Baseline survey of sexually transmitted infections in a cohort of female bar workers in Mbeya Region, Tanzania

HIV epidemiologic trends among occupational groups in Rakai, Uganda: A population-based longitudinal study, 1999-2016

Certain occupations have been associated with heightened risk of HIV acquisition and spread in sub-Saharan Africa, including female bar and restaurant work and male transportation work. However, data on changes in population prevalence of HIV infection and HIV incidence within occupations following mass scale-up of African HIV treatment and prevention programs is very limited. We evaluated prospective data collected between 1999 and 2016 from the Rakai Community Cohort Study, a longitudinal population-based study of 15- to 49-year-old persons in Uganda. Adjusted prevalence risk ratios for overall, treated, and untreated, prevalent HIV infection, and incidence rate ratios for HIV incidence with 95% confidence intervals were estimated using Poisson regression to assess changes in HIV outcomes by occupation. Analyses were stratified by gender. There were 33,866 participants, including 19,113 (56%) women. Overall, HIV seroprevalence declined in most occupational subgroups among men, but increased or remained mostly stable among women. In contrast, prevalence of untreated HIV substantially declined between 1999 and 2016 in most occupations, irrespective of gender, including by 70% among men (12.3 to 4.2%; adjPRR = 0.30; 95%CI:0.23-0.41) and by 78% among women (14.7 to 4.0%; adjPRR = 0.22; 95%CI:0.18-0.27) working in agriculture, the most common self-reported primary occupation. Exceptions included men working in transportation. HIV incidence similarly declined in most occupations, but there were no reductions in incidence among female bar and restaurant workers, women working in local crafts, or men working in transportation. In summary, untreated HIV infection and HIV incidence have declined within most occupational groups in Uganda. However, women working in bars/restaurants and local crafts and men working in transportation continue to have a relatively high burden of untreated HIV and HIV incidence, and as such, should be considered priority populations for HIV programming.

Uptake of and adherence to oral pre-exposure prophylaxis among adolescent girls and young women at high risk of HIV-infection in Kampala, Uganda: A qualitative study of experiences, facilitators and barriers

Background

There is limited information on factors that influence oral pre-exposure prophylaxis (PrEP) uptake and adherence among adolescent girls and young women (AGYW). We conducted a qualitative methods study to explore experiences, facilitators and barriers of PrEP uptake and adherence to PrEP among AGYW at risk of Human Immunodeficiency Virus (HIV) infection in Kampala, Uganda.

Methods

This study was nested in a prospective cohort study that offered daily oral PrEP to AGYW. Between April 2019 and October 2020 we conducted in-depth interviews with 26 AGYW aged 14–24 years who had been offered or had been using PrEP for at least 6 months, including PrEP adherers (8), non-adherers (8) and those who had declined PrEP (10). After 12 months, follow-up interviews were conducted with 12 AGYW who had adhered to PrEP and those who had dropped it. Thematic analysis was conducted and data were further examined and categorized into the 5 constructs of the Socio-Ecological Model (SEM).

Results

PrEP uptake and adherence were facilitated by factors including: perceptions that one’s own or partner’s sexual behaviour was high risk, a negative attitude towards condoms, social support and wanting to maintain a negative HIV status after receiving a negative HIV test result. Good adherence to PrEP was enabled by effective counselling, support tools such as alarms and phone reminders and incentives like free treatment for STIs and other illnesses during study visits. Barriers to uptake included: anxiety about the pill burden, perceptions of being too young for PrEP and fear of being labelled `prostitute’ or `HIV positive’. Poor adherence was attributed to doubt over the efficacy of PrEP as a result of beliefs that because HIV was incurable, no medicine could prevent it. Alcohol use, side effects experienced, and mobility all had a negative impact on adherence. The majority of PrEP users reported feeling safe as a result of using PrEP which had both good and negative implications on their sexual behaviour, specifically the number of sexual partners and condom use.

Conclusion

Addressing community misconceptions to maximize uptake of PrEP among AGYW is important. Targeted education messages, and counselling to address misconceptions in ways that capture the attention of AGYW in communities are required.

High prevalence of sexually transmitted infections among asymptomatic women opting for the intrauterine contraceptive device use in Mwanza, Tanzania: An urgent call for control interventions

Objective:

Placement of intrauterine contraceptive device (IUCD) in asymptomatic woman infected with sexually transmitted infection (STIs) can lead to pelvic inflammatory diseases (PID) and infertility if not well treated. The current study investigated the magnitude of sexually transmitted infections among women opting for IUCD use in the city of Mwanza, Tanzania.

Methods:

A cross-sectional study involving 150 asymptomatic women was conducted from August to December 2017. Detection of Chlamydia trachomatis antigen from endocervical swabs was done using immunochromatographic rapid tests while sera were used for detection of Treponema pallidum, human immunodeficiency virus (HIV) and herpes simplex virus Type 2 (HSV-2) antibodies.

Results:

The overall prevalence of STIs was 45/150 (30%, 95% CI: 22–37) while that of individual STIs were 27.3%, 5.3%, and 2.6% for C trachomatis, T pallidum, and HSV-2, respectively. History of dysuria (aOR 6.6; 95% CI 2.3–18.8; p < 0.001) and history of STIs (aOR 4.6; 95%CI 1.0–20.8; p = 0.049) independently predicted presence of STIs.

Conclusions:

Prevalence of STIs among women opted for IUCD use in the city of Mwanza, Tanzania is alarmingly high and is predicted by past history of dysuria and history of partner’s STIs, calling for the need of screening of the STIs among high-risk women in low- and middle-income countries (LMICs) opting for IUCD use.

HIV Prevalence, Risk Factors for Infection, and Uptake of Prevention, Testing, and Treatment among Female Sex Workers in Namibia

Background: In most settings, Female Sex Workers (FSW) bear a disproportionate burden of Human Immunodeficiency Virus (HIV) disease worldwide. Representative data to inform the development of behavioral and biomedical interventions for FSW in Namibia have not been published.

Objectives: Our objectives were to measure HIV prevalence, identify risk factors for infection, and describe uptake of prevention, testing, and treatment among FSW in Namibia.

Methods: We conducted cross-sectional surveys using Respondent-driven Sampling (RDS) in the Namibian cities of Katima Mulilo, Oshikango, Swakopmund/Walvis Bay, and Windhoek. Participating FSW completed behavioral questionnaires and rapid HIV testing.

Results: City-specific ranges of key indicators were: HIV prevalence (31.0–52.3%), reached by prevention programs in the past 12 months (46.9–73.6%), condom use at last sex with commercial (82.1–91.1%) and non-commercial (87.0–94.2%) partners, and tested for HIV within past 12 months or already aware of HIV-positive serostatus (56.9–82.1%). Factors associated with HIV infection varied by site and included: older age, having multiple commercial or non-commercial sex partners, unemployment, being currently out of school, and lower education level. Among HIV-positive FSW, 57.1% were aware of their HIV-positive serostatus and 33.7% were on antiretroviral treatment.

Discussion: Our results indicate extremely high HIV prevalence and low levels of case identification and treatment among FSW in Namibia. Our results, which are the first representative community-based estimates among FSW in Namibia, can inform the scale-up of interventions to reduce the risk for HIV acquisition and onward transmission, including treatment as prevention and pre-exposure prophylaxis.

Socio-demographic characteristics and risk factors for HIV transmission in female bar workers in sub-Saharan Africa: a systematic literature review

Background

Although sex workers are considered a key population in the HIV epidemic in sub-Saharan Africa (SSA), less consideration has been given to female bar workers (FBW), whose primary occupation is not sex work but who often engage in transactional sex. Understanding FBWs’ risk profiles is central to designing targeted HIV prevention interventions for them. This systematic review describes the socio-demographic characteristics and risk factors for HIV transmission among FBWs in SSA.

Methods

We searched six databases: PubMed, Google Scholar, Web of Science, Popline, Embase and additionally the World Health Organization’s WHOLIS database for grey literature between July and September 2017. Inclusion criteria were reporting (1) primary socio-demographic or behavioral data; on (2) women who sold or delivered drinks to clients; (3) in establishments serving alcohol; (4) in SSA. We excluded studies not presenting separate data on FBWs. We extracted quantitative and qualitative data from the selected studies and conducted a qualitative synthesis of findings.

Results

We found 4565 potentially eligible articles, including duplicates. After applying inclusion and exclusion criteria, we retained 19 articles. FBWs often migrated from rural to urban areas due to economic need or social marginalization. They began bar-based transactional sex due to low wages, peer pressure and to increase financial independence. FBWs had high HIV risk awareness but low agency to negotiate condom use, particularly with regular partners or when offered higher prices for condomless sex. FBWs were also vulnerable to violence and stigmatization.

Conclusions

FBWs are a vulnerable population for HIV infection. Despite social stigmatization and elevated risk of contracting STIs, bar work remains attractive because it enables unskilled women to both, make a living and maintain some independence. FBWs face HIV-related risk factors at the individual, community and societal level and may benefit from biomedical, behavioral and structural interventions.

