transmission in sub-Saharan Africa, such as multi-partner sex, paid sex and co-infections, become less important as HIV epidemics mature and prevalence increases.

Methods and Findings

We conducted a systematic review of 68 African epidemiological studies from 1986 to 2006 involving 17,000 HIV positive adults and 73,000 controls. We used random-effects methods and stratified results by gender, time, background HIV prevalence rates and other variables. The number of sex partners, history of paid sex, and infection with herpes simplex virus (HSV-2) or other sexually-transmitted infections (STIs) each showed significant associations with HIV infection. Among the general population, the odds ratio (OR) of HIV infection for women reporting 3+ sex partners versus 0–2 was 3.64 (95%CI [2.87–4.62]), with similar risks for men. About 9% of infected women reported ever having been paid for sex, versus 4% of control women (OR = 2.29, [1.45–3.62]). About 31% of infected men reported ever paying for sex versus 18% of uninfected men (OR = 1.75, [1.30–2.36]). HSV-2 infection carried the largest risk of HIV infection: OR = 4.62, [2.85–7.47] in women, and OR = 6.97, [4.68–10.38] in men. These risks changed little over time and stratification by lower and higher HIV background prevalence showed that risk ratios for most variables were larger in high prevalence settings. Among uninfected controls, the male-female differences in the number of sex partners and in paid sex were more extreme in the higher HIV prevalence settings than in the lower prevalence settings.

Significance

Multi-partner sex, paid sex, STIs and HSV-2 infection are as important to HIV transmission in advanced as in early HIV epidemics. Even in high prevalence settings, prevention among people with high rates of partner change, such as female sex workers and their male clients, is likely to reduce transmission overall.

Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda

OBJECTIVE

To assess whether male circumcision of the primary sex partner is associated with women's risk of HIV.

DESIGN

Data were analyzed from 4417 Ugandan and Zimbabwean women participating in a prospective study of hormonal contraception and HIV acquisition. Most were recruited from family planning clinics; some in Uganda were referred from higher-risk settings such as sexually transmitted disease clinics.

METHODS

Using Cox proportional hazards models, time to HIV acquisition was compared for women with circumcised or uncircumcised primary partners. Possible misclassification of male circumcision was assessed using sensitivity analysis.

RESULTS

At baseline, 74% reported uncircumcised primary partners, 22% had circumcised partners and 4% had partners of unknown circumcision status. Median follow-up was 23 months, during which 210 women acquired HIV (167, 34, and 9 women whose primary partners were uncircumcised, circumcised, or of unknown circumcision status, respectively). Although unadjusted analyses indicated that women with circumcised partners had lower HIV risk than those with uncircumcised partners, the protective effect disappeared after adjustment for other risk factors [hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.69-1.53]. Subgroup analyses suggested a non-significant protective effect of male circumcision on HIV acquisition among Ugandan women referred from higher-risk settings: adjusted HR 0.16 (95% CI, 0.02-1.25) but little effect in Ugandans (HR, 1.33; 95% CI, 0.72-2.47) or Zimbabweans (HR, 1.12; 95% CI, 0.65-1.91) from family planning clinics.

CONCLUSIONS

After adjustment, male circumcision was not significantly associated with women's HIV risk. The potential protection offered by male circumcision for women recruited from high-risk settings warrants further investigation.

Is smoking tobacco an independent risk factor for HIV infection and progression to AIDS? A systemic review

OBJECTIVES

To systematically review the evidence of the relation between smoking tobacco and HIV seroconversion and progression to AIDS.

METHODS

A systematic review was undertaken of studies to look at tobacco smoking as a risk factor for either HIV seroconversion or progression to AIDS.

RESULTS

Six studies were identified with HIV seroconversion as an outcome measure. Five of these indicated that smoking tobacco was an independent risk factor after adjusting for important confounders with adjusted odds ratios ranging from 1.6 to 3.5. 10 studies were identified using progression to AIDS as an end point of which nine found no relation with tobacco smoking.

