Contraceptive vaginal ring experiences among women and men in Kisumu, Kenya: A qualitative study.

BACKGROUND: Future HIV prevention options for women will likely include Antiretroviral (ARV)-based intravaginal rings. Valuable insights may be gained by examining user experiences with a similar licensed technology, a contraceptive ring, especially in settings where this technology may not be currently available. METHODS: In-depth interviews with 24 females enrolled in a trial assessing acceptability and use of a contraceptive ring, and 20 male sexual partners were conducted September 2014-April 2015. Elements of ethnography and phenomenological anthropology were used to collect, analyze, interpret, and describe ring users' experiences. Thematic analysis was completed in MaxQDA-10. RESULTS: Experiences with the contraceptive ring reflected a broader Family Planning (FP) paradigm that centered around three themes: latitudes and drawbacks of FP (being free); an FP method needs to be compatible with a woman's body (feeling normal); and dealing with fertility control uncertainties (how well does it really work). FP intentions and disclosure practices were influenced by partner support, socioeconomic factors, religion, cultural beliefs, and societal norms, including female sexuality. A user-friendly FP design was emphasized. Non-suppression of menstruation was favored by most. Unease with vaginal insertion as well as ring placement issues (slippage, expulsion) created initial challenges requiring clinician assistance and practice for some participants. While minor side-effects were described, concerns centered on ring efficacy, negative effect on a woman's sexual desire, and future fertility issues. CONCLUSIONS: Awareness of the multiple contexts in ring users' experience may inform the development, education, and promotion approaches for future ARV rings.

Persons at high risk for HIV infection in Kisumu, Kenya: identifying recruitment strategies for enrolment in HIV-prevention studies.

A combination of in-depth interviews (n = 38) and surveys (n = 203) were used to (1) identify strategies to recruit persons at high risk for HIV infection; (2) determine whether one strategy was more successful than others; and (3) describe motivators and barriers to participation in HIV-prevention studies. From in-depth interviews, four main recruitment strategies were identified: (1) use of a person with specific knowledge of a target population (link person mobilization); (2) use of co-workers or contemporaries (peer mobilization); (3) use of group or association leaders (leader mobilization); and (4) contacting persons by study staff directly (staff contact mobilization). The odds of inconsistently using condoms during sex were greater among those recruited using the peer mobilization (adjusted odds ratio [AOR] = 3.59; 95% confidence interval [CI] = 1.35-9.54) and the leader mobilization strategies (AOR = 2.76; 95% CI = 1.04-7.38) compared with the link person mobilization strategy. The main motivators for taking part in an HIV research study were receiving HIV-prevention education, HIV information or counselling, and receiving compensation for study participation. The main barriers were fear of lack of confidentiality and HIV testing concerns. Using evaluated strategies to recruit persons at high risk for HIV infection and addressing barriers to participation will improve the conduct and outcome of HIV-prevention studies.

National Immunization Information Hotline: Calls concerning adverse events, 1998-2000.

Data from the National Immunization Information Hotline (NIIH) concerning vaccine adverse event inquiries were analyzed from 1998 to 2000 (total n = 23,841 [public n = 14,330; health care professionals n = 9,511]). Approximately 20% of calls from the public from 1998 to 2000 concerned vaccine adverse events. These calls increased 199.5% from 1998 (n = 422) to 1999 (n = 1,264), then declined 12.4% from 1999 to 2000 (n = 1,107). A Lexus Nexus search showed that the number of news stories mentioning vaccine safety showed a similar pattern. Women were more likely to call the NIIH concerning vaccine adverse events than men, and persons 40-59 years old and persons 60 years old and over were less likely to call about vaccine adverse events than those 20-39 years. The parallel trends in news stories mentioning vaccine safety and calls to the NIIH concerning adverse events suggests that news stories may stimulate questions about vaccine safety. Understanding that news stories may elicit questions about vaccine adverse events and examining the characteristics of persons who ask vaccine adverse event questions may guide future informational interventions toward those most in need.

The National Immunization Information Hotline.

