Japheth K.G. Mati

Sexual behavior, sexually transmitted diseases, male circumcision and risk of HIV infection among women in Nairobi, Kenya

ObjectiveTo study risk factors for HIV infection among women in Nairobi, Kenya, as the epidemic moves beyond high-risk groups. DesignA cross-sectional case-control study among women attending two peri-urban family planning clinics. MethodsA total of 4404 women were enrolled after giving written informed consent. Information on risk factors was obtained by interview using a structured questionnaire. Blood was taken for HIV and syphilis testing, and genital specimens for gonorrhea and trichomoniasis screening. ResultsTwo hundred and sixteen women (4.9%; 95% confidence interval, 4.3–5.5) were HIV-1-positive. Although risk of HIV was significantly increased among unmarried women and among women with multiple sex partners, most seropositive women were married and reported only a single sex partner in the last year. Women with a history or current evidence of sexually transmitted disease were at significantly increased risk; however, the prevalence of these exposures was low. Women whose husband or usual sex partner was uncircumcised had a threefold increase in risk of HIV, and this risk was present in almost all strata of potential confounding factors. Only 5.2% of women reported ever having used a condom. ConclusionsThese data suggest that, among women who are not in high-risk groups, risk of HIV infection is largely determined by their male partners behavior and circumcision status. Interventions designed to change male sexual behavior are urgently needed.

Contraceptive methods and the transmission of HIV: implications for family planning.

Heterosexual transmission is the predominant mode of spread of the Human Immunodeficiency Virus (HIV) in most of the world. Whether the use of hormonal contraceptives, IUDs and spermicides is associated with an increased or decreased risk for HIV acquisition remains controversial. Several mechanisms whereby contraceptive methods may influence the transmission of HIV have been proposed. As contraceptive use increases among women of reproductive age, the group most vulnerable to HIV infection, any associations between contraceptive method and HIV risk become even more important. The available studies of these associations are predominantly cross-sectional and give conflicting results. We review the published evidence for associations between HIV and individual contraceptive methods. At this time no definitive conclusions regarding these associations can be drawn. Further research, especially prospective epidemiological studies and basic biological research on mechanisms of heterosexual transmission and the effect of contraceptives on these mechanisms, is urgently needed.

The relationship between HIV infection and cervical intraepithelial neoplasia among women attending two family planning clinics in Nairobi, Kenya

ObjectiveTo determine the relationship between HIV-1 infection and cervical intraepithelial neoplasia (IN) among women at relatively low risk for both conditions. DesignA case-control study comparing women with cytological evidence of IN (cases) with those without IN (controls) and HIV-1 serostatus as the principal exposure of interest. MethodsA total of 4058 women attending two family planning clinics in Nairobi, Kenya between October 1989 and May 1991 were enrolled following HIV pretest counseling and informed consent. Structured interviews by trained nurses and medical students were used to obtain data on social, demographic, contraceptive practice and sexual behavior variables. A Papanicolaou smear specimen for cervical cytology and an endocervical swab for gonorrhea culture were obtained. HIV-1 serostatus was determined by enzyme-linked immunosorbent assay and confirmed by Western blot; syphilis serostatus was determined by the rapid plasma reagin test. ResultsEighty-two of the 4058 (2.02%) women had cytological evidence of IN. We observed a significant positive association between HIV-1 infection and IN that remained after controlling for sexual behavior, contraceptive practices and other potential confounding variables (odds ratio, 2.78; 95% confidence interval 1.32–5.85). linical symptoms and signs were uncommon among the HIV-1-seropositive women, suggesting that they were still in the early stages of the infection. ConclusionThe risk of IN among women even in the early stages of HIV-1 infection is increased.

Risk factors for gonorrhoea, syphilis, and trichomonas infections among women attending family planning clinics in Nairobi, Kenya.

OBJECTIVE--To identify the risk factors for gonorrhoea, syphilis, and trichomonas infections among low risk women in Nairobi, Kenya. METHOD--In a cross-sectional study, 4,404 women attending two peri-urban family planning clinics between 1989 and 1991 were interviewed using a structured questionnaire and examined for signs of sexually transmitted disease (STD) infection. Cervical cultures for gonorrhoea, PAP smear (including microscopy for trichomonas), RPR and HIV testing were done. RESULTS--Positive cervical cultures for gonorrhoea were found in 3.2% of women, positive syphilis serology in 1.9%, and positive trichomonas microscopy in 5.2%. Genital ulcers were found in 1.9% of women. Although unmarried status and reporting more than one sex partner in the previous year were both significantly associated with each disease in the crude analysis, these associations were attenuated after controlling for each other and for other risk factors. The population attributable risks (PARs) for these factors were low (7-16%) owing to the high proportion of cases who were married and monogamous. The majority of women with microbiological evidence of infection had normal pelvic examinations. Clinical diagnostic algorithms for STDs in this population had a low sensitivity and positive predictive value. Nevertheless, a strong association between HIV seropositivity and STDs was observed. CONCLUSION--The low population attributable risks found in this study suggest that behaviour change messages directed to women, particularly if they are married have a low potential for preventing STDs. The poor performance of clinical diagnostic algorithms illustrates the desirability of testing these algorithms in a variety of populations and reinforces the need for low-cost methods of microbiologic diagnosis if populations with relatively low prevalences of these infections are to be included in programmes to diagnose and treat STDs.

Cervical Cancer in Kenya: Prospects for Early Detection at Primary Level

Objectives: To assess the feasibility of cytologic screening services for rural women and to establish the prevalence of abnormal cytology in Kenya. Method: Women at four maternal and child health/family planning (MCH/FP) clinics were screened, and some screens were repeated. After Pap staining they were graded in classes I–IV, where abnormal smears referred to classes III and IV. Results: The prevalence of abnormal cytology was 2.9% and 2.6% for the first and second screen, respectively. Enrolled community nurses took adequate smears and were able to diagnose overt lesions of the cervix. Training of technicians in cytologic techniques and setting up of a network of laboratories down to district level was considered feasible. Conclusions: Cytology services may be extended to rural populations through existing MCH/FP clinics. Enrolled nurses can take adequate cervical smears and diagnose overt cervical lesions, and could be used in a downstaging and screening program extending to rural areas.

Contraception, Family Planning, and HIV

Throughout the world the predominant mode of HIV transmission is heterosexual intercourse. It is to be expected, therefore, that the HIV/AIDS epidemic will have an impact on reproductive behaviors and choices, including those involving contraception. The fact that individual methods of contraception may decrease or increase the risk of acquiring HIV, given exposure, broadens this impact considerably.