Factors Associated with Early Sexual Debut among Ghanaian Women from the Manya – Krobo District, – Ghana, 2011

Affiliation: Department of Epidemiology and Biostatistics GW, School of Public Health and Health Services Title: Factors associated with early sexual debut among Ghanaian women from the Manya – Krobo district, – Ghana, 2011 Background: The dipo, a Krobo puberty initiation rite practiced annually among an estimated 2,000 Ghanaian females ages 2–20, is a cultural rite of passage into womanhood that is intended to promote abstinence from sexual activity until marriage. Objectives: This study examined the risk of early sexual debut among dipo-initiated Krobo females versus uninitiated Krobo females. This study also assessed Manya–Krobo societal opinions regarding the sexual health outcomes of initiates and existing modifications of the rite. Methods: Mixed-methods. Utilizing a retrospective cohort study design, we surveyed 306 unwed Krobo females from Agormanya ages 13–20. We employed Cox proportional hazard regressions assessing the effects of model covariates upon sexual debut and age at sexual debut. Qualitative analysis included nine interviews conducted among Manya–Krobo district community members who either supported or opposed the dipo. Responses were analyzed using Dedoose QDA software to determine patterns in attitudes and opinions regarding initiates’ sexual behaviors and to identify current ceremonial changes. Results: Dipo initiated participants had a 1.8 increased hazard rate of early sexual debut as compared to uninitiated participants after adjusting for covariates, however, results were not statistically significant (aHR: 1.8, 95% C.I: 0.8–4.0). Qualitative data indicated that some dipo opponents stated participation promotes promiscuity and teen pregnancy while select supporters asserted the rite protects participants from these outcomes. Key ceremonial changes included a reduction in age eligibility and length of dipo preparatory period. Conclusions: These study findings do not offer conclusive evidence that participation in the dipo increases the risk of early sexual debut among initiated versus uninitiated Krobo females. Study findings suggest the reduction in age of dipo eligibility may increase the likelihood of sexual debut following the ceremony. Participants who received the rite as toddlers had a greater length of time between the dipo and adulthood to become sexually active post-initiation than females who were initiated during their late teens/early twenties

Prevalence and Trends in Transmitted and Acquired Antiretroviral Drug Resistance, Washington, DC, 1999-2014.

Background Drug resistance limits options for antiretroviral therapy (ART) and results in poorer health outcomes among HIV-infected persons. We sought to characterize resistance patterns and to identify predictors of resistance in Washington, DC. Methods We analyzed resistance in the DC Cohort, a longitudinal study of HIV-infected persons in care in Washington, DC. We measured cumulative drug resistance (CDR) among participants with any genotype between 1999 and 2014 (n = 3411), transmitted drug resistance (TDR) in ART-naïve persons (n = 1503), and acquired drug resistance (ADR) in persons with genotypes before and after ART initiation (n = 309). Using logistic regression, we assessed associations between patient characteristics and transmitted resistance to any antiretroviral. Results Prevalence of TDR was 20.5%, of ADR 40.5%, and of CDR 45.1% in the respective analysis groups. From 2004 to 2013, TDR prevalence decreased for nucleoside and nucleotide analogue reverse transcriptase inhibitors (15.0 to 5.5%; p = 0.0003) and increased for integrase strand transfer inhibitors (INSTIs) (0.0–1.4%; p = 0.04). In multivariable analysis, TDR was not associated with age, race/ethnicity, HIV risk group, or years from HIV diagnosis. Conclusions In this urban cohort of HIV-infected persons, almost half of participants tested had evidence of CDR; and resistance to INSTIs was increasing. If this trend continues, inclusion of the integrase-encoding region in baseline genotype testing should be strongly considered

Interruptions of antiretroviral therapy in children and adolescents with HIV infection in clinical practice: a retrospective cohort study in the USA.

