HPV prevalence around the time of sexual debut in adolescent girls in Tanzania.

OBJECTIVES: Cervical cancer is the leading cause of cancer-related mortality among women in sub-Saharan Africa (SSA). Data on human papillomavirus (HPV) epidemiology in adolescent girls in SSA are essential to inform HPV vaccine policy recommendations for cervical cancer prevention. We assessed the burden of HPV infection, and risk factors for infection, among adolescent girls around the time of sexual debut. METHODS: Cross-sectional study of secondary school girls aged 17-18 years in Tanzania. Consenting participants provided samples for HPV and STI testing. Vaginal swabs were tested for 37 HPV genotypes by Roche Linear Array. Logistic regression was used to identify factors associated with HPV infection. Y chromosome was tested as a marker of recent condomless sex. RESULTS: 163/385 girls (42.3%) reported previous penetrative sex. HPV was detected in 125/385 (32.5%) girls, including 84/163 (51.5%) girls reporting previous sex and 41/222 (18.5%) reporting no previous sex. High-risk (HR) genotypes were detected in 70/125 (56.0%) girls with HPV infection. The most common HR genotype was HPV-16 (15/385; 3.9%). The prevalence of other HR HPV vaccine genotypes was between 0.8% and 3.1%. Among 186 girls who reported no previous sex, were negative for Y chromosome, and had no STI, 32 (17%) had detectable HPV. Lactobacillus sp and bacterial vaginosis-associated bacteria were negatively and positively associated, respectively, with HPV. CONCLUSIONS: HPV prevalence among adolescent girls around the time of sexual debut was high. However, prevalence of most vaccine genotypes was low, indicating that extending the age range of HPV vaccination in this region may be cost-effective.

Results from a cross-sectional sexual and reproductive health study among school girls in Tanzania: high prevalence of bacterial vaginosis.

OBJECTIVES: Bacterial vaginosis (BV) increases women's susceptibility to sexually transmitted infections (STIs) and HIV and may partly explain the high incidence of STI/HIV among girls and young women in East and southern Africa. The objectives of this study were to investigate the association between BV and sexual debut, to investigate other potential risk factors of BV and to estimate associations between BV and STIs. METHODS: Secondary school girls in Mwanza, aged 17 and 18 years, were invited to join a cross-sectional study. Consenting participants were interviewed and samples were obtained for STI and BV testing. Factors associated with prevalent BV were analysed using multivariable logistic regression. Y-chromosome was tested as a biomarker for unprotected penile-vaginal sex. RESULTS: Of the 386 girls who were enrolled, 163 (42%) reported having ever had penile-vaginal sex. Ninety-five (25%) girls had BV. The prevalence of BV was 33% and 19% among girls who reported or did not report having ever had penile-vaginal sex, respectively. BV was weakly associated with having ever had one sex partner (adjusted odds ratio (aOR) 1.59;95% CI 0.93 to 2.71) and strongly associated with two or more partners (aOR = 3.67; 95% CI 1.75 to 7.72), receptive oral sex (aOR 6.38; 95% CI 1.22 to 33.4) and having prevalent human papillomavirus infection (aOR = 1.73; 95% CI 1.02 to 2.95). Of the 223 girls who reported no penile-vaginal sex, 12 (5%) tested positive for an STI and 7 (3%) tested positive for Y-chromosome. Reclassifying these positive participants as having ever had sex did not change the key results. CONCLUSIONS: Tanzanian girls attending school had a high prevalence of BV. Increasing number of sex partner was associated with BV; however, 19% of girls who reported no penile-vaginal sex had BV. This suggests that penile-vaginal sexual exposure may not be a prerequisite for BV. There was evidence of under-reporting of sexual debut.

Stigma reduction in relation to HIV test uptake in low- and middle-income countries: a realist review.

