Abigail Norris Turner

Highly effective contraception and acquisition of HIV and other sexually transmitted infections

A key question for clinicians is whether an aetiological association exists between highly effective contraceptive methods and womens risk of acquiring sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). The authors searched the peer-reviewed literature for prospective studies published from January 1966 to August 2008 that assessed contraception and STI/HIV risk. The focus was on combined oral contraceptives (OCs), depot-medroxyprogesterone acetate (DMPA), the T380a copper intra-uterine device (IUD) and the risk of infection with HIV, Chlamydia trachomatis and Neisseria gonorrhoeae. Current data suggest that neither OCs nor DMPA increase HIV risk among women in the general population. Data are equivocal for women in high-risk groups (e.g. sex workers). Current data suggest an increased risk of chlamydial infection associated with OC use, with weaker evidence supporting a harmful effect of DMPA. Reports of OCs and gonococcal infection are inconsistent, and DMPA does not appear to be associated with gonorrhoea acquisition. Data suggest no increased STI/HIV risk among copper IUD users. Prospective data on highly effective contraceptive methods and womens STI/HIV risk are limited, and many studies have important methodological weaknesses. Additional information about the STI/HIV risks associated with these highly effective contraceptive methods is needed.

Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda

Objective:To assess whether male circumcision of the primary sex partner is associated with womens risk of HIV. Design:Data were analyzed from 4417 Ugandan and Zimbabwean women participating in a prospective study of hormonal contraception and HIV acquisition. Most were recruited from family planning clinics; some in Uganda were referred from higher-risk settings such as sexually transmitted disease clinics. Methods:Using Cox proportional hazards models, time to HIV acquisition was compared for women with circumcised or uncircumcised primary partners. Possible misclassification of male circumcision was assessed using sensitivity analysis. Results:At baseline, 74% reported uncircumcised primary partners, 22% had circumcised partners and 4% had partners of unknown circumcision status. Median follow-up was 23 months, during which 210 women acquired HIV (167, 34, and 9 women whose primary partners were uncircumcised, circumcised, or of unknown circumcision status, respectively). Although unadjusted analyses indicated that women with circumcised partners had lower HIV risk than those with uncircumcised partners, the protective effect disappeared after adjustment for other risk factors [hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.69–1.53]. Subgroup analyses suggested a non-significant protective effect of male circumcision on HIV acquisition among Ugandan women referred from higher-risk settings: adjusted HR 0.16 (95% CI, 0.02–1.25) but little effect in Ugandans (HR, 1.33; 95% CI, 0.72–2.47) or Zimbabweans (HR, 1.12; 95% CI, 0.65–1.91) from family planning clinics. Conclusions:After adjustment, male circumcision was not significantly associated with womens HIV risk. The potential protection offered by male circumcision for women recruited from high-risk settings warrants further investigation.

Vaginal microbicide and diaphragm use for sexually transmitted infection prevention: a randomized acceptability and feasibility study among high-risk women in Madagascar.

Background: In preparation for a randomized controlled trial (RCT), we conducted a pilot RCT of the acceptability and feasibility of diaphragms and candidate vaginal microbicide for sexually transmitted infection prevention among high-risk women in Madagascar. Methods: Participants were randomized to four arms: (1) diaphragm (worn continuously) with Acidform™ applied in the dome; (2) diaphragm (worn continuously) with placebo gel hydroxyethylcellulose (HEC) in the dome; (3) HEC applied intravaginally before sex; (4) Acidform applied intravaginally before sex. All women were given condoms. Participants were followed weekly for 4 weeks. We fit unadjusted negative binomial regression models with robust variance estimators to generate the proportion of sex acts with casual partners where condoms and experimental study products were used. Results: Retention was 98% among 192 participants. Experimental product use with casual partners was high, reported in 85%, 91%, 74%, and 81% of sex acts for women in the Acidform-diaphragm, HEC-diaphragm, HEC-alone, and Acidform-alone arms, respectively. However, the proportion reporting product use during 100% of acts with casual partners over the full follow-up period was much lower: 28% to 29% in the gel-diaphragm arms and 6% to 10% in gel-alone arms. Women used condoms in 62% to 67% of sex acts with casual partners, depending on the randomization arm. Participants found diaphragms easy to insert (97%) and remove (96%). Acidform users (with or without the diaphragm) reported more genitourinary symptoms than HEC users (14% vs. 5% of visits). Conclusions: A sexually transmitted infection prevention RCT of candidate microbicide with and without the diaphragm appears acceptable and feasible in this population.

