Rotavirus A infection in children under five years old with a double health problem: undernutrition and diarrhoea - a cross-sectional study in four provinces of Mozambique.

BACKGROUND: Mozambique has a high burden of group A rotavirus (RVA) infection and chronic undernutrition. This study aimed to determine the frequency and potential risk factors for RVA infection in undernourished children under 5 years old with diarrhoea in Mozambique. METHODS: The analysis was conducted using data from March 2015 to December 2017, regarding children under 5 years old with at least one type of undernutrition. Anthropometric measures were used to calculate indices of weight-for-age, weight-for-height and height-for-age through the Z-Scores. RVA results were extracted from the National Diarrhoea Surveillance database. Descriptive statistics, chi-square test was used for qualitative variables and organized in contingency tables and 95% Confidence Intervals (CI) were considered for the calculation of RVA infection proportion and in the multiple logistic regression models to estimate the adjusted odds ratios (AOR). RESULTS: Of the 842 undernourished children included in the analysis, 27.2% (95% CI: 24.3-30.3%) were positive for RVA. The rate of RVA infection was 42.7% (95% CI: 38.0-47.5%) in the pre-vaccine period, with great reduction to 12.2% (95% CI: 9.4-15.6%) in the post-vaccine period. Most of the RVA undernourished children had severe wasting (33.3%) and severe stunting (32.0%). The risk of infection was significantly high in children from 0 to 11 months (p-value < 0.001) when compared to the age group of 24-59 months. A higher proportion of RVA infection was detected in households with five or more members (p-value = 0.029). Similar proportions of RVA were observed in children fed only by breast milk (34.9%) and breast milk with formula (35.6%). A higher proportion of undernourished HIV-positive children co-infected with RVA (7.4%) was observed. CONCLUSIONS: The frequency of RVA infection in undernourished children declined following the introduction of the vaccine in Mozambique. Beyond the temporal variation, Maputo province, age and crowded households were also associated to RVA infection. A high proportion of RVA infection was observed in children with severe wasting and a triple burden of disease: undernutrition, RVA and HIV, highlighting the need to conduct follow-up studies to understand the long-term impact of these conditions on children's development.

Who Are the Men Who Pay for Sex in Mozambique? Results from the National HIV/AIDS Indicator Survey 2015.

Mozambique has one of the highest burdens of HIV in the world, where the prevalence is estimated at 13.2% among adults aged 15-49 years. Men who pay for sex (MPS) are considered a bridging population for HIV infection. However, the characteristics of MPS in Mozambique are poorly understood. The objective of this study was to estimate the prevalence of paid sex among men 15-49 years and investigate risk factors associated with paid sex. We analyzed data collected from 4724 men, aged 15-49 years, as part of the 2015 Mozambique AIDS Indicator Survey. Chi-squared tests and logistic regression models accounting for survey design were used to assess the associations between paying for sex and demographic characteristics and the number of lifetime and recent sex partners, condom use at last sex, and self-reported sexually transmitted infection symptoms. The prevalence of paid sex in the last 12 months was 10.4% (95% CI 9.0-12.1), with Cabo Delgado province having the highest prevalence (38.8%). MPS in the last 12 months were most frequently between the ages of 20-24 years (13.5%), not in a relationship (17.8%), had a primary education (11.9%), from poor households (14.0%), had more than three sexual partners excluding their spouse in the last 12 months (44.7%), and self-reported a STI in the past 12 months (44.2%). HIV prevalence was higher among men who ever paid for sex compared with men who did not (13.1% vs. 9.4%, p = .02). Men who reported 10+ lifetime partner (aOR 7.7; 95% CI 4.5-13.0; p < .001), from Cabo Delgado (aOR 4.0; 95% CI 2.2-7.4; p < .001), who reported STI symptoms in the past 12 months (aOR 2.7; 95% CI 1.7-4.2; p < .001), and HIV positive (aOR 1.6; 95% CI 1.0-3.7; p = .05) were more likely to have paid for sex in the last 12 months. These findings present the HIV prevalence among Mozambican MPS and highlight the need for a comprehensive behavioral, structural, and biomedical approach to interventions to reduce the risks of commercial and transactional sex.

Characterization of HIV Recent Infection Among High-Risk Men at Public STI Clinics in Mumbai.

