HIV transmission risk behavior among HIV-infected adults in Uganda: results of a nationally representative survey

Translation of biomedical prevention strategies for HIV: prospects and pitfalls

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.

Sexual risk behaviour, marriage and ART: a study of HIV-positive people in Papua New Guinea

Background

The prevention of intimate partner transmission of HIV remains an important component of comprehensive HIV prevention strategies. In this paper we examine the sexual practices of people living with HIV on antiretroviral therapy (ART) in Papua New Guinea (PNG).

Method

In 2008, a total of 374 HIV-positive people over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. This accounted for around 18% of adults on ART at the time. A further 36 people participated in semi-structured interviews. All interviews were thematically analysed using NVivo qualitative data analysis software.

Results

Less than forty per cent (38%) of participants reported having had sexual intercourse in the six months prior to the survey. Marital status was by far the most important factor in determining sexual activity, but consistent condom use during vaginal intercourse with a regular partner was low. Only 46% reported consistent condom use during vaginal intercourse with a regular partner in the last six months, despite 77% of all participants reporting that consistent condom use can prevent HIV transmission. Consistent condom use was lowest amongst married couples and those in seroconcordant relationships. The vast majority (91.8%) of all participants with a regular heterosexual partner had disclosed their status to their partner. Qualitative data reinforced low rates of sexual activity and provided important insights into sexual abstinence and condom use.

Conclusions

Considering the importance of intimate partner transmission of HIV, these results on the sexual practices of people with HIV on ART in PNG suggest that one-dimensional HIV prevention messages focussing solely on condom use fail to account for the current practices and needs of HIV-positive people, especially those who are married and know their partners’ HIV status.

Predictors of HIV Serodiscordance among Couples in Southwestern Ethiopia

BACKGROUND

With transmission of HIV occurring mainly through heterosexual contact, it is paramount to identify serodiscordant couples and implement preventive strategies that will protect the negative partner. The burden of serodiscordance and its predictors in Ethiopia is not clearly understood due to the dearth of data.

OBJECTIVE

To assess the prevalence and predictors of HIV serodiscordance among couples tested in Jimma University Specialized Hospital (JUSH) Voluntary Counseling and Testing (VCT) center.

METHODS

The study employed a case-control study design conducted at VCT center of JUSH in all registered serodiscordant couples and seroconcordant couples that were selected from the registered clients in the period from 2003 to 2010. A pretested structured questionnaire was used for data collection using medical chart abstraction. Data were entered, cleaned, and coded using Statistical Package of Social Sciences (SPSS) version 16.

RESULTS

The prevalence of serodiscordance in the study population was found to be 8.4%. Male and female discordants accounted for 5.8% (137) and 2.6% (62), respectively. Rare use of condom (adjusted odds ratio [AOR] = 7.2; 95% confidence interval [CI] = 1.59-32.54) and active tuberculosis (TB) at enrollment (AOR= 17.7; 95% CI = 2.3-139.2) were significantly found to be the predictors of serodiscordance.

CONCLUSION

The prevalence of serodiscordance in the study area was found to be low, but it contributes to a clinically significant population that mandates implementation of preventive strategy. Sero-positive individuals who use condoms rarely should be encouraged to have their partners tested, and the association between active TB and serodiscordance underscores the need for further study.

Factors associated with not testing for HIV and consistent condom use among men in Soweto, South Africa

Background

Besides access to medical male circumcision, HIV testing, access to condoms and consistent condom use are additional strategies men can use to prevent HIV acquisition. We examine male behavior toward testing and condom use.

Objective

To determine factors associated with never testing for HIV and consistent condom use among men who never test in Soweto.

Methods

A cross-sectional survey in Soweto was conducted in 1539 men aged 18–32 years in 2007. Data were collected on socio-demographic and behavioral characteristics to determine factors associated with not testing and consistent condom use.

Results

Over two thirds (71%) of men had not had an HIV test and the majority (55%, n = 602) were young (18–23). Of those not testing, condom use was poor (44%, n = 304). Men who were 18–23 years (aOR: 2.261, CI: 1.534–3.331), with primary (aOR: 2.096, CI: 1.058–4.153) or high school (aOR: 1.622, CI: 1.078–2.439) education, had sex in the last 6 months (aOR: 1.703, CI: 1.055–2.751), and had ≥1 sexual partner (aOR: 1.749, CI: 1.196–2.557) were more likely not to test. Of those reporting condom use (n = 1036, 67%), consistent condom use was 43% (n = 451). HIV testing did not correlate with condom use.

Conclusion

Low rates of both condom use and HIV testing among men in a high HIV prevalence setting are worrisome and indicate an urgent need to develop innovative behavioral strategies to address this shortfall. Condom use is poor in this population whether tested or not tested for HIV, indicating no association between condom use and HIV testing.

Evaluation of current rapid HIV test algorithms in Rakai, Uganda

Rapid HIV tests are a crucial component of HIV diagnosis in resource limited settings. In Uganda, the Ministry of Health allows both serial and parallel HIV rapid testing using Determine, Stat-Pak and Uni-Gold. In serial testing, a non-reactive result on Determine ends testing. The performance of serial and parallel algorithms with Determine and Stat-Pak test kits was assessed. A cross-sectional diagnostic test accuracy evaluation using three rapid HIV test kits as per the recommended parallel test algorithm was followed by EIA-WB testing with estimates of the performance of serial testing algorithm. In 2520 participants tested by parallel rapid algorithms, 0.6% had weakly reactive result. Parallel testing had 99.7% sensitivity and 99.8% specificity. If Stat-Pak was used as the first screening test for a serial algorithm, the sensitivity was 99.6% and specificity was 99.7%. However, if Determine was used as the screening test, sensitivity was 97.3% and specificity was 99.9%. Serial testing with Stat-Pak as the initial screening test performed as well as parallel testing, but Determine was a less sensitive screen. Serial testing could be cost saving.

HIV prevention in care and treatment settings: baseline risk behaviors among HIV patients in Kenya, Namibia, and Tanzania

HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP).

HIV testing and care in Burkina Faso, Kenya, Malawi and Uganda: ethics on the ground

BACKGROUND

The ethical discourse about HIV testing has undergone a profound transformation in recent years. The greater availability of antiretroviral therapy (ART) has led to a global scaling up of HIV testing and counseling as a gateway to prevention, treatment and care. In response, critics raised important ethical questions, including: How do different testing policies and practices undermine or strengthen informed consent and medical confidentiality? How well do different modalities of testing provide benefits that outweigh risks of harm? To what degree do current testing policies and programs provide equitable access to HIV services? And finally, what lessons have been learned from the field about how to improve the delivery of HIV services to achieve public health objectives and protections for human rights? This article reviews the empirical evidence that has emerged to answer these questions, from four sub-Saharan African countries, namely: Burkina Faso, Kenya, Malawi and Uganda.

DISCUSSION

Expanding access to treatment and prevention in these four countries has made the biomedical benefits of HIV testing increasingly clear. But serious challenges remain with regard to protecting human rights, informed consent and ensuring linkages to care. Policy makers and practitioners are grappling with difficult ethical issues, including how to protect confidentiality, how to strengthen linkages to care, and how to provide equitable access to services, especially for most at risk populations, including men who have sex with men.

SUMMARY

The most salient policy questions about HIV testing in these countries no longer address whether to scale up routine PITC (and other strategies), but how. Instead, individuals, health care providers and policy makers are struggling with a host of difficult ethical questions about how to protect rights, maximize benefits, and mitigate risks in the face of resource scarcity.

A population-based study of Kaposi Sarcoma-associated herpesvirus seropositivity in Uganda using principal components analysis

Background

Kaposi sarcoma-associated herpesvirus (KSHV) seropositivity is associated with sexual, environmental, and socioeconomic exposures. Whether these characteristics are independent risk factors is uncertain because of reliance on selected high-risk or hospital-based populations and incomplete adjustment for confounding. Therefore, we evaluated risk factors for KSHV seropositivity in a population-based study in Uganda using principal components analysis (PCA).

