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This pre-post evaluation aimed to measure changes in knowledge and attitudes towards drug users among community representatives in Kabul, Afghanistan, over a period of expansion of harm reduction and drug dependence programming. A convenience sample of 160 professionals aged 18+ years completed interview questionnaires in 2007 and 2009. Views endorsing programme quality and the provision of condoms, infection counselling/testing and needle/syringe distribution increased significantly over the 2-year period. In 13 of 38 statements, there was a substantial (> 10%) change in agreement level, most commonly among men and medical professionals. Attitudes concerning support of drug users remained largely positive, with substantial attitude changes in some subgroups of the population. Further community education through the media and a more cohesive government drug policy may be needed to strengthen community support for harm reduction/drug treatment in Afghanistan.

OBJECTIVES: This study assessed the prevalence and correlates of asymptomatic genital tract infection with Neisseria gonorrhoeae and Chlamydia trachomatis among emergency department patients. METHODS: Individuals seeking emergency department evaluation for nongenitourinary complaints provided urine samples for N gonorrhoeae and C trachomatis testing by ligase chain reaction and completed a sociodemographic and behavioral questionnaire. RESULTS: Asymptomatic N gonorrhoeae or C trachomatis was found in 9.7% of persons tested. Correlates of C trachomatis infection included younger age, residence in high-morbidity zip code areas, previous history of N gonorrhoeae or C trachomatis, and number of sex partners in the past year. CONCLUSIONS: Urine-based screening of asymptomatic emergency department patients detected significant numbers of N gonorrhoeae and C trachomatis infections. Targeted screening programs may contribute to community-level prevention and control of sexually transmitted infections. [ABSTRACT FROM AUTHOR]

Background: Zambian adolescent girls and young women (AGYW) have high HIV incidence and face barriers to the use of pre-exposure prophylaxis (PrEP). Parental support improves PrEP use and adherence in some settings, but negative parental attitudes toward HIV prevention may inhibit engagement with AGYW. We explored perceptions of future PrEP methods among AGYW and parents and parent-youth engagement on HIV prevention and PrEP use., Methods: We conducted a qualitative descriptive study among AGYW and parents of AGYW in five provinces in Zambia in September-October 2021. We conducted 10 focus group discussions (FGDs) and four in-depth interviews (IDIs) with AGYW participants (n = 87) and seven FGDs and four IDIs among parents of AGYW (n = 62). All FGDs and IDIs were audio-recorded, transcribed verbatim, and analyzed to identify qualitative themes., Results: Most AGYW participants preferred the discreet nature and longer duration of injectable PrEP compared to the PrEP ring and oral PrEP. Many AGYWs reported inability to disclose PrEP use to their parents due to lack of parental support based on cultural taboos against premarital sex. Nevertheless, AGYW participants said they would like to talk to their parents about PrEP so their parents could support their use. Many parents also described difficulties discussing PrEP with their daughters because of cultural and religious beliefs about abstinence from sex before marriage. However, parents acknowledged that the threat of HIV is real and said they need PrEP knowledge and guidance on speaking with their children about HIV prevention and PrEP., Conclusions: Although many parents are currently not playing a role in daughters' decisions about PrEP use, both parents and AGYW are willing to engage with each other on HIV prevention issues. To foster parent-child engagement, HIV prevention programs should not only provide information about PrEP but also address social norms that impede discussion of HIV prevention and equip both parents and AGYW with skills and support for such conversations. Community sensitization is also needed as new PrEP products are introduced, to create an enabling environment for parent-child engagement by increasing awareness, countering misconceptions, and reducing stigma., (© 2024. The Author(s).)

Introduction: While young women in South Africa may navigate both HIV infection and pregnancy risks, intrauterine contraceptive (IUC) use is low. Though IUCs have low failure rates, concerns exist about whether the IUC is an appropriate method choice for women living with HIV (WLHIV). In this qualitative study, we explore WLHIVs' experiences of using IUC and reasons for discontinuation., Methods: This qualitative study included in-depth interviews (IDIs) with 17 WLHIV who electively discontinued their allocated IUC while participating in a randomized controlled trial comparing the safety of the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (C-IUD) in Cape Town, South Africa. The transcripts were coded and emergent themes were grouped to examine women's experiences with IUC use and reasons for discontinuation, highlighting experiential differences between the two methods., Results: Women's experience with the allocated IUC related most commonly to bleeding and/or abdominal pain just after insertion. Most C-IUD discontinuers, but only one LNG-IUS discontinuer, complained of pain and/or increased bleeding as the main reason for removal. Three women (two LNG-IUS, one C-IUD) requested removal because they desired pregnancy, while two others discontinued due to fears the IUC was exacerbating non-gynecologic conditions (hypertension, diabetes). Generally, women acknowledged advantages of IUC use and many expressed their desire to continue use if not for the side effects., Conclusions: In the South African context, IUC use for WLHIV should be promoted with specific counseling considerations. Both providers and potential users should receive specific information about potential menstrual-related side effects and countering common misperceptions to enable informed contraceptive decision-making., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Pradhan, Tolley, Langwenya, Jones, Hoover, Petro, Myer and Todd.)

Objective: Digital health technologies have contributed to the adoption of beneficial reproductive, maternal, newborn, and child health (RMNCH) behaviors through social and behavior change programming, including in hard-to-reach settings. On-demand digital health interventions rely on promotions to build awareness and increase use among target audiences. There is little research on preferred content and use of promotional approaches for RMNCH digital health activities., Methods: We conducted a retrospective descriptive analysis of Mobile for Reproductive Health (m4RH) data in Afghanistan to assess the use and changes in call volume via the 2-3-4 platform by promotional approaches over 23 months between October 2017 and August 2019., Results: There were 103,859 completed messages (CM) heard. Most callers reporting demographics were under 18 years, with roughly even distribution by gender. The number of CMs listened to across all menus increased with time. The basic m4RH family planning menu was most popular, with callers most frequently selecting information on intrauterine contraceptive devices. Nine types of promotional approaches were implemented. Compared against call volume, SMS blast promotion was the most productive promotional approach, radio broadcasts had modest increases, and social media and interpersonal communication demonstrated no clear change., Conclusions: m4RH use increased over time, particularly among younger people. The number of promotional approaches used does not appear as important as the type of approach used to generate program awareness. Mass media communications, including SMS blast promotions and radio broadcasts, may be the most effective strategies. Deeper program data analysis can guide tailoring of message content and promotional approaches to reach target audiences with the RMNCH content they most value., (© The Author(s) 2022.)

