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BackgroundReproductive tract infections (RTIs) are a major cause of morbidity and mortality, yet RTI testing remains limited in resource-constrained settings. We assessed performance of an existing RTI risk assessment screening tool among women living with HIV (WLHIV) considering intrauterine contraceptive (IUC) use.MethodsWe conducted a cross-sectional analysis among WLHIV screened for participation in an IUC trial in Cape Town, South Africa (NCT01721798). RTI testing included Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and bacterial vaginosis. Tool scoring was based on five separately scored criteria: (1) age under 25 years, (2) cohabitation with a partner, (3) secondary education, (4) self-reported intermenstrual bleeding and (5) number of current sexual partners and condom use frequency (score 0–5). We assessed tool performance in detecting RTI at 0 vs 1–5, 0–1 vs 2–5 and 0–2 vs 3–5 score thresholds.ResultsOf 303 women, 52% (n=157) reported antiretroviral therapy use and median age was 31 years. The prevalence of any RTI was 38% (gonorrhoea=7%, chlamydia=11%, trichomoniasis=12% and bacterial vaginosis=18%) and 8% of women had multiple RTIs. Overall, 4%, 27% and 69% of women had screening tool scores of 0, 1 or 2+, respectively. At a threshold of at least one scored criterion, the tool demonstrated high sensitivities (95%–97%) but low specificities (3%–4%) for detecting any RTI. Increasing the score threshold and/or inclusion of abnormal vaginal discharge marginally improved specificity.ConclusionThe prevalence of RTIs observed in this population was high, and the screening tool had no discriminatory power to detect prevalent RTIs.

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.

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., Catherine Todd and colleagues study an intrauterine contraceptive device in women with HIV infection., Author summary Why was this study done? Women living with HIV (WLHIV) infection must consider their contraceptive options in tandem with and complicated by potential interactions between hormonal contraception and HIV disease. These issues potentially contribute to lower use of highly effective hormonal contraceptive methods among WLHIV. Global use of intrauterine contraception (IUC), specifically the levonorgestrel intrauterine system (LNG-IUS), has increased across the last decade. However, there are few trials comparing safety of the LNG-IUS with that of the copper intrauterine device (C-IUD) among WLHIV and none focusing specifically on impact on HIV disease. What did the researchers do and find? In a randomized controlled trial in Cape Town, South Africa, 199 women with confirmed HIV seropositivity and not desiring pregnancy in the next 30 months were recruited and allocated, with 98 receiving the C-IUD and 101 the LNG-IUS. Participants had genital tract samples collected by menstrual cup and blood taken for genital and plasma viral load levels at enrollment and at 3-, 6-, 12-, 18-, and 24-month visits. Women could return at any time for unscheduled visits and remained in the study even if the IUC was removed on request. Women receiving the LNG-IUS did not have any significant difference in change in detectable genital tract viral load compared with C-IUD users, regardless of ART status. However, women receiving the C-IUD were more likely to have the IUC removed than those receiving the LNG-IUS through the study period. What do these findings mean? This study is among the first comparing a hormonal to nonhormonal long-acting reversible contraceptive method with genital tract HIV RNA as the primary outcome among WLHIV. These data suggest that LNG-IUS is as safe as the C-IUD for WLHIV and will strengthen international medical eligibility guidelines. The high continuation rates of the LNG-IUS, critically important for a device with a 5-year duration of use, should prompt including this method in the available method mix to promote the ability of WLHIV to meet their fertility goals.

HIV prevention and care is changing rapidly; guideline revisions and programmatic scale-up require innovative approaches to in-service training and care extension to improve provider practice and care access. We assessed recent (≤12 months) peer-reviewed publications on electronic health (eHealth), telemedicine, and other innovative provider-targeted interventions for HIV-related care.Key developments included systems merging electronic medical records (EMR) with provider clinical decision aids to prompt action, demonstration eHealth, and telemedicine projects, reviews or descriptions of technology to improve connectivity in lower resource settings, and a few trials on provider-centered interventions. Most publications were program reports and few data were available regarding efficacy of eHealth interventions for providers on patient HIV-related outcomes, notably identification and management of antiretroviral treatment failure in Kenya. Better evidence is needed for strategies to train providers and care extenders with the goal to improve impact of HIV prevention and care interventions.Rapid technology introduction and expansion may change the paradigm for improving provider knowledge and practice. Although new, the developments are promising for HIV provider-targeted eHealth and innovations for traditional training. More rigorous testing with randomized trials is needed to demonstrate impact on services for people living with HIV.

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.

