We investigated depression in relationship to sexual risk behavior with primary partners among HIVclients in Uganda.
Baseline data were analyzed from a cohort of clients starting ART. The Patient Health Questionnaire (PHQ-9) was used to classify depressive severity (none, minor and major depression) and symptom type (cognitive and somatic). Condom use was assessed over the past 6 months and during the last episode of sexual intercourse.
386 participants had a primary sex partner, with whom 41.6% always used condoms during sex over the past 6 months, and 62.4% during last sex. Use of a condom during last sex was associated with having no depression and lower PHQ-9 total and cognitive and somatic subscale scores in bivariate analyses; most of these relationships were marginally significant for sex over the past 6 months. Controlling for demographics, HIV disclosure and partner HIV status, only minor depression was associated with unprotected sex.
Depressive symptoms, even if not a clinical disorder, warrant early detection and treatment for promoting HIV prevention among HIV-affected couples.
depression; HIV; Uganda; sexual risk behavior; condom use
HIV facilitates an increase in human papillomavirus (HPV) associated conditions. HIV-positive men living in a substance use context in Los Angeles were recruited using Respondent Driven Sampling, completed a questionnaire and had biological samples including an anal HPV swab taken. 316 evaluable men were enrolled in the study. The prevalence of all HPV, high-risk (HR) infection, and multiple type infection was highest for men who have sex with men (MSM) (93.9%, 64.6%, 29.7% respectively). When all HPV and HR-HPV prevalence in all men was stratified by age, the youngest group had 100% and 68.2% prevalence respectively with similarly high rates maintained up to 49 years. The individual’s use of alcohol, marijuana, cocaine, methamphetamine or heroin was not significantly associated with anal HPV isolation. In this marginalized population, high anal HPV and HR-HPV prevalence rates over a wide age range may increase the individual’s risk for anal dysplasia and anal cancer.
human papillomavirus (HPV); substance use; anal; HIV; men who have sex with men (MSM)
Negotiation for condom use by female sex workers (FSWs) with their male clients can enhance condom use. A cross-sectional study was conducted among 1395 FSWs; 439 from two brothels, 442 from 30 hotels, and 514 from streets of two cities in Bangladesh to determine the predictors of condom use negotiation. Consistent condom use rates in the seven days prior to interview were reported to be 16.2%, 21.7%, and 4.5% among the brothel, hotel, and street based FSWs respectively. Overall, 28.1% of FSWs negotiated for condom use with their clients. Participation in behaviour change communication (BCC) programmes (AOR, 1.5; 95% CI, 1.2.–2.0), and self-perceived risk of HIV infection (AOR, 1.8 95% CI, 1.6–2.1) were positive predictors for condom negotiation. Compared to the hotel based FSWs, street (AOR, 0.6; 95% CI, 0.4–0.9), and brothel based FSWs (AOR, 0.7; 95% CI, 0.5–0.9) were less likely to negotiate for condom use. FSWs in Bangladesh are at high risk for STI/HIV infection because of low overall negotiation for condom use. Participation in BCC programmes had positive effect on condom negotiation by FSWs, and should be strengthened in commercial sex venues.
Condom use negotiation; Female sex workers; Bangladesh
Adolescents are at high risk for HIV acquisition, and thus need to be included in HIV vaccine trials. In preparation for inclusion of adolescents in HIV vaccine trials in an urban community in Cape Town with a high antenatal HIV prevalence, the study assessed the attitudes towards the inclusion of adolescents in HIV vaccine trials. A total of 18 focus group discussions were conducted using a semistructured interview guide. The participants (n = 200) were adolescents, young adults, parents and other key informants. Participants from all groups welcomed the inclusion of adolescents in HIV vaccine trials due to their high-risk status. There were, however, concerns about sexual disinhibition, fear of side-effects, fear of HIV testing and disclosure of HIV status, mistrust of nurses and clinics. The study highlighted a number of ethical and social issues that need to be addressed before the trials.
