sti epidemiology: global and zimbabwe danuta kasprzyk, phd daniel montaño, phd update on sexually...
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STI Epidemiology: Global and Zimbabwe
Danuta Kasprzyk, PhD
Daniel Montaño, PhD
Update on Sexually Transmitted Infections (STIs) September 28, 2009
Global Burden of STD: WHO Estimates, 2002
Overall 2.9 million deaths (5.2% of total) 91.9 million DALYs (6.3%) all
STDs excluding HIV 179,673 deaths (6.2% of all due to unsafe sex) 11,347,067 DALYs (12.2% of all due to unsafe sex)
Cervical cancer 238,814 deaths (8.2% of all due to unsafe sex) 3,286,698 DALYs (3.4% of all due to unsafe sex)
WHO Global Burden of Disease Project
WHO Estimates of Global Burden of Curable STI in Adults
Estimated Curable
Year Global population STI Cases
1990 5.27 billion 198 million*1995 5.69 billion 333 million1999 5.98 billion 340 million2005 6.46 billion pending
*earlier methodology
HIV/AIDS Global Data
AIDS cases were reported around the world in the early to mid-eighties
AIDS started out as reporting from disease cluster/outbreak investigations First cases reported:
US and Europe: 1981-1982Africa – central: 1983Africa – southern: 1984, 1985Asia – Thailand: 1985
Adults and children estimated to be living Adults and children estimated to be living with HIV as of end 2007with HIV as of end 2007
Total: 33 (30 – 36) million
Western/Central Europe
730 000730 000
Eastern Europe & Central Asia1.5 million1.5 millionNorth America
1.2 million1.2 million
South &SEast Asia4.2 million4.2 million
Oceania
74 00074 000
Sub-Saharan Africa22 million22 million
Latin America1.7 million1.7 million
North Africa & Middle East380 000380 000Caribbean
230 000230 000
Estimated number of adults and childrenEstimated number of adults and childrennewly infected with HIV during 2007newly infected with HIV during 2007
Total: 2.7 (2.2–3.2) million
Western/Central Europe31 00031 000
North Africa & Middle East35 00035 000
Sub-Saharan Africa1.9 million1.9 million
Eastern Europe & Central Asia 150 000150 000
East Asia 92 00092 000
South & SE Asia340 000340 000
Oceania13 00013 000
North America46 00046 000
Caribbean17 00017 000
Latin America100 000100 000
Estimated adult and child deaths Estimated adult and child deaths from HIV/AIDS during 2007from HIV/AIDS during 2007
Total: 2.1 (1.8–2.3) million
Western/Central Europe
8 0008 000North Africa &
Middle East36 00036 000
Sub-Saharan Africa1.51.5 million million
Eastern Europe & Central Asia58 00058 000
East Asia 40 00040 000South
& SE Asia270 000270 000
Oceania1 0001 000
North America23 00023 000
Caribbean14 00014 000
Latin America63 00063 000
Estimated number of adult and child deaths Estimated number of adult and child deaths due to AIDS globally, 1990–2007due to AIDS globally, 1990–2007
This bar indicates the range
Year
90 95 98
Mill
ions
93 96 042000 02 06
0
1.0
1.5
2.0
2.5
91 9992 94 97 0501 03 07
0.5
3.0
Number of adult and child deaths due to AIDS
3
Estimated adult Estimated adult (15–49 years)(15–49 years) HIV prevalence rate HIV prevalence rate (%)(%)
globally and in Sub-Saharan Africa, 1990–2007globally and in Sub-Saharan Africa, 1990–2007
Year
