Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials

'I still desire to have a child': a qualitative analysis of intersectional HIV- and childlessness-related stigma in rural southwestern Uganda

This study explored the intersecting forms of stigma experienced by HIV-serodifferent couples with unmet reproductive goals in rural Uganda. The parent mixed-methods study, which included 131 HIV-exposed women with plans for pregnancy, offered comprehensive HIV prevention counselling and care over a nine-month period. In-depth interviews were conducted with 37 women and seven male partners to explore care experiences and the use of safer conception strategies. This secondary analysis explored how challenges conceiving informed pregnancy plans and HIV prevention behaviours. The following themes were developed (1) partnership conflicts arise from HIV- and infertility-related forms of stigma, contributing to gender-based violence, partnership dissolution and the pursuit of new partners; (2) cultural and gender norms pressure men and women to conceive and maintain partnerships, which is complicated by the stigma directed towards serodifferent couples; (3) frustration with low partner participation in safer conception strategies led to the decreased use of these methods of HIV prevention; (4) health care provider support promotes continued hope of conception and helps overcome stigma. In HIV-affected partnerships, these intersecting forms of stigma may impact HIV prevention. Seeking to fulfil their reproductive needs, partners may increase HIV transmission opportunities as they engage in condomless sex with additional partners and decrease adherence to prevention strategies. Future research programmes should consider the integration of fertility counselling with reproductive and sexual health care.

The Impact of Genital Ulcers on HIV Transmission Has Been Underestimated—A Critical Review

In the early 1990s, several observational studies determined that genital ulcer disease (GUD), in either the index or the exposed person, facilitates HIV transmission. Several meta-analyses have since presented associated risk ratios (RR) over the baseline per-act transmission probability (PATP) usually in the range of 2–5. Here we review all relevant observational studies and meta-analyses, and show that the estimation of RRs was, in most cases, biased by assuming the presence of GUD at any time during long follow-up periods, while active genital ulcers were present in a small proportion of the time. Only two studies measured the GUD co-factor effect in PATPs focusing on acts in which ulcers were present, and both found much higher RRs (in the range 11–112). We demonstrate that these high RRs can be reconciled with the studies on which currently accepted low RRs were based, if the calculations are restricted to the actual GUD episodes. Our results indicate that the effect of genital ulcers on the PATP of HIV might be much greater than currently accepted. We conclude that the medical community should work on the assumption that HIV risk is very high during active genital ulcers.

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial

BACKGROUND

Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates.

METHODS

In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16-34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044.

FINDINGS

Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16-34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84-1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15-1·65; p=0·0006).

INTERPRETATION

Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities.

FUNDING

Australian National Health and Medical Research Council.

The prevalence and associated factors of Treponema pallidum among HIV-positive and HIV-negative individuals who attended voluntary counseling and testing center of St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia: A cross-sectional study design

Background:

Treponema pallidum and HIV are among the most common public health problems in Ethiopia. These infections are interrelated. Treponema pallidum causes genital ulcer which enhances HIV transmission and complicates HIV by causing severe ulcer among HIV-positive individuals. Although Treponema pallidum and HIV have a similar route of transmission, screening services for Treponema pallidum are not available in most of the voluntary counseling and testing centers.

Objectives:

This study aimed to assess the seroprevalence of Treponema pallidum and sociodemographic factors among HIV-positive and HIV-negative individuals from the voluntary counseling and testing center of St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia.

Methods:

In this research, a cross-sectional study was conducted and a total of 292 consecutive samples were collected from the voluntary counseling and testing center of St. Paul’s Hospital Millennium Medical College. Data were collected using an interviewer-administered questionnaire. A blood specimen was tested for the presence of Treponema pallidum using rapid plasma reagin and a rapid test kit for HIV. The data were entered and analyzed using SPSS version 20.

Results:

The overall prevalence of Treponema pallidum was 5/292 (1.7%). All HIV-positive clients were negative for Treponema pallidum. None of the risk factors were significantly associated with Treponema pallidum.

Conclusion:

In this study, the prevalence of Treponema pallidum was 5/292 (1.7%). None of the study participants were co-infected with Treponema pallidum and HIV.

Recommendation:

There was a lack of association between syphilis and HIV in this study, but still the prevalence of Treponema pallidum among voluntary counseling and testing center clients is a public health problem. Therefore, Treponema pallidum infection control strategies should be designed in parallel with HIV control strategy and actions should be taken to avert the problem, including the provision of better health education and screening services at voluntary counseling and testing centers parallel with HIV.

Proportion of Incident Human Immunodeficiency Virus Cases Among Men Who Have Sex With Men Attributable to Gonorrhea and Chlamydia: A Modeling Analysis

BACKGROUND

Sexually transmitted infections (STIs) are associated with an increased risk of human immunodeficiency virus (HIV) acquisition and transmission. We estimated the proportion of HIV incidence among men who have sex with men attributable to infection with the 2 most common bacterial STIs, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT).

METHODS

We used a stochastic, agent-based model of a sexual network of MSM with cocirculating HIV, NG, and CT infections. Relative risk (RR) multipliers, specific to anatomic site of infection, modified the risk of HIV transmission and acquisition based on STI status. We estimated the effect of NG and CT on HIV incidence overall and on HIV acquisition and HIV transmission separately. Each scenario was simulated for 10 years. The population attributable fraction (PAF) was determined for each combination of RRs by comparing the incidence in the final year of a scenario to a scenario in which the RRs associated with NG and CT were set to 1.0.

RESULTS

Overall, 10.2% (interquartile range [IQR], 7.9-12.4) of HIV infections were attributable to NG/CT infection. Then in sensitivity analyses, the PAF for HIV transmission ranged from 3.1% (IQR, 0.5-5.2) to 20.4% (IQR, 17.8-22.5) and the PAF for HIV acquisition ranged from 2.0% (IQR, -0.7 to 4.3) to 13.8% (IQR, 11.7-16.0).

CONCLUSIONS

Despite challenges in estimating the causal impact of NG/CT on HIV risk, modeling is an alternative approach to quantifying plausible ranges of effects given uncertainty in the biological cofactors. Our estimates represent idealized public health interventions in which STI could be maximally prevented, setting targets for real-world STI interventions that seek to reduce HIV incidence.

Using partner notification to address curable sexually transmitted infections in a high HIV prevalence context: a qualitative study about partner notification in Botswana

BACKGROUND

Partner notification is an essential component of sexually transmitted infection (STI) management. The process involves identifying exposed sex partner(s), notifying these partner(s) about their exposure to a curable STI, and offering counselling and treatment for the STI as a part of syndromic management or after results from an STI test. When implemented effectively, partner notification services can prevent the index patient from being reinfected with a curable STI from an untreated partner, reduce the community burden of curable STIs, and prevent adverse health outcomes in both the index patient and his or her sex partner(s). However, partner notification and treatment rates are often low. This study seeks to explore experiences and preferences related to partner notification and treatment for curable STIs among pregnant women receiving care in an antenatal clinic with integrated HIV and curable STI testing. Results are intended to inform efforts to improve partner notification and treatment rates in Southern Africa.

METHODS

We conducted qualitative interviews among women diagnosed with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and/or Trichomonas vaginalis (TV) infection while seeking antenatal care in Gaborone, Botswana. Semi-structured interviews were used to obtain women's knowledge about STIs and their experiences and preferences regarding partner notification.

RESULTS

Fifteen women agreed to participate in the study. The majority of women had never heard of CT, NG, or TV infections prior to testing. Thirteen out of 15 participants had notified partners about the STI diagnosis. The majority of notified partners received some treatment; however, partner treatment was often delayed. Most women expressed a preference for accompanying partners to the clinic for treatment. Experiences and preferences did not differ by HIV infection status.

CONCLUSIONS

The integration of STI, HIV, and antenatal care services may have contributed to most women's willingness to notify partners. However, logistical barriers to partner treatment remained. More research is needed to identify effective and appropriate strategies for scaling-up partner notification services in order to improve rates of partners successfully contacted and treated, reduce rates of STI reinfection during pregnancy, and ultimately reduce adverse maternal and infant outcomes attributable to antenatal STIs.

Global Challenges to Human Immunodeficiency Virus Prevention

Because of the high prevalence of human immunodeficiency virus (HIV), men who have sex with men (MSM) is socially branded in many countries, and epidemiological approaches have become difficult for this group. This study reviewed the clinical development and political challenges associated with HIV infection. Organizing and disseminating clinical medical advances can help us eliminate social stigmas and the dishonor linked to MSM. In addition, dealing with the worldwide infection problem of MSM can help to reestablish international joint confrontation and political agendas to promote disease eradication efforts. In many countries, socioeconomic problems are not related to increased numbers of HIV infections. Improving social issues such as human rights and economic problems depending on the circumstances of each country should help reduce the risk of HIV infection. The stigmas affecting HIV-infected persons vary greatly depending on the country. It is a serious problem in many countries, including Korea. It is also an important obstacle to those who work to prevent HIV infection. This stigma is a factor that prevents HIV patients from being diagnosed and treated at an early stage. Delayed diagnosis of and delayed treatment for HIV-infected people not only worsen an individual's prognosis but also can spread HIV socially. Efforts to reduce the stigma are necessary not only for individuals with HIV but also for public health.