Malnutrition contributes to direct and indirect causes of maternal mortality, which is particularly high in Afghanistan. Women's nutritional status before, during, and after pregnancy affects their own well-being and mortality risk and their children's health outcomes. Though maternal nutrition interventions have documented positive impact on select child health outcomes, there are limited data regarding the effects of maternal nutrition interventions on maternal health outcomes globally. This scoping review maps policies, data, and interventions aiming to address poor maternal nutrition outcomes in Afghanistan. We used broad search categories and approaches including database and website searches, hand searches of reference lists from relevant articles, policy and programme document requests, and key informant interviews. Inclusion and exclusion criteria were developed by type of source document, such as studies with measures related to maternal nutrition, relevant policies and strategies, and programmatic research or evaluation by a third party with explicit interventions targeting maternal nutrition. We abstracted documents systematically, summarized content, and synthesized data. We included 20 policies and strategies, 29 data reports, and nine intervention evaluations. The availability of maternal nutrition intervention data and the inclusion of nutrition indicators, such as minimum dietary diversity, have increased substantially since 2013, yet few nutrition evaluations and population surveys include maternal outcomes as primary or even secondary outcomes. There is little evidence on the effectiveness of interventions that target maternal nutrition in Afghanistan. Policies and strategies more recently have shifted towards multisectoral efforts and specifically target nutrition needs of adolescent girls and women of reproductive age. This scoping review presents evidence from more than 10 years of efforts to improve the maternal nutrition status of Afghan women. We recommend a combination of investments in measuring maternal nutrition indicators and improving maternal nutrition knowledge and behaviours., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Rural Afghan populations have low skilled birth attendance rates and high maternal and infant mortality. Insecurity and armed conflict, geographic barriers, and cultural norms often hinder women's access to facility-based reproductive, maternal, newborn, and child health (RMNCH) services. Community health workers (CHWs) are critical agents for behavioral change in this and similarly fragile settings, where RMNCH information exposure is limited by low literacy and mass media access. We assessed the feasibility and acceptability of a computer tablet-based health video library (HVL) to enhance CHW counseling on RMNCH topics in three rural Afghan districts., Methods: The HVL was introduced by trained CHWs in 10 pilot communities within one rural district in each of Balkh, Herat, and Kandahar provinces. We used a mixed-methods study design to assess exposure to and perception of the HVL 6 months post-introduction. We surveyed married women ( n  = 473) and men ( n  = 468) with at least one child under 5 years and conducted in-depth interviews with CHWs and community leaders ( shuras and Family Health Action groups) within pilot communities ( n  = 80). Program improvement needs were summarized using quantitative and qualitative data., Results: Higher proportions of women in Balkh (60.3%) and Herat (67.3%) reported viewing at least one HVL video compared to women in Kandahar (15%), while male HVL exposure was low (8-17%) across all districts. Most HVL-exposed clients (85-93% of women and 74-92% of men) reported post-video counseling by CHWs. Nearly all (94-96% of women and 85-92% of men) were very interested in watching videos on other health topics in the future. Participants recommended increasing the number of videos and range of topics, using tablets with larger screens, and translating videos into additional local languages to improve the HVL program., Conclusion: The HVL was a highly acceptable tool for relaying health information, but coverage of female audiences in Kandahar and male audiences broadly was low. The HVL should better engage men and other key influencers to engineer local solutions that directly facilitate male HVL exposure, indirectly improve women's HVL access, and support collaborative spousal health decision-making. A larger efficacy trial is warranted to measure the HVL's effect on knowledge and health-related behavioral outcomes., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Background: Mobile phone apps for health promotion have expanded in many low- and middle-income countries. Afghanistan, with high maternal and newborn morbidity and mortality rates, a fragile health infrastructure, and high levels of mobile phone ownership, is an ideal setting to examine the utility of such programs. We adapted messages of the Mobile Alliance for Maternal Action (MAMA) program, which was designed to promote healthy behaviors during pregnancy and a newborn's first year of life, to the Afghan context. We then piloted and assessed the program in the provinces of Kabul, Herat, Kandahar, and Balkh., Objective: The aim of this study was to assess the feasibility and acceptability of the MAMA pilot program, and to examine changes in reported maternal, newborn, and child health (MNCH) knowledge and attitudes among participants from baseline to follow up., Methods: We conducted a single-group study with data collected within 10 weeks of enrollment, and data collection was repeated approximately 6 months later. Data were collected through face-to-face interviews using structured questionnaires. Eligible participants included pregnant women who had registered to receive fully automated mobile health messages and their husbands. Assessment questionnaires queried sociodemographic details; knowledge, attitudes, and health care-seeking practices; and intervention experience and acceptability at follow up. The number of messages received by a given phone number was extracted from the program database. We descriptively analyzed the feasibility and acceptability data and compared the change in MNCH knowledge between baseline and follow-up measures using the McNemar Chi square test., Results: Overall, 895 women were enrolled in the MAMA program. Data from 453/625 women (72.5% of the pretest sample) who received voice (n=302) or text (n=151) messages, and 276/427 men (64.6% of the pretest sample) who received voice (n=185) or text (n=91) messages contributing data at both time points were analyzed. At follow up, 699/729 (95.9%) participants were still enrolled in the MAMA program; voice message and SMS text messaging subscribers received 43 and 69 messages on average over the 6-month period, respectively. Participants who were voice message subscribers and female participants more commonly reported missing messages compared with the text message subscribers and men; predominant reasons for missed messages were the subscribers being busy with chores or not having their shared phone with them. Over 90% of men and women reported experiencing benefits from the program, mainly increased knowledge, and 226/453 (49.9%) of the female participants reported referring someone else to the program. Most of the participants (377/453, 83.2% women and 258/276, 93.5% men) believed it was beneficial to include husbands in the program. Joint decision making regarding maternal and child health care increased overall. The proportions of participants with correct knowledge significantly increased for all but one MNCH measure at follow up., Conclusions: This assessment indicates that the pilot MAMA program is feasible and acceptable in the Afghan context. Further research should be conducted to determine whether program participation leads to improved MNCH knowledge, health practices, and health service utilization in this fragile setting prior to larger scale up., (©Victoria Lebrun, Lisa Dulli, Sayed Omar Alami, Arzoo Sidiqi, Ahmad Shah Sultani, Sayed Haroon Rastagar, Iftikhar Halimzai, Sharif Ahmadzai, Catherine S Todd. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 20.07.2020.)

