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1.  Seroprevalence and correlates of HIV, syphilis, and hepatitis B and C virus among intrapartum patients in Kabul, Afghanistan 
Little current information is available for prevalence of vertically-transmitted infections among the Afghan population. The purpose of this study is to determine prevalence and correlates of human immunodeficiency virus (HIV), syphilis, and hepatitis B and C infection among obstetric patients and model hepatitis B vaccination approaches in Kabul, Afghanistan.
This cross-sectional study was conducted at three government maternity hospitals in Kabul, Afghanistan from June through September, 2006. Consecutively-enrolled participants completed an interviewer-administered survey and whole blood rapid testing with serum confirmation for antibodies to HIV, T. pallidum, and HCV, and HBsAg. Descriptive data and prevalence of infection were calculated, with logistic regression used to identify correlates of HBV infection. Modeling was performed to determine impact of current and birth dose vaccination strategies on HBV morbidity and mortality.
Among 4452 women, prevalence of HBsAg was 1.53% (95% CI: 1.18 – 1.94) and anti-HCV was 0.31% (95% CI: 0.17 – 0.53). No cases of HIV or syphilis were detected. In univariate analysis, HBsAg was associated with husband's level of education (OR = 1.13, 95% CI: 1.01 – 1.26). Modeling indicated that introduction of birth dose vaccination would not significantly reduce hepatitis-related morbidity or mortality for the measured HBsAg prevalence.
Intrapartum whole blood rapid testing for HIV, syphilis, HBV, and HCV was acceptable to patients in Afghanistan. Though HBsAg prevalence is relatively low, periodic assessments should be performed to determine birth dose vaccination recommendations for this setting.
PMCID: PMC2557011  PMID: 18798996
2.  HIV, hepatitis B, and hepatitis C prevalence and associated risk behaviors among female sex workers in three Afghan cities 
AIDS (London, England)  2010;24(0 2):S69-S75.
To assess prevalence of HIV, syphilis, and hepatitis B (HBV) and C virus and associated risk behaviors among female sex workers (FSWs) in three Afghan cities. Design: Cross-sectional prevalence assessment.
Consented FSWs from Jalalabad, Kabul, and Mazar-i-Sharif completed an interviewer-administered questionnaire, pre and post-test counseling, and rapid and confirmatory testing for HIV, HCV, HBV and syphilis. Logistic regression was used to detect correlates associated with HBV infection.
Of 520 participants, median age and age of initiating sex work were 29 and 23 years, respectively, and median number of monthly clients was 12. Few FSWs reported ever having used illicit drugs (6.9%) or alcohol (4.7%). Demographic and risk behaviors varied significantly by enrollment site, with Kabul FSWs more likely to report sexually-transmitted infection (STI) symptoms, longer sex work duration, and sex work in other cities. Prevalence of HIV was 0.19%, HCV was 1.92%, and HBV was 6.54%, with no cases of syphilis detected. HBV was independently associated with ≥12 clients monthly (AOR=3.15, 95% CI: 1.38 – 7.17), ever using alcohol (AOR=2.61, 95% CI: 1.45 – 4.69), anal sex (AOR=2.42, 95% CI: 1.15 – 5.08), and having children (AOR=2.12, 95% CI: 1.72 – 2.63) in site-controlled multivariate analysis.
While prevalence of HIV, HCV, and syphilis is currently low in these three Afghan cities, risky sexual practices were common and associated with HBV. Programming inclusive of voluntary testing for HIV, viral hepatitis, and STIs, hepatitis vaccination, substance abuse prevention, and condom promotion for both FSWs and clients should be pursued in Afghanistan.
PMCID: PMC3650731  PMID: 20610952
HIV; hepatitis B; female sex worker; Afghanistan
3.  Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: A cross-sectional assessment 
A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population.
IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use.
Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58 - 22.38 and AOR = 2.33, 95% CI: 1.38 - 3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22 - 5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16 - 2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06 - 2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08 - 1.82).
HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.
PMCID: PMC3180253  PMID: 21867518
injection drug user; Afghanistan; HIV; hepatitis C; harm reduction
4.  Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A cross-sectional comparison of former refugees to those remaining during conflict 
Little is known about human immunodeficiency virus (HIV) awareness among Afghan injecting drug users (IDUs), many of whom initiated injecting as refugees. We explored whether differences in HIV awareness and knowledge exist between Afghan IDUs who were refugees compared to those never having left Afghanistan.
A convenience sample of IDUs in Kabul, Afghanistan was recruited into a cross-sectional study through street outreach over a one year period beginning in 2005. Participants completed an interviewer-administered questionnaire and underwent voluntary counseling and testing for HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibody. Differences in HIV awareness and specific HIV knowledge between IDU who lived outside the country in the last decade versus those who had not were assessed with logistic regression.
Of 464 IDUs, 463 (99%) were male; median age and age at first injection were 29 and 25 years, respectively. Most (86.4%) had lived or worked outside the country in the past ten years. Awareness of HIV was reported by 46.1%; those having been outside the country in the last decade were significantly more likely to have heard of HIV (48.3% vs. 31.7%; OR = 2.00, 95% CI: 1.14 – 3.53). However, of those aware of HIV, only 38.3% could name three correct transmission routes; specific HIV knowledge was not significantly associated with residence outside the country.
