Association of HIV infection with distribution and viral load of HPV types in Kenya: a survey with 820 female sex workers.

BACKGROUND: Human papillomavirus (HPV) and HIV are each responsible for a considerable burden of disease. Interactions between these infections pose substantial public health challenges, especially where HIV prevalence is high and HPV vaccine coverage low. METHODS: Between July 2005 and January 2006, a cross-sectional community-based survey in Mombasa, Kenya, enrolled female sex workers using snowball sampling. After interview and a gynaecological examination, blood and cervical cytology samples were taken. Quantitative real-time PCR detected HPV types and viral load measures. Prevalence of high-risk HPV was compared between HIV-infected and -uninfected women, and in women with abnormal cervical cytology, measured using conventional Pap smears. RESULTS: Median age of the 820 participants was 28 years (inter-quartile range [IQR] = 24-36 years). One third of women were HIV infected (283/803; 35.2%) and these women were y more likely to have abnormal cervical cytology than HIV-negative women (27%, 73/269, versus 8%, 42/503; P < 0.001). Of HIV-infected women, 73.3% had high-risk HPV (200/273) and 35.5% had HPV 16 and/or 18 (97/273). Corresponding figures for HIV-negative women were 45.5% (229/503) and 15.7% (79/503). After adjusting for age, number of children and condom use, high-risk HPV was 3.6 fold more common in HIV-infected women (95%CI = 2.6-5.1). Prevalence of all 15 of the high-risk HPV types measured was higher among HIV-infected women, between 1.4 and 5.5 fold. Median total HPV viral load was 881 copies/cell in HIV-infected women (IQR = 33-12,110 copies/cell) and 48 copies/cell in HIV-uninfected women (IQR = 6-756 copies/cell; P < 0.001). HPV 16 and/or HPV 18 were identified in 42.7% of LSIL (32/75) and 42.3% of HSIL (11/26) lesions (P = 0.98). High-risk HPV types other than 16 and 18 were common in LSIL (74.7%; 56/75) and HSIL (84.6%; 22/26); even higher among HIV-infected women. CONCLUSIONS: HIV-infected sex workers had almost four-fold higher prevalence of high-risk HPV, raised viral load and more precancerous lesions. HPV 16 and HPV 18, preventable with current vaccines, were associated with cervical disease, though other high-risk types were commoner. HIV-infected sex workers likely contribute disproportionately to HPV transmission dynamics in the general population. Current efforts to prevent HIV and HPV are inadequate. New interventions are required and improved implementation of existing strategies.

Psychological well-being and socio-economic hardship among AIDS orphans and other vulnerable children in Guinea.

Over the past decade, the effects of AIDS-related parental death on children's socio-economic, educational and psychological well-being have become apparent. Most studies, however, have compared the plight of so-called AIDS orphans with non-orphaned children only. Consequently, such study designs are unable to establish if the AIDS-related cause of death of the parents confers effects additional to those of parent-bereavement. We therefore conducted a cross-sectional survey to assess the psychological well-being and socio-economic hardship among 140 non-orphaned children, 133 children orphaned by causes other than AIDS (O) and 124 children orphaned by AIDS (O-A) in Conakry, N'Zerekore and the villages around N'Zerekore, Guinea. Multi-way analysis of variance and multiple (ordinal) logistic regression models were applied to measure the association between the orphan status and psychological well-being, school attendance, economic activities, frequency of going to bed hungry and sleeping commodity. After adjustment for confounding factors, the psychological well-being score (PWS) was significantly lower among AIDS-orphaned children than among O (P<0.001). Additionally, AIDS-orphaned children were more likely to be engaged in economic activities (adjusted odds ratio (AOR) = 3.04; 95% CI: 1.45-6.36) and to go to bed hungry on a daily basis (AOR = 2.73; 95% CI: 1.24-6.02) than other orphans. The differences in school attendance and the proportion of children with a bed or couch to sleep between AIDS-orphaned children and O were not statistically significant. This situation calls for sustainable and holistic approaches to ensure the psychological and socio-economic stability of AIDS orphans and other vulnerable children.

Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: a cluster randomised trial.