CONCLUSIONS

Tobacco smoking may be an independent risk factor for HIV infection although residual confounding is another possible explanation. Smoking did not appear to be related to progression to AIDS although this finding may not be true in developing countries or with the longer life expectancies seen with highly active antiretroviral therapy.

Current trends in Rwanda's HIV/AIDS epidemic

OBJECTIVE

To review the trajectory of Rwanda's HIV epidemic, including long term trends and more recent trends in HIV prevalence, markers of HIV incidence, and behavioural indicators.

METHODS

This paper reviews the history of HIV serological and behavioural surveillance efforts in Rwanda, dating back to the early 1980s, synthesising findings from surveillance, research, and other relevant HIV programmatic data. The documentation reviewed includes published findings, conference abstracts, and unpublished analyses. Special emphasis is given to more recent sentinel surveillance results and data collected using known, documented methods. Recent trends in HIV prevalence were assessed among sites participating in the three most recent consecutive rounds of antenatal clinic sentinel surveillance.

RESULTS

Early HIV surveillance in Rwanda documented high HIV prevalence in urban areas with HIV widely disseminated into rural areas by 1986. Between 1988 and 1996, HIV prevalence among pregnant women ranged from 21% to 33% in Kigali, from 8% to 22% in other urban settings, and from 2% to 12% in rural settings. More recent surveillance among pregnant women has demonstrated more moderate prevalence, with urban/rural differences narrowing slightly. Between 1998 and 2003, HIV prevalence may have declined in urban areas, whereas rural areas appear to have remained stable. Age at first sexual intercourse is relatively late in Rwanda (20 years for both males and females) and has remained stable since at least 1992.

CONCLUSIONS

The present analysis suggests that Rwanda may have experienced declines over the long term in HIV prevalence in urban areas, especially in Kigali, and may have stable or slightly rising HIV prevalence in rural areas. The limited behavioural data available suggest that, on the national level, Rwanda may benefit from a unique combination of low numbers of partners and late sexual debut, which may have had a mitigating effect on HIV prevalence.

Integrating Prevention of Mother-to-Child HIV Transmission Into Routine Antenatal Care

With funds from Elizabeth Glaser Pediatric AIDS Foundation, the Cameroon Baptist Convention Health Board implemented a program to prevent mother-to-child transmission of HIV-1 (PMTCT) as part of its routine antenatal care, with single-dose maternal and infant peripartum nevirapine (NVP) prophylaxis of HIV-positive mothers and their babies. Nurses, midwives, nurse aides, and trained birth attendants counseled pregnant women, obtained risk factor data, and offered free HIV testing with same-day results. From February 2000 through December 2004, this program rapidly expanded to 115 facilities in 6 of Cameroon's 10 provinces, not only to large hospitals but to remote health centers staffed by trained birth attendants. We trained 690 health workers in PMTCT and counseled 68,635 women, 91.9% of whom accepted HIV testing. Of 63,094 women tested, 8.7% were HIV-1-positive. Independent risk factors for HIV-1 infection included young age at first sexual intercourse, multiple sex partners, and positive syphilis serology (P < 0.001 for each). We counseled 98.7% of positive and negative mothers on a posttest basis. Of 5550 HIV-positive mothers, we counseled 5433 (97.9%) on single-dose NVP prophylaxis. Consistent training and programmatic support contributed to rapid upscaling and high uptake and counseling rates.

Intraoperative pediatric blood transfusion therapy: a review of common issues. Part I: hematologic and physiologic differences from adults; metabolic and infectious risks

Pediatric intraoperative transfusion therapy, particularly the approach to massive blood transfusion (blood loss > or =one blood volume) can be quite complex because of the unique relationship between the patient's blood volume and the volume of the individual blood product transfused. This paper is divided into two parts: part 1 presents an overview of the physiologic and hematologic differences between children and adults as well as an overview of the metabolic consequences of blood transfusions, risks of disease transmission, and blood compatibility issues.

