Excluding blood donors at high risk of HIV infection in a west African city

Re-engineering the medical assessment of blood donors in South Africa: The balance between supply and safety

BACKGROUND

The balance between ensuring blood donor and recipient safety while maintaining a sufficient blood supply can be affected by excessive deferral of blood donors. In 2018, a biannual regulatory review of donor eligibility criteria provided the South African National Blood Service (SANBS) the opportunity to review the existing criteria. Changes to these criteria were implemented in April 2019 after an extensive review.

STUDY DESIGN AND METHODS

We conducted a cross-sectional study of SANBS whole-blood donor presentations to determine the impact of the changed donor eligibility criteria on deferrals and blood safety. We compared donor presentations, deferrals, and HIV-positive cases for the 12-month period (April 2019-March 2020) after the implementation of the updated donor eligibility criteria to those of the previous year.

RESULTS

Of the 2,112,917 donor presentations, 51.1% (1079506) occurred in the post-implementation study period. Overall, deferrals decreased from 18.6% to 14.5%, whereas HIV-positive donations increased by 0.03%. A multivariable logistic regression analysis adjusted for sex, age, geographical location, donor, and clinic type showed significantly lower odds of deferral (OR 0.70; 95% CI: 0.69-0.70) and greater odds of HIV-positive cases in the study period than those in the control period (OR 1.17; 95% CI: 1.10-1.25).

CONCLUSION

We confirmed that the change in donor eligibility criteria was associated with a decrease in deferrals and an increase in the country's blood supply. The impact of the increased number of HIV-positive donations on blood safety in a country performing individual donation nucleic acid amplification testing requires further investigation.

Risk factors for human immunodeficiency virus among blood donors in Cameroon: evidence for the design of an Africa-specific donor history questionnaire

BACKGROUND

In sub-Saharan Africa improving the deferral of at-risk blood donors would be a cost-effective approach to reducing transfusion-transmitted human immunodeficiency virus (HIV) infections. We performed a pilot case-control study to identify the risk factors for HIV infection and to develop an adapted donor history questionnaire (DHQ) for sub-Saharan Africa.

STUDY DESIGN AND METHODS

We recruited 137 HIV-positive donors (cases) and 256 HIV-negative donors (controls) and gathered risk factor data using audio computer-assisted self-interview. Variables with univariate associations were entered into a logistic regression model to assess independent associations. A scoring scheme to distinguish between HIV-positive and HIV-negative donors was developed using receiver operating characteristics curves.

RESULTS

We identified 16 risk factors including sex with sex worker, past history or treatment for sexually transmitted infections, and having a partner who used injected or noninjected illegal drugs. Two novel risks were related to local behavior: polygamy (odds ratio [OR], 22.7; 95% confidence interval [CI], 5.9-86.7) and medical or grooming treatment on the street (OR, 1.8; 95% CI, 1.0-3.0). Using the 16 selected items the mean scores (>100) were 82.6 ± 6.7 (range, 53.2-95.1) and 85.1 ± 5.2 for HIV-negative donors versus 77.9 ± 6.8 for HIV-positive ones (p = 0.000). Donors who scored between 80 and 90 were more likely to be HIV negative than those who scored less (OR, 31.4; 95% CI, 3.1-313.9).

CONCLUSION

We identified both typical and novel HIV risk factors among Cameroonian blood donors. An adapted DHQ and score that discriminate HIV-negative donors may be an inexpensive means of reducing transfusion-transmitted HIV through predonation screening.

Blood supply safety in Afghanistan: a national assessment of high-volume facilities

BACKGROUND

Little information is available regarding blood supply safety in Afghanistan. The purpose of this study was to assess blood safety through serologic and observational measures in Afghanistan.

STUDY DESIGN AND METHODS

This cross-sectional assessment included the 40 highest-volume facilities collecting and transfusing blood nationally identified in a previous survey. At each facility, study representatives completed a standardized instrument assessing staff performance of transfusion-related activities and performed rapid testing for human immunodeficiency virus, syphilis, and hepatitis B and C with rapid diagnostic tests on clinically discarded specimens. Reactive samples received confirmatory testing. Descriptive statistics were generated, with differences analyzed using chi-square or Fisher's exact tests.

