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      Sexual Risk Factors for HIV Infection in Early and Advanced HIV Epidemics in Sub-Saharan Africa: Systematic Overview of 68 Epidemiological Studies

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      1 , 1 , * , 1 , 2 , 1 , 1 , 3 , 4 , 5 , for the International Studies of HIV/AIDS (ISHA) Investigators
      PLoS ONE
      Public Library of Science

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          Abstract

          Background

          It is commonly assumed that sexual risk factors for heterosexual HIV transmission in sub-Saharan Africa, such as multi-partner sex, paid sex and co-infections, become less important as HIV epidemics mature and prevalence increases.

          Methods and Findings

          We conducted a systematic review of 68 African epidemiological studies from 1986 to 2006 involving 17,000 HIV positive adults and 73,000 controls. We used random-effects methods and stratified results by gender, time, background HIV prevalence rates and other variables. The number of sex partners, history of paid sex, and infection with herpes simplex virus (HSV-2) or other sexually-transmitted infections (STIs) each showed significant associations with HIV infection. Among the general population, the odds ratio (OR) of HIV infection for women reporting 3+ sex partners versus 0–2 was 3.64 (95%CI [2.87–4.62]), with similar risks for men. About 9% of infected women reported ever having been paid for sex, versus 4% of control women (OR = 2.29, [1.45–3.62]). About 31% of infected men reported ever paying for sex versus 18% of uninfected men (OR = 1.75, [1.30–2.36]). HSV-2 infection carried the largest risk of HIV infection: OR = 4.62, [2.85–7.47] in women, and OR = 6.97, [4.68–10.38] in men. These risks changed little over time and stratification by lower and higher HIV background prevalence showed that risk ratios for most variables were larger in high prevalence settings. Among uninfected controls, the male-female differences in the number of sex partners and in paid sex were more extreme in the higher HIV prevalence settings than in the lower prevalence settings.

          Significance

          Multi-partner sex, paid sex, STIs and HSV-2 infection are as important to HIV transmission in advanced as in early HIV epidemics. Even in high prevalence settings, prevention among people with high rates of partner change, such as female sex workers and their male clients, is likely to reduce transmission overall.

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          Most cited references130

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          Sexual behaviour in context: a global perspective.

          Research aimed at investigating sexual behaviour and assessing interventions to improve sexual health has increased in recent decades. The resulting data, despite regional differences in quantity and quality, provide a historically unique opportunity to describe patterns of sexual behaviour and their implications for attempts to protect sexual health at the beginning of the 21st century. In this paper we present original analyses of sexual behaviour data from 59 countries for which they were available. The data show substantial diversity in sexual behaviour by region and sex. No universal trend towards earlier sexual intercourse has occurred, but the shift towards later marriage in most countries has led to an increase in premarital sex, the prevalence of which is generally higher in developed countries than in developing countries, and is higher in men than in women. Monogamy is the dominant pattern everywhere, but having had two or more sexual partners in the past year is more common in men than in women, and reported rates are higher in industrialised than in non-industrialised countries. Condom use has increased in prevalence almost everywhere, but rates remain low in many developing countries. The huge regional variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.
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            Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies.

            To estimate the sex-specific effect of herpes simplex virus type 2 (HSV-2) on the acquisition of HIV infection. The increased number of longitudinal studies available since the last meta-analysis was published allows for the calculation of age- and sexual behaviour-adjusted relative risks (RR) separately for men and women. Systematic review and meta-analysis of longitudinal studies. PubMed, Embase and relevant conference abstracts were systematically searched to identify longitudinal studies in which the relative timing of HSV-2 infection and HIV infection could be established. Where necessary, authors were contacted for separate estimates in men and women, adjusted for age and a measure of sexual behaviour. Summary adjusted RR were calculated using random-effects meta-analyses where appropriate. Studies on recent HSV-2 incidence as a risk factor for HIV acquisition were also collated. Of 19 eligible studies identified, 18 adjusted for age and at least one measure of sexual behaviour after author contact. Among these, HSV-2 seropositivity was a statistically significant risk factor for HIV acquisition in general population studies of men [summary adjusted RR, 2.7; 95% confidence interval (CI), 1.9-3.9] and women (RR, 3.1; 95% CI, 1.7-5.6), and among men who have sex with men (RR, 1.7; 95% CI, 1.2-2.4). The effect in high-risk women showed significant heterogeneity, with no overall evidence of an association. Prevalent HSV-2 infection is associated with a three-fold increased risk of HIV acquisition among both men and women in the general population, suggesting that, in areas of high HSV-2 prevalence, a high proportion of HIV is attributable to HSV-2.
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              Bias in location and selection of studies.

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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS ONE
                plos
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2007
                3 October 2007
                : 2
                : 10
                : e1001
                Affiliations
                [1 ]Centre for Global Health Research, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
                [2 ]Division of Medical Sciences, Island Medical Program, University of Victoria, Victoria, British Columbia, Canada
                [3 ]Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
                [4 ]Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
                [5 ]Department of Community Medicine, Al Ain University, Al Ain, United Arab Emirates
                Medical Research Council South Africa, South Africa
                Author notes
                * To whom correspondence should be addressed. E-mail: prabhat.jha@ 123456utoronto.ca

                Conceived and designed the experiments: PJ LC BS TD. Analyzed the data: NN LC. Contributed reagents/materials/analysis tools: SS TD. Wrote the paper: PJ RK NN LC BS SS TD.

                Article
                07-PONE-RA-01000R3
                10.1371/journal.pone.0001001
                1994584
                17912340
                939a484c-263d-46db-b495-72a4db510c85
                Chen et al. 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
                : 30 March 2007
                : 3 September 2007
                Page count
                Pages: 1
                Categories
                Research Article
                Infectious Diseases/HIV Infection and AIDS
                Public Health and Epidemiology/Epidemiology
                Public Health and Epidemiology/Infectious Diseases

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                Uncategorized

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