Methods

The study population comprised 2,681 individuals randomly selected from a nationally-representative population-based HIV/AIDS sero-behavioral survey conducted in 2004/05. Questionnaire and laboratory data (97 variables) were transformed into a smaller set of uncorrelated variables using PCA. Multivariable logistic regression models were fitted to estimate odds ratios and 95% confidence intervals for the association between components and KSHV seropositivity.

Results

Data were reduced to three principal components (PCs) labeled as Sexual behavioral, Socioeconomic, and Knowledge PCs. In crude analysis, KSHV seropositivity was associated with the Knowledge (p_trend = 0.012) and Socioeconomic components (p_trend = 0.0001), but not with the Sexual-behavioral component (p_trend = 0.066). KSHV seropositivity was associated with the Socioeconomic PC (p_trend = 0.037), but not with the Sexual-behavioral and Knowledge PCs, in the models including PCs, age, gender and geographic region.

Conclusions

Our results fit with the view that in Uganda socioeconomic characteristic may influence KSHV seropositivity. Conversely, the results fit with the interpretation that in Uganda sexual-behavioral characteristics, if relevant, contribute minimally.

Determinants of previous HIV testing and knowledge of partner's HIV status among men attending a voluntary counseling and testing clinic in Dar es Salaam, Tanzania

Voluntary Counseling and Testing (VCT) remains low among men in sub-Saharan Africa. The factors associated with previous HIV testing and knowledge of partner's HIV status are described for 9,107 men who visited the Muhimbili University College of Health Sciences' VCT site in Dar es Salaam, Tanzania, between 1997 and 2008. Data are from intake forms administered to clients seeking VCT services. Most of the men (64.5%) had not previously been tested and 75% were unaware of their partner's HIV status. Multivariate logistic regression revealed that age, education, condom use, and knowledge of partner's HIV status were significant predictors of previous HIV testing. Education, number of sexual partners, and condom use were also associated with knowledge of partner's HIV status. The low rate of VCT use among men underscores the need for more intensive initiatives to target men and remove the barriers that prevent HIV disclosure.

Home-based HIV counseling and testing: client experiences and perceptions in Eastern Uganda

BACKGROUND

Though prevention and treatment depend on individuals knowing their HIV status, the uptake of testing remains low in Sub-Saharan Africa. One initiative to encourage HIV testing involves delivering services at home. However, doubts have been cast about the ability of Home-Based HIV Counseling and Testing (HBHCT) to adhere to ethical practices including consent, confidentiality, and access to HIV care post-test. This study explored client experiences in relation these ethical issues.

METHODS

We conducted 395 individual interviews in Kumi district, Uganda, where teams providing HBHCT had visited 6-12 months prior to the interviews. Semi-structured questionnaires elicited information on clients' experiences, from initial community mobilization up to receipt of results and access to HIV services post-test.

RESULTS

We found that 95% of our respondents had ever tested (average for Uganda was 38%). Among those who were approached by HBHCT providers, 98% were informed of their right to decline HIV testing. Most respondents were counseled individually, but 69% of the married/cohabiting were counseled as couples. The majority of respondents (94%) were satisfied with the information given to them and the interaction with the HBHCT providers. Most respondents considered their own homes as more private than health facilities. Twelve respondents reported that they tested positive, 11 were referred for follow-up care, seven actually went for care, and only 5 knew their CD4 counts. All HIV infected individuals who were married or cohabiting had disclosed their status to their partners.

CONCLUSION

These findings show a very high uptake of HIV testing and satisfaction with HBHCT, a large proportion of married respondents tested as couples, and high disclosure rates. HBHCT can play a major role in expanding access to testing and overcoming disclosure challenges. However, access to HIV services post-test may require attention.

Contraceptive use and associated factors among women enrolling into HIV care in southwestern Uganda

BACKGROUND

Preventing unintended pregnancies among women living with HIV is an important component of prevention of mother-to-child HIV transmission (PMTCT), yet few data exist on contraceptive use among women entering HIV care.

METHODS

This was a retrospective study of electronic medical records from the initial HIV clinic visits of 826 sexually active, nonpregnant, 18-49-year old women in southwestern Uganda in 2009. We examined whether contraceptive use was associated with HIV status disclosure to one's spouse.

RESULTS

The proportion reporting use of contraception was 27.8%. The most common method used was injectable hormones (51.7%), followed by condoms (29.6%), and oral contraceptives (8.7%). In multivariable analysis, the odds of contraceptive use were significantly higher among women reporting secondary education, higher income, three or more children, and younger age. There were no significant independent associations between contraceptive use and HIV status disclosure to spouse.

DISCUSSION

Contraceptive use among HIV-positive females enrolling into HIV care in southwestern Uganda was low. Our results suggest that increased emphasis should be given to increase the contraception uptake for all women especially those with lower education and income. HIV clinics may be prime sites for contraception education and service delivery integration.

Depression in the pathway of HIV antiretroviral effects on sexual risk behavior among patients in Uganda

HIV antiretroviral therapy (ART) can increase safe sex or lead to disinhibition and less condom use. We conducted one of the first controlled studies of ART effects on sexual risk behavior in sub-Saharan Africa, and the potential explanatory roles of physical and mental health. Participants (302 non-ART, 300 ART) were followed for the first 12 months of HIV care in Uganda. Multivariate intention-to-treat regression analysis showed that frequency of sex increased significantly in both groups, but more among ART patients; when added to the model in separate analyses, changes in physical health functioning and depression were both significant predictors, as was time in HIV care, but there was no longer an ART effect. Both ART and non-ART groups had similar dramatic increases in consistent condom use over time; however, change in depression, unlike physical health functioning, was a significant predictor of consistent condom use when added to this model, and there remained a similar level of increased condom use among ART and non-ART patients. HIV care and ART increase sexual activity and condom use, but depression undercuts the prevention benefits of ART, highlighting the need to integrate mental health services into HIV care.

"What took you so long?" The impact of PEPFAR on the expansion of HIV testing and counseling services in Africa

HIV testing and counseling services in Africa began in the early 1990s, with limited availability and coverage. Fears of stigma and discrimination, complex laboratory systems, and lack of available care and treatment services hampered expansion. Use of rapid point-of-care tests, introduction of services to prevent mother-to-child transmission, and increasing provision of antiretroviral drugs were key events in the late 1990s and early 2000s that facilitated the expansion of HIV testing and counseling services. Innovations in service delivery included providing HIV testing in both clinical and community sites, including mobile and home testing. Promotional campaigns were conducted in many countries, and evolutions in policies and guidance facilitated expansion and uptake. Support from President's Emergency Plan for AIDS Relief and national governments, other donors, and the Global Fund for AIDS, Tuberculosis, and Malaria contributed to significant increases in the numbers of persons tested in many countries. Quality of both testing and counseling, limited number of health care workers, uptake by couples, and effectiveness of linkages and referral systems remain challenges. Expansion of antiretroviral treatment, especially in light of the evidence that treatment contributes to prevention of transmission, will require greater yet strategic coverage of testing services, especially in clinical settings and in combination with other high-impact HIV prevention strategies. Continued support from President's Emergency Plan for AIDS Relief, governments, and other donors is required for the expansion of testing needed to achieve international targets for the scale-up of treatment and universal access to knowledge of HIV status.

HIV-1 prevention for HIV-1 serodiscordant couples

A substantial proportion of HIV-1 infected individuals in sub-Saharan Africa are in stable relationships with HIV-1 uninfected partners, and HIV-1 serodiscordant couples thus represent an important target population for HIV-1 prevention. Couple-based HIV-1 testing and counseling facilitates identification of HIV-1 serodiscordant couples, counseling about risk reduction, and referrals to HIV-1 treatment, reproductive health services, and support services. Maximizing HIV-1 prevention for HIV-1 serodiscordant couples requires a combination of strategies, including counseling about condoms, sexual risk, fertility, contraception, and the clinical and prevention benefits of antiretroviral therapy (ART) for the HIV-1-infected partner; provision of clinical care and ART for the HIV-1-infected partner; antenatal care and services to prevent mother-to-child transmission for HIV-1-infected pregnant women; male circumcision for HIV-1-uninfected men; and, pending guidelines and demonstration projects, oral pre-exposure prophylaxis (PrEP) for HIV-1-uninfected partners.

