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1.  Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia 
The HIV Prevention Trials Network (HPTN) is conducting the HPTN 071(PopART) study in 21 communities in Zambia and South Africa with support from a consortium of funders. HPTN 071(PopART) is a community-randomized trial of a combination prevention strategy to reduce HIV incidence in the context of the generalized epidemic of southern Africa. The full PopART intervention strategy is anchored in home-based HIV testing and facilitated linkage of HIV-infected persons to care through community health workers, and universal antiretroviral therapy for seropositive persons regardless of CD4+ cell count or HIV viral load. In order to further reduce risk of HIV acquisition among uninfected individuals, the study aims to expand voluntary medical male circumcision, diagnosis and treatment of sexually transmitted infections, behavioral counseling, and condom distribution. The full PopART intervention strategy also incorporates promotion of other interventions designed to reduce HIV and tuberculosis transmission, including optimization of the prevention of mother to child HIV transmission and enhanced individual and public health tuberculosis services. Success for the PopART strategy depends upon the ability to increase coverage for the study interventions whose uptake is a necessary antecedent to a prevention effect. Processes will be measured to assess the degree of penetration of the interventions into the communities. A randomly sampled population cohort from each community will be used to measure the impact of the PopART strategy on HIV incidence over three years. We describe the strategy being tested and progress to date in the HPTN 071(PopART) study.
doi:10.1097/QAI.0b013e318299c3f4
PMCID: PMC3739051  PMID: 23764639
HIV; prevention; combination prevention; cluster randomized trial; treatment for prevention; antiretroviral therapy; HIV testing; circumcision; South Africa; Zambia
2.  Massive Benefits of Antiretroviral Therapy in Africa 
The Journal of Infectious Diseases  2013;209(4):483-485.
doi:10.1093/infdis/jit586
PMCID: PMC3903380  PMID: 24307740
HIV; antiretroviral therapy; outcomes; mortality; Africa; health policy; modeling
3.  Antiretroviral Therapy Program Expansion in Zambézia Province, Mozambique: Geospatial Mapping of Community-Based and Health Facility Data for Integrated Health Planning 
PLoS ONE  2014;9(10):e109653.
Objective
To generate maps reflecting the intersection of community-based Voluntary Counseling and Testing (VCT) delivery points with facility-based HIV program demographic information collected at the district level in three districts (Ile, Maganja da Costa and Chinde) of Zambézia Province, Mozambique; in order to guide planning decisions about antiretroviral therapy (ART) program expansion.
Methods
Program information was harvested from two separate open source databases maintained for community-based VCT and facility-based HIV care and treatment monitoring from October 2011 to September 2012. Maps were created using ArcGIS 10.1. Travel distance by foot within a 10 km radius is generally considered a tolerable distance in Mozambique for purposes of adherence and retention planning.
Results
Community-based VCT activities in each of three districts were clustered within geographic proximity to clinics providing ART, within communities with easier transportation access, and/or near the homes of VCT volunteers. Community HIV testing results yielded HIV seropositivity rates in some regions that were incongruent with the Ministry of Health’s estimates for the entire district (2–13% vs. 2% in Ile, 2–54% vs. 11.5% in Maganja da Costa, and 23–43% vs. 14.4% in Chinde). All 3 districts revealed gaps in regional disbursement of community-based VCT activities as well as access to clinics offering ART.
Conclusions
Use of geospatial mapping in the context of program planning and monitoring allowed for characterizing the location and size of each district’s HIV population. In extremely resource limited and logistically challenging settings, maps are valuable tools for informing evidence-based decisions in planning program expansion, including ART.
doi:10.1371/journal.pone.0109653
PMCID: PMC4201452  PMID: 25329169
4.  Multidimensional Poverty in Rural Mozambique: A New Metric for Evaluating Public Health Interventions 
PLoS ONE  2014;9(9):e108654.
Background
Poverty is a multidimensional phenomenon and unidimensional measurements have proven inadequate to the challenge of assessing its dynamics. Dynamics between poverty and public health intervention is among the most difficult yet important problems faced in development. We sought to demonstrate how multidimensional poverty measures can be utilized in the evaluation of public health interventions; and to create geospatial maps of poverty deprivation to aid implementers in prioritizing program planning.
Methods
Survey teams interviewed a representative sample of 3,749 female heads of household in 259 enumeration areas across Zambézia in August-September 2010. We estimated a multidimensional poverty index, which can be disaggregated into context-specific indicators. We produced an MPI comprised of 3 dimensions and 11 weighted indicators selected from the survey. Households were identified as “poor” if were deprived in >33% of indicators. Our MPI is an adjusted headcount, calculated by multiplying the proportion identified as poor (headcount) and the poverty gap (average deprivation). Geospatial visualizations of poverty deprivation were created as a contextual baseline for future evaluation.
