Identifying modifiable factors that increase women's vulnerability to HIV is a critical step in developing effective female-initiated prevention interventions. The primary objective of this study was ...to pool individual participant data from prospective longitudinal studies to investigate the association between intravaginal practices and acquisition of HIV infection among women in sub-Saharan Africa. Secondary objectives were to investigate associations between intravaginal practices and disrupted vaginal flora; and between disrupted vaginal flora and HIV acquisition.
We conducted a meta-analysis of individual participant data from 13 prospective cohort studies involving 14,874 women, of whom 791 acquired HIV infection during 21,218 woman years of follow-up. Data were pooled using random-effects meta-analysis. The level of between-study heterogeneity was low in all analyses (I(2) values 0.0%-16.1%). Intravaginal use of cloth or paper (pooled adjusted hazard ratio aHR 1.47, 95% confidence interval CI 1.18-1.83), insertion of products to dry or tighten the vagina (aHR 1.31, 95% CI 1.00-1.71), and intravaginal cleaning with soap (aHR 1.24, 95% CI 1.01-1.53) remained associated with HIV acquisition after controlling for age, marital status, and number of sex partners in the past 3 months. Intravaginal cleaning with soap was also associated with the development of intermediate vaginal flora and bacterial vaginosis in women with normal vaginal flora at baseline (pooled adjusted odds ratio OR 1.24, 95% CI 1.04-1.47). Use of cloth or paper was not associated with the development of disrupted vaginal flora. Intermediate vaginal flora and bacterial vaginosis were each associated with HIV acquisition in multivariable models when measured at baseline (aHR 1.54 and 1.69, p<0.001) or at the visit before the estimated date of HIV infection (aHR 1.41 and 1.53, p<0.001), respectively.
This study provides evidence to suggest that some intravaginal practices increase the risk of HIV acquisition but a direct causal pathway linking intravaginal cleaning with soap, disruption of vaginal flora, and HIV acquisition has not yet been demonstrated. More consistency in the definition and measurement of specific intravaginal practices is warranted so that the effects of specific intravaginal practices and products can be further elucidated. Please see later in the article for the Editors' Summary.
Climate change, driven by anthropogenic greenhouse gas emissions, is among the greatest threats to human health. The World Health Organisation (WHO), has led global efforts to respond to emerging ...public health threats including the control of hazardous substances such as tobacco, alcohol, lead and asbestos, with remarkable health gains. BODY: Despite WHO's clear messaging on the enormous and growing health risks of climate change, greenhouse gases are not yet classified as hazardous substances, requiring control through a global strategy or framework. Additionally, WHO has not classified disease attributable to climate change as a result of the promulgation of these hazards as a Public Health Emergency of International Concern (PHEIC), despite the serious and preventable health risks it poses globally. Several historical precedents set the stage for WHO to declare excess greenhouse gases as health hazards, including the control of ozone-depleting substances and breast-milk substitutes where the public benefit of control exceeded the potential benefit of their promulgation. In addition, WHO's undertaking within the International Health Regulations to protect global health, providing imperative to declare climate change a PHEIC, with Tedros Adhanom Ghebreyesus, director-general of WHO, declaring: "The climate crisis is a health crisis, fuelling outbreaks, contributing to higher rates of noncommunicable diseases, and threatening to overwhelm our health workforce and health infrastructure". Importantly, the health sector, perhaps more than other sectors, has successfully overcome formidable, vested interests in combatting these threats to health.
It is thus imperative that WHO make full use of their credibility and influence to establish a global framework for the control of greenhouse gases through the declaration of excess greenhouse gas emissions as a hazardous substance, and declaring climate change a PHEIC. Who else is better placed to drive the considerable societal transformation needed to secure a liveable future?
To review facility-based maternal deaths at a tertiary-level center in Johannesburg, South Africa, during a 5-year period (2003 to 2007) and to investigate the proportion of deaths attributable to ...human immunodeficiency virus (HIV), the etiology of deaths, and the effects of antiretroviral treatment introduced in late 2004.
Patient case files, birth registers, death certificates, and mortality summaries were reviewed. Cause of death was assigned through clinical case discussion. Annual maternal mortality ratios were calculated and disaggregated by HIV status.
