Objectives

Patient-initiated partner STI notification, i.e., patients informing their sexual partners of diagnosis, is a cornerstone of STI prevention. Growing evidence suggests that women exposed to intimate partner violence (IPV) may fear such notification, or face negative consequences in response to STI disclosure. The current study assessed associations of IPV with fear of partner STI notification, and experiences of partner STI notification, among adolescent and young adult female family planning clinic patients.

Methods

Females patients ages 16–29 years in five family planning clinics in Northern California (n=1282) participated in a cross-sectional survey.

Results

History of physical or sexual IPV was associated with fear of partner STI notification. Moreover, participants exposed to IPV were more likely to have partners say it was not from them or otherwise accuse them of cheating in response to STI notification. Such partners were less likely to seek indicated STI treatment or testing.

Conclusions

Current findings suggest that STI partner notification may be compromised by IPV. Clinical practices and policies to support effective partner STI notification should include IPV assessment, and provide mechanisms to address related fears concerning partner notification.

Summary

The pharmacokinetics of antiretroviral drugs in pregnancy is poorly understood. We reviewed the use of therapeutic drug monitoring (TDM) in clinical settings to document plasma concentrations of lopinavir during pregnancy and investigated how clinicians acted upon TDM results. A retrospective review was carried out of all HIV-infected pregnant women taking boosted lopinavir-based highly active antiretroviral therapy (HAART) at five National Health Service (NHS) centres in the UK between May 2004 and March 2007. Seventy-three women in receipt of lopinavir were identified, of whom 89% had plasma lopinavir concentrations above the suggested minimum recommended for wild-type HIV. Initial TDM results prompted dosage change in 10% and assessment of adherence and/or pharmacist review in 11%. TDM was repeated in 29%. TDM can play an important role in the clinical management of HIV-positive pregnant women, allowing informed dose modification and an alternative measure of adherence.

Background

Implementing HIV voluntary counseling and testing (VCT) in bathhouses is a proven public health strategy for reaching high-risk men who have sex with men (MSM) and efficiently identifying new HIV cases. However, some bathhouse managers are concerned that VCT programs could adversely affect business. This study examined whether offering VCT on the premises of a bathhouse changed patterns of patron visits.

Methods

A collaborating bathhouse provided electronic anonymized patron data from their entire population of attendees. VCT was offered on premises with varying frequencies over the course of 3 years. Club entrances and exits were modeled as a function of intensity of VCT programming.

Results

Club entrances did not differ as a function of how many days per week testing was being offered in a given month. Additionally, club entrances did not decrease, nor did club exits increase during specific half-hour time periods when testing was offered.

Conclusions

Implementing bathhouse-based VCT did not have any demonstrable impact on patronage. Public health officials can leverage these results to help alleviate club managers’ concerns about patron reactions to providing testing on site, and to support expanding sexual health programs for MSM in these venues.

SUMMARY

We examined associations between stimulant use (methamphetamine and cocaine) and other substances (nicotine, marijuana, alcohol, inhaled nitrites) with immune function biomarkers among HIV-seropositive (HIV+) men using highly active antiretroviral therapy (ART) and -seronegative (HIV−) men in the Multicenter AIDS Cohort Study (MACS). Among HIV+ men, cumulative adherence to ART (4.07, 95% CI: 3.52, 4.71, per 10 years of adherent HAART use), and recent cohort enrollment (1.38; 95% CI: 1.24, 1.55) were multiplicatively associated with increases in CD4+/CD8+ ratios. Cumulative use of methamphetamine (0.93; 95% CI: 0.88, 0.98, per 10 use years), cocaine (0.93; 95% CI: 0.89, 0.96, per 10 use years), and cumulative medical visits (0.99; 95% CI: 0.98, 0.99, per 10 visit years), each showed small negative associations with CD4+/CD8+ ratios. Among HIV- men, cumulative medical visits (0.996; 95% CI: 0.993, 0.999), cumulative number of male sexual partners (0.999; 95% CI: 0.998, 0.9998, per 10 partner years) and cigarette pack years (1.10; 95% CI: 1.02, 1.18, per 10 pack years) were associated with CD4+/CD8+ ratios over the same period. ART adherence is associated with a positive immune function independent of stimulant use, underscoring the influence of ART on immune health for HIV+ men who engage in stimulant use.

