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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Association of HIV infection with poor genital hygiene and medical treatment for prior serious illness suggests latrogenic transmission. Authors' reply [letter]. JAIDS.
Author: Magaret, A. S.; . = Bukusi EA; Cohen CR, and Holmes KK.
Source: Journal of Acquired Immune Deficiency Syndromes. 2007 Mar 1; 44(3):366.
Abstract: Brody and colleagues provide a useful critique of our article that questions whether causation can be attributed to the detected association between genital hygiene and HIV-1 status among Kenyan males participating in a study of bacterial vaginosis (BV) in their female partners. They point to a potential confounder, injection treatment for illness, which they argue could possibly explain the associations of "ever treated for serious illness" and the hygiene measure with HIV-1 seropositivity. Previous studies from our group have indeed implicated penicillin injections as risk factors for hepatitis B virus infection and for human T-lymphotropic virus type 1 (HTLV-1) infection but not for HIV infection in female sex workers in another developing country setting. With regard to the issue of causation, we had stated in our results that "the decreased odds of HIV-1 infection associated with large values of hygiene component 2 suggest an inverse association between good hygiene and prevalence of HIV-1." In the discussion section, we further stressed our unwillingness to assert causation, citing the cross--sectional nature of our study as a limitation. Considering injection for illness as a plausible confounder and source of HIV-1 acquisition, we can provide additional clarification about the variables presented. Twenty-one of 150 male participants had been previously treated for a "serious illness," a self-described condition, which was further specified by respondents: 8 had had tuberculosis (TB); 2 each had had road accidents and ulcers; and 1 each had had allergies, asthma, arthritis, chronic bronchitis, diabetes, hypertension, phimosis, pneumonia, and typhoid. In Nairobi, injection treatment is often used for some but not all of these conditions. It is plausible that some of the association of treatment for a serious illness could be attributable to iatrogenic transmission. The chronologic relation of HIV-1 infection and these illnesses (as with hygiene practices) is not known; however, it is quite likely that the most common of the serious illnesses reported-TB-and perhaps certain others simply reflect complications of HIV infection. (excerpt)

Quid pro quo: a journalistic look at NGO-media interaction in Africa.
Author: Malan, M.
Source: Brown Journal of World Affairs. 2005 Winter-2006 Spring; 11(2):173-184.
Abstract: On the opening day of the fifteenth International Conference on HIV/AIDS, South Africa's Health Minister, Dr. Manto Tshabala-Msimang, addressed journalists and compatriots at the country's booth. She said, "There is increasing evidence suggesting that Nevirapine [a cost-effective drug used to prevent mother-to-child-transmission of HIV] creates resistance in HIV-positive mothers and their babies, making its use unsafe if they later want to use the drug as an anti-retroviral." The Minister referred to a preliminary study to support her statements. This statement, along with an announcement by the country's Medicines Control Council (MCC) that it is considering the deregistration of single-dose Nevirapine, raised eyebrows. Two years prior to the conference, South Africa's highest court had ordered Dr. Tshabalala-Msimang to make drug available, free of charge, to HIV-positive pregnant women and their babies. The Minister has displayed resistance to the order ever since. (excerpt)

Prevalence of dyslipidemia and dysglycaemia in HIV infected patients.
Author: Manuthu, E. M.; Joshi, M. D.; Lule, G. N., and Karari, E.
Source: East Afr Med J. 2008 Jan; 85(1):10-7.
Abstract: Background:

Highly active antiretroviral therapy (HAART) has dramatically reduced AIDS morbidity and mortality, however long-term metabolic consequences including dysglycaemia and dyslipidemia have raised concern regarding accelerated cardiovascular disease risk.


Objective:

To determine the period prevalence of dyslipidemia and dysglycaemia in HIV-infected patients.


Design: Cross-sectional comparative group study.
Setting: Kenyatta National Hospital, a tertiary HIV dedicated out-patient facility.
Subjects: Consecutive HIV- positive adult patients.
Main outcome measures:

Dyslipidemia: presence of raised total or LDL cholesterol or low HDL cholesterol, or raised triglycerides. Dysglycaemia: presence of impaired fasting glucose or impaired glucose tolerance, or diabetes mellitus.


