The ABCs of HIV prevention in men: associations with HIV risk and protective behaviors

To elucidate associations between beliefs in abstinence, fidelity, and condom use (the "ABCs" of preventing HIV and other sexually transmitted infections) and associated self-reported risk behaviors among Kenyan men.

We assessed associations of beliefs in the ABCs with sociodemographic

characteristics and sexual risk behaviors in a respondent-driven sample of 500

men in Nairobi.

Younger age, single marital status, and higher education

were associated with beliefs in abstinence and condom use as "best" prevention

methods; and older age and marriage were associated with belief in fidelity. Many of these and other associations persisted in multivariate models. Men citing abstinence or fidelity belief less often reported sex with a female sex worker (FSW) ever or recent concurrent partnerships less often. Belief in fidelity was negatively associated with reported use of condoms ever. Belief in condom use to prevent HIV was most common among those having recent concurrent partnerships.

Beliefs in abstinence, fidelity ("being faithful"), or condom use

were associated, in plausible directions, with life stages and other demographic

factors and with corresponding risk and preventive behaviors. Context-specific

and selective educational promotion of individual ABC components rather than

comprehensive education from an early age in a wide repertoire of prevention

strategies ignores the evolution of sexual behaviors and the relative utility of

different approaches throughout the life course.

Birx DL
Source: J Acquir Immune Defic Syndr. 2006 Sep;43(1):102-6.

factors for HIV-1 infection among agricultural plantation residents in Kericho,

Kenya. Volunteers were recruited, interviewed, and phlebotomized for HIV-1

serologic testing. Sex-specific adjusted odds ratios were estimated using

logistic regression. The overall HIV-1 prevalence was 9.9% (81/820), with

prevalence in women more than twice that in men (17.4% vs 8.0%, P=0.001). Among men, elevated HIV-1 prevalence was seen with increasing age, peaking in those older than 30 years (10.3%), marriage (10.4%), Luo tribe affiliation (23.5%), employment (8.9%), travel (11.0%), and being uncircumcised (29.2%). Among women, elevated HIV-1 prevalence was seen in those with no formal education (36.8%) and those who received goods in exchange for sex (36.0%). More than 97% of volunteers expressed a willingness to participate in future HIV-1 studies requiring semiannual visits. HIV prevention efforts have been implemented, along with further research to characterize this population for future cohort feasibility studies and HIV-1 vaccine efficacy trials.

To describe the methods used in the Demographic and Health Surveys

(DHS) to collect nationally representative data on the prevalence of human

immunodeficiency virus (HIV) and assess the value of such data to country HIV

surveillance systems.
Methods:

During 2001-04, national samples of adult women

and men in Burkina Faso, Cameroon, Dominican Republic, Ghana, Mali, Kenya, United Republic of Tanzania and Zambia were tested for HIV. Dried blood spot samples were collected for HIV testing, following internationally accepted ethical

standards. The results for each country are presented by age, sex, and urban

versus rural residence. To estimate the effects of non-response, HIV prevalence

among non-responding males and females was predicted using multivariate

statistical models for those who were tested, with a common set of predictor

variables.

Rates of HIV testing varied from 70% among Kenyan men to 92%

among women in Burkina Faso and Cameroon. Despite large differences in HIV

prevalence between the surveys (1-16%), fairly consistent patterns of HIV

infection were observed by age, sex and urban versus rural residence, with

considerably higher rates in urban areas and in women, especially at younger

ages. Analysis of non-response bias indicates that although predicted HIV

prevalence tended to be higher in non-tested males and females than in those

tested, the overall effects of non-response on the observed national estimates of

HIV prevalence are insignificant.

Population-based surveys can provide reliable, direct estimates of national and regional HIV seroprevalence among men and women irrespective of pregnancy status. Survey data greatly enhance surveillance systems and the accuracy of national estimates in generalized epidemics.

surveillance in antenatal clinics since 1990. The system started with 13 sites

and now has over 35. Behaviours have been measured through national Demographic and Health Surveys in 1993, 1998, and 2003. The surveillance data indicate that prevalence has declined substantially starting in 1998 in five of the original 13 sites and starting in 2000 in another four sites. No decline is evident in the other five original sites although the 2004 estimate is the lowest recorded.