Summary

Early sexual partnerships place young women in sub-Saharan Africa at high risk for HIV. Few studies have examined both individual- and partnership-level characteristics of sexual relationships among adolescent girls. A cross-sectional survey of sexual history and partnerships was conducted among 761 adolescent girls aged 15–19 years in Nairobi, Kenya. Rapid HIV testing was conducted and correlates of HIV infection were determined using multivariate logistic regression. The HIV prevalence was 7% and seropositive adolescents had a younger age at sexual debut (P < 0.01), more sexual partners in 12 months (P = 0.03), and were more likely to report transactional or non-consensual sex (P < 0.01). Girls who reported not knowing their partner’s HIV status were 14 times as likely to be HIV-seropositive than girls who knew their partner’s status (adjusted odds ratio: 14.2 [1.8, 109.3]). Public health messages to promote HIV testing and disclosure within partnerships could reduce sexual risk behaviours and HIV transmission among adolescents.

Summary

We assessed risk behaviour in a heterosexual cohort undergoing prescreening for the first Phase I/II HIV vaccine trials in Soweto. We developed a survey and collected self-reported data from HIV-negative potential volunteers. Of 488 participants, most were single and approximately half were from households with incomes below the poverty level. Males reported higher rates of heavy alcohol use (P < 0.001), marijuana use (P < 0.001) and other recreational drug use (P < 0.01). Males reported more sex partners than females in the previous six months (P < 0.001), as well as more casual/anonymous partners (P < 0.001) and one-night stands (P < 0.001). Multivariate analyses revealed substance use and male gender predicted higher risk behaviours, including <100% condom use with known/suspected HIV-positive partners, having casual/anonymous partners and having more than two partners. For this population, male volunteers may need increased risk-reduction counselling during Phase I/II trials and additional recruitment methods may be necessary to identify high-risk female volunteers for Phase III efficacy trials.

Objective

To test the hypothesis that a short anovaginal distance may increase the risk of bacterial vaginosis (BV) due to fecal contamination and disruption of the vaginal microbiota.

Methods

Women attending two STD clinics in Baltimore, Maryland who complained of a vaginal discharge were asked to participate in a study to measure mucosal immune responses. In this pilot study of all enrolled women, a small plastic ruler was used to measure the anatomic distance from the posterior fourchette to the anus with the participant in the lithotomy position. Cases of BV, defined by Amsel’s clinical criteria (n=62), were compared to controls (n=31) without BV. We used linear and logistic regression models to adjust for potential confounders.

Results

A total of 93 women were recruited (median age 28.6 years, 93% Black, 4.4% gonorrhea infection, 7.4% Chlamydia infection, 8.6% trichomonas infection, 62% BV diagnosed). Mean anovaginal distance was 3.22 cm (SD:0.74, range 1.8–5.2) for controls and 3.37 cm (SD:0.76, range: 1.8–5.7) for cases (p=0.38). There was no difference between cases and controls when comparing median values, quartiles, and after adjusting for potential confounders.

Conclusions

Among high-risk women with multiple co-infections, there was no association between anovaginal distance and clinical diagnosis of BV.

Summary

This study examined whether social vulnerability is associated with HIV testing among South African MSM. A community-based survey was conducted with 300 MSM in Pretoria in 2008. The sample was stratified by age, race, and residential status. Social vulnerability was assessed using measures of demographic characteristics, psychosocial determinants, and indicators of sexual minority stress. Being Black, living in a township and lacking HIV knowledge reduced MSM’s likelihood of ever having tested for HIV. Among those who had tested, lower income and not self-identifying as gay reduced men’s likelihood of having tested more than once. Lower income and internalized homophobia reduced men’s likelihood of having tested recently. Overall, MSM in socially vulnerable positions were less likely to get tested for HIV. Efforts to mitigate the effects of social vulnerability on HIV testing practices are needed in order to encourage regular HIV testing among South African MSM.