HIV vaccine trials; adolescents; community consultation; South Africa
Adaptive immunity requires antigenic priming of the lymphatic system. As lymphatic tissue is abundant in the oropharynx, oral sex could lead to effective immune stimulation and prevent pelvic inflammatory disease (PID).
To determine whether oral sex could be a protective factor for PID.
The relationship between self-reported oral sex and endometritis was analysed among 619 women with clinically suspected PID who participated in the PID Evaluation and Clinical Health (PEACH) study.
Nearly one quarter of participants reported oral sex in the past 4 weeks. These women also reported a higher number of sexual partners, a new partner within the past 4 weeks, and a higher frequency of sexual intercourse (all p< 0.03). They were more likely to smoke (p<0.0001) and use alcohol (p<0.004) and recreational drugs (p<0.02). Participants reporting oral sex were significantly less likely to be black or to have a positive test for Neisseria gonorrhoeae (7.8% vs 21.6%, p= 0.001).
Women who disclosed oral sex were significantly less likely to have endometritis after adjusting for race, number of partners, recent new partner, smoking, alcohol use, and drug use (adjusted OR 0.5 (0.3 – 0.8)).
This is the first paper showing a negative association between oral sex and endometritis. This may be mediated by a protective immune response in the genital tract following priming in the pharynx. This hypothesis needs to be tested in further studies.
Research on HIV infection and sexual behaviour in sub-Saharan Africa typically focuses on individuals aged 15-49 under the assumption that both become less relevant for older individuals. We test this assumption using data from rural Malawi to compare sexual behaviour and HIV infection for individuals aged 15-49 with individuals aged 50-64 and 65+. Although general declines with age were observed, levels of sexual activity and HIV remained considerable: 26.7% and 73.8% of women and men aged 65+ reported having sex in the last year; men's average number of sexual partners remained above 1; and HIV prevalence is significantly higher for men aged 50-64 (8.9%) than men aged 15-49 (4.1%). We conclude that older populations are relevant to studies of sexual behaviour and HIV risk. Their importance is likely to increase as access to ARVs in Africa increases. We recommend inclusion of adults over 49 in African HIV/AIDS research and prevention efforts.
We assessed prevalence and factors associated with hepatitis B in a cross-section of HIV-infected primary care and anti-natal clinic patients in South Africa and evaluated a rapid hepatitis B surface antigen (HBsAg) assay. We enrolled 998 patients; 88% were women, median age was 29 years, and median CD4 count was 354 cells/mm3. HBsAg ELISA, anti-hepatitis B core (HBc) antibodies, and hepatitis C virus antibody were positive among 4.2%, 37%, and 0.1% of subjects, respectively. Univariate and multivariate associations were assessed using logistic regression. Anti-HBc antibodies were associated with alcohol use, traditional medicines, and higher CD4. HBsAg positivity was associated with lower CD4. Compared to the HBsAg ELISA, a rapid HBsAg test had a sensitivity of 75.0% and specificity of 99.6%. In conclusion, we identified a moderate prevalence of both HBsAg and anti-HBc. Importantly, we found subjects with HBsAg positivity had lower CD4 counts.
HIV/AIDS; HBV; HBsAg; HCV; rapid test; Africa
We assessed trends in the relative prevalences of HIV-1, HIV-2 and dual HIV-1/HIV-2 infection in 10,321 women attending outpatient clinics in Senegal between 1990 and 2009. The relative prevalence of HIV-1 (defined as the proportion of seropositive subjects having HIV-1) rose sharply from 38% in 1990 until 1993 (P < 0.001), whereupon it continued to rise, but at a slower rate, reaching 72% of HIV infections in 2009. As compared with HIV-1, the relative prevalence of HIV-2 decreased sharply from 54% in 1990 until 1993 (P < 0.001) and continued to decrease at a slower rate through 2009. The relative prevalence of dual infection, as compared with HIV-1, was stable from 1990 to 1993, but decreased slightly thereafter (P < 0.001). These study findings indicate that during the early 1990s, the relative prevalence of HIV-1 increased markedly, while the relative prevalence of HIV-2 decreased and the relative prevalence of dual infection remained stable in Senegal. From 1993 to 2009, the relative prevalence of HIV-1 increased at a slower rate, while the relative prevalences of HIV-2 and dual infection decreased. These results confirm trends in HIV prevalence observed in other West African populations and provide a critical update on HIV transmission risk among women in Senegal.
