Trends of human immunodeficiency virus type-1 infection in female prostitutes and males diagnosed with a sexually transmitted disease in Djibouti, east Africa

HIV epidemiology among female sex workers and their clients in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

BACKGROUND

HIV epidemiology among female sex workers (FSWs) and their clients in the Middle East and North Africa (MENA) region is poorly understood. We addressed this gap through a comprehensive epidemiological assessment.

METHODS

A systematic review of population size estimation and HIV prevalence studies was conducted and reported following PRISMA guidelines. Risk of bias (ROB) assessments were conducted for all included studies using various quality domains, as informed by Cochrane Collaboration guidelines. The pooled mean HIV prevalence was estimated using random-effects meta-analyses. Sources of heterogeneity and temporal trends were identified through meta-regressions.

RESULTS

We identified 270 size estimation studies in FSWs and 42 in clients, and 485 HIV prevalence studies in 287,719 FSWs and 69 in 29,531 clients/proxy populations. Most studies had low ROB in multiple quality domains. The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range = 0.2-2.4%) and of men reporting currently/recently buying sex was 5.7% (range = 0.3-13.8%). HIV prevalence ranged from 0 to 70% in FSWs (median = 0.1%) and 0-34.6% in clients (median = 0.4%). The regional pooled mean HIV prevalence was 1.4% (95% CI = 1.1-1.8%) in FSWs and 0.4% (95% CI = 0.1-0.7%) in clients. Country-specific pooled prevalence was < 1% in most countries, 1-5% in North Africa and Somalia, 17.3% in South Sudan, and 17.9% in Djibouti. Meta-regressions identified strong subregional variations in prevalence. Compared to Eastern MENA, the adjusted odds ratios (AORs) ranged from 0.2 (95% CI = 0.1-0.4) in the Fertile Crescent to 45.4 (95% CI = 24.7-83.7) in the Horn of Africa. There was strong evidence for increasing prevalence post-2003; the odds increased by 15% per year (AOR = 1.15, 95% CI = 1.09-1.21). There was also a large variability in sexual and injecting risk behaviors among FSWs within and across countries. Levels of HIV testing among FSWs were generally low. The median fraction of FSWs that tested for HIV in the past 12 months was 12.1% (range = 0.9-38.0%).

CONCLUSIONS

HIV epidemics among FSWs are emerging in MENA, and some have reached stable endemic levels, although still some countries have limited epidemic dynamics. The epidemic has been growing for over a decade, with strong regionalization and heterogeneity. HIV testing levels were far below the service coverage target of "UNAIDS 2016-2021 Strategy."

How important are venue-based HIV risks among male clients of female sex workers? A mixed methods analysis of the risk environment in nightlife venues in Tijuana, Mexico

In 2008, 400 males ≥18 years old who paid or traded for sex with a female sex worker (FSW) in Tijuana, Mexico, in the past 4 months completed surveys and HIV/STI testing; 30 also completed qualitative interviews. To analyze environmental sources of HIV vulnerability among male clients of FSWs in Tijuana, we used mixed methods to investigate correlates of clients who met FSWs in nightlife venues and clients' perspectives on venue-based HIV risk. Logistic regression identified micro-level correlates of meeting FSWs in nightlife venues, which were triangulated with clients' narratives regarding macro-level influences. In a multivariate model, offering increased pay for unprotected sex and binge drinking were micro-level factors that were independently associated with meeting FSWs in nightlife venues versus other places. In qualitative interviews, clients characterized nightlife venues as high risk due to the following macro-level features: social norms dictating heavy alcohol consumption; economic exploitation by establishment owners; and poor enforcement of sex work regulations in nightlife venues. Structural interventions in nightlife venues are needed to address venue-based risks.

Epidemiology of HIV infection in the Middle East and North Africa

OBJECTIVE

The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data, raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region.

METHODS

A comprehensive systematic review of HIV, sexually transmitted infections (STIs) and risk behavior studies in MENA, irrespective of design, was undertaken. Sources of data included Medline for peer-reviewed publications, Google Scholar for other scientific literature published in nonindexed local and regional journals, international organizations reports and databases, country-level reports and database including governmental and nongovernmental organizations publications, as well as various other institutional documents.

RESULTS

Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users, men who have sex with men (MSM) and to a lesser extent female sex workers, with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited.

CONCLUSION

Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.

Understanding the scourge of HIV/AIDS in sub-Saharan Africa

Sub-Saharan Africa is the part of the world that has been hit hardest by the HIV epidemic. To fight the spread of HIV in the continent, it is necessary to know and effectively address the factors that drive the spread of HIV. The purpose of this article is to review the factors associated with the spread of the HIV epidemic in sub-Saharan Africa and to propose 6 essential activities, which we refer to by the acronym "ESCAPER," to help curb the spread of HIV/AIDS in Africa.

Does increased general schooling protect against HIV infection? A study in four African cities

BACKGROUND

The association between educational attainment and risk of HIV infection varies between populations and over time. Earlier studies in sub-Saharan Africa have found that those with more education are at increased risk of HIV infection.

METHODS

We investigated the associations between general schooling and both HIV and herpes simplex-2 (HSV-2) infection using data from the multicentre study on factors determining the differential spread of HIV in four African cities. Cross-sectional general population studies were conducted in 1997-1998 in Cotonou (Benin), Yaoundé (Cameroon), Kisumu (Kenya), and Ndola (Zambia), including about 2000 adults in each city.

