A research and development (R&D) roadmap for broadly protective coronavirus vaccines: A pandemic preparedness strategy

Broadly protective coronavirus vaccines are an important tool for protecting against future SARS-CoV-2 variants and could play a critical role in mitigating the impact of future outbreaks or pandemics caused by novel coronaviruses. The Coronavirus Vaccines Research and Development (R&D) Roadmap (CVR) is aimed at promoting the development of such vaccines. The CVR, funded by the Bill & Melinda Gates Foundation and The Rockefeller Foundation, was generated through a collaborative and iterative process, which was led by the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota and involved 50 international subject matter experts and recognized leaders in the field. This report summarizes the major issues and areas of research outlined in the CVR and identifies high-priority milestones. The CVR covers a 6-year timeframe and is organized into five topic areas: virology, immunology, vaccinology, animal and human infection models, and policy and finance. Included in each topic area are key barriers, gaps, strategic goals, milestones, and additional R&D priorities. The roadmap includes 20 goals and 86 R&D milestones, 26 of which are ranked as high priority. By identifying key issues, and milestones for addressing them, the CVR provides a framework to guide funding and research campaigns that promote the development of broadly protective coronavirus vaccines.

High HIV incidence among young women in South Africa: Data from a large prospective study

Introduction

South Africa has the highest national burden of HIV globally. Understanding drivers of HIV acquisition in recently completed, prospective studies in which HIV was an endpoint may help inform the strategy and investments in national HIV prevention efforts and guide the design of future HIV prevention trials. We assessed HIV incidence and correlates of incidence among women enrolled in ECHO (Evidence for Contraceptive Options and HIV Outcomes), a large, open-label randomized clinical trial that compared three highly effective. reversible methods of contraception and rates of HIV acquisition.

Methods

During December 2015 to October 2018, ECHO followed sexually active, HIV-seronegative women, aged 16–35 years, seeking contraceptive services and willing to be randomized to one of three contraceptive methods (intramuscular depot medroxyprogesterone acetate, copper intrauterine device, or levonorgestrel implant) for 12–18 months at nine sites in South Africa. HIV incidence based on prospectively observed HIV seroconversion events. Cox proportional hazards regression models were used to define baseline cofactors related to incident HIV infection.

Results

5768 women were enrolled and contributed 7647 woman-years of follow-up. The median age was 23 years and 62.5% were ≤24 years. A total of 345 incident HIV infections occurred, an incidence of 4.51 per 100 woman-years (95%CI 4.05–5.01). Incidence was >3 per 100 woman-years at all sites. Age ≤24 years, baseline infection with sexually transmitted infections, BMI≤30, and having new or multiple partners in the three months prior to enrollment were associated with incident HIV.

Conclusions

HIV incidence was high among South African women seeking contraceptive services. Integration of diagnostic management of sexually transmitted infections alongside delivery of HIV prevention options in health facilities providing contraception services are needed to mitigate ongoing risks of HIV acquisition for this vulnerable population.

Clinical trial registration

ClinicalTrials.gov, number NCT02550067 was the main Clinical Trial from which this secondary, non-randomized / observational analysis was derived with data limited to just South African sites.

Estimating the Population Size of Female Sex Workers in Three South African Cities: Results and Recommendations From the 2013-2014 South Africa Health Monitoring Survey and Stakeholder Consensus

Background

Robust population size estimates of female sex workers and other key populations in South Africa face multiple methodological limitations, including inconsistencies in surveillance and programmatic indicators. This has, consequently, challenged the appropriate allocation of resources and benchmark-setting necessary to an effective HIV response. A 2013-2014 integrated biological and behavioral surveillance (IBBS) survey from South Africa showed alarmingly high HIV prevalence among female sex workers in South Africa’s three largest cities of Johannesburg (71.8%), Cape Town (39.7%), and eThekwini (53.5%). The survey also included several multiplier-based population size estimation methods.

Objective

The objective of our study was to present the selected population size estimation methods used in an IBBS survey and the subsequent participatory process used to estimate the number of female sex workers in three South African cities.

Methods

In 2013-2014, we used respondent-driven sampling to recruit independent samples of female sex workers for IBBS surveys in Johannesburg, Cape Town, and eThekwini. We embedded multiple multiplier-based population size estimation methods into the survey, from which investigators calculated weighted estimates and ranges of population size estimates for each city’s female sex worker population. Following data analysis, investigators consulted civil society stakeholders to present survey results and size estimates and facilitated stakeholder vetting of individual estimates to arrive at consensus point estimates with upper and lower plausibility bounds.

