HIV Prevention in Care and Treatment Settings: Baseline Risk Behaviors among HIV Patients in Kenya,Namibia, and Tanzania

HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP).

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01256463","term_id":"NCT01256463"}}NCT01256463     

Dog and owner demographic characteristics and dog personality trait associations

The aim of this study was to analyze the relationships between four personality traits (calmness, trainability, dog sociability and boldness) of dogs (Canis familiaris) and dog and owner demographics on a large sample size with 14,004 individuals. German speaking dog owners could characterize their dog by filling out a form on the Internet. There were five demographic variables for dogs and nine for owners. Two statistical methods were used for investigating the associations between personality and demographic traits: the more traditional general linear methods and regression trees that are ideal for analyzing non-linear relationships in the structure of the data. The results showed that calmness is influenced primarily by the dog's age, the neutered status, the number of different types of professional training courses (e.g. obedience, agility) the dog had experienced and the age of acquisition. The least calm dogs were less than 2.5 years old, neutered and acquired after the first 12 weeks of age, while the calmest dogs were older than 6.9 years. Trainability was affected primarily by the training experiences, the dog's age, and the purpose of keeping the dog. The least trainable dogs had not received professional training at all and were older than 3 years. The most trainable dogs were those who participated in three or more types of professional training. Sociability toward conspecifics was mainly determined by the age, sex, training experience and time spent together. The least sociable dogs were older than 4.8 years and the owners spent less than 3 h with the dog daily. The most sociable dogs were less than 1.5 years old. Males were less sociable toward their conspecifics than females. Boldness was affected by the sex and age of the dog and the age of acquisition. The least bold were females acquired after the age of 1 year or bred by the owner. The boldest dogs were males, acquired before the age of 12 weeks, and were younger than 2 years old. Other variables, including the owner's gender, age, education, previous experience with dogs, the number of people and dogs in the household, and purpose of keeping the dogs had minor, but detectable effects. The results suggest that on-line questionnaires are a very effective means for collecting data about dog behavior, especially if owners are motivated by instant feedback. However, note that the characteristics of dogs in the present study were reported by the owners, and the associations with the traits do not necessarily represent a causal relationship.     

Creating an African HIV Clinical Research and Prevention Trials Network: HIV Prevalence,Incidence and Transmission

HIV epidemiology informs prevention trial design and program planning. Nine clinical research centers (CRC) in sub-Saharan Africa conducted HIV observational epidemiology studies in populations at risk for HIV infection as part of an HIV prevention and vaccine trial network. Annual HIV incidence ranged from below 2% to above 10% and varied by CRC and risk group, with rates above 5% observed in Zambian men in an HIV-discordant relationship, Ugandan men from Lake Victoria fishing communities, men who have sex with men, and several cohorts of women. HIV incidence tended to fall after the first three months in the study and over calendar time. Among suspected transmission pairs, 28% of HIV infections were not from the reported partner. Volunteers with high incidence were successfully identified and enrolled into large scale cohort studies. Over a quarter of new cases in couples acquired infection from persons other than the suspected transmitting partner.     

Incidence of HIV and the Prevalence of HIV,Hepatitis B and Syphilis among Youths in Maputo,Mozambique: A Cohort Study

Background

Prevalence of HIV in Mozambique among individuals aged 15–49 years is 11.5%. The HIV prevalence is higher in women than in men across the country, peaking at ages 25–29 years and 35–39 years, respectively. In this study, we aimed at determining the prevalence and incidence of HIV, prevalence of Hepatitis B (HBV), and prevalence of syphilis in youths. We also characterized a cohort of youths for future participation in phase I/II HIV vaccine trials.

Methods

The study was conducted at a youth clinic in Maputo Central Hospital from August 2009 to October 2011. Youths of both genders aged 18–24 years (n = 1380) were screened for HIV using a sequential algorithm of two immunochromatographic assays, HBV using an enzyme linked immunosorbant test, and syphilis using a treponemal immunochromatographic strip test. The HIV seronegative participants (n = 1309) were followed-up for 12 months with quarterly study visits. The clinical and behavioral data were collected using structured questionnaires. The HIV seroconversions were confirmed by a molecular assay.