Summary

The risk of death is significantly higher in HIV-infected patients with tuberculosis (TB). This study aims to evaluate the impact of demographic, clinical and laboratory characteristics on the treatment outcome and mortality of TB/HIV co-infected patients in a tertiary TB centre in Iran. In total, 111 patients were recruited from 2004 to 2007. Mycobacteriological studies and demographic, clinical, and laboratory data from all patients were analysed and predictors of unsuccessful outcomes as well as mortality were determined. The mean age for all 111 TB-HIV patients was 38 ± 9 years (range 22–70) and 107 (96.3%) were men; 104 (93.7%) had a history of drug abuse and 96 (86.4%) had a history of imprisonment. The method of HIV transmission was intravenous drug use in 88 (79.3%). Twenty-three (20.7%) had a history of Category 1 (CAT I) TB treatment and six (5.4%) Category 2 (CAT II) treatment. Combination antiretroviral therapy (cART) was given to 48 (43.2%). No significant associations were found between treatment outcomes or mortality and gender, smoking, drug and alcohol abuse, imprisonment, method of transmission, history of CAT I and CAT II treatments, CD4 counts or adverse effects (P > 0.05). Administration of cART led to significantly better outcomes (P <0.001). Lower serum albumin levels and low body weight were significantly associated with mortality.

Objective

To review a quality control and quality assurance (QC/QA) model established to ensure the validity and reliability of collection, storage, and analysis of biological outcome data, and to promote good laboratory practices and sustained operational improvements in international clinical laboratories.

Methods

A two-arm randomized community-level HIV behavioral intervention trial was conducted in five countries: China, India, Peru, Russia, and Zimbabwe. The trial was based on diffusion theory utilizing a Community Popular Opinion Leaders (C-POL) intervention model with behavioral and biological outcomes. The model was established by the Biological Outcome Workgroup (BOWG), which collaborated with the Data Coordinating Center (DCC) and John Hopkins University Reference Laboratory. Five international laboratories conducted Chlamydia/gonorrhea PCR, HSV2 EIA, Syphilis RPR/TPPA, HIV EIA/Western Blot, and trichomonas culture. Data were collected at baseline, 12, and 24 months.

Results

Laboratory performance and infrastructure improved throughout the trial. Recommendations for improvement were consistently followed.

Conclusions

Quality laboratories in resource-poor settings can be established, operating standards can be improved, and certification can be obtained with consistent training, monitoring, and technical support. Building collaborative partnership relations can establish a sustainable network for clinical trials, and can lead to accreditation and international laboratory development.

Summary

Expanding the availability, utilization and coverage of HIV testing services is a critical step towards primary prevention and successful delivery of antiretroviral therapy (ART) in Zimbabwe. We used data from the Zimbabwe Demographic and Health Survey (2005–2006) to examine the coverage and correlates of recent HIV testing (HIV testing, <24 months preceding the survey) among HIV-positive and HIV-negative adults. We estimated the relative contribution of HIV testing in both the antenatal care (ANC) setting and non-ANC settings. Uptake of recent HIV testing was 14.4% among women and 11.1% among men, with HIV testing in ANC accounting for 42.3% and 10.3% of all recent testing among women and men, respectively. In the multivariate analyses, recent pregnancies and being aware of ART were independent correlates after controlling for demographic and socioeconomic variables. HIV testing in ANC was an important contributor to HIV testing coverage in Zimbabwe by reaching not only pregnant women but also their partners.

Background

It is controversial whether starting highly active antiretroviral therapy (HAART) during primary HIV infection (PHI) is beneficial.

Methods

Subjects in this observational cohort began HAART <30 days (group 1: acute treatment, n=40), 31–180 days (group 2: early treatment, n=82), or >180 days (group 3: delayed treatment, n=35) after HIV infection and were compared to 27 historical and 60 contemporary controls.

Results

Time to HIV-related diagnoses did not differ for group 1 (aHR 1.44, p=.3) or group 2 (aHR 1.17, p=.5) compared to contemporary controls, but it was delayed for both treated groups (aHR 0.38 for group 1, p=.01; and aHR 0.28 for group 2, p<.0001) compared to historical controls.

Conclusions

Although rates of HIV-related diagnoses were similar in acutely-treated subjects and contemporary controls, results were confounded by associations between higher CD4 counts, lower HIV RNA levels and delayed disease progression as reasons for deferring treatment. Randomized trials are needed to address benefits of HAART during PHI.