We examined associations with HIV recent infection and estimated transmitted drug resistance (TDR) prevalence among 3345 men at sexually transmitted infection clinics in Mumbai (2002-2005). HIV seroincidence was 7.92% by the BED-CEIA and was higher at a clinic located near brothels (12.39%) than at a hospital-based clinic (3.94%). HIV recent infection was associated with a lifetime history of female sex worker (FSW) partners, HSV-2, genital warts, and gonorrhea. TDR prevalence among recent infection cases was 5.7%. HIV testing services near sex venues may enhance case detection among high-risk men who represent a bridging population between FSWs and the men's other sexual partners.

Estimating the Prevalence and Predictors of Incorrect Condom Use Among Sexually Active Adults in Kenya: Results From a Nationally Representative Survey.

BACKGROUND: Condom use continues to be an important primary prevention tool to reduce the acquisition and transmission of HIV and other sexually transmitted infections. However, incorrect use of condoms can reduce their effectiveness. METHODS: Using data from a 2012 nationally representative cross-sectional household survey conducted in Kenya, we analyzed a subpopulation of sexually active adults and estimated the percent that used condoms incorrectly during sex, and the type of condom errors. We used multivariable logistic regression to determine variables to be independently associated with incorrect condom use. RESULTS: Among 13,720 adolescents and adults, 8014 were sexually active in the previous 3 months (60.3%; 95% confidence interval [CI], 59.0-61.7). Among those who used a condom with a sex partner, 20% (95% CI, 17.4-22.6) experienced at least one instance of incorrect condom use in the previous 3 months. Of incorrect condom users, condom breakage or leakage was the most common error (52%; 95% CI, 44.5-59.6). Factors found to be associated with incorrect condom use were multiple sexual partnerships in the past 12 months (2 partners: adjusted odds ratio [aOR], 1.5; 95% CI, 1.0-2.0; P = 0.03; ≥3: aOR, 2.3; 95% CI, 1.5-3.5; P < 0.01) and reporting symptoms of a sexually transmitted infection (aOR, 2.8; 95% CI, 1.8-4.3; P < 0.01). CONCLUSIONS: Incorrect condom use is frequent among sexually active Kenyans and this may translate into substantial HIV transmission. Further understanding of the dynamics of condom use and misuse, in the broader context of other prevention strategies, will aid program planners in the delivery of appropriate interventions aimed at limiting such errors.

Evaluation of Kenya's readiness to transition from sentinel surveillance to routine HIV testing for antenatal clinic-based HIV surveillance.

BACKGROUND: Sentinel surveillance for HIV among women attending antenatal clinics using unlinked anonymous testing is a cornerstone of HIV surveillance in sub-Saharan Africa. Increased use of routine antenatal HIV testing allows consideration of using these programmatic data rather than sentinel surveillance data for HIV surveillance. METHODS: To gauge Kenya's readiness to discontinue sentinel surveillance, we evaluated whether recommended World Health Organization standards were fulfilled by conducting data and administrative reviews of antenatal clinics that offered both routine testing and sentinel surveillance in 2010. RESULTS: The proportion of tests that were HIV-positive among women aged 15-49 years was 6.2% (95% confidence interval [CI] 4.6-7.7%] in sentinel surveillance and 6.5% (95% CI 5.1-8.0%) in routine testing. The agreement of HIV test results between sentinel surveillance and routine testing was 98.0%, but 24.1% of specimens that tested positive in sentinel surveillance were recorded as negative in routine testing. Data completeness was moderate, with HIV test results recorded for 87.8% of women who received routine testing. CONCLUSIONS: Additional preparation is required before routine antenatal HIV testing data can supplant sentinel surveillance in Kenya. As the quality of program data has markedly improved since 2010 a repeat evaluation of the use of routine antenatal HIV testing data in lieu of ANC sentinel surveillance is recommended.

Prevalence of HIV, sexually transmitted infections, and risk behaviours among female sex workers in Nairobi, Kenya: results of a respondent driven sampling study.

