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1.  Risk Factors for Delayed Entrance into Care after Diagnosis among Patients with Late-Stage HIV Disease in Southern Vietnam 
PLoS ONE  2014;9(10):e108939.
We surveyed HIV patients with late-stage disease in southern Vietnam to determine if barriers to access and service quality resulted in late HIV testing and delays from initial diagnosis to entry into HIV care.
196 adult patients at public HIV clinics with CD4 counts less than 250 cells/mm3 completed a standardized questionnaire. We used multivariate analysis to determine risk factors for delayed entry into care, defined as >3 months time from diagnosis to registration.
Common reasons for delayed testing were feeling healthy (71%), fear of stigma and discrimination in the community (43%), time conflicts with work or school (31%), did not want to know if infected (30%), and fear of lack of confidentiality (27%). Forty-five percent of participants delayed entry into care with a median CD4 count of 65 cells/mm3. The most common reasons for delayed entry were feeling healthy (51%), fear of stigma and discrimination in the community (41%), time conflicts with work or school (33%), and fear of lack of confidentiality (26%). Independent predictors for delayed entry were feeling healthy (aOR 3.7, 95% CI 1.5–9.1), first positive HIV test at other site (aOR 2.9, CI 1.2–7.1), history of injection drug use (IDU) (aOR 2.9, 95% CI 1.1–7.9), work/school conflicts (aOR 4.3, 95% CI 1.7–10.8), prior registration at another clinic (aOR 77.4, 95% CI 8.6–697), detention or imprisonment (aOR 10.3, 95% CI 1.8–58.2), and perceived distance to clinic (aOR 3.7, 95% CI 1.0–13.7).
Delayed entry into HIV care in Vietnam is common and poses a significant challenge to preventing AIDS and opportunistic infections, decreasing mortality, and reducing HIV transmission. Improved linkages between testing and care are needed, particularly for patients who feel healthy, as well as incarcerated and drug-using populations who may face structural and social barriers to accessing care.
PMCID: PMC4199603  PMID: 25330196
2.  HIV, hepatitis B, and hepatitis C prevalence and associated risk behaviors among female sex workers in three Afghan cities 
AIDS (London, England)  2010;24(0 2):S69-S75.
To assess prevalence of HIV, syphilis, and hepatitis B (HBV) and C virus and associated risk behaviors among female sex workers (FSWs) in three Afghan cities. Design: Cross-sectional prevalence assessment.
Consented FSWs from Jalalabad, Kabul, and Mazar-i-Sharif completed an interviewer-administered questionnaire, pre and post-test counseling, and rapid and confirmatory testing for HIV, HCV, HBV and syphilis. Logistic regression was used to detect correlates associated with HBV infection.
Of 520 participants, median age and age of initiating sex work were 29 and 23 years, respectively, and median number of monthly clients was 12. Few FSWs reported ever having used illicit drugs (6.9%) or alcohol (4.7%). Demographic and risk behaviors varied significantly by enrollment site, with Kabul FSWs more likely to report sexually-transmitted infection (STI) symptoms, longer sex work duration, and sex work in other cities. Prevalence of HIV was 0.19%, HCV was 1.92%, and HBV was 6.54%, with no cases of syphilis detected. HBV was independently associated with ≥12 clients monthly (AOR=3.15, 95% CI: 1.38 – 7.17), ever using alcohol (AOR=2.61, 95% CI: 1.45 – 4.69), anal sex (AOR=2.42, 95% CI: 1.15 – 5.08), and having children (AOR=2.12, 95% CI: 1.72 – 2.63) in site-controlled multivariate analysis.
While prevalence of HIV, HCV, and syphilis is currently low in these three Afghan cities, risky sexual practices were common and associated with HBV. Programming inclusive of voluntary testing for HIV, viral hepatitis, and STIs, hepatitis vaccination, substance abuse prevention, and condom promotion for both FSWs and clients should be pursued in Afghanistan.
PMCID: PMC3650731  PMID: 20610952
HIV; hepatitis B; female sex worker; Afghanistan
3.  Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits 
BMC Infectious Diseases  2012;12:196.
Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits.
A cross-sectional sample of male ANA recruits aged 18–35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates.
Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 – 0.93), and HCV (0.82%, 95% CI: 0.58 – 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 – 2.05).
Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.
PMCID: PMC3482585  PMID: 22909128
Afghanistan; Military populations; HIV; Sexual risk behavior; Drug use
4.  Awareness and Interest in Intrauterine Contraceptive Device Use among HIV-Positive Women in Cape Town, South Africa 
Objective. To assess awareness of and interest in intrauterine contraceptive device (IUCD) use among HIV-positive women in Cape Town, South Africa. Design. Cross-sectional survey. Methods. HIV-positive women aged 18 through 45 years presenting for care at a primary health care clinic in Cape Town, South Africa participated in this study. Consented participants completed a staff-administered questionnaire in a private setting. Descriptive statistics were generated. Comparisons between demographic and reproductive health-related variables and IUCD awareness and interest were performed with multiple logistic regression. Analyses for IUCD interest excluded women with prior surgical sterilization. Results. Of 277 HIV-positive women, 37% were aware of the IUCD; awareness was independently associated with greater age (adjusted odds ratio (AOR) = 1.15, 95%; confidence interval (CI): 1.10–1.20) and not switching contraceptive methods in the last year (AOR = 2.45, 95% CI: 1.03–5.83). Following an IUCD information session, 86% of women (n = 206/240) were interested in IUCD use. IUCD interest was inversely associated with age (AOR = 0.91, 95% CI: 0.86–0.97) and marginally positively associated with current menstrual bleeding pattern complaints (AOR = 2.14, 95% CI: 0.98–4.68). Conclusions. Despite low levels of method awareness, HIV-positive women in this setting are frequently interested in IUCD use, indicating need for programming to expand method access.
PMCID: PMC3388580  PMID: 22778537
5.  Contraceptive Utilization and Pregnancy Termination Among Female Sex Workers in Afghanistan 
Journal of Women's Health  2010;19(11):2057-2062.
To determine the prevalence and correlates of prior pregnancy termination and unmet need for contraception among female sex workers (FSWs) in Afghanistan.
FSWs in Jalalabad, Kabul, and Mazar-i-Sharif were recruited between June 2006 and December 2007 through outreach programs. Participants completed an interviewer-administered survey describing demographics, behaviors associated with risk of sexually transmitted infections (STIs) and unplanned pregnancy, and medical history. Correlates of prior pregnancy termination and current unmet need for contraception were assessed with logistic regression analysis, controlling for site.
Of 520 FSWs, most (82.3%) had been pregnant at least once (mean 4.9 ± 2.7, range 1–17), among whom unplanned pregnancy (36.9%) and termination (33.2%) were common. Jalalabad participants were more likely to report both prior unplanned pregnancy (60.6% vs. 48.3% in Kabul or 20.7% in Mazar, p < 0.001) and prior termination (54.9% vs. 31.8% in Kabul or 26.8% in Mazar, p < 0.001). Most FSWs (90.0%) stated pregnancy was not currently desirable, and 85.2% were using contraception. Unmet need for contraception (14.7% of participants) was positively associated with having sold sex outside their city of residence (adjusted odds ratio [AOR] 1.88, 95% confidence interval [CI] 1.28-2.77) and inversely associated with illicit drug use (AOR 0.41, 95% CI 0.31-0.53).
Although FSWs in Afghanistan report high rates of contraceptive use, unplanned pregnancy is common. Reproductive health services should be included in programming for FSWs to reduce unplanned pregnancies and to reduce HIV/STI risks.
PMCID: PMC2971650  PMID: 20879869
6.  Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: A cross-sectional assessment 
A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population.
IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use.
Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58 - 22.38 and AOR = 2.33, 95% CI: 1.38 - 3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22 - 5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16 - 2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06 - 2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08 - 1.82).
HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.