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., Catherine Todd and colleagues reveal that nutritional education and micronutrient supplements can reduce intrapartum and postpartum complications in pregnant women in Bangladesh., Author summary Why was this study done? Adequate nutrition during pregnancy reduces risks of poor infant outcomes, like low birthweight, but there is relatively little information about whether nutrition is linked to reducing a woman’s risk of pregnancy complications. Maternal nutrition interventions starting during pregnancy are being implemented at scale in multiple settings, including in Bangladesh, and determining whether these interventions reduce maternal complications may strengthen efforts to implement similar interventions to optimize maternal and newborn health. What did the researchers do and find? At the time of the endline evaluation for the parent trial—which compared an intervention of home-based intensive maternal nutrition counseling and iron and calcium supplement provision combined with home-based antenatal care to home-based antenatal care alone—we interviewed women who had delivered within the last 60 days to inquire about complications during pregnancy, during delivery, and after delivery. This study included 594 women in the intervention group and 506 in the control group across 4 districts in Bangladesh; women in the 2 groups were similar with regard to number of prior pregnancies, age, and household assets. Reported complication rates during pregnancy or during delivery were somewhat lower among women from intervention areas, while reported complications after delivery were significantly lower among women from intervention areas, compared to those from control areas. What do these findings mean? Differences in reported complication rates may be due to actual differing levels resulting from intervention exposure, or to different perceptions of what conditions constitute pregnancy complications, which could also result from intervention exposure. The intervention did not appear to impact care-seeking during pregnancy or during labor based on similar skilled/facility-based care statistics for the intervention and control groups. Community-based care providers recorded key obstetric events accurately and at high rates, but greater understanding of client and provider perceptions regarding what constitutes maternal complications and ensuring provision of appropriate care are needed. Given the cross-sectional nature of the study and that complications were self-reported, the findings should be interpreted with caution.

Background: Hormonal contraceptives may increase genital tract HIV viral load (gVL) and risk for sexual transmission in women living with HIV (WLHIV). We compared detectable gVL and intrauterine contraceptive (IUC) continuation between levonorgestrel intrauterine system (LNG-IUS) versus copper intrauterine device (C-IUD) in Cape Town, South Africa. Methods: In this double-masked, randomised controlled trial, eligible WLHIV were: ages 18-40, not pregnant or desiring pregnancy within 30 months, and virologically-suppressed using antiretroviral therapy (ART) or with CD4+ lymphocyte count above treatment threshold at enrolment (non-ART). At enrolment, we randomised within ART groups and provided the allocated IUC to consenting women. At all visits, participants completed questionnaires and provided specimens for gVL, plasma VL, and pregnancy testing. We assessed gVL through six and 24 months controlling for baseline gVL, ART group, age, and reproductive tract infection. Results: We enrolled 67 non-ART (36 LNG-IUS, 31 C-IUD) and 132 ART-using (65 LNG-IUS, 67 C-IUD) women. Detectable gVL did not differ between LNGIUS compared to C-IUD across six (Adjusted Odds Ratio (AOR): 0·82, 95% Confidence Interval (CI): 0·46-1·47) and 24 months (AOR: 0·96, 95% CI: 0·63-1·45). Overall IUC continuation was 80%; C-IUD users experienced higher expulsion (8% vs 1%, p=0·02) and elective discontinuation (adjusted Hazard Ratio: 8·75, 95% CI: 3·08-24·8) rates. Interpretation: The LNG-IUS has no significant effect on gVL, and higher continuation rates when compared with the C-IUD, among WLHIV. Clinical Registration Number: NCT01721798. Funding Statement: Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. National Institutes of Health (5R01HD071804); Preventive Technologies Agreement (No. GHO‑A‑00‑09‑00016-00), U.S. Agency for International Development. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The University of Cape Town and FHI 360 institutional review boards approved the study, and all participants provided written informed consent prior to trial participation.

Objective To identify correlates of severe acute maternal morbidity (SAMM) in Kabul, Afghanistan. Methods The present case-control study enrolled postpartum couples at four public maternity hospitals between September 2007 and December 2009. Eligibility was determined by: spousal consent; SAMM criteria from chart review for cases; and matching by age, parity, and time since previous delivery for controls (uncomplicated deliveries). Staff administered questionnaires to women and their husbands separately. SAMM correlates were analyzed with conditional logistic regression in models including (proximate) and excluding (distal) care factors. Results Among 285 case and 285 control couples, the most frequent SAMM diagnoses were obstructed labor (104 [36.5%]) and hemorrhage requiring transfusion (102 [35.8%]). In both models, SAMM was associated with the husband having more than one wife (distal: adjusted odds ratio [aOR] 48.6, 95% CI 5.4–436.5; proximate: 141.8, 3.5–5819.0), prior stillbirth(s) (distal: 16.2, 6.1–42.9; proximate: 8.0, 2.9–22.4), and complications in a prior pregnancy (distal: 5.4, 95% CI 2.5–12.1; proximate: 7.1, 2.5–20.4). In the proximate model, SAMM was associated with visiting another facility before hospitalization (aOR 7.5, 95% CI 3.1–17.9), male-reported planned home delivery (5.5, 1.5–20.0), and provider-determined care-seeking (4.8, 1.6–14.9). Conclusion Planned home delivery and referral to multiple facilities or by providers are factors associated with SAMM that are potentially amenable to intervention in Afghanistan.

Objective The objective was to assess associations between tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) exposure and levonorgestrel (LNG) concentrations among Kenyan HIV prevention trial participants using Sino-implant (II) LNG implants for contraception. Methods Women were offered implants among other contraceptive methods, were randomized to daily TDF-FTC or placebo, and followed monthly up to 56 weeks. Associations between TDF-FTC exposure and mean LNG values were analyzed with linear mixed models. Results Of 739 women, 29 (3.9%) received implants with no incident pregnancies and one discontinuation. Mean LNG concentrations over 56 weeks among 28 women contributing data ranged between 214.0 and 659.8 pg/mL with no significant difference between TDF-FTC and placebo arms or between variable levels of TDF-FTC adherence. Conclusion Concomitant TDF-FTC use was not associated with a significant change in plasma LNG concentrations among women using Sino-implant (II) in the first year of use.

