Morbidity in the first year postpartum among HIV-infected women in Kenya

Prevalence of perinatal depression among HIV-positive women: a systematic review and meta-analysis

BACKGROUND

Increasing attention has been paid to differences in the prevalence of perinatal depression by HIV status, although inconsistent results have been reported. The aim of this systematic review and meta-analysis was to assess the relationship between perinatal depression and HIV infection. A comprehensive meta-analysis of comparative studies comparing the prevalence of antenatal or postnatal depression between HIV-infected women and HIV-negative controls was conducted.

METHODS

Studies were identified through PubMed/Medline, Scopus, Web of Science, Cochrane Library, Embase and PsycINFO, and the reading of complementary references in August 2019. Subgroup analyses were performed for anticipated explanation of heterogeneity using methodological quality and pre-defined study characteristics, including study design, geographical location and depression screening tools for depression. The overall odds ratio (OR) and mean prevalence of each group were calculated.

RESULTS

Twenty-three studies (from 21 publications), thirteen regarding antenatal depression and ten regarding postnatal depression were included, comprising 3165 subjects with HIV infection and 6518 controls. The mean prevalence of antenatal depressive symptoms in thirteen included studies was 36% (95% CI: 27, 45%) in the HIV-positive group and 26% (95% CI: 20, 32%) in the control group. The mean prevalence of postnatal depressive symptoms in ten included studies was 21% (95% CI: 14, 27%) in the HIV-positive group and 16% (95% CI: 10, 22%) in the control group. Women living with HIV have higher odds of antenatal (OR: 1.42; 95% CI: 1.12, 1.80) and postnatal depressive symptoms (OR: 1.58; 95% CI: 1.08, 2.32) compared with controls. Publication bias and moderate heterogeneity existed in the overall meta-analysis, and heterogeneity was partly explained by the subgroup analyses.

CONCLUSIONS

Women with HIV infection exhibit a significantly higher OR of antenatal and postnatal depressive symptoms compared with controls. For the health of both mother and child, clinicians should be aware of the significance of depression screening before and after delivery in this particular population and take effective measures to address depression among these women.

Concomitant contraceptive implant and efavirenz use in women living with HIV: perspectives on current evidence and policy implications for family planning and HIV treatment guidelines

Introduction: Preventing unintended pregnancies is important among all women, including those living with HIV. Increasing numbers of women, including HIV-positive women, choose progestin-containing subdermal implants, which are one of the most effective forms of contraception. However, drug–drug interactions between contraceptive hormones and efavirenz-based antiretroviral therapy (ART) may reduce implant effectiveness. We present four inter-related perspectives on this issue.

Discussion: First, as a case study, we discuss how limited data prompted country-level guidance against the use of implants among women concomitantly using efavirenz in South Africa and its subsequent negative effects on the use of implants in general. Second, we discuss the existing clinical data on this topic, including the observational study from Kenya showing women using implants plus efavirenz-based ART had three-fold higher rates of pregnancy than women using implants plus nevirapine-based ART. However, the higher rates of pregnancy in the implant plus efavirenz group were still lower than the pregnancy rates among women using common alternative contraceptive methods, such as injectables. Third, we discuss the four pharmacokinetic studies that show 50–70% reductions in plasma progestin concentrations in women concurrently using efavirenz-based ART as compared to women not on any ART. These pharmacokinetic studies provide the biologic basis for the clinical findings. Fourth, we discuss how data on this topic have marked implications for both family planning and HIV programmes and policies globally.

Conclusion: This controversy underlines the importance of integrating family planning services into routine HIV care, counselling women appropriately on increased risk of pregnancy with concomitant implant and efavirenz use, and expanding contraceptive method mix for all women. As global access to ART expands, greater research is needed to explore implant effectiveness when used concomitantly with newer ART regimens. Data on how HIV-positive women and their partners choose contraceptives, as well as information from providers on how they present and counsel patients on contraceptive options are needed to help guide policy and service delivery. Lastly, greater collaboration between HIV and reproductive health experts at all levels are needed to develop successful strategies to ensure the best HIV and reproductive health outcomes for women living with HIV.

Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers

AIMS

To investigate putative links between alcohol use, and unsafe sex and incident HIV infection in sub-Saharan Africa.