The National Immunization Information Hotline (NIIH) has been providing information regarding immunizations to the public and to health care professionals since March 1997. We describe the operations of the NIIH, its experience over the first two and a half years of operation and lessons learned for other immunization hotlines. From 1998-2000, the hotline answered 246,859 calls. Calls concerning immunization information requests totaled 175,367; data about the calls were collected from 35,102. Approximately a third of the 35,102 calls were from health care providers. Of the remaining calls from the public, the greatest number of calls concerned childhood immunizations. Immunization schedule queries from the public increased 323.0% from 1998 to 2000. While the major goal of the NIIH is to provide accurate and reliable information to the public and to health care providers, data from the hotline can be used to monitor changes over time in calls concerning inquiries about the immunization schedule in addition to other variables of interest.

Parental perceptions surrounding risks and benefits of immunization.

In recent years, parental concerns about vaccine safety have increased as the threat of disease has decreased. A national survey showed that, in general, parents agree that vaccines benefit their children and that their children may be at risk for contracting a disease if unvaccinated. When asked about understanding the benefits and risks of vaccines, most parents (57%) found numbers and statistics most helpful. A substantial minority (17%) of parents were somewhat or not confident in vaccine safety. Parents less confident in vaccine safety agreed less with the statement that they usually followed the advice of their child's doctor. Incomes and education levels affected responses. This positive relationship between confidence in vaccine safety and reliance on doctors for advice may indicate the need for healthcare providers to identify opportunities to (1) solicit questions about vaccine safety, (2) address vaccine safety-related questions in a way meaningful to parents, and (3) strengthen doctor-patient relationships. A parent communication tool is proposed.

Activity of the hypothalamic-pituitary-adrenal axis is altered by aging and exposure to social stress in female rhesus monkeys.

Age-related changes in glucocorticoid negative feedback inhibition of hypothalamic CRF and pituitary ACTH are observed in rodents. Attempts to study similar effects in humans have produced mixed results due in part to the difficulty in matching older subjects on social and lifestyle variables. The present study used female rhesus monkeys as a model for women by comparing young adult (n = 20) to old (n = 20) females to test the hypotheses that the hypothalamic-pituitary-adrenal axis is altered in older animals and that this difference is exacerbated by exposure to social stress. The effects of age on the response to two doses of dexamethasone and two doses of CRF were assessed in females living in a stable social environment (control) and in socially stressed females removed from their group and housed temporarily in a remote, nonsocial environment (separated). The suppression of serum cortisol was not different between the two doses of dexamethasone. Before dexamethasone administration (2100 h), serum cortisol was significantly higher in old control females than in either young or old separated females, who were not different from one another. The young control females had baseline cortisol concentrations significantly lower than all other groups. Serum cortisol was suppressed approximately 75% below baseline values in all groups by 10 h after dexamethasone administration. Age significantly affected serum cortisol after dexamethasone, as the old control group showed a release from suppression 19 h posttreatment compared to the young control group and compared to the separated groups. Social condition had a significant effect on the responses of serum cortisol and plasma ACTH to CRF administration. At baseline (0930 h), serum cortisol was significantly higher in young controls compared with older controls, with both separated groups having intermediate values. Similarly, plasma ACTH at baseline was significantly higher in young controls compared to all other groups. Social separation significantly diminished the elevation of both serum cortisol and ACTH after stimulation with either dose of CRF. Control females showed a prolonged increase in plasma ACTH through 60 min and an increase in serum cortisol through 120 min after CRF. In contrast, these hormones either declined by 60 min or did not increase in socially separated females after CRF administration. These data suggest that the circadian rhythm in serum cortisol may be affected by aging, as levels were higher in the evening and lower in the morning in old control compared to young control females. The effect of age on the response to dexamethasone treatment among the control groups lends support to the hypothesis that the sensitivity of glucocorticoid negative feedback diminishes with aging. Although age did not affect the response to CRF, social separation diminished the elevation in both serum cortisol and plasma ACTH. Whether this effect was due to stress-induced down-regulation of pituitary CRF receptors remains to be determined.

Effect of companions in modulating stress associated with new group formation in juvenile rhesus macaques.

