african drylands institute for sustainability

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Following the endorsement by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) of male circumcision as an additional strategy to HIV prevention, initiatives to introduce safe, voluntary medical male circumcision (VMMC) services commenced in 2008 in several sub-Saharan African communities. Information regarding perceptions of circumcision as a method of HIV prevention, however, is largely limited to data collected before this important endorsement and the associated increase in the availability of VMMC services. To address this, we completed a community-based survey of male circumcision (MC) perceptions in the major non-circumcising community in Kenya, which is the current focus of VMMC programs in the country. Data was collected between November 2008 and April 2009, immediately before VMMC program scale-up commenced. Here we present results limited to women (n = 1088) and uncircumcised males (n = 460) to provide insight into factors contributing to the acceptability and preference for MC in those targeted by VMMC programs. Separate multivariable models examining preference for circumcision were defined for married men, unmarried men, and women. Belief in the protective effect of circumcision on HIV risk was strongly associated with preference for MC in all models. Other important factors included education, perceived improvement in sexual pleasure, and perceptions of impact on condom utilization. Identified barriers to circumcision were the belief that circumcision was not part of the local culture, the perception of a long healing period following the procedure, the lack of a specific impetus to seek out services, and the general fear of pain associated with becoming circumcised. A minority of participants expressed beliefs suggesting that behavioral risk compensation with increased MC prevalence and awareness is a possibility. This work describes the early impact of a large-scale VMMC program on beliefs and behaviors regarding MC and HIV risk. It is hoped that our findings may offer guidance into anticipating potential impacts that similar programs may observe in populations throughout Eastern Africa.

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PURPOSE:

Injuries to the penis during intercourse represent a hypothesized mechanism by which uncircumcised men are at increased risk for HIV. There are no published, systematically collected data regarding mild penile coital trauma to our knowledge. We identified risks of self-reported penile coital injuries in men 18 to 24 years old in a randomized trial of circumcision to prevent HIV in Kisumu, Kenya.

MATERIALS AND METHODS:

Each participant underwent standardized interview, medical history and physical examination at baseline, and 6, 12, 18 and 24 months after enrollment. Self-reported penile coital injuries were assessed at each visit, and were defined as penis feels sore during sex, penis gets scratches, cuts or abrasions during sex, and skin of the penis bleeds after sex. Generalized estimating equation analysis estimated odds ratios for penile coital injuries.

RESULTS:

From February 2002 to September 2005, 2,784 participants were randomized. At baseline 1,775 (64.4%) men reported any coital injury including 1,313 (47.6%) soreness, 1,328 (48.2%) scratches, abrasions or cuts and 461 (16.7%) bleeding. On multivariable analysis coital injury risk was lower for circumcised than for uncircumcised men with soreness (OR 0.71, 95% CI 0.64-0.80), scratches/abrasions/cuts (OR 0.52, 95% CI 0.46-0.59), bleeding (OR 0.62, 95% CI 0.51-0.75) and any coital injury (OR 0.61, 95% CI 0.54-0.68). Other significant risks included increasing age, multiple recent sex partners, HSV-2 seropositivity and genital ulcers (p <0.05). Condom use, cleaning the penis soon after intercourse and being married/cohabiting were protective (p <0.05, each).

CONCLUSIONS:

Self-reported penile coital injuries were common in these healthy young men. Circumcised

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BACKGROUND: 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. METHODS AND FINDINGS: 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. CONCLUSION: 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.

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).

OBJECTIVES: Female sex workers (FSWs) form a core group at high risk of both sexual HIV acquisition and secondary transmission. The magnitude of these risks may vary by sexual risk taking, partner HIV prevalence, host immune factors and genital co-infections. We examined temporal trends in HIV prevalence and per-act incidence, adjusted for behavioral and other variables, in FSWs from Nairobi, Kenya. METHODS: An open cohort of FSWs followed since 1985. Behavioral and clinical data were collected six monthly from 1985 to 2005, and sexually transmitted infection (STI) diagnostics and HIV serology performed. A Cox proportional hazards model with time-dependent covariables was used to estimate infection risk as a function of calendar time. RESULTS: HIV prevalence in new FSW enrollees peaked at 81% in 1986, and was consistently below 50% after 1997. Initially uninfected FSWs remained at high risk of acquiring HIV throughout the study period, but the rate of HIV acquisition during unprotected sex with a casual client declined by over four-fold. This reduction correlated closely with decreases in gonorrhea prevalence, and predated reductions in the Kenyan HIV population prevalence by over a decade. CONCLUSIONS: The per-act rate of HIV acquisition in high-risk Nairobi FSWs fell dramatically between 1985 and 2005. This decline may represent the impact of improved STI prevention/therapy, immunogenetic shifts in at-risk women, or changes in the proportion of HIV exposures occurring with clients who had acute HIV infection. Declining HIV incidence in high-risk cohorts may predict and/or be causally related to future reductions in population prevalence.

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).

BACKGROUND: 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. METHODS AND FINDINGS: 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. CONCLUSION: 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.

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.

Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.

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Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.

Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.

Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.

Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.

Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.

Introduction. Male circumcision is being promoted for HIV prevention in high-risk heterosexual populations. However, there is a concern that circumcision may impair sexual function. Aim. To assess adult male circumcision's effect on men's sexual function and pleasure. Methods. Participants in a controlled trial of circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised, HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0 mmol/L. Exclusion criteria included foreskin covering less than half the glans, a condition that might unduly increase surgical risks, or a medical indication for circumcision. Participants were randomized 1:1 to either immediate circumcision or delayed circumcision after 2 years (control group). Detailed evaluations occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual function between circumcised and uncircumcised men; and (ii) sexual satisfaction and pleasure over time following circumcision. Results. Between February 2002 and September 2005, 2,784 participants were randomized, including the 100 excluded from this analysis because they crossed over, were not circumcised within 30 days of randomization, did not complete baseline interviews, or were outside the age range. For the circumcision and control groups, respectively, rates of any reported sexual dysfunction decreased from 23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time were not associated with circumcision status. Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at month 24. Conclusions. Adult male circumcision was not associated with sexual dysfunction. Circumcised men reported increased penile sensitivity and enhanced ease of reaching orgasm. These data indicate that integration of male circumcision into programs to reduce HIV risk is unlikely to adversely effect male sexual function.

{ We investigated the association between albumin levels and HIV-1 disease progression among 78 Kenyan women followed from before infection through a median of 70 months. With HIV-1 acquisition, median albumin decreased from 38.5 g/liter to 36.8 g/liter (p = 0.07) and the prevalence of hypoalbuminemia increased from 16% to 32% (p = 0.02). Each 1 g/liter decrease in albumin with HIV-1 acquisition was associated with a 13% increase (p = 0.01) in the risk of progressing to a CD4 count <200 cells/mul, after adjustment for set point plasma viral load. A decrease in albumin of over 10% was associated with a 3.5-fold increase in the risk of progressing to a CD4 count <200 cells/mul (95% CI 1.4-9.0

BACKGROUND: Studies of the effect of hormonal contraceptive use on the risk of HIV-1 acquisition have generated conflicting results. A recent study from Uganda and Zimbabwe found that women using hormonal contraception were at increased risk for HIV-1 if they were seronegative for herpes simplex virus type 2 (HSV-2), but not if they were HSV-2 seropositive. OBJECTIVE: To explore the effect of HSV-2 infection on the relationship between hormonal contraception and HIV-1 in a high-risk population. Hormonal contraception has previously been associated with increased HIV-1 risk in this population. METHODS: Data were from a prospective cohort study of 1206 HIV-1 seronegative sex workers from Mombasa, Kenya who were followed monthly. Multivariate Cox proportional hazards analyses were used to adjust for demographic and behavioral measures and incident sexually transmitted diseases. RESULTS:: Two hundred and thirty-three women acquired HIV-1 (8.7/100 person-years). HSV-2 prevalence (81%) and incidence (25.4/100 person-years) were high. In multivariate analysis, including adjustment for HSV-2, HIV-1 acquisition was associated with use of oral contraceptive pills [adjusted hazard ratio (HR), 1.46; 95% confidence interval (CI), 1.00-2.13] and depot medroxyprogesterone acetate (adjusted HR, 1.73; 95% CI, 1.28-2.34). The effect of contraception on HIV-1 susceptibility did not differ significantly between HSV-2 seronegative versus seropositive women. HSV-2 infection was associated with elevated HIV-1 risk (adjusted HR, 3.58; 95% CI, 1.64-7.82). CONCLUSIONS: In this group of high-risk African women, hormonal contraception and HSV-2 infection were both associated with increased risk for HIV-1 acquisition. HIV-1 risk associated with hormonal contraceptive use was not related to HSV-2 serostatus.