Results

In total, 764, 650, and 766 female sex workers participated in the survey in Johannesburg, Cape Town, and eThekwini, respectively. For size estimation, investigators calculated preliminary point estimates as the median of the multiple estimation methods embedded in the IBBS survey and presented these to a civil society-convened stakeholder group. Stakeholders vetted all estimates in light of other data points, including programmatic experience, ensuring inclusion only of plausible point estimates in median calculation. After vetting, stakeholders adopted three consensus point estimates with plausible ranges: Johannesburg 7697 (5000-10,895); Cape Town 6500 (4579-9000); eThekwini 9323 (4000-10,000).

Conclusions

Using several population size estimates methods embedded in an IBBS survey and a participatory stakeholder consensus process, the South Africa Health Monitoring Survey produced female sex worker size estimates representing approximately 0.48%, 0.49%, and 0.77% of the adult female population in Johannesburg, Cape Town, and eThekwini, respectively. In data-sparse environments, stakeholder engagement and consensus is critical to vetting of multiple empirically based size estimates procedures to ensure adoption and utilization of data-informed size estimates for coordinated national and subnational benchmarking. It also has the potential to increase coherence in national and key population-specific HIV responses and to decrease the likelihood of duplicative and wasteful resource allocation. We recommend building cooperative and productive academic-civil society partnerships around estimates and other strategic information dissemination and sharing to facilitate the incorporation of additional data as it becomes available, as these additional data points may minimize the impact of the known and unknown biases inherent in any single, investigator-calculated method.

Increased Access to Antiretroviral Therapy Is Associated with Reduced Maternal Mortality in Johannesburg, South Africa: An Audit from 2003-2012

OBJECTIVE

To assess the impact of expanded access to antiretroviral treatment (ART) on maternal mortality in Johannesburg, South Africa between 2003 and 2012.

METHODS

Audit of patient files, birth registers and death certificates at a tertiary level referral hospital. Cause of death was assigned independently, by two reviewers. We compared causes of deaths and the maternal mortality ratios (MMR, deaths/100,000 live births) over three periods corresponding to changes in government policy on ART provision: period one, 2003-2004 (pre-ART); period two, 2005-2009 (ART eligibility with CD4 count <200cells/μL or WHO stage 4 disease); and period three, 2010-2012 (eligibility with CD4 count <350 cells/μL).

RESULTS

There were 232 deaths and 80,376 deliveries in the three periods. The proportion of pregnant women tested for HIV rose from 43.4% in 2003 to 94.6% in 2012. MMR was 301, 327 and 232 in the three periods, (p = 0.10). The third period MMR was lower than the first and second combined (p = 0.03). Among HIV-positive women, the MMR fell from 836 in the first time period to 431 in the third (p = 0.008) but among HIV negative women it remained unchanged over the three periods, averaging 148. Even in the third period, however, the MMR among HIV-infected women was 3-fold higher than in other women. Mortality from direct obstetric causes such as hemorrhage did not decline over time, but deaths from tuberculosis and HIV-associated malignancy did. In 38.3% of deaths, women had not attended antenatal care.

CONCLUSION

Higher coverage of HIV testing and ART has substantially reduced MMR in this hospital setting. Though the gap in MMR between women with and without HIV narrowed, a third of deaths still remain attributable to HIV. Lowering overall MMR will require further strengthening of HIV services, increased antenatal care coverage, and improved care for obstetric emergencies at all levels of care.

Field evaluation of Standard Diagnostics' Bioline HIV/Syphilis Duo test among female sex workers in Johannesburg, South Africa

BACKGROUND

Point-of-care tests provide immediate results with the opportunity for same-day interventions with improved public health outcomes. A dual HIV/syphilis test enables early treatment of both diseases.

METHODS

We conducted a field evaluation of the Standard Diagnostics' SD Bioline HIV/Syphilis Duo test (SD Bioline) among female sex workers. SD Bioline was conducted on finger-prick blood according to manufacturer's instructions and compared with (i) Genscreen HIV1/2 (third generation) and Vironostika Ag/Ab (fourth generation) assays for HIV, and (ii) Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR) assays for syphilis. A negative TPPA test was considered negative, a TPPA-confirmed RPR titre ≤1:4 as past infection and a TPPA-confirmed RPR titre ≥1:8 as active syphilis. Sensitivity, specificity, positive and negative predictive values were calculated.