RESULTS

There was no association between schooling and HIV infection in men or women in Kisumu or Ndola. Women in Yaoundé and men in Cotonou, with more schooling, were less likely to be HIV positive. These associations persisted after adjusting for sociodemographic factors. Similar trends in men in Yaoundé and women in Cotonou were not statistically significant. Increased schooling was associated with significantly decreased risk of HSV-2 infection in women in Kisumu and Ndola and men in Cotonou. In all the cities those with more education tended to report less risky sexual behaviour.

CONCLUSIONS

There was no evidence of an increased risk of HIV infection associated with education as seen in earlier studies. In each city there was some evidence of lower HIV or HSV-2 infection rates and less risky sexual behaviour associated with increased education levels. The most educated may be responding more readily to health education programmes. The challenge is to extend this to the rest of the population.

Evolution and diversity of HIV-1 in Africa--a review

The HIV/AIDS pandemic represents a major development crisis for the African continent, which is the worst affected region in the world. Currently, almost 30 of the 42 million people infected with HIV worldwide live in Africa. AIDS in humans is caused by two lentiviruses, HIV-1 and HIV-2, which entered the human population by zoonotic transmissions from at least two different African primate species. Extensive phylogenetic analyses of partial and full-length genome sequences have helped to gain insights into the evolutionary biology and population dynamics of HIV. One of the major characteristics of HIV is its rapid evolution, which has resulted in substantial genetic diversity amongst different isolates, the majority of which are represented in Africa. Genetic variability of HIV and any consequent phenotypic variation poses a significant challenge to disease control and surveillance in different geographic regions of Africa. This review focuses on the origins and evolution of HIV, current classification and diversity of HIV isolates in Africa and provides an extensive account of the geographic distribution of HIV types, groups, and subtypes in each of the 49 African countries. Numerous epidemiological studies have provided a picture of HIV distribution patterns in most countries in Africa, and these show increasing evidence of the importance of HIV-1 recombinants. In particular, this review highlights that our current understanding of HIV distribution in Africa is incomplete and inadequately represents the diversity of the virus, and underscores the need for ongoing surveillance.

HIV infection and risk factors among female sex workers in southern Vietnam

OBJECTIVES

To determine the extent of HIV infection among female commercial sex workers (CSW), to identify risk factors, and to provide baseline data for developing and targeting prevention measures.

SUBJECTS AND METHODS

A total of 968 female CSW were enrolled in a cross-sectional study from August 1995 to October 1996. Information was obtained from confidential face-to-face interview, physical examination, and laboratory testing.

RESULTS

A total of 65.5% of female CSW reported inconsistent condom use. Overall seroprevalence was 5.2%. The highest seroprevalence (9.5%) was detected in An Giang province, a border area adjacent to Cambodia. Out of seven HIV isolates in An Giang province, six were characterized as Thai subtype E and one as subtype B. Multiple logistic regression analysis showed an independent significant association between HIV seroprevalence and the following: age < or = 30 years [odds ratio (OR), 5.1; 95% confidence interval (CI), 1.7-15.2]; high frequency of sex (> 20 times per week; OR, 13.5; 95% CI, 3.6-50.2); inconsistent condom use (OR, 2.8; 95% CI, 1.01-8.0; sign of genital ulcers (OR, 18.1; 95% CI, 1.8-182); venereal warts (OR, 9.0; 95% CI, 2.5-33.0); brothels as sex venue (OR, 7.0; 95% CI, 2.0-24.3); and working at the border area (OR, 5.1; 95% CI, 2.4-11.0). Brothels as work-sites were significantly related to inconsistent condom use and the socioeconomic background of clients. Only 0.5% of CSW reported injecting drug use.

CONCLUSIONS

Female CSW at brothels who reported inconsistent condom use and ulcerous sexually transmitted disease, particularly in the border area with Cambodia, had greater risk of HIV infection. Brothels were more frequently used as sex venues in the border area and were more likely to be visited by occasional clients who were difficult to access. Drug use among female CSW in this region was rare. The development of prevention measures should be based on these results.

Comparative field evaluation of HIV rapid diagnostic assays using serum, urine, and oral mucosal transudate specimens

BACKGROUND

Comparative field utility of selected HIV-1 assays using homologous collections of serum, urine and oral mucosal transudate (OMT) was determined in adult populations from a tuberculosis hospital and STD clinic in Djibouti, East Africa.

STUDY DESIGN

Enzyme immunoassay with confirmatory Western blot was performed on all serum specimens for comparison with rapid, instrument-free assays (SUDS HIV-1, Murex: TestPack HIV-1/2. Abbott; and COMBAIDS HIV 1 + 2, SPAN Diagnostics) using various specimen sources. Delayed (48 h post-collection) testing was also performed on urine. Sensitivity and specificity for the rapid assays, in descending order, were as follows: serum SUDS HIV-1 assay (100%, 98.3%), serum COMBAIDS HIV-1/2 assay (98.4%, 99.6%), and OMT SUDS HIV-1 assay (98.4%, 94.5%).

RESULTS

The OMT EIA optical density cutoff value was modified resulting in an improved specificity from 89.1 to 99.6%, however, sensitivity decreased from 100 to 98.5%. Urine EIA and rapid assays demonstrated unacceptable test performance for use as a screening test.