To determine if the presence of one or more familiar peers buffers the physiological effect of a stressor, 10 juvenile rhesus monkeys were removed from their natal group and placed together to form a new peer group. Six of the 10 juveniles were from the natal group of one or more others (companion subjects) whereas four juveniles came from entirely separate natal groups (alone subjects). Moreover, six matched juveniles remained in their natal group serving as controls. Two baseline blood samples were collected from all subjects, and then at 24 h, 1 week, and 4 weeks following the peer group formation. There was a significant interaction among the three study groups and sample times for absolute numbers of helper/inducer T lymphocytes, suppressor/cytotoxic T lymphocytes, and B lymphocytes, but not cortisol concentrations. Planned post hoc comparisons found that subjects introduced to the peer group, both those alone and those with companion(s), showed a significantly greater decline from baseline in lymphocyte subsets 24 h later compared to control subjects. It is of note that the alone subjects showed a significantly greater percent decline from baseline in helper/inducer T lymphocytes than companion subjects at 24 h, but not in suppressor/cytotoxic T lymphocytes or B lymphocytes, Planned post hoc comparisons for cortisol found that alone subjects showed significantly higher cortisol concentrations than those subjects with a companion only at the 1-week sample point. Proximity accounted for a significant portion of the variation (R = 0.66) in percent change in helper/inducer T lymphocytes at 24 h and this was a result of the companion subjects staying together. Results of this study confirm the stressful effect of removal from the natal group to a new social situation in juvenile rhesus monkeys and also adds to the growing body of human and nonhuman primate literature that the presence of companions can modulate the physiological effects of a stressor.

Group formation of female pigtail macaques (Macaca nemestrina).

Human epidemiological studies have suggested that social variables can modulate the effects of stress on the immune system, and this concept has been gaining increasing attention with positive results emerging from empirical studies using nonhuman primates over the last two decades. Results from a previous study in rhesus monkeys suggested that receiving grooming positively affected recovery of T-helper and T-suppressor cells following the initial stress associated with group formation, and this co-varied with high dominance rank. Thus, the present study was undertaken in order to determine: (1) if the stress effect of formation could be replicated in another species and (2) if social behaviors or dominance rank, given that formation is a stressor, might independently correlate with physiological recovery from the stressor. Eight adult female pigtail macaques were moved from individual cages and simultaneously introduced into an outdoor enclosure along with an adult male, while eight weight-matched controls remained in individual caging. Behavioral data were collected during the introduction and over 4 weeks thereafter. Blood samples were collected prior to and at intervals for 4 weeks following formation. Compared to control subjects, the test subjects showed an increase in basal cortisol secretion (+28.9%) and a significant decrease in T-helper cells (-33.6%), T-suppressor cells (-30.8%), and B cells (-22.5%), while there was a significant increase in white blood cells (+29.5%) 24 hr following formation. When dominance rank and seven behavioral categories were analyzed, only the frequency of receiving grooming significantly predicted change, with animals who received a greater frequency of grooms showing a lesser negative percent change from baseline in the absolute number of T-helper cells 1 week following formation. The establishment of a dominance hierarchy, apparent within 1 week, was accomplished with no serious fighting and a complete absence of wounding or trauma, suggesting that psychosocial stress was responsible for the physiological changes observed. © 1996 Wiley-Liss, Inc.

Effect of a preferred companion in modulating stress in adult female rhesus monkeys.

Using a counterbalanced design, seven adult female rhesus monkeys were removed from their social group and housed in a novel environment both alone and with a companion chosen on the basis of quantitative affiliative behaviors. Blood samples (n = 2) were collected from all study animals before the exposure to the novel environment, then at 2, 24, and 96 h thereafter for cortisol and immunological analyses. During both conditions, subjects showed evidence of stress as indicated by elevated cortisol concentrations and decreases in absolute numbers of lymphocyte subsets. There was no significant interaction between condition (alone vs. companion) and time in cortisol percent change and further planned post hoc analyses showed no significant between-condition differences for any of the postseparation time points. Similarly, no significant interaction was found between conditions and time for the absolute number of CD4+CD8-T cells, CD8+CD4- T cells, or CD20+CD2- B cells. However, planned post hoc comparisons showed that subjects in the companion condition exhibited a significantly smaller percent change from baseline than in the alone condition at the 24 h and 96 h sample periods in absolute numbers of CD4+CD8- and CD8+CD4- T cells. Results showed that adult female rhesus monkeys exhibited a profound stress response when removed from their social group to a novel environment and that recovery time of T cell subsets was significantly enhanced by the presence of a preferred companion.

Relationship between social factors and pituitary-adrenocortical activity in female rhesus monkeys (Macaca mulatta).

