Judith Vandepitte

HIV and Other Sexually Transmitted Infections in a Cohort of Women Involved in High-Risk Sexual Behavior in Kampala, Uganda

Background: Uganda has long been successful in controlling the HIV epidemic; however, there is evidence that HIV prevalence and incidence are increasing again. Data on the HIV/STI epidemic among sex workers are so far lacking from Uganda. This paper describes the baseline epidemiology of HIV/STI in a newly established cohort of women involved in high-risk sexual behavior in Kampala, Uganda. Methods Women were recruited from red-light areas in Kampala. Between April 2008 and May 2009, 1027 eligible women were enrolled. Sociodemographic and behavioral information were collected; blood and genital samples were tested for HIV/STI. Risk factors for HIV infection were examined using multivariate logistic regression. Results: HIV seroprevalence was 37%. The prevalence of Neisseria gonorrhoeae was 13%, Chlamydia trachomatis, 9%; Trichomonas vaginalis, 17%; bacterial vaginosis, 56% and candida infection, 11%. Eighty percent had herpes simplex virus 2 antibodies (HSV-2), 21% were TPHA-positive and 10% had active syphilis (RPR+TPHA+). In 3% of the genital ulcers, Treponema pallidum (TP) was identified, Haemophilus ducreyi in 6%, and HSV-2 in 35%. Prevalent HIV was independently associated with older age, being widowed, lack of education, sex work as sole income, street-based sex work, not knowing HIV-status, using alcohol, and intravaginal cleansing with soap. HIV infection was associated with N. gonorrhoeae, T. vaginalis, bacterial vaginosis, HSV-2 seropositivity and active syphilis. Conclusions: Prevalence of HIV/STI is high among women involved in high-risk sexual behavior in Kampala. Targeted HIV prevention interventions including regular STI screening, voluntary HIV testing and counseling, condom promotion, and counseling for reducing alcohol use are urgently needed in this population.

Prevalence and Correlates of Mycoplasma genitalium Infection Among Female Sex Workers in Kampala, Uganda

BACKGROUND The importance of Mycoplasma genitalium in human immunodeficiency virus (HIV)-burdened sub-Saharan Africa is relatively unknown. We assessed the prevalence and explored determinants of this emerging sexually transmitted infection (STI) in high-risk women in Uganda. METHODS Endocervical swabs from 1025 female sex workers in Kampala were tested for Mycoplasma genitalium using a commercial Real-TM polymerase chain reaction assay. Factors associated with prevalent Mycoplasma genitalium, including sociodemographics, reproductive history, risk behavior, and HIV and other STIs, were examined using multivariable logistic regression. RESULTS The prevalence of Mycoplasma genitalium was 14% and higher in HIV-positive women than in HIV-negative women (adjusted odds ratio [OR], 1.64; 95% confidence interval [CI], 1.12-2.41). Mycoplasma genitalium infection was less prevalent in older women (adjusted OR, 0.61; 95% CI, .41-.90 for women ages 25-34 years vs <25 years; adjusted OR, 0.32; 95% CI, .15-.71 for women ≥ 35 years vs those <25 years) and in those who had been pregnant but never had a live birth (adjusted OR, 2.25; 95% CI, 1.04-4.88). Mycoplasma genitalium was associated with Neisseria gonorrhoeae (adjusted OR, 1.84; 95% CI, 1.13-2.98) and with Candida infection (adjusted OR, 0.41; 95% CI, .18-.91), and there was some evidence of association with Trichomonas vaginalis (adjusted OR, 1.56; 95% CI, 1.00-2.44). CONCLUSIONS The relatively high prevalence of Mycoplasma genitalium and its association with prevalent HIV urgently calls for further research to explore the potential role this emerging STI plays in the acquisition and transmission of HIV infection.

Alcohol use mycoplasma genitalium and other STIs associated With HIV incidence among women at high risk in Kampala Uganda.

Background:In 2008, the first clinic for women involved in high-risk sexual behavior was established in Kampala, offering targeted HIV prevention. This article describes rates, determinants, and trends of HIV incidence over 3 years. Methods:A total of 1027 women at high risk were enrolled into a closed cohort. At 3-monthly visits, data were collected on sociodemographic variables and risk behavior; biological samples were tested for HIV and other reproductive tract infections/sexually transmitted infections (RTI/STIs). Hazard ratios for HIV incidence were estimated using Cox proportional hazards regression among the 646 women HIV negative at enrolment. Results:HIV incidence was 3.66/100 person-years (pyr) and declined from 6.80/100 pyr in the first calendar year to 2.24/100 pyr and 2.53/100 pyr in the following years (P trend = 0.003). Sociodemographic and behavioral factors independently associated with HIV incidence were younger age, younger age at first sex, alcohol use (including frequency of use and binge drinking), number of paying clients in the past month, inconsistent condom use with clients, and not being pregnant. HIV incidence was also independently associated with Mycoplasma genitalium infection at enrolment [adjusted hazard ratio (aHR) = 2.28, 95% confidence interval (CI): 1.15 to 4.52] and with Neisseria gonorrhoeae (aHR = 5.91, 95% CI: 3.04 to 11.49) and Trichomonas vaginalis infections at the most recent visit (aHR = 2.72, 95% CI: 1.27 to 5.84). The population attributable fractions of HIV incidence for alcohol use was 63.5% (95% CI: 6.5 to 85.8) and for treatable RTI/STIs was 70.0% (95% CI: 18.8 to 87.5). Conclusions:Alcohol use and STIs remain important risk factors for HIV acquisition, which call for more intensive control measures in women at high risk. Further longitudinal studies are needed to confirm the association between M. genitalium and HIV acquisition.

