Publications

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2015
2014
"Male Spouse Perpetrated Psychological and Sexual Abuse among Pregnant Women in Nairobi, Kenya." International Journal of Medicine and Medical Sciences (ISSN: 2315-9844). 2014;Vol. 1(11)((ISSN: 2315-9844)):pp. 178-184.publication.pdf
Ngugi E. "A Reasoned Action Model of Male Client Involvement in Commercial Sex Work in Kibera, A Large Informal Settlement in Nairobi, Kenya." Human Organization. 2014; Vol. 73(No. 2, 2014):174-182. Abstract

A Reasoned Action Model of Male Client
Involvement in Commercial Sex Work in Kibera,
A Large Informal Settlement in Nairobi, Kenya
Eric Abella Roth, Elizabeth Ngugi, Cecilia Benoit,
Mikael Jansson, and Helga Hallgrimsdottir
Male clients of female sex workers (FSWs) are epidemiologically important because they can form bridge groups linking high- and
low-risk subpopulations. However, because male clients are hard to locate, they are not frequently studied. Recent research emphasizes
searching for high-risk behavior groups in locales where new sexual partnerships form and the threat of HIV transmission is high. Sub-
Saharan Africa public drinking venues satisfy these criteria. Accordingly, this study developed and implemented a rapid assessment
methodology to survey men in bars throughout the large informal settlement of Kibera, Nairobi, Kenya, with the goal of delineating
cultural and economic rationales associated with male participation in commercial sex. The study sample consisted of 220 male patrons
of 110 bars located throughout Kibera’s 11 communities. Logistic regression analysis incorporating a modified Reasoned Action Model
indicated that a social norm condoning commercial sex among male peers and the cultural belief that men should practice sex before
marriage support commercial sex involvement. Conversely, lacking money to drink and/or pay for sexual services were barriers to male
commercial sex involvement. Results are interpreted in light of possible harm reduction programs focusing on FSWs’ male clients.
Key words: commercial sex work, rapid assessment methodology, Reasoned Action Model, Kenya

2013
E.N. PN. "HLA class I associations with rates of HIV-1 seroconversion and disease progression in the Pumwani Sex Worker Cohort.". 2013. Abstract

Tissue Antigens. 2013 Feb;81(2):93-107. doi: 10.1111/tan.12051.
HLA class I associations with rates of HIV-1 seroconversion and disease progression in the Pumwani Sex Worker Cohort.
Peterson TA, Kimani J, Wachihi C, Bielawny T, Mendoza L, Thavaneswaran S, Narayansingh MJ, Kariri T, Liang B, Ball TB, Ngugi EN, Plummer FA, Luo M.
Source
HIV and Human Genetics, National Microbiology Laboratory, Winnipeg, MB, Canada.
Abstract
Class I human leukocyte antigens (HLA) play an important role in the adaptive immune response by presenting antigens to CD8+ T cells. Studies have reported that several HLA class I alleles are associated with differential disease progression in human immunodeficiency virus (HIV)-infected individuals, however, few class I associations with resistance or susceptibility to HIV-1 infection have been reported. We typed HLA-A, -B and -C of >1000 women enrolled in the Pumwani Sex Worker Cohort using a sequence-based typing method. Kaplan-Meier analysis was used to identify alleles influencing seroconversion and disease progression to acquired immune deficiency syndrome (CD4 < 200/mm³). A*01 (P = 0.020), C*06:02 (P = 0.042) and C*07:01 (P = 0.050) are independently associated with protection from seroconversion. Women with any of these alleles are less likely to seroconvert [P = 0.00001, odds ratio (OR): 0.503, 95% confidence interval (CI): 0.320-0.790]. Conversely, A*23:01 (P = 0.004), B*07:02 (P = 0.003) and B*42:01 (P = 0.025) are independently associated with rapid seroconversion. Women with any of these alleles are twice as likely to seroconvert (P = 0.002, OR: 2.059, 95% CI: 1.290-3.285). The beneficial alleles confer threefold protection from seroconversion when compared with the susceptible alleles (P = 0.000001, OR: 0.268, 95% CI: 0.132-0.544). B*07:02 is the contributing allele, within the B7 supertype, to the rapid seroconversion. A*74:01 (P = 0.04/P = 0.006), B*14 (P = 0.003/P = 0.003) and B*57:03 (P = 0.012/P = 0.038) are independently associated with slower CD4+ decline and LTNP phenotype, while B*07:02 (P = 0.020), B*15:10 (P = 0.022) and B*53:01 (P = 0.007) are independently associated with rapid CD4+ T-cell decline. B7 supertype (P = 0.00006), B*35*-Py (P = 0.028) and B*35-Px (P = 0.001) were also significantly associated with rapid CD4+ T-cell decline. Understanding why these HLA class I alleles are associated with protection/susceptibility to HIV-1 acquisition and disease progression could contribute to the development of effective prophylactic and therapeutic vaccines for HIV-1.
© 2013 John Wiley & Sons A/S.
PMID:
23330720
[PubMed - in process]

Ngugi EN, Pinkham S, Malinowska-Sempruch K. "Women, harm reduction and HIV.". 2013. Abstract

This paper compares and contrasts number of partners and condom use behaviour for female sex workers and a sample of women working in other economic activities, with both samples drawn from the large informal settlement of Kibera, Nairobi. As expected, univariate analysis revealed much higher numbers of overall sexual partners and higher levels of condom use among female sex workers compared to Kibera women in other occupations. An unexpected finding, however, was that female sex workers with a romantic partner had significantly fewer sexual partners per unit time than female sex workers without such a partner. This finding held for multivariate analysis, with negative binomial regression analyses showing that having a romantic partner was significantly associated with reductions in total number of both sexual partners overall and with sexual partners who did not use condoms. In contrast, HIV status, education, number of immediate family members and levels of alcohol consumption were non-significant factors for both regression analyses. Results suggest that female sex workers' romantic partners act as more than sources of possible HIV infection; rather, romantic partners appear to have an important positive impact on health. We discuss this finding in light of possible harm-reduction programmes focusing on female sex workers and their romantic partners.

2012
E.N. PN. "Family Kinship Patterns and Female Sex Work in the Informal . . Urban Settlement of Kibera, Nairobi, Kenya.". 2012. Abstract

Hum Ecol (2012) 40:397-403
DOl 10.1007/s10745-012-9478-3
Family Kinship Patterns and Female Sex Work in the Informal . .
Urban Settlement of Kibera, Nairobi, Kenya
Elizabeth N. Ngugi . Cecilia Benoit-
Helga Hallgrimsdottir· Mikael Jansson- Eric A. Roth
Published online: 4 April 2012
(~) Springer Science+Business Media. LLC 2012
Abstract A basic ecological and epidemiological question
is why some women enter into commercial sex work while
other women in the same socio-economic environment never
do. To address this question respondent driven sampling
principles were adopted to recruit and collect data for 161
female sex workers and 159 same aged women who never
engaged in commercial sex in Kibera, a large informal
settlement in Nairobi, Kenya. Univariate analysis indicated
that basic kinship measures, including number of family
members seen during adolescence and at present, not having
a male guardian while growing up, and earlier times of
ending relationships with both male and female guardians
were associated with commercial sex work in Kibera.
Multivariate analysis via logistic regression modeling
showed that not having a male guardian during childhood,
low education attainment and a small number of family
members seen at adolescence were all significant predictors
of entering sex work. By far the most important predictor of
entering sex work was not having any male guardian, e.g.,
father, uncle, older brother, etc. during childhood. Results
are interpreted in light of the historic pattem of sub-Saharan
African child fostering and their relevance for young women
in Kibcra today.
Keywords Urban ecology- Female sex work HIV/AIDS .
Nairobi Kenya
E. N. Ngugi . C. Benoit· H. Hallgrimsdortir: M. Jansson'
E. A. Roth ([81)
University of Victoria,
Victoria, BC, Canada
e-mail: ericroth@uvic.ca
Introduction
Epidemiologists, medical personnel and public health officials
have long recognized the importance of female sex
workers (FSWs) in the sub-Saharan African AIDS pandemic
(D'Costa et al. J 985; Ngugi et al. 1988; Moses et at. 1991)
where they can serve as core groups, i.e., sub-populations
whose high rates of partner change sustain sexual infections
at epidemic levels. Today female commercial sex work
remains an important source of HIV infection within sub-
Saharan Africa's generalized AIDS epidemic because of
FSWs' high HIV prevalence rates (Steen and Dallabctta
2003; Cote et al. 2004; Gouws et al. 2006; Talbott 2007;
Morris et al. 2009). Yet, despite extensive epidemiological
research on the biological parameters of Hl'V transmission
between African FSWs and their commercial clients, there
remain important knowledge gaps in the basic social epidemiology,
defined as the study of the distributions of health
outcomes and their social determinants of African commercial
sex work (Berkman and Kawachi 2000; Poundstone et
al. 2004). For example, while commercial sex work is a high
risk occupation both in tcnns of STI/HIV infection and
violence (Rekart 2005), few studies consider why or how
African women become FSWs, even though "effective prevention
programs cannot be established until there is a better
understanding of why women enter into commercial sex
exchanges" (Kalipeni et al. 2004:66).
At face value the question of why women enter sex work
appears overly simplistic, with economic need combined with
a lack of opportunities the apparently overwhelming answer.
However, in a study of rural Ugandan sex workers, Gysels et
al. (2002) noted that not all disadvantaged women turn to sex
work, while an analysis of Thai child labor (Taylor 2005)
found that wealth and education were positively associated
with high risk behavior, including commercial sex.
.g) Springer

E.N. PN. "Identifying at-risk populations in Kenya and South Africa HIV incidence in cohorts of men who report sex with men, sex workers, and youth.". 2012. Abstract

J Acquir Immune Defic Syndr. 2012 Feb 1;59(2):185-93. doi: 10.1097/QAI.0b013e31823d8693.
Identifying at-risk populations in Kenya and South Africa: HIV incidence in cohorts of men who report sex with men, sex workers, and youth.
Price MA, Rida W, Mwangome M, Mutua G, Middelkoop K, Roux S, Okuku HS, Bekker LG, Anzala O, Ngugi E, Stevens G, Chetty P, Amornkul PN, Sanders EJ.
Source
Department of Medical Affairs, International AIDS Vaccine Initiative, New York, NY, USA. mprice@iavi.org
Abstract
OBJECTIVE:
To identify and describe populations at risk for HIV in 3 clinical research centers in Kenya and South Africa.
DESIGN:
Prospective cohort study.
METHODS:
Volunteers reporting recent sexual activity, multiple partners, transactional sex, sex with an HIV-positive partner, or, if male, sex with men (MSM; in Kenya only) were enrolled. Sexually active minors were enrolled in South Africa only. Risk behavior, HIV testing, and clinical data were obtained at follow-up visits.
RESULTS:
From 2005 to 2008, 3023 volunteers were screened, 2113 enrolled, and 1834 contributed data on HIV incidence. MSM had the highest HIV incidence rate of 6.8 cases per 100 person-years [95% confidence interval (CI): 4.9 to 9.2] followed by women in Kilifi and Cape Town (2.7 cases per 100 person-years, 95% CI: 1.7 to 4.2). No seroconversions were observed in Nairobi women or men in Nairobi or Cape Town who were not MSM. In 327 MSM, predictors of HIV acquisition included report of genital ulcer (Hazard Ratio: 4.5, 95% CI: 1.7 to 11.6), not completing secondary school education (HR: 3.4, 95% CI: 1.6 to 7.2) and reporting receptive anal
intercourse (HR: 8.2, 95% CI: 2.7 to 25.0). Paying for sex was inversely associated with HIV infection (HR: 0.2, 95% CI: 0.04 to 0.8). 279 (13.0%) volunteers did not return after the first visit; subsequent attrition rates ranged from 10.4 to 21.8 volunteers per 100 person-years across clinical research centers.
CONCLUSIONS:
Finding, enrolling, and retaining risk populations for HIV prevention trials is challenging in Africa. African MSM are not frequently engaged for research, have high HIV incidence, need urgent risk reduction counseling, and may represent a suitable population for future HIV prevention trials.

E.N. PN. "Partners and clients of female sex workers in an informal urban settlement in Nairobi, Kenya.". 2012. Abstract

Cult Health Sex. 2012;14(1):17-30. doi: 10.1080/13691058.2011.608436. Epub 2011 Sep 21.
Partners and clients of female sex workers in an informal urban settlement in Nairobi, Kenya.
Ngugi E, Benoit C, Hallgrimsdottir H, Jansson M, Roth EA.
Source
Centre for HIV Prevention and Research, University of Nairobi, Nairobi, Kenya.
Abstract
This paper compares and contrasts number of partners and condom use behaviour for female sex workers and a sample of women working in other economic activities, with both samples drawn from the large informal settlement of Kibera, Nairobi. As expected, univariate analysis revealed much higher numbers of overall sexual partners and higher levels of condom use among female sex workers compared to Kibera women in other occupations. An unexpected finding, however, was that female sex workers with a romantic partner had significantly fewer sexual partners per unit time than female sex workers without such a partner. This finding held for multivariate analysis, with negative binomial regression analyses showing that having a romantic partner was significantly associated with reductions in total number of both sexual partners overall and with sexual partners who did not use condoms. In contrast, HIV status, education, number of immediate family members and levels of alcohol consumption were non-significant factors for both regression analyses. Results suggest that female sex workers' romantic partners act as more than sources of possible HIV infection; rather, romantic partners appear to have an important positive impact on health. We discuss this finding in light of possible harm-reduction programmes focusing on female sex workers and their romantic partners.
PMID:
21936649

2011
E.N. PN. "Determinants of condom use among female sex workers in Kenya: a case-crossover analysis.". 2011. Abstract

J Womens Health (Larchmt). 2011 May;20(5):733-8. doi: 10.1089/jwh.2010.2436. Epub 2011 Mar 25.
Determinants of condom use among female sex workers in Kenya: a case-crossover analysis.
Gallo MF, Warner L, Bell AJ, Bukusi EA, Sharma A, Njoroge B, Ngugi E, Jamieson DJ, Eschenbach DA.
Source

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724, USA. mgallo@cdc.gov
Abstract
BACKGROUND:

We evaluated predictors of consistent condom use among female sex workers (FSWs), a core group for controlling the spread of HIV.
METHODS:

In an analysis of data collected in 2004-2005 from 140 Kenyan FSWs who completed questionnaires administered during a baseline study visit and three bimonthly follow-up visits, we used a case-crossover design to identify predictors of consistent condom use during all coital acts in the preceding 2 weeks, overall and by partner type.
RESULTS:

Participants (n=140) completed the baseline visit and 390 bimonthly follow-up visits. Alcohol use during sex was negatively associated with consistent condom use with helping partners (defined as regular sex partners to whom the woman could go for help or support if needed) (adjusted odds ratio [AOR], 2.6, 95% confidence interval [CI] 1.0-6.5) but not associated with condom use with other partners. Coital frequency was associated with condom use with other partners only. Women who reported 1-5 (AOR 11.0, 95% CI 4.3-28.3) or 6-9 recent coital acts (AOR 3.8, 95% CI 1.7-8.8) with other partners were more likely to report consistent condom use with those partners than were women who reported ≥10 acts. Having a recent partner delay payment was inversely associated with consistent condom use with helping, other, or all partners.
CONCLUSIONS:

Correlates of consistent condom use differed by partner type. By using a case-crossover design, we were able to identify potentially modifiable factors associated with consistent condom use by FSWs who used condoms consistently with a given partner type during some periods but not others.

PMID:
21438697
[PubMed - indexed for MEDLINE]

Plummer FA, Moses S, Willbond B, Rao PJVR, Ngugi EN, Nagelkerke NJD, Jha P. "Reducing HIV Transmission in Developing Countries.". 2011. Abstract

Although the global response to the HIV/AIDS epidemic in the developing world has, in general, been inadequate, there are key interventions which have been proven to be effective in reducing the incidence of HIV and relevant risky behaviors. We review and analyze these interventions according to three criteria: importance to HIV transmission, amenability to change, and cost-effectiveness.