BACKGROUND: Limited data are available on whether sampling from the penile shaft or urethra increases detection of penile HPV infection in men beyond that found in the glans and coronal sulcus. METHODS: Within a randomized clinical trial, a validation study of penile sampling was conducted in Kisumu, Kenya. Young men (18-24 years) were invited to provide penile exfoliated cells using prewetted Dacron swabs to determine the best site for HPV detection. beta-Globin gene PCR and HPV DNA type GP5+/6+ PCR status were ascertained from 3 anatomical sites. RESULTS: A total of 98 young HIV-seronegative, uncircumcised men participated. Penile HPV prevalence varied by anatomical site: 50% in penile exfoliated cells from the glans, coronal sulcus, and inner foreskin tissue; 43% in the shaft and external foreskin tissue; and 18% in the urethra (P <0.0001). For each anatomical site, over 87% of samples were beta-globin positive. Beyond that found in the glans/coronal sulcus, urethral sampling resulted in no increase in HPV positivity and shaft sampling resulted in an additional 7.3% of overall HPV positivity. The prevalence of high-risk HPV positivity varied by anatomical site: 39% in glans/coronal sulcus, 31% in shaft, and 13% in the urethra (P <0.0001). HPV 16 was the most common type identified. DISCUSSION: Penile HPV prevalence was approximately 50% among young men in Kisumu, Kenya. Urethral sampling for HPV detection in men added no sensitivity for HPV detection over that found from sampling the glans/coronal sulcus and penile shaft. These data will help inform studies on HPV transmission dynamics, and on the efficacy of HPV prophylactic vaccines on penile HPV carriage in men.

BACKGROUND: Low vitamin E levels are often found in HIV-1 infection, and studies have suggested that higher levels may decrease the risk of disease progression. However, vitamin E supplementation has also been reported to increase CCR5 expression, which could increase HIV-1 replication. We hypothesized that vitamin E levels at HIV-1 acquisition may influence disease progression. METHODS: Vitamin E status was measured in stored samples from the last pre-infection visit for 67 Kenyan women with reliably estimated dates of HIV-1 acquisition. Regression analyses were used to estimate associations between pre-infection vitamin E and plasma viral load, time to CD4 count <200 cells/muL, and mortality. RESULTS: After controlling for potential confounding factors, each 1 mg/L increase in pre-infection vitamin E was associated with 0.08 log10 copies/mL (95% CI -0.01 to +0.17) higher set point viral load and 1.58-fold higher risk of mortality (95% CI 1.15-2.16). The association between higher pre-infection vitamin E and mortality persisted after adjustment for set point viral load (HR 1.55, 95% CI 1.13-2.13). CONCLUSION: Higher pre-infection vitamin E levels were associated with increased mortality. Further research is needed to elucidate the role vitamin E plays in HIV-1 pathogenesis.

OBJECTIVES: STI prevention interventions often aim to reduce HIV incidence. Understanding STI risks may lead to more effective HIV prevention. GOAL: To identify STI risks among men aged 18-24 in Kisumu, Kenya. STUDY DESIGN: We analyzed baseline data from a randomized trial of male circumcision. Participants were interviewed for sociodemographic and behavioral risks. Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were diagnosed by polymerase chain reaction assay and Trichomonas vaginalis (TV) by culture. The outcome for logistic regression analysis was infection with NG, CT, or TV. RESULTS: Among 2743 men, 214 (7.8%; 95% CI: 6.8%-8.8%) were infected with any STI. In multivariable analysis, statistically significant risks for infection were: living one's whole life in Kisumu (OR = 1.50; 95% CI: 1.12-2.01), preferring "dry" sex (OR = 1.47; 95% CI: 1.05-2.07), HSV-2 seropositivity (OR = 1.37; 95% CI: 1.01-1.86), and inability to ejaculate during sex (OR = 2.04; 95% CI: 1.15-3.62). Risk decreased with increasing age and education, and cleaning one's penis less than 1 hour after sex (OR = 0.51; 95% CI: 0.33-0.80). CONCLUSION: Understanding how postcoital cleaning, "dry" sex, and sexual dysfunction relate to STI acquisition may improve STI and HIV prevention.

OBJECTIVES: To investigate sexual practices and risk factors for prevalent HIV infection among young men in Kisumu, Kenya. GOAL: The goal of this study was to identify behaviors associated with HIV in Kisumu to maximize the effectiveness of future prevention programs. STUDY DESIGN: Lifetime sexual histories were collected from a nested sample of 1337 uncircumcised participants within the context of a randomized controlled trial of male circumcision to reduce HIV incidence. RESULTS: Sixty-five men (5%) tested positive for HIV. Multiple logistic regression revealed the following independent predictors of HIV: older age, less education, being married, being Catholic, >4 lifetime sex partners, prior treatment for an STI, sex during partner's menstruation, ever practicing bloodletting, and receipt of a medical injection in the last 6 months. Prior HIV testing and postcoital cleansing were protective. CONCLUSIONS: This analysis confirms the importance of established risk factors for HIV and identifies practices that warrant further investigation.

BACKGROUND: Male circumcision could provide substantial protection against acquisition of HIV-1 infection. Our aim was to determine whether male circumcision had a protective effect against HIV infection, and to assess safety and changes in sexual behaviour related to this intervention. METHODS: We did a randomised controlled trial of 2784 men aged 18-24 years in Kisumu, Kenya. Men were randomly assigned to an intervention group (circumcision; n=1391) or a control group (delayed circumcision, 1393), and assessed by HIV testing, medical examinations, and behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. HIV seroincidence was estimated in an intention-to-treat analysis. This trial is registered with ClinicalTrials.gov, with the number NCT00059371. FINDINGS: The trial was stopped early on December 12, 2006, after a third interim analysis reviewed by the data and safety monitoring board. The median length of follow-up was 24 months. Follow-up for HIV status was incomplete for 240 (8.6%) participants. 22 men in the intervention group and 47 in the control group had tested positive for HIV when the study was stopped. The 2-year HIV incidence was 2.1% (95% CI 1.2-3.0) in the circumcision group and 4.2% (3.0-5.4) in the control group (p=0.0065); the relative risk of HIV infection in circumcised men was 0.47 (0.28-0.78), which corresponds to a reduction in the risk of acquiring an HIV infection of 53% (22-72). Adjusting for non-adherence to treatment and excluding four men found to be seropositive at enrollment, the protective effect of circumcision was 60% (32-77). Adverse events related to the intervention (21 events in 1.5% of those circumcised) resolved quickly. No behavioural risk compensation after circumcision was observed. INTERPRETATION: Male circumcision significantly reduces the risk of HIV acquisition in young men in Africa. Where appropriate, voluntary, safe, and affordable circumcision services should be integrated with other HIV preventive interventions and provided as expeditiously as possible.

BACKGROUND: Antiretroviral therapy (ART) may decrease HIV-1 infectivity in women by reducing genital HIV-1 shedding. OBJECTIVES: To evaluate the time course and magnitude of decay in cervical and vaginal HIV-1 shedding as women initiate ART. METHODS: This prospective, observational study of 20 antiretroviral-naive women initiating ART with stavudine, lamivudine, and nevirapine measured HIV-1 RNA in plasma, cervical secretions, and vaginal secretions. Qualitative polymerase chain reaction estimated HIV-1 DNA in cervical and vaginal samples. Perelson's two-phase viral decay model and non-linear random effects were used to compare RNA decay rates. Decreases in proviral DNA were evaluated using logistic regression and generalized estimating equations. RESULTS: Significant decreases in the quantity of HIV-1 RNA were observed by day 2 in plasma (P < 0.001), day 2 in cervical secretions (P = 0.001), and day 4 in vaginal secretions (P < 0.001). Modeled initial and subsequent RNA decay rates in plasma, cervical secretions, and vaginal secretions were 0.6, 0.8, and 1.2 log10 virions/day, and 0.04, 0.05, and 0.06 log10 virions/day, respectively. The initial decay rate for vaginal HIV-1 RNA was more rapid than for plasma RNA (P = 0.02). Detection of HIV-1 DNA decreased significantly in vaginal secretions during the first week (P < 0.001). At day 28, 10 women had detectable HIV-1 RNA or proviral DNA in genital secretions. CONCLUSIONS: Genital HIV-1 shedding decreased rapidly after ART initiation, consistent with a rapid decrease in infectivity. However, incomplete viral suppression in half of these women may indicate an ongoing risk of transmission.

{ BACKGROUND: Bacterial vaginosis (BV) is highly prevalent among African women and has been associated with adverse pregnancy outcomes, sexually transmitted diseases, and HIV-1. GOAL: The goal of this study was to analyze the relationship among intravaginal practices, bathing, and BV. STUDY DESIGN: The authors conducted a cross-sectional study of HIV-1-seronegative Kenyan female sex workers without symptoms of vaginal infections. RESULTS: Of 237 women enrolled, 206 (87%) reported vaginal washing using either a finger or cloth. Increasing frequency of vaginal washing was associated with a higher likelihood of BV (chi(2) test for trend

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.