OBJECTIVES: To compare two post-abortion family planning (FP) service packages on contraceptive use and repeat abortion rate among young women in three cities in China. METHODS: In this cluster-randomized trial, one FP service package included provision of limited information and referral to existing FP services, and the other, more comprehensive, package consisted--in addition to the above simple package--of individual counselling, free provision of contraceptive materials, and involvement of the male partner. Eight matched pairs of hospitals were certified by centralized randomization. Women undergoing abortion were followed up for six months, and data were collected in two rounds, before and after the intervention. RESULTS: We followed a total of 2336 women younger than 25 years (555 before and 555 after the simple intervention package; 634 before and 592 after the comprehensive intervention package). Both packages increased use of any contraceptive method, but the comprehensive approach also increased use of more effective methods. Odds ratios for consistent and correct use of condoms were 2.32 (95% confidence interval 1.55-3.46) and 2.78 (1.81-4.26), respectively, compared with the simple package. The rates of unwanted pregnancies and repeat abortions were somewhat reduced for both packages, with no significant statistical difference between them. CONCLUSION: Couples who received the comprehensive post-abortion FP service appear to use more effective contraceptive methods and show better compliance.

Palestinian women's sexual and reproductive health rights in a longstanding humanitarian crisis.

This paper results from a study conducted in the Occupied Palestinian Territory in September 2002 to test the usefulness of a guide for a comprehensive approach to sexual and reproductive health rights and needs of refugee women. In-depth interviews with key informants from 19 organisations and two focus group discussions were carried out in the West Bank and Gaza. Three refugee camps were visited as well as five health facilities. The findings revealed that severe restrictions on mobility had reduced access to health facilities for both staff and patients in a significant way. For pregnant women, this had resulted in decreased access to antenatal and post-natal care and an increasing number of home deliveries, induced deliveries and deliveries at military checkpoints. Lack of donor interest and withdrawal of donor support were mentioned as hampering the implementation of the National Reproductive Health Guidelines, and the sustainability and quality of existing sexual and reproductive health services. Family planning had become a politically sensitive issue, and there were indications of increased gender-based violence. Lack of access to reproductive health services was the most visible aspect of the impact of the conflict on women's sexual and reproductive health. Little attention is paid to the less visible evidence that women's reproductive rights have been subordinated to the political situation.

Where have all the condoms gone in adolescent programmes in the Democratic Republic of Congo.

Decades of mismanagement, combined with the withdrawal of international cooperation and a protracted war, have seriously affected the health system in the Democratic Republic of Congo (DRC) and the health status of the population. As part of a Belgian development cooperation programme, we conducted a study in Kinshasa and Bukavu in April-May 2004 on how a rights-based approach could contribute to an effective and appropriate response to the sexual and reproductive health needs of Congolese adolescents. Access to condom information and supplies was studied in this context. A qualitative methodology was used, consisting of focus group discussions with adolescents and interviews with peer education programme officers. These programmes were supposed to be based on the recognition of adolescent sexual and reproductive health rights and the so-called ABC approach (abstinence, be faithful, condom use). We found, however, that sociocultural barriers and strict obedience to Vatican doctrine prevented adolescents from receiving accurate and comprehensive sexuality education and that condom supplies were blocked by peer education programme officers. The promotion of adolescent sexual and reproductive health rights is the responsibility of States, but the international community, non-governmental and faith-based organisations and donors play an essential role in assisting States in this respect and should never act in violation of adolescents' rights.

Vulnerability of women in an African setting: lessons for mother-to-child HIV transmission prevention programmes.

After discussing advantages and risks, only a third of the 290 HIV-infected women included in an intervention study to reduce mother-to-child transmission of HIV in Mombasa, Kenya, informed their partners of their results. Despite careful counselling, 10% subsequently experienced violence or disruption of their relationship. To increase the uptake of interventions to reduce perinatal HIV transmission safely, we recommend the involvement of partners in HIV testing. In addition, the counselling of women has to address methods and skills to deal with violence.

Prevalence of sexually transmitted infections in women attending antenatal care in Tete province, Mozambique.