Implementation of a comprehensive safer conception intervention for HIV-serodiscordant couples in Kenya: uptake, use and effectiveness

INTRODUCTION

Safer conception strategies minimize HIV risk during condomless sex to become pregnant. Gaps remain in understanding the acceptability, feasibility and choices HIV-serodiscordant couples make when multiple safer conception options are available.

METHODS

We conducted a pilot study of a comprehensive safer conception package for HIV-serodiscordant couples with immediate fertility desires in Kenya from March 2016 to April 2018. The intervention package included antiretroviral therapy (ART) for HIV-positive partners, oral pre-exposure prophylaxis (PrEP) for HIV-negative partners, daily fertility and sexual behaviour tracking via short message service (SMS) surveys, counselling on self-insemination, and referrals for voluntary medical male circumcision and fertility care. Couples attended monthly visits until pregnancy with HIV testing for negative partners at each visit. We estimated the number of expected HIV seroconversions using a counterfactual cohort simulated from gender-matched couples in the placebo arm of a previous PrEP clinical trial. We used bootstrap methods to compare expected and observed seroconversions.

RESULTS

Of the 74 enrolled couples, 54% were HIV-negative female/HIV-positive male couples. The 6 and 12-month cumulative pregnancy rates were 45.3% and 61.9% respectively. In the month preceding pregnancy, 80.9% of HIV-positive partners were virally suppressed, 81.4% of HIV-negative partners were highly adherent to PrEP, and SMS surveys indicated potential timing of condomless sex to peak fertility (median of sex acts = 10, interquartile range (IQR) 7 to 12; median condomless sex acts = 3.5, IQR 1 to 7). Most (95.7%) pregnancies were protected by ≥2 strategies: 57.4% were protected by high PrEP and ART adherence, male circumcision with or without timed condomless sex; 10 (21.3%) were protected by viral suppression in the HIV-positive partner and male circumcision with or without timed condomless sex; 8 (17.0%) were protected by high PrEP adherence and male circumcision with or without timed condomless sex. We observed 0 HIV seroconversions (95% CI 0.0 to 6.0 per 100 person years), indicating a 100% reduction in HIV risk (p = 0.04).

CONCLUSIONS

The use of multiple safer conception strategies, primarily PrEP, ART, male circumcision and/or tracking fertility, was acceptable and feasible for African HIV-serodiscordant couples and significantly reduced HIV transmission risk. It is important to increase the availability of and counselling about safer conception services in regions with HIV epidemics involving heterosexual transmission and high fertility.

Prevalence of sexually transmitted infections (HIV, hepatitis B virus, herpes simplex virus type 2, and syphilis) in pregnant women in Ethiopia: Trends over 10 years (2005-2014)

OBJECTIVES

This study was performed to determine the trends in seroprevalence of four major sexually transmitted infections (STIs) (HIV, hepatitis B virus (HBV), herpes simplex virus type 2 (HSV-2), and syphilis) over a 10-year period (2005-2014) in pregnant women in Ethiopia.

METHODS

Pregnant women (15-49 years old) who were enrolled in the antenatal care-based national HIV surveillance were included. Serological tests for HIV, HBV, HSV-2, and syphilis were done on serum/plasma samples.

RESULTS

A total of 4887 pregnant women were included. Results showed a decline in prevalence of these STIs by 40-60% over the 10 years (2005-2014): HIV (10.5% to 5.5%), syphilis (2.5% to 1.1%), HBV (12.6% to 6.7%), and HSV-2 (47.5% to 28.5%). In 2014, 109/4887 (2.2%) women had triple infections. In 2005, 2007, and 2009, the prevalence of HSV-2 in the older age group (35-45 years) (47.1%, 47.4%, and 50.0%, respectively) was higher than that in the younger age group (15-24 years) (40.9%, 19.5%, and 20.2%, respectively). Age category (Chi-square=22.4, p<0.001), study sites/residence (Chi-square=135.2, p=0.001), and time/years (Chi-square=58.9, p=0.001) were associated with a positive HSV-2 test result.

CONCLUSIONS

A decline in HIV, HBV, HSV-2, and syphilis of >40% was seen over the years in Ethiopia. However, an intermediate endemicity level of HBV and higher prevalence of HIV and HSV-2 by 2014, suggest the need to strengthen prevention strategy for STIs.

The role of sexual networks in studies of how BV and STIs increase the risk of subsequent reinfection

Prior studies have demonstrated that both bacterial vaginosis (BV) and sexually transmitted infections (STIs) are strong independent risk factors for subsequent STI. In observational studies of this biological enhancement (BE) hypothesis, it is important to adjust for the risk of STI exposure so that the independent effect of BE can be assessed. We sought to model if two markers of local sexual network (partner concurrency and cumulative number of STIs) represented residual confounding in the models of risk for subsequent infection in a study that screened 3620 women for STIs every 3 months for a year. Mixed-effects logistic regression was used to calculate the odds ratios for an incident diagnosis of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and BV following a diagnosis of any of these four at the prior visit, controlling for the cumulative number of STIs and partner concurrency variables. We found that partner concurrency and cumulative number of STIs were each associated with incident infection, and in general, controlling for these variables reduced the strength of the association between prior and incident infections. We conclude that the frequently found association between prior and incident STIs is associated with both BE and sexual network structure.

Prevalence and risk factors associated with sexually transmitted infections (STIs) among women of reproductive age in Swaziland

BACKGROUND

Sexually transmitted infections (STIs) remain an important public health problem with approximately half a billion new cases annually among persons aged 15-49 years. Epidemiological data on STIs among women of reproductive age in Swaziland are limited. The availability of epidemiological data on STIs and associated risk factors in this population is essential for the development of successful prevention, diagnosis and management strategies in the country. The study aimed to determine the prevalence and risk factors associated with STIs.

METHODS

A total of 655 women aged 15-49 years were systematically enrolled from five health facilities using a cross-sectional study design. Cervical specimen were tested using GeneXpert CT/NG Assays for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), GeneXpertTV Assay for Trichomonas vaginalis (TV), and GeneXpert HPV Assays for hr-HPV. Blood samples were tested using Alere Determine HIV-1/2Ag/Ab Combo and Trinity Biotech Uni-Gold Recombigen HIV test for confirmation for HIV, and Rapid Plasma Reagin and TPHA test for confirmation for Treponema pallidum (syphilis). Genital warts were assessed prior to specimen collection. Survey weighted analyses were done to estimate the population burden of STIs.

RESULTS

The four most common curable STIs: CT, NG, TV, Treponema pallidum (syphilis), as well as genital warts were considered in this study. The overall weighted prevalence of any of these five STIs was 19.4% (95% CI: 14.9-24.8), corresponding to 72 990 women with STIs in Swaziland. The estimated prevalences were 7.0% (95% CI: 4.1-11.2) for CT, 6.0% (95% CI: 3.8-8.8) for NG, 8.4% (95% CI: 5.4-12.8) for TV, 1.4% (95% CI: 1.1-10.2) for syphilis and 2.0% (95% CI: 1.0-11.4) for genital warts. The overall weighted HIV prevalence was 42.7% (95%CI: 35.7-46.2). Among hr-HPV positive women, 18.8% (95% CI: 13.1-26.3) had one STI, while 6.3% (95% CI: 3.3-11.7) had multiple STIs. Risk factors associated with STIs were being employed (OR = 2.2, 95% CI: 1.0-4.7), self-employed (OR = 2.8, 95% CI: 1.5-5.5) and being hr-HPV positive (OR = 2.0, 95% CI: 1.3-3.1). Age (0.9, 95% CI: 0.8-0.9), being married (OR = 0.4, 95% CI: 0.3-0.7) and not using condoms with regular partners (OR = 0.5, 95% CI: 0.3-0.9) were inversely associated with STIs.

CONCLUSION

STIs are highly prevalent among women of reproductive age in Swaziland. Thus, a comprehensive STIs screening, surveillance and treatment programme would be justified and could potentially lower the burden of STIs in the country.

Effect of immediate initiation of antiretroviral therapy on risk of severe bacterial infections in HIV-positive people with CD4 cell counts of more than 500 cells per μL: secondary outcome results from a randomised controlled trial

BACKGROUND

The effects of antiretroviral therapy on risk of severe bacterial infections in people with high CD4 cell counts have not been well described. In this study, we aimed to quantify the effects of immediate versus deferred ART on the risk of severe bacterial infection in people with high CD4 cell counts in a preplanned analysis of the START trial.