In their study of South African women's intravaginal practices and risk of human immunodeficiency virus (HIV) infection, Myer et al. (1) found a significant association between intravaginal practices and HIV serostatus at baseline but not during follow-up. Their results contrast with those from our prospective study of the effect of vaginal washing on HIV acquisition among women in Mombasa, Kenya (2). Compared with women who did not perform vaginal washing, we found an increased risk of HIV acquisition among women who used water (adjusted hazard ratio (HR) = 2.64, 95 percent confidence interval (CI): 1.00, 6.79) or soap (adjusted HR = 3.84, 95 percent CI: 1.51, 9.77) to clean inside the vagina (2). These findings were significant after adjustment for multiple potentially confounding factors

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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.

BACKGROUND: There is limited information on the natural history of human immunodeficiency virus type 1 (HIV-1) infection in Africa, especially from individuals with well-defined dates of infection. We used data from a prospective cohort study of female sex workers in Mombasa, Kenya, who were followed up monthly from before the date of HIV-1 infection. METHODS: Antiretroviral-naive women who had a well-defined date of HIV-1 infection were included in this analysis. The effects of set point plasma viral load (measured 4-24 months after infection), early CD4+ cell count, and symptoms of acute HIV-1 infection on mortality were assessed using Cox proportional hazards analysis. RESULTS: Among 218 women, the median duration of follow-up after HIV-1 infection was 4.6 years. Forty women died, and at 8.7 years (the time of the last death), the cumulative survival rate was 51% by Kaplan-Meier analysis. Higher set point viral load, lower early CD4+ cell count, and more-symptomatic acute HIV-1 illness each predicted death. In multivariate analysis, set point viral load (hazard ratio [HR], 2.28 per 1 log10 copies/mL increase; P=.001) and acute HIV-1 illness (HR, 1.14 per each additional symptom; P=.05) were independently associated with higher mortality. CONCLUSION: Among this group of African women, the survival rate was similar to that for HIV-1-infected individuals in industrialized nations before the introduction of combination antiretroviral therapy. Higher set point viral load and more-severe acute HIV-1 illness predicted faster progression to death. Early identification of individuals at risk for rapid disease progression may allow closer clinical monitoring, including timely initiation of antiretroviral treatment.

BACKGROUND: There is limited information on the natural history of human immunodeficiency virus type 1 (HIV-1) infection in Africa, especially from individuals with well-defined dates of infection. We used data from a prospective cohort study of female sex workers in Mombasa, Kenya, who were followed up monthly from before the date of HIV-1 infection. METHODS: Antiretroviral-naive women who had a well-defined date of HIV-1 infection were included in this analysis. The effects of set point plasma viral load (measured 4-24 months after infection), early CD4+ cell count, and symptoms of acute HIV-1 infection on mortality were assessed using Cox proportional hazards analysis. RESULTS: Among 218 women, the median duration of follow-up after HIV-1 infection was 4.6 years. Forty women died, and at 8.7 years (the time of the last death), the cumulative survival rate was 51% by Kaplan-Meier analysis. Higher set point viral load, lower early CD4+ cell count, and more-symptomatic acute HIV-1 illness each predicted death. In multivariate analysis, set point viral load (hazard ratio [HR], 2.28 per 1 log10 copies/mL increase; P=.001) and acute HIV-1 illness (HR, 1.14 per each additional symptom; P=.05) were independently associated with higher mortality. CONCLUSION: Among this group of African women, the survival rate was similar to that for HIV-1-infected individuals in industrialized nations before the introduction of combination antiretroviral therapy. Higher set point viral load and more-severe acute HIV-1 illness predicted faster progression to death. Early identification of individuals at risk for rapid disease progression may allow closer clinical monitoring, including timely initiation of antiretroviral treatment.

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-naïve 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

{ BACKGROUND: Low serum selenium has been associated with lower CD4 counts and greater mortality among HIV-1-seropositive individuals, but most studies have not controlled for serum albumin and the presence of an acute phase response. METHODS: A cross-sectional study was conducted to evaluate relationships between serum selenium concentrations and CD4 count, plasma viral load, serum albumin, and acute phase response markers among 400 HIV-1-seropositive women. RESULTS: In univariate analyses, lower CD4 count, higher plasma viral load, lower albumin, and the presence of an acute phase response were each significantly associated with lower serum selenium concentrations. In multivariate analyses including all four of these covariates, only albumin remained significantly associated with serum selenium. For each 0.1 g/dl increase in serum albumin, serum selenium increased by 0.8 microg/l (p < 0.001). Women with an acute phase response also had lower serum selenium (by 5.6 microg/l

{ BACKGROUND: Low serum selenium has been associated with lower CD4 counts and greater mortality among HIV-1-seropositive individuals, but most studies have not controlled for serum albumin and the presence of an acute phase response. METHODS: A cross-sectional study was conducted to evaluate relationships between serum selenium concentrations and CD4 count, plasma viral load, serum albumin, and acute phase response markers among 400 HIV-1-seropositive women. RESULTS: In univariate analyses, lower CD4 count, higher plasma viral load, lower albumin, and the presence of an acute phase response were each significantly associated with lower serum selenium concentrations. In multivariate analyses including all four of these covariates, only albumin remained significantly associated with serum selenium. For each 0.1 g/dl increase in serum albumin, serum selenium increased by 0.8 microg/l (p < 0.001). Women with an acute phase response also had lower serum selenium (by 5.6 microg/l

{ BACKGROUND: Low serum selenium has been associated with lower CD4 counts and greater mortality among HIV-1-seropositive individuals, but most studies have not controlled for serum albumin and the presence of an acute phase response. METHODS: A cross-sectional study was conducted to evaluate relationships between serum selenium concentrations and CD4 count, plasma viral load, serum albumin, and acute phase response markers among 400 HIV-1-seropositive women. RESULTS: In univariate analyses, lower CD4 count, higher plasma viral load, lower albumin, and the presence of an acute phase response were each significantly associated with lower serum selenium concentrations. In multivariate analyses including all four of these covariates, only albumin remained significantly associated with serum selenium. For each 0.1 g/dl increase in serum albumin, serum selenium increased by 0.8 microg/l (p < 0.001). Women with an acute phase response also had lower serum selenium (by 5.6 microg/l

Numerous epidemiologic studies have found significant associations between lack of circumcision and HIV-1 acquisition in men. To our knowledge, this is the first study of human foreskin tissue that examines biologic mechanisms that increase susceptibility of uncircumcised African men to HIV-1. Foreskin specimens from 20 men with and 19 men with no history of sexually transmitted infections were examined for HIV-1 target cells. Most Langerhans cells were found in the epithelium; most CD4+ T cells and macrophages were in the submucosa. There were no differences in HIV-1 target cells between men with and those without history of sexually transmitted infections. However Langerhans cells and macrophages were more abundant in the group with a history of infection. The densities and positions of HIV-1 target cells in the foreskin tissue of these Kenyan men indicate that the inner mucosal surface of the human foreskin contains cells that make it highly susceptible to HIV infection.

There are multiple subtypes of HIV-1 circulating worldwide, but recently, subtype C has become highly prevalent, particularly in certain geographic regions. It is unclear whether the dominance of subtype C or other subtypes is due to increased fitness of certain subtypes for transmission, or a founder effect in new, rapidly growing epidemics. To examine whether the prevalence of one subtype increases over the course of an expanding epidemic that includes several circulating subtypes, we examined the distribution of HIV-1 subtypes in Kenya from 1986 to 2000. We found no evidence for an increase in the prevalence of subtype C, which remained low throughout this approximately 15-year period. Interestingly, the percentage of subtype D present in the population decreased significantly over that period, with a slight increase in subtype A. Throughout that period, intersubtype recombinant viruses were detected, including at the early stages of the epidemic. This latter finding suggests that reinfection may have occurred in high-risk groups early in the epidemic, leading to intersubtype recombinant viruses that underwent secondary spread.

As part of a study on etiology of sexually transmitted infections (STI) among 520 women presenting at the STI clinic in Nairobi, data on partner violence and its correlates were analyzed. Prevalence of lifetime physical violence was 26%, mainly by an intimate partner (74%). HIV seropositive women had an almost twofold increase in lifetime partner violence. Women with more risky sexual behavior such as early sexual debut, number of sex partners, history of condom use and of STI, experienced more partner violence. Parity and miscarriage were associated with a history of lifetime violence. We found an inverse association between schooling and level of violence. Six percent of the women had been raped. Gender-based violence screening and services should be integrated into voluntary counseling and testing programs as well as in reproductive health programs. Multi-sector approaches are needed to change prevailing attitudes towards violence against women.

