A nested case-control study of sexual practices and risk factors for prevalent HIV-1 infection among young men in Kisumu, Kenya

Application of the matched nested case-control design to the secondary analysis of trial data

BACKGROUND

A nested case-control study is an efficient design that can be embedded within an existing cohort study or randomised trial. It has a number of advantages compared to the conventional case-control design, and has the potential to answer important research questions using untapped prospectively collected data.

METHODS

We demonstrate the utility of the matched nested case-control design by applying it to a secondary analysis of the Abnormal Doppler Enteral Prescription Trial. We investigated the role of milk feed type and changes in milk feed type in the development of necrotising enterocolitis in a group of 398 high risk growth-restricted preterm infants.

RESULTS

Using matching, we were able to generate a comparable sample of controls selected from the same population as the cases. In contrast to the standard case-control design, exposure status was ascertained prior to the outcome event occurring and the comparison between the cases and matched controls could be made at the point at which the event occurred. This enabled us to reliably investigate the temporal relationship between feed type and necrotising enterocolitis.

CONCLUSIONS

A matched nested case-control study can be used to identify credible associations in a secondary analysis of clinical trial data where the exposure of interest was not randomised, and has several advantages over a standard case-control design. This method offers the potential to make reliable inferences in scenarios where it would be unethical or impractical to perform a randomised clinical trial.

Voluntary Medical Male Circumcision and Perceived Sexual Functioning, Satisfaction, and Risk Behavior: A Qualitative Study in Botswana

This article examines perceptions of sexual functioning, satisfaction, and risk-taking related to voluntary medical male circumcision (VMMC) in Botswana. Twenty-seven focus group discussions were conducted in four purposively selected communities with community leaders, men, and women. Discussions were analyzed using an inductive content analytic approach. Perceptions of VMMC's impact on sexual functioning and satisfaction varied. Increased satisfaction was attributed to improved penile health and increased ejaculatory latency time, whereas decreased satisfaction was attributed to erectile dysfunction and increased vaginal irritation during sex. Most participants thought sexual disinhibition occurred after circumcision; nevertheless, some women said they used male circumcision status as a marker of HIV status, thereby influencing sexual decision-making and partner selection. Messaging should emphasize that VMMC does not afford complete HIV protection. Optimizing VMMC's impact requires increasing uptake while minimizing behavioral disinhibition, with a balance between potential messaging of improved sexual functioning and satisfaction and the potential impact on sexual disinhibition.

Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population, 2008-2013

BACKGROUND

Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors.

METHODS

Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference.

RESULTS

The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception.

CONCLUSIONS

The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.

Transactional sex and risk for HIV infection in sub-Saharan Africa: a systematic review and meta-analysis

INTRODUCTION

Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women's heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesized. We set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarize the findings through a meta-analysis.

METHODS

The search strategy included 8 databases, hand searches in 10 journals, and searches across 17 websites and portals for organizations as informed by expert colleagues. A systematic review of cross-sectional and longitudinal studies was carried out for studies on women and men who engage in transactional sex published up through 2014. Random effects meta-analysis was used to further examine the relationship between transactional sex and prevalent HIV infection across a subset of studies with the same exposure period. Analyses were conducted separately for men and women.

RESULTS

Nineteen papers from 16 studies met our inclusion criteria. Of these 16 studies, 14 provided data on women and 10 on men. We find a significant, positive, unadjusted or adjusted association between transactional sex and HIV in 10 of 14 studies for women, one of which used a longitudinal design (relative risk (RR)=2.06, 95% confidence interval (CI): 1.22 -3.48). Out of 10 studies involving men, only 2 indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. The meta-analysis confirmed general findings from the systematic review (unadjusted meta-analysis findings are significant for women (n=4; pooled odds ratio (OR)=1.54, 95% CI: 1.04-2.28; I2=42.5%, p=0.156), but not for men (n=4; pooled OR=1.47, 95% CI: 0.85-2.56; I2=50.8%, p=0.107).

CONCLUSIONS

Transactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the causal pathways between transactional sex and HIV.