METHODS

The START trial was a randomised controlled trial in ART-naive HIV-positive patients with CD4 cell count of more than 500 cells per μL assigned to immediate ART or deferral until their CD4 cell counts were lower than 350 cells per μL. We used Cox proportional hazards regression to model time to severe bacterial infection, which was defined as a composite endpoint of bacterial pneumonia (confirmed by the endpoint review committee), pulmonary or extrapulmonary tuberculosis, or any bacterial infectious disorder of grade 4 severity, that required unscheduled hospital admissions, or caused death. This study is registered with ClinicalTrials.gov, number NCT00867048.

FINDINGS

Patients were recruited from April 15, 2009, to Dec 23, 2013. The data cutoff for follow-up was May 26, 2015. Of 4685 HIV-positive people enrolled, 120 had severe bacterial infections (immediate-initiation group n=34, deferred-initiation group n=86; median 2·8 years of follow-up). Immediate ART was associated with a reduced risk of severe bacterial infection compared with deferred ART (hazard ratio [HR] 0·39, 95% CI 0·26-0·57, p<0·0001). In the immediate-initiation group, average neutrophil count over follow-up was 321 cells per μL higher, and average CD4 cell count 194 cells per μL higher than the deferred-initiation group (p<0·0001). In univariable analysis, higher time-updated CD4 cell count (0·78, 0·71-0·85, p=0·0001) was associated with reduced risk of severe bacterial infection. Time-updated neutrophil count was not associated with severe bacterial infection. After adjustment for time-updated factors in multivariable analysis, particularly the CD4 cell count, the HR for immediate-initiation group moved closer to 1 (HR 0·84, 0·50-1·41, p=0·52). These results were consistent when subgroups of the severe bacterial infection composite were analysed separately.

INTERPRETATION

Immediate ART reduces the risk of several severe bacterial infections in HIV-positive people with high CD4 cell count. This is partly explained by ART-induced increases in CD4 cell count, but not by increases in neutrophil count.

FUNDING

National Institute of Allergy and Infectious Diseases National Institutes of Health, Agence Nationale de Recherches sur le SIDA et les Hépatites Virales, Bundesministerium für Bildung und Forschung, European AIDS Treatment Network, Australian National Health and Medical Research Council, UK National Institute for Health Research and Medical Research Council, Danish National Research Foundation.

Prevalence and Determinants of Herpes Simplex Virus Type 2 (HSV-2)/Syphilis Co-Infection and HSV-2 Mono-Infection among Human Immunodeficiency Virus Positive Men Who Have Sex with Men: a Cross-Sectional Study in Northeast China

This study assessed the prevalence and determinants of herpes simplex virus type 2 (HSV-2)/syphilis co-infection and HSV-2 mono-infection in human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) in China. A cross-sectional study was conducted of 545 HIV-positive MSM in Shenyang between February 2009 and October 2014. Participants underwent physical examinations and serological tests for HSV-2 and syphilis. A multinomial logistic regression was used to identify the risk factors associated with HSV-2/syphilis co-infection and HSV-2 mono-infection. The prevalence of HSV-2 mono-infection, syphilis mono-infection, and HSV-2/syphilis co-infection (95% confidence interval) was 48.6% (44.4-52.8%), 34.3% (30.3-38.3%), and 22.9% (19.4-26.5%), respectively. After controlling within HSV-2/syphilis-seropositive cases, regression analysis revealed that the related factors for HSV-2/syphilis co-infection included age (25-50 vs. ≤ 24 years: adjusted odds ratio [aOR], 4.55; > 50 vs. ≤ 24 years: aOR, 43.02), having regular female sexual partner(s) in the past 6 months (aOR, 0.43), and age at first MSM experience (≤ 18 vs. > 18 years: aOR, 2.59) (all P < 0.05). The high prevalence of HSV-2 mono infection and HSV-2/syphilis co-infection in HIV-positive MSM indicates a high secondary HIV transmission risk. A campaign for detection and treatment of HSV-2 and syphilis is urgently required for HIV-positive MSM in China.

Genital inflammation, immune activation and risk of sexual HIV acquisition

PURPOSE OF REVIEW

Women who have genital inflammation are at increased risk of sexual HIV infection. The purpose of this review is to evaluate the mechanisms for this relationship, causes of genital inflammation, and strategies to manage this condition.

RECENT FINDINGS

We have recently shown in a cohort of South African women that HIV seroconversion was associated with persistently raised genital inflammatory cytokines (including MIP-1α, MIP-1β, and IP-10). Elevated inflammatory cytokine concentrations may facilitate HIV infection by recruiting and activating HIV target cells and disrupting the mucosal epithelial barrier. Bacterial vaginosis and sexually transmitted infections (STIs), which are predominantly asymptomatic in women, cause lower genital tract inflammation and increased HIV acquisition risk. In Africa, where syndromic management of STIs and bacterial vaginosis is standard-of-care, the substantial burden of asymptomatic infections has likely contributed to high-HIV incidence rates.

SUMMARY

A genital inflammatory profile contributes to the high risk of HIV acquisition in African women. STIs and bacterial vaginosis are poorly managed in Africa and other developing nations and as such remain major drivers of persistent genital inflammation and HIV acquisition among these women.

New Biomedical Technologies and Strategies for Prevention of HIV and Other Sexually Transmitted Infections

Sexually transmitted infections remain to be of public health concern in many developing countries. Their control is important, considering the high incidence of acute infections, complications and sequelae, and their socioeconomic impact. This article discusses the new biomedical technologies and strategies for the prevention of HIV and other sexually transmitted infections.

High HIV incidence epidemic among men who have sex with men in china: results from a multi-site cross-sectional study

BACKGROUND

Recent upsurge of new HIV infections among men who have sex with men (MSM) is a major concern in China. Paucity of national-level information regarding the burden and predictors of this progressive epidemic of new infections called for a multi-centric, timely and comprehensive investigation.

METHODS

Mixed methods were used to recruit MSM from seven cities in China between 2012 and 2013. Recent and established HIV infections were estimated by Western Blot and BED HIV-1 capture enzyme immunoassay. Syphilis and herpes simplex virus-2 (HSV-2) were also tested.

RESULTS

A total of 4496 eligible MSM were recruited. The majority was aged ≤35 years (77.5 %), migrants (60.3 %), never married (69.8 %), and played receptive role in anal sex (70.5 %). The HIV prevalence was 9.9 %, and 41.9 % were recently infected, with sensitivity/specificity adjusted HIV incidence of 8.9 (95 % CI: 7.6-10.2)/100 Person-Years. The prevalence of history HSV-2 and syphilis were 12.5 % and 8.5 %, respectively. Recent HIV infection was associated with having multiple male partners (aOR = 1.4, 95 % CI 1.1-1.9), recreational drug use (aOR = 2.2, 95 % CI 1.6-3.0), anal bleeding (aOR = 2.1, 95 % CI 1.4-3.0), syphilis infection (aOR = 2.8, 95 % CI 1.9-4.3) and history HSV-2 infection (aOR = 2.3, 95 % CI 1.5-3.3).

CONCLUSION

High rate of recent HIV infection is potentially resulting in progressive deterioration of the overall HIV epidemic among MSM in China. Targeted interventions to address high-risk MSM including those having multiple partners, history of recreational drug use and syphilis or HSV-2 infection seemed to be the need of the hour.

Risk factors for incident HIV infection among antenatal mothers in rural Eastern Cape, South Africa

BACKGROUND

The prevalence of HIV among antenatal clients in South Africa has remained at a very high rate of about 29% despite substantial decline in several sub-Saharan countries. There is a paucity of data on risk factors for incident HIV infection among antenatal mothers and women within the reproductive age bracket in local settings in the Eastern Cape, South Africa.

OBJECTIVE

To establish the risk factors for incident HIV infection among antenatal clients aged 18-49 years attending public antenatal clinics in rural Eastern Cape, South Africa.

DESIGN

This was an unmatched case-control study carried out in public health antenatal clinics of King Sabata District Municipality between January and March 2014. The cases comprised 100 clients with recent HIV infection; the controls were 200 HIV-negative antenatal clients. Socio-demographic, sexual, and behavioral data were collected using interviewer-administered questionnaires adapted from the standard DHS5 women's questionnaire. Multivariate logistic regression models were used to identify the independent risk factors for HIV infection. A p<0.05 was considered statistically significant.

RESULTS

The independent risk factors for incident HIV infection were economic dependence on the partner, having older male partners especially among women aged ≤20 years, and sex under the influence of alcohol.