Viral load monitoring of antiretroviral therapy, cohort viral load and HIV transmission in Southern Africa: a mathematical modelling analysis

OBJECTIVES

In low-income settings, treatment failure is often identified using CD4 cell count monitoring. Consequently, patients remain on a failing regimen, resulting in a higher risk of transmission. We investigated the benefit of routine viral load monitoring for reducing HIV transmission.

DESIGN

Mathematical model.

METHODS

We developed a stochastic mathematical model representing the course of individual viral load, immunological response and survival in a cohort of 1000 HIV-infected patients receiving antiretroviral therapy (ART) in southern Africa. We calculated cohort viral load (CVL; sum of individual viral loads) and used a mathematical relationship between individual viral load values and transmission probability to estimate the number of new HIV infections. Our model was parameterized with data from the International epidemiologic Databases to Evaluate AIDS Southern African collaboration. Sensitivity analyses were performed to assess the validity of the results in a universal 'test and treat' scenario, wherein patients start ART earlier after HIV infection.

RESULTS

If CD4 cell count alone was regularly monitored, the CVL was 2.6 × 10 copies/ml and the treated patients transmitted on average 6.3 infections each year. With routine viral load monitoring, both CVL and transmissions were reduced by 31% to 1.7 × 10 copies/ml and 4.3 transmissions, respectively. The relative reduction of 31% between monitoring strategies remained similar for different scenarios.

CONCLUSION

Although routine viral load monitoring enhances the preventive effect of ART, the provision of ART to everyone in need should remain the highest priority.

Predicting partner HIV testing and counseling following a partner notification intervention

Provider-assisted methods of partner notification increase testing and counseling among sexual partners of patients diagnosed with HIV, however they are resource-intensive. The sexual partners of individuals enrolled in a clinical trial comparing different methods of HIV partner notification were analyzed to identify who was unlikely to seek testing on their own. Unconditional logistic regression was used to identify partnership characteristics, which were assigned a score based on their coefficient in the final model, and a risk score was calculated for each participant. The risk score included male partner sex, relationship duration 6-24 months, and index education > primary. A risk score of ≥ 2 had a sensitivity of 68% and specificity of 78% in identifying partners unlikely to seek testing on their own. A risk score to target partner notification can reduce the resources required to locate all partners in the community while increasing the testing yield compared to patient-referral.

Lack of knowledge of HIV status a major barrier to HIV prevention, care and treatment efforts in Kenya: results from a nationally representative study

BACKGROUND

We analyzed HIV testing rates, prevalence of undiagnosed HIV, and predictors of testing in the Kenya AIDS Indicator Survey (KAIS) 2007.

METHODS

KAIS was a nationally representative sero-survey that included demographic and behavioral indicators and testing for HIV, HSV-2, syphilis, and CD4 cell counts in the population aged 15-64 years. We used gender-specific multivariable regression models to identify factors independently associated with HIV testing in sexually active persons.

RESULTS

Of 19,840 eligible persons, 80% consented to interviews and blood specimen collection. National HIV prevalence was 7.1% (95% CI 6.5-7.7). Among ever sexually active persons, 27.4% (95% CI 25.6-29.2) of men and 44.2% (95% CI 42.5-46.0) of women reported previous HIV testing. Among HIV-infected persons, 83.6% (95% CI 76.2-91.0) were unaware of their HIV infection. Among sexually active women aged 15-49 years, 48.7% (95% CI 46.8-50.6) had their last HIV test during antenatal care (ANC). In multivariable analyses, the adjusted odds ratio (AOR) for ever HIV testing in women ≥35 versus 15-19 years was 0.2 (95% CI: 0.1-0.3; p<0.0001). Other independent associations with ever HIV testing included urban residence (AOR 1.6, 95% CI: 1.2-2.0; p = 0.0005, women only), highest wealth index versus the four lower quintiles combined (AOR 1.8, 95% CI: 1.3-2.5; p = 0.0006, men only), and an increasing testing trend with higher levels of education. Missed opportunities for testing were identified during general or pregnancy-specific contacts with health facilities; 89% of adults said they would participate in home-based HIV testing.

CONCLUSIONS

The vast majority of HIV-infected persons in Kenya are unaware of their HIV status, posing a major barrier to HIV prevention, care and treatment efforts. New approaches to HIV testing provision and education, including home-based testing, may increase coverage. Targeted interventions should involve sexually active men, sexually active women without access to ANC, and rural and disadvantaged populations.

The measurement of condom use in four countries in East and southern Africa

Measurement of condom use is important to assess progress in increasing use. Since 2003, the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) have included new measures of self-reported condom use. We use data from Namibia, Swaziland, Tanzania, and Zambia to compare measures of condom use accounting for type of sexual partner. Condom use at last sex ranged from 20% in Tanzania to 57% in Namibia for men, and from 12% in Tanzania to 41% in Namibia for women. Reported condom use was lower in response to questions about condom use every time with last partner (from 13 to 47% for men and from 8 to 33% for women). Condom use was highest among people with two or more partners in the last year and lowest with marital partners. Overall, the prevalence of condom use was low, and there was wide variability across the various measures, countries, sexes, and types of partner. Promotion of condom use in all partnerships, but especially in non-marital relationships and among individuals with multiple partners, remains a critical strategy. New condom use questions in the DHS and AIS expand options for measuring and studying condom use.

Correlates of HIV Infection Among Sexually Active Adults in Kenya: A National Population-Based Survey

OBJECTIVE

To identify factors associated with prevalent HIV in a national HIV survey in Kenya.

METHODS

The Kenya AIDS Indicator Survey was a nationally representative population-based sero-survey that examined demographic and behavioral factors and serologic testing for HIV, HSV-2 and syphilis in adults aged 15-64 years. We analyzed questionnaire and blood testing data to identify significant correlates of HIV infection among sexually active adults.

RESULTS

Of 10,957 eligible women and 8,883 men, we interviewed 10,239 (93%) women and 7,731 (87%) men. We collected blood specimens from 9,049 women and 6,804 men of which 6,447 women and 5,112 men were sexually active during the 12 months prior to the survey. HIV prevalence among sexually active adults was 7.4%. Factors independently associated with HIV among women were region (Nyanza vs Nairobi: adjusted OR [AOR] 1.6, 95%CI 1.1-2.3), number of lifetime sex partners (6-9 vs 0-1 partners: AOR 3.0, 95%CI 1.6-5.9), HSV-2 (AOR 6.5, 95%CI 4.9-8.8), marital status (widowed vs never married: AOR 2.7, 95%CI 1.5-4.8) and consistent condom use with last sex partner (AOR 2.3, 95%CI 1.6-3.4). Among men, correlates of HIV infection were 30-to-39-year-old age group (AOR 5.2, 95%CI 2.6-10.5), number of lifetime sex partners (10+ vs 0-1 partners, AOR 3.5, 95%CI 1.4-9.0), HSV-2 (AOR 4.7, 95%CI 3.2-6.8), syphilis (AOR 2.4, 95%CI 1.4-4.0), consistent condom use with last sex partner (AOR 2.1, 95% CI 1.5-3.1) and lack of circumcision (AOR 4.0, 95%CI 2.8 - 5.5).

CONCLUSION

Kenya's heterogeneous epidemic will require regional and gender-specific prevention approaches.

