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Jones HS, Anderson RL, Cust H, McClelland RS, Richardson BA, Thirumurthy H, Malama K, Hensen B, Platt L, Rice B, Cowan FM, Imai-Eaton JW, Hargreaves JR, Stevens O. HIV incidence among women engaging in sex work in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Glob Health 2024; 12:e1244-e1260. [PMID: 39030057 DOI: 10.1016/s2214-109x(24)00227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/08/2024] [Accepted: 05/24/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Women who engage in sex work in sub-Saharan Africa have a high risk of acquiring HIV infection. HIV incidence has declined among all women in sub-Saharan Africa, but trends among women who engage in sex work are poorly characterised. We synthesised data on HIV incidence among women who engage in sex work in sub-Saharan Africa and compared these with the total female population to understand relative incidence and trends over time. METHODS We searched MEDLINE, Embase, Global Health, and Google Scholar from Jan 1, 1990, to Feb 28, 2024, and grey literature for studies that reported empirical estimates of HIV incidence among women who engage in sex work in any sub-Saharan Africa country. We calculated incidence rate ratios (IRRs) compared with total female population incidence estimates matched for age, district, and year, did a meta-analysis of IRRs, and used a continuous mixed-effects model to estimate changes in IRR over time. FINDINGS From 32 studies done between 1985 and 2020, 2194 new HIV infections were observed among women who engage in sex work over 51 490 person-years. Median HIV incidence was 4·3 per 100 person years (IQR 2·8-7·0 per 100 person-years). Incidence among women who engage in sex work was eight times higher than matched total population women (IRR 7·8 [95% CI 5·1-11·8]), with larger relative difference in western and central Africa (19·9 [9·6-41·0]) than in eastern and southern Africa (4·9 [3·4-7·1]). There was no evidence that IRRs changed over time (IRR per 5 years: 0·9 [0·7-1·2]). INTERPRETATION Across sub-Saharan Africa, HIV incidence among women who engage in sex work remains disproportionately high compared with the total female population. However, constant relative incidence over time indicates HIV incidence among women who engage in sex work has declined at a similar rate. Location-specific data for women who engage in sex work incidence are sparse, but improved surveillance and standardisation of incidence measurement approaches could fill these gaps. Sustained and enhanced HIV prevention for women who engage in sex work is crucial to address continuing inequalities and ensure declines in new HIV infections. FUNDING Bill & Melinda Gates Foundation, UK Research and Innovation, National Institutes of Health. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Harriet S Jones
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Rebecca L Anderson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Henry Cust
- Institute of Global Health, University College London, London, UK
| | - R Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Kalonde Malama
- Ingram School of Nursing, McGill University, Montréal, Quebec, QC, Canada
| | - Bernadette Hensen
- Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Rice
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, UK
| | - Frances M Cowan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Jeffrey W Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - James R Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Oliver Stevens
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
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Jones HS, Anderson RL, Cust H, McClelland RS, Richardson BA, Thirumurthy H, Malama K, Hensen B, Platt L, Rice B, Cowan FM, Imai-Eaton JW, Hargreaves JR, Stevens O. HIV incidence among women engaging in sex work in sub-Saharan Africa: a systematic review and meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.17.23297108. [PMID: 37905066 PMCID: PMC10615019 DOI: 10.1101/2023.10.17.23297108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Introduction HIV incidence among women in sub-Saharan Africa (SSA) has declined steadily, but it is unknown whether new infections among women who engage in sex work (WESW) have declined at a similar rate. We synthesised estimates of HIV incidence among WESW in SSA and compared these to the wider female population to understand levels and trends in incidence over time. Methods We searched Medline, Embase, Global Health, Popline, Web of Science, and Google Scholar from January 1990 to October 2022, and grey literature for estimates of HIV incidence among WESW in SSA. We included studies reporting empirical estimates in any SSA country. We calculated incidence rate ratios (IRR) compared to age-district-year matched total female population incidence estimates. We conducted a meta-analysis of IRRs and used a continuous mixed-effects model to estimate changes in IRR over time. Results From 32 studies between 1985 and 2020, 2,194 new HIV infections were observed in WESW over 51,000 person-years (py). Median HIV incidence was 4.3/100py (IQR 2.8-7.0/100py), declining from a median of 5.96/100py between 1985 and 1995 to a median of 3.2/100py between 2010 and 2020. Incidence among WESW was nine times higher than in matched total population women (RR 8.6, 95%CI: 5.7-12.9), and greater in Western and Central Africa (RR 22.4, 95%CI: 11.3-44.3) than in Eastern and Southern Africa (RR 5.3, 95%CI: 3.7-7.6). Annual changes in log IRRs were minimal (-0.1% 95%CI: -6.9 to +6.8%). Conclusions Across SSA, HIV incidence among WESW remains disproportionately high compared to the total female population but showed similar rates of decline between 1990 and 2020. Improved surveillance and standardisation of approaches to obtain empirical estimates of sex worker incidence would enable a clearer understanding of whether we are on track to meet global targets for this population and better support data-driven HIV prevention programming.
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Affiliation(s)
- Harriet S Jones
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rebecca L Anderson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Henry Cust
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - R Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kalonde Malama
- University of Toronto Factor-Inwentash Faculty of Social Work, Toronto Ontario, Canada
| | - Bernadette Hensen
- Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Rice
- Sheffield Centre for Health and Related Research (SCHARR); School of Medicine and Population Health, University of Sheffield, UK
| | - Frances M Cowan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Jeffrey W Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - James R Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Oliver Stevens
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
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Ganley KY, Wilson-Barthes M, Zullo AR, Sosa-Rubí SG, Conde-Glez CJ, García-Cisneros S, Lurie MN, Marshall BDL, Operario D, Mayer KH, Galárraga O. Incidence and time-varying predictors of HIV and sexually transmitted infections among male sex workers in Mexico City. Infect Dis Poverty 2021; 10:7. [PMID: 33461615 PMCID: PMC7814587 DOI: 10.1186/s40249-020-00792-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/28/2020] [Indexed: 11/21/2022] Open
Abstract
Background Male sex workers are at high-risk for acquisition of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). We quantified incidence rates of STIs and identified their time-varying predictors among male sex workers in Mexico City. Methods From January 2012 to May 2014, male sex workers recruited from the largest HIV clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and HIV at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model. Results Among 227 male sex workers, median age was 24 and baseline HIV prevalence was 32%. Incidence rates (per 100 person-years) were as follows: HIV [5.23; 95% confidence interval (CI): 2.15–10.31], chlamydia (5.15; 95% CI: 2.58–9.34), gonorrhea (3.93; 95% CI: 1.88–7.83), syphilis (13.04; 95% CI: 8.24–19.94), hepatitis B (2.11; 95% CI: 0.53–4.89), hepatitis C (0.95; 95% CI: 0.00–3.16), any STI except HIV (30.99; 95% CI: 21.73–40.26), and any STI including HIV (50.08; 95% CI: 37.60–62.55). In the multivariable-adjusted model, incident STI (excluding HIV) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% CI: 0.00–0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse. Conclusions Incidence of STIs is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for STIs, and should be an important component of interventions to prevent incident infections. ![]()
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Affiliation(s)
- Karla Y Ganley
- Department of Narrative Medicine, Columbia University, New York, NY, USA
| | - Marta Wilson-Barthes
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 South Main Street, Box G-121S-2, Providence, RI, 02912, USA
| | | | | | | | - Mark N Lurie
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Don Operario
- Department of Behavioral and Social Science, School of Public Health, Brown University, Providence, RI, USA
| | | | - Omar Galárraga
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 South Main Street, Box G-121S-2, Providence, RI, 02912, USA.
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Missed Study Visits and Subsequent HIV Incidence Among Women in a Predominantly Sex Worker Cohort Attending a Dedicated Clinic Service in Kampala, Uganda. J Acquir Immune Defic Syndr 2020; 82:343-354. [PMID: 31658178 DOI: 10.1097/qai.0000000000002143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited evidence on the relationship between sustained exposure of female sex workers (FSWs) to targeted HIV programmes and HIV incidence. We investigate the relationship between the number of missed study visits (MSVs) within each episode of 2 consecutively attended visits (MSVs) and subsequent HIV risk in a predominantly FSW cohort. METHODS Women at high risk of HIV are invited to attend an ongoing dedicated clinic offering a combination HIV prevention intervention in Kampala, Uganda. Study visits are scheduled once every 3 months. The analysis included HIV-seronegative women with ≥1 follow-up visit from enrollment (between April 2008 and May 2017) to August 2017. Cox regression models were fitted adjusted for characteristics on sociodemographic, reproductive, behavioral, and sexually transmitted infections (through clinical examination and serological testing for syphilis). FINDINGS Among 2206 participants, HIV incidence was 3.1/100 (170/5540) person-years [95% confidence interval (CI): 2.6 to 3.5]. Incidence increased from 2.6/100 person-years (95% CI: 2.1 to 3.2) in episodes without a MSV to 3.0/100 (95% CI: 2.2 to 4.1) for 1-2 MSVs and 4.3/100 (95% CI: 3.3 to 5.6) for ≥3 MSVs. Relative to episodes without a MSV, the hazard ratios (adjusted for confounding variables) were 1.40 (95% CI: 0.93 to 2.12) for 1-2 MSVs and 2.00 (95% CI: 1.35 to 2.95) for ≥3 MSVs (P-trend = 0.001). CONCLUSION Missing study visits was associated with increased subsequent HIV risk. Although several factors may underlie this association, the finding suggests effectiveness of targeted combination HIV prevention. But exposure to targeted interventions needs to be monitored, facilitated, and sustained in FSWs.
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Bahemuka UM, Abaasa A, Seeley J, Byaruhanga M, Kamali A, Mayaud P, Kuteesa M. Feasibility of establishing an HIV vaccine preparedness cohort in a population of the Uganda Police Force: Lessons learnt from a prospective study. PLoS One 2020; 15:e0231640. [PMID: 32302334 PMCID: PMC7164600 DOI: 10.1371/journal.pone.0231640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/29/2020] [Indexed: 11/19/2022] Open
Abstract
Background Members of uniformed armed forces are considered to be at high risk for HIV infection and have been proposed as suitable candidates for participation in HIV intervention studies. We report on the feasibility of recruitment and follow up of individuals from the community of the Uganda Police Force (UPF) for an HIV vaccine preparedness study. Methods HIV-negative volunteers aged 18–49 years, were identified from UPF facilities situated in Kampala and Wakiso districts through community HIV counselling and testing. Potential volunteers were referred to the study clinic for screening, enrolment and quarterly visits for one year. HIV incidence, retention rates were estimated and expressed as cases per 100 person years of observation (PYO). Rate ratios were used to determine factors associated with retention using Poisson regression models. Results We screened 560 to enroll 500 volunteers between November 2015 and May 2016. One HIV seroconversion occurred among 431 PYO, for an incidence rate of 0.23/100 PYO (95% confidence interval [CI]: 0.03–1.64). Overall, retention rate was 87% at one year, and this was independently associated with residence duration (compared to <1 year, 1 to 5 years adjusted rate ratio (aRR) = 1.19, 95%CI: 1.00–1.44); and >5 years aRR = 1.34, 95%CI: 0.95–1.37); absence of genital discharge in the last 3 months (aRR = 1.97, 95% CI: 1.38–2.83, absence of genital ulcers (aRR = 1.90, 95%CI: 1.26–2.87, reporting of new sexual partner in the last month (aRR = 0.57, 95%CI: 0.45–0.71, being away from home for more than two nights (aRR = 1.27, 95%CI: 1.04–1.56, compared to those who had not travelled) and absence of knowledge on HIV prevention (aRR = 2.67, 95%CI: 1.62–4.39). Conclusions While our study demonstrates the feasibility of recruiting and retaining individuals from the UPF for HIV research, we did observe lower than anticipated HIV incidence, perhaps because individuals at lower risk of HIV infection may have been the first to come forward to participate or participants followed HIV risk reduction measures. Our findings suggest lessons for recruitment of populations at high risk of HIV infection.