Chiao C, Morisky DE, Rosenberg R, Ksobiech K, Malow R, Ngugi EN. "The relationship between HIV/Sexuaily Transmitted Infection risk and alcohol use during commercial sex episodes: results from the study of female commercial sex workers in the Philippines.". 2011. Abstract

The results of this study will be particularly important in designing more responsive interventions for alcohol-related behaviour towards better control of HIV and sexually transmitted infections. This interesting finding involved a large sample size (1114 female commercial sex workers). geographical distribution (four provinces in the Philippines) and duration which were large enough for generalization. The authors re-demonstrate the association between alcohol use amongst female sex-workers and clients and HIV/sexually transmitted disease risk.

"Utilisation of sexual health services by female sex workers in Nepal.". 2011. Abstract

The Nepal Demographic Health Survey (NDHS) in 2006 showed that more than half (56%) of the women with sexually transmitted infections (STIs), including HIV, in Nepal sought sexual health services. There is no such data for female sex workers (FSWs) and the limited studies on this group suggest they do not even use routine health services. This study explores FSWs use of sexual health services and the factors associated with their use and non-use of services. METHODS: This study aimed to explore the factors associated with utilisation of sexual health services by FSWs in the Kathmandu Valley of Nepal, and it used a mixed-method approach consisting of an interviewer administered questionnaire-based survey and in-depth interviews. RESULTS: The questionnaire survey, completed with 425 FSWs, showed that 90% FSWs self-reported sickness, and (30.8%) reported symptoms of STIs. A quarter (25%) of those reporting STIs had never visited any health facilities especially for sexual health services preferring to use non-governmental clinics (72%), private clinics (50%), hospital (27%) and health centres (13%). Multiple regression analysis showed that separated, married and street- based FSWs were more likely to seek health services from the clinics or hospitals. In- depth interviews with 15 FSWs revealed that FSWs perceived that personal, structural and socio-cultural barriers, such as inappropriate clinic opening hours, discrimination, the judgemental attitude of the service providers, lack of confidentiality, fear of public exposure, and higher fees for the services as barriers to their access and utilisation of sexual health services. CONCLUSION: FSWs have limited access to information and to health services, and operate under personal, structural and socio-cultural constraints. The 'education' to change individual behaviour, health worker and community perceptions, as well as the training of the health workers, is necessary.

2010
E.N. PN. "Antiretroviral therapy in a core transmission group of Kenyan female sex workers is not associated with increased sexual risk taking.". In: Future Medicinal Chemistry. African Wildlife Foundation. Nairobi; 2010. Abstract

Although antiretroviral therapy (ART) prolongs life and reduces infectiousness, in some contexts it has been associated with increased sexual risk taking. We compared self-reported condom use, client numbers, and STI incidence in HIV-infected Kenyan female sex workers (FSW) before and after starting ART (n=62), as well in control FSWs not starting ART (n=40). Sexual behaviour with casual clients did not change after ART initiation; condom use increased and STI incidence decreased in both cases and controls, likely due to successful cohort-wide HIV prevention efforts. ART provision was not associated with increases in unsafe sex in this core transmission group.

E.N. PN. "Assessment of changes in condom use among female sex workers in a prospective cohort study introducing diaphragm use for disease prevention.". 2010. Abstract

Am J Epidemiol. 2010 Sep 1;172(5):606-12. doi: 10.1093/aje/kwq158. Epub 2010 Jul 26.
Assessment of changes in condom use among female sex workers in a prospective cohort study introducing diaphragm use for disease prevention.
Gallo MF, Warner L, Bell AJ, Wiener J, Eschenbach DA, Bukusi EA, Sharma A, Njoroge B, Ngugi E, Jamieson DJ.
Source

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341-3724, USA. mgallo@cdc.gov
Abstract

Changes in the rates of condom use and number of sexual partners were evaluated among 140 female sex workers in Kibera, Kenya, participating in a 6-month study of diaphragm safety and acceptability for prevention of sexually transmitted infections conducted in 2004-2005. Analyses were stratified by partner type. Multivariable Tobit regression modeling was used to assess the association between study visit and proportion of acts protected. Participants completed 140 baseline visits and 390 bimonthly follow-up visits. The mean percentage of coital acts reported as protected by a condom increased from 56% at baseline to 68% at the 6-month visit (P < 0.01). Similar increases were observed for condom use by all partner types. Additionally, the mean number of sexual partners decreased over the study. Furthermore, consistent (i.e., 100%) diaphragm use during follow-up was associated with a higher proportion of coital acts protected by a condom in analyses adjusted for study visit and coital frequency. These findings suggest that, despite concerns that introduction of the diaphragm would result in more risky sexual behaviors, reported condom use increased and number of partners decreased.

PMID:
20660519
[PubMed - indexed for MEDLINE]

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E.N. PN. "Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1) a randomised trial.". 2010. Abstract

Lancet. 2010 Nov 27;376(9755):1838-45. doi: 10.1016/S0140-6736(10)61997-6. Epub 2010 Nov 9.
Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial.
Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball TB, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA.
Source
Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya. rlester.id@gmail.com
Abstract
BACKGROUND:
Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load.
METHODS:
WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00830622.
FINDINGS:
Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3).
INTERPRETATION:
Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings.
FUNDING:
US President's Emergency Plan for AIDS Relief.
Copyright © 2010 Elsevier Ltd. All rights reserved.

E.N. PN. "ENTERING SEX WORK IN THE INFORMAL URBAN SETTLEMENT OF KIBERA, NAIROBI, KENYA.". In: Future Medicinal Chemistry. African Wildlife Foundation. Nairobi; 2010. Abstract

Female sex work has long been recognized as an important factor in the urban sub-Saharan Africa HIV/AIDS pandemic, and in some cities remains a driving force for HIV transmission. However, despite a long history of epidemiological studies, there are still gaps in our knowledge of the social epidemiology of African female sex work. For example, the basic question of why some women enter into sex work, while others in the same socio-economic environment never do, remains under researched. We investigated this question for two samples of same-aged women, one of whom is currently practicing commercial sex, and another who has never done so. Both come from the informal urban settlement of Kibera, located in Nairobi, Kenya. Inclusion of another sample of women who can serve as comparisons to female sex workers is a notable feature of our research design, and one missing from many ecological and intervention studies. Using respondent driven sampling, we collected socio-economic and sexual behavioural data for a total for 320 women, evenly divided between female sex workers and Kibera women working in other occupations (e.g. hair-dressing, tailoring, hotel workers and food servers) from all ten Kibera communities to test the hypothesis that past and present family ties and structure are important predictors of entry into sex work. Results of univariate and multivariate analyses testing this hypothesis are discussed with respect to the African cultural practice of child fostering and future interventions.

Ngugi EN, Bonell C, Rhodes T, Jolley E, Sorhaindo A, Fletcher A, Grenfell P, Platt L. "Systematic review examining differences in HIV, sexually transmitted infections and health-related harms between migrant and non-migrant female sex workers.". 2010. Abstract

I have picked this evaluation because it focuses on the special needs of migrant female sex workers (FSWs), in particular those in Sub-Saharan Africa, where the prevalence of sexually transmitted infections (STls) and HIV is high and the health infrastructure is insufficient to respond to these problems. In addition, migrant FSWs might initially be too afraid to immediately seek medical help in the 'new country' due to the fear of being apprehended for real or perceived reasons. By the same token, they might not have access to male or female condoms, but may have a high incidence of partner change and unprotected sex. Fear of stigma and discrimination might also keep them away from appropriate services.

N. PROFNGUGIELIZABETH. "Reproductive Health of Female Sex Workers in the Urban Informal Settlement of Kibera, Nairobi, Kenya.". In: Future Medicinal Chemistry. African Wildlife Foundation. Nairobi; 2010. Abstract
Female sex workers (FSWs) have long been recognized as important factors in the sub-Saharan HIV/AIDS epidemic. Because of their large number of sexual partners and high rate of partner change they may act as core groups that keep incidence rates high and as bridge populations, linking high-risk with low-risk sub-populations. What is far less recognized and researched are the roles that African FSWs fulfill as lovers and mothers. In these roles they are epidemiologically important due to mother-child HIV transmission while socially FSWs must provide childcare when they work outside the home. Building upon recently analyzed data for FSWs in the urban informal settlement of Kibera, Nairobi, Kenya, this proposal outlines a pilot study employing a social epidemiological perspective to: 1) delineate and analyze FSWs reproductive histories, future fertility plans, and knowledge, access and usage of contraception methods and, 2) explore possible family-based intervention programs to provide child care for FSWs.
2009
E.N. PN. "Effects of micro-enterprise services on HIV risk behaviour among female sex workers in Kenya urban slums.". 2009. Abstract

AIDS Behav. 2009 Jun;13(3):449-61. doi: 10.1007/s10461-008-9485-y. Epub 2008 Nov 8.
Effects of micro-enterprise services on HIV risk behaviour among female sex workers in Kenya's urban slums.
Odek WO, Busza J, Morris CN, Cleland J, Ngugi EN, Ferguson AG.
Source
Department of Community Health, University of Nairobi, P.O. Box 1086, City Square 00200, Nairobi, Kenya. odekw@yahoo.co.uk
Abstract
This study assessed individual-level effects of adding micro-enterprise services to a peer-mediated HIV/AIDS intervention among 227 female sex workers (FSWs) in Kenya. Survey data were collected in May-July 2003 and July-August 2005. Two-thirds of participants had operational businesses by end-line survey. Nearly half reported to have stopped sex work. Self-reported weekly mean number of all sexual partners changed from 3.26 (SD 2.45) at baseline to 1.84 (SD 2.15) at end-line survey (P < 0.001). Weekly mean number of casual partners did not change significantly. Weekly mean number of regular partners changed from 1.96 (SD 1.86) to 0.73 (SD 0.98) over the follow-up period (P < 0.001). Consistent condom use with regular partners increased by 18.5% and remained above 90% with casual partners. Micro-enterprise services may empower FSWs by giving them an alternative livelihood when they wish to exit or reduce reliance on sex work. Determinants of successful business operation by FSWs deserve further research.
PMID:
18998204
[PubMed - indexed for MEDLINE]

E.N. PN. "The HAART cell phone adherence trial (WelTel Kenya1) a randomized controlled trial protocol.". 2009. Abstract

Background The objectives are to compare the effectiveness of cell phone-supported SMS messaging to standard care on adherence, quality of life, retention, and mortality in a population receiving antiretroviral therapy (ART) in Nairobi, Kenya. Methods and Design A multi-site randomized controlled open-label trial. A central randomization centre provided opaque envelopes to allocate treatments. Patients initiating ART at three comprehensive care clinics in Kenya will be randomized to receive either a structured weekly SMS ('short message system' or text message) slogan (the intervention) or current standard of care support mechanisms alone (the control). Our hypothesis is that using a structured mobile phone protocol to keep in touch with patients will improve adherence to ART and other patient outcomes. Participants are evaluated at baseline, and then at six and twelve months after initiating ART. The care providers keep a weekly study log of all phone based communications with study participants. Primary outcomes are self-reported adherence to ART and suppression of HIV viral load at twelve months scheduled follow-up. Secondary outcomes are improvements in health, quality of life, social and economic factors, and retention on ART. Primary analysis is by 'intention-to-treat'. Sensitivity analysis will be used to assess per-protocol effects. Analysis of covariates will be undertaken to determine factors that contribute or deter from expected and determined outcomes. Discussion This study protocol tests whether a novel structured mobile phone intervention can positively contribute to ART management in a resource-limited setting.

Fujita M;, Ngugi EN;, Rotha EA. "HIV/AIDS risk and worry in Northern Kenya HIV/AIDS risk and worry in Northern Kenya.". 2009. Abstract

Data from a 2003 survey of sexual behaviour (n = 400) conducted in the Ariaal community of Karare, Marsabit District, northern Kenya, were used to delineate patterns of risk and worry about contracting HIV/AIDS. Despite widespread reporting of high-risk sexual behaviours (including multiple partners, concurrency, sexual mixing and not using condoms) by survey participants, logistic regression analysis found only one statistically significant positive association between these behaviours and self-assessment of being at high risk of contracting HIV/AIDS. In contrast, log-linear analysis of worry patterns found highly significant relationships between self-assessment of high risk of HIV/AIDS and worry about one's partner's sexual behaviour. These findings indicate that in relation to contracting HIV/AIDS currently Ariaal are more concerned about the sexual behaviour of others, rather than their own behaviour. More generally, results point to the potential for combining concepts of worry with risk assessment in HIV/AIDS research to generate insights into how both concepts are linked to individual, dyadic and population-level factors within specific cultural settings.

E.N. PN. "Levels of innate immune factors in genital fluids: association of alpha defensins and LL-37 with genital infections and increased HIV acquisition.". 2009. Abstract

AIDS. 2009 Jan 28;23(3):309-17. doi: 10.1097/QAD.0b013e328321809c.
Levels of innate immune factors in genital fluids: association of alpha defensins and LL-37 with genital infections and increased HIV acquisition.
Levinson P, Kaul R, Kimani J, Ngugi E, Moses S, MacDonald KS, Broliden K, Hirbod T; Kibera HIV Study Group.

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Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Solna, Stockholm, Sweden.
Abstract
BACKGROUND:

Several mucosal innate immune proteins exhibit HIV inhibitory activity and their analogues are potential microbicide candidates. However, their clinical associations and in-vivo role in cervicovaginal host defense against HIV acquisition are poorly defined.
METHODS:

Cervicovaginal secretions (CVSs) were collected from HIV uninfected Kenyan sex workers at enrolment into an HIV prevention trial. After trial completion, CVS from participants acquiring HIV (cases) and matched controls were assessed for levels of innate immune factors and HIV neutralizing capacity, by blinded investigators. Cross-sectional and prospective associations of innate immune factors were examined.
RESULTS:

CVS contained high levels of defensins (human neutrophil peptide-1-3 and human beta defensin-2-3), LL-37 and secretory leukocyte protease inhibitor. Regulated upon activation normal T-cell expressed and secreted levels were lower, and IFNalpha was undetectable. CVS from 20% of participants neutralized a clade A primary HIV isolate, and 12% neutralized both clade A and C isolates. HIV neutralization was correlated with human neutrophil peptide-1-3 (alpha-defensins) and LL-37 levels. However, alpha-defensin and LL-37 levels were increased in participants with bacterial sexually transmitted infections and were independently associated with increased HIV acquisition in multivariate analysis.
CONCLUSIONS:

Despite significant HIV inhibitory activity, cervicovaginal levels of alpha-defensins and LL-37 were associated with increased HIV acquisition, perhaps due to their association with bacterial sexually transmitted infections.

