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Zaba B.,London School of Hygiene and Tropical Medicine | Calvert C.,London School of Hygiene and Tropical Medicine | Marston M.,London School of Hygiene and Tropical Medicine | Isingo R.,National Institute for Medical Research | And 11 more authors.
The Lancet

Background: Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa. Methods: The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum. Findings: 138 074 women aged 15-49 years contributed 636 213 person-years of observation. 49 568 women had 86 963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17·2% (95% CI 17·0-17·3), but 60 of 118 (50·8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20·5 (18·9-22·4) in women who were not pregnant or post partum and 8·2 (5·7-11·8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51·8 (47·8-53·8) per 1000 person-years in women who were not pregnant or post partum and 11·8 (8·4-15·3) per 1000 person-years in pregnant or post-partum women. Interpretation: HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women. © 2013. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Source

Thoma M.E.,National Health Research Institute | Gray R.H.,Family and Reproductive Health | Kiwanuka N.,Makerere University | Aluma S.,Rakai Health science Program | And 2 more authors.
Sexually Transmitted Diseases

Background: Studies evaluating clinical and behavioral factors related to short-term fluctuations in vaginal microbiota are limited. We sought to describe changes in vaginal microbiota evaluated by Gram stain and assess factors associated with progression to and resolution of bacterial vaginosis (BV) at weekly intervals. Methods: A cohort of 255 sexually experienced, postmenarcheal women provided self-collected vaginal swabs to assess vaginal microbiota by Nugent score criteria at weekly visits for up to 2 years contributing 16,757 sequential observations. Absolute differences in Nugent scores (0-10) and transition probabilities of vaginal microbiota states classified by Nugent score into normal (0-3), intermediate (4-6), and BV (7-10) between visits were estimated. Allowing each woman to serve as her own control, weekly time-varying factors associated with progression from normal microbiota to BV and resolution of BV to normal microbiota were estimated using conditional logistic regression. Results: The distribution of absolute difference in Nugent scores was fairly symmetric with a mode of 0 (no change) and a standard deviation of 2.64. Transition probabilities showed weekly persistence, was highest for normal (76.1%) and BV (73.6%) states; whereas, intermediate states had similar probabilities of progression (36.6%), resolution (36.0%), and persistence (27.4%). Weekly fluctuation between normal and BV states was associated with menstrual cycle phase, recency of sex, treatment for vaginal symptoms, pregnancy, and prior Nugent score. Conclusions: Weekly changes in vaginal microbiota were common in this population. Clinical and behavioral characteristics were associated with vaginal microbiota transitioning, which may be used to inform future studies and clinical management of BV. Copyright © 2011 American Sexually Transmitted Diseases All rights reserved. Source

Higgins J.A.,University of Wisconsin - Madison | Gregor L.,University of Wisconsin - Madison | Mathur S.,Columbia University | Nakyanjo N.,Rakai Health science Program | And 2 more authors.
Journal of Sexual Medicine

Introduction: Although understudied in the context of AIDS, use of withdrawal (coitus interruptus) with or in place of other prevention methods affects exposure to both pregnancy and human immunodeficiency virus (HIV). Aim: We used mixed methods to assess use of withdrawal among 15-24-year-olds in a rural Ugandan setting with considerable HIV prevalence. Methods: We measured withdrawal reporting among (i) sexually active 15-24-year-olds enrolled in a quantitative community survey (n=6,722) and (ii) in-depth qualitative interview participants systematically selected from the latest round of the community survey (N=60). Respondents were asked about family planning and HIV prevention practices, including a direct question about withdrawal in the in-depth interviews. Main Outcome Measures: The main outcome measures were reports of current use of withdrawal on the quantitative survey (general question about family planning methods) and reports of current or recent use withdrawal in qualitative interviews (specific question about withdrawal). Qualitative interviews also probed for factors associated with withdrawal use. Results: Although less than 1% of quantitative survey participants spontaneously named withdrawal as their current family planning method, 48% of qualitative interview respondents reported current or lifetime use of withdrawal. Withdrawal was often used as a pleasurable alternative to condoms, when condoms were not available, and/or as a "placeholder" method before obtaining injectable contraception. A few respondents described using withdrawal to reduce HIV risk. Conclusion: Qualitative findings revealed widespread withdrawal use among young adults in Rakai, mainly as a condom alternative. Thus, withdrawal may shape exposure to both pregnancy and HIV. Future behavioral surveys should assess withdrawal practices directly-and separately from other contraceptives and HIV prevention methods. Further clinical research should further document withdrawal's association with HIV risk. © 2013 International Society for Sexual Medicine. Source