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Affiliation(s)
- Ubaldo Mushabe Bahemuka
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit & London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
- * E-mail: ,
| | - Andrew Abaasa
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit & London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit & London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Moses Byaruhanga
- Uganda Police Force, Directorate of Health Services, Kampala, Uganda
| | - Anatoli Kamali
- International AIDS Vaccine Initiative, New York, New York, United States of America
| | - Philippe Mayaud
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit & London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Monica Kuteesa
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit & London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
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Owen BN, Baggaley RF, Elmes J, Harvey A, Shubber Z, Butler AR, Silhol R, Anton P, Shacklett B, van der Straten A, Boily MC. What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis. AIDS Behav 2020; 24:697-713. [PMID: 30953304 PMCID: PMC6778486 DOI: 10.1007/s10461-019-02477-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
HIV is more efficiently acquired during receptive anal intercourse (AI) compared to vaginal intercourse (VI) and may contribute substantially to female sex workers' (FSW) high HIV burden. We aim to determine how common and frequent AI is among FSW globally. We searched PubMed, Embase and PsycINFO for studies reporting the proportion of FSW practising AI (prevalence) and/or the number of AI acts (frequency) worldwide from 01/1980 to 10/2018. We assessed the influence of participant and study characteristics on AI prevalence (e.g. continent, study year and interview method) through sub-group analysis. Of 15,830 identified studies, 131 were included. Nearly all (N = 128) reported AI prevalence and few frequency (N = 13), over various recall periods. Most studies used face-to-face interviews (N = 111). Pooled prevalences varied little by recall period (lifetime: 15.7% 95%CI 12.2-19.3%, N = 30, I2 = 99%; past month: 16.2% 95%CI 10.8-21.6%, N = 18, I2 = 99%). The pooled proportion of FSW reporting < 100% condom use tended to be non-significantly higher during AI compared to during VI (e.g. any unprotected VI: 19.1% 95%CI 1.7-36.4, N = 5 and any unprotected AI: 46.4% 95%CI 9.1-83.6, N = 5 in the past week). Across all study participants, between 2.4 and 15.9% (N = 6) of all intercourse acts (AI and VI) were anal. Neither AI prevalence nor frequency varied substantially by any participant or study characteristics. Although varied, AI among FSW is generally common, inconsistently protected with condoms and practiced sufficiently frequently to contribute substantially to HIV acquisition in this risk group. Interventions to address barriers to condom use are needed.
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Affiliation(s)
- Branwen Nia Owen
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, St Mary's Campus, Praed Street, London, W2 1NY, UK.
| | - Rebecca F Baggaley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Jocelyn Elmes
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, St Mary's Campus, Praed Street, London, W2 1NY, UK
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Amy Harvey
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, St Mary's Campus, Praed Street, London, W2 1NY, UK
| | - Zara Shubber
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, St Mary's Campus, Praed Street, London, W2 1NY, UK
| | - Ailsa R Butler
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, St Mary's Campus, Praed Street, London, W2 1NY, UK
| | - Romain Silhol
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, St Mary's Campus, Praed Street, London, W2 1NY, UK
| | - Peter Anton
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Barbara Shacklett
- Department of Medical Microbiology and Immunology, University of California, Davis, USA
| | - Ariane van der Straten
- Women's Global Health Imperative Program, RTI International, San Francisco, USA
- Department of Medicine, Center for AIDS Prevention Studies, UCSF, San Francisco, USA
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, St Mary's Campus, Praed Street, London, W2 1NY, UK
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Stannah J, Silhol R, Elmes J, Owen B, Shacklett BL, Anton P, McGowan I, van der Straten A, Dimitrov D, Baggaley RF, Boily MC. Increases in HIV Incidence Following Receptive Anal Intercourse Among Women: A Systematic Review and Meta-analysis. AIDS Behav 2020; 24:667-681. [PMID: 31486008 PMCID: PMC7018785 DOI: 10.1007/s10461-019-02651-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Receptive anal intercourse (RAI) carries a greater per-act risk of HIV acquisition than receptive vaginal intercourse (RVI) and may influence HIV epidemics driven by heterosexual sex. This systematic review explores the association between RAI and incident HIV among women, globally. We searched Embase and Medline through September 2018 for longitudinal studies reporting crude (cRR) or adjusted (aRR) relative risks of HIV acquisition by RAI practice among women. Of 27,563 articles identified, 17 eligible studies were included. We pooled independent study estimates using random-effects models. Women reporting RAI were more likely to acquire HIV than women not reporting RAI (pooled cRR = 1.56 95% CI 1.03–2.38, N = 18, I2 = 72%; pooled aRR = 2.23, 1.01–4.92, N = 5, I2 = 70%). In subgroup analyses the association was lower for women in Africa (pooled cRR = 1.16, N = 13, I2 = 21%) than outside Africa (pooled cRR = 4.10, N = 5, I2 = 79%) and for high-risk (pooled aRR = 1.69, N = 4, I2 = 63%) than general-risk women (pooled aRR = 8.50, N = 1). Interview method slightly influenced cRR estimates (p value = 0.04). In leave-one-out sensitivity analyses pooled estimates were generally robust to removing individual study estimates. Main limitations included poor exposure definition, incomplete adjustment for confounders, particularly condom use, and use of non-confidential interview methods. More and better data are needed to explain differences in risk by world region and risk population. Women require better counselling and greater choice in prevention modalities that are effective during RVI and RAI.
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Kenyon C. To What Extent Should We Rely on Antibiotics to Reduce High Gonococcal Prevalence? Historical Insights from Mass-Meningococcal Campaigns. Pathogens 2020; 9:pathogens9020134. [PMID: 32085650 PMCID: PMC7168587 DOI: 10.3390/pathogens9020134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 12/22/2022] Open
Abstract
In the absence of a vaccine, current antibiotic-dependent efforts to reduce the prevalence of Neisseria gonorrhoeae in high prevalence populations have been shown to result in extremely high levels of antibiotic consumption. No randomized controlled trials have been conducted to validate this strategy and an important concern of this approach is that it may induce antimicrobial resistance. To contribute to this debate, we assessed if mass treatment in the related species, Neisseria meningitidis, was associated with the emergence of antimicrobial resistance. To this end, we conducted a historical review of the effect of mass meningococcal treatment programmes on the prevalence of N. meningitidis and the emergence of antimicrobial resistance. We found evidence that mass treatment programmes were associated with the emergence of antimicrobial resistance.
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Affiliation(s)
- Chris Kenyon
- HIV/STI Unit, Institute of Tropical Medicine, 2000 Antwerp, Belgium; ; Tel.: +32-3-2480796; Fax: +32-3-2480831
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Anzio Road, Observatory 7700, South Africa
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9
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Cohen MS, Council OD, Chen JS. Sexually transmitted infections and HIV in the era of antiretroviral treatment and prevention: the biologic basis for epidemiologic synergy. J Int AIDS Soc 2019; 22 Suppl 6:e25355. [PMID: 31468737 PMCID: PMC6715951 DOI: 10.1002/jia2.25355] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 06/26/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION HIV is a unique sexually transmitted infection (STI) that is greatly affected by other concomitant "classical" bacterial and viral STIs that cause genital ulcers and/or mucosal inflammation. STIs also serve as a marker for risky sexual behaviours. STIs increase infectiousness of people living with HIV by increasing the viral concentration in the genital tract, and by increasing the potential for HIV acquisition in people at risk for HIV. In addition, some STIs can increase blood HIV concentration and promote progression of disease. This review is designed to investigate the complex relationship between HIV and classical STIs. DISCUSSION Treatment of STIs with appropriate antibiotics reduces HIV in blood, semen and female genital secretions. However, community-based trials could not reliably reduce the spread of HIV by mass treatment of STIs. Introduction of antiretroviral agents for the treatment and prevention of HIV has led to renewed interest in the complex relationship between STIs and HIV. Antiretroviral treatment (ART) reduces the infectiousness of HIV and virtually eliminates the transmission of HIV in spite of concomitant or acquired STIs. However, while ART interrupts HIV transmission, it does not stop intermittent shedding of HIV in genital secretions. Such shedding of HIV is increased by STIs, although the viral copies are not likely replication competent or infectious. Pre-exposure prophylaxis (PrEP) of HIV with the combination of tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) prevents HIV acquisition in spite of concomitant STIs. CONCLUSIONS STIs remain pandemic, and the availability of ART may have led to an increase in STIs, as fear of HIV has diminished. Classical STIs present a huge worldwide health burden that cannot be separated from HIV, and they deserve far more attention than they currently receive.