Adult HIV preva-lence rate (%)
0
1
2
3
4
5
6
7
8
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
GlobalGlobal
Sub-Saharan AfricaSub-Saharan Africa
2007 2001
Adult & child deaths due to AIDSAdult prevalence (%)
TOTAL 2.1 million [1.9 – 2.4 million]
1.7 million [1.6 – 2.3 million]
0.8% [0.7% - 0.9%]
0.8% [0.7% - 0.9%]
Regional HIV and AIDS statistics,Regional HIV and AIDS statistics,2001 and 20072001 and 2007
1
North America
Eastern Europe & Central Asia
Latin America
South and South-East Asia
Sub-Saharan Africa
Oceania
Western & Central Europe
Caribbean
East Asia
Middle East & North Africa
55 000[42 000 – 88 000]
21 000[18 000 – 31 000]
58 000[49 000 – 91 000]
270 000[230 000 – 380 00]
1.6 million[1.5 – 2.0 million]
1200[<500 – 2700]
12 000[<15 000]
11 000[9800 – 18 000]
32 000[28 000 – 49 000]
25 000[20 000 – 34 000]
8000[5500 – 14 000]
21 000[18 000 – 31 000]
51 000[44 000 – 100 000]
170 000[120 000 – 220 000]
1.4 million[1.3 – 1.9 million]
<500[1100]
10 000[<15 000]
14 000[13 000 – 21 000]
12 000[8200 – 17 000]
22 000[11 000 – 39 000]
0.6% [0.4% – 0.8%]
0.4% [0.3% – 0.6%]
0.4% [0.3% – 0.5%]
0.3% [0.2% – 0.4%]
5.8% [5.5% – 6.6%]
0.2% [0.1% – 0.3%]
0.2% [0.1% – 0.3%]
1.0% [0.9% – 1.2%]
<0.1% [<0.2%]
0.3% [0.2% – 0.4%]
0.6% [0.5% – 0.9%]
0.9% [0.7% – 1.2%]
0.5% [0.4% – 0.6%]
0.3% [0.2% – 0.4%]
5.0% [4.6% – 5.5%]
0.4% [0.3% – 0.7%]
0.3% [0.2% – 0.4%]
1.0% [0.9% – 1.2%]
0.1% [<0.2%]
0.3% [0.2% – 0.4%]
2007 2001
Regional HIV and AIDS statistics,Regional HIV and AIDS statistics,2001 and 20072001 and 2007
33.2 million [30.6 – 36.1 million]
2007 2001
Adults & children newly infected with HIVAdults & children living with HIV
2.7 million [2.2 – 3.2 million]
3.2 million [2.1 – 4.4 million]
29.0 million [26.9 – 32.4 million]
TOTAL
1
110 000[70 000 – 290 000]
54 000[38 000 – 68 000]
140 000[47 000 – 220 000]
330 000[180 000 – 740 000
1.9 million[1.4 – 2.4 million]
13 000[ 11 000 – 26 000]
27 000[19 000 – 86 000]
20 000[15 000 – 23 000]
52 000[21 000 – 220 000]
40 000[16 000 – 65 000]
230 000[98 000 – 340 000]
44 000[40 000 – 63 000]
130 000[56 000 – 220 000]
450 000[150 000 – 800 000]
2.2 million[1.7 – 2.7 million]
3800[ 3000 – 5600]
32 000[19 000 – 76 000]
20 000[17 000 – 25 000]
77 000[4900 – 130 000]
41 000[17 000 – 58 000]
2007 200122.0 million
[20.9 – 24.3 million]
1.1 million[480 000 – 1.9 million]
1.5 million [1.2 – 2.1 million]
1.7 million [1.4 – 1.9 million]
4.2 million[3.3 – 5.1 million]
74 000[53 000 – 120 000]
730 000[600 000 – 1.1 million]
230 000[210 000 – 270 000]
740 000[620 000 – 960 000]
380 000[270 000 – 500 000]
North America
Eastern Europe & Central Asia
Latin America
South and South-East Asia
Sub-Saharan Africa
Oceania
Western & Central Europe
Caribbean
East Asia
Middle East & North Africa
20.9 million[19.7 – 23.6 million]
1.1 million[390 000 – 1.6 million]
630 000[490 000 – 1.1 million]
1.3 million [1.2 – 1.6 million]
3.5 million[2.9 – 4.5 million]
26 000[19 000 – 39 000]
620 000[500 000 – 870 000]
190 000[180 000 – 250 000]
420 000[350 000 – 510 000]
300 000[220 000 – 400 000]
Global summary of the HIV epidemic, December 2007
The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information..