Background: Child health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries., Methods: We reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings., Results: We included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited., Conclusions: This review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.

Background: Women living with HIV (WLHIV) have lower rates of contraceptive use than noninfected peers, yet concerns regarding contraceptive efficacy and interaction with antiretroviral therapy (ART) complicate counseling. Hormonal contraceptives may increase genital tract HIV viral load (gVL) and sexual transmission risk to male partners. We compared gVL, plasma VL (pVL), and intrauterine contraceptive (IUC) continuation between the levonorgestrel intrauterine system (LNG-IUS) and copper intrauterine device (C-IUD) in Cape Town, South Africa., Methods and Findings: In this double-masked, randomized controlled noninferiority trial, eligible WLHIV were ages 18-40, not pregnant or desiring pregnancy within 30 months, screened and treated (as indicated) for reproductive tract infections (RTIs) within 1 month of enrollment, and virologically suppressed using ART or above treatment threshold at enrollment (non-ART). Between October 2013, and December 2016, we randomized consenting women within ART groups, using 1:1 permuted block randomization stratified by ART use, age (18-23, 24-31, 32-40), and recent injectable progestin contraceptive (IPC) exposure, and provided the allocated IUC. At all visits, participants provided specimens for gVL (primary outcome), pVL, RTI, and pregnancy testing. We assessed gVL and pVL across 6 and 24 months controlling for enrollment measures, ART group, age, and RTI using generalized estimating equation and generalized linear models (non-ART group pVL and hemoglobin) in as-treated analyses. We measured IUC discontinuation rates with Kaplan-Meier estimates and Cox proportional hazards models. We enrolled 71 non-ART (36 LNG-IUS, 31 C-IUD; 2 declined and 2 were ineligible) and 134 ART-using (65 LNG-IUS, 67 C-IUD; 1 declined and 1 could not complete IUC insertion) women. Participant median age was 31 years, and 95% had 1 or more prior pregnancies. Proportions of women with detectable gVL were not significantly different comparing LNG-IUS to C-IUD across 6 (adjusted odds ratio [AOR]: 0.78, 95% confidence interval [CI] 0.44-1.38, p = 0.39) and 24 months (AOR: 1.03, 95% CI: 0.68-1.57, p = 0.88). Among ART users, proportions with detectable pVL were not significantly different at 6 (AOR = 0.83, 95% CI 0.37-1.86, p = 0.65) and 24 months (AOR = 0.94, 95% CI 0.49-1.81, p = 0.85), whereas among non-ART women, mean pVL was not significantly different at 6 months (-0.10 log10 copies/mL, 95% CI -0.29 to 0.10, p = 0.50) between LNG-IUS and C-IUD users. IUC continuation was 78% overall; C-IUD users experienced significantly higher expulsion (8% versus 1%, p = 0.02) and elective discontinuation (adjusted hazard ratio: 8.75, 95% CI 3.08-24.8, p < 0.001) rates. Sensitivity analysis adjusted for differential IUC discontinuation found similar gVL results. There were 39 serious adverse events (SAEs); SAEs believed to be directly related to IUC use (n = 7) comprised 3 pelvic inflammatory disease (PID) cases and 4 pregnancies with IUC in place with no discernible trend by IUC arm. Mean hemoglobin change was significantly higher among LNG-IUS users across 6 (0.57 g/dL, 95% CI 0.24-0.90; p < 0.001) and 24 months (0.71 g/dL, 95% CI 0.47-0.95; p < 0.001). Limitations included not achieving non-ART group sample size following change in ART treatment guidelines and truncated 24 months' outcome data, as 17 women were not yet eligible for their 24-month visit at study closure. Also, a change in VL assay during the study may have caused some discrepancy in VL values because of different limits of detection., Conclusions: In this study, we found that the LNG-IUS did not increase gVL or pVL and had low levels of contraceptive failure and associated PID compared with the C-IUD among WLHIV. LNG-IUS users were significantly more likely to continue IUC use and had higher hemoglobin levels over time. The LNG-IUS appears to be a safe contraceptive with regard to HIV disease and may be a highly acceptable option for WLHIV., Trial Registration: ClinicalTrials.gov NCT01721798., Competing Interests: The authors have declared that no competing interests exist.

Background: Community health workers (CHWs) in Afghanistan are a critical care extender for primary health services, including reproductive, maternal, neonatal, and child health (RMNCH) care. However, volunteer CHWs face challenges including an ever-expanding number of tasks and insufficient time to conduct them. We piloted a health video library (HVL) intervention, a tablet-based tool to improve health promotion and counseling by CHWs. We qualitatively assessed provider-level acceptability and operational feasibility., Methods: CHWs implemented the HVL pilot in three rural districts of Balkh, Herat, and Kandahar provinces. We employed qualitative methods, conducting 47 in-depth interviews (IDIs) with male and female CHWs and six IDIs with community health supervisors. We used semi-structured interview guides to explore provider perceptions of program implementation processes and solicit feedback on how to improve the HVL intervention to inform scale-up. We conducted a thematic analysis., Results: CHWs reported that the HVL increased time efficiencies, reduced work burden, and enhanced professional credibility within their communities. CHWs felt video content and format were accessible for low literacy clients, but also identified challenges to operational feasibility. Although tablets were considered easy-to-use, certain technical issues required continued support from supervisors and family. Charging tablets was difficult due to inconsistent electricity access. Although some CHWs reported reaching most households in their catchment area for visits with the HVL, others were unable to visit all households due to sizeable populations and gender-related barriers, including women's limited mobility., Conclusions: The HVL was acceptable and feasible for integration into existing CHW duties, indicating it may improve RMNCH counseling, contributing to increased care-seeking behaviors in Afghanistan. Short-term challenges with technology and hardware can be addressed through continued training and provision of solar chargers. Longer-term challenges, including tablet costs, community coverage, and gender issues, require further consideration with an emphasis on equitable distribution.