In low-income settings, many women and girls face activity restrictions during menses, owing to lack of affordable menstrual products. The menstrual cup (MC) is a nonabsorbent reusable cup that collects menstrual blood. We assessed the acceptability and performance of the MPower® MC compared to pads or tampons among women in a low-resource setting.We conducted a randomized two-period crossover trial at one site in Durban, South Africa, between January and November 2013. Participants aged 18-45 years with regular menstrual cycles were eligible for inclusion if they had no intention of becoming pregnant, were using an effective contraceptive method, had water from the municipal system as their primary water source, and had no sexually transmitted infections. We used a computer-generated randomization sequence to assign participants to one of two sequences of menstrual product use, with allocation concealed only from the study investigators. Participants used each method over three menstrual cycles (total 6 months) and were interviewed at baseline and monthly follow-up visits. The product acceptability outcome compared product satisfaction question scores using an ordinal logistic regression model with individual random effects. This study is registered on the South African Clinical Trials database: number DOH-27-01134273.Of 124 women assessed, 110 were eligible and randomly assigned to selected menstrual products. One hundred and five women completed all follow-up visits. By comparison to pads/tampons (usual product used), the MC was rated significantly better for comfort, quality, menstrual blood collection, appearance, and preference. Both of these comparative outcome measures, along with likelihood of continued use, recommending the product, and future purchase, increased for the MC over time.MC acceptance in a population of novice users, many with limited experience with tampons, indicates that there is a pool of potential users in low-resource settings.

Background Women living with HIV (WLHIV) experience high rates of unmet contraceptive need and unintended pregnancy. Contraceptive method-specific continuation rates and associated factors are critical for guiding providers tasked with both reproductive health (RH) and HIV care. We conducted this systematic review to determine whether contraceptive continuation rates differ between WLHIV and uninfected women and, for WLHIV, whether differences are impacted by method type, antiretroviral therapy use or other factors. Methods We searched Ovid MEDLINE, POPLINE and PubMed.gov for studies published between January 1, 2000, and August 31, 2016. Inclusion criteria comprised prospective data of WLHIV, nonbarrier method continuation as an outcome measure, and recorded method switching and/or discontinuation. Results Of 939 citations screened, 22 articles from 18 studies were eligible. For studies with comparator groups, data quality was moderate overall based on Grading of Recommendations, Assessment, Development and Evaluations and Newcastle–Ottawa Quality Assessment scales. Of four studies comparing women by HIV serostatus, two showed higher rates of contraceptive continuation among WLHIV versus uninfected women, while two others detected lower continuation rates for the same comparison. Generally, baseline method continuation exceeded 60% for studies with >12 months of follow-up. Studies providing contraception had higher continuation rates than studies not providing contraception, while women allocated to contraceptive methods in trials had similar continuation rates to those choosing contraceptive methods. Across all studies, continuation rates differed by method and context, with the copper intrauterine device showing greatest variability between sites (51%–91% continuation rates at ≥12 months). Implant continuation rates were ≥86%, though use was low relative to other methods and limited to few studes. Conclusions Contraceptive continuation among WLHIV differs by method and context. More longitudinal studies with contraceptive continuation as a measured outcome following ≥12 months are needed to strengthen integration of RH and HIV care.

Background Central Asia is culturally and demographically diverse, both between and within its respective countries. That diversity is represented in the range of individual, network, community, and structural risks for female sex workers (FSWs) regionally. FSWs have several risk factors for HIV acquisition and transmission including behavioral, biological, and structural risk factors. Across Central Asia, sexual risks have become conflated with risks associated with injection and non-injection illicit drug use. Methods Peer-reviewed literature databases and gray literature were searched for articles on sex work in Central Asia. The medial subject heading (MeSH) of “sex work” was cross-referenced with terms associated with Uzbekistan, Tajikistan, Turkmenistan, Kazakhstan, Kyrgyzstan, Mongolia, and Afghanistan. Results HIV prevalence data for FSWs suggest sustained or increasing prevalence in the region. There are increasing data directly linking HIV among FSWs to injection drug use; odds of HIV are up to 20 times higher among FSWs reporting injecting drug use. Though injecting drug use among FSWs is rare in some settings, recreational drugs and alcohol use limits other risk reduction behaviors, such as condom use. Conclusions The Central Asian HIV epidemic has traditionally been assumed to be driven nearly exclusively by drug use, resulting in surveillance systems focused on parenteral transmission. The reviewed data highlight limited attention to characterizing the burden of HIV and risk factors for HIV acquisition and transmission among FSWs who use drugs. Moving forward will require enhanced HIV surveillance and research to inform HIV prevention approaches to address all levels of HIV risks affecting FSWs in Central Asia.