Number of people living with HIV Total 33.2 million (30.6 – 36.1 M)
People newly infected with HIV in 2007 Total 2.5 million (1.8 – 4.1 M)
Deaths due to AIDS in 2007 2.1 million (1.9 – 2.4 M)
Western & Central Europe
13001300[<1000 – 1800][<1000 – 1800]
Middle East & North Africa26 00026 000
[18 000 – 34 000][18 000 – 34 000]
Sub-Saharan Africa1.8 million1.8 million
[1.7 – 2.0 million][1.7 – 2.0 million]
Eastern Europe & Central Asia
12 000 12 000 [9100 – 15 000][9100 – 15 000]
South & South-East Asia
140 000140 000[110 000 – 180 000][110 000 – 180 000]
Oceania11001100[1200][1200]
North America4400
[2600 – 7300]
Latin America44 00044 000
[37 000 – 58 000][37 000 – 58 000]
East Asia78007800
[5300 – 11 000][5300 – 11 000]Caribbean
11 000[9400 – 12 000]
Children (<15 years) estimated to be living with HIV, 2007
Total: 2.0 million (1.9 – 2.3 million)
Estimated deaths in children (<15 years) from HIV/AIDS during 2007
Western Europe< 200< 200
North Africa & Middle East
4 4004 400Sub-Saharan Africa
240 000240 000
Eastern Europe &Central Asia 16001600
East Asia 1 2001 200
South & South-East Asia 17 000 17 000 Oceania
< 500< 500
North America< 200< 200
Caribbean1 2001 200
Latin America3 1003 100
Total: 270 000 (250 000 – 290 000)
Western & Central Europe
<200[<100]
Middle East & North Africa57005700
[3800 – 8000[3800 – 8000]]
Sub-Saharan Africa330 000330 000
[300 000 – 360 000][300 000 – 360 000]
Eastern Europe & Central Asia
3200 3200 [2400 – 4300][2400 – 4300]
South & South-East Asia21 00021 000
[14 000 – 29 000][14 000 – 29 000]
Oceania<1000<1000
North America<<500[<200]
Latin America46004600
[4200 – 8300][4200 – 8300]
East Asia20002000
[1200 – 3100][1200 – 3100]Caribbean
1800[1500 – 2100]
Estimated number of children (<15 years) newly infected with HIV, 2007
Total: 370 000 (330 000 – 410 000)
Estimated number of children under 18 orphaned by AIDS in sub-Saharan Africa (1990–2007)
6.2 Source: UNAIDS/WHO, 2008
Mill
ion
s
1990 20062003 20051995 2000 200420020
2
4
6
8
10
12
2007
Estimated number of people living with HIV Estimated number of people living with HIV globally, 1990–2007globally, 1990–2007
This bar indicates the range
Year
90 95 98
Mill
ions
93 96 042000 02 06
0
10
20
30
40
91 9992 94 97 0501 03 07
Number of people living with HIV
1
Percent of adults (15+) living with HIV who are Percent of adults (15+) living with HIV who are female, 1990–2007female, 1990–2007
0
10
20
30
40
50
60
70
Percent female (%)
Sub-Saharan AfricaGLOBALCaribbeanAsiaE Europe & C AsiaLatin America
1990‘91‘92 ‘93‘94‘95‘96‘97‘98‘99‘00‘01 ‘02‘03‘04 ‘05‘062007
Year
Estimated number of adults and children living with Estimated number of adults and children living with HIV, by region, 1990–2007HIV, by region, 1990–2007
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20070
5
10
15
20
25
30
35
40
Milli
ons
Number of people living with HIV
OceaniaMiddle East & North AfricaEastern Europe & Central AsiaLatin America and CaribbeanNorth America and W & C Europe
AsiaSub-Saharan Africa
Year
Over 7400 new HIV infections a day in 2007
• More than 96% are in low and middle income countries
• About 1000 are in children under 15 years of age
• About 6300 are in adults aged 15 years and older
of whom:— almost 50% are among women— about 45% are among young people (15-24)
• For every 2 individuals put on treatment, 5 are newly infected
HIV/AIDS in sub-Saharan Africa
2006-2007
HIV prevalence in adults in sub-Saharan Africa, 1990−2005
HIV prevalence (%) in adults (15–49) in Africa, 2007
2.8
Estimated number of people living with HIV in sub-Saharan Africa, 1986–2006
Number of people living with HIV
0
5
10
15
20
25
30
Mill
ion
1986 1992 1996 2006
Year
1988 1990 1994 20021998 2000 2004
Estimated number of people newly infected with Estimated number of people newly infected with HIV in Sub-Saharan Africa, 1990–2007HIV in Sub-Saharan Africa, 1990–2007
Year