METHODS

A cohort of 400 HIV-negative female sex workers was established in Mombasa, Kenya. Associations between categories of the Alcohol Use Disorders Identification Test (AUDIT) and the incidence at one year of unsafe sex, HIV and pregnancy were assessed using Cox proportional hazards models. Violence or STIs other than HIV measured at one year was compared across AUDIT categories using multivariate logistic regression.

RESULTS

Participants had high levels of hazardous (17.3%, 69/399) and harmful drinking (9.5%, 38/399), while 36.1% abstained from alcohol. Hazardous and harmful drinkers had more unprotected sex and higher partner numbers than abstainers. Sex while feeling drunk was frequent and associated with lower condom use. Occurrence of condom accidents rose step-wise with each increase in AUDIT category. Compared with non-drinkers, women with harmful drinking had 4.1-fold higher sexual violence (95% CI adjusted odds ratio [AOR] = 1.9-8.9) and 8.4 higher odds of physical violence (95% CI AOR = 3.9-18.0), while hazardous drinkers had 3.1-fold higher physical violence (95% CI AOR = 1.7-5.6). No association was detected between AUDIT category and pregnancy, or infection with Syphilis or Trichomonas vaginalis. The adjusted hazard ratio of HIV incidence was 9.6 comparing women with hazardous drinking to non-drinkers (95% CI = 1.1-87.9).

CONCLUSIONS

Unsafe sex, partner violence and HIV incidence were higher in women with alcohol use disorders. This prospective study, using validated alcohol measures, indicates that harmful or hazardous alcohol can influence sexual behaviour. Possible mechanisms include increased unprotected sex, condom accidents and exposure to sexual violence. Experimental evidence is required demonstrating that interventions to reduce alcohol use can avert unsafe sex.

[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]

OBJECTIVE

The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit.

METHODS

We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS.

RESULTS AND CONCLUSIONS

The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).

Maternal anaemia and duration of zidovudine in antiretroviral regimens for preventing mother-to-child transmission: a randomized trial in three African countries

BACKGROUND

Although substantiated by little evidence, concerns about zidovudine-related anaemia in pregnancy have influenced antiretroviral (ARV) regimen choice for preventing mother-to-child transmission of HIV-1, especially in settings where anaemia is common.

METHODS

Eligible HIV-infected pregnant women in Burkina Faso, Kenya and South Africa were followed from 28 weeks of pregnancy until 12-24 months after delivery (n = 1070). Women with a CD4 count of 200-500 cells/mm(3) and gestational age 28-36 weeks were randomly assigned to zidovudine-containing triple-ARV prophylaxis continued during breastfeeding up to 6-months, or to zidovudine during pregnancy plus single-dose nevirapine (sd-NVP) at labour. Additionally, two cohorts were established, women with CD4 counts: <200 cells/mm(3) initiated antiretroviral therapy, and >500 cells/mm(3) received zidovudine during pregnancy plus sd-NVP at labour. Mild (haemoglobin 8.0-10.9 g/dl) and severe anaemia (haemoglobin < 8.0 g/dl) occurrence were assessed across study arms, using Kaplan-Meier and multivariable Cox proportional hazards models.

RESULTS

At enrolment (corresponded to a median 32 weeks gestation), median haemoglobin was 10.3 g/dl (IQR = 9.2-11.1). Severe anaemia occurred subsequently in 194 (18.1%) women, mostly in those with low baseline haemoglobin, lowest socio-economic category, advanced HIV disease, prolonged breastfeeding (≥ 6 months) and shorter ARV exposure. Severe anaemia incidence was similar in the randomized arms (equivalence P-value = 0.32). After 1-2 months of ARV's, severe anaemia was significantly reduced in all groups, though remained highest in the low CD4 cohort.

CONCLUSIONS

Severe anaemia occurs at a similar rate in women receiving longer triple zidovudine-containing regimens or shorter prophylaxis. Pregnant women with pre-existing anaemia and advanced HIV disease require close monitoring.

TRIAL REGISTRATION NUMBER

ISRCTN71468401.