Accurate HIV knowledge among Afghan IDUs is low, though former refugees had greater HIV awareness. Reported high-risk injecting behavior was not significantly different between IDU that were refugees and those that did not leave the country, indicating that all Afghan IDU should receive targeted prevention programming.
PMCID: PMC1847809  PMID: 17411457
5.  Correlates of HIV, HBV, HCV and syphilis infections among prison inmates and officers in Ghana: A national multicenter study 
Prisons are known to be high-risk environments for the spread of bloodborne and sexually transmitted infections. Prison officers are considered to have an intermittent exposure potential to bloodborne infectious diseases on the job, however there has been no studies on the prevalence of these infections in prison officers in Ghana.
A national multicenter cross-sectional study was undertaken on correlates of human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis infections in sample of prison inmates and officers from eight of ten regional central prisons in Ghana. A total of 1366 inmates and 445 officers were enrolled between May 2004 and December 2005. Subjects completed personal risk-factor questionnaire and provided blood specimens for unlinked anonymous testing for presence of antibodies to HIV, HCV and Treponema pallidum; and surface antigen of HBV (HBsAg). These data were analyzed using both univariate and multivariate techniques.
Almost 18% (1336) of 7652 eligible inmates and 21% (445) of 2139 eligible officers in eight study prisons took part. Median ages of inmates and officers were 36.5 years (range 16–84) and 38.1 years (range 25–59), respectively. Among inmates, HIV seroprevalence was 5.9%, syphilis seroprevalence was 16.5%, and 25.5% had HBsAg. Among officers tested, HIV seroprevalence was 4.9%, HCV seroprevalence was 18.7%, syphilis seroprevalence was 7.9%, and 11.7% had HBsAg. Independent determinants for HIV, HBV and syphilis infections among inmates were age between 17–46, being unmarried, being illiterate, female gender, being incarcerated for longer than median time served of 36 months, history of homosexuality, history of intravenous drug use, history of sharing syringes and drug paraphernalia, history of participation in paid sexual activity, and history of sexually transmitted diseases. Independent determinants for HIV, HBV, HCV and syphilis infections among officers were age between 25–46, fale gender, being unmarried, being employed in prison service for longer than median duration of employment of 10 years, and history of sexually transmitted diseases.
The comparably higher prevalence of HIV, HBV, HCV and syphilis in prison inmates and officers in Ghana suggests probable occupational related transmission. The implementation of infection control practices and risk reduction programs targeted at prison inmates and officers in Ghana is urgently required to address this substantial exposure risk.
PMCID: PMC2311310  PMID: 18328097
6.  Herpes simplex virus 2 and syphilis among young drug users in Baltimore, Maryland 
Sexually Transmitted Infections  2005;81(3):248-253.
Objectives: To examine the sex specific seroprevalence and correlates of herpes simplex virus 2 (HSV-2) and syphilis among a cohort of young drug users.
Methods: Drug users aged 15–30 years old who used heroin, cocaine, or crack were recruited between October 1999 and August 2002. Baseline interviews gathered information on sociodemographics, drug use and sexual behaviours. Serum was tested at baseline for HSV-2 and syphilis seroreactivity. For each sexually transmitted infection (STI), infected and non-infected participants were stratified by sex and compared using χ2, Mann-Whitney tests, and logistic regression.
Results: Of the 543 participants recruited, 42.4% were female and 39.3% were African-American. The seroprevalence of STIs among females and males, respectively, were HSV-2: 58.7% and 22.0%; syphilis: 4.3% and 0.3%. In multivariate models, older age, African-American race, having over 30 lifetime sex partners, current HIV infection and previous incarceration were independently associated with HSV-2 infection among males. For females, older age, African-American race, sex trade, and daily heroin use were independently associated with HSV-2. For females, only a self reported previous syphilis diagnosis was associated with current syphilis seroreactivity in multivariate analyses.
Conclusions: Examination of this cohort revealed a particularly high seroprevalence of HSV-2 and syphilis, especially among female drug users. Few infected participants had been previously diagnosed with these infections.
PMCID: PMC1744972  PMID: 15923296
7.  Infection status and risk factors of HIV, HBV, HCV, and syphilis among drug users in Guangdong, China - a cross-sectional study 
BMC Public Health  2010;10:657.
China has witnessed a remarkable increase in sexually transmitted infections (STIs) and HIV. The study is to assess the prevalence of HIV, HBV, HCV and syphilis and related risk factors among drug users in mandatory detoxification center Qingyuan, Guangdong, China.
A cross-sectional study on drug use behaviors, sex behaviors, and presence of antibodies to HIV, HCV, Treponema pallidum, and surface antigen of HBV (HBsAg) was conducted among drug users recruited from 3 detoxification centers in Qingyuan, Guangdong, China. Risk factors for each of four infections were analyzed with logistic regression model.