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Affiliation(s)
- Myron S Cohen
- UNC School of MedicineInstitute for Global Health & Infectious DiseasesChapel HillNCUSA
| | | | - Jane S Chen
- Department of EpidemiologyGillings School of Global Public HealthUNCChapel HillNCUSA
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Masha SC, Cools P, Sanders EJ, Vaneechoutte M, Crucitti T. Trichomonas vaginalis and HIV infection acquisition: a systematic review and meta-analysis. Sex Transm Infect 2018; 95:36-42. [PMID: 30341233 PMCID: PMC6580735 DOI: 10.1136/sextrans-2018-053713] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/20/2018] [Accepted: 09/18/2018] [Indexed: 01/08/2023] Open
Abstract
Objectives Trichomoniasis is the most prevalent curable STI globally, with the highest incidence and prevalence in sub-Saharan Africa (sSA). STIs have largely been associated with an increase in HIV acquisition. Our objective was to assess the existing literature available in English regarding the association of Trichomoniasis and HIV-1 acquisition. Methods The review protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) under number CRD42018082702. We searched MEDLINE, Embase and Scopus databases to collect articles measuring the association of Trichomonas vaginalis infection and HIV acquisition and performed a meta-analysis and qualitative synthesis of the literature. Results We identified 1806 unduplicated citations, of which 18 papers and 1 conference abstract were eligible for inclusion in the review after applying our inclusion and exclusion criteria. All the studies included in the systematic review had been carried out in sSA. The articles reported various measures of effects, namely: HRs, rate ratios, risk ratios and ORs. In a meta-analysis restricted to 11 studies reporting HR, individuals infected with T. vaginalis were 1.5 times more likely to acquire HIV compared with individuals not infected with T. vaginalis (95% CI 1.3 to 1.7; p<0.001). Conclusions T. vaginalis is an important factor in HIV acquisition especially in sSA where the prevalence of both T. vaginalis and HIV-1 are high. This systematic review and meta-analysis confirms the evidence that infection with T. vaginalis augments HIV acquisition with 50%. Diagnosis and treatment of T. vaginalis infection in both high-risk and low-risk individuals may be a potential tool to reduce new HIV infections. Trial registration number CRD42018082702
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Affiliation(s)
- Simon Chengo Masha
- Centre for Geographic Medicine Research - Coast, Kenya Medical Research Institute, Kilifi, Kenya .,Laboratory for Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Biological Sciences, Pwani University, Kilifi, Kenya
| | - Piet Cools
- Laboratory for Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Eduard J Sanders
- Centre for Geographic Medicine Research - Coast, Kenya Medical Research Institute, Kilifi, Kenya.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Mario Vaneechoutte
- Laboratory for Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Tania Crucitti
- HIV/STI Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
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11
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García JI, Sabidó M, Nikiforov M, Smith A, Hernández G, Ortiz R, Ardani L, Cajas A, Camey E, Torrelles JB, Wang SH, Campbell CNJ, Folch C, Casabona J. The UALE project: a cross-sectional approach for trends in HIV/STI prevalence among key populations attending STI clinics in Guatemala. BMJ Open 2018; 8:e022632. [PMID: 30232112 PMCID: PMC6150151 DOI: 10.1136/bmjopen-2018-022632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To describe and compare trends in prevalence, sexual behaviour and HIV transmission knowledge data related to sexually transmitted infections (STI) and HIV in patients attending three STI clinics over an 8-year period in Escuintla Department, Guatemala. METHODS STI clinic attendees were classified into transmission groups as follows: female sex workers (FSW), men who have sex with men (MSM) and 'high-risk heterosexuals' (HRH). Annual cross-sectional analysis and multivariable Poisson regression adjusted for sociodemographic variables were used for prevalence comparisons and adjusted prevalence trends for HIV/STI outcomes and used for adjusted trends in proportions in sexual behaviour and HIV transmission knowledge outcomes. Endocervical swabs were obtained to detect trichomonas, chlamydia and neisseria infections. Serologies for syphilis and HIV were performed using rapid tests. For reactive HIV samples, positivity was confirmed by an ELISA. All reactive syphilis samples were further confirmed for diagnosis of active syphilis disease. RESULTS From a total of 4027 clinic attendees, 3213 (79.78%) were FSW, 229 (5.69%) were MSM and 585 (14.53%) were HRH. The proportion of FSW, MSM and HRH who had a single visit was 56.42%, 57.23% and 91.10%, respectively. Overall, HIV prevalence was 2.10% in FSW, 8.17% in MSM and 4.12% in HRH. Prevalence trends in HIV and syphilis decreased in FSW. Prevalence trends in gonorrhoea did not decrease over time neither in FSW nor in HRH. Chlamydia and trichomonas infections in HRH showed an increase prevalence trend. In FSW, trends in condom use in last sexual intercourse with regular and occasional clients were above 93%. CONCLUSIONS FSW show a decreasing trend in HIV, syphilis and chlamydia prevalence. Gonorrhoea prevalence in FSW and HRH did not decrease over time. HRH is a hard to engage population with low follow-up rates and high potential to act as a bridge population.
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Affiliation(s)
- Juan Ignacio García
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
- Center for Epidemiological Studies on HIV/AIDS and STI of Catalonia (CEEISCAT), Generalitat de Catalunya, Badalona, Spain
- Department of Paediatrics, Obstetrics and Gynaecology, Preventive Medicine, and Public Health. PhD Programme in Methodology of Biomedical Research and Public Health., Univeristat Autònoma de Barcelona, Barcelona, Spain
| | - Meritxell Sabidó
- TransLab, Department of Medical Sciences, Universitat de Girona, Girona, Spain
- CIBER Epidemiología y Salud Pública, Madrid, Spain
| | - Mikhail Nikiforov
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
| | - Adriana Smith
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
| | - Gabriela Hernández
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
| | - Rudy Ortiz
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
| | - Luis Ardani
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
| | - Alba Cajas
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
| | - Elsy Camey
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
| | | | - Shu-Hua Wang
- Department of Internal Medicine, Division of Infectious Diseases. The Ohio State University, Columbus, Ohio, USA
| | - Colin N J Campbell
- TB Section, National Infection Service, Public Health England, London, UK
| | - Cinta Folch
- Center for Epidemiological Studies on HIV/AIDS and STI of Catalonia (CEEISCAT), Generalitat de Catalunya, Badalona, Spain
- CIBER Epidemiología y Salud Pública, Madrid, Spain
| | - Jordi Casabona
- Fundació Sida i Societat, Technical Advisor Unit (UAT), Hospital Nacional de Escuintla, Escuintla, Guatemala
- Center for Epidemiological Studies on HIV/AIDS and STI of Catalonia (CEEISCAT), Generalitat de Catalunya, Badalona, Spain
- CIBER Epidemiología y Salud Pública, Madrid, Spain
- Department of Paediatrics, Obstetrics and Gynaecology, Preventive Medicine and Public Health, Univeristat Autonoma de Barcelona, Barcelona, Spain
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Nguyen T, Stewart DE, Lee CTP, Dang TNH. Prevalence of HIV Infection and Risk Factors Among Female Sex Workers in a Southeast Province of Vietnam. AIDS Behav 2017; 21:2332-2340. [PMID: 27605366 DOI: 10.1007/s10461-016-1544-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Female sex workers (FSWs) are at heightened risk of HIV infection. This research aims to determine the prevalence of HIV and relevant risk factors and related behavior among FSWs in Ba Ria - Vung Tau, a southeast province of Vietnam. 420 FSWs were interviewed using a structured questionnaire and biological samples tested for HIV. 2.6 % were found to be HIV positive. HIV infection was significantly higher in FSWs who had low income (≤AUD 200 per month), have had anal sex, have had sex with injecting drug users, and had a low level of HIV/AIDS-related knowledge. Improved employment opportunities and income are important to reduce the pressure for young women to engage in sex work for income purposes, but in public health terms, existing HIV treatment, prevention and intervention programs needs better targeting and improvements to reduce the risk of HIV infection.
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13
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Awungafac G, Delvaux T, Vuylsteke B. Systematic review of sex work interventions in sub-Saharan Africa: examining combination prevention approaches. Trop Med Int Health 2017; 22:971-993. [PMID: 28449198 DOI: 10.1111/tmi.12890] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The incidence of HIV and sexually transmitted infections is disproportionately high among sex workers (SW). We aimed to update the evidence on the effectiveness of SW interventions in sub-Saharan Africa and to provide more insights into combination prevention. METHODS The Systematic review followed PRISMA guidelines in a search of PUBMED and POPLINE for peer-reviewed literature published between 1 January 2000 and 22 July 2016 (registration number on PROSPERO: CRD42016042529). We considered cohort interventions, randomised controlled trials and cross-sectional surveys of SW programmes. A framework was used in the description and mapping of intervention to desired outcomes. RESULTS Twenty-six papers(reporting on 25 studies) were included. A strategy that empowered peer educator leaders to steer community activities showed a twofold increase in coverage of behaviour change communication and utilisation of health facility among SW. Brief alcohol harm reduction effort demonstrated a significant effect on sexual violence and engagement in sex trading. A risk reduction counselling intervention among drug-injecting SW showed an effect on alcohol, substance use and engagement in sex work. No study on a promising intervention like PrEP among SWs was found. We observed that interventions that combined some structural components, biomedical and behavioural strategies tend to accumulate more desired outcomes. CONCLUSION The evidence base that can be considered in intervention designs to prevent HIV in SW in SSA is vast. The health sector should consider interventions to reduce binge alcohol intake and intravenous drug use among sex workers. Programmes should staunchly consider multicomponent approaches that explore community-based structural approaches.
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Affiliation(s)
- George Awungafac
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia.,Ministry of Health, Yaoundé, Cameroon
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14
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Abstract
PURPOSE OF REVIEW We explore the potential benefits of integrating preexposure prophylaxis (PrEP) into combination HIV prevention for female sex workers (FSWs) and the likely challenges to implementation. RECENT FINDINGS Evidence for the biological effectiveness of PrEP in women who can adhere to daily dosing is strong. FSWs in many countries bear the brunt of the HIV epidemic. Current combination prevention approaches enable many FSWs to remain HIV-free, but in some settings FSWs are unable to mitigate their risk. PrEP provides a new prevention tool for these women. To benefit, HIV-negative FSWs need to perceive that they are at risk, be motivated and able to take PrEP daily and to attend health services for prescription refill and clinical monitoring. FSWs face particular structural challenges to PrEP uptake and use, including stigmatizing health services; fear of disclosure to other FSWs and clients; fear of the authorities; lack of social support; substance use; unplanned travel and risk compensation many of which can be addressed through combination prevention approaches. SUMMARY For those FSWs who are unable to mitigate their HIV risk, PrEP, if adequately supported and integrated with combination prevention, may empower them to remain HIV-free.
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Bigna JJR, Plottel CS, Koulla-Shiro S. Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count. Infect Dis Poverty 2016; 5:85. [PMID: 27593965 PMCID: PMC5011352 DOI: 10.1186/s40249-016-0179-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 07/29/2016] [Indexed: 11/10/2022] Open
Abstract
Introduction Recently published large randomized controlled trials, START, TEMPRANO and HPTN 052 show the clinical benefit of early initiation of antiretroviral treatment (ART) in HIV-infected persons and in reducing HIV transmission. The trials influenced the World Health Organization (WHO) decision to issue updated recommendations to prescribe ART to all individuals living with HIV, irrespective of age and CD4 cell count. Discussion It is clear that the new 2015 WHO recommendations if followed, will change the face of the HIV epidemic and probably curb its burden over time. Implementation however, requires that health systems, especially those in low and middle-income settings, be ready to face this challenge on a large scale. HIV prevention and treatment are easy in theory yet hard in practice. The new WHO guidelines for initiation of ART regardless of CD4 cell count will lead to upfront increases in the costs of healthcare delivery as the goal is to treat all those now newly eligible for ART. Around 22 million people living with HIV qualify and will therefore require ART. Related challenges immediately follow: firstly, that everyone must be tested for HIV; secondly, that anyone who has had an HIV test should know their result and understand its significance; and, thirdly, that every person identified as HIV-positive should receive and remain on ART. The emergence of HIV drug resistant strains when treatment is started at higher CD4 cell count thresholds is a further concern as persons on HIV treatment for longer periods of time are at increased risk of intermittent medication adherence. Conclusions The new WHO recommendations for ART are welcome, but lacking as they fail to consider meaningful solutions to the challenges inherent to implementation. They fail to incorporate actual strategies on how to disseminate and adopt these far-reaching guidelines, especially in sub-Saharan Africa, an area with weak healthcare infrastructures. Well-designed, high-quality research is needed to assess the feasibility, safety, acceptability, impact, and cost of innovations such as the universal voluntary testing and immediate treatment approaches, and broad consultation must address community, human rights, ethical, and political concerns. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0179-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jean Joel R Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, 451, Rue 2005, P.O. Box 1274, Yaounde, Cameroon. .,Bordeaux School of Public Health, University of Bordeaux, Bordeaux, France.
| | - Claudia S Plottel
- Department of Medicine, Division of Translational Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Sinata Koulla-Shiro
- Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaoundé, Cameroon.,Infectious Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon
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16
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Implementation and Operational Research: Cohort Analysis of Program Data to Estimate HIV Incidence and Uptake of HIV-Related Services Among Female Sex Workers in Zimbabwe, 2009-2014. J Acquir Immune Defic Syndr 2016; 72:e1-8. [PMID: 27093516 DOI: 10.1097/qai.0000000000000920] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource. METHODS Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach. RESULTS Data were available for 13,360 women, 31,389 visits, 14,579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the program only once. FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9). CONCLUSIONS Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.