We conducted a respondent driven sampling survey to estimate HIV prevalence and risk behavior among female sex workers (FSWs) in Nairobi, Kenya. Women aged 18 years and older who reported selling sex to a man at least once in the past 3 months were eligible to participate. Consenting FSWs completed a behavioral questionnaire and were tested for HIV and sexually transmitted infections (STIs). Adjusted population-based prevalence and 95 % confidence intervals (CI) were estimated using RDS analysis tool. Factors significantly associated with HIV infection were assessed using log-binomial regression analysis. A total of 596 eligible participants were included in the analysis. Overall HIV prevalence was 29.5 % (95 % CI 24.7-34.9). Median age was 30 years (IQR 25-38 years); median duration of sex work was 12 years (IQR 8-17 years). The most frequent client-seeking venues were bars (76.6 %) and roadsides (29.3 %). The median number of clients per week was seven (IQR 4-18 clients). HIV testing was high with 86.6 % reported ever been tested for HIV and, of these, 63.1 % testing within the past 12 months. Of all women, 59.7 % perceived themselves at 'great risk' for HIV infection. Of HIV-positive women, 51.0 % were aware of their infection. In multivariable analysis, increasing age, inconsistent condom use with paying clients, and use of a male condom as a method of contraception were independently associated with unrecognized HIV infection. Prevalence among STIs was low, ranging from 0.9 % for syphilis, 1.1 % for gonorrhea, and 3.1 % for Chlamydia. The data suggest high prevalence of HIV among FSWs in Nairobi. Targeted and routine HIV and STI combination prevention strategies need to be scaled up or established to meet the needs of this population.

Comparison of HIV behavioral indicators among men who have sex with men across two survey methodologies, San Francisco, 2004 and 2008.

BACKGROUND: Our goal was to examine whether community-based behavioral surveys can augment data collected for the National HIV Behavioral Surveillance System (NHBS) among men who have sex with men (MSM) in San Francisco. METHODS: We compared estimates of sexual risk behaviors among MSM using data from two cycles of NHBS (2004 and 2008) and outreach surveys conducted by STOP AIDS Project (SAP) during the same years. We compared estimates of unprotected anal intercourse (UAI) and other indicators to assess concordance of estimates across methodologies. RESULTS: Of the 3248 interviews conducted, the NHBS sample included more nonwhite and older MSM, more self-reported HIV positive, and less sexually active men than the SAP sample. Estimates of UAI in the last 6 months were slightly higher in the NHBS survey than in the SAP surveys (2004: 40% vs. 36%, P = 0.03; 2008: 44% vs. 38%, P = 0.08). In 2008, where respondent-partner HIV-discordant status could be measured, estimates of UAI with a potentially discordant partner were similar (12% vs. 12%, P = 0.87). Also, the NHBS and SAP surveys observed similar estimates of UAI by high-risk positioning with potentially discordant partners (HIV-positive men reporting insertive UAI with a potentially HIV-negative partner: 13% vs. 11%, P = 0.45; HIV-negative men reporting receptive UAI with a potentially HIV-positive person: 5% vs. 4%, P = 0.85). CONCLUSIONS: Behavioral estimates drawn from convenience sampling methods can provide informative surveillance estimates of key behavioral indictors that can augment data from more rigorous national HIV behavioral surveillance surveys.

Male circumcision programmes in Kenya: lessons from the Kenya AIDS Indicator Survey 2007.

OBJECTIVE: To provide guidance for male circumcision programmes in Kenya by estimating the population of uncircumcised men and investigating the association between circumcision and infection with the human immunodeficiency virus (HIV), with particular reference to uncircumcised, HIV-uninfected men. METHODS: Data on men aged 15 to 64 years were derived from the 2007 Kenya AIDS Indicator Survey, which involved interviews and blood collection to test for HIV and herpes simplex virus 2 (HSV-2). The prevalence of HIV infection and circumcision in Kenyan provinces was calculated and the demographic characteristics and sexual behaviour of circumcised and uncircumcised, HIV-infected and HIV-uninfected men were recorded. FINDINGS: The national prevalence of HIV infection in uncircumcised men was 13.2% (95% confidence interval, CI: 10.8-15.7) compared with 3.9% (95% CI: 3.3-4.5) among circumcised men. Nyanza province had the largest estimated number of uncircumcised, HIV-uninfected men (i.e. 601 709), followed by Rift Valley, Nairobi and Western Province, respectively, and most belonged to the Luo ethnic tribe. Of these men, 77.8% did not know their HIV status and 33.2% were HSV-2-positive. In addition, 65.3% had had unprotected sex with a partner of discordant or unknown HIV status in the past 12 months and only 14.7% consistently used condoms with their most recent partner. However, only 21.8% of the uncircumcised, HIV-uninfected men aged 15 to 19 years were sexually active. CONCLUSION: The Kenyan male circumcision strategy should focus on the provinces with the highest number of uncircumcised, HIV-uninfected men and target young men before or shortly after sexual debut.