RESULTS

Of 263 women recruited, 14 (5.3%) declined an HIV test. Among the remaining 249 women, 187 (75.1%) were HIV positive, 51 (20.5%) had syphilis antibodies with seven (2.8%) active infections. For HIV, the sensitivity and specificity were 98.9% (95% CI 95.8% to 99.8%) and 100% (95% CI 92.7% to 100%). For syphilis, the sensitivity and specificity were 66.7% (95% CI 52.0% to 78.9%) and 98.0% (95% CI 94.5% to 99.3%). Sera with high TPPA titres were more likely to test positive.

CONCLUSIONS

In field conditions, while the SD Bioline test has high sensitivity and specificity for HIV and high specificity for syphilis, the test has lower sensitivity for syphilis than reported from laboratory evaluations. As the dual test detects only two thirds of syphilis cases, it should only be used in areas with weak screening programmes.

Concurrent sexual partnerships and human immunodeficiency virus risk among South African youth

BACKGROUND

To estimate the prevalence of concurrency (more than 1 sex partner overlapping in time), the attitudes/behaviors of those engaged in concurrency, length of relationship overlap, and the association between concurrency and human immunodeficiency virus (HIV) among South Africans aged 15 to 24 years.

METHODS

A cross-sectional, nationally representative, household survey of HIV infection, and sexual attitudes and behaviors was conducted among 11,904 15 to 24 year old South Africans in 2003. Analyses were conducted among sexually experienced youth.

RESULTS

Men were more likely to report having concurrent (24.7%) than serial partners (5.7%) in the past 12 months, but concurrency was not associated with HIV. Among women, concurrency and serial monogamy were equally common (4.7%), and concurrency, defined by respondent reports of multiple ongoing partners, was associated with HIV in multivariate analysis (odds ratio, 3.4; 95% confidence interval, 1.8-6.5). Median length of relationship overlap was approximately 4 months for women and 3 months for men. Compared to serial monogamists, concurrents reported less consistent condom use, and female concurrents were more likely to report transactional sex and problems negotiating condoms and refusing intercourse.

CONCLUSIONS

Concurrency is a common partnership pattern among those youth with multiple partners, especially men. For women, having concurrent relationships may be associated with relationship power imbalances and less ability to protect against HIV. Given the prevalence and likely significance of concurrency in the spread of HIV throughout a sexual network, our findings underscore the need for prevention efforts targeting fidelity.

Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene

South Africa has a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. Much evidence indicates that alcohol independently influences decisions around sex, and undermines skills for condom negotiation and correct use. Thus, not surprisingly, people with problem drinking in Africa have twofold higher risk for HIV than non-drinkers. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising and provision of Brief Interventions. Alcohol counselling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. Within positive-prevention services, alcohol reduction interventions could diminish HIV transmission. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence. However, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable disease, including unsafe sex, sexual violence, unintended pregnancy and, likely, HIV transmission.

Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa

Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked. Physiological and behavioural research indicates that alcohol independently affects decision-making concerning sex, and skills for negotiating condoms and their correct use. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care), must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.

Sexual violence and reproductive health outcomes among South African female youths: a contextual analysis

OBJECTIVES

We studied whether female youths from communities with higher sexual violence were at greater risk of negative reproductive health outcomes.

METHODS

We used data from a 2003 nationally representative household survey of youths aged 15-24 years in South Africa. The key independent variable was whether a woman had ever been threatened or forced to have sex. We aggregated this variable to the community level to determine, with control for individual-level experience with violence, whether the community-level prevalence of violence was associated with HIV status and adolescent pregnancy among female, sexually experienced, never-married youths.

RESULTS

Youths from communities with greater sexual violence were significantly more likely to have experienced an adolescent pregnancy or to be HIV-positive than were youths from communities experiencing lower sexual violence. Youths from communities with greater community-level violence were also less likely to have used a condom at their last sexual encounter. Individual-level violence was only associated with condom nonuse.