Sexual behaviour, changes in sexual behaviour and associated factors among women at high risk of HIV participating in feasibility studies for prevention trials in Tanzania

INTRODUCTION

Risk reduction towards safer behaviour is promoted after enrolment in HIV prevention trials. We evaluated sexual behaviour, changes in sexual behaviour and factors associated with risky behaviour after one-year of follow-up among women enrolled in HIV prevention trials in Northern Tanzania.

METHODS

Self-reported information from 1378 HIV-negative women aged 18-44 enrolled in microbicide and vaccine feasibility studies between 2008-2010,was used to assess changes in behaviour during a 12-month follow-up period. Logistic regression with random intercepts was used to estimate odds ratios for trends in each behaviour over time. A behavioural risk score was derived from coefficients of three behavioural variables in a Poisson regression model for HIV incidence and thereafter, dichotomized to risky vs less-risky behaviour. Logistic regression was then used to identify factors associated with risky behaviour at 12 months.

RESULTS

At baseline, 22% reported multiple partners, 28% were involved in transactional sex and only 22% consistently used condoms with non-regular partners. The proportion of women reporting multiple partners, transactional sex and high-risk sex practices reduced at each 3-monthly visit (33%, 43% and 47% reduction in odds per visit respectively, p for linear trend <0.001 for all), however, there was no evidence of a change in the proportion of women consistently using condoms with non-regular partners (p = 0.22). Having riskier behaviours at baseline, being younger than 16 years at sexual debut, having multiple partners, selling sex and excessive alcohol intake at baseline were strongly associated with increased odds of risky sexual behaviour after 12 months (p<0.005 for all).

CONCLUSION

An overall reduction in risky behaviours over time was observed in HIV prevention cohorts. Risk reduction counselling was associated with decreased risk behaviour but was insufficient to change behaviours of all those at highest risk. Biological HIV prevention interventions such as PrEP for individuals at highest risk, should complement risk reduction counselling so as to minimize HIV acquisition risk.

Structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition among female bar workers in Dar es Salaam, Tanzania

In sub-Saharan Africa, female bar workers (FBWs) often serve as informal sex workers. Little is known about the prevalence of HIV and HIV-related risk factors among FBWs in Dar es Salaam (DSM), Tanzania. Using an adapted Structural HIV Determinants Framework, we identified structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition. We compared the prevalence of HIV and HIV-related risk factors among a random sample of 66 FBWs from DSM to an age-standardized, representative sample of female DSM-residents from the 2016 Demographic and Health and 2011-2012 AIDS Indicator Surveys. Compared to other women in DSM, FBWs had elevated prevalence of all four groups of risk factors. Key risk factors included gender and economic inequalities (structural); sexual violence and challenges negotiating condom use (interpersonal); depression, post-traumatic stress disorder, and low social support (psychosocial); and history of unprotected sex, multiple sex partners, and high alcohol consumption (behavioral). HIV prevalence did not differ between FBWs (7.1%, 95% CI 3.7-13.3%) and survey respondents (7.7%, 95% CI: 5.3-11.1%), perhaps due to FBWs' higher - though sub-optimal - engagement with HIV prevention strategies. Elevated exposure to HIV-related risk factors but low HIV prevalence suggests economic, psychosocial, and biomedical interventions may prevent HIV among FBWs in DSM.

HIV risk and pre-exposure prophylaxis interest among female bar workers in Dar es Salaam: cross-sectional survey

OBJECTIVE

Female bar workers (FBW) in East Africa often conduct sex work to supplement their incomes, and may be vulnerable to HIV acquisition. Pre-exposure prophylaxis (PrEP) offers protection against HIV acquisition. However, there is little research on FBW's sexual health. Our objective was to determine HIV risk behaviours and interest in PrEP among FBW in the largest city in East Africa.

DESIGN

Cross-sectional survey covering respondents' work and personal lives, including social and behavioural risk factors for HIV. The survey aimed to determine the feasibility of working with FBW and HIV prevalence estimates. Those who did not report being HIV positive were asked about their knowledge of and interest in PrEP. All women were offered free on-site HIV testing and counselling (HTC).

SETTING

Eight randomly selected workplaces, that is, bars, in Kinondoni district, Dar es Salaam (DSM).

PARTICIPANTS

66 FBW (≥18 years) selected at random from all women working in selected bars on the day of visit.

RESULTS

Half of respondents reported having had sex for money: 20% with bar clients only, 15% with other men only and 15% with both. Almost all (98%) reported ≥1 non-commercial partners in the past 12 months; only 30% reported using condoms with these partners. 85% of respondents had ever been pregnant; 44% had had an unintended pregnancy. Only 5% of respondents had ever heard of PrEP. However, 54% were somewhat/very interested in daily-pill PrEP and 79% were somewhat/very interested in long-acting injectable PrEP. When asked to rank modalities, long-acting injectable PrEP was the most preferred. Seven per cent of the 56 respondents who completed HTC tested HIV positive.

CONCLUSIONS

FBW in DSM have elevated risk factors for HIV acquisition, and PrEP appears highly acceptable. Studies developing PrEP delivery models and assessing PrEP initiation and adherence in FBW appear warranted.

Phenotypic Changes on Mycobacterium Tuberculosis-Specific CD4 T Cells as Surrogate Markers for Tuberculosis Treatment Efficacy

Background: The analysis of phenotypic characteristics on Mycobacterium tuberculosis (MTB)-specific T cells is a promising approach for the diagnosis of active tuberculosis (aTB) and for monitoring treatment success. We therefore studied phenotypic changes on MTB-specific CD4 T cells upon anti-tuberculosis treatment initiation in relation to the treatment response as determined by sputum culture. Methods: Peripheral blood mononuclear cells from subjects with latent MTB infection (n = 16) and aTB (n = 39) at baseline, weeks 9, 12, and 26 (end of treatment) were analyzed after intracellular interferon gamma staining and overnight stimulation with tuberculin. Liquid sputum cultures were performed weekly until week 12 and during 4 visits until week 26. Results: T cell activation marker expression on MTB-specific CD4 T cells differed significantly between subjects with aTB and latent MTB infection with no overlap for the frequencies of CD38^pos and Ki67^pos cells (both p < 0.0001). At 9 weeks after anti-TB treatment initiation the frequencies of activation marker (CD38, HLA-DR, Ki67) positive MTB-specific, but not total CD4 T cells, were significantly reduced (p < 0.0001). Treatment induced phenotypic changes from baseline until week 9 and until week 12 differed substantially between individual aTB patients and correlated with an individual's time to stable sputum culture conversion for expression of CD38 and HLA-DR (both p < 0.05). In contrast, the frequencies of maturation marker CD27 positive MTB-specific CD4 T cells remained largely unchanged until week 26 and significantly differed between subjects with treated TB disease and latent MTB infection (p = 0.0003). Discussion: Phenotypic changes of MTB-specific T cells are potential surrogate markers for tuberculosis treatment efficacy and can help to discriminate between aTB (profile: CD38^pos, CD27^low), treated TB (CD38^neg, CD27^low), and latent MTB infection (CD38^neg, CD27^high).

Vaginal microbiota and susceptibility to HIV

: Bacterial vaginosis, characterized by the replacement of the Lactobacillus-dominant microbiota with anaerobic bacteria and facultative Gram-negative rods, has been associated with adverse reproductive health outcomes including HIV acquisition. With the advent of newer molecular techniques, the vaginal microbiota can be investigated in more detail and the association with HIV examined more thoroughly. This review examines recent evidence suggesting that vaginal dysbiosis with increased microbial diversity, specific vaginal bacterial communities, and the presence and concentrations of some individual bacterial species, may increase HIV susceptibility. Potential mechanisms through which vaginal microbiota could impact HIV susceptibility are discussed. On the basis of the available data, this review finds that there is a modest, but growing, body of evidence linking vaginal microbiota to HIV susceptibility in women. The evidence could be strengthened through two main pathways. First, laboratory studies such as ex-vivo or animal experiments are needed to move from plausible mechanisms towards proven mechanisms that explain an effect of the vaginal microbiota on HIV susceptibility. Second, experimental evidence could directly test the hypothesis that sustaining optimal microbiota reduces HIV risk, though there are important obstacles to conducting such studies. Finally, this review examines strong evidence from a recent publication suggesting that deviations from an optimal vaginal microbiome, and particularly the presence of some bacterial communities with high relative abundance of Gardnerella vaginalis, reduces the efficacy of vaginal tenofovir-based microbicides.

Project Shikamana: Baseline Findings From a Community Empowerment-Based Combination HIV Prevention Trial Among Female Sex Workers in Iringa, Tanzania

Background:

Community empowerment approaches have been found to be effective in responding to HIV among female sex workers (FSWs) in South Asia and Latin America. To date, limited rigorous evaluations of these approaches have been conducted in sub-Saharan Africa.

Methods:

A phase II community randomized controlled trial is being conducted in Iringa, Tanzania, to evaluate the effectiveness of a community empowerment–based combination HIV prevention model (Project Shikamana) among a stratified sample of HIV-infected and HIV-uninfected FSWs. Cohort members were recruited from entertainment venues across 2 communities in the region using time-location sampling. All study participants gave consent, and were surveyed and screened for HIV at baseline. Primary biological study outcomes are viral suppression among the HIV-infected and remaining free of HIV among HIV-uninfected women.

