Hiv testing and counselling for women attending child health clinics: An opportunity for entry to prevent mother-to-child transmission and hiv treatment. Author



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Author: McClelland, R. S.; Hassan, W. M.; Lavreys, L.; Richardson, B. A.; Mandaliya, K.; Ndinya-Achola, J.; Jaoko, W.; Kurth, A. E., and Baeten, J. M.
Source: AIDS. 2006 Oct 3; 20(15):1969-73.
Abstract: Background:

Changes in sexual risk behaviour may occur following HIV-1 infection.


Objective:

To test the hypothesis that HIV-1 seroconversion and disease progression are associated with changes in risk behaviours, using data from a cohort of Kenyan female sex workers (FSWs).


Methods:

HIV-1-seronegative FSWs were enrolled in a prospective cohort study of risk factors for HIV-1 acquisition. At monthly visits, standardized interviews were conducted to assess sexual risk behaviour and HIV-1 serologic testing was performed. Seroconverters were invited to continue with follow-up. Between 1993 and 2004 (when antiretroviral therapy was introduced in the cohort), 265 women seroconverted for HIV-1 (incidence 7.7/100 person-years) and were included in this analysis.


Results:

Unprotected intercourse was reported at 546/2037 (27%) pre-seroconversion visits versus 557/3732 (15%) post-seroconversion visits (P < 0.001). These findings remained significant after adjustment for potential confounding factors [adjusted odds ratio (AOR) 0.69; 95% confidence interval (CI), 0.55-0.86]. Compared with HIV-1-seronegative women, there was a progressive stepwise decrease in unprotected intercourse among HIV-1-seropositive women with CD4 cell counts > or = 500 (AOR, 0.93; 95% CI, 0.62-1.39), 200-499 (AOR, 0.58; 95% CI, 0.41-0.82) and < 200 cells/microl (AOR, 0.45; 95% CI, 0.25-0.82). Decreases in unprotected intercourse reflected increases in both abstinence and 100% condom use. Women also reported fewer partners and fewer episodes of intercourse after HIV-1 seroconversion.


Conclusions:

HIV-1 seroconversion and disease progression were associated with decreases in sexual risk behaviour among Kenyan FSWs.



Vaginal washing and increased risk of HIV-1 acquisition among African women: a 10-year prospective study.
Author: McClelland, R. S.; Lavreys, L.; Hassan, W. M.; Mandaliya, K.; Ndinya-Achola, J. O., and Baeten, J. M.
Source: AIDS. 2006 Jan 9; 20(2):269-73.
Abstract: Background:

No prospective study has examined the risk of HIV-1 acquisition associated with vaginal washing, although intravaginal practices have been identified as potentially important contributors to HIV-1 susceptibility.


Objective:

To evaluate the contribution of vaginal washing to incident HIV-1 infection.


Design: Prospective cohort study.
Methods:

Data were derived from a 10-year study of risk factors for HIV-1 acquisition among 1270 Kenyan female sex workers. Intravaginal practices were ascertained at study enrollment. At monthly follow-up visits, women completed a standardized interview and specimens were collected for diagnosis of HIV-1 and genital tract infections.


Results:

Compared with women who did not perform vaginal washing, there was an increased risk for acquiring HIV-1 among women who used water [adjusted hazard ratio (HR), 2.64; 95% confidence interval (CI), 1.00-6.97] or soap (adjusted HR 3.84; 95% CI, 1.51-9.77) to clean inside the vagina, after adjustment for demographic factors, sexual behavior, and sexually transmitted infections. Furthermore, women who performed vaginal washing with soap or other substances were at higher risk for HIV-1 compared with those who used water alone (adjusted HR, 1.47; 95% CI, 1.02-2.13).


Conclusions:

In populations where vaginal washing is common, this practice may be an important factor promoting the spread of HIV-1. Intervention strategies aimed at modifying intravaginal practices should be evaluated as a possible female-controlled HIV-1 prevention strategy.



Contribution of HIV-1 infection to acquisition of sexually transmitted disease: a 10-year prospective study.
Author: McClelland, R. S.; Lavreys, L.; Katingima, C.; Overbaugh, J.; Chohan, V.; Mandaliya, K.; Ndinya-Achola, J., and Baeten, J. M.
Source: J Infect Dis. 2005 Feb 1; 191(3):333-8.
Abstract: Background:

Sexually transmitted diseases (STDs) enhance human immunodeficiency virus (HIV)-1 susceptibility, but few studies have examined the reciprocal effect of HIV-1 on STD acquisition.


