Zoe R. Edelstein

Behavioral, biological, and demographic risk and protective factors for new HIV infections among youth in Rakai, Uganda.

Background:Prevalence of HIV infection is considerable among youth, although data on risk factors for new (incident) infections are limited. We examined incidence of HIV infection and risk and protective factors among youth in rural Uganda, including the role of gender and social transitions. Methods:Participants were sexually experienced youth (15–24 years old) enrolled in the Rakai Community Cohort Study, 1999–2008 (n = 6741). Poisson regression with robust standard errors was used to estimate incident rate ratios (IRR) and 95% confidence intervals (CI) of incident HIV infection. Results:HIV incidence was greater among young women than young men (14.1 vs. 8.3 per 1000 person-years, respectively); this gender disparity was greater among teenagers (14.9 vs. 3.6). Beyond behavioral (multiple partners and concurrency) and biological factors (sexually transmitted infection symptoms), social transitions such as marriage and staying in school influenced HIV risk. In multivariate analyses among women, HIV incidence was associated with living in a trading village (adjusted IRR (aIRR) = 1.48; 95% CI: 1.04 to 2.11), being a student (aIRR = 0.22; 95% CI: 0.07 to 0.72), current marriage (aIRR = 0.55; 95% CI: 0.37 to 0.81), former marriage (aIRR = 1.73; 95% CI: 1.01 to 2.96), having multiple partners, and sexually transmitted infection symptoms. Among men, new infections were associated with former marriage (aIRR = 5.57; 95% CI: 2.51 to 12.36), genital ulceration (aIRR = 3.56; 95% CI: 1.97 to 6.41), and alcohol use (aIRR = 2.08; 95% CI: 1.15 to 3.77). Conclusions:During the third decade of the HIV epidemic in Uganda, HIV incidence remains considerable among youth, with young women particularly at risk. The risk for new infections was strongly shaped by social transitions such as leaving school, entrance into marriage, and marital dissolution; the impact of marriage was different for young men than women.

Abstinence promotion under PEPFAR: The shifting focus of HIV prevention for youth

Abstract Abstinence-until-marriage (AUM) – strongly supported by religious conservatives in the USA – became a key element of initial human immunodeficiency virus (HIV) prevention efforts under the Presidents Emergency Plan for AIDS Relief (PEPFAR). AUM programmes have demonstrated limited efficacy in changing behaviours, promoted medically inaccurate information and withheld life-saving information about risk reduction. A focus on AUM also undermined national efforts in Africa to create integrated youth HIV prevention programmes. PEPFAR prevention efforts after 2008 shifted to science-based programming, however, vestiges of AUM remain. Primary prevention programmes within PEPFAR are essential and nations must be able to design HIV prevention based on local needs and prevention science.

Characterization of three novel human papillomavirus types isolated from oral rinse samples of healthy individuals

BACKGROUND Despite the strong evidence of HPV infection as the etiological agent in a subset of oral cancer, oral α-HPV detection is rare in healthy individuals, and little is known of the existing of novel HPV types in oral cavity. OBJECTIVE We determined whether novel HPV types can be isolated from oral rinse samples collected from healthy individuals. STUDY DESIGN We performed rolling circle amplification (RCA) coupled with degenerated PCR assay on 48 oral rinse samples to amplify novel HPV types. Full length HPV DNA was cloned using long range PCR. Quantitative type specific Taqman assays were used to determine the prevalence of novel HPV types in 158 archived oral tissue samples. RESULTS We were able to isolate four novel human papillomavirus types. Full length HPV DNA was cloned for three of the four novel HPV types. All four HPV types belong to the genus Gammapapillomavirus (γ-PV), where HPV 171 is most closely related to HPV 169, showing 88% similarity; HPV 172 is most closely related to HPV 156, showing 70% similarity; HPV 173 is most closely related to HPV 4, showing 73% similarity; oral sample lavage (OSL) 37 is most closely related to HPV 144, showing 69% similarity. Finally, we showed that HPV 173 was rarely present in oral tissues (2/158), HPV 172 was only detected in normal oral tissues (25/76), and HPV 171 was more prevalent in malignant oral tissues (17/82 vs. 10/76, p=0.21). CONCLUSIONS Novel γ-HPV types are present in oral cavity of healthy individuals.

Trends in HIV acquisition, risk factors and prevention policies among youth in Uganda, 1999-2011.

