Preparing for the Rollout of Pre-Exposure Prophylaxis (PrEP): A Vignette Survey to Identify Intended Sexual Behaviors among Women in Kenya and South Africa if Using PrEP

Introduction

Several clinical trials have demonstrated the efficacy of pre-exposure prophylaxis (PrEP) in reducing HIV risk. One concern with introducing PrEP is whether users will engage in riskier sexual behaviors.

Methods

We assessed the effect that PrEP may have on sexual risk behaviors by administering a survey to 799 women in Bondo, Kenya, and Pretoria, South Africa. Participants were asked about their sexual behavior intentions twice — once as if they were taking PrEP and once as if they were not taking PrEP — within four risk situations (vignettes). They responded using a 5-point ordinal scale. We used a series of linear mixed effects models with an unstructured residual covariance matrix to estimate the between- and within-subject differences in the mean likelihood of engaging in risky sexual behavior across the PrEP and non-PrEP contexts. We also calculated the total percentage of participants who reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP, by vignette.

Results

We found statistically significant differences in the mean likelihood of engaging in risky sexual behavior with the between-subject comparison (-0.17, p < 0.01) and with the within-subject comparison (-0.31, p < 0.001). Depending on the vignette, 27% to 40% of participants reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP.

Conclusions

Our findings indicate that modest increases in risky sexual behavior could occur with PrEP. Although responses from the majority of participants suggest they would not be more likely to engage in risky sexual behavior if they took PrEP, a substantial proportion might. Programs rolling out PrEP should be prepared to assist similar women in making informed choices about reducing their risk of HIV and about their sexual health beyond HIV prevention.     

Prevalence and Correlates of HIV Infection among Street Boys in Kisumu,Kenya

Introduction

Despite their perceived vulnerability to HIV, East African street youth have been neglected in HIV prevention research. We examined HIV seroprevalence and correlates of HIV infection in a sample of male street youth in Kisumu, Kenya.

Methods

We enrolled a street-recruited sample of 13–21 year old street youth. Participants completed a survey followed by voluntary HIV counseling and testing. Survey items included demographics, homelessness history, survival activities, sexual behavior and substance use. We examined the relationship between predictor variables, markers of coercion and marginalization and HIV.

Results

The sample included 296 males. Survival activities included garbage picking (55%), helping market vendors (55%), begging (17%), and working as porters (46%) or domestic workers (4%). Forty-nine percent of participants reported at least weekly use of alcohol and 32% marijuana. Forty-six percent of participants reported lifetime inhalation of glue and 8% fuel. Seventy-nine percent of participants reported lifetime vaginal sex, 6% reported lifetime insertive anal sex and 8% reported lifetime receptive anal sex. Twelve (4.1%; 95% CI: 2.3–7.0) participants tested positive for HIV. Of those, all had been on the street for at least one year and all had engaged in vaginal sex. Occupations placing youth at particular risk of coercion by adults, including helping market vendors (prevalence ratio (PR) = 8.8; 95% CI: 1.2–67.5) and working as domestic workers (PR = 4.6; 95% CI: 1.1–19.0), were associated with HIV infection. Both insertive anal sex (PR = 10.2; 95% CI: 3.6–29.4) and receptive anal sex (PR = 3.9; 95% CI: 1.1–13.4) were associated with HIV infection. Drug use, begging, and garbage picking were not associated with HIV infection.

Conclusions

Although HIV prevalence in our sample of street youth is comparable to that of similarly-aged male youth in Nyanza Province, our findings highlight behavioral factors associated with HIV infection that offer opportunities for targeted prevention among street youth in East Africa.     

Voluntary medical male circumcision: translating research into the rapid expansion of services in Kenya, 2008-2011

Since the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended implementation of medical male circumcision (MC) as part of HIV prevention in areas with low MC and high HIV prevalence rates in 2007, the government of Kenya has developed a strategy to circumcise 80% of uncircumcised men within five years. To facilitate the quick translation of research to practice, a national MC task force was formed in 2007, a medical MC policy was implemented in early 2008, and Nyanza Province, the region with the highest HIV burden and low rates of circumcision, was prioritized for services under the direction of a provincial voluntary medical male circumcision (VMMC) task force. The government's early and continuous engagement with community leaders/elders, politicians, youth, and women's groups has led to the rapid endorsement and acceptance of VMMC. In addition, several innovative approaches have helped to optimize VMMC scale-up. Since October 2008, the Kenyan VMMC program has circumcised approximately 290,000 men, mainly in Nyanza Province, an accomplishment made possible through a combination of governmental leadership, a documented implementation strategy, and the adoption of appropriate and innovative approaches. Kenya's success provides a model for others planning VMMC scale-up programs.     

Surgical Efficiencies and Quality in the Performance of Voluntary Medical Male Circumcision (VMMC) Procedures in Kenya,South Africa,Tanzania, and Zimbabwe

Introduction

This analysis explores the association between elements of surgical efficiency in voluntary medical male circumcision (VMMC), quality of surgical technique, and the amount of time required to conduct VMMC procedures in actual field settings. Efficiency outcomes are defined in terms of the primary provider’s time with the client (PPTC) and total elapsed operating time (TEOT).