Methods:

Data from a prospective cohort study conducted among female sex workers in Mombasa, Kenya between 1993 and 2003 were used to determine the effect of HIV-1 infection on STD susceptibility. The cohort included 1215 HIV-1-seronegative women who underwent monthly HIV-1 and STD screening, of whom 238 experienced seroconversion to HIV-1 during follow-up. Andersen-Gill proportional-hazards models were used to compare the incidence rates for genital-tract infections (syphilis, genital ulcer disease [GUD], Neisseria gonorrhoeae infection, Chlamydia trachomatis infection, Trichomonas vaginalis infection, vulvovaginal candidiasis, and bacterial vaginosis) in HIV-1-seropositive versus HIV-1-seronegative women, after controlling for sexual behavior and other potential confounding factors.


Results:

HIV-1 infection was associated with a significantly higher incidence of GUD (hazard ratio [HR], 2.8; 95% confidence interval [CI], 2.0-3.9), gonorrhea (HR, 1.6; 95% CI, 1.1-2.2), and vulvovaginal candidiasis (HR, 1.5; 95% CI, 1.3-1.8). The risks of GUD and vulvovaginal candidiasis increased with progressive levels of immunosuppression.


Conclusions:

The increased incidence of genital-tract infections among HIV-1-seropositive women could promote the spread of both HIV-1 and other STDs, particularly in areas where these conditions are highly prevalent.



A prospective study of risk factors for bacterial vaginosis in HIV-1-seronegative African women.
Author: McClelland, R. S.; Richardson, B. A.; Graham, S. M.; Masese, L. N.; Gitau, R.; Lavreys, L.; Mandaliya, K.; Jaoko, W.; Baeten, J. M., and Ndinya-Achola, J. O.
Source: Sex Transm Dis. 2008 Jun; 35(6):617-23.

Abstract: Background:

Bacterial vaginosis (BV) is common and has been associated with increased HIV-1 susceptibility. The objective of this study was to identify risk factors for BV in African women at high risk for acquiring HIV-1.


Methods:

We conducted a prospective study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant women were eligible if they did not have symptoms of abnormal vaginal itching or discharge at the time of enrollment. At monthly follow-up, a vaginal examination and laboratory testing for genital tract infections were performed. Multivariate Andersen-Gill proportional hazards analysis was used to identify correlates of BV.


Results:

Participants completed a median of 378 (interquartile range 350-412) days of follow-up. Compared with women reporting no vaginal washing, those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95% confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98-2.61), and >28 times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of BV. Higher BV incidence was also associated with the use of cloth for intravaginal cleansing (aHR 1.48, 95% CI 1.06-2.08) and with recent unprotected intercourse (aHR 1.75, 95% CI 1.47-2.08). Women using depot medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48-0.73).


Conclusions:

Vaginal washing and unprotected intercourse were associated with increased risk of BV. These findings could help to inform the development of novel vaginal health approaches for HIV-1 risk reduction in women.



Improvement of vaginal health for Kenyan women at risk for acquisition of human immunodeficiency virus type 1: results of a randomized trial.
Author: McClelland, R. S.; Richardson, B. A.; Hassan, W. M.; Chohan, V.; Lavreys, L.; Mandaliya, K.; Kiarie, J.; Jaoko, W.; Ndinya-Achola, J. O.; Baeten, J. M.; Kurth, A. E., and Holmes, K. K.
Source: J Infect Dis. 2008 May 15; 197(10):1361-8.
Abstract: Background:

Vaginal infections are common and have been associated with increased risk for acquisition of human immunodeficiency virus type 1 (HIV-1).


Methods:

We conducted a randomized trial of directly observed oral treatment administered monthly to reduce vaginal infections among Kenyan women at risk for HIV-1 acquisition. A trial intervention of 2 g of metronidazole plus 150 mg of fluconazole was compared with metronidazole placebo plus fluconazole placebo. The primary end points were bacterial vaginosis (BV), vaginal candidiasis, trichomoniasis vaginalis (hereafter, "trichomoniasis"), and colonization with Lactobacillus organisms.