Results:

A cohort of 496 FSWs was established and is currently under follow-up. Baseline HIV prevalence was 40.9% (203/496). Among HIV-infected FSWs, 30.5% (62/203) were previously aware of their HIV status; among those who were aware, 69.4% were on antiretroviral therapy (43/62); and for those on antiretroviral therapy, 69.8% (30/43) were virally suppressed. Factors associated with both HIV infection and viral suppression at baseline included community, age, number of clients, and substance use. Amount of money charged per client and having tested for sexually transmitted infection in the past 6 months were protective for HIV infection. Social cohesion among FSWs was protective for viral suppression.

Conclusions:

Significant gaps exist in HIV service coverage and progress toward reaching the 90-90-90 goals among FSWs in Iringa, Tanzania. Community empowerment approaches hold promise given the high HIV prevalence, limited services and stigma, discrimination, and violence.

Concordance Between Laboratory Diagnosed Sexually Transmitted Infections and Self-Reported Measures of Risky Sex by Partner Type Among Rural Ugandan Outpatients

Numerous HIV risk reduction interventions which show effects on sexual risk behaviors fail to find effects on STIs. We examined the concordance between laboratory diagnosed STIs and sexual risk behavior among Ugandan outpatients (n = 328). We screened for STIs and assessed sexual behavior at baseline and 6 month follow-up. Less risk was associated with an STI at baseline. At follow-up more unprotected sex with casual partners was associated with incident Syphilis, more unprotected sex with primary and secondary regular partners was associated with incident Chlamydia or Gonorrhea. Our results suggest ways to improve concordance between behavioral measures and STIs.

Comparison of Diagnostic Accuracy of PCR Targeting the 47-Kilodalton Protein Membrane Gene of Treponema pallidum and PCR Targeting the DNA Polymerase I Gene: Systematic Review and Meta-analysis

Treponema pallidum PCR (Tp-PCR) testing now is recommended as a valid tool for the diagnosis of primary or secondary syphilis. The objectives were to systematically review and determine the optimal specific target gene to be used for Tp-PCR. Comparisons of the performance of the two main targets are tpp47 and polA genes were done using meta-analysis. Three electronic bibliographic databases, representing abstract books from five conferences specialized in infectious diseases from January 1990 to March 2015, were searched. Search keywords included ("syphilis" OR "Treponema pallidum" OR "neurosyphilis") AND ("PCR" OR "PCR" OR "molecular amplification"). We included diagnostic studies assessing the performance of Tp-PCR targeting tpp47 (tpp47-Tp-PCR) or the polA gene (polA-Tp-PCR) in ulcers from early syphilis. All studies were assessed against quality criteria using the QUADAS-2 tool. Of 37 studies identified, 62.2% were judged at low risk of bias or applicability. Most used the U.S. Centers for Disease Control and Prevention (CDC) case definitions for primary or secondary (early) syphilis (89.2%; n = 33); 15 (40.5%) used darkfield microscopy (DFM). We did not find differences in sensitivity and specificity between the two Tp-PCR methods in the subgroup of studies using adequate reference tests. Among studies using DFM as the reference test, sensitivities were 79.8% (95% confidence intervals [CI], 72.7 to 85.4%) and 71.4% (46.0 to 88.0%) for tpp47-Tp-PCR and polA-Tp-PCR (P = 0.217), respectively; respective specificities were 95.3% (93.5 to 96.6%) and 93.7% (91.8 to 95.2%) (P = 0.304). Our findings suggest that the two Tp-PCR methods have similar accuracy and could be used interchangeably.

A qualitative study of discourses on heterosexual anal sexual practice among key, and general populations in Tanzania: implications for HIV prevention

Background

The risk of contracting HIV through heterosexual anal sex (HAS) is significantly higher than from vaginal intercourse. Little has been done to understand the discourses around HAS and terms people use to describe the practice in Tanzania. A better understanding of discourses on HAS would offer useful insights for measurement of the practice as well as designing appropriate interventions to minimise the risks inherent in the practice.

Methods

This study employed qualitative approaches involving 24 focus group discussions and 81 in-depth interviews. The study was conducted in 4 regions of Tanzania, and included samples from the general population and among key population groups (fishermen, truck drivers, sex workers, food and recreational facilities workers). Discourse analysis was conducted with the aid of NVIVO versions 8 and 10 software.

Results

Six discourses were delineated in relation to how people talked about HAS. Secrecy versus openness discourse describes the terms used when talking about HAS. “Other” discourse involved participants’ perception of HAS as something practiced by others unrelated to them and outside their communities. Acceptability/trendiness discourse: young women described HAS as something trendy and increasingly gaining acceptability in their communities. Materiality discourse: describes HAS as a practice that was more profitable than vaginal sex. Masculinity discourse involved discussions on men proving their manhood by engaging in HAS especially when women initiated the practice. Masculine attitudes were also reflected in how men described the practice using a language that would be considered crude. Public health discourse: describes HAS as riskier for HIV infection than vaginal sex. The reported use of condoms was low due to the perceptions that condoms were unsuitable for anal sex, but also perceptions among some participants that anal sex was safer than vaginal sex.

Conclusion

Discourses among young women and adult men across the study populations were supportive of HAS. These findings provide useful insights in understanding how different population groups talked about HAS and offer a range of terms that interventions and further research on magnitude of HAS could draw on when addressing health risks of HAS among different study populations.

Differences in HIV type 1 neutralization breadth in 2 geographically distinct cohorts in Africa

To investigate whether distinct populations have differing human immunodeficiency virus type 1 (HIV) neutralizing antibody responses, we compared 20 women from Tanzania's HIV Superinfection Study (HISIS) cohort, who were infected multiple HIV subtypes, and 22 women from the Centre for the AIDS Programme of Research in South Africa (CAPRISA) cohort, who were infected exclusively with HIV subtype C. By 2 years after infection, 35% of HISIS subjects developed neutralization breadth, compared with 9% of CAPRISA subjects (P = .0131). Cumulative viral loads between 3 and 12 months were higher in the HISIS group (P = .046) and strongly associated with breadth (P < .0001). While viral load was the strongest predictor, other factors may play a role, as the odds of developing breadth remained higher in HISIS even after correction for viral load.

The role of relationship types on condom use among urban men with concurrent partners in Ghana and Tanzania

Multiple concurrent partnerships are hypothesized to be important drivers of HIV transmission. Despite the demonstrated importance of relationship type (i.e., wife, girlfriend, casual partner, sex worker) on condom use, research on concurrency has not examined how different combinations of relationship types might affect condom use. We address this gap, using survey data from a sample of men from Ghana (GH: n = 807) and Tanzania (TZ: n = 800) who have at least three sexual partners in the past three months. We found that approximately two-thirds of men's reported relationships were classified as a girlfriend. Men were more likely to use a condom with a girlfriend if their other partner was a wife compared to if their other partner was a sex worker (GH: OR 3.10, 95% CI, 1.40, 6.86; TZ: OR 2.34, 95% CI 1.35, 4.06). These findings underscore the importance of considering relationship type when designing HIV prevention strategies in these settings.

The epidemiology of HIV and HSV-2 infections among women participating in microbicide and vaccine feasibility studies in Northern Tanzania

OBJECTIVES

To prepare for future HIV prevention trials, we conducted prospective cohort studies among women working in food and recreational facilities in northern Tanzania. We examined the prevalence and incidence of HIV and HSV-2, and associated risk factors.

METHODS

Women aged 18-44 years working in food and recreational facilities were screened to determine their eligibility for the studies. Between 2008-2010, HIV-negative women were enrolled and followed for 12 months. At enrolment and 3-monthly, we collected socio-demographic and behavioural data, and performed clinical examinations for collection of biological specimens that were tested for reproductive tract infections. Risk factors for HIV and HSV-2 incidence were investigated using Poisson regression models.

RESULTS

We screened 2,229 and enrolled 1,378 women. The median age was 27 years (interquartile range, IQR 22, 33), and median duration working at current facility was 2 years. The prevalences of HIV at screening and HSV-2 at enrolment were 16% and 67%, respectively. Attendance at the 12-month visit was 86%. HIV and HSV-2 incidence rates were 3.7 (95% confidence interval, CI: 2.8,5.1) and 28.6 (95% CI: 23.5,35.0)/100 person-years, respectively. Women who were separated, divorced, or widowed were at increased risk of HIV (adjusted incidence rate ratio, aRR = 6.63; 95% CI: 1.97,22.2) and HSV-2 (aRR = 2.00; 95% CI: 1.15,3.47) compared with married women. Women reporting ≥3 partners in the past 3 months were at higher HIV risk compared with women with 0-1 partner (aRR = 4.75; 95% CI: 2.10,10.8), while those who had reached secondary education or above were at lower risk of HSV-2 compared with women with incomplete primary education (aRR = 0.42; 95% CI: 0.22,0.82).

CONCLUSIONS

HIV and HSV-2 rates remain substantially higher in this cohort than in the general population, indicating urgent need for effective interventions. These studies demonstrate the feasibility of conducting trials to test new interventions in this highly-mobile population.

