Rachel A. Royce

Sexual transmission of HIV

This article focuses on the epidemiology and biology of the host-related factors that affect the sexual transmission of HIV. It discusses host susceptibility and infectiousness environment biologic agent and preventing sexually transmitted HIV infection.

Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1

BACKGROUND Transmission of HIV-1 is predominantly by heterosexual contact in sub-Saharan Africa, where sexually transmitted diseases (STDs) are also common. Epidemiological studies suggest that STDs facilitate transmission of HIV-1, but the biological mechanism remains unclear. We investigated the hypothesis that STDs increase the likelihood of transmission of HIV-1 through increased concentration of the virus in semen. METHODS HIV-1 RNA concentrations were measured in seminal and blood plasma from 135 HIV-1-seropositive men in Malawi; 86 had urethritis and 49 controls did not have urethritis. Men with urethritis received antibiotic treatment according to the guidelines of the Malawian STD Advisory Committee. Samples were analysed at baseline and at week 1 and week 2 after antibiotic therapy in urethritis patients, and at baseline and week 2 in the control group. FINDINGS HIV-1-seropositive men with urethritis had HIV-1 RNA concentrations in seminal plasma eight times higher than those in seropositive men without urethritis (12.4 vs 1.51 x 10(4) copies/mL, p = 0.035), despite similar CD4 counts and concentrations of blood plasma viral RNA. Gonorrhoea was associated with the greatest concentration of HIV-1 in semen (15.8 x 10(4) copies/mL). After the urethritis patients received antimicrobial therapy directed against STDs, the concentration of HIV-1 RNA in semen decreased significantly (from 12.4 x 10(4) copies/mL to 8.91 x 10(4) copies/mL at 1 week [p = 0.03] and 4.12 x 10(4) copies/mL at 2 weeks [p = 0.0001]). Blood plasma viral RNA concentrations did not change. There was no significant change in seminal plasma HIV-1 RNA concentrations during the 2-week period in the control group (p = 0.421). INTERPRETATION These results suggest that urethritis increases the infectiousness of men with HIV-1 infection. HIV-1-control programmes, which include detection and treatment of STDs in patients already infected with HIV-1, may help to curb the epidemic. Targeting of gonococcal urethritis may be a particularly effective strategy.

High Levels of Human Immunodeficiency Virus Type 1 in Blood and Semen of Seropositive Men in Sub-Saharan Africa

High levels of human immunodeficiency virus type 1 (HIV-1) replication, as reflected in HIV-1 RNA concentrations in blood and semen, probably contribute to both rapid disease progression and enhanced sexual transmission. Semen and blood were collected from 49 Malawian and 61 US and Swiss (US/Swiss) HIV-1-seropositive men with similar CD4 cell counts and no urethritis or exposure to antiretroviral drugs. Median seminal plasma and blood plasma HIV-1 RNA concentrations were >3-fold (P = .034) and 5-fold (P = .0003) higher, respectively, in the Malawian men. Similar differences were observed in subsets of the Malawian and US/Swiss study groups matched individually for CD4 cell count (P = .035 and P < .002, respectively). These observations may help explain the high rates of HIV-1 sexual transmission and accelerated HIV-1 disease progression in sub-Saharan Africa.

The natural history of HIV-1 infection : staging classifications of disease

We evaluated and compared four staging classification systems for HIV infection in a population-based cohort: (1) a staging based on prodromal clinical criteria; (2) the Walter Reed Staging Classification (WRSC); (3) the immunologie staging system (ISS), and (4) a simple staging based on oral disease and CD4+ T-cell depletion. The staging systems were applied to 386 HIV-infected men in the San Francisco Mens Health Study cohort who did not have AIDS at the baseline examination. After 48–56 months of follow-up the cumulative incidence of AIDS and the cumulative mortality by stage was determined for each staging. Unlike the other systems, the WRSC could not classify a substantial proportion of HIV-infected men (51.9%). The WRSC and ISS include one or more stages which did not appear to be associated with a prognosis substantially different from that of adjacent stages. The simplified staging system based on CD4 + T-cell depletion and oral disease may be the most effective of the systems studied. A more complete understanding of the pathophysiology during the evolution of HIV infection will be required to define a more detailed staging of this disease.