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17
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Abstract
Despite the availability of inexpensive antimicrobial treatment, syphilis remains prevalent worldwide, affecting millions of individuals. Furthermore, syphilis infection is suspected of increasing both susceptibility to, and tendency to transmit, HIV. Development of a syphilis vaccine would be a potentially promising step towards control, but the value of dedicating resources to vaccine development should be evaluated in the context of the anticipated benefits. Here, we use a detailed mathematical model to explore the potential impact of rolling out a hypothetical syphilis vaccine on morbidity from both syphilis and HIV and compare it to the impact of expanded ‘screen and treat’ programmes using existing treatments. Our results suggest that an efficacious vaccine has the potential to sharply reduce syphilis prevalence under a wide range of scenarios, while expanded treatment interventions are likely to be substantially less effective. Our modelled interventions in our simulated study populations are expected to have little effect on HIV, and in some scenarios lead to small increases in HIV incidence, suggesting that interventions against syphilis should be accompanied with interventions against other sexually transmitted infections to prevent the possibility that lower morbidity or lower perceived risk from syphilis could lead to increases in other sexually transmitted diseases.
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18
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Abstract
There is evidence that HIV prevention programs for sex workers, especially female sex workers, are cost-effective in several contexts, including many western countries, Thailand, India, the Democratic Republic of Congo, Kenya, and Zimbabwe. The evidence that sex worker HIV prevention programs work must not inspire complacency but rather a renewed effort to expand, intensify, and maximize their impact. The PLOS Collection "Focus on Delivery and Scale: Achieving HIV Impact with Sex Workers" highlights major challenges to scaling-up sex worker HIV prevention programs, noting the following: sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; sex worker HIV and sexually transmitted infection services receive limited domestic financing in many countries; many sex worker HIV prevention programs are inadequately codified to ensure consistency and quality; and many sex worker HIV prevention programs have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile- and internet-based sex workers. Based on the wider collection of papers, this article presents three major clusters of recommendations: (i) HIV programs focused on sex workers should be prioritized, developed, and implemented based on robust evidence; (ii) national political will and increased funding are needed to increase coverage of effective sex worker HIV prevention programs in low and middle income countries; and (iii) comprehensive, integrated, and rapidly evolving HIV programs are needed to ensure equitable access to health services for individuals involved in all forms of sex work.
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Affiliation(s)
- David Wilson
- World Bank, Global HIV/AIDS Program, Washington, D.C., United States of America
- * E-mail:
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19
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Rush to judgment: the STI-treatment trials and HIV in sub-Saharan Africa. J Int AIDS Soc 2015; 18:19844. [PMID: 25990095 PMCID: PMC4438085 DOI: 10.7448/ias.18.1.19844] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 03/24/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The extraordinarily high incidence of HIV in sub-Saharan Africa led to the search for cofactor infections that could explain the high rates of transmission in the region. Genital inflammation and lesions caused by sexually transmitted infections (STIs) were a probable mechanism, and numerous observational studies indicated several STI cofactors. Nine out of the ten randomized controlled trials (RCTs), however, failed to demonstrate that treating STIs could lower HIV incidence. We evaluate all 10 trials to determine if their design permits the conclusion, widely believed, that STI treatment is ineffective in reducing HIV incidence. DISCUSSION Examination of the trials reveals critical methodological problems sufficient to account for statistically insignificant outcomes in nine of the ten trials. Shortcomings of the trials include weak exposure contrast, confounding, non-differential misclassification, contamination and effect modification, all of which consistently bias the results toward the null. In any future STI-HIV trial, ethical considerations will again require weak exposure contrast. The complexity posed by HIV transmission in the genital microbial environment means that any future STI-HIV trial will face confounding, non-differential misclassification and effect modification. As a result, it is unlikely that additional trials would be able to answer the question of whether STI control reduces HIV incidence. CONCLUSIONS Shortcomings in published RCTs render invalid the conclusion that treating STIs and other cofactor infections is ineffective in HIV prevention. Meta-analyses of observational studies conclude that STIs can raise HIV transmission efficiency two- to fourfold. Health policy is always implemented under uncertainty. Given the known benefits of STI control, the irreparable harm from not treating STIs and the likely decline in HIV incidence resulting from STI control, it is appropriate to expand STI control programmes and to use funds earmarked for HIV prevention to finance those programmes.
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20
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Shey MS, Garrett NJ, McKinnon LR, Passmore JAS. The role of dendritic cells in driving genital tract inflammation and HIV transmission risk: are there opportunities to intervene? Innate Immun 2015; 21:99-112. [PMID: 24282122 PMCID: PMC4033703 DOI: 10.1177/1753425913513815] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Effective prevention of new HIV infections will require an understanding of the mechanisms involved in HIV acquisition. HIV transmission across the female genital tract is the major mode of new HIV infections in sub-Saharan Africa and involves complex processes, including cell activation, inflammation and recruitment of HIV target cells. Activated CD4(+) T-cells, dendritic cells (DC) and macrophages have been described as targets for HIV at the genital mucosa. Activation of these cells may occur in the presence of sexually-transmitted infections, disturbances of commensal flora and other inflammatory processes. In this review, we discuss causes and consequences of inflammation in the female genital tract, with a focus on DC. We describe the central role these cells may play in facilitating or preventing HIV transmission across the genital mucosa, and in the initial recognition of HIV and other pathogens, allowing activation of an adaptive immune response to infection. We discuss studies that investigate interventions to limit DC activation, inflammation and HIV transmission. This knowledge is essential in the development of novel strategies for effective HIV control, including microbicides and pre-exposure prophylaxis.
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Affiliation(s)
| | | | | | - Jo-Ann S Passmore
- CAPRISA, Durban, South Africa Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa National Health Laboratory Service, Cape Town, South Africa
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Moore L, Chersich MF, Steen R, Reza-Paul S, Dhana A, Vuylsteke B, Lafort Y, Scorgie F. Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review. Global Health 2014; 10:47. [PMID: 24916108 PMCID: PMC4074148 DOI: 10.1186/1744-8603-10-47] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
Background Female sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation. Methods In November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community. Results Of 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations. Conclusions Most FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.
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Affiliation(s)
- Lizzie Moore
- MatCH (Maternal, Adolescent and Child Health), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
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Dhana A, Luchters S, Moore L, Lafort Y, Roy A, Scorgie F, Chersich M. Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa. Global Health 2014; 10:46. [PMID: 24916010 PMCID: PMC4070634 DOI: 10.1186/1744-8603-10-46] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 04/07/2014] [Indexed: 12/19/2022] Open
Abstract
Background Several biological, behavioural, and structural risk factors place female sex workers (FSWs) at heightened risk of HIV, sexually transmitted infections (STIs), and other adverse sexual and reproductive health (SRH) outcomes. FSW projects in many settings have demonstrated effective ways of altering this risk, improving the health and wellbeing of these women. Yet the optimum delivery model of FSW projects in Africa is unclear. This systematic review describes intervention packages, service-delivery models, and extent of government involvement in these services in Africa. Methods On 22 November 2012, we searched Web of Science and MEDLINE, without date restrictions, for studies describing clinical and non-clinical facility-based SRH prevention and care services for FSWs in low- and middle-income countries in Africa. We also identified articles in key non-indexed journals and on websites of international organizations. A single reviewer screened titles and abstracts, and extracted data from articles using standardised tools. Results We located 149 articles, which described 54 projects. Most were localised and small-scale; focused on research activities (rather than on large-scale service delivery); operated with little coordination, either nationally or regionally; and had scanty government support (instead a range of international donors generally funded services). Almost all sites only addressed HIV prevention and STIs. Most services distributed male condoms, but only 10% provided female condoms. HIV services mainly encompassed HIV counselling and testing; few offered HIV care and treatment such as CD4 testing or antiretroviral therapy (ART). While STI services were more comprehensive, periodic presumptive treatment was only provided in 11 instances. Services often ignored broader SRH needs such as family planning, cervical cancer screening, and gender-based violence services. Conclusions Sex work programmes in Africa have limited coverage and a narrow scope of services and are poorly coordinated with broader HIV and SRH services. To improve FSWs’ health and reduce onward HIV transmission, access to ART needs to be addressed urgently. Nevertheless, HIV prevention should remain the mainstay of services. Service delivery models that integrate broader SRH services and address structural risk factors are much needed. Government-led FSW services of high quality and scale would markedly reduce SRH vulnerabilities of FSWs in Africa.
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Affiliation(s)
| | | | | | | | | | | | - Matthew Chersich
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
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Mack N, Odhiambo J, Wong CM, Agot K. Barriers and facilitators to pre-exposure prophylaxis (PrEP) eligibility screening and ongoing HIV testing among target populations in Bondo and Rarieda, Kenya: results of a consultation with community stakeholders. BMC Health Serv Res 2014; 14:231. [PMID: 24886646 PMCID: PMC4051373 DOI: 10.1186/1472-6963-14-231] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 05/07/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND As pre-exposure prophylaxis (PrEP) moves closer to availability in developing countries, practical considerations for implementation become important. We conducted a consultation with district-level community stakeholders experienced in HIV-prevention interventions with at-risk populations in Bondo and Rarieda, Kenya to generate locally grounded approaches to the future rollout of oral PrEP to four populations: fishermen, widows, female sex workers, and serodiscordant couples. METHODS The 20 consultation participants represented the Ministry of Health, faith- and community-based organizations, health facilities, community groups, and nongovernmental organizations. Participants divided into breakout groups and followed a structured discussion guide asking them to identify barriers to implementing HIV-prevention interventions (including PrEP) with each population. Questions also solicited solutions for addressing these barriers, as well as other facilitators for PrEP implementation. In particular, questions focused on how to encourage people to screen for PrEP eligibility by having HIV and other blood tests and how to encourage compliance with ongoing HIV testing. RESULTS The barriers and facilitators/solutions discussants provided were frequently population-specific, but there were also broad-level similarities across populations. Service delivery barriers to HIV-prevention interventions concerned the need for staff trained to address the needs of particular populations. Service delivery facilitators to provision of ongoing HIV testing consisted of offering testing options besides facility-based testing. Stigma was the main community-level barrier for all groups, whereas barriers at the level of target populations included mobility; lifestyle and life circumstances, especially cultural norms among fishermen and widows; and fears, lack of awareness, and misinformation. Proposed facilitators and strategies for addressing community- and population-level barriers included topic-specific education within the populations and community, involvement of partners and family members, mass HIV testing, and peer educators. Barriers to PrEP uptake included non-adherence to pill taking and missing clinic visits. For drug adherence, facilitators were counselling and involving family members. Discussants suggested that client reminders, e.g., home visits, were needed to encourage clients to keep their clinic appointments. CONCLUSIONS Strategies for encouraging eligibility screening and ongoing HIV testing will have local and population-specific aspects. Our results nonetheless apply to similar populations throughout sub-Saharan Africa and reach beyond oral PrEP to other ARV-based PrEP formulations.
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Affiliation(s)
- Natasha Mack
- Social and Behavioral Health Sciences, Durham, NC FHI 360, USA.