0
1
2
3
4
5
199019911992 199319941995 199619971998 199920002001 200220032004 200520062007
Milli
ons
Upper range
Estimate
Lower range
Number of people newly infected with HIV
Estimated number of adult and child deaths Estimated number of adult and child deaths due to AIDS in Sub-Saharan Africa, 1990–2007due to AIDS in Sub-Saharan Africa, 1990–2007
This bar indicates the range
Year
1990 1995 1998
Mill
ions
1993 1996 20042000 2002 2006
0
0.5
1.0
1.5
2.0
1991 19991992 1994 1997 20052001 2003 2007
2.5
Number of adult and child deaths due to AIDS
Median HIV prevalence among women (15-49 years) attending Median HIV prevalence among women (15-49 years) attending antenatal clinics in consistent sites in southern African antenatal clinics in consistent sites in southern African
countries, 1998–2006countries, 1998–2006
Botswana
Lesotho
Namibia
South Africa
Swaziland
Zimbabwe
1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
05
1015202530354045
% HIV prevalence
Sources: Various antenatal clinic surveys.6
Global HIV epidemic, 1990-2005* HIV epidemic in sub-Saharan Africa, 1985-2005*
Number of people living with HIV
% HIV prevalence, adult (15-49)
% HIV prevalence, adult (15‒49)
Number of peopleliving with HIV (millions)
0
10
20
30
40
50
1990 1995 2000 2005
0.0
1.0
2.0
3.0
4.0
5.0
1985 1990 1995 2000 2005
0
5
10
15
20
25
30
0.0
2.5
5.0
7.5
12.5
15.0
% HIV prevalence, adult (15‒49)
Number of peopleliving with HIV (millions)
Estimated number of people living with HIV and adult HIV Estimated number of people living with HIV and adult HIV prevalenceprevalence
This bar indicates the range around the estimate
*Even though the HIV prevalence rates have stabilized in sub-Saharan Africa, the actual number of people infected continues to grow because of population growth. Applying the same prevalence rate to a growing population will result in increasing numbers of people living with HIV.
10.0
Leading causes of death in Africa, 2000
Source: The World Health Report 2001, WHO
22.6
10.1 9.16.7
5.5 4.3 3.6 3.1 2.9 2.3
0.0
5.0
10.0
15.0
20.0
25.0
HIV/AIDS Malaria Perinatalconditions
Tuberculosis
Cerebrovascular disease
Diarrhoeal disease
Lowerrespiratory infections
Measles Ischaemic Heart
disease
Maternalconditions
% ofTotal
Leading causes of disease burden in
Africa, 2000
Source: The World Health Report 2001, WHO
* Unintentional injuries aside from traffic accidents, poisoning, falls, fires and drowning
20.6
10.18.6
6.3 6.14.5 3.6 2.8 1.9 1.8
0.0
5.0
10.0
15.0
20.0
25.0
HIV/AIDS
Malaria
Lowerrespiratoryinfections
Perinatalconditions
Diarrhoealdiseases
Measles
Maternalconditions
Tuberculosis
Otherunintentionalinjuries*
Pertussis
% ofTotal
Impact of AIDS on life expectancy in five African countries, 1970–Impact of AIDS on life expectancy in five African countries, 1970–20102010
Life expectancy at birth (years)
Source: United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database.
Botswana
South Africa
Swaziland
Zambia
Zimbabwe
1970–1975 1975–1980
1980–19851985–1990
1990–19951995–2000
2000–20052005–2010
70
65
60
55
50
45
40
35
30
25
20
4.1
Percentage of distribution of deaths by age in southern Africa, Percentage of distribution of deaths by age in southern Africa, 1985–1990 and 2000–20051985–1990 and 2000–2005
0–4 5–19 20–29 30–39 40–49 50–59 60+
40
35
30
25
20
15
10
5
0
1985-1990 2000-2005
Percentage of total deaths
Age-groups:
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (2005). World Population Prospects: The 2004 Revision. Highlights. New York: United Nations. 4.2
Estimated impact of AIDS on under-five mortality rates 2002–2005, Estimated impact of AIDS on under-five mortality rates 2002–2005, selected countries in sub-Saharan Africaselected countries in sub-Saharan Africa
Without AIDS With AIDS
Sources: UNICEF (2005); United Nations Population Division, World Population Prospects: The 2004 Revision, database.