Herpes simplex virus type 2 (HSV-2) infection is one of the most commonly sexually transmitted infections worldwide. While glycoprotein G-2 ELISA based assays are commonly used for the serologic detection of HSV-2 infections, they have low specificity in developing countries. Euroline Western blot (WB) is a commercially available assay that is easy to perform; however, little is known about its performance characteristics. This study evaluated Euroline WB for the detection of HSV-2 antibodies compared to University of Washington Western blot in three geographically different regions, Baltimore, Maryland, Rakai, Uganda, and Kunming, China. Among the 135 American men attending an STD clinic in Baltimore, Maryland, 72% (n=97) were HSV-2 positive by Euroline WB. The Euroline WB had a sensitivity of 97.8% and a specificity of 81.8%. Among the 273 commercial sex workers in Kunming, 62.3% were HSV-2 positive by Euroline WB. The Euroline WB had a sensitivity of 96.9% and a specificity of 89.1%. Among the 437 Ugandans in Rakai, 67.3% were HSV-2 positive by Euroline WB. The Euroline WB had a sensitivity of 98.7% and a specificity of 65.4%. The Euroline WB has a consistently high sensitivity, but specificity varied significantly among the different locations.

This study examined Pre-Exposure Prophylaxis (PrEP) acceptability among female sex workers, male-to-female transgendered persons, and men who have sex with men in Lima, Peru. Focus groups explored social issues associated with PrEP acceptability and conjoint analysis assessed preferences among eight hypothetical PrEP scenarios with varying attribute profiles and their relative impact on acceptability. Conjoint analysis revealed that PrEP acceptability ranged from 19.8 to 82.5 out of a possible score of 100 across the eight hypothetical PrEP scenarios. Out-of-pocket cost had the greatest impact on PrEP acceptability (25.2, p <0.001), followed by efficacy (21.4, p <0.001) and potential side effects (14.7, p <0.001). Focus group data supported these findings, and also revealed that potential sexual risk disinhibition, stigma and discrimination associated with PrEP use, and mistrust of health care professionals were also concerns. These issues will require careful attention when planning for PrEP roll-out if proven efficacious in ongoing clinical trials.

SUMMARY

Human Papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States, and has major physical and psychological consequences including fear, anxiety, and stigma. To date, there is no measure of health-related quality of life specifically designed to assess symptoms and functioning for people with HPV infection. In the present study, we set out to develop an HPV-specific measure of health-related quality of life. We conducted literature reviews, open-ended interviews with patients, clinican surveys, and cognitive interviews which guided item development. The result is a 36-item measure, the Functional Assessment of Chronic Illness Therapy – HPV, which assesses the physical and psychological health-related quality of life aspects of HPV infection.

SUMMARY

This study examined HIV testing behaviors, perceived vulnerability to HIV, and correlates of sexual risk behaviors of young adult Latino and African American male gang members in Los Angeles, California. Data were collected from 249 gang members ages 18–26 years old. The majority (59%) of gang members reported unprotected vaginal intercourse (UVI) in the past 12 months. Only one-third (33.2%) of gang members had ever been tested for HIV. In our multivariate analysis, gang members who reported UVI were more likely to have engaged in the following behaviors: had sex with someone they just met (Adjusted Odds Ratio [AOR] = 4.51), had sex with someone they think or know had an STD (AOR = 4.67), or had sex while incarcerated (AOR = 8.92). In addition, gang members with a higher perceived vulnerability to HIV were less likely to report UVI in the previous 12 months (AOR= 0.75). These findings offer implications for development of an HIV prevention intervention for young Latino and African American male gang members.