During the 5-year period, 106 maternal deaths occurred out of 36,708 births (facility-based maternal mortality ratios 289/100,000 live births, 95% confidence interval CI 237-349/100,000). In 72% of cases, HIV status was known (76/106), with the majority being HIV-infected (78%, 59/76). Among HIV-infected women, only two had initiated antiretroviral treatment, and 70% of deaths were HIV-related (41/59), mainly from tuberculosis (21) and pneumonia (12). Direct obstetric causes of death such as hypertension and pregnancy-related sepsis predominated in women who were HIV-negative or of unknown status (48.9%, 23/47). Maternal mortality ratios in HIV-infected women were 776/100,000 (95% CI 591-1,000/100,000), 6.2-fold higher (95% CI 3.6-11.4) than in HIV-negative women (124/100,000, 95% CI 72-199/100,000). Changes in mortality over time were not detected. Although HIV testing increased 1.4-fold each year (95% CI 1.3-1.4) and estimated coverage of antiretroviral treatment for pregnant women reached 59.2% in 2007, levels remain suboptimal.
In Johannesburg, HIV remains the major cause of maternal mortality despite integration of antiretroviral treatment into prenatal services. Maternal health services should target barriers to uptake of HIV treatment and care.
III.
OBJECTIVETo estimate the incidence; persistence and correlates of human papillomavirus (HPV) infection and anogenital warts (AGW) among men living with human immunodeficiency virus (MLHIV).
...METHODSOverall, 304 MLHIV 18 years or older were enrolled and attended follow-up visits at 6, 12, and 18 months. Clinicians examined for AGW, collected blood, and penile swabs for HPV testing (Roche Linear Array) at each visit. Time to AGW incidence or clearance was estimated by Kaplan-Meier method. Factors associated with persistent HPV infection and AGW clearance were evaluated with generalized estimating equations and Cox regression, respectively.
RESULTSMean age of participants was 38 years (standard deviation, 8 years); 25% reported more than 1 sexual partner in the past 3 months. Most (65%) participants were on antiretroviral treatment (ART) with a median CD4 count of 445 cells/μL (interquartile range, 328–567). Prevalence of HPV infection and AGW at enrolment were 79% (224 of 283) and 12% (36 of 304), respectively. Two hundred fifty-nine men were followed up for a median (interquartile range) 1.4 years (0.5–1.7 years). Incidence of any-genital HPV infection was 2.9 (95% confidence interval, 1.5–5.5) per 100 person-years. Persistence of any-genital HPV infection was 35% (68 of 192) and was higher among MLHIV with low CD4 count (adjusted odds ratio, 3.54; 95% confidence interval, 2.07–6.05). Incidence of AGW was 1.4 per 100 person-years. Men living with human immunodeficiency virus with high CD4 count were more likely to clear AGW than those with low CD4 count (adjusted hazard ratio, 3.69; 95% confidence interval, 1.44–9.47). No associations were observed between persistent genital HPV infection, AGW clearance with enrolment ART status or duration.
CONCLUSIONSHuman immunodeficiency virus–positive men have a high burden of genital HPV infection and AGW. The ART and HPV vaccine could reduce this burden.
References 1. 1. The Rockefeller Foundation., 100 Resilient Cities., Arup.: How to Build a Resilient City: The City Resilience Framework. In. New York; 2014. 2. 2. Fast-Track cities reaching the ...90–90–90 targets http://www.unaids.org/en/resources/presscentre/featurestories/2016/july/20160718_cities Accessed 3 Mar 2017. 3. 3. Myburgh C, Moolla A, Poggenpoel M. The lived experiences of children living on the streets of Hillbrow. Curationis. 2015:38(1). 4. 4. District Health Barometer 2015/16. http://www.hst.org.za/publications/district-health-barometer-201516-0 Accessed 4 Apr 2017. 5. 5. Naicker N, Mathee A, Barnes B, Naidoo S, Swart A. The prevalence and health implications of violence in impoverished communities in Johannesburg. South Afr J Epidemiol Infect. 2010;25(4):41–6. * Google Scholar 6. 6. Horowitz S. The Nurse in the University: A History of University Education for South African Nurses: A Case Study of the University of the Witwatersrand. Nursing Research and Practice. 2011;2011:813270. * Google Scholar 7. 7. Black V, Hoffman RM, Sugar CA, Menon P, Venter F, Currier JS, Rees H. Safety and efficacy of initiating highly active antiretroviral therapy in an integrated antenatal and HIV clinic in Johannesburg, South Africa. J Acquir Immune Defic Syndr. 2008;49(3):276–81. * Article * PubMed * PubMed Central * Google Scholar 8. 