RESULTS

Between November 2010 and May 2011, a total of 332 blood donor collection procedures were observed. Only 52.4% of observed encounters correctly screened and deferred donors by international criteria. Public and private facilities demonstrated glove use, proper sharps disposal, and patient counseling and relayed screening test results in less than 75% of observed events, significantly less likely than military facilities (p < 0.01). Of 1612 specimens assessed, confirmed cases of hepatitis B (n = 6), hepatitis C (n = 1), and syphilis (n = 3) were detected among units already prescreened and accepted for transfusion.

CONCLUSION

Lapses in proper donor screening contributed to the presence of confirmed-positive units available for transfusion, as detected in this study. Steps must be taken to ensure standardization of testing kits requirements, documentation, and mandatory training and continuing education for blood bank staff with regard to counseling, drawing, processing, and transfusion of blood products.

Translation of biomedical prevention strategies for HIV: prospects and pitfalls

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

Institutional incentives for altruism: gifting blood in China

BACKGROUND

In mainland China, the motivation behind voluntary blood donation is a relatively new and understudied behavior. In recent times provincial governments in China have implemented various institutional incentive measures. However, little is known regarding the effectiveness of such measures. This qualitative study investigated the nature and outcomes of some identified institutionalized mechanisms, in particular how these were created and distributed in the form of incentives for voluntary blood donation.

METHODS

Participatory observations were conducted at two blood donation stations and four blood collecting vehicles in Changsha city, China. In-depth interviews were conducted with 17 staff and 58 blood donors at the aforementioned venues from May to October 2008 in Changsha.

RESULTS

Thematic analysis revealed the operation of four primary type incentives: policy-driven, symbolic, information feedback and role models, which constituted the system of institutional incentives. The current blood reimbursement system was not the primary motivation for blood donation; instead this system was a subtheme of future assurance for emergency blood needs. It was evident that symbolic incentives stressed the meaning and value of blood donation. Furthermore, post-donation information services and the inherent mechanisms of communication, enhanced by some public role models, served to draw the public to donate blood.

CONCLUSIONS

At the institutional level, blood donation was not only informed by altruism, but also carried a system of benefit and reward for the donors and their family members. We would recommend that such arrangements, if accommodated effectively into China's health promotion strategies, would increase the likelihood of blood donation.

The evolving epidemiology of HIV/AIDS

Following its recognition in 1981, the HIV/AIDS epidemic has evolved to become the greatest challenge in global health, with some 34 million persons living with HIV worldwide. Early epidemiologic studies identified the major transmission routes of the virus before it was discovered, and enabled the implementation of prevention strategies. Although the first identified cases were in MSM in the United States and western Europe, the greatest impact of the epidemic has been in sub-Saharan Africa, where most of the transmission occurs between heterosexuals. Nine countries in southern Africa account for less than 2% of the world's population but now they represent about one third of global HIV infections. Where broadly implemented, HIV screening of donated blood and antiretroviral treatment (ART) of pregnant women have been highly effective in preventing transfusion-associated and perinatally acquired HIV, respectively. Access to sterile equipment has also been a successful intervention for injection drug users. Prevention of sexual transmission has been more difficult. Perhaps the greatest challenge in terms of prevention has been in the global community of MSM in which HIV remains endemic at high prevalence. The most promising interventions are male circumcision for prevention of female-to-male transmission and use of ART to reduce infectiousness, but the extent to which these interventions can be brought to scale will determine their population-level impact.

Retrospective surveillance of HIV prevalence in blood donors can help in the selection of the best social group for blood donation in Mali

The National Centre for Blood Transfusion, Bamako, Mali has collected data that characterizes trend in HIV prevalence over 10 years by gender, age, occupation, marital status and donor category. These data help to describe national HIV prevalence and assist in formulating blood donation policies. Donations from 1993 to 2002 were categorized by donor age (decade), occupation (student, military and other), marital status (single, married and other), gender and donor status (volunteer, occasional and family). Comparisons were made using conservative estimates of donation frequency/donor category. Donations increased by more than 400%. By 1999, increased HIV prevalence in donations from women was consistently present. Donations from the age group of 30-39 years showed an increased prevalence beginning in 2000, which by 2002 was almost 10 times greater than in the low-prevalence (<20 years) group (5.9 vs. 0.6%). By 2000, both categories - students and military were less likely to be HIV positive than those from other occupational categories, and donations from married persons were less likely to be HIV positive by 1997. The highest prevalence was observed in the 'occasional' donor category, which increased to >14% by 2001; volunteer donation HIV positive peaked at 2.3% in 1999. HIV prevalence in blood donations in Bamako, Mali, demonstrates important trends from 1993 to 2002. The prevalence of > 14% in donations from occasional donors and significant trends by decade, gender, marital status and occupation argue for increased analysis of the blood donor population to improve blood safety and to understand the demographics of HIV infection in Mali.