HIV; epidemiology; HIV-1; HIV-2; trends; seroprevalence; Africa; Senegal; dual infection
This study examined the prevalence and factors associated with Mycoplasma genitalium (MG) infection among HIV-positive women and the association between MG and vaginal HIV-1 RNA shedding. HIV-positive women attending an outpatient clinic in New Orleans, Louisiana, USA, from 2002 to 2005 were examined for a battery of sexually transmitted infections (STIs) and underwent a behavioural survey. A selected subset had a measurement of vaginal shedding analysed. Of the 324 HIV-positive women, 32 (9.9%) were infected with MG. HIV-positive women with MG were more likely to be co-infected with Neisseria gonorrhoeae and Chlamydia trachomatis and to have had ≥1 male sexual partners in the last month. In the subset (n = 164), no differences were found in the presence of detectable vaginal HIV-1 RNA between women infected and not infected with MG (30.8% versus 34.8% shedding; P = 0.69). While MG was a common co-STI in this sample of HIV-positive women, it was not associated with vaginal HIV shedding.
Mycoplasma genitalium; HIV-infected women; vaginal shedding
Professional organizations recommend rescreening chlamydia-infected women. The iwantthekit Internet-screening program offered rescreening opportunities by using iwantthekit. Mailed, home-collected vaginal swabs were tested for chlamydia, gonorrhea, and trichomonas by nucleic acid amplification tests. Demographics and risk behaviors of repeat users were determined from questionnaires. Predictors of repeat users were measured in a matched case–control study. Of 1747 women, 304 (17%), who used iwantthekit, indicated they had used the kit previously. Mean age was 24.7 ± 5.7 year and 69% were African American. Repeat iwantthekit users were more likely to be ≥20 years (OR = 2.10); were more likely to have been treated for a sexually transmitted infection (OR = 2.32); less likely to drink alcohol before sex (OR = 0.63); and to never use condoms (OR = 0.43). Of repeaters, 84.2% had a negative prior test and 15.8% had a positive. At current test, 13.2% were infected. Previous trichomonas was associated with current trichomonas (p < 0.05). The iwantthekit may offer rescreening opportunities for previously infected women.
Chlamydia (Chlamydia trachomatis); sexually transmitted infection; gonorrhea; Neisseria gonorrhoeae; epidemiology; screening; sexual behavior; trichomonas
Despite successes in efforts to integrate HIV testing into routine care in emergency departments, challenges remain. Kiosk-facilitated, directed HIV self-testing offers one novel approach to address logistical challenges.
Emergency department patients, 18–64 years, were recruited to evaluate use of tablet-based-kiosks to guide patients to conduct their own point-of-care HIV tests followed by standard-of-care HIV tests by healthcare workers. Both tests were OraQuick Advance tests.
Of 955 patients approached, 473 (49.5%) consented; 467 completed the test, and 100% had concordant results with healthcare workers. Median age was 41 years, 59.6% were female, 74.8% were African-American, and 19.6% were White. In all, 99.8% of patients believed the self-test was “definitely” or “probably” correct; 91.7% of patients “trusted their results very much”; 99.8% reported “overall” self-testing was “easy or somewhat easy” to perform. Further, 96.9% indicated they would “probably” or “definitely” test themselves at home were the HIV test available for purchase; 25.9% preferred self-testing versus 34.4% who preferred healthcare professional testing (p > 0.05).