Unprotected sex following HIV testing among women in Uganda and Zimbabwe: short- and long-term comparisons with pre-test behaviour

BACKGROUNDnDespite widespread condom promotion for HIV prevention, prospective measurement of condom use before and after HIV testing is infrequent.nnnMETHODSnWe analysed data from a prospective study of hormonal contraception and HIV acquisition among Zimbabwean and Ugandan women (1999-2004), in which HIV testing and counselling were performed approximately every 3 months. We used zero-inflated negative binomial (ZINB) models to examine the number and proportion of unprotected sex acts, comparing behaviour reported 2-6 months before HIV testing with behaviour reported both 2-6 months (short-term analysis) and 12-16 months (long-term analysis) after HIV testing.nnnRESULTSnShort- and long-term analyses were similar, so we present only long-term findings from 151 HIV-infected and 650 uninfected participants. The proportion of HIV-infected women reporting any unprotected acts in a typical month declined from 74% (pre-infection behaviour) to 56% (12-16 months after HIV diagnosis). In multivariable models, HIV-infected women were twice as likely to report that all sex acts were protected by condoms after diagnosis compared with beforehand [adjusted odds ratio (aOR): 1.99, 95% confidence interval (CI): 1.12-3.53]; uninfected women were somewhat less likely to report that all acts were protected (aOR: 0.82, 95% CI: 0.64-1.04). HIV-infected women also reduced their number of unprotected acts by 38% (95% CI: -16 to -55%). However, their proportion of unprotected acts changed little (7% reduction, 95% CI: -18 to + 6%). Uninfected women reported little change in number or proportion of unprotected acts over the same time period.nnnCONCLUSIONSnHIV-infected women reduced the number, but not the proportion, of unprotected acts. HIV-negative women did not increase condom use after testing and counselling, but neither did they decrease condom use, suggesting that testing negative was not interpreted as endorsement of risky behaviour.

Unmet need for contraception among sex workers in Madagascar

BACKGROUNDnThe study was conducted to investigate past and future pregnancy preferences and contraceptive need among Malagasy sex workers.nnnSTUDY DESIGNnWe analyzed data on pregnancy and contraceptive use collected during the baseline visit of a randomized, prospective formative trial which assessed diaphragm and microbicide acceptability among sex workers. To be eligible, women could not be pregnant or planning pregnancy for the next 2 months.nnnRESULTSnWomen (N=192) from four cities (Antananarivo, Antsiranana, Mahajanga and Toamasina) reported a median of 10 sex acts per week. Fifty-two percent reported a prior unwanted pregnancy, 45% at least one induced abortion and 86% that preventing future pregnancy was moderately to very important. During the last sex act, 24% used a hormonal method, 36% used a male condom, 2% used a traditional method and 38% used no method. Nearly 30% of participants reported that pregnancy prevention was moderately or very important but used no contraception at last sex; these women were categorized as having unmet need for contraception. In multivariable binomial regression analyses, factors associated with unmet need included low knowledge of contraceptive effectiveness [age- and site-adjusted prevalence ratio (PR): 2.1; 95% confidence interval (CI): 1.4-3.0] and low self-efficacy to negotiate condom use (age- and site-adjusted PR: 2.0; 95% CI: 1.4-3.0).nnnCONCLUSIONSnAmong these women, prior unwanted pregnancy and induced abortion were common and preventing future pregnancy was important, yet gaps in contraceptive use were substantial. Contraceptive knowledge and self-efficacy should be improved to promote contraceptive use by sex workers.

Male circumcision and women's risk of incident chlamydial, gonococcal and trichomonal infections

Background: Male circumcision (MC) decreases the risk of human immunodeficiency virus (HIV) acquisition in men. We explored associations between MC of the primary sex partner and womens risk of acquisition of chlamydial (Ct), gonococcal (GC), or trichomonal (Tv) infections. Methods: We analyzed data from a prospective study on hormonal contraception and incident human immunodeficiency virus/sexually transmitted infection (STI) among women from Uganda, Zimbabwe, and Thailand. At enrollment and each follow-up visit, we collected endocervical swabs for polymerase chain reaction identification of Ct and GC; Tv was diagnosed by wet mount. Using Cox proportional hazards models, we compared time to STI acquisition for women according to their partners MC status. Results: Among 5925 women (2180 from Uganda, 2228 from Zimbabwe, and 1517 from Thailand), 18.6% reported a circumcised primary partner at baseline, 70.8% reported an uncircumcised partner, and 9.7% did not know their partners circumcision status. During follow-up, 408, 305, and 362 participants had a first incident Ct, GC, or Tv infection, respectively. In multivariate analysis, after controlling for contraceptive method, age, age at coital debut, and country, the adjusted hazard ratio (HR) comparing women with circumcised partners with those with uncircumcised partners for Ct was 1.25 [95% confidence interval (CI) 0.96–1.63]; for GC, adjusted HR 0.99 (95% CI 0.74–1.31); for Tv, adjusted HR 1.05 (95% CI 0.80–1.36), and for the 3 STIs combined, adjusted HR 1.02 (95% CI 0.85–1.21). Conclusions: MC was not associated with womens risk of acquisition of Ct, GC, or Tv infection in this cohort.