Behavior Assessment of Blood Donors Facing the Risk of HIV Infection, Abidjan, Côte D'Ivoire, 2001-2002

Despite precautions taken to guarantee blood safety, in the National Blood Transfusion Center (CNTS) of Abidjan, about 30 regular blood donors are detected with HIV seroconversion each year, two-thirds of them men. A survey through face-to-face interviews was carried out at the CNTS of Abidjan from September 2001 to March 2002 among HIV-positive and HIV-negative regular blood donors, informed about their serologic status. HIV-negative regular blood donors informed about their serologic status since a median time of 67 months (n = 50) disclosed more risky behaviors such as multiple sexual partners (68%) than HIV-positive blood donors informed about their status (n = 112) since a median time of 35 months (41%) (P < 0.001). Condoms were systematically used by 17% of HIV-negative blood donors and 55% of HIV-positive blood donors (P < 0.001). Enhanced counseling and awareness could reduce in the future the number of cases of seroconversion among regular blood donors and improve their subsequent behavior. Blood donors who have unprotected sex with partners of unknown HIV serologic status and especially with casual partners are strongly exposed to HIV transmission and should be discouraged to continue giving blood, after adequate counseling.

[Interventions for HIV/STD prevention in Latin America and the Caribbean: a review of the regional experience]

The HIV/AIDS epidemic has completed its second decade in Latin America and the Caribbean, the latter being the second most heavily affected region in the world. In UNGASS (2001), governments renewed their commitment to confront the epidemic with adequate prevention and care. This review begins by characterizing the regional epidemic as concentrated on vulnerable groups (except for certain areas of generalization). Subsequently, we summarize the prevention work with each target group and contrast it with the epidemiological profile, concluding that the epidemic was not addressed in either timely or sufficient fashion in vulnerable groups, all of which are linked to other population groups. We also point out conditions that could foster greater impact by prevention strategies and analyze ways by which prevention activities could be better integrated with impact/reduction measures. Finally, we analyze the available information on expenditures in prevention.

Exposure to the 'SIDA dans la Cité' AIDS prevention television series in Côte' d'Ivoire, sexual risk behaviour and condom use

This study assesses factors associated with viewing of 'SIDA dans la Cite', a weekly television soap opera on AIDS in Côte d'Ivoire, and the relationship between 'SIDA dans la Cite' viewing, sexual risk behaviour and condom use. The study uses across-sectional survey of 2150 respondents aged 15-49 in three regions. Logistic regression analysis was used to assess the effect of'SIDA dans la Cite' exposure on condom use. The results show that 65% of the sample had seen at least one 'SIDA dans la Cite' episode. Among viewers, 27% of males and 41% of females had seen ten or more episodes. Persons who had risky sexual partners were particularly likely to watch the programme. Women who had seen ten or more episodes were 1.4 times more likely than non-viewers to have used a condom in last sex. Men who had seen ten or more episodes were 2. 7 times more likely to have used a condom. We conclude that television soap operas on AIDS, such as 'SIDA dans la Cite',can be an important tool for promoting condom use. The programme was most appealing to viewers who engaged in risky behaviour, who are the core transmitters of the virus. HIV prevention programmes that provide continuous information, through multiple media channels or through series of broadcasts, are likely to have the greatest impact on condom use.

Clinical and biological evolution of HIV-1 seroconverters in Abidjan, Côte d'Ivoire, 1997-2000

OBJECTIVE

To describe the clinical and biologic evolution of HIV-1 infection in Africa.

METHODS

One hundred four HIV-1-infected individuals were identified prospectively from regular blood donors in Abidjan, Côte d'Ivoire. The date of seroconversion was estimated from results of sequential serologic tests. Biologic and clinical follow-up was performed every 6 months, starting as early as possible after seroconversion. Case management followed national guidelines.