A qualitative study of barriers to consistent condom use among HIV-1 serodiscordant couples in Kenya

This study explored barriers to consistent condom use among heterosexual HIV-1 serodiscordant couples who were aware of the HIV-1 serodiscordant status and had been informed about condom use as a risk reduction strategy. We conducted 28 in-depth interviews and 9 focus group discussions among purposively selected heterosexual HIV-1 serodiscordant couples from Thika and Nairobi districts in Kenya. We analyzed the transcribed data with a grounded theory approach. The most common barriers to consistent condom use included male partners' reluctance to use condoms regardless of HIV-1 status coupled with female partners' inability to negotiate condom use, misconceptions about HIV-1 serodiscordance, and desire for children. Specific areas of focus should include development of skills for women to effectively negotiate condom use, ongoing information on HIV-1 serodiscordance and education on safer conception practices that minimize risk of HIV-1 transmission.

HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention

BACKGROUND

Sexual partners of persons with newly diagnosed HIV infection require HIV counseling, testing and, if necessary, evaluation for therapy. However, many African countries do not have a standardized protocol for partner notification, and the effectiveness of partner notification has not been evaluated in developing countries .

METHODS

Individuals with newly diagnosed HIV infection presenting to sexually transmitted infection clinics in Lilongwe, Malawi, were randomized to 1 of 3 methods of partner notification: passive referral, contract referral, or provider referral. The passive referral group was responsible for notifying their partners themselves. The contract referral group was given seven days to notify their partners, after which a health care provider contacted partners who had not reported for counseling and testing. In the provider referral group, a health care provider notified partners directly.

RESULTS

Two hundred forty-five index patients named 302 sexual partners and provided locator information for 252. Among locatable partners, 107 returned for HIV counseling and testing; 20 of 82 [24%; 95% confidence interval (CI): 15% to 34%] partners returned in the passive referral arm, 45 of 88 (51%; 95% CI: 41% to 62%) in the contract referral arm, and 42 of 82 (51%; 95% CI: 40% to 62%) in the provider referral arm (P < 0.001). Among returning partners (n = 107), 67 (64%) of were HIV infected with 54 (81%) newly diagnosed.

DISCUSSION

This study provides the first evidence of the effectiveness of partner notification in sub-Saharan Africa. Active partner notification was feasible, acceptable, and effective among sexually transmitted infections clinic patients. Partner notification will increase early referral to care and facilitate risk reduction among high-risk uninfected partners.

Unsafe sex among HIV-infected adults in Kenya: results of a nationally representative survey

OBJECTIVE

Assess factors associated with knowledge of HIV status, sexual activity, and unprotected sex with a partner of unknown or negative HIV status (unsafe sex) among HIV-infected adults in Kenya.

DESIGN

Nationally representative Kenya AIDS Indicator Survey among adults aged 15-64 years in 2007.

METHODS

A standardized questionnaire was administered and blood samples tested for HIV. We assessed factors associated with knowledge of HIV infection, sexual activity, and unsafe sex. Analyses took into account stratification and clustering in the survey design and estimates were weighted to account for sampling probability.

RESULTS

Of 15,853 participants with blood samples, 1104 (6.9%) were HIV infected. Of these, 83.8% did not know their HIV status (56% had never tested; 27.8% reported their last HIV test was negative), and 80.4% were sexually active. Of 861 sexually active adults, 76.9% reported unsafe sex in the past year. Adults who did not know their HIV status were more likely to be sexually active [never tested adjusted odds ratio (AOR): 5.5, 95% confidence interval (CI): 2.8 to 10.7; ever tested, incorrect knowledge AOR: 6.5, CI: 2.1 to 19.6) and to report unsafe sex (never tested AOR: 51.7, CI: 27.3 to 97.6; ever tested, incorrect knowledge of status AOR: 18.6, CI: 8.6 to 40.5) than those who knew their status.

CONCLUSIONS

The majority of adults did not know they were infected and engaged in unsafe sex. Adults who knew their HIV status were less likely to be sexually active and report unsafe sex compared with those unaware of their infection. HIV prevention interventions that target HIV-infected adults are urgently needed.

Sexual behaviour and HIV sero-discordance among HIV patients receiving HAART in rural Uganda

Globally, HIV sero-discordance is a major public health problem, due to increased risk of HIV transmission to HIV-negative partners. From January to August 2009, we assessed the sexual behaviour of HIV-infected patients attending an HIV treatment centre in Uganda and analysed characteristics associated with HIV sero-discordance. Of the 278 respondents, 256 (92.1%) were female, 218 (78.1%) were on antiretroviral drugs and 107 (38.7%) belonged to a sero-discordant couple. In the prior 3 months, 238 (88.5%) had more than one sexual partner and 98 (35.8%) had acquired new sexual partners. Only 171 (61.5%) had ever disclosed sero-status to main sexual partners. Participants who had changed sexual partners in the previous 3 months were more likely to be sero-discordant (OR 1.87, 95% CI 1.13, 3.11). Respondents who used condoms during their last sexual intercourse and those currently on ARVs were significantly less likely to be sero-discordant (OR 0.52 95% CI 0.28, 0.96 and OR 0.52 95% CI 0.30, 0.94, respectively). Only disclosure of sero-status was independently though inversely associated with discordance (adjusted OR 0.41, 95% CI 0.20, 0.64). Our findings indicate that HIV patients continue exhibiting high risk behaviour characterised by changing sexual partners, having multiple sexual partners and non-use of condoms.

Changes in sexual risk behavior before and after HIV seroconversion in Southern African women enrolled in a HIV prevention trial

BACKGROUND

We examine changes in sexual risk behaviors before and after HIV seroconversion in southern African women enrolled in the Methods for Improving Reproductive Health in Africa trial.

METHODS

HIV testing and counseling, and assessment of sexual behaviors by audio computer-assisted self-interviewing were performed approximately every 3 months. We compared the following sexual behaviors: being sexually active, coital frequency, consistent male condom use, use of any female condoms, anal sex, and >1 sex partner, at study visits before and after HIV seroconversion.

RESULTS

During the trial, 327 women seroconverted to HIV, contributing 718 pre-HIV and 1110 post-HIV study visits. Women were significantly more likely to report consistent condom use at visits after HIV seroconversion compared with visits before HIV infection [adjusted odds ratio, (AOR): 1.36 (95% confidence interval (CI): 1.11 to 1.67)] and were less likely to have >1 male sex partner after serconversion [AOR: 0.66 (95% CI: 0.48 to 0.91)]. Women reported less frequently being sexually active [AOR: 0.63 (95% CI: 0.39 to 1.02)], fewer episodes of sex [>4 sex acts over the past week AOR: 0.74 (95% CI: 0.60 to 0.91)], and a reduction in anal sex [AOR: 0.58 (95% CI: 0.36 to 0.95)] at visits after HIV seroconversion. The observed reductions in sexual risk behaviors persisted over time.

CONCLUSIONS

Women significantly decreased their sexual risk behaviors after HIV seroconversion, but these changes were relatively modest, suggesting the need for further secondary prevention. Timely notification of HIV status coupled with prevention messages can contribute to reductions in sexual risk behaviors.

High acceptance of home-based HIV counseling and testing in an urban community setting in Uganda

Background

HIV testing is a key component of prevention and an entry point into HIV/AIDS treatment and care however, coverage and access to testing remains low in Uganda. Home-Based HIV Counseling and Testing (HBHCT) has potential to increase access and early identification of unknown HIV/AIDS disease. This study investigated the level of acceptance of Home-Based HIV Counseling and Testing (HBHCT), the HIV sero-prevalence and the factors associated with acceptance of HBHCT in an urban setting.

Methods

A cross-sectional house-to-house survey was conducted in Rubaga division of Kampala from January-June 2009. Residents aged ≥ 15 years were interviewed and tested for HIV by trained nurse-counselors using the national standard guidelines. Acceptance of HBHCT was defined as consenting, taking the HIV test and receipt of results offered during the home visit. Multivariable logistic regression analysis was performed to determine significant factors associated with acceptance of HBHCT.