Hepatitis C virus (HCV) prevalence is high among injecting drug users in Afghanistan, but transmission dynamics are poorly understood. Samples from HCV-infected injecting drug users were sequenced to determine circulating genotypes and potential transmission linkages. Serum samples were obtained from injecting drug user participants in Hirat, Jalalabad, and Mazar-i-Sharif between 2006 and 2008 with reactive anti-HCV rapid tests. Specimens with detected HCV viremia were amplified and underwent sequence analysis. Of 113 samples evaluated, 25 samples (35.2%) were only typeable in NS5B, nine samples (12.7%) were only typeable in CE1, and 37 samples (52.1%) were genotyped in both regions. Of those with typeable HCV, all were Afghan males with a mean age of 31.1 (standard deviation [SD] ± 8.0) years and mean duration of injecting of 3.9 (SD ± 4.3) years. Most reported residence outside Afghanistan in the last decade (90.1%) and prior incarceration (76.8%). HCV genotypes detected were: 1a, (35.2%, n = 25), 3a (62.0%, n = 44), and 1b (2.8%, n = 2). Cluster formation was detected in NS5B and CE1 and were generally from within the same city. All participants within clusters reported being a refugee in Iran compared to 93.5% of those outside clusters. Only 22.2% (4/11) of those within clusters had been refugees in Pakistan and these four individuals had also been refugees in Iran. Predominance of genotype 3a and the association between HCV viremia and having been a refugee in Iran potentially reflects migration between Afghanistan and Iran among IDUs from Mazar-i-Sharif and Hirat and carry implications for harm reduction programs for this migratory population. J. Med. Virol. 85:1170–1179, 2013. © 2013 Wiley Periodicals, Inc.

Problem How does menstrual cup (MC) compare to other genital sampling methods for HIV RNA recovery? Method of study We compared HIV RNA levels between MC, endocervical swab (ECS), and ECS-enriched cervicovaginal lavage (eCVL) specimens in 51 HIV-positive, antiretroviral therapy-naive women at enrollment, 3 and 6 months, with order rotated by visit. Paired comparisons were analyzed with McNemar's exact tests, signed-rank tests, and an extension of Somer's D for pooled analyses across visits. Results MC specimens had the highest proportion of quantifiable HIV VL at enrollment and month 3, but more MC specimens (n=12.8%) were insufficient for testing, compared with ECS (2%, P=0.006) and eCVL (0%, P

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.التغر الذي طرأ عى الاتجاهات والمعارف المتعلقة بمشكلة تعاطي المخدرات والحدّ من أضرارها لدى إحدى الفئات المجتمعية في كابول بأفغانستان.كاثرين تود، م. رازا ستانيكزاي، عبد الناصر، كاتيا فيكرت، مارك أور، ستيفاني ستراثدي، ديفيد فلاوف.هذا التقييم لما قبل وما بعد تطبيق البرنامج يهدف إلى قياس التغرات التي طرأت عى المعارف والاتجاهات تجاه متعاطي المخدرات لدى ممثلن عن المجتمع في كابول بأفغانستان خال فرة من فرات التوسع في تطبيق برنامج لمعالجة إدمان المخدرات والحد من أضرارها. فقد قامت عينة ملائمة تضم 160 مهنياً أعمارهم 18 سنة فا فوق بملء استبيانات مقابَلة في عامي 2007و2009. فتبن أن الآراء المؤيدة لجودة البرنامج ولتوفر الواقي الذكري وتقديم المشورة والاختبارات الخاصة بالعدوى وتوزيع الإبر والمحاقن قد ازدادت زيادة ملحوظة خال هذين العامن. وكان هناك تغر جوهري في مستوى القبول (أكثر من % 10 ) في 13 بياناً من أصل 38، لا سيّما لدى الرجال وأصحاب المهن الطبية. المتعلقة بدعم متعاطي المخدرات إيجابية إلى حد كبر، مع تغرات كبرة في مواقف بعض المجموعات السكانية الفرعية. ربا تكون هناك حاجة إلى مزيد من تثقيف المجتمع - عن طريق وسائل الإعام - وإلى سياسة حكومية أكثر تماسكاً بشأن المخدرات، تعزِّز دعم المجتمع لمعالجة تعاطي المخدرات والحد من أضرارها في أفغانستان.Évolution des attitudes et des connaissances en matière de toxicomanies et de réduction des effets nocifs au sein d’une cohorte communautaire à Kaboul (Afghanistan).La présente évaluation pré-post visait à mesurer l’acquisition de connaissances et les changements d’attitudes à l’égard des toxicomanes parmi les représentants d’une communauté à Kaboul (Afghanistan) au cours d’une période d’élargissement des programmes de réduction des effets nocifs et de traitement de la dépendance aux drogues. Un échantillon de commodité de 160 professionnels âgés de plus de 18 ans a rempli des questionnaires dans le cadre d’entretiens en 2007 et en 2009. Les opinions au sujet de l’application de programmes de qualité et de la fourniture de préservatifs, du conseil et du dépistage en matière d’infections, ainsi que de la distribution d’aiguilles/de seringues se sont considérablement améliorées au cours de ces deux années. Dans 13 des 38 déclarations, on a pu noter un changement notable (10 %) dans le niveau d’acceptation, le plus souvent parmi les hommes et les professionnels de santé. Les attitudes concernant le soutien à apporter aux toxicomanes sont restées positives dans une large mesure, avec des changements d’attitude notables dans certains sous-groupes de la population. Une éducation plus poussée des communautés par le biais des médias et des politiques gouvernementales de lutte contre la drogue plus cohérentes sont nécessaires pour renforcer le soutien communautaire à la réduction des effets nocifs/au traitement des toxicomanies en Afghanistan.