RESULTS

The median interval between estimated seroconversion and study inclusion was 9.7 months, and the median window of seroconversion was 2.8 months. At baseline, all but two patients were asymptomatic; the median CD4 + cell count was 527/mm 3 (interquartile range [IR], 395-684), and the median plasma HIV RNA level was 4.6 log 10 copies/ml (IR, 3.8-4.9). The median follow-up was 23.9 months, and 95% of the patients received primary prophylaxis with co-trimoxazole for opportunistic infections. Of the patients, 1 presented with wasting syndrome, 3 developed tuberculosis, and 17 had a Centers for Disease Control and Prevention category B-defining event. The 3-year AIDS-free and symptom-free probabilities were 96.7% (95% confidence interval [CI], 87.0-99.2] and 79.3% (95% CI, 67.5-87.2), respectively. During the first 3 years of follow-up, we observed that the median plasma viral load stabilized at >4 log 10 copies/ml and that the median CD4 + cell count declined by 20 to 25/mm 3 per year.

CONCLUSION

These African seroconverters were moderately immunosuppressed. The median HIV RNA level was high and varied very little during the first 3 years, and there were few clinical events.

Increase in condom use and decline in HIV and sexually transmitted diseases among female sex workers in Abidjan, Côte d'Ivoire, 1991-1998

OBJECTIVE

To assess clinic- and community-based trends in demographic and behavioral characteristics and clinic-based trends in HIV infection and other sexually transmitted diseases (STD) in female sex workers in Abidjan, Côte d'Ivoire.

DESIGN

Multiyear cross-sectional study of first-time attenders in Clinique de Confiance, a confidential STD clinic; biannual community-based behavioral surveys.

METHODS

From 1992 to 1998, female sex workers were invited to attend Clinique de Confiance, where they were counseled, interviewed, clinically examined during their first visit and tested for STD and HIV infection. Community-based surveys, conducted in 1991, 1993, 1995, and 1997, interviewed women regarding socio-demographic characteristics and HIV/STD-related knowledge, attitudes and behavior.

RESULTS

Among female sex workers in Abidjan, there was a trend toward shorter duration of sex work, higher prices, and more condom use. Among sex workers attending Clinique de Confiance for the first time, significant declines were found in the prevalence of HIV infection (from 89 to 32%), gonorrhoea (from 33 to 11%), genital ulcers (from 21 to 4%), and syphilis (from 21 to 2%). In a logistic regression model that controlled for socio-demographic and behavioral changes, the year of screening remained significantly associated with HIV infection.

CONCLUSION

The increase in condom use and the decline in prevalence of HIV infection and other STD may well have resulted from the prevention campaign for female sex workers, and such campaigns should therefore be continued, strengthened, and expanded.

Effect of interventions to control sexually transmitted disease on the incidence of HIV infection in female sex workers

OBJECTIVE

To compare the seroincidence of HIV infection among female sex workers in Abidjan, Côte d'Ivoire before and during an intervention study to control sexually transmitted diseases (STD) and to study the effect of two STD diagnosis and treatment strategies on the prevalence of STD and on the seroincidence of HIV infection.

METHOD

A screening facility for STD and HIV had been available since October 1992 for female sex workers. From June 1994, women who were HIV seronegative or HIV-2 positive during the screening could enroll in the intervention study in which participants reported once a month to a confidential clinic where they received health education, condoms and STD treatment if indicated. Women in the study were randomized either to a basic STD diagnosis and treatment strategy, which included a gynecologic examination when symptomatic, or to an intensive strategy that included a gynecologic examination regardless of symptoms. An outcome assessment every 6 months included a gynecologic examination, HIV serology and laboratory tests for STD.

RESULTS

Of 542 women enrolled in the study, 225 (42%) had at least one outcome assessment. The HIV-1 seroincidence rate during the intervention study was significantly lower than before the study (6.5 versus 16.3 per 100 person-years; P = 0.02). During the study, the HIV-1 seroincidence rate was slightly lower in the intensive than in the basic strategy (5.3 versus 7.6 per 100 person-years; P = 0.5).

CONCLUSION

National AIDS control programs should consider adopting as policy the type of integrated approach used in this intervention study for HIV prevention in female sex workers.

The Côte d'Ivoire national HIV counseling and testing program for tuberculosis patients: implementation and analysis of epidemiologic data

OBJECTIVES

To describe the implementation of a free, voluntary and confidential HIV counseling and testing program for patients with newly diagnosed tuberculosis at the eight large outpatient tuberculosis centers in Côte d'Ivoire, and to present epidemiologic findings on participating patients.