INTRODUCTION: Changes in combination antiretroviral therapy (cART) throughout childhood challenge the continuity of paediatric HIV treatment. This study aimed to evaluate the prevalence of treatment interruption (TI), including lamivudine (3TC) monotherapy, and the relationship of TI to virologic and immunologic parameters in HIV-infected paediatric patients. METHODS: Nested within a prospective observational study of a city-wide cohort of HIV-infected persons in the District of Columbia, this sub-study collected retrospective data on antiretroviral therapy, enrolment (endpoint) and historic (lifelong) CD4 counts and HIV RNA viral load (VL) of the paediatric cohort. TI was defined as interruption of cART ≥4 consecutive weeks. Data on TI, including 3TC monotherapy TI (MTI), were collected. Descriptive statistics and univariate testing were used to compare children with TI and MTI to children on continuous treatment (CT). RESULTS: Thirty-eight (28%) out of 136 enrolled children (median age=12.9 years) experienced TI, with 14 (37%) of those placed on 3TC MTI. Significantly lower endpoint median CD4 counts (598 cells/mm(3) vs. 815 cells/mm(3); p=0.003) and CD4% (27.5% vs. 33%; p=0.006) were observed in the TI cohort as compared to the CT cohort. The median endpoint VL in the overall TI cohort was ~4 times higher than among the CT cohort (1427 copies/mL vs. 5581 copies/mL; p CONCLUSIONS: In our study, we observed high frequency of the TI in HIV in paediatric HIV clinical practice. All TIs, including 3TC MTI, were associated with significantly lower endpoint median CD4 counts and higher median VLs, as compared to CT in paediatric patients. The high frequency of TI and associated poor outcomes suggest a need for a better strategy in managing the course of the paediatric and adolescent cART

Comparing Cost-Effectiveness of HIV Testing Strategies: Targeted and Routine Testing in Washington, DC.

BACKGROUND: Routine HIV testing is an essential approach to identifying undiagnosed infections, linking people to care and treatment, and preventing new infections. In Washington, DC, where HIV prevalence is 2.4%, a combination of routine and targeted testing approaches has been implemented since 2006. METHODS: We sought to evaluate the cost effectiveness of the District of Columbia (DC) Department of Health\u27s routine and targeted HIV testing implementation strategies. We collected HIV testing data from 3 types of DC Department of Health-funded testing sites (clinics, hospitals, and community-based organizations); collected testing and labor costs; and calculated effectiveness measures including cost per new diagnosis and cost per averted transmission. RESULTS: Compared to routine testing, targeted testing resulted in higher positivity rates (1.33% vs. 0.44%). Routine testing averted 34.30 transmissions per year compared to targeted testing at 17.78. The cost per new diagnosis was lower for targeted testing ($2,467 vs.$7,753 per new diagnosis) as was the cost per transmission averted ($33,160 vs.$104,205). When stratified by testing site, both testing approaches were most cost effective in averting new transmissions when conducted by community based organizations ($25,037 routine;$33,123 targeted) compared to hospitals or clinics. CONCLUSIONS: While routine testing identified more newly diagnosed infections and averted more infections than targeted testing, targeted testing is more cost effective per diagnosis and per transmission averted overall. Given the high HIV prevalence in DC, the DC Department of Health\u27s implementation strategy should continue to encourage routine testing implementation with emphasis on a combined testing strategy among community-based organizations

Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort

Background Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the leading mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission. Methods We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV-infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for incident STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk. Results Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5 months (4% chlamydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5–4.1); age 18–34 years, 10.8 (95% CI, 9.7–12.0); transgender women, 9.9 (95% CI, 6.9–14.0); Hispanics, 9.2 (95% CI, 7.2–11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1–8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL. Conclusions STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation

Use of National Standards to Monitor HIV Care and Treatment in a High Prevalence City-Washington, DC.