Background Little information is available regarding blood supply safety in Afghanistan. The purpose of this study was to assess blood safety through serologic and observational measures in Afghanistan. Study Design and Methods This cross-sectional assessment included the 40 highest-volume facilities collecting and transfusing blood nationally identified in a previous survey. At each facility, study representatives completed a standardized instrument assessing staff performance of transfusion-related activities and performed rapid testing for human immunodeficiency virus, syphilis, and hepatitis B and C with rapid diagnostic tests on clinically discarded specimens. Reactive samples received confirmatory testing. Descriptive statistics were generated, with differences analyzed using chi-square or Fisher's exact tests. Results Between November 2010 and May 2011, a total of 332 blood donor collection procedures were observed. Only 52.4% of observed encounters correctly screened and deferred donors by international criteria. Public and private facilities demonstrated glove use, proper sharps disposal, and patient counseling and relayed screening test results in less than 75% of observed events, significantly less likely than military facilities (p

BACKGROUND: The purpose of this study was to assess functionality and resources of facilities providing blood collection and transfusion services in Afghanistan. STUDY DESIGN AND METHODS: This national cross-sectional assessment included facilities collecting or transfusing blood identified through official data sources and private key informants. At each facility, study representatives completed a standardized instrument assessing presence of records logbook, electricity, refrigeration, and required transfusion-transmitted infection (TTI; human immunodeficiency virus, syphilis, and hepatitis B and C) test kits. Descriptive statistics were generated, with differences analyzed using chi-square or Fisher's exact tests. RESULTS: Between August and November 2010, a total of 243 facilities were surveyed with public (52.3%, n = 127) and private (43.2%, n = 105) sector comprising the majority. Most (63%) facilities were urban, with 23.5% located in Kabul province. Of 92,682 units collected nationally in the 12 months before evaluation, 7.5% (n = 6952) had no disposition record. Many (62%, n = 151) facilities had an established recordkeeping system; the remainder provided estimates. Half of surveyed facilities had regular power supply (57.8%), refrigerators for storing blood (52.3%), or all necessary TTI test kits (62.1%). Military (83.3%) and public (74.8%) facilities were more likely to have all TTI test kits present compared to private (46.7%, p

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.

Introduction and Aims. Problem drug use has been identified as a significant public health problem in Afghanistan. The study aim was to assess community knowledge and attitude toward drug use and harm reduction in Kabul, Afghanistan. Design and Methods. A cross-sectional convenience sample of community representatives of 10 possible professions were recruited, distributed between the 17 Kabul city districts in 2007. A questionnaire measured sociodemographic characteristics and awareness, knowledge, and attitudes toward drug use and harm reduction. Logistic regression and cluster analysis were performed to test for associations with participant attitude. Results. Of 210 participants, mean age was 36.7 years. Most (98.6%) were Afghan and employed (87.6%). Most (88.6%) were aware of problem drug use in Afghanistan, primarily attributed to unemployment. The majority of participants agreed that addiction is a disease (88.6%) and believed more and better treatment and vocational training facilities were needed (90.5%). Use of only punitive measures in response to drug use was favoured by few (7.1%) participants. Only 33.3% of participants could correctly identify legal consequences of drug use. Discussion and Conclusions. Community acknowledgement of problem drug use and support for addiction treatment are present in Kabul, Afghanistan. However, knowledge gaps concerning drug laws and harm reduction should be addressed in efforts to introduce culturally appropriate harm reduction programming.[Stanekzai MR, Todd CS, Orr MG, Bayan S, Rasuli MZ, Wardak S-R, Strathdee SA. Baseline assessment of community knowledge and attitudes toward drug use and harm reduction in Kabul, Afghanistan. Drug Alcohol Rev 2012;31:451–460]

There is little information about HIV awareness or condom use among female sex workers (FSWs) in Afghanistan. The purpose of this cross-sectional study was to assess HIV awareness, knowledge, and condom use among FSWs in three Afghan cities. FSWs residing in Jalalabad, Kabul, and Mazar-i-Sharif were recruited through outreach programs and completed an interviewer-administered questionnaire and rapid tests for hepatitis B surface antigen, HIV, syphilis, and hepatitis C virus. Logistic regression identified factors associated with HIV awareness, comprehensive HIV knowledge (knowledge that HIV cannot be detected by sight, that condoms prevent HIV, and rejection of local misconceptions about HIV transmission), and consistent condom use (use with every sex act) with clients in the last six months. Of 520 participants, 76.9% had no formal education and 37.7% lived outside Afghanistan in the last five years. Nearly half (44.2%) were aware of HIV but, of these, only 17.4% (N = 40) had comprehensive HIV knowledge. There were significant differences by site; FSWs in Jalalabad were more likely to be aware of HIV but FSWs in Kabul were more likely to have correct HIV knowledge and use condoms consistently with clients. Consistent client condom use was reported by 11.5% (N = 60) and was independently associated with having more clients per month (AOR = 1.99, 95% CI: 1.04-3.81). In conclusion, comprehensive HIV knowledge and consistent condom use with clients are low among Afghan FSWs in these cities. Efforts to reach this population should focus on relaying accurate information and expanding condom use with clients.