A total of 740 subjects were recruited, the median age was 31 years old (range 24-38). The seroprevalence rates of HIV, HBsAg, HCV and syphilis were 4.6%, 19.3%, 71.6% and 12.6%, respectively. Risk factors for HIV were intravenous drug use and co-infection with syphilis. Having a regular sexual partner who was a drug user was considered to be a risk factor for HBV. Intravenous drug use was a risk factor for HCV. However, the consistent use of condoms with commercial sex partners was protective for HCV infection. Compared to drug users living in urban area, those living in rural areas were more likely to be infected with syphilis, and there was an association between commercial sex and syphilis.
The prevalence of HIV, HBV, HCV and syphilis were high among drug users in detoxification centers in Qingyuan, thus, risk reduction programs for the drug user population is urgently required.
PMCID: PMC3091571  PMID: 21040549
8.  Prevalence of Sexually Transmitted Infections (HIV, Hepatitis B, Herpes Simplex Type 2 and Syphilis) Among Asymptomatic Pregnant Women 
To determine the current prevalence of four major sexually transmitted infections (STIs: HIV, Hepatitis B, Herpes simplex virus 2, and Syphilis) in asymptomatic pregnant women.
This is a prospective study of 500 consecutive, apparently healthy asymptomatic pregnant women who were attending the antenatal clinic. The information regarding their socio-demographic and behavioral characteristics and obstetric performance was recorded. The blood samples was collected after obtaining their informed written consent from those who were tested for the HIV antibodies (NACO guidelines), HBsAg (ELISA test), HSV2-IgM (ELISA test), and Syphilis (VDRL and TPHA tests).
The overall prevalence of one or the other four STIs studied was 4.8 % with the highest prevalence of HBV (2.4 %), followed by HSV-2 (2 %), and HIV (0.4 %). No woman tested positive for syphilis and multiple infections. All the infections were more common in illiterate, multigravida, monogamous women of low socio-economic status. High-risk sexual behavior of the husbands, history of STIs in husbands, and blood transfusions were the other factors associated with the prevalence of these infections.
The relatively high prevalence of HBV and HSV-2 infections in asymptomatic pregnant women suggests that there is need of screening for HBV and HSV-2 infections along with the pre-existing screening for HIV and Syphilis and universal immunization of HBV high-risk infants.
PMCID: PMC3425675  PMID: 23542821
Asymptomatic pregnant women; HSV-2; HBV; HIV; Syphilis
9.  Prevalence and Risk Factors of HIV, Syphilis, Hepatitis B and C Among Female Prisoners in Isfahan, Iran 
Hepatitis Monthly  2012;12(7):442-447.
Female prisoners are at risk of acquiring sexually transmitted infections (STIs). There has been no previous study regarding the epidemiological status of STIs among female prisoners in Isfahan, central Iran.
The aim of this study was to investigate the prevalence and risk factors of the aforementioned infections among women incarcerated in the central prison, Isfahan, to determine appropriate prevention measures.
Patients and Methods
In a cross-sectional study, all of the 163 women incarcerated in the central prison, Isfahan in 2009, were voluntarily enrolled by the census method. After completing a checklist consisting of demographic, social, and risk factors, a 5ml blood sample was taken from each individual. The sera were analyzed for markers of the hepatitis B virus (HBV; HBsAg, HBsAb, HBcAb), hepatitis C virus (HCV; HCV antibodies), human immunodeficiency virus (HIV; HIV antibodies), and syphilis (RPR). Confirmatory tests were performed on HCV antibody-positive cases.
The mean age of the participants in the study was 34.54 ± 11.2 years old, 94.3% of these women were Iranian, and many of them had only a primary level of education. The prevalence of HBsAg, HBcAb, HBsAb, and HCV antibodies were; 1.2%, 7.4%, 12.9% and 7.4% respectively. No positive RPR or HIV antibodies were detected.
A significant relationship was seen between the HCV antibody, drug injection and illegal sex in the women, and also between HBc-Ab and drug injection. Regular screening, educational programs, and facilitation of access to suitable treatment care should be widely implemented in the prison population. Testing for immunity against HBV should be considered on admission, and afterwards vaccination of all prisoners and an appropriate preventative approach should be applied.
PMCID: PMC3437455  PMID: 23008724
HIV; Hepatitis B Virus; Hepatitis C; Syphilis; Prevalence; Risk Factors
10.  Prevalence of HIV and other sexually transmitted infections and factors associated with syphilis among female sex workers in Panama 
Sexually Transmitted Infections  2012;89(2):156-164.
Biological and behavioural surveillance of HIV and sexually transmitted infections (STIs) among populations at highest risk have been used to monitor trends in prevalence and in risk behaviours. Sex work in Panama is regulated through registration with the Social Hygiene Programme, Ministry of Health. We estimated prevalence of HIV and STIs, and factors associated with active syphilis among female sex workers (FSWs).
A cross-sectional study using venue-based, time-space sampling was conducted among FSWs in Panama from 2009 to 2010. FSWs were interviewed about sociodemographic characteristics, sexual risk behaviour, health history and drug use using an anonymous structured questionnaire. Blood was collected for serological testing of HIV and other STIs. Factors associated with active syphilis were studied using logistic regression analysis.