CONCLUSIONS

Therefore, effective prevention of HIV among antenatal mothers in KSDM must target the improvement of the economic status of women, thereby reducing economic dependence on their sexual partners; address the prevalent phenomenon of cross-generation sex among women aged <20 years; and regulate the brewing, marketing, and consumption of alcohol.

Changes in the contribution of genital tract infections to HIV acquisition among Kenyan high-risk women from 1993 to 2012

OBJECTIVE

The objective of this study was to understand temporal trends in the contribution of different genital tract infections to HIV incidence over 20 years of follow-up in a cohort of high-risk women.

DESIGN

A prospective cohort study.

METHODS

We performed monthly evaluations for HIV, vaginal yeast, bacterial vaginosis, Trichomonas vaginalis, Neisseria gonorrhoeae, nonspecific cervicitis, herpes simplex virus type two (HSV-2), genital ulcer disease (GUD) and genital warts. We used Cox regression to evaluate the association between sexually transmitted infections (STIs) and HIV acquisition over four time periods (1993-1997, 1998-2002, 2003-2007, 2008-2012). Models were adjusted for age, workplace, sexual risk behaviour, hormonal contraceptive use and other STIs. The resulting hazard ratios were used to calculate population attributable risk percentage (PAR%).

RESULTS

Between 1993 and 2012, 1964 women contributed 6135 person-years of follow-up. The overall PAR% for each infection was prevalent HSV-2 (48.3%), incident HSV-2 (4.5%), bacterial vaginosis (15.1%), intermediate microbiota (7.5%), vaginal yeast (6.4%), T. vaginalis (1.1%), N. gonorrhoeae (0.9%), nonspecific cervicitis (0.7%), GUD (0.8%) and genital warts (-0.2%). Across the four time periods, the PAR% for prevalent HSV-2 (40.4%, 61.8%, 58.4%, 48.3%) and bacterial vaginosis (17.1%, 19.5%, 14.7%, 17.1%) remained relatively high and had no significant trend for change over time. The PAR% for trichomoniasis, gonorrhoea, GUD and genital warts remained less than 3% across the four periods.

CONCLUSION

Bacterial vaginosis and HSV-2 have consistently been the largest contributors to HIV acquisition risk in the Mombasa Cohort over the past 20 years. Interventions that prevent these conditions would benefit women's health and could reduce their risk of becoming infected with HIV.

The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia

Data reporting sexually transmitted infection (STI) incidence rates among HIV-negative U.S. men who have sex with men (MSM) are lacking. In addition, it is difficult to analyze the effect of STI on HIV acquisition given that sexual risk behaviors confound the relationship between bacterial STIs and incident HIV. The InvolveMENt study was a longitudinal cohort of black and white HIV-negative, sexually active MSM in Atlanta who underwent routine screening for STI and HIV and completed behavioral questionnaires. Age-adjusted incidence rates were calculated for urethral and rectal Chlamydia (CT), gonorrhea (GC), and syphilis, stratified by race. Propensity-score-weighted Cox proportional hazards models were used to estimate the effect of STI on HIV incidence and calculate the population attributable fraction (PAF) for STI. We included 562 HIV-negative MSM with 843 person-years of follow-up in this analysis. High incidence rates were documented for all STIs, particularly among black MSM. Having a rectal STI was significantly associated with subsequent HIV incidence in adjusted analyses (aHR 2.7; 95% CI 1.2, 6.4) that controlled for behavioral risk factors associated with STI and HIV using propensity score weights. The PAF for rectal STI was 14.6 (95% CI 6.8, 31.4). The high incidence of STIs among Atlanta MSM and the association of rectal STI with HIV acquisition after controlling for behavioral risk underscore the importance of routine screening and treatment for STIs among sexually active MSM. Our data support targeting intensive HIV prevention interventions, such as preexposure chemoprophylaxis (PrEP), for Atlanta MSM diagnosed with rectal STIs.

Rush to judgment: the STI-treatment trials and HIV in sub-Saharan Africa

INTRODUCTION

The extraordinarily high incidence of HIV in sub-Saharan Africa led to the search for cofactor infections that could explain the high rates of transmission in the region. Genital inflammation and lesions caused by sexually transmitted infections (STIs) were a probable mechanism, and numerous observational studies indicated several STI cofactors. Nine out of the ten randomized controlled trials (RCTs), however, failed to demonstrate that treating STIs could lower HIV incidence. We evaluate all 10 trials to determine if their design permits the conclusion, widely believed, that STI treatment is ineffective in reducing HIV incidence.

DISCUSSION

Examination of the trials reveals critical methodological problems sufficient to account for statistically insignificant outcomes in nine of the ten trials. Shortcomings of the trials include weak exposure contrast, confounding, non-differential misclassification, contamination and effect modification, all of which consistently bias the results toward the null. In any future STI-HIV trial, ethical considerations will again require weak exposure contrast. The complexity posed by HIV transmission in the genital microbial environment means that any future STI-HIV trial will face confounding, non-differential misclassification and effect modification. As a result, it is unlikely that additional trials would be able to answer the question of whether STI control reduces HIV incidence.

CONCLUSIONS

Shortcomings in published RCTs render invalid the conclusion that treating STIs and other cofactor infections is ineffective in HIV prevention. Meta-analyses of observational studies conclude that STIs can raise HIV transmission efficiency two- to fourfold. Health policy is always implemented under uncertainty. Given the known benefits of STI control, the irreparable harm from not treating STIs and the likely decline in HIV incidence resulting from STI control, it is appropriate to expand STI control programmes and to use funds earmarked for HIV prevention to finance those programmes.

West African female sex workers in Mali: reduction in HIV prevalence and differences in risk profiles of sex workers of differing nationalities of origin

BACKGROUND

Female sex workers (FSW) in Mali are highly vulnerable to HIV. Their prevalence in 2009 was 9 times higher (24.2%) than that among pregnant women (2.7%).

METHODS

Four Integrated HIV/sexually transmitted infection (STI) Surveillance and Behavioral Surveys among FSW in Mali (2000, 2003, 2006, and 2009) tracked demographic characteristics, behavior, and HIV and STI prevalence. Logistic regression using generalized estimating equations to control for the cluster effect identified factors associated with HIV-positive serostatus adjusting for potential confounding.

RESULTS

Of 2430 FSW, 40.8% were Nigerian, 36.8% were Malian, and 22.4% were from other neighboring countries. Between 2003 and 2009, HIV prevalence dropped from 44.14% to 28.49% (P < 0.0001) among Malians, from 21.33% to 12.71% (P = 0.0082) among Nigerians, and from 43.42% to 33.67% (P = 0.0442) among "others." Between 2000 and 2009, condom availability increased (89.18%-99.3%; P < 0.0001) as did HIV testing (40%-75%; P < 0.0001). Consistent condom use with clients improved for Malians (72.3%-81.5%; P = 0.0092), but not among Nigerians (92.7%-90.94%; P = 0.8240) and "others" (88.9%-88.48%; P = 0.8452). Consistent condom use with boyfriends was low and improved only for Nigerians (9.8%-28.4%; P = 0.0003). Factors associated with HIV prevalence in the multivariate model were older age, study year (2003 and 2006), nationality, lack of education, mobility, STI symptoms, gonorrhea prevalence, and younger age at first sex.

CONCLUSIONS

This study documents progress in the fight against HIV among FSW in Mali. The different vulnerabilities to HIV found for different nationality FSW should be considered in programming and future research.

Prevalence and factors associated with sexually transmitted infections among HIV positive women opting for intrauterine contraception

Background

Women living with HIV/AIDS (WLHA) are a high risk group for sexually transmitted infections (STIs). However, the majority of women with STIs are asymptomatic. Data on prevalence of STIs among WLHA in Uganda are limited. The objective of the study was to determine prevalence and factors associated with STIs among WLHA opting for intrauterine contraceptive device (IUD).

Methods

Three hundred fifty one WLHA deemed free of STIs using a syndromic logarithm were enrolled into the study. Endo-cervical swabs were taken before IUD insertion and PCR test for Nisseria gonorrhea (NG), Trichomonas vaginalis (TV) and Chlamydia trachomatis (CT) infections conducted.

Results

Participants’ mean age was 29.4 ± 6.2 years, 83% were under 35years, 50% had secondary education and 73% were married. The majority (69%) had disclosed their HIV sero status to their spouses, 82% used Cotrimoxazole prophylaxis, 70% were on antiretroviral therapy, 90% had CD4 count greater than 350, about 60% reported condoms use and 70% were of parity 2-4. Over 50% of the participants’ spouses were older than 35 years and 72% had attained secondary education. STIs prevalence was 11.1%, (95% CI 7.8-14.4) and individual prevalence for TV, NG, and CT was 5.9%, 5.4% and 0.9% respectively. Factors independently associated with STI were having primary or less education (OR= 2.3, 95% CI: 1.09 - 4.85) having a spouse of primary or less education (OR= 3.3, 95% CI: 1.6 - 6.78) and muslim faith (OR= 0.2, 95% CI: 0.04 - 0.78).