Objective: To qualitatively assess the influence of patient–provider communication on contraceptive choice among HIV-positive women in the context of universal antiretroviral therapy (ART) access. Methods: Focus group discussions (FGD; n = 3), in-depth (IDI; n = 15) and freelist interviews (FLI; n = 36) were conducted with HIV-positive women aged 18–40 years recruited from public health units in Rio de Janeiro/Brazil. Results: Of 70 participants, 49 used ART and the median time since HIV diagnosis was 6 years (range: 1– 18). The majority of participants (71.4%) reported some degree of dissatisfaction with their health providers (usually lack of open dialogue) and a few reported experiences of stigma/prejudice during appointments. Intra, interpersonal and social factors modulated behaviors and reproductive health decisions, and those issues were rarely addressed by providers during HIV clinical care. Conclusion: Despite dramatic increases in survival and life quality after universal ART implementation in Brazil, reproductive health issues are neglected by multiple cadres of HIV health providers. Communication on reproductive health issues remains fragmented and potentially contradictory, compromising care in these settings. Practice implications: Adequate provider training to address reproductive health-related issues in a comprehensive, culturally sensitive manner and improved integration of HIV and reproductive health care are urgently needed in this setting.

To determine the prevalence and correlates of prior pregnancy termination and unmet need for contraception among female sex workers (FSWs) in Afghanistan.FSWs in Jalalabad, Kabul, and Mazar-i-Sharif were recruited between June 2006 and December 2007 through outreach programs. Participants completed an interviewer-administered survey describing demographics, behaviors associated with risk of sexually transmitted infections (STIs) and unplanned pregnancy, and medical history. Correlates of prior pregnancy termination and current unmet need for contraception were assessed with logistic regression analysis, controlling for site.Of 520 FSWs, most (82.3%) had been pregnant at least once (mean 4.9 ± 2.7, range 1-17), among whom unplanned pregnancy (36.9%) and termination (33.2%) were common. Jalalabad participants were more likely to report both prior unplanned pregnancy (60.6% vs. 48.3% in Kabul or 20.7% in Mazar, p0.001) and prior termination (54.9% vs. 31.8% in Kabul or 26.8% in Mazar, p0.001). Most FSWs (90.0%) stated pregnancy was not currently desirable, and 85.2% were using contraception. Unmet need for contraception (14.7% of participants) was positively associated with having sold sex outside their city of residence (adjusted odds ratio [AOR] 1.88, 95% confidence interval [CI] 1.28-2.77) and inversely associated with illicit drug use (AOR 0.41, 95% CI 0.31-0.53).Although FSWs in Afghanistan report high rates of contraceptive use, unplanned pregnancy is common. Reproductive health services should be included in programming for FSWs to reduce unplanned pregnancies and to reduce HIV/STI risks.

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 Contraceptive preferences of HIV-infected women must be considered in efforts to integrate HIV and reproductive health services. In South Africa, contraception is often discontinued due to bleeding pattern changes. It is unknown whether HIV-infected women are more sensitive to menstrual changes and how this affects contraceptive choice. This study describes perceptions toward menses and contraceptive-induced amenorrhea among HIV-infected women. Study Design A convenience sample of 42 HIV-infected women aged 15 to 45 years was purposively recruited for three focus groups and 15 in-depth qualitative interviews which were conducted at the Perinatal HIV Research Unit, South Africa. Transcripts were coded and emergent themes grouped. Results One third of women reported HIV-related menstrual changes, unchanged by antiretroviral use. Menstruation was believed to purge the body of “dirty blood.” Women perceived that menstruation had a negative effect on male partner sexual desire, with concern about higher HIV transmission during menstruation. Ninety-six percent of injectable contraceptive users experienced amenorrhea, regarded as troublesome and a reason for discontinuation. Conclusion In Soweto, HIV diagnosis may accentuate linking menstruation with health, leading to avoidance or discontinuation of methods causing amenorrhea. Providers should intensify education on the safety of contraceptive-induced oligo/amenorrhea.

Afghanistan has one of the highest maternal mortality ratios and lowest contraceptive prevalence rates globally. Limited information is known regarding Afghan men and women's attitudes toward childbearing, child spacing, and contraceptive use, which is essential for delivery of appropriate services. We conducted a qualitative study among postpartum couples enrolled at maternity hospitals in Kabul, Afghanistan. We identified important themes that highlight the complex inter-relationship between acknowledged risks of childbearing, desire for family planning, rationales for limited contraceptive use, and sociocultural barriers to contraceptive use. We offer practical recommendations for application of findings toward family planning and maternal mortality reduction programs.