OBJECTIVE: To develop a standard procedure for male circumcision in a resource-poor medical setting and prospectively evaluate the outcome in a randomized, controlled trial with the incidence of human immunodeficiency virus (HIV) as the main outcome, as studies suggest that circumcision is associated with a lower incidence of HIV and other sexually transmitted infections in high-risk populations. SUBJECTS AND METHODS: Healthy, uncircumcised, HIV-seronegative men aged 18-24 years from Kisumu District, Kenya, were offered participation in a clinical trial using a standard circumcision procedure based on "usual" medical procedures in Western Kenya. The follow-up included visits at 3, 8 and 30 days after circumcision, with additional visits if necessary. Healing, satisfaction and resumption of activities were assessed at these visits and 3 months from randomization. RESULTS: Overall, 17 (3.5%) of the 479 circumcisions were associated with adverse events judged definitely, probably or possibly related to the procedure. The most common adverse events were wound infections (1.3%), bleeding (0.8%), and delayed wound healing or suture line disruption (0.8%). After 30 days, 99% of participants reported being very satisfied with the procedure; approximately 23% reported having had sex and 15% reported that their partners had expressed an opinion, all of whom were very satisfied with the outcome. About 96% of the men resumed normal general activities within the first week after the procedure. CONCLUSION: Safe and acceptable adult male circumcision services can be delivered in developing countries should male circumcision ultimately be advocated as a public-health measure.

We examined the association between host factors present near the time of human immunodeficiency virus type 1 (HIV-1) acquisition and subsequent virus loads, in a prospective cohort study of women in Mombasa, Kenya. Women were prospectively followed monthly before HIV-1 infection. One hundred sixty-one commercial sex workers who became infected with HIV-1 were followed for a median of 34 months, and 991 plasma samples collected > or =4 months after infection were tested for HIV-1 RNA. The median virus set point at 4 months after infection was 4.46 log10 copies/mL, and the average virus load increase during subsequent follow-up was 0.0094 log10 copies/mL/month. In a multivariate analysis that controlled for sexual behavior, the use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA) at the time of HIV-1 infection was associated with a higher virus set point, and the presence of genital ulcer disease (GUD) during the early phase of HIV-1 infection was associated with greater change in virus load during follow-up. These findings suggest that, in women, the use of DMPA and the presence of GUD during the early phase of HIV-1 infection may influence the natural course of infection.

MRC Human Immunology Unit, University of Oxford, Oxford, UK. The IFN-y enzyme-linked immunospot (ELI-Spot) assay is often used to map HIV-specific CD8 T-cell responses. We compared overlapping 15-mer pools with optimized CD8 epitopes to screen ELISpot responses in HIV-infected individuals. The 15-mer pools detected responses to previously undefined epitopes, but often missed low-level responses to predefined epitopes, particularly when the epitope was central in the 15-mer, rather than at the N-terminus or C-terminus. These factors should be considered in the monitoring of HIV vaccine trials.

To measure HIV -1 seroprevalence in pregnant women in Nairobi. Design: Six serial surveys were carried out between November 1991 and April 1997. Methods: Women attending four Nairobi City Council clinics for first antenatal clinic visit answered a standard questionnaire on demographic histories and were screened for Hl'V-I. Results: Hlv-I seroprevalence rose from 12.1% at the first survey to 16.2% in the third survey, which finished in October 1993. No rise was seen in subsequent .surveys up to April 1997. Significant differences in seroprevalence was seen between women who said that their province of origin was Nyanza (22.4%), Western or Rift Valley Provinces (14.1 %), and the provinces to the east of the country (8.9%) [p

{ OBJECTIVE: To investigate the association between the cervical shedding of herpes simplex virus (HSV) and HIV-1. DESIGN: A cross-sectional study on 200 women seropositive for both HSV-2 and HIV-1 was conducted in a family planning clinic at the Coast Provincial General Hospital, Mombasa, Kenya. MAIN OUTCOME MEASURES: Quantities of HSV DNA (types 1 and 2) and HIV-1 RNA as well as the presence or absence of HIV-1 proviral DNA in cervical secretions were determined and compared. RESULTS: There was a significant correlation between the quantities of HSV DNA and HIV-1 RNA in the cervical secretions of HSV-shedding women (Pearson's r = 0.24

BACKGROUND: Health-seeking and sexual behaviors are important elements in the control of sexually transmitted infections (STIs). GOAL: To examine patterns of health-seeking behavior and related sexual behavior relevant to improved prevention and care among patients attending primary healthcare (PHC) clinics. STUDY DESIGN: A questionnaire covering social, demographic, and healthcare-seeking and sexual behavior information was administered to 555 patients attending three primary healthcare clinics in low socioeconomic areas of Nairobi, Kenya. RESULTS: Women's knowledge about health in general and STIs in particular was poor. A major gender difference in delay of health seeking for STIs was observed (5 days for men versus 14 days for women). Significantly more men than women reported a history of STIs (68% versus 47%; P = 0.04). Men reported more extramarital affairs (17% versus 8%; P < 0.001). A high prevalence of gonorrhea (3%) and chlamydia (6%) was found in this population, with no difference between the genders. The urine dipstick was ineffective for the detection of these STIs. CONCLUSIONS: There is a need for better understanding of behavioral factors, as well as gender and social aspects of health care. Health education and health promotion in these areas should be strengthened. Improved screening tests are needed for the detection of STI.

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{ BACKGROUND: We have completed a randomised clinical trial of breastfeeding and formula feeding to identify the frequency of breastmilk transmission of HIV-1 to infants. However, we also analysed data from this trial to examine the effect of breastfeeding on maternal death rates during 2 years after delivery. We report our findings from this secondary analysis. METHODS: Pregnant women attending four Nairobi city council clinics were offered HIVtests. At about 32 weeks' gestation, 425 HIV-1 seropositive women were randomly allocated to either breastfeed or formula feed their infants. After delivery, mother-infant pairs were followed up monthly during the first year and quarterly during the second year until death, or 2 years after delivery, or end of study. FINDINGS: Mortality among mothers was higher in the breastfeeding group than in the formula group (18 vs 6 deaths, log rank test

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{ OBJECTIVES To compare sociodemographic profiles, child care, child feeding practices and growth indices of children born to HIV-1 seropositive and seronegative mothers. METHODS: A cohort study of 234 children (seropositive and seronegative) born to HIV-1 seropositive mothers and 139 children born to seronegative mothers in Pumwani Maternity Hospital which serves a low-income population in Nairobi, Kenya from December 1991 and January 1994. RESULTS: With few exceptions, at the time of their birth children in all three cohorts had parents with similar characteristics, lived in similar housing in similar geographical areas, had their mothers as their primary care givers, had similar feeding practices and similar growth status and patterns. However, the HIV-1 seropositive mothers were slightly younger (23.8 years vs. 25.0 years, P < 0.01), if married they were less likely to be their husband's first wife (79% vs. 91%

We aimed to determine the knowledge and attitudes towards HIV/STDs among women attending an STD clinic by interviewing 520 randomly selected women. Nearly all had heard of HIV/AIDS/STDs, with posters, pamphlets and the radio being the main source of their information. The years of schooling was the only predictive factor of knowing a preventive measure of HIV. Two-thirds thought they were at risk of contracting HIV from their regular partner. Knowledge of the sexual habits of their male partners was low with 260 (50%) of the women distrusting their partner. Only 52 (10%) of respondents admitted to sex in exchange for gifts or money. In the event of a positive HIV test result, the perceived partner response would be to blame the woman for introducing the infection into the relationship. After a positive HIV test result, only 3.5% would resort to using condoms while another 3.7% would try to pass on the disease to other people. The quality of their knowledge of the transmission of HIV was low in spite of the fact that most respondents have heard of HIV/AIDS/STDs. Violence against women was expected in relation to a positive test result. There is a need for better educative effort on the modes of transmission and prevention of HIV, also in 'low risk' populations.