The overall HIV-1 prevalence of 0.7% varied by FSW category; 1.6% in 379 unregistered, and 0.2% in 620 registered FSWs. Overall prevalence (and 95% CI) of STIs were: syphilis antibody, 3.8% (2.7% to 5.2%); herpes simplex virus type 2 antibody (anti-HSV-2), 74.2% (71.4% to 76.9%); hepatitis B surface antigen, 0.6% (0.2% to 1.3%); hepatitis B core antibody, 8.7% (7.0% to 10.6%); and hepatitis C antibody, 0.2% (0.0% to 0.7%). In multivariate analysis, registration (adjusted OR (AOR)=0.35; 95% CI 0.16 to 0.74), having a history of STI (AOR=2.37; 95% CI 1.01 to 5.58), forced sex (AOR=2.47; 95% CI 1.11 to 5.48), and anti-HSV-2 (AOR=10.05; 95% CI 1.36 to 74.38) were associated with active syphilis.
Although HIV prevalence is low among FSWs in Panama, unregistered FSWs bear a higher burden of HIV and STIs than registered FSWs. Programmes aimed at overcoming obstacles to registration, and HIV, STI and harm reduction among unregistered FSWs is warranted to prevent HIV transmission, and to improve their sexual and reproductive health.
PMCID: PMC3595153  PMID: 23002191
Surveillance; Commercial Sex; HIV; Seroprevalence; Syphilis
11.  Syndemics of syphilis, HCV infection, and methamphetamine use along the east coast of China 
BMC Public Health  2014;14:172.
An upsurge in club drug use has been observed in recent years in some cities of China, especially methamphetamine, which is quickly replacing heroin to become the most widespread drug across the nation. This study investigated the type of drugs used, syphilis and hepatitis C virus (HCV) infection and the correlates for syphilis, HCV and unprotected commercial sex behavior among drug users in two cities along the east coast of China.
A cross-sectional survey conducted in 2010 provided demographics, sexual and drug use behaviors, HIV knowledge and the utilization of intervention services among drug users. Blood samples were tested for HIV, syphilis, and HCV infection.
Of 805 eligible participants, 0.2% were infected with HIV, 3.7% with HCV, and 9.6% with syphilis. Of the participants, 96.6% were methamphetamine users, 11.9% reported ever having used ≥2 types of these drugs, and 11.4% reported ever injecting drugs. In the multivariable logistic regression analysis, participants infected with syphilis were more likely to be female (adjusted odds ratio (AOR)=2.8, 95% confidence interval (CI): 1.2-6.5), have ever had commercial sex in the past 12 months (AOR=2.0, 95% CI: 1.0-3.9), be infected with HCV (AOR=12.1, 95% CI: 4.1-20.3) and less likely to have ever had sex with regular partners in the past 12 months (AOR=0.2, 95% CI: 0.1-0.6). Participants infected with HCV were more likely to have ever injected drugs (AOR=2.7, 95% CI: 1.1-6.5) and be infected with syphilis (AOR=8.0, 95% CI: 3.5-18.0). Participants who had unprotected sex with commercial sex partners in the last sexual encounter were more likely to be female (AOR=2.9, 95% CI:1.7-4.9), have middle school or lower level education (AOR=3.4, 95% CI:2.0-5.5), never have received intervention in the last year (AOR=2.1, 95%CI:1.2-3.6) and be infected with syphilis (AOR=4.2, 95% CI:2.4-7.4).
Methamphetamine is the predominant drug used among the drug users, the prevalence of syphilis and HCV infection are alarmingly high, and unprotected commercial sex was common among this group. The findings highlight the need for effective, multifaceted interventions addressing sexual and drug use-related risky behaviors among this group. Further research is needed to better understand the causal pathway of the syndemics.
PMCID: PMC3936988  PMID: 24533587
Syphilis; HCV; Methamphetamine; Sexual behavior; Drug user
12.  Surveillance of HIV in the army of the Republic of Cyprus (SHARC); rationale, design, and implementation of an inexpensive system 
Objectives: To design and implement an HIV surveillance system using periodic cross sectional prevalence surveys in National Guard recruits of the Republic of Cyprus.
Methods: HIV infection surveillance used unlinked anonymous screening (UAS) methodology, which tested residual blood originally collected for other purposes. Residual blood from samples collected for ABO blood group typing at intake and samples from blood collected for hepatitis testing at discharge was used. Screening was unlinked and anonymous.
Results: The system operated for four semiannual recruitment seasons: summer 1998 to the end of winter 2000. No recruits screened at entry into the ranks tested positive.
Conclusions: This was the first large scale HIV surveillance project in Cyprus. Without nationwide HIV surveys, periodic measurements of prevalence could lead to estimates of HIV incidence and provide insights on temporal changes in HIV infection rates. The prevalence data collected provide useful epidemiological information about the status of the HIV epidemic in this segment of the population in Cyprus.
PMCID: PMC1763710  PMID: 11872860
13.  Prevalence of HIV, Herpes Simplex Virus-2, and Syphilis in male sex partners of pregnant women in Peru 
BMC Public Health  2008;8:65.
Sexually active heterosexual men may represent an important risk factor for HIV infection and STI transmission to their female partners and unborn children, though little is known about the prevalence of STIs in this population. We sought to determine the prevalence of HIV, herpes simplex virus type 2 (HSV-2), and syphilis infection and associated risk behaviors among male sex partners of pregnant women in Peru.