OBJECTIVES To assess diagnosis and management of suspected pulmonary tuberculosis (TB) among patients with respiratory complaints attending Comprehensive Health Centers (CHCs) in Afghanistan. METHODS Consecutive consenting patients presenting with respiratory complaints at 24 health centres in eight provinces were enrolled between November 2005 and February 2006. Demographics, health histories, clinic provider and study representative exam findings and diagnoses, and diagnostic test results were recorded. Correlates of TB-suggestive symptoms (defined as cough >2 weeks and/or haemoptysis) were assessed by logistic regression. RESULTS There were 1401 participants; 24.6% (n = 345) were children (age 17 or under). The TB-suggestive symptoms of cough >2 weeks and/or haemoptysis were reported by 407 (31.3%) and 44(3.3%), respectively, with 39 participants reporting both symptoms. Of 413 participants reporting TB-suggestive symptoms, only 178 (43%) were diagnosed as having suspected TB; 22.0% received no clinical diagnosis. Suspected TB was significantly associated with having a household member residing in a refugee camp within the last 2 years (OR = 6.0; 95% CI: 4.1-8.7), seven or more people sleeping in the same room (OR = 1.9; 95% CI: 1.4-2.6) and cooking with a wood fire in the sleeping room (OR = 1.6; 95% CI: 1.2-2.2) in univariate analysis. CONCLUSIONS Diagnostic sensitivity by the health worker for possible cases of pulmonary TB was low, as 22% of persons with suspected tuberculosis received no diagnosis. Further, some common/chronic respiratory ailments were under-diagnosed. There is great need for improved practical training and continuing education in pulmonary disease diagnosis for clinical health workers.

The purpose of this study was to describe prior use of detoxification and addiction-treatment programs among injection drug users (IDUs) in Kabul, Afghanistan. From 2005-2006, IDUs (n = 464) recruited into this cross-sectional study completed an interviewer-administered questionnaire and whole blood rapid testing with fingerstick samples for HIV, syphilis, and hepatitis C antibody and B surface antigen testing. Participants were predominantly male (99.8%), Afghan (98.9%), and had little formal education. Correlates of detoxification and addiction treatment were identified with logistic regression. The majority (94.0%, n = 435) felt great/urgent need for treatment, of whom 56.3% (n = 245) reported inability to access treatment. Prior detoxification was associated with new needle use with each injection (AOR = 1.91, 95% CI: 1.12-3.26) and prior incarceration (AOR = 1.81, 95% CI: 1.04-3.13). The study's limitations are noted. Rapid scale-up and subsidy of needle and syringe programs and opioid agonist treatment is urgently needed in Kabul.

Objective To determine attitudes toward and utilization of testing for HIV, syphilis, and hepatitis B among obstetric care providers in Kabul, Afghanistan. Design Cross-sectional survey. Setting Three public maternity hospitals in Kabul, Afghanistan. Participants One hundred and fourteen (114) doctors and midwives. Main Outcome Measure Prevalence and correlates of ever having tested patients for HIV, syphilis, and hepatitis B and agreement with statements concerning attitudes toward testing and care. Results Less than half of the patient care providers surveyed had previously tested a patient for HIV, syphilis, or hepatitis B. Presumed rarity of these infections in Afghanistan was the most frequently stated reason for not testing, although many midwives stated that they did not have the authority to order tests. Most providers supported testing to promote neonatal health, but some midwives expressed concern regarding patient and family perceptions. Conclusions Due to logistical and cultural barriers, obstetric care providers underutilize testing for antenatal patients in Afghanistan. Improved training, empowerment of female providers, and availability of rapid testing are needed.

We describe receptive and distributive needle/syringe sharing among injection drug users (IDUs) in Kabul, Afghanistan. In this cross-sectional study, IDUs completed an interviewer-administered questionnaire. Logistic regression identified correlates of needle sharing in the last six months. Receptive and distributive sharing in the last six months were reported by 28.2% and 28.7% of participants, respectively, and were both independently associated with reported difficulty obtaining new syringes (Receptive sharing: AOR = 2.60, 95% CI: 1.66-4.06; Distributive: AOR = 1.56, 95% CI: 1.02-2.39). Receptive and distributive sharing are common among IDU in Kabul; scaling up availability of sterile, no-cost injecting equipment is urgently needed.

BACKGROUND: Theoretical work posits that drug-related risk behaviour increases during armed conflict; however, few studies have been conducted in conflict settings. The objective of this analysis is to determine whether conflict or local displacement impact risk behaviours among people who inject drugs (PWID) in Kabul, Afghanistan. METHODS: Consenting PWIDs aged ≥18 years completed interviews at 3, 6, 9, 12, 18, and 24 months of follow-up. Quarters with peak conflict or local displacement exposure were defined and associations with injecting drug use and sexual risk behaviours analysed with generalized estimating equations. RESULTS: Of 483 PWID enrolled, 385 completed ≥1 follow-up visit (483.8 person-years) between 2007 and 2009. All participants were male, with 35% initiating injecting as a refugee. Sharing syringes (Odds Ratio (OR))=8.53, 95% Confidence Interval (CI): 2.58 – 28.2) and sexually transmitted infection (STI) symptoms (OR=1.72, 95% CI: 1.00 – 2.96) increased significantly during peak conflict quarters, while odds of STI symptoms (OR=0.06, 95% CI: 0.02 – 0.20) and arrest (OR=0.61, 95% CI: 0.40 – 0.93) were significantly lower during periods of displacement. CONCLUSION: Syringe sharing significantly increased during peak conflict periods amongst PWID in Kabul. Programming should include instruction for coping with conflict and prepare clients for harm reduction needs during conflict.