BACKGROUND: This realist review was conducted to understand how stigma is reduced in relation to HIV test uptake in low- and middle-income countries (LMICs). METHODS: A systematic search of eight databases resulted in 34 articles considered for synthesis. Data synthesis was guided by a preliminary programme theory and included coding the meaning units to develop themes or intervention pathways that corresponded to context-mechanism-outcome configurations. RESULTS: We found that the interventions produced an effect through two pathways: (a) knowledge leads to changes in stigmatizing attitudes and increases in HIV test uptake and (b) knowledge and attitudes lead to changes in stigmatizing behaviours and lead to HIV test uptake. We also found one competing pathway that illustrated the direct impact of knowledge on HIV test uptake without changing stigmatizing attitudes and behaviour. The identified pathways were found to be influenced by some structural factors (e.g., anti-homosexuality laws, country-specific HIV testing programmes and policies), community factors (e.g., traditional beliefs and practices, sexual taboos and prevalence of intimate partner violence) and target-population characteristics (e.g., age, income and urban-rural residence). CONCLUSIONS: The pathways and underlying mechanisms support the adaptation of intervention strategies in terms of social context and the target population in LMICs.

Mothers' willingness to pay for daughters' HPV vaccine in northern Vietnam.

HPV vaccine is effective in preventing human papillomavirus, the main cause of cervical cancer. In Vietnam, at first, it was subsidized at $5 a dose and reached the coverage of 96% in two pilot provinces, indicating potentially high acceptance. Currently, it is provided at $120-195 for three doses. This is a cross-sectional study, conducted in two northern rural districts of Vietnam. Researchers present findings to show 53.1% of mothers stated their willingness to pay (WTP) for HPV vaccine for their daughters. Perceptions on cost and condom use were associated with WTP. Mothers' affordability ranged from under $23 to $46. Measures should be implemented soon to make HPV vaccine more affordable.

Development and validation of the HCV-MOSAIC risk score to assist testing for acute hepatitis C virus (HCV) infection in HIV-infected men who have sex with men (MSM).

Current guidelines recommend hepatitis C virus (HCV) testing for HIV-infected men who have sex with men (MSM) with ongoing risk behaviour, without specifying the type of risk behaviour. We developed and validated the HCV-MOSAIC risk score to assist HCV testing in HIV-infected MSM. The risk score consisted of six self-reported risk factors identified using multivariable logistic regression using data from the Dutch MOSAIC study (n = 213, 2009-2013). Area under the ROC curve (AUC), sensitivity, specificity, post-test-probability-of-disease and diagnostic gain were calculated. The risk score was validated in case-control studies from Belgium (n = 142, 2010-2013) and the United Kingdom (n = 190, 2003-2005) and in cross-sectional surveys at a Dutch sexually transmitted infections clinic (n = 284, 2007-2009). The AUC was 0.82; sensitivity 78.0% and specificity 78.6%. In the validation studies sensitivity ranged from 73.1% to 100% and specificity from 56.2% to 65.6%. The post-test-probability-of-disease ranged from 5.9% to 20.0% given acute HCV prevalence of 1.7% to 6.4%, yielding a diagnostic gain of 4.2% to 13.6%. The HCV-MOSAIC risk score can successfully identify HIV-infected MSM at risk for acute HCV infection. It could be a promising tool to improve HCV testing strategies in various settings.

[Does the National HIV /AIDS Control programme provide support for district hospitals in Cameroon?]. / Le programme national de lutte contre le VIH/sida renforce-t-il les hôpitaux de district au Cameroun?

The aim of this study was to investigate the effects of the national HIV/AIDS control programme on district hospitals in Cameroon. A multiple case study was conducted in two district hospitals- one public and one faith-based. Data were collected by document review, semi-structured interviews and observation of managerial processes and health care delivery. Programme interventions result in a series of positive and negative effects on the functioning of district hospitals and local health systems. High input and support of staff skills were observed for antiretroviral therapy and the management of opportunistic infections. However, the impact of the programme on the stewardship function is problematic. The low implication of district management teams in the implementation of HIV /AIDS activities reduces their structural capacity to run the local health systems. Programme and health system managers failed to take advantage of opportunities to develop synergies between the HIV/AIDS programme and local health systems. The HIV/AIDS programme weakens the systemic and structural capacity of local health systems. Managers of both programmes and general health systems should analyse and adapt their interventions in order to effective' strengthen health systems. One of the research questions is to understand why health system stakeholders do not seize opportunities to develop synergies between programmes and the general system and to strengthen health systems.