Conclusion

STI prevalence was 11.1%. TV and NG were the commonest STIs in this population. Having primary or less education for both participant and spouse was associated with increased risk while being of muslim faith was associated with reduced risk of STI.

Combination HIV prevention for female sex workers: what is the evidence?

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

Knowledge and skills for management of sexually transmitted infections among rural medical practitioners in Bangladesh

Sexually transmitted infection (STI) management is considered rudimentary among rural medical practitioners (RMPs) in Bangladesh. We sought to understand the level of knowledge and skills in STI management and to assess the impact of a two-day training orientation among RMPs in Tangail district. Data were collected through a baseline survey of 225 practicing RMPs in the study area and a three-month follow-up survey of 99 RMPs who participated in a two-day STI/HIV orientation training. The level of formal training among RMPs ranged from none (22.7%), to paramedical training (14.7%) and local medical assistant training (62.6%). The baseline survey revealed a low level of STI/HIV knowledge and misconceptions about the transmission of STI/HIV among RMPs. RMPs mostly prescribed first line antibiotics for treatment of common reproductive tract infections (RTIs) including STIs, but they rarely prescribed the correct dosages according to the national RTI/STI management guidelines. Only 3% of RMPs were able to correctly answer all four HIV transmission (unprotected sexual intercourse, blood transfusion, needle sharing and mother to child transmission) questions at baseline, while 94.9% of RMPs answered all four correctly at three months following the training (p=0.001). Only 10% of RMPs reported suggesting the recommended drug (azithromycin) and only 2% mentioned about the recommended dosage (2gm single dose) for the treatment of urethritis/cervicitis; compared to 49.5% suggested azithromycin at follow-up with 39.4% mentioned the recommended 2gm single dose (p=0.001). Our study found low level of knowledge and poor practices related RTI/STI management among RMPs. Short orientation training and education intervention shown promise to increase knowledge and management skills for RTIs/STIs.

No association between gender inequality and peak HIV prevalence in developing countries - an ecological study

The prevalence of both gender inequality and HIV prevalence vary considerably both within all developing countries and within those in sub-Saharan Africa. We test the hypothesis that the extent of gender inequality is associated with national peak HIV prevalence. Linear regression was used to test the association between national peak HIV prevalence and three markers of gender equality - the gender-related development index (GDI), the gender empowerment measure (GEM), and the gender inequality index (GII). No evidence was found of a positive relationship between gender inequality and HIV prevalence, either in the analyses of all developing countries or those limited to Africa. In the bivariate analyses limited to Africa, there was a positive association between the two measures of gender "equality" and peak HIV prevalence (GDI: coefficient 28, 95% confidence interval (CI) 9.1-46.8; GEM: coefficient 54.8, 95% CI 20.5-89.1). There was also a negative association between the marker of gender "inequality" and peak HIV prevalence (GII: coefficient -66.9, 95% CI -112.8 to -21.0). These associations all disappeared on multivariate analyses. We could not find any evidence to support the hypothesis that variations in the extent of gender inequality explain variations in HIV prevalence in developing countries.

Modelling in concentrated epidemics: informing epidemic trajectories and assessing prevention approaches

PURPOSE OF THE REVIEW

This review summarizes recent mathematical modelling studies conducted among key populations including MSM, people who inject drugs (PWID), and female sex workers (FSWs) in low prevalence settings used as a marker of concentrated epidemics.

RECENT FINDINGS

Most recent studies focused on MSM, Asian settings or high-income countries, studied the transmission dynamics or modelled pre-exposure prophylaxis, treatment as prevention or behavioural interventions specific to each key population (e.g., needle exchange programme or use of low-dead space syringes for PWID). Biological interventions were deemed effective and cost-effective, though still expensive, and often deemed unlikely to result in HIV elimination if used alone. Targeting high-risk individuals even within key populations improved efficiency. Some studies made innovative use of models to formally evaluate HIV prevention programmes, to interpret genetic or co-infection data, and to address methodological questions and validate epidemiological tools.

CONCLUSION

More work is needed to optimize combination prevention focusing on key populations in different settings. The gaps identified include the limited number of studies modelling drug resistance, structural interventions, treatment as prevention among FSWs, and estimating the contribution of key populations to overall transmission in different settings.

High HIV seroprevalence, rectal STIs and risky sexual behaviour in men who have sex with men in Dar es Salaam and Tanga, Tanzania

OBJECTIVES

To assess HIV and sexually transmitted infection (STI) prevalence and associated risk factors in men who have sex with men (MSM) in two cities in mainland Tanzania.

METHODS

We conducted respondent-driven sampling of 300 MSM in Dar es Salaam and Tanga.

RESULTS

In Dar es Salaam, 172 (86%) men (median age 23, IQR 21-28) consented to HIV/STI testing, and 30.2% were HIV seropositive. Only five reported a previous positive HIV test: >90% were new HIV detections. 2.5% were syphilis-exposed and none hepatitis B positive, but 21.4% had a curable STI. Over 90% of the gonorrhoea and chlamydia was rectal. In Tanga, 11.1% of MSM were HIV seropositive, 8% hepatitis B positive and 0% were syphilis-exposed, with 4.4% having a curable STI. Predictors of HIV infection were number of MSM known, city, identifying as gay and having first sex with a man. Predictors for STIs were recent unprotected receptive anal intercourse, and number of MSM seen in the last month. 30% of the sample reported that they sold sex. There was no significant association between HIV and STI infection.

CONCLUSIONS

HIV and STI rates were substantially lower in MSM in a provincial city than in a large metropolis and rates appear to depend on larger numbers of MSM known. Most HIV detected were new cases, and there was a high burden of asymptomatic curable rectal STIs (>1 in 5 MSM). Owing to stigma, MSM may not report homosexuality and thus not have rectal STIs treated. High need for tailored HIV testing and STI screening and treatment of MSM in Tanzania is apparent.

Variations in KIR genes: a study in HIV-1 serodiscordant couples

Background. NK cells have anti-HIV activity mediated through killer cell immunoglobulin-like receptors (KIRs). The current prospective cohort study evaluated whether variation in KIR genes is associated with HIV infection in discordant couples (DCs), where one spouse remains seronegative (HSN) despite repeated exposure to the HIV. Methods. KIR was genotyped using PCR SSP. Viral load and CD4 counts were estimated using commercially available reagents. Data were analyzed using SPSS software. Results. Among the 47 DCs, HSN spouses had significantly (P = 0.006) higher frequencies of KIR3DS1. Regression analysis revealed significant (P = 0.009) association of KIR2DS1 with low viral load. KIR2DS4 variant was associated (P = 0.032) with high viral load. Three pairs of KIR genes were in strong LD in HSNs and two pairs in HSPs. There were 60 KIR genotypes, and 16 are reported the first time in the Indian population. Exclusive genotypes were present either in HSPs (N = 22, 11 unique genotypes) or in HSNs (n = 27, 9 unique genotypes). Conclusions. This study highlights for the first time in the Indian population an association of KIR genes in HIV infection where presence of exclusive and unique genotypes indicates possible association with either HIV infection or with protection.

Mycoplasma genitalium promotes epithelial crossing and peripheral blood mononuclear cell infection by HIV-1

BACKGROUND

Mycoplasma genitalium co-infection in HIV-infected individuals has been reported to increase the shedding of HIV in the urogenital region of females. To better understand this relationship, we investigated the influence of M. genitalium on the transmission and replication of HIV using an in vitro model.

METHODS

The Transwell co-culture system was employed to assess the crossing of an endocervical cell barrier by HIV-1. Immunocytochemistry and confocal microscopy were used to assess the distribution of the nectin-1 molecule on M. genitalium-infected epithelial cells of the End1/E6E7 endocervical cell line, grown as monolayers in the insert wells. Peripheral blood mononuclear cells (PBMC) were cultured in the bottom wells to assess the effects of M. genitalium, passing through the semipermeable culturing membrane, on subsequent HIV infection of susceptible target cells.

RESULTS

Infection of the endocervical cells with the adhesion-positive M. genitalium G37 strain (wild-type) significantly elevated the passage of HIV across the epithelial cell barrier relative to HIV transfer across endocervical cells infected with the adhesion-negative M. genitalium JB1 strain. Immunostaining of the M. genitalium-G37-infected epithelial cells disclosed capping and internalization of the junctional regulatory protein nectin-1, in association with reduced transepithelial resistance (TER) in the cell monolayer. When PBMC were cultured beneath insert wells containing M. genitalium-G37-infected epithelial cell monolayers, we observed significantly enhanced infectivity and replication of HIV added afterward to the cultures.