Attitudes toward family planning among HIV-positive pregnant women enrolled in a prevention of mother-to-child transmission study in Kisumu, Kenya

Background

Preventing unintended pregnancies among HIV-positive women through family planning (FP) reduces pregnancy-related morbidity and mortality, decreases the number of pediatric HIV infections, and has also proven to be a cost-effective way to prevent mother-to-child HIV transmission. A key element of a comprehensive HIV prevention agenda, aimed at avoiding unintended pregnancies, is recognizing the attitudes towards FP among HIV-positive women and their spouse or partner. In this study, we analyze FP attitudes among HIV-infected pregnant women enrolled in a PMTCT clinical trial in Western Kenya.

Methods and Findings

Baseline data were collected on 522 HIV-positive pregnant women using structured questionnaires. Associations between demographic variables and the future intention to use FP were examined using Fisher's exact tests and permutation tests. Most participants (87%) indicated that they intended to use FP. However, only 8% indicated condoms as a preferred FP method, and 59% of current pregnancies were unintended. Factors associated with positive intentions to use FP were: marital status (p = 0.04), having talked to their spouse or partner about FP (p<0.001), perceived spouse or partner approval of FP (p<0.001), previous use of a FP method (p = 0.006), attitude toward the current pregnancy (p = 0.02), disclosure of a sexually transmitted infection (STI) diagnosis (p = 0.03) and ethnic group (p = 0.03).

Conclusion

A significant gap exists between future FP intentions and current FP practices. Support and approval by the spouse or partner are key elements of FP intentions. Counseling services should be offered to both members of a couple to increase FP use, especially given the high number of unplanned pregnancies among HIV-positive women. Condoms should be promoted as part of a dual use method for HIV and STI prevention and for contraception. Integration of individual and couple FP services into routine HIV care, treatment and support services is needed in order to avoid unintended pregnancies and to prevent mother-to-child HIV transmission.

Determinants of anemia in postpartum HIV-negative women in Dar es Salaam, Tanzania

OBJECTIVE

The determinants of anemia during both pregnancy and postpartum recovery remain incompletely understood in sub-Saharan African women.

SUBJECTS/METHODS

In a prospective cohort study among pregnant women, we assessed dietary, biochemical, anthropometric, infectious and sociodemographic factors at baseline. In multivariate Cox proportional hazards models, we examined predictors of incident anemia (hemoglobin <11 g/dl) and iron deficiency anemia (anemia plus mean corpuscular volume <80fL), and recovery from anemia and iron deficiency anemia through 18 months postpartum at antenatal clinics in Dar es Salaam, Tanzania between 2001 and 2005. A total of 2364 non-anemic pregnant women and 4884 anemic women were enrolled between 12 and 27 weeks of gestation.

RESULTS

In total, 292 women developed anemia during the postpartum period and 165 developed iron deficiency anemia, whereas 2982 recovered from baseline anemia and 2044 from iron deficiency anemia. Risk factors for postpartum anemia were delivery complications (RR 1.6, 95% confidence interval (CI) 1.13, 2.22) and low postpartum CD4 cell count (RR 1.73, 95% CI 0.96, 3.17). Iron/folate supplementation during pregnancy had a protective relationship with the incidence of iron deficiency anemia. Absence of delivery complications, education status and iron/folate supplementation were positively associated with time to recovery from iron deficiency.

CONCLUSION

Maternal nutritional status during pregnancy, prenatal iron/folate supplementation, perinatal care, and prevention and management of infections, such as malaria, are modifiable risk factors for the occurrence of, and recovery from, anemia.

Changes in sexual behaviour among HIV-infected women in west and east Africa in the first 24 months after delivery

OBJECTIVE

Describe changes in sexual behaviour and determinants of unsafe sex among HIV-infected women in the 24 months after delivery.

DESIGN

Cohort analysis nested within a prevention of mother-to-child transmission trial in Burkina Faso (n = 339) and Kenya (n = 432).

METHODS

Women were followed during pregnancy and until 12-24 months after delivery. At each visit, structured questionnaires were administered about sexual activity and condom use, and risk-reduction counselling and condoms were provided.

RESULTS

At study entry, a median 2 months after HIV testing (interquartile range =1-4), 411/770 (53.4%) of women reported partner disclosure, increasing to 284/392 (71.9%) at the final visit. Although most partners were supportive following disclosure, between 5 and 10% of disclosed women experienced hostile or unsupportive partner responses during follow-up visits. At each visit, about a third of sexually active women reported unsafe sex (unprotected sex with HIV-uninfected or unknown status partner). In multivariable logistic regression, unsafe sex was 1.70-fold more likely in Kenyan than in Burkinabe women [95% confidence interval (95% CI) = 1.14-2.54], and in those with less advanced HIV disease or aged 16-24 years. Compared with women who disclosed their status to partners and others, unsafe sex was over six-fold higher in nondisclosers (95% CI = 3.31-12.11), the effect size reducing with increasing disclosure.