Prevalence and correlates of bacterial vaginosis in different sub-populations of women in sub-Saharan Africa: a cross-sectional study.

BACKGROUND: Clinical development of vaginally applied products aimed at reducing the transmission of HIV and other sexually transmitted infections, has highlighted the need for a better characterisation of the vaginal environment. We set out to characterise the vaginal environment in women in different settings in sub-Saharan Africa. METHODS: A longitudinal study was conducted in Kenya, Rwanda and South-Africa. Women were recruited into pre-defined study groups including adult, non-pregnant, HIV-negative women; pregnant women; adolescent girls; HIV-negative women engaging in vaginal practices; female sex workers; and HIV-positive women. Consenting women were interviewed and underwent a pelvic exam. Samples of vaginal fluid and a blood sample were taken and tested for bacterial vaginosis (BV), HIV and other reproductive tract infections (RTIs). This paper presents the cross-sectional analyses of BV Nugent scores and RTI prevalence and correlates at the screening and the enrolment visit. RESULTS: At the screening visit 38% of women had BV defined as a Nugent score of 7-10, and 64% had more than one RTI (N. gonorrhoea, C. trachomatis, T. vaginalis, syphilis) and/or Candida. At screening the likelihood of BV was lower in women using progestin-only contraception and higher in women with more than one RTI. At enrolment, BV scores were significantly associated with the presence of prostate specific antigen (PSA) in the vaginal fluid and with being a self-acknowledged sex worker. Further, sex workers were more likely to have incident BV by Nugent score at enrolment. CONCLUSIONS: Our study confirmed some of the correlates of BV that have been previously reported but the most salient finding was the association between BV and the presence of PSA in the vaginal fluid which is suggestive of recent unprotected sexual intercourse.

Clinical characteristics associated with Mycoplasma genitalium infection among women at high risk of HIV and other STI in Uganda.

BACKGROUND: Mycoplasma genitalium is a common infection of the genitourinary tract, but its pathogenic effects have not been well described, especially in women. The increasing evidence that M. genitalium is associated with HIV infection calls for an urgent consensus on how best to control this infection. The aim of this study was to describe symptoms and signs associated with M. genitalium infection among high-risk women in Uganda. METHODS: A cohort of 1027 female sex workers was recruited in Kampala in 2008. At enrollment, HIV testing was performed, genital specimens were tested for other sexually transmitted infection, and urogenital symptoms and signs were recorded. Endocervical swabs were tested for M. genitalium using a commercial Real-TM PCR assay (Sacace Biotechnologies, Como, Italy). The associations of clinical signs and symptoms with prevalent M. genitalium were investigated using multivariable logistic regression models. RESULTS: Reported dysuria and presence of mucopurulent vaginal discharge were significantly associated with M. genitalium infection (OR: 1.85, 95% confidence interval: 1.13-3.03 and OR: 1.55, 95% confidence interval: 1.06-2.29, respectively). There was little evidence for an association with cervicitis or with pelvic inflammatory disease. CONCLUSIONS: In this specific population, we found evidence that symptoms of urethritis and mucopurulent vaginal discharge were associated with M. genitalium infection. This supports earlier studies showing that M. genitalium may lead to clinically relevant genitourinary disorders and should be treated. In the absence of sensitive screening tests, further work is needed to validate clinical findings as possible indicators of M. genitalium infection to guide a possible syndromic approach for its control.

Trichomonas vaginalis is highly prevalent in adolescent girls, pregnant women, and commercial sex workers in Ndola, Zambia.

