The aim of this study was to identify factors associated with prevention of mother-to-child transmission (PMTCT) in an area of Kenya with widely accessible free PMTCT services. A matched case-control study was conducted at 31 public facilities in western Kenya. HIV-infected mothers with infants aged 6 weeks to 6 months were interviewed and medical charts were reviewed. Cases were mothers of infants with a definitive diagnosis of HIV. Controls were mothers of infants testing HIV negative. Cases and controls were matched in a 1:3 ratio on socio-demographic factors. Fifty cases and 135 controls were enrolled. Conditional (matched) logistic regression analysis was conducted. Odds of being a case were higher for women who first learned their HIV status during pregnancy [OR:2.85, 95%CI:1.41-5.78], did not adhere to antiretroviral therapy (ART) [OR:3.35, 95%CI:1.48-7.58], or had a home delivery [OR:2.42, 95%CI:1.01-5.80]. Based on medical record review, cases had higher odds of their provider not following guidelines for prescription of ART for mothers [OR:8.61, 95%CI:2.83-26.15] and infants [OR:9.72, 95%CI:2.75-34.37]. Stigma from the community [OR:0.37, 95% CI:0.14-1.02] or facility [OR:0.38, 95%CI:0.04-3.41], did not increase the odds of MTCT. Poor adherence to PMTCT guidelines and recommendations by both infected women and health care providers hamper efforts to attain elimination of MTCT.

Background

Besides access to medical male circumcision, HIV testing, access to condoms and consistent condom use are additional strategies men can use to prevent HIV acquisition. We examine male behavior toward testing and condom use.

Objective

To determine factors associated with never testing for HIV and consistent condom use among men who never test in Soweto.

Methods

A cross-sectional survey in Soweto was conducted in 1539 men aged 18-32 years in 2007. Data were collected on socio-demographic and behavioral characteristics to determine factors associated with not testing and consistent condom use.

Results

Over two thirds (71%) of men had not had an HIV test and the majority (55%, n = 602) were young (18-23). Of those not testing, condom use was poor (44%, n = 304). Men who were 18-23 years (aOR: 2.261, CI: 1.534-3.331), with primary (aOR: 2.096, CI: 1.058-4.153) or high school (aOR: 1.622, CI: 1.078-2.439) education, had sex in the last 6 months (aOR: 1.703, CI: 1.055-2.751), and had ≥1 sexual partner (aOR: 1.749, CI: 1.196-2.557) were more likely not to test. Of those reporting condom use (n = 1036, 67%), consistent condom use was 43% (n = 451). HIV testing did not correlate with condom use.

Conclusion

Low rates of both condom use and HIV testing among men in a high HIV prevalence setting are worrisome and indicate an urgent need to develop innovative behavioral strategies to address this shortfall. Condom use is poor in this population whether tested or not tested for HIV, indicating no association between condom use and HIV testing.

Objective

Throughout most of sub-Saharan Africa (SSA), prevention of mother-to-child transmission (PMTCT) services are readily available. However, PMTCT programs in SSA have had suboptimal performance compared to other regions of the world. The main objective of this study is to explore the socio-ecological and individual factors influencing the utilization of PMTCT services among HIV-positive pregnant women in western Kenya using a social ecological model as our analytical lens.

Methods

Data were collected using in-depth interviews with 33 HIV-infected women attending government health facilities in rural western Kenya. Women with HIV-infected infants aged between 6 weeks to 6 months with a definitive diagnosis of HIV in the infant, as well as those with an HIV-negative test result in the infant were interviewed between November 2012 and June 2013. Coding and analysis of the transcripts followed grounded theory tenets. Coding reports were discussed in a series of meetings held among the authors. We then employed constant comparative analysis to discover dominant individual, family, society and structural determinants of PMTCT use.

Results

Barriers to women's utilization of PMTCT services fell within the broad constructs of the socio-ecological model of individual, family, society and structural determinants. Several themes cut across the different steps of PMTCT cascade and relate to different constructs of the socio-ecological model. These themes include: self-motivation, confidence and resilience, family support, absence or reduced stigma, right provider attitude and quality of health services provided. We also found out that these factors ensured enhanced maternal health and HIV negative children.

