In-depth analysis of a heterosexually acquired human immunodeficiency virus type 1 superinfection: evolution, temporal fluctuation, and intercompartment dynamics from the seronegative window period through 30 months postinfection.

Human immunodeficiency virus type 1 (HIV-1) superinfection refers to the acquisition of another strain by an already infected individual. Here we report a comprehensive genetic analysis of an HIV-1 superinfection acquired heterosexually. The infected individual was in a high-risk cohort in Tanzania, was exposed to multiple subtypes, and was systematically evaluated every 3 months with a fluorescent multi-region genotyping assay. The subject was identified in the window period and was first infected with a complex ACD recombinant strain, became superinfected 6 to 9 months later with an AC recombinant, and was monitored for >2.5 years. The plasma viral load exceeded 400,000 copies/ml during the first 9 months of infection but resolved to the set point of 67,000 copies/ml by 3 months after superinfection; the CD4 cell count was 377 cells/mul at 30 months. Viral diversity was evaluated with techniques designed to fully sample the quasi-species, permitting direct observation of the evolution, temporal fluctuation, and intercompartment dynamics of the initial and superinfecting strains and recombinants derived from them. Within 3 months of superinfection, seven different molecular forms were detected in gag and six were detected in env. The proportions of forms fluctuated widely over time in plasma and peripheral blood mononuclear cells, illustrating how challenging the detection of dually infected individuals can be. Strain-specific nested PCR confirmed that the superinfecting strain was not present until the 9 month follow-up. This study further defines the parameters and dynamics of superinfection and will foster appropriate studies and approaches to gain a more complete understanding of risk factors for superinfection and its impact on clinical progression, epidemiology, and vaccine design.

Baseline survey of sexually transmitted infections in a cohort of female bar workers in Mbeya Region, Tanzania.

OBJECTIVES: To determine baseline prevalence of sexually transmitted infections (STI) and other reproductive tract infections (RTI) and their association with HIV as well as sociodemographic and behavioural characteristics in a newly recruited cohort of female bar workers in Mbeya Region, Tanzania. METHODS: 600 female bar workers were recruited from 17 different communities during September to November 2000 and underwent gynaecological examination, laboratory testing for HIV/STI, and interviews using structured questionnaires. RESULTS: HIV-1 seroprevalence was 68%. Prevalences of STI/RTI were high titre syphilis (TPPA/RPR >/=1/8), 9%; herpes simplex virus 2 antibodies, 87%; chlamydia, 12%; gonorrhoea, 22%; trichomoniasis, 24%; and bacterial vaginosis, 40%. HIV infection was associated with TPPA and HSV-2 seropositivity, bacterial vaginosis and clinically diagnosed genital ulcers, blisters, and warts. Reported high risk sexual behaviour during the past year (having multiple casual partners) was associated with prevalent STI. CONCLUSION: Female bar workers in Mbeya are at high risk of STI and HIV infection. Targeted STI/HIV prevention interventions for these women and their sexual partners need to be reinforced. Methods should be sought to improve healthcare seeking and to provide easily accessible and affordable STI care services.

A survey of STI policies and programmes in Europe: preliminary results.

OBJECTIVES: A survey was conducted to assess the adequacy of sexually transmitted infections (STI) prevention and control policies and programmes in the European region (including the central Asian republics). METHODS: An adapted World Health Organization (WHO) model questionnaire was sent to ministry of health officials in all 45 countries of Europe and central Asia. The questionnaire included questions on STI programme structure; STI case management; the different types and levels of services, including public and private service providers; partner notification and screening policies; services for vulnerable populations; monitoring and supervision; surveillance and research. RESULTS: Western European countries largely leave STI prevention and care to individual practitioners. Licensed providers exist at all levels of care, and access to consultations and treatment is usually free of charge. In the newly independent states (NIS), by contrast, programme efforts emphasise state guidance and supervision of local providers rather than individual practitioners. Access to services is limited in that in several NIS, only public sector specialists are licensed to treat STI. Formerly free of charge policies have been severely eroded. While in western Europe access to condoms appears to be good, in the NIS there are many fewer condom outlets. Regionwide, in 40% of countries the distribution of condoms is part of STI consultations. CONCLUSIONS: Non-availability of affordable high quality STI services, including STI treatment and condoms, may be one of the causes for the much higher STI prevalence in parts of eastern Europe and NIS than in western Europe.

Adolescence--a dynamic concept.