DESIGN

HIV counseling and testing program with ongoing HIV serosurveillance.

METHODS

HIV counseling and testing services were established at the two tuberculosis centers in Abidjan in 1989 and were extended to six centers in the Côte d'Ivoire interior in the first half of 1994. Characteristics of counseled patients, acceptance rates of HIV testing, and HIV serologic results were analyzed for all eight centers from 1994 to 1996. Temporal trends in HIV seropositivity rates were examined for the two centers of Abidjan from 1989 to 1996.

RESULTS

From July 1994 through December 1996, 17 946 (91.8%) out of 19 594 patients who were counseled at the eight centers in Côte d'Ivoire consented to HIV testing, of whom 7749 (43.2%) were HIV-seropositive. The highest rates of 47.0 and 45.6% were found in the two centers in Abidjan, with rates ranging from 32.9 to 42.4% in the six centers in the interior. HIV-seropositive tuberculosis patients from each of the 50 districts in Côte d'Ivoire were identified. In Abidjan, the HIV seropositivity rate remained relatively stable among men (46.7% in 1989, 48.5% in 1991, 43.6% in 1996), but rose sharply among women from 32.7% in 1989 to 50.1% in 1996.

CONCLUSIONS

The high HIV seropositivity rates among tuberculosis patients in all geographic regions of Côte d'Ivoire indicate that the HIV epidemic has now spread throughout the country. However, the successful implementation of an extensive HIV counseling and testing program for more than 37000 tuberculosis patients to date demonstrates the commitment of the Côte d'Ivoire Ministry of Health to integrating HIV/AIDS prevention activities with tuberculosis control efforts. When logistically and economically feasible, the extension of HIV-related social and clinical services to HIV-seropositive tuberculosis patients should be considered by other national tuberculosis control programs in Africa.

Blood transfusion in developing countries: problems, priorities and practicalities

The acute medical services could not exist without blood transfusions--life-savers in many situations. But transfusions can also be a quick and easy route for the transmission of infectious agents such as HIV, HBV, HCV and malaria. Infection through blood supply is a major issue in all countries but particularly in those with economic constraints which limit safety. This study was carried out in India (March-May 1997) and involved centres in Delhi, Calcutta and Vellore. It examined many aspects of blood transfusion including donor screening, use of professional donors, blood testing and criteria for blood use. The many problems in Indian blood transfusion services are mirrored in other countries. Here we examine the problems, priorities and practicalities of blood transfusion particularly in developing countries.

The associations between cervicovaginal HIV shedding, sexually transmitted diseases and immunosuppression in female sex workers in Abidjan, Côte d'Ivoire

OBJECTIVE

To measure the frequency and associated factors of cervicovaginal HIV shedding and to determine the impact of sexually transmitted disease (STD) treatment on HIV shedding.

DESIGN

Cross-sectional study with 1-week follow-up.

SETTING

Confidential clinic for female sex workers in Abidjan, Côte d'Ivoire.

PARTICIPANTS

A total of 1201 female sex workers.

INTERVENTIONS

STD treatment based on clinical signs.

MAIN OUTCOME MEASURES

HIV serostatus; cervicovaginal HIV shedding at enrollment and at 1-week follow-up; STD status at enrollment and at 1-week follow-up.

RESULTS

Cervicovaginal shedding of HIV-1 in HIV-1-seropositive women was more frequent (96 out of 404, 24%) than shedding of HIV-2 in HIV-2-seropositive women [one out of 21, 5%; odds ratio (OR), 6.2; 95% confidence interval (CI), 1.0-261]. Among 609 HIV-1-seropositive or dually seroreactive women, HIV-1 shedding was significantly more frequent in immunosuppressed women [adjusted OR (AOR), 6.3; 95% CI, 3.4-11.9; and AOR, 2.9; 95% CI, 1.6-5.0 for CD4 < 14% and CD4 14-28%, respectively, versus CD4 > 28%], and in women with Neisseria gonorrhoeae (AOR, 1.9; 95% CI, 1.2-3.0), those with Chlamydia trachomatis (AOR, 2.5; 95% CI, 1.1-5.8), and with a cervical or vaginal ulcer (AOR, 3.9; 95% CI, 2.1-7.4). HIV-1 shedding decreased from 42 to 21% (P < 0.005) in women whose STD were cured.