PMCID: PMC3180253  PMID: 21867518
injection drug user; Afghanistan; HIV; hepatitis C; harm reduction
7.  Distinct Circulating Recombinant HIV-1 Strains Among Injecting Drug Users and Sex Workers in Afghanistan 
Little information is available regarding a circulating HIV genotype among high-risk groups in Afghanistan; we describe HIV genotypes among injecting drug users (IDUs) and sex workers (SWs) in four Afghan cities. Participants completed behavioral questionnaires and HIV testing. Western blot–confirmed specimens had peripheral mononuclear blood cells isolated for genotyping. Analysis of recombinants was done by bootscanning and manual sequence alignment. The single SW sample harbored a CRF01_AE strain. Of 10 IDUs available for analysis, all were CRF35_AD and from Hirat. Analyzed subregions (gag p17 and env C1-C5) revealed close homology between the Hirat specimens. Three distinct subclusters comprising two or three strains were identified, whereas two other strains were generally equidistant from previously identified Kabul strains. Results suggest that the nascent HIV epidemic among IDUs in Hirat is largely, if not entirely, subtype CRF35_AD, and the close homology suggests recent infection; harm reduction should be supported to avert further transmission.
PMCID: PMC2933162  PMID: 20438383
8.  Cross-sectional analysis of factors associated with prior contraceptive use among hospitalized obstetric patients in Kabul, Afghanistan 
Contraception  2008;78(3):249-256.
This study was conducted to assess prevalence and correlates of prior contraceptive use among hospitalized obstetric patients in Kabul, Afghanistan.
Study design
Medically-eligible (e.g., conditions not requiring urgent medical attention, such as eclampsia, or not imminently delivering (dilation ≥8 cm)) obstetric patients admitted to three Kabul public hospitals were consecutively enrolled in this cross-sectional study. An interviewer-administered questionnaire assessed demographic information, health utilization history, including prior contraceptive use, and intent to use contraception. Correlates of prior contraceptive use were determined with logistic regression.
Of 4452 participants, the mean age was 25.7 years (SD±5.7 years), 66.4% repoited pregnancy prior to the presenting gestation, 88.4% had ≥1 prenatal care visit, and 82.4% reported the current pregnancy was desired. Most (67.4%) had no formal education. One-fifth (22.8%) reported using contraception prior to this pregnancy. Among women with any pregnancy prior to the current gestation (98.6% of prior users), prior contraceptive use was independently associated with having lived outside Afghanistan in the last five years (AOR=1.35, 95% CI: 1.12 – 1.63), having a skilled attendant at the last birth (AOR=1.35, 95% CI: 1.07 – 1.71), having a greater number of living children (AOR=1.30, 95% CI: 1.20 – 1.41), longer mean birth interval (years) (AOR=1.21, 95% CI: 1.11 – 1.38), and higher educational level (AOR=1.16, 95% CI: 1.09 – 1.22). Immediate desire for another pregnancy and spousal disapproval were the most common reasons for not utilizing contraception.
Prior contraceptive use is low among women in Kabul, Afghanistan, particularly for younger, less educated women. Programming in Kabul to strengthen postpartum contraceptive counseling should address barriers to contraceptive use, including immediate desire for pregnancy and spousal attitudes.
PMCID: PMC2585412  PMID: 18692617
Afghanistan; contraception; birth-spacing; contraceptive prevalence; intrapartum; population
9.  Seroprevalence and correlates of HIV, syphilis, and hepatitis B and C virus among intrapartum patients in Kabul, Afghanistan 
Little current information is available for prevalence of vertically-transmitted infections among the Afghan population. The purpose of this study is to determine prevalence and correlates of human immunodeficiency virus (HIV), syphilis, and hepatitis B and C infection among obstetric patients and model hepatitis B vaccination approaches in Kabul, Afghanistan.
This cross-sectional study was conducted at three government maternity hospitals in Kabul, Afghanistan from June through September, 2006. Consecutively-enrolled participants completed an interviewer-administered survey and whole blood rapid testing with serum confirmation for antibodies to HIV, T. pallidum, and HCV, and HBsAg. Descriptive data and prevalence of infection were calculated, with logistic regression used to identify correlates of HBV infection. Modeling was performed to determine impact of current and birth dose vaccination strategies on HBV morbidity and mortality.