Results

The study population was female dominant (76.8%). All participants had a formal education, with 44.6% studying for technical or higher education degrees. The mean age at sexual debut was 16.6 years (SD: ±1.74), with 85.6% reporting more than one sexual partner in life. The screening showed the prevalence of HIV, HBV, and syphilis at 5.1% (95% CI: 3.97–6.31), 12.2% (95% CI 10.5%–14.0%), and 0.36% (95% CI 0.15%–0.84%), respectively. The HIV incidence rate was found to be 1.14/100 person years (95% CI: 0.67–1.92). Retention rates were stable throughout the study being 85.1% at the last visit.

Conclusion

Incidence of HIV in this cohort of youths in Maputo was relatively low. Also, the prevalence of HIV and syphilis was lower than the national values in this age group. However, the HBV prevalence was higher than in previous reports in the country.     

Species–habitat associations and demographic rates of forest trees

Niche‐driven effects on demographic processes generated in response to habitat heterogeneity partly shape local distributions of species. Thus, tree distributions are commonly studied in relation to habitat conditions to understand how niche differentiation contributes to species coexistence in forest communities. Many such studies implicitly assume that local abundance reflects habitat suitability, and that abundance is relatively stable over time. We compared models based on abundance with those based on demographic performance for making inferences about habitat association for 287 tree species from three large dynamic plots located in tropical, subtropical and temperate forests. The correlation between the predictions of the abundance‐based models and the demography‐based models varied widely, with correlation coefficients ranging nearly from ?1 to 1.This suggests that the two types of models capture different information about species–habitat associations. Demography‐based models evaluate habitat quality by focusing on population processes and thus should be preferred for understanding responses of tree species to habitat conditions, especially when habitat conditions are changing and species–habitat interactions cannot be considered to be at equilibrium.     

Endemism in Namibia: patterns, processes and predictions

Sandwiched between the Namib and Kalahari Deserts of southwestern Africa are the karooid and escarpment biotopes of Namibia which are rich in endemics of many taxa. Most plant, invertebrate, amphibian, reptile, mammal and bird species endemic to Namibia are found in a zone running through, and to the west of, Namibia's escarpment region. There is also an important region of endemism for succulent plants, reptiles and invertebrates in the Succulent Karoo biome. Congruence between endemism hotspots, particularly on rocky substrates, is remarkably high for most taxa, implying broadly similar speciation processes. Possible speciation mechanisms in different parts of the country include the spatial isolation of rupicolous taxa such as insects and reptiles by the formation of large coastal dune fields; the expansion and contraction of wooded savannas during pluvial and interpluvial periods; and global temperature shifts which created highland refugia for frost-susceptible plants and poikilotherms. Areas of endemism and species richness overlap poorly for Namibia's mainly arid-dwelling endemic vertebrates, as richness is highest in the mesic wetlands and woodlands of northeast Namibia. The overlap for succulent plants, insects and arachnids, however, is relatively high. Centres of endemism for plants and vertebrates fall mainly outside protected areas, as few parks were established with biodiversity indices in mind. Our analysis of endemism congruence provides a strong platform for the promulgation of new protected areas to safeguard Namibia's unique biota. Furthermore, analysis of speciation patterns and processes is a useful predictive tool for the identification of other biotically important sites.     

A Decline in New HIV Infections in South Africa: Estimating HIV Incidence from Three National HIV Surveys in 2002, 2005 and 2008

Background

Three national HIV household surveys were conducted in South Africa, in 2002, 2005 and 2008. A novelty of the 2008 survey was the addition of serological testing to ascertain antiretroviral treatment (ART) use.

Methods and Principal Findings

We used a validated mathematical method to estimate the rate of new HIV infections (HIV incidence) in South Africa using nationally representative HIV prevalence data collected in 2002, 2005 and 2008. The observed HIV prevalence levels in 2008 were adjusted for the effect of antiretroviral treatment on survival. The estimated “excess” HIV prevalence due to ART in 2008 was highest among women 25 years and older and among men 30 years and older. In the period 2002–2005, the HIV incidence rate among men and women aged 15–49 years was estimated to be 2.0 new infections each year per 100 susceptible individuals (/100pyar) (uncertainty range: 1.2–3.0/100pyar). The highest incidence rate was among 15–24 year-old women, at 5.5/100pyar (4.5–6.5). In the period 2005–2008, incidence among men and women aged 15–49 was estimated to be 1.3/100 (0.6–2.5/100pyar), although the change from 2002–2005 was not statistically significant. However, the incidence rate among young women aged 15–24 declined by 60% in the same period, to 2.2/100pyar, and this change was statistically significant. There is evidence from the surveys of significant increases in condom use and awareness of HIV status, especially among youth.