Deaths per 1,000 live births
117
173
143
74
78
123
118
106
78
142
73
43
43
71
98
42
0 20 40 60 80 100 120 140 160 180 200
Botswana
Kenya
Lesotho
Namibia
South Africa
Swaziland
Zambia
Zimbabwe
4.6
The Zimbabwe AIDS Epidemic: Summary
First reported case: 1984 Prevalence peaked in 1998 at over 30% Overall 2007 HIV prevalence ~ 15.6% Estimated 1.3 million PLWHA
1.1 million adults ~133,000 children
Estimated 135,000 new infections annually Estimated 180,950 annual deaths ~ 3,500 individuals weekly deaths
Zimbabwe HIV Prevalence
Overall Adult2005 (ZDHS)
Urban: 17%Rural: 15%
Total Prevalence %
15.2 – 16.7
16.7 – 18.4
<15.2
18.5 – 19.7>19.7
The Zimbabwe AIDS Epidemic
Annual Trends (1990 – 2007):
HIV prevalence People Living with HIV
The Zimbabwe AIDS Epidemic
The Zimbabwe AIDS EpidemicTrends in ARV Coverage: Adults PMTCT
Zimbabwe: HIV and AIDS AIDS knowledge is universal: 96% of
women have heard of AIDS; 99% of men
17% of women can’t cite a way of avoiding AIDS; 7% of men
Most widely cited ways: condom use (76% men; 66% women); limit sexual partners (69% men; 63%
women)
Trends in partners and condom use
Data Sources: ZDHS
The Zimbabwe AIDS Epidemic: Trends Decline in prevalence 15-49 year olds
2005 = 19.4% 2007 = 15.6%
Decline in prevalence in 15-24 year olds Antenatal clinics
2004 = 17.4% 2006 = 13.1%
Decline of HIV prevalence related to: Slight reduction in average number of partners
and Increased condom use
Zimbabwe: HIV and AIDS An estimated 504,583 individuals were tested for
HIV in Jan – Oct 2007281,003 in stand alone sites, e.g. VCTs223,580 in health facilities, including ANCs, TB
clinics, hospitals, etc. Testing:
12% women; 9% menThose who know their results: 6.6% women;
6.6% men 60% of untested men and women say they want
to be tested
HIV CPOL Prevention Trial NIMH funded, Multi-national Collaborative Trial to test
HIV/STD prevention intervention First multi-national test of the Community Popular Opinion
Leader (CPOL) Model Intervention: Prevention intervention based on diffusion model
Multi-site: Conducted in 5 countries China/UCLA; India/JHU; Peru/UCSF-UCLA;
Russia/Medical College of WI; Zimbabwe/Battelle Two armed, randomized, community-level Trial Assessment of effect through behavioral survey and
biological sample data collection Behavioral and biological endpoints Three data collections points:
Baseline;12-month and 24-month follow-up Intervention implementation after Baseline
HIV CPOL Prevention Trial Conducted in multiple phases Used both qualitative and quantitative
methods Qualitative methods to provide data to tailor
the intervention Quantitative epidemiological study to
determine HIV/STD prevalence and behavioral risks (2001)
RCT to Assess impact of CPOL intervention (2003-2007)
Epidemiological Study: Design Rural Villages outside 32 Growth Points Random sample of 70 Participants Over-sampling to insure that 50 agree to
participate and provide specimens Administration of a behavioral risk
assessment Collection of biological specimens
Epidemiological Study: Methods Ethnography team
Community preparation with selected villages Enumerated and randomly select 70 households
Nursing team Explained study to residents in each household Enumerated household for all residents between 16-30 Randomly selected participant Obtained informed consent Conducted ACASI interview Conducted symptom assessment Pretest counselling Biologic sample collection (blood, urine, 3 swabs) Treated syndromically as indicated
Rural Household selectedfor inclusion
