Professional Documents
Culture Documents
Kenrad E. Nelson, MD
Professor, Department of Epidemiology
Bloomberg School of Public Health,
Johns Hopkins University
HIV infection rates among IV drug users in
Bangkok and national median rates, 1985-1991
Seroprevelence of Elisa Positivity to HIV by Month Among
Female Prostitutes Attending Health Department STD Clinics
Chiang Mai, Thailand, Jan,1988 - Aug, 1989
Median provincial seroprevalence rates for selected
groups in national surveys
2001
25
20
15
10
0
0 20 40 60 80 100
% Circumcised males
Senegal
Sierra Leone
Guinea
Burkina Faso
Ghana
Cameroon
Lesotho
Botswana
0 10 20 30 40
Sources: ORC/MACRO, 2005, USAID, 2002
Cochrane Review of HIV and Circumcision
in High Risk Heterosexual Men
Traditional/tribal,
safety of surgery
Heterogeneity p = 0.23
Heterogeneity p = 0.005
20
15
10 8.2
5
0 0 0
0
<10,000 10,000-49,999 >50,000
HIV+ Female viral load
nasio
gray
telzak
reynolds
seed
new ell
donovan
bw ayo
simonsen
30
Circumcised 25.6
25
25 Uncircumcised
Transmission/100py
20
15 12.6
10 6.9
5
0 0
0
<10,000 10,000-49,999 >50,000
Male Viral load
47 couples in which circumcised male partner was HIV+ AND whose viral load was
<50,000 particles, 0 of female partners were infected after two years, vs. 26 of 143
female partners of uncircumcised HIV+ men (9.6/100 py) (p = 0.02).
Gray et al AIDS 2000
Circumcision and Male-to-Female HIV & STI
Transmission in Rakai (Gray et al CROI 2006)
*P<0.05
Biological Rationale for circumcision & HIV
Biological plausibility
Inner mucosa of foreskin is rich in HIV target cells (9x
cervix)
External foreskin/ shaft keratinized and not vulnerable
Balanitis/phimosis
Reduced GUD,
Reduced HIV STI cofactor
Target cells effects
KERATIN THICKNESS ON THE EXTERNAL AND INTERNAL
MUCOSAL SURFACES OF HUMAN FORESKIN
Keratin
Infected T-cells
Three trials:
South Africa (ANRS),
Kenya (NIH),
Uganda (NIH)
Similar designs:
Enroll HIV- uncircumcised men, randomize to:
Immediate circumcision (Intervention)
Endpoints:
HIV incidence
Safety
Behavioral disinhibition
STIs
Trial Site Community Characteristics
2.4
H IV Incidence/100 py
RR 0.5
1.9 RR 0.4
RR 0.3
1.4
Current incidence
1.24/100 py
0.9
0.4 1 2 3 4
Behavioral disinhibition can offset all benefit, even at high circumcision efficacy
AIDS Link to Intravenous
Experience (ALIVE II)
Prospective cohort study, began 1988.
Eligibility: AIDS free, injection drug use < 10
yrs prior, over 18 yrs.
Re-opened recruitment in 1994 and 1998
Semi-annual HIV antibody screen and interview
Endpoints: HIV seroconversion, death
HIV seroconverters enter parallel cohort study
of HIV natural history
ALIVE-II
3. Importance
a. HIV incidence & risk behaviors
b. Control for drug use in analysis of HIV-
related morbidity and morbidity
4. Populations
a. N= 1,532 (1988-9)
b. N= 338 (1994)
c. N= 400 (1998)
Heterosexual Sex and IDU Risks
for HIV Incidence
Exposures No p/yrs Scs Inc RI (95% CI)
SC Rate/100 PY: All cohorts SC Rate/100 PY: 70's SC Rate/100 PY: 80's
4.5
3.5
2.5
1.5
0.5
0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Trends of Reported Drug Use in ALIVE Sero-negative participants: 1988 - 2003
60
50
40
Rate per year (%)
30
20
10
No Data Reported
0% HIV/AIDS cases among IDUs
< 10% HIV/AIDS cases among IDUs
10-40% HIV/AIDS cases among IDUs
SOURCE: WHO, UNAIDS
40%+ HIV/AIDS cases among IDUs
Proportion of Injecting Drug Users Among
Reported HIV Cases*
11% <20%
20-40%
40-60%
60-80%
>80%
19.5% 3.7%
11.2%
85%
39.8% 92.7%
8% 76.3%
7.3% 10.8%
72.3%
87.1%
6.5% 78%
14.4% 62.5%
16% 82%
4%
22.7%
1.3% 69.4%
11.8% 24.5%
49.7% 1% 60%
2.6% 83% 76%
32%
63.5% 12.5%
<0.1%
24%
59.6% 50.7%*
2.5% 70.9%
47.7%
1.3% 13.6%
49.2%
3.8% 7.5%
10%
*Proportion among AIDS cases in countries not reporting HIV data (Sources:
European Commission;
* EuroHIV; Council of Europe)
12.3%
States (N= 26) with at least one site with
HIV prevalence > 20% in IDU in 2005
Belarus Burma
Estonia China
Kazakhstan India
Russia Indonesia
Ukraine Malaysia
Iran Nepal
Thailand
Italy Vietnam
Netherlands
Portugal Argentina
Serbia & Montenegro Brazil
Spain Canada
Uruguay
Libya Puerto Rico
USA
* Denotes recent emergence [Adapted: Aceijas, et al, AIDS 2004 18:2295-2302]
Emerging Epidemics: Former Soviet Union (FSU)
• Overall, 142 of 243 HIV positive participants did not know they
were HIV infected