CONCLUSION

HIV-infected women who recently delivered have a high potential for further HIV transmission, especially as HIV discordance is common in Africa. Longitudinal care for women, including positive-prevention interventions, is needed within new services providing antiretroviral prophylaxis during breastfeeding - this repeated interface with services could focus on reducing unsafe sex. Much remains unknown about how to facilitate beneficial disclosure.

Family planning and the burden of unintended pregnancies

Family planning is hailed as one of the great public health achievements of the last century, and worldwide acceptance has risen to three-fifths of exposed couples. In many countries, however, uptake of modern contraception is constrained by limited access and weak service delivery, and the burden of unintended pregnancy is still large. This review focuses on family planning's efficacy in preventing unintended pregnancies and their health burden. The authors first describe an epidemiologic framework for reproductive behavior and pregnancy intendedness and use it to guide the review of 21 recent, individual-level studies of pregnancy intentions, health outcomes, and contraception. They then review population-level studies of family planning's relation to reproductive, maternal, and newborn health benefits. Family planning is documented to prevent mother-child transmission of human immunodeficiency virus, contribute to birth spacing, lower infant mortality risk, and reduce the number of abortions, especially unsafe ones. It is also shown to significantly lower maternal mortality and maternal morbidity associated with unintended pregnancy. Still, a new generation of research is needed to investigate the modest correlation between unintended pregnancy and contraceptive use rates to derive the full health benefits of a proven and cost-effective reproductive technology.

Use of antiretrovirals during pregnancy and breastfeeding in low-income and middle-income countries

PURPOSE OF REVIEW

The purpose of the study was to review recent evidence on the use of antiretrovirals during pregnancy and breastfeeding in low-income and middle-income settings.

RECENT FINDINGS

Access to antiretroviral prophylaxis strategies for HIV-infected pregnant women has increased globally, but two-thirds of women in need still do not receive even the simplest regimen for the prevention of mother-to-child transmission of HIV, and most pregnant women in need of antiretroviral treatment do not receive it. The use of combination antiretroviral treatment in pregnancy in low-resource settings is safe and effective, and increasing evidence supports starting ongoing antiretroviral treatment at a CD4 cell count below 350/microl in pregnant women. The use of appropriate short-course antiretroviral prophylactic regimens is effective for prevention of mother-to-child transmission of HIV in women with higher CD4 cell counts. New data on the use of antiretroviral prophylaxis to prevent transmission through breastfeeding demonstrate that both maternal antiretroviral treatment and extended infant prophylaxis are effective.

SUMMARY

Antiretroviral use in pregnancy can benefit mothers in need of treatment and reduce the risk of mother-to-child transmission. Emerging evidence of the effectiveness of antiretroviral prophylaxis in preventing transmission through breastfeeding is encouraging and likely to influence practice in the future.

Association of HIV infection with distribution and viral load of HPV types in Kenya: a survey with 820 female sex workers

BACKGROUND

Human papillomavirus (HPV) and HIV are each responsible for a considerable burden of disease. Interactions between these infections pose substantial public health challenges, especially where HIV prevalence is high and HPV vaccine coverage low.

METHODS

Between July 2005 and January 2006, a cross-sectional community-based survey in Mombasa, Kenya, enrolled female sex workers using snowball sampling. After interview and a gynaecological examination, blood and cervical cytology samples were taken. Quantitative real-time PCR detected HPV types and viral load measures. Prevalence of high-risk HPV was compared between HIV-infected and -uninfected women, and in women with abnormal cervical cytology, measured using conventional Pap smears.