Young Men's Social Network Characteristics and Associations with Sexual Partnership Concurrency in Tanzania

Social network influence on young people's sexual behavior is understudied in sub-Saharan Africa. Previous research identified networks of mostly young men in Dar es Salaam who socialize in "camps". This study describes network characteristics within camps and their relationship to young men's concurrent sexual partnerships. We conducted surveys with a nearly complete census of ten camp networks (490 men and 160 women). Surveys included name generators to identify camp-based networks. Fifty seven percent of sexually active men (n = 471) reported past year concurrency, measured using the UNAIDS method. In a multivariable model, men's individual concurrency was associated with being a member of a closer knit camp in which concurrency was the normative behavior. Younger men who had older members in their networks were more likely to engage in concurrency. Respondent concurrency was also associated with inequitable personal gender norms. Our findings suggest strategies for leveraging social networks for HIV prevention among young men.

Characteristics and quantities of HIV host cells in human genital tract secretions

Human immunodeficiency virus (HIV)-infected leukocytes have been detected in genital secretions from HIV-infected men and women and may play an important role in the sexual transmission of HIV. However, they have been largely overlooked in studies on mechanisms of HIV transmission and in the design and testing of HIV vaccine and microbicide candidates. This article describes the characteristics and quantities of leukocytes in male and female genital secretions under various conditions and also reviews evidence for the involvement of HIV-infected cells in both horizontal and vertical cell-associated HIV transmission. Additional research is needed in this area to better target HIV prevention strategies.

Measuring prevalence and correlates of concurrent sexual partnerships among young sexually active men in Kisumu, Kenya

Our objectives were to: (1) compare multiple measures of partnership concurrency, including the UNAIDS-recommended definition and (2) describe the prevalence and correlates of concurrent sexual partnerships among young Kenyan men. We analyzed 10,907 lifetime partnerships of 1,368 men ages 18-24 years enrolled in a randomized trial of male circumcision to reduce HIV-1 incidence in Kisumu. Partnership concurrency was determined by overlapping dates and examined over varying recall periods and assumptions. The lifetime prevalence of concurrency was 77 %. Sixty-one percent of all partnerships were concurrent and factors associated with concurrency differed by partner type. Point prevalence of concurrency at the time of the interview was consistently the highest and UNAIDS-recommended definition was the most conservative (25 vs. 18 % at baseline, respectively). Estimates of concurrency were influenced by methods for definition and measurement. Regardless of definition, concurrent partnerships are frequent in this population of young, sexually active men in high HIV prevalence Kisumu, Kenya.

From coitus to concurrency: sexual partnership characteristics and risk behaviors of 15-19 year old men recruited from urban venues in Tanzania

Understanding the uptake and patterns of sexual partnerships of adolescent males reveals their risky behaviors that could persist into adulthood. Using venue-based sampling, we surveyed 671 male youth ages 15-19 from an urban Tanzanian neighborhood about their sexual partnerships during the past 6 months. The proportion of males who had ever had sex increased with age (21 % at age 15; 70 % at age 17; 94 % at age 19), as did the proportion who engaged in concurrency (5 % at age 15; 28 % at age 17; 44 % at age 19). Attendance at ≥2 social venues per day and meeting a sexual partner at a venue was associated with concurrency. Concurrency was associated with alcohol consumption before sex among 18-19 year olds and with not being in school among 15-17 year olds. We find that concurrency becomes normative over male adolescence. Venue-based sampling may reach youth vulnerable to developing risky sexual partnership patterns.

Intravaginal practices and microbicide acceptability in Papua New Guinea: implications for HIV prevention in a moderate-prevalence setting

BACKGROUND

The acceptability of female-controlled biomedical prevention technologies has not been established in Papua New Guinea, the only country in the Pacific region experiencing a generalised, moderate-prevalence HIV epidemic. Socio-cultural factors likely to impact on future product uptake and effectiveness, such as women's ability to negotiate safer sexual choices, and intravaginal hygiene and menstrual practices (IVP), remain unclear in this setting.

METHODS

A mixed-method qualitative study was conducted among women and men attending a sexual health clinic in Port Moresby. During in-depth interviews, participants used copies of a hand-drawn template to indicate how they wash/clean the vulva and/or vagina. Interviewers pre-filled commercially available vaginal applicators with 2-3mL KY Jelly® to create a surrogate vaginal microbicide product, which was demonstrated to study participants.