Conclusions

Our analysis demonstrates how serial measures of HIV prevalence obtained in population-based surveys can be used to estimate national HIV incidence rates. We also show the need to determine the impact of ART on observed HIV prevalence levels. The estimation of HIV incidence and ART exposure is crucial to disentangle the concurrent impact of prevention and treatment programs on HIV prevalence.     

Premarital fertility in Namibia: trends, factors and consequences

Premarital fertility, defined as fertility before first marriage, was found to be highly prevalent in Namibia. According to data from the 1992 and 2000 DHS surveys, the proportion of premarital births was 43% for all births, and 60% for the first birth. This seemed to be primarily due to a late mean age at first marriage (26.4 years) and low levels of contraception before first marriage. Data were analysed using a variety of demographic methods, including multiple decrement life table and multivariate logistic models. Major variations were found by ethno-linguistic groups: Herero and Nama/Damara had the highest levels of premarital fertility (above 60%); Ovambo and Lozi had intermediate levels of premarital fertility (around 40%); Kavongo and San appeared to have kept a more traditional behaviour of early marriage and low levels of premarital fertility (around 20%). The largest ethno-linguistic group, the Ovambo, were in a special situation, with fast increasing age at marriage and average level of premarital fertility. Whites and mixed races also differed, with Afrikaans-speaking groups having a behaviour closer to the average, whereas other Europeans had less premarital fertility despite an average age at marriage. Ethnic differences remained stable after controlling for various socioeconomic factors, such as urbanization, level of education, wealth, access to mass media, and religion. Results are discussed in light of the population dynamics and political history of Namibia in the 20th century.     

HIV Drug Resistance Early Warning Indicators in Namibia for Public Health Action

Background

HIV drug resistance (HIVDR) testing is not routinely available in many resource-limited settings, therefore antiretroviral therapy (ART) program and site factors known to be associated with emergence of HIVDR should be monitored to optimize the quality of patient care and minimize the emergence of preventable HIVDR.

Methods

In 2010, Namibia selected five World Health Organization Early Warning Indicators (EWIs) and scaled-up monitoring from 9 to 33 ART sites: ART prescribing practices, Patients lost to follow-up (LTFU) at 12 months, Patients switched to a second-line regimen at 12 months, On-time antiretroviral (ARV) drug pick-up, and ARV drug-supply continuity.

Results

Records allowed reporting on three of the five selected EWIs. 22 of 33 (67%) sites met the target of 100% initiated on appropriate first-line regimens. 17 of 33 (52%) sites met the target of ≤20% LTFU. 15 of 33 (45%) sites met the target of 0% switched to a second-line regimen.

Conclusions

EWI monitoring directly resulted in public health action which will optimize the quality of care, specifically the strengthening of ART record systems, engagement of ART sites, and operational research for improved adherence assessment and ART patient defaulter tracing.     

Individual and Population Level Impact of Key HIV Risk Factors on HIV Incidence Rates in Durban,South Africa

We aimed to estimate the individual and joint impact of age, marital status and diagnosis with sexually transmitted infections (STIs) on HIV acquisition among young women at a population level in Durban, KwaZulu-Natal, South Africa. A total of 3,978 HIV seronegative women were recruited for four biomedical intervention trials from 2002–2009. Point and interval estimates of partial population attributable risk (PAR) were used to quantify the proportion of HIV seroconversions which can be prevented if a combination of risk factors is eliminated from a target population. More than 70% of the observed HIV acquisitions were collectively attributed to the three risk factors: younger age (<25 years old), unmarried and not cohabiting with a stable/regular partner and diagnosis with STIs. Addressing these risks requires targeted structural, behavioural, biomedical and cultural interventions in order to impact on unacceptably high HIV incidence rates among young women and the population as a whole.     