We sought to benchmark the quality of HIV care being received by persons living with HIV in care in Washington, DC and identify individual-level and structural-level differences. Data from the DC Cohort, an observational HIV cohort of persons receiving outpatient care in DC, were used to estimate the Institute of Medicine (IOM) and Department of Health and Human Services (HHS) quality of care measures. Differences in care by demographics and clinic type were assessed using χ2 tests and multivariable regression models. Among 8,047 participants, by HHS standards, 69% of participants were retained in care (RIC), 95% were prescribed antiretroviral therapy (ART), and 84% were virally suppressed (VS). By IOM standards, 84% were in continuous care; and 78% and 80% underwent regular CD4 and VL monitoring, respectively. Screening for syphilis, chlamydia, and gonorrhea was 51%, 31%, and 26%, respectively. Older participants were 1.5 times more likely to be RIC compared to younger participants (OR: 1.5; 95% CI: 1.3, 1.8). Participants enrolled in community-based clinics were more likely to be RIC (OR: 1.7; 95% CI: 1.4, 2.0) versus those enrolled at hospital-based clinics. Older participants were more likely to achieve VS than younger participants (OR: 1.8; 95% CI: 1.5, 2.2) while Black participants were less likely compared to white participants (OR: 0.4; 95% CI: 0.3, 0.5). Despite high measures of quality of care, disparities remain. Continued monitoring of the quality of HIV care and treatment can inform the development of public health programs and interventions to optimize care delivery

HIV testing implementation in two urban cities: Practice, policy and perceived barriers

Background Although funding has supported the scale up of routine, opt-out HIV testing in the US, variance in implementation mechanisms and barriers in high-burden jurisdictions remains unknown. Methods We conducted a survey of health care organizations in Washington, DC and Houston/Harris County to determine number of HIV tests completed in 2011, policy and practices associated with HIV testing, funding mechanisms, and reported barriers to testing in each jurisdiction and to compare results between jurisdictions. Results In 2012, 43 Houston and 35 DC HIV-testing organizations participated in the survey. Participants represented 85% of Department of Health-supported testers in DC and 90% of Department of Health-supported testers in Houston. The median number of tests per organization was 568 in DC and 1045 in Houston. Approximately 50% of organizations in both DC and Houston exclusively used opt-in consent and most conducted both pre- and post-test counseling with HIV testing (80% of organizations in DC, 70% in Houston). While the most frequent source of funding in DC was the Department of Health, Houston organizations primarily billed the patient or third-party payers. Barriers to testing most often reported were lack of funding, followed by patient discomfort/refusal with more barriers reported in DC. Conclusions Given unique policies, resources and programmatic contexts, DC and Houston have taken different approaches to support routine testing. Many organizations in both cities reported opt-in consent approaches and pre-test counseling, suggesting 2006 national HIV testing recommendations are not being followed consistently. Addressing the barriers to testing identified in each jurisdiction may improve expansion of testing

La renovación de la palabra en el bicentenario de la Argentina : los colores de la mirada lingüística

El libro reúne trabajos en los que se exponen resultados de investigaciones presentadas por investigadores de Argentina, Chile, Brasil, España, Italia y Alemania en el XII Congreso de la Sociedad Argentina de Lingüística (SAL), Bicentenario: la renovación de la palabra, realizado en Mendoza, Argentina, entre el 6 y el 9 de abril de 2010. Las temáticas abordadas en los 167 capítulos muestran las grandes líneas de investigación que se desarrollan fundamentalmente en nuestro país, pero también en los otros países mencionados arriba, y señalan además las áreas que recién se inician, con poca tradición en nuestro país y que deberían fomentarse. Los trabajos aquí publicados se enmarcan dentro de las siguientes disciplinas y/o campos de investigación: Fonología, Sintaxis, Semántica y Pragmática, Lingüística Cognitiva, Análisis del Discurso, Psicolingüística, Adquisición de la Lengua, Sociolingüística y Dialectología, Didáctica de la lengua, Lingüística Aplicada, Lingüística Computacional, Historia de la Lengua y la Lingüística, Lenguas Aborígenes, Filosofía del Lenguaje, Lexicología y Terminología