STI Epidemiology: Global and Zimbabwe Danuta Kasprzyk, PhD Daniel Montaño, PhD Update on Sexually...

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


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]


<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


2007 2001

Adults & children newly infected with HIVAdults & children living with HIV




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


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]


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]




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


Latin America

South and South-East Asia

Sub-Saharan Africa

Oceania


Caribbean

East Asia

Middle East & North Africa


1.1 million[390 000 – 1.6 million]

630 000[490 000 – 1.1 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)


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]


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]


[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


Total: 270 000 (250 000 – 290 000)


<200[<100]

Middle East & North Africa57005700

[3800 – 8000[3800 – 8000]]

Sub-Saharan Africa330 000330 000

[300 000 – 360 000][300 000 – 360 000]


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


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


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


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


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*


% 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

STI Epidemiology: Global and Zimbabwe Danuta Kasprzyk, PhD Daniel Montaño, PhD Update on Sexually...

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