8. Meyers AM, Furman KI, Botha JR, Milne FJ, Thomson PD, Louridas G, Seggie J, Myburgh JA. The treatment of end-stage renal at the Johannesburg Hospital: A 17 year experience. S Afr Med J. 1983;64(14):515–21. * CAS * PubMed * Google Scholar 9. 9. Shipton EA, Beeton AG, Minkowitz HS. Introducing a patient-controlled analgesia-based acute pain relief service into southern Africa--the first 10 months. S Afr Med J. 1993;83(7):501–5. * CAS * PubMed * Google Scholar 10. 10. Rawat H. The Hillbrow primary health care project. Urban Health Newsl. 1996;28:53–9. * Google Scholar 11. 11. Stadler J, Delany S. The 'healthy brothel': the context of clinical services for sex workers in Hillbrow, South Africa. Cult Health Sex. 2006;8(5):451–64. * Article * PubMed * Google Scholar 12. 12. UNAIDS. The cities report. Geneva: UNAIDS; 2014. * Google Scholar 13. 13. Wojcicki JM, Malala J. Condom use, power and HIV/AIDS risk: sex-workers bargain for survival in Hillbrow/Joubert Park/Berea, Johannesburg. Soc Sci Med. 2001;53(1):99–121. * CAS * Article * PubMed * Google Scholar 14. 14. Dunkle KL, Beksinska ME, Rees VH, Ballard RC, Htun Y, Wilson ML. Risk factors for HIV infection among sex workers in Johannesburg, South Africa. Int J STD AIDS. 2005;16(3):256–61. * CAS * Article * PubMed * Google Scholar 15. 15. Richter ML, Chersich M, Temmerman M, Luchters S. Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa. S Afr Med J. 2013;103(4):246–51. * CAS * Article * PubMed * Google Scholar 16. 16. Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Reproductive health matters. 2006;14(27):109–18. * Article * PubMed * Google Scholar 17. 17. Decker MR, Peitzmeier S, Olumide A, Acharya R, Ojengbede O, Covarrubias L, Gao E, Cheng Y, Delany-Moretlwe S, Brahmbhatt H. Prevalence and health impact of intimate partner violence and non-partner sexual violence among female adolescents aged 15-19 years in vulnerable urban environments: a multi-country study. J Adolesc Health. 2014;55(6 Suppl):S58–67. * Article * PubMed * Google Scholar 18. 18. Olumide AO, Robinson AC, Levy PA, Mashimbye L, Brahmbhatt H, Lian Q, Ojengbede O, Sonenstein FL, Blum RW. Predictors of substance use among vulnerable adolescents in five cities: findings from the well-being of adolescents in vulnerable environments study. J Adolesc Health. 2014;55(6 Suppl):S39–47. * Article * PubMed * PubMed Central * Google Scholar 19. 19. Ompad DC, Galea S, Caiaffa WT, Vlahov D. Social determinants of the health of urban populations: methodologic considerations. J Urban Health. 2007;84(3 Suppl):i42–53. * Article * PubMed * Google Scholar 20. 20. Vlahov D, Freudenberg N, Proietti F, Ompad D, Quinn A, Nandi V, Galea S. Urban as a determinant of health. J Urban Health. 2007;84(3 Suppl):16–26. * Article * PubMed Central * Google Scholar 21. 21. Vearey J, Palmary I, Nunez L, Drime S. Urban health in Johannesburg: the importance of place in understanding intra-urban inequalities in a context of migration and HIV. Health Place. 2010;16:694–702. * Article * PubMed * Google Scholar 22. 22. Decker MR, Marshall BD, Emerson M, Kalamar A, Covarrubias L, Astone N, Wang Z, Gao E, Mashimbye L, Delany-Moretlwe S, et al. Respondent-driven sampling for an adolescent health study in vulnerable urban settings: a multi-country study. J Adolesc Health. 2014;55(6 Suppl):S6–S12. * Article * PubMed * PubMed Central * Google Scholar 23. 23. Mmari K, Blum R, Sonenstein F, Marshall B, Brahmbhatt H, Venables E, Delany-Moretlwe S, Lou C, Gao E, Acharya R, et al. Adolescents' perceptions of health from disadvantaged urban communities: findings from the WAVE study. Soc Sci Med. 2014;104:124–32. * Article * PubMed * Google Scholar 24. 24. Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Zungu N, Labadarios D, Onoya D, et al. South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town: HSRC Press; 2014. * Google Scholar 25. 25. Karim QA, Baxter C. Microbicides for the prevention of sexually transmitted HIV infection. Expert Rev Anti-Infect Ther. 2013;11(1):13–23. * Article * PubMed * Google Scholar 26. 26. Karim QA, Baxter C, Karim SA. Topical microbicides--what's new? J Acquir Immune Defic Syndr. 2013;63(Suppl 2):S144–9. * Article * PubMed * Google Scholar 27. 27. Karim QA, Kharsany AB, Frohlich JA, Baxter C, Yende N, Mansoor LE, Mlisana KP, Maarschalk S, Arulappan N, Grobler A, et al. Recruitment of high risk women for HIV prevention trials: baseline HIV prevalence and sexual behavior in the CAPRISA 004 tenofovir gel trial. Trials. 2011;12:67. * Article * PubMed * PubMed Central * Google Scholar 28. 28. Venables E: Gendered Hillbrow, Healthy Hillbrow? Men's involvement in clinical trials in Johannesburg, South Africa. In: UJ Sociology, Anthropology & Development Seminar, 14 April Johannesburg; 2010. Download references