Background: Afghanistan has high maternal and infant mortality which is in part driven by high fertility and low modern contraceptive use. Using modern contraceptive methods can reduce maternal and infant mortality, however there are several barriers to modern contraceptive use in Afghanistan. Married men have the potential to hinder or facilitate their wives' contraceptive use. Internally displaced persons (IDP), a growing population in Afghanistan, are rarely included in reproductive health research. We explored whether married men's, including IDPs', gender-related attitudes and other factors were associated with reported modern contraceptive use to inform programming to meet reproductive health needs of married couples., Methods: Cross-sectional study using data from 885 married men determined to have contraceptive need in seven Afghan provinces. We explored associations between sociodemographic factors, IDP status, wives' involvement in household decision-making and men's attitudes towards intimate partner violence (IPV) with reported modern contraceptive use using logistic regression analysis., Results: Most men (78%) had ≥2 children, 60% reported any formal education, and 30% reported being IDPs. Only 38% of married men and 24% of IDPs with contraceptive need reported using modern contraception with their wives. Most (80% overall, 63% of IDPs) reported their wives' involvement in some/all household decisions, while 47% overall and 57% of IDPs reported IPV was justified in one or more listed circumstances. In bivariate analysis, men responding that IPV was not justified in any listed circumstance were more likely and IDPs less likely to report modern contraceptive use. In multivariable analysis, involvement by wives in household decision-making (AOR 2.57; 95% CI: 1.51, 4.37), owning a radio and/or television (AOR 1.69; 95% CI: 1.10, 2.59), having more children, age, and province of interview were independently associated with reported modern contraceptive use, while IDP status was not., Conclusions: Our findings reflect positive associations between wives' participation in household decisions and mass media exposure (television/radio ownership) with reported modern contraceptive use. Reproductive health initiatives engaging men to promote communication within couples and through mass media channels may further increase modern contraceptive use and advance Afghanistan's family planning goals. As fewer IDPs owned a radio/television, additional outreach methods should be tested for this group.

Background: Afghanistan ranks among the most disadvantaged globally for many key reproductive, maternal, newborn and child health (RMNCH) indicators, despite important gains in the past decade. Youth (15 to 24 years) are a key audience for RMNCH information as they enter adulthood, marry and begin families; however, reaching Afghan youth with health information is challenging. Internally displaced persons (IDPs), including youth, experience additional challenges to obtaining health-related information and services. This study measured current and preferred RMNCH information channels to explore the feasibility of using mobile phone technology to provide RMNCH information to IDP youth in Afghanistan. Methods: We conducted a sub-group analysis of survey data from a mixed-methods, cross-sectional, formative assessment to understand current access to RMNCH information. The target population for this analysis includes 15-25-year-old male and female IDP youth from three Afghan Provinces. Survey data were collected using a structured questionnaire administered through face-to-face interviews. Data were analyzed descriptively. Results: A total of 450 IDP youth were surveyed in the three provinces (225 male and 225 female). Access to RMNCH information outside of health facilities was limited. Mobile phone ownership was nearly universal among male participants, yet considerably lower among females; nearly all participants without personal phones reported access to phones when needed. Although few participants spontaneously mentioned mobile phones as a preferred source of RMNCH information, most male and female respondents reported they would be very or somewhat likely to use a free, mobile-phone-based system to access such information if offered. Conclusions: Given widespread access and considerable interest voiced by participants, mobile phones may be a viable way to reach IDP youth with important RMNCH health information in this fragile setting. Interventions should be designed and pilot-tested to identify the most appropriate platforms and information content and to further document feasibility and acceptability., Competing Interests: No competing interests were disclosed., (Copyright: © 2019 Alami SO et al.)

Background: Maternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh., Methods and Findings: We conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42-60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32-0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19-0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15-0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11-0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers' catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use., Conclusions: Reported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women's ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes., Competing Interests: The authors have declared that no competing interests exist.

Silver nanowire (AgNW) diameters are typically characterized by manual measurement from high magnification electron microscope images. Measurement is monotonous and has potential ergonomic hazards. Because of this, statistics regarding wire diameter distribution can be poor, costly, and low-throughput. In addition, manual measurements are of unknown uncertainty and operator bias. In this paper we report an improved microscopy method for diameter and yield measurement of nanowires in terms of speed/automation and reduction of analyst variability. Each step in the process to generate these measurements was analyzed and optimized: microscope imaging conditions, sample preparation for imaging, image acquisition, image analysis, and data processing. With the resulting method, average diameter differences between samples of just a few nanometers can be confidently and statistically distinguished, allowing the identification of subtle incremental improvements in reactor processing conditions, and insight into nucleation and growth kinetics of AgNWs.

A new method of image texture analysis is presented, based on the mean and standard deviation of gray levels within domains in an image. The calculations are performed recursively on domains of various sizes within the images. These gray level calculations are used as the input matrix for principal component analysis. The technique analyzes the entire image as a whole and is not for image segmentation. The analysis routine operates across all distances, frequencies and directions in the image, and is not computationally burdensome. The method was applied to scanning electron microscope images of reverse osmosis membranes on domains from 23 nm to 3 µm. The texture analysis technique performed well in identifying the surface morphology and, once calibrated, in predicting the surface roughness as measured by atomic force microscopy.

