Impact of five years of peer-mediated interventions on sexual behavior and sexually transmitted infections among female sex workers in Mombasa, Kenya

Since 2000, peer-mediated interventions among female sex workers (FSW) in Mombasa Kenya have promoted behavioural change through improving knowledge, attitudes and awareness of HIV serostatus, and aimed to prevent HIV and other sexually transmitted infection (STI) by facilitating early STI treatment. Impact of these interventions was evaluated among those who attended peer education and at the FSW population level.

A pre-intervention survey in 2000, recruited 503 FSW using snowball sampling. Thereafter, peer educators provided STI/HIV education, condoms, and facilitated HIV testing, treatment and care services. In 2005, data were collected using identical survey methods, allowing comparison with historical controls, and between FSW who had or had not received peer interventions.

Over five years, sex work became predominately a full-time activity, with increased mean sexual partners (2.8 versus 4.9/week; P < 0.001). Consistent condom use with clients increased from 28.8% (145/503) to 70.4% (356/506; P < 0.001) as well as the likelihood of refusing clients who were unwilling to use condoms (OR = 4.9, 95%CI = 3.7-6.6). In 2005, FSW who received peer interventions (28.7%, 145/506), had more consistent condom use with clients compared with unexposed FSW (86.2% versus 64.0%; AOR = 3.6, 95%CI = 2.1-6.1). These differences were larger among FSW with greater peer-intervention exposure. HIV prevalence was 25% (17/69) in FSW attending > or = 4 peer-education sessions, compared with 34% (25/73) in those attending 1-3 sessions (P = 0.21). Overall HIV prevalence was 30.6 (151/493) in 2000 and 33.3% (166/498) in 2005 (P = 0.36).

Peer-mediated interventions were associated with an increase in protected sex. Though peer-mediated interventions remain important, higher coverage is needed and more efficacious interventions to reduce overall vulnerability and risk.

"Sugar daddy" relationships, which are characterized by large age and economic asymmetries between partners, are believed to be a major factor in the spread of HIV in Sub-Saharan Africa. Information is needed about sugar daddy partnerships-and about age and economic asymmetries more generally-to determine how common they are and whether they are related to unsafe sexual behavior.

The sample comprised 1,052 men aged 21-45 who were surveyed in Kisumu, Kenya, in 2001. Data on these men and their 1,614 recent non-marital partnerships were analyzed to calculate the prevalence of sugar daddies and sugar daddy relationships, as well as a range of age and economic disparities within non-marital partnerships. Logistic regression models were constructed to assess relationships between condom use at last sexual intercourse and various measures of age and economic asymmetry.

The mean age difference between non-marital sexual partners was 5.5 years, and 47% of men's female partners were adolescents. Fourteen percent of partnerships involved an age difference of at least 10 years, and 23% involved more than the mean amount of male-to-female material assistance. Men who reported at least one partnership with both these characteristics were defined as sugar daddies and made up 5% of the sample; sugar daddy relationships accounted for 4% of partnerships. Sugar daddy partnerships and the largest age and economic asymmetries we constructed were associated with decreased odds of condom use.

Although sugar daddy relationships are not as pervasive as generally assumed, age and economic asymmetries in non-marital partnerships are relatively common. All these types of asymmetries are associated with nonuse of condoms. Increasing women's power within asymmetric sexual relationships could improve their ability to negotiate safer sexual behaviors, such as condom use.

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.

To determine the period prevalence of dyslipidemia and dysglycaemia in HIV-infected patients. DESIGN: Cross-sectional comparative group study.

Kenyatta National Hospital, a tertiary HIV dedicated out-patient facility.

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.

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.

To evaluate retention in care and response to therapy for patients enrolled in an antiretroviral treatment program in a severely resource-constrained setting.

We evaluated patients enrolled between February 26, 2003, and February 28, 2005, in a community clinic in Kibera, an informal settlement, in Nairobi, Kenya. Midlevel providers offered simplified, standardized antiretroviral therapy (ART) regimens and monitored patients clinically and with basic laboratory tests. Clinical, immunologic, and virologic indicators were used to assess response to ART; adherence was determined by 3-day recall. A total of 283 patients (70% women; median baseline CD4 count, 157 cells/ mm(3); viral load, 5.16 log copies/mL) initiated ART and were followed for a median of 7.1 months (n = 2384 patient-months).

At 1 year, the median CD4 count change was +124.5 cells/mm(3) (n = 74; interquartile range, 42 to 180), and 71 (74%) of 96 patients had viral load <400 copies/mL. The proportion of patients reporting 100% adherence over the 3 days before monthly clinic visits was 94% to 100%. As of February 28, 2005, a total of 239 patients (84%) remained in care, 22 (8%) were lost to follow-up, 12 (4%) were known to have died, 5 (2%) had stopped ART, 3 (1%) moved from the area, and 2 (< 1% ) transferred care.

Response to ART in this slum population was comparable to that seen in industrialized settings. With government commitment, donor support, and community involvement, it is feasible to implement successful ART programs in extremely challenging social and environmental conditions.

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.

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

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.

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.

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.

Three randomized controlled trials (RCTs) have confirmed that male circumcision (MC) significantly reduces acquisition of HIV-1 infection among men. The objective of this study was to perform a comprehensive, prospective evaluation of risk compensation, comparing circumcised versus uncircumcised controls in a sample of RCT participants.

Between March 2004 and September 2005, we systematically recruited men enrolled in a RCT of MC in Kenya. Detailed sexual histories were taken using a modified Timeline Followback approach at baseline, 6, and 12 months. Participants provided permission to obtain circumcision status and laboratory results from the RCT. We evaluated circumcised and uncircumcised men's sexual behavior using an 18-item risk propensity score and acquisition of incident infections of gonorrhea, chlamydia, and trichomoniasis. Of 1780 eligible RCT participants, 1319 enrolled (response rate = 74%). At the baseline RCT visit, men who enrolled in the sub-study reported the same sexual behaviors as men who did not. We found a significant reduction in sexual risk behavior among both circumcised and uncircumcised men from baseline to 6 (p<0.01) and 12 (p = 0.05) months post-enrollment. Longitudinal analyses indicated no statistically significant differences between sexual risk propensity scores or in incident infections of gonorrhea, chlamydia, and trichomoniasis between circumcised and uncircumcised men. These results are based on the most comprehensive analysis of risk compensation yet done.

In the context of a RCT, circumcision did not result in increased HIV risk behavior. Continued monitoring and evaluation of risk compensation associated with circumcision is needed as evidence supporting its' efficacy is disseminated and MC is widely promoted for HIV prevention.

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.

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.

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).

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.