RESULTS

A total of 28 IDIs were conducted (women=16; men=12). A diverse range of IVP were reported. The majority of women described washing the vulva only with soap and water as part of their daily routine; in preparation for sex; and following sexual intercourse. Several women described cleaning inside the vagina using fingers and soap at these same times. Others reported cleaning inside the vagina using a hose connected to a tap; using vaginal inserts, such as crushed garlic; customary menstrual 'steaming' practices; and the use of material fragments, cloth and newspaper to absorb menstrual blood. Unprotected sex during menstruation was common. The majority of both women and men said that they would use a vaginal microbicide gel for HIV/STI protection, should a safe and effective product become available. Microbicide use was considered most appropriate in 'high-risk' situations, such as sex with non-regular, transactional or commercial partners. Most women felt confident that they would be able to negotiate vaginal microbicide use with male sexual partners but if necessary would be prepared to use product covertly.

CONCLUSIONS

Notional acceptability of a vaginal microbicide gel for HIV/STI prevention was high among both women and men. IVP were diverse in nature, socio-cultural dimensions and motivators. These factors are likely to impact on the future acceptability and uptake of vaginal microbicides and other biomedical HIV prevention technologies in this setting.

Variation in concurrent sexual partnerships and sexually transmitted diseases among African men in Cape Town, South Africa

BACKGROUND

Most studies that assess the relationship between concurrent sexual partnerships and sexually transmitted diseases (STDs) use dichotomous measures of whether concurrency was reported or not. However, different forms of concurrency have different degrees of associated risk for disease transmission, and this should be considered. This article examines variation in both individual concurrency and partner concurrency among African men in Cape Town, South Africa, and assesses the relationship between different types of concurrent partnerships and STDs.

METHODS

Longitudinal data from sexual partner history tables are used to form measures of concurrency and the type of partner (main vs. nonmain) and degree of condom use (consistent vs. inconsistent) associated with these concurrent relationships. Cross-sectional data from a self-administered module are also used to assess the number of partners men have had concurrently and duration of individual concurrency. Probit regression models assess the association between the partner concurrency measures and self-reported STD history.

RESULTS

Substantial differences between concurrent sexual partnerships were observed and these variations were associated with different disease risk. Men had a greater chance of reporting an STD when partner concurrency was associated with main partners and inconsistent condom use.

CONCLUSION

Partnership dynamics must be taken into account in studies assessing the role of concurrency in STD transmission.

Molecular epidemiology of HIV-1 transmission in a cohort of HIV-1 concordant heterosexual couples from Dakar, Senegal

Background

A large number of HIV-1 infections in Africa occur in married couples. The predominant direction of intracouple transmission and the principal external origins of infection remain important issues of debate.

Methods

We investigated HIV-1 transmission in 46 HIV-1 concordant positive couples from Dakar, Senegal. Intracouple transmission was confirmed by maximum-likelihood phylogenetic analysis and pairwise distance comparisons of HIV-1 env gp41 sequences from both partners. Standardized interview data were used to deduce the direction as well as the external sources of the intracouple transmissions.

Results

Conservative molecular analyses showed linked viruses in 34 (74%) couples, unlinked viruses in 6 (13%) couples, and indeterminate results for 6 (13%) couples. The interview data corresponded completely with the molecular analyses: all linked couples reported internal transmission and all unlinked couples reported external sources of infection. The majority of linked couples (93%) reported the husband as internal source of infection. These husbands most frequently (82%) reported an occasional sexual relationship as external source of infection. Pairwise comparisons of the CD4 count, antiretroviral therapy status, and the proportion of gp41 ambiguous base pairs within transmission pairs correlated with the reported order of infection events.

Conclusions

In this suburban Senegalese population, a majority of HIV-1 concordant couples showed linked HIV-1 transmission with the husband as likely index partner. Our data emphasize the risk of married women for acquiring HIV-1 as a result of the occasional sexual relationships of their husbands.

The psychosocial determinants of the intention to reduce the number of sexual partners among recent traditionally initiated and circumcized men in the Eastern Cape Province, South Africa

This study focuses on the factors associated with the intention to reduce the number of sexual partners. An individual face-to-face interview was used to collect data amongst 2337 traditionally initiated and circumcized men in the rural areas of Eastern Cape Province, South Africa. About 55.5% reported having a main sexual partner and of those 41.4% indicated having other sexual partners. The strongest association with intention was found for self-efficacy towards having one sexual partner, which accounted for almost 49% of the variance. These findings provide specific information for the development of a focused cultural sensitive STI/HIV prevention programme in sexually active young men, which can be integrated into the initiation and health education practices.