CONCLUSIONS

Programs to reduce adolescent pregnancies and HIV risk in South Africa and elsewhere in sub-Saharan Africa must address sexual violence as part of effective prevention strategies.

Bone mineral density in young women aged 19-24 after 4-5 years of exclusive and mixed use of hormonal contraception

BACKGROUND

Use of depot-medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN) and low-dose combined oral contraceptives (COCs) has been associated with loss of bone mineral density (BMD) in adolescents. However, the effect of using a combination of these methods over time in this age group is limited. The aim of this cross-sectional study was to investigate BMD in young women (aged 19-24 years) with a history of mixed hormonal contraceptive use.

STUDY DESIGN

BMD was measured at the spine, hip and femoral neck using dual X-ray absorptiometry. Women were classified into three groups: (1) injectable users (DMPA, NET-EN or both) (n=40), (2) mixed COC and injectable users (n=13) and (3) non-user control (n=41).

RESULTS

Women in the injectables-only user group were found to have lower BMDs compared to the non-user group at all three sites, and there was evidence of a difference in BMD between these two groups at the spine after adjusting for body mass index (p=.042), hip (p=.025) and femoral neck (p=.023). The mixed COC/injectable user group BMD values were lower than those for controls; however, there was no evidence of a significant difference between this group and the non-user group at any of the three sites.

CONCLUSION

This study suggests that BMD is lower in long-term injectable users but not when women have mixed injectable and COC use.

Keep them in school: the importance of education as a protective factor against HIV infection among young South African women

OBJECTIVE

To identify risk factors for HIV infection among young women aged 15-24 years reporting one lifetime partner in South Africa. Design In 2003, we conducted a nationally representative household survey of sexual behaviour and HIV testing among 11 904 young people aged 15-24 years in South Africa. This analysis focuses on the subset of sexually experienced young women with only one reported lifetime sex partner (n = 1708).

METHODS

Using the proximate determinants framework and the published literature we identified factors associated with HIV in young women. The associations between these factors and HIV infection were explored in multivariable logistic regression models.

RESULTS

Of the young women, 15% reporting one lifetime partner were HIV positive. In multivariable analyses, young women who had not completed high school were more likely to be infected with HIV compared with those that had completed high school (AOR 3.75; 95% CI 1.34-10.46).

CONCLUSIONS

Young South African women in this population were at high risk of HIV infection despite reporting only having one lifetime partner. Few individual level factors were associated with HIV infection, emphasizing the importance of developing HIV prevention interventions that address structural and partner level risk factors.

Contraception use and pregnancy among 15-24 year old South African women: a nationally representative cross-sectional survey

BACKGROUND

Adolescent reproductive health has not continued to receive the attention it deserves since the start of the HIV epidemic. In South Africa, high numbers of adolescent women report pregnancies that are unwanted and yet few have accessed available termination of pregnancy services. Enabling contraception use is vital for meeting the goals of HIV prevention.

METHODS

A nationally representative survey of South African 15-24 year olds was undertaken. Participants completed a questionnaire on sexual behaviour and provided an oral fluid sample for HIV testing. Analysis of the data was restricted to women (n = 6217), particularly those who reported being sexual active in the last 12 months (n = 3618) and was conducted using svy methods in the program STATA 8.0 to take account of sampling methods. Univariate and multivariate analyses were conducted to explore factors associated with contraceptive use.

RESULTS

Two thirds of all women reported having ever been sexually active and among these 87% were sexually active in the past 12 months. Among women who reported currently being sexually active, 52.2% reported using contraceptives. There was evidence of association between contraceptive use and being employed or a student (vs unemployed); fewer sex partners; type of last sex partner; having talked to last partner about condom use and having ever been pregnant.

CONCLUSION

Specific emphasis must be placed on encouraging young women to use contraceptive methods that offer protection against pregnancy and STIs/HIV. Our consistent finding of a relationship between discussing condom use with partners and condom use indicates the importance of involvement of male partners in women's contraceptive decisions.

Challenge of evaluating a national HIV prevention programme: the case of loveLife, South Africa

Although 50% of all new global HIV infections occur among young people, our knowledge to date of the impact of adolescent HIV prevention interventions in developing country settings is limited. During 1999, a national HIV prevention programme for youth, called loveLife, was launched in South Africa. This paper describes the challenges faced in trying to evaluate such a national programme and the types of evidence that could be used to better understand the effect of programmes of national scale. A range of methods were planned to evaluate the programme, including national household surveys and programme monitoring data. Given the urgent need to scale-up programmes in an effort to reduce new HIV infections, a range of evidence should be assessed to measure the effect of large-scale, complex behavioural interventions as an alternative to randomised controlled trials.