RESULTS

Median age of the 820 participants was 28 years (inter-quartile range [IQR] = 24-36 years). One third of women were HIV infected (283/803; 35.2%) and these women were y more likely to have abnormal cervical cytology than HIV-negative women (27%, 73/269, versus 8%, 42/503; P < 0.001). Of HIV-infected women, 73.3% had high-risk HPV (200/273) and 35.5% had HPV 16 and/or 18 (97/273). Corresponding figures for HIV-negative women were 45.5% (229/503) and 15.7% (79/503). After adjusting for age, number of children and condom use, high-risk HPV was 3.6 fold more common in HIV-infected women (95%CI = 2.6-5.1). Prevalence of all 15 of the high-risk HPV types measured was higher among HIV-infected women, between 1.4 and 5.5 fold. Median total HPV viral load was 881 copies/cell in HIV-infected women (IQR = 33-12,110 copies/cell) and 48 copies/cell in HIV-uninfected women (IQR = 6-756 copies/cell; P < 0.001). HPV 16 and/or HPV 18 were identified in 42.7% of LSIL (32/75) and 42.3% of HSIL (11/26) lesions (P = 0.98). High-risk HPV types other than 16 and 18 were common in LSIL (74.7%; 56/75) and HSIL (84.6%; 22/26); even higher among HIV-infected women.

CONCLUSIONS

HIV-infected sex workers had almost four-fold higher prevalence of high-risk HPV, raised viral load and more precancerous lesions. HPV 16 and HPV 18, preventable with current vaccines, were associated with cervical disease, though other high-risk types were commoner. HIV-infected sex workers likely contribute disproportionately to HPV transmission dynamics in the general population. Current efforts to prevent HIV and HPV are inadequate. New interventions are required and improved implementation of existing strategies.

Maternal morbidity in the first year after childbirth in Mombasa Kenya; a needs assessment

BACKGROUND

In sub-Saharan Africa, few services specifically address the needs of women in the first year after childbirth. By assessing the health status of women in this period, key interventions to improve maternal health could be identified. There is an underutilised opportunity to include these interventions within the package of services provided for woman-child pairs attending child-health clinics.

METHODS

This needs assessment entailed a cross-sectional survey with 500 women attending a child-health clinic at the provincial hospital in Mombasa, Kenya. A structured questionnaire, clinical examination, and collection of blood, urine, cervical swabs and Pap smear were done. Women's health care needs were compared between the early (four weeks to two months after childbirth), middle (two to six months) and late periods (six to twelve months) since childbirth.

RESULTS

More than one third of women had an unmet need for contraception (39%, 187/475). Compared with other time intervals, women in the late period had more general health symptoms such as abdominal pain, fever and depression, but fewer urinary or breast problems. Over 50% of women in each period had anaemia (Hb <11 g/l; 265/489), with even higher levels of anaemia in those who had a caesarean section or had not received iron supplementation during pregnancy. Bacterial vaginosis was present in 32% (141/447) of women, while 1% (5/495) had syphilis, 8% (35/454) Trichomonas vaginalis and 11% (54/496) HIV infection.

CONCLUSION

Throughout the first year after childbirth, women had high levels of morbidity. Interface with health workers at child health clinics should be used for treatment of anaemia, screening and treatment of reproductive tract infections, and provision of family planning counselling and contraception. Providing these services during visits to child health clinics, which have high coverage both early and late in the year after childbirth, could make an important contribution towards improving women's health.

Benefits and costs of expanding access to family planning programs to women living with HIV

OBJECTIVE

This analysis models the potential benefits and costs of adding family planning to national strategies for achieving universal access to programs to prevent mother-to-child HIV transmission.

METHODS

We assume a service delivery perspective and estimate the cost-effectiveness of programs to reduce the number of HIV-infected children through using antiretroviral prophylaxis to prevent perinatal transmission, and of family planning programs to avert additional infant infections not already averted by antiretroviral prophylaxis, as well as of family planning to reduce the number of total unintended births to women living with HIV. Data are presented from the 139 countries included in the 2008 Annual United Nations Joint Programme on HIV/AIDS Report, although the main results are for the 14 countries with the largest number of HIV-infected pregnant women.

RESULTS

Programs to prevent perinatal HIV transmission would, if accessed by all women in need with the most efficacious antiretroviral regimen available, prevent over 240,000 dollars infant HIV infections in the top 14 countries (over 300,000 globally) at an estimated cost of over 131 million dollars (208 million dollars globally). However, almost 72,000 infant HIV infections would still occur in the 14 countries (over 90,000 globally) that could have been averted by preventing unintended pregnancies at a cost of only about 26 million dollars (over 33 million dollars globally). If all unintended births (whether or not resulting in HIV-infected children) to HIV-positive women were prevented with family planning, the cost per birth averted would be 61 dollars in the 14 countries (63 dollars globally).