Climate change is likely to have wide-ranging impacts on maternal and neonatal health in Africa. Populations in low-resource settings already experience adverse impacts from weather extremes, a high ...burden of disease from environmental exposures, and limited access to high-quality clinical care. Climate change is already increasing local temperatures. Neonates are at high risk of heat stress and dehydration due to their unique metabolism, physiology, growth, and developmental characteristics. Infants in low-income settings may have little protection against extreme heat due to housing design and limited access to affordable space cooling. Climate change may increase risks to neonatal health from weather disasters, decreasing food security, and facilitating infectious disease transmission. Effective interventions to reduce risks from the heat include health education on heat risks for mothers, caregivers, and clinicians; nature-based solutions to reduce urban heat islands; space cooling in health facilities; and equitable improvements in housing quality and food systems. Reductions in greenhouse gas emissions are essential to reduce the long-term impacts of climate change that will further undermine global health strategies to reduce neonatal mortality.
Systematically assess the effectiveness of HIV-prevention interventions in changing sexual behaviour of young people (10-25 years) in sub-Saharan Africa.
Three online databases were searched using ...prespecified terms. Additional articles were identified on websites of international organizations and by searching bibliographies. Randomized and nonrandomized trials of interventions aiming to reduce risk behaviour were included as well as single-arm studies reporting effects of differential exposure to an intervention. Data were extracted independently in duplicate using predefined data fields.
Thirty-one studies on 28 interventions met the inclusion criteria, including 11 randomized trials. Difficulties with implementing planned activities were reportedly common and differential exposure to intervention was high. Two hundred and seventeen outcome measures were extracted: 88 early (within 1 year of intervention) and 129 late outcomes (more than 1 year after the end of the intervention). Sex education and condom promotion among youth did not increase sexual behaviour as well as risky sexual behaviour. No positive effects on sexual behaviour were detected either and condom use at last sex only increased among males relative risk = 1.46; 95% confidence interval = 1.31-1.64. One study reported a reduction of herpes simplex virus-2, but not HIV incidence.
There remains a stark mismatch between the HIV burden in youth and the number of attempts to design and test prevention interventions - only two trials report biological outcomes. More effective interventions targeting youth are needed. Attention should go to studying implementation difficulties, sex differences in responses to interventions, determinants of exposure to interventions and perhaps inclusion of other factors apart from HIV/AIDS which influence sexual behaviour.
Intersections between migration and sex work are underexplored in southern Africa, a region with high internal and cross-border population mobility, and HIV prevalence. Sex work often constitutes an ...important livelihood activity for migrant women. In 2010, sex workers trained as interviewers conducted cross-sectional surveys with 1,653 female sex workers in Johannesburg (Hillbrow and Sandton), Rustenburg and Cape Town. Most (85.3 %) sex workers were migrants (1396/1636): 39.0 % (638/1636) internal and 46.3 % (758/1636) cross-border. Cross-border migrants had higher education levels, predominately worked part-time, mainly at indoor venues, and earned more per client than other groups. They, however, had 41 % lower health service contact (adjusted odds ratio = 0.59; 95 % confidence interval = 0.40–0.86) and less frequent condom use than non-migrants. Police interaction was similar. Cross-border migrants appear more tenacious in certain aspects of sex work, but require increased health service contact. Migrant-sensitive, sex work-specific health care and health education are needed.