Methods

Two serial cross-sectional surveys of VMMC sites were conducted in Kenya, Republic of South Africa, Tanzania and Zimbabwe in 2011 and 2012. Trained clinicians observed quality of surgical technique and timed 9 steps in the VMMC procedure. Four elements of efficiency (task-shifting, task-sharing [of suturing], rotation among multiple surgical beds, and use of electrocautery) and quality of surgical technique were assessed as explanatory variables. Mann Whitney and Kruskal Wallis tests were used in the bivariate analysis and linear regression models for the multivariate analyses to test the relationship between these five explanatory variables and two outcomes: PPTC and TEOT. The VMMC procedure TEOT and PPTC averaged 23–25 minutes and 6–15 minutes, respectively, across the four countries and two years. The data showed time savings from task-sharing in suturing and use of electrocautery in South Africa and Zimbabwe (where task-shifting is not authorized). After adjusting for confounders, results demonstrated that having a secondary provider complete suturing and use of electrocautery reduced PPTC. Factors related to TEOT varied by country and year, but task-sharing of suturing and/or electrocautery were significant in two countries. Quality of surgical technique was not significantly related to PPTC or TEOT, except for South Africa in 2012 where higher quality was associated with lower TEOT.

Conclusions

SYMMACS data confirm the efficiency benefits of task-sharing of suturing and use of electrocautery for decreasing TEOT. Reduced TEOT and PPTC in high volume setting did not result in decreased quality of surgical care.     

The primary structures and myotropic activities of two tachykinins isolated from the African clawed frog,Xenopus laevis

Two peptides with limited structural similarity to mammalian substance P (SP) and neurokinin A (NKA) have been isolated from extracts of the intestine of the African clawed frog (Xenopus laevis). The primary structure of an SP-like peptide was established as: Lys-Pro-Arg-Pro-Asp-Gln-Phe-Tyr-Gly-Leu-Met.NH(2), which is identical to the previously characterized peptide, bufokinin isolated from the toad Bufo marinus. The primary structure of an NKA-related peptide was established as Thr-Leu-Thr-Thr-Gly-Lys-Asp-Phe-Val-Gly-Leu-Met.NH(2). Only the five amino acids at the C-terminal region of the peptide are identical to mammalian NKA whereas the N-terminal region shows no structural similarity to previously characterized tachykinins. Immunohistochemical investigations of the gut wall revealed a dense network of nerve fibres and nerve cell bodies containing SP/NKA-like substances. The myotropic effects of the Xenopus tachykinins were compared with the contractile effect of mammalian SP and NKA on isolated strips of circular smooth muscle from Xenopus stomach. No significant differences in potencies (-log EC(50)) or in intrinsic activities were observed between the Xenopus and mammalian peptides. The potencies for the Xenopus SP-like (8.49+/-0.15) and the NKA-like peptide (8.12+/-0.06) were similar suggesting that the amino acid sequence at the N-terminal region of the tachykinins is not important in activating the tachykinin receptors in Xenopus gastric smooth muscle. The maximum response to Xenopus SP (alpha=0.59+/-0.06) was significantly lower than to the NKA-like peptide (alpha=1.0) suggesting a more effective interaction of the NKA-like peptide with the tachykinin receptor(s) in Xenopus stomach.     

Widow inheritance and HIV prevalence in Bondo District, Kenya: baseline results from a prospective cohort study

Background

Widow Inheritance is a widespread cultural practice in sub-Saharan Africa that has been postulated as contributing to risk of HIV transmission. We present baseline results from a study designed to investigate the association between widow inheritance and HIV acquisition.

Methods and Findings

We performed a cross-sectional analysis of baseline data from a prospective cohort study to investigate if widow inheritance is a risk practice for HIV infection. Study participants were 1,987 widows who were interviewed regarding their inheritance status and sexual behavior profile and tested for HIV. Of these widows, 56.3% were inherited. HIV prevalence, at 63%, was similar among non-inherited and inherited widows. We stratified exposure status by the relationship of the widow to the inheritor and the reason for inheritance, and reexamined the HIV status of four subgroups of inherited women relative to the HIV status of non-inherited women. When adjusting for age and level of formal education, widows who were inherited by non-relatives for sexual ritual were significantly more likely to be infected than widows who were not inherited (OR = 2.07; 95%CI 1.49–2.86); widows who were inherited by relatives for sexual ritual also had elevated odds of HIV infection (OR = 1.34; 95%CI = 1.07–1.70). Widows who were inherited by relatives for companionship were less likely than women who were not inherited to be infected with HIV (OR = 0.85; 95%CI 0.63–1.14).

Conclusions

HIV prevalence among inherited widows varied depending upon why and by whom they were inherited. The cohort study will determine the risk for HIV acquisition among the HIV seronegative widows in this sample.