Estimation of HIV Incidence in a Large,Community-Based,Randomized Clinical Trial: NIMH Project Accept (HIV Prevention Trials Network 043)

Background

National Institute of Mental Health Project Accept (HIV Prevention Trials Network [HPTN] 043) is a large, Phase III, community-randomized, HIV prevention trial conducted in 48 matched communities in Africa and Thailand. The study intervention included enhanced community-based voluntary counseling and testing. The primary endpoint was HIV incidence, assessed in a single, cross-sectional, post-intervention survey of >50,000 participants.

Methods

HIV rapid tests were performed in-country. HIV status was confirmed at a central laboratory in the United States. HIV incidence was estimated using a multi-assay algorithm (MAA) that included the BED capture immunoassay, an avidity assay, CD4 cell count, and HIV viral load.

Results

Data from Thailand was not used in the endpoint analysis because HIV prevalence was low. Overall, 7,361 HIV infections were identified (4 acute, 3 early, and 7,354 established infections). Samples from established infections were analyzed using the MAA; 467 MAA positive samples were identified; 29 of those samples were excluded because they contained antiretroviral drugs. HIV prevalence was 16.5% (range at study sites: 5.93% to 30.8%). HIV incidence was 1.60% (range at study sites: 0.78% to 3.90%).

Conclusions

In this community-randomized trial, a MAA was used to estimate HIV incidence in a single, cross-sectional post-intervention survey. Results from this analysis were subsequently used to compare HIV incidence in the control and intervention communities.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00203749","term_id":"NCT00203749"}}NCT00203749     

Distributions and habitat associations of the bridled monocle bream Scolopsis bilineatus (Nemipteridae): a demographic approach

This study focussed on the demography and ecology of Scolopsis bilineatus at three locations on the Great Barrier Reef: the Lizard Island Group, Orpheus Island and One Tree Island. Scolopsis bilineatus lived for up to 16 years and had four distinct life‐history stages, which varied in their distribution patterns, habitat use and reproductive behaviour. Pre‐maturational sex change occurred whereby all males were derived from immature females, and males grew faster and larger than females. Small females and larger males generally formed pairs, which influenced their spatial distributions at small scales. Distributions of S. bilineatus were influenced by depth and exposure within reefs, particularly for juveniles, and most fish were found in shallow, sheltered habitats. Abundance was influenced by benthic cover, and was higher in areas of high coral cover and low where algae were abundant. Habitat associations were stronger at the microhabitat scale, and shelter sites were important for adults. Ontogenetic changes in microhabitat associations were found: juveniles occupied sand and rubble, and adults occupied shelters such as caves and overhangs. Adults showed site fidelity for shelter sites over a period of 4 days and returned to specific shelter sites repeatedly. These findings illustrate the importance of understanding the spatial ecology and habitat use of coral reef fishes, particularly with reference to size‐based changes within species.     

Consanguinity in Spain: socioeconomic,demographic, and geographic influences

Information on consanguinity in Spain was reanalyzed in order to obtain a more complete picture of consanguinity patterns by considering temporal, geographical, demographic, and economic factors. To obtain data on consanguineous marriages, we reviewed 106 published references. Only populations with homogeneous geographical characteristics, economic activities, transportation facilities, and the like, were considered. Two-way analysis of variance (ANOVA) provided highly significant differences (p < 0.001) for a both for time periods and for urban versus rural patterns, but there was no interaction between the latter two. A regression analysis shows that for rural areas the geographic characteristics, economy, communications, and index of demographic tendency were significant predictors of the inbreeding coefficient. The results obtained indicate that urban and rural patterns differ significantly and that the temporal factor needs to be taken into account before comparing inbreeding coefficients. In urban areas the census size and altitude are included in the regression equation as significant variables, but association was not found between alpha and the index of demographic tendency (population increase or decrease). Instead, the absolute number of inhabitants (census size) was significant. In rural areas geographic characteristics, communications, and index of demographic tendency were significant predictors of the inbreeding coefficient.     