Prevalence, incidence and risk factors for anogenital warts in Sub Saharan Africa: a systematic review and meta analysis

Introduction

The quadrivalent HPV vaccine is highly effective in primary prevention of anogenital warts (AGWs). However, there is lack of systematic review in the literature of the epidemiology of AGWs in Sub Saharan Africa (SSA).

Objective

To review the prevalence, incidence and risk factors for AGWs in SSA prior to the introduction of HPV vaccination programs.

Methods

PubMed/MEDLINE, Africa Index Medicus and HINARI websites were searched for peer reviewed English language published medical literature on AGWs from January 1, 1984 to June 30, 2012. Relevant additional references cited in published papers were also evaluated for inclusion. For inclusion, the article had to meet the following criteria (1) original studies with estimated prevalence and/or incidence rates among men and/or women (2) detailed description of the study population (3) clinical or self-reported diagnosis of AGWs (4) HPV genotyping of histologically confirmed AGWs. The final analysis included 40 studies. Data across different studies were synthesized using descriptive statistics for various subgroups of females and males by geographical area. A meta - analysis of relative risk was conducted for studies that had data reported by HIV status.

Results

The prevalence rates of clinical AGWs among sex workers and women with sexually transmitted diseases (STDs) or at high risk of sexually transmitted infection (STIs) range from 3.3% - 10.7% in East, 2.4% - 14.0% in Central and South, and 3.5% - 10.5% in West African regions. Among pregnant women, the prevalence rates range from 0.4% - 3.0% in East, 0.2% - 7.3% in Central and South and 2.9% in West African regions. Among men, the prevalence rates range from 3.5% - 4.5% in East, 4.8% - 6.0% in Central and South and 4.1% to 7.0% in West African regions. In all regions, the prevalence rates were significantly higher among HIV+ than HIV- women with an overall summary relative risk of 1.62 (95% CI: 143–1.82).

The incidence rates range from 1.1 – 2.7 per 100 person-years among women and 1.4 per 100 person years among men. Incidence rate was higher among HIV+ (3.0 per 100 person years) and uncircumcised men (1.7 per 100 person-years) than circumcised men (1.3 per 100 person-years).

HIV positivity was a risk factor for AGWs among both men and women. Other risk factors in women include presence of abnormal cervical cytology, co-infection with HPV 52, concurrent bacteria vaginoses and genital ulceration. Among men, other risk factors include cigarette smoking and lack of circumcision.

Conclusions

AGWs are common among selected populations particularly HIV infected men and women. However, there is need for population-based studies that will guide policies on effective prevention, treatment and control of AGWs.

Effect of genital herpes on cervicovaginal HIV shedding in women co-infected with HIV AND HSV-2 in Tanzania

OBJECTIVES

To compare the presence and quantity of cervicovaginal HIV among HIV seropositive women with clinical herpes, subclinical HSV-2 infection and without HSV-2 infection respectively; to evaluate the association between cervicovaginal HIV and HSV shedding; and identify factors associated with quantity of cervicovaginal HIV.

DESIGN

Four groups of HIV seropositive adult female barworkers were identified and examined at three-monthly intervals between October 2000 and March 2003 in Mbeya, Tanzania: (1) 57 women at 70 clinic visits with clinical genital herpes; (2) 39 of the same women at 46 clinic visits when asymptomatic; (3) 55 HSV-2 seropositive women at 60 clinic visits who were never observed with herpetic lesions; (4) 18 HSV-2 seronegative women at 45 clinic visits. Associations of genital HIV shedding with HIV plasma viral load (PVL), herpetic lesions, HSV shedding and other factors were examined.

RESULTS

Prevalence of detectable genital HIV RNA varied from 73% in HSV-2 seronegative women to 94% in women with herpetic lesions (geometric means 1634 vs 3339 copies/ml, p = 0.03). In paired specimens from HSV-2 positive women, genital HIV viral shedding was similar during symptomatic and asymptomatic visits. On multivariate regression, genital HIV RNA (log10 copies/mL) was closely associated with HIV PVL (β = 0.51 per log10 copies/ml increase, 95%CI:0.41-0.60, p<0.001) and HSV shedding (β = 0.24 per log10 copies/ml increase, 95% CI:0.16-0.32, p<0.001) but not the presence of herpetic lesions (β = -0.10, 95%CI:-0.28-0.08, p = 0.27).

CONCLUSIONS

HIV PVL and HSV shedding were more important determinants of genital HIV than the presence of herpetic lesions. These data support a role of HSV-2 infection in enhancing HIV transmissibility.

Unexpectedly high injection drug use, HIV and hepatitis C prevalence among female sex workers in the Republic of Mauritius

Female sex workers (FSW) often have a disproportionately high prevalence of HIV infection and they, along with their clients, are considered a core group contributing to the transmission of HIV in many countries. In 2010, females who reported having vaginal/anal/oral sex in the last 6 months with a male in exchange for money or gifts, aged ≥15 years, and living in Mauritius were recruited into a survey using respondent driven sampling. Consenting females (n = 299) completed a behavioral questionnaire and provided venous blood for HIV, HCV and HBV testing. HIV seroprevalence among FSW was 28.9 % and 43.8 % were infected with HCV; among HIV seropositive FSW, 88.2 % were also infected with HCV. Almost 40 % of FSW reported injecting drugs sometime in their lives and 30.5 % of all FSW reported doing so in the previous 3 months. Among those who ever injected drugs, 82.5 % did so in the past 3 months and among those 60 % reported injecting drugs at least once a day. Among FSW who ever injected drugs, 17.5 % reported sharing a needle at last injection. Regression analyses found injection drug use behaviors to be positively associated with HIV seroprevalence. These findings indicate that FSW, especially those who inject drugs, are at high risk for HIV and HCV infection and transmission and illustrates the need for gender responsive HIV and injection drug use prevention and treatment models that respond to the unique situations that affect this population.

Socio-demographic characteristics and behavioral risk factors of female sex workers in sub-saharan Africa: a systematic review

Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioral underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers (FSW) in this region, their occupational contexts and key behavioral risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. FSW commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalization, high mobility and hazardous alcohol use. These, in turn, predict behaviors such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviors such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of FSW, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Targeted services at sufficiently high coverage, taking into account the behavioral and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by FSW on the continent.

HIV type 1 subtype distribution, multiple infections, sexual networks, and partnership histories in female sex workers in Kampala, Uganda

We investigated for the first time the subtype distribution, prevalence of multiple HIV-1 infections, sexual networks, and partnership histories in a cohort of women engaged in high-risk sexual behavior such as female sex workers (FSWs) and women employed in entertainment facilities. Viral RNA was extracted from blood samples collected from 324 HIV-1-positive women; the gp-41 and pol-IN genes were directly sequenced. Women found to have closely related viruses and those with recombinant viruses were further analyzed in the pol-IN gene by clonal sequencing to determine HIV-1 multiple infections. Individual partnership histories were used to provide information on when sex work was undertaken and where. Subtyping in both gp-41 and pol-IN was successfully done in 210/324 (64.8%) women. Subtype distribution in these two genes was 54.3% (n=114) A/A, 2.9% (n=6) C/C, 24.3% (n=51) D/D, 11.9% (n=25) A/D, 4.8% (n=10) D/A, 0.5% (n=1) C/A, 1.0% (n=2) B/A, and 0.5% (n=1) B/D. Sexual networks were identified in six pairs and one triplet of women with closely related subtype A viruses. Partnership histories showed that women having phylogenetically similar viruses had worked in the same localities. Five cases of multiple infections were confirmed: four dual infections and one triple infection. In this first molecular epidemiology study among FSWs in Kampala, subtype A was the predominant subtype. About 9% of a subgroup had multiple infections. Partnership histories and multiple infections observed in this population suggest sexual mixing of the FSWs and their clients confirming their high-risk characteristics.

Pregnancy and contraceptive use among women participating in an HIV prevention trial in Tanzania

Objectives

Information on pregnancy rates and factors associated with pregnancy and contraceptive use is important for clinical trials in women in sub-Saharan Africa where withdrawal of investigational products may be required in the event of pregnancy with a consequent effect on sample size and trial power.

Methods

A prospective cohort analysis of pregnancy and contraceptive use was conducted in Tanzanian women enrolled in a randomised placebo-controlled trial of herpes simplex virus-suppressive therapy with acyclovir to measure the effect on HIV incidence in HIV-negative women and on genital and plasma HIV viral load in HIV-positive women. The cohort was followed every 3 months for 12–30 months. Women at each visit were categorised into users or non-users of contraception. Pregnancy rates and factors associated with pregnancy incidence and contraceptive use were measured.

Results

Overall 254 of 1305 enrolled women became pregnant at least once during follow-up (pregnancy rate: 12.0/100 person-years). Younger age, being unmarried, higher baseline parity and changes in contraceptive method during follow-up were independently associated with pregnancy. Having paid sex and being HIV positive were associated with lower risk of pregnancy. Uptake of contraception was associated with young age, being unmarried, occupation, parity and the number and type of sexual partners.

Conclusions

Data on use of contraceptive methods and risk factors for pregnancy can help to guide decisions on trial eligibility and the need for additional counselling. Mandatory reliable contraceptive use in study participants may be required to reduce pregnancy rates in studies where pregnancy is contraindicated.