Results
In our rural (96%) and urban (4%) interviewees, the 33% deprivation cut-off suggested 58.2% of households were poor (29.3% of urban vs. 59.5% of rural). Among the poor, households experienced an average deprivation of 46%; thus the MPI/adjusted headcount is 0.27 ( = 0.58×0.46). Of households where a local language was the primary language, 58.6% were considered poor versus Portuguese-speaking households where 73.5% were considered non-poor. Living standard is the dominant deprivation, followed by health, and then education.
Conclusions
Multidimensional poverty measurement can be integrated into program design for public health interventions, and geospatial visualization helps examine the impact of intervention deployment within the context of distinct poverty conditions. Both permit program implementers to focus resources and critically explore linkages between poverty and its social determinants, thus deriving useful findings for evidence-based planning.
doi:10.1371/journal.pone.0108654
PMCID: PMC4182519  PMID: 25268951
5.  Safety and tolerability of tenofovir for pre-exposure prophylaxis among men who have sex with men 
Journal of acquired immune deficiency syndromes (1999)  2013;64(1):10.1097/QAI.0b013e3182a3979c.
doi:10.1097/QAI.0b013e3182a3979c
PMCID: PMC3819194  PMID: 23881239
tenofovir; pre-exposure prophylaxis; HIV; transmission; safety; tolerability; men who have sex with men (homosexual men; gay men)
6.  Home-Based HIV Testing for Men Who Have Sex with Men in China: A Novel Community-Based Partnership to Complement Government Programs 
PLoS ONE  2014;9(7):e102812.
Background
The coverage of HIV testing among Chinese men who have sex with men (MSM) remains low after the scale-up of free HIV testing at government-sponsored testing sites. We evaluated the feasibility of home-based HIV self-testing and the willingness to be HIV tested at community-based organizations (CBO).
Methods
We recruited MSM via on-line advertisement, where they completed an on-line informed consent and subsequent questionnaire survey. Eligible MSM received HIV rapid testing kits by mail, performed the test themselves and reported the result remotely.
Results
Of the 220 men taking a home-based HIV self-testing, 33 MSM (15%) were seropositive. Nearly 65% of the men reported that they were willing to take HIV testing at CBO, while 28% preferred receiving free HIV testing in the government programs at local Centers for Disease Control and Prevention (CDC). Older and lower-income MSM, those who self-reported homosexual orientation, men with no history of sexually transmitted diseases and a lower number of sexual partners in the past six months were associated with preference for taking HIV testing at CBOs. The top three self-reported existing barriers for HIV testing were: no perception of HIV risk (56%), fear of an HIV positive result being reported to the government (41%), and fear of a positive HIV test result (36%).
Conclusion
Home-based HIV self-testing is an alternative approach for increasing the coverage of HIV testing among Chinese MSM. CBO-based HIV testing is a potential alternative, but further studies are needed to evaluate its feasibility.
doi:10.1371/journal.pone.0102812
PMCID: PMC4106852  PMID: 25051160
7.  Assessment of High-Risk Human Papillomavirus Infections Using Clinician- and Self-Collected Cervical Sampling Methods in Rural Women from Far Western Nepal 
PLoS ONE  2014;9(6):e101255.
Introduction
Nepal has one of the highest cervical cancer rates in South Asia. Only a few studies in populations from urban areas have investigated type specific distribution of human papillomavirus (HPV) in Nepali women. Data on high-risk HPV (HR-HPV) types are not currently available for rural populations in Nepal. We aimed to assess the distribution of HR- HPV among rural Nepali women while assessing self-collected and clinician-collected cervico-vaginal specimens as sample collection methods for HPV screening.
Methods
Study participants were recruited during a health camp conducted by Nepal Fertility Care Center in Achham District of rural far western Nepal. Women of reproductive age completed a socio-demographic and clinical questionnaire, and provided two specimens; one cervical-vaginal specimen using a self-collection method and another cervical specimen collected by health camp auxiliary nurse midwives during a pelvic examination. All samples were tested for 14 different HR-HPV mRNA and also specific for HPV16/18/45 mRNA.