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Kuhlmann AS, Galavotti C, Hastings P, Narayanan P, Saggurti N. Investing in communities: evaluating the added value of community mobilization on HIV prevention outcomes among FSWs in India. AIDS Behav 2014; 18:752-66. [PMID: 24129843 PMCID: PMC3961594 DOI: 10.1007/s10461-013-0626-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Community mobilization often requires greater time and resource investments than typical interventions, yet few evaluations exist to justify these investments. We evaluated the added benefit of community mobilization on HIV prevention outcomes among female sex workers (FSWs) using a composite measure of volunteer participation in program committees by FSWs. After adjusting for treatment propensity, we used multilevel structural equation modeling (MSEM) to test our program theory. We hypothesized that stronger community mobilization would be associated with increased levels of consistent condom use and with increased levels of perceived fairness, mediated by psychosocial processes. Community mobilization had an indirect effect on consistent condom use mediated through social cohesion and an indirect effect on perceived fairness mediated by collective efficacy. Our results suggest higher levels of community mobilization help improve condom use and reduce perceived discrimination beyond the effects of the core HIV intervention program. We recommend further testing of this model.
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Affiliation(s)
- Anne Sebert Kuhlmann
- Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130 USA
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Kjetland EF, Hegertun IEA, Baay MFD, Onsrud M, Ndhlovu PD, Taylor M. Genital schistosomiasis and its unacknowledged role on HIV transmission in the STD intervention studies. Int J STD AIDS 2014; 25:705-15. [DOI: 10.1177/0956462414523743] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of sexually transmitted infections (STIs) has been hypothesised to decrease HIV transmission. Although observational studies show an association between STIs and HIV, only one prospective randomised controlled trial (RCT) has confirmed this. Female genital schistosomiasis can cause genital lesions, accompanied by bloody discharge, ulcers or malodorous discharge. Genital schistosomiasis is common, starts before puberty and symptoms can be mistaken for STIs. Three observational studies have found an association between schistosomiasis and HIV. Genital lesions that develop in childhood are chronic. This paper sought to explore the possible effects of schistosomiasis on the RCTs of STI treatment for HIV prevention. In the study sites, schistosomiasis was a likely cause of genital lesions. The studies recruited women that may have had genital schistosomal lesions established in childhood. Schistosomiasis endemic areas with different prevalence levels may have influenced HIV incidence in intervention and control sites differently, and some control group interventions may have influenced the impact of schistosomiasis on the study results. Schistosomiasis is a neglected cause of genital tract disease. It may have been an independent cause of HIV incidence in the RCTs of STI treatment for HIV prevention and may have obscured the findings of these trials.
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Affiliation(s)
- Eyrun F Kjetland
- Norwegian Centre for Imported and Tropical Diseases, Department of Infectious Diseases Ullevaal, Oslo University Hospital, Oslo, Norway
- Discipline of Public Health Medicine, Nelson R Mandela School of Medicine, School of Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Ingrid EA Hegertun
- Norwegian Centre for Imported and Tropical Diseases, Department of Infectious Diseases Ullevaal, Oslo University Hospital, Oslo, Norway
| | - Marc FD Baay
- Norwegian Centre for Imported and Tropical Diseases, Department of Infectious Diseases Ullevaal, Oslo University Hospital, Oslo, Norway
- Laboratory of Cancer Research and Clinical Oncology, University of Antwerp, Wilrijk, Belgium
| | - Mathias Onsrud
- Department of Gynaecology and Obstetrics, Oslo University Hospital, Oslo, Norway
| | | | - Myra Taylor
- Discipline of Public Health Medicine, Nelson R Mandela School of Medicine, School of Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Campos PE, Buffardi AL, Cárcamo CP, García PJ, Buendia C, Chiappe M, Garnett GP, Xet-Mull AM, Holmes KK. Reaching the unreachable: providing STI control services to female sex workers via mobile team outreach. PLoS One 2013; 8:e81041. [PMID: 24282565 PMCID: PMC3839873 DOI: 10.1371/journal.pone.0081041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/17/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND As part of a community-randomized trial of a multicomponent intervention to prevent sexually transmitted infections, we created Mobile Teams (MTs) in ten intervention cities across Peru to improve outreach to female sex workers (FSW) for strengthened STI prevention services. METHODS Throughout 20 two-month cycles, MTs provided counseling; condoms; screening and specific treatment for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), and vaginal Trichomonas vaginalis (TV) infections; and periodic presumptive metronidazole treatment for vaginal infections. RESULTS MTs had 48,207 separate encounters with 24,814 FSW; numbers of sex work venues and of FSW reached increased steadily over several cycles. Approximately 50% of FSW reached per cycle were new. Reported condom use with last client increased from 73% to 93%. Presumptive metronidazole treatment was accepted 83% of times offered. Over 38 months, CT prevalence declined from 15.4% to 8.2%, and TV prevalence from 7.3% to 2.6%. Among participants in ≥ 9 cycles, CT prevalence decreased from 12.9% to 6.0% (p <0.001); TV from 4.6% to 1.5% (p <0.001); and NG from 0.8% to 0.4% (p = 0.07). CONCLUSIONS Mobile outreach to FSW reached many FSW not utilizing government clinics. Self-reported condom use substantially increased; CT and TV prevalences declined significantly. The community-randomized trial, reported separately, demonstrated significantly greater reductions in composite prevalence of CT, NG, TV, or high-titer syphilis serology in FSW in these ten intervention cities than in ten matched control cities.
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Affiliation(s)
- Pablo E. Campos
- Epidemiology, STD/AIDS Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Anne L. Buffardi
- Center for AIDS & STD, University of Washington, Seattle, Washington, United States of America
| | - César P. Cárcamo
- Epidemiology, STD/AIDS Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Patricia J. García
- Epidemiology, STD/AIDS Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
- * E-mail:
| | - Clara Buendia
- Epidemiology, STD/AIDS Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marina Chiappe
- Epidemiology, STD/AIDS Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Geoff P. Garnett
- Department of Infectious Diseases Epidemiology, Imperial College, London, United Kingdom
| | - Ana Maria Xet-Mull
- Center for AIDS & STD, University of Washington, Seattle, Washington, United States of America
| | - King K. Holmes
- Center for AIDS & STD, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
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Chemaitelly H, Awad SF, Abu-Raddad LJ. The risk of HIV transmission within HIV-1 sero-discordant couples appears to vary across sub-Saharan Africa. Epidemics 2013; 6:1-9. [PMID: 24593916 DOI: 10.1016/j.epidem.2013.11.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 09/22/2013] [Accepted: 11/11/2013] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Representative and precise estimates for the annual risk of HIV transmission (ϕ) from the infected to the uninfected partner in a stable HIV-1 sero-discordant couple (SDC) are not available. Nevertheless, quantifying HIV infectiousness is critical to understanding HIV epidemiology and implementing prevention programs. MATERIALS AND METHODS We estimated ϕ and examined its variation across 23 countries in sub-Saharan Africa (SSA) by constructing and analyzing a mathematical model that describes HIV dynamics among SDCs. The model was parameterized using empirical measures such as those of the nationally representative Demographic and Health Surveys. Uncertainty and sensitivity analyses were conducted to assess the robustness of the findings. RESULTS We estimated a median ϕ of 11.1 per 100 person-years across SSA. A clustering based on HIV population prevalence was observed with a median ϕ of 7.5 per 100 person-years in low HIV prevalence countries (<5%) compared to 19.5 per 100 person-years in high prevalence countries (>5%). The association with HIV prevalence explained 67% of the variation in ϕ, and suggested an increase of 0.95 per 100 person-years in ϕ for every 1% increase in HIV prevalence. CONCLUSIONS Empirical measures from cohort studies appear to underestimate HIV infectiousness in SSA. The risk of HIV transmission among SDCs appears also to vary across SSA, and this may have contributed to the contrasting HIV epidemic trajectories in this continent.
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Affiliation(s)
- Hiam Chemaitelly
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - Susanne F Awad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; Department of Public Health, Weill Cornell Medical College, Cornell University, New York, NY, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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Saggurti N, Mishra RM, Proddutoor L, Tucker S, Kovvali D, Parimi P, Wheeler T. Community collectivization and its association with consistent condom use and STI treatment-seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India. AIDS Care 2013; 25 Suppl 1:S55-66. [PMID: 23745631 PMCID: PMC4003583 DOI: 10.1080/09540121.2012.749334] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We examine community collectivization among female sex workers (FSWs) and high-risk men who have sex with men and transgenders (HR-MSM) following several years of HIV prevention programming with these populations, and its association with selected outcome indicators measuring individual behaviors (condom use with different partners and sexually transmitted infection [STI] treatment-seeking from government health facilities). Data for this study were collected from a large-scale cross-sectional survey conducted in 2010–2011 among FSWs (sample size: 3557) and HR-MSM (sample size: 2399) in Andhra Pradesh, India. We measured collectivization among FSWs in terms of three binary (low, high) indices of collective efficacy, collective agency, and collective action. Collectivization among HR-MSM was measured by participation in a public event (no, yes), and a binary (low, high) index of collective efficacy. Adjusted odds ratios (adjusted OR) and their 95% confidence intervals (CI) were computed to assess the relationships between collectivization and outcome indicators directly and through mediation of variables such as self-efficacy for condom use and utilization of government health facilities. Results show that among FSWs, high levels of collective efficacy (adjusted OR: 1.3, 95% CI: 1.1–1.7) and collective action (adjusted OR:1.3, 95% CI: 1.1–1.8) were associated with consistent condom use (CCU) with regular clients. Among HR-MSM, participation in a public event (adjusted OR: 2.7, 95% CI: 2.0–3.6) and collective efficacy (adjusted OR: 1.9, 95% CI: 1.5–2.3) were correlated with condom use with paying partners. The association between collectivization and outcome indicators continued to be significant in most cases even after adjusting for the potential mediators. Indicators of collectivization exhibited significant positive association with self-efficacy for condom use and service utilization from government health facilities among both FSWs and HR-MSM. The association of high levels of collectivization with CCU, STI treatment- seeking from government health facilities, ability to negotiate for condom use, and self-efficacy in utilizing government health facilities is relevant to effort to improve the effectiveness and sustainability of HIV prevention programs in India and beyond.
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Aho J, Koushik A, Coutlée F, Diakité SL, Rashed S. Prevalence of HIV, human papillomavirus type 16 and herpes simplex virus type 2 among female sex workers in Guinea and associated factors. Int J STD AIDS 2013; 25:280-8. [DOI: 10.1177/0956462413500242] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Female sex workers are at high risk for HIV infection. Sexually transmitted infections are known to be co-factors for HIV infection. Our aims were (1) to assess the prevalence of HIV and other sexually transmitted infections in this population; (2) to determine the association between sociodemographic characteristics, behavioural variables, and variables related to HIV prevention and HIV infection. A cross-sectional study was conducted in Conakry, Guinea, among a convenience sample of 223 female sex workers. A questionnaire on sociodemographic characteristics, risk factors, and exposure to prevention was administered. Screening for HIV, herpes simplex virus type 2, human papillomavirus type 16, Neisseria gonorrhoeae, and Chlamydia trachomatis was performed. Prevalences of HIV, herpes simplex virus type 2, human papillomavirus type 16, N. gonorrhoeae, and C. trachomatis were 35.3%, 84.1%, 12.2%, 9.0%, and 13.6%, respectively. Having a child, lubricant use, and human papillomavirus type 16 infection were associated with HIV infection. Interventions that promote screening and treatment of sexually transmitted infections are needed in order to achieve successful interventions to prevent HIV among female sex workers in resource-limited settings.