PMID:
19114868
[PubMed - indexed for MEDLINE]

Harper GW, Ngugi EN, Lemos D, Gikuni A, Riplinger AJ, Hooks K, Hooks K. "Sources of resillience among kenyan youth newly diagnosed with HIV/AIDS in the nairobi slum of kibera: Implications for intervetion.". 2009. Abstract

Adolescents and young adults who are living with HIV in Kenya comprise a growing percentage of the population. Currently, youth (ages 15-35) represent 38% of the Kenyan population, yet over 60% of new HIV infections occur among this group. In 2008, adolescents and young adults living with HIV accounted for an estimated 6 % of the adolescent population between the ages of 15 and 24 (KDHS, 2009). Of these, the prevalence rates are nearly 6 times higher among young women (2.7% for 15 to 24 year old females; 6.4% for 20 to 24 year old females) as compared to young men (0.7% for 15 to 19 year old males; 1.5% for 20 to 24 year old males) (KDHS, 2009). The difference in prevalence rates among age groups suggests that many youth are becoming infected during adolescence (NASCOP, 2009). Geographic disparities also exist with regards to HIV infection. HIV is more prevalent in urban areas (7.2%) than in rural areas (6.2%). The vast majority ofthe infections are attributed to heterosexual contact in regular partnerships, men who have sex with men, and prisoners (HIV Prevention, Response and Modes of Transmission Analysis, 2009). A study on HIV seroprevalence study found this disparity is even greater in young women aged 15-24 who are four times more likely to become infected with HIV than men of the same age (KDHS, 2009). While having multiple sex partners is seen as a risk factor for HIV transmission, it has also been reported that married persons (6.4%) have higher HIV prevalence rates than nonmarried persons (4.2%) in Kenya, suggesting the need for tailored messages for married partners. Additionally, despite the urgent need for focus on HIV in Kenya, with limited resources there is a need also to focus on urban slum settlements in Kenya as they have higher rates of HIV prevalence than urban regions in general (12% versus 7.1%).

2008
E.N. PN. "Associations of human leukocyte antigen DRB with resistance or susceptibility to HIV-1 infection in the Pumwani Sex Worker Cohort.". 2008. Abstract

AIDS. 2008 May 31;22(9):1029-38. doi: 10.1097/QAD.0b013e3282ffb3db.
Associations of human leukocyte antigen DRB with resistance or susceptibility to HIV-1 infection in the Pumwani Sex Worker Cohort.
Lacap PA, Huntington JD, Luo M, Nagelkerke NJ, Bielawny T, Kimani J, Wachihi C, Ngugi EN, Plummer FA.
Source
National Microbiology Laboratory, Winnipeg, Canada.
Abstract
OBJECTIVE:
A group of commercial sex workers in the Pumwani Sex Worker Cohort, established in 1985 in Nairobi, Kenya, remain HIV-1 uninfected despite heavy exposure to HIV-1 through active sex work. Previous studies showed that this resistance is associated with a strong CD4+ T-cell response, which suggested that human leukocyte antigen class II antigens are important in resistance/susceptibility to HIV-1 infection. DRB1 is the most polymorphic locus among class II genes and forms haplotypes with DRB3, DRB4 and DRB5. The aim of this study is to investigate the role of DRB alleles/haplotypes on resistance/susceptibility to HIV-1 infection.
DESIGN:
In total, 1090 women enrolled in the Pumwani cohort were genotyped for DRB1, DRB3, DRB4 and DRB5 using a high-resolution sequence-based method. Allele/haplotype frequencies were compared between HIV-positive women and women who have remained HIV negative for more than 3 years despite frequent exposure.
METHODS:
Human leukocyte antigen DRB genes were amplified, sequenced and genotyped using a two-step sequence-based method. Allele/haplotype frequencies were determined using PyPop32-0.6.0. Statistical analysis was conducted using SPSS 11.0 for Windows.
RESULTS:
Three DRB1 alleles were associated with resistance: DRB1*010101 (P = 0.016; odd ratio (OR): 2.55; 95% confidence interval (CI): 1.16-5.61), DRB1*010201 (P = 0.019; OR: 1.86; 95% CI: 1.10-3.15), and DRB1*1102 (P = 0.025; OR: 1.72; 95% CI: 1.07-2.78). DRB1*030201 (P = 0.038; OR: 0.48; 95% CI: 0.23-0.98), DRB1*070101 (P = 0.035; OR: 0.54; 95% CI: 0.30-0.97), DRB1*1503 (P = 0.0004; OR: 0.34; 95% CI: 0.19-0.64), and DRB5*010101 (P = 0.001; OR: 0.37; 95% CI: 0.20-0.67) were associated with susceptibility. The haplotype DRB1*1102-DRB3*020201 was associated with HIV-1 resistance (P = 0.041; OR: 1.68; 95% CI: 1.02-2.78),
whereas the haplotypes DRB1*070101-DRB4*01010101 (P = 0.041; OR: 0.52; 95% CI: 0.28-0.98) and DRB1*1503-DRB5*01010101 (P = 0.0002; OR: 0.30; 95% CI: 0.15-0.58) were associated with susceptibility. These associations with resistance/susceptibility to HIV-1 were independent of previously reported alleles HLA-DRB1*01 and HLA-A*2301.
CONCLUSION:
Our findings indicate that human leukocyte antigen DRB-specific CD4+ T-cell responses are an important factor in resistance/susceptibility to HIV-1 infection.
PMID:
18520346
[PubMed - indexed for MEDLINE]

E.N. PN. "Coinfection with herpes simplex virus type 2 is associated with reduced HIV-specific T cell responses and systemic immune activation.". 2008. Abstract

Coinfection with herpes simplex virus type 2 is associated with reduced HIV-specific T cell responses and systemic immune activation.
Sheth PM, Sunderji S, Shin LY, Rebbapragada A, Huibner S, Kimani J, Macdonald KS, Ngugi E, Bwayo JJ, Moses S, Kovacs C, Loutfy M, Kaul R.
Source

Department of Medicine, University of Toronto, Toronto, Canada.
Abstract
BACKGROUND:

Chronic coinfection with herpes simplex virus type 2 (HSV-2) and human immunodeficiency virus (HIV) has been associated with an increased HIV viral load and more rapid disease progression, perhaps related to HSV-2-associated alterations in host immunity.
METHODS:

Studies were nested within (1) a cross-sectional study of men coinfected with HIV and HSV-2 and (2) women not infected with HIV, both before and after HSV-2 acquisition. HSV-2 infection status was determined by ELISA. HIV-specific CD8(+) T cell epitopes were mapped, and proliferation of HIV-specific cells was also assessed. Systemic inflammatory and regulatory T cell populations were assayed by flow cytometry.
RESULTS:

The breadth of both the HIV-specific CD8(+) T cell interferon-gamma and proliferative responses was reduced in participants coinfected with HIV and HSV-2, independent of the HIV plasma viral load and CD4(+) T cell count, and the magnitude of the responses was also reduced. HSV-2 infection in this group was associated with increased T cell CD38 expression but not with differences in the proportion of CD4(+) FoxP3(+) regulatory T cells. However, in women not infected with HIV, acquisition of HSV-2 was associated with an increase in the proportion of regulatory T cells.
CONCLUSIONS:

HSV-2 coinfection was associated with reduced HIV-specific T cell responses and systemic inflammation. The immune effects of HSV-2 may underlie the negative impact that this coinfection has on the clinical course of HIV infection.

PMID:
18444797
[PubMed - indexed for MEDLINE]

Free full text

E.N. PN. "A common human leucocyte antigen-DP genotype is associated with resistance to HIV-1 infection in Kenyan sex workers.". 2008. Abstract

AIDS. 2008 Oct 1;22(15):2038-42. doi: 10.1097/QAD.0b013e328311d1a0.
A common human leucocyte antigen-DP genotype is associated with resistance to HIV-1 infection in Kenyan sex workers.
Hardie RA, Knight E, Bruneau B, Semeniuk C, Gill K, Nagelkerke N, Kimani J, Wachihi C, Ngugi E, Luo M, Plummer FA.
Source
Department of Medical Microbiology, University of Manitoba, Canada.
Abstract
Human leucocyte antigen-DP presents peptides to CD4 T cells and plays an important role in parasitic infections and autoimmune diseases, yet its influence on HIV-1 susceptibility has not been well studied. Here, we report several human leucocyte antigen-DP genotypes associated with HIV-1 susceptibility in Kenyan sex workers. Among these, one common genotype stands out. DPA1*010301 (frequency = 60.4%) was associated with HIV-1 resistance (P = 0.033, odds ratio = 1.585, 95% confidence interval = 1.036-2.425) and slower seroconversion (P = 0.001, log rank = 0.595, 95% confidence interval = 0.433-0.817). The discovery of common human leucocyte antigen-DP genotypes contributing to HIV-1 immunity may help overcome difficulties encountered with highly polymorphic human leucocyte antigens.
PMID:
18784467
[PubMed - indexed for MEDLINE]
PMCID:
PMC2683274
Free PMC Article

E.N. PN. "HIV-neutralizing immunoglobulin A and HIV-specific proliferation are independently associated with reduced HIV acquisition in Kenyan sex workers.". 2008. Abstract

AIDS. 2008 Mar 30;22(6):727-35. doi: 10.1097/QAD.0b013e3282f56b64.
HIV-neutralizing immunoglobulin A and HIV-specific proliferation are independently associated with reduced HIV acquisition in Kenyan sex workers.
Hirbod T, Kaul R, Reichard C, Kimani J, Ngugi E, Bwayo JJ, Nagelkerke N, Hasselrot K, Li B, Moses S; Kibera HIV Study Group, MacDonald KS, Broliden K.

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Infectious Diseases Unit, Department of Medicine, Solna, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, Sweden.
Abstract
OBJECTIVES:

HIV-neutralizing immunoglobulin A (IgA) and HIV-specific cellular immunity have been described in highly exposed, persistently seronegative (HEPS) individuals, but well controlled studies have not been performed. We performed a prospective, nested case-control study to examine the association of genital IgA and systemic cellular immune responses with subsequent HIV acquisition in high-risk Kenyan female sex workers (FSWs).
DESIGN AND METHODS:

A randomized trial of monthly antibiotic prophylaxis to prevent sexually transmitted disease/HIV infection was performed from 1998 to 2002 in HIV-uninfected Kenyan FSWs. After the completion of trial, FSWs who had acquired HIV (cases) were matched 1: 4 with persistently uninfected controls based on study arm, duration of HIV-seronegative follow-up, and time of cohort enrolment. Blinded investigators assayed the ability at enrolment of genital IgA to neutralize primary HIV isolates as well as systemic HIV-specific cellular IFNgamma-modified enzyme-linked immunospot and proliferative responses.
RESULTS:

The study cohort comprised 113 FSWs: 24 cases who acquired HIV and 89 matched controls. Genital HIV-neutralizing IgA was associated with reduced HIV acquisition (P = 0.003), as was HIV-specific proliferation (P = 0.002), and these associations were additive. HIV-specific IFNgamma production did not differ between case and control groups. In multivariable analysis, HIV-neutralizing IgA and HIV-specific proliferation each remained independently associated with lack of HIV acquisition. Genital herpes (HSV2) was associated with increased HIV risk and with reduced detection of HIV-neutralizing IgA.
CONCLUSION:

Genital HIV-neutralizing IgA and systemic HIV-specific proliferative responses, assayed by blinded investigators, were prospectively associated with HIV nonacquisition. The induction of these immune responses may be an important goal for HIV vaccines.

E.N. PN. "Human leukocyte antigen-DQ alleles and haplotypes and their associations with resistance and susceptibility to HIV-1 infection.". 2008. Abstract

AIDS. 2008 Apr 23;22(7):807-16. doi: 10.1097/QAD.0b013e3282f51b71.
Human leukocyte antigen-DQ alleles and haplotypes and their associations with resistance and susceptibility to HIV-1 infection.
Hardie RA, Luo M, Bruneau B, Knight E, Nagelkerke NJ, Kimani J, Wachihi C, Ngugi EN, Plummer FA.
Source
Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada.
Abstract
OBJECTIVES:
To determine the association of DQ antigens with resistance and susceptibility to HIV-1.
DESIGN:
Despite repeated exposure to HIV-1, a subset of women in the Pumwani Sex Worker cohort established in Nairobi, Kenya in 1985 have remained HIV-1 negative for at least 3 years and are classified as resistant. Differential susceptibility to HIV-1 infection is associated with HIV-1 specific CD4 and CD8 T cell responses. As human leukocyte antigen-DQ antigens present viral peptides to CD4 cells, we genotyped human leukocyte antigen -DQ alleles for 978 women enrolled in the cohort and performed cross-sectional and longitudinal analyses to identify associations of human leukocyte antigen -DQ with resistance/susceptibility to HIV-1.
METHODS:
DQA1 and DQB1 were genotyped using taxonomy-based sequence analysis. SPSS 13.0 was used to determine associations of DQ alleles/haplotypes with HIV-1 resistance, susceptibility, and seroconversion rates.
RESULTS:
Several DQB1 alleles and DQ haplotypes were associated with resistance to HIV-1 infection. These included DQB1*050301 (P = 0.055, Odds Ratio = 12.77, 95% Confidence Interval = 1.44-112), DQB1*0603 and DQB1*0609 (P = 0.037, Odds Ratio = 3.25, 95% Confidence Interval = 1.12-9.47), and DQA1*010201-DQB1*0603 (P = 0.044, Odds Ratio = 17.33, 95% Confidence Interval = 1.79-168). Conversely, DQB1*0602 (P = 0.048, Odds Ratio = 0.68, 95% Confidence Interval = 0.44-1.05) and DQA1*010201-DQB1*0602 (P = 0.039, Odds Ratio = 0.64, 95% Confidence Interval = 0.41-1.03) were overrepresented in the HIV-1 infected population. DQA1*0504-DQB1*0201, DQA1*010201-DQB1*0201, DQA1*0402-DQB1*0402 and DQA1*0402-DQB1*030101 genotypes were only found in HIV-1 positive subjects (Odds Ratio = 0.30-0.31, 95% Confidence Interval = 0.03-3.70), and these women seroconverted rapidly. The
associations of these DQ alleles and haplotypes with resistance and susceptibility to HIV-1 were independent of the previously reported human leukocyte antigen-DRB*01, human leukocyte antigen A2/6802, and human leukocyte antigen-A*2301.
CONCLUSION:
The associations of DQ alleles and haplotypes with resistance and susceptibility to HIV-1 emphasize the importance of human leukocyte antigen-DQ and CD4 in anti-HIV-1 immunity

E.N. PN. "Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence.". 2008. Abstract

AIDS. 2008 Jan 2;22(1):131-7.
Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence.
Kimani J, Kaul R, Nagelkerke NJ, Luo M, MacDonald KS, Ngugi E, Fowke KR, Ball BT, Kariri A, Ndinya-Achola J, Plummer FA.
Source

Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya.
Abstract
OBJECTIVES:

Female sex workers (FSWs) form a core group at high risk of both sexual HIV acquisition and secondary transmission. The magnitude of these risks may vary by sexual risk taking, partner HIV prevalence, host immune factors and genital co-infections. We examined temporal trends in HIV prevalence and per-act incidence, adjusted for behavioral and other variables, in FSWs from Nairobi, Kenya.
METHODS:

An open cohort of FSWs followed since 1985. Behavioral and clinical data were collected six monthly from 1985 to 2005, and sexually transmitted infection (STI) diagnostics and HIV serology performed. A Cox proportional hazards model with time-dependent covariables was used to estimate infection risk as a function of calendar time.
RESULTS:

HIV prevalence in new FSW enrollees peaked at 81% in 1986, and was consistently below 50% after 1997. Initially uninfected FSWs remained at high risk of acquiring HIV throughout the study period, but the rate of HIV acquisition during unprotected sex with a casual client declined by over four-fold. This reduction correlated closely with decreases in gonorrhea prevalence, and predated reductions in the Kenyan HIV population prevalence by over a decade.
CONCLUSIONS:

The per-act rate of HIV acquisition in high-risk Nairobi FSWs fell dramatically between 1985 and 2005. This decline may represent the impact of improved STI prevention/therapy, immunogenetic shifts in at-risk women, or changes in the proportion of HIV exposures occurring with clients who had acute HIV infection. Declining HIV incidence in high-risk cohorts may predict and/or be causally related to future reductions in population prevalence.