Tablet-based kiosk testing proved to be highly feasible, acceptable, and an accurate method of conducting rapid HIV self-testing in this study; however, rates of engagement were moderate. More research will be required to ascertain barriers to increased engagement for self-testing.
Human immunodeficiency virus; screening
This paper assesses the associations between intimate partner violence (IPV) and STIs and sexual risks among HIV-positive female drinkers in St. Petersburg, Russia. Survey and STI data were analyzed from 285 women in HERMITAGE, a secondary prevention study with HIV-positive heavy drinkers. Logistic and Poisson regression analyses assessed associations of IPV with STI and risky sex. Most women (78%) experienced IPV and 19% were STI-positive; 15% sold sex. IPV was not significantly associated with STI, but was with selling sex (AOR=3.56, 95% CI=1.02–12.43). In conclusion, IPV is common and associated with sex trade involvement among Russian HIV-positive female drinkers.
Russia; sex work; substance use; HIV-positive; sexually transmitted infections (STI); intimate partner violence (IPV)
Female entertainment workers (FEWs) in China are at increased risk of HIV and other STIs, but correlates of their risky sexual behavior remain poorly understood. Using data from a series of four surveys, this paper employs repeated measures analysis to identify individual and social correlates of consistent condom use among FEWs in Shanghai. Results reveal that both individual cognitive and social influence factors are statistically significant in their bivariate relationships to consistent condom use with a stable or non-stable partner; only prevention motivation and perceived self-efficacy in condom use remain significant in the multiple regressions. When individual and social correlates are examined together, only peer support for condom use remains a significant and independent correlate of consistent condom use in sex with a non-stable partner. Behavioral intervention is urgently needed and should take a multi-level approach, emphasizing individual prevention motivation and behavioral skills training and promoting peer/social support.
High-risk behavior; sex workers; women; HIV; Asia
The performance characteristics of HIV rapid diagnostic tests (RDTs) vary by test and by population. We assessed five commercial RDTs in Uganda where all but one RDT (Determine; Abbott Laboratories, Germany) performed close to manufacturer’s expectations. Determine had low specificity (85.2%, positive predictive value 67.3%) due to false-positive results with weak-positive bands. Properly trained staff, good quality control programmes and validation of RDTs with laboratories having confirmatory testing capacity may be warranted to assure accuracy in each setting.
HIV; rapid diagnostic testing; Uganda; point of care tests; resource-poor settings
The need for viral load (VL) monitoring of HIV patients receiving antiretroviral therapy (ART) in resource-limited settings (RLS) has become apparent with studies showing the limitations of immunological monitoring. We compared the Abbott m2000 Real-Time (Abbott) HIV-1 assay with the Roche AMPLICOR Monitor v1.5 (Roche) HIV-1 assay over a range of VL concentrations. Three hundred and eleven plasma samples were tested, including 164 samples from patients on ART ≥ six months and 147 from ART-naïve patients. The Roche assay detected ≥400 copies/mL in 158 (50.8%) samples. Of these, Abbott produced 145 (91.8%) detectable results ≥400 copies/mL; 13 (8.2%) samples produced discrepant results. Concordance between the assays for detecting HIV-1 RNA ≥400 copies/mL was 95.8% (298/311). The sensitivity, specificity, positive predictive value and negative predictive value of Abbott to detect HIV-1 RNA ≥400 copies/mL were 91.8%, 100%, 100% and 92.2%, respectively. For the 151 samples with HIV-1 RNA ≥400 copies/mL for both assays, a good linear correlation was found (r = 0.81, P < 0.0001; mean difference, 0.05). The limits of agreement were −0.97 and 1.07 log10 copies/mL (mean ± 2 SD). The Abbott assay performed well in our setting, offering an alternative methodology for HIV-1 VL for laboratories with realtime polymerase chain reaction (PCR) capacity.
