Susan M. Graham

HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya

Background:The role of homosexuality and anal sex practices in the African HIV -1 epidemic is not well described. We aimed to assess the risk factors for prevalent HIV-1 infection among men who have sex with men (MSM) to guide HIV-1 prevention efforts. Methods:Socio-behavioural characteristics, signs and symptoms of sexually transmitted diseases (STD), and serological evidence of HIV-1 were determined for 285 MSM at enrolment into a vaccine preparedness cohort study. We used multivariate logistic regression to assess risk factors for prevalent HIV-1 infection. Results:HIV-1 prevalence was 43.0% [49/114, 95% confidence interval (CI), 34–52%] for men who reported sex with men exclusively (MSME), and 12.3% (21/171, 95% CI, 7–17%) for men who reported sex with both men and women (MSMW). Eighty-six (75%) MSME and 69 (40%) MSMW reported recent receptive anal sex. Among 174 MSM sexually active in the last week, 44% reported no use of condoms with casual partners. In the previous 3 months, 210 MSM (74%) reported payment for sex, and most clients (93%) were local residents. Prevalent HIV-1 infection was associated with recent receptive anal sex [odds ratio (OR), 6.1; 95% CI, 2.4–16], exclusive sex with men (OR, 6.3; 95% CI, 2.3–17), and increasing age (OR, 1.1 per year; 95% CI, 1.04–1.12). Only four MSM reported injecting drug use. Conclusions:The high prevalence of HIV-1 in Kenyan MSM is probably attributable to unprotected receptive anal sex. There is an urgent need for HIV-1 prevention programmes to deliver targeted risk-reduction interventions and STD services to MSM in Kenya.

Initiation of antiretroviral therapy leads to a rapid decline in cervical and vaginal HIV-1 shedding.

Background:Antiretroviral therapy (ART) may decrease HIV-1 infectivity in women by reducing genital HIV-1 shedding. Objectives:To evaluate the time course and magnitude of decay in cervical and vaginal HIV-1 shedding as women initiate ART. Methods:This prospective, observational study of 20 antiretroviral-naive women initiating ART with stavudine, lamivudine, and nevirapine measured HIV-1 RNA in plasma, cervical secretions, and vaginal secretions. Qualitative polymerase chain reaction estimated HIV-1 DNA in cervical and vaginal samples. Perelsons two-phase viral decay model and non-linear random effects were used to compare RNA decay rates. Decreases in proviral DNA were evaluated using logistic regression and generalized estimating equations. Results:Significant decreases in the quantity of HIV-1 RNA were observed by day 2 in plasma (P < 0.001), day 2 in cervical secretions (P = 0.001), and day 4 in vaginal secretions (P < 0.001). Modeled initial and subsequent RNA decay rates in plasma, cervical secretions, and vaginal secretions were 0.6, 0.8, and 1.2 log10 virions/day, and 0.04, 0.05, and 0.06 log10 virions/day, respectively. The initial decay rate for vaginal HIV-1 RNA was more rapid than for plasma RNA (P = 0.02). Detection of HIV-1 DNA decreased significantly in vaginal secretions during the first week (P < 0.001). At day 28, 10 women had detectable HIV-1 RNA or proviral DNA in genital secretions. Conclusions:Genital HIV-1 shedding decreased rapidly after ART initiation, consistent with a rapid decrease in infectivity. However, incomplete viral suppression in half of these women may indicate an ongoing risk of transmission.

High HIV-1 incidence, correlates of HIV-1 acquisition, and high viral loads following seroconversion among MSM

Background:HIV-1 incidence estimates and correlates of HIV-1 acquisition in African MSM are largely unknown. Methods:Since 2005, HIV-1-uninfected men who reported sex with men and women (MSMW) or sex with men exclusively (MSME) were followed at scheduled visits for collection of behavioural and clinical examination data and plasma for HIV-1 testing. Urethral or rectal secretions were collected from symptomatic men to screen for gonorrhoea. Poisson regression methods were used to estimate adjusted incidence rate ratios to explore associations between risk factors and incident HIV-1 infection. Plasma viral loads (PVLs) were assessed over 2 years following seroconversion. Results:Overall HIV-1 incidence in 449 men was 8.6 [95% confidence interval (CI) 6.7–11.0] per 100 person-years. Incidence was 5.8 (95% CI 4.2–7.9) per 100 person-years among MSMW, and 35.2 (95% CI 23.8–52.1) per 100 person-years among MSME. Unprotected sex, receptive anal intercourse, exclusive sex with men, group sex, and gonorrhoea in the past 6 months were strongly associated with HIV-1 acquisition, adjusted for confounders. PVL in seroconverters was more than 4 log10 copies/ml at 230 (73.4%) of 313 visits in MSMW and 153 (75.0%) of 204 visits in MSME. Conclusion:HIV-1 incidence is very high among MSM in coastal Kenya, and many seroconverters maintain high PVL for up to 2 years after infection. Effective HIV-1 prevention interventions, including treatment as prevention, are urgently needed in this population.