PMID:
18090401
[PubMed - indexed for MEDLINE]

2007
E.N. PN. "Girls and the BudenJden of HlV/AlDS." The Contract. Vol 10 (2007):12.
E.N. PN. "Personal digital assistants for HIV treatment adherence, safer sex behavior support, and provider training in resource-constrained settings.". 2007. Abstract

AMIA Annu Symp Proc. 2007 Oct 11:1018.
Personal digital assistants for HIV treatment adherence, safer sex behavior support, and provider training in resource-constrained settings.
Kurth AE, Curioso WH, Ngugi E, McClelland L, Segura P, Cabello R, Berry DL.
Source

University of Washington, Seattle, WA, USA.
Abstract

We developed a Web-based application delivered on PDAs (Colecta-PALM in Peru, Pambazuko-PALM in Kenya), to collect data from HIV patients and to facilitate HIV provider training. Colecta-PALM provides tailored feedback (behavioral messaging) based on risk assessment responses for HIV patients. Pambazuko-PALM collects patient risk assessment data, and delivers counseling protocol training and evaluation to nurses involved in HIV care.

PMID:
18694116
[PubMed - indexed for MEDLINE]

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E.N. PN. "Prevalent herpes simplex virus type 2 infection is associated with altered vaginal flora and an increased susceptibility to multiple sexually transmitted infections.". 2007. Abstract

J Infect Dis. 2007 Dec 1;196(11):1692-7. Epub 2007 Oct 25.
Prevalent herpes simplex virus type 2 infection is associated with altered vaginal flora and an increased susceptibility to multiple sexually transmitted infections.
Kaul R, Nagelkerke NJ, Kimani J, Ngugi E, Bwayo JJ, Macdonald KS, Rebbaprgada A, Fonck K, Temmerman M, Ronald AR, Moses S; Kibera HIV Study Group.
Source

Department of Medical Microbiology, University of Nairobi, Kenya. rupert.kaul@utoronto.ca
Abstract
BACKGROUND:

Prevalent herpes simplex virus type 2 (HSV-2) infection increases human immunodeficiency virus acquisition. We hypothesized that HSV-2 infection might also predispose individuals to acquire other common sexually transmitted infections (STIs).
METHODS:

We studied the association between prevalent HSV-2 infection and STI incidence in a prospective, randomized trial of periodic STI therapy among Kenyan female sex workers. Participants were screened monthly for infection with Neisseria gonorrhoeae and Chlamydia trachomatis, and at least every 6 months for bacterial vaginosis (BV) and infection with Treponema pallidum, Trichomonas vaginalis, and/or HSV-2.
RESULTS:

Increased prevalence of HSV-2 infection and increased prevalence of BV were each associated with the other; the direction of causality could not be determined. After stratifying for sexual risk-taking, BV status, and antibiotic use, prevalent HSV-2 infection remained associated with an increased incidence of infection with N. gonorrhoeae (incidence rate ratio [IRR], 4.3 [95% confidence interval {CI}, 1.5-12.2]), T. vaginalis (IRR, 2.3 [95% CI, 1.3-4.2]), and syphilis (IRR, 4.7 [95% CI, 1.1-19.9]). BV was associated with increased rates of infection with C. trachomatis (IRR, 2.1 [95% CI, 1.1-3.8]) and T. vaginalis (IRR, 8.0 [95% CI, 3.2-19.8]). CONCLUSION; Increased prevalences of HSV-2 infection and BV were associated with each other and also associated with enhanced susceptibility to an overlapping spectrum of other STIs. Demonstration of causality will require clinical trials that suppress HSV-2 infection, BV, or both.

Plummer FA, Ngugi EN, Embree J, Fowke K, Ndinya-Achola J, MacDonald K, Ball T, Nagelkerke N, Kimani J, Ma L. "Rapid selection for HLA alleles that protect against HIV-1 infection correlates significantly to the declining incidence of HIV-1 in an East African sex worker population."; 2007.
E.N. PN. "The role of relationship intimacy in consisten condom use among female sex workers and regular paying partners in Dominican Republic.". 2007. Abstract

J Acquir Immune Defic Syndr. 2007 Aug 15;45(5):588-94.
Sustained changes in sexual behavior by female sex workers after completion of a randomized HIV prevention trial.
Ngugi EN, Chakkalackal M, Sharma A, Bukusi E, Njoroge B, Kimani J, MacDonald KS, Bwayo JJ, Cohen CR, Moses S, Kaul R; Kibera HIV Study Group.
Source
Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya.
Abstract
INTRODUCTION:
Behavioral interventions in female sex workers (FSWs) are associated with changes in sexual behavior and reduced rates of sexually transmitted infections (STIs) and HIV We examined the sustainability of such interventions.
METHODS:
HIV-uninfected Kenyan FSWs were enrolled in a clinical trial that provided free male condoms, community and clinic-based counseling, and STI management. After trial completion, scaled-back community-based resources remained in place. More than a year later, women were invited to complete a follow-up behavioral questionnaire and to undergo STI/HIV counseling and testing. Individual changes in sexual behavior were assessed by paired analysis.
RESULTS:
One hundred seventy-two women participated in the resurvey 1.2 years after trial termination. Client numbers had risen (paired t test, P < 0.001), but condom use had also increased (P < 0.001); both remained substantially lower than at enrollment. Regular partners accounted for a greater proportion of unprotected FSW sexual encounters (35% vs. 10%; P < 0.001). Only 9 (5.2%) of 172 women had a conventional STI, and the follow-up HIV incidence of 1.6 per 100 person-years (PYs) was similar to that during the trial period (3.7 per 100 PYs). Incident STIs and HIV were associated with the frequency of unprotected sex and younger age.
CONCLUSIONS:
Less intensive community-based risk reduction services after clinical trial termination may support ongoing reductions in STIs and HIV among high-risk FSWs.
PMID:
17589374
[PubMed - indexed for MEDLINE]

Shahmanesh M, Wayal S, Cowan F, Mabey D, Copas A, Patel V, Ngugi EN. "Suicidal behavior among female sex workers in Goa, India: the silent epidemic.". 2007. Abstract

Given that sex work is stigmatized In more countries Ihan not, it is likely to cause stress and increase sUicidal behaviour. This is significant and Iherefore the interventions should also include psychosocial counselling in order to support the sex workers' coping mechanisms. The findings of this study show that sooro-eccoormc empowerment reduces HIV risks in female sex workers who are from a low socio-economic class. My experience too has shown thai an empathetic attitude from care providers increases the sex-workers' self-worth and therefore the ability to cope. Studies have shown that female sex work in Africa, part of ASia and some inner cities of developed countries is poverty-driven. The majority of women are really practising survival as they also have children to feed, clothe and send to school. My experience in Kenya is that the interaction between poverty and stigma increases stress and therefore SUicidal tendency. The added problem is when the female sex worker would also turn out to be HIV-infected. Holistic and responsive interventions are recommended for quality mental health in female sex workers A major question that still remains IS how can poverty-driven sex work be effectively reduced. A limitation of the study is that the study population size was not sufficiently large to allow generalization. For further reading please see ret (1}. on which I am an author. whose results give female sex workers power to reduce dependency on sex income or exit.

Wamalwa D, Benki-Nugent S, Langat A, Tapia K, Ngugi E;, Slyker JA, Richardson BA, John-Stewart GC. "Survival benefit of early infant antiretroviral therapy is compromised when diagnosis is delayed.". 2007. Abstract

Late presentation is common among African HIV-1-infected infants. Incidence and correlates of mortality were examined in 99 infants with HIV-1 diagnosis by 5 months of age. Twelve-month survival was 66.8% (95% confidence interval: 55.9-75.6%). World Health Organization stage 3 or 4, underweight, wasting, microcephaly, low hemoglobin, pneumonia and gastroenteritis predicted mortality. Early HIV-1 diagnosis with antiretroviral therapy before symptomatic disease is critical for infant survival.

E.N. PN. "Sustained changes in sexual behavior by female sex workers after completion of a randomized HIV prevention trial.". 2007. Abstract

J Acquir Immune Defic Syndr. 2007 Aug 15;45(5):588-94.
Sustained changes in sexual behavior by female sex workers after completion of a randomized HIV prevention trial.
Ngugi EN, Chakkalackal M, Sharma A, Bukusi E, Njoroge B, Kimani J, MacDonald KS, Bwayo JJ, Cohen CR, Moses S, Kaul R; Kibera HIV Study Group.
Source

Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya.
Abstract
INTRODUCTION:

Behavioral interventions in female sex workers (FSWs) are associated with changes in sexual behavior and reduced rates of sexually transmitted infections (STIs) and HIV We examined the sustainability of such interventions.
METHODS:

HIV-uninfected Kenyan FSWs were enrolled in a clinical trial that provided free male condoms, community and clinic-based counseling, and STI management. After trial completion, scaled-back community-based resources remained in place. More than a year later, women were invited to complete a follow-up behavioral questionnaire and to undergo STI/HIV counseling and testing. Individual changes in sexual behavior were assessed by paired analysis.
RESULTS:

One hundred seventy-two women participated in the resurvey 1.2 years after trial termination. Client numbers had risen (paired t test, P < 0.001), but condom use had also increased (P < 0.001); both remained substantially lower than at enrollment. Regular partners accounted for a greater proportion of unprotected FSW sexual encounters (35% vs. 10%; P < 0.001). Only 9 (5.2%) of 172 women had a conventional STI, and the follow-up HIV incidence of 1.6 per 100 person-years (PYs) was similar to that during the trial period (3.7 per 100 PYs). Incident STIs and HIV were associated with the frequency of unprotected sex and younger age.
CONCLUSIONS:

Less intensive community-based risk reduction services after clinical trial termination may support ongoing reductions in STIs and HIV among high-risk FSWs.

PMID:
17589374
[PubMed - indexed for MEDLINE]

2006
E.N. PN. "Anal and dry sex in commercial sex work, and relation to risk for sexually transmitted infections and HIV in Meru, Kenya.". 2006. Abstract

Anal and dry sex in commercial sex work, and relation to risk for sexually transmitted infections and HIV in Meru, Kenya
M Schwandt, C Morris, A Ferguson, E Ngugi, and S Moses
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Abstract
Objective

To examine the practices of anal intercourse and dry sex within a cohort of female sex workers (FSWs) in Kenya, focusing on the prevalence and perceived risk of the practices, demographic and behavioural correlates, and association with sexually transmitted infections (STI).
Methods

A survey was conducted among FSWs in Meru, Kenya, with 147 participants randomly sampled from an existing cohort of self identified FSWs.
Results

40.8% of participants reported ever practising anal intercourse and 36.1% reported ever practising dry sex. Although the majority of women surveyed believed anal intercourse and dry sex to be high risk practices for HIV infection compared with vaginal sex, about one third of women reported never or rarely using condoms during anal intercourse, and about 20% never or rarely using condoms during dry sex. Reported consistent condom use was lower with both of these practices than with penile‐vaginal intercourse. Anal intercourse was associated with experience of recent forced sexual intercourse, while dry sex was not. Anal intercourse was almost always initiated by clients, whereas dry sex was likely to be initiated by the women themselves. Sex workers reported charging higher fees for both practices than for vaginal intercourse. Both practices were associated with reported symptoms and diagnoses of STI.
Conclusions

Both anal intercourse and dry sex were common in this sample, and although perceived as high risk practices, were not adequately protected with condom use. Education and other interventions regarding these high risk sexual behaviours need to be translated into safer practices, particularly consistent condom use, even in the face of financial vulnerability.
Keywords: anal intercourse, dry sex, high risk practices, female sex workers, sexually transmitted infections, HIV, Kenya

Roth EA, Ngugi EN, Masako F. "Self-deception does not explain high-risk sexual behavior in the face of HIV/AIDS: A test from northern Kenya.". 2006. Abstract

Throughout sub-Saharan Africa, there is resistance to changing sexual behavior despite survey data indicating high levels of knowledge about HIV transmission patterns and high-risk behavior. Previous explanations for this paradox emphasize indigenous cultural models. An alternative explanation is that, due to a strong natural selection for sexual gratification, individuals evoke the evolved trait of selfdeception to continue practicing high-risk sexual behavior. This alternative is tested using survey data from an Ariaal community in Marsabit District, northern Kenya. Results indicate that respondents make highly accurate self-assessments of HIV risk, negating the concept of self-deception in this study. These results are discussed within the larger context of the applicability of evolutionary theory to the AIDS pandemic.

E.N. PN. "Sex preparation and diaphragm acceptability in sex work in Nairobi, Kenya.". 2006. Abstract

Sex preparation and diaphragm acceptability in sex work in
Nairobi, Kenya

Anjali Sharma A , B r H , J I Elizabeth Bukusi A , B , C I Samuel Posner 0 I Doug/as Feldman E ,
Elizabeth Ngugi F and Craig R. Cohen G

A Centre for Microbiology Research, Kenya Medical Research Institute,. Kenyatta National Hospital,
PO Box 19464-00202, Nairobi, Kenya. ,
B Department of Obstetrics and Gynecology, University of Washington School of Medicine, 1959 NE
Pacific St, Box 356460, Seattle, WA 98195, USA.
c Department of Obstetrics and Gynecology, University of Nairobi, Kenyatta National Hospital, PO
Box 19676, Nairobi, Kenya.
o Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341, USA.
E Department of Anthropology, State University of New York College, 350 New Campus Drive,
Brockport, NY 14420, USA.
F Department of Community Health Sciences, University of Nairobi, Kenyatta National Hospital, PO
Box 19676, Nairobi, Kenya.
G Department of Obstetrics, Gynecology, Reproductive Sciences, University of California, 50 Beale
St, San Francisco, CA 94105, USA.
H Present address: Suite 311, 3rd Floor, Theodak Plaza, National Hospital Road, Off Constitution
Ave, Central Business District, P.M.B. 69, Garki, Abuja, Nigeria.
I Corresponding author. Email: aSharma@csrtkenya.orgoranjali_sharma@hotmail.com

Abstract

Background: Women in sex work stand to benefit if the contraceptive diaphragm alone or
combined with a microbicide proves to be an effective barrier method against HIV and sexually
transmissible infection CSTI). Currently, contraceptive diaphragm users are advised to leave the
diaphragm in situ without concomitant use of other intravaginal substances for at least 6 h after
intercourse. Methods: We conducted in-depth interviews on sexual behaviour including post-coital
intravaginal practices with 36 women in sex work and 26 of their clients and held two focus-group
discussions, each with 10 women. Results: The women described a.gapting several potentially
harmful substances, such as cloth and soapy water, for post-coital vaginal use to ensure personal
hygiene, disease prevention and client pleasure. Some wanted to clean themselves and remove
the diaphragm early, fearing exposure to HIV infection for themselves and their subsequent
clients. Clients indicated their desire for 'dry sex', vaginal cleanliness and reduced risk of infection
through vaginal cleaning. Conclusions: The diaphragm as a female-controlled barrier method for
HIVjSTI prevention may have limited acceptability among women in sex work if its effectiveness - ,
depends on a 6-h post-coital wait before removal, along with avoidance of concomitant use of
intravaginal substances. In keeping with the beliefs of the the female sex workers and their needs
and practices, alternative intravaginal substances and modes of insertion that will not disrupt
vaginal flora, injure vaginal epithelium, damage the diaphragm or counteract potentially beneficial
effects of microbicides are needed. The possibility of removing the diaphragm sooner than the
recommended 6 h for contraception should be further studied.