Gray R.H.,Family and Reproductive Health | Serwadda D.,Rakai Health science Program | Kong X.,Family and Reproductive Health | Makumbi F.,Rakai Health science Program | And 16 more authors.
Journal of Infectious Diseases

Methods. Uncircumcised human immunodeficiency virus (HIV)-negative men aged 15-49 years were randomized to immediate circumcision (intervention arm, 441 subjects) or delayed circumcision (control arm, 399 subjects). Human papillomavirus (HPV) was detected by Roche HPV Linear Array at enrollment, and at 6, 12, and 24 months. Incident high-risk HPV (HR-HPV) was estimated in men who acquired a new HR-HPV genotype. HR-HPV clearance was determined in men with prior genotype-specific HR-HPV infections. Rate ratios (RRs) and 95% confidence intervals (CIs) of HR-HPV acquisition were estimated by Poisson multiple regression. Results. Enrollment characteristics were comparable between study groups. HR-HPV incidence was 19.7 cases per 100 person-years (PYs) in the intervention arm (70 cases per 355.8 PYs) and 29.4 cases per 100 PYs (125 cases per 424.8 PYs) in the control arm (RR, 0.67; 95% CI, 0.51-0.89; P = .006). The incidence of multiple HRHPV infections was 6.7 cases per 100 PYs in the intervention arm and 14.8 cases per 100 PYs in the control arm (RR, 0.45; 95% CI, 0.28-0.73), but there was no significant effect on single infections (RR, 0.89; 95% CI, 0.60-1.30). HR-HPV incidence was lower in the intervention arm for all genotypes and demographic/behavioral subgroups. The clearance of preexisting HR-HPV infections was 215.8 cases per 100 PYs (205 cases per 95 PYs) in the intervention arm and 159.1 cases per 100 PYs (255 cases per 160.25 PYs) in the control arm (adjusted RR, 1.39; 95% CI, 1.17-1.64). Conclusions. Male circumcision reduces the incidence of multiple HR-HPV infections and increases clearance of HR-HPV infections in HIV-uninfected men. Trial Registration. ClinicalTrials.gov identifier: NCT00425984. © 2010 by the Infectious Diseases Society of America. All rights reserved. Source

Nalugoda F.,Rakai Health science Program | Guwatudde D.,Makerere University | Bwaninka J.B.,Rakai Health science Program | Makumbi F.E.,Rakai Health science Program | And 12 more authors.
Journal of Acquired Immune Deficiency Syndromes

Objective: Studies suggest that the prevalence of HIV is higher among long-term marital/consensual relationships than in the unmarried. We assessed the risk of incident HIV infection by marital status in rural Rakai, Uganda. Design: Longitudinal data from the Rakai Community Cohort Study between 1999 and 2011. Methods: We estimated HIV incidence per 100 person years (py) in sexually active individuals aged 15-49 years with a total of 44,179.6 py who were never married (women 2929 py and men 4261 py), currently married or in long-term consensual relationships (currently married women 29,823 py and men 21,299 py) and previously married (women 3563 py and men 1475). Poisson multivariable regression was used to estimate the unadjusted and adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) of HIV acquisition. Results: The HIV incidence among currently married persons was 0.93/100 py, which was lower than that for the never-married (1.51/100 py) and previously married (2.85/100 py) persons. The risk of HIV acquisition was significantly lower in the currently married compared with that in the never married among women (Adj IRR = 0.26, 95% CI: 0.16 to 0.42), but not among men (Adj IRR = 0.69, 95% CI: 0.31 to 1.52). HIV incidence was lower among first marriages (0.73/100 py) compared with that among second-or higherorder marriages (1.38/100 py). Multiple sex partners significantly increased the risk of HIV acquisition in both women (Adj IRR = 2.53, 95% CI: 1.6 to 3.97) and men (Adj IRR = 1.77, 95% CI: 1.20 to 2.60). Conclusions: Current marriage especially first-order marriage was associated with a reduced risk of HIV acquisition in women, but not in men, and multiple sex partnerships increased HIV risk for both sexes. Copyright © 2013 by Lippincott Williams & Wilkins. Source

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