Predictors of condom use among young adults in South Africa: the Reproductive Health and HIV Research Unit National Youth Survey

OBJECTIVES

We examined correlates of condom use among a national random probability sample of sexually experienced young adults aged 15 to 24 years (n = 7686) in South Africa.

METHODS

Using data from the Reproductive Health and HIV Research Unit National Youth Survey, we conducted gender-stratified bivariate and multivariate logistic regression analyses to determine predictors of whether respondents had used a condom during their most recent sexual intercourse.

RESULTS

Condom use at sexual debut and talking with one's first sexual partner about condoms were the most significant predictors of condom use at most recent intercourse. Other significant predictors included high condom use self-efficacy, optimism about the future, and reported behavior change attributable to HIV/AIDS. Young adults who were married or had been involved in a relationship for 6 months or more were significantly less likely to have used a condom during their most recent sexual intercourse.

CONCLUSIONS

Our findings point to the importance of exposing youths to sexuality education before their sexual debut as well as voluntary counseling and testing and programming that supports young adults, particularly young women, in making informed decisions about sexual intercourse and condoms.

Highly efficient HIV transmission to young women in South Africa

BACKGROUND

Young women in sub-Saharan Africa are at very high risk of HIV acquisition, and high prevalence levels have been observed among women reporting one lifetime partner and few sexual contacts. Such findings have led to hypotheses that the probability of HIV transmission from men to women must be far higher than previously appreciated.

METHODS

We used the data from a cross-sectional national household survey of HIV among South African women aged 15-24 years to estimate the per-partnership transmission probability from men to women. Estimates were obtained using maximum likelihood methods and a transmission probability model allowing for random error in the self-reported number of lifetime partners. Sensitivity analyses were employed to assess the robustness of the per-partnership transmission probability estimates to the assumed HIV prevalence in male partners.

RESULTS

HIV prevalence in women was 21.2% (95% confidence interval 17.9-24.5). The mean reported number of lifetime partners was 2.3. A significant increase in prevalence was observed with increasing lifetime partner numbers (P = 0.02). For a range of plausible values of the partner prevalence, the estimated per-partnership transmission probability varied from 0.74 to 1.00 with 95% confidence intervals ranging from 0.56 to 1.00.

DISCUSSION

The per-partnership probability of HIV transmission from men to women in this population was very high. Before this, the majority of studies examining per-partnership transmission probabilities estimated values below 50%. Identifying the factors that may drive the efficient spread of HIV in sub-Saharan Africa is essential for the development of effective prevention interventions.

Factors associated with self-efficacy for condom use and sexual negotiation among South african youth

OBJECTIVES

To use logistic regression modeling to identify factors associated with high self-efficacy for sexual negotiation and condom use in a sample of South African youth.

METHODS

The Reproductive Health and HIV Research Unit (RHRU) National Youth Survey examined a nationally representative sample of 7409 sexually active South African youth aged 15 to 24 years. We used logistic regression modeling in this sample to identify factors associated with the main outcome of high self-efficacy.

RESULTS

Among female respondents (n = 3890), factors associated with high self-efficacy in the adjusted model were knowing how to avoid HIV (odds ratio [OR] = 2.30, 95% confidence interval [CI]: 1.05 to 5.00), having spoken with someone other than a parent or guardian about HIV/AIDS (OR = 1.46, 95% CI: 1.01 to 2.10), and having life goals (OR = 1.28, 95% CI: 1.10 to 1.48). Not using condoms during their first sexual encounter (OR = 0.61, 95% CI: 0.50 to 0.76), a history of unwanted sex (OR = 0.66, 95% CI: 0.51 to 0.86), and believing that condom use implies distrust in one's partner (OR = 0.57, 95% CI: 0.51 to 0.86) were factors associated with low self-efficacy among female respondents. Male respondents (n = 3519) with high self-efficacy were more likely to take HIV seriously (OR = 4.03, 95% CI: 1.55 to 10.52), to believe they are not at risk for HIV (OR = 1.38, 95% CI: 1.12 to 1.70), to report that getting condoms is easy (OR = 1.85, 95% CI: 1.23 to 2.77), and to have life goals (OR = 1.30, 95% CI: 1.10 to 1.54). Not using condoms during their first sexual experience (OR = 0.51, 95% CI: 0.39 to 0.67), a history of having unwanted sex (OR = 0.47, 95% CI: 0.34 to 0.64), believing condom use is a sign of not trusting one's partner (OR = 0.63, 95% CI: 0.46 to 0.87), and refusing to be friends with HIV-infected persons (OR = 0.52, 95% CI: 0.32 to 0.85) were factors associated with low self-efficacy among male respondents in the fully adjusted model.