OBJECTIVE: To determine the prevalence, incidence, and correlates of HIV-1 infection in a cohort of east African trucking company employees. METHODS: HIV-1-seronegative trucking company employees were enrolled in a prospective cohort study and evaluated at 3 monthly intervals for HIV-1 seroconversion, sexually transmitted diseases, and sexual behavior. RESULTS: The baseline seroprevalence of HIV-1 among 1500 trucking company employees was 17.8%. Among 752 HIV-1-seronegative men who were followed, the HIV-1 annual seroincidence was 3.1%. In univariate analysis, HIV-1 acquisition was associated with age under 25 years, 10 years or less of sexual activity, occupation as a driver/driver's assistant, occupational travel for more than 14 days per month, religion other than Christian or Muslim, uncircumcised status, sex with a prostitute, sex with a girlfriend/casual partner, extramarital sex, and enrollment seropositivity to Treponema pallidum, Haemophilus ducreyi, and Herpes simplex virus type 2 (all P values < or = 0.05). Using multivariate analysis, HIV-1 acquisition was independently associated with 10 years or less of sexual activity (hazard rate ratio (HRR) 2.0, 95% confidence interval (CI) 1.0-4.3), occupation as a driver/driver's assistant (HRR 3.9, 95% CI 1.7-9.0), religion other than Christian or Muslim (HRR 6.1, 95% CI 1.4-25.7), uncircumcised status (HRR 2.3, 95% CI 1.0-5.0), and unprotected sex with a prostitute (HRR 2.8, 95% CI 1.1-7.0). CONCLUSIONS: Trucking company employees had a high HIV-1 seroprevalence rate at enrollment and a high HIV-1 seroincidence during follow-up. Risk factors for HIV-1 seroconversion included years of sexual activity, occupation, religion, uncircumcised status, and unprotected sex with a prostitute. This population is an appropriate target for HIV-1 prevention trials and behavioral interventions.

A prospective cohort study was conducted to examine the relationship between vaginal colonization with lactobacilli, bacterial vaginosis (BV), and acquisition of human immunodeficiency virus type 1 (HIV-1) and sexually transmitted diseases in a population of sex workers in Mombasa, Kenya. In total, 657 HIV-1-seronegative women were enrolled and followed at monthly intervals. At baseline, only 26% of women were colonized with Lactobacillus species. During follow-up, absence of vaginal lactobacilli on culture was associated with an increased risk of acquiring HIV-1 infection (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.2-3.5) and gonorrhea (HR, 1.7; 95% CI, 1.1-2.6), after controlling for other identified risk factors in separate multivariate models. Presence of abnormal vaginal flora on Gram's stain was associated with increased risk of both HIV-1 acquisition (HR, 1.9; 95% CI, 1.1-3.1) and Trichomonas infection (HR, 1.8; 95% CI, 1.3-2.4). Treatment of BV and promotion of vaginal colonization with lactobacilli should be evaluated as potential interventions to reduce a woman's risk of acquiring HIV-1, gonorrhea, and trichomoniasis.

In sub-Saharan Africa, where the effects of human immunodeficiency virus type 1 (HIV-1) have been most devastating, there are multiple subtypes of this virus. The distribution of different subtypes within African populations is generally not linked to particular risk behaviors. Thus, Africa is an ideal setting in which to examine the diversity and mixing of viruses from different subtypes on a population basis. In this setting, it is also possible to address whether infection with a particular subtype is associated with differences in disease stage. To address these questions, we analyzed the HIV-1 subtype, plasma viral loads, and CD4 lymphocyte levels in 320 women from Nairobi, Kenya. Subtype was determined by a combination of heteroduplex mobility assays and sequence analyses of envelope genes, using geographically diverse subtype reference sequences as well as envelope sequences of known subtype from Kenya. The distribution of subtypes in this population was as follows: subtype A, 225 (70.3%); subtype D, 65 (20.5%); subtype C, 22 (6.9%); and subtype G, 1 (0.3%). Intersubtype recombinant envelope genes were detected in 2.2% of the sequences analyzed. Given that the sequences analyzed represented only a small fraction of the proviral genome, this suggests that intersubtype recombinant viral genomes may be very common in Kenya and in other parts of Africa where there are multiple subtypes. The plasma viral RNA levels were highest in women infected with subtype C virus, and women infected with subtype C virus had significantly lower CD4 lymphocyte levels than women infected with the other subtypes. Together, these data suggest that women in Kenya who are infected with subtype C viruses are at more advanced stages of immunosuppression than women infected with subtype A or D. There are at least two models to explain the data from this cross-sectional study; one is that infection with subtype C is associated with a more rapid disease progression, and the second is that subtype C represents an older epidemic in Kenya. Discriminating between these possibilities in a longitudinal study will be important for increasing our understanding of the role of specific subtypes in the transmission and pathogenesis of HIV-1.

If human immunodeficiency virus type 1 (HIV-1) vaccines are to be highly effective, it is essential to understand the virologic factors that contribute to HIV-1 transmission. It is likely that transmission is determined, in part, by the genotype or phenotype (or both) of infectious virus present in the index case, which in turn will influence the quantity of virus that may be exchanged during sexual contact. Transmission may also depend on the fitness of the virus for replication in the exposed individual, which may be influenced by whether a virus encounters a target cell that is susceptible to infection by that specific variant. Of interest, our data suggest that the complexity of the virus that is transmitted may be different in female and male sexual exposures.

To monitor and analyse trends in HIV-1 seroprevalence among antenatal women in Nairobi, Kenya. Design: Six sequential surveys were carried out among antenatal clinic attenders at four Nairobi City Council health centres between November 1991 and April 1997. Methods: A total of 6828 women attending for first antenatal clinic visit were administered a standard questionnaire to obtain demographic information and were screened for HIV-1. Results: HIV-1 seroprevalence rose from 12.1% in the first survey to 16.2% in the third, completed in October 1993. No rise was observed in subsequent surveys, and seroprevalence among women under the age of 20 declined after the third survey. Significant differences in seroprevalence (P < 0.001) were observed in all survey rounds between women who reported that their province of origin was Nyanza (22.4% overall), compared with those from other provinces in western Kenya (14.1%), and the eastern group of provinces (8.9%). The rise in HIV-1 seroprevalence observed between 1991 and 1993 was almost entirely attributable to the rising seroprevalence among women from Nyanza. There were considerable differences in HIV-1 seroprevalence among the four health centres, partly accounted for by differences in the proportion of clinic attenders from different provinces of origin, which also changed significantly over time. Conclusions: HIV-1 seroprevalence has stabilized in antenatal women attending these health centres in Nairobi, and may be declining among women in the youngest age group. This may reflect stabilization of HIV-1 incidence, but further observation is required. The levels of infection among Nairobi residents reflect the evolution of the HIV epidemic in their provinces of origin, and changing client composition influences HIV-1 seroprevalence at different clinics. HIV sentinel surveillance should be carried out at multiple sites in large urban centres to monitor accurately the evolution of the HIV epidemic and the impact of control efforts in reducing transmission.

OBJECTIVES: To study the burden of disease of reproductive tract infections (RTIs) and cervical dysplasia in women attending a family planning clinic in Nairobi, Kenya, and to assess the acceptability of integrating reproductive healthcare services into existing family planning facilities. METHODS: In a family planning clinic in Nairobi, Kenya, 520 women were enrolled in a study on RTI and cervical dysplasia. RESULTS: RTI pathogens were detected in over 20% of women, the majority being asymptomatic. HIV-1 testing was positive in 10.2%. The diagnosis of cervical dysplasia was made on 12% of the cytology smears (mild in 5.8%, moderate in 3.5%, severe in 1.2%), and 1.5% had invasive cervical cancer. The intervention of case detection of RTI and Papanicolaou smear taking was well received by clients and considered feasible by the staff. CONCLUSIONS: Early detection and treatment of potentially curable cervical lesions and RTI provide a unique opportunity to improve women's health. In Kenya, where the current contraceptive prevalence rate is 33%, family planning clinics are excellent sites to introduce health interventions.

OBJECTIVES: To study the burden of disease of reproductive tract infections (RTIs) and cervical dysplasia in women attending a family planning clinic in Nairobi, Kenya, and to assess the acceptability of integrating reproductive healthcare services into existing family planning facilities. METHODS: In a family planning clinic in Nairobi, Kenya, 520 women were enrolled in a study on RTI and cervical dysplasia. RESULTS: RTI pathogens were detected in over 20% of women, the majority being asymptomatic. HIV-1 testing was positive in 10.2%. The diagnosis of cervical dysplasia was made on 12% of the cytology smears (mild in 5.8%, moderate in 3.5%, severe in 1.2%), and 1.5% had invasive cervical cancer. The intervention of case detection of RTI and Papanicolaou smear taking was well received by clients and considered feasible by the staff. CONCLUSIONS: Early detection and treatment of potentially curable cervical lesions and RTI provide a unique opportunity to improve women's health. In Kenya, where the current contraceptive prevalence rate is 33%, family planning clinics are excellent sites to introduce health interventions.