HIV and other sexually transmitted infections in a cohort of women involved in high-risk sexual behavior in Kampala, Uganda

BACKGROUND

Uganda has long been successful in controlling the HIV epidemic; however, there is evidence that HIV prevalence and incidence are increasing again. Data on the HIV/STI epidemic among sex workers are so far lacking from Uganda. This paper describes the baseline epidemiology of HIV/STI in a newly established cohort of women involved in high-risk sexual behavior in Kampala, Uganda.

METHODS

Women were recruited from red-light areas in Kampala. Between April 2008 and May 2009, 1027 eligible women were enrolled. Sociodemographic and behavioral information were collected; blood and genital samples were tested for HIV/STI. Risk factors for HIV infection were examined using multivariate logistic regression.

RESULTS

HIV seroprevalence was 37%. The prevalence of Neisseria gonorrhoeae was 13%, Chlamydia trachomatis, 9%; Trichomonas vaginalis, 17%; bacterial vaginosis, 56% and candida infection, 11%. Eighty percent had herpes simplex virus 2 antibodies (HSV-2), 21% were TPHA-positive and 10% had active syphilis (RPR+TPHA+). In 3% of the genital ulcers, Treponema pallidum (TP) was identified, Haemophilus ducreyi in 6%, and HSV-2 in 35%. Prevalent HIV was independently associated with older age, being widowed, lack of education, sex work as sole income, street-based sex work, not knowing HIV-status, using alcohol, and intravaginal cleansing with soap. HIV infection was associated with N. gonorrhoeae, T. vaginalis, bacterial vaginosis, HSV-2 seropositivity and active syphilis.

CONCLUSIONS

Prevalence of HIV/STI is high among women involved in high-risk sexual behavior in Kampala. Targeted HIV prevention interventions including regular STI screening, voluntary HIV testing and counseling, condom promotion, and counseling for reducing alcohol use are urgently needed in this population.

Risk factors of alcohol problem drinking among female bar/hotel workers in Moshi, Tanzania: a multi-level analysis

There is limited information on alcohol problem drinking, which has been associated with sexually transmitted infections (STIs), including HIV, among female bar/hotel workers in Africa. This paper aimed to identify the individual- and facility-level determinants of alcohol problem drinking in this setting. Problem drinking was defined based on the CAGE alcohol screening scale. Multi-level logistic regression was used to identify individual- and facility-level factors associated with problem drinking. About 37.3% of women (N = 1629) were classified as having probable or definite problem drinking. In multi-level analysis, main characteristics associated with problem drinking included: having 3-4 partners in the past 5 years compared to having 1-2, used a condom in the last sex comparing to non-use, history of transactional sex, having more pregnancies, and facilities whose employees do not live on the premises. Interventions which combine alcohol and sexual risk reduction counseling are urgently needed in this population.

Preferential infection and depletion of Mycobacterium tuberculosis-specific CD4 T cells after HIV-1 infection

HIV-1 preferentially infects M. tuberculosis-specific CD4+ T cells due to their increased production of IL-2.

HIV-1 infection results in the progressive loss of CD4 T cells. In this study, we address how different pathogen-specific CD4 T cells are affected by HIV infection and the cellular parameters involved. We found striking differences in the depletion rates between CD4 T cells to two common opportunistic pathogens, cytomegalovirus (CMV) and Mycobacterium tuberculosis (MTB). CMV-specific CD4 T cells persisted after HIV infection, whereas MTB-specific CD4 T cells were depleted rapidly. CMV-specific CD4 T cells expressed a mature phenotype and produced very little IL-2, but large amounts of MIP-1β. In contrast, MTB-specific CD4 T cells were less mature, and most produced IL-2 but not MIP-1β. Staphylococcal enterotoxin B–stimulated IL-2–producing cells were more susceptible to HIV infection in vitro than MIP-1β–producing cells. Moreover, IL-2 production was associated with expression of CD25, and neutralization of IL-2 completely abrogated productive HIV infection in vitro. HIV DNA was found to be most abundant in IL-2–producing cells, and least abundant in MIP-1β–producing MTB-specific CD4 T cells from HIV-infected subjects with active tuberculosis. These data support the hypothesis that differences in function affect the susceptibility of pathogen-specific CD4 T cells to HIV infection and depletion in vivo, providing a potential mechanism to explain the rapid loss of MTB-specific CD4 T cells after HIV infection.

How informed is consent in vulnerable populations? Experience using a continuous consent process during the MDP301 vaginal microbicide trial in Mwanza, Tanzania

BACKGROUND

HIV prevention trials conducted among disadvantaged vulnerable at-risk populations in developing countries present unique ethical dilemmas. A key concern in bioethics is the validity of informed consent for trial participation obtained from research subjects in such settings. The purpose of this study was to investigate the effectiveness of a continuous informed consent process adopted during the MDP301 phase III vaginal microbicide trial in Mwanza, Tanzania.

METHODS

A total of 1146 women at increased risk of HIV acquisition working as alcohol and food vendors or in bars, restaurants, hotels and guesthouses have been recruited into the MDP301 phase III efficacy and safety trial in Mwanza. During preparations for the trial, participatory community research methods were used to develop a locally-appropriate pictorial flipchart in order to convey key messages about the trial to potential participants. Pre-recorded audio tapes were also developed to facilitate understanding and compliance with gel-use instructions. A comprehension checklist is administered by clinical staff to all participants at screening, enrolment, 12, 24, 40 and 50 week follow-up visits during the trial. To investigate women's perceptions and experiences of the trial, including how well participants internalize and retain key messages provided through a continuous informed consent process, a random sub-sample of 102 women were invited to participate in in-depth interviews (IDIs) conducted immediately after their 4, 24 and 52 week follow-up visits.

RESULTS

99 women completed interviews at 4-weeks, 83 at 24-weeks, and 74 at 52 weeks (a total of 256 interviews). In all interviews there was evidence of good comprehension and retention of key trial messages including that the gel is not currently know to be effective against HIV; that this is the key reason for conducting the trial; and that women should stop using gel in the event of pregnancy.

CONCLUSIONS

Providing information to trial participants in a focussed, locally-appropriate manner, using methods developed in consultation with the community, and within a continuous informed-consent framework resulted in high levels of comprehension and message retention in this setting. This approach may represent a model for researchers conducting HIV prevention trials among other vulnerable populations in resource-poor settings.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN64716212.

Are women who work in bars, guesthouses and similar facilities a suitable study population for vaginal microbicide trials in Africa?

BACKGROUND

A feasibility study was conducted to investigate whether an occupational at-risk cohort of women in Mwanza, Tanzania are a suitable study population for future phase III vaginal microbicide trials.

METHODOLOGY/PRINCIPAL FINDINGS

1573 women aged 16-54 y working in traditional and modern bars, restaurants, hotels, guesthouses or as local food-handlers were enrolled at community-based reproductive health clinics, provided specimens for HIV/STI and pregnancy testing, and asked to attend three-monthly clinical follow-up visits for 12-months. HIV positive and negative women were eligible to enter the feasibility study and to receive free reproductive health services at any time. HIV prevalence at baseline was 26.5% (417/1573). HIV incidence among 1156 sero-negative women attending at baseline was 2.9/100PYs. Among 1020 HIV sero-negative, non-pregnant women, HIV incidence was 2.0/100PYs, HSV-2 incidence 12.7/100PYs and pregnancy rate 17.8/100PYs. Retention at three-months was 76.3% (778/1020). Among 771 HIV sero-negative, non-pregnant women attending at three-months, subsequent follow-up at 6, 9 and 12-months was 83.7%, 79.6%, and 72.1% respectively. Older women, those who had not moved home or changed their place of work in the last year, and women working in traditional bars or as local food handlers had the highest re-attendance.

CONCLUSIONS/SIGNIFICANCE

Women working in food outlets and recreational facilities in Tanzania and other parts of Africa may be a suitable study population for microbicide and other HIV prevention trials. Effective locally-appropriate strategies to address high pregnancy rates and early losses to follow-up are essential to minimise risk to clinical trials in these settings.

Microbicides development programme: engaging the community in the standard of care debate in a vaginal microbicide trial in Mwanza, Tanzania

BACKGROUND

HIV prevention research in resource-limited countries is associated with a variety of ethical dilemmas. Key amongst these is the question of what constitutes an appropriate standard of health care (SoC) for participants in HIV prevention trials. This paper describes a community-focused approach to develop a locally-appropriate SoC in the context of a phase III vaginal microbicide trial in Mwanza City, northwest Tanzania.

METHODS

A mobile community-based sexual and reproductive health service for women working as informal food vendors or in traditional and modern bars, restaurants, hotels and guesthouses has been established in 10 city wards. Wards were divided into geographical clusters and community representatives elected at cluster and ward level. A city-level Community Advisory Committee (CAC) with representatives from each ward has been established. Workshops and community meetings at ward and city-level have explored project-related concerns using tools adapted from participatory learning and action techniques e.g. chapati diagrams, pair-wise ranking. Secondary stakeholders representing local public-sector and non-governmental health and social care providers have formed a trial Stakeholders' Advisory Group (SAG), which includes two CAC representatives.