CONCLUSIONS

We used the social cognitive model (SCM) to identify factors associated with self-efficacy for condom use and sexual negotiation. Many of these factors are modifiable and suggest potential ways to improve self-efficacy and reduce HIV sexual risk behavior in South African youth.

A community-based study to examine the effect of a youth HIV prevention intervention on young people aged 15-24 in South Africa: results of the baseline survey

OBJECTIVES

To determine whether South African youths living in communities that had either of two youth human immunodeficiency virus (HIV) prevention interventions [(a) loveLife Youth Centre or (b) loveLife National Adolescent Friendly Clinic Initiative] would have a lower prevalence of HIV, sexually transmitted infections (STIs), and high risk sexual behaviours than communities without either of these interventions.

METHODS

In 2002 the baseline survey of a quasi-experimental, community-based study was conducted in South Africa. In total 33 communities were included in three study arms (11 communities per study arm). The final sample included 8735 youths aged 15-24 years. All participants took part in a behavioural interview and were tested for HIV, gonorrhoea (Neisseria gonorrhoeae) and Chlamydia (Chlamydia trachomatis).

RESULTS

HIV prevalence was 20.0% among females and 7.5% among males (OR 3.93 95% CI 2.51-6.15). There were no significant differences between study arms for HIV, NG or CT prevalence at baseline. In multiple regression analyses, HIV was significantly associated with NG infection (OR 1.96 95% CI 1.24-3.12) but not with CT infection. Youths who reported >1 lifetime partner were also significantly more likely to be infected with HIV (OR 1.98 95% CI 1.55-2.52), as were those who reported ever having engaged in transactional sex (OR 1.86 P = 0.02) or having had genital ulcers in the past 12 months (OR 1.71 P < or = 0.001).

CONCLUSIONS

HIV prevention programmes must ensure that gender inequities that place young women at greater risk for HIV infection are urgently addressed and they must continue to emphasize the importance of reducing the number of sexual partners and STI treatment.

Young people's sexual health in South Africa: HIV prevalence and sexual behaviors from a nationally representative household survey

OBJECTIVES

To determine the prevalence of HIV infection, HIV risk factors, and exposure to national HIV prevention programs, and to identify factors associated with HIV infection among South African youth, aged 15-24 years.

DESIGN

A cross-sectional, nationally representative, household survey.

METHODS

From March to August 2003 we conducted a national survey of HIV prevalence and sexual behavior among 11 904 15-24 year olds. Multivariable models for HIV infection were restricted to sexually experienced youth.

RESULTS

Young women were significantly more likely to be infected with HIV in comparison with young men (15.5 versus 4.8%). Among men, a history of genital ulcers in the past 12 months was associated with HIV infection [adjusted odds ratio (AOR), 1.91; 95% confidence interval (CI), 1.04-3.49) whereas among women a history of unusual vaginal discharge in the past 12 months was associated with HIV infection (AOR, 1.75; 95% CI, 1.26-2.44). Young women with older partners were also at increased risk of HIV infection. Among both men and women, increasing partner numbers and inconsistent condom use were significantly associated with HIV infection. Males and females who reported participation in at least one loveLife program were less likely to be infected with HIV (AOR, 0.60; 95% CI, 0.40-0.89; AOR, 0.61; 95% CI, 0.43-0.85, respectively).

CONCLUSION

This survey confirms the high HIV prevalence among young people in South Africa and, in particular, young women's disproportionate risk. Programs for youth must continue to promote partner reduction, consistent condom use and prompt treatment for sexually transmitted infections while also addressing contextual factors that make it difficult for them to implement behavior change.