HIV-specific cytotoxic T lymphocytes (CTL) are believed to play a major role in controlling virus levels through the asymptomatic period of HIV infection. For the rational design of an HIV vaccine, we need to know whether protective immunity can ever develop following HIV exposure in people who remain uninfected. We have detected HIV-specific CTL in 5/6 repeatedly exposed, persistently seronegative female sex-workers in The Gambia. Their CTL, repeatedly detected over two years, recognise epitopes presented by HLA-B35 which are cross-reactive between HIV-1 & HIV-2, suggesting they could have been primed first by HIV-2 exposure and subsequently boosted by exposure to HIV-1. Using previously identified clade B HIV-1 epitope peptides, we have now detected HIV-specific CTL in 6/15 highly exposed and apparently HIV-resistant Kenyan prostitutes, predominantly towards epitopes highly conserved between B and the Kenyan A & D clades of HIV-1. This CTL activity towards conserved virus epitopes may represent protective immunity to HIV generated in response to repeated exposure, and prophylactic HIV vaccines should aim to generate similar CTL responses.

PIP: During the asymptomatic phase of HIV infection, HIV-specific cytotoxic T lymphocytes (CTL) are believed to play a major role in controlling virus levels. The design of an HIV vaccine requires knowledge about whether protective immunity can ever develop after exposure to the virus and the mechanisms underlying such natural immunity. The authors' research has focused on HIV-specific CTL responses in highly HIV-exposed commercial sex workers in The Gambia, West Africa, and in Nairobi, Kenya. HIV CTL was detected in 5 of 6 repeatedly exposed, persistently seronegative female sex workers in The Gambia. Their CTL recognized epitopes presented by HLA-835 that are cross-reactive between HIV-1 and HIV-2, suggesting they could have been primed first by HIV-2 exposure and subsequently boosted by exposure to HIV-1. Through use of previously identified clade B HIV-1 epitope peptides, the authors also detected HIV-specific CTL in 6 of 15 highly exposed and apparently resistant Kenyan prostitutes, predominantly toward epitopes highly conserved between B and Kenyan A and D clades of HIV-1. This CTL activity toward conserved virus epitopes may represent protective immunity to HIV in response to HIV generated by repeated exposure. HIV vaccines should aim to generate similar CTL responses. There is currently no evidence that genetic factors, other than weak HLA associations, influence susceptibility or resistance to HIV infection.

{ We aimed to determine if the clinical and histological features of chancroid are altered by HIV infection. Male patients presenting to the Nairobi special treatment clinic with a clinical diagnosis of chancroid were eligible for the study. A detailed history, physical examination, swabs for Haemophilus ducreyi culture and blood for HIV serology, syphilis serology and CD4 counts were obtained from all patients. Punch biopsies from an ulcer were obtained from 10 patients and either fixed in 10% formalin or snap frozen in Optimum Cutting Temperature (OCT) medium compound at -70 degrees C. Patients were treated with erythromycin and followed for 3 weeks. Chi-square and Student's t-test were used to determine if the clinical and laboratory features of chancroid differed between HIV-seropositive and seronegative individuals. Cox regression survival analysis was used to determine if HIV infection altered cure rates of chancroid at 21 days. Immunohistochemical staining was performed using lymphocytic and macrophage markers and tissue sections were analysed by 2 pathologists in a blinded manner. Between February and November 1994, 109 HIV-seropositive and 211 HIV-seronegative individuals were enrolled in the study. HIV patients had ulcers of longer duration than HIV-seronegative patients (P=0.03). Although cure rates were similar at 3 weeks, HIV patients had lower cure rates at 1 week (23% v 54%

Transport workers (n = 504) in Mombasa, Kenya, were screened for urethral infection by history, clinical examination, and laboratory testing of urethral swabs and first-catch urine specimens. The prevalence of Neisseria gonorrhoeae was 3.4%, Chlamydia trachomatis, 3.6%, and Trichomonas vaginalis, 6.0%; more than two-thirds of infections were asymptomatic. A complaint of urethral discharge, dysuria, or both was twice as sensitive as the sign of discharge on physical examination (34.5% vs. 15.5%) in identifying infection. A positive leukocyte esterase dipstick (LED) test on urine predicted infection with a sensitivity of 95.0% and a specificity of 59.3% in symptomatic men and with a sensitivity of 55.3% and a specificity of 82.8% in asymptomatic men. Demographic and behavioral factors were not independent predictors of infection. In resource-poor settings with high prevalences of urethral infection, an effective screening and management strategy would be to treat symptomatic men, as well as asymptomatic men with a positive LED test, for all three infection

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{ Sexually transmitted diseases (STDs) are highly prevalent in pregnant women in many developing countries and have been associated with poor obstetric outcomes. Case detection and treatment of STDs in women is problematic and expensive, underscoring the need for other strategies. To explore the potential benefits of routine antimicrobial therapy on pregnancy outcome, we carried out a randomized, double-blind, clinical trial in one of the antenatal clinics in Nairobi, Kenya. Four hundred pregnant women between 28 and 32 weeks' gestation were given a single dose of 250 mg ceftriaxone intramuscularly or a placebo. There was a significant difference between ceftriaxone and placebo-treated women in infant birth weight (3,209 versus 3,056 g

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{ Sexually transmitted diseases (STDs) are highly prevalent in pregnant women in many developing countries and have been associated with poor obstetric outcomes. Case detection and treatment of STDs in women is problematic and expensive, underscoring the need for other strategies. To explore the potential benefits of routine antimicrobial therapy on pregnancy outcome, we carried out a randomized, double-blind, clinical trial in one of the antenatal clinics in Nairobi, Kenya. Four hundred pregnant women between 28 and 32 weeks' gestation were given a single dose of 250 mg ceftriaxone intramuscularly or a placebo. There was a significant difference between ceftriaxone and placebo-treated women in infant birth weight (3,209 versus 3,056 g

{ Sexually transmitted diseases (STDs) are highly prevalent in pregnant women in many developing countries and have been associated with poor obstetric outcomes. Case detection and treatment of STDs in women is problematic and expensive, underscoring the need for other strategies. To explore the potential benefits of routine antimicrobial therapy on pregnancy outcome, we carried out a randomized, double-blind, clinical trial in one of the antenatal clinics in Nairobi, Kenya. Four hundred pregnant women between 28 and 32 weeks' gestation were given a single dose of 250 mg ceftriaxone intramuscularly or a placebo. There was a significant difference between ceftriaxone and placebo-treated women in infant birth weight (3,209 versus 3,056 g

{ Sexually transmitted diseases (STDs) are highly prevalent in pregnant women in many developing countries and have been associated with poor obstetric outcomes. Case detection and treatment of STDs in women is problematic and expensive, underscoring the need for other strategies. To explore the potential benefits of routine antimicrobial therapy on pregnancy outcome, we carried out a randomized, double-blind, clinical trial in one of the antenatal clinics in Nairobi, Kenya. Four hundred pregnant women between 28 and 32 weeks' gestation were given a single dose of 250 mg ceftriaxone intramuscularly or a placebo. There was a significant difference between ceftriaxone and placebo-treated women in infant birth weight (3,209 versus 3,056 g

{ Sexually transmitted diseases (STDs) are highly prevalent in pregnant women in many developing countries and have been associated with poor obstetric outcomes. Case detection and treatment of STDs in women is problematic and expensive, underscoring the need for other strategies. To explore the potential benefits of routine antimicrobial therapy on pregnancy outcome, we carried out a randomized, double-blind, clinical trial in one of the antenatal clinics in Nairobi, Kenya. Four hundred pregnant women between 28 and 32 weeks' gestation were given a single dose of 250 mg ceftriaxone intramuscularly or a placebo. There was a significant difference between ceftriaxone and placebo-treated women in infant birth weight (3,209 versus 3,056 g

{ Sexually transmitted diseases (STDs) are highly prevalent in pregnant women in many developing countries and have been associated with poor obstetric outcomes. Case detection and treatment of STDs in women is problematic and expensive, underscoring the need for other strategies. To explore the potential benefits of routine antimicrobial therapy on pregnancy outcome, we carried out a randomized, double-blind, clinical trial in one of the antenatal clinics in Nairobi, Kenya. Four hundred pregnant women between 28 and 32 weeks' gestation were given a single dose of 250 mg ceftriaxone intramuscularly or a placebo. There was a significant difference between ceftriaxone and placebo-treated women in infant birth weight (3,209 versus 3,056 g

{ Sexually transmitted diseases (STDs) are highly prevalent in pregnant women in many developing countries and have been associated with poor obstetric outcomes. Case detection and treatment of STDs in women is problematic and expensive, underscoring the need for other strategies. To explore the potential benefits of routine antimicrobial therapy on pregnancy outcome, we carried out a randomized, double-blind, clinical trial in one of the antenatal clinics in Nairobi, Kenya. Four hundred pregnant women between 28 and 32 weeks' gestation were given a single dose of 250 mg ceftriaxone intramuscularly or a placebo. There was a significant difference between ceftriaxone and placebo-treated women in infant birth weight (3,209 versus 3,056 g