Sexual Health 3(4) 261-268

Submitted: 23 March 2006 Accepted: 6 August 2006 Published: 17 November 2006

Full text 001: lO.1071/SH06021

@ (SIRO 2006

hrtp:/!www.publish.csiro.aulindex.cfm?paper=SH06021 11127/2007

2005
E.N. PN. "Associations of sexual risk taking among Kenyan female sex workers after enrollment in an HIV-1 prevention trial.". 2005. Abstract

J Acquir Immune Defic Syndr. 2005 Mar 1;38(3):329-34.
Associations of sexual risk taking among Kenyan female sex workers after enrollment in an HIV-1 prevention trial.
Yadav G, Saskin R, Ngugi E, Kimani J, Keli F, Fonck K, Macdonald KS, Bwayo JJ, Temmerman M, Moses S, Kaul R; Kibera HIV Study Group.
Source

Faculty of Arts and Sciences, University of Toronto, Toronto, Ontario, Canada.
Abstract
BACKGROUND:

Female sex workers (FSWs) often lack the ability to negotiate safer sex and are at high risk for HIV-1 infection and sexually transmitted infections (STIs).
METHODS:

Seronegative FSWs were enrolled in an STI/HIV-1 prevention trial in Nairobi, Kenya. Demographics and sexual risk taking were assessed every 3 months. Predictors of reduced risk taking were defined using multivariate logistic regression.
RESULTS:

Four hundred sixty-six FSWs were enrolled and followed for just over 2 years each. A spectrum of sex work was apparent: FSWs working in night clubs were younger, charged more for sex, and used condoms more frequently; FSWs working from home were older, charged less, and used condoms the least; and those working in bars were intermediate. Increases in reported condom use were most significant and sustained for FSWs working from home and charging less for sex and were poorly maintained for bar-based FSWs. Self-reported lower condom use, higher client numbers, and alcohol use were associated with higher STI rates.
CONCLUSIONS:

Home-based FSWs and those charging less for sex used condoms the least at baseline but showed the greatest and most sustained improvements over time. Potential response heterogeneity in FSW subgroups should be considered in the design of HIV-1 prevention programs.

PMID:
15735453
[PubMed - indexed for MEDLINE]

2004
E.N. PN. "Associationsof Sexual RiskTaking Among Kenyan Female Sex Workers After Enrollment in an HIV-l Prevention Trial.". 2004. Abstract

ORIGINAL ARTICLE
Associationsof Sexual RiskTaking Among Kenyan Female Sex
Workers After Enrollment in an HIV-l Prevention Trial
G. Yadav, * R. Saskin,f§ E. N. Ngugi, # J. Kimani, 11F. Keli, 11K. Fonck; 11** K. S. MacDonald, ti
J. J. Bwayo,II M. Temmerman, ** The Kibera HJV Study Group, S. Moses, II and R. Kault§lI
Background: Female sex workers (FSWs) often lack the ability to
negotiate safer sex and arc at high risk for mv-I infection and sexually
transmitted infections (STIs).
Methods: Seronegative FSWs were enrolled in an STlJHIV-! prevention
trial in Nairobi, Kenya. Demographies and sexual risk taking
were assessed every 3 months. Predictors of reduced risk taking were
defined using multivariate logistic regression.
Results: Foul' hundred sixty-six FSWs were enrolled and followed
for just over 2 years each. A spectrum of sex work was apparent:
FSWs working in night clubs were younger, charged more for sex,
and used condoms more frequently; FSWs working from home were
older, charged less, and used condoms the least; and those working in
bars were intermediate. Increases in reported condom use were most
significant and sustained for FSWs working from home and charging
less for sex and were poorly maintained for bar-based FSWs. Selfreported
lower condom use, higher client numbers, and alcohol use
were associated with higher STl rates.
Conclusions: Home-based FSWs and those charging less for sex
used condoms the least at baseline but showed the greatest and most
sustained improvements over time. Potential response heterogeneity
Received for publication December 8, 2003; accepted May 6, 2004.
From the *Faculty of Arts and Sciences, University of Toronto, Toronto,
Ontario, Canada; [Dcpartrnent of Medicine, University of Toronto,
Toronto, Ontario, Canada; ~Mount Sinai Hospital, Toronto. Ontario,
Canada; §University Health Network, Toronto, Ontario, Canada; BOepart.
men! of Community Health Sciences and Medicine, University of
Manitoba, Winnipeg, Manitoba, Canada; 1jDepartment of Medical Microbiology,
University of Nairobi, Nairobi, Kenya; #Department of'Communiry
Health, University of Nairobi, Nairobi, Kenya; and "International
Centre for Reproductive Health, Department of Obstetrics and Gynaecology.
University of Ghent. Ghent, Belgium.
Members of The Kibera HIV Study Group are listed under ACknowledgments.
Supported by The Rockefeller Foundation (2000 HE 025), the European Cornmission
(DG Vlllf8, contract no. 7-RPR-28), the Canadian Research Chair
Programme (to R.K.), the Ontario HIV Treatment Network (to K.M.;
Career Scientist), and the Canadian Institutes of Health Research (to S.M.;
Investigator Award).
Reprints: Rupert Kaul, Clinical Science Division, Medical Sciences Building
#6356, University of Toronto. Toronto, Ontario, Canada M5S IA8 (e-mail:
rupert. kaul@utoronto.ca).
Copyright i\:i 2004 by Lippincott Williams & Wilkins
I Acquir Immune Defie Syndr • Volume 00, Number 0, Month ° 2004
in FSW subgroups should be considered in the design of Hlv-I prevention
programs.
Key Words: female sex workers, male condom, prospective, Africa,
workplace
(J Acquir Immune Defic Syndr 2004;00:000-000)
Female sex workers (FSWs) play an important role in the
dynamics of the HIV -1 epidemic in Africa. Factors including
gender inequality, economic disempowerment, and lack of
resources and education combine to place these women at an
enormously increased risk of acquiring HlV-I infection. 1.2 Infected
FSWs may also act as "core groups" in the HIV-l epidemic,
with male clients serving as bridges into the general
population.v" For these reasons, many HIV -1 prevention programs
have focused specifically on FSWs5 and have often
been very successful in reducing high-risk sexual behavior
and/or rates of sexually transmitted infections (STls) and
HIV-l infection.v"? However, there is a broad spectrum of
commercial sex work, with varying levels of sexual risk taking
and prevalence ofHIV-J infection among different FSW subpopulations.
I I It is therefore possible that the uptake or durability
ofHIV-l risk reduction interventions will vary, depending
on the demographics of the subpopulation targeted. It is
important to carefully document and evaluate the efficacy of
prevention programs in different situations and populations, 12
because resources allocated to HIV-l prevention fall far short
of what is necessary. J3
In 1998, a trial of antibiotic prophylaxis for acquisition
of both STls and HIV -1 infection was initiated in a cohort of
HIV -l-seronegative sex workers from the Kibera district of
Nairobi.14•15 A risk reduction program was provided for all
enrolled FSWs, and this was very successful in reducing rates
of high-risk behavior and STIsY However, self-identified
FSWs in this cohort practiced sex work in a number of very
different environments, as has- been reported for sex worker
cohorts elsewhere in Africa. II Therefore, tile purpose of this
study was to determine whether baseline factors could be identified
that predicted a greater or more sustained response to the
risk reduction intervention (ie, increased condom use and/or
Yadav et of / Aequir Immune Oefie Syncfr • Volume 00, Number 0, Month °2004
reduced client numbers), with the aim of improving our understanding
of how prevention strategies can be targeted to better
address the needs of vulnerable FSWs.
METHODS
Recruitment into this HIV/STI prevention trial was mediated
through a previously established network of FSW peer
educators 10,16 from May 1998 to January 2002. The study design
and baseline findings have been reported previously.v'"
Sex workers were defined as women who reported receiving
money or gifts in exchange for sex during the month before
initial screening. FSWs attended the clinic every month and
were administered the study drug as directly observed therapy.
All study subjects were provided with HIV -I prevention services
that included peer and clinic risk reduction counseling,
the provision of free condoms, and prompt treatment of symptomatic
STls. Two standardized l-hour risk reduction counseling
sessions were provided to all women at enrollment, and
subsequent clinic-based counseling was provided based on the
clients' perceived needs and self-reported risk behavior. Peerbased
risk reduction counseling was also provided to all study
participants through a series on monthly cohort "barazas" and
smaller community meetings. This peer-based counseling followed
a previously described model.'? with the addition of
counseling regarding the need to negotiate consistent condom
use with regular clients and boyfriends in addition to their
more commercial clients. I I A behavioral questionnaire was
administered at baseline and at 3-month intervals to assess
risk-taking behavior. Ethics approvals for the study were obtained
from institutional review boards at Kenyatta National
Hospital, Nairobi, Kenya, and the University of Manitoba,
Winnipeg Manitoba, Canada.
Laboratory Methods
All women underwent complete physical examination
and STI testing and treatment at enrollment, every 6 months,
and whenever clinically indicated. Cervical swabs were obtained
for Neisseria gonorrhoeae and Chlamydia trachomatis
polymerase chain reaction assays (Amplicor PCR Diagnostics,
Roche Diagnostic Systems. Ontario, Canada) and for N. gonorrhoeae
culture. If a genital ulcer was present, a swab of the
@ ulcer base was taken for M-polymerase chain reaction detection
of Haemophilus ducreyi, herpes simplex virus, and Treponema
palliduin (Roche Molecular Systems, Ontario, Canada).
Trichomonas iaginalis culture was performed using In Pouch
TV (Biorned Diagnostics, San Jose, CA), and blood specimens
were obtained for mV-I and syphilis serology. Any infections
identified were treated according to the Kenya National STl
Treatment Guidelines. In addition, monthly urine specimens
were collected at the time of directly observed study drug administration,
stored at -20°C, and tested for N. gonorrhoeae
and C. trachoma/is by polymerase chain reaction assay after
study completion.
2
Statistical Analysis
All FSWs undergoing HIV-I counseling and testing
completed a baseline clinic questionnaire and had ongoing access
to medical care through the clinic, whether they agreed to
participate in the randomized trial. For enrolled FSWs, selfreported
condom use, weekly client numbers, and hormonal
contraceptive use were recorded at baseline and every 3
months. Condom use was reported on a scale of 0 to 5, where
o represented no condom use and 5 represented condom use
with all clients. All other demographic and behavioral data
were collected only at the time of enrollment. Women were
divided into 3 groups based on their place of work 14 as follows:
group 1, work only from their own or client's home; group 2,
work from a nightclub or disco; group 3, work in a local bar or
lodging.
Baseline (enrollment) associations of sexual risk taking,
prevalent STls, and HIV -1 infection were examined using a
table for either l-way analysis of variance (for continuous variables)
or l test (for dichotomous variables) in SPSS version
10.0 (SPSS, Chicago, IL). The impact of baseline demographic
and behavioral factors on subsequent changes in risk taking
and STI rates was then prospectively modeled using multivariate
Poisson regression and logistic regression models for
correlated data (generalized estimating equations; PROC
GENMOD, SAS for Windows version 8.1, SAS Institute,
Cary, NC). Variables included in the model were those previously
associated with increased risk taking in other FSW cohorts
and those associated with differences in risk taking in the
baseline analysis (P < 0.05). These were place of work, charge
per sex act (dichotomized into charge for sex more or less the
cohort average), daily alcohol consumption, ever smoking,
and age at enrollment. Rates of condom use were analyzed
only at visits where women reported at least 1 weekly client
(ie, they were still active in sex work).
RESULTS
Cohort Characteristics and Follow-up
Four hundred sixty-six HIV -l=-seronegative FSWs were
enrolled in the trial from May 1998 to January 2002. Participants
were encouraged to remain in the trial for at least 2 years,
after which time they were free to choose to continue in the
trial or to exit the trial and attend the clinic as needed for routine
medical care. The mean duration of follow-up was 760
days, for a total of 969.6 person years of follow-up, and the
mean number of visits was 23.9.
Risk-Taking Behavior at Study Enrollment
When grouped according to place of work, significant
differences were observed between FSW subgroups with respect
to several behavioral and biologic variables at baseline
(Table I). Women working out of their homes or their clients' ffl@~!
e]004 Lippincott Williams & I-Vilkins

E.N. PN. "Monthly antibiotic chemoprophylaxis and incidence of sexually transmitted infections and HIV-1 infection in Kenyan sex workers a randomized controlled trial.". 2004. Abstract

JAMA. 2004 Jun 2;291(21):2555-62.
Monthly antibiotic chemoprophylaxis and incidence of sexually transmitted infections and HIV-1 infection in Kenyan sex workers: a randomized controlled trial.
Kaul R, Kimani J, Nagelkerke NJ, Fonck K, Ngugi EN, Keli F, MacDonald KS, Maclean IW, Bwayo JJ, Temmerman M, Ronald AR, Moses S; Kibera HIV Study Group.
Source
Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya. rupert.kaul@utoronto.ca
Abstract
CONTEXT:
Sexually transmitted infections (STIs) are common in female sex workers (FSWs) and may enhance susceptibility to infection with human immunodeficiency virus type 1 (HIV-1).
OBJECTIVE:
To examine regular antibiotic prophylaxis in FSWs as a strategy for reducing the incidence of bacterial STIs and HIV-1.
DESIGN, SETTING, AND PARTICIPANTS:
Randomized, double-blind, placebo-controlled trial conducted between 1998-2002 among FSWs in an urban slum area of Nairobi, Kenya. Of 890 FSWs screened, 466 who were seronegative for HIV-1 infection were enrolled and randomly assigned to receive azithromycin (n = 230) or placebo (n = 236). Groups were well matched at baseline for sexual risk taking and STI rates.
INTERVENTION:
Monthly oral administration of 1 g of azithromycin or identical placebo, as directly observed therapy. All participants were provided with free condoms, risk-reduction counseling, and STI case management.
MAIN OUTCOME MEASURES:
The primary study end point was incidence of HIV-1 infection. Secondary end points were the incidence of STIs due to Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Treponema pallidum, and Haemophilus ducreyi, as well as bacterial vaginosis. Analysis of herpes simplex virus type 2 (HSV-2) infection was performed post hoc.
RESULTS:
Seventy-three percent of participants (n = 341) were followed up for 2 or more years or until they reached an administrative trial end point. Incidence of HIV-1 did not differ between treatment and placebo groups (4% [19 cases per 473 person-years of follow-up] vs 3.2% [16 cases per 495 person-years of follow-up] rate ratio [RR], 1.2; 95% CI, 0.6-2.5). Incident HIV-1 infection was associated with preceding infection with N gonorrhoeae (rate ratio [RR], 4.9; 95% CI, 1.7-14.3) or C trachomatis (RR, 3.0; 95% CI, 1.1-8.9). There was a reduced incidence in the treatment group of infection with N gonorrhoeae (RR, 0.46; 95% CI, 0.31-0.68), C trachomatis (RR, 0.38; 95% CI, 0.26-0.57), and T vaginalis (RR, 0.56; 95% CI, 0.40-0.78). The seroprevalence of HSV-2 infection at enrollment was 72.7%, and HSV-2 infection at baseline was independently associated with HIV-1 acquisition (RR, 6.3; 95% CI, 1.5-27.1).
CONCLUSIONS:
Despite an association between bacterial STIs and acquisition of HIV-1 infection, the addition of monthly azithromycin prophylaxis to established HIV-1 risk reduction strategies substantially reduced the incidence of STIs but did not reduce the incidence of HIV-1. Prevalent HSV-2 infection may have been an important cofactor in acquisition of HIV-1.
Comment in
 The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface controlAntibiotic chemoprophylaxis and HIV infection in Kenyan sex workers. [JAMA. 2004]
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Destroy user interface controlEvidence-based global health. [JAMA. 2004]
PMID:
15173146
[PubMed - indexed for MEDLINE]

"Sexual patterning and condom use among a group of HIV vulnerable men in Thika, Kenya.". 2004. Abstract

Sex Transm Infect. 2004 Dec;80(6):435-9.
Sexual patterning and condom use among a group of HIV vulnerable men in Thika, Kenya.
Ferguson A, Pere M, Morris C, Ngugi E, Moses S.
Source

Department of Medical Microbiology, University of Manitoba and Strengthening STD/HIV Control in Kenya Project, PO Box 19676, Nairobi, Kenya. alanf@stdhivkenya.org
Abstract

Background/aim: A composite sample of 37 peer educators and 215 members of self help groups of male informal sector workers in Thika, Kenya, targeting HIV/AIDS prevention, were interviewed about their sexual behaviour, using a customised template, as part of a broader survey on gender attitudes and peer pressure.
METHOD:

Details on each sexual partner reported by each man over a 12 month recall period included type of partner, months during which sexual relations took place, and condom use.
RESULTS:

The men reported 471 sexual partners over the recall period, with a range of 0-16 partners, and an average of just under two partners. 8% of men had had no sexual partner, half were monogamous, and 3% had multiple partners with whom they used condoms exclusively, leaving 39% at varying degrees of risk. Condom use increased significantly with reduced intimacy of partner. 16% of men reported having at least one liaison with a female sex worker and two thirds of such liaisons were exclusively protected by condom use. Younger, single men had significantly more partners, but were more likely to use condoms. Duration of membership in self help groups was strongly associated with exclusive use of condoms with casual or FSW partners. Recorded attitudes corresponded somewhat with practice, but the data showed large gaps between the two, and low levels of gender sensitivity.
CONCLUSION:

There is some evidence that group membership has resulted in increased condom use and partner reduction, but there are doubts as to the extent to which the "ABC" strategy can be successful in stemming the HIV/AIDS epidemic. It may be necessary for interventions to target contextual issues, particularly gender relations, if the approach is to be more successful.