Results:

Of 310 HIV-1-seronegative female sex workers enrolled (155 per arm), 303 were included in the primary end points analysis. A median of 12 follow-up visits per subject were recorded in both study arms (P = .8). Compared with control subjects, women receiving the intervention had fewer episodes of BV (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.49-0.63) and more frequent vaginal colonization with any Lactobacillus species (HR, 1.47; 95% CI, 1.19-1.80) and H(2)O(2)-producing Lactobacillus species (HR, 1.63; 95% CI, 1.16-2.27). The incidences of vaginal candidiasis (HR, 0.84; 95% CI, 0.67-1.04) and trichomoniasis (HR, 0.55; 95% CI, 0.27-1.12) among treated women were less than those among control subjects, but the differences were not statistically significant.


Conclusions:

Periodic presumptive treatment reduced the incidence of BV and promoted colonization with normal vaginal flora. Vaginal health interventions have the potential to provide simple, female-controlled approaches for reducing the risk of HIV-1 acquisition.



Infection with Trichomonas vaginalis increases the risk of HIV-1 acquisition.
Author: McClelland, R. S.; Sangare, L.; Hassan, W. M.; Lavreys, L.; Mandaliya, K.; Kiarie, J.; Ndinya-Achola, J.; Jaoko, W., and Baeten, J. M.
Source: J Infect Dis. 2007 Mar 1; 195(5):698-702.
Abstract: We conducted a prospective study among women in Mombasa, Kenya, to determine whether Trichomonas vaginalis infection was associated with an increased risk of human immunodeficiency virus type 1 (HIV-1) infection. At monthly follow-up visits, laboratory screening for HIV-1 and genital tract infections was conducted. Among 1335 HIV-1-seronegative women monitored for a median of 566 days, there were 806 incident T. vaginalis infections (23.6/100 person-years), and 265 women seroconverted to HIV-1 (7.7/100 person-years). Trichomoniasis was associated with a 1.52-fold (95% confidence interval, 1.04-2.24-fold) increased risk of HIV-1 acquisition after adjustment for potential confounding factors. Treatment and prevention of T. vaginalis infection could reduce HIV-1 risk in women.

Implication of Ariaal sexual mixing on gonorrhea.
Author: McCluskey, C. C.; Roth, E., and van den Driessche, P.
Source: Am J Hum Biol. 2005 May-2005 Jun 30; 17(3):293-301.
Abstract: Recent research on sexual mixing in populations of sub-Saharan Africa raises the question as to whether STDs can persist in these populations without the presence of a core group. A mathematical model is constructed for the spread of gonorrhea among the Ariaal population of Northern Kenya. A formula for the basic reproduction number R(0) (the expected number of secondary infections caused by a single new infective introduced into a susceptible population) is determined for this population in the absence of a core group. Survey data taken in 2003 on sexual behavior from the Ariaal population are used in the model which is formulated for their age-set system including four subpopulations: single and married, female and male. Parameters derived from the data, and other information from sub-Saharan Africa are used to estimate R(0). Results indicate that, even with the elevating effect of the age-set system, the disease should die out since R(0) < 1. Thus, the persistence of gonorrhea in the population must be due to factors not included in the model, for example, a core group of commercial sex workers or concurrent partnerships.

Cross-clade CD8(+) T-cell responses with a preference for the predominant circulating clade.
Author: McKinnon, L. R.; Ball, T. B.; Kimani, J.; Wachihi, C.; Matu, L.; Luo, M.; Embree, J.; Fowke, K. R., and Plummer, F. A.
Source: J Acquir Immune Defic Syndr. 2005 Nov 1; 40(3):245-9.
Abstract: Human immunodeficiency virus (HIV) genetic diversity is a major impediment to the design of a successful vaccine. Even if an HIV vaccine is proven effective, it remains to be seen whether this protection will extend to inter-clade, intra-clade, and recombinant strains. We used recombinant vaccinia-based interferon gamma (IFN) Elispot assays to test the inter-clade crossreactivity of clades A, B, C, and D HIV Env in two cohorts of HIV-infected Kenyans. Despite the tremendous diversity in this HIV protein, a substantial proportion of multi-clade responses were observed. Although these multi-clade responses correlated well with each other in regression analyses, clade A responses were seen at a higher frequency and at greater relative magnitudes in a proportion of these patients, when compared to the other three clades. Epitope mapping indicates CD8(+) T cell recognition of conserved regions of Env, accounting for the high degree of cross-reactivity but not the clade A preference. A better understanding of cross-clade CD8(+) T cell responses to HIV may help to predict whether a successful vaccine could be used to stop geographically and genetically distinct HIV epidemics.