Is Audio Computer-Assisted Self-Interview (ACASI) Useful in Risk Behaviour Assessment of Female and Male Sex Workers, Mombasa, Kenya?

Background Audio computer-assisted self-interview (ACASI) may elicit more frequent reporting of socially sensitive behaviours than face-to-face (FtF)-interview. However, no study compared responses to both methods in female and male sex workers (FSW; MSW) in Africa. Methodology/Principal Findings We sequentially enrolled adults recruited for an HIV-1 intervention trial into a comparative study of ACASI and FtF-interview, in a clinic near Mombasa, Kenya. Feasibility and acceptability of ACASI, and a comparative analysis of enrolment responses between ACASI and FtF on an identical risk assessment questionnaire were evaluated. In total, 139 women and 259 men, 81% of eligible cohort participants, completed both interviews. ACASI captured a higher median number of regular (2 vs. 1, p<0.001, both genders) and casual partners in the last week (3 vs. 2, p = 0.04 in women; 2 vs. 1, p<0.001 in men). Group sex (21.6 vs. 13.5%, p<0.001, in men), intravenous drug use (IDU; 10.8 vs. 2.3%, p<0.001 in men; 4.4 vs. 0%, p = 0.03 in women), and rape (8.9 vs. 3.9%, p = 0.002, in men) were reported more frequently in ACASI. A surprisingly high number of women reported in ACASI that they had paid for sex (49.3 vs. 5.8%, p<0.001). Behaviours for recruitment (i.e. anal sex, sex work, sex between males) were reported less frequently in ACASI. The majority of women (79.2%) and men (69.7%) felt that answers given in ACASI were more honest. Volunteers who were not able to take ACASI (84 men, and 37 women) mostly lacked reading skills. Conclusions/Significance About 1 in 5 cohort participants was not able to complete ACASI, mostly for lack of reading skills. Participants who completed ACASI were more likely to report IDU, rape, group sex, and payment for sex by women than when asked in FtF interview. ACASI appears to be a useful tool for high risk behaviour assessments in the African context.

Are you on the market?': a capture-recapture enumeration of men who sell sex to men in and around Mombasa, Kenya.

Background:Men who have sex with men (MSM) are highly vulnerable to HIV infection, but this population can be particularly difficult to reach in sub-Saharan Africa. We aimed to estimate the number of MSM who sell sex in and around Mombasa, Kenya, in order to plan HIV prevention research. Methods:We identified 77 potential MSM contact locations, including public streets and parks, brothels, bars and nightclubs, in and around Mombasa and trained 37 MSM peer leader enumerators to extend a recruitment leaflet to MSM who were identified as ‘on the market’, that is, a man who admitted to selling sex to men. We captured men on two consecutive Saturdays, 1 week apart. A record was kept of when, where and by whom the invitation was extended and received, and of refusals. The total estimate of MSM who sell sex was derived from capture–recapture calculation. Results:Capture 1 included 284 men (following removal of 15 duplicates); 89 men refused to participate. Capture 2 included 484 men (following removal of 35 duplicates); 75 men refused to participate. Of the 484 men in capture 2, 186 were recaptures from capture 1, resulting in a total estimate of 739 (95% confidence interval, 690–798) MSM who sell sex in the study area. Conclusions:We estimated that 739 MSM sell sex in and around Mombasa. Of these, 484 were contacted through trained peer enumerators in a single day. MSM who sell sex in and around Mombasa represent a sizeable population who urgently need to be targeted by HIV prevention strategies.

Prospective Study of Vaginal Bacterial Flora and Other Risk Factors for Vulvovaginal Candidiasis

BACKGROUND It has been suggested that vaginal colonization with lactobacilli may reduce the risk of vulvovaginal candidiasis (VVC), but supporting data are limited. Our objective was to determine the relationship between vaginal bacterial flora and VVC. METHODS We conducted a prospective cohort analysis that involved 151 Kenyan sex workers. At monthly follow-up visits, VVC was defined as the presence of yeast buds, pseudohyphae, or both on a wet preparation (including potassium hydroxide preparation) of vaginal secretions. Generalized estimating equations were used to identify correlates of VVC. RESULTS Participants returned for a median of 12 visits (interquartile range, 11-12 visits). VVC was identified at 162 visits, including 26 involving symptomatic VVC. Bacterial vaginosis was associated with fewer episodes of VVC (adjusted odds ratio [aOR], 0.29 [95% confidence interval {CI}, 0.16-0.50]). After excluding women with concurrent bacterial vaginosis, another possible cause of vaginal symptoms, the likelihood of symptomatic VVC was higher among those who had had yeast identified on wet preparation of vaginal secretions during the past 60 days (aOR, 4.06 [95% CI, 1.12-14.74]) and those with concurrent vaginal Lactobacillus colonization (aOR, 3.75 [95% CI, 1.30-10.83]). CONCLUSIONS Contrary to the commonly posited hypothesis that vaginal Lactobacillus colonization has a protective effect, we found that such colonization was associated with a nearly 4-fold increase in the likelihood of symptomatic VVC.

Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya

Healthcare workers (HCWs) in Africa typically receive little or no training in the healthcare needs of men who have sex with men (MSM), limiting the effectiveness and reach of population‐based HIV control measures among this group. We assessed the effect of a web‐based, self‐directed sensitivity training on MSM for HCWs (www.marps‐africa.org), combined with facilitated group discussions on knowledge and homophobic attitudes among HCWs in four districts of coastal Kenya.

Antiretroviral Adherence and Development of Drug Resistance Are the Strongest Predictors of Genital HIV-1 Shedding among Women Initiating Treatment

Persistent genital human immunodeficiency virus type 1 (HIV-1) shedding among women receiving antiretroviral therapy (ART) may present a transmission risk. We investigated the associations between genital HIV-1 suppression after ART initiation and adherence, resistance, pretreatment CD4 cell count, and hormonal contraceptive use. First-line ART was initiated in 102 women. Plasma and genital HIV-1 RNA levels were measured at months 0, 3, and 6. Adherence was a strong and consistent predictor of genital HIV-1 suppression (P < .001), whereas genotypic resistance was associated with higher vaginal HIV-1 RNA level at month 6 (P = .04). These results emphasize the importance of adherence to optimize the potential benefits of ART for reducing HIV-1 transmission risk.

A Prospective Study of Risk Factors for Bacterial Vaginosis in HIV-1-Seronegative African Women

Background: Bacterial vaginosis (BV) is common and has been associated with increased HIV-1 susceptibility. The objective of this study was to identify risk factors for BV in African women at high risk for acquiring HIV-1. Methods: We conducted a prospective study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant women were eligible if they did not have symptoms of abnormal vaginal itching or discharge at the time of enrollment. At monthly follow-up, a vaginal examination and laboratory testing for genital tract infections were performed. Multivariate Andersen-Gill proportional hazards analysis was used to identify correlates of BV. Results: Participants completed a median of 378 (interquartile range 350–412) days of follow-up. Compared with women reporting no vaginal washing, those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95% confidence interval (CI) 0.88–1.89], 15 to 28 (aHR 1.60, 95% CI 0.98–2.61), and >28 times/wk (aHR 2.39, 95% CI 1.35–4.23) were at increased risk of BV. Higher BV incidence was also associated with the use of cloth for intravaginal cleansing (aHR 1.48, 95% CI 1.06–2.08) and with recent unprotected intercourse (aHR 1.75, 95% CI 1.47–2.08). Women using depot medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48–0.73). Conclusions: Vaginal washing and unprotected intercourse were associated with increased risk of BV. These findings could help to inform the development of novel vaginal health approaches for HIV-1 risk reduction in women.

A prospective study of risk factors for herpes simplex virus type 2 acquisition among high-risk HIV-1 seronegative women in Kenya

Objectives: Several studies have demonstrated an association between herpes simplex virus type 2 (HSV-2) and HIV-1, but available data on risk factors for HSV-2 acquisition are limited. The objective of this analysis was to determine the incidence and risk factors for HSV-2 acquisition among HIV-1-seronegative female sex workers in Kenya. Methods: Between February 1993 and December 2006, HIV-1-seronegative women attending a municipal sexually transmitted infection (STI) clinic were invited to enroll in a prospective cohort study. Screening for HIV-1 and STIs were done at monthly follow-up visits. Archived blood samples were tested for HSV-2. Results: Of 1527 HIV-1-seronegative women enrolled, 302 (20%) were HSV-2 seronegative at baseline of whom 297 had at least one follow-up visit. HSV-2 incidence was high (23 cases/100 person-years; 115 cases). In multivariate analysis, HSV-2 was significantly associated with more recent entry into sex work, workplace and higher number of sex partners per week. Condom use was protective, although this was statistically significant only for the intermediate strata (25–75% condom use; HR 0.43; p = 0.05). There were statistical trends for bacterial vaginosis to increase HSV-2 risk (HR 1.56; p = 0.07) and for oral contraceptive use to decrease risk (HR 0.50; p = 0.08). The 23% annual HSV-2 incidence in this study is among the highest reported anywhere in the world. Conclusions: Women were at increased risk if they had recently entered sex work, had a higher number of sex partners or worked in bars. HSV-2 risk reduction interventions are urgently needed among high-risk African women.