PMID:
15572609
[PubMed - indexed for MEDLINE]
PMCID:
PMC1744931

Free PMC Article

Odek W, Costigan A, Ngugi EN, Oneko M, Plummer F. "THE UPTAKE OF ALTERNATIVE ECONOMIC ACTIVmES AMONG FEMALE'SEX WORKERS AND IMPACT ON SEXUAL BEHAVIOUR: INSIGHTS FROM, AN ACTION RESEARCH PROJECT IN NAIROBI, KENYA.". 2004. Abstract

The growing rate of HIV infection particularly among women in 'subSaharan African region suggests the need tor a. broader framework for prevention and care efforts. In particular, the socio-economic context that draws women into commercial sex is a key factor to be addressed. In this context, the Strengthening STDjAIDS Control in Kenya Project, in collaboration with Improve Your Business-Kenya, a small enterprise development organisation, initiated an operational research in February 1999, to assess the eftecnvecess of alternative economic activities support for women engaged in commerdal sex work in the slums of Nairobi as an HIV prevention strategy. The rnajoritv of the women had been in commercial sex work for more than 3 years and reported having an average of 4 different commercial sex clients per day with whom close to a. quarter used condoms only sometimes. Corroborative data from previous studies have shown female sex workers in Nairobi to be 50-80% HIV infected. In view of their risk of HIV infection, the women expressed the need for support for alternative income sources to enable them exercise more control over their sexual behaviour or exit sex work altogether. The financial support for the study was provided by the Canadian International Development Agency (CIDA).

2003
Jackson DJ, Ngugi EN, Plumme FA, Kariuki C, Ndinya-Achola JO, Bwayo JJ, Moses S. "Stabilised antenatal HIV-l seroprevalence in Nairobi, in the face of high population mobility: is age restriction now appropriate in screening.". 2003. Abstract

To measure HIV -1 seroprevalence in pregnant women in Nairobi. Design: Six serial surveys were carried out between November 1991 and April 1997. Methods: Women attending four Nairobi City Council clinics for first antenatal clinic visit answered a standard questionnaire on demographic histories and were screened for Hl'V-I. Results: Hlv-I seroprevalence rose from 12.1% at the first survey to 16.2% in the third survey, which finished in October 1993. No rise was seen in subsequent .surveys up to April 1997. Significant differences in seroprevalence was seen between women who said that their province of origin was Nyanza (22.4%), Western or Rift Valley Provinces (14.1 %), and the provinces to the east of the country (8.9%) [p

2002
E.N. PN, Hirschfeld M, Lindsey E, Kimani V, Mwanthi M, Olenja J, Pigott W, Messervy P, Mudongo K, Ncube E, Rantona K, Bale S, Limtragool P, Nunthachaipun P. COMMUNITY HOME-BASED CARE IN RESOURCE-LIMITED SETTINGS. Geneva: THE CROSS CLUSTER INITIATIVE ON HOME-BASED LONG-TERM CARE, NON-COMMUNICABLE DISEASES AND MENTAL HEALTH AND THE DEPARTMENT OF HIV/AIDS, FAMILY AND COMMUNITY HEALTH, WORLD HEALTH ORGANIZATION; 2002. AbstractWebsite

COMMUNITY HOME-BASED CARE IN RESOURCE-LIMITED SETIINGS
EXECUTIVE SUMMARY
6
his document provides a systematic framework for establishing and maintaining community home-based care (CRBC) in resource-limited
settings for people with RIV / AIDS and those with other chronic or disabling conditions. Most CRBC services so far have been established through unsystematic, needs-based efforts. As the RIV / AIDS epidemic continues to grow, many organizations and communities are now considering expanding in a more programmatic approach, and countries are looking for scaled-up responses and national strategies for CRBe. This document therefore provides an important framework to guide governments, national and international donor agencies and community-based organizations (including nongovernmental organizations, faith-based organizations and community groups) in developing or expanding CRBC programmes. The need for such a document has been clearly identified.
CRBC is defined as any form of care given to ill people in their homes. Such care includes physical, psychosocial, palliative and spiritual activities. The goal of CRBC is to provide hope through high-quality and appropriate care that helps ill people and families to maintain their independence and achieve the best possible quality of life.
This document targets three important audiences: policy-makers and senior administrators, middle managers and those who develop and run CRBC programmes. Although the roles and responsibilities of these target audiences differ somewhat, developing effective partnerships among the three is essential. Policy-makers and senior administrators must be involved in developing and monitoring CRBC programmes, and the people who manage and run the programmes must share information and feedback with senior administrators. In this sense, policy and action are interrelated as each partner learns from and guides the other. To this end, this document is divided into four interrelated sections: a policy framework for CRBC; the roles and responsibilities for CRBC at the national, district and local levels of administration; the essential elements of CRBC; and the strategies for action in establishing and maintaining CRBC in resource-limited settings.

Jackson DJ;, Branigan E;, Ngugi EN. "Interventions for Commercial Sex Workers and Their Clients.". 2002.
Baeten J, Richardson B, Martin H, Nyange P, Lavreys L, Ngugi EN, Bwayo JJ, Kreiss J, Mandaliya K. "Rapid Decline in Risk of HIV-l Acquisition After Enrollment in a Vaccine Preparedness Cohort of Kenyan Prostitutes: Implications for the Design of HIV -1 Vaccine Efficacy Trials.". 2002. Abstract

In designing HIY-l vaccine efficacy trials, it will be important to accounrfor changes in HIY -1 incidence, especially changes over time and while participating in riskreduction programs. Methods: Data from an open cohort of female prostitutes in Mombasa, Kenya were analyzed. Individuals were censored after 3 years of follow-up or at HIY -J seroconversion. Models of HIY -J and sexually transmitted disease incidence and sexual risk behaviors over time were constructed using generalized estimating equations. Annual HIV -1 incidence for the entire cohort was calculated. Results: The risk of HIY -J infection declined I O-fold during 3 years of follow-up (from 17.4 to 1.7 cases per 100 person-years for the first and last six months of follow-up, respectively, p

Plummer FA, Holton D, Anzala A, Wambugu P, Ngugi EN, Ndinya Achola JO. "Rapid Development Of Symptomatic Hiv-1 Related Disease In East-african Prostitutes.". 2002.
E.N. PN. "Reduced HIV risk-taking and low HIV incidence after enrollment and risk-reduction counseling in a sexually transmitted disease prevention trial in Nairobi, Kenya.". 2002. Abstract

J Acquir Immune Defic Syndr. 2002 May 1;30(1):69-72.
Reduced HIV risk-taking and low HIV incidence after enrollment and risk-reduction counseling in a sexually transmitted disease prevention trial in Nairobi, Kenya.
Kaul R, Kimani J, Nagelkerke NJ, Fonck K, Keli F, MacDonald KS, Ronald AR, Plummer FA, Bwayo JJ, Ngugi EN, Temmerman M, Moses S.
Source
Department of Medical Microbiology, University of Nairobi, Kenya. rupertkaul@hotmail.com
Abstract
There is an urgent need in sub-Saharan Africa to develop more effective methods of HIV prevention, including improved strategies of sexually transmitted infection (STI) prevention or an HIV vaccine. The efficacy of these strategies may be tested through clinical trials within cohorts at high risk for STI and HIV, such as female commercial sex workers. For ethical reasons, standard HIV prevention services, including access to free condoms, risk-reduction counseling, and STI therapy, will generally be offered to all study subjects. Because study subjects would often not otherwise have access to these prevention services, it is possible that enrollment in such clinical trials will itself reduce incidence rates of STI and HIV below expected levels, reducing the power to test the efficacy of the randomized intervention. We show that the provision of standard HIV prevention services as part of a randomized STI/HIV prevention trial is temporally associated with a dramatic reduction in sexual risk-taking, and that this reduction is directly associated with reduced STI incidence. This finding should be considered in the design of clinical trials with an endpoint of HIV incidence, in particular HIV preventive vaccine trials.
PMID:
12048365
[PubMed - indexed for MEDLINE]

E.N. PN. "Response of a sexually transmitted infection epidemic to a treatment and prevention programme in Nairobi, Kenya.". 2002. Abstract

Sex Transm Infect. 2002 Apr;78 Suppl 1:i114-20.
Response of a sexually transmitted infection epidemic to a treatment and prevention programme in Nairobi, Kenya.
Moses S, Ngugi EN, Costigan A, Kariuki C, Maclean I, Brunham RC, Plummer FA.
Source
Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada. smoses@cc.umanitoba.ca
Abstract
Although it seems possible in a developing country context such as Kenya, given appropriate inputs and a sound approach, to shift a sexually transmitted disease (STI) epidemic from phase II to III, it is not entirely clear how to go beyond this stage, to low levels of endemicity or even elimination. Perhaps the most important challenge now is to expand STI treatment and community STI/HIV prevention programmes to a much larger scale. Although successful programmes have been implemented in many areas of sub-Saharan Africa on a small scale, a significant impact in reducing the STI/HIV burden will not occur until programme reach is expanded to district, provincial, and national levels.
PMID:
12083429
[PubMed - indexed for MEDLINE]
PMCID:
PMC1765810
Free PMC Article

2001
E.N. PN. "Family Kinship Patterns and Female Sex Work in the Informal Urban Settlement of Kibera, Nairobi, Kenya.". 2001. Abstract

Family Kinship Patterns and Female Sex Work in the Informal
Urban Settlement of Kibera, Nairobi, Kenya
Elizabeth N. Ngugi . Cecilia Benoit-
Helga HaJlgrimsdottir . Mikael Jansson- Eric A. Roth
Published online: 4 April 2012
;i,;~ Springer Science+ Business Media, LLC 2012
Abstract A basic ecological and epidemiological question
is why some women enter into commercial sex work while
other women in the same socio-economic environment never
do. To address this question respondent driven sampling
principles were adopted to recrui t and co llect data for 161
female sex workers and 159 same aged women who never
engaged in commercial sex in Kibera, a large informal
settlement in Nairobi, Kenya. Univariate analysis indicated
that basic kinship measures, including number of family
members seen during adolescence and at present, not having
a male guardian while growing up, and earlier times of
ending relationships with both male and female guardians
were associated with commercial sex work in Kibera.
Multivariate analysis via logistic regression modeling
showed that not having a male guardian during childhood,
low education attainment and a small number of family
members seen at adolescence were all significant predictors
of entering sex work. By far the most important predictor of
entering sex work was not having any male guardian, e.g.,
father, uncle, older brother, etc. during childhood, Results
are interpreted in light of the historic pattern of sub-Saharan
African child fostering and their relevance for young women
in Kibera today.
Keywords Urban ecology- Female sex work· HIV! AIDS·
Nairobi Kenya
E. N. Ngugi . C. Benoit· H. Hallgrimsdortir . M. Jansson'
E. A. Roth (12J)
University of Victoria.
Victoria. Be. Canada
e-rnail: ericroth@uvic.ca
Introduction
Epidemiologists, medical personnel and public health officials
have long recognized the importance of female sex
workers (FSWs) in the sub-Saharan African AIDS pandemic
(D'Costaetal. 1985; Ngugi er rz/, 1988;Mosesetal.1991)
where they can serve as core groups, i.e., sub-populations
whose high rates of partner change sustain sexual infections
at epidemic levels. Today female commercial sex work
remains an important source of HIV infection within sub-
Saharan Africa's generalized AIDS epidemic because of
FSWs' high HIV prevalence rates (Steen and Dallabetta
2003; Cote et al. 2004; Gouws et al. 2006: Talbott 2007;
Morris et al. 2009). Yet, despite extensive epidemiological
research on the biological parameters of HIV transmis: ion
between African FSWs and their commercial clients, there
remain important knowledge gaps in the basic social epidemiology,
defined as the study of the distributions of health
outcomes and their social determinants of African commcrcial
sex work (Berkman and Kawachi 2000; Poundstone et
al. 2004). For example, while commercial sex work is a high
risk occupation both in terms of STIIHIV infection and
violence (Rekart 2005), few studies consider why or how
African women become FSWs, even though "effective prevention
programs cannot be established until there is a better
understanding of why women enter into commercial sex
exchanges" (Kalipeni et al. 2004:66).
At face value the question of why women enter sex work
appears overly simplistic, with economic need combined with
a lack of opportunities the apparently overwhelming answer.
However, in a study of rural Ugandan sex workers, Gyscls et
al. (2002) noted that not all disadvantaged women turn to sex
work, while an analysis of Thai child labor (Taylor 2005)
found that wealth and education were positively associated
with higb risk behavior, including commercial sex,
~ Springer

E.N. PN. "Female education, adolescent sexuality and the risk of sexually transmitted infection in Ariaal Rendille culture.". 2001. Abstract

-
Female education, adolescent sexuality and the risk of
sexually transmitted infection in Ariaal Rendille culture
ERIC A. ROTH, ELLIOT M, FRATKlN, ELIZABETH N, NGVGl
and BARRYW. GLICKMAN
For over 20 years, demographic analyses have shown female education associated with
decreased fertility and infant/child mortality in sub-Saharan Africa. Far less studied are the
pathways and overall effects of female education upon Sexually Transmitted Infections
(ST!s). An earlier 1996 study of one community of Ariaal Rendille pastoralists in Marsabit
District of northern Kenya, suggested that female education may reduce the risk of STls by
removing educated adolescent women from the cultural tradition of pre-marital sexual relationships
featuring early sexual debut and frequent partner change, Log-linear analysis of a
1998 sample of 127 adolescent women supports this model, with female education being
negatively associated with the nyken tradition. However, the full potential of female education
for lowering STf risk may be negated by traditional Ariaal cultural patterns of differentially
sending boy rather than girl: to school,
Introduction
Sub-Saharan Africa today features the world's highest levels of fertility,
infant and child mortality and sexually transmitted infectious diseases,
with t.he last including Acquired Immune Deficiency Syndrome (AIDS)
(National Academy of Sciences 1996). All three param iters are affected by
female education. Beginning with Caldwell's (1979) seminal analysis of
Nigerian survey data, two decades of research link maternal education with
decreased fertility and child/infant mortality (see, for example, United
Nations 1985, Cleland and Kaufmann 1998, Cleland and Van Ginneken
1989). Relationships between maternal education and fertility are, however,
not as straightforward as the 'dose and response' patterns measured for
infant/child mortality, and in some cases may actually reveal a positive
relationship (Jejeebhoy 1995, United Nation, 1995, Bledsoe et al. 1999a),
Nonetheless the International Conference on Population and Development
in Cairo, 1994, strongly called for universal female access to education
because:
Eric A. Rott, is Professor in the Department of !\nthropology at the Univc rsity of Victoria, British
Columbia. Canada. Elliot .Il. Fro/kin is Associarc Professor at Smith College, British Columbia.
Elissobeth i\'. .Ygugi is Lecturer in the Department of Community Tlealth at the University of Nairobi,
Barry nr Oliclonan is Director of rhe Centre for Environmental Health and Professor, in the
Department of Biology at the University of icroria. ,\11 correspondence to Erie Roth, Department
of Anthropology, University of Victoria, PO Box 3050, Victoria, British Columbia. Canada V8W 3P5;
e-rnail: cricroth@>uvic.ca
('I/II/I/'{', I leatth (:if Sex/wlil)'
ISHN 1369-1058 print/ISS,", 1464-5351 online ZOOlTaylor & Francis