Results
Of 261 women with both clinician- and self-collected cervical samples, 25 tested positive for HR-HPV, resulting in an overall HR-HPV prevalence of 9.6% (95% confidence Interval [CI]: 6.3–13.8). The overall Kappa value assessing agreement between clinician- and self-collected tests was 0.62 (95% CI: 0.43–0.81), indicating a “good” level of agreement. Abnormal cytology was reported for 8 women. One woman identified with squamous cell carcinoma (SCC), and 7 women with high grade squamous intraepithelial lesions (HSIL). Seven of the 8 women tested positive for HR-HPV (87.5%) in clinician-collected samples and 6 in self-collected samples (75.0%).
Conclusion
This is the first study to assess HR-HPV among rural Nepali women. Self-collected sampling methods should be the subject of additional research in Nepal for screening HR-HPV, associated with pre-cancer lesions and cancer, in women in rural areas with limited access to health services.
doi:10.1371/journal.pone.0101255
PMCID: PMC4076302  PMID: 24978811
8.  Translation of biomedical prevention strategies for HIV: Prospects and pitfalls 
Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother to child transmission. In recent years, antiretroviral drugs to reduce risk of transmission (when the infected person takes the medicines; treatment as prevention or TasP) or reduce risk of acquisition (when the seronegative person takes them; pre-exposure prophylaxis or PrEP) have proven efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (i.e., screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV prevention strategies such as family planning for HIV-infected women who do not want more children and prevention mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.
doi:10.1097/QAI.0b013e31829202a2
PMCID: PMC3725750  PMID: 23673881
Condoms; PMTCT; TasP; PrEP; PEP; male circumcision; vaccines; complimentary strategies
9.  Alcohol Use among Chinese Men Who Have Sex with Men: An Epidemiological Survey and Meta-Analysis 
BioMed Research International  2014;2014:414381.
The HIV/AIDS epidemic among Chinese men who have sex with men (MSM) has become a significant public health concern. Knowledge of alcohol consumption in this population is limited. In this study, 1,155 Chinese MSM were surveyed to assess alcohol use and its correlates. A meta-analysis was also performed to aggregate pooled prevalence of current alcohol use. MSM who were unmarried (aOR: 1.87; 95% CI: 1.29–2.71) or unemployed/retired (aOR: 2.77; 95% CI: 1.73–4.45) were more likely to drink alcohol more than once per week. MSM who consumed alcohol more than once per week were more likely to use drug (P < 0.01), have sex with women (P < 0.01), have unprotected insertive (P = 0.04) or receptive (P = 0.03) anal sex with men, have more than 10 lifetime male sex partners (P < 0.01), predominantly practice insertive anal sex (P < 0.01), and trade sex for money (P < 0.01). Pooled overall alcohol use prevalence was 32%. Pooled prevalence for MSM who drank alcohol more than once per week and who drank alcohol before sex with male partners was 23%. Our findings provide the basis for further exploring the alcohol-HIV association and developing risk reduction interventions.
doi:10.1155/2014/414381
PMCID: PMC3966324  PMID: 24711993
10.  Bacteremia as a Cause of Fever in Ambulatory, HIV-Infected Mozambican Adults: Results and Policy Implications from a Prospective Observational Study 
PLoS ONE  2013;8(12):e83591.
Fever is typically treated empirically in rural Mozambique. We examined the distribution and antimicrobial susceptibility patterns of bacterial pathogens isolated from blood-culture specimens, and clinical characteristics of ambulatory HIV-infected febrile patients with and without bacteremia. This analysis was nested within a larger prospective observational study to evaluate the performance of new Mozambican guidelines for fever and anemia in HIV-infected adults (clinical trial registration NCT01681914, www.clinicaltrials.gov); the guidelines were designed to be used by non-physician clinicians who attended ambulatory HIV-infected patients in very resource-constrained peripheral health units. In 2012 (April-September), we recruited 258 HIV-infected adults with documented fever or history of recent fever in three sites within Zambézia Province, Mozambique. Although febrile patients were routinely tested for malaria, blood culture capacity was unavailable in Zambézia prior to study initiation. We confirmed bacteremia in 39 (15.1%) of 258 patients. The predominant organisms were non-typhoid Salmonella, nearly all resistant to multiple first-line antibiotics (ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole). Features most associated with bacteremia included higher temperature, lower CD4+ T-lymphocyte count, lower hemoglobin, and headache. Introduction of blood cultures allowed us to: 1) confirm bacteremia in a substantial proportion of patients; 2) tailor specific antimicrobial therapy for confirmed bacteremia based on known susceptibilities; 3) make informed choices of presumptive antibiotics for patients with suspected bacteremia; and 4) construct a preliminary clinical profile to help clinicians determine who would most likely benefit from presumptive bacteremia treatment. Our findings demonstrate that in resource-limited settings, there is urgent need to expand local microbiologic capacity to better identify and treat cases of bacteremia in HIV-infected and other patients, and to support surveillance. Data on the prevalence and susceptibility patterns of important pathogens can guide national formulary and prescribing practices.