Results

We enrolled 588 participants, 408 (69%, 95% CI: 66%-73%) accepted testing. After adjusting for confounding, being male (adj. OR 1.65; 95%CI 1.03, 2.73), age 25-34 (adj. OR 0.63; 95% CI 0.40, 0.94) and ≥35 years (adj. OR 0.30; 95%CI 0.17, 0.56), being previously married (adj. OR 3.22; 95%CI 1.49, 6.98) and previous HIV testing (adj. OR 0.50; 95%CI 0.30, 0.74) were significantly associated with HBHCT acceptance. Of 408 who took the test, 30 (7.4%, 95% CI: 4.8%- 9.9%) previously unknown HIV positive individuals were identified and linked to HIV care.

Conclusions

Acceptance of home-based counseling and testing was relatively high in this urban setting. This strategy provided access to HIV testing for previously untested and unknown HIV-infected individuals in the community. Age, sex, marital status and previous HIV test history are important factors that may be considered when designing programs for home-based HIV testing in urban settings in Uganda.

Continued high risk sexual behavior following diagnosis with acute HIV infection in South Africa and Malawi: implications for prevention

Understanding sexual behavior following diagnosis of acute HIV infection (AHI) is key to developing prevention programs targeting individuals diagnosed with AHI. We conducted separate qualitative and quantitative interviews with individuals newly diagnosed (n = 19) with AHI at 1-, 4- and 12-weeks post-diagnosis and one qualitative interview with individuals who had previously been diagnosed with AHI (n = 18) in Lilongwe, Malawi and Johannesburg, South Africa between October 2007 and June 2008. The majority of participants reported engaging in sexual activity following diagnosis with AHI with a significant minority reporting unprotected sex during this time. Most participants perceived to have changed their behavior following diagnosis. However, participants reported barriers to condom use and abstinence, in particular, long term relationships and the need for disclosure of sero-status. Understanding of increased infectiousness during AHI was limited. Participants reported a desire for a behavioral intervention at the time of AHI diagnosis, however, there were differences by country in the types of interventions participants found acceptable. Studies are underway to determine the feasibility, acceptability and potential effectiveness of interventions designed for individuals with AHI.

'Pregnancy comes accidentally--like it did with me': reproductive decisions among women on ART and their partners in rural Uganda

Background

As highly active antiretroviral therapy (ART) restores health, fertility and sexual activity among HIV-infected adults, understanding how ART influences reproductive desires and decisions could inform interventions to reduce sexual and vertical HIV transmission risk.

Methods

We performed a qualitative sub-study among a Ugandan cohort of 1,000 adults on ART with four purposively selected categories of participants: pregnant, not pregnant, delivered, and aborted. In-depth interviews examined relationships between HIV, ART and pregnancy, desire for children, perceived risks and benefits of pregnancy, decision-making regarding reproduction and family planning (FP) among 29 women and 16 male partners. Analysis focused on dominant explanations for emerging themes across and within participant groups.

Results

Among those who had conceived, most couples stated that their pregnancy was unintentional, and often occurred because they believed that they were infertile due to HIV. Perceived reasons for women not getting pregnant included: ill health (included HIV infection and ART), having enough children, financial constraints, fear of mother-to-child HIV transmission or transmission to partner, death of a child, and health education. Most women reported FP experiences with condoms and hormonal injections only. Men had limited FP information apart from condoms.

Conclusions

Counselling at ART initiation may not be sufficient to enable women who do not desire children to adopt relevant family planning practices. On-going reproductive health education and FP services, with emphasis on the restoration of fertility after ART initiation, should be integrated into ART programs for men and women.

Human herpesvirus 8 seropositivity among sexually active adults in Uganda

INTRODUCTION

Sexual transmission of human herpesvirus 8 (HHV8) has been implicated among homosexual men, but the evidence for sexual transmission among heterosexual individuals is controversial. We investigated the role of sexual transmission of HHV8 in a nationally representative sample in Uganda, where HHV8 infection is endemic and transmitted mostly during childhood.

MATERIALS AND METHODS

The study population was a subset of participants (n = 2681) from a population-based HIV/AIDS serobehavioral survey of adults aged 15-59 years conducted in 2004/2005. High risk for sexual transmission was assessed by questionnaire and serological testing for HIV and herpes simplex virus 2. Anti-HHV8 antibodies were measured using two enzyme immunoassays targeting synthetic peptides from the K8.1 and orf65 viral genes. The current study was restricted to 2288 sexually active adults. ORs and 95% CIs for HHV8 seropositivity were estimated by fitting logistic regression models with a random intercept using MPLUS and SAS software.

RESULTS

The weighted prevalence of HHV8 seropositivity was 56.2%, based on 1302 seropositive individuals, and it increased significantly with age (P(trend)<0.0001). In analyses adjusting for age, sex, geography, education, and HIV status, HHV8 seropositivity was positively associated with reporting two versus one marital union (OR:1.52, 95% CI: 1.17-1.97) and each unit increase in the number of children born (OR: 1.04, 95% CI: 1.00-1.08), and was inversely associated with ever having used a condom (OR: 0.64, 95% CI: 0.45-0.89). HHV8 seropositivity was not associated with HIV (P = 0.660) or with herpes simplex virus 2 (P = 0.732) seropositivity. Other sexual variables, including lifetime number of sexual partners or having had at least one sexually transmitted disease, and socioeconomic variables were unrelated to HHV8 seropositivity.

CONCLUSION

Our findings are compatible with the conclusion that sexual transmission of HHV8 in Uganda, if it occurs, is weak.

Sexual behavior and HIV transmission risk of Ugandan adults taking antiretroviral therapy: 3 year follow-up

BACKGROUND

Long-term impact of antiretroviral therapy (ART) on sexual HIV-transmission risk in Africa is unknown. We assessed sexual behavior changes and estimated HIV transmission from HIV-infected adults on ART in Uganda.

METHODS

Between 2003 and 2007, we enrolled and followed ART-naive HIV-infected adults in a home-based AIDS program with annual counseling and testing for cohabitating partners, participant transmission risk-reduction plans, condom distribution and prevention support for cohabitating discordant couples. We assessed participants' HIV plasma viral load and partner-specific sexual behaviors. We defined risky sex as intercourse with inconsistent/no condom use with HIV-negative or unknown serostatus partners in previous 3 months. We compared rates using Poisson regression models, estimated transmission risk using established viral load-specific transmission estimates, and documented sero-conversion rates among HIV-discordant couples.

RESULTS

Of 928 participants, 755 (81%) had 36 months data: 94 (10%) died and 79 (9%) missing data. Sexual activity increased from 28% (baseline) to 41% [36 months (P < 0.001)]. Of sexually active participants, 22% reported risky sex at baseline, 8% at 6 months (P < 0.001), and 14% at 36 months (P = 0.018). Median viral load among those reporting risky sex was 122,500 [interquartile range (IQR) 45 100-353 000] copies/ml pre-ART at baseline and undetectable at follow-up. One sero-conversion occurred among 62 cohabitating sero-discordant partners (0.5 sero-conversions/100 person-years). At 36 months, consistent condom use was 74% with discordant partners, 55% with unknown and 46% with concordant partners. Estimated HIV transmission risk reduced 91%, from 47.3 to 4.2/1000 person-years.

CONCLUSIONS

Despite increased sexual activity among HIV-infected Ugandans over 3 years on ART, risky sex and estimated risk of HIV transmission remained lower than baseline levels. Integrated prevention programs could reduce HIV transmission in Africa.

The better the worse: risk factors for HIV infection among women in Kenya and Uganda: demographic and health survey

The objective of the study was to investigate socio-economic status (SES) factors as risk factors for HIV among women in Kenya and Uganda. Individual data from cross-sectional, population based 2003-Kenya Demographic and Health Survey (KDHS) and 2004-Uganda AIDS Indicator Survey (AIS) were used and the probability of being HIV-positive was analysed. Contrary to the public health literature, women of high SES were also vulnerable to HIV risk. Both Ugandan and Kenyan women had similar SES risk factors to HIV and harmonising policies in the two countries to deal with the disadvantages of the social and cultural roles of women would help reduce vulnerability to HIV for women. Policies in both countries need to be broad based to cut across all socio-economic groups and deal with the complexity of HIV/AIDS. Nyanza region needs exceptional policies to deal with the high HIV prevalence and reduce risk through cultural practices like widow inheritance.