E.N. PN. "Public health. Reducing HIV transmission in developing countries.". 2001. Abstract

Science. 2001 Apr 13;292(5515):224-5.
Public health. Reducing HIV transmission in developing countries.
Jha P, Nagelkerke JD, Ngugi EN, Prasada Rao JV, Willbond B, Moses S, Plummer FA.
Source
Economics Advisory Service, World Health Organization, Geneva, Switzerland.
PMID:
11305312
[PubMed - indexed for MEDLINE]
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E.N. PN. "Resistance to HIV-1 infection among African sex workers is associated with global hyporesponsiveness in interleukin 4 production.". 2001. Abstract

FASEB J. 2001 Aug;15(10):1795-7.
Resistance to HIV-1 infection among African sex workers is associated with global hyporesponsiveness in interleukin 4 production.
Trivedi HN, Plummer FA, Anzala AO, Njagi E, Bwayo JJ, Ngugi EN, Embree JE, Hayglass KT.
Source
Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada R3E 0W3.
PMID:
11481233
[PubMed - indexed for MEDLINE]
Free full text

E.N. PN. "Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya.". 2001. Abstract

Sex Transm Infect. 2001 Aug;77(4):271-5.
Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya.
Fonck K, Kaul R, Keli F, Bwayo JJ, Ngugi EN, Moses S, Temmerman M.
Source
International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium.
Abstract
OBJECTIVE:
To assess the association between vaginal douching and sexually transmitted infections (STI) among a group of female sex workers (FSWs) in Nairobi, Kenya.
METHODS:
This study was part of a randomised, placebo controlled trial of monthly prophylaxis with 1 g of azithromycin to prevent STIs and HIV infection in a cohort of Nairobi FSWs. Consenting women were administered a questionnaire and screened for STIs.
RESULTS:
The seroprevalence of HIV-1 among 543 FSWs screened was 30%. HIV infection was significantly associated with bacterial vaginosis (BV), trichomoniasis, gonorrhoea, and the presence of a genital ulcer. Regular douching was reported by 72% of the women, of whom the majority inserted fluids in the vagina, generally after each sexual intercourse. Water with soap was the fluid most often used (81%), followed by salty water (18%), water alone (9%), and a commercial antiseptic (5%). Douching in general and douching with soap and water were significantly associated with bacterial vaginosis (p = 0.05 and p = 0.04 respectively). There was a significant trend for increased frequency of douching and higher prevalence of BV. There was no direct relation observed between douching and risk for HIV infection or other STIs.
CONCLUSION:
The widespread habit of douching among African female sex workers was confirmed. The association between vaginal douching and BV is of concern, given the increased risk of HIV infection with BV, which has now been shown in several studies. It is unclear why we could not demonstrate a direct association between douching and HIV infection. Further research is required to better understand the complex relation between douching, risk for bacterial vaginosis, and risk for HIV and other STIs.
PMID:
11463927
[PubMed - indexed for MEDLINE]
PMCID:
PMC1744330
Free PMC Article

2000
E.N. PN. "HIV AIDS Social / Economic Impact.". In: African Health Sciences Congress. KEMRI Headquarters, Nairobi; 2000.ngugi-hiv_aids_soial_economic_impact.pdf
"Acute sexually transmitted infections increase human immunodeficiency virus type 1 plasma viremia, increase plasma type 2 cytokines, and decrease CD4 cell counts.". 2000. Abstract

J Infect Dis. 2000 Aug;182(2):459-66. Epub 2000 Jul 12.
Acute sexually transmitted infections increase human immunodeficiency virus type 1 plasma viremia, increase plasma type 2 cytokines, and decrease CD4 cell counts.
Anzala AO, Simonsen JN, Kimani J, Ball TB, Nagelkerke NJ, Rutherford J, Ngugi EN, Bwayo JJ, Plummer FA.
Source
Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada.
Abstract
In Kenya, the median incubation time to AIDS in seroconverting sex workers is 4 years; this incubation time is specific to female sex workers. We studied the influence of acute sexually transmitted infections (STIs) on several immunologic parameters in 32 human immunodeficiency virus type 1 (HIV-1)-positive and 10 HIV-1-negative women sex workers who were followed for 1-5 months. Plasma cytokines, soluble cytokine receptors, CD4 and CD8 T cell counts, and HIV-1 plasma viremia were quantitated before, during, and after episodes of STI. Increases in interleukin (IL)-4, IL-6, IL-10, soluble tumor necrosis factor (TNF)-alpha, and viremia and a decline in CD4(+) T cell counts occurred during gonococcal cervicitis and returned to baseline after treatment. Increases in viremia correlated with increased IL-4 and decreased IL-6 concentrations. Similar changes were seen among women with acute pelvic inflammatory disease. Acute bacterial STI resulted in increased HIV-1 viremia. This may be mediated through increased inflammatory cytokines or through modulation of immune responses that control HIV-1 viremia.
PMID:
10915076
[PubMed - indexed for MEDLINE]
Free full text

Kimani, J; Oyugi NEWKR-JNBJJ; PFA; LJ; N; J;. "Influence of HLA supertypes on susceptibility and resistance to human immunodeficiency virus type 1 infection.". 2000. Abstract

Certain human leukocyte antigens, by presenting conserved immunogenic epitopes for T cell recognition, may, in part, account for the observed differences in human immunodeficiency virus type 1 (HIV-1) susceptibility. To determine whether HLA polymorphism influences HIV-1 susceptibility, a longitudinal cohort of highly HIV-1-exposed female sex workers based in Nairobi, Kenya, was prospectively analyzed. Decreased HIV-1 infection risk was strongly associated with possession of a cluster of closely related HLA alleles (A2/6802 supertype; incidence rate ratio [IRR], 0.45; 95% confidence interval [CI], 0.27-0.72; P=.0003). The alleles in this supertype are known in some cases to present the same peptide epitopes for T cell recognition. In addition, resistance to HIV-1 infection was independently associated with HLA DRB1*01 (IRR, 0.22; 95% CI, 0.06-0.60; P=.0003), which suggests that anti-HIV-1 class II restricted CD4 effector mechanisms may play an important role in protecting against viral challenge. These data provide further evidence that resistance to HIV-1 infection in this cohort of sex workers is immunologically mediate

N NE. "A randomized, placebo-controlled trial of monthly azithromycin prophylaxis to prevent sexually transmitted infections and HIV-1 in Kenyan sex workers: study design and baseline findings.". 2000. Abstract

Center for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Belgium.
Abstract
Our objectives were to describe the baseline findings of a trial of antibiotic prophylaxis to prevent sexually transmitted infections (STIs) and HIV-1 in a cohort of Nairobi female sex workers (FSWs). A questionnaire was administered and a medical examination was performed. HIV-negative women were randomly assigned to either one gram azithromycin or placebo monthly. Mean age of the 318 women was 32 years, mean duration of sex work 7 years and mean number of clients was 4 per day. High-risk behaviour was frequent: 14% practised anal intercourse, 23% sex during menses, and 3% used intravenous drugs. While 20% reported condom use with all clients, 37% never use condoms. However, STI prevalence was relatively low: HIV-1 27%, bacterial vaginosis 46%, Trichomonas vaginalis 13%, Neisseria gonorrhoeae 8%, Chlamydia trachomatis 7%, syphilis 6% and cervical intraepithelial neoplasia (CIN) 3%. It appears feasible to access a population of high-risk FSWs in Nairobi with prevention programmes, including a proposed trial of HIV prevention through STI chemoprophylaxis.
PMID:
11138916
[PubMed - indexed for MEDLINE]

Anzala AO, Simonsen JN, Kimani J, Ball TB, Ngugi EN, Bwayo JJ, Nagelkerke N, Kakai NJD, Plummer FA. "Role of Sexually Transmitted Infections in Accelerated HIV-1 Disease Progression.". 2000.
E.N. PN. "Trends in HIV-1 incidence in a cohort of prostitutes in Kenya implications for HIV-1 vaccine efficacy trials.". 2000. Abstract

J Acquir Immune Defic Syndr. 2000 Aug 15;24(5):458-64.
Trends in HIV-1 incidence in a cohort of prostitutes in Kenya: implications for HIV-1 vaccine efficacy trials.
Baeten JM, Richardson BA, Martin HL Jr, Nyange PM, Lavreys L, Ngugi EN, Mandaliya K, Ndinya-Achola JO, Bwayo JJ, Kreiss JK.
Source
Departments of Epidemiology, Biostatistics, and Medicine, University of Washington, Seattle, Washington, USA. jbaeten@u.washington.edu
Abstract
BACKGROUND:
Accurate predictions of HIV-1 incidence in potential study populations are essential for designing HIV-1 vaccine efficacy trials. Little information is available on the estimated incidence of HIV-1 in such populations, especially information on incidence over time and incidence while participating in risk-reduction programs.
OBJECTIVES:
To examine time trends in HIV-1 incidence in a vaccine preparedness cohort.
DESIGN:
Prospective cohort study of female prostitutes in Mombasa, Kenya.
METHODS:
HIV-1 incidence was determined using open and closed cohort designs. Generalized estimating equations were used to model HIV-1 and sexually transmitted disease (STD) incidence and sexual risk behaviors over time.
RESULTS:
When analyzed as a closed cohort, HIV-1 incidence declined 10-fold during 3 years of follow-up (from 17.4 to 1.7 cases/100 person-years; p <.001). More than 50% of the cases of HIV-1 occurred during the first 6 months after enrollment, and 73% during the first 12 months. When analyzed as an open cohort, HIV-1 incidence density fell during the first 4 calendar years, influenced by accumulation of lower risk participants and variations in study recruitment. Significant declines occurred in both STD incidence and high-risk sexual behaviors during follow-up.
CONCLUSIONS:
This study documents a dramatic decline in the risk of HIV-1 infection while participating in a prospective cohort, with most seroconversions occurring within 1 year of enrollment. Variations in HIV-1 incidence within high-risk populations should be anticipated during the design of vaccine trials.
PMID:
11035617
[PubMed - indexed for MEDLINE]

1999
E.N. PN. Workshop Summary. Kenya Colege of Communication Technology (KCCT) Mbagathi; 1999.
E.N. PN. "HIV-1-specific mucosal IgA in a cohort of HIV-1-resistant Kenyan sex workers.". 1999. Abstract

AIDS. 1999 Jan 14;13(1):23-9.
HIV-1-specific mucosal IgA in a cohort of HIV-1-resistant Kenyan sex workers.
Kaul R, Trabattoni D, Bwayo JJ, Arienti D, Zagliani A, Mwangi FM, Kariuki C, Ngugi EN, MacDonald KS, Ball TB, Clerici M, Plummer FA.
Source
Department of Medical Microbiology and Community Health, University of Nairobi, Kenya.
Abstract
OBJECTIVES:
Most HIV-1 transmission is sexual; therefore, immune responses in the genital mucosa may be important in mediating protection against HIV infection. This study examined HIV-1-specific mucosal IgA in a cohort of HIV-1-resistant Kenyan female sex workers.
METHODS:
HIV-1-specific immune responses were compared in HIV-1-resistant and HIV-1-infected sex workers, and in lower risk uninfected women. Cervical and vaginal samples from each group were tested for HIV-1-specific IgA and IgG by enzyme immunoassay. Systemic T-helper lymphocyte cell responses to HIV-1 envelope peptide epitopes were assayed using an interleukin 2 bioassay. HIV-1 risk-taking behaviours were assessed using standardized questionnaires.
RESULTS:
HIV-1-specific IgA was present in the genital tract of 16 out of 21 (76%) HIV-1-resistant sex workers, five out of 19 (26%) infected women, and three out of 28 (11%) lower risk women (P < 0.0001). Among lower risk women, the presence of HIV-1-specific IgA was associated with HIV-1 risk-taking behaviour. Systemic T-helper lymphocyte responses to HIV-1 envelope peptides were present in 11 out of 20 (55%) HIV-1-resistant women, four out of 18 (22%) infected women, and one out of 25 (4%) lower risk women (P < 0.001). T-helper lymphocyte responses did not correlate with the presence or titre of virus-specific mucosal IgA in any study group.
CONCLUSIONS:
HIV-1-specific IgA is present in the genital tract of most HIV-1-resistant Kenyan sex workers, and of a minority of lower risk uninfected women, where it is associated with risk-taking behaviour. These data suggest a role for mucosal HIV-1-specific IgA responses in HIV-1 resistance, independent of host cellular responses.
PMID:
10207541
[PubMed - indexed for MEDLINE]

E.N. PN. "Stable antenatal HIV-1 seroprevalence with high population mobility and marked seroprevalence variation among sentinel sites within Nairobi, Kenya.". 1999. Abstract

AIDS. 1999 Apr 1;13(5):583-9.
Stable antenatal HIV-1 seroprevalence with high population mobility and marked seroprevalence variation among sentinel sites within Nairobi, Kenya.
Jackson DJ, Ngugi EN, Plummer FA, Kirui P, Kariuki C, Ndinya-Achola JO, Bwayo JJ, Moses S.
Source
Department of Community Health, University of Nairobi, Kenya.
Abstract
OBJECTIVES:
To monitor and analyse trends in HIV-1 seroprevalence among antenatal women in Nairobi, Kenya.
DESIGN:
Six sequential surveys were carried out among antenatal clinic attenders at four Nairobi City Council health centres between November 1991 and April 1997.
METHODS:
A total of 6828 women attending for first antenatal clinic visit were administered a standard questionnaire to obtain demographic information and were screened for HIV-1.
RESULTS:
HIV-1 seroprevalence rose from 12.1% in the first survey to 16.2% in the third, completed in October 1993. No rise was observed in subsequent surveys, and seroprevalence among women under the age of 20 declined after the third survey. Significant differences in seroprevalence (P < 0.001) were observed in all survey rounds between women who reported that their province of origin was Nyanza (22.4% overall), compared with those from other provinces in western Kenya (14.1%), and the eastern group of provinces (8.9%). The rise in HIV-1 seroprevalence observed between 1991 and 1993 was almost entirely attributable to the rising seroprevalence among women from Nyanza. There were considerable differences in HIV-1 seroprevalence among the four health centres, partly accounted for by differences in the proportion of clinic attenders from different provinces of origin, which also changed significantly over time.
CONCLUSIONS:
HIV-1 seroprevalence has stabilized in antenatal women attending these health centres in Nairobi, and may be declining among women in the youngest age group. This may reflect stabilization of HIV-1 incidence, but further observation is required. The levels of infection among Nairobi residents reflect the evolution of the HIV epidemic in their provinces of origin, and changing client composition influences HIV-1 seroprevalence at different clinics. HIV sentinel surveillance should be carried out at multiple sites in large urban centres to monitor accurately the evolution of the HIV epidemic and the impact of control efforts in reducing transmission.
PMID:
10203383
[PubMed - indexed for MEDLINE]

1998
E.N. PN. "Cytotoxic T cell responses to multiple conserved HIV epitopes in HIV-resistant prostitutes in Nairobi.". 1998. Abstract

Cytotoxic T cell responses to multiple conserved HIV epitopes in HIV-resistant prostitutes in Nairobi.
S L Rowland-Jones, T Dong, K R Fowke, J Kimani, P Krausa, H Newell, T Blanchard, K Ariyoshi, J Oyugi, E Ngugi, J Bwayo, K S MacDonald, A J McMichael, and F A Plummer
Author information ► Copyright and License information ►
See commentary "What immunity can protect against HIV infection." on page 1643.
This article has been cited by other articles in PMC.
Abstract
Many people who remain persistently seronegative despite frequent HIV exposure have HIV-specific immune responses. The study of these may provide information about mechanisms of natural protective immunity to HIV-1. We describe the specificity of cytotoxic T lymphocyte responses to HIV in seronegative prostitutes in Nairobi who are apparently resistant to HIV infection. These women have had frequent exposure to a range of African HIV-1 variants, primarily clades A, C, and D, for up to 12 yr without becoming infected. Nearly half of them have CTL directed towards epitopes previously defined for B clade virus, which are largely conserved in the A and D clade sequences. Stronger responses are frequently elicited using the A or D clade version of an epitope to stimulate CTL, suggesting that they were originally primed by exposure to these virus strains. CTL responses have been defined to novel epitopes presented by HLA class I molecules associated with resistance to infection in the cohort, HLA-A*6802 and HLA-B18. Estimates using a modified interferon-gamma Elispot assay indicate a circulating frequency of CTL to individual epitopes of between 1:3,200 and 1:50,000. Thus, HIV-specific immune responses-particularly cross-clade CTL activity- may be responsible for protection against persistent HIV infection in these African women.