OBJECTIVE: To study the impact of maternal human immunodeficiency virus type 1 (HIV-1) infection on pregnancy outcome. METHODS: Between January 1989 and December 1991, 406 HIV-1-seropositive and 407 HIV-1-seronegative age- and parity-matched pregnant women from Nairobi, Kenya, all at less than 28 weeks' gestation, were recruited into a prospective study of HIV-1 infection in pregnant women and their offspring. Both groups were followed until 6 weeks postpartum. RESULTS: Three hundred fifteen HIV-1-seropositive women and 311 HIV-1-seronegative controls were followed until delivery. Seropositive women were younger at sexual debut and reported more lifetime partners and more sexually transmitted diseases (STDs) than the seronegative controls. The seropositive women had higher rates of genital ulcer disease (4.7 versus 2.0%; P = .08), genital warts (4.9 versus 2.0%; P = .03), and positive syphilis serology (7.9 versus 3.2%; P < .001), but there were no differences between the groups in isolation rates of Neisseria gonorrhoeae (6.8 versus 7.1%) and Chlamydia trachomatis (11.5 versus 9.0%). Maternal HIV-1 infection was associated with significantly lower birth weight (2913 versus 3072 g; P = .0003) and with prematurity (21.1 versus 9.4%; P < .0001), but not with small for gestational age size (4.2 versus 3.2%; P = .7). The stillbirth rate was higher in seropositive women, yet not statistically significant (3.8 versus 1.9%; P = .2). Women with a CD4 count lower than 30% had a higher risk of preterm delivery (26.3 versus 10.1%; P < .001). Postpartum endometritis was more common in HIV-1-infected women than in seronegative controls (10.3 versus 4.2%; P = .01) and was inversely correlated with the CD4 percentage. No histopathologic placental abnormalities attributable to HIV-1 were detected. CONCLUSION: Maternal HIV-1 infection was significantly associated with prematurity and postpartum endometritis, but not with fetal growth retardation. There was a trend toward a higher stillbirth rate in HIV-1-seropositive mothers.

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The sexual transmission of human immunodeficiency virus type 1 (HIV-1) continues at an alarming rate in sub-Saharan Africa despite the fact that awareness of AIDS is high. One explanation for this alarming rate may be that individuals do not believe that they are personally at risk for AIDS and are not sufficiently motivated to make changes in their behavior. We conducted a cross-sectional study of men with genital ulcer disease to assess their sexual behavior and their perceived risk of AIDS. We studied 787 men between the ages of 17 and 54 years who presented to a referral clinic for sexually transmitted diseases (STDs) in Nairobi, Kenya. Of these 787 men, 188 (24%) were infected with HIV-1. Awareness of AIDS was essentially universal in this population; however, only 64 men (8%) thought that they were personally at risk of developing AIDS. A logistic regression analysis found that men who believed they were personally at risk knew someone with AIDS (odds ratio [OR], 8.9; 95% confidence interval [CI], 4.0-19.7), received information about AIDS from television or video (OR, 3.0; 95% CI, 1.7-5.5), or had previously had an STD (OR, 2.2; 95% CI, 1.2-4.1). Except for a modest increase in condom use, there was no significant difference in sexual behavior between the group who considered themselves to be at risk for AIDS and the group who did not consider themselves to be at risk. The results of this study challenge the current strategies on HIV/AIDS education and prevention for urban men in Kenya.

Acute salpingitis complicating cervical gonococcal infection is a significant cause of infertility. Relatively little data are available concerning the pathophysiologic mechanisms of this disease. A cohort of 243 prostitutes residing in Nairobi were followed between March 1985 and April 1988. Gonococcal cultures were performed at each visit, and acute salpingitis was diagnosed clinically. Serum at enrollment was tested by immunoblot for antibody to gonococcal outer membrane proteins. 8.6% (146/1689) of gonococcal infections were complicated by salpingitis. Increased risk of salpingitis was associated with younger age, shorter duration of prostitution, HIV infection, number of gonococcal infections, and episodes of nongonococcal salpingitis. Rmp antibody increased the risk of salpingitis. Antibody to Opa decreased the risk of salpingitis. By logistic regression analysis, antibody to Opa was independently associated with decreased risk of gonococcal salpingitis (adjusted odds ratio [OR], 0.35; 95% confidence interval [95%CI], 0.17-0.76); HIV infection (adjusted OR, 3.5; 95% CI, 0.96-12.8) and episodes of nongonococcal salpingitis (adjusted OR, 3.4; 95% CI, 1.8-6.4) were independently associated with an increased risk of salpingitis. Antibody to Opa appears to protect against ascending gonococcal infection, perhaps by interfering with Opa mediated adherence and endocytosis. The demonstration of natural immunity that protects against upper genital tract infection in women suggests that a vaccine to prevent gonococcal salpingitis is possible.

The severe adverse effects of gonococcal infection on human fertility suggests that Neisseria gonorrhoeae would exert powerful selection for the development of a protective immune response in humans. N. gonorrhoeae is an obligate human pathogen and must persist in humans to survive. Since it is an ecologically successful organism, it must have evolved strategies to evade any human immune response it elicits. In a longitudinal study among 243 women working as prostitutes and experiencing frequent gonococcal infection, younger women, women with HIV infection, and women with antibody to the gonococcal outer membrane protein 3 (Rmp) were at increased risk of infection (adjusted odds ratio 3.4, CI95% 1.1-10.4, P < 0.05). Rmp is highly conserved in N. gonorrhoeae and the blocking of mucosal defences may be one of its functions. As similar proteins occur in many gram negative mucosal pathogens, the enhancing effect of such proteins may be a general strategy whereby bacteria evade human immune responses.

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Between March 1985 and July 1986 researchers enrolled 243 female prostitutes in Pumwani community of Nairobi, Kenya, in a longitudinal study to examine the relationship between the antibody to the gonococcal outer membrane protein 3 (Rmp Ab) and gonococcal mucosal infection. Few women used condoms. 69% were HIV-1 seropositive. Just 9.5% (23) of the women had not had any gonococcal infections, despite probable exposure to them, indicating the possibility of some acquired protective immunity to Neisseria gonorrhoea. 90.5% had had at least 1 gonococcal infection. Women with Rmp Ab faced a greater risk of gonococcal infection than those who were Rmp Ab negative (OR = 3.4;l p .05), denoting that Rmp Ab increases susceptibility to gonococcal mucosal infections. Women older than 29 years were at lower risk of gonococcal infection than those younger than 29 years (odds ratio [OR] = 0.3; p .03). Women who used oral contraceptives (OCs) were also likely to be infected with N. gonorrhoea (OR = 3; p = .062). Further, 31% of OC users had cervical ectopy compared to just 14% of nonusers (OR = 2.8; p .005), suggesting that the effect of OCs on the cervix make it more susceptible to gonococcal infection. Rmp Ab also exists in many other gram-negative mucosal pathogens, often playing the same role as it does in N. gonorrhoea infection. Thus, Rmp Ab may be a common scheme bacteria used to elude human immune responses. These findings provide more understanding as to why N. gonorrhoea is an ecologically successful human pathogen

Ceftriaxone in a dose of 250 mg given intramuscularly is currently recommended for the treatment of chancroid. Among 133 men in Nairobi, Kenya, with culture-proven chancroid, who were treated with ceftriaxone, treatment failed in 35%. Poor outcome was associated with human immunodeficiency virus type 1 seropositivity. Thus, treatment recommendations for chancroid should be reevaluated.

OBJECTIVE: To determine the prevalence of HIV-1 and syphilis antibodies in a population of pregnant women in Nairobi, Kenya, between 1989 and 1991. METHODS: As part of an ongoing prospective study on the effect of HIV-1 infection and sexually transmitted diseases, 4883 pregnant women were screened for HIV-1 and syphilis antibodies in one health-centre in Nairobi. RESULTS: HIV-1 seroprevalence increased from 6.5 to 13.0% (P < 0.001) and syphilis seroreactivity from 2.9 to 5.3% (P = 0.002), while there was no change in gonococcal infection rates. The most rapid increase in HIV-1 prevalence was observed in women aged less than 25 years. There was no evidence of demographic fluctuations in the population during this time, or of changes in sexual behaviour, except that fewer women enrolled in 1991 reported having more than one sex partner, compared with women enrolled in 1989 (39.1 versus 20.0%; P = 0.0001). HIV-1-seropositive women were more likely to be seroreactive for syphilis than HIV-1-seronegative mothers (7.7 versus 3.2%; odds ratio = 2.5; 95% confidence interval, 1.7-3.8; P < 0.001), but there was no difference between the two groups in terms of gonorrhoea prevalence. CONCLUSION: These data confirm an association between HIV-1 and syphilis infection, and indicate that both are spreading rapidly among women in Nairobi outside high-risk groups. Increased efforts to control both infections are urgently required.