Measurement of cytokines in the lower female genital tract offer insight into risk for HIV infection and reproductive complications. However, few studies have systematically compared mucosal collection methods or whether collection order matters. We compared longitudinal cytokine profiles in matched genital samples collected from women living with HIV using menstrual cup (MC), endocervical swabs (ECS) and swab-enriched cervicovaginal lavage (eCVL). Samples were collected at enrollment [MC:ECS:eCVL], 3-months (ECS:eCVL:MC) and 6-months (eCVL:MC:ECS) and concentrations of 28 cytokines determined by Luminex. Cytokine clustering was assessed using Principle Component Analysis (PCA), Partial Least Squares Discriminant Analysis (PLSDA) and factor analysis. Generally, higher cytokine concentrations were detected in MC samples, followed by ECS and eCVL, irrespective of study visit or sampling order. Factor analysis and PCA identified ECS to be inferior for measuring regulatory cytokines and IP-10 than eCVL or MC. Although concentrations differed, the majority of cytokines correlated between methods. Sampling order influenced cytokine concentrations marginally, and cytokines clustered more strongly by method than study visit. Variance in profiles was lowest in MC, suggesting greater consistency of sampling compared to other methods. We conclude that MC sampling offered advantages over other methods for detecting cytokines in women, with order marginally influencing profiles.

Background: High HIV incidence has been detected among men who have sex with men (MSM) in Thailand, but the relationship and timing of HIV, herpes simplex virus 2 (HSV-2), and syphilis is unknown. This analysis measures incidence, temporal relationships, and risk factors for HIV, HSV-2, and syphilis among at-risk MSM in the Bangkok MSM Cohort Study., Methods: Between April 2006 and December 2010, 960 men negative for HIV, HSV-2, and syphilis at entry enrolled and contributed 12-60 months of follow-up data. Behavioral questionnaires were administered at each visit; testing for HIV antibody was performed at each visit, while testing for syphilis and HSV-2 were performed at 12 month intervals. We calculated HIV, HSV-2, and syphilis incidence, assessed risk factors with complementary log-log regression, and among co-infected men, measured temporal relationships between infections with Kaplan-Meier survival analysis and paired t-test., Results: The total number of infections and incidence density for HIV, HSV-2, and syphilis were 159 infections and 4.7 cases/100 PY (95 % Confidence Interval (CI): 4.0-5.4), 128 infections and 4.5/100 PY (95 % CI: 3.9-5.5), and 65 infections and 1.9/100 PY (95 % CI: 1.5-2.5), respectively. Among men acquiring >1 infection during the cohort period, mean time to HIV and HSV-2 infection was similar (2.5 vs. 2.9 years; p = 0.24), while syphilis occurred significantly later following HIV (4.0 vs. 2.8 years, p < 0.01) or HSV-2 (3.8 vs. 2.8 years, p = 0.04) infection. The strongest independent predictor of any single infection in adjusted analysis was acquisition of another infection; risk of syphilis (Adjusted Hazards Ratio (AHR) = 3.49, 95 % CI: 1.89-6.42) or HIV (AHR = 2.26, 95 % CI: 1.47-3.48) acquisition during the cohort was significantly higher among men with incident HSV-2 infection. No single independent behavioral factor was common to HIV, HSV-2, and syphilis acquisition., Conclusion: HIV and HSV-2 incidence was high among this Thai MSM cohort. However, acquisition of HIV and co-infection with either HSV-2 or syphilis was low during the time frame men were in the cohort. Evaluation of behavioral risk factors for these infections suggests different risks and possible different networks.

People who inject drugs (PWID) are at increased HIV transmission risk because of unsafe injecting practices and a host of other individual, network, and structural factors. Thus, PWID have a great need for services within the Cascade of HIV prevention, diagnosis, care, and treatment (HIV Cascade). Yet the systems that monitor their progress through the Cascade are often lacking. Subsequently, fewer reliable data are available to guide programs targeting this key population (KP). Programmatic data, which are helpful in tracking PWID through the Cascade, also are limited because not all countries have harm reduction programming from which to estimate Cascade indicators. Also, due to stigma and the illegal nature of drug use, PWID may not disclose their drug use behavior or HIV status when accessing services. Consequently, PWID appear to have low HIV testing rates and, for those living with HIV, lower access to health services and lower viral suppression rates than do other KP groups. This commentary, based on outcomes from an international stakeholder meeting, identifies data gaps and proposes solutions to strengthen strategic information (SI), the systematic collection, analysis, and dissemination of information, to optimize HIV prevention, care, and treatment programming for PWID.

Background: Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan., Methods: Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007-December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models., Results: Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9-125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3-44.6) and 1.5/100 p-y (95 % CI 0.6-3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31-0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01-1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01-100.3) independently predicted HIV infection., Conclusion: There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

Background: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection are prevalent among men who have sex with men (MSM) and may infect multiple anatomic sites. We measured site-specific prevalence and correlates of CT and NG infection among Bangkok MSM Cohort Study participants., Methods: In April 2006 to November 2010, 1744 men enrolled in the Bangkok MSM Cohort Study. Participants provided historical information and underwent physical examination. Rectal, urethral, and pharyngeal CT and NG screening were performed by nucleic acid amplification and/or culture. Logistic regression was used to identify correlates of site-specific CT, NG, and coinfection., Results: Among 1743 participants, 19.2% were infected with CT and/or NG. CT, NG, and CT-NG coinfection were detected in 11.6%, 4.6%, and 2.9%, of participants, respectively. Rectal, urethral, and pharyngeal CT infections were detected in 9.5%, 4.5%, and 3.6% of cases. N. gonorrhoeae was present at these sites in 6.1%, 1.8%, and 0.5% of cases. Most infections were asymptomatic (CT: 95.3%, NG: 83.2%). Rectal CT and NG infections were mutually associated (CT: adjusted odds ratio [AOR], 5.4; 95% confidence interval [CI], 3.4-8.7; NG: AOR, 2.4; 95% CI, 1.1-5.2) and independently associated with HIV infection (CT: AOR, 1.6, 95% CI, 1.0-2.4; NG: AOR, 2.0, 95% CI, 1.3-3.1). Numerous behavioral correlates of infection were observed., Conclusions: CT and NG infections are highly prevalent among MSM in Bangkok, most frequently affect the rectum, and are most often asymptomatic. Routine screening of asymptomatic MSM for CT and NG infection should include rectal sampling and focus on men with HIV and a history of other sexually transmitted infections.