Variations in condom use by type of partner in 13 sub-Saharan African countries

Using nationally representative data from 13 sub-Saharan African countries, we reinforce and expand upon previous findings that men report using condoms more frequently than women do and that unmarried respondents report that they use condoms with casual partners more frequently than married individuals report using them with their spouses. Based on descriptive, bivariate, and multivariate analyses, we also demonstrate to a degree not previously shown in the current literature that married men from most countries report using condoms with extramarital partners about as frequently as unmarried men report using them with casual partners. Married women from most of the countries included in the study reported using condoms with extramarital partners less frequently than unmarried women reported using them with casual partners. This result is especially troubling because marriage usually ensures regular sexual intercourse, thereby providing more opportunities for a person to pass HIV infection from an extramarital partner to his or her spouse. These findings about high-risk behaviors can be used to better target future HIV-transmission-prevention efforts.

To use or not to use a condom: a prospective cohort study comparing contraceptive practices among HIV-infected and HIV-negative youth in Uganda

Background

Unwanted pregnancy and HIV infection are issues of significant concern to young people. Limited data exists on contraceptive decision-making and practices among HIV-infected and HIV-negative young people in low resource settings with generalized HIV epidemics.

Methods

From July 2007 until April 2009, we recruited, and followed up over a one year period, a cohort of 501 HIV-negative and 276 HIV-infected young women and men aged 15-24 years residing in Kampala and Wakiso districts. We compared contraceptive use among HIV-infected and HIV-negative young people and assessed factors associated with contraceptive decision-making and use, using multivariate logistic regression modelling to estimate odds ratios (OR) and 95% confidence intervals (CI).

Results

Contraceptive use among sexually active HIV-infected young people was 34% while it was 59% among the HIV-negative group. The condom was the most frequently used method of contraception. Only 24% of the HIV-infected used condoms consistently compared to 38% among the negative group OR 0.56 (95% CI 0.38, 0.82). HIV-infected young people were more likely to discuss safe sex behaviour with health workers OR 1.70 (95% CI 1.13, 2.57), though its effect on fertility decision-making was not significant. Throughout the year's follow-up, only 24% among the HIV-negative and 18% among the HIV-infected continued to use contraception while 12% and 28% among the HIV-negative and infected respectively did not use contraception at all. At multivariate analysis, the HIV-infected young people were less likely to maintain contraceptive use. Other factors independently associated with sustained contraceptive use were age of the respondent, marital status and being a male. Conversely, HIV-infected young people were less likely to initiate use of contraception. Being married or in a relationship was associated with higher odds of initiating contraceptive use.

Conclusion

Compared to the HIV-negative group, sexually active HIV-infected young people are less likely to use contraception and condoms. Initiating or sustaining contraceptive use was also significantly less among the HIV-infected group. Strengthening family planning services and developing new innovative ideas to re-market condom use are needed. Policy and guidelines that empower health workers to help young people (especially the HIV infected) express their sexuality and reproduction should urgently be developed.

Knowledge and perceptions of couples' voluntary counseling and testing in urban Rwanda and Zambia: a cross-sectional household survey

Background

Most incident HIV infections in sub-Saharan Africa occur between cohabiting, discordant, heterosexual couples. Though couples' voluntary HIV counseling and testing (CVCT) is an effective, well-studied intervention in Africa, <1% of couples have been jointly tested.

Methods

We conducted cross-sectional household surveys in Kigali, Rwanda (n = 600) and Lusaka, Zambia (n = 603) to ascertain knowledge, perceptions, and barriers to use of CVCT.

Results

Compared to Lusaka, Kigali respondents were significantly more aware of HIV testing sites (79% vs. 56%); had greater knowledge of HIV serodiscordance between couples (83% vs. 43%); believed CVCT is good (96% vs. 72%); and were willing to test jointly (91% vs. 47%). Stigma, fear of partner reaction, and distance/cost/logistics were CVCT barriers.

Conclusions

Though most respondents had positive attitudes toward CVCT, the majority were unaware that serodiscordance between cohabiting couples is possible. Future messages should target gaps in knowledge about serodiscordance, provide logistical information about CVCT services, and aim to reduce stigma and fear.

Sexual behaviors over a 3-year period among individuals with advanced HIV/AIDS receiving antiretroviral therapy in an urban HIV clinic in Kampala, Uganda

BACKGROUND

Few studies have prospectively examined sexual behaviors of HIV-infected person on antiretroviral therapy (ART) in sub-Saharan Africa.

METHODS

Between 2004 and 2005, 559 HIV-infected, ART-naïve individuals initiating ART at an HIV clinic in Kampala, Uganda, were enrolled into a prospective study and followed to 2008. Clinical and sexual behavior information was assessed at enrollment and semiannually for 3 years after ART initiation. Using log-binomial regression models, we estimated prevalence ratios (PRs) to determine factors associated with being sexually active and having unprotected sex over 3 years after initiating ART.

RESULTS

Five hundred fifty-nine adults contributed 2594 person-visits of follow-up. At the time of ART initiation, 323 (57.9%) were sexually active of which 176 (54.5%) had unprotected sex at last sexual intercourse. The majority (63.4%) of married individuals were unaware of their partner's HIV status. Female gender (PR, 2.97; 95% confidence interval, 1.85-4.79), being married (PR, 1.48; 95% confidence interval, 1.06-2.06), and reporting unprotected sex before ART (PR, 1.68; 95% confidence interval, 1.16-2.42) were among the factors independently associated with unprotected sex while on ART. Overall, 7.3% of visit intervals of unprotected sex, 1.0% of intervals of sexual activity, occurred when plasma viral load greater than 1500 copies/mL, representing periods of greater HIV transmission risk.

CONCLUSIONS

Although unprotected sex reduced over time, women reported unprotected sex more often than men. Disclosure of HIV status was low. Integration of comprehensive prevention programs into HIV care is needed, particularly ones specific for women.

A cost-effectiveness analysis of alternative HIV retesting strategies in sub-saharan Africa

BACKGROUND

Guidelines in sub-Saharan Africa on when HIV-seronegative persons should retest range from never to annually for lower-risk populations and from annually to every 3 months for high-risk populations.

METHODS

We designed a mathematical model to compare the cost-effectiveness of alternative HIV retesting frequencies. Cost of HIV counseling and testing, linkage to care, treatment costs, disease progression, and mortality, and HIV transmission are modeled for three hypothetical cohorts with posited annual HIV incidence of 0.8%, 1.3%, and 4.0%, respectively. The model compared costs, quality-adjusted life-years gained, and secondary infections averted from testing intervals ranging from 3 months to 30 years. Input parameters from sub-Saharan Africa were used and explored in sensitivity analyses.

RESULTS

Accounting for secondary infections averted, the most cost-effective testing frequency was every 7.5 years for 0.8% incidence, every 5 years for 1.3% incidence, and every 2 years for 4.0% incidence. Optimal testing strategies and their relative cost-effectiveness were most sensitive to assumptions about HIV counseling and testing and treatment costs, rates of CD4 decline, rates of HIV transmission, and whether tertiary infections averted were taken into account.

CONCLUSIONS

While higher risk populations merit more frequent HIV testing than low risk populations, regular retesting is beneficial even in low-risk populations. Our data demonstrate benefits of tailoring testing intervals to resource constraints and local HIV incidence rates.

Factors associated with HIV infection in married or cohabitating couples in Kenya: results from a nationally representative study

Background

In order to inform prevention programming, we analyzed HIV discordance and concordance within couples in the Kenya AIDS Indicator Survey (KAIS) 2007.

Methods

KAIS was a nationally representative population-based sero-survey that examined demographic and behavioral indicators and serologic testing for HIV, HSV-2, syphilis, and CD4 cell counts in 15,853 consenting adults aged 15–64 years. We analyzed interview and blood testing data at the sexual partnership level from married or cohabitating couples. Multivariable regression models were used to identify factors independently associated with HIV discordant and concordant status.