Results:

Between January and April 2006, out of 342 screened patients, 295 were recruited and 58% were females. One hundred and thirty four (45%) were on HAART, 82% of whom were on stavudine, lamivudine and either nevirapine or efavirenz. Overall prevalence of dyslipidemiawas 63.1% and dysglycaemia was 20.7%. High total cholesterol occurred in 39.2% of HAART and 10.0% HAART naive patients (p<0.0001, OR 5.18, CI 3.11-10.86), whereas high LDL cholesterol occurred in 40.8% and in 11.2% respectively (p<0.0001, OR 5.43, CI 2.973-9.917). HDL levels were low in 14.6% and 51.3% among HAART and HAART naive patients, respectively, (p<0.0001, OR 0.16, CI 0.091-0.29) while high triglycerides occurred in 25.6% and 22.5% respectively (p=0.541 OR 1.184 CI 0.688-2.037). Among patients on HAART compared to HAART naive patients, diabetes was found in 1.5% against 1.2% (p=0.85), impaired fasting in 2.2% against 0.6% (p=0.30) and impaired glucose tolerance in 16.4% against 21.1% (p=0.22), respectively.


Conclusions:

HIV- infected patients demonstrated a high prevalence of dyslipidemia. HAART use was associated with high levels of total, and LDL cholesterol and high triglyceride levels, an established athrogenic lipid profile. However, HAART was not associated with low HDL cholesterol and had no significant effect on dysglycaemia.



Using mass media campaigns to promote voluntary counseling and HIV-testing services in Kenya.
Author: Marum, E.; Morgan, G.; Hightower, A.; Ngare, C., and Taegtmeyer, M.
Source: AIDS. 2008 Oct 1; 22(15):2019-24.
Abstract: Background:

Kenya, a country with high HIV prevalence, has seen a rapid scale-up of voluntary counseling and HIV-testing (VCT) services from three sites in 2000 to 585 by June 2005. From 2002 onwards, services were promoted by a four-phase professionally designed mass media campaign.


Objective:

To assess the impact of a mass media campaign on VCT services. DESIGN: Observational data from client records.


Methods:

VCT client data from 131 voluntary counseling and testing sites were included. Descriptive statistics and Poisson regression were used to assess the impact of campaign phases.


Results:

Client records (381,160) from 131 sites were analyzed. A linear increase in new sites and an exponential increase in client utilization were observed. Regression analysis revealed that the first phase of the campaign increased attendance by 28.5% (95% confidence interval = 15.9, 42.5%) and the fourth by 42.5% (95% confidence interval = 28.4, 64.1%). These two phases, which directly mentioned HIV, had more impact on utilization than the second and third phases, which did not have a significant effect.


Conclusion:

The Kenyan experience suggests that a professional, intensive mass media campaign is likely to contribute to increases in utilization of testing. Expansion of programs for counseling and HIV testing in developing countries is likely to be facilitated by mass media promotion of these services.


Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya.
Author: Mattson, C. L.; Bailey, R. C.; Muga, R.; Poulussen, R., and Onyango, T.
Source: AIDS Care. 2005 Feb; 17(2):182-94.
Abstract: Numerous epidemiologic studies report significant associations between lack of male circumcision and HIV-1 infection, leading some to suggest that male circumcision be added to the limited armamentarium of HIV prevention strategies in areas where HIV prevalence is high and the mode of transmission is primarily heterosexual. This cross-sectional survey of 107 men and 110 women in Nyanza Province, Kenya, assesses the attitudes, beliefs, and predictors of circumcision preference among men and women in a traditionally non-circumcising region. Sixty per cent (n=64) of uncircumcised men and 69% (n=68) of women who had uncircumcised regular partners reported that they would prefer to be circumcised or their partners to be circumcised. Men's circumcision preference was associated with the belief that it is easier for uncircumcised men to get penile cancer, sexually transmitted diseases, and HIV/AIDS, and that circumcised men have more feeling in their penises, enjoy sex more, and confer more pleasure to their partners. Women with nine or more years of school were more likely to prefer circumcised partners. Men who preferred to remain uncircumcised were concerned about the pain and cost of the procedure, and pain was a significant deterrent for women to agree to circumcision for their sons. If clinical trials prove circumcision to be efficacious in reducing risk of HIV infection, it is likely that the procedure will be sought by a significant proportion of the population, especially if it is affordable and minimally painful.