doi:10.1371/journal.pone.0083591
PMCID: PMC3875454  PMID: 24386229
11.  Meta-Analysis of Interventions for Reducing Number of Sexual Partners and Drug and Alcohol Abuse among People Living with HIV/AIDS 
Objective
To perform a systematic review and meta-analysis of the efficacy of risk reduction interventions on HIV-related risk behaviors among people living with HIV/AIDS (PLWHA)
Methods
Studies included in the meta-analysis were randomized clinical trials (RCTs) of risk reduction interventions, which targeted PLWHA aged 18 year or older and assessed the changes of number of sexual partners, drug use, needle sharing, and/or alcohol abuse between pre- and post-intervention. The standardized mean differences (SMD) between study arms as well as between baseline and post-intervention, defined as the effect sizes (ES), were calculated in random effects models. Heterogeneity of studies was estimated by the I2 statistic.
Results
Twelve RCTs involving 3993 PLWHA were included in our analysis: seven reported impacts on the number of sexual partners, and three reported impacts on drug use, needle sharing, and alcohol abuse, respectively. There were no statistically significant impacts of risk reduction interventions on the number of total sexual partners (mean ES, -0.10; 95% confidence interval [CI], -0.26, 0.06; P=0.22) or on the subset of HIV-negative or unknown-status sexual partners (mean ES, 0.003; 95% CI, -0.54, 0.54; P=0.99). Overall, risk reduction intervention studies documented a reduction of drug abuse (mean ES: -0.26; 95% CI: -0.51, -0.01; P=0.04) among HIV-infected drug users, but this impact was mainly attributable to one study. Risk reduction interventions did not show a reduction of needle sharing (mean ES, -0.15; 95% CI, -0.43, 0.13; P=0.29) or of alcohol abuse (mean ES, -0.10; 95% CI, -0.36, 0.17; P=0.47). No heterogeneity or publication bias was found across individual studies.
Conclusions
Our meta-analysis did not find a positive impacts of risk reduction interventions on number of sexual partners, drug use, needle sharing, or alcohol abuse among PLWHA, but the small number of studies meeting our review criteria limits these findings.
doi:10.4172/2155-6113.1000213
PMCID: PMC3819193  PMID: 24224118
People living with HIV/AIDS (PLWHA); Randomized clinical trial (RCT); Sexual partners; Positive prevention; Drug use; Alcohol abuse; Meta-analysis
12.  Utilization of Cervical Cancer Screening Services and Trends in Screening Positivity Rates in a ‘Screen-And-Treat’ Program Integrated with HIV/AIDS Care in Zambia 
PLoS ONE  2013;8(9):e74607.
Background
In the absence of stand-alone infrastructures for delivering cervical cancer screening services, efforts are underway in sub-Saharan Africa to dovetail screening with ongoing vertical health initiatives like HIV/AIDS care programs. Yet, evidence demonstrating the utilization of cervical cancer prevention services in such integrated programs by women of the general population is lacking.
Methods
We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia (CCPPZ), the largest public sector programs of its kind in sub-Saharan Africa. We evaluated patterns of utilization of screening services by HIV serostatus, examined contemporaneous trends in screening outcomes, and used multivariable modeling to identify factors associated with screening test positivity.
Results
Between January 2006 and April 2011, CCPPZ services were utilized by 56,247 women who underwent cervical cancer screening with visual inspection with acetic acid (VIA), aided by digital cervicography. The proportion of women accessing these services who were HIV-seropositive declined from 54% to 23% between 2006–2010, which coincided with increasing proportions of HIV-seronegative women (from 22% to 38%) and women whose HIV serostatus was unknown (from 24% to 39%) (all p-for trend<0.001). The rates of VIA screening positivity declined from 47% to 17% during the same period (p-for trend <0.001), and this decline was consistent across all HIV serostatus categories. After adjusting for demographic and sexual/reproductive factors, HIV-seropositive women were more than twice as likely (Odds ratio 2.62, 95% CI 2.49, 2.76) to screen VIA-positive than HIV-seronegative women.
Conclusions
This is the first ‘real world’ demonstration in a public sector implementation program in a sub-Saharan African setting that with successful program scale-up efforts, nurse-led cervical cancer screening programs targeting women with HIV can expand and serve all women, regardless of HIV serostatus. Screening program performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making.
doi:10.1371/journal.pone.0074607
PMCID: PMC3776830  PMID: 24058599
13.  Predictors of HIV testing among men who have sex with men in a large Chinese city 
Sexually transmitted diseases  2013;40(3):235-240.
