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      High risk exposure to HIV among sexually active individuals who tested negative on rapid HIV Tests in the Tshwane District of South Africa—The importance of behavioural prevention measures

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          Abstract

          Objective

          To assess the prevalence of HIV risk behaviour among sexually active HIV sero-negative individuals in the Tshwane district of South Africa (SA).

          Methods

          Demographic and HIV risk behaviour data were collected on a questionnaire from participants of a cross-sectional study that screened for early HIV infection using pooled nucleic acid amplification testing (NAAT). The study enrolled individuals who tested negative on rapid HIV tests performed at five HIV counseling and testing (HCT) clinics, which included four antenatal clinics and one general HCT clinic.

          Results

          The study enrolled 9547 predominantly black participants (96.6%) with a median age of 27 years (interquartile range [IQR]: 23–31). There were 1661 non-pregnant and 7886 pregnant participants largely enrolled from the general and antenatal HCT clinics, respectively. NAAT detected HIV infection in 61 participants (0.6%; 95% confidence interval [CI]: 0.4–0.8) in the whole study. A high proportion of study participants, 62.8% and 63.0%, were unaware of their partner’s HIV status; and also had high prevalence, 88.5% and 99.5%, of recent unprotected sex in the general and pregnant population, respectively. Consistent use of condoms was associated with protection against HIV infection in the general population. Trends of higher odds for HIV infection were observed with most demographic and HIV risk factors at univariate analysis, however, multivariate analysis did not show statistical significance for almost all these factors. A significantly lower risk of HIV infection was observed in circumcised men ( p <0.001).

          Conclusions

          These data show that a large segment of sexually active people in the Tshwane district of SA have high risk exposure to HIV. The detection of newly diagnosed HIV infections in all study clinics reflects a wide distribution of individuals who are capable of sustaining HIV transmission in the setting where HIV risk behaviour is highly prevalent. A questionnaire that captures HIV risk behaviour would be useful during HIV counselling and testing to ensure that there is a systematic way of identifying HIV risk factors and that counselling is optimised for each individual. HIV risk behaviour surveillance could be used to inform relevant HIV prevention interventions that could be implemented at a community or population level.

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          Most cited references29

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          Concurrent partnerships and the spread of HIV.

          To examine how concurrent partnerships amplify the rate of HIV spread, using methods that can be supported by feasible data collection. A fully stochastic simulation is used to represent a population of individuals, the sexual partnerships that they form and dissolve over time, and the spread of an infectious disease. Sequential monogamy is compared with various levels of concurrency, holding all other features of the infection process constant. Effective summary measures of concurrency are developed that can be estimated on the basis of simple local network data. Concurrent partnerships exponentially increase the number of infected individuals and the growth rate of the epidemic during its initial phase. For example, when one-half of the partnerships in a population are concurrent, the size of the epidemic after 5 years is 10 times as large as under sequential monogamy. The primary cause of this amplification is the growth in the number of people connected in the network at any point in time: the size of the largest "component'. Concurrency increases the size of this component, and the result is that the infectious agent is no longer trapped in a monogamous partnership after transmission occurs, but can spread immediately beyond this partnership to infect others. The summary measure of concurrency developed here does a good job in predicting the size of the amplification effect, and may therefore be a useful and practical tool for evaluation and intervention at the beginning of an epidemic. Concurrent partnerships may be as important as multiple partners or cofactor infections in amplifying the spread of HIV. The public health implications are that data must be collected properly to measure the levels of concurrency in a population, and that messages promoting one partner at a time are as important as messages promoting fewer partners.
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            Population-level HIV declines and behavioral risk avoidance in Uganda.

            Uganda provides the clearest example that human immunodeficiency virus (HIV) is preventable if populations are mobilized to avoid risk. Despite limited resources, Uganda has shown a 70% decline in HIV prevalence since the early 1990s, linked to a 60% reduction in casual sex. The response in Uganda appears to be distinctively associated with communication about acquired immunodeficiency syndrome (AIDS) through social networks. Despite substantial condom use and promotion of biomedical approaches, other African countries have shown neither similar behavioral responses nor HIV prevalence declines of the same scale. The Ugandan success is equivalent to a vaccine of 80% effectiveness. Its replication will require changes in global HIV/AIDS intervention policies and their evaluation.
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              Rethinking the heterosexual infectivity of HIV-1: a systematic review and meta-analysis.