OBJECTIVE: To determine the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and syphilis in pregnant women. METHODS: A cross-sectional study was conducted among women attending antenatal care clinics (ANCs). Blood samples were tested for syphilis using the rapid plasma reagin (RPR) and treponemal haemagglutination (TPHA) tests; CT and NG were diagnosed using a manual polymerase chain reaction assay on first-void urine samples. A socio-demographic questionnaire was completed. Results were compared with previous published data on sexually transmitted infection (STI) prevalence in Mozambique. RESULTS: Blood and urine samples were collected from 1 119 and 835 women, respectively. The prevalence of CT was 4.1%, and that of NG 2.5%. The RPR test was positive in 5.2% of the women, and 7.1% had a positive TPHA test. Active syphilis was found in 4.7%. In univariate analysis, CT was associated with having had any level of education (p<0.05), reactive RPR and TPHA were associated with illiteracy (p<0.05), and TPHA was associated with age >25. Multivariate analysis did not show any significant association. In comparison with published data from 1993, a decline was observed for CT (p<0.05), NG and syphilis (p<0.001). CONCLUSIONS: Compared with available data, a decline of STI prevalence was observed in our setting. This might be the result of community-based education programmes focusing on changes to sexual behaviour, as well as the widespread use of the syndromic approach to managing STIs and the expansion of syphilis screening in primary health care settings. However, STI rates are still high, and the problem needs more concrete and sustained efforts for its control.

Female genital mutilation: knowledge, attitudes and practices of Flemish gynaecologists.

OBJECTIVE: To assess the knowledge, attitudes and practices with regard to female genital mutilation (FGM) among gynaecologists in Flanders, Belgium. METHODS: A questionnaire-based survey was sent to 724 Flemish gynaecologists and trainees. RESULTS: Three-hundred-and-thirty-four questionnaires were returned. The survey revealed gaps in the knowledge of FGM and the provision of care by Flemish gynaecologists to women who had been mutilated. It also appeared that FGM was not properly addressed in the basic and specialized medical training in Flanders, that little was known about codes of conduct issued by the hospitals when these were not lacking altogether, and that knowledge about legislation concerning FGM was deficient. There was much confusion whether re-infibulation is authorized, and what its legal status is. Some respondents considered cosmetic vaginal surgery as a form of FGM and many were in favour of the medicalization of FGM. Gynaecologists were most commonly confronted with complaints related to sexual problems caused by FGM. Finally, the study also showed that only about a third of the gynaecologists were discouraging women from having their daughters excised. CONCLUSION: There is a need for a thorough discussion among all those concerned of the ethical and legal aspects of re-infibulation, medicalization of FGM and cosmetic vaginal surgery.

HIV testing and sexually transmitted infection care among sexually active youth in the Balkans.

In light of the imminent threat of a growing HIV epidemic in east and southeast Europe, optimal accessibility of primary and secondary HIV preventative interventions, including HIV testing and sexually transmitted infection (STI) care, are fast becoming public health priorities. We surveyed 2150 high school students in Bosnia and Herzegovina, FYR of Macedonia, Serbia, and Montenegro to examine the uptake of HIV testing and associated predictors. Among sexually active youth (n = 651), 5.9% had already been tested for HIV. In marginal logistic regression, country of origin, type of high school, knowing a friend or relative with HIV, poor self-assessed health status, suspicion of having had an STI, and not having used a condom at first sex were independently associated with HIV testing. Fear of the diagnosis, fear of violation of confidentiality, and not knowing where to go for HIV testing were reported as barriers to HIV testing. Of sexually active adolescents who thought they might have contracted an STI, only 42% had subsequently visited a doctor or health facility. The main reasons for not doing so were spontaneous disappearance of the complaints, fear of the diagnosis and being ashamed of discussing the problem. In conclusion, the uptake of HIV testing among this population of sexually active, urban high school students was found to be low, although a higher prevalence of HIV testing history was observed among students showing evidence of risky sexual behavior. Practical and psychological factors seem to challenge the accessibility of facilities for HIV testing and STI care.

Antenatal HIV screening in Europe: a review of policies.