Social Exchange and Sexual Behavior in Young Women's Premarital Relationships in Kenya

Transactional sex, or the exchange of money and gifts for sexual activities within nonmarital relationships, has been widely considered a contributing factor to the disproportionate prevalence of HIV/AIDS among young women in sub-Saharan Africa. This study applied social exchange theory to premarital relationships in order to investigate the linkages between a variety of young women's resources-including employment and material transfers from male partners-and sexual behaviors. Data on the first month of premarital relationships (N=551 relationships) were collected from a random sample of young adult women ages 18-24 in Kisumu, Kenya, using a retrospective life history calendar. Consistent with the hypotheses, results showed that young women's income increases the likelihood of safer sexual activities, including delaying sex and using condoms consistently. Material transfers from the male partner displayed the opposite effect, supporting the view that resources obtained from within the relationship decrease young women's negotiating power.

Circumcision preference among women and uncircumcised men prior to scale-up of male circumcision for HIV prevention in Kisumu, Kenya

Following the endorsement by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) of male circumcision as an additional strategy to HIV prevention, initiatives to introduce safe, voluntary medical male circumcision (VMMC) services commenced in 2008 in several sub-Saharan African communities. Information regarding perceptions of circumcision as a method of HIV prevention, however, is largely limited to data collected before this important endorsement and the associated increase in the availability of VMMC services. To address this, we completed a community-based survey of male circumcision (MC) perceptions in the major non-circumcising community in Kenya, which is the current focus of VMMC programs in the country. Data was collected between November 2008 and April 2009, immediately before VMMC program scale-up commenced. Here we present results limited to women (n = 1088) and uncircumcised males (n = 460) to provide insight into factors contributing to the acceptability and preference for MC in those targeted by VMMC programs. Separate multivariable models examining preference for circumcision were defined for married men, unmarried men, and women. Belief in the protective effect of circumcision on HIV risk was strongly associated with preference for MC in all models. Other important factors included education, perceived improvement in sexual pleasure, and perceptions of impact on condom utilization. Identified barriers to circumcision were the belief that circumcision was not part of the local culture, the perception of a long healing period following the procedure, the lack of a specific impetus to seek out services, and the general fear of pain associated with becoming circumcised. A minority of participants expressed beliefs suggesting that behavioral risk compensation with increased MC prevalence and awareness is a possibility. This work describes the early impact of a large-scale VMMC program on beliefs and behaviors regarding MC and HIV risk. It is hoped that our findings may offer guidance into anticipating potential impacts that similar programs may observe in populations throughout Eastern Africa.

Concurrent sexual partnerships among youth in urban Kenya: Prevalence and partnership effects

Research on concurrent sexual partnerships is hindered by lack of accurate partnership data. Using unique life-history calendar data from a population-based sample of youths aged 18-24 in urban Kenya, we estimated the prevalence and correlates of concurrency. In the sixth month before the survey, 3.5 per cent of females and 4.0 per cent of males were engaged in concurrent sexual partnerships. In the previous 9.5 years, males experienced more concurrent partnerships than females and they were of shorter duration. Using survival analysis, we find that the characteristics of initial partnerships affect entry into a second (concurrent) relationship. For females, geographic separation from a partner increases the risk of concurrency, while concurrency is positively associated with the duration of the initial relationship for males. For both sexes, the perception of partner infidelity increases the risk, suggesting that concurrency expands individuals' sexual networks and bridges additional networks involving partners' other sexual partners.

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

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

Timing is everything: international variations in historical sexual partnership concurrency and HIV prevalence

BACKGROUND

Higher prevalence of concurrent partnerships is one hypothesis for the severity of the HIV epidemic in the countries of Southern Africa. But measures of the prevalence of concurrency alone do not adequately capture the impact concurrency will have on transmission dynamics. The importance of overlap duration and coital exposure are examined here.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a comparison of data from three studies of sexual behavior carried out in the early 1990s in Uganda, Thailand and the US. Using cumulative concurrency measures, the three countries appeared somewhat similar. Over 50% of both Thai and Ugandan men reported a concurrency within the last three partnerships and over 20% reported a concurrency in the last year, the corresponding rates among US men were nearly 20% for Blacks and Hispanics, and about 10% for other racial/ethnic groups. Concurrency measures that were more sensitive to overlap duration, however, showed large differences. The point prevalence of concurrency on the day of interview was over 10% among Ugandan men compared to 1% for Thai men. Ugandan concurrencies were much longer duration - a median of about two years - than either the Thai (1 day) or US concurrencies (4-9 months across all groups), and involved 5-10 times more coital risk exposure with the less frequent partner. In the US, Blacks and Hispanics reported higher prevalence, longer duration and greater coital exposure than Whites, but were lower than Ugandans on nearly every measure. Together, the differences in the prevalence, duration and coital exposure of concurrent partnerships observed align with the HIV prevalence differentials seen in these populations at the time the data were collected.