Prevalence of HIV, viral hepatitis B/C and tuberculosis and treatment outcomes among people who use drugs: Results from the implementation of the first drop-in-center in Mozambique.

BACKGROUND: People who use drugs (PWUD) which includes both people who inject drugs (PWID) and non-injection drug users (NIDU) are marginalized, experience high levels of stigma and discrimination, and are likely to have challenges with accessing health services. Mozambique implemented the first drop-in center (DIC) for PWUD in Maputo City in 2018. This analysis aims to assess the prevalence of HIV, viral hepatitis B (HBV) and C (HCV) and tuberculosis (TB) among PWUD, and assess their linkage to care and associated correlates. METHODS: We conducted a cross-sectional retrospective analysis of routine screening data collected from the first visit at the drop-in center (DIC) during the period of May 2018 to November 2019 (18 months). Descriptive and multivariable logistic regression analysis were conducted to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of HIV, HBV, HCV and TB infections among PWID and NIDU. Cox proportional hazards models of determinants were used to estimate time from HIV diagnosis to linkage to care for PWUD. RESULTS: A total of 1,818 PWUD were screened at the DIC, of whom 92.6% were male. The median age was 27 years (range:14-63). Heroin was the most consumed drug (93.8%), and among people who used it, 15.5% injected it. Prevalence of HIV (43.9%), HCV (22.6%) and HBV (5.9%) was higher among PWID (p<0.001). Linkage to HIV care was observed in 40.5% of newly diagnosed PWID. Factors associated with shorter time to linkage to care included drug injection (aHR=1.6) and confirmed TB infection (aHR=2.9). CONCLUSION: This was the first analysis conducted on the implementation of the DIC in Mozambique and highlights the importance of targeted services for this high-risk population. Our analysis confirmed a high prevalence of HIV, HBV and HCV, and highlight the challenges with linkage to care among PWID. The expansion of DIC locations to other high-risk localities to enhance HIV testing, treatment services and linkage to care to reduce ongoing transmission of HIV, HBV, HCV and TB and improve health outcomes.

Rotavirus A infection in pre- and post-vaccine period: Risk factors, genotypes distribution by vaccination status and age of children in Nampula Province, Northern Mozambique (2015-2019).

Mozambique introduced the monovalent rotavirus vaccine (Rotarix®, GSK Biologicals, Rixensart, Belgium) in September 2015. Previous analysis, showed that Nampula province continues reporting a high frequency of Rotavirus A (RVA) infection and the emergence of G9P[6], G9P[4] and G3P[4] genotypes. This analysis aimed to determine the RVA frequency; risk factors; genotype distribution by vaccination status and age between pre- and post-vaccine periods in children under-five years old with diarrhea in Nampula. A cross-sectional, hospital-based surveillance study was conducted in the Hospital Central de Nampula in Mozambique. Socio-demographic and clinical data were collected to assess factors related to RVA infection in both periods. Stool specimens were screened to detect RVA by ELISA, and positive samples were genotyped. Between 2015 (pre-vaccine period) and 2016-2019 (post-vaccine period), 614 stool specimens were collected and tested for RVA in which 34.9% (67/192) were positive in pre-vaccine period and 21.8% (92/422) in post-vaccine (p = 0.001). In the post-vaccine period, age, year, and contact with different animal species (chicken, duck, or multiple animals) were associated with RVA infection. RVA infection was higher in children partially vaccinated (40.7%, 11/27) followed by the fully vaccinated (29.3%, 56/191) and the unvaccinated (15.3%, 21/137) (p = 0.002). G1P[8] and G9P[4] were common in vaccinated children less than 12 months. The present analysis showed that RVA infection reduced slightly in the post-vaccine period, with a high proportion of infection and genotype diversity in children, under 12 months of age, vaccinated. Further research on factors associated with RVA infection on vaccinated compared to unvaccinated children and vaccination optimization should be done.

Intestinal protozoan infections among children 0-168 months with diarrhea in Mozambique: June 2014 - January 2018.