Epitope cross-reactivity frequently differs between central and effector memory HIV-specific CD8+ T cells.
Author: McKinnon, L. R.; Ball, T. B.; Wachihi, C.; McLaren, P. J.; Waruk, J. L.; Mao, X.; Ramdahin, S.; Anzala, A. O.; Kamene, J.; Luo, M.; Fowke, K. R., and Plummer, F. A.
Source: J Immunol. 2007 Mar 15; 178(6):3750-6.
Abstract: HIV diversity may limit the breadth of vaccine coverage due to epitope sequence differences between strains. Although amino acid substitutions within CD8(+) T cell HIV epitopes can result in complete or partial abrogation of responses, this has primarily been demonstrated in effector CD8(+) T cells. In an HIV-infected Kenyan cohort, we demonstrate that the cross-reactivity of HIV epitope variants differs dramatically between overnight IFN-gamma and longer-term proliferation assays. For most epitopes, particular variants (not the index peptide) were preferred in proliferation in the absence of corresponding overnight IFN-gamma responses and in the absence of the variant in the HIV quasispecies. Most proliferating CD8(+) T cells were polyfunctional via cytokine analyses. A trend to positive correlation was observed between proliferation (but not IFN-gamma) and CD4 counts. We present findings relevant to the assessment of HIV vaccine candidates and toward a better understanding of how viral diversity is tolerated by central and effector memory CD8(+) T cells.

Association of hygiene, socioeconomic status, and circumcision with reduced risk of HIV infection among Kenyan men.
Author: Meier, A. S.; Bukusi, E. A.; Cohen, C. R., and Holmes, K. K.
Source: J Acquir Immune Defic Syndr. 2006 Sep; 43(1):117-8.
Abstract: Among Kenyan men recruited as sex partners of women with genital symptoms, 22 of 150 were HIV seropositive. Because male HIV infection and male hygiene were unexpectedly found to be associated with each other, we examined the relationship of 5 hygiene variables with HIV infection in the men in a principal components analysis, controlling for socioeconomic status and other potential confounders. By multivariate analyses, HIV infection in men was not only independently associated with previous illness (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.4-19.1) and inversely associated with being circumcised (OR, 0.12; 95% CI, 0.02-0.91), but also independently associated with a combined measure of hygiene (OR, 0.41; 95% CI, 0.19-0.90).312

The impact of onset controllability on stigmatization and supportive communication goals toward persons with HIV versus lung cancer: a comparison between Kenyan and U.S. participants.
Author: Miller, A. N.; Fellows, K. L., and Kizito, M. N.
Source: Health Commun. 2007; 22(3):207-19.
Abstract: This study examined the impact of controllability of onset (i.e., means of transmission), disease type (HIV and lung cancer), and culture (Kenya and U.S.) on stigmatizing attitudes and goals for supportive communication. Four hundred sixty-four Kenyan students and 526 American students, and 441 Kenyan nonstudents and 591 American nonstudents were randomly assigned to 1 of 12 hypothetical scenario conditions and asked to respond to questions regarding 3 different types of stigmatizing attitudes and 6 types of supportive communication goals with respect to the character in the scenario. Means of transmission had a strong effect on the blame component of stigma, but none on cognitive attitudes and social interaction components. Similarly, although an effect for means of transmission emerged on intention to provide "recognize own responsibility" and "see others' blame" types of support, no effect was evident for most other supportive interaction goals. Although effects for culture were small, Kenyan participants, student and nonstudent alike, were not as quick as American participants to adopt goals of communicating blame in any direction. Implications for measurement of stigma in future research are discussed.

Motivations and methods for self-disclosure of HIV seropositivity in Nairobi, Kenya.
Author: Miller, A. N. and Rubin, D. L.
Source: AIDS Behav. 2007 Sep; 11(5):687-97.
Abstract: This study employed structured interviews with 307 people living with HIV (PLHIVs) in Nairobi, Kenya to investigate their serostatus disclosure with respect to four types of relationships in their lives: partners, friends, family members, and religious leaders/clergy. Regarding motivations for disclosure, it was found that a sense of duty and seeking material support motivated disclosure to family and partners, fear of loss of confidentiality inhibited disclosure to friends, and the need for advice encouraged disclosure to religious leaders. The method of disclosure most frequently mentioned was direct, with males less likely than females to use direct methods when disclosing to spouses or partners. Intermediated disclosure was common in partner/spouse relationships with around one-third of partners preferring to disclose through a third party. Methods used to disclose as well as reasons for doing so varied by relationship type