Background
HIV testing is the gateway for prevention and care. We explored factors associated with HIV testing among Chinese men who have sex with men (MSM).
Methods
In Chongqing City, we recruited 492 MSM in 2010 using respondent driven sampling in a cross-sectional study. Computer-assisted self-interviews were conducted to collect information on history of HIV testing.
Results
Only 58% of participants reported ever having taken an HIV test. MSM who had a college degree [adjusted odds ratio (AOR): 1.7; 95% confidence interval (CI): 1.2-2.6; P=0.008] were more likely to take a test; those who preferred a receptive role in anal sex were less likely to do so than those with insertive sex preference (AOR: 0.6; 95% CI: 0.35-0.94; P=0.03); those who used condoms with the recent male partner during the past 6 months were more likely to get tested (AOR: 2.87; 95%CI: 1.25-6.62; P=0.01). Principal perceived barriers to testing included: fear of knowing a positive result, fear of discrimination if tested positive, low perceived risk of HIV infection, and not knowing where to take a test. Factors reported to facilitate testing were sympathetic attitudes from health staff and guaranteed confidentiality. Prevalence was high: 11.7% HIV-positive and 4.7% syphilis positive.
Conclusion
The HIV testing rate among MSM in Chongqing is still low, though MSM prevalence is high compared to other Chinese cities. MSM preferring receptive anal sex are less likely to get testing and perceive having lower HIV risk. Along with expanded education and social marketing, a welcoming and non-judgmental environment for HIV testing is needed.
doi:10.1097/OLQ.0b013e31827ca6b9
PMCID: PMC3725775  PMID: 23403605
Human immunodeficiency virus; syphilis; men who have sex with men; HIV testing; respondent driven sampling; China
14.  Cervical Cancer Prevention in Low- and Middle-Income Countries: Feasible, Affordable, Essential 
The annual worldwide burden of the preventable disease cervical cancer is over 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMICs), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology-based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in “screen-and-treat-or-refer”’ programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is co-infection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon® present an historic opportunity to expand cervical cancer screening in LMICs.
doi:10.1158/1940-6207.CAPR-11-0540
PMCID: PMC3586242  PMID: 22158053
15.  Transitioning HIV care and treatment programs in southern Africa to full local management 
AIDS (London, England)  2012;26(10):1303-1310.
doi:10.1097/QAD.0b013e3283552185
PMCID: PMC3576840  PMID: 22706012
AIDS; HIV; Africa; HIV care; HIV treatment; antiretroviral therapy; Botswana; South Africa; Mozambique; Zambia; cost; coverage; health care system; policy; financing
16.  Improved HIV testing coverage after scale-up of antiretroviral therapy programs in urban Zambia: Evidence from serial hospital surveillance 
Medical journal of Zambia  2010;37(2):71-77.
Background
We evaluated changing HIV testing coverage and prevalence rates before and after expanding city-wide antiretroviral therapy (ART) programs in Lusaka, Zambia.
Methods
We conducted serial cross-sectional surveys on the University Teaching Hospital medical ward to assess HIV prevalence among inpatients of unknown status in 2003 and 2006. Willing participants received counseling and dual HIV rapid tests. We compared the proportion of inpatients receiving their test results in 2003 (off-the-ward testing) to 2006 (on-the-ward).
Results
In 2003, none of 103 inpatients knew their HIV status or took ART; 99.0% (102/103) agreed to testing. In 2006, 49.3% (99 of 201) patients knew they were HIV-infected and were on ART; of those with unknown status, 98.0% (100/102) agreed to testing. In 2003, only 54.9% (56/102) received post-test counseling and 98.2% (55/56) learned their status. In 2006, 99.0% (99/100) received post-test counseling and 99.1% (98 of 99) learned their status. In 2003, 62.8% (64 of 102) of status-unknown inpatients who agreed to testing were seropositive by dual rapid test, compared to 48.0% (48 of 100) of status-unknown inpatients in 2006. When including inpatients who already knew their seropositive status plus those unknowns who tested seropositive, the proportion of inpatients that was seropositive in 2006 was 73.1% (147 of 201), higher than in 2003.
Conclusions
After ART program expansion, inpatients in 2006 were far more likely than their 2003 counterparts to know their HIV status and to be taking ART. In both years, 63–73% of medical inpatients were HIV-infected and 98.5% of inpatients agreed to testing. On-the-ward testing in 2006 avoided the 2003 problem of patient discharge before learning of their test results. Hospital-based HIV testing is an essential clinical service in high prevalence settings and can serve further as a surveillance system to help track the community impact of outpatient AIDS services in Africa.