Objective:The objective of this study is to understand how trends in HIV acquisition among youth can be influenced by change in HIV risk factors, social factors and prevention and treatment programmes. Design:Trends in HIV incidence (per 1000 person-years), by sex and age group, were estimated using data from youth (15–24 years: n = 22 164) in the Rakai Community Cohort Study. Trends in HIV incidence were compared with trends in previously identified HIV risk factors, social factors and programmes. Methods:Poisson and linear regression were used to test for statistical significance and decomposition was used to calculate attribution of risk factors to HIV incidence. Results:Substantial declines between 1999 and 2011 occurred in sexual experience, multiple partners and sexual concurrency among adolescents and young adults. HIV acquisition declined substantially (86%, P = 0.006) among adolescent women (15–19 years) but not among men or young adult women. Changes in HIV incidence and risk behaviours coincided with increases in school enrolment, decline in adolescent marriage, availability of antiretroviral therapy (ART) and increases in male medical circumcision (MMC). Much of the decline in HIV incidence among adolescent women (71%) was attributable to reduced sexual experience; the decline in sexual experience was primarily attributable to increasing levels of school enrolment. Conclusion:Dramatic decreases in HIV incidence occurred among adolescent women in Rakai. Changes in school enrolment and sexual experience were primarily responsible for declining HIV acquisition over time among adolescent women. Given limited improvement among young men and young adult women, the need for effective HIV prevention for young people remains critical.

Mobility among youth in Rakai, Uganda: Trends, characteristics, and associations with behavioural risk factors for HIV

ABSTRACT Mobility, including migration and travel, influences risk of HIV. This study examined time trends and characteristics among mobile youth (15–24 years) in rural Uganda, and the relationship between mobility and risk factors for HIV. We used data from an annual household census and population-based cohort study in the Rakai district, Uganda. Data on in-migration and out-migration were collected among youth (15–24 years) from 43 communities from 1999 to 2011 (N = 112,117 observations) and travel among youth residents from 2003 to 2008 (N = 18,318 observations). Migration and travel were more common among young women than young men. One in five youth reported out-migration. Over time, out-migration increased among youth and in-migration remained largely stable. Primary reasons for migration included work, living with friends or family, and marriage. Recent travel within Uganda was common and increased slightly over time in teen women (15–19 years old), and young adult men and women (20–24 years old). Mobile youth were more likely to report HIV-risk behaviours including: alcohol use, sexual experience, multiple partners, and inconsistent condom use. Our findings suggest that among rural Ugandan youth, mobility is increasingly common and associated with HIV-risk factors. Knowledge of patterns and characteristics of a young, high-risk mobile population has important implications for HIV interventions.

Adolescent Risk-Taking, Cancer Risk, and Life Course Approaches to Prevention

Adolescent risk-taking may have long-term consequences for adult cancer risk. Behaviors such as smoking and sexual activity, commonly initiated during adolescence, may result--decades later--in cancer. Life course epidemiology focuses on unique vulnerabilities at specific development periods and their importance to later development of disease. A life course epidemiological perspective that integrates social and biological risk processes can help frame our understanding how specific adult cancers develop. Moreover, life course perspectives augment traditional public health approaches to prevention by emphasizing the importance of unique windows of opportunity for prevention.

Factors associated with incident HIV infection versus prevalent infection among youth in Rakai, Uganda

Factors associated with prevalent and incident HIV infection were compared among sexually experienced Ugandans aged 15–24. Most factors were similar. However, in women, older age and current marriage were associated with prevalent, but not incident, infection. It is important to recognize the limitations of prevalence analyses for identifying at-risk youth.

Evaluating the 2010 New York State HIV testing law in NYC ambulatory practices using electronic health records.

Introduction:In 2010, the New York State Legislature made it mandatory to offer an HIV test to people aged 13–64 years receiving hospital or primary care services, with limited exceptions. In this study, we used data from New York City practices to evaluate the impact of the law on HIV testing rates in ambulatory care. Methods:We collected quarterly testing data from the electronic health records of 218 practices. We calculated overall and stratified crude testing rates. Using univariate and multivariate generalized estimating equation models, we assessed the odds of testing in the year before the law (baseline) versus the first and second year after the laws implementation (year 1 and year 2). Results:During baseline, the odds of testing did not increase significantly. During year 1, the odds of testing significantly increased by 50% in the univariate model and 200% after adjusting for confounders. During year 2, the odds of testing increased 10%. This was only significant in the univariate model. The crude quarterly testing rate increased from 2.8% to 5.7% from baseline to year 2. Conclusions:Our evaluation showed that after the implementation of the HIV testing law, there was an increase in HIV testing among NYC ambulatory practices. Testing rates remained modest, but considerable improvement was seen in community health centers, in age ranges targeted by the law and in practices that were screening for HIV at baseline. This study suggests that legislation may be effective when used in a comprehensive prevention strategy.