Survey and seroprevalence data were collected from 1,835 male partners of pregnant women in four cities in Peru. Serum was tested for antibodies to HIV, HSV-2, and syphilis.
Among the 1,835 male participants, HIV prevalence was 0.8% (95% CI = 0.5–1.4%), HSV-2 16.0% (95% CI = 14.3–17.8%), and syphilis 1.6% (95% CI = 1.0–2.2%). Additionally, 11.0% reported a lifetime history of intercourse with men, and 37.1% with female sex workers. Unprotected intercourse with men during the previous year was reported by 0.9% and with female sex workers by 1.2%.
Pregnant women's sex partners reported lifetime sexual contact with core risk groups, had an elevated prevalence of HSV-2, and demonstrated the potential to spread HIV and other STIs to their partners. Though the prevalence of HIV in the population was not significantly higher than observed in other samples of heterosexuals in Peru, the risk of HIV transmission to their female partners may be exacerbated by their increased prevalence of HSV-2 infection. Further study of heterosexual populations is necessary to fully understand the epidemiology of HIV/STIs in Latin America.
PMCID: PMC2265685  PMID: 18284696
14.  Correlates of Incident Infections for HIV, Syphilis, and Hepatitis B Virus in A Cohort of Men Who Have Sex with Men in Beijing 
AIDS Patient Care and STDs  2010;24(9):595-602.
Recent data suggest that the prevalence of HIV/syphilis infections among men who have sex with men (MSM) in China increased rapidly. This cohort study was to assess the correlates of the incident infections for HIV, syphilis, and hepatitis B virus (HBV) among sexually active and HIV–negative MSM in China. A cohort of 507 HIV-seronegative MSM was recruited from November 2006 to February 2007. Sociodemographics, sexual and drug use behaviors, uptake of HIV-prevention services, and HIV, syphilis, and HBV seroconversions were assessed at 6- and 12- month follow-up. The incidence rates were 2.6 per 100 person-years for HIV, 16.9 per 100 person-years for syphilis, and 3.3 per 100 person-years for HBV. Multivariate Cox regression analyses showed that syphilis infection (hazard ratio [HR] = 3.6; 95% confidence interval [CI]: 1.1–11.6) and no perceived risk of HIV infection (HR = 6.0; 95% CI: 1.6–22.7) were independently associated with HIV seroconversion. Predictors for syphilis seroconversion included less education (HR = 1.87; 95% CI: 1.1–3.3), found male sex partners through bathhouses/public washrooms/parks (HR = 2.19; 95% CI: 1.2–4.0), drank alcohol 4 or more times monthly (HR = 1.95; 95% CI: 1.1–3.6), and had sexually transmitted diseases (HR = 2.65; 95% CI: 1.5–4.5). The only predictor for incident HBV seroconvension was having more male sex partners in the past 3 months (HR = 11.8; 95% CI: 1.5–90.4). Alarmingly high incidence rates of HIV, syphilis, and HBV were found among MSM concurrently with high prevalent risky behaviors and low uptakes of health care services. The findings of this study underscore the urgent needs for a comprehensive intervention strategy to curtail the rapid spread of HIV, syphilis, and HBV.
PMCID: PMC2957630  PMID: 20731610
15.  Female sex work interventions and changes in HIV and syphilis infection risks from 2003 to 2008 in India: a repeated cross-sectional study 
BMJ Open  2013;3(6):e002724.
We examined if increased spending and coverage of female sex worker (FSW) interventions were associated with declines in HIV or syphilis risk among young pregnant women (as a proxy for new infections in the general population) in the high-burden southern states of India.
Repeated cross-sectional analysis.
We used logistic regression to relate district-level spending, number of sexually transmitted infections (STIs) treated, FSWs reached or condoms distributed to the declines in the annual risk of HIV and syphilis from 2003 to 2008 among prenatal clinic attendees in the four high-HIV burden states of Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu.
386 961 pregnant women aged 15–24 years (as a proxy for incident infections in the adult population).
We examined National AIDS Control Organisation (NACO) data on 868 FSW intervention projects implemented between 1995 and 2008.
Primary and secondary outcome measures
HIV or syphilis infection.
HIV and syphilis prevalence declined substantially among young pregnant women. Each additional STI treated (per 1000 people) reduced the annual risk of HIV infection by −1.7% (95% CI −3.3 to −0.1) and reduced the annual risk of syphilis infection by −10.9% (95%CI −15.9 to −5.8). Spending, FSWs reached or condoms distributed did not reduce HIV risk, but each was significantly associated with reduced annual risk of syphilis infection. There were no major differences between the NACO-funded and Avahan-funded districts in the annual risk of either STI.
Targeted FSW interventions are associated with reductions in syphilis risk and STI treatment is associated with reduced HIV risk. Both more and less costly FSW interventions have comparable effectiveness.
PMCID: PMC3686231  PMID: 23794571
Public Health; Infectious Diseases
16.  Social determinants of syphilis in South China: the effect of sibling position on syphilis and sexual risk behaviours 
BMJ Open  2013;3(5):e002834.