Intimacy revealed: sexual experimentation and the construction of risk among young people in Mozambique

The expanding AIDS epidemic in Mozambique is fuelled principally by heterosexual transmission, with young people identified as a key group for prevention efforts. However, little is known about the sexual behaviour of young people in Mozambique and the protective practices they adopt. This paper seeks to identify the contexts and rules governing sexual risk-taking among young people in Maputo. In doing so, the paper affirms the importance of context in understanding risk practices, but highlights the fluidity of practice as an important limitation for the use of contextual analysis in prevention interventions. By focusing on one innovation, the saca cena one-night stand, this paper shows how a subgroup of young people in Maputo has redefined a "risky" sexual practice to include exclusive condom use. As a risk context, the saca cena dictates a set of implicit rules emphasizing anonymity, discretion, verbal and non-verbal cues, and for a set of select innovators, condom use. The saca cena challenges the hegemonic gender roles found among many young people in Maputo of male dominance through sexual conquest and female acquiescence. Instead, the practice allows young people to be both adventurous and responsible. The discourse demonstrates how sexual identities have been redefined to combine risk reduction with sexual experimentation and the satiation of desire.

A critique of international indicators of sexual risk behaviour

OBJECTIVES

To investigate whether the indicators of sexual risk behaviour, defined by UNAIDS for use among members of general populations, have been found as risk factors, to examine how information on sexual behaviour is collected and summarised in order to calculate the indicators, and to look for possible sources of error in the data and in interpretation of those indicators.

METHODS

The literature on risk factors for HIV infection was reviewed. Indicators were calculated for countries where data were available for two or more points in time.

RESULTS

Indicators of sexual behaviour describe behaviours that are relevant to HIV risk and that are amenable to change. These behaviours do not correspond closely to the individual risk factors for HIV infection that have been identified in observational studies.

CONCLUSIONS

Although potential errors of both measurement and interpretation exist, most of the indicators currently defined can fulfil their purpose, providing they are used with caution. Many of the indicators should not be interpreted in isolation but need supporting information to make sense of trends or differences between groups. Much of this information is provided by other indicators. The source of the data used to calculate the indicator is potentially important and should always be provided with indicator estimates. Some estimate of the accuracy of the estimate, either by means of confidence intervals or the number of respondents, should be given.

Male neonatal circumcision: indications, controversies and complications

The debate about whether to circumcise infants in the neonatal period likely will continue. As the medical and ethical issues are discussed and studied, however, economic factors are beginning to limit the practice in the United States. As the shift in reimbursement occurs, parents who believe that circumcision is a medically necessary practice will need to be reassured that their child may lead a healthy life with an intact foreskin.

Predictors of HIV seropositivity following intrapartum voluntary counseling and testing among Rwandan women

We investigated risk factors associated with HIV infection in women who accepted voluntary counselling and testing (VCT) intrapartum. A survey questionnaire containing information on sociodemographic characteristics was administered to parturients at the Central Hospital Kigali after informed consent had been obtained. Participants were then offered VCT for HIV, and those who accepted were informed of their results. Of the 427 eligible participants, 317 accepted VCT (74.2%). The results of 312 (98.4%) of these women were obtained and 50 tested positive for HIV, yielding an HIV seroprevalence of 16.0% intrapartum. Women who had been pregnant three or more times were three times as likely to test positive for HIV in comparison to those of lower parity (OR=2.9; 95% confidence interval (CI)=1.1 - 8.0). This finding contradicts earlier studies performed antenatally among women of childbearing age and pregnant women in general. This may be attributable to some inadequacy in the existing health-care infrastructure to effectively detect HIV in multiparous women antenatally, or may represent a signal that a change in the nature of the epidemic in Rwanda is occurring.