Sexual power and HIV risk, South Africa

Gender power inequities are believed to play a key role in the HIV epidemic through their effects on women's power in sexual relationships. We hypothesized that lack of sexual power, measured with a four-point relationship control scale and by a woman's experience of forced sex with her most recent partner, would decrease the likelihood of consistent condom use and increase the risk for HIV infection among sexually experienced, 15- to 24-year-old women in South Africa. While limited sexual power was not directly associated with HIV, it was associated with inconsistent condom use: women with low relationship control were 2.10 times more likely to use condoms inconsistently (95% confidence interval [CI] 1.17-3.78), and women experiencing forced sex were 5.77 times more likely to use condoms inconsistently (95% CI 1.86-17.91). Inconsistent condom use was, in turn, significantly associated with HIV infection (adjusted odds ratio 1.58, 95% CI 1.10-2.27).

Detection of raised FSH levels among older women using depomedroxyprogesterone acetate and norethisterone enanthate

The objective of this study was to investigate whether follicle-stimulating hormone (FSH) levels can be used reliably to indicate approaching menopause in older (aged 40-49), long-term users of depomedroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN). One-hundred and seventeen women using DMPA, 60 NET-EN users and 161 nonusers of contraception were recruited. At recruitment, serum FSH levels were measured and questions were asked regarding menopausal symptoms, menstrual cycle and date of last injection. Results of the recruitment blood test showed that 32% of the nonusers had FSH levels in the menopausal range >25.8 mIU/mL compared to 28% of the DMPA users and 9% of the NET-EN group. After adjusting for age, there was no significant difference between the 3 groups (p = 0.13). An increase of 1 year in age increased the FSH level by 3 mIU/mL (p < 0.001). All the hormonal contraceptive users were between 1 day and 12 weeks of their injection interval. Many had been using the injectable contraceptive method for over 10 years and almost all were amenorrheic at the time of recruitment. The data show that a raised FSH level can be detected during use of DMPA and NET-EN and could be used as a menopausal indicator without interrupting method use in this group of contraceptive users.

The acceptability of reuse of the female condom among urban South African women

This study assessed whether reuse of the female condom was acceptable among two groups of women in central Johannesburg, South Africa, who were taking part in two separate studies of female condom reuse. The first group consisted of women (aged 17 to 43 years) attending a family planning/sexually transmitted infections (STIs) clinic who were participating in a cross-sectional survey of the acceptability of female condoms reuse (n = 100). The second group included women (aged 18-40 years) at high risk for STI (80% self-declared sex workers) who were taking part in an ongoing cohort study to investigate the safety of reuse of the female condom through a structural integrity and microbial retention study (n = 50). Among women participating in the acceptability study, 83% said that they would be willing to reuse the female condom, and 91% thought the idea of reuse of the female condom was acceptable. All women taking part in the safety of reuse study and who reused the female condom up to seven times (n = 49) reported that the steps involved in reusing the device were easy to perform and acceptable. All 49 women said they would reuse the female condom at least once, while 45% said they would use it a maximum of seven or eight times. From the results of the interviews with both study groups, it can be concluded that, among women in a South African urban environment who have used a male and/or female condom, the concept of reuse of the female condom is acceptable and thought to be a good idea.

Vaginal discharge: a perceived side effect and minor reason for discontinuation in hormonal injectable users in South Africa

Poor compliance and high discontinuation rates have been observed in users of injectable hormonal contraception in South Africa. The objective of this study was to assess the side effects and reasons for discontinuation in new users of both depot-medroxyprogesterone acetate (DMPA) and norethisterone oenanthate (NET-EN). One hundred and eighty nine women were recruited into a two-year follow-up study. At each visit for a repeat injection, users were asked about bleeding patterns and side effects. Vaginal discharge, often described as watery in consistency, was perceived to be a problem amongst women and their partners. In total, one fifth (20%) of women reported an increase in discharge during use of the method and three women cited this discharge to be the primary reason for discontinuation of the method. This side effect was mainly noted in the first few months of use. Health care providers believed that this was a side effect of both DMPA and NET-EN, and women who presented with this complaint were rarely investigated for presence of sexually transmitted diseases.