Polyvinylidene chloride (PVDC) co-polymer resins are commonly formulated with a variety of solid additives for the purpose of processing or stabilization. A homogeneous distribution of these additives during handling and processing is important. The Dow Chemical Company developed a process to incorporate solid materials in latex form onto PVDC resin bead surfaces using a coagulation process. In this context, we present a method to characterize the distribution and thickness of these latex coatings. The difference in backscattered electron signal from the higher mean atomic number PVDC core and lower atomic number latex coating in conjunction with scanning electron microscopy (SEM) imaging using a range of accelerating voltages was used to characterize latex thickness and distribution across large numbers of beads quickly and easily. Monte Carlo simulations were used to quantitatively estimate latex thickness as a function of brightness in backscatter electron images. This thickness calibration was validated by cross-sectioning using a focused ion-beam SEM. Thicknesses from 100 nm up to about 1.3 µm can be determined using this method.

Background: We surveyed HIV patients with late-stage disease in southern Vietnam to determine if barriers to access and service quality resulted in late HIV testing and delays from initial diagnosis to entry into HIV care., Methodology: 196 adult patients at public HIV clinics with CD4 counts less than 250 cells/mm3 completed a standardized questionnaire. We used multivariate analysis to determine risk factors for delayed entry into care, defined as >3 months time from diagnosis to registration., Results: Common reasons for delayed testing were feeling healthy (71%), fear of stigma and discrimination in the community (43%), time conflicts with work or school (31%), did not want to know if infected (30%), and fear of lack of confidentiality (27%). Forty-five percent of participants delayed entry into care with a median CD4 count of 65 cells/mm3. The most common reasons for delayed entry were feeling healthy (51%), fear of stigma and discrimination in the community (41%), time conflicts with work or school (33%), and fear of lack of confidentiality (26%). Independent predictors for delayed entry were feeling healthy (aOR 3.7, 95% CI 1.5-9.1), first positive HIV test at other site (aOR 2.9, CI 1.2-7.1), history of injection drug use (IDU) (aOR 2.9, 95% CI 1.1-7.9), work/school conflicts (aOR 4.3, 95% CI 1.7-10.8), prior registration at another clinic (aOR 77.4, 95% CI 8.6-697), detention or imprisonment (aOR 10.3, 95% CI 1.8-58.2), and perceived distance to clinic (aOR 3.7, 95% CI 1.0-13.7)., Conclusion: Delayed entry into HIV care in Vietnam is common and poses a significant challenge to preventing AIDS and opportunistic infections, decreasing mortality, and reducing HIV transmission. Improved linkages between testing and care are needed, particularly for patients who feel healthy, as well as incarcerated and drug-using populations who may face structural and social barriers to accessing care.

Background: Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits., Methods: A cross-sectional sample of male ANA recruits aged 18-35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates., Results: Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 - 0.93), and HCV (0.82%, 95% CI: 0.58 - 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 - 2.05)., Conclusion: Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.

Objective: To assess awareness of and interest in intrauterine contraceptive device (IUCD) use among HIV-positive women in Cape Town, South Africa., Design: Cross-sectional survey., Methods: HIV-positive women aged 18 through 45 years presenting for care at a primary health care clinic in Cape Town, South Africa participated in this study. Consented participants completed a staff-administered questionnaire in a private setting. Descriptive statistics were generated. Comparisons between demographic and reproductive health-related variables and IUCD awareness and interest were performed with multiple logistic regression. Analyses for IUCD interest excluded women with prior surgical sterilization., Results: Of 277 HIV-positive women, 37% were aware of the IUCD; awareness was independently associated with greater age (adjusted odds ratio (AOR)=1.15, 95%; confidence interval (CI): 1.10-1.20) and not switching contraceptive methods in the last year (AOR=2.45, 95% CI: 1.03-5.83). Following an IUCD information session, 86% of women (n=206/240) were interested in IUCD use. IUCD interest was inversely associated with age (AOR=0.91, 95% CI: 0.86-0.97) and marginally positively associated with current menstrual bleeding pattern complaints (AOR=2.14, 95% CI: 0.98-4.68)., Conclusions: Despite low levels of method awareness, HIV-positive women in this setting are frequently interested in IUCD use, indicating need for programming to expand method access.

Closed cell polymer foam skin thickness can be assessed by taking backscatter electron (BSE) images in a scanning electron microscope (SEM) at a series of accelerating voltages. Under a given set of experimental conditions, the electron beam mostly passes through thin polymer skin cell walls. That cell appears dark compared to adjacent thicker-skinned cells. Higher accelerating voltages lead to a thicker skin being penetrated. Monte Carlo modeling of beam-sample interactions indicates that at 5 keV, skin less than ∼0.5 μm in thickness will appear dark, whereas imaging at 30 keV allows skin thicknesses up to ∼4 μm to be identified. The distribution of skin thickness can be assessed over square millimeters of foam surface in this manner. Qualitative comparisons of the skin thicknesses of samples can be made with a simple visual inspection of the images. A semiquantitative comparison is possible by applying image analysis. The proposed method is applied to two example foams. Characterizing foam skin thickness by this method is possible using any SEM that is capable of collecting useful BSE images over a range of accelerating voltages. Imaging in low vacuum, where an electrically conductive metal coating is not required, leads to more sensitivity in skin thickness characterization.

Background: A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population., Methods: IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use., Results: Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58 - 22.38 and AOR = 2.33, 95% CI: 1.38 - 3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22 - 5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16 - 2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06 - 2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08 - 1.82)., Conclusions: HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.

Objectives: To assess differences between injecting drug users (IDUs) with hepatitis C virus (HCV) viremia and IDUs with HCV antibody (Ab) or no evidence of prior infection in three Afghan cities., Methods: IDUs in Hirat, Jalalabad, and Mazar-i-Sharif completed questionnaires and rapid testing for blood-borne infections including HCV Ab. HCV Ab was confirmed with a recombinant immunoblot assay (RIBA); RIBA-positive specimens underwent reverse transcriptase polymerase chain reaction (RT-PCR) for HCV. Risk behaviors associated with viremia were assessed with site-controlled ordinal regression analysis., Results: Of 609 participants, 223 (36.6%) had confirmed HCV Ab. Of 221 with serum available for PCR evaluation, 127 (57.5%) were viremic. HCV viremia prevalence did not differ by site (range 41.7-59.1%; p=0.52). Among all IDUs, in age and site-controlled ordinal regression analysis, HCV was independently associated with HIV co-infection (adjusted odds ratio (AOR) 7.16, 95% confidence interval (CI) 4.41-11.64), prior addiction treatment (AOR 1.95, 95% CI 1.57-2.42), ever aspirating and re-injecting blood (AOR 1.62, 95% CI 1.18-2.23), prior incarceration (AOR 1.60, 95% CI 1.04-2.45), and sharing injecting equipment in the last 6 months (AOR 1.35, 95% CI 1.02-1.80)., Conclusion: HCV viremia was present in many participants with prior HCV infection and was associated with some injecting risk behaviors, indicating a substantial risk for transmission. Current harm reduction programs should aim to improve HCV awareness and prevention among IDUs in Afghanistan as a matter of urgency., (Copyright © 2010 International Society for Infectious Diseases. All rights reserved.)