Incidence of oral human papillomavirus infection

1 Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ 2009; 338: b1860. 2 Courvoisier DS, Agoritsas T, Perneger TV, Schmidt RE, Cullati S. Regrets associated with providing healthcare: qualitative study of experiences of hospital-based physicians and nurses. PLoS One 2011; 6: e23138. 3 West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA 2009; 302: 1294–300. 4 Courvoisier DS, Cullati S, Haller C, et al. Validation of a 10-item care-related regret intensity scale (RIS-10) for healthcare professionals. Med Care 2013; 51: 285–91. 5 Croskerry P, Abbass AA, Wu AW. How doctors feel: aff ective issues in patients’ safety. Lancet 2008; 372: 1205–06. at home from an aortic dissection. Debriefi ng with supervisors and peers was helpful, because most admitted they would have done the same. Yet the resident was left with an emotion that lasted for years and haunted many nights: regret. Such stories are common as clinicians make countless decisions and actions daily, often on the basis of complex and uncertain information, and under severe time pressure. Regret is the emotion that occurs when one feels another course of action would have led to a better outcome. Although involvement with perceived medical errors is common among medical students and residents, regret often stems from decisions and actions unrelated to errors. The effect of aff ective processes on health care has received little attention. Yet intense or repeated regrets might lead to sleep disorders, resulting in increased risk of future errors, and can influence decision making—eg, clinicians might order unnecessary tests. Regret is an unavoidable consequence of clinical practice. Whether its experience produces positive or negative consequences depends on the coping strategies clinicians use. Some strategies can act as powerful incentives to improve patient-centred care and lead to relevant changes in practice. By contrast, maladaptive coping strategies, such as suppression and rumination, can lead to sleep disorders, depression, and burnout, as well as to an over-acceptance of potentially preventable mistakes (appendix). Clinicians who make a mistake are now sometimes considered as second victims and provided with support to deal with their feelings of inadequacy and regret. We believe that all clinicians should be offered similar support for any decisions and actions that trigger strong negative feelings, even when they involve no medical error. Because prevention is better than cure, the best support could be the implementation of specific See Online for appendix Incidence of oral human papillomavirus infection

O11.6 Migration and HIV Risk in Rakai Youth, 2000–2010

Background Migration is common among youth in Africa and is connected to life transitions. Migration has also long been associated with increased risk of being HIV-infected. Although this association has been observed in multiple studies, the temporal order between infection and migration is often unclear. This investigation uses unique cohort data from Rakai, Uganda to test whether recent in-migration places youth at a higher risk of HIV acquisition. Methods We used data from the Rakai Community Cohort Study, 1999–2011. Respondents included were aged 15–24, sexually experienced and initially HIV negative (n = 9365). Migration and HIV status were assessed at each annual survey round. Poisson regression with robust standard errors was used to estimate age-adjusted incidence rate ratios (aIRR) of HIV acquisition among in-migrants versus non-migrants, by geographic origin and reason for migration. Additional adjustment for characteristics assessed at follow-up was explored. Results In young men, HIV incidence in recent in-migrants (14.3 per 1000 person-years (py)) was 2 times greater than non-migrants (6.6 per 1000 py) (aIRR = 2.04; 95% confidence interval (CI): 1.07–3.92). In young women, incidence among in-migrants (12.6 per 1000 py) was similar to non-migrants (11.5 per 1000 py) (aIRR = 1.07; CI: 0.74–1.55). Associations were not affected by geographic origin. Men who had migrated for marriage were at particularly high risk (141 per 1000 py) compared to non-migrants (aIRR = 17.16; CI: 3.15–93.35). However, this was uncommon (< 1% of py) and only in men aged > 19. Women who had migrated for work were at increased risk (30.3 per 1000 py) compared to non-migrants (aIRR = 2.59; CI: 1.41–4.76). IRRs were relatively unchanged with adjustment for marital status, number of partners in last 12 months or sexual concurrency. Conclusion Recent in-migration is associated with increased HIV risk in young Ugandan men. Among young women, the increase in HIV risk may be specific to migration for work.