Seroepidemiological survey of hepatitis B and C virus infections in Ghanaian children

The seroprevalences of hepatitis B virus (HBV) and hepatitis C virus (HCV) markers were evaluated in a random sample of 803 children attending school in Ashanti‐Akim North district in Ghana in order to gain a better understanding of transmission patterns of these viruses, particularly horizontal transmission of HBV. This rural district is typical of 70% of the Ghanaian population. The overall seroprevalence of at least one marker of HBV infection was 61.2%, with rates increasing from 48% to 80% between the ages of 6–18 years (P < 0.001). The overall HBsAg seroprevalence was 15.8%, with the proportion of HBsAg positives amongst those with anti‐HBc increasing from 39.3% in 6–7‐year‐olds to 51.8% in 12–13‐year‐old. It appears that horizontal transmission during this age period was accompanied by a high rate of HBsAg carriage. Among those infected but not carriers, i.e., those HBsAg negative and anti‐HBc positive, >50% lacked detectable levels of anti‐HBs, an unusual pattern of convalescent immune response to HBV. The overall seroprevalence of anti‐HCV was 5.4% and did not differ significantly by age or gender. Anti‐HCV seroprevalence was not associated with the presence of any HBV marker. A better understanding of the unusually high prevalences of HBV and HCV infections demonstrated in this population is likely to influence vaccination and blood transfusion policies and to stimulate further evaluations of these infections and their vehicles of spread in highly endemic regions such as sub‐Saharan Africa.

Effects of Short Interpregnancy Intervals on Small-for-gestational Age and Preterm Births

We examined the effects of short interpregnancy intervals on small-for-gestational age and preterm births in a biracial population using North Carolina birth certificate data from 1988 to 1994. We defined small-for-gestational age birth as being below the 10th percentile on a race-, sex-, and parity-specific growth curve after a gestation of 37-42 weeks. We defined preterm birth as a gestation of less than 37 weeks. We analyzed birth records from all eligible singleton births to black or white women ages 15-45 years after an interpregnancy interval of 0-3 months (N = 11,451) and a random sample of singleton births after an interval of 4-24 months (N = 23,118). We defined interpregnancy interval exposure categories as 0-3, 4-12, and 13-24 months. The multivariate adjusted odds ratio for small-for-gestational age births after interpregnancy intervals of 0-3 months compared with 13-24-month intervals was 1.6 (95% confidence interval = 1.4-1.8). The odds ratio for preterm birth after interpregnancy intervals of 0-3 months was 1.2 (95% confidence interval = 1.1-1.3). Odds ratios did not vary substantially by race for either outcome.More than 50% of infants with Down syndrome have associated defects that cause considerable morbidity and mortality. We evaluated the hypothesis that the trisomic genome interacts with environmental factors to increase the risk for specific associated defects. We evaluated risk factors present during early pregnancy in a multiracial population of 687 infants with Down syndrome. Mothers cigarette smoking was associated with the grouped cardiac defects [odds ratio (OR)=2.0; 95% confidence interval (CI) = 1.2-3.2]. When adjusted for other cardiac defects and maternal race, the following specific defects were associated with smoking: atrioventricular canal (OR = 2.3; 95% CI = 1.2-4.5), tetralogy of Fallot (OR = 4.6; 95% CI = 1.2-17.0), and atrial septal defects without ventricular septal defect (OR = 2.2; 95% CI = 1.1-4.3). Hirschsprung disease was associated with mothers daily consumption of more than three cups of coffee (OR = 6.02; 95% CI = 1.2-29.7) and with mothers fever (OR = 3.4; 95% CI = 0.7-16.4), but the number of cases was small. Use of alcohol was not associated with any defect. Mothers race, age, parity, income, or education did not confound the associations. Results suggest that environmental factors can modify the occurrence of associated anomalies in the embryo with Down syndrome.

HIV-1 infected women and prenatal care utilization: barriers and facilitators.