Nationally, adult prevalence has declined from 10% in the late 1990s to under 7%

today. Surveys indicate that both age at first sex and use of condoms are rising

and that the percentage of adults with multiple partners is falling. It is clear

that HIV prevalence is now declining in Kenya in a pattern similar to that seen

in Uganda but seven or eight years later. Although the coverage of preventive

interventions has expanded rapidly since 2000 this expansion was too late to

account for the beginnings of the decline in prevalence. More work is needed to

understand fully the causes of this decline, but it is encouraging to see Kenya

join the small list of countries experiencing significant declines in HIV

prevalence.
Language: English
Keywords: |ADOLESCENT |ADULT |FEMALE |HIV INFECTIONS EPIDEMIOLOGY |PSYCHOLOGY|HUMANS |KENYA|EPIDEMIOLOGY |MALE |MIDDLE AGED |PREVALENCE |SENTINEL SURVEILLANCE |SEXUAL BEHAVIOR|PSYCHOLOGY|STATISTICS & NUMERICAL DATA

|SEXUALLY TRANSMITTED DISEASES|EPIDEMIOLOGY

Late marriage and the HIV epidemic in sub-Saharan Africa.
Author: Bongaarts J,
Source: Popul Stud (Camb). 2007 Mar;61(1):73-83.
Abstact: The causes of large variation in the sizes of HIV epidemics among countries in sub-Saharan Africa are not well understood. Here we assess the potential roles of

late age at marriage and a long period of premarital sexual activity as

population risk factors, using ecological data from 33 sub-Saharan African

countries and with individual-level data from Demographic and Health Surveys

(DHS) in Kenya and Ghana in 2003. The ecological analysis finds a significant

positive correlation between HIV prevalence and median age at first marriage, and between HIV prevalence and interval between first sexual intercourse and first marriage. The individual-level analysis shows that HIV infection per year of

exposure is higher before than after first marriage. These findings support the

hypothesis of a link between a high average age at marriage and a long period of

premarital intercourse during which partner changes are relatively common and

facilitate the spread of HIV.

To determine whether observed changes in HIV prevalence in countries with generalised HIV epidemics are associated with changes in sexual risk

behaviour.
Methods:

A mathematical model was developed to explore the relation

between prevalence recorded at antenatal clinics (ANCs) and the pattern of

incidence of infection throughout the population. To create a null model a range

of assumptions about sexual behaviour, natural history of infection, and sampling biases in ANC populations were explored to determine which factors maximised declines in prevalence in the absence of behaviour change. Modelled prevalence, where possible based on locally collected behavioural data, was compared with the observed prevalence data in urban Haiti, urban Kenya, urban Cote d'Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia.
Results:

Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and urban Haiti, like Uganda before them, could only be replicated in the model through reductions in risk associated with changes in behaviour. In contrast, prevalence trends in urban Cote d'Ivoire, Malawi, urban Ethiopia, and Rwanda show no signs of changed sexual behaviour. CONCLUSIONS: Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are quite recent and caution is required because of doubts over the accuracy and representativeness of these estimates. Nonetheless, the observed changes are consistent with behaviour change and not the natural course of the HIV epidemic.

There are few data on African children infected with nonclade B HIV-1

in endemic settings, which limits generalizations about pathogenesis and

progression. Genotypic and phenotypic variations in host immunogenetics and HIV-1 negative factor (nef) accessory protein may influence disease progression and have frequently been characterized in subjects infected with clade B HIV-1.

In this descriptive study, we report nef gene sequence variation and

host genetic polymorphisms in 32 Kenyan children, including 12 slow progressors.

Results:

Phylogenetic analysis identified HIV-1 clades A, C and D and a

recombinant A/D subtype. Grossly defective nef genes or significant changes from relevant clade reference sequences were not identified in children with delayed disease progression.
Conclusions:

nef sequence variations may not be common in perinatally infected African children. Further studies are warranted in HIV-1-infected subjects in settings where infection is endemic.

The HIV epidemic has caused a dramatic increase in tuberculosis (TB) in East and southern Africa. Several strategies have the potential to reduce the burden of TB in high HIV prevalence settings, and cost and cost-effectiveness analyses can help to prioritize them when budget constraints exist. However, published cost and cost-effectiveness studies are limited.