Psychosocial stress in humans has been related to the occurrence or progression of certain diseases and a positive social environment has been shown, in some cases, to ameliorate this effect. In many experimental studies changes in serum cortisol levels have been used as an endocrine-defined stress response, however, the variation in this measure under unchanging conditions in socially housed animals is not well documented. The present study was designed to examine the relationship between specific social behaviors and concentrations of serum cortisol in female rhesus monkeys. Subjects were members of one of two social groups. One was an established long-term (8 years) group with members which had from one to many kin, while the second was a group formed 5 months prior to the onset of the present study composed of initially unfamiliar animals. Blood samples were collected weekly and a total of 16 hr of behavioral data was collected on each subject. For purposes of analyses, the year-long study was organized according to calendar quarters (3 months) with cortisol concentrations averaged and behavioral categories cumulated. When regression techniques were applied, it is of note that neither group nor dominance rank was a predictor of cortisol levels. However, when a correlation analysis was applied to each group separately to assess the effect of dominance rank, rank significantly correlated with cortisol levels in the established but not in the recently formed group. In each quarter, analyses revealed behavioral categories which combined to account for a significant proportion of the variance in cortisol levels, but these behaviors were not identical over the four quarters. For three of the four quarters analyzed, and for the year as a whole, an affiliative behavioral category was predictive of cortisol levels in addition to agonistic behavioral categories. These data suggest that cortisol levels are influenced by not only negative interactions, such as receiving bites, but also by positive interactions such as receiving grooms. Results also showed that reconciliatory behaviors occurred significantly more frequently following dyadic agonistic episodes in the recently formed versus the long-term group. The higher rate of reconciliatory behaviors exhibited by the recently formed group may account for the lack of a dominance rank/cortisol relationship.

Response to removal from and return to a social group in adult male rhesus monkeys.

The removal of four adult rhesus monkeys from a large social group (n = 85) to peer housing resulted in no significant changes in basal cortisol levels or absolute numbers of T lymphocyte subsets 24 h later. However, the return of these males 1 year later to the same social group resulted in significant increases in cortisol levels (66 +/- 21%) and significant decreases in T-helper (-31.6 +/- 15.8%) and T-suppressor cells (-35.2 +/- 8.7%) 24 h later. Blood samples for immune and cortisol measurements were obtained before and 24 h following both the removal and the return 1 year later. Aggressive and sexual behavioral data were recorded on audiotape for 3.5 h following the reintroduction using an all occurrences of some behaviors sampling technique. Analyses revealed a negative correlation between percent change from baseline in T-helper cells 24 h following the return and the frequency of bites (nonwounding) and chases received during the 3.5 h following the return. The absence of a stress response to separation in adult males is in contrast to the presence of a stress response observed in infants, juveniles, and adult females and possibly is due to sex differences in group attachment in sexually mature males. On the other hand, the return to the social group did induce a psychosocial stress response in the males, and the degrees of the stress, as determined by cortisol and immune cell measures, was related to the agonistic interactions experienced by the individuals.

Behavioral and physiological response of juvenile sooty mangabeys to reunion with their mothers following a year's absence.

The return of 6 juvenile mangabey monkeys to their social group following an absence of a year resulted in increased basal cortisol secretion for both the offspring and the mothers and in significant decrements in the absolute number of lymphocyte subsets for the offspring. Six 9-month-old sooty mangabeys were removed from their socially housed mothers, subsequently peer housed, and returned to the maternal social group 1 year later. Offspring showed a significant increase in cortisol levels 24 hr following reunion (48 +/- 6%) and this difference persisted through 1 month, while the mothers showed a significant increase only at the 24-hr sample point (18 +/- 3%). Moreover, the offspring, but not the mothers, showed a significant decrease in lymphocyte subsets which were evident through the 1-month sample point. Behavioral data revealed a significant positive correlation between the percent of total scan samples offspring were with their mothers (proximity, contact, huddle) the day of return and the offspring's percent change from baseline in total T cells 24 hr later, r = 0.84. All mother-offspring pairs with the exception of one exhibited frequent affiliative behaviors toward one another by 6 days following the return. These data demonstrate that the reunion of juvenile mangabeys with their mothers after a year's absence is an acute stressor for the mothers and a relatively longer term stressor for the offspring, and that behavioral interactions which characterize the return of individual subjects to the natal group can predict acute physiological responses.

Removal from natal social group to peer housing affects cortisol levels and absolute numbers of T cell subsets in juvenile rhesus monkeys.