CONCLUSIONS

M. genitalium influences events on both sides of a cultured mucosal epithelial monolayer: (1) by infecting the epithelial cells and reducing the integrity of the barrier itself, and (2) by activating HIV target cells below it, thereby promoting HIV infection and progeny virus production.

Genital schistosomiasis and its unacknowledged role on HIV transmission in the STD intervention studies

Treatment of sexually transmitted infections (STIs) has been hypothesised to decrease HIV transmission. Although observational studies show an association between STIs and HIV, only one prospective randomised controlled trial (RCT) has confirmed this. Female genital schistosomiasis can cause genital lesions, accompanied by bloody discharge, ulcers or malodorous discharge. Genital schistosomiasis is common, starts before puberty and symptoms can be mistaken for STIs. Three observational studies have found an association between schistosomiasis and HIV. Genital lesions that develop in childhood are chronic. This paper sought to explore the possible effects of schistosomiasis on the RCTs of STI treatment for HIV prevention.

In the study sites, schistosomiasis was a likely cause of genital lesions. The studies recruited women that may have had genital schistosomal lesions established in childhood. Schistosomiasis endemic areas with different prevalence levels may have influenced HIV incidence in intervention and control sites differently, and some control group interventions may have influenced the impact of schistosomiasis on the study results. Schistosomiasis is a neglected cause of genital tract disease. It may have been an independent cause of HIV incidence in the RCTs of STI treatment for HIV prevention and may have obscured the findings of these trials.

The Young Person Check: screening for sexually transmitted infections and chronic disease risk in remote Aboriginal and Torres Strait Islander youth

OBJECTIVE

This paper describes the implementation and selected outcomes of the Young Person Check (YPC), a high-coverage screening program in far north Queensland targeting remote youth aged 15-24 years for sexually transmissible infections (STI) and chronic disease risk. The YPC was conducted 19 times in eight discrete remote communities and one community cluster between 2009 and 2012.

METHODS

Narrative description of consultation processes, YPC planning, recruitment strategies, logistics, screen design, additional costs and data management; analysis of coverage by location, age group and gender, selected STI management outcomes, and clinic-based STI testing separate from YPCs.

RESULTS

A total of 3,686 episodes of care were delivered, including 3,083 to Indigenous youth aged 15-24 years. Overall coverage of the 15-24 population was 73% for females and 72% for males. Median time to treatment for chlamydia/gonorrhoea cases was 13 days and 63% of cases had at least one contact treated. Clinic-based STI testing did not decrease.

CONCLUSIONS

Positive outcomes of the YPC program, including satisfactory participation, rest on a rigorous approach to planning, recruitment and implementation; provision for STI follow-up; and data management.

IMPLICATIONS

Testing and treatment strategies form an important element of efforts to address endemic STI and reduce HIV risk in remote Australian populations. Complementary population testing strategies will continue to be utilised and may contribute, if coverage is satisfactory. Programs such as the YPC should be considered in settings where the conditions outlined here can be met.

Performance and comparison of self-reported STI symptoms among high-risk populations - MSM, sex workers, persons living with HIV/AIDS - in El Salvador

Resource-limited countries have limited laboratory capability and rely on syndromic management to diagnose sexually transmitted infections (STIs). We aimed to estimate the sensitivity, specificity and positive predictive value (PPV) of STI syndromic management when used as a screening method within a study setting. Men who have sex with men (MSM), female sex workers (FSWs) and people living with HIV/AIDS (PLWHA) participated in a behavioural surveillance study. Data were obtained on demographics, sexual behaviours, STI history and service utilisation. Biological specimens were tested for genital inflammatory infections (Neisseria gonorrhoeae [GC], Chlamydia trachomatis [CT], Mycoplasma genitalium [MG], Trichomonas vaginalis [TV]) and genital ulcerative infection (syphilis and Herpes simplex virus-2). There was a high prevalence of Herpes simplex virus-2 (MSM 48.1%, FSW 82.0% and PLWHA 84.4%). Most participants reported no ulcerative symptoms and the majority of men reported no inflammatory symptoms. Sensitivity and PPV were poor for inflammatory infections among PLWHA and MSM. Sensitivity in FSWs for inflammatory infections was 75%. For ulcerative infections, sensitivity was poor, but specificity and PPV were high. Reliance on self-reported symptoms may not be an effective screening strategy for these populations. STI prevention studies should focus on symptom recognition and consider routine screening and referral for high-risk populations.

The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models

BACKGROUND

It is often assumed that local sexual networks play a dominant role in HIV spread in sub-Saharan Africa. The aim of this study was to determine the extent to which continued HIV transmission in rural communities--home to two-thirds of the African population--is driven by intra-community sexual networks versus viral introductions from outside of communities.

METHODS AND FINDINGS

We analyzed the spatial dynamics of HIV transmission in rural Rakai District, Uganda, using data from a cohort of 14,594 individuals within 46 communities. We applied spatial clustering statistics, viral phylogenetics, and probabilistic transmission models to quantify the relative contribution of viral introductions into communities versus community- and household-based transmission to HIV incidence. Individuals living in households with HIV-incident (n = 189) or HIV-prevalent (n = 1,597) persons were 3.2 (95% CI: 2.7-3.7) times more likely to be HIV infected themselves compared to the population in general, but spatial clustering outside of households was relatively weak and was confined to distances <500 m. Phylogenetic analyses of gag and env genes suggest that chains of transmission frequently cross community boundaries. A total of 95 phylogenetic clusters were identified, of which 44% (42/95) were two individuals sharing a household. Among the remaining clusters, 72% (38/53) crossed community boundaries. Using the locations of self-reported sexual partners, we estimate that 39% (95% CI: 34%-42%) of new viral transmissions occur within stable household partnerships, and that among those infected by extra-household sexual partners, 62% (95% CI: 55%-70%) are infected by sexual partners from outside their community. These results rely on the representativeness of the sample and the quality of self-reported partnership data and may not reflect HIV transmission patterns outside of Rakai.

CONCLUSIONS

Our findings suggest that HIV introductions into communities are common and account for a significant proportion of new HIV infections acquired outside of households in rural Uganda, though the extent to which this is true elsewhere in Africa remains unknown. Our results also suggest that HIV prevention efforts should be implemented at spatial scales broader than the community and should target key populations likely responsible for introductions into communities.

Reciprocal sex partner concurrency and STDs among heterosexuals at high-risk of HIV infection

Inconsistent findings on the relationship of sex partner concurrency to infection with HIV and other sexually transmitted diseases (STDs) may result from differences in how sex partner concurrency is conceptualized. We examine the relationship of reciprocal sex partner concurrency (RSPC) to diagnosed STDs among heterosexuals. Heterosexually active adults (N = 717) were recruited for a cross-sectional study using respondent-driven sampling (RDS) from high-HIV-risk areas in New York City (NYC, 2006-2007) and interviewed about their sexual risk behaviors, number of sex partners, last sex partners, and STD diagnoses (prior 12 months). RSPC was when both the participant and her/his last sex partner had sex with other people during their sexual relationship. Odds ratios (OR), adjusted odds ratios (aOR), and 95 % confidence intervals (95%CI) were estimated by logistic regression. The sample was 52.4 % female, 74.3 % Black; median age was 40 years. RSPC was reported by 40.7 % and any STD diagnoses by 23.4 %. Any STDs was reported by 31.5 % of those reporting RSPC vs. 17.9 % of those who did not (OR = 2.11, 95%CI = 1.49-3.0). Any STDs was independently associated with RSPC (aOR = 1.54, 95%CI = 1.02-2.32), female gender (aOR = 2.15, 95%CI = 1.43-3.23), having more than three sex partners (aOR = 1.72, 95%CI = 1.13-2.63), and unprotected anal sex (aOR = 1.65, 95%CI = 1.12-2.42). Heterosexuals in high-HIV-risk neighborhoods in sexual partnerships that involve RSPC are at greater risk of STDs and, potentially, HIV. RSPC, in addition to sexual risk behaviors and the number of sex partners, may facilitate the heterosexual spread of HIV through STD cofactors and linkage into larger STD/HIV sexual transmission networks.

Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia

The HIV Prevention Trials Network (HPTN) is conducting the HPTN 071 (PopART) study in 21 communities in Zambia and South Africa with support from a consortium of funders. HPTN 071 (PopART) is a community-randomized trial of a combination prevention strategy to reduce HIV incidence in the context of the generalized epidemic of southern Africa. The full PopART intervention strategy is anchored in home-based HIV testing and facilitated linkage of HIV-infected persons to care through community health workers and universal antiretroviral therapy for seropositive persons regardless of CD4+ cell count or HIV viral load. To further reduce the risk of HIV acquisition among uninfected individuals, the study aims to expand voluntary medical male circumcision, diagnosis and treatment of sexually transmitted infections, behavioral counseling, and condom distribution. The full PopART intervention strategy also incorporates promotion of other interventions designed to reduce HIV and tuberculosis transmission, including optimization of the prevention of mother-to-child HIV transmission and enhanced individual and public health tuberculosis services. Success for the PopART strategy depends on the ability to increase coverage for the study interventions whose uptake is a necessary antecedent to a prevention effect. Processes will be measured to assess the degree of penetration of the interventions into the communities. A randomly sampled population cohort from each community will be used to measure the impact of the PopART strategy on HIV incidence over 3 years. We describe the strategy being tested and progress to date in the HPTN 071 (PopART) study.