Gender inequity in the lives of women involved in sex work in Kampala, Uganda

Gender inequity is manifested in the social and economic burden women carry in relation to men. We investigate womens experiences of gender relations from childhood to adult life and how these may have led to and kept women in sex work.

Association between Mycoplasma genitalium infection and HIV acquisition among female sex workers in Uganda: evidence from a nested case-control study.

Objectives Cross-sectional studies have shown a strong association between Mycoplasma genitalium and HIV infections. We previously reported that in a cohort of female sex workers in Uganda, M genitalium infection at baseline was associated with HIV seroconversion. Here we examine the temporal association between the M genitalium infection status shortly before HIV seroconversion and HIV acquisition. Methods A nested case-control study was conducted within a cohort of women at high risk for HIV in Kampala. Cases were those of women acquiring HIV within 2 years of enrolment. For each of the 42 cases, 3 controls were selected from women HIV negative at the visit when the corresponding case first tested HIV seropositive. The association between HIV acquisition and M genitalium infection immediately prior to HIV testing was analysed using conditional logistic regression. Results There was weak evidence of an association between M genitalium infection and HIV acquisition overall (crude OR=1.57; 95% CI 0.67 to 3.72, aOR=2.28: 95% CI 0.81 to 6.47). However, time of M genitalium testing affected the association (p value for effect-modification=0.004). For 29 case-control sets with endocervical samples tested 3 months prior to the first HIV-positive result, M genitalium infection increased the risk of HIV acquisition (crude OR=3.09; 95% CI 1.06 to 9.05, aOR=7.19; 95% CI 1.68 to 30.77), whereas there was little evidence of an association among the 13 case-control sets with samples tested at an earlier visit (crude OR=0.30: 95% CI 0.04 to 2.51; aOR=0.34; 95% CI 0.02 to 5.94). Conclusions Our study showed evidence of a temporal relationship between M genitalium infection and HIV acquisition that suggests that M genitalium infection may be a co-factor in the acquisition of HIV infection.

Natural history of Mycoplasma genitalium infection in a cohort of female sex workers in Kampala, Uganda

Background There have been few studies of the natural history of Mycoplasma genitalium in women. We investigated patterns of clearance and recurrence of untreated M. genitalium infection in a cohort of female sex workers in Uganda. Methods Women diagnosed as having M. genitalium infection at enrollment were retested for the infection at 3-month intervals. Clearance of infection was defined as testing negative after having a previous positive result: persistence was defined as testing positive after a preceding positive test result, and recurrence as testing positive after a preceding negative test result. Adjusted hazard ratios for M. genitalium clearance were estimated using Cox proportional hazards regression. Results Among 119 participants infected with M. genitalium at enrollment (prevalence, 14%), 55% had spontaneously cleared the infection within 3 months; 83%, within 6; and 93%, within 12 months. The overall clearance rate was 25.7/100 person-years (pyr; 95% confidence interval, 21.4–31.0). HIV-positive women cleared M. genitalium infection more slowly than did HIV-negative women (20.6/100 pyr vs. 31.3/100 pyr, P = 0.03). The clearance rate was slower among HIV-positive women with CD4 counts less than 350/mL3 than among those with higher CD4 counts (9.88/100 pyr vs. 29.5/100 pyr, P <; 0.001). After clearing the infection, M. genitalium infection recurred in 39% women. Conclusions M. genitalium is likely to persist and recur in the female genital tract. Because of the urogenital tract morbidity caused by the infection and the observed association with HIV acquisition, further research is needed to define screening modalities, especially in populations at high risk for HIV, and to optimize effective and affordable treatment options.

Condom use among female sex workers in Uganda

Consistent condom use can prevent HIV infection, yet levels of condom use are low in many settings. This paper examines determinants of inconsistent condom use among 905 women enrolled in a high-risk cohort in Kampala, Uganda, who reported sexual intercourse with paying clients in the last month. Among these, 40% participants reported using condoms inconsistently with paying clients in the past month. The most common reason for inconsistent condom use was client preference. Factors independently associated with inconsistent condom use included: sex work not being the sole source of income [adjusted odds ratio (aOR) = 1.54; 95% confidence interval (CI): 1.13–2.09], sexual debut before 14 years (aOR = 1.46; 95% CI: 1.09–1.96), daily consumption of alcohol (aOR = 1.90; 95% CI: 1.26–2.88) and being currently pregnant (aOR = 2.11; 95% CI: 1.25–3.57). Being currently married (aOR = 0.36; 95% CI: 0.18–0.73) and a higher number of sexual partners per month (p-trend = 0.001) were associated with a lower risk of inconsistent condom use. Targeted programmes should be developed to promote consistent condom use in high-risk women, alongside interventions to reduce alcohol use.

Trichomonas vaginalis is highly prevalent in adolescent girls, pregnant women, and commercial sex workers in Ndola, Zambia.

Objectives: The aim of the study was to assess the prevalence of Trichomonas sp. infection among adolescent girls, pregnant women, and commercial sex workers in Ndola, Zambia. Methods: A cross-sectional study was conducted among 460 girls attending school, 307 pregnant women, and 197 commercial sex workers. Self-collected specimens from the vagina, rectum, and mouth were tested by polymerase chain amplification assays for the presence of Trichomonas vaginalis, Pentatrichomonas hominis, and Trichomonas tenax. Genotyping was performed on specimens that tested positive for T. vaginalis. Results: The prevalence of vaginal infection with T. vaginalis was 24.6% among the adolescents, 32.2% among the pregnant women, and 33.2% among the commercial sex workers. Trichomonads other than T. vaginalis were rarely found in the vagina, rectum, and mouth. The presence of T. vaginalis in the rectum was associated with T. vaginalis in the vagina. T. tenax was also detected in the vagina. A total of 9 actin genotypes of T. vaginalis were identified. The distribution of the actin genotypes of T. vaginalis was similar in the 3 study groups. Conclusion: We detected high prevalence rates of trichomoniasis among women in Ndola, Zambia. Prevalence among adolescent girls was lower than among pregnant women and commercial sex workers but was still high. We were not able to detect differences in T. vaginalis actin genotypes among the 3 study groups.

Toward a Reliable Evaluation of Forecasting Systems for Plant Diseases: A Case Study Using Fusarium Head Blight of Wheat

Despite great efforts to forecast plant diseases, many of the existing systems often fall short in providing farmers with accurate predictions. One of the main problems arises from the existence of year and location effects, so that more advanced procedures are required for evaluating existing systems in an unbiased manner. This paper illustrates the case of Fusarium head blight of winter wheat in Belgium. We present a new cross-validation strategy that enables the evaluation of the predictive performance of a forecasting system for years and locations that are different from the years and locations on which the forecast was developed. Four different cross-validation strategies and five regression techniques are used. The results demonstrated that traditional evaluation strategies are too optimistic in their predictions, whereas the cross-year cross-location validation strategy yielded more realistic outcomes. Using this procedure, the mean squared error increased and the coefficient of determination decreased in predicting disease severity and deoxynivalenol content, suggesting that existing evaluation strategies may generate a substantial optimistic bias. The strongest discrepancies between the cross-validation strategies were observed for multiple linear regression models.

Clinical Characteristics Associated With Mycoplasma genitalium Infection Among Women at High Risk of HIV and Other STI in Uganda.

Background: Mycoplasma genitalium is a common infection of the genitourinary tract, but its pathogenic effects have not been well described, especially in women. The increasing evidence that M. genitalium is associated with HIV infection calls for an urgent consensus on how best to control this infection. The aim of this study was to describe symptoms and signs associated with M. genitalium infection among high-risk women in Uganda. Methods: A cohort of 1027 female sex workers was recruited in Kampala in 2008. At enrollment, HIV testing was performed, genital specimens were tested for other sexually transmitted infection, and urogenital symptoms and signs were recorded. Endocervical swabs were tested for M. genitalium using a commercial Real-TM PCR assay (Sacace Biotechnologies, Como, Italy). The associations of clinical signs and symptoms with prevalent M. genitalium were investigated using multivariable logistic regression models. Results: Reported dysuria and presence of mucopurulent vaginal discharge were significantly associated with M. genitalium infection (OR: 1.85, 95% confidence interval: 1.13–3.03 and OR: 1.55, 95% confidence interval: 1.06–2.29, respectively). There was little evidence for an association with cervicitis or with pelvic inflammatory disease. Conclusions: In this specific population, we found evidence that symptoms of urethritis and mucopurulent vaginal discharge were associated with M. genitalium infection. This supports earlier studies showing that M. genitalium may lead to clinically relevant genitourinary disorders and should be treated. In the absence of sensitive screening tests, further work is needed to validate clinical findings as possible indicators of M. genitalium infection to guide a possible syndromic approach for its control.