Print media reporting of male circumcision for preventing HIV infection in sub-Saharan Africa.

OBJECTIVE: To review the types, content and accuracy of print media reports on male circumcision for preventing HIV infection among men in sub-Saharan Africa. METHODS: We conducted a trilingual search (English, French, Portuguese) of LexisNexis(R) with the phrase 'male circumcision' for the period from 28 March 2007 to 30 June 2008. The articles identified were screened for the central theme of male circumcision for preventing HIV infection in men in sub-Saharan Africa and for publication types targeting lay audiences - newspapers, magazines, newswires or newsletters. We judged the accuracy of the reports and determined the context, public perceptions, misconceptions and areas of missing information in the print media. We also explored whether the media could be better used to maximize the impact of male circumcision. FINDINGS: We identified 412 articles, of which 219 were unique and 193 were repeats. 'Peaks and valleys' occurred in the volume of articles over time. Most articles (56.0%) presented male circumcision for the prevention of HIV infection in a positive light. Those that portrayed it negatively had an overall repeat rate 2.9 times higher than positive articles. Public health messages formulated by international health agencies were few but generally accurate. CONCLUSION: The accuracy of the reports was good, although the articles were few and frequently omitted important messages. This suggests that public health authorities must help the media understand important issues. A communication strategy to sequence important themes as male circumcision programmes are scaled up would allow strategic coverage of accurate messages over time.

Clinical prognostic value of RNA viral load and CD4 cell counts during untreated HIV-1 infection--a quantitative review.

BACKGROUND: The prognostic value of CD4 counts and RNA viral load for identifying treatment need in HIV-infected individuals depends on (a) variation within and among individuals, and (b) relative risks of clinical progression per unit CD4 or RNA difference. METHODOLOGY/PRINCIPAL FINDINGS: We reviewed these measurements across (a) 30 studies, and (b) 16 cohorts of untreated seropositive adults. Median within-population interquartile ranges were 74,000 copies/mL for RNA with no significant change during the course of infection; and 330 cells/microL for CD4, with a slight proportional increase over infection. Applying measurement and physiological fluctuations observed on chronically infected patients, we estimate that 45% of population-level variation in RNA, and 25% of variation in CD4, were due to within-patient fluctuations. Comparing a patient with RNA at upper 75(th) centile with a patient at median RNA, 5-year relative risks were 1.4 (95% CI 1.2-1.7) for AIDS and 1.5 (1.3-1.9) for death, without change over the course of infection. In contrast, for a patient with CD4 count at the lower 75(th) centile, relative risks increased from 1.0 at seroconversion to maxima of 6.3 (4.4-8.9) for AIDS and 5.5 (2.7-10.1) for death by year 6, when the population median had fallen to 300 cells/microL. Below 300 cells/microL, prognostic power did not increase, due to a narrower CD4 range. CONCLUSIONS: Findings support the current WHO recommendation (used with clinical criteria) to start antiretroviral treatment in low-income settings at CD4 thresholds of 200-350 cells/microL, without pre-treatment RNA monitoring--while not precluding earlier treatment based on clinical, socio-demographic or public health criteria.

An estimate of the global prevalence and incidence of herpes simplex virus type 2 infection.

OBJECTIVE: To estimate the global prevalence and incidence of herpes simplex virus type 2 (HSV-2) infection in 2003. METHODS: A systematic review was undertaken of published seroprevalence surveys describing the prevalence or incidence of HSV-2 by age and gender. For each of 12 regions, pooled prevalence values by age and gender were generated in a random-effect model. HSV-2 incidence was then estimated from these pooled values using a constant-incidence model. Values of the HSV-2 seroprevalence from the model fits were applied to the total population to estimate the numbers of people infected. FINDINGS: The total number of people aged 15-49 years who were living with HSV-2 infection worldwide in 2003 is estimated to be 536 million, while the total number of people who were newly infected with HSV-2 in 2003 is estimated to be 23.6 million. While the estimates are limited by poor availability of data, general trends are evident. For example, more women than men were infected, and the number infected increased with age. Although prevalence varied substantially by region, predicted prevalence was mostly higher in developing regions than developed regions. CONCLUSION: The prevalence of HSV-2 is relatively easy to measure since infection is lifelong and has a specific serological test. The burden of disease is less easy to quantify. Despite the often sparse data on which these estimates are based, it is clear that HSV-2 infection is widespread. The dramatic differences in prevalence between regions are worthy of further exploration.

HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990--2005.

The effectiveness of HIV voluntary counseling and testing (VCT) in reducing HIV risk behaviors in developing countries was assessed using meta-analytic methods. A standardized protocol was used for searching, acquiring, and extracting study data and meta-analyzing the results. Seven studies met the inclusion criteria. VCT recipients were significantly less likely to engage in unprotected sex when compared to behaviors before receiving VCT, or as compared to participants who had not received VCT [OR 1.69; 95%CI 1.25-2.31]. VCT had no significant effect on the number of sex partners [OR 1.22; 95%CI 0.89-1.67]. While these findings provide only moderate evidence in support of VCT as an effective prevention strategy, neither do they negate the need to expand access to HIV testing and counseling services. Such expansion, however, must be accompanied by rigorous evaluation in order to test, refine and maximize the preventive benefits of learning one's HIV infection status through HIV testing and counseling.

The need and plan for global elimination of congenital syphilis.

In every society, congenital syphilis (CS) has significant medical, economic, societal and emotional burdens; these are poorly characterized but high. Inexplicably, the elimination of CS has failed to attract international attention. Yet, the cornerstones of programs to do this universally are in place, the recent development of new diagnostic tools offers the now-practical possibility of testing every pregnant woman, testing is cost-effective, and programs for the elimination of CS can be joined with other programs to enhance efficiency. The magnitude of the CS burden, globally, rivals that of HIV infection in neonates yet receives little attention. The newly proposed World Health Organization Strategy for the Global Elimination of Congenital Syphilis aims to mobilize resources and provide a plan to address this under-recognized health problem.

On-site rapid antenatal syphilis screening with an immunochromatographic strip improves case detection and treatment in rural South African clinics.

OBJECTIVES: Congenital syphilis is a significant cause of adverse pregnancy outcomes. In South Africa, rural clinics perform antenatal screening offsite, but unreliable transport and poor client follow up impede effective treatment. We compared 3 syphilis screening strategies at rural clinics: on-site rapid plasma reagin (RPR), on-site treponemal immunochromatographic strip (ICS) test, and the standard practice offsite RPR with Treponema pallidum hemagglutination assay (RPR/TPHA). METHODS: Eight rural clinics performed the on-site RPR and ICS tests and provided immediate treatment. Results were compared with RPR/TPHA at a reference laboratory. Chart reviews at 8 standard practice clinics established diagnosis and treatment rates for offsite RPR/TPHA. FINDINGS: Seventy-nine (6.3%) of 1,250 women screened on-site had active syphilis according to the reference laboratory. The on-site ICS resulted in the highest percentage of pregnant women correctly diagnosed and treated for syphilis (89.4% ICS, 63.9% on-site RPR, 60.8% offsite RPR/TPHA). The on-site RPR had low sensitivity (71.4% for high-titer syphilis). The offsite approach suffered from poor client return rates. One percent of women screened with the ICS may have received penicillin unnecessarily. There were no adverse treatment outcomes. CONCLUSIONS: The on-site ICS test can reduce syphilis-related adverse outcomes of pregnancy through accurate diagnosis and immediate treatment of pregnant women with syphilis.

Sexual and reproductive health: a matter of life and death.

Despite the call for universal access to reproductive health at the 4th International Conference on Population and Development in Cairo in 1994, sexual and reproductive health was omitted from the Millennium Development Goals and remains neglected (panel 1). Unsafe sex is the second most important risk factor for disability and death in the world's poorest communities and the ninth most important in developed countries. Cheap effective interventions are available to prevent unintended pregnancy, provide safe abortions, help women safely through pregnancy and child birth, and prevent and treat sexually transmitted infections. Yet every year, more than 120 million couples have an unmet need for contraception, 80 million women have unintended pregnancies (45 million of which end in abortion), more than half a million women die from complications associated with pregnancy, childbirth, and the postpartum period, and 340 million people acquire new gonorrhoea, syphilis, chlamydia, or trichomonas infections. Sexual and reproductive ill-health mostly affects women and adolescents. Women are disempowered in much of the developing world and adolescents, arguably, are disempowered everywhere. Sexual and reproductive health services are absent or of poor quality and underused in many countries because discussion of issues such as sexual intercourse and sexuality make people feel uncomfortable. The increasing influence of conservative political, religious, and cultural forces around the world threatens to undermine progress made since 1994, and arguably provides the best example of the detrimental intrusion of politics into public health.