The World Health Organization (WHO) defines adolescents as persons between 10 and 19 years of age. (WHO 1998) Although adolescents make up about 20 per cent of the world's population (of whom 85 per cent live in developing countries), they have traditionally been neglected as a distinct target group and subsumed under the promotion of family, women's and child welfare and health. This has at least partially been because adolescents were seen as a relatively healthy age group, one that did not have a heavy 'burden of disease', at least as compared with young infants or older adults. However, there is increasing recognition that adolescents have special health-related vulnerabilities. Among the major causes of morbidity and mortality in young people are suicide, road accidents, tobacco use and sexual and reproductive ill-health. (WHO 1998) Furthermore, adolescents are increasingly seen as 'gateways to health' because behavioural patterns acquired during this period tend to last throughout adult life--roughly 70 per cent of premature deaths among adults are due to behaviours initiated in adolescence. (WHO 1998) This paper describes the social, economic, cultural, legal and health issues which affect the experience of adolescence. It shows that while young people around the world may experience the same physical changes and sensations during adolescence, the manner in which these are interpreted and give rise to social and legal prescriptions varies tremendously.

Sexually transmitted infections among adolescents: the need for adequate health services.

The World Health Organization (WHO) estimates that two-thirds of all STIs worldwide occur in young people--teenagers and those in their early twenties (WHO 1993, WHO 1995). The provision of STI services to these age groups should therefore be high on the agenda of STI programme planners and adolescent/young people's health programmers alike. However, attempts to promote the sexual health of young people have so far tended to focus on prevention, education and counselling, while the provision of services to those who have already faced the consequences of unprotected sexual activity, including pregnancy and STI, or sexual violence, has lagged behind. In 1999-2000 a review was commissioned by GTZ of the characteristics of adolescent sexuality, evidence of STI risk in adolescents, the profile of adolescents in need of STI care, types and evidence of success of different STI service delivery models for adolescents and the advantages and disadvantages of each of these, and to what extent a youth-specific approach to STI services or an STI-specific approach to adolescent health service delivery, is warranted. This review will be published jointly by GTZ and WHO with the title Sexually Transmitted Infections among Adolescents: The Need for Adequate Health Services. This is a shortened form of the Summary and Conclusions of this book.

Recent declines in reported syphilis rates in eastern Europe and central Asia: are the epidemics over?

BACKGROUND: Since the early 1990s, major syphilis epidemics have occurred in the Newly Independent States (NIS) of the former Soviet Union. The new and rapidly changing societal and economic conditions in these countries challenge their traditional approaches to the control of sexually transmitted infections (STI). Nevertheless, following a steady increase until 1997, reported syphilis incidence has declined during the past 3 years in most parts of the region. We examine these trends against a background of ongoing changes in service delivery, care seeking behaviour, and case finding practices. METHODS: National syphilis surveillance data reported to the WHO Regional Office for Europe were compiled and analysed, and supplemented with information presented at recent expert meetings and with results from ongoing research. RESULTS: Since 1997, reported syphilis incidence either stabilised or declined in many locations in the NIS, but further increased in others, especially in rural areas. Congenital syphilis continued to increase in all countries, except Latvia. The proportion of self presenting cases versus cases detected through screening declined, and so did notifications of early compared with late forms of syphilis. Patients increasingly seek care in the private formal and informal healthcare sectors which hardly participate in case reporting. CONCLUSIONS: Recent declines in syphilis notifications in the NIS are at least partially a reflection of a reduced intensity of active case finding and of changes in reporting completeness because of a shift in service utilisation from the public to the private/informal sectors. Syphilis rates are still high, indicating that both public and private sectors have to respond more efficiently to the needs of many people at risk of STI. The collection of serial STI prevalence data is recommended to be able to validate trends in notifications.

Estimating the number of HIV transmissions through reused syringes and needles in the Mbeya Region, Tanzania.

OBJECTIVE: HIV infection attributable to medical injections is suspected to be low, although case-control studies have not provided definite results. This study aims to determine the number of HIV infections caused by the reuse of syringes and needles in the Mbeya Region, Tanzania. METHODS: The direct identification or detection of HIV in syringes and needles under field conditions was not appropriate, therefore a surrogate marker consisting of two components for possible HIV transmission was used: insufficient sterilization, and blood remaining from a previous patient. The assumption was that HIV infection can only occur if both markers are positive. Samples were collected in nine health-care facilities. All syringes and needles prepared for use in these facilities were collected without prior notification. The samples were rinsed and the resulting fluid was cultured for bacteria. Traces of blood were detected by urine stick test for haemoglobin volumes > 0.0015 microliters. RESULTS: Bacterial contamination was found in 32.8% of the total 1219 syringes and needles; 67% was caused by improper handling of the equipment after sterilization. Blood was detected in 12.5% of the samples. In the following three sampling strata, both contamination criteria were positive either on the syringe or the needle: wards/outpatient departments (OPD), 1.39%; laboratories, 7.45%; expanded programme on immunization (EPI), < 0.1%. We calculated that from 1.1 million patients injected in wards/OPD in any 1 year, fewer than 13 become infected, in laboratories fewer than 12 (160,000 blood-taking procedures), and less than one child in the EPI (850,000 vaccinations). CONCLUSION: With an established AIDS intervention programme supporting the health system, less than 0.4% of the total annual incidence of 4500-8500 is attributable to medical injections in the Mbeya Region.