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      A Systematic Review and Meta-Analysis of Risk Factors for Sexual Transmission of HIV in India

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      Author(s): 1 , 3 , * , 2 , 1 , 3
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      Publication date (Electronic):
      Journal: PLoS ONE
      Publisher: Public Library of Science

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          Abstract

          Background

          Approximately 2.4 million people are living with HIV in India. This large disease burden, and potential for epidemic spread in some areas, demands a full understanding of transmission in that country. We wished to quantify the effects of key sexual risk factors for HIV infection for each gender and among high- and low-HIV risk populations in India.

          Methodology

          We conducted a systematic review of sexual risk factors for HIV infection from 35 published studies. Risk factors analyzed were: male circumcision/religion, Herpes Simplex Virus 2, syphilis, gonorrhoea, genital ulcer, multiple sexual partners and commercial sex. Studies were included if they met predetermined criteria. Data were extracted and checked by two researchers and random-effects meta analysis of effects was conducted. Heterogeneity in effect estimates was examined by I 2 statistic. Publication bias was tested by Begg's test and funnel plots. Meta regression was used to assess effect modification by various study attributes.

          Results

          All risk factors were significantly associated with HIV status. The factor most strongly associated with HIV for both sexes was HSV-2 infection (OR men: 5.87; 95%CI: 2.46–14.03; OR women: 6.44; 95%CI: 3.22–12.86). The effect of multiple sexual partners was similar among men (OR = 2.46; 95%CI: 1.91–3.17,) and women (OR = 2.02; 95%CI: 1.43–2.87) and when further stratified by HIV-risk group. The association between HSV-2 and HIV prevalence was consistently stronger than other STIs or self-reported genital ulcer. If the strong associations between HSV-2 and HIV were interpreted causally, these results implied that approximately half of the HIV infections observed in our study population were attributable to HSV-2 infection.

          Conclusions

          The risk factors examined in our analysis should remain targets of HIV prevention programs. Our results confirm that sexual risk factors for HIV infection continue to be an important part of Indian HIV epidemic 26 years after it began.

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          Most cited references52

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          Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda.

          R Gray, M Wawer, R Brookmeyer … (2001)
          The probability of HIV-1 transmission per coital act in representative African populations is unknown. We aimed to calculate this probability overall, and to estimate how it is affected by various factors thought to influence infectivity. 174 monogamous couples, in which one partner was HIV-1 positive, were retrospectively identified from a population cohort in Rakai, Uganda. Frequency of intercourse and reliability of reporting within couples was assessed prospectively. HIV-1 seroconversion was determined in the uninfected partners, and HIV-1 viral load was measured in the infected partners. Adjusted rate ratios of transmission per coital act were estimated by Poisson regression. Probabilities of transmission per act were estimated by log-log binomial regression for quartiles of age and HIV-1 viral load, and for symptoms or diagnoses of sexually transmitted diseases (STDs) in the HIV-1-infected partners. The mean frequency of intercourse was 8.9 per month, which declined with age and HIV-1 viral load. Members of couples reported similar frequencies of intercourse. The overall unadjusted probability of HIV-1 transmission per coital act was 0.0011 (95% CI 0.0008-0.0015). Transmission probabilities increased from 0.0001 per act at viral loads of less than 1700 copies/mL to 0.0023 per act at 38 500 copies/mL or more (p=0.002), and were 0.0041 with genital ulceration versus 0.0011 without (p=0.02). Transmission probabilities per act did not differ significantly by HIV-1 subtypes A and D, sex, STDs, or symptoms of discharge or dysuria in the HIV-1-positive partner. Higher viral load and genital ulceration are the main determinants of HIV-1 transmission per coital act in this Ugandan population.
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            Fixed- versus random-effects models in meta-analysis: model properties and an empirical comparison of differences in results.

            Frank L. Schmidt, In-Sue Oh, Theodore L. Hayes (2009)
            Today most conclusions about cumulative knowledge in psychology are based on meta-analysis. We first present an examination of the important statistical differences between fixed-effects (FE) and random-effects (RE) models in meta-analysis and between two different RE procedures, due to Hedges and Vevea, and to Hunter and Schmidt. The implications of these differences for the appropriate interpretation of published meta-analyses are explored by applying the two RE procedures to 68 meta-analyses from five large meta-analytic studies previously published in Psychological Bulletin. Under the assumption that the goal of research is generalizable knowledge, results indicated that the published FE confidence intervals (CIs) around mean effect sizes were on average 52% narrower than their actual width, with similar results being produced by the two RE procedures. These nominal 95% FE CIs were found to be on average 56% CIs. Because most meta-analyses in the literature use FE models, these findings suggest that the precision of meta-analysis findings in the literature has often been substantially overstated, with important consequences for research and practice.
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              Genital herpes.

              Rachna Gupta, Terri Warren, Anna Wald (2007)
              Genital herpes is the main cause of genital ulcers worldwide; the prevalence of herpes simplex virus (HSV) type 2 infections in the general population ranges from 10% to 60%. Most genital herpes is caused by HSV-2, although HSV-1 accounts for about half of new cases in developed countries. The risk of HIV acquisition is three times higher in people with HSV-2. Neonatal herpes is an uncommon but serious complication of genital herpes. Most genital HSV-2 infections are unrecognised and undiagnosed; infected individuals, even with mild symptoms, shed HSV, and can infect sexual partners. Since clinical diagnosis is neither sensitive nor specific, virological and type-specific serological tests should be used routinely. Oral antiviral drugs for HSV infections are safe and effective and can be used both to treat episodes and to prevent recurrences. Antiviral treatment of the infected partners and condom use reduce the risk of sexual transmission of HSV-2.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 28 August 2012
                Volume: 7
                Issue: 8
                Electronic Location Identifier: e44094
                Affiliations
                [1 ]Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
                [2 ]Department of Community Medicine, United Arab Emirates University, Al-Ain, Abu Dhabi, United Arab Emirates
                [3 ]Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
                University of Washington, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: PA PJ. Performed the experiments: PA. Analyzed the data: PA. Contributed reagents/materials/analysis tools: PA NN. Wrote the paper: PA NN PJ.

                Article
                Publisher ID: PONE-D-12-03623
                DOI: 10.1371/journal.pone.0044094
                PMC ID: 3429412
                PubMed ID: 22937158
                SO-VID: 3998f9fc-0cd0-471e-b7a1-56de89f5d2be
                Copyright statement: Copyright @ 2012
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 3 February 2012
                Date accepted : 30 July 2012
                Page count
                Pages: 11
                Funding
                The authors have no support or funding to report.
                Categories
                Subject: Research Article
                Subject: Biology
                Subject: Population Biology
                Subject: Epidemiology
                Subject: Infectious Disease Epidemiology
                Subject: Medicine
                Subject: Clinical Research Design
                Subject: Systematic Reviews
                Subject: Infectious Diseases
                Subject: Viral Diseases
                Subject: HIV
                Subject: HIV epidemiology
                Subject: HIV prevention
                Subject: Sexually Transmitted Diseases
                Subject: Public Health

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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