              Studies of cumulative HIV incidence suggest that cofactors such as genital ulcer disease, HIV disease stage, and male circumcision influence HIV transmission; however, the heterosexual infectivity of HIV-1 is commonly cited as a fixed value (approximately 0.001, or one transmission per 1000 contacts). We sought to estimate transmission cofactor effects on the heterosexual infectivity of HIV-1 and to quantify the extent to which study methods have affected infectivity estimates. We undertook a systematic search (up to April 27, 2008) of PubMed, Web of Science, and relevant bibliographies to identify articles estimating the heterosexual infectivity of HIV-1. We used meta-regression and stratified random-effects meta-analysis to assess differences in infectivity associated with cofactors and study methods. Infectivity estimates were very heterogeneous, ranging from zero transmissions after more than 100 penile-vaginal contacts in some serodiscordant couples to one transmission for every 3.1 episodes of heterosexual anal intercourse. Estimates were only weakly associated with study methods. Infectivity differences, expressed as number of transmissions per 1000 contacts, were 8.1 (95 % CI 0.4-15.8) when comparing uncircumcised to circumcised susceptible men, 6.0 (3.3-8.8) comparing susceptible individuals with and without genital ulcer disease, 1.9 (0.9-2.8) comparing late-stage to mid-stage index cases, and 2.5 (0.2-4.9) comparing early-stage to mid-stage index cases. A single value for the heterosexual infectivity of HIV-1 fails to reflect the variation associated with important cofactors. The commonly cited value of 0.001 was estimated among stable couples with low prevalences of high-risk cofactors, and represents a lower bound. Cofactor effects are important to include in epidemic models, policy considerations, and prevention messages.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: Formal analysisRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                2 February 2018
                2018
                : 13
                : 2
                : e0192357
                Affiliations
                [1 ] Department of Medical Virology, University of Pretoria, City of Tshwane, South Africa
                [2 ] National Health Laboratory Service-Tshwane Academic Division (NHLS-TAD), City of Tshwane, South Africa
                [3 ] Toga Laboratories, Johannesburg, South Africa
                [4 ] Biostatistics unit, Medical Research Council, City of Tshwane, South Africa
                [5 ] South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
                [6 ] Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
                [7 ] Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
                [8 ] Division of Infectious Diseases, Department of Internal Medicine, University of Pretoria, City of Tshwane, South Africa
                University of Toronto, CANADA
                Author notes

                Competing Interests: All authors declare no competing interests. Toga Laboratories provided support in the form of salaries for [DJM]. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-5453-4353
                Article
                PONE-D-17-20716
                10.1371/journal.pone.0192357
                5796711
                29394288
                b0e343f9-552e-4d4c-922b-f04064646927

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                : 30 May 2017
                : 20 January 2018
                Page count
                Figures: 0, Tables: 3, Pages: 14
                Funding
                Funded by: NHLS Research Trust fund
                Award Recipient :
                Funded by: University of Pretoria research assistant grant
                Award Recipient :
                Funded by: MRC-SIR grant
                Award Recipient :
                Funded by: Discovery Foundation grant
                Award Recipient :
                Funded by: The Division of Intramural Research, NIAID, NIH
                Award Recipient :
                Funded by: NHLS Research Trust fund
                Award Recipient :
                This work was supported by NHLS Research Trust fund - SHM & DJM, University of Pretoria research assistant grant - SHM, MRC-SIR grant - SHM, Discovery Foundation grant - SHM, and The Division of Intramural Research, NIAID, NIH - TCQ. Prof Desmond J. Martin [DJM] is an employee of a commercial company, Toga Laboratories. The Toga Laboratories provided support in the form of salaries for [DJM], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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