PMCID: PMC3503145  PMID: 23180895
HIV; AIDS; seroprevalence; counseling and testing; Zambia; hospital; antiretroviral therapy; program evaluation
17.  Does Douching Increase Risk for Sexually Transmitted Infections? A Prospective Study in High-Risk Adolescents 
Objective
To examine the association between douching and four sexually transmitted infections (STIs).
Study Design
We followed 411 high-risk HIV-infected and uninfected female adolescents ages 12–19 over a median three-year period, both by time from study entry/first STI-free visit until an incident STI for participants who never, intermittently, and always douched, and also by reported douching at a given STI-free visit and incidence of STI at the next visit, using adjusted Cox proportional hazards models to calculate hazards ratios (HR).
Results
The time to STI was shorter for adolescents who always (HR=2.1; 95% CI, 1.2–3.4) and intermittently (HR=1.5; 95% CI:1.0–2.2) douched compared to never-douchers. An adjusted hazard for STI was 1.8 times larger for always-douchers (95%CI:1.1–3.1) and 1.4 times larger for intermittent-douchers (95%CI:0.9–2.0) compared to never-douchers. When classifying by follow-up post an STI-free visit, always-douchers had a shorter STI-free time than never-douchers (HRadj=2.1; 95%CI:1.5–3.1).
Conclusion
Counseling to discourage douching may reduce STI risk in adolescents.
doi:10.1016/j.ajog.2008.06.026
PMCID: PMC3199592  PMID: 18667177
18.  Risk factors for HIV infection among Haitian adolescents and young adults seeking counseling and testing in Port-au-Prince 
Many Haitian adolescents are highly vulnerable to HIV infection. Among 3,391 sexually active 13-25-year-olds in our Voluntary Counseling and Testing (VCT) Center in Port-au-Prince from October 2005 to September 2006, we assessed associations between demographic and behavioral factors and HIV status using multivariable logistic regression analyses. We diagnosed HIV infection in 6.3% of 2,533 females and 5.5% of 858 males. Age-specific prevalence was 3.4% for 13-15-year-olds, 4.7% for 16-19, and 6.8% for 20-25 (P=0.02). Poor education, not residing with parents, currently or formerly married, having a child, and being self-referred to VCT services by others were significant predictors of HIV in females. HIV infection was associated with considering oneself at higher risk, though most youth did not recognize this risk. HIV in females was also associated with suspected/confirmed sexually transmitted infection (STI), especially genital ulcers (ORadj=2.28, 95%CI:1.26-4.13), years of sexual activity (Ptrend=0.07), and suspicion that partners had other partners or an STI. Among males, HIV was associated with drug use (though uncommon), as well as sexual debut with a casual/unknown person (ORadj=3.18, 95%CI:1.58-6.42). HIV-infected young people were more likely to be RPR positive and less likely to use condoms. Young Haitians are a key target for HIV prevention and care and avail themselves readily of youth-focused VCT services.
doi:10.1097/QAI.0b013e3181ac12a8
PMCID: PMC3196358  PMID: 19738486
HIV; sexual behavior; adolescent; youth; Haiti; counseling; HIV testing
19.  Risk factors and prevalence of tuberculosis, human immunodeficiency virus, syphilis, hepatitis B virus, and hepatitis C virus among prisoners in Pakistan 
Background
We evaluated the burden of sexual- or injection drug use (IDU)-related infections in male prisoners in Karachi, Pakistan.
Methods
We administered a structured questionnaire in a cross-sectional survey of 365 randomly selected imprisoned men. We analyzed blood for human immunodeficiency virus (HIV) and Hepatitis B and C by ELISA, and for syphilis by rapid plasma reagin and Treponema pallidum hemagglutination assay confirmation. Subjects with possible tuberculosis (WHO criteria) provided sputum samples for an acid fast bacillus smear and culture.
Results
Prevalence of tuberculosis was 2.2% (95%CI: 0.71, 3.8). HIV infected 2.0% (95%CI: 0.55, 3.4) of 357 randomly selected prisoners (8 refused to give blood), with confirmed syphilis in 8.9% (95%CI: 6.0, 11.8), hepatitis B virus in 5.9% (95%CI: 3.5, 8.3), and hepatitis C virus in 15.2% (95%CI: 11.7, 18.8). By self-report, 59.0% had used any illicit drugs, among whom 11.8% (95%CI: 8.5, 15.0) had injected drugs. The median length of stay in the prison had been 3.2 (range 1-72) months.