SUMMARY

We estimated the effectiveness and cost-effectiveness of changes in concurrent sexual partnerships in reducing the spread of HIV in sub-Saharan Africa. Using data from Swaziland, Tanzania, Uganda, and Zambia, we estimated country-specific concurrency behavior from sexual behavior survey data on the number of partners in the past 12 months, and we developed a network model to compare the impact of three behavior changes on the HIV epidemic: (1) changes in concurrent partnership patterns to strict monogamy; (2) partnership reduction among those with the greatest number of partners; and (3) partnership reduction among all individuals. We estimated the number of new HIV infections over ten years and the cost per infection averted. Given our assumptions and model structure, we find that reducing concurrency among high-risk individuals averts the most infections and increasing monogamy the least (11.7% versus 8.7% reduction in new infections, on average, for a 10% reduction in concurrent partnerships). A campaign that costs $1 per person annually is likely cost-saving if it reduces concurrency by 9% on average, given our baseline estimates of concurrency. In sensitivity analysis, the rank ordering of behavior change scenarios was unaffected by potential over-estimation of concurrency, though the number of infections averted decreased and the cost per HIV infection averted increased. Concurrency reduction programs may be effective and cost-effective in reducing HIV incidence in sub-Saharan Africa if they can achieve even modest impacts at similar costs to past mass media campaigns in the region. Reduced concurrency among high-risk individuals appears to be most effective in reducing HIV incidence, but concurrency reduction in other risk groups may yield nearly as much benefit.

Summary

The sensitivity and specificity of rapid HIV-1 tests may be altered during pregnancy and postpartum. We conducted a study to determine the prevalence and correlates of false-positive Abbott Determine™ and false-negative Uni-Gold™ rapid HIV-1 test results among antenatal and postnatal mothers attending a primary care clinic in Nairobi, Kenya. Mothers were tested for HIV-1 using Abbott Determine™ and non-reactive results were considered HIV-1 antibody negative. Reactive samples by Determine were re-tested by Uni-Gold™. Vironostika HIV-1 and Uni-FORM II Enzyme-linked immunosorbent assays were used to confirm samples that had positive Abbott Determine™ and negative Uni-Gold™. Among 2311 women who accepted HIV-1 testing, 1238 (54%) were tested antenatally and 1073 (46%) were tested postnatally. Of tested women, 274 (12%) women were reactive by Abbott Determine™ and on retesting with Uni-Gold™ 30 (11%) had indeterminate results. The prevalence of indeterminate results was significantly higher in antenatal women than in postnatal women (2% versus 1%, P = 0.03). In conclusion, indeterminate rapid HIV-1 test results are more common in the antenatal period and appropriate safeguards to confirm HIV-1 infection status should be implemented in antenatal programmes.

Cryptococcus remains an important opportunistic infection in HIV patients despite considerable declines in prevalence during the HAART era. This is particularly apparent in sub-Saharan Africa, where Cryptococcus continues to cause significant mortality and morbidity. This review discusses the microbiology, epidemiology, pathogenesis, and clinical presentation of cryptococcal infections in HIV patients. Additionally, a detailed approach to the management of cryptococcosis is provided.

Background

Herpes Simplex Virus-2 (HSV-2) is a risk factor for HIV-1 infection; HSV-2 serology may be useful for HIV-1 prevention. We characterized HSV-2 serology assay performance in HIV-positive and HIV-negative Africans.

Methods

Serostatus for HSV-2 and HIV-1 was determined in 493 serum specimens stored from a community HSV-2 prevalence survey in Kampala, Uganda. HSV-2 serology by Focus HerpeSelect ELISA, Biokit HSV-2 rapid assay, and Kalon HSV-2 were compared to Western Blot (WB) by HIV-1 serostatus.

Results

Sensitivity/specificity were: 99.5%/70.2% for Focus, 97.0%/86.4% for Biokit, and 97.5%/96.2% for Kalon. Focus with Biokit confirmation improved sensitivity/specificity (99.4%/96.8%, respectively). Use of a higher Focus index value cutoff of 2.2 instead of 1.1 increased specificity from 70.2% to 92.4%. Kalon had higher specificity than Focus (p<.001).

Conclusion

Of commercially available HSV-2 serologic assays, Kalon alone, or Focus ELISA followed by Biokit confirmation perform best. Improved HSV-2 assays are needed for HSV-2 and HIV-1 public health activities in Africa.