Temporary discontinuation: a compliance issue in injectable users

This study examined compliance in injectable users and followed women post-discontinuation to document their contraceptive practices. A cohort of 189 predominantly new users of depot-medroxyprogesterone acetate and norethisterone oenanthate were recruited and followed for 2 years regardless of whether or not they continued the method. Continuation rates were 42% at 1 year and 21% at 2 years. Of the 78 women who discontinued the method, 31 reported that they were "taking a break." For 20 of these women, this break (nonuse segment) occurred within the 2-year period, and 15 of them returned to the injection before the end of study period. The other five switched methods after the nonuse segment. The mean length of the nonuse segment was 7 months (range 2-13 months). In all 20 women, no other contraceptive method was used, they remained sexually active, and started the break within 6 months of commencing use of the injectable. In addition, 11 women were in a self-reported nonuse segment at the end of the study and stated their intention to return to the method at a later date. Menstrual disturbances were cited as the main reason for the break. Strengthened counseling at method acceptance was identified as a strategy to decrease the frequency of breaks in injectable method use.

Structural integrity of the female condom after multiple uses, washing, drying, and re-lubrication

Establishing the safety of re-using the female condom could significantly increase women's access to barrier methods especially in poorer countries. In this study, the structural integrity of female condoms was tested (n = 295) after multiple acts of vaginal intercourse. Fifty women were recruited to the study. Each woman re-used one condom up to eight times and washed, dried, and re-lubricated between each use. Structural integrity was measured using standard quality control testing; water-leakage, air-burst, and seam tensile strength. All results were compared to the United States Food and Drug Administration (US FDA) standards for an unused female condom. The results of the structural integrity tests for all cycles were above the FDA minimum standards for seam strength and burst tests. There was no deterioration detected in condoms used 8 times when compared to new female condoms in these tests. Five holes were detected by the water leakage test across all cycles, of which three were detected by the subjects themselves and reported to the investigators, therefore, giving a breakage rate of 1.7%. The holes were not associated with increased number of uses. This study provides further evidence that suggests the structural integrity of the female condom after multiple use is still within FDA minimum standards, although random holes resulting from handling occur infrequently with the re-use procedure.

In vitro assessment of the structural integrity of the female condom after multiple wash, dry, and re-lubrication cycles

Since the introduction of the female condom in the early 90s, there have been numerous reports of reuse of the device. In response to these reports, studies were undertaken to evaluate the safety of female condom reuse. If reuse were shown to be safe, then programmatic costs of introduction of the female condom would be reduced allowing it to be more widely available. This article outlines the results of in vitro structural integrity testing of the female condom after multiple wash, dry, and re-lubrication cycles. Devices were tested up to 10 washes using water leakage, burst, and tensile seam testing. All results were compared to the United States Food and Drug Administration (US FDA) standards for an unused female condom. The results of the structural integrity tests for all 6 washing procedures examined in this study were above the FDA minimum standards for seam strength and burst tests. For the water leakage test, 3 of 6 washing procedures tested passed the required FDA minimum standards (no holes detected). From the results of the study, it seems that washing, drying, and re-lubricating the female condom up to 10 times leads to some deterioration in the structural integrity of the device for specified washing procedures. Further studies are currently being conducted to establish the safety of female condom reuse with respect to microbial retention, structural integrity after in vivo use, and viral permeability.

The practice and prevalence of dry sex among men and women in South Africa: a risk factor for sexually transmitted infections?

OBJECTIVES

To establish the prevalence of "dry sex" practice in a South African periurban population. To investigate the reasons for and factors influencing the practice of dry sex and to evaluate dry sex practice as a risk factor for sexually transmitted disease (STD).

DESIGN

Cross sectional sample survey.

METHODS

A random community sample of men and women aged between 16 and 35 in Gauteng Province, South Africa, were interviewed regarding the practice of dry sex using a structured interviewer administered questionnaire.

RESULTS

Dry sex practices were reported by 60% of men and 46% of women. Among younger individuals dry sex practice is far more common among the less educated, but there was no significant difference between education groups in the older respondents. A higher proportion of men practising dry sex than not practising dry sex reported having a past history of STD infection (56% versus 41%) although this difference was only marginally significant (p = 0.05). There was no difference in reported history of STD between women who practised dry sex and those who did not.

CONCLUSIONS

This study shows that dry sex practice is common in this community. The younger less educated group were the most likely to practise dry sex. Dry sex practice was associated with an increased prevalence of self reported STDs in men but not in women.