Sunanda Ray

HIV seroincidence and correlates of seroconversion in a cohort of male factory workers in Harare, Zimbabwe.

OBJECTIVES Given that health promotion messages on transmission of HIV and other sexually transmitted diseases (STD) have been widely publicized in Zimbabwe and elsewhere in the late 1980s, it is vital to analyse which risk events still expose individuals to infection. A cohort was established with the objectives of estimating HIV seroincidence, behavioural and biological determinants of infection, and ultimately, evaluating the impact of AIDS prevention interventions in the workplace. METHODS HIV seroincidence was estimated in a prospectively followed cohort of male factory workers recruited in Harare, Zimbabwe during the period prior to a workplace AIDS prevention intervention. Correlates of HIV seroconversion were identified using Cox regression analysis. RESULTS There were 51 seroconversions among 1607 HIV-negative participants following 1738 person-years (PY) of observation [seroincidence, 2.93 per 100 PY; 95% confidence interval (CI), 2.18-3.86]. The prevalence of HIV in the cohort was 19.1%. HIV seroincidence was significantly increased among men who were younger [hazard ratio (HR) per year, 0.96; 95% CI, 0.93-0.99], were single (HR, 3.29; 95% CI, 1.56-6.96), were married but resided separately from their wives (HR, 2.18; 95% CI, 0.99-4.80), reported having any STD (HR, 3.00; 95% CI, 1.53-5.86), reported having a genital ulcer (HR, 4.87; 95% CI, 2.18-10.91), and reported paying for sex (HR, 2.01; 95% CI, 1.06-3.77). Seroincidence also increased with the number of sex partners reported in the year preceding enrolment (HR per partner, 1.10; 95% CI, 1.01-1.21). In multiple Cox regression analysis, three independent associations with HIV seroconversion were reporting a genital ulcer (adjusted HR, 3.55; 95% CI, 1.52-8.29), number of sex partners (adjusted HR, 1.10; 95% CI, 1.01-1.21), and being married but residing separately from ones wife (adjusted HR, 2.21; 95% CI, 1.00-4.89). CONCLUSIONS Innovative and sustained workplace-based interventions are needed to address the high risk of HIV infection in this economically productive population. The predictors of HIV seroconversion described in this study underscore the need for public health efforts to simultaneously address the biological, socioeconomic and behavioural factors that continue to place individuals at risk of HIV in general populations of Africa.

Constraints faced by sex workers in use of female and male condoms for safer sex in urban Zimbabwe

We investigated whether female condoms are acceptable to sex workers in Harare and whether improved access to male and female condoms increases the proportion of protected sex episodes with clients and boyfriends. Sex workers were randomly placed in groups to receive either male and female condoms (group A, n=99) or male condoms only (group B, n=50) and were followed prospectively for about 3 months each. We found a considerable burden of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) in our cohort at enrollment (86% tested HIV positive and 34% had at least one STI). Consistent male condom use with clients increased from 0% to 52% in group A and from 0% to 82% in group B between enrollment and first follow-up 2 weeks later and remained high throughout the study. Few women in group A reported using female condoms with clients consistently (3%–9%), and use of either condom was less common with boyfriends than with clients throughout the study (8%–39%) for different study groups, visits, and types of condom). Unprotected sex still took place, as evidenced by an STI incidence of 16 episodes per 100 woman-months of follow-up. Our questionnaire data indicated high self-reported acceptability of female condoms, but focus group discussions revealed that a main obstacle to female condom use was client distrust of unfamiliar methods. This study shows that a simple intervention of improving access to condoms can lead to more protected sex episodes between sex workers and clients. However, more work is needed to help sex workers achieve safer sex in noncommercial relationships.

Acceptability of the female condom in Zimbabwe: Positive but male-centred responses

Abstract An acceptability study of the female condom was carried out in Zimbabwe among sex workers (89), urban women attending a family planning clinic in Harare (84), and rural women (23). Their main reason for trying this new method was as protection from sexually transmitted infections, including HIV. Over 50 per cent of the women in all three groups said that they and their partners liked the condom very much and preferred it to the male condom. Less than 10 per cent did not like it. The main problems were with the inner ring and too much lubrication, but questions remain on sustainability, and cost is a major obstacle. Further, even though it did not interfere with the womens sexual pleasure, most of the reasons for liking the method were male-centred.