Our objective was to compare the cost, affordability and cost-effectiveness of seven strategies for reducing the burden of TB in countries with high HIV prevalence. A compartmental difference equation model of TB and HIV and recent cost data were used to assess the costs (year 2003 USD prices) and effects (TB cases averted, deaths averted, DALYs gained) of these strategies in Kenya during the period 2004-2023.

The three lowest cost and most cost-effective strategies were

improving TB cure rates, improving TB case detection rates, and improving both

together. The incremental cost of combined improvements to case detection and

cure was below USD 15 million per year (7.5% of year 2000 government health

expenditure); the mean cost per DALY gained of these three strategies ranged from USD 18 to USD 34. Antiretroviral therapy (ART) had the highest incremental costs, which by 2007 could be as large as total government health expenditures in year 2000. ART could also gain more DALYs than the other strategies, at a cost per DALY gained of around USD 260 to USD 530. Both the costs and effects of treatment for latent tuberculosis infection (TLTI) for HIV+ individuals were low; the cost per DALY gained ranged from about USD 85 to USD 370. Averting one HIV infection for less than USD 250 would be as cost-effective as improving TB case detection and cure rates to WHO target levels.

To reduce the burden of TB in high HIV prevalence settings, the immediate goal should be to increase TB case detection rates and, to the extent possible, improve TB cure rates, preferably in combination. Realising the full potential of ART will require substantial new funding and strengthening of health system capacity so that increased funding can be used effectively.

To explore the role of primary health centers in provision of voluntary counseling and testing (VCT) in Kenya.

Prospective service evaluation at 3 (1 urban and 2 rural) government health centers. SUBJECTS: Consecutive adult clients.

Uptake of services, user characteristics, quality of service.

Counseling services received 2315 new clients over 26 months. The last quarter averaged 101 clients per clinic. More than 80% of clients lived locally. Overall 93% opted to test, 91% receiving results, 82% on the same day. Most clients tested HIV negative (81%). Youth and men were well represented. Few couples (10%) attended. Seventeen percent of women were pregnant. Self-referral was common and illness was an uncommon reason for testing (<20%). Thirty-one percent of clients were referred from VCT to other health center services. Counseling was perceived as high quality by users and providers. Validation of the test algorithm showed a sensitivity of 98.0% and specificity of 98.7%.

Government health centers in Kenya can be appropriate providers of VCT. This pilot helped initiate a new strategy of health center-based VCT in Kenya and this has facilitated rapid expansion and more equitable provision for Kenyans.

provision of comprehensive post-rape care, including the free provision of HIV

post-exposure prophylaxis (PEP). It is a typical rural Kenyan district in terms

of resources and patient throughput. The high rate of children attending for

post-rape services was unexpected and had significant programming implications. An age-disaggregated analysis of existing quantitative data from the first 8 months of service provision was conducted. Ninety-four case records were reviewed, of whom 48 (51%) were in the age range 1.5-17 years inclusive. All three cases of male rape were in children. Children were more likely to know

their assailant than adults and were more likely to be HIV-negative at baseline.

The majority (86%) of children presented in time for PEP, with adherence and

completion rates similar to adults but lower rates of 6-week follow-up. The use

of weight bands to determine drug dosages greatly simplified the appropriate and early administration of paediatric PEP. The high rates of childhood rape and

demand for post-rape services were an enormous challenge for service providers

and policy-makers.
Language: English
Keywords: |ADOLESCENT |ADULT |ANTI-HIV AGENTS |ADMINISTRATION & DOSAGE |BODY WEIGHT |CHILD|CHILD ABUSE, SEXUAL |CHILD, PRESCHOOL |FEASIBILITY STUDIES |FEMALE |HIV INFECTIONS |PREVENTION & CONTROL |HUMANS |INFANT

|KENYA |LAMIVUDINE |ADMINISTRATION & DOSAGE

|MALE |PILOT PROJECTS |PRACTICE GUIDELINES AS TOPIC

|RAPE| RISK FACTORS| RURAL HEALTH|SEXUALLY TRANSMITTED DISEASES/PREVENTION & CONTROL|ZIDOVUDINE |ADMINISTRATION & DOSAGE

Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya.
Author: Krieger JN, Bailey RC, Opeya J, Ayieko B, Opiyo F, Agot K, Parker C, Ndinya-Achola JO, Magoha GA, Moses S
Source: BJU Int. 2005 Nov;96(7):1109-13.