CONCLUSIONS/SIGNIFICANCE

There were substantial variations in the patterns of concurrent partnerships within and between populations. More long-term overlapping partnerships, with regular coital exposure, were found in populations with greater HIV epidemic severity.

Prevalence and risk factors for sexually transmitted infections in a high-risk occupational group: the case of fishermen along Lake Victoria in Kisumu, Kenya

The aim of this study was to assess prevalence and risk factors for sexually transmitted infections (STIs) among fishermen along Lake Victoria, Kenya. This cross-sectional study surveyed 250 fishermen from beaches in Kisumu District using proportional-to-size sampling based on the number of registered boats per beach. Participants provided demographic and sexual behaviour information, blood for HIV-1 herpes simplex virus type 2 (HSV-2) and syphilis serological tests urine for transcription-mediated amplification assays for Neisseria gonorrhoeae and Chlamydia trachomatis and penile and scrotal swabs for human papillomavirus (HPV) DNA assay. Consistent condom use with the three most recent sexual partners was reported by 30%; 38% reported concurrent sexual partnerships and 65% reported ever having transactional sex. HIV seroprevalence was 26%, HSV-2 seroprevalence by Western blot assay was 58% and 9.5% were rapid plasma reagin and Treponema pallidum particle agglutination assay positive. Genital HPV DNA of any type was detected in 57.2% with 74% of these having two or more HPV types. C. trachomatis and N. gonorrhoeae were detected in 3.2% and 1.2% respectively. Risk factors for syphilis seropositivity included working on multiple beaches during the past year (adjusted odds ratio [AOR] 3.81; 95% confidence interval [CI] 1.29–11.28). HPV infection was associated with owning a radio which is a marker for higher socioeconomic status (AOR 6.33; 95% CI 2.94–7.14) and reporting transactional sex with the most recent sexual partner (AOR 3.03; 95% CI 1.23–7.69). In conclusion, 90% of fishermen had evidence of one or more STIs. This exceptionally high-risk occupational group represents a high priority for preventive interventions.

Concurrent sexual partnerships do not explain the HIV epidemics in Africa: a systematic review of the evidence

The notion that concurrent sexual partnerships are especially common in sub-Saharan Africa and explain the region's high HIV prevalence is accepted by many as conventional wisdom. In this paper, we evaluate the quantitative and qualitative evidence offered by the principal proponents of the concurrency hypothesis and analyze the mathematical model they use to establish the plausibility of the hypothesis.We find that research seeking to establish a statistical correlation between concurrency and HIV prevalence either finds no correlation or has important limitations. Furthermore, in order to simulate rapid spread of HIV, mathematical models require unrealistic assumptions about frequency of sexual contact, gender symmetry, levels of concurrency, and per-act transmission rates. Moreover, quantitative evidence cited by proponents of the concurrency hypothesis is unconvincing since they exclude Demographic and Health Surveys and other data showing that concurrency in Africa is low, make broad statements about non-African concurrency based on very few surveys, report data incorrectly, report data from studies that have no information about concurrency as though they supported the hypothesis, report incomparable data and cite unpublished or unavailable studies. Qualitative evidence offered by proponents of the hypothesis is irrelevant since, among other reasons, there is no comparison of Africa with other regions.Promoters of the concurrency hypothesis have failed to establish that concurrency is unusually prevalent in Africa or that the kinds of concurrent partnerships found in Africa produce more rapid spread of HIV than other forms of sexual behaviour. Policy makers should turn attention to drivers of African HIV epidemics that are policy sensitive and for which there is substantial epidemiological evidence.

