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Background: Cervicitis increases the quantity of HIV-1 RNA in cervical secretions when women are not taking antiretroviral therapy (ART), and successful treatment of cervicitis reduces HIV-1 shedding in this setting. Objective: To determine the effect of acquisition and treatment of cervical infections on genital HIV-1 shedding in women receiving ART. Design: Prospective cohort study. Methods: We followed 147 women on ART monthly for incident nonspecific cervicitis, gonorrhea, and chlamydia. Cervical swabs for HIV-1 RNA quantitation were collected at every visit. The lower limit for linear quantitation was 100 copies per swab. We compared the prevalence of HIV-1 RNA detection before (baseline) versus during and after treatment of cervical infections. Results: Thirty women contributed a total of 31 successfully treated episodes of nonspecific cervicitis (N= 13), gonorrhea (N= 17), and chlamydia (N= 1). HIV-1 RNA was detected in cervical secretions before, during, and after cervicitis at one (3.2%), five (16.1 %), and three (9.7%) visits, respectively. Compared with baseline, detection of HIV-1 RNA was increased when cervical infections were present (adjusted odds ratio 5.7, 95% confidence interval 1.0-30.3, P=0.04). However, even in the subset of women with cervical HIV-1 RNA levels above the threshold for quantitation, most had low concentrations during cervical infections (median 115, range 100-820 copies per swab). Conclusion: Although these data show a statistically significant increase in cervical HIV-1 RNA detection when cervical infections are present, most cervical HIV-1 RNA concentrations were near the threshold for detection, suggesting that infectivity remains low. Antiretroviral therapy appears to limit increases in genital HIV-1 shedding caused by cervical infections.

OBJECTIVE: The objective of this study was to test the hypothesis that sexual risk behavior would increase following initiation of antiretroviral therapy (ART) in Kenyan female sex workers (FSWs). DESIGN: Prospective cohort study. SETTING: FSW cohort in Mombasa Kenya 1993-2008. SUBJECTS: Eight hundred and ninety-eight women contributed HIV-1-seropositive follow-up visits of whom 129 initiated ART. INTERVENTION: Beginning in March 2004 ART was provided to women qualifying for treatment according to Kenyan National Guidelines. Participants received sexual risk reduction education and free condoms at every visit. MAIN OUTCOME MEASURES: Main outcome measures included unprotected intercourse abstinence 100% condom use number of sexual partners and frequency of sex. Outcomes were evaluated at monthly follow-up visits using a 1-week recall interval. RESULTS: Compared with non-ART-exposed follow-up visits following ART initiation were not associated with an increase in unprotected sex [adjusted odds ratio (AOR) 0.86 95% confidence interval (CI) 0.62-1.19 P = 0.4]. There was a nonsignificant decrease in abstinence (AOR 0.81 95% CI 0.65-1.01 P = 0.07) which was offset by a substantial increase in 100% condom use (AOR 1.54 95% CI 1.07-2.20 P = 0.02). Numbers of sex partners and frequency of sex were similar before versus after starting ART. A trend for decreased sexually transmitted infections following ART initiation provides additional support for the validity of the self-reported behavioral outcomes (AOR 0.67 95% CI 0.44-1.02 P = 0.06). CONCLUSION: In the setting of ongoing risk reduction education and provision of free condoms initiation of ART was not associated with increased sexual risk behavior in this cohort of Kenyan FSWs.

Background: Men who have sex with men (MSM) are highly vulnerable to HIV infection, but this population can be particularly difficult to reach in sub-Saharan Africa. We aimed to estimate the number of MSM who sell sex in and around Mombasa, Kenya, in order to plan HIV prevention research. Methods: We identified 77 potential MSM contact locations, including public streets and parks, brothels, bars and nightclubs, in and around Mombasa and trained 37 MSM peer leader enumerators to extend a recruitment leaflet to MSM who were identified as ‘on the market’, that is, a man who admitted to selling sex to men. We captured men on two consecutive Saturdays, 1 week apart. A record was kept of when, where and by whom the invitation was extended and received, and of refusals. The total estimate of MSM who sell sex was derived from capture–recapture calculation. Results: Capture 1 included 284 men (following removal of 15 duplicates); 89 men refused to participate. Capture 2 included 484 men (following removal of 35 duplicates); 75 men refused to participate. Of the 484 men in capture 2, 186 were recaptures from capture 1, resulting in a total estimate of 739 (95% confidence interval, 690–798) MSM who sell sex in the study area. Conclusions: We estimated that 739 MSM sell sex in and around Mombasa. Of these, 484 were contacted through trained peer enumerators in a single day. MSM who sell sex in and around Mombasa represent a sizeable population who urgently need to be targeted by HIV prevention strategies.

BACKGROUND Antiretroviral therapy (ART) may decrease HIV-1 infectivity in women by reducing genital HIV-1 shedding. OBJECTIVES To evaluate the time course and magnitude of decay in cervical and vaginal HIV-1 shedding as women initiate ART. METHODS This prospective, observational study of 20 antiretroviral-naive women initiating ART with stavudine, lamivudine, and nevirapine measured HIV-1 RNA in plasma, cervical secretions, and vaginal secretions. Qualitative polymerase chain reaction estimated HIV-1 DNA in cervical and vaginal samples. Perelson's two-phase viral decay model and non-linear random effects were used to compare RNA decay rates. Decreases in proviral DNA were evaluated using logistic regression and generalized estimating equations. RESULTS Significant decreases in the quantity of HIV-1 RNA were observed by day 2 in plasma (P < 0.001), day 2 in cervical secretions (P = 0.001), and day 4 in vaginal secretions (P < 0.001). Modeled initial and subsequent RNA decay rates in plasma, cervical secretions, and vaginal secretions were 0.6, 0.8, and 1.2 log10 virions/day, and 0.04, 0.05, and 0.06 log10 virions/day, respectively. The initial decay rate for vaginal HIV-1 RNA was more rapid than for plasma RNA (P = 0.02). Detection of HIV-1 DNA decreased significantly in vaginal secretions during the first week (P < 0.001). At day 28, 10 women had detectable HIV-1 RNA or proviral DNA in genital secretions. CONCLUSIONS Genital HIV-1 shedding decreased rapidly after ART initiation, consistent with a rapid decrease in infectivity. However, incomplete viral suppression in half of these women may indicate an ongoing risk of transmission.