HIV seroprevalence, associated risk behavior, and alcohol use among male Rwanda Defense Forces military personnel

A cross-sectional study was conducted among active-duty male soldiers, aged ≥21 years, in the Rwanda Defense Forces (RDF) and included an anonymous behavioral survey and HIV rapid testing to determine risk factors associated with HIV seroprevalence. Overall prevalence was 2.6 % (95 % CI: 1.84-3.66); personnel who were divorced, separated or widowed, served ≥6 years, never deployed, uncircumcised, reported STI symptoms, had ≥6 lifetime sex partners, or screened positive for harmful alcohol use (via Alcohol Use Disorders Identification Test) had higher HIV prevalence. Ever being divorced, separated or widowed (OR = 29.8; 95 % CI: 5.5-159.9), and STI symptoms (OR = 3.4; 95 % CI: 1.5-7.6) were significantly associated with infection, after multivariable adjustment, while circumcision was protective (OR = 0.4; 95 % CI: 0.2-0.9). Despite mobility and other factors that uniquely influence HIV transmission in militaries, RDF prevalence was similar to the general population. A reason for this finding may be conservative sexual behavior combined with effective leadership-supported prevention programs. Data suggest a concentrated rather than generalized epidemic, with targets identified for intervention.

Coverage, context and targeted prevention: optimising our impact

Development of efficacious interventions is only the first step in achieving population level impact. Efficacious interventions impact infection levels in the population only if they are implemented at the right scale. Coverage must be prioritised across subpopulations based on the diversity and clustering of infections and risk in society, and expanded rapidly without delay. It is important to prioritise those who are most likely to transmit infection first.

Behavioral and biomedical combination strategies for HIV prevention

Around 2.5 million people become infected with HIV each year. This extraordinary toll on human life and public health worldwide will only be reversed with effective prevention. What's more, in the next few years, it is likely at least, that no single prevention strategy will be sufficient to contain the spread of the disease. There is a need for combination prevention as there is for combination treatment, including biomedical, behavioral, and structural interventions. Expanded HIV prevention must be grounded in a systematic analysis of the epidemic's dynamics in local contexts. Although 85% of HIV is transmitted sexually, effective combinations of prevention have been shown for people who inject drugs. Combination prevention should be based on scientifically derived evidence, with input and engagement from local communities that fosters the successful integration of care and treatment.

Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections and genital tract inflammation in high-risk women in South Africa

BACKGROUND

Diagnosis and treatment of sexually transmitted infections (STIs) is a public health priority, particularly in regions where the incidence of human immunodeficiency virus (HIV) infection is high. In most developing countries, STIs are managed syndromically. We assessed the adequacy of syndromic diagnosis of STIs, compared with laboratory diagnosis of STIs, and evaluated the association between STI diagnosis and the risk of HIV acquisition in a cohort of high-risk women.

METHODS

HIV-uninfected high-risk women (n = 242) were followed for 24 months. Symptoms of STIs were recorded, and laboratory diagnosis of common STI pathogens was conducted every 6 months. Forty-two cytokines were measured by Luminex in cervicovaginal lavage specimens at enrollment. Human immunodeficiency virus type 1 (HIV-1) infection was evaluated monthly.

RESULTS

Only 12.3% of women (25 of 204) who had a laboratory-diagnosed, discharge-causing STI had clinically evident discharge. Vaginal discharge was thus a poor predictor of laboratory-diagnosed STIs (sensitivity, 12.3%; specificity, 93.8%). Cervicovaginal cytokine concentrations did not differ between women with asymptomatic STIs and those with symptomatic STIs and were elevated in women with asymptomatic STIs, compared with women with no STIs or bacterial vaginosis. Although laboratory-diagnosed STIs were associated with increased risk of HIV infection (hazard ratio, 3.3 [95% confidence interval, 1.5-7.2)], clinical symptoms were not.

CONCLUSIONS

Syndromic STI diagnosis dependent on vaginal discharge was poorly predictive of laboratory-diagnosed STI. Laboratory-diagnosed STIs were associated with increased susceptibility to HIV acquisition, while vaginal discharge was not.

African women recently infected with HIV-1 and HSV-2 have increased risk of acquiring Neisseria gonorrhoeae and Chlamydia trachomatis in the Methods for Improving Reproductive Health in Africa trial

BACKGROUND

Neisseria gonorrhoeae and Chlamydia trachomatis are 2 common causative agents of cervical bacterial sexually transmitted infections (STI). Against the background of the concurrent epidemics of STIs and HIV in sub-Saharan Africa, we examined the effect of HIV-1 and HSV-2 on acquiring N. gonorrhoeae and C. trachomatis in a cohort of southern African women at risk for HIV infection.

METHODS

We examined incidence of first infection with N. gonorrhoeae and C. trachomatis in the multisite randomized controlled trial Methods for Improving Reproductive Health in Africa. Multivariable Cox proportional hazards models with time-dependent covariates were used.

RESULTS

The incidence rates of C. trachomatis and N. gonorrhoeae infections were 6.14 per 100 woman-years and 2.42 per 100 women-years, respectively. In multivariable analyses, women who became infected with HIV-1 were more likely to acquire C. trachomatis (adjusted hazard ratio [adj. HR], 1.86; 95% confidence interval [CI], 1.34-2.57) and N. gonorrhoeae (adj. HR, 2.29; 95% CI, 1.47-3.56) compared with HIV-uninfected women. Similarly, HSV-2 infected women were more likely to acquire C. trachomatis (adj. HR, 1.29; 95% CI, 1.05-1.58) and N. gonorrhoeae (adj. HR, 1.57; 95% CI, 1.11-2.21). Women who were of younger age, who did not live with their primary male partner, and who changed sex partners during the study were also more likely to acquire a cervical STI.

CONCLUSIONS

Women recently infected with HIV-1 and HSV-2 were at increased risk of acquiring N. gonorrhoeae and C. trachomatis. Proactive screening and treatment of these common cervical infections, particularly among those infected with HIV-1 and HSV-2, should be considered for young sexually active women in settings with a high prevalence of HIV/STIs.

HIV testing and antiretroviral treatment strategies for prevention of HIV infection: impact on antiretroviral drug resistance

'Test and treat' is a strategy in which widespread screening for human immunodeficiency virus (HIV) is followed by immediate antiretroviral therapy for those testing positive, thereby potentially reducing infectiousness in larger cohorts of infected patients. However, there is a concern that test and treat could lead to increased the levels of transmissible drug-resistant HIV, especially if viral load and/or drug resistance is not routinely monitored. Reviews of the existing literature show that up to now, even in the absence of laboratory tests, drug resistance has not created major problems in sub-Saharan Africa. Here, we discuss the current evidence for the effectiveness of a preventive test and treat approach and the challenges and implications for daily clinical practice and public health.

Factors associated with HIV testing history and HIV-test result follow-up among female sex workers in two cities in Yunnan, China

BACKGROUND

The majority of people living with HIV/AIDS in China are unaware of their serostatus, and increasing the utilization of HIV testing may help to control the epidemic.

METHODS

This longitudinal study was conducted among female sex workers (FSWs) in 2 cities in Yunnan Province, China. Participants were surveyed in face-to-face interviews and tested for HIV and STDs. Factors associated with HIV-testing history and HIV-test follow-up were analyzed.

RESULTS

Of the 1642 study participants, 291 (17.7%) had been previously tested and 868 (52.9%) returned for post-test follow-up. Factors associated with having a previous HIV test included attending the Kaiyuan study (aOR: 4.9, 95% CI: 2.3-10.1), ≥ 9 years of schooling (aOR: 10.9, 95% CI: 2.6-45.5), <5 clients in the recent week (aOR: 1.7, 95% CI: 1.2-2.3), having a regular sexual partner (aOR: 1.9, 95% CI: 1.4-2.5), illegal drug use history (aOR: 2.2, 95% CI: 1.5-3.1), pelvic pain in the past 12 months (aOR: 1.9, 95% CI: 1.1-3.6), HIV-seropositivity (aOR: 1.8, 95% CI: 1.2-2.8), and high perception of HIV risk (aOR: 1.5, 95% CI: 1.1-2.2). FSWs who had ≥ 9 years of schooling (aOR: 1.4, 95% CI: 1.1-1.9), had <5 clients in the recent week (aOR: 1.3, 95% CI: 1.1-1.6), or were from another province (aOR: 1.9, 95% CI: 1.4-2.5) or city (aOR: 1.4, 95% CI: 1.1-1.8) were more likely to follow-up.