BACKGROUND: Intestinal parasites such as Cryptosporidium spp., Giardia lamblia and Entamoeba histolytica can cause severe diarrhea, especially among children in developing countries. This study aims to determine the frequency of Cryptosporidium spp., Giardia lamblia and Entamoeba histolytica in children with diarrhea and identify risk factors for infection. METHODOLOGY: We conducted a cross-sectional study in children aged 0-168 months hospitalized with diarrhea in three regions of Mozambique, from June 2014 to January 2018. Following consent, caretakers were interviewed and a single stool specimen was collected from each child to diagnose Cryptosporidium spp., G. lamblia and E. histolytica using commercial immune-enzymatic assay (TechLab, Inc, Blacksburg, VA, USA). Anthropometric data were collected from the clinical reports. Multivariable logistic regression models were built to identify risk factors for Cryptosporidium spp. and G. lamblia infection. RESULTS: Twenty-one percent of all specimens (212/1008) presented at least one parasitic infection. Cryptosporidium spp. infection was the most common 12.0% (118/985), followed by G. lamblia 9.7% (95/983) and E. histolytica 2.0% (20/1004). Risk factors for infection by Cryptosporidium spp. were: provenience (children from Nampula province showed the highest risk, OR: 8.176; CI: 1.916-34.894; p-value < 0.01); animal contact (children with animal contact had a protective effect OR: 0.627; CI: 0.398-0.986; p-value < 0.05); underweight (children severely underweight showed a risk of 2.309; CI: 1.310-4.069; p-value < 0.05). Risk factors for infection by G. lamblia were: age (group with highest risk, 60-168 months (OR: 2.322; CI: 1.000-5.393, p-value > 0.05)); and living in a household with five or more members (OR: 2.141; CI: 1.286-3.565, p-value < 0.01). CONCLUSIONS: Parasitic infection is common among children with diarrhea. Routine testing, standard treatment, and assessment for risk exposure of children with diarrhea should be implemented at health facilities in Mozambique.

Modes of HIV transmission among adolescents and young adults aged 10-24 years in Kenya.

Understanding how HIV is acquired can inform interventions to prevent infection. We constructed a risk profile of 10-24 year olds participating in the 2012 Kenya AIDS Indicator Survey and classified them as perinatally infected if their biological mother was infected with HIV or had died, or if their father was infected with HIV or had died (for those lacking mother's data). The remaining were classified as sexually infected if they had sex, and the remaining as parenterally infected if they had a blood transfusion. Overall, 84 (1.6%) of the 5298 10-24 year olds tested HIV positive; 9 (11%) were aged 10-14 and 75 (89%) 15-24 years. Five (56%) 10-14 year olds met criteria for perinatal infection; 4 (44%) did not meet perinatal, sexual or parenteral transmission criteria and parental HIV status was not established. Of the 75 HIV-infected, 15 to 24 year olds, 5 (7%) met perinatal transmission, 63 (84%) sexual and 2 (3%) parenteral criteria; 5 (7%) were unclassified. Perinatal transmission likely accounted for 56% and sexual transmission for 84% of infections among 10-14 year olds and 15-24 year olds, respectively. Although our definitions may have introduced some uncertainty, and with the number of infected participants being small, our findings suggest that mixed modes of HIV transmission exist among adolescents and young people.

Where No Universal Health Care Identifier Exists: Comparison and Determination of the Utility of Score-Based Persons Matching Algorithms Using Demographic Data.