This study evaluated the relationship between sibling position and sexual risk based on behavioural and syphilis infection data from sexually transmitted infection (STI) patients in South China.
A cross-sectional study examining sexual behaviours and syphilis infection.
4 STI clinics in the Pearl River Delta of South China.
1792 Chinese men and women attending STI clinics.
Primary outcome measures
STI history, syphilis infection defined as positive non-treponemal and treponemal tests.
Among all clinic patients, 824 (46.3%) were first-born, 354 (19.9%) were middle-born and 602 (33.8%) were final-born. Middle-born individuals had a higher percentage of reported STI history (44.7% compared to 34.7%, p<0.001) and syphilis infection (9.7% compared to 4.9%, p=0.01) among men (n=1163) compared to other sibling positions in bivariate analyses, but not in the final multivariate model. The relationship between sibling position and syphilis was independent of income and education level. There was no trend observed between middle-born position and female sexual risk behaviours (n=626). Higher education was significantly associated with syphilis among women and men in respective multivariate models.
This study suggests that middle-born men in China may have an increased sexual risk compared to other sibling positions. As Chinese family and social structures change, a more thorough understanding of how demographic factors influence sexual risk behaviours is needed.
PMCID: PMC3657676  PMID: 23793689
Public Health
17.  Prevalence of HIV, Syphilis, HCV and Their High Risk Behaviors among Migrant Workers in Eastern China 
PLoS ONE  2013;8(2):e57258.
The goal of this study was to understand the knowledge about AIDS, identify the correlates and determine the prevalence of HIV infection, syphilis, HCV among migrant workers in Zhejiang, China.
A cross-sectional study using face-to-face anonymous questionnaire interviews was conducted and blood samples were collected for HIV, syphilis and Hepatitis C infection screening.
17,377 (92.8%) of 18,730 migrant workers approached were interviewed. Among 17,377 participants, the HIV/AIDS knowledge rate was 66.2%. A total of 12,694 (73%) of the participants reported having ever had sexual intercourse, with 30.1% of single participants reporting having had sexual intercourse. Among those respondents with sexual experiences, 7.5% admitted they had two or more sexual partners and 4.9% reported having had sex with casual (unpaid) partners in the previous 12 months, whilst 3.7% had paid for sex. More than half of those who had paid for sex (59.4%) had not used a condom every time in their sexual acts with the sex workers. Multiple logistic regression analysis indicated that high risk sexual behavior (defined as sex with a casual or commercial sex partner without using a condom consistently) was associated with being divorced or widowed (P<0.05 for single); male gender; shorter duration of stay in Zhejiang; working in factory, market or domestic service (P<0.05 for odd job); having a province of origin inside Zhejiang; and drug use. The prevalence of HIV and HCV infections were 0.02% (95% CI: 0.01%–0.06%) and 0.40% (95%CI: 0.31%–0.51%), respectively. The prevalence of syphilis among those who were sexually active was 0.55% (95% CI: 0.43%–0.70%). Risk factors for syphilis included shorter duration of stay in Zhejiang, ethnic minority status, being divorced or widowed and having had multiple sex partners.
Much greater efforts are needed to promote safer sex, and programs for the control of syphilis need to be tailored for migrant workers in China.
PMCID: PMC3579873  PMID: 23451193
18.  Hepatitis C virus infection and biological false-positive syphilis tests 
The diagnosis of syphilis requires two-step serological testing. Not infrequently, sensitive screening tests are reactive but are not confirmed by more specific confirmatory tests yielding a biological false positive (BFP). This study sought to describe the prevalence of BFP in a large population of hepatitis C virus (HCV)-infected and uninfected women.
A cross-sectional serosurvey of HIV-seropositive and HIV-seronegative women enrolled in the Women’s Interagency HIV Study, a multicentre collaborative study of the natural history of HIV in women.
Among HCV-infected women 4% had a BFP compared with 1% among those who were HCV uninfected (odds ratio (OR) 3.3, 95% CI 2.1 to 5.1). Controlling for both HIV infection and a history of intravenous drug use among all tests for syphilis a BFP also occurred more commonly in HCV-infected women compared with HCV-uninfected women (6% vs 1%, OR 7.62, 95% CI 1.9 to 12.5).
HCV infection is associated with various effects on immune function including alterations in serological test results. Women with HCV are more likely to have a BFP syphilis test than women without HCV.
PMCID: PMC2981071  PMID: 20332367
19.  Monkey Bites among US Military Members, Afghanistan, 2011 
Emerging Infectious Diseases  2012;18(10):1647-1649.
If you were to list all the dangers faced by US military personnel serving in Afghanistan, your list would be long, but would it include monkey bites? It should. The US Army recently examined this risk and found that in just 4 months, 10 service members were bitten by monkeys. And there may have been more, unreported, bites. Most monkeys were pets owned by Afghan National Security Forces and Afghan civilians, so the risk of being bitten could increase as US forces work more closely with these Afghan people. Monkey bites can spread rabies, tetanus, or other bacterial infections, or B-virus infection to humans. Bites can be minimized by enforcing military policies that prohibit pet adoption and animal contact, and secondary infections can be reduced by providing better training to military health care providers on how to treat animal bites.