Conclusion

The findings of this study suggest that a woman's social environment is an important determinant of MTCT. PMTCT Interventions must comprehensively address multiple factors across the different ecological levels. More research is however required for the development of multi-component interventions that combine strategies at different ecological levels.

Objective

Preventing unintended pregnancy among HIV-positive women constitutes a critical and cost-effective approach to primary prevention of mother-to-child transmission of HIV and is a global public health priority for addressing the desperate state of maternal and child health in HIV hyper-endemic settings. We sought to investigate whether the prevalence of contraceptive use and method preferences varied by HIV status and receipt of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa.

Methods

We used survey data from 563 sexually active, non-pregnant women (18-44 years) recruited from the Perinatal HIV Research Unit in Soweto (May-December, 2007); 171 women were HIV-positive and receiving HAART (median duration of use = 31 months; IQR = 28, 33), 178 were HIV-positive and HAART-naïve, and 214 were HIV-negative. Medical record review was conducted to confirm HIV status and clinical variables. Logistic regression models estimated adjusted associations between HIV status, receipt of HAART, and contraceptive use.

Results

Overall, 78% of women reported using contraception, with significant variation by HIV status: 86% of HAART users, 82% of HAART-naïve women, and 69% of HIV-negative women (p<0.0001). In adjusted models, compared with HIV-negative women, women receiving HAART were significantly more likely to use contraception while HAART-naïve women were non-significantly more likely (AOR: 2.40; 95% CI: 1.25, 4.62 and AOR: 1.59; 95% CI: 0.88, 2.85; respectively). Among HIV-positive women, HAART users were non-significantly more likely to use contraception compared with HAART-naïve women (AOR: 1.55; 95% CI: 0.84, 2.88). Similar patterns held for specific use of barrier (primarily male condoms), permanent, and dual protection contraceptive methods.

Conclusion

Among HIV-positive women receiving HAART, the observed higher prevalence of contraceptive use overall and condoms in particular promises to yield fewer unintended pregnancies and reduced risks of vertical and sexual HIV transmission. These findings highlight the potential of integrated HIV and reproductive health services to positively impact maternal, partner, and child health.

Background

There is increased focus on HIV prevention with African men who report experiencing childhood sexual (CSA) or physical abuse (CPA).

Objective

To better understand the effects of a community-based intervention (Project Accept HPTN 043) on HIV prevention behaviors among men who report CSA or CPA experiences.

Methods

Project Accept compared a community-based voluntary mobile counseling and testing (CBVCT) intervention with standard VCT. The intervention employed individual HIV risk reduction planning with motivational interviewing in 34 African communities (16 communities at 2 sites in South Africa, 10 in Tanzania, and 8 in Zimbabwe). Communities were randomized unblinded in matched pairs to CBVCT or SVCT, delivered over 36 months. The post-intervention assessment was conducted using a single, cross-sectional random survey of 18-32 year-old community members (total N = 43,292). We analyzed the effect of the intervention on men with reported CSA or CPA across the African sites. Men were identified with a survey question asking about having experienced CSA or CPA across the lifespan. The effect of intervention on considered outcomes of the preventive behavior was statistically evaluated using the logistic regression models.

Results

Across the sites, the rates of CSA or CPA among men indicated that African men reflected the global prevalence (20%) with a range of 13-24%. The statistically significant effect of the intervention among these men was seen in their increased effort to receive their HIV test results (OR 2.71; CI: (1.08, 6.82); P: 0.034). The intervention effect on the other designated HIV prevention behaviors was less pronounced.

Conclusion

The effect of the intervention on these men showed increased motivation to receive their HIV test results. However, more research is needed to understand the effects of community-based interventions on this group, and such interventions need to integrate other keys predictors of HIV including trauma, coping strategies, and intimate partner violence.