Local voices: What some Harare men say about preparation for sex

Abstract For more effective prevention strategies against heterosexual transmission of HIV to be developed in Africa, it is essential to look at lay beliefs and attitudes towards sex, as well as negotiation strategies and gender relations between sexual partners. Anyreduction in practices which enhance womens vulnerability will require the willingness ofmen. The study described here was a pilot study among male factory workers in Harare, to examine theirperceptions of techniques used in preparation for sex by men and women. The men described the use of herbs and aphrodisiacs by men to enhance sexual performance, and the use of drying agents by women for vaginal cleansingpurposes and for enhancement of sexual pleasure for male partners. Within the context of high HIV prevalence in the country, this paper recommends strategies of peer education and involving health workers and families to address sexual beliefs and behaviour, to encourage safer sex practices. Para desarrollar estrategias de prevencion mas efectivas contra la transmision heterosexual del VIH en Africa es importante examinar las creencias y actitudes comunes hacia el sexo, las estrategias de negociacion y las relaciones de genero entre la pareja sexual. Para lograr una reduccion de las practicas que aumentan la vulnerabilidad de la mujer hace falta contar con la voluntad del hombre. Este ensayo describe un estudio piloto realizado con obreros de fabrica en Harare, para examinar su perception de las tecnicas utilizadas por hombres y mujeres antes del acto sexual. Los hombres describen et efo masculino de hierbas y afrodisiacos para aumentar el desempeno sexual, y el uso femenino de sustancias secantes para limpiar la vagina y para aumentar el placer sexual del companero. En el contexto de la alta prevalencia del VIH en el pais, este ensayo recomienda estrategias dirigidas a la educacion de grupos coetaneos, y a que los trabajadores de salud y las familias traten el terra de las creencias y comportamiento sexuales, para alentar a que se practique el sexo mas seguro.

Primary subtype C HIV-1 infection in Harare, Zimbabwe

Heterosexual transmission of HIV-1 is widespread in Southern Africa. Heteroduplex mobility assays (HMA) and phylogenetic analyses of V3-V5 envelope (env) gene sequences demonstrate that subtype C predominates in Zimbabwe. To elucidate factors contributing to the epidemic in Zimbabwe, clinical and virologic characteristics of recently acquired subtype C HIV-1 infection among 21 men and 1 woman were determined. In 12 of 19 men providing clinical histories, a sexually transmitted infection preceded serologic evidence of HIV-1, and 14 of 19 men complained of rash or fever before seroconversion. Quantitative p24 antigen levels, reverse transcriptase activity, and HIV RNA levels of 22 viral isolates correlated with in vitro infectivity in peripheral blood mononuclear cells (p < .05). Biologic phenotype assessed in MT-2 cells demonstrated that 3 of 22 isolates (14%) were syncytia inducing (SI) and the remaining 19 nonsyncytium inducing (NSI). Early growth of virus in culture was associated with increased plasma HIV RNA levels, decreased CD4 cell levels, and SI virus. Recent subtype C HIV-1 infection through heterosexual transmission in Zimbabwe demonstrated clinical and virologic features consistent with reports of seroconversion to subtype B viruses.

Antimicrobial resistance in gonococci isolated from patients and from commercial sex workers in Harare Zimbabwe.