The objective of this paper is to describe prevalence and correlates of sexual risk behaviors among injection drug users (IDUs) in Tashkent, Uzbekistan. Participants in this cross-sectional study completed a questionnaire detailing sociodemographic, medical and drug and sexual risk behaviors and HIV antibody testing. Of 701 IDUs surveyed, only 20.5% reported consistent condom use, which was more likely for women. Prior sexually-transmitted infection (STI) diagnosis was reported by 36.2% of participants and was associated with early (/=18 years) drug initiation, group drug use, being older, higher educational level, marriage, needle sharing, multiple sex partners in the preceding month and daily injection use. Having multiple partners in the preceding month was common (29.71%) and related to employment, consistent condom use with regular partners and STI self-treatment in multivariate logistic regression. Participants with a history of sharing needles were less likely to have had multiple partners in the previous month. Risky sexual behaviors are common and interrelated with risky injection habits among IDUs in Tashkent, Uzbekistan, representing a continued threat of infection with HIV and other blood-borne agents.

BackgroundArmed 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.MethodsConsenting 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.ResultsOf 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 28years and a median duration of injecting of 2years. 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 24months, 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.ConclusionThere 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.

This analysis measures prevalence and correlates of consistent lubricant use among a cohort of Thai men who have sex with men (MSM). Lubricant use was queried at the 12-month follow-up visit. Consistent lubricant use was evaluated with logistic regression. Consistent lubricant use was reported by 77.0% of men and was associated with consistent condom use with casual partners, while binge drinking, payment for sex, and inconsistent condom use with casual, and steady, partners were negatively associated. Though consistent lubricant use is common among this Thai MSM cohort, further promotion is needed with MSM engaging in risky sexual practices.

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.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.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.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.

Objective This study aimed to describe reported contraceptive and abortion utilization and their relationship to human immunodeficiency virus (HIV) infection among female sex workers (FSW) in Tashkent, Uzbekistan. Methods For this cross-sectional study, women were recruited through outreach workers affiliated with Istiqbolli Avlod. Participants completed a self-administered questionnaire and underwent HIV testing. Results Of 448 participants, the majority (86.2%, n =386) used contraception; 39.6% reported inconsistent use. Methods most frequently utilized were condoms (50.9%) and intrauterine devices (16.1%). One fourth (24.3%, n =109) reported multiple (≥3) prior abortions. Inconsistent contraceptive users were more likely to be infected with HIV (AOR=2.72, 95% CI=1.19–6.22), but such infection was not related to a specific contraceptive method, including condoms, or utilization of abortion. Conclusions Inconsistent contraceptive use is common and may be a predictor of HIV infection among Tashkent FSW. Factors preventing consistent contraceptive use may be related to HIV risk and require further study in this population.

Little is known about sex work in Tashkent, Uzbekistan, despite rapid increases in HIV infection. Consistent client condom use and prior HIV testing are described among 448 female sex workers (FSW) completing a self-administered questionnaire, health provider interview, and HIV testing between April 2003 and March 2004. Participants were recruited through outreach workers using modified snowball sampling. Consistent client condom use was more likely for FSW who were married, knew condoms prevent HIV, and from countries in south Central Asia. Prior HIV testing was less likely for FSW younger than 21 years, who shared drugs with clients, initiated sex work at 18 years or less and had engaged in sex work less than 2 years. Low rates of condom use, particularly by those with risky drug behaviors, indicate that targeted risk-reduction interventions are urgently needed.

Objective To assess unintended pregnancy risk and associated factors among female urban Baltimore emergency department (ED) attendees. Methods A cross-sectional anonymous questionnaire study was completed by 790 women, sufficient to detect a 5% difference of unintended pregnancy risk in the national population and a 10% intersite difference with 80% power. The results were analyzed with chi-square tests, univariate and multivariate logistic regression analyses. Results Female ED attendees are at greater risk for unintended pregnancy (33.5%), particularly those of lower income (p=.006) and without a primary care provider (p=.003). Unintended pregnancy risk did not vary between sites by any variable except young age despite the fact that sites varied significantly by race, insurance and income measures. Conclusion Women using the ED are at increased risk for unintended pregnancy and are less likely to have access to a regular medical care source; thus, the ED represents a possible contraceptive provision site.

To assess contraceptive provision site preferences in female urban Baltimore emergency department patients.This cross-sectional questionnaire study was completed by 790 women, a population sufficient to detect a 10% intersite difference. The results were analyzed with chi-square, univariate and multivariate logistic regression analyses.Obtaining contraception other than from a physician's office was acceptable to 57.2% of the subjects, particularly those uninsured (p=.006) and without primary care providers (p.001). Contraceptive provision in the emergency department (ED) was acceptable to 44.0%, particularly those who are frequent ED users (p=.003) and those at risk for unintended pregnancy (p=.024; pooled, p.001). Care in nontraditional settings may preclude pelvic examination; 34.0% of the subjects felt safe obtaining contraception without this examination, significantly for those desiring contraceptive provision in the ED.Contraceptive services are acceptable in nontraditional settings, including the ED, particularly to women of limited resources. This service is acceptable without pelvic examination for a sizable proportion of the women using the ED.