Bites from Macaca mulatta monkeys, native to Afghanistan, can cause serious infections. To determine risk for US military members in Afghanistan, we reviewed records for September–December 2011. Among 126 animal bites and exposures, 10 were monkey bites. Command emphasis is vital for preventing monkey bites; provider training and bite reporting promote postexposure treatment.
PMCID: PMC3471630  PMID: 23017939
animal bite; monkey; Simian; nonhuman primate; rabies; rabies postexposure prophylaxis; herpes B virus; Macacine herpesvirus 1; tetanus; military; Afghanistan; B-virus; viruses; zoonoses
20.  Contraceptive Utilization and Pregnancy Termination Among Female Sex Workers in Afghanistan 
Journal of Women's Health  2010;19(11):2057-2062.
To determine the prevalence and correlates of prior pregnancy termination and unmet need for contraception among female sex workers (FSWs) in Afghanistan.
FSWs in Jalalabad, Kabul, and Mazar-i-Sharif were recruited between June 2006 and December 2007 through outreach programs. Participants completed an interviewer-administered survey describing demographics, behaviors associated with risk of sexually transmitted infections (STIs) and unplanned pregnancy, and medical history. Correlates of prior pregnancy termination and current unmet need for contraception were assessed with logistic regression analysis, controlling for site.
Of 520 FSWs, most (82.3%) had been pregnant at least once (mean 4.9 ± 2.7, range 1–17), among whom unplanned pregnancy (36.9%) and termination (33.2%) were common. Jalalabad participants were more likely to report both prior unplanned pregnancy (60.6% vs. 48.3% in Kabul or 20.7% in Mazar, p < 0.001) and prior termination (54.9% vs. 31.8% in Kabul or 26.8% in Mazar, p < 0.001). Most FSWs (90.0%) stated pregnancy was not currently desirable, and 85.2% were using contraception. Unmet need for contraception (14.7% of participants) was positively associated with having sold sex outside their city of residence (adjusted odds ratio [AOR] 1.88, 95% confidence interval [CI] 1.28-2.77) and inversely associated with illicit drug use (AOR 0.41, 95% CI 0.31-0.53).
Although FSWs in Afghanistan report high rates of contraceptive use, unplanned pregnancy is common. Reproductive health services should be included in programming for FSWs to reduce unplanned pregnancies and to reduce HIV/STI risks.
PMCID: PMC2971650  PMID: 20879869
21.  Deciphering the epidemic synergy of herpes simplex virus type 2 (HSV-2) on human immunodeficiency virus type 1 (HIV-1) infection among women in sub-Saharan Africa 
BMC Research Notes  2012;5:451.
Herpes Simplex Virus Type 2 (HSV-2) is highly prevalent in regions disproportionately affected by the human immunodeficiency virus (HIV-1) epidemic. The objective of our study was to identify the risk factors of HSV-2 and HIV-1 infections and to examine the association between the two infections.
The study participants were recruited through a community based cross-sectional study that was conducted from November 2002 to March 2003 in the Moshi urban district of Northern Tanzania. A two-stage sampling design was used in recruiting the study participants. Information on socio-demographics, alcohol use, sexual behaviors, and STIs symptoms were obtained. Blood and urine samples were drawn for testing of HIV-1, HSV-2 and other STIs.
The prevalence of HSV-2 infection among all study participants was 43%. The prevalence rate of HSV-2 among the HIV-negative and HIV-positive women was 40% and 65%, respectively. We found 2.72 times odds of having HIV-1 in an HSV-2 positive woman than in an HSV-2 negative woman. Furthermore, HIV-1 and HSV-2 shared common high-risk sexual behavior factors such as early onset of sexual debut, and testing positive for other STIs.
Our findings suggest that HSV-2 may be both a biological and risk-associated cofactor for HIV-1 acquisition. In resource-limited countries, where both infections are prevalent efforts at symptomatic and diagnostic screening and treatment of HSV-2 should be part of HIV-1 prevention programs.
PMCID: PMC3519592  PMID: 22909236
22.  Prevalence of syphilis among antenatal clinic attendees in Karachi: Imperative to begin universal screening in Pakistan 
Sexually transmitted infections are thought by some to be rare in socially conservative Muslim countries. Little is known about prevalence of syphilis in Pakistani women from the general population. We determined syphilis prevalence in a multi-center cross-sectional study of low risk pregnant women in Karachi, Pakistan.
We administered a structured questionnaire and obtained a blood sample for syphilis serology (rapid plasma reagin test with Treponema pallidum hemagglutination assay confirmation) from all women giving informed consent over six weeks in 2007.
The prevalence of confirmed syphilis was less than one percent (0.9%; 95%CI: 0.4, 1.8) in a sample size of 800 women recruited from three urban sites (≈1% refusal rate). Women who lived in an area where male drug use is prevalent (Ibrahim Hyderi Hospital) had 1% (1.5%) higher prevalence rates than women from the other two sites 0.5%.