Participant listening to explanation of ACASI, doing ACASI
Epidemiological Study: Methods Nursing team
Transported computers and biological samples to ZiCHIRe office and UZARI laboratory
Downloaded ACASI data Laboratory team
Field lab tech processed and read Trich, BV in field Processed swabs for Trich, CT/GC, BV (females) Processed bloods for Syphilis, HIV, HSV2 Processed urines for CT, GC (males)
Results Nursing team 2-3 weeks later nurses went back to each community and
gave results to participants All participants who came for results were given post-test
counselling Participants with lab diagnosed STDs were treated
Epidemiological Study Methods: Lab tests
STI Gonorrhea/Chlamydia Syphillis
Trichomonasis Bacterial Vaginosis Herpes Simplex II HIV
Test kit used
Roche Amplicor Spin React RPR
TPPA Serodia: Confirmatory
TV InPouch
BV Blue
Focus Technologies Organon Technika
(Vironostika)Bio-Rad Sinofi (second)
Zichire lab site visit – July 2001
Lab and lab techs in action
Demographics of sample Total N = 1601
906 females (57%) 695 males (43%)
Mean age females: 23 (sd = 4.1) Mean age males: 22 (sd = 3.8) Education
8% less than primary 38% completed primary 52% secondary 3% Technical, College, University
Prevalence of STIs (n = 1601)STI N positive Percent
Chlamydia 27 2
Gonorrhea 15 1
Syphilis 28 2
Trichomoniasis 135 15
Bacterial Vaginosis 183 33
Herpes Simplex 2 691 44
HIV 409 26
Co-Infection with any STI = 27%
Of 295 who report not having sex, 46 had an STI
16 18 20 22 24 26 28 30
0
10
20
30
40
50
60%
HIV
Age
Figure 6: Cumulative HIV Prevalence by Sex
HIV % M
HIV % W
16 18 20 22 24 26 28 30
0
20
40
60
80
100
% H
SV2
Age
Figure 7: Cumulative HSV2 Prevalence by Sex
HSV2 % M
HSV2 % W
STI self-report19% ever had genital ulcer
20% of men 19% of women
28% ever had abnormal genital discharge 22% of men 33% of women
23% reported ever had an STI 26% of men 20% of women
HIV: Geographic variation
Across all 32 growth point villagesRates ranged from 10% to 42%Female rates ranged from 19% to
55%Male rates ranged from 3% to 33%
#
#
#
#
#
#
#
#
#
#
#
#
#
##
#
#
#
#
#
#
#
#
#
#
#
#
#
##
#
#
24%
30%
28%
24%
28%
19%
34%
31%
38%
16%
26%
30%
18%
20%28%
30%
16%
26%
26%
24%
25%
28%
10%
32%
22%
42%
26%
20%
12% 14%
42%
30%
Zambia
Botswana
MozambiqueSouth Africa
Model showing factors associated with geographic variation
Variable Sig.
Population size/commercial infrastructure
.027
Commercial farming .049
Distance to highway .048
Public service infrastructure .059
Distance to border .091
Schools/housing .280
Lodging infrastructure .242
Model of relative riskVariable RR Sig.
Sex 3.3 .000
Age 1.1 .000
Age X Sex .9 .000
Injection 1.7 .003
Blood transfusion -- .429
Nyora nyora marks -- .433
Lifetime partners 1.1 .001
Drinking -- .726
CSW exposure -- .263
HSV2 8.8 .000
CT -- .385
Conclusions CT, GC and Syphilis were low Female HIV rates were more than twice
male rates: Females 1 in 3 Males 1 in 7
Prevalence among sexually active respondents a little higher
Villages with highest female HIV rates were not the same as villages with highest male HIV rates
HIV/STD Prevention Trial: Cohort Methods Accrued cohort through purposive selection
of approximately 185 individuals (30 Growth Points)
Conduct Baseline (N=5,547) Personal Interview Assessment:
Demographic, Behavioral, IBM Health Assessment, including STD symptoms Biologic samples (Bacterial and Viral STDs)
Implement intervention (15 growth points randomly assigned)
Follow-ups at 12 and 24 months (30 growth points)
.