Prevalence and indicators of HIV and AIDS among adults admitted to medical and surgical wards in Blantyre, Malawi

Despite high seroprevalence there are few recent studies of the effect of human immunodeficiency virus (HIV) on hospitals in sub-Saharan Africa. We examined 1226 consecutive patients admitted to medical and surgical wards in Blantyre, Malawi during two 2-week periods in October 1999 and January 2000: 70% of medical patients were HIV-positive and 45% had acquired immune deficiency syndrome (AIDS); 36% of surgical patients were HIV-positive and 8% had AIDS. Seroprevalence rose to a peak among 30-40 year olds; 91% of medical, 56% of surgical and 80% of all patients in this age group were HIV-positive. Seropositive women were younger than seropositive men (median age 29 vs. 35 years, P < 0.0001). Symptoms strongly indicative of HIV were history of shingles, chronic diarrhoea or fever or cough, history of tuberculosis (TB), weight loss and persistent itchy rash (adjusted odds ratios [AORs] all > 5). Clinical signs strongly indicative of HIV were oral hairy leukoplakia, shingles scar, Kaposi's sarcoma, oral thrush and hair loss (AORs all > 10). Of surgical patients with 'deep infections' (breast abscess, pyomyositis, osteomyelitis, septic arthritis and multiple abscesses), 52% were HIV-positive (OR compared with other surgical patients = 2.4). Severe bacterial infections, TB and AIDS caused 68% of deaths. HIV dominates adult medicine, is a major part of adult surgery, is the main cause of death in hospital and affects the economically active age group of the population.

Voluntary counseling and testing for HIV among pregnant women presenting in labor in Kigali, Rwanda

This study investigated factors related to acceptability of voluntary counseling and testing (VCT) for HIV among pregnant women presenting in labor in Kigali, Rwanda, in an era of free and effective antiretroviral drugs for prevention of perinatal transmission of HIV. A pilot-tested questionnaire was administered to study participants to solicit information regarding their intentions to accept or refuse VCT and treatment of HIV infection during labor and delivery if confirmed infected. Two factors correlated significantly with the acceptance rate. The strongest predictive factor for acceptability of HIV testing was the profession of the male partner. Women whose partners had skilled and well-paid jobs were about four times more likely to accept HIV testing than were women whose partners were unemployed (adjusted odds ratio, 3.5; confidence interval, 1.16-10.85). The other factor significantly associated with the acceptance rate was maternal age. The likelihood of acceptance of HIV testing was about three times higher among women 35 years or older than among younger mothers (adjusted odds ratio, 3.1; confidence interval, 1.01-9.4). For every 5-year increment in maternal age, the odds of acceptance of HIV testing increased by a factor of 1.20. Using this important finding, we constructed an acceptance rate probability curve that could serve as a useful tool to evaluate the efficacy of future interventions aimed at improving the acceptability rate of HIV testing among pregnant women at the study site.

Male circumcision and HIV prevention: current knowledge and future research directions

Over the past decade, numerous epidemiological studies have reported a significant association between lack of male circumcision and risk for HIV infection, leading to recommendations for male circumcision to be added to the armamentarium of effective HIV prevention strategies. We review the epidemiological data from studies that have investigated this association, including ecological, cross-sectional/case-control, and prospective studies. We discuss problematic issues in interpreting the epidemiological data, including the presence of other sexually transmitted infections, age of circumcision, and potential confounders such as religion, cultural practices, and genital hygiene. In addition, we review studies of biological mechanisms by which the presence of the foreskin may increase HIV susceptibility, data on risks associated with the circumcision procedure, and available data on the acceptability and feasibility of introducing male circumcision in societies where it is traditionally not practised. Although the evidence in support of male circumcision as an effective HIV prevention measure is compelling, residual confounding in observational studies cannot be excluded. Taken together with concerns over the potential disinhibiting effect of male circumcision on risk behaviour, and safety of the circumcision procedure, randomised trials of male circumcision to prevent HIV infection are recommended. An individual's choice to undergo male circumcision or a community's decision to promote the practice should be made in the light of the best available scientific evidence. More knowledge is required to assist individuals and communities in making those decisions. We conclude with recommendations for future research.

Ecological and individual level analysis of risk factors for HIV infection in four urban populations in sub-Saharan Africa with different levels of HIV infection

OBJECTIVE

To identify factors that could explain differences in rate of spread of HIV between different regions in sub-Saharan Africa.