BACKGROUND: The increased prevalence of HIV infection in women is leading to a rising number of children born to HIV-infected mothers. As therapeutic possibilities for HIV/AIDS increase, the detection of undiagnosed HIV infections in pregnant women, followed by adequate management, is of crucial interest. Therapeutic protocols are being updated and increasingly applied in most European countries, but there is no structured information on policies and strategies with regard to antenatal HIV screening as such. METHODS: In order to identify national policies with regard to antenatal HIV screening, a structured questionnaire was sent to key-informants within the ministries of health and national institutes for public health in each of the 25 EU Member States. RESULTS: Information was obtained from all EU Member States with the exception of Cyprus and Luxembourg. Eighteen countries issued a national policy with regard to antenatal HIV screening, 16 opted for a system in which HIV testing is offered to all women attending antenatal services while only two opted for selective screening. None of the 18 countries with a national policy supports a mandatory screening strategy. The voluntary testing strategies are of two types: opting in versus opting out. In almost all EU countries with antenatal HIV screening policies, screening conditions are defined. CONCLUSION: Policies are in place in most EU countries. Nevertheless, there is a need for more integrated European policies and region-specific recommendations on the performance of antenatal HIV screening as an opportunity for comprehensive HIV/AIDS service delivery. This would enable the different aspects of prevention to be linked and also address both the needs of pregnant women and mothers as well as that of their infants.

Health care in Europe for women with genital mutilation.

The increasing number of immigrants from African countries practicing female genital mutilation (FGM) has raised concern in Europe. Health care professionals have developed three main responses: (1) technical guidelines for clinical management; (2) codes of conduct on quality of care; and (3) specialised health services for medical and psychological care and counselling. Much remains to be done, however, to ensure adequate care in Europe: (1) medico-legal/ethical discussions; (2) development of protocols to assist in making informed decisions; and (3) development of guidelines on counselling, communication strategies, and referral procedures. All agencies working in the field of FGM should be interlinked at the national level, in which members of the affected communities should be included. At the European level, a coordinated approach between all agencies should be developed.

Reproductive health in Afghanistan: results of a knowledge, attitudes and practices survey among Afghan women in Kabul.

A reproductive-health knowledge, attitudes and practices (KAP) survey was carried out among 468 Afghan women of reproductive age. A convenience sample of women was selected from attendees in the outpatient departments of four health facilities in Kabul. Seventy-nine per cent of respondents had attended at least one antenatal consultation during their last pregnancy. Two-thirds (67 per cent) delivered their first child between 13 and 19 years. The Caesarean-section rate was low (1.6 per cent). Two-thirds (67 per cent) of deliveries occurred in the home. The contraceptive prevalence rate was 23 per cent (16 per cent modern and 7 per cent natural methods). Twenty-four per cent had knowledge of any STIs, although most of these women did not know correctly how to prevent them. Most of the women (93 per cent) needed authorization from their husband or a male relative before seeking professional health-care. In multivariate analysis, women's schooling was significantly associated with antenatal-care attendance (AOR 4.78), institutional delivery (AOR 2.29), skilled attendance at birth (AOR 2.07) and use of family planning (AOR 4.59). Reproductive-health indicators were noted to be poor even among these women living in Kabul, a group often considered to be the most privileged. To meet the reproductive-health needs of Afghan women, the socio-cultural aspects of their situation--especially their decision-making abilities -- will need to be addressed. A long-standing commitment from agencies and donors is required, in which the education of women should be placed as a cornerstone of the reconstruction process of Afghanistan.

Distribution of human papillomavirus in a family planning population in nairobi, kenya.

BACKGROUND: In sub-Saharan Africa, cervical cancer is the leading cancer among women. The causative role of different human papillomavirus (HPV) types in cervical cancer is established, but the distribution of HPV types within this region is largely unknown. GOAL: The goal was to study the distribution of HPV among family planning clinic attendees in Nairobi, Kenya. STUDY DESIGN: This was a cross-sectional study of persons attending a family planning center in Nairobi, Kenya. RESULTS: HPV data of 429 women were analyzed; 7.0% had low-grade intraepithelial lesions, 6.8% had high-grade intraepithelial lesions, and 0.23% had invasive cancer. One hundred ninety samples (44.3%) were HPV-positive (28.4% were positive for multiple types). The most common HPV types were HPV 52 (17.9% of positive samples), HPV 16 (14.7%), HPV 35 (11.6%), and HPV 66 (9.0%). The risk of high-grade squamous intraepithelial lesions (HSIL) was 88.5 times higher (95% CI, 8.5-1.4 x 10 ) in HPV 16-positive women than in HPV-negative women. Relative risks were 54.3 (95% CI, 4.0-1.4 x 10 ) for HPV 35, 49.2 (95% CI, 3.6-9.5 x 10 ) for HPV 52, and 21.7 (95% CI, 0.0-1.9 x 10 ) for HPV 18. The prevalence of HSIL was not increased in association with HIV-positivity, yet HIV-1 was significantly associated with high-risk HPV types ( P< 0.00001). CONCLUSION: The pattern of HPV distribution in this population was different from that in other regions in the world, which has important consequences for HPV vaccine development.