This study explored perceptions towards and utilization of contraception among HIV-positive, reproduction-age women in Kericho, Kenya, an area with high HIV and low contraceptive prevalence rates. Qualitative methods were used in three focus group discussions and 15 in-depth interviews to gather data from 46 HIV-positive women ages 18 to 45, purposively selected by age strata. Analysis was performed using ATLAS-ti (ATLAS-ti Center, Berlin). Most participants reported familiarity with modern contraceptives. Participants generally perceived that men opposed contraception. Some women indicated that their HIV status dictated contraceptive decisions, particularly with regard to abstinence. Women reported method discontinuation because of side effects, having met desired parity, and menstrual changes. Findings suggested that perceptions about side effects, opinions of the male partner, and HIV disease progression play important roles in contraceptive decisions. Counseling can dispel incorrect information and optimize contraceptive practice in this setting.

Background: : Injecting drug use is increasing in Afghanistan but little is known about sexual risk behaviors and sexually transmitted infection (STI) prevalence among injection drug users (IDU). The purpose of this study is to assess prevalence and correlates of syphilis and condom use with female sex workers (FSWs) among male IDUs in Hirat, Jalalabad, Kabul, and Mazar-i-Sharif, Afghanistan., Methods: : Participants in this cross-sectional study completed an interviewer-administered questionnaire and serologic testing for syphilis between June 2005 and January 2008. Factors associated with syphilis condom use with FSWs were assessed with site-controlled logistic regression analysis., Results: : Of 1078 male IDUs, most (90.3%) reported prior sexual experience, of whom 27.6% reported any condom use. Sexual experiences with FSWs (58.1%) and men or boys (25.7%) were common, although prior condom use with FSWs (32.6%) or male partners (10.8%) was relatively rare. Few reported having a lifetime STI diagnosis (6.3%, n = 68) or symptoms (10.4%, n = 110) in the last 6 months. Prevalence of syphilis was 3.72% (95% CI: 2.66%-5.06%) and varied significantly between sites ranging from 0% (Jalalabad) to 13.9% (Mazar-i-Sharif) (P < 0.001)). Syphilis was significantly associated with STI diagnosis (adjusted odds ratio [AOR] = 3.84) or sex with FSWs (AOR = 3.82) in the last 6 months, and with lower (≤6 years) educational level (AOR = 2.20). Prior condom use with FSWs was independently associated with living outside Afghanistan in the last decade (AOR = 5.52, 95% CI: 1.83-16.71), higher income (AOR = 2.03, 95% CI: 1.17-3.51), greater number of lifetime partners (AOR = 1.80, 95% CI: 1.32-2.45), and younger age (AOR = 0.985, 95% CI: 0.973-0.998)., Conclusions: : Although prevalence of syphilis and condom use varied significantly by site, high levels of risky sexual behavior were common, and consistent condom use was rare among IDUs in Afghanistan. Harm reduction programming should incorporate sexual risk reduction and condom promotion and distribution in Afghan cities.

Background: Hepatitis C virus (HCV) prevalence is high among injection drug users (IDUs) in Afghanistan. Duration of injection and young age at first injection are common risk factors for HCV in IDU populations. The association of HCV with these time factors was analyzed., Methods: Socio-demographic and drug use behavior information were collected. Participants had rapid testing for HCV with recombinant immunoblot assay confirmation. Modeling of non-linear associations was performed using fractional polynomial logistic regression., Results: Among 459 male IDUs, age at first injection had a constant HCV risk (odds ratio (OR): 1.01 per year; 95% confidence interval (CI): 0.98-1.03), while each additional year of injection drug use had a significantly increased risk (OR: 4.72 per year, 95% CI: 2.92-7.66). HCV risk increased significantly with each additional year of injecting drug use by groups of injectors: young (< or =22 years, OR: 1.97; 95% CI: 1.27-3.07), middle (23-28 years, OR: 1.76; 95% CI: 1.28-2.43) and older (> or =29 years, OR: 7.56; 95% CI: 3.15-18.14)., Conclusion: The probability of HCV infection increased markedly by duration of injection drug use and varied according to age at first injection. Drug counseling and educational efforts should be directed to older drug users who have not yet initiated injecting and to young IDUs to avert infection and reduce risky drug use behaviors.

Objective: To assess prevalence of HIV, syphilis, and hepatitis B (HBV) and C virus (HCV) and associated risk behaviors among female sex workers (FSWs) in three Afghan cities., Design: Cross-sectional prevalence assessment., Methods: Consented FSWs from Jalalabad, Kabul, and Mazar-i-Sharif completed an interviewer-administered questionnaire, pretest and posttest counseling, and rapid and confirmatory testing for HIV, HCV, HBV, and syphilis. Logistic regression was used to detect correlates associated with HBV infection., Results: Of 520 participants, median age and age of initiating sex work were 29 and 23 years, respectively, and the median number of monthly clients was 12. Few FSWs reported ever having used illicit drugs (6.9%) or alcohol (4.7%). Demographic and risk behaviors varied significantly by enrollment site, with Kabul FSWs more likely to report sexually transmitted infection symptoms, longer sex work duration, and sex work in other cities. Prevalence of HIV was 0.19%, HCV was 1.92%, and HBV was 6.54%, with no cases of syphilis detected. HBV was independently associated with at least 12 clients monthly [adjusted odds ratio (AOR) = 3.15, 95% confidence interval (CI) 1.38-7.17], ever using alcohol (AOR = 2.61, 95%CI 1.45-4.69), anal sex (AOR = 2.42, 95%CI 1.15-5.08), and having children (AOR = 2.12, 95%CI 1.72-2.63) in site-controlled multivariable analysis., Conclusion: Although prevalence of HIV, HCV, and syphilis is currently low in these three Afghan cities, risky sexual practices were common and associated with HBV. Programming inclusive of voluntary testing for HIV, viral hepatitis, and sexually transmitted infections, hepatitis vaccination, substance abuse prevention, and condom promotion for both FSWs and clients should be pursued in Afghanistan.