Female sex workers (FSWs) aged ≥18 years without known HIV infection living in Tijuana and Ciudad Juarez who had recent unprotected sex with clients underwent interviews and testing for Chlamydia and gonorrhea using nucleic acid amplification. Correlates of each infection were identified with logistic regression. Among 798 FSWs, prevalence of Chlamydia and gonorrhea was 13.0% and 6.4%. Factors independently associated with Chlamydia were being younger, working in Tijuana versus Ciudad Juarez, and recent methamphetamine injection. Factors independently associated with gonorrhea were working in Tijuana versus Ciudad Juarez, using illegal drugs before or during sex, and having a recent male partner who injects drugs. Chlamydia and gonorrhea infection were more closely associated with FSWs’ drug use behaviors and that of their sexual partners than with sexual behaviors. Prevention should focus on subgroups of FSWs and their partners who use methamphetamine and who inject drugs.

Summary

We identified demographic, clinical and biological determinants of herpes simplex virus type 2 (HSV-2) shedding among HIV-infected participants in the Women’s HIV Interagency Study (WIHS). Cervicovaginal lavage (CVL) specimens from 369 HIV-infected HSV seropositive women were tested with TaqMan polymerase chain reaction (PRC) for detection HSV-2 DNA. Seven percent of women tested positive for HSV-2 DNA in CVL. Significant correlates of the presence of HSV-2 DNA in CVL were being younger, African American or Hispanic race/ethnicity and injecting drugs in the past six months (P < 0.05). A borderline significant trend for reduced viral shedding with higher CD4+ T cell counts was observed (P = 0.08). All women who were never observed with any genital lesions and had consistently negative self-reported history of genital sores throughout the follow-up (n = 29, 8%) were negative for CVL HSV-2 DNA. HSV-2 DNA quantity was significantly associated with having frequent subsequent lesion recurrences (Spearman rho = 0.48, P = 0.016; adjusted prevalence ratio [APR] = 2.5, P = 0.012). Increasing the age of the host was inversely correlated with decreased viral shedding over time. However, a subset of older women continued to shed significant amounts of virus despite passage of time. This study provides genital HSV-2 DNA titre as a quantitative and symptom- and sign-based measures as qualitative predictors of HSV-2 shedding from the lower genital tract among HIV-infected women.

Summary

There is still a paucity of research on the sociodemographic and other underlying factors associated with HIV transmission among women in India. This study was designed to investigate such factors in sexually experienced Indian women. We used data from the National Family Health Survey 3 (NFHS-3), which tested 52,853 women for HIV, including 27,556 husband and wife pairs. Significant risk factors for all women and married women only were: aged 26–35 years (adjusted odds ratios [AORs] = 3.65 and 2.53, respectively), being poor (AORs = 1.57 and 1.79), having had a genital sore in the last 12 months (AORs = 3.16 and 3.01) and having more than one sexual partner (AORs = 5.95 and 5.15). For husband and wife pairs, suffering sexual violence (AOR = 2.63), husband having other wife/wives (AOR = 3.40) and husband’s education being secondary level or higher (AOR = 0.43) were significant. Intervention strategies in India should target young married (aged 25–35 years) and formerly married urban women who are poor, as well as those who have suffered sexual violence from their husbands, and/or are (or whose husbands are) multi-partnered. Empowerment of women is fundamental to HIV/AIDS prevention in India.

Summary

HIV-infected women with sexually transmitted infections (STIs) or bacterial vaginosis (BV) during pregnancy are at increased risk for poor obstetric outcomes. In resource-limited settings, diagnostic testing for STIs and BV is often not available and most pregnant women are managed using syndromic algorithms. As part of a Nairobi perinatal cohort, HIV-1-infected pregnant women were interviewed and samples were collected for STIs and BV testing. Diagnostic accuracy of STIs and BV by syndromic algorithms was evaluated with comparison to the reference standard. Among 441 women, prevalence of BV was 37%, trichomoniasis 16%, chlamydia 4%, syphilis 3% and gonorrhoea 2%. Significantly more women with STIs were aged 21-years-old, had not attended secondary school and had a history of STIs. Syndromic diagnosis of STIs and BV demonstrated a sensitivity of 45% and 57%, and positive predictive value of 30% and 42%, respectively. Among these HIV-infected, pregnant women, STIs and vaginal infections were common and syndromic diagnosis was insensitive, resulting in missed opportunities to intervene and improve infant and maternal health.