Previous research has linked alcohol use with an increased number of sexual partners, inconsistent condom use and a raised incidence of sexually transmitted infections (STIs). However, alcohol ...measures have been poorly standardised, with many ill-suited to eliciting, with adequate precision, the relationship between alcohol use and sexual risk behaviour. This study investigates which alcohol indicator--single-item measures of frequency and patterns of drinking ( > = 6 drinks on 1 occasion), or the Alcohol Use Disorders Identification Test (AUDIT)--can detect associations between alcohol use and unsafe sexual behaviour among male sex workers.
A cross-sectional survey in 2008 recruited male sex workers who sell sex to men from 65 venues in Mombasa district, Kenya, similar to a 2006 survey. Information was collected on socio-demographics, substance use, sexual behaviour, violence and STI symptoms. Multivariate models examined associations between the three measures of alcohol use and condom use, sexual violence, and penile or anal discharge.
The 442 participants reported a median 2 clients/week (IQR = 1-3), with half using condoms consistently in the last 30 days. Of the approximately 70% of men who drink alcohol, half (50.5%) drink two or more times a week. Binge drinking was common (38.9%). As defined by AUDIT, 35% of participants who drink had hazardous drinking, 15% harmful drinking and 21% alcohol dependence. Compared with abstinence, alcohol dependence was associated with inconsistent condom use (AOR = 2.5, 95%CI = 1.3-4.6), penile or anal discharge (AOR = 1.9, 95%CI = 1.0-3.8), and two-fold higher odds of sexual violence (AOR = 2.0, 95%CI = 0.9-4.9). Frequent drinking was associated with inconsistent condom use (AOR = 1.8, 95%CI = 1.1-3.0) and partner number, while binge drinking was only linked with inconsistent condom use (AOR = 1.6, 95%CI = 1.0-2.5).
Male sex workers have high levels of hazardous and harmful drinking, and require alcohol-reduction interventions. Compared with indicators of drinking frequency or pattern, the AUDIT measure has stronger associations with inconsistent condom use, STI symptoms and sexual violence. Increased use of the AUDIT tool in future studies may assist in delineating with greater precision the explanatory mechanisms which link alcohol use, drinking contexts, sexual behaviours and HIV transmission.
To investigate putative links between alcohol use, and unsafe sex and incident HIV infection in sub-Saharan Africa.
A cohort of 400 HIV-negative female sex workers was established in Mombasa, Kenya. ...Associations between categories of the Alcohol Use Disorders Identification Test (AUDIT) and the incidence at one year of unsafe sex, HIV and pregnancy were assessed using Cox proportional hazards models. Violence or STIs other than HIV measured at one year was compared across AUDIT categories using multivariate logistic regression.
Participants had high levels of hazardous (17.3%, 69/399) and harmful drinking (9.5%, 38/399), while 36.1% abstained from alcohol. Hazardous and harmful drinkers had more unprotected sex and higher partner numbers than abstainers. Sex while feeling drunk was frequent and associated with lower condom use. Occurrence of condom accidents rose step-wise with each increase in AUDIT category. Compared with non-drinkers, women with harmful drinking had 4.1-fold higher sexual violence (95% CI adjusted odds ratio AOR = 1.9-8.9) and 8.4 higher odds of physical violence (95% CI AOR = 3.9-18.0), while hazardous drinkers had 3.1-fold higher physical violence (95% CI AOR = 1.7-5.6). No association was detected between AUDIT category and pregnancy, or infection with Syphilis or Trichomonas vaginalis. The adjusted hazard ratio of HIV incidence was 9.6 comparing women with hazardous drinking to non-drinkers (95% CI = 1.1-87.9).
Unsafe sex, partner violence and HIV incidence were higher in women with alcohol use disorders. This prospective study, using validated alcohol measures, indicates that harmful or hazardous alcohol can influence sexual behaviour. Possible mechanisms include increased unprotected sex, condom accidents and exposure to sexual violence. Experimental evidence is required demonstrating that interventions to reduce alcohol use can avert unsafe sex.
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