RESULTS

Key recommendations from participatory community workshops, CAC and SAG meetings conducted in the first year of the trial relate to the quality and range of clinic services provided at study clinics as well as broader standard of care issues. Recommendations have included streamlining clinic services to reduce waiting times, expanding services to include the children and spouses of participants and providing care for common local conditions such as malaria. Participants, community representatives and stakeholders felt there was an ethical obligation to ensure effective access to antiretroviral drugs and to provide supportive community-based care for women identified as HIV positive during the trial. This obligation includes ensuring sustainable, post-trial access to these services. Post-trial access to an effective vaginal microbicide was also felt to be a moral imperative.

CONCLUSION

Participatory methodologies enabled effective partnerships between researchers, participant representatives and community stakeholders to be developed and facilitated local dialogue and consensus on what constitutes a locally-appropriate standard of care in the context of a vaginal microbicide trial in this setting.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN64716212.

Knowledge and practice among healthcare providers in rural Vietnam regarding sexually transmitted infections

OBJECTIVES

To assess knowledge and reported practice regarding sexually transmitted infections (STI) among healthcare providers in rural Vietnam and to examine background characteristics possibly associated with knowledge and practice.

METHODS

A cross-sectional study using a self-completed questionnaire was carried out in 2006 among 465 healthcare providers in rural Vietnam. The questionnaire included questions on providers' characteristics, STI knowledge, and case scenarios of 4 common STI syndromes. Correct answer was scored 1, "do not know" or incorrect answer was scored 0. Linear and logistic regressions were applied.

RESULTS

Diseases considered as STI were gonorrhea and syphilis by 83% of the respondents, 70% believed partner treatment necessary for bacterial vaginosis or candidiasis cases. Sharing clothes/food or kissing was commonly mentioned as transmission routes (60%). Median scores of knowledge and reported practice were 29 (range: 0-50) and 2 (range: 0-20), respectively. Among the respondents, 34% had a knowledge score of less than 25 and 78% had a practice score of less than 10. Characteristics predicting higher level of knowledge were being a medical doctor, assistant medical doctor, midwife, or serving STI patients. Characteristics predicting higher level of practice were serving STI patients, being a midwife or female provider, and having participated in STI or reproductive tract infection training courses. Respondents who reported treating STI patients had a higher level of knowledge and reported practice than the others.

Minor viral and host genetic polymorphisms can dramatically impact the biologic outcome of an epitope-specific CD8 T-cell response

Human immunodeficiency virus-1 subtypes A and C differ in the highly conserved Gag-TL9 epitope at a single amino acid position. Similarly, the TL9 presenting human leukocyte antigen (HLA) class I molecules B42 and B81 differ only at 6 amino acid positions. Here, we addressed the influence of such minor viral and host genetic variation on the TL9-specific CD8 T-cell response. The clonotypic characteristics of CD8 T-cell populations elicited by subtype A or subtype C were distinct, and these responses differed substantially with respect to the recognition and selection of TL9 variants. Irrespective of the presenting HLA class I molecule, CD8 T-cell responses elicited by subtype C exhibited largely comparable TL9 variant cross-recognition properties, expressed T-cell receptors that used almost exclusively the TRBV 12-3 gene, and selected for predictable patterns of viral variation within TL9. In contrast, subtype A elicited TL9-specific CD8 T-cell populations with completely different, more diverse TCRBV genes and did not select for viral variants. Moreover, TL9 variant cross-recognition properties were extensive in B81(+) subjects but limited in B42(+) subjects. Thus, minor viral and host genetic polymorphisms can dramatically alter the immunologic and virologic outcome of an epitope-specific CD8 T-cell response.

The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant women

BACKGROUND

Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV-1 transmission. This has led to renewed research interest in its treatment.

OBJECTIVES

To assess the effects of antimicrobial agents on BV in non-pregnant women.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date).

SELECTION CRITERIA

Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram-stain criteria of BV.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data.

MAIN RESULTS

Twenty-four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re-analysed the remainder.Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four-week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole.

AUTHORS' CONCLUSIONS

Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better-designed trials with larger sample sizes to test the effectiveness of promising drugs.

Genital tract infections among HIV-infected pregnant women in Malawi, Tanzania and Zambia

SUMMARY

The aim of this study was to compare the prevalence and factors associated with genital tract infections among HIV-infected pregnant women from African sites. Participants were recruited from Blantyre and Lilongwe, Malawi; Dar es Salaam, Tanzania; and Lusaka, Zambia. Genital tract infections were assessed at baseline. Of 2627 eligible women enrolled, 2292 were HIV-infected. Of these, 47.8% had bacterial vaginosis (BV), 22.4% had vaginal candidiasis, 18.8% had trichomoniasis, 8.5% had genital warts, 2.6% had chlamydia infection, 2.2% had genital ulcers and 1.7% had gonorrhoea. The main factors associated with genital tract infections included genital warts (adjusted odds ratio [AOR] 1.8, 95% CI 1.2-2.7), genital ulcers (AOR 2.4, 95% CI 1.2-5.1) and abnormal vaginal discharge (AOR 2.5, 95% CI 1.9-3.3) for trichomoniasis. BV was the most common genital tract infection followed by candidiasis and trichomoniasis. Differences in burdens and risk factors call for enhanced interventions for identification of genital tract infections among HIV-infected women.

Risk factors for HIV incidence in women participating in an HSV suppressive treatment trial in Tanzania

OBJECTIVES

A randomized, double-blind, placebo-controlled trial (RCT) of herpes simplex virus type 2 suppressive therapy with acyclovir 400 mg twice daily conducted among women in northwestern Tanzania reported a similar rate of HIV acquisition in both trial arms (Current Controlled Trials number ISRCTN35385041). Risk factors for HIV incidence were examined in the context of 3-monthly follow-up visits offering both voluntary counselling and testing and care for sexually transmitted infections.

DESIGN

Prospective cohort analysis of trial participants enrolled and followed for up to 30 months.

METHODS

Risk factors for HIV acquisition were analysed using Cox regression.

RESULTS

Overall, 821 herpes simplex virus type 2 seropositive, HIV seronegative women were randomized; 400 randomized to acyclovir and 421 to placebo; 659 (80.3%) completed follow-up. HIV incidence was 4.27 per 100 person-years. There was no overall impact of acyclovir on HIV incidence [hazard ratio = 1.01; 95% confidence interval (CI) 0.61-1.66]. HIV acquisition was independently associated with younger age at enrolment (age 16-19 vs. 30-35: hazard ratio = 4.02; 95% CI 1.67-9.68), alcohol consumption at enrolment (> or =30 drinks/week vs. none: hazard ratio = 4.39, 95% CI 1.70-11.33), having paid sex within the previous 3 months (hazard ratio = 1.82, 95% CI 1.09-3.05), recent infection with gonorrhoea (hazard ratio = 3.62, 95% CI 1.62-8.08) and injections in the previous 3 months (hazard ratio = 3.45, 95% CI 1.62-7.34). There was some evidence of an association between HIV incidence and living in the recruitment community for less than 2 years (hazard ratio = 1.75, 95% CI 0.98-3.10) and exposure to hormonal contraception (hazard ratio = 1.60, 95% CI 0.93-2.76).

CONCLUSION

A high incidence of HIV was observed in this trial cohort, especially in young women. Interventions are needed to address the risk associated with alcohol use and to sustain control of other sexually transmitted infections.

Sustained high prevalence of sexually transmitted infections among female sex workers in Cambodia: high turnover seriously challenges the 100% Condom Use Programme

Background

Cambodia's 100% Condom-Use Programme (CUP), implemented nationally in 2001, requires brothel-based female sex workers (FSWs) to use condoms with all clients. In 2005, we conducted a sexually transmitted infection (STI) survey among FSWs. This paper presents the STI prevalence and related risk factors, and discusses prevalence trends in the context of the 100% CUP in Cambodia.

Methods

From March-May, 1079 FSWs from eight provinces consented to participate, provided specimens for syphilis, chlamydia, and gonorrhoea testing, and were interviewed. Univariate and multivariate logistic regression analysis was used to determine factors associated with STIs. STI prevalence was compared with data from the 1996 and 2001 STI surveys.

Results

Most FSWs were young (55% aged 15–24) and new to sex work (60% had worked 12 ≤ months). Consistent condom use with clients was reported by 80% of FSWs, but only 38% of FSWs always used condoms with sweethearts or casual partners. Being new to sex work was the only factor significantly associated with "any STI" (OR = 2.1). Prevalence of syphiliwas 2.3%; chlamydia, 14.4%; gonorrhoea, 13.0%; and any STI, 24.4%. Prevalence of each STI in 2005 was significantly lower than in 1996, but essentially the same as prevalence observed in 2001.

Conclusion

New FSWs were found to have substantially higher prevalence than those with longer experience. The percent of FSWs who used condoms consistently was high with clients but remained low with non-paying sex partners. Because of the high turnover of FSWs, the prevention needs of new FSWs should be ascertained and addressed. Despite 100% CUP implementation, the prevalence of STIs among FSWs was the same in 2005 as it was in 2001. Limited coverage and weak implementation capacity of the programme along with questionable quality of the STI services are likely to have contributed to the sustained high prevalence. The programme should be carefully reviewed in terms of intensity, quality and coverage.

Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies

OBJECTIVES

To assess and summarize the published literature on the extent to which bacterial vaginosis may increase the risk of HIV acquisition.

DESIGN

Meta-analysis of published studies.

METHODS

Medline and other electronic databases were systematically searched for eligible publications. The association between bacterial vaginosis and incident HIV was separately analyzed from that between bacterial vaginosis and prevalent HIV. The latter was further analyzed, stratified by bacterial vaginosis diagnostic method, HIV risk profile of the study population, and whether or not adjusted estimates were presented.

RESULTS

Twenty-three eligible publications were identified, including a total of 30,739 women. Bacterial vaginosis was associated with an increased risk of HIV acquisition in HIV-incidence studies (relative risk = 1.6, 95% confidence interval: 1.2, 2.1). All but one of 21 HIV-prevalence studies reported estimates above the null. The latter results were heterogeneous and showed some evidence of funnel plot asymmetry, precluding the estimation of a single summary measure. The association between bacterial vaginosis and HIV in prevalence studies appeared stronger for women without high-risk sexual behavior.

CONCLUSION

Bacterial vaginosis was consistently associated with an increased risk of HIV infection. High bacterial vaginosis prevalence may result in a high number of HIV infections being attributable to bacterial vaginosis. More prospective studies are needed to accurately evaluate the role of bacterial vaginosis in HIV acquisition in low-risk versus high-risk women. Furthermore, randomized clinical trials may be worth considering to determine the effect of bacterial vaginosis control measures on HIV acquisition.

Effect of herpes simplex suppression on incidence of HIV among women in Tanzania

BACKGROUND

Infection with herpes simplex virus type 2 (HSV-2) is associated with an increased risk of acquiring infection with the human immunodeficiency virus (HIV). This study tested the hypothesis that HSV-2 suppressive therapy reduces the risk of HIV acquisition.

METHODS

Female workers at recreational facilities in northwestern Tanzania who were 16 to 35 years of age were interviewed and underwent serologic testing for HIV and HSV-2. We enrolled female workers who were HIV-seronegative and HSV-2-seropositive in a randomized, double-blind, placebo-controlled trial of suppressive treatment with acyclovir (400 mg twice daily). Participants attended mobile clinics every 3 months for a follow-up period of 12 to 30 months, depending on enrollment date. The primary outcome was the incidence of infection with HIV. We used a modified intention-to-treat analysis; data for participants who became pregnant were censored. Adherence to treatment was estimated by a tablet count at each visit.

RESULTS

A total of 821 participants were randomly assigned to receive acyclovir (400 participants) or placebo (421 participants); 679 (83%) completed follow-up. Mean follow-up for the acyclovir and placebo groups was 1.52 and 1.62 years, respectively. The incidence of HIV infection was 4.27 per 100 person-years (27 participants in the acyclovir group and 28 in the placebo group), and there was no overall effect of acyclovir on the incidence of HIV (rate ratio for the acyclovir group, 1.08; 95% confidence interval, 0.64 to 1.83). The estimated median adherence was 90%. Genital HSV was detected in a similar proportion of participants in the two study groups at 6, 12, and 24 months. No serious adverse events were attributable to treatment with acyclovir.

CONCLUSIONS

These data show no evidence that acyclovir (400 mg twice daily) as HSV suppressive therapy decreases the incidence of infection with HIV. (Current Controlled Trials number, ISRCTN35385041 [controlled-trials.com].).

Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations

Background: Women who work commercially in sex work (female sex workers [FSW]) are considered a high-risk group for sexually transmissible infections (STI), yet the level of reported pathogens varies in studies around the world. This study reviewed STI rates reported in 42 studies of FSW around the world published between 1995 and 2006 and analysed the trends and types of populations surveyed, emphasising difficult to access FSW populations. Methods:Studies were retrieved by PUBMED and other search engines and were included if two or more pathogens were studied and valid laboratory methods were reported. Results: The five most commonly assessed pathogens were Neisseria gonorrhea (prevalence 0.5–41.3), Chlamydia trachomatis (0.61–46.2), Treponema pallidum (syphilis; 1.5–60.5), HIV (0–76.6), and Trichomonas vaginalis (trichmoniasis; 0.11–51.0). Neisseria gonorrhea and C. trachomatis were the most commonly tested pathogens and high prevalence levels were found in diverse areas of the world. HIV was highly prevalent mostly in African countries. Although human papillomavirus infection was surveyed in few studies, prevalence rates were very high and its aetiological role in cervical cancer warrant its inclusion in future FSW monitoring. Hard-to-access FSW groups tended to have higher rates of STI. Conclusions: The five most commonly detected pathogens correspond to those that are highly prevalent in the general population, however there is an urgent need to develop rapid testing diagnostics for all five pathogens to increase prevention and treatment, especially in outreach programs to the most vulnerable groups among FSW.

Risk factors for herpes simplex virus type 2 and HIV among women at high risk in northwestern Tanzania: preparing for an HSV-2 intervention trial

OBJECTIVES

To determine prevalence of and risk factors for herpes simplex virus type 2 (HSV-2) and HIV among women being screened for a randomized, controlled trial of HSV suppressive therapy in northwestern Tanzania.

METHODS

Two thousand seven hundred nineteen female facility workers aged 16 to 35 were interviewed and underwent serological testing for HIV and HSV-2. Factors associated with HSV-2 and HIV in women aged 16 to 24 were examined using logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

HSV-2 seroprevalence was 80%, and HIV seroprevalence was 30%. Among women aged 16 to 24, both infections were significantly and independently associated with older age, being a bar worker, working at a truck stop, and having more lifetime sexual partners. HSV-2 infection was also associated with lower socioeconomic status, increased alcohol intake, younger age at first sex, inconsistent condom use, and vaginal douching. There was a strong association between the 2 infections after adjustment for other factors (OR = 4.22, 95% CI: 2.6 to 6.9).

CONCLUSIONS

Female facility workers in northwestern Tanzania are vulnerable to HSV-2 and HIV infections. Programs designed to increase safer sexual behavior and reduce alcohol use could be effective in reducing HSV-2 incidence and, in turn, HIV infection. This is a suitable population for an HSV suppressive therapy trial.

Microbicides development program, Tanzania-baseline characteristics of an occupational cohort and reattendance at 3 months

OBJECTIVES

To determine baseline characteristics of an occupational cohort of women in Mwanza City, Tanzania, and factors associated with reattendance at 3 months, in preparation for a microbicide trial.

STUDY DESIGN

One thousand five hundred seventy-three women aged 16-54 years working in food outlets and recreational facilities were enrolled, interviewed, and examined at community-based reproductive health clinics, provided specimens for HIV/STI and pregnancy testing, and attended 3 monthly clinical follow-up.

RESULTS

Baseline prevalence of HIV was 25.5%; pregnancy 9.7%; herpes simplex virus type-2 74.6%; active syphilis 10.2%, bacterial vaginosis 52.6%; gonorrhea 5.5%; chlamydia 5.9%; and trichomoniasis 12.3%. Reattendance at 3 months was 74.1% and was higher in older women, less mobile women, and in those who received an HIV-negative result at enrollment.

CONCLUSIONS

Baseline characteristics of this occupational group suggest their suitability for microbicide trials. A screening round, locally appropriate informed consent procedures, and effective community tracing may help reduce losses to follow-up in such settings.

Sexual risk factors for HIV infection in early and advanced HIV epidemics in sub-Saharan Africa: systematic overview of 68 epidemiological studies

Background

It is commonly assumed that sexual risk factors for heterosexual HIV transmission in sub-Saharan Africa, such as multi-partner sex, paid sex and co-infections, become less important as HIV epidemics mature and prevalence increases.

Methods and Findings

We conducted a systematic review of 68 African epidemiological studies from 1986 to 2006 involving 17,000 HIV positive adults and 73,000 controls. We used random-effects methods and stratified results by gender, time, background HIV prevalence rates and other variables. The number of sex partners, history of paid sex, and infection with herpes simplex virus (HSV-2) or other sexually-transmitted infections (STIs) each showed significant associations with HIV infection. Among the general population, the odds ratio (OR) of HIV infection for women reporting 3+ sex partners versus 0–2 was 3.64 (95%CI [2.87–4.62]), with similar risks for men. About 9% of infected women reported ever having been paid for sex, versus 4% of control women (OR = 2.29, [1.45–3.62]). About 31% of infected men reported ever paying for sex versus 18% of uninfected men (OR = 1.75, [1.30–2.36]). HSV-2 infection carried the largest risk of HIV infection: OR = 4.62, [2.85–7.47] in women, and OR = 6.97, [4.68–10.38] in men. These risks changed little over time and stratification by lower and higher HIV background prevalence showed that risk ratios for most variables were larger in high prevalence settings. Among uninfected controls, the male-female differences in the number of sex partners and in paid sex were more extreme in the higher HIV prevalence settings than in the lower prevalence settings.

Significance

Multi-partner sex, paid sex, STIs and HSV-2 infection are as important to HIV transmission in advanced as in early HIV epidemics. Even in high prevalence settings, prevention among people with high rates of partner change, such as female sex workers and their male clients, is likely to reduce transmission overall.