BACKGROUND: A universal health care identifier (UHID) facilitates the development of longitudinal medical records in health care settings where follow up and tracking of persons across health care sectors are needed. HIV case-based surveillance (CBS) entails longitudinal follow up of HIV cases from diagnosis, linkage to care and treatment, and is recommended for second generation HIV surveillance. In the absence of a UHID, records matching, linking, and deduplication may be done using score-based persons matching algorithms. We present a stepwise process of score-based persons matching algorithms based on demographic data to improve HIV CBS and other longitudinal data systems. OBJECTIVE: The aim of this study is to compare deterministic and score-based persons matching algorithms in records linkage and matching using demographic data in settings without a UHID. METHODS: We used HIV CBS pilot data from 124 facilities in 2 high HIV-burden counties (Siaya and Kisumu) in western Kenya. For efficient processing, data were grouped into 3 scenarios within (1) HIV testing services (HTS), (2) HTS-care, and (3) within care. In deterministic matching, we directly compared identifiers and pseudo-identifiers from medical records to determine matches. We used R stringdist package for Jaro, Jaro-Winkler score-based matching and Levenshtein, and Damerau-Levenshtein string edit distance calculation methods. For the Jaro-Winkler method, we used a penalty (р)=0.1 and applied 4 weights (ω) to Levenshtein and Damerau-Levenshtein: deletion ω=0.8, insertion ω=0.8, substitutions ω=1, and transposition ω=0.5. RESULTS: We abstracted 12,157 cases of which 4073/12,157 (33.5%) were from HTS, 1091/12,157 (9.0%) from HTS-care, and 6993/12,157 (57.5%) within care. Using the deterministic process 435/12,157 (3.6%) duplicate records were identified, yielding 96.4% (11,722/12,157) unique cases. Overall, of the score-based methods, Jaro-Winkler yielded the most duplicate records (686/12,157, 5.6%) while Jaro yielded the least duplicates (546/12,157, 4.5%), and Levenshtein and Damerau-Levenshtein yielded 4.6% (563/12,157) duplicates. Specifically, duplicate records yielded by method were: (1) Jaro 5.7% (234/4073) within HTS, 0.4% (4/1091) in HTS-care, and 4.4% (308/6993) within care, (2) Jaro-Winkler 7.4% (302/4073) within HTS, 0.5% (6/1091) in HTS-care, and 5.4% (378/6993) within care, (3) Levenshtein 6.4% (262/4073) within HTS, 0.4% (4/1091) in HTS-care, and 4.2% (297/6993) within care, and (4) Damerau-Levenshtein 6.4% (262/4073) within HTS, 0.4% (4/1091) in HTS-care, and 4.2% (297/6993) within care. CONCLUSIONS: Without deduplication, over reporting occurs across the care and treatment cascade. Jaro-Winkler score-based matching performed the best in identifying matches. A pragmatic estimate of duplicates in health care settings can provide a corrective factor for modeled estimates, for targeting and program planning. We propose that even without a UHID, standard national deduplication and persons-matching algorithm that utilizes demographic data would improve accuracy in monitoring HIV care clinical cascades.

HIV-associated mortality in the era of antiretroviral therapy scale-up - Nairobi, Kenya, 2015.

BACKGROUND: Declines in HIV prevalence and increases in antiretroviral treatment coverage have been documented in Kenya, but population-level mortality associated with HIV has not been directly measured. In urban areas where a majority of deaths pass through mortuaries, mortuary-based studies have the potential to contribute to our understanding of excess mortality among HIV-infected persons. We used results from a cross-sectional mortuary-based HIV surveillance study to estimate the association between HIV and mortality for Nairobi, the capital city of Kenya. METHODS AND FINDINGS: HIV seropositivity in cadavers measured at the two largest mortuaries in Nairobi was used to estimate HIV prevalence in adult deaths. Model-based estimates of the HIV-infected and uninfected population for Nairobi were used to calculate a standardized mortality ratio and population-attributable fraction for mortality among the infected versus uninfected population. Monte Carlo simulation was used to assess sensitivity to epidemiological assumptions. When standardized to the age and sex distribution of expected deaths, the estimated HIV positivity among adult deaths aged 15 years and above in Nairobi was 20.9% (95% CI 17.7-24.6%). The standardized mortality ratio of deaths among HIV-infected versus uninfected adults was 4.35 (95% CI 3.67-5.15), while the risk difference was 0.016 (95% CI 0.013-0.019). The HIV population attributable mortality fraction was 0.161 (95% CI 0.131-0.190). Sensitivity analyses demonstrated robustness of results. CONCLUSIONS: Although 73.6% of adult PLHIV receive antiretrovirals in Nairobi, their risk of death is four-fold greater than in the uninfected, while 16.1% of all adult deaths in the city can be attributed to HIV infection. In order to further reduce HIV-associated mortality, high-burden countries may need to reach very high levels of diagnosis, treatment coverage, retention in care, and viral suppression.

Assessing the feasibility of harm reduction services for MSM: the late night breakfast buffet study.