Fishermen as a Suitable Population for HIV Intervention Trials

Background. Suitable populations to sustain continued evaluation of HIV and sexually transmitted infection (STI) prevention interventions are required. We sought to determine whether fishermen are a suitable population for HIV intervention trials. Methods. In a cross-sectional descriptive survey, we selected 250 fishermen from proportional to size sampled boats. We collected socioeconomic and behavioral information, and specimens for HIV, herpes simplex virus (HSV-2), syphilis, gonorrhea, chlamydia and human papillomavirus (HPV) tests from consenting participants. Results. One third of the fishermen had concurrent sexual partnerships and two thirds were involved in transactional sex. About 70% were involved in extramarital sex with only one quarter using condoms in their three most recent sexual encounters. HIV prevalence was 26% and HSV-2 and HPV was 57%. Over 98% were willing to participate in a future HIV prevention clinical trial. Conclusion. Fishermen are a high-risk group for HIV/STI infections that may be suitable for HIV prevention trials. A cohort study would be useful to measure the incidence of HIV/STIs to ultimately determine the feasibility of enrolling this population in an HIV/STI prevention clinical trial.

Concurrent sexual partnerships and the HIV epidemics in Africa: evidence to move forward

The role of concurrent sexual partnerships is increasingly recognized as important for the transmission of sexually transmitted infections, particularly of heterosexual HIV transmission in Africa. Modeling and empirical evidence suggest that concurrent partnerships-compared to serial partnerships-can increase the size of an HIV epidemic, the speed at which it infects a population, and its persistence within a population. This selective review of the published and unpublished literature on concurrent partnerships examines various definitions and strategies for measuring concurrency, the prevalence of concurrency from both empirical and modeling studies, the biological plausibility of concurrency, and the social and cultural underpinnings of concurrency in southern Africa.

Scaling sexual behavior or "sexual risk propensity" among men at risk for HIV in Kisumu, Kenya

We present a scale to measure sexual risk behavior or "sexual risk propensity" to evaluate risk compensation among men engaged in a randomized clinical trial of male circumcision. This statistical approach can be used to represent each respondent's level of sexual risk behavior as the sum of his responses on multiple dichotomous and rating scale (i.e. ordinal) items. This summary "score" can be used to summarize information on many sexual behaviors or to evaluate changes in sexual behavior with respect to an intervention. Our 18 item scale demonstrated very good reliability (Cronbach's alpha of 0.87) and produced a logical, unidimensional continuum to represent sexual risk behavior. We found no evidence of differential item function at different time points (except for reporting a concurrent partners when comparing 6 and 12 month follow-up visits) or with respect to the language with which the instrument was administered. Further, we established criterion validity by demonstrating a statistically significant association between the risk scale and the acquisition of incident sexually transmitted infections (STIs) at the 6 month follow-up and HIV at the 12 month follow-up visits. This method has broad applicability to evaluate sexual risk behavior in the context of other HIV and STI prevention interventions (e.g. microbicide or vaccine trials), or in response to treatment provision (e.g., anti-retroviral therapy).

Adult male circumcision does not reduce the risk of incident Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis infection: results from a randomized, controlled trial in Kenya

BACKGROUND

We examined the effect of male circumcision on the acquisition of 3 nonulcerative sexually transmitted infections (STIs).

METHODS

We evaluated the incidence of STI among men aged 18-24 years enrolled in a randomized trial of circumcision to prevent human immunodeficiency virus (HIV) infection in Kisumu, Kenya. The outcome was first incident nonulcerative STI during 2 years of follow-up. STIs examined were laboratory-detected Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis infection.

RESULTS

There were 342 incident infections among 2655 men followed up. The incidences of infection due to N. gonorrhoeae, C. trachomatis, and T. vaginalis were 3.48, 4.55, and 1.32 cases per 100 person-years, respectively. The combined incidence of N. gonorrhoeae and C. trachomatis infection was 7.26 cases per 100 person-years (95% confidence interval, 6.49-8.13 cases per 100 person-years). The incidences of these STIs, individually or combined, did not differ by circumcision status as a time-dependent variable or a fixed variable based on assignment. Risks for incident STIs in multivariate analysis included an STI at enrollment, multiple sex partners within <30 days, and sexual intercourse during menses in the previous 6 months; condom use was protective.

CONCLUSIONS

Circumcision of men in this population did not reduce their risk of acquiring these nonulcerative STIs. Improved STI control will require more-effective STI management, including partner treatment and behavioral risk reduction counseling.