By comparing younger to older participants enrolled in a HIV vaccine efficacy trial, we aimed to gain insights into the inclusion of adolescents in future trials. This was a sub-analysis of a multisite HIV vaccine randomized clinical trial in South Africa, conducted January-September 2007. Motivations for trial enrolment, social harms, adverse events and loss to follow-up were compared between younger (18-20 years old) and older participants (21-35 years old). Both younger (n = 238) and older participants (n = 563) were equally likely to report enrolling for altruistic reasons. Younger females were less likely than older participants to join for trial reimbursement (p = 0.005), while younger males were more likely to enrol because the vaccine may provide protection from HIV-acquisition (p < 0.001). There were no significant differences in the number of social harms reported. Compared to males over 20 years old, 18-20-year-old females were less likely to experience adverse events (OR = 0.1, CI 0.01-0.80) and no more likely to be lost to follow-up (OR = 0.7, CI 0.39-1.25), while 18-20-year-old males were no more likely to experience adverse events (OR = 1.3, CI 0.58-2.83) or loss to follow-up (OR = 0.8, CI 0.51-1.41). Our data support the inclusion of younger participants who are at risk for HIV in future HIV vaccine efficacy trials.

Background

Fourth-generation HIV assays detect both antigen and antibody, facilitating detection of acute/early HIV infection. The Bio-Rad GS HIV Combo Ag/Ab assay (Bio-Rad Combo) is an enzyme immunoassay that simultaneously detects HIV p24 antigen and antibodies to HIV-1 and HIV-2 in serum or plasma.

Objective

To evaluate the performance of the Bio-Rad Combo assay for detection of HIV infection in adults from Southern Africa.

Study design

Samples were obtained from adults in Soweto and Vulindlela, South Africa and Dar es Salaam, Tanzania (300 HIV-positive samples; 300 HIV-negative samples; 12 samples from individuals previously classified as having acute/early HIV infection). The samples were tested with the Bio-Rad Combo assay. Additional testing was performed to characterize the 12 acute/early samples.

Results

All 300 HIV-positive samples were reactive using the Bio-Rad Combo assay; false positive test results were obtained for 10 (3.3%) of the HIV-negative samples (sensitivity: 100%, 95% confidence interval [CI]: 98.8-100%); specificity: 96.7%, 95% CI: 94.0-98.4%). The assay detected 10 of the 12 infections classified as acute/early. The two infections that were not detected had viral loads<400 copies/mL; one of those samples contained antiretroviral drugs consistent with antiretroviral therapy.

Conclusions

The Bio-Rad Combo assay correctly classified the majority of study specimens. The specificity reported here may be higher than that seen in other settings, since HIV-negative samples were pre-screened using a different fourth-generation test. The assay also had high sensitivity for detection of acute/early infection. False-negative test results may be obtained in individuals who are virally suppressed.

Abstract Background Study-based global health interventions, especially those that are conducted on an international or multi-site basis, frequently require site-specific adaptations in order to (1) respond to socio-cultural differences in risk determinants, (2) to make interventions more relevant to target population needs, and (3) in recognition of ‘global health diplomacy' issues. We report on the adaptations development, approval and implementation process from the Project Accept voluntary counseling and testing, community mobilization and post-test support services intervention. Methods We reviewed all relevant documentation collected during the study intervention period (e.g. monthly progress reports; bi-annual steering committee presentations) and conducted a series of semi-structured interviews with project directors and between 12 and 23 field staff at each study site in South Africa, Zimbabwe, Thailand and Tanzania during 2009. Respondents were asked to describe (1) the adaptations development and approval process and (2) the most successful site-specific adaptations from the perspective of facilitating intervention implementation. Results Across sites, proposed adaptations were identified by field staff and submitted to project directors for review on a formally planned basis. The cross-site intervention sub-committee then ensured fidelity to the study protocol before approval. Successfully-implemented adaptations included: intervention delivery adaptations (e.g. development of tailored counseling messages for immigrant labour groups in South Africa) political, environmental and infrastructural adaptations (e.g. use of local community centers as VCT venues in Zimbabwe); religious adaptations (e.g. dividing clients by gender in Muslim areas of Tanzania); economic adaptations (e.g. co-provision of income generating skills classes in Zimbabwe); epidemiological adaptations (e.g. provision of ‘youth-friendly’ services in South Africa, Zimbabwe and Tanzania), and social adaptations (e.g. modification of terminology to local dialects in Thailand: and adjustment of service delivery schedules to suit seasonal and daily work schedules across sites). Conclusions Adaptation selection, development and approval during multi-site global health research studies should be a planned process that maintains fidelity to the study protocol. The successful implementation of appropriate site-specific adaptations may have important implications for intervention implementation, from both a service uptake and a global health diplomacy perspective.