BACKGROUND: Despite the leveling off in new HIV infections among men who have sex with men (MSM) in San Francisco, new evidence suggests that many recent HIV infections are linked with the use of Methamphetamine (MA). Among anonymous HIV testers in San Francisco, HIV incidence among MA users was 6.3% compared to 2.1% among non-MA users. Of particular concern for prevention programs are frequent users and HIV positive men who use MA. These MSM pose a particular challenge to HIV prevention efforts due to the need to reach them during very late night hours. METHODS: The purpose of the Late Night Breakfast Buffet (LNBB) was to determine the feasibility and uptake of harm reduction services by a late night population of MSM. The "buffet" of services included: needle exchange, harm reduction information, oral HIV testing, and urine based sexually transmitted infection (STI) testing accompanied by counseling and consent procedures. The study had two components: harm reduction outreach and a behavioral survey. For 4 months during 2004, we provided van-based harm reduction services in three neighborhoods in San Francisco from 1-5 a.m. for anyone out late at night. We also administered a behavioral risk and service utilization survey among MSM. RESULTS: We exchanged 2000 needles in 233 needle exchange visits, distributed 4500 condoms/lubricants and provided 21 HIV tests and 12 STI tests. Fifty-five MSM enrolled in the study component. The study population of MSM was characterized by low levels of income and education whose ages ranged from 18-55. Seventy-eight percent used MA in the last 3 months; almost 25% used MA every day in the same time frame. Of the 65% who ever injected, 97% injected MA and 13% injected it several times a day. MA and alcohol were strong influences in the majority of unprotected sexual encounters among both HIV negative and HIV positive MSM. CONCLUSION: We reached a disenfranchised population of MA-using MSM who are at risk for acquiring or transmitting HIV infection through multiple high risk behaviors, and we established the feasibility and acceptability of late night harm reduction for MSM and MSM who inject drugs.

Detectable HIV Viral Load in Kenya: Data from a Population-Based Survey.

INTRODUCTION: At the individual level, there is clear evidence that Human Immunodeficiency Virus (HIV) transmission can be substantially reduced by lowering viral load. However there are few data describing population-level HIV viremia especially in high-burden settings with substantial under-diagnosis of HIV infection. The 2nd Kenya AIDS Indicator Survey (KAIS 2012) provided a unique opportunity to evaluate the impact of antiretroviral therapy (ART) coverage on viremia and to examine the risks for failure to suppress viral replication. We report population-level HIV viral load suppression using data from KAIS 2012. METHODS: Between October 2012 to February 2013, KAIS 2012 surveyed household members, administered questionnaires and drew serum samples to test for HIV and, for those found to be infected with HIV, plasma viral load (PVL) was measured. Our principal outcome was unsuppressed HIV viremia, defined as a PVL ≥ 550 copies/mL. The exposure variables included current treatment with ART, prior history of an HIV diagnosis, and engagement in HIV care. All point estimates were adjusted to account for the KAIS 2012 cluster sampling design and survey non-response. RESULTS: Overall, 61·2% (95% CI: 56·4-66·1) of HIV-infected Kenyans aged 15-64 years had not achieved virological suppression. The base10 median (interquartile range [IQR]) and mean (95% CI) VL was 4,633 copies/mL (0-51,596) and 81,750 copies/mL (59,366-104,134), respectively. Among 266 persons taking ART, 26.1% (95% CI: 20.0-32.1) had detectable viremia. Non-ART use, younger age, and lack of awareness of HIV status were independently associated with significantly higher odds of detectable viral load. In multivariate analysis for the sub-sample of patients on ART, detectable viremia was independently associated with younger age and sub-optimal adherence to ART. DISCUSSION: This report adds to the limited data of nationally-representative surveys to report population- level virological suppression. We established heterogeneity across the ten administrative and HIV programmatic regions on levels of detectable viral load. Timely initiation of ART and retention in care are crucial for the elimination of transmission of HIV through sex, needle and syringe use or from mother to child. Further refinement of geospatial mapping of populations with highest risk of transmission is necessary.

Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco.

We examined the association between amphetamine use and HIV incidence for 2991 men who have sex with men (MSM) who tested anonymously for HIV in San Francisco. HIV incidence among 290 amphetamine users was 6.3% per year (95% CI 1.9-10.6%), compared with 2.1% per year (95% CI 1.3-2.9%) among 2701 non-users (RR 3.0, 95% CI 1.4-6.5). HIV prevention programmes in San Francisco should include efforts to reduce amphetamine use and associated high-risk sexual behaviors.

Perpetrators and context of child sexual abuse in Kenya.