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Affiliation(s)
- Joséphine Aho
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Anita Koushik
- Université de Montreal Hospital Research Center, Montreal, Canada
| | - François Coutlée
- Université de Montreal Hospital Research Center, Montreal, Canada
| | | | - Sélim Rashed
- Département de Pédiatrie, Université de Montréal, Montreal, Canada
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Béhanzin L, Diabaté S, Minani I, Boily MC, Labbé AC, Ahoussinou C, Anagonou S, Zannou DM, Lowndes CM, Alary M. Decline in the prevalence of HIV and sexually transmitted infections among female sex workers in Benin over 15 years of targeted interventions. J Acquir Immune Defic Syndr 2013; 63:126-34. [PMID: 23337368 DOI: 10.1097/qai.0b013e318286b9d4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND An HIV-preventive intervention targeting the sex work milieu and involving fully integrated components of structural interventions, communication for behavioral change and care for sexually transmitted infections (STIs), was implemented in Benin by a Canadian project from 1992 to 2006. It first covered Cotonou before being extended to other main cities from 2000. At the project end, the Beninese authorities took over the intervention, but structural interventions were interrupted and other intervention components were implemented separately. We estimated time trends in HIV/STI prevalence among female sex workers (FSWs) from 1993 to 2008 and assessed the impact of the change in intervention model on trends. METHODS Six integrated biological and behavioral surveys were carried out among FSWs. Time trend analysis controlled for potential sociodemographic confounders using log-binomial regression. RESULTS In Cotonou, from 1993 to 2008, there was a significant decrease in HIV (53.3%-30.4%), gonorrhea (43.2%-6.4%), and chlamydia (9.4%-2.8%) prevalence (all adjusted P = 0.0001). The decrease in HIV and gonorrhea prevalence was also significant in the other cities between 2002 and 2008. In 2002, gonorrhea prevalence was lower in Cotonou than elsewhere (prevalence ratio = 0.53, 95% confidence interval: 0.32 to 0.88). From 2005 to 2008, there was an increase in gonorrhea prevalence (prevalence ratio = 1.76, 95% confidence interval: 1.17 to 2.65) in all cities combined. CONCLUSIONS Our results suggest a significant impact of this targeted preventive intervention on HIV/STI prevalence among FSWs. The recent increase in gonorrhea prevalence could be related to the lack of integration of the intervention components.
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Affiliation(s)
- Luc Béhanzin
- Unité de Recherche en Santé des Populations, Centre de Recherche FRQS du CHA Universitaire de Québec, Québec, Canada
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Abstract
OBJECTIVE To discuss the epidemiology of Trichomonas vaginalis (TV) and HIV co-infections, the role of TV in acquisition and transmission of HIV, special treatment considerations for TV among women with HIV and the prevention of TV among HIV-infected persons. DESIGN Systematic review. DATA SOURCE Review of literature of EMBASE and PubMed databases from January 1990 to February 2013. Search keywords included TV, HIV co-infections, HIV acquisition, HIV transmission, HIV shedding, TV treatment, HIV and couples studies. REVIEW METHOD We included studies of any design that contained the selected search words and were published during the specified time frame. We then searched the reference lists of included papers for additional papers and included these when relevant. RESULTS There is strong evidence that TV increases both transmission and acquisition of HIV among women, and that successful treatment for TV can reduce HIV genital shedding. Single dose metronidazole (MTZ) should no longer be used for HIV+ women with TV given the high rates of asymptomatic bacterial vaginosis co-infections and other factors that may render MTZ less effective in HIV+ women. Prevention of TV among HIV+ persons is similar to among HIV, including promotion of condoms as well as regular screening and prompt treatment. There may be a role for expedited partner treatment for the prevention of repeat infections, but most repeat infections are clinical treatment failures. Diligence in screening and treating TV among both HIV- susceptible and HIV+ persons is an important public health strategy.
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Affiliation(s)
- Patricia Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana 70012, USA.
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Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services. J Int AIDS Soc 2013; 16:17980. [PMID: 23462140 PMCID: PMC3589546 DOI: 10.7448/ias.16.1.17980] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/17/2012] [Accepted: 10/24/2012] [Indexed: 12/04/2022] Open
Abstract
Introduction Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery. Methods We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes. Results We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection. Conclusions There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.
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Béhanzin L, Diabaté S, Minani I, Lowndes CM, Boily MC, Labbé AC, Anagonou S, Zannou DM, Buvé A, Alary M. Decline in HIV prevalence among young men in the general population of Cotonou, Benin, 1998-2008. PLoS One 2012; 7:e43818. [PMID: 22952773 PMCID: PMC3429516 DOI: 10.1371/journal.pone.0043818] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 07/26/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess changes in the prevalence of HIV and other sexually transmitted infections, as well as in different proximal and distal factors related to HIV infection, in the general population of Cotonou between 1998 and 2008, while an intensive preventive intervention targeting the sex work milieu was ongoing. METHODS A two-stage cluster sampling procedure was used to select the participants in each study. Subjects aged 15-49 who agreed to participate were interviewed and tested for HIV, syphilis, HSV-2, gonorrhoea and chlamydia. We used the Roa-Scott Chi-square test (proportions) and the Student's t test (means) for bivariate comparisons, and adjusted logistic regression models taking into account the cluster effect for multivariate analyses. RESULTS HIV prevalence decreased significantly in men (3.4% in 1998 versus 2.0% in 2008, p = 0.048), especially in those aged 15-29 (3.0% to 0.5%, p = 0.002). Among men, the prevalence of gonorrhoea decreased significantly (1.1% to 0.3%, p = 0.046) while HSV-2 prevalence increased from 12.0% to 18.1% (p = 0.0003). The proportion of men who reported condom use at least once (29.3% to 61.0%, p<0.0001) and of those having attained a secondary educational level or more (17.1% to 61.3%, p<0.0001) also increased significantly. There was an overall decrease in the prevalence of syphilis (1.5% to 0.6%, p = 0.0003). CONCLUSION This is the first population-based study reporting a significant decline in HIV prevalence among young men in an African setting where overall prevalence has never reached 5%. The decline occurred while preventive interventions targeting the sex work milieu were ongoing and the educational level was increasing.
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Affiliation(s)
- Luc Béhanzin
- Unite de recherche en santé des populations (URESP), Centre de recherche FRSQ du CHA universitaire de Québec, Québec Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | - Souleymane Diabaté
- Unite de recherche en santé des populations (URESP), Centre de recherche FRSQ du CHA universitaire de Québec, Québec Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | | | - Catherine M. Lowndes
- Unite de recherche en santé des populations (URESP), Centre de recherche FRSQ du CHA universitaire de Québec, Québec Canada
- Health Protection Agency, London, United Kingdom
| | - Marie-Claude Boily
- Unite de recherche en santé des populations (URESP), Centre de recherche FRSQ du CHA universitaire de Québec, Québec Canada
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
| | - Annie-Claude Labbé
- Département de microbiologie, Hôpital Maisonneuve-Rosemont, Montréal, Canada
| | - Séverin Anagonou
- Faculté des sciences de la santé, Université d’Abomey-Calavi, Cotonou, Bénin
- Centre national hospitalier universitaire, Cotonou, Bénin
| | - Djimon Marcel Zannou
- Faculté des sciences de la santé, Université d’Abomey-Calavi, Cotonou, Bénin
- Centre national hospitalier universitaire, Cotonou, Bénin
| | - Anne Buvé
- Unit of Epidemiology and Control of HIV/STD, Institute of Tropical Medicine, Antwerp, Belgium
| | - Michel Alary
- Unite de recherche en santé des populations (URESP), Centre de recherche FRSQ du CHA universitaire de Québec, Québec Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
- Institut national de santé publique du Québec, Québec, Canada
- * E-mail:
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Galavotti C, Wheeler T, Kuhlmann AS, Saggurti N, Narayanan P, Kiran U, Dallabetta G. Navigating the swampy lowland: a framework for evaluating the effect of community mobilisation in female sex workers in Avahan, the India AIDS Initiative. J Epidemiol Community Health 2012; 66 Suppl 2:ii9-15. [PMID: 22760219 PMCID: PMC3603680 DOI: 10.1136/jech-2011-200465] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Few models of how community mobilisation works have been elaborated in the scientific literature, and evaluation of the impact of these programmes on HIV and other health outcomes is extremely limited. Avahan, the India AIDS Initiative, has been implementing community mobilisation as part of its prevention programming with groups of high-risk individuals across six states since 2005. Purpose To articulate a programme theory and evaluation framework for evaluation of Avahan's approach to community mobilisation among female sex workers in four southern states in India. Methods The authors use a goal-based evaluation approach to describe the programme goals and an underlying programme theory that specifies how the programme is expected to work. Using multilevel structural equation modelling with propensity score matching, the evaluation will compare what is observed in the data with the predicted relationships specified by the model. Results The Avahan model of community mobilisation posits that meaningful participation in high-risk group intervention, structural intervention and organisational development activities leads to identification, collectivisation and ownership, which in turn leads to improved programme outcomes. Strong community groups and an enabling environment reinforce social norm and behaviour change outcomes and lead to sustained impact. Discussion Specifying an explicit programme theory can aid in the evaluation of complex interventions, especially when the evaluation design is observational. In addition to articulating Avahan's community mobilisation approach in a model that can be tested, we recommend some specific measures and methods that could be used to improve evaluation efforts in the future.
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Scorgie F, Chersich MF, Ntaganira I, Gerbase A, Lule F, Lo YR. Socio-demographic characteristics and behavioral risk factors of female sex workers in sub-saharan Africa: a systematic review. AIDS Behav 2012; 16:920-33. [PMID: 21750918 DOI: 10.1007/s10461-011-9985-z] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioral underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers (FSW) in this region, their occupational contexts and key behavioral risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. FSW commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalization, high mobility and hazardous alcohol use. These, in turn, predict behaviors such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviors such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of FSW, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Targeted services at sufficiently high coverage, taking into account the behavioral and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by FSW on the continent.
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Affiliation(s)
- Fiona Scorgie
- Maternal, Adolescent and Child Health, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, Durban, South Africa.
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Wariki WMV, Ota E, Mori R, Koyanagi A, Hori N, Shibuya K. Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries. Cochrane Database Syst Rev 2012; 2012:CD005272. [PMID: 22336811 PMCID: PMC11345029 DOI: 10.1002/14651858.cd005272.pub3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Various interventions have been adopted to reduce HIV transmission among sex workers and their clients but the effectiveness of these strategies has yet to be investigated using meta-analytic techniques. OBJECTIVES To evaluate the effectiveness of behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane HIV/AIDS group specialized register, the Cochrane Database of Systematic Reviews, MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, Dissertation Abstract International (DAI), EMBASE, LILACS, BIOSIS, SciSearch, INDMED, Proquest, and various South Asian abstracting databases were included in the database list. The publication sites of the World Health Organization, the US Centers for Disease Control and Prevention, and other international research and non-governmental organizations also appeared in the database list. SELECTION CRITERIA Randomized controlled trials (RCTs) and quasi-RCTs examining the effects on HIV transmission risk of different behavioral interventions or comparing behavioral interventions with no intervention, where described any one of the outcome measures, such as HIV incidence and prevalence, STI incidence and prevalence, change in self-reported of condom use, and other HIV-related outcome. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials, extracted data and assessed the risk bias. Heterogeneity amongst trials was also tested. MAIN RESULTS A total of 13 trials with 8,698 participants were included. Primary outcomes (HIV and STI prevalence and incidence) were reported in seven trials. Of these, HIV incidence was reported in only three trials. After a 6-month follow-up assessment, there was no evidence that social cognitive behavioral intervention was effective in reducing HIV incidence (RR 0.12, 95% CI 0.01 to 2.22). However, there was a reduction in HIV incidence at 3-month follow-up assessment of promotion of female and male condom (RR 0.07, 95% CI 0.00 to 1.38). Social cognitive interventions and promotion of female and male condom use were significantly reduced STIs incidence (RR 0.57, 95% CI 0.34 to 0.96) and (RR 0.63, 95% CI 0.45 to 0.88), respectively. Secondary outcomes were identified in 13 trials. Meta-analyses showed evidence that interventions to promote the use of female and male condoms do reduce non-condom use (RR 0.83, 95% CI 0.65 to 1.05) compared to promotion of male condoms alone, and that social cognitive interventions reduced drug use among sex workers (RR 0.65, 95% CI 0.36 to 1.16) compared to standard care. AUTHORS' CONCLUSIONS Available evidence nevertheless suggests that compared with standard care or no intervention, behavioral interventions are effective in reducing HIV and the incidence of STIs amongst female sex workers (FSWs). Given the benefits of social cognitive theory and the promotion of condom use in reducing HIV/STI and the public health need to control transmission amongst FSWs, there is a clear finding in favour of behavioral interventions. However, it should be recognized that there is a lack of information about most other outcomes and target populations, and that all of the trials were conducted in low- and middle-income countries.