Background: Little current information is available for prevalence of vertically-transmitted infections among the Afghan population. The purpose of this study is to determine prevalence and correlates of human immunodeficiency virus (HIV), syphilis, and hepatitis B and C infection among obstetric patients and model hepatitis B vaccination approaches in Kabul, Afghanistan., Methods: This cross-sectional study was conducted at three government maternity hospitals in Kabul, Afghanistan from June through September, 2006. Consecutively-enrolled participants completed an interviewer-administered survey and whole blood rapid testing with serum confirmation for antibodies to HIV, T. pallidum, and HCV, and HBsAg. Descriptive data and prevalence of infection were calculated, with logistic regression used to identify correlates of HBV infection. Modeling was performed to determine impact of current and birth dose vaccination strategies on HBV morbidity and mortality., Results: Among 4452 women, prevalence of HBsAg was 1.53% (95% CI: 1.18 - 1.94) and anti-HCV was 0.31% (95% CI: 0.17 - 0.53). No cases of HIV or syphilis were detected. In univariate analysis, HBsAg was associated with husband's level of education (OR = 1.13, 95% CI: 1.01 - 1.26). Modeling indicated that introduction of birth dose vaccination would not significantly reduce hepatitis-related morbidity or mortality for the measured HBsAg prevalence., Conclusion: Intrapartum whole blood rapid testing for HIV, syphilis, HBV, and HCV was acceptable to patients in Afghanistan. Though HBsAg prevalence is relatively low, periodic assessments should be performed to determine birth dose vaccination recommendations for this setting.

Limited prevalence data for HIV, hepatitis B surface antigen (HBsAg), and hepatitis C virus (HCV) exist for Afghanistan. We studied a cross-sectional sample of adult injection drug users (IDUs) in Kabul, Afghanistan, from June 2005 through June 2006. Study participants completed interviewer-administered questionnaires and underwent testing for HIV, antibody to HCV, and HBsAg. Overall prevalences of HIV, HCV, and HBsAg were 3.0% (95% confidence interval [CI] 1.7%-5.1%), 36.6% (95% CI 32.2%-41.0%), and 6.5% (95% CI 4.2%-8.7%), respectively (N = 464). Among male IDUs (n = 463), risky behavior, including sharing syringes (50.4%), paying women for sex (76.2%), and having sex with men or boys (28.3%), were common. Needle sharing, injecting for > or = 3 years, and receiving injections from nonmedical providers were independently associated with increased risk for HCV infection. The high prevalence of risky behavior indicate that Kabul is at risk for an HIV epidemic. Scale-up of harm-reducing interventions is urgently needed.

Background: Little is known about human immunodeficiency virus (HIV) awareness among Afghan injecting drug users (IDUs), many of whom initiated injecting as refugees. We explored whether differences in HIV awareness and knowledge exist between Afghan IDUs who were refugees compared to those never having left Afghanistan., Methods: A convenience sample of IDUs in Kabul, Afghanistan was recruited into a cross-sectional study through street outreach over a one year period beginning in 2005. Participants completed an interviewer-administered questionnaire and underwent voluntary counseling and testing for HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibody. Differences in HIV awareness and specific HIV knowledge between IDU who lived outside the country in the last decade versus those who had not were assessed with logistic regression., Results: Of 464 IDUs, 463 (99%) were male; median age and age at first injection were 29 and 25 years, respectively. Most (86.4%) had lived or worked outside the country in the past ten years. Awareness of HIV was reported by 46.1%; those having been outside the country in the last decade were significantly more likely to have heard of HIV (48.3% vs. 31.7%; OR = 2.00, 95% CI: 1.14 - 3.53). However, of those aware of HIV, only 38.3% could name three correct transmission routes; specific HIV knowledge was not significantly associated with residence outside the country., Conclusion: Accurate HIV knowledge among Afghan IDUs is low, though former refugees had greater HIV awareness. Reported high-risk injecting behavior was not significantly different between IDU that were refugees and those that did not leave the country, indicating that all Afghan IDU should receive targeted prevention programming.

Objectives/goal: To assess prevalence of and correlates to human immunodeficiency virus (HIV) infection among female sex workers in Tashkent, Uzbekistan., Study Design: Women participating in this cross-sectional study completed a questionnaire and HIV testing between April 2003 and March 2004. Logistic regression analyses determined correlation of variables to HIV infection., Results: Of 448 women, 10% (45) were HIV infected, which was associated with ever injecting drugs (AOR = 20.20; 95% confidence interval [CI], 7.69-53.07), street-based sex work (AOR = 4.52; 95% CI, 1.84-11.12), exchanging sex for drugs (AOR = 4.74; 95% CI, 1.84-12.18), and more sexually transmitted infection treatments in the preceding 3 months (AOR = 2.43; 95% CI, 1.14-5.17)., Conclusions: Although injection drug use is the strongest correlate to HIV infection, sexual risk behaviors are independently related and should receive focus in prevention efforts targeted to this population.

Opium has been cultivated in Afghanistan since 1100 A.D., although production has steadily increased since 1979. Currently, Afghanistan produces three-quarters of the global opium supply, with injection drug use and HIV currently following the opium trade route through Central Asia. Although systematic studies are lacking, heroin use appears to be on the rise in Afghanistan. The purpose of this paper is to briefly provide historical background and current statistics for drug production and use in Afghanistan, to discuss the new government's policies towards problem drug use and available rehabilitation programs, and to assess Afghan harm reduction needs with consideration of regional trends.