PIP: Between January 1989 and December 1991, health workers took blood samples from 4883 pregnant women attending the Nairobi City Commission's Langata Clinic in Nairobi, Kenya to determine demographic factors and indicators of sexual behavior to explain the increase in HIV-1 infection and syphilis among these women of low socioeconomic status. HIV-1 seroprevalence stood at 8.8%. Syphilis seroreactivity was 3.6%. HIV-1 seropositive mothers were 2.5 times more likely to also test positive for syphilis than were HIV-1 seronegative mothers (7.7% vs. 3.2%; p.001). There was no significant association between HIV-1 seropositivity and gonococcal infection rate (7.3% vs. 8.9%), however. Women who tested HIV-1 positive tended to be from western Kenya (60.1% vs. 39.1%; p.0001). Between 1989 and 1991, annual HIV-1 seroprevalence rates increased from 6.5% to 13% (p.001) as did annual syphilis seroreactivity rates (2.9-5.3%; p=.02). The HIV-1 seroprevalence rates remained high, but did not rise significantly among syphilis seroreactive women between 1989 and 1991 (17.9-20.7%). They did rise among syphilis seronegative women (6.9-12.5%; p.0001), however. The HIV-1 infection rate increase was greater among 25-year old women (5.6-13.2%; p.001) than it was among 25-year old women (6.8-12.7%; p=.09). Indeed the annual incidence rate for 25-year old women was 3-4%. Between 1989-1991, there was a decrease in the percentage of both HIV-1 seropositive and seronegative women who had had 1 sex partner during the last 2 years (39.1% vs. 20%; p=.0001). Demographic factors remained the same throughout the study period. These results verified the link between HIV-1 infection and syphilis and their rapid rise among women in low risk groups. Thus there was a pressing need to improve HIV-1 and sexually transmitted disease prevention programs.

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We standardized a serologic enzyme immunoassay (EIA) for human immunoglobulin G and M antibodies against Haemophilus ducreyi. We evaluated the performance of this test with respect to the time from acute chancroid and coinfection with human immunodeficiency virus (HIV). Antibody to a crude, soluble bacterial antigen of one H. ducreyi strain was detected in a panel of serum samples from clinically and microbiologically confirmed cases of chancroid and from controls. Test interpretation was standardized for optimal sensitivity and specificity. Performance of the EIA was enhanced in the period of early convalescence from acute primary chancroid and was not diminished in the presence of HIV coinfection. The EIA performed adequately as a serologic screening test for field evaluation and epidemiologic application in conjunction with sexually transmitted disease and HIV detection and control efforts.

Sexually transmitted diseases (STDs) have a significant adverse effect on reproductive and child health worldwide. The control of STDs such as gonorrhea is therefore an absolute priority. Cefixime, an oral third-generation cephalosporin with in vitro activity similar to that of ceftriaxone, may be an effective candidate for the treatment of gonorrhea. The efficacy of a single oral 400-mg dose of cefixime was compared with that of a single intramuscular 250-mg dose of ceftriaxone for the treatment of Neisseria gonorrhoeae urethritis in 190 men and cervicitis in 46 women in Nairobi, Kenya. A bacteriologic cure was recorded in 100% of 63 evaluatable patients treated with ceftriaxone and 118 (98%) of 121 evaluatable patients treated with cefixime. Cefixime, as a single oral dose, is an effective alternative for the treatment of uncomplicated gonococcal urethritis in men and cervicitis in women

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A total of 120 sets of blood cultures were performed aerobically from 60 children with clinically diagnosed septicaemia at Kenyatta National Hospital, Nairobi. Out of these, 36 (30%) sets from 19 (31.7%) patients yielded bacterial growth while 84 (70%) sets from 41 (68.3%) were negative. Salmonella typhimurium was the most frequently isolated bacteria (63%), followed by SlIlphylococcus aureus (15.8%). Salmonella typhimurium isolates were mostly multi-antibiotic resistant, most of them only sensitive to amlkacln and cefotaxime, while all were resistant to ampicillin and co-trimoxazole, the most frequently used antibiotic in this hospital.

Analyzing why the rate of transmission of AIDS varies widely in Africa is the basis for designing strategies for intervention. Promiscuity, i.e. high rates of sex partner change, is not the only reason for rapid transmission, but it is a prerequisite for the explosive spread seen in certain groups. High frequency groups include mobile single men and prostitutes. Research and strategies must focus on sex practices, concepts of personal vulnerability, and possibility of behavioral change. The sexually transmitted diseases that are thought to increase susceptibility to HIV, i.e., genital ulcer diseases, can be controlled with appropriate strategies. Male circumcision is associated with lower HIV seroprevalence. Thus strategies must be concentrate on sustained prevention among high STD transmitters, providing early, effective care for STDs, increasing economic alternatives for women, and offering voluntary circumcision where culturally acceptable.

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Increasing resistance of Haemophilus ducreyi to antimicrobials necessitates further trials of new antimicrobial agents for treating chancroid. Enoxacin has excellent in vitro activity against H ducreyi, and a randomised clinical trial of three doses of enoxacin 400 mg at intervals of 12 hours compared with a single dose of trimethoprim/sulphametrole (TMP/SMT) 640/3200 mg was therefore conducted. Of 169 men enrolled in the study, 86 received enoxacin and 83 received TMP/SMT. Ulcers were improved or cured in 65/73 men treated with enoxacin and 57/70 men treated with TMP/SMT. This difference was not significant. At 72 hours after treatment, H ducreyi was eradicated from ulcers of 72/77 men treated with enoxacin and of 67/74 of those treated with TMP/SMT. Patients with buboes responded equally well to both treatments. Of 100 H ducreyi strains tested, all were susceptible to both 0.25 mg/l enoxacin and the combination of 0.25 mg/l TMP and 5 mg/l SMT. Although most men treated with either regimen were cured, neither regimen appeared to be the optimum treatment for chancroid. This study shows the efficacy of enoxacin for a soft tissue infection caused by Gram negative organisms.

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Stratégies générales pour le contrôle de l'infection. Prévention primaire de la transmission sexuelle du HIV, stratégies pour la réduction de l'exposition des sujets sensibles. Contrôle des transmissions périnatales et parentérales

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Amoxycillin and clavulanic acid (Augmentin; Beecham Research Laboratories) was used to treat patients with bacteriologically proved chancroid in three different dose regimens. A single dose of Augmentin (amoxycillin 3 g, clavulanic acid 350 mg) was found to be ineffective. A similar dose repeated after 24 hours was equally ineffective, but a dose (amoxycillin 500 mg, clavulanic acid 250 mg) given every 8 hours for three days was found to be effective. The drug was well tolerated and no side effects were noted in any of the patients treated

Routine procedures used to isolate Haemophilus ducreyi in a busy laboratory are reported. Identification was based on colony morphology and nutritional and biochemical properties of 120 fresh isolates of H. ducreyi. These isolates grew very well on Gonococcal Agar and Mueller-Hinton Agar incubated at 34 degrees C in candle extinction jars containing moistened filter paper. Colonies varied in size, giving a polymorphic appearance. They were smooth, dome-shaped, and buff-yellow to grey in colour, and measured 2 mm in diameter. They could be pushed intact across the agar surface. By microscopic examination of gram-stained smears the isolates were gram-negative coccobacilli arranged in short chains, clumps or whorls and occasionally in typical "rail track" arrangements. Individual bacteria showed bipolar staining. Colonies autoagglutinated in saline. All strains were catalase-negative and did not produce indole or H2S. They were oxidase- and beta-lactamase positive and required X but not V factor for growth. Now that reliable techniques have been developed and characteristics established it is possible for most clinical laboratories to isolate and identify this organism from most patients with chancroid.

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The efficacy of a single 2.5-g dose of thiamphenicol against infection with penicillinase-producing strains of Neisseria gonorrhoeae (PPNG) or non-penicillinase-producing strains (non-PPNG) was studied in a two-phase clinical trial in Nairobi. The first phase included men who had had a urethral discharge for less than seven days, were infected with either PPNG or non-PPNG, and had not received previous treatment. The second phase included men with PPNG infections that had not responded to treatment with penicillin. The overall cure rate (determined by follow-up examinations and cultures three and ten days after treatment) was 90.6% in the first phase of the study and 92.1% in the second phase. A second 2.5-g dose of thiamphenicol was administered to four of the six patients in the second phase whose cultures yielded gonococci after the initial dose; the infections of all four patients were cured. The results of disk diffusion tests of gonococcal isolates did not correlate well with the outcome of treatment.

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