In an effort to understand issues affecting prenatal care access and utilization from the perspectives of human immunodeficiency virus (HIV)-infected women who receive inadequate prenatal care, we conducted three in-depth qualitative and quantitative interviews. From a thematic analysis of the narrative interviews, four broad areas emerged as pertinent to these womens prenatal care experiences. These were issues related to pregnancy, HIV, psychosocial conditions, and the health care system. For these women, the barriers to prenatal care utilization included the unexpected and unplanned nature of the pregnancy and mental health issues related to HIV infection. Poverty, periodic homelessness, addiction to illicit substances, and lack of social support were also important barriers. Furthermore, perceptions of the health care system as threatening, including fears related to consequences of disclosing illicit activities, discrimination, and breach of confidentiality emerged as salient barriers. Facilitating factors included the pregnancy being experienced as a life-transforming event, concern for their children, especially preventing HIV-1 vertical transmission, availability of treatment, and support from health care professionals. Prominent throughout the interviews were the womens mental health concerns and need for professional support.

Physical and Sexual Violence During Pregnancy and After Delivery: A Prospective Multistate Study of Women With or at Risk for HIV Infection.

OBJECTIVES We sought to describe and compare prevalence rates of and risk factors for violence against women during pregnancy and postpartum. METHODS Physical and sexual violence and violence risk factors were assessed during late pregnancy and 6 months postpartum in a prospective study of pregnant women with (n=336) and without (n=298) HIV in 4 US states. RESULTS Overall, 10.6% of women reported having experienced violence, 8.9% during pregnancy and 4.9% after delivery. Of these women, 61.7% were abused only during their pregnancy, 21.7% were repeatedly abused, and 16.7% were abused only after their delivery. Sexual violence rarely occurred in the absence of physical violence. The strongest predictor of violence was engaging in bartered sex (adjusted odds ratio [OR]=5.54; 95% confidence interval [CI] =2.0, 15.4). Other predictors included frequent changes in residence (adjusted OR=1.57; 95% CI=1.1, 2.2), financial support from family or partners (adjusted OR=0.42; 95% CI=0.2, 0.8), and HIV diagnosis during current pregnancy (adjusted OR=0.30; 95% CI=0.1, 0.7). CONCLUSIONS Women more commonly experienced violence during than after their pregnancy, but violence was best predicted by socioeconomic and behavioral indicators whose influence did not vary over time.

What's driving an epidemic? The spread of syphilis along an interstate highway in rural North Carolina.

OBJECTIVES The purpose of this study was to determine whether county syphilis rates were increased along Interstate Highway 95 (I-95) in North Carolina during a recent epidemic. METHODS Ecological data on syphilis cases demographic data, highway data, and drug activity data were used to conduct a cross-sectional and longitudinal study of North Carolina countries from 1985 to 1994. Crude and adjusted incidence rate ratios (IRRs) were determined by means of standard and longitudinal Poisson regression models adjusted for sociodemographic factors and drug use. RESULTS Ten-year syphilis rates in I-95 counties greatly exceeded rates in non-I-95 counties (38 vs 16 cases per 100,000 persons) and remained higher after adjustment for race, age, sex, poverty, large cities, and drug activity (adjusted IRR = 2.05, 95% confidence interval [CI] = 1.84, 2.28). Syphilis rates were stable until 1989, when rates increased sharply in I-95 counties but remained stable in non-I-95 counties. Increased drug activity in I-95 counties preceded the rise in syphilis cases. CONCLUSIONS A better understanding of the relationship between high-ways and the spread of sexually transmitted diseases may guide future prevention interventions.

Violence During Pregnancy Among Women With or at Risk for HIV Infection

OBJECTIVES This study estimated the prevalence of violence during pregnancy in relation to HIV infection. METHODS Violence, current partnerships, and HIV risk behaviors were assessed among 336 HIV-seropositive and 298 HIV-seronegative at-risk pregnant women. RESULTS Overall, 8.9% of women experienced recent violence; 21.5% currently had abusive partners. Violence was experienced by women in all partnership categories (range = 3.8% with nonabusive partners to 53.6% with physically abusive partners). Neither experiencing violence nor having an abusive partner differed by serostatus. Receiving an HIV diagnosis prenatally did not increase risk. Disclosure-related violence occurred, but was rare. CONCLUSIONS Many HIV-infected pregnant women experience violence, but it is not typically attributable to their serostatus. Prenatal services should incorporate screening and counseling for all women at risk for violence.