A high viral burden predicts the loss of CD8 T-cell responses specific for subdominant gag epitopes during chronic human immunodeficiency virus infection

Human immunodeficiency virus (HIV)-specific CD8 T-cell responses targeting products encoded within the Gag open reading frame have frequently been associated with better viral control and disease outcome during the chronic phase of HIV infection. To further clarify this relationship, we have studied the dynamics of Gag-specific CD8 T-cell responses in relation to plasma viral load and time since infection in 33 chronically infected subjects over a 9-month period. High baseline viral loads were associated with a net loss of breadth (P < 0.001) and a decrease in the total magnitude of the Gag-specific T-cell response in general (P = 0.03). Most importantly, the baseline viral load predicted the subsequent change in the breadth of Gag recognition over time (P < 0.0001, r(2) = 0.41). Compared to maintained responses, lost responses were low in magnitude (P < 0.0001) and subdominant in the hierarchy of Gag-specific responses. The present study indicates that chronic exposure of the human immune system to high levels of HIV viremia is a determinant of virus-specific CD8 T-cell loss.

Possible reasons for an increase in the proportion of genital ulcers due to herpes simplex virus from a cohort of female bar workers in Tanzania

OBJECTIVES

To determine trends in the prevalence and aetiological distribution of genital ulcer syndrome (GUS) in a cohort of female bar workers and to assess factors associated with these trends.

METHODS

An open cohort of 600 women at high risk of HIV and sexually transmitted infection (STI) was offered screening and treatment for STI at 3-month intervals. The prevalence of GUS and associated aetiological agents (Herpes simplex virus (HSV), Treponema pallidum and Haemophilus ducreyi) were monitored over 27 months through clinical examination, dry lesion swabbing and multiplex polymerase chain reaction. The effects of HIV status and other factors on the prevalence trends of STI were assessed.

RESULTS

A total of 753 women were recruited into the cohort over 10 examination rounds. At recruitment, the seroprevalence was 67% for HIV and 89% for HSV type 2 (HSV-2). During follow-up, 57% of ulcers had unknown aetiology, 37% were due to genital herpes and 6% to bacterial aetiologies, which disappeared completely in later rounds. The absolute prevalence of genital herpes remained stable at around 2%. The proportion of GUS caused by HSV increased from 22% to 58%, whereas bacterial causes declined. These trends were observed in both HIV-negative and HIV-positive women.

CONCLUSIONS

The changes observed in the frequency and proportional distribution of GUS aetiologies suggest that regular STI screening and treatment over an extended period can effectively reduce bacterial STI and should therefore be sustained. However, in populations with a high prevalence of HSV-2, there remains a considerable burden of genital herpes, which soon becomes the predominant cause of GUS. Given the observed associations between genital herpes and HIV transmission, high priority should be given to the evaluation of potential interventions to control HSV-2 either through a vaccine or through episodic or suppressive antiviral therapy and primary prevention.

Impact of a social influence intervention on condom use and sexually transmitted infections among establishment-based female sex workers in the Philippines: a multilevel analysis

The authors assessed the relative impact of structural and social influence interventions on reducing sexually transmitted infections (STIs) and HIV risk behavior among female sex workers in the Philippines (N = 897). Four conditions included manager influence, peer influence, combined manager-peer influence, and control. Intervention effects were assessed at the establishment level in multilevel models because of statistical dependencies among women employed within the same establishments. Control group membership predicted greater perceived risk, less condom use, less HIV/AIDS knowledge, and more negative condom attitudes. Combination participants reported more positive condom attitudes, more establishment policies favoring condom use, and fewer STIs. Manager-only participants reported fewer STIs, lower condom attitudes, less knowledge, and higher perceived risk than peer-only participants. Because interventions were implemented at the city level, baseline and follow-up city differences were analyzed to rule out intervention effects due to preexisting differences.

Mature glycoprotein g presents high performance in diagnosing herpes simplex virus type 2 infection in sera of different tanzanian cohorts

Herpes simplex virus type 2 (HSV-2) is a common sexually transmitted infection in sub-Saharan Africa. Glycoprotein G (gG) of HSV-2 elicits a type-specific antibody response and is widely used for serodiagnosis. gG is cleaved into a secreted portion (sgG-2) and a highly O-glycosylated mature portion (mgG-2). The performances of these two native immunosorbent purified antigens were compared in an enzyme-linked immunosorbent assay (ELISA) format with a commercially available assay (FOCUS2) using sera from blood donors (n = 194) and individuals (n = 198) with genital ulcer disease (GUD) from Tanzania. Discordant results were resolved by Western blotting. The HSV-2 seroprevalence for blood donors was estimated as 42%, and that for the GUD cohort was estimated as 78%. The prevalence increased significantly with age for both cohorts and was higher among human immunodeficiency virus (HIV)-positive individuals than among HIV-negative subjects. In the GUD cohort with a high HSV-2 prevalence, all three assays showed statistically similar performances, with sensitivities between 97% and 99% and specificities in the range of 86% to 91%. In contrast, among blood donors with a lower seroprevalence, the mgG-2-based ELISA presented significantly higher specificity (97%) than the sgG-2 ELISA (89%) and FOCUS2 (74%). Overall, the mgG-2 ELISA gave a high performance, with negative and positive predictive values of 96% for blood donors and a negative predictive value of 95% and a positive predictive value of 97% for the GUD cohort. We conclude that native purified mgG-2 showed the highest accuracy for detection of HSV-2 in patient sera from Tanzania and is therefore suitable for seroprevalence studies as well as in clinical settings.

Frequency of HIV type 1 dual infection and HIV diversity: analysis of low- and high-risk populations in Mbeya Region, Tanzania

HIV-1 diversity, frequency of recombinants, and dual infection were determined in two populations with different HIV risk behavior. A high-risk cohort of 600 female bar workers and a normal-risk population of 1,108 antenatal clinic attendees and blood donors were recruited. Behavioral data were assessed and blood for HIV- 1 diagnosis and genotyping was sampled. HIV-1 subtypes were defined through the multiregion hybridization assay (MHA(acd)). HIV-1 prevalence differed significantly among the two populations. The prevalence was 67.8% in the population of bar workers and 17% in the normal-risk population (antenatal care attendees and blood donors). Within the normal-risk population the HIV-1 prevalence was lowest in the group of volunteer blood donors. The frequency of HIV-1 infection in women was 1.7 times higher than in men. The overall subtype distribution was A (8.5%), C (40.8%), D (3.8%), AC (25.4%), AD (5.4%), CD (8.8%), and ACD (7.3%). In the high-risk population there was a higher percentage of HIV-1 recombinant strains (54% vs. 40%, p < 0.05) and a higher frequency of dual infections (19% vs. 9%, p < 0.02) compared to the normal-risk population. High-risk populations may play an important role in the evolution of HIV, as they can provide an opportunity for the virus to coinfect, recombine, and adapt to the host-specific genetic background.

Sexual behavior, psychosocial and knowledge differences between consistent, inconsistent and non-users of condoms: a study of female bar and hotel workers in Moshi, Tanzania

Understanding psychosocial, sexual behavior and knowledge differences between never, inconsistent and consistent condom users can improve interventions to increase condom use in resource-poor countries, but they have not been adequately studied. We examined these differences in a cohort of 961 female hotel and bar workers in Moshi, Tanzania. Forty-nine percent of women reported no condom use; 39% reported inconsistent use, and 12% reported consistent use. Women with multiple sexual partners in the past five years were less likely to be consistent rather than inconsistent users as were women who had ever exchanged sex for gifts or money. Inconsistent users had higher condom knowledge and higher perceived acceptability of condom use than did never users, but they did not differ from consistent users by these factors. There are important differences between women by level of condom use. These findings can help inform interventions to increase condom use.

Human immunodeficiency virus type 1 among bar and hotel workers in northern Tanzania: the role of alcohol, sexual behavior, and herpes simplex virus type 2

GOALS

We assessed baseline prevalence of human immunodeficiency virus type 1 (HIV-1) and other STDs, as well as behavioral and biologic risk factors for HIV-1 in a population of female bar/hotel workers in Moshi, Tanzania.

STUDY DESIGN

Between 2002 and 2003, we enrolled 1042 female bar/hotel workers in an ongoing prospective cohort study. We analyzed data collected at baseline to assess the associations between alcohol, sexual behavior, STDs, and HIV-1 infection.

RESULTS

The prevalence of HIV-1 infection was 19.0% (95% confidence interval [CI] = 16.6%-21.4%). Consistent condom use was low (11.1%). HIV-1 was associated with genital ulcers on examination (adjusted odds ratio [AOR] = 2.08, 95% CI = 1.16-3.74), herpes simplex virus type 2 (HSV-2) (AOR = 3.80, 95% CI = 2.42-5.97), and problem drinking (AOR = 1.92, 95% CI = 1.06-3.47). Other independent predictors of HIV-1 were increasing age, number of sex partners, cohabitating, formerly married, location of employment, and having a husband with another wife.

CONCLUSIONS

These findings suggest that programs designed to control HSV-2, reduce the number of sexual partners and alcohol use, and promote condom use could be effective in reducing transmission of HIV-1 in this population.