Psychosocial stress associated with the removal of six naive juvenile rhesus monkeys from their natal social group to peer housing resulted in increased basal cortisol secretion and significant decrements in the absolute numbers of the T lymphocyte subsets in the peripheral blood. Six subjects matched for age and social rank remained in the group of 80 animals serving as controls. Baseline immune and cortisol measurements were obtained before the six test subjects were removed from the group and housed together in an outdoor circular enclosure. Blood samples were taken 24 h following removal of the test subjects from the group and at intervals thereafter through 11 weeks. Compared to controls, test subjects showed a significant decrease in the absolute numbers of CD4+ (-56.9%) and CD8+ T cells (-57.6%) and a significant increase in basal cortisol levels (+43.9%) 24 h following removal to peer housing. Group difference in the absolute numbers of most immune cells persisted through 11 weeks, whereas cortisol differences lasted only through 2 weeks. These data, when compared to an earlier study employing an identical protocol, with the exception that subjects were housed in indoor individual cages following separation, fail to demonstrate a modulating effect of randomly chosen peer-mates on the stress effects produced by social separation.

Social separation and reunion affects immune system in juvenile rhesus monkeys.

Removal of juvenile rhesus monkeys from their natal social group to indoor individual caging resulted in increased basal cortisol secretion and significant decrements in the frequency of lymphoid subpopulations. Fourteen juvenile rhesus monkeys, which had never been removed from the group, were studied. Baseline immune and cortisol measurements were obtained before seven of the subjects were removed from social housing to standard individual cages. The remaining seven subjects, matched for age, sex, weight, and rank, remained in the social group throughout the study serving as controls. Blood samples were taken 24 hours after removal of the test subjects from the group and at specific intervals thereafter through 11 weeks. At 24 hours after the separation test subjects showed a significant increase in basal cortisol levels (40%) and a significant decrease in several immune parameters, with absolute numbers of total T cells declining 72 +/- 12%. Significant group differences in immune parameters persisted through 11 weeks. Eighteen weeks following removal, the test subjects were returned to the group which produced a cortisol rise in both test and controls at the 24-hour postreturn sample. Although there were no group differences in the frequency of lymphoid subsets 24 hours after return, some test subjects showed marked decrements which were inversely related to cortisol and were predicted by behavioral events. These data demonstrate that the removal of naive juvenile rhesus monkeys from their natal social group to individual indoor caging is a potent psychosocial stressor and that the behavioral interactions which characterize the return of the individual subjects to the natal group may predict physiological response.

Formation of a new social group of unfamiliar female rhesus monkeys affects the immune and pituitary adrenocortical systems.

Social stress associated with the formation of a new group of rhesus monkeys resulted in increased basal cortisol secretion and significant decreases in immunological parameters. Eight adult female rhesus monkeys, all of which had been raised in social groups, but with no common social history, were simultaneously introduced into an outdoor enclosure along with an adult male. Behavioral data were collected during the introduction and over 9 weeks thereafter. Blood samples were collected prior to and at intervals for 9 weeks following formation. The establishment of a dominance hierarchy, apparent within 48 h, was accomplished with no serious fighting and a complete absence of wounding or trauma. Overall, the group showed a significant increase in cortisol and a significant decrease in the absolute number of total lymphocytes and CD4+ and CD8+ T cells at 24 h postformation, but not thereafter. However, when partitioned into high and low dominance rank, differences in CD4+ and CD8+ T cells were evident for up to 9 weeks with low ranking subjects showing significantly lower values. The housing condition of the subjects immediately prior to introduction, either indoors in individual caging or outdoors in social groups, may have influenced behavior, rank acquisition, and possibly differences in immune parameters. These data demonstrate that social group formation is a potent psychosocial stressor in primates, since stress-sensitive changes were observed in the absence of serious aggression and wounding.

Peer interaction in infant chimpanzees.

The peer interactions of 6 infant chimpanzees (Pan troglodytes) ranging in age from 18 to 50 months were observed in a seminatural context. The infants and their mothers lived as members of a captive social group at the Yerkes Regional Primate Research Center. An analysis of contact initiations between infants indicated that the most preferred peer interactant was the youngest and the least preferred was the oldest infant. Infants also initiated more interactions with the offspring of adults that had the closest relationships with both themselves and their mothers. These results indicate that a number of factors may influence the peer affiliations of infant chimpanzees, including the age of the infant and the mother's social relationships.