Child sexual abuse (CSA) interventions draw from a better understanding of the context of CSA. A survey on violence before age 18 was conducted among respondents aged 13-17 and 18-24 years. Among females (13-17), the key perpetrators of unwanted sexual touching (UST) were friends/classmates (27.0%) and among males, intimate partners (IP) (35.9%). The first incident of UST among females occurred while traveling on foot (33.0%) and among males, in the respondent's home (29.1%). Among females (13-17), the key perpetrators of unwanted attempted sex (UAS) were relatives (28.9%) and among males, friends/classmates (31.0%). Among females, UAS occurred mainly while traveling on foot (42.2%) and among males, in school (40.8%). Among females and males (18-24 years), the main perpetrators of UST were IP (32.1% and 43.9%) and the first incident occurred mainly in school (24.9% and 26.0%), respectively. The main perpetrators of UAS among females and males (18-24 years) were IP (33.3% and 40.6%, respectively). Among females, UAS occurred while traveling on foot (32.7%), and among males, in the respondent's home (38.8%); UAS occurred mostly in the evening (females 60.7%; males 41.4%) or afternoon (females 27.8%; males 37.9%). Among females (18-24 years), the main perpetrators of pressured/forced sex were IP and the first incidents occurred in the perpetrator's home. Prevention interventions need to consider perpetrators and context of CSA to increase their effectiveness. In Kenya, effective CSA prevention interventions that target intimate relationships among young people, the home and school settings are needed.

Factors Associated with Uptake of HIV Test Results in a Nationally Representative Population-Based AIDS Indicator Survey.

Population-based surveys with HIV testing in settings with low testing coverage provide opportunities for participants to learn their HIV status. Survey participants (15-64 years) in a 2007 nationally representative population-based HIV serologic survey in Kenya received a voucher to collect HIV test results at health facilities 6 weeks after blood draw. Logistic regression models were fitted to identify predictors of individual and couple collection of results. Of 15,853 adults consenting to blood draw, 7,222 (46.7%) collected HIV test results (46.5% men, 46.8% women). A third (39.5%) of HIV-infected adults who were unaware of their infection and 48.2% of those who had never been tested learned their HIV status during KAIS. Individual collection of HIV results was associated with older age, with the highest odds among adults aged 60-64 years (adjusted odds ratio [AOR], 1.6, 95% confidence interval [CI] 1.2-2.1); rural residence (AOR 1.8, 95%CI 1.2-2.6); and residence outside Nairobi, with the highest odds in the sparsely populated North Eastern province (AOR 8.0, 95%CI 2.9-21.8). Of 2,685 married/cohabiting couples, 18.5% collected results as a couple. Couples in Eastern province and in the second and middle wealth quintiles were more likely to collect results than those in Nairobi (AOR 3.2, 95%CI 1.1-9.4) and the lowest wealth quintile (second AOR 1.5, 95%CI 1.1-2.3; middle AOR 1.6, 95% CI 1.2-2.3, respectively. Many participants including those living with HIV learned their HIV status in KAIS. Future surveys need to address low uptake of results among youth, urban residents, couples and those with undiagnosed HIV infection.

Tuberculosis and HIV at the national level in Kenya: results from the Second Kenya AIDS Indicator Survey.

BACKGROUND: Co-morbidity with tuberculosis and HIV is a common cause of mortality in sub-Saharan Africa. In the second Kenya AIDS Indicator Survey, we collected data on knowledge and experience of HIV and tuberculosis, as well as on access to and coverage of relevant treatment services and antiretroviral therapy (ART) in Kenya. METHODS: A national, population-based household survey was conducted from October 2012 to February 2013. Information was collected through household questionnaires, and blood samples were taken for HIV, CD4 cell counts, and HIV viral load testing at a central laboratory. RESULTS: Overall, 13,720 persons aged 15-64 years participated; 96.7% [95% confidence interval (CI): 96.3 to 97.1] had heard of tuberculosis, of whom 2.0% (95% CI: 1.7 to 2.2) reported having prior tuberculosis. Among those with laboratory-confirmed HIV infection, 11.6% (95% CI: 8.9 to 14.3) reported prior tuberculosis. The prevalence of laboratory-confirmed HIV infection in persons reporting prior tuberculosis was 33.2% (95% CI: 26.2 to 40.2) compared to 5.1% (95% CI: 4.5 to 5.8) in persons without prior tuberculosis. Among those in care, coverage of ART for treatment-eligible persons was 100% for those with prior tuberculosis and 88.6% (95% CI: 81.6 to 95.7) for those without. Among all HIV-infected persons, ART coverage among treatment-eligible persons was 86.9% (95% CI: 74.2 to 99.5) for persons with prior tuberculosis and 58.3% (95% CI: 47.6 to 69.0) for those without. CONCLUSIONS: Morbidity from tuberculosis and HIV remain major health challenges in Kenya. Tuberculosis is an important entry point for HIV diagnosis and treatment. Lack of knowledge of HIV serostatus is an obstacle to access to HIV services and timely ART for prevention of HIV transmission and HIV-associated disease, including tuberculosis.