DESIGN

Cross-sectional study.

METHODS

The study took place in two cities with a relatively low HIV prevalence (Cotonou, Benin and Yaoundé, Cameroon), and two cities with a high HIV prevalence (Kisumu, Kenya and Ndola, Zambia). In each of these cities, a representative sample was taken of about 1000 men and 1000 women aged 15-49 years. Consenting men and women were interviewed about their socio-demographic background and sexual behaviour; and were tested for HIV, herpes simplex virus type 2 (HSV-2), syphilis, Chlamydia trachomatis and Neisseria gonorrhoea infection, and (women only) Trichomonas vaginalis. Analysis of risk factors for HIV infection was carried out for each city and each sex separately. Adjusted odds ratios (aOR) were obtained by multivariate logistic regression.

RESULTS

The prevalence of HIV infection in sexually active men was 3.9% in Cotonou, 4.4% in Yaoundé, 21.1% in Kisumu, and 25.4% in Ndola. For women, the corresponding figures were 4.0, 8.4, 31.6 and 35.1%. High-risk sexual behaviour was not more common in the high HIV prevalence cities than in the low HIV prevalence cities, but HSV-2 infection and lack of circumcision were consistently more prevalent in the high HIV prevalence cities than in the low HIV prevalence cities. In multivariate analysis, the association between HIV infection and sexual behavioural factors was variable across the four cities. Syphilis was associated with HIV infection in Ndola in men [aOR = 2.7, 95% confidence interval (CI) = 1.5-4.91 and in women (aOR = 1.7, 95% CI = 1.1-2.6). HSV-2 infection was strongly associated with HIV infection in all four cities and in both sexes (aOR ranging between 4.4 and 8.0). Circumcision had a strong protective effect against the acquisition of HIV by men in Kisumu (aOR = 0.25, 95% CI = 0.12-0.52). In Ndola, no association was found between circumcision and HIV infection but sample sizes were too small to fully adjust for confounding.

CONCLUSION

The strong association between HIV and HSV-2 and male circumcision, and the distribution of the risk factors, led us to conclude that differences in efficiency of HIV transmission as mediated by biological factors outweigh differences in sexual behaviour in explaining the variation in rate of spread of HIV between the four cities.

Monitoring the AIDS epidemic using HIV prevalence data among young women attending antenatal clinics: prospects and problems

OBJECTIVE

To assess the potential of antenatal surveillance data on HIV prevalence in young women as an indicator of trends in HIV incidence.

DESIGN

Review of empirical data and discussion of problems encountered with surveillance systems, illustrated using cohort-component projection models.

METHODS

Simple descriptive analyses are presented of prevalence and incidence data, with projection models used to explore aspects of the dynamic relationships between changes in HIV incidence and prevalence in young pregnant women for which empirical data are not yet available. Incidence changes due to change in risk among sexually active, and change in pattern of sexual debut are explored separately, and the resulting prevalence trends in pregnant women under age 25 years, and those expecting their first two births are described.

RESULTS

HIV prevalence levels in young pregnant women categorized by age and by parity have different relationships to recent incidence levels. Age categorized prevalence data provide a reasonable indication of incidence under stable conditions, but may be very misleading if the age pattern of sexual debut changes. Prevalence levels categorized by parity are a reliable guide to incidence in the sexually active, but not necessarily to incidence in the population as a whole.

CONCLUSIONS

Ante-natal surveillance systems should categorize prevalence data by both age and parity to aid in the interpretation of underlying incidence levels.

Is care and support associated with preventive behaviour among people with HIV?