Placental inflammation and perinatal transmission of HIV-1.

The effect of placental membrane inflammation on mother-to-child transmission (MTCT) of HIV-1 is reported. Placentas from HIV-1-infected women were examined as part of a perinatal HIV-1 project in Mombasa, Kenya. Polymerase chain reaction analysis was used to test for HIV-1 in the infants at birth and at 6 weeks. The maternal HIV-1 seroprevalence was 13.3% (298 of 2,235). The overall rate of MTCT of HIV-1 was 25.4%; polymerase chain reaction analysis revealed that of the 201 infants 6.0% (12) were already HIV-1-positive at birth (intrauterine transmission) and 19.4% (39) were infected during the peripartum period or in early neonatal life (perinatal transmission). The prevalence of acute chorioamnionitis was 8.8%, that of deciduitis was 10.8%, and that of villitis was 1.6%. Acute chorioamnionitis was independently associated with peripartum HIV-1 transmission but not with in utero MTCT (17.9% vs. 6.7%, respectively; adjusted odds ratio, 3.9; 95% confidence interval, 1.2-12.5; p =.025). Other correlates of perinatal MTCT were presence of HIV in the genital tract and in the baby's oral cavity and a high maternal viral load in peripheral blood. The adjusted population attributable fraction of 12.8% (95% confidence interval, 1.5%-22.8%) indicated that approximately 3% of MTCT could be prevented if acute chorioamnionitis was eliminated. We suggest that further research on the role of antimicrobial treatment in the prevention of chorioamnionitis and the reduction of peripartum MTCT needs to be performed.

Placental malaria and perinatal transmission of human immunodeficiency virus type 1.

Prevalence of placental malaria in human immunodeficiency virus (HIV) type 1-infected and -uninfected women and the effect of placental malaria on genital shedding and perinatal transmission of HIV-1 were examined. Genital samples for HIV-1 DNA RNA were collected during labor. Infants were tested for HIV-1 at 1 day and 6 weeks postpartum. Placental malaria was diagnosed by histopathological examination: 372 placentas of HIV-1-infected women and 277 of HIV-1-uninfected women were processed. A higher prevalence of placental malaria was seen in HIV-1-infected women. No association was found between placental malaria and either maternal virus load, genital HIV-1 DNA, or HIV-1 RNA. Placental malaria did not correlate with in utero or peripartal transmission of HIV-1.

Diversity of the human immunodeficiency virus type 1 (HIV-1) env sequence after vertical transmission in mother-child pairs infected with HIV-1 subtype A.

Although several virologic and immunologic factors associated with an increased risk of perinatal human immunodeficiency virus type 1 (HIV-1) transmission have been described, the mechanism of mother-to-child transmission is still unclear. More specifically, the question of whether selective pressures influence the transmission remains unanswered. The aim of this study was to assess the genetic diversity of the transmitted virus after in utero transmission and after peripartum transmission and to compare the viral heterogeneity in the child with the viral heterogeneity in the mother. To allow a very accurate characterization of the viral heterogeneity in a single sample, limiting-dilution sequencing of a 1016-bp fragment of the env gene was performed. Thirteen children were tested, including 6 with in utero infections and 7 with peripartum infections. Samples were taken the day after birth and at the ages of 6 and 14 weeks. A homogeneous virus population was seen in six (46.2%) infants, of whom two were infected in utero and four were infected peripartum. A more heterogeneous virus population was detected in seven infants (53.8%), four infected in utero and three infected peripartum. The phylogenetic trees of the mother-child pairs presented a whole range of different tree topologies and showed infection of the child by one or more maternal variants. In conclusion, after HIV-1 transmission from mother to child a heterogeneous virus population was detected in approximately one-half of the children examined. Heterogeneous virus populations were found after peripartum infection as well as after in utero infection. Phylogenetic tree topologies argue against selection processes as the major mechanism driving mother-to-child transmission but support the hypothesis that virus variability is mainly driven by the inoculum level and/or exposure time.