HIV-1; viral load; antiretroviral treatment; monitoring; resource-limited; realtime polymerase chain reaction
This study attempted to determine the acceptability of neonatal circumcision in Hispanic expectant and new parents and to explore potential associations with lower acceptability. Overall, we found surprisingly high rates of acceptability in this community that contrasts with the actual low rates of circumcision in Hispanics in the USA. This gap is important since newborn circumcision has been suggested as an additional long-range tool in reducing longstanding ethnic disparities in HIV incidence in the USA. A larger study will be needed to determine what factors are associated with low acceptability and how one might effectively address these concerns in this population.
neonatal circumcision; HIV; STD; Hispanics; patient acceptability
Liver enzyme elevations among patients on antiretroviral therapy (ART) were determined by prospectively evaluating aspartate aminotransferase (AST) data in a cohort of patients in Kampala over 36 months. A proportion of patients had hepatitis B virus (HBV) status determined. Hepatotoxicity was graded I to IV according to the AIDS Clinical Trial Group criteria. Of 546 patients, 377 (69%) were women; overall median baseline CD4+ T-cell was 97/μL (interquartile range [IQR] 20–164). Hepatitis B surface antigen (HBsAg) was detected in 42 (9%) of 470 persons. ART included lamivudine, with either nevirapine and d4T (74%) or efavirenz and AZT (26%). Median (IQR) AST level at baseline was 35 (27, 53 IU/L). Over 36 months, only eight patients had grade III AST elevation. Neither HBsAg nor ART regimen influenced AST levels. Male gender and CD4+ change from baseline were correlated with AST elevation. Patients with HIV/HBV co-infection were not at an increased risk of AST elevation, which occurred uncommonly in this setting.
liver toxicity; AST; antiretroviral therapy; nevirapine
We assessed the potential for anticipated changes in sexual risk-taking behaviour following hypothetical administration of a low-efficacy preventive HIV vaccine. We developed a survey and collected self-reported data from 158 HIV-negative volunteers in a cohort undergoing prescreening for Phase I/II HIV vaccine trials in Soweto. Overall, 22% reported they might use condoms less frequently; 9% reported that they might increase their frequency of sex with casual/anonymous partners; and 55% reported their sexual partners might want to use condoms less frequently knowing they were vaccinated. Multivariate analyses revealed that anticipated decrease in condom use was predicted by poor comprehension and by young age. Individuals may increase their risk-taking behaviour knowing that a vaccine would provide only incomplete protection against HIV transmission. In HIV vaccine trials and future vaccination programmes, education and risk-reduction counselling will be needed for vaccinated individuals and their partners, and mass media education campaigns may be necessary.
HIV risk behaviour; sexual risk behaviour; HIV vaccine trials; vaccination; risk compensation; Africa
Stigma toward people living with HIV is pervasive in China and related to poor service utilization, psychosocial distress, and diminished quality of life. In an effort to identify mechanisms to reduce HIV stigma and its negative consequences, we examined whether social support mediates the relation between enacted stigma and both depressive symptoms and quality of life among 120 HIV outpatients in Beijing, China. Generally, perceived social support was associated with less stigma, less depressive symptomatology, and better quality of life. Using multivariable regression models, we found that social support was a full mediator of the impact of stigma on both depressive symptomatology and quality of life. The findings suggest social support may be an important target of interventions to reduce the impact of stigma on poor psychosocial health outcomes.
Skin and soft tissue infections (SSTIs) occur at higher rates among HIV-infected persons, but current trends and risk factors are largely undefined. We evaluated SSTIs among a prospective cohort of HIV-infected persons during the late HAART era (2006-2010). Of the 1918 HIV-infected persons evaluated, 379 (20%) developed an SSTI during a median of 3.7 years of follow-up; of these,118 (31%) developed at least one recurrent SSTI. The incidence rate of SSTIs was 101 (95% CI 93-109) cases per 1000 PYs, and rates did not significantly change during the study period. Compared to not receiving HAART and having an HIV RNA level ≥1000 copies/ml, patients receiving HAART with an HIV RNA level <1000 copies/ml had a reduced risk of an SSTI (HR 0.64, 95% CI 0.48-0.86, p<0.01). In summary, initial and recurrent SSTIs are common among HIV-infected persons. HIV control is associated with a lower risk of SSTIs.