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Affiliation(s)
- Windy M V Wariki
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Laga M, Vuylsteke B. Evaluating AVAHAN's design, implementation and impact: lessons learned for the HIV Prevention Community. BMC Public Health 2011; 11 Suppl 6:S16. [PMID: 22376320 PMCID: PMC3287554 DOI: 10.1186/1471-2458-11-s6-s16] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Marie Laga
- ITM-HIV-AIDS- Center, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium.
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Ota E, Wariki WM, Mori R, Hori N, Shibuya K. Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries. Cochrane Database Syst Rev 2011:CD006045. [PMID: 22161397 DOI: 10.1002/14651858.cd006045.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Interventions to change behaviour among sex workers and their clients have been identified as a strategy to reduce HIV transmission. However, there has been no systematic review that has examined and summarized their effects. OBJECTIVES To identify and evaluate the effects of the studies performed on behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries. SEARCH METHODS Electronic searches were undertaken using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and other databases between January 1980 and July 2010. Experts in the field were contacted to locate any other studies. SELECTION CRITERIA Randomised controlled trials or specified quasi-experimental designs with comparison groups that examined the effects of behavioural interventions aimed at reducing the risk of HIV or sexually transmitted infections (STIs) transmission among sex workers in high-income countries. We reviewed studies for outcome relevance and methodological rigor. DATA COLLECTION AND ANALYSIS Two reviewers independently applied the inclusion criteria to potential studies, and any disagreements were resolved by discussion. Studies were assessed for completeness of reporting and extracted data. MAIN RESULTS A total of four studies were included, comprising two randomised controlled trials and two quasi-experimental pretest-posttest trials with control groups involving 1795 participants. No trials reported HIV prevalence/incidence as outcomes.Overall, the effects of behavioural interventions for sex workers in high-income countries on STI incidence did not differ significantly among two studies using a random effects model (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.11 to 1.98). Only one study found that the self-reported STI prevalence in clients of female sex workers was statistically significant (RR 0.09, 95%CI 0.01 to 0.72, P=0.02). There was no significant difference after behavioural intervention for condom use. Two studies demonstrated the effectiveness of intervention for knowledge of HIV transmission among sex workers (RR 1.82, 95%CI 1.55 to 2.14) and clients of sex workers (RR 1.93, 95%CI 1.46 to 2.55). AUTHORS' CONCLUSIONS There is limited evidence from randomised controlled trials for the effectiveness of behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries. Further randomised controlled trials are very likely to have important impacts on our confidence in the estimates of the effects, and are likely to change the estimates for effective interventions with outcomes of HIV incidence or prevalence and a variety of different settings among sex workers and their clients in high-income countries. Randomised controlled trials that test for the identification of effective interventions for HIV prevention with outcomes of biological endpoints, such as HIV incidence or prevalence, are needed for these neglected populations. More research is also needed for male or transgender sex workers and their clients in high-income countries.
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Affiliation(s)
- Erika Ota
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, Japan, 113-0011
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Linking HIV prevention and care for community interventions among high-risk women in Burkina Faso--the ARNS 1222 "Yerelon" cohort. J Acquir Immune Defic Syndr 2011; 57 Suppl 1:S50-4. [PMID: 21857287 DOI: 10.1097/qai.0b013e3182207a3f] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Interventions targeting core groups such as high-risk women in Africa have focused mostly on HIV prevention. In this marginalized group, the delegation of HIV care to public services may jeopardize the effectiveness of prevention activities. We assessed the effect of an intervention combining prevention and care among high-risk women on HIV exposure and treatment outcomes. METHODS In Burkina Faso, high-risk women were recruited by peer educators in an open-cohort study with 4-monthly follow-up visits. Primary prevention included peer-led information, education and communication sessions, condom distribution, regular HIV counselling and testing, and sexually transmitted infections management. Participants were offered free medical care including antiretroviral therapy (ART) and treatment adherence support by psychologists. RESULTS From December 2003, 658 high-risk women were enrolled and followed up for a median 20.8 months. Seven of the 489 HIV-uninfected women seroconverted (HIV incidence 0.9 of 100 person-years, 95% confidence interval: 0.24 to 1.58). HIV incidence tended to be higher during the first 8 months of follow-up than thereafter (1.43 vs. 0.39 per 100 person-years). Among 47 of 169 HIV-seropositive women who started ART, 79.4% achieved undetectable plasma viral load 6 months after initiation and 81.8% at 36 months. Condom use at last sexual intercourse with clients increased from 81.7% at enrollment to 98.2% at 12 months (P < 0.001) and from 67.2% to 95.9% (P < 0.001) with regular clients. CONCLUSIONS The integration of HIV care services, including the provision and support of ART, with a peer-led primary prevention package is pivotal to reduce HIV incidence and is likely to modify the local HIV dynamics.
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Ramjee G. Antiretroviral-based microbicides and oral pre-exposure prophylaxis for HIV prevention. Future Virol 2011. [DOI: 10.2217/fvl.11.64] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Numerous HIV prevention options have been tested, with limited success. Microbicides have been the focus of research specifically targeted to prevent new infections among women. After decades of research using non-HIV-specific microbicides, we now have proof of concept for antiretroviral-based microbicides. Issues of drug resistance, frequency of HIV testing and adherence to treatment remain to be explored. Drugs used for HIV treatment and with good safety profiles have been shown to provide protection to men who have sex with men. Ethical issues surrounding cost, access, future design of HIV prevention trials and composition of the prevention package offered to trial participants remain. The role of advocacy and market research will be crucial to ensure effective interventions are accessed and supported. There is renewed hope in the HIV prevention field with collective efforts needed to ensure we get the new prevention tools and options into the hands of men and women at risk of HIV infection. The purpose of this paper is to provide a review of existing research and identify issues for future enquiry.
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Affiliation(s)
- Gita Ramjee
- HIV Prevention Research Unit, Medical Research Council, Durban, South Africa and Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
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High Human Immunodeficiency Virus Incidence in a Cohort of Rwandan Female Sex Workers. Sex Transm Dis 2011; 38:385-94. [DOI: 10.1097/olq.0b013e31820b8eba] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shepherd JP, Frampton GK, Harris P. Interventions for encouraging sexual behaviours intended to prevent cervical cancer. Cochrane Database Syst Rev 2011; 2011:CD001035. [PMID: 21491379 PMCID: PMC4040418 DOI: 10.1002/14651858.cd001035.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions. OBJECTIVES To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer. SEARCH STRATEGY Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria. SELECTION CRITERIA Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer). DATA COLLECTION AND ANALYSIS A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations. MAIN RESULTS A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting. AUTHORS' CONCLUSIONS Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.
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Affiliation(s)
- Jonathan P Shepherd
- University of SouthamptonSouthampton Health Technology Assessments Centre (SHTAC)1st Floor Epsilon HouseEnterprise Road, Southampton Science ParkChilworth, SouthamptonHampshireUKSO16 7NS
| | - Geoff K Frampton
- University of SouthamptonSouthampton Health Technology Assessments CentreFirst Floor, Epsilon House, Enterprise Road, Southampton Science Park, ChilworthSouthamptonHampshireUKSO16 7NS
| | - Petra Harris
- University of SouthamptonSouthampton Health Technology Assessments Centre (SHTAC)1st Floor Epsilon HouseEnterprise Road, Southampton Science ParkChilworth, SouthamptonHampshireUKSO16 7NS
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Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. PLoS Med 2011; 8:e1000416. [PMID: 21358808 PMCID: PMC3039685 DOI: 10.1371/journal.pmed.1000416] [Citation(s) in RCA: 188] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 01/05/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Identifying modifiable factors that increase women's vulnerability to HIV is a critical step in developing effective female-initiated prevention interventions. The primary objective of this study was to pool individual participant data from prospective longitudinal studies to investigate the association between intravaginal practices and acquisition of HIV infection among women in sub-Saharan Africa. Secondary objectives were to investigate associations between intravaginal practices and disrupted vaginal flora; and between disrupted vaginal flora and HIV acquisition. METHODS AND FINDINGS We conducted a meta-analysis of individual participant data from 13 prospective cohort studies involving 14,874 women, of whom 791 acquired HIV infection during 21,218 woman years of follow-up. Data were pooled using random-effects meta-analysis. The level of between-study heterogeneity was low in all analyses (I(2) values 0.0%-16.1%). Intravaginal use of cloth or paper (pooled adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.18-1.83), insertion of products to dry or tighten the vagina (aHR 1.31, 95% CI 1.00-1.71), and intravaginal cleaning with soap (aHR 1.24, 95% CI 1.01-1.53) remained associated with HIV acquisition after controlling for age, marital status, and number of sex partners in the past 3 months. Intravaginal cleaning with soap was also associated with the development of intermediate vaginal flora and bacterial vaginosis in women with normal vaginal flora at baseline (pooled adjusted odds ratio [OR] 1.24, 95% CI 1.04-1.47). Use of cloth or paper was not associated with the development of disrupted vaginal flora. Intermediate vaginal flora and bacterial vaginosis were each associated with HIV acquisition in multivariable models when measured at baseline (aHR 1.54 and 1.69, p<0.001) or at the visit before the estimated date of HIV infection (aHR 1.41 and 1.53, p<0.001), respectively. CONCLUSIONS This study provides evidence to suggest that some intravaginal practices increase the risk of HIV acquisition but a direct causal pathway linking intravaginal cleaning with soap, disruption of vaginal flora, and HIV acquisition has not yet been demonstrated. More consistency in the definition and measurement of specific intravaginal practices is warranted so that the effects of specific intravaginal practices and products can be further elucidated. Please see later in the article for the Editors' Summary.