OBJECTIVES: The aim of the study was to assess the prevalence of Trichomonas sp. infection among adolescent girls, pregnant women, and commercial sex workers in Ndola, Zambia. METHODS: A cross-sectional study was conducted among 460 girls attending school, 307 pregnant women, and 197 commercial sex workers. Self-collected specimens from the vagina, rectum, and mouth were tested by polymerase chain amplification assays for the presence of Trichomonas vaginalis, Pentatrichomonas hominis, and Trichomonas tenax. Genotyping was performed on specimens that tested positive for T. vaginalis. RESULTS: The prevalence of vaginal infection with T. vaginalis was 24.6% among the adolescents, 32.2% among the pregnant women, and 33.2% among the commercial sex workers. Trichomonads other than T. vaginalis were rarely found in the vagina, rectum, and mouth. The presence of T. vaginalis in the rectum was associated with T. vaginalis in the vagina. T. tenax was also detected in the vagina. A total of 9 actin genotypes of T. vaginalis were identified. The distribution of the actin genotypes of T. vaginalis was similar in the 3 study groups. CONCLUSION: We detected high prevalence rates of trichomoniasis among women in Ndola, Zambia. Prevalence among adolescent girls was lower than among pregnant women and commercial sex workers but was still high. We were not able to detect differences in T. vaginalis actin genotypes among the 3 study groups.

Dose-ranging phase 1 study of TMC120, a promising vaginal microbicide, in HIV-negative and HIV-positive female volunteers.

OBJECTIVE: To evaluate the short-term safety, tolerability, and systemic exposure of a vaginal microbicide gel containing the nonnucleoside reverse transcriptase inhibitor TMC120. DESIGN: Randomized, controlled, double-blind, phase 1 trial of a gel containing 3 different concentrations of TMC120 versus placebo. METHODS: Of the 48 HIV-negative and 16 HIV-positive women enrolled, 52 women received active product. Participants applied the gel twice daily for 7 days and were assessed on 6 occasions. Colposcopic evaluation was performed before and after first gel application and on day 8. Laboratory safety assessments were carried out on all visits except day 7. Plasma levels of TMC120 were measured on days 1 and 7. RESULTS: All TMC120 concentrations were well tolerated, and there were no apparent differences in safety parameters. Four women (6%) had treatment-emergent mild cervical findings (petechiae in 3 women and erythema in 1 woman) of <5 mm. Plasma levels of TMC120 were quantifiable on day 1 in 7 (13%) participants and on day 7 in 39 (75%) participants using TMC120 gel. CONCLUSIONS: The TMC120 vaginal gel was well-tolerated in this short study by HIV-negative and HIV-positive women. The implications of the absorption of TMC120 should be studied further in expanded safety and effectiveness trials.

Performance of commercially available enzyme immunoassays for detection of antibodies against herpes simplex virus type 2 in African populations.

Data are accumulating on the performance of enzyme immunoassays (EIAs) for the detection of herpes simplex virus type 2 (HSV-2) infection in North America and Europe, but little is known about their performance in other populations. Nine test kits were evaluated with 330 serum samples from sub-Saharan Africa. The tests were first compared to the monoclonal antibody (MAb) EIA (Central Public Health Laboratory, London, United Kingdom). Samples that gave discordant results in the MAb EIA and in the three tests that performed best compared to the MAb EIA were tested by Western blotting (University of Washington, Seattle). A random sample of concordant samples was also tested, and the sensitivities and specificities of the different tests were calculated, taking into account this sampling strategy. The sensitivities of the tests ranged from 86 to 100%; the specificities ranged from 47 to 99%. The tests that performed best were the Gull Premier EIA (sensitivity, 86.3%; specificity, 97.6%) and the Kalon Biological (sensitivity, 92.3%; specificity, 97.7%) and Biokit (sensitivity, 86.7%; specificity, 92.6%) tests. It cannot be assumed that enzyme immunoassays for the detection of HSV-2 infection that perform well in industrialized countries will perform equally well in other populations.