HIV; Skin and soft tissue infection; SSTI; MRSA; epidemiology; risk factors
To identify factors associated with repeat visits among patients attending a clinic for sexually transmitted infections (STIs) in Kisumu, Kenya, we examined records of clinic visits from March 2009 to May 2010. Multivariable logistic regression identified factors associated with repeat visits occurring >30 days after the initial visit. Among 1473 clients (1296 single-visit individuals versus 177 individuals with repeat visits), the median age was 24 years, 67% were men and 8.6% self-reported being HIV-positive. In adjusted analyses, men with repeat visits were more likely to report ≥2 recent sexual partners (adjusted odds ratio [aOR] = 1.60) and being HIV-positive (aOR = 2.35). They were less likely to have been referred from other health facilities (aOR = 0.14) and more likely to have urethral discharge at their initial visit (aOR = 2.46). Among women, repeat visits were associated with vaginal discharge (aOR = 2.22), but attending the clinic with a partner was protective (aOR = 0.38). The association between sexual risk, HIV positivity and repeat visits among male clients highlights the need to focus intervention efforts on this group. For women, attending with a partner may reflect a decreased risk of re-infection if both partners are treated and counselled together.
Kenya; syndromic management; sexually transmitted infection; repeat visit; re-infection; core transmitters
This study aims to describe and compare the gender-specific prevalence of chlamydia and gonorrhea, sexual behaviors and experiences, and risk factors associated with STIs among migrants vs. rural as well as urban residents in China. Data were abstracted from the Chinese Health and Family Life Survey conducted from 1999 to 2000 which provided a nationally representative adult (ages 20 to 64) sample. STI results were determined using a urine-based technology. Of the samples, the prevalence of chlamydia for migrant women was triple that of rural non-migrant women. Migrants were more likely to engage in STI-associated risk behaviors than non-migrants (e.g., receiving money for sex). Being female was a significant risk factor of STIs among migrants. The high STI prevalence among migrants highlighted the urgent need to implement comprehensive sexual behavior prevention and intervention programs targeting the cultural, social and structural needs for migrants in the city, especially female migrants.
Sexually transmitted infection; Migrants; Prevalence; Risk factors
Men who have sex with men (MSM) in India are a core risk group for HIV. Heavy alcohol consumption is associated with increased sexual risk-taking behaviours in many cultures, in particular among MSM. However, no studies to date have explored alcohol use and HIV risk among MSM in India. MSM in Chennai, India (n = 210) completed an interviewer-administered behavioural and psychosocial assessment. Bivariate and multivariable logistic regression procedures examined behavioural and demographic associations with weekly alcohol consumption. Twenty-eight percent of the sample (n = 58) reported using alcohol at least weekly to the point of being buzzed/intoxicated, which was associated with older age, being married to a woman, being panthi (masculine appearing, predominantly insertive partners) versus kothi (feminine acting/appearing and predominantly receptive partners), weekly tobacco use, unprotected anal sex and unprotected vaginal sex in the three months prior to study enrolment (all P < 0.05). In a multivariable model, unprotected vaginal sex in the previous three months and being married to a women were unique variables associated with weekly alcohol use (all P < 0.01). Further investigation of alcohol use within the context of sexual risk taking is warranted among Indian MSM. Panthis and MSM who are married to women may be particularly likely to benefit from interventions to decrease alcohol intake and concurrent unsafe sex.
men who have sex with men (MSM); alcohol; HIV; sexually transmitted infections (STI); prevention; intervention; India