Cancer Incidence following Expansion of HIV Treatment in Botswana

BackgroundThe expansion of combination antiretroviral treatment (ART) in southern Africa has dramatically reduced mortality due to AIDS-related infections, but the impact of ART on cancer incidence in the region is unknown. We sought to describe trends in cancer incidence in Botswana during implementation of the first public ART program in Africa.MethodsWe included 8479 incident cases from the Botswana National Cancer Registry during a period of significant ART expansion in Botswana, 2003–2008, when ART coverage increased from 7.3% to 82.3%. We fit Poisson models of age-adjusted cancer incidence and counts in the total population, and in an inverse probability weighted population with known HIV status, over time and estimated ART coverage.FindingsDuring this period 61.6% of cancers were diagnosed in HIV-infected individuals and 45.4% of all cancers in men and 36.4% of all cancers in women were attributable to HIV. Age-adjusted cancer incidence decreased in the HIV infected population by 8.3% per year (95% CI -14.1 to -2.1%). However, with a progressively larger and older HIV population the annual number of cancers diagnosed remained constant (0.0% annually, 95% CI -4.3 to +4.6%). In the overall population, incidence of Kaposi’s sarcoma decreased (4.6% annually, 95% CI -6.9 to -2.2), but incidence of non-Hodgkin lymphoma (+11.5% annually, 95% CI +6.3 to +17.0%) and HPV-associated cancers increased (+3.9% annually, 95% CI +1.4 to +6.5%). Age-adjusted cancer incidence among individuals without HIV increased 7.5% per year (95% CI +1.4 to +15.2%).InterpretationExpansion of ART in Botswana was associated with decreased age-specific cancer risk. However, an expanding and aging population contributed to continued high numbers of incident cancers in the HIV population. Increased capacity for early detection and treatment of HIV-associated cancer needs to be a new priority for programs in Africa.     

Prevalence,Recurrence, and Incidence of Current Depressive Symptoms among People Living with HIV in Ontario,Canada: Results from the Ontario HIV Treatment Network Cohort Study

IntroductionCurrent studies of depression among people living with HIV focus on describing its point prevalence. Given the fluctuating nature of depression and its profound impacts on clinical and quality-of-life outcomes, this study aimed to examine the prevalence, recurrence and incidence of current depressive symptoms and its underlying catalysts longitudinally and systematically among these individuals.MethodsWe conducted a prospective cohort study between October 1, 2007 and December 31, 2012 using longitudinal linked data sources. Current depressive symptoms was identified using the Centre for Epidemiologic Studies Depression Scale or the Kessler Psychological Distress Scale, first at baseline and again during follow-up interviews. Multivariable regressions were used to characterize the three outcomes.ResultsOf the 3,816 HIV-positive participants, the point prevalence of depressive symptoms was estimated at 28%. Of the 957 participants who were identified with depressive symptoms at baseline and who had at least two years of follow-up, 43% had a recurrent episode. The cumulative incidence among 1,745 previously depressive symptoms free participants (at or prior to baseline) was 14%. During the five-year follow-up, our multivariable models showed that participants with greater risk of recurrent cases were more likely to feel worried about their housing situation. Participants at risk of developing incident cases were also likely to be younger, gay or bisexual, and unable to afford housing-related expenses.ConclusionsDepressive symptoms are prevalent and likely to recur among people living with HIV. Our results support the direction of Ontario’s HIV/AIDS Strategy to 2026, which addresses medical concerns associated with HIV (such as depression) and the social drivers of health in order to enhance the overall well-being of people living with or at risk of HIV. Our findings reinforce the importance of providing effective mental health care and demonstrate the need for long-term support and routine management of depression, particularly for individuals at high risk.     

Asymptotic worst-case mixing in simple demographic models of HIV/AIDS.

The majority of published modeling work regarding the impact of mixing patterns among subgroups on the spread of HIV infection assumes either that the overall population size remains constant, the aggregate immigration to the population occurs at a constant annual rate, or that no immigration occurs and the population in question declines due to HIV or other causes. In this paper, immigration rates are modeled as simple functions of population size and may be interpreted as aggregate birth rates. This assumption implies asymptotic exponential growth in the disease-free population as long as per capita birth rates exceed per capita mortality rates. The introduction of HIV infection to such a population may change this situation, and the asymptotic population growth rate can be reduced substantially as a result. The specific manner in which this occurs depends in part upon difficult to observe mixing patterns among those with different sexual activity rates. Rather than attempting to explicitly model a variety of mixing patterns, a bound on the impact of worst-case mixing is produced, where "worst case" refers to the mixing pattern that maximizes the asymptotic prevalence of infection, which is equivalent to minimizing the asymptotic population growth rate. These new techniques are illustrated with a numerical example.