CONCLUSIONS

These data help to explain the difference in transmissibility between HIV-1 and HIV-2 and the increased infectiousness of HIV in the presence of immunosuppression and STD. In addition, they lend biological plausibility to arguments for making STD control an integral part of HIV prevention strategies in Africa.

HIV and blood transfusion in sub-Saharan Africa

Blood transfusion services were poorly developed until the mid 1980s in most of sub-Saharan Africa, and were unable to provide adequate supplies of blood with acceptable safety. The pandemic of HIV was recognized seroepidemiologically from 1985 onwards. Blood transfusion was contributing from 10 to 15% to transmission in Africa. Groups at highest risk are children with malaria and anaemia, women with pregnancy-related haemorrhage or anaemia, victims of trauma and subjects with sickle-cell disease. Haemophiliacs are not a major risk group in comparison. Blood transfusion services have undoubtedly benefitted from the international, national and regional responses to the AIDS epidemic. Organizational structures have been established. There have been concerted moves to recruit voluntary unremunerated blood donors, selected from population groups with low seroprevalence. Serological screening for HIV, hepatitis viruses and syphilis has been introduced or strengthened. Standards for blood group serology, blood storage and handling have been improved. Guidelines for the appropriate use of blood have been formulated and adopted. There have been many training and retraining programmes. Much remains to be completed, however, using national and international resources, before the blood supply reaches acceptable standards of safety and is adequate in remote as well as in central areas of Africa.

Epidemiology and prevention of transfusion-associated human immunodeficiency virus transmission in sub-Saharan Africa

BACKGROUND AND OBJECTIVES

Compared to industrialised nations, countries in sub-Saharan Africa experience a greater amount of transfusion-associated HIV transmission due to high rates of transfusion in some groups of patients, a higher incidence and prevalence of HIV infection in donor populations, a lack of HIV antibody screening in some areas, and a higher residual risk of contamination in blood supplies despite antibody screening.

MATERIALS AND METHODS

Epidemiologic review.

RESULTS

Epidemiologic evidence supports the effectiveness of three relatively inexpensive strategies to prevent transfusion-associated HIV transmission in sub-Saharan Africa: HIV antibody screening, avoidance of unnecessary use of blood products, and exclusion of donors at high risk of infection. Such prevention strategies have not been universally implemented.

CONCLUSIONS

International aid to establish and maintain HIV antibody screening programmes, implementation of sound criteria for transfusion, and the search for HIV risk factors to use as donor exclusion criteria must be expanded in the region.

High rates of sexual contact with female sex workers, sexually transmitted diseases, and condom neglect among HIV-infected and uninfected men with tuberculosis in Abidjan, Côte d'Ivoire

To characterize human immunodeficiency virus (HIV) risk practices among men with tuberculosis, and to determine what factors are associated with HIV infection in this population, we conducted a case-control analysis of data collected during enrollment in a prospective cohort study in the two large tuberculosis treatment centers of Abidjan, Côte d'Ivoire. Demographic information and data on risk factors for HIV infection, including history of sex with female sex workers (FSWs) and history of sexually transmitted diseases (STDs), were collected on 490 HIV-infected and 239 HIV-uninfected men diagnosed with pulmonary tuberculosis between 1989 and 1992. HIV-infected men were significantly more likely than uninfected men to have had sex with FSWs in their lifetime [83 versus 63%, odds ratio (OR) 2.9, 95% confidence internal (CI) 2.0-4.2], genital ulcer disease in the past 5 years (38 versus 15%, OR 3.4, 95% CI 2.2-5.2), urethritis in the past 5 years (44 versus 23%, OR 2.6, 95% CI 1.8-3.8), and sex with FSWs in the past year (43 versus 25%, OR 2.3, 95% CI 1.6-3.3); no difference was found in the proportion with at least one non-FSW partner in the past year (84 versus 79%, OR 1.3, 95% CI 0.9-2.0). Among all men, 74% never used condoms, and only 1.4% always used condoms. In a multivariate analysis, sex with FSWs, genital ulcer disease, urethritis, and lack of circumcision were all significantly associated with HIV. This study demonstrates the critical roles of commercial sex, STDs, and condom neglect in fueling the HIV/AIDS epidemic in Abidjan, and illustrates the urgent need for widespread HIV education both in the general population and in men with tuberculosis.