Conducting unlinked anonymous HIV surveillance in developing countries: ethical, epidemiological, and public health concerns.

Stuart Rennie and colleagues argue that while unlinked anonymous HIV testing is valuable and ethical, such surveillance can be conducted in ethically questionable ways in certain circumstances.

Effect of consistent condom use on 6-month prevalence of bacterial vaginosis varies by baseline BV status.

Objectivesu2002 Bacterial vaginosis (BV) is a condition characterized by a disturbed vaginal ecosystem which fluctuates in response to extrinsic and intrinsic factors. BV recurrence is common. To explore whether consistent condom use was associated with BV occurrence or recurrence, we compared the effect of condom use on BV prevalence after 6u2003months, among women with and without BV at baseline.

Evidence-based planning of a randomized controlled trial on diaphragm use for prevention of sexually transmitted infections

Objectives: We conducted formative research to evaluate the acceptability and feasibility of continuous diaphragm use among low-income women highly exposed to sexually transmitted infections (STIs) in Madagascar. Goal: To identify potential obstacles to researching the effectiveness of diaphragm use for STI prevention in a randomized controlled trial. Study Design: Mixed methods to collect complex information. In a quantitative pilot study, women were asked to use diaphragms continuously (removing once daily for cleaning) for 8 weeks and promote consistent male condom use; they were interviewed and examined clinically during follow-up. Focus group discussions (FGDs) were conducted pre-/postpilot study. Audiotaped FGDs were transcribed, translated, coded, and analyzed. Results: Ninety-three women participated in prepilot FGDs, 91 in the pilot study, and 82 in postpilot FGDs. Diaphragm use was acceptable and feasible, but participants reported lower condom use in FGDs than during interviews. Most participants reported in interviews that they used their diaphragms continuously, but FGDs revealed that extensive intravaginal hygiene practices may impede effective continuous diaphragm use. Despite counseling by study staff, FGDs revealed that participants believed the diaphragm provided effective protection against STIs and pregnancy. Conclusions: Mixed methods formative research generated information that the prospective pilot study alone could not provide and revealed contradictory findings. Results have methodological and ethical implications that affect trial design including provision of free hormonal contraceptives, and additional instructions for vaginal hygiene to avoid displacing the diaphragm. Mixed methods formative research should be encouraged to promote evidence-based study design and implementation.

Increased risk of chlamydial and gonococcal infection in adolescent sex workers in Madagascar

Goal: To examine and compare young sex workers’ risk of acquisition of sexually transmitted infections (STIs) with the risk among their older counterparts. Objective: To evaluate the effect of young age—16–19 years vs. 20 years and older—on risk of incident infection with Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT). Study Design: A randomized controlled trial of 1,000 sex workers in Madagascar was conducted. STI testing was conducted at baseline, 6, 12, and 18 months. Results: About 13% of the cohort (n = 134) was composed of young women aged 16–19 years. STI incidence rates in this group over the 18-month study period were high: 51.9/100 woman-years (WY) for GC and 47.4/100 WY for CT compared to 27.4/100 WY and 19.1/100 WY for sex workers over age 20, respectively. In multivariable models, young sex workers were at significantly higher STI risk compared with their older peers: The adjusted risk ratio (aRR) for GC comparing younger to older women was 1.50 (95% confidence interval (CI): 1.20, 1.88); for CT, the aRR was 1.72 (95% CI: 1.35, 2.19) and for GC or CT combined, the aRR was 1.42 (95% CI: 1.22, 1.66). Conclusions: This exploratory analysis suggests that additional research is warranted to identify effective and acceptable prevention strategies that benefit young women, and interventions already proven effective among adolescents should be given high priority for scale-up.