Conclusions
All four infections were prevalent among the prisoners in Pakistan. Prisons are excellent venues for infectious disease screening and intervention given conditions of poverty and drug addiction. Collaboration with community-based health providers is vital for post-discharge planning.
doi:10.1016/j.ijid.2009.11.012
PMCID: PMC2905608  PMID: 20189863
Infectious disease; substance abuse; prison; epidemiology; Pakistan
20.  Addressing HIV prevention research priorities in the United States 
More than half a million Americans became newly infected with HIV in the first decade of the new millennium. The domestic epidemic has had the heaviest impact on men who have sex with men (MSM) and people from racial and ethnic minority populations, particularly African-Americans. For example, Black MSM represent <1% of the U.S. population but 25% of the new HIV cases, as per CDC estimates published in 2008. While Black and Hispanic women constitute 24% of all U.S. women, they accounted for 82% of HIV cases in women in 2005, based on data from 33 states with confidential name-based reporting. There is a nearly 23-fold higher rate of AIDS diagnoses for Black women (45.5/100,000 women) and nearly 6-fold higher rate for Hispanic women (11.2/100,000) compared to the rate for white women (2.0/100,000). Investigators from the HIV Prevention Trials Network (HPTN), an NIH-sponsored collaborative clinical trials group, have crafted a domestic research agenda with community input. Two new domestic studies are in progress (2009) and a community-based clinical trial feasibility effort is in development (2010 start date). These studies focus on outreach, testing, and treatment of infected persons as a backbone for HIV prevention. Reaching persons not receiving health message and service with novel approaches to both prevention and care/treatment is an essential priority for HIV control in the U.S.; our research is designed to guide the best approaches and assess the impact of bridging treatment and prevention.
doi:10.1086/651485
PMCID: PMC2862583  PMID: 20397942
HIV; prevention; United States; homosexual; women; transmission; antiretroviral treatment; black; Hispanic
21.  HIV-prevention science at a crossroads: advances in reducing sexual risk 
Current opinion in HIV and AIDS  2009;4(4):266-273.
Purpose of review
We review the current state of evidence-based prevention strategies for reducing sexual transmission of HIV. The combined programmatic and scientific efforts through 2008 to reduce sexual transmission of HIV have failed to reduce substantially the global pandemic.
Recent findings
Prevention interventions to reduce HIV infection target behavioral, biomedical, and structural risk factors. Some of these prevention strategies have been evaluated in randomized clinical trials (RCTs) with HIV seroincidence endpoints. When RCTs are not feasible, a variety of observational and quasiexperimental research approaches can provide insight as to program effectiveness of specific strategies. Only five RCTs have demonstrated a notable decrease in sexually acquired HIV incidence. These include the Mwanza study of syndromic management of sexually transmitted diseases and three male circumcision trials in East Africa; a microbicide trial reported in 2009 shows substantial promise for the efficacy of PRO 2000 (0.5% gel).
Summary
The combined programmatic and scientific efforts to reduce sexual transmission of HIV have made incremental progress. New prevention tools are needed to stem the continued spread of HIV, though microbicides and vaccines will take many more years to develop, test, and deploy. Combination strategies of existing modalities should be tested to evaluate the potential for more proximate prevention benefits.
doi:10.1097/COH.0b013e32832c91dd
PMCID: PMC2995247  PMID: 19532063
circumcision; HIV; microbicide; microbicide; prevention; sexual behavior; sexually transmitted disease
22.  Early neurologic abnormalities associated with human T-cell lymphotropic virus type 1 infection in a cohort of Peruvian children 
The Journal of pediatrics  2009;155(5):700-706.
Objective
Because human T-cell lymphotropic virus type 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) may occur in some children infected with HTLV-1-infected, we sought to determine the prevalence of neurologic abnormalities and any associations with infective dermatitis in these children.
Study design
We enrolled 58 children infected with HTLV-1 and 42 uninfected children (ages 3-17) of mothers infected with HTLV-1 in a family study in Lima, Peru. We obtained medical and developmental histories, surveyed current neurologic symptoms, and conducted a standardized neurologic examination without prior knowledge of HTLV-1 status.