HIV infection, antiretroviral therapy, and CD4+ cell count distributions in African populations.

BACKGROUND: The variability in CD4+ cell counts within and among human immunodeficiency virus (HIV)-positive and -negative African populations has not been explained but has important implications for understanding the incidence of HIV-related opportunistic infections, especially tuberculosis, in both individuals and populations. METHODS: In HIV-negative African adults, CD4+ cell counts vary within populations (interquartile ranges [IQRs], 169-603 cells/microL) and among populations (means vary from 699 to 1244 cells/microL), with similarly wide variations in HIV-positive adults. We developed dynamic mathematical models to predict the distribution of CD4+ cell counts in HIV-positive adults using the distribution in HIV-negative adults. RESULTS: Under the assumption that survival is independent of the CD4+ cell count before seroconversion, we fitted the observed distributions in HIV-positive adults. At a CD4+ cell count of 200 cells/microL, the median life expectancy of HIV-positive Zambians (4.0 years) was predicted to be 1.7 times that of HIV-positive South Africans (2.3 years). CONCLUSIONS: The model provides a way to estimate the changing distribution of CD4+ cell counts and, hence, the changing incidence of HIV-related opportunistic infections as the epidemic matures. This could substantially improve the planning of health services, including the need and demand for antiretroviral therapy. Better data are needed to test the model and its assumptions more rigorously and to fully understand the variability in CD4+ cell counts within and among populations.

Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries.

BACKGROUND: A comprehensive approach to preventing HIV infection in infants has been recommended, including: (a) preventing HIV in young women, (b) reducing unintended pregnancies among HIV-infected women, (c) preventing vertical transmission (PMTCT), and (d) providing care, treatment, and support to HIV-infected women and their families. Most attention has been given to preventing vertical transmission based on analysis showing nevirapine to be inexpensive and cost-effective. METHODS: The following were determined using data from eight African countries: national program costs and impact on infant infections; reductions in adult HIV prevalence and unintended pregnancies among HIV-infected women that would have equivalent impact on infant HIV infections averted as the nevirapine intervention; and the cost threshold for drugs with greater efficacy than nevirapine yielding an equivalent cost per DALY saved. RESULTS: Average national annual program cost was 4.8 million dollars. There was, per country, an average of 1898 averted infant HIV infections (2517 US dollars per HIV infection and 84 US dollars per DALY averted). Lowering HIV prevalence among women by 1.25% or reducing unintended pregnancy among HIV-infected women by 16% yielded an equivalent reduction in infant cases. An antiretroviral drug with 70% efficacy could cost 152 US dollars and have the same cost per DALY averted as nevirapine at 47% efficacy. CONCLUSIONS: Cost-effectiveness of nevirapine prophylaxis is influenced by health system costs, low client uptake, and poor effectiveness of nevirapine. Small reductions in maternal HIV prevalence or unintended pregnancy by HIV-infected women have equivalent impacts on infant HIV incidence and should be part of an overall strategy to lessen numbers of infant infections.

Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections.

During the past year, a group has argued that unsafe injections are a major if not the main mode of HIV-1 transmission in sub-Saharan Africa. We review the main arguments used to question the epidemiological interpretations on the lead role of unsafe sex in HIV-1 transmission, and conclude there is no compelling evidence that unsafe injections are a predominant mode of HIV-1 transmission in sub-Saharan Africa. Conversely, though there is a clear need to eliminate all unsafe injections, epidemiological evidence indicates that sexual transmission continues to be by far the major mode of spread of HIV-1 in the region. Increased efforts are needed to reduce sexual transmission of HIV-1.