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Hayes R, Watson-Jones D, Celum C, van de Wijgert J, Wasserheit J. Treatment of sexually transmitted infections for HIV prevention: end of the road or new beginning? AIDS 2010; 24 Suppl 4:S15-26. [PMID: 21042049 PMCID: PMC3827743 DOI: 10.1097/01.aids.0000390704.35642.47] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Observational and biological data provide compelling evidence of the importance of sexually transmitted infections (STIs) in HIV transmission, but only one of nine intervention trials has shown an effect. This article reviews the observational studies, critically examines the nine randomized controlled trials evaluating the impact of STI treatment interventions on HIV incidence, and discusses implications for HIV prevention policy, programs and future research. The role of other vaginal infections is also briefly considered. In aggregate, the evidence strongly supports the concept that STI treatment prevents HIV infection. However, issues in trial design and conduct, including HIV epidemic phase, STI prevalence, intervention in comparison groups, and power have affected five of the six trials of treatment of curable STIs. In the three herpes intervention trials, antivirals for HSV suppression were insufficiently potent to alleviate persistent genital inflammation in HIV-negative HSV2-positive persons, and the reduction in HIV levels in HIV-positive persons was insufficient to reduce HIV transmission. It is time for a new phase of exploration of how, when, and in whom to include STI control as a key component of HIV prevention, driven by basic research to elucidate the mechanisms by which STIs and vaginal infections facilitate HIV transmission. From a policy perspective, treatment of curable STIs is an essential part of primary healthcare and is a cheap, simple, and effective intervention when appropriately targeted and delivered. It should be promoted as an essential component of HIV control programs in communities in which the burden of STIs is substantial.
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Affiliation(s)
- Richard Hayes
- London School of Hygiene & Tropical Medicine, London, UK.
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Lafort Y, Geelhoed D, Cumba L, Lázaro CDDM, Delva W, Luchters S, Temmerman M. Reproductive health services for populations at high risk of HIV: Performance of a night clinic in Tete province, Mozambique. BMC Health Serv Res 2010; 10:144. [PMID: 20507644 PMCID: PMC2890643 DOI: 10.1186/1472-6963-10-144] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 05/28/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Different models exist to provide HIV/STI services for most-at-risk populations (MARP). Along the Tete traffic corridor in Mozambique, linking Malawi and Zimbabwe, a night clinic opening between 4 and 10 PM was established targeting female sex workers (FSW) and long-distance truck drivers (LDD). The clinic offers free individual education and counselling, condoms, STI care, HIV testing, contraceptive services and outreach peer education. To evaluate this clinic model, we assessed relevance, service utilisation, efficiency and sustainability. METHODS In 2007-2009, mapping and enumeration of FSW and LDD was conducted; 28 key informants were interviewed; 6 focus group discussions (FGD) were held with FSW from Mozambique and Zimbabwe, and LDD from Mozambique and Malawi. Clinic outputs and costs were analysed. RESULTS An estimated 4,415 FSW work in the area, or 9% of women aged 15-49, and on average 66 trucks stay overnight near the clinic. Currently on average, 475 clients/month visit the clinic (43% for contraception, 24% for counselling and testing and 23% for STI care). The average clinic running cost is US$ 1408/month, mostly for human resources. All informants endorsed this clinic concept and the need to expand the services. FGD participants reported high satisfaction with the services and mentioned good reception by the health staff, short waiting times, proximity and free services as most important. Participants were in favour of expanding the range of services, the geographical coverage and the opening times. CONCLUSIONS Size of the target population, satisfaction of clients and endorsement by health policy makers justify maintaining a separate clinic for MARP. Cost-effectiveness may be enhanced by broadening the range of SRHR-HIV/AIDS services, adapting opening times, expanding geographical coverage and targeting additional MARP. Long-term sustainability remains challenging and requires private-public partnerships or continued project-based funding.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, University Ghent, Ghent, Belgium.
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Vallely A, Hambleton IR, Kasindi S, Knight L, Francis SC, Chirwa T, Everett D, Shagi C, Cook C, Barberousse C, Watson-Jones D, Changalucha J, Ross D, Hayes RJ. Are women who work in bars, guesthouses and similar facilities a suitable study population for vaginal microbicide trials in Africa? PLoS One 2010; 5:e10661. [PMID: 20498833 PMCID: PMC2871045 DOI: 10.1371/journal.pone.0010661] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 04/20/2010] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND A feasibility study was conducted to investigate whether an occupational at-risk cohort of women in Mwanza, Tanzania are a suitable study population for future phase III vaginal microbicide trials. METHODOLOGY/PRINCIPAL FINDINGS 1573 women aged 16-54 y working in traditional and modern bars, restaurants, hotels, guesthouses or as local food-handlers were enrolled at community-based reproductive health clinics, provided specimens for HIV/STI and pregnancy testing, and asked to attend three-monthly clinical follow-up visits for 12-months. HIV positive and negative women were eligible to enter the feasibility study and to receive free reproductive health services at any time. HIV prevalence at baseline was 26.5% (417/1573). HIV incidence among 1156 sero-negative women attending at baseline was 2.9/100PYs. Among 1020 HIV sero-negative, non-pregnant women, HIV incidence was 2.0/100PYs, HSV-2 incidence 12.7/100PYs and pregnancy rate 17.8/100PYs. Retention at three-months was 76.3% (778/1020). Among 771 HIV sero-negative, non-pregnant women attending at three-months, subsequent follow-up at 6, 9 and 12-months was 83.7%, 79.6%, and 72.1% respectively. Older women, those who had not moved home or changed their place of work in the last year, and women working in traditional bars or as local food handlers had the highest re-attendance. CONCLUSIONS/SIGNIFICANCE Women working in food outlets and recreational facilities in Tanzania and other parts of Africa may be a suitable study population for microbicide and other HIV prevention trials. Effective locally-appropriate strategies to address high pregnancy rates and early losses to follow-up are essential to minimise risk to clinical trials in these settings.
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Affiliation(s)
- Andrew Vallely
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Padian NS, McCoy SI, Balkus JE, Wasserheit JN. Weighing the gold in the gold standard: challenges in HIV prevention research. AIDS 2010; 24:621-35. [PMID: 20179575 PMCID: PMC3695696 DOI: 10.1097/qad.0b013e328337798a] [Citation(s) in RCA: 169] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE(S) Few HIV prevention interventions have been evaluated in randomized controlled trials (RCTs). We examined design, implementation, and contextual considerations that may limit detection of a positive or adverse effect in HIV prevention trials. DESIGN A systematic review of late phase RCTs for prevention of sexual transmission of HIV that randomly allocated intervention and comparison groups; evaluated interventions to prevent sexual transmission in nonpregnant populations; and reported HIV incidence as the primary or secondary outcome. METHODS PubMed/MEDLINE, other electronic databases, and electronic conference proceedings of recent HIV/AIDS-related conferences were searched to identify published or unpublished trials meeting the inclusion criteria. Descriptive, methodological, and contextual factors were abstracted from each trial. RESULTS The review included 37 HIV prevention RCTs reporting on 39 unique interventions. Only six RCTs, all evaluating biomedical interventions, demonstrated definitive effects on HIV incidence. Five of the six RCTs significantly reduced HIV infection: all three male circumcision trials, one trial of sexually transmitted infection treatment and care, and one vaccine trial. One microbicide trial of nonoxynol-9 gel produced adverse results. Lack of statistical power, poor adherence, and diluted versions of the intervention in comparison groups may have been important issues for the other trials that demonstrated 'flat' results. CONCLUSION Almost 90% of HIV prevention trials had 'flat' results, which may be attributable to trial design and/or implementation. The HIV prevention community must not only examine evidence from significant RCTs, but must also examine flat trials and address design and implementation issues that limit detection of an effect.
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Affiliation(s)
- Nancy S Padian
- School of Public Health, University of California, Berkeley, California, USA.
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A study comparing sexually transmitted infections and HIV among ex-red-light district and non-red-light district sex workers after the demolition of Baina red-light district. J Acquir Immune Defic Syndr 2010; 52:253-7. [PMID: 19525855 DOI: 10.1097/qai.0b013e3181ab6d75] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In June 2004, the red-light area of Goa was demolished. We compare HIV and sexually transmitted infections (STIs) between sex workers who had been based in Baina red-light district (ex-RLD-SWs) with sex workers who had never worked in Baina (non-RLD-SWs). METHODS Three hundred twenty-six sex workers recruited using respondent-driven sampling, completed interviewer-administered questionnaires, and were tested for Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, and antibodies to HIV. The association between ever working in Baina red-light area and HIV and STIs was examined using multivariate analysis. RESULTS Non-RLD-SWs made up 55.3% (n = 201) of the sample, 48% of whom had entered sex work since the demolition. Non-RLD-SWs more likely to be less than 20 years old, Goan, have experienced sexual and intimate partner violence, to work part time, from home or the streets, and to have fewer clients. Ex-RLD-SWs were less likely to have curable STIs adjusted odds ratio of 0.27 (95% confidence interval: 0.10 to 0.73) and were more likely to have been exposed to HIV prevention and report consistent condom use with clients. CONCLUSIONS Non-RLD-SWs were more likely to be engaged in high-risk sexual activity. Although partly explained by lack of exposure to HIV prevention and inconsistent condom use, social and professional isolation and greater experience of intimate partner and sexual violence may play a role.
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Hilber AM, Francis SC, Chersich M, Scott P, Redmond S, Bender N, Miotti P, Temmerman M, Low N. Intravaginal practices, vaginal infections and HIV acquisition: systematic review and meta-analysis. PLoS One 2010; 5:e9119. [PMID: 20161749 PMCID: PMC2817741 DOI: 10.1371/journal.pone.0009119] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 01/07/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intravaginal practices are commonly used by women to manage their vaginal health and sexual life. These practices could, however, affect intravaginal mucosal integrity. The objectives of this study were to examine evidence for associations between: intravaginal practices and acquisition of HIV infection; intravaginal practices and vaginal infections; and vaginal infections and HIV acquisition. METHODOLOGY/PRINCIPAL FINDINGS We conducted a systematic review of prospective longitudinal studies, searching 15 electronic databases of journals and abstracts from two international conferences to 31(st) January 2008. Relevant articles were selected and data extracted in duplicate. Results were examined visually in forest plots and combined using random effects meta-analysis where appropriate. Of 2120 unique references we included 22 publications from 15 different studies in sub-Saharan Africa and the USA. Seven publications from five studies examined a range of intravaginal practices and HIV infection. No specific vaginal practices showed a protective effect against HIV or vaginal infections. Insertion of products for sex was associated with HIV in unadjusted analyses; only one study gave an adjusted estimate, which showed no association (hazard ratio 1.09, 95% confidence interval, CI 0.71, 1.67). HIV incidence was higher in women reporting intravaginal cleansing but confidence intervals were wide and heterogeneity high (adjusted hazard ratio 1.88, 95%CI 0.53, 6.69, I(2) 83.2%). HIV incidence was higher in women with bacterial vaginosis (adjusted effect 1.57, 95%CI 1.26, 1.94, I(2) 19.0%) and Trichomonas vaginalis (adjusted effect 1.64, 95%CI 1.28, 2.09, I(2) 0.0%). CONCLUSIONS/SIGNIFICANCE A pathway linking intravaginal cleaning practices with vaginal infections that increase susceptibility to HIV infection is plausible but conclusive evidence is lacking. Intravaginal practices do not appear to protect women from vaginal infections or HIV and some might be harmful.
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Affiliation(s)
| | - Suzanna C. Francis
- Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew Chersich
- Faculty of Medicine and Health Sciences, International Center for Reproductive Health, Ghent University, Ghent, Belgium
- Reproductive Health and HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Pippa Scott
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Shelagh Redmond
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicole Bender
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Paolo Miotti
- Office of AIDS Research, United States National Institutes of Health, Bethesda, Maryland, United States of America
| | - Marleen Temmerman
- Faculty of Medicine and Health Sciences, International Center for Reproductive Health, Ghent University, Ghent, Belgium
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- * E-mail:
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