Results

Of 3256 couples identified in the survey, 2748 (84.4%) had interview and blood testing data. Overall, 3.8% of couples were concordantly infected with HIV, and in 5.8% one partner was infected, translating to 338,000 discordant couples in Kenya. In 83.6% of HIV-infected Kenyans living in married or cohabitating couples neither partner knew their HIV status. Factors independently associated with HIV-discordance included young age in women (AOR 1.5, 95% CI: 1.2–1.8; p<0.0001), increasing number of lifetime sexual partners in women (AOR 1.5, 95% CI: 1.3–1.8; p<0.0001), HSV-2 infection in either or both partners (AOR 4.1, 95% CI: 2.3–7.2; p<0.0001), and lack of male circumcision (AOR 1.6, 95% CI: 1.0–2.5; p = 0.032). Independent factors for HIV-concordance included HSV-2 infection in both partners (AOR 6.5, 95% CI: 2.3–18.7; p = 0.001) and lack of male circumcision (AOR 1.8, 95% CI: 1.0–3.3; p = 0.043).

Conclusions

Couple prevention interventions should begin early in relationships and include mutual knowledge of HIV status, reduction of outside sexual partners, and promotion of male circumcision among HIV-uninfected men. Mechanisms for effective prevention or suppression of HSV-2 infection are also needed.

Concurrent partnerships and HIV: an inconvenient truth

The strength of the evidence linking concurrency to HIV epidemic severity in southern and eastern Africa led the Joint United Nations Programme on HIV/AIDS and the Southern African Development Community in 2006 to conclude that high rates of concurrent sexual partnerships, combined with low rates of male circumcision and infrequent condom use, are major drivers of the AIDS epidemic in southern Africa. In a recent article in the Journal of the International AIDS Society, Larry Sawers and Eileen Stillwaggon attempt to challenge the evidence for the importance of concurrency and call for an end to research on the topic. However, their "systematic review of the evidence" is not an accurate summary of the research on concurrent partnerships and HIV, and it contains factual errors concerning the measurement and mathematical modelling of concurrency.Practical prevention-oriented research on concurrency is only just beginning. Most interventions to raise awareness about the risks of concurrency are less than two years old; few evaluations and no randomized-controlled trials of these programmes have been conducted. Determining whether these interventions can help people better assess their own risks and take steps to reduce them remains an important task for research. This kind of research is indeed the only way to obtain conclusive evidence on the role of concurrency, the programmes needed for effective prevention, the willingness of people to change behaviour, and the obstacles to change.

Antiretroviral therapy initiated soon after HIV diagnosis as standard care: potential to save lives?

In 2008, an estimated 33.4 million people were infected with human immunodeficiency virus (HIV) and ~4 million people were receiving antiretroviral therapy (ART). However, in 2007, an estimated 6.7 million people were in need of ART under the current World Health Organization guidelines, and 2.7 million more people became infected with HIV. Most of those not currently eligible for ART will become eligible within the next decade, making the current treatment strategy unsustainable. The development of cheaper, less toxic, and more potent antiretrovirals over the past decade has made it possible to consider novel strategies of arresting the HIV/AIDS epidemic. Evidence is growing that ART can be used to prevent HIV transmission and that earlier initiation of treatment is beneficial for those infected with HIV. A mathematical model predicts that by testing whole communities annually and treating all who are infected immediately, up to 7.2 million AIDS-related deaths could be prevented in the next 40 years, long-term funding required to fight the HIV epidemic could be reduced, and, most importantly, control of the HIV/ AIDS epidemic could be regained within 1–2 years of full-scale implementation of the strategy. We discuss the development of the concept of ART for the prevention of HIV transmission and the modeled impact that a test-and-treat strategy could have on the HIV epidemic, and consequently argue that a field trial should be carried out to confirm model parameters, highlight any practical problems, and test the model’s predictions.

Who gets tested for HIV in a South African urban township? Implications for test and treat and gender-based prevention interventions

BACKGROUND

With increasing calls for linking HIV-infected individuals to treatment and care via expanded testing, we examined sociodemographic and behavioral characteristics associated with HIV testing among men and women in Soweto, South Africa.

METHODS

We conducted a cross-sectional household survey involving 1539 men and 1877 women as part of the community-randomized prevention trial Project ACCEPT/HPTN043 between July 2007 to October 2007. Multivariable logistic regression models, stratified by sex, assessed factors associated with HIV testing and then repeated testing.

RESULTS

Most women (64.8%) and 28.9% of men reported ever having been tested for HIV, among whom 57.9% reported repeated HIV testing. In multivariable analyses, youth and students had a lower odds of HIV testing. Men and women who had conversations about HIV/AIDS with increasing frequency and who had heard about antiretroviral therapy were more likely to report HIV testing, and repeated testing. Men who had ≥ 12 years of education and who were of high socioeconomic status, and women who were married, who were of low socioeconomic status, and who had children under their care had a higher odds of HIV testing. Women, older individuals, those with higher levels of education, married individuals, and those with children under their care had a higher odds of reporting repeated HIV testing. Uptake of HIV testing was not associated with condom use, having multiple sex partners, and HIV-related stigma.

CONCLUSIONS

Given the low uptake of HIV testing among men and youth, further targeted interventions could facilitate a test and treat strategy among urban South Africans.

'Test-and-treat': the end of the HIV epidemic?

PURPOSE OF REVIEW

The aim is to review recent literature on 'test-and-treat', a prevention strategy that promotes high levels of HIV testing and initiating antiretroviral therapy upon diagnosis, regardless of CD4 cell count. Antiretroviral therapy (ART) has been shown to dramatically reduce viral load which is strongly associated with the risk of transmission, therefore there is the potential to reduce HIV transmissions with ART.

RECENT FINDINGS

Recent papers from observational studies on heterosexual sero-discordant couples found an overall rate of transmission of HIV-1 from ART-treated patients of 0.46 per 100 person-years, confirming the possibility of using ART as a prevention strategy. Several models have been used to predict the effect of this strategy and the potential risks of it. Randomized controlled trials are currently ongoing investigating the effect of ART on reducing infectiousness and the feasibility of this policy.

SUMMARY

More precise estimations of the transmission risk under virally suppressive ART (especially in MSM) and of change in sex risk behaviour at diagnosis and at start of ART are needed. Further, the benefit to individual health of very early ART initiation and the feasibility of this policy need to be evaluated. Achieving very high levels of testing should be a high priority due to the benefits of initiating ART in all those who are in need (CD4 cell count < 350 cells/μl) and potential benefits on incidence due to reductions in risk behaviour in those diagnosed. Use of ART immediately at diagnosis in those with high CD4 cell counts should await results from further studies.

Sex and geographic patterns of human herpesvirus 8 infection in a nationally representative population‐based sample in Uganda

BACKGROUND

Human herpesvirus 8 (HHV8), the infectious cause of Kaposi sarcoma, varies dramatically across Africa, suggesting that cofactors correlated with large-area geographic or environmental characteristics may influence risk of infection. Variation in HHV8 seropositivity across small-area regions within countries in Africa is unknown. We investigated this issue in Uganda, where Kaposi sarcoma distribution is uneven and well described.

METHODS

Archival samples from individuals aged 15-59 years randomly selected from a nationally representative 2004-2005 human immunodeficiency virus-AIDS serobehavioral survey were tested for HHV8 seropositivity with use of enzyme immunoassays based on synthetic peptides from the K8.1 and orf65 viral genes. Adjusted odds ratios and 95% confidence intervals (CIs) of association of HHV8 seropositivity with demographic risk factors were estimated.

RESULTS

Among 2681 individuals tested, HHV8 seropositivity was 55.4%. HHV8 seropositivity was lower in female than in male persons (adjusted odds ratio, 0.82 [95% CI, 0.69-0.97]) and increased 2.2% (95% CI, 1.0%-3.6%) in female persons and 1.2% (95% CI, 1.0%-2.3%) in male persons per year of age. HHV8 seropositivity was inversely associated with education ( P = .01, for trend) and was elevated in the West Nile region, compared with the Central region (adjusted odds ratio, 1.49 [95% CI, 1.02-2.18]) but not with other regions.