Among 4452 women, prevalence of HBsAg was 1.53% (95% CI: 1.18 – 1.94) and anti-HCV was 0.31% (95% CI: 0.17 – 0.53). No cases of HIV or syphilis were detected. In univariate analysis, HBsAg was associated with husband's level of education (OR = 1.13, 95% CI: 1.01 – 1.26). Modeling indicated that introduction of birth dose vaccination would not significantly reduce hepatitis-related morbidity or mortality for the measured HBsAg prevalence.
Intrapartum whole blood rapid testing for HIV, syphilis, HBV, and HCV was acceptable to patients in Afghanistan. Though HBsAg prevalence is relatively low, periodic assessments should be performed to determine birth dose vaccination recommendations for this setting.
PMCID: PMC2557011  PMID: 18798996
10.  HIV, Hepatitis C, and Hepatitis B Infections and Associated Risk Behavior in Injection Drug Users, Kabul, Afghanistan 
Emerging Infectious Diseases  2007;13(9):1327-1331.
Behavior of injection drug users increases the risk for an HIV epidemic.
Limited prevalence data for HIV, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) exist for Afghanistan. We studied a cross-sectional sample of adult injection drug users (IDUs) in Kabul, Afghanistan, from June 2005 through June 2006. Study participants completed interviewer-administered questionnaires and underwent testing for HIV, antibody to HCV, and HBsAg. Overall prevalences of HIV, HCV, and HBsAg were 3.0% (95% confidence interval [CI] 1.7%–5.1%), 36.6% (95% CI 32.2%–41.0%), and 6.5% (95% CI 4.2%–8.7%), respectively (N = 464). Among male IDUs (n = 463), risky behavior, including sharing syringes (50.4%), paying women for sex (76.2%), and having sex with men or boys (28.3%), were common. Needle sharing, injecting for >3 years, and receiving injections from nonmedical providers were independently associated with increased risk for HCV infection. The high prevalence of risky behavior indicate that Kabul is at risk for an HIV epidemic. Scale-up of harm-reducing interventions is urgently needed.
PMCID: PMC2857281  PMID: 18252103
HIV; Afghanistan; injection drug users; hepatitis C; hepatitis B; needle sharing; research
11.  Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A cross-sectional comparison of former refugees to those remaining during conflict 
Little is known about human immunodeficiency virus (HIV) awareness among Afghan injecting drug users (IDUs), many of whom initiated injecting as refugees. We explored whether differences in HIV awareness and knowledge exist between Afghan IDUs who were refugees compared to those never having left Afghanistan.
A convenience sample of IDUs in Kabul, Afghanistan was recruited into a cross-sectional study through street outreach over a one year period beginning in 2005. Participants completed an interviewer-administered questionnaire and underwent voluntary counseling and testing for HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibody. Differences in HIV awareness and specific HIV knowledge between IDU who lived outside the country in the last decade versus those who had not were assessed with logistic regression.
Of 464 IDUs, 463 (99%) were male; median age and age at first injection were 29 and 25 years, respectively. Most (86.4%) had lived or worked outside the country in the past ten years. Awareness of HIV was reported by 46.1%; those having been outside the country in the last decade were significantly more likely to have heard of HIV (48.3% vs. 31.7%; OR = 2.00, 95% CI: 1.14 – 3.53). However, of those aware of HIV, only 38.3% could name three correct transmission routes; specific HIV knowledge was not significantly associated with residence outside the country.
Accurate HIV knowledge among Afghan IDUs is low, though former refugees had greater HIV awareness. Reported high-risk injecting behavior was not significantly different between IDU that were refugees and those that did not leave the country, indicating that all Afghan IDU should receive targeted prevention programming.
PMCID: PMC1847809  PMID: 17411457
13.  Drug use and harm reduction in Afghanistan 
Opium has been cultivated in Afghanistan since 1100 A.D., although production has steadily increased since 1979. Currently, Afghanistan produces three-quarters of the global opium supply, with injection drug use and HIV currently following the opium trade route through Central Asia. Although systematic studies are lacking, heroin use appears to be on the rise in Afghanistan. The purpose of this paper is to briefly provide historical background and current statistics for drug production and use in Afghanistan, to discuss the new government's policies towards problem drug use and available rehabilitation programs, and to assess Afghan harm reduction needs with consideration of regional trends.
PMCID: PMC1262742  PMID: 16146577

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