We documented higher-than-expected syphilis seroprevalence rates in a low risk population of antenatal clinic attendees in Pakistan. Bridge populations for syphilis may include drug users, who are usually married, and Hijras or their clients. Hijras are transgender and/or transvestite men who may provide sex for money to men. In accordance with our results, the national policy for syphilis control in Pakistan should be modified to include universal syphilis screening in antenatal clinics with subsequent partner notification.
PMCID: PMC3574871  PMID: 22356034
syphilis; prevalence; pregnancy; antenatal care; policy; Pakistan
23.  Risk Factors for Syphilis and Prevalence of HIV, Hepatitis B and C among Men Who Have Sex with Men in Beijing, China: Implications for HIV Prevention 
AIDS and behavior  2008;13(4):663-670.
To examine the correlates for syphilis and the prevalence for HIV, hepatitis B, hepatitis C among men-who-have-sex-with-men (MSM) in Beijing, China. A total of 541 MSM was recruited using peer-referral, community outreach, and Internet. Questionnaire-based interviews provided information including, demographics, sexual and other risk behaviors. HIV prevalence was 4.8%, syphilis 19.8%, HCV 0.4% and HBsAg 6.5%. The median number of lifetime male sex partners was ten. In the past 3 months, 20.7% drank alcohol ≥1 times per week. In the past month, 21.3 and 14.6% had unprotected anal intercourse with regular and casual male sex partners, respectively. Syphilis infection was associated with less education, alcohol use, finding male sex partners through bathhouses/public washrooms/parks, and diagnoses of sexual transmitted diseases (STDs). Syphilis is now epidemic among Beijing's MSM. Prevention efforts are urgent as HIV prevalence is already near 5%. Education, condom promotion, STD control, and alcohol-related intervention are needed urgently.
PMCID: PMC2747785  PMID: 19082879
China; Men who have sex with men; Syphilis; HIV; Sexually transmitted disease (STD); Risk behavior
24.  Rapid assessment of sexually transmitted diseases in a sentinel population in Thailand: prevalence of chlamydial infection, gonorrhoea, and syphilis among pregnant women--1996 
Sexually Transmitted Infections  1998;74(3):189-193.
OBJECTIVE: To determine the prevalence of sexually transmitted diseases (STDs) among pregnant women in Thailand, where case reporting suggests a marked decrease in STDs following a campaign promoting condom use during commercial sex. DESIGN: Cross sectional study of women at their first visit to the study hospitals' antenatal clinics in Chiang Rai (n = 500) and Bangkok (n = 521). METHODS: First catch urine specimens were tested for Chlamydia trachomatis and Neisseria gonorrhoeae using the Amplicor CT/NG polymerase chain reaction assay. Syphilis and HIV serological testing were performed in the study hospitals' laboratories. RESULTS: The prevalence of chlamydial infection was 5.7%, gonorrhoea 0.2%, and syphilis 0.5% (all VDRL or RPR titres were < or = 1:4). The prevalence of HIV infection was 7.1% in Chiang Rai and 2.9% in Bangkok. In a multivariate logistic regression analysis, chlamydial infection was associated with younger age and with higher gestational age at first antenatal clinic visit, but was not associated with marital status, gravidity, city of enrollment, or HIV infection status. CONCLUSIONS: There was a low prevalence of gonorrhoea and syphilis among these pregnant women in Thailand. Chlamydial infection was detected at a higher prevalence, especially among younger women and women registering later for antenatal care. Testing of pregnant women using easily collected urine specimens and a sensitive nucleic acid amplification assay is a feasible method of rapidly assessing chlamydial and gonococcal prevalence. 

PMCID: PMC1758120  PMID: 9849554
25.  Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta‐analysis 
Sexually Transmitted Infections  2006;82(2):101-110.
Male circumcision is associated with reduced risk of HIV infection. This may be partly because of a protective effect of circumcision on other sexually transmitted infections (STI), especially those causing genital ulcers, but evidence for such protection is unclear. Our objective was to conduct a systematic review and meta‐analyses of the associations between male circumcision and infection with herpes simplex virus type 2 (HSV‐2), Treponema pallidum, or Haemophilus ducreyi.
Electronic databases (1950–2004) were searched using keywords and text terms for herpes simplex, syphilis, chancroid, ulcerative sexually transmitted diseases, or their causative agents, in conjunction with terms to identify epidemiological studies. References of key articles were hand searched, and data were extracted using standardised forms. Random effects models were used to summarise relative risk (RR) where appropriate.
26 articles met the inclusion criteria. Most syphilis studies reported a substantially reduced risk among circumcised men (summary RR = 0.67, 95% confidence interval (CI) 0.54 to 0.83), although there was significant between study heterogeneity (p = 0.01). The reduced risk of HSV‐2 infection was of borderline statistical significance (summary RR = 0.88, 95% CI 0.77 to 1.01). Circumcised men were at lower risk of chancroid in six of seven studies (individual study RRs: 0.12 to 1.11).
This first systematic review of male circumcision and ulcerative STI strongly indicates that circumcised men are at lower risk of chancroid and syphilis. There is less association with HSV‐2. Potential male circumcision interventions to reduce HIV in high risk populations may provide additional benefit by protecting against other STI.
PMCID: PMC2653870  PMID: 16581731
male circumcision; syphilis; chancroid; herpes simplex; systematic review

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