Men who have sex with men and HIV/AIDS in sub-Saharan Africa

Globally, men who have sex with men (MSM) continue to bear a high burden of HIV infection. In sub-Saharan Africa, same-sex behaviours have been largely neglected by HIV research up to now. The results from recent studies, however, indicate the widespread existence of MSM groups across Africa, and high rates of HIV infection, HIV risk behaviour, and evidence of behavioural links between MSM and heterosexual networks have been reported. Yet most African MSM have no safe access to relevant HIV/AIDS information and services, and many African states have not begun to recognise or address the needs of these men in the context of national HIV/AIDS prevention and control programmes. The HIV/AIDS community now has considerable challenges in clarifying and addressing the needs of MSM in sub-Saharan Africa; homosexuality is illegal in most countries, and political and social hostility are endemic. An effective response to HIV/AIDS requires improved strategic information about all risk groups, including MSM. The belated response to MSM with HIV infection needs rapid and sustained national and international commitment to the development of appropriate interventions and action to reduce structural and social barriers to make these accessible.

Exploratory study of blood exposures that are risks for HIV among Luo and Kisii ethnic groups in Nyanza province, Kenya

Adult HIV prevalence exceeds 5% among all Kenyans, and 20% among the Luo ethnic group. Recent studies have associated HIV infections in Kenya with several invasive health care and cosmetic procedures. To explore the various blood exposures that could contribute to HIV infections in Kenya, we surveyed 320 adolescents and adults aged 15-29 years from the Luo and Kisii ethnic groups. Survey participants reported a wide range of invasive procedures in health care (including circumcisions, dental care, blood tests, and 1-60 injections or infusions for specific health problems), in cosmetic services (including tattooing and piercing) and around the home (through shaving body hair, fights, sports and other activities). Luo were significantly more likely than Kisii to report some risks (e.g. tattooing by a traditional expert, piercing), but less likely to report others (e.g. blood tests for malaria, anaesthetic injections during circumcision).

Denialism undermines AIDS prevention in sub-Saharan Africa

Some denialists, widely reviled, contend that HIV does not cause AIDS. Other denialists, widely respected, contend that HIV transmits so poorly through trace blood exposures that iatrogenic infections are rare. This second group of denialists has had a corrosive effect on public health and HIV programmes in sub-Saharan Africa. Guided by this second group of denialists, no African government has investigated unexplained HIV infections. Denialists have withheld and ignored research findings showing that non-sexual risks account for substantial proportions of HIV infections in Africa. Denialists have promoted invasive procedures for HIV prevention in Africa--injections for sexually transmitted infections, and adult male circumcision--without addressing unreliable sterilization of reused instruments. By denying that health care causes more than rare infections, denialists blame (stigmatize) HIV-positive African adults for causing their own infections through sexual behaviour. Denialism must be overcome to ensure safe health care and to combat HIV-related stigma in Africa.

Risk compensation is not associated with male circumcision in Kisumu, Kenya: a multi-faceted assessment of men enrolled in a randomized controlled trial

Background

Three randomized controlled trials (RCTs) have confirmed that male circumcision (MC) significantly reduces acquisition of HIV-1 infection among men. The objective of this study was to perform a comprehensive, prospective evaluation of risk compensation, comparing circumcised versus uncircumcised controls in a sample of RCT participants.

Methods and Findings

Between March 2004 and September 2005, we systematically recruited men enrolled in a RCT of MC in Kenya. Detailed sexual histories were taken using a modified Timeline Followback approach at baseline, 6, and 12 months. Participants provided permission to obtain circumcision status and laboratory results from the RCT. We evaluated circumcised and uncircumcised men's sexual behavior using an 18-item risk propensity score and acquisition of incident infections of gonorrhea, chlamydia, and trichomoniasis. Of 1780 eligible RCT participants, 1319 enrolled (response rate = 74%). At the baseline RCT visit, men who enrolled in the sub-study reported the same sexual behaviors as men who did not. We found a significant reduction in sexual risk behavior among both circumcised and uncircumcised men from baseline to 6 (p<0.01) and 12 (p = 0.05) months post-enrollment. Longitudinal analyses indicated no statistically significant differences between sexual risk propensity scores or in incident infections of gonorrhea, chlamydia, and trichomoniasis between circumcised and uncircumcised men. These results are based on the most comprehensive analysis of risk compensation yet done.

Conclusion

In the context of a RCT, circumcision did not result in increased HIV risk behavior. Continued monitoring and evaluation of risk compensation associated with circumcision is needed as evidence supporting its' efficacy is disseminated and MC is widely promoted for HIV prevention.