Background

In resource-limited settings, HIV infection is often diagnosed using 2 rapid tests. If the results are discordant, a third tie-breaker test is often used to determine HIV status. This study characterized samples with discordant rapid tests and compared different testing strategies for determining HIV status in these cases.

Methods

Samples were previously collected from 173 African adults in a population-based survey who had discordant rapid test results. Samples were classified as HIV positive or HIV negative using a rigorous testing algorithm that included two fourth-generation tests, a discriminatory test, and 2 HIV RNA tests. Tie-breaker tests were evaluated, including rapid tests (1 performed in-country), a third-generation enzyme immunoassay, and two fourth-generation tests. Selected samples were further characterized using additional assays.

Results

Twenty-nine samples (16.8%) were classified as HIV positive and 24 of those samples (82.8%) had undetectable HIV RNA. Antiretroviral drugs were detected in 1 sample. Sensitivity was 8.3%-43% for the rapid tests; 24.1% for the third-generation enzyme immunoassay; 95.8% and 96.6% for the fourth-generation tests. Specificity was lower for the fourth-generation tests than the other tests. Accuracy ranged from 79.5% to 91.3%.

Conclusions

In this population-based survey, most HIV-infected adults with discordant rapid tests were virally suppressed without antiretroviral drugs. Use of individual assays as tie-breaker tests was not a reliable method for determining HIV status in these individuals. More extensive testing algorithms that use a fourth-generation screening test with a discriminatory test and HIV RNA test are preferable for determining HIV status in these cases.

To better understand the transmission of human immunodeficiency virus type 1 (HIV-1), the genetic characteristics of blood and genital viruses from males were compared to those of the imputed founding virus population in their female partners. Initially serodiscordant heterosexual African couples with sequence-confirmed male-to-female HIV-1 transmission and blood and genital specimens collected near the time of transmission were studied. Single viral templates from blood plasma and genital tract RNA and DNA were sequenced across HIV-1 env gp160. Eight of 29 couples examined yielded viral sequences from both tissues. Analysis of these couples' sequences demonstrated, with one exception, that the women's founding viral populations arose from a single viral variant and were CCR5 tropic, even though CXCR4 variants were detected within four males. The median genetic distance of the imputed most recent common ancestor of the women's founder viruses showed that they were closer to the semen viruses than to the blood viruses of their transmitting male partner, but this finding was biased by detection of a greater number of viral clades in the blood. Using multiple assays, the blood and genital viruses were consistently found to be compartmentalized in only two of eight men. No distinct amino acid signatures in the men's viruses were found to link to the women's founders, nor did the women's env sequences have shorter variable loops or fewer N-linked glycosylation sites. The lack of selective factors, except for coreceptor tropism, is consistent with others' findings in male-to-female and high-risk transmissions. The infrequent compartmentalization between the transmitters' blood and semen viruses suggests that cell-free blood virus likely includes HIV-1 sequences representative of those of viruses in semen.IMPORTANCE Mucosal transmissions account for the majority of HIV-1 infections. Identification of the viral characteristics associated with transmission would facilitate vaccine design. This study of HIV strains from transmitting males and their seroconverting female partners found that the males' genital tract viruses were rarely distinct from the blood variants. The imputed founder viruses in women were genetically similar to both the blood and genital tract variants of their male partners, indicating a lack of evidence for genital tract-specific lineages. These findings suggest that targeting vaccine responses to variants found in blood are likely to also protect from genital tract variants.