Local women selling vegetables outside a store at Nedziwa Growth Point
People shopping at Gokwe Growth Point
Men drinking Chibuku at a bottle store in Mamina Growth Point
Shops at Dema Growth Point
HIV/STD Prevention Trial Results 5,547 study participants attending micro-
venues including general dealers, bottle stores, markets were assessed
Prevalence of bacterial STDs ~ 12% Percent of participants with at least 1 + STD
result Highest prevalence STD: HSV2 ~ 30% 1,098 cases of HIV ~ 20% ~ 37% had sex with non-spousal partners ~ 22% had unprotected sex with non-spousal
partners
HIV/STD Prevention Trial Results
Baseline STD rates
(N = 5185) (2003-2004)
Herpes = 30% HIV = 20% GC/NG = 3% CT = 3% Syphilis = 1%
Epi study STD rates
(N = 1601) (2001)
Herpes = 44% HIV = 26% GC/NG = 1% CT = 2% Syphilis = 2%
Prevalence of STDs and HIV
STIBaseline
N=5538
12-month follow-upN=4291
24-month follow-upN=4425
Gonorrhea 2.8% 1.5 1.1
Chlamydia 4.1% 2.5 3.2
HIV 20.3% 23.0 26.9
HSV2 (1.1 cut-off) 34.1% 37.8 41.1
HSV2 (3.5 cut-off) 24.7 30.4 32.9
Syphilis 1.1% 0.9 1.0
Trichomaniasis (females only) 16.4% 3.0 2.2
Participants who ‘ever had sex’
N = 4,263 Males (52%)
Females (48%)
Age at first sex 18.3 18.0Age of first partner 16.8 22.8
Median lifetime partners
3 2
Ever had transactional sex
11% 5%
Know how to use condom
87% 58%
Overall: 16% had concurrent partners in past 12 months
We confirmed biomedical and behavioral risks
Prevalence of risks among participants led to medical intervention, i.e., presumptive treatment for STD symptoms
Lab diagnosed STDs were treated when nurses’ results team went out
Risk Total
Traditional razor marks (6 Mo) 6%
Medical / vitamin injections (6Mo) 22%
Skin pierced (6 Mo) 5%
Episodes painful urination (6 Mo) 24%
Episodes genital discharge (6 Mo) 13%
Episodes genital ulcers (6 Mo) 9%
> 1 partner (6 Mo) 21%
1 + steady partners (6 Mo) 50%
1 + casual partners (6 Mo) 6%
Concurrent partners (12 Mo) 17%
Exchanged money/goods for sex 7%
Behavioral / Biomedical Risk
Incidence at 24 months N=2,951:
HIV-negative at baselineAssessed at both baseline and 12 or 24 months
Total Male Female Sig.
HIV Incidence 11% 10% 13%
325? individuals were found to be HIV positive after being assessed in follow-up interviews
HIV Incidence by RiskRisk Factor Yes No Sig Male Female
Not married 12% 9% 16%
Episodes painful urination (6 Mo) 14% 11% 13%
Episodes genital ulcers (6 Mo) 13% 11% 16%
> 1 partner (6 Mo) 14% 11% 13% 25%
1 + steady partners (6 Mo) 14% 9% 12% 18%
1 + casual partners (6 Mo) 20% 11% 18% 38%
Concurrent partners (12 Mo) 13% 11% 30%
Exchanged money/goods for sex 16% 11% 38%
Partner 5+ years older (6 Mo) 14% 11%
Drank before sex - last 10 times 13% 11% 35%
Risk Variables by HIV Incidence
Risk FactorHIV + HIV - Sig Male Female
Age at first sex (mean) 18.1 18.3
Number partners - 6 months (mean)
2.0 1.2
Number partners - lifetime (mean)
8.1 4.8
Summary – HIV Prevalence High prevalence in rural growth points Association with:
Marital status, age first sex (F) Razor marks, injections (F) STI symptoms (M & F) Sexual behavior (Nearly doubles for M & F)
> 1 partner Concurrent partners Casual partner Exchange money/goods Alcohol and sex
Summary – HIV Incidence High incidence despite intervention Association with:
Marital status (F) STI symptoms (M) Sexual behavior (Nearly triples for F)
> 1 partner Concurrent partners Steady partner Casual partner Exchange money/goods Alcohol and sex
Conclusions Demographics, current & past sexual behavior
associated with prevalence Recent sexual behavior associated with incidence Interventions need to focus on changing current
sexual behavior Clear need for continued behavior change
interventions in rural Zimbabwe
ACKNOWLEDGEMENTSFunded by: US NIH: NIAAA, NIMH Battelle Team: Lisa Cubbins, PhD (PI – NIAAA grant: Alcohol Study) Terry Johnson, VP, CPHRE William Grady, Seattle site managerZiCHIRe Team: Mufuta Tshimanga, MD, MPH, director Zichire Godfrey Woelk, PhD (Co-PI CPOL Trial) Philani Moyo and Ethnography Team Reggie Mutsindiri and Nurses Team Patrick Mateta and Lab Team Walter Chikanya and Intervention Team Pesenai Chatikobo and Process Evaluation Team Rachel Gatsi and Transcription Team Gay Hendrikse and Admin Staff Gift Mutepfe and Driving Team CPOL/Alcohol Study Participants
AcknowledgementsMaps, data, charts and graphs: MOCHW, Zimbabwe United States Centers for Disease Control
and Prevention, Division of HIV, STD, TB Prevention
United States Census Bureau World Health Organization, UNAIDS Program Christian Richard: Battelle