Results
HTLV-1 infection was associated with reported symptoms of lower extremity weakness/fatigue (OR=6.1, CI:0.7–281), lumbar pain (odds ratio [OR] = 1.7, 95% confidence interval [CI]:0.4–8), and paresthesia/dysesthesia (OR=2.6, CI:0.6–15.8). HTLV-1 infection was associated with lower-extremity hyperreflexia (OR=3.1, CI:0.8–14.2), ankle clonus (OR=5.0, CI:1.0–48.3), and extensor plantar reflex (OR undefined; p = 0.2). Among children infected HTLV-1, a history of infective dermatitis was associated with weakness (OR=2.7, CI:0.3–33), lumbar pain (OR=1.3, CI:0.2–8), paresthesia/dysesthesia (OR=2.9, CI:0.5–20), and urinary disturbances (OR=5.7, CI:0.5–290).
Conclusions
Abnormal neurologic findings were common in Peruvian children infected with HTLV-1, and several findings were co-prevalent with infective dermatitis. Pediatricians should monitor children infected with HTLV-1 for neurologic abnormalities.
doi:10.1016/j.jpeds.2009.05.027
PMCID: PMC2764792  PMID: 19628219
Tropical Spastic Paraparesis; Infective dermatitis
23.  HIV Incidence Rates and Risk Factors for Urban Women in Zambia: Preparing for a Microbicide Clinical Trial 
Sexually transmitted diseases  2009;36(3):129-133.
Objectives
A preparedness study was conducted to evaluate the suitability of sites and populations following the same study procedures intended for a larger scale microbicide efficacy trial. In the process the study evaluated human immunodeficiency virus (HIV) incidence, prevalence, and risk profiles for HIV-acquisition among young women in urban Zambia.
Methods
Women aged 16 to 49 years were screened for participation in the study that involved HIV/sexually transmitted infection testing and the assessment of sexual behavioral characteristics. Two hundred thirty-nine eligible women were enrolled and followed up for 12 months.
Results
Baseline HIV prevalence at screening was 38.7% (95% CI: 34.2%–43.3%). The highest age-specific prevalence of HIV was 54.1% (95% CI: 46.3%–61.8%) seen in women aged 26 to 34 years. HIV incidence was 2.6% per 100 woman years. Pregnancy rates were high at 17.4 per 100 woman years (95% CI: 12.2–24.1).
Conclusion
It was concluded that our general population sample, characterized by high HIV prevalence and ongoing incidence rates despite receiving regular risk reduction counseling and free condoms qualifies for future microbicide studies.
A microbicide preparedness study conducted in Lusaka, Zambia found high HIV prevalence and appreciable HIV incidence in a population of women in an urban setting.
doi:10.1097/OLQ.0b013e318190191d
PMCID: PMC2889146  PMID: 19174729
24.  Factors Associated with Delayed Initiation of HIV Medical Care Among Infected Persons Attending a Southern HIV/AIDS Clinic 
Southern medical journal  2006;99(5):472-481.
Background
Despite the proven benefits conferred by early human immunodeficiency virus (HIV) diagnosis and presentation to care, delays in HIV medical care are common; these delays are not fully understood, especially in the southern United States.
Methods
We evaluated the extent of, and characteristics associated with, delayed presentation to HIV care among 1,209 patients at an HIV/AIDS Outpatient Clinic in Birmingham, Alabama between 1996 and 2005.
Results
Two out of five (41.2%) patients first engaged care only after they had progressed to CDC-defined AIDS. Among these, 53.6% were diagnosed with HIV in the year preceding entry to care. Recent presentation (2002 – 2005), male sex, age ≥25, Medicare or Medicaid insurance coverage, and presentation within six months of HIV diagnosis were independently associated with initiating care after progression to AIDS.
Conclusions
A high proportion of patients entered clinical care after experiencing substantial disease progression. Interventions that effectively improve the timing of HIV diagnosis and presentation to care are needed.
PMCID: PMC2761649  PMID: 16711309
HIV; AIDS; health care; access; Alabama; delay
25.  SHORT REPORT: HIGH PREVALENCE OF HIV AND SYPHILIS IN A REMOTE NATIVE COMMUNITY OF THE PERUVIAN AMAZON 
Little data are available on how HIV and other sexually transmitted infections (STIs) affect indigenous people in Latin America, including Peru. We conducted a sero-epidemiologic survey of HIV infection and syphilis in a native community, the Chayahuita, an indigenous population in the Amazon region of Peru. The seroprevalences of HIV and syphilis in adults were 7.5% (6 of 80) and 6.3% (5 of 80), respectively. None of the participants had ever used a condom. Male to male sexual behavior was common. At the current levels of HIV prevalence, there is the risk of a negative impact on the survival of the Chayahuita ethnic group as a whole. The outcomes of this study highlight the need for urgent medical and anthropologic approaches to stop HIV transmission in indigenous Amazonian communities.
PMCID: PMC2745971  PMID: 17426174

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