CONCLUSION

This analysis suggests that national strategies should adopt a comprehensive approach to preventing mother-to-child transmission and thus focus on preventing perinatal HIV transmission as well as unintended pregnancies. Family planning is cost-effective for preventing HIV transmission and unintended pregnancies and will also reduce infant and maternal mortality and result in fewer orphans.

Effect of human immunodeficiency virus treatment on maternal mortality at a tertiary center in South Africa: a 5-year audit

OBJECTIVE

To review facility-based maternal deaths at a tertiary-level center in Johannesburg, South Africa, during a 5-year period (2003 to 2007) and to investigate the proportion of deaths attributable to human immunodeficiency virus (HIV), the etiology of deaths, and the effects of antiretroviral treatment introduced in late 2004.

METHODS

Patient case files, birth registers, death certificates, and mortality summaries were reviewed. Cause of death was assigned through clinical case discussion. Annual maternal mortality ratios were calculated and disaggregated by HIV status.

RESULTS

During the 5-year period, 106 maternal deaths occurred out of 36,708 births (facility-based maternal mortality ratios 289/100,000 live births, 95% confidence interval [CI] 237-349/100,000). In 72% of cases, HIV status was known (76/106), with the majority being HIV-infected (78%, 59/76). Among HIV-infected women, only two had initiated antiretroviral treatment, and 70% of deaths were HIV-related (41/59), mainly from tuberculosis (21) and pneumonia (12). Direct obstetric causes of death such as hypertension and pregnancy-related sepsis predominated in women who were HIV-negative or of unknown status (48.9%, 23/47). Maternal mortality ratios in HIV-infected women were 776/100,000 (95% CI 591-1,000/100,000), 6.2-fold higher (95% CI 3.6-11.4) than in HIV-negative women (124/100,000, 95% CI 72-199/100,000). Changes in mortality over time were not detected. Although HIV testing increased 1.4-fold each year (95% CI 1.3-1.4) and estimated coverage of antiretroviral treatment for pregnant women reached 59.2% in 2007, levels remain suboptimal.

CONCLUSION

In Johannesburg, HIV remains the major cause of maternal mortality despite integration of antiretroviral treatment into prenatal services. Maternal health services should target barriers to uptake of HIV treatment and care.

LEVEL OF EVIDENCE

III.

Vulnerability of women in southern Africa to infection with HIV: biological determinants and priority health sector interventions

OBJECTIVE

To review biomedical determinants of women's vulnerability to infection with HIV and interventions to counter this, within the southern African context.

RESULTS

Apart from number of exposures, if any, several factors influence the efficiency of HIV transmission during sex. Acute HIV infection, with extraordinarily high semen viral load, in conjunction with concurrent partnerships maximizes this efficiency. Delaying sexual debut and avoiding HIV exposure among biologically and socially vulnerable youth is critical. Reducing unintended pregnancies keeps girls in school and prevents vertical (also possibly horizontal) transmission. Female condoms, especially newer versions, are an under-exploited prevention technology. Control of sexually transmitted infections (STI), which facilitate HIV acquisition and transmission, remains important, especially among the most at-risk populations. Pathogens, such as herpes simplex virus type 2, which contribute most to HIV transmission in southern Africa must be targeted, although the importance of bacterial vaginosis and Trichomonas vaginalis is under-recognized. Also, heavy episodic alcohol use affects sexual decision-making and condom skills. Moreover, prevailing social contexts, partly a consequence of poor leadership, constrain the behavioural 'choices' available for girls and women.

CONCLUSIONS

Priority health sector interventions for preventing HIV are: male and female condom programming; prevention and control of STI; outreach to most vulnerable populations; HIV testing in all patient-provider encounters; male circumcision; and the integration of HIV prevention within sexual and reproductive health services. Future interventions during acute HIV infection and microbicides will reduce women's biological vulnerability. Far-reaching measures, such as sexual equity and alcohol control, create conditions necessary for achieving sustained prevention results. These are, however, contingent on stronger, more informed cultural and political leadership.