HIV infection does not disproportionately affect the poorer in sub-Saharan Africa.
Author: Mishra, V.; Assche, S. B.; Greener, R.; Vaessen, M.; Hong, R.; Ghys, P. D.; Boerma, J. T.; Van Assche, A.; Khan, S., and Rutstein, S.
Source: AIDS. 2007 Nov; 21 Suppl 7:S17-28.
Abstract: Background:

Wealthier populations do better than poorer ones on most measures of health status, including nutrition, morbidity and mortality, and healthcare utilization.


Objectives:

This study examines the association between household wealth status and HIV serostatus to identify what characteristics and behaviours are associated with HIV infection, and the role of confounding factors such as place of residence and other risk factors.


Methods:

Data are from eight national surveys in sub-Saharan Africa (Kenya, Ghana, Burkina Faso, Cameroon, Tanzania, Lesotho, Malawi, and Uganda) conducted during 2003-2005. Dried blood spot samples were collected and tested for HIV, following internationally accepted ethical standards and laboratory procedures. The association between household wealth (measured by an index based on household ownership of durable assets and other amenities) and HIV serostatus is examined using both descriptive and multivariate statistical methods.


Results:

In all eight countries, adults in the wealthiest quintiles have a higher prevalence of HIV than those in the poorer quintiles. Prevalence increases monotonically with wealth in most cases. Similarly for cohabiting couples, the likelihood that one or both partners is HIV infected increases with wealth. The positive association between wealth and HIV prevalence is only partly explained by an association of wealth with other underlying factors, such as place of residence and education, and by differences in sexual behaviour, such as multiple sex partners, condom use, and male circumcision.


Conclusion:

In sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of association with poverty as most other diseases. HIV programmes should also focus on the wealthier segments of the population.



Comparison of HIV prevalence estimates from antenatal care surveillance and population-based surveys in sub-Saharan Africa.
Author: Montana, L. S.; Mishra, V., and Hong, R.
Source: Sex Transm Infect. 2008 Aug; 84 Suppl 1:i78-i84.
Abstract: Objective:

To compare HIV seroprevalence estimates obtained from antenatal care (ANC) sentinel surveillance surveys in Ethiopia, Kenya, Malawi, Tanzania and Uganda with those from population-based demographic and health surveys (DHS) and AIDS indicator surveys (AIS).


Methods:

Geographical information system methods were used to map ANC surveillance sites and DHS/AIS survey clusters within a 15-km radius of the ANC sites. National DHS/AIS HIV prevalence estimates for women and men were compared with national prevalence estimates from ANC surveillance. DHS/AIS HIV prevalence estimates for women and men residing within 15 km of ANC sites were compared with those from ANC surveillance. For women, these comparisons were also stratified by current pregnancy status, experience of recent childbirth and receiving ANC for the last birth.


Results:

In four of the five countries, national DHS/AIS estimates of HIV prevalence were lower than the ANC surveillance estimates. Comparing women and men in the catchment areas of the ANC sites, the DHS/AIS estimates were similar to ANC surveillance estimates. DHS/AIS estimates for men residing in the catchment areas of ANC sites were much lower than ANC surveillance estimates for women in all cases. ANC estimates were higher for younger women than DHS/AIS estimates for women in ANC catchment areas, but lower at older ages. In all cases, urban prevalence was higher than rural prevalence but there were no consistent patterns by education.


Conclusions:

ANC surveillance surveys tend to overestimate HIV prevalence compared to prevalence among women in the general population in DHS/AIS surveys. However, the ANC and DHS/AIS estimates are similar when restricted to women and men, or to women only, residing in catchment areas of ANC sites. Patterns by age and urban/rural residence suggest possible bias in the ANC estimates.



Estimation of the sexual transmission of HIV in Kenya and Uganda on the trans-Africa highway: the continuing role for prevention in high risk groups.
Author: Morris, C. N. and Ferguson, A. G.
Source: Sex Transm Infect. 2006 Oct; 82(5):368-71.
Abstract: Objective:

To explore the effect of transactional sex on the trans-Africa highway from Mombasa-Kampala in contributing to the HIV epidemic and the impact that an effective prevention intervention could have.



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