Care and support should play a critical role in assisting people who are HIV-positive to understand the need for prevention and to enable them to protect others. Differences in sexual risk reduction among 154 newly diagnosed HIV-positive individuals from semi-urban Tanzania were examined using a randomized control design, which assigned a control group to regular health services and an experimental group to enhanced care and support. Data were collected at baseline, three months and six months on self-reported sexual risk behaviours, disclosure of serostatus, reproductive health and psychosocial support. Over the six-month period, significant risk reduction occurred among both groups, with most of the behaviour change occurring during the first three months, e.g. 86 respondents (56%) reported condom use at last intercourse at 3 months compared with 24(16%) at baseline (p = 0.05). Extra care and support did not lead to increased risk reduction among the experimental group. The study population as a whole significantly changed their behaviour, suggesting that in the short term, learning one is HIV-positive has an impact on risk reduction.

Risk of HIV infection in oral contraceptive pill users: a meta-analysis

OBJECTIVE

To review the literature and present a summary estimate of the association between HIV-1 acquisition or HIV-1 serostatus and oral contraceptives.

DATA SOURCES

MEDLINE database (January 1986-October 1997), AIDSLINE database (January 1980-October 1997), bibliographies of identified articles, and experts in the field of heterosexual HIV transmission.

STUDY SELECTION

In all, 591 articles were examined. Twenty-eight studies provided adequate data to calculate a risk estimate for the association of HIV-1 serostatus or HIV-1 seroconversion with oral contraceptives and were selected for inclusion.

RESULTS

The overall summary odds ratio (OR) for the association between seroprevalent or seroincident HIV-1 infection and use of oral contraceptives in the 28 studies was 1.19 (95% confidence interval [CI], 0.99-1.42). The summary OR for 21 cross-sectional studies was 1.21 (95% CI, 1.01-1.44), whereas the summary relative risk for seven prospective studies was 1.32 (95% CI, 1.12-1.57). Study quality was assessed by applying a scale reflecting study design, measurement of exposure, ability to assess confounding, and publication status. The summary OR for the eight best studies was 1.60 (95% CI, 1.05-2.44). When analysis was limited to studies conducted in Africa, the summary OR was 1.45 (95% CI, 1.15-1.83) for the 14 studies overall, and 1.65 (95% CI, 1.09-2.52) for the seven best studies.

CONCLUSION

This meta-analysis found a significant association between oral contraceptive use and HIV-1 seroprevalence or seroincidence. For women at risk of HIV-1 infection, oral contraceptive use for prevention of pregnancy should be accompanied by condom use for prevention of HIV-1 infection.

Cervical dysplasia and HIV type 1 infection in African pregnant women: a cross sectional study, Kigali, Rwanda. The Pregnancy and HIV Study Group (EGE)

OBJECTIVE

To study the prevalence of cervical squamous intraepithelial lesions (SILs) and their association with HIV-1 infection and immunodeficiency among pregnant women in Kigali, Rwanda.

METHODS

As part of a cohort study on the impact of HIV-1 infection on pregnancy outcome, HIV-1 seropositive (HIV+) and seronegative (HIV-) pregnant women were enrolled during the last trimester of pregnancy at the maternity ward of the Centre Hospitalier de Kigali from July 1992 to August 1993. At inclusion, women were screened for sexually transmitted diseases (STDs)--syphilis, Neisseria gonorrhoeae, chlamydia trachomatis, Trichomonas vaginalis. CD4+ lymphocyte counts were measured and a Papanicolaou smear performed.

RESULTS

Papanicolaou smear was interpretable in 103 HIV+ women and 107 HIV- women. Prevalence of SILs was significantly higher in HIV+ women than in HIV- women: 24.3% v 6.5% (odds ratio = 4.6; 95% CI: 1.8-12.3). SIL+ women (n = 32) tended to have more STDs than SIL- women (n = 178), but this did not reach a statistical difference: 37.5% and 24.7% respectively (p = 0.13). They also had a mean CD4 count significantly lower than SIL- women (623 and 784 CD4+ cells x 10(6)/l, respectively; p = 0.02).

CONCLUSION

SILs were HIV related and the association with immunosuppression was statistically significant. Prevalence of SILs was high in this population of pregnant women with high HIV/STDs prevalence. Screening policy for STDs and SILs in African women should be assessed in prenatal care.

Circumcision and HIV infection: review of the literature and meta-analysis

Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded.