Patricia Claeys

Vulnerability of women in an African setting: lessons for mother-to-child HIV transmission prevention programmes.

After discussing advantages and risks, only a third of the 290 HIV-infected women included in an intervention study to reduce mother-to-child transmission of HIV in Mombasa, Kenya, informed their partners of their results. Despite careful counselling, 10% subsequently experienced violence or disruption of their relationship. To increase the uptake of interventions to reduce perinatal HIV transmission safely, we recommend the involvement of partners in HIV testing. In addition, the counselling of women has to address methods and skills to deal with violence.

Effect of a syphilis control programme on pregnancy outcome in Nairobi Kenya.

Objectives: To assess the impact of a syphilis control programme of pregnant women on pregnancy outcome in Kenya. Method: Women who came to deliver to Pumwani Maternity Hospital (PMH) between April 1997 and March 1998 were tested for syphilis. Reactive rapid plasma reagin (RPR) tests were titrated and confirmed with treponema haemagglutination test (TPHA). Equal numbers of RPR and TPHA negative women were enrolled. Antenatal syphilis screening and treatment history were examined from the antenatal cards. Results: Of 22 466 women giving birth, 12 414 (55%) were tested for syphilis. Out of these, 377 (3%) were RPR reactive of whom 296 were confirmed by TPHA. Syphilis seroreactive women had a more risky sexual behaviour and coexistent HIV antibody positivity; 26% were HIV seropositive compared with 11% among syphilis negative mothers. The incidence of adverse obstetric outcome defined as low birth weight and stillbirth, was 9.5%. Syphilis seropositive women had a higher risk for adverse obstetric outcome (OR 4.1, 95% CI 2.4–7.2). Antenatal treatment of RPR reactive women significantly improved pregnancy outcome but the risk of adverse outcome remained 2.5-fold higher than the risk observed in uninfected mothers. Conclusions: These data confirm the adverse effect of syphilis on pregnancy outcome. This study also shows the efficacy of antenatal testing and prompt treatment of RPR reactive mothers on pregnancy outcome.

Distribution of human papillomavirus in a family planning population in nairobi, kenya.

Background In sub-Saharan Africa, cervical cancer is the leading cancer among women. The causative role of different human papillomavirus (HPV) types in cervical cancer is established, but the distribution of HPV types within this region is largely unknown. Goal The goal was to study the distribution of HPV among family planning clinic attendees in Nairobi, Kenya. Study Design This was a cross-sectional study of persons attending a family planning center in Nairobi, Kenya. Results HPV data of 429 women were analyzed; 7.0% had low-grade intraepithelial lesions, 6.8% had high-grade intraepithelial lesions, and 0.23% had invasive cancer. One hundred ninety samples (44.3%) were HPV-positive (28.4% were positive for multiple types). The most common HPV types were HPV 52 (17.9% of positive samples), HPV 16 (14.7%), HPV 35 (11.6%), and HPV 66 (9.0%). The risk of high-grade squamous intraepithelial lesions (HSIL) was 88.5 times higher (95% CI, 8.5–1.4 × 105) in HPV 16-positive women than in HPV-negative women. Relative risks were 54.3 (95% CI, 4.0–1.4 × 105) for HPV 35, 49.2 (95% CI, 3.6–9.5 × 104) for HPV 52, and 21.7 (95% CI, 0.0—1.9 × 105) for HPV 18. The prevalence of HSIL was not increased in association with HIV-positivity, yet HIV-1 was significantly associated with high-risk HPV types (P < 0.00001). Conclusion The pattern of HPV distribution in this population was different from that in other regions in the world, which has important consequences for HPV vaccine development.

Vaginal lavage with chlorhexidine during labour to reduce mother-to-child HIV transmission: clinical trial in Mombasa Kenya.

ObjectivesTo evaluate the effect of vaginal lavage with diluted chlorhexidine on mother-to child transmission of HIV (MTCT) in a breastfeeding population. MethodsThis prospective clinical trial was conducted in a governmental hospital in Mombasa, Kenya. On alternating weeks, women were allocated to non-intervention or to intervention consisting of vaginal lavage with 120 ml 0.2% chlorhexidine, later increased to 0.4%, repeated every 3 h from admission to delivery. Infants were tested for HIV by DNA polymerase chain reaction within 48 h and at 6 and 14 weeks of life. ResultsEnrolment and follow-up data were available for 297 and 309 HIV-positive women, respectively, in the non-lavage and the lavage groups. There was no evidence of a difference in intrapartum MTCT (17.2 versus 15.9%, OR 0.9, 95% CI 0.6–1.4) between the groups. Lavage solely before rupture of the membranes tended towards lower MTCT with chlorhexidine 0.2% (OR O.6, 95% CI 0.3–1.1), and even more with chlorhexidine 0.4% (OR 0.1, 95% CI 0.0–0.9). ConclusionThe need remains for interventions reducing MTCT without HIV testing, often unavailable in countries with a high prevalence of HIV. Vaginal lavage with diluted chlorhexidine during delivery did not show a global effect on MTCT in our study. However, the data suggest that lavage before the membranes are ruptured might be associated with a reduction of MTCT, especially with higher concentrations of chlorhexidine.

Comparison of pap smear, visual inspection with acetic acid, human papillomavirus DNA-PCR testing and cervicography

To assess the test qualities of four screening methods to detect cervical intra‐epithelial neoplasia in an urban African setting.

Diversity of the Human Immunodeficiency Virus Type 1 (HIV-1) env Sequence after Vertical Transmission in Mother-Child Pairs Infected with HIV-1 Subtype A

ABSTRACT Although several virologic and immunologic factors associated with an increased risk of perinatal human immunodeficiency virus type 1 (HIV-1) transmission have been described, the mechanism of mother-to-child transmission is still unclear. More specifically, the question of whether selective pressures influence the transmission remains unanswered. The aim of this study was to assess the genetic diversity of the transmitted virus after in utero transmission and after peripartum transmission and to compare the viral heterogeneity in the child with the viral heterogeneity in the mother. To allow a very accurate characterization of the viral heterogeneity in a single sample, limiting-dilution sequencing of a 1,016-bp fragment of the env gene was performed. Thirteen children were tested, including 6 with in utero infections and 7 with peripartum infections. Samples were taken the day after birth and at the ages of 6 and 14 weeks. A homogeneous virus population was seen in six (46.2%) infants, of whom two were infected in utero and four were infected peripartum. A more heterogeneous virus population was detected in seven infants (53.8%), four infected in utero and three infected peripartum. The phylogenetic trees of the mother-child pairs presented a whole range of different tree topologies and showed infection of the child by one or more maternal variants. In conclusion, after HIV-1 transmission from mother to child a heterogeneous virus population was detected in approximately one-half of the children examined. Heterogeneous virus populations were found after peripartum infection as well as after in utero infection. Phylogenetic tree topologies argue against selection processes as the major mechanism driving mother-to-child transmission but support the hypothesis that virus variability is mainly driven by the inoculum level and/or exposure time.

Placental Malaria and Perinatal Transmission of Human Immunodeficiency Virus Type 1

Prevalence of placental malaria in human immunodeficiency virus (HIV) type 1-infected and -uninfected women and the effect of placental malaria on genital shedding and perinatal transmission of HIV-1 were examined. Genital samples for HIV-1 DNA RNA were collected during labor. Infants were tested for HIV-1 at 1 day and 6 weeks postpartum. Placental malaria was diagnosed by histopathological examination: 372 placentas of HIV-1-infected women and 277 of HIV-1-uninfected women were processed. A higher prevalence of placental malaria was seen in HIV-1-infected women. No association was found between placental malaria and either maternal virus load, genital HIV-1 DNA, or HIV-1 RNA. Placental malaria did not correlate with in utero or peripartal transmission of HIV-1.

Association of HIV infection with distribution and viral load of HPV types in Kenya: a survey with 820 female sex workers.

BackgroundHuman papillomavirus (HPV) and HIV are each responsible for a considerable burden of disease. Interactions between these infections pose substantial public health challenges, especially where HIV prevalence is high and HPV vaccine coverage low.MethodsBetween July 2005 and January 2006, a cross-sectional community-based survey in Mombasa, Kenya, enrolled female sex workers using snowball sampling. After interview and a gynaecological examination, blood and cervical cytology samples were taken. Quantitative real-time PCR detected HPV types and viral load measures. Prevalence of high-risk HPV was compared between HIV-infected and -uninfected women, and in women with abnormal cervical cytology, measured using conventional Pap smears.ResultsMedian age of the 820 participants was 28 years (inter-quartile range [IQR] = 24-36 years). One third of women were HIV infected (283/803; 35.2%) and these women were y more likely to have abnormal cervical cytology than HIV-negative women (27%, 73/269, versus 8%, 42/503; P < 0.001). Of HIV-infected women, 73.3% had high-risk HPV (200/273) and 35.5% had HPV 16 and/or 18 (97/273). Corresponding figures for HIV-negative women were 45.5% (229/503) and 15.7% (79/503). After adjusting for age, number of children and condom use, high-risk HPV was 3.6 fold more common in HIV-infected women (95%CI = 2.6-5.1). Prevalence of all 15 of the high-risk HPV types measured was higher among HIV-infected women, between 1.4 and 5.5 fold. Median total HPV viral load was 881 copies/cell in HIV-infected women (IQR = 33-12,110 copies/cell) and 48 copies/cell in HIV-uninfected women (IQR = 6-756 copies/cell; P < 0.001). HPV 16 and/or HPV 18 were identified in 42.7% of LSIL (32/75) and 42.3% of HSIL (11/26) lesions (P= 0.98). High-risk HPV types other than 16 and 18 were common in LSIL (74.7%; 56/75) and HSIL (84.6%; 22/26); even higher among HIV-infected women.ConclusionsHIV-infected sex workers had almost four-fold higher prevalence of high-risk HPV, raised viral load and more precancerous lesions. HPV 16 and HPV 18, preventable with current vaccines, were associated with cervical disease, though other high-risk types were commoner. HIV-infected sex workers likely contribute disproportionately to HPV transmission dynamics in the general population. Current efforts to prevent HIV and HPV are inadequate. New interventions are required and improved implementation of existing strategies.

Placental inflammation and perinatal transmission of HIV-1.

&NA; The effect of placental membrane inflammation on mother‐to‐child transmission (MTCT) of HIV‐1 is reported. Placentas from HIV‐1‐infected women were examined as part of a perinatal HIV‐1 project in Mombasa. Kenya. Polymerase chain reaction analysis was used to test for HIV‐1 in the infants at birth and at 6 weeks. The maternal HIV‐1 seroprevalence was 13.3% (298 of 2,235). The overall rate of MTCT of HIV‐1 was 25.4%; polymerase chain reaction analysis revealed that of the 201 infants 6.0% (12) were already HIV‐1‐positive at birth (intrauterine transmission) and 19.4% (39) were infected during the peripartum period or in early neonatal life (perinatal transmission). The prevalence of acute chorioamnionitis was 8.8%, that of deciduitis was 10.8%, and that of villitis was 1.6%. Acute chorioamnionitis was independently associated with peripartum HIV‐1 transmission but not with in utero MTCT (17.9% vs. 6.7%, respectively; adjusted odds ratio, 3.9; 95% confidence interval, 1.2‐12.5; p = .025). Other correlates of perinatal MTCT were presence of HIV in the genital tract and in the babys oral cavity and a high maternal viral load in peripheral blood. The adjusted population attributable fraction of 12.8% (95% confidence interval, 1.5%‐22.8%) indicated that approximately 3% of MTCT could be prevented if acute chorioamnionitis was eliminated. We suggest that further research on the role of antimicrobial treatment in the prevention of chorioamnionitis and the reduction of peripartum MTCT needs to be performed.

Risk factors for human papillomavirus and cervical precancerous lesions, and the role of concurrent HIV-1 infection

Objectives: To identify risk factors for human papillomavirus (HPV) infection and squamous intraepithelial lesions (SIL) of the cervix, and to measure the impact of concurrent HIV‐1 infection. Methods: Women were studied at a family planning clinic in Nairobi, Kenya. Demographic and historical information was obtained using a semi‐structured questionnaire and specimens were collected for sexually transmitted diseases (STDs), HPV, cervical cytology, and HIV‐1 testing. Results: HPV was detected in 87 of 513 women (17%), including 81 (93%) oncogenic types (16, 18, 31, 33 and others) and six (7%) non‐oncogenic types (6 and 11). HIV‐1 prevalence was 10%. HPV detection was associated with HIV‐1 infection [adjusted odds ratio (aOR) 3.9, 95% confidence interval (CI), 2.0–7.7], sexual behavior indicators including the number of sex partners and inflammatory STDs, as well as the number of pregnancies (0 or 1 vs. ≥3, aOR 0.4; 95% CI, 0.2–0.9). SIL was detected in 61 women (11.9%), including 28 (46%) with low‐grade lesions (LSIL) and 33 (54%) with high‐grade lesions (HSIL). HPV infection was strongly associated with HSIL (OR 14.9; 95% CI, 6.8–32.8). In a multivariate model predictors of HSIL included HIV‐1 serpositivity (aOR 4.8; 95% CI, 1.8–12.4), the number of lifetime sex partners (0–1 vs. ≥4; aOR 3.8; 95% CI, 1.1–13.5), and older age (<26 vs. >30; OR 3.9; 95% CI, 1.1–13.6). An analysis stratified by HIV‐1 showed a stronger association between HPV and HSIL in HIV‐1 negative women (OR 17.0; 95% CI, 6.4–46.3) then in HIV‐1 positive women (OR 4.5; 95% CI, 0.8–27.4). Conclusions: Our results indicate that HSIL and even invasive cancer are highly prevalent in this setting of women on reproductive age considered to be at low risk for STDs, suggesting that routine Pap smear screening may save lives.