CONCLUSIONS

Our findings suggest that HHV8 seropositivity in Uganda may be influenced by cofactors correlated with small-area geography, age, sex, and education.

Comparison of home and clinic-based HIV testing among household members of persons taking antiretroviral therapy in Uganda: results from a randomized trial

OBJECTIVE

Due to high rates of undiagnosed and untreated HIV infection in Africa, we compared HIV counseling and testing (VCT) uptake among household members of patients receiving antiretroviral therapy.

METHODS

HIV-infected persons attending an AIDS clinic were randomized to a home-based or clinic-based antiretroviral therapy program including VCT for household members. Clinic arm participants were given free VCT vouchers and encouraged to invite their household members to the clinic for VCT. Home arm participants were visited, and their household members offered VCT using a 3-test rapid finger-stick testing algorithm. VCT uptake and HIV prevalence were compared.

FINDINGS

Of 7184 household members, 3974 (55.3%) were female and 4798 (66.8%) were in the home arm. Home arm household members were more likely to receive VCT than those from the clinic arm (55.8% vs. 10.9%, odds ratio: 10.41, 95% confidence interval: 7.89 to 13.73; P < 0.001), although the proportion of HIV-infected household members was higher in the clinic arm (17.3% vs. 7.1%, odds ratio: 2.76, 95% confidence interval: 1.97 to 3.86, P < 0.001). HIV prevalence among all household members tested in the home arm was 56% compared with 27% in the clinic arm. Of 148 spouses of HIV-infected patients, 69 (46.6%) were uninfected. Persons aged 15-24 were less likely to test than other age groups, and in the home arm, women were more likely to test than men.

CONCLUSIONS

Home-based VCT for household members of HIV-infected persons was feasible, associated with lower prevalence, higher uptake, and increased identification of HIV-infected persons than clinic-based provision.

Disclosure of HIV results among discordant couples in Rakai, Uganda: a facilitated couple counselling approach

Disclosure of HIV sero-positive results among HIV-discordant couples in sub-Saharan Africa is generally low. We describe a facilitated couple counselling approach to enhance disclosure among HIV-discordant couples. Using unique identifiers, 293 HIV-discordant couples were identified through retrospective linkage of married or cohabiting consenting adults individually enrolled into a cohort study and into two randomised trials of male circumcision in Rakai, Uganda. HIV-discordant couples and a random sample of HIV-infected concordant and HIV-negative concordant couples (to mask HIV status) were invited to sensitisation meetings to discuss the benefits of disclosure and couple counselling. HIV-infected partners were subsequently contacted to encourage HIV disclosure to their HIV-uninfected partners. If the index positive partner agreed, the counsellor facilitated the disclosure of HIV results, and provided ongoing support. The proportion of disclosure was determined. Eighty-one per cent of HIV-positive partners in discordant relationships disclosed their status to their HIV-uninfected partners in the presence of the counsellor. The rates of disclosure were 81.3% in male HIV-positive and 80.2% in female HIV-positive discordant couples. Disclosure did not vary by age, education or occupation. In summary, disclosure of HIV-positive results in discordant couples using facilitated couple counselling approach is high, but requires a stepwise process of sensitisation and agreement by the infected partner.

Determinants of consistent condom use vary by partner type among young men in Kisumu, Kenya: a multi-level data analysis

To evaluate whether determinants of consistent condom use vary by partner type among young sexually active Kenyan men, we conducted a cross-sectional assessment of lifetime sexual histories from a sub-sample of men enrolled in a clinical trial of male circumcision. 7913 partnerships of 1370 men were analyzed. 262 men (19%) reported never, 1018 (74%) sometimes and 92 (7%) always using a condom with their partners. Condoms were always used in 2672 (34%) of the total relationships-212 (70%) of the relationships with sex workers, 1643 (40%) of the casual and 817 (23%) of the regular/marital relationships. Factors influencing condom use varied significantly by partner type, suggesting that HIV prevention messages promoting condom use with higher-risk partners have achieved a moderate level of acceptance. However, in populations of young, single men in generalized epidemic settings, interventions should promote consistent condom use in all sexual encounters, independently of partner type and characteristics.

Integrating HIV screening into routine health care in resource-limited settings

The United Nations is committed to achieving universal access to human immunodeficiency virus (HIV) care, treatment, and prevention. Although the gateway to HIV care and secondary prevention is knowledge of serostatus, use of voluntary counseling and testing in resource-limited settings with the highest burden of HIV infection and AIDS has been limited. On the basis of evidence of increased patient uptake and the opportunity to avoid missed HIV testing opportunities in health care facilities, in 2007, the World Health Organization recommended provider-initiated HIV testing as a standard part of medical care in settings with generalized HIV epidemics. Although provider-initiated testing has shown promise, optimal implementation strategies that ensure broad coverage, while preserving human rights, remain an active area of research. We review the benefits of knowledge of HIV serostatus and evidence from multiple countries surrounding the successes and pitfalls of provider-initiated testing in health care and home-based settings.

Increasing access to HIV counseling and testing through mobile services in Kenya: strategies, utilization, and cost-effectiveness

INTRODUCTION

This study compares client volume, demographics, testing results, and costs of 3 "mobile" HIV counseling and testing (HCT) approaches with existing "stand-alone" HCT in Kenya. A retrospective cohort of 62,173 individuals receiving HCT between May 2005 and April 2006 was analyzed. Mobile HCT approaches assessed were community-site mobile HCT, semimobile container HCT, and fully mobile truck HCT. Data were obtained from project monitoring data, project accounts, and personnel interviews.

RESULTS

Mobile HCT reported a higher proportion of clients with no prior HIV test than stand-alone (88% vs. 58%). Stand-alone HCT reported a higher proportion of couples than mobile HCT (18% vs. 2%) and a higher proportion of discordant couples (12% vs. 4%). The incremental cost-effectiveness of adding mobile HCT to stand-alone services was $14.91 per client tested (vs. $26.75 for stand-alone HCT); $16.58 per previously untested client (vs. $43.69 for stand-alone HCT); and $157.21 per HIV-positive individual identified (vs. $189.14 for stand-alone HCT).

CONCLUSIONS

Adding mobile HCT to existing stand-alone HCT seems to be a cost-effective approach for expanding HCT coverage for reaching different target populations, including women and young people, and for identifying persons with newly diagnosed HIV infection for referral to treatment and care.

How HIV treatment could result in effective prevention

As the number of HIV infections continues to surpass treatment capacity, new HIV prevention strategies are imperative. Beyond individual clinical benefits, by rendering an individual less infectious, expanding access to highly active antiretroviral therapy (HAART) could also have a larger public health impact of curbing new HIV infections. Recent guidelines have moved towards initiating HAART at higher CD4 cell counts, thus increasing the number of individuals in need of treatment. A new treatment strategy is wanting that can simultaneously curb the epidemic and provide necessary treatment to those most in need. A recent debate has centered on whether an expansion of free and universal treatment, regardless of CD4 cell count, could be a means of HIV prevention. In light of the growing access to HAART in resource-limited settings and increasing evidence suggesting the clinical and prevention benefits of initiating treatment at higher CD4 cell counts, it is conceivable that, in the future, HAART will be an integral part of both individual-level clinical treatment programs as well as public health-based HIV prevention interventions.

Adapting positive prevention interventions for international settings: applying U.S. evidence to epidemics in developing countries

HIV prevention efforts with people living with HIV are critical, and Positive Prevention (PP) interventions have expanded globally to address this growing need. This article provides an overview of U.S. PP literature addressing evidence-based interventions. It continues by looking at the prevention needs and care issues of people living with HIV in Mozambique and the larger African context, and then discusses which U.S. PP models may be best suited for adaptation and use in Mozambique. The research suggests that the lessons learned from these U.S.-developed interventions can be modified to develop theoretically sound interventions. These interventions must be culturally specific and include a collaborative approach for best results.