The objective is to compare antibiotic resistance amongst gonococci isolated from different patient groups in Harare, Zimbabwe. Antimicrobial susceptibilities of Neisseria. gonorrhoeae were determined by disc sensitivity tests. The MICs for penicillin, kanamycin, ceftriaxone, norfloxacin and ciprofloxacin were determined using E-test strips. There were 147 isolates from symptomatic men, 47 isolates from symptomatic women, 29 isolates from asymptomatic women and 41 isolates from female commercial sex workers. A total of 119 (45%) isolates were PPNG and 23 (16%) non-PPNG isolates had a penicillin MIC > 0.64 mg/l. Over 90% of isolates were resistant to TMP/SMX and 16% were resistant to tetracycline. Resistance was uncommon against kanamycin (6%), erythromycin (2%) or ceftriaxone ( < 1%). For kanamycin, the MIC90 was 32 mg/l, for ceftriaxone the MIC90 was < 0.032 mg/l for non-PPNG and < 0.064 mg/l for PPNG. For norfloxacin and ciprofloxacin the MIC90 was < 0.064 mg/l for both PPNG and non-PPNG. Isolates from the commercial sex workers showed a significantly increased prevalence of PPNG, of penicillin-tolerant non-PPNG and of tetracycline resistance. Four of the 41 isolates from sex workers showed multiple resistance (to penicillin, TMP/SMX, tetracycline and kanamycin) compared to 1/223 isolates from other groups (OR = 24.0). Antimicrobial resistance is common amongst gonococci in Harare, especially with isolates from commercial sex workers. In order for STD treatment to be implemented as an effective strategy in HIV control, continued monitoring of resistance patterns is essential.

AZT therapy should now be evaluated for six months post-partum

Thailand was conducted in a population of HIVinfected women who did not breastfeed. With the availability of an effective, simplified regimen applicable to many countries in the developing world, it is essential to now evaluate the effectiveness of a very short AZT regimen in pregnant women who do not present at antenatal clinics before the time of delivery and in women who breastfeed both of which are common in many countries in the developing world. Because HIV can also be transmitted through breastmilk, it is possible that efficacy of the shortened regimen may be lessened in countries where breasifeeding is the norm. Further evaluation of the shortened regimen in such countries is therefore essential, as well as exploration of the relevance of early weaning or other strategies. It will also be important to evaluate regimens that are even simpler than the CDC short-course AZ’l’ regimen to establish their efficacy in reducing HIV transmission. Additionally, it needs to be established whether there is further advantage in using other antiretroviral drugs or combinations of drugs for reducing transmission. Excerpted with kind permission of PROCAARE, 2 March 1998.

Antimicrobial susceptibility patterns amongst group B streptococci from women in Harare, Zimbabwe

As part of a larger study of vaginal pathogens in women in Harare, we have examined the antimicrobial susceptibility patterns of 130 isolates of group B streptococci (GBS). These organisms are important because of their association with preterm labour, premature rupture of membranes and neonatal sepsis. All of the isolates in Harare were fully sensitive to beta-lactams, with an MIC(90) for ampicillin of 0.38 mg/l, but five isolates were resistant in vitro to erythromycin, and each of these had an MIC >4 mg/l. Seven isolates showed resistance to clindamycin. Some isolates showed an intermediate sensitivity to gentamicin, but the great majority were resistant to this antibiotic. Studies in developed countries have shown that an intervention strategy, using intrapartum chemoprophylaxis, is effective in reducing the incidence of complications of GBS colonization in pregnant women. Our data suggest that ampicillin would be a suitable antibiotic for use in an intervention programme of intrapartum chemoprophylaxis in Harare.

Prevention of HIV/STI transmission: clarifying the research questions

This letter to the editor registers disappointment that as-yet-unpublished research findings point to the failure of nonoxynol-9 use with condoms by sex workers in Cameroon to provide extra protection against transmission of HIV or sexually transmitted diseases. It is vital to distinguish whether transmission occurred because of method failure or compliance failure and the latter must be suspected because the failure of nonoxynol-9 to have an impact on any of the infecting agents is contrary to in vitro results. It is also important to determine if the prostitutes may have chosen not to use nonoxynol-9 because the frequency of use increased irritation. It will be interesting to see what research question prompted the use of prostitutes in the study because it is often difficult to generalize such results to a wider population. While studies of other populations of women may require more time and larger sample sizes it may be more appropriate to concentrate on women who have difficulty negotiating condom use with their husbands. The fact that the Cameroon study reports lower HIV incidence in both study areas than previously estimated has been attributed to increased condom use counseling and treatment. These interventions have already been established as being effective in protecting prostitutes and their clients. Governments must put these findings into practice and researchers must continue to investigate 1) the value of chemical microbicides in creating a realistic method of protection for women in the general population and 2) development of nonirritating chemical microbicides for frequent users.