Scaling Sexual Behavior or "Sexual Risk Propensity" Among Men at Risk for HIV in Kisumu, Kenya.
Author: Mattson, C. L.; Campbell, R. T.; Karabatsos, G.; Agot, K.; Ndinya-Achola, J. O.; Moses, S., and Bailey, R. C.
Source: AIDS Behav. 2008 Jul 24.
Abstract: We present a scale to measure sexual risk behavior or "sexual risk propensity" to evaluate risk compensation among men engaged in a randomized clinical trial of male circumcision. This statistical approach can be used to represent each respondent's level of sexual risk behavior as the sum of his responses on multiple dichotomous and rating scale (i.e. ordinal) items. This summary "score" can be used to summarize information on many sexual behaviors or to evaluate changes in sexual behavior with respect to an intervention. Our 18 item scale demonstrated very good reliability (Cronbach's alpha of 0.87) and produced a logical, unidimensional continuum to represent sexual risk behavior. We found no evidence of differential item function at different time points (except for reporting a concurrent partners when comparing 6 and 12 month follow-up visits) or with respect to the language with which the instrument was administered. Further, we established criterion validity by demonstrating a statistically significant association between the risk scale and the acquisition of incident sexually transmitted infections (STIs) at the 6 month follow-up and HIV at the 12 month follow-up visits. This method has broad applicability to evaluate sexual risk behavior in the context of other HIV and STI prevention interventions (e.g. microbicide or vaccine trials), or in response to treatment provision (e.g., anti-retroviral therapy).

A comparison of genital HIV-1 shedding and sexual risk behavior among Kenyan women based on eligibility for initiation of HAART according to WHO guidelines.
Author: McClelland, R. S.; Baeten, J. M.; Richardson, B. A.; Lavreys, L.; Emery, S.; Mandaliya, K.; Ndinya-Achola, J. O., and Overbaugh, J.
Source: J Acquir Immune Defic Syndr. 2006 Apr 15; 41(5):611-5.
Abstract: Background:

Guidelines for initiating antiretrovirals are based on markers of advanced disease and are not directly linked to markers of HIV-1 transmission such as viral shedding.


Methods:

We evaluated genital HIV-1 shedding and risk behavior among 650 antiretroviral-naive women stratified by WHO criteria for initiating antiretrovirals based on CD4 count and symptoms.


Results:

Genital HIV-1 concentrations increased in stepwise fashion with declining CD4 counts and the presence of symptoms. Compared with the reference group (asymptomatic with CD4 >350 cells/microL), those with advanced immunosuppression (CD4 <200 cells/microL) had significantly higher cervical HIV-1 RNA concentrations (2.4 log10 copies/swab vs. 3.8 log10 copies/swab, P < 0.001). However, women with CD4 counts <200 cells/microL were also less likely than the reference group to report intercourse during the past week (58% vs. 26%, P < 0.001).


Conclusions:

Antiretroviral guidelines focusing on individuals with the most advanced immunosuppression will target those with the highest genital HIV-1 concentrations. However, individuals with less advanced immunosuppression also have high levels of genital HIV-1 and may be more sexually active. The effect of increased antiretroviral availability on the spread of HIV-1 might be enhanced by extending treatment, in addition to other risk reduction services, to those with less advanced disease.



HIV-1 acquisition and disease progression are associated with decreased high-risk sexual behaviour among Kenyan female sex workers.
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.


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.



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.

Herpes simplex virus type 2 infection among young uncircumcised men in Kisumu, Kenya.
Author: Mehta, S. D.; . = Moses S; Agot K; Agingu W, and Parker C.
Source: Sexually Transmitted Infections. 2008 Feb 1; 84(1):42-48.
Abstract: The objectives were to identify factors associated with herpes simplex virus type 2 (HSV-2) infection among men aged 18-24 in Kisumu, Kenya. Baseline data from a randomised trial of male circumcision were analysed. Participants were interviewed for sociodemographic and behavioural risks. The outcome was HSV-2 by antibody status. Risk factors were considered singly and in combination through logistic regression models. Among 2771 uncircumcised men, 766 (27.6%; 95% confidence interval (CI) 26.0% to 29.3%) tested antibody positive for HSV-2. The median age at first sex was 16 years, and the median number of lifetime sexual partners was four. HSV-2 seroprevalence increased from 19% among 18-year-olds to 43% among 24-year-olds (p less than 0.001). In multivariable analysis, statistically significant risks for infection were increasing age (adjusted odds ratio (AOR)=1.22-2.58), being married or having a live-in female partner (AOR=1.80; 95% CI 1.28 to 2.53), preferring "dry" sex (AOR=1.39; 95% CI 1.14 to 1.69), reported penile cuts or abrasions during sex (AOR=1.58; 95% CI 1.32 to 1.91), increasing lifetime sex partners (multiple response categories; AORs ranging from 1.65 to 1.97), and non-student occupation (multiple response categories; AORs ranging from 1.44 to 1.93). Risk decreased with reported condom used at last sex (AOR=0.82; 95% CI 0.68 to 0.99). Primary prevention efforts should be initiated at an early age. The same behavioural interventions used currently for HIV prevention-abstinence, reducing the number of sex partners and increasing condom use-should be effective for HSV-2 prevention. (author's)


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