CONCLUSIONS

The low HIV-testing history and follow-up rates found in this is study is a significant public health problem as many high-risk individuals are not aware of their serostatus. Immediate action needs to be taken to increase the utilization of HIV testing services and notify people of their HIV status.

Challenges in the design of HIV prevention trials in the United States

The design of studies evaluating the safety and efficacy of interventions for HIV prevention is challenging in the US context, where there is low generalized prevalence. HIV incidence is sufficiently high in the at-risk US population of men who have sex with men that prevention trials using HIV infection end points are feasible. In other US populations at higher risk of HIV exposure, efficacy trials of HIV prevention are likely not feasible. However, for interventions where efficacy is already established, conducting trials that test different implementation strategies in these populations could provide definitive evidence about how to achieve high levels of coverage.

The relative contribution of viral and bacterial sexually transmitted infections on HIV acquisition in southern African women in the Methods for Improving Reproductive Health in Africa study

We assess the relative contribution of viral and bacterial sexually transmitted infections (STIs) on HIV acquisition among southern African women in a nested case-control study within the Methods for Improving Reproductive Health in Africa (MIRA) trial. Cases were women with incident HIV infection; controls were HIV-uninfected at the time of case seroconversion selected in a 1 to 3 case to control ratio (risk-set sampling), matched on study site and time of follow-up. Conditional logistic regression models were used to calculate adjusted odds ratios (AORs) and population-attributable fractions (PAF). Among 4948 enrolled women, we analysed 309 cases and 927 controls. The overall HIV incidence rate was 4.0 per 100 women-years. The incidence of HIV infection was markedly higher in women who had prevalent Herpes simplex virus type 2 (HSV-2) (AOR: 2.14; 95% confidence interval [CI]: 1.55–2.96), incident HSV-2 (AOR: 4.43; 95% CI: 1.77–11.05) and incident Neisseria gonorrhoeae (AOR: 6.92; 95% CI: 3.01–15.90). The adjusted PAF of HIV incidence for prevalent HSV-2 was 29.0% (95% CI: 16.8–39.3), for incident HSV-2 2.1% (95% CI: 0.6–3.6) and for incident N. gonorrhoeae 4.1% (95% CI: 2.5–5.8). Women's greatest risk factors for HIV acquisition were incident bacterial and viral STIs. Women-centred interventions aimed at decreasing HIV incidence in young African women need to address these common co-morbid conditions.

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

BACKGROUND

The transmission of sexually transmitted infections (STIs) is closely related to the sexual transmission of human immunodeficiency virus (HIV). Similar risk behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of HIV and STIs, and there is clear evidence that many STIs increase the likelihood of HIV transmission. STI control, especially at the population or community level, may have the potential to contribute substantially to HIV prevention.This is an update of an existing Cochrane review. The review's search methods were updated and its inclusion and exclusion criteria modified so that the focus would be on one well-defined outcome. This review now focuses explicitly on population-based biomedical interventions for STI control, with change in HIV incidence being an outcome necessary for a study's inclusion.

OBJECTIVES

To determine the impact of population-based biomedical STI interventions on the incidence of HIV infection.

SEARCH STRATEGY

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science/Social Science, PsycINFO, and Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS), for the period of 1 January1980 - 16 August 2010. We initially identified 6003 articles and abstracts. After removing 776 duplicates, one author (TH) removed an additional 3268 citations that were clearly irrelevant. Rigorously applying the inclusion criteria, three authors then independently screened the remaining 1959 citations and abstracts. Forty-six articles were chosen for full-text scrutiny by two authors. Ultimately, four studies were included in the review.We also searched the Aegis database of conference abstracts, which includes the Conference on Retroviruses and Opportunistic Infections (CROI), the International AIDS Conference (IAC), and International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS) meetings from their inception dates (1993, 1985 and 2001, respectively) through 2007. We manually searched the web sites of those conferences for more recent abstracts (up to 2010, 2010 and 2009, respectively)  In addition to searching the clinical trials registry at the US National Institutes of Health, we also used the metaRegister of Controlled Trials.We checked the reference lists of all studies identified by the above methods.

SELECTION CRITERIA

Randomised controlled trials involving one or more biomedical interventions in general populations (as opposed to occupationally or behaviourally defined groups, such as sex workers) in which the unit of randomisation was either a community or a treatment facility and in which the primary outcome was incident HIV infection. The term "community" was interpreted to include a group of villages, an arbitrary geographical division, or the catchment population of a group of health facilities.

DATA COLLECTION AND ANALYSIS

Three authors (BN, LB, TH) independently applied the inclusion criteria to potential studies, with any disagreements resolved by discussion. Trials were examined for completeness of reporting. Data were abstracted independently using a standardised abstraction form.

MAIN RESULTS

We included four trials. One trial evaluated mass treatment of all individuals in a particular community. The other three trials evaluated various combinations of improved syndromic STI management in clinics, STI counselling, and STI treatment.In the mass treatment trial in rural southwestern Uganda, after three rounds of treatment of all community members for STIs, the adjusted rate ratio (aRR) of incident HIV infection was 0.97 (95% CI 0.81 - 1.2), indicating no effect of the intervention. The three STI management intervention studies were all conducted in rural parts of Africa. One study, in northern Tanzania, showed that the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (aRR = 0.58, 95% CI 0.42 - 0.79), corresponding to a 42% reduction (95% CI 21.0% - 58.0%) in HIV incidence in the intervention group. Another study, conducted in rural southwestern Uganda, showed that the aRR of behavioural intervention and STI management compared to control on HIV incidence was 1.00 (95% CI 0.63 - 1.58). In the third STI management trial, in eastern Zimbabwe, there was no effect of the intervention on HIV incidence (aRR = 1.3, 95% CI 0.92 - 1.8). These are consistent with data from the mass treatment trial showing no intervention effect. Overall, pooling the data of the four studies showed no significant effect of any intervention (rate ratio [RR] = 0.97, 95% CI 0.78 - 1.2).Combining the mass treatment trial and one of the STI management trials, we find that there is a significant 12.0% reduction in the prevalence of syphilis for those receiving a biomedical STI intervention (RR 0.88, 95% CI 0.80 - 0.96). For gonorrhoea, we find a statistically significant 51.0% reduction in its prevalence in those receiving any of these interventions (RR 0.49, 95% CI 0.31 - 0.77). Finally, for chlamydia, we found no significant difference between any biomedical intervention and control (RR 1.03, 95% CI 0.77 - 1.4).

AUTHORS' CONCLUSIONS

We failed to confirm the hypothesis that STI control is an effective HIV prevention strategy. Improved STI treatment services were shown in one study to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services were poor and where STIs were highly prevalent; Incidence was not reduced in two other settings. There is no evidence for substantial benefit from a presumptive treatment intervention for all community members. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided.

Sexual behaviour does not reflect HIV-1 prevalence differences: a comparison study of Zimbabwe and Tanzania

BACKGROUND

Substantial heterogeneity in HIV prevalence has been observed within sub-Saharan Africa. It is not clear which factors can explain these differences. Our aim was to identify risk factors that could explain the large differences in HIV-1 prevalence among pregnant women in Harare, Zimbabwe, and Moshi, Tanzania.

METHODS

Cross-sectional data from a two-centre study that enrolled pregnant women in Harare (N = 691) and Moshi (N = 2654) was used. Consenting women were interviewed about their socio-demographic background and sexual behaviour, and tested for presence of sexually transmitted infections and reproductive tract infections. Prevalence distribution of risk factors for HIV acquisition and spread were compared between the two areas.

RESULTS

The prevalence of HIV-1 among pregnant women was 26% in Zimbabwe and 7% in Tanzania. The HIV prevalence in both countries rises constantly with age up to the 25-30 year age group. After that, it continues to rise among Zimbabwean women, while it drops for Tanzanian women. Risky sexual behaviour was more prominent among Tanzanians than Zimbabweans. Mobility and such infections as HSV-2, trichomoniasis and bacterial vaginosis were more prevalent among Zimbabweans than Tanzanians. Reported male partner circumcision rates between the two countries were widely different, but the effect of male circumcision on HIV prevalence was not apparent within the populations.

CONCLUSIONS

The higher HIV-1 prevalence among pregnant women in Zimbabwe compared with Tanzania cannot be explained by differences in risky sexual behaviour: all risk factors tested for in our study were higher for Tanzania than Zimbabwe. Non-sexual transmission of HIV might have played an important role in variation of HIV prevalence. Male circumcision rates and mobility could contribute to the rate and extent of spread of HIV in the two countries.