1997
Ayah R;, Ngugi E. "Impact of user fees in health.". 1997. Abstract

OBJECTIVE: To determine the local aetiological spectrum of surgically relevant causes of abdominal pain. DESIGN: A prospective descriptive study was carried out. SETTING: Kenyatta National Hospital, Nairobi, Kenya during the month of October 2002. SUBJECTS: Patients aged 13 years and older presenting to the casualty department with abdominal pain were followed through the hospital system to determine whether they would undergo laparotomy and, in those cases who underwent laparotomy, to determine the nature of the pathology found at laparatomy. RESULTS: Abdominal pain was a presenting complaint in 1557 (16.7%) of patients presenting to the casualty department during the study period. Abdominal pain accounted for 17.9% (398 out of 2225 patients) of all admissions via the casualty department. Laparotomy was performed on 68 (4.4%) of patients who presented with abdominal pain to the casualty department. In female patients presenting with abdominal pain, the incidence of ectopic pregnancy and acute appendicitis was 65.3% and 16.3% respectively. The incidence of neoplasia found at laparatomy, for abdominal pain, on patients admitted to the general surgical ward was 3.0%. The incidence of neoplasia, as a cause of abdominal pain resulting in laparatomy was 3.3%. CONCLUSION: The results highlight the fact, with respects to abdominal pain, that there are significant differences between the disease patterns in different geographical locations. Assuming the converse could adversely affect the management of patients with abdominal pain locally.

E.N. PN. "Isoniazid preventive therapy for tuberculosis in HIV-1-infected adults: results of a randomized controlled trial.". 1997. Abstract

AIDS. 1997 Jun;11(7):875-82.
Isoniazid preventive therapy for tuberculosis in HIV-1-infected adults: results of a randomized controlled trial.
Hawken MP, Meme HK, Elliott LC, Chakaya JM, Morris JS, Githui WA, Juma ES, Odhiambo JA, Thiong'o LN, Kimari JN, Ngugi EN, Bwayo JJ, Gilks CF, Plummer FA, Porter JD, Nunn PP, McAdam KP.
Source
Department of Clinical Sciences, London School of Hygiene and Tropical Medicine, UK.
Abstract
OBJECTIVES:
To determine the efficacy of isoniazid 300 mg daily for 6 months in the prevention of tuberculosis in HIV-1-infected adults and to determine whether tuberculosis preventive therapy prolongs survival in HIV-1-infected adults.
DESIGN AND SETTING:
Randomized, double-blind, placebo-controlled trial in Nairobi, Kenya.
SUBJECTS:
Six hundred and eighty-four HIV-1-infected adults.
MAIN OUTCOME MEASURES:
Development of tuberculosis and death.
RESULTS:
Three hundred and forty-two subjects received isoniazid and 342 received placebo. The median CD4 lymphocyte counts at enrolment were 322 and 346 x 10(6)/l in the isoniazid and placebo groups, respectively. The overall median follow-up from enrolment was 1.83 years (range, 0-3.4 years). The incidence of tuberculosis in the isoniazid group was 4.29 per 100 person-years (PY) of observation [95% confidence interval (CI) 2.78-6.33] and 3.86 per 100 PY of observation (95% CI, 2.45-5.79) in the placebo group, giving an adjusted rate ratio for isoniazid versus placebo of 0.92 (95% CI, 0.49-1.71). The adjusted rate ratio for tuberculosis for isoniazid versus placebo for tuberculin skin test (TST)-positive subjects was 0.60 (95% CI, 0.23-1.60) and for the TST-negative subjects, 1.23 (95% CI, 0.55-2.76). The overall adjusted mortality rate ratio for isoniazid versus placebo was 1.18 (95% CI, 0.79-1.75). Stratifying by TST reactivity gave an
adjusted mortality rate ratio in those who were TST-positive of 0.33 (95% CI, 0.09-1.23) and for TST-negative subjects, 1.39 (95% CI, 0.90-2.12).
CONCLUSIONS:
Overall there was no statistically significant protective effect of daily isoniazid for 6 months in the prevention of tuberculosis. In the TST-positive subjects, where reactivation is likely to be the more important pathogenetic mechanism, there was some protection and some reduction in mortality, although this was not statistically significant. The small number of individuals in this subgroup made the power to detect a statistically significant difference in this subgroup low. Other influences that may have diluted the efficacy of isoniazid include a high rate of transmission of new infection and rapid progression to disease or insufficient duration of isoniazid in subjects with relatively advanced immunosuppression. The rate of drug resistance observed in subjects who received isoniazid and subsequently developed tuberculosis was low.
PMID:
9189212
[PubMed - indexed for MEDLINE]

E.N. PN. "Risk factors for genital ulcerations in Kenyan sex workers. The role of human immunodeficiency virus type 1 infection.". 1997. Abstract

Sex Transm Dis. 1997 Aug;24(7):387-92.
Risk factors for genital ulcerations in Kenyan sex workers. The role of human immunodeficiency virus type 1 infection.
Kaul R, Kimani J, Nagelkerke NJ, Plummer FA, Bwayo JJ, Brunham RC, Ngugi EN, Ronald A.
Source
Department of Medical Microbiology, University of Nairobi, Kenya.
Abstract
BACKGROUND AND OBJECTIVES:
Genital ulcer disease (GUD) is a major risk factor for human immunodeficiency virus (HIV) transmission. Cross-sectional studies have suggested that HIV infection may itself predispose to genital ulceration (GU).
GOAL:
To prospectively study the effects of HIV type 1 (HIV-1) infection and behavioral variables on GU incidence.
METHODS:
A cohort of 302 Kenyan female sex-workers was established in April 1991. Women were scheduled for assessment every 2 weeks, and bloods were collected every 6 months for HIV serology, rapid plasma reagin (RPR) and CD4 counts. Logistic regression was used to study risk factors for incident genital ulcers.
RESULTS:
189 women (62.5%) had at least one incident ulcer over 24.3 +/- 15.3 months. GU incidence was higher in seropositive than initially seronegative women (82% vs. 48%; odds ratio [OR]) = 4.33; P < 0.01). Only HIV-1 seropositivity (OR = 3.42), a CD4 count < 200/ml (OR = 1.94), and oral contraceptive use (OR = 1.35) were associated (P < 0.05) with GU incidence in regression analysis. For those ulcers where an etiology was actively sought, Hemophilus ducreyi was confirmed in 54 (19%) of cases, and syphilis in 30 (29%).
CONCLUSION:
GU incidence in Kenyan sex workers is independently affected by HIV-1 serostatus, degree of immunosuppression, and oral contraceptive use.
PIP:
Both cross-sectional and prospective studies in Africa have revealed an association between genital ulcer disease (GUD) and HIV-1; it is unclear, however, which of these infections facilitates the other. The epidemiology of GUD was investigated in a prospective cohort study of 302 female sex workers from a slum area in Nairobi, Kenya. At study intake in 1985, 157 women (52%) were HIV-1 seropositive. After a mean follow-up duration of 27.2 months, 36 (25%) initially HIV-negative women seroconverted. 189 women (62.5%) had at least 1 incident ulcer in the follow-up period and a total of 541 new cases were diagnosed. GUD incidence was significantly higher in HIV-positive women (82%) than initially seronegative women (48%). The mean number of new genital ulcerations recorded during the follow-up period was 1.8 (2.7 in initially seropositive women and 1.0 in initially seronegative women). The only significant risk factors for GUD incidence in the regression analyses were HIV-1 seropositivity (odds ratio (OR), 3.42), a CD4 count under 200/ml (OR, 1.94), and oral contraceptive use (OR, 1.35). The significant increase in GUD incidence observed relatively soon after primary HIV infection among the 36 seroconverters strongly suggests that HIV-1 itself plays a causal role in the etiology of genital ulcers. Moreover, the finding that the duration of prostitution was negatively associated with the incidence of ulcers in HIV-negative but not HIV-positive women implies that HIV-1 infection may attenuate the acquisition or retention of effective immune responses against the etiologic agents of GUD.
PMID:
9263358
[PubMed - indexed for MEDLINE]

1996
E.N. PN. "Focused peer-mediated educational programs among female sex workers to reduce sexually transmitted disease and human immunodeficiency virus transmission in Kenya and Zimbabwe.". 1996. Abstract

J Infect Dis. 1996 Oct;174 Suppl 2:S240-7.
Focused peer-mediated educational programs among female sex workers to reduce sexually transmitted disease and human immunodeficiency virus transmission in Kenya and Zimbabwe.
Ngugi EN, Wilson D, Sebstad J, Plummer FA, Moses S.
Source
Department of Community Health, University of Nairobi, Kenya.
Abstract
Peer-mediated education programs in Kenya and Zimbabwe focusing on female sex workers for the control of human immunodeficiency virus (HIV) infection and other sexually transmitted diseases (STDs) have led to increased condom use and increased adoption of other safer sex practices, as well as declines in STD and HIV incidence among female sex workers. It is likely that similar declines have occurred among their clients and possibly in the general community, although supporting data are limited. These results are encouraging. However, progress in increasing the scale and coverage of intervention programs among female sex workers has been slow. Constraints to expanding program coverage include inadequate political commitment; deficiencies in program planning, management, and human resources; and insufficient funding. The challenges currently are to show that behavioral change can be sustained and to scale up activities from small demonstration projects to district, provincial, and national levels.
PMID:
8843254
[PubMed - indexed for MEDLINE]
Free full text

E.N. PN. "Resistance to HIV-1 infection among persistently seronegative prostitutes in Nairobi, Kenya.". 1996. Abstract

Lancet. 1996 Nov 16;348(9038):1347-51.
Resistance to HIV-1 infection among persistently seronegative prostitutes in Nairobi, Kenya.
Fowke KR, Nagelkerke NJ, Kimani J, Simonsen JN, Anzala AO, Bwayo JJ, MacDonald KS, Ngugi EN, Plummer FA.
Source
Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada.
Abstract
BACKGROUND:
There is indirect evidence that HIV-1 exposure does not inevitably lead to persistent infection. Heterogeneity in susceptibility to infection could be due to protective immunity. The objective of this study was to find out whether in highly HIV-1-exposed populations some individuals are resistant to infection.
METHODS:
We did an observational cohort study of incident HIV-1 infection-among 424 initially HIV-1-seronegative prostitutes in Nairobi, Kenya, between 1985 and 1994. 239 women seroconverted to HIV-1 during the study period. Exponential, Weibull, and mixture survival models were used to examine the effect of the duration of follow-up on incidence of HIV-1 infection. The influence of the duration of exposure to HIV-1 through prostitution on seroconversion risk was examined by Cox proportional hazards modelling, with control for other known or suspected risk factors for incident HIV-1 infection. HIV-1 PCR with env, nef, and vif gene primers was done on 43 persistently seronegative prostitutes who remained seronegative after 3 or more years of follow-up.
FINDINGS:
Modelling of the time to HIV-1 seroconversion showed that the incidence of HIV-1 seroconversion decreased with increasing duration of exposure, which indicates that there is heterogeneity in HIV-1 susceptibility or acquired immunity to HIV-1. Each weighted year of exposure through prostitution resulted in a 1.2-fold reduction in HIV-1 seroconversion risk (hazard ratio 0.83 [95% CI 0.79-0.88], p < 0.0001). Analyses of epidemiological and laboratory data, show that persistent seronegativity is not explained by seronegative HIV-1 infection or by differences in risk factors for HIV-1 infection such as safer sexual behaviours or the incidence of other sexually transmitted infections. Interpretation: We conclude that a small proportion of highly exposed individuals, who may have natural protective immunity to HIV-1, are resistant to HIV-1.
PIP:
A cohort study conducted in 1985-94 among 424 prostitutes from Nairobi, Kenya, who were initially human immunodeficiency virus (HIV)-1 seronegative, tended to provide support for the observation that some individuals in highly exposed populations may be resistant to infection. During the 10-year study period, 239 of these women seroconverted. The overall HIV-1 incidence was 42/100 person-years. After the first 2 years of follow up, in which the majority of seroconversions occurred, HIV-1 prevalence reached a plateau and then began a steep decline. To determine whether the risk of HIV-1 infection declined over time as a result of the selection of resistance, incidence rates among women with less than 3 years' versus more than 3 years' duration of prostitution were compared for 1989-93. An increasing protective effect for each seronegative year of exposure was observed. The estimated cumulative protective effect for women practicing prostitution from 1984-93 and remaining seronegative, compared to women who entered prostitution in 1994, was over 100-fold. To rule out the possibility that the decrease in seroconversion with duration of exposure reflected differences in sexual behavior or immunity to sexually transmitted diseases that facilitate HIV transmission, Cox proportional hazards modelling was performed. The weighted duration of prostitution was independently associated with a decreased risk of seroconversion. Each weighted year of exposure resulted in a 1.2-fold decrease in risk. Women who seroconverted were more likely to report 1 or more regular partners and to use condoms with these partners than their counterparts who remained seronegative. Elucidation of the protective mechanisms and the factors mediating the development of immunity against HIV-1 could be important to HIV-1 vaccine research.
Comment inThe following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface controlLoss to follow-up effect in investigations of HIV-1 incidence. [Lancet. 1997]
PMID:
8918278
[PubMed - indexed for MEDLINE]

1995
E.N. PN. "Comparison of the declines in CD4 counts in HIV-1-seropositive female sex workers and women from the general population in Nairobi, Kenya.". 1995. Abstract

J Acquir Immune Defic Syndr Hum Retrovirol. 1995 Dec 1;10(4):457-61.
Comparison of the declines in CD4 counts in HIV-1-seropositive female sex workers and women from the general population in Nairobi, Kenya.
Bwayo JJ, Nagelkerke NJ, Moses S, Embree J, Ngugi EN, Mwatha A, Kimani J, Anzala A, Choudhri S, Achola JO, et al.
Source
Department of Medical Microbiology, University of Nairobi, Kenya.
Abstract
Studies from Kenya have reported rapid clinical disease progression among HIV-infected professional sex workers. The reasons for this rapid decline are unknown. To better understand factors influencing the course of disease, HIV-1 disease progression was explored in terms of declines in CD4 counts. Two samples from Nairobi, Kenya, were studied, one from a cohort of female sex workers and another, as a comparison group, from mothers enrolled in an HIV-1 vertical-transmission study. A Markov model was used to analyze transitions between HIV-1 disease stages as defined by CD4 counts. It appears that sex workers experience a rapid decline in CD4 counts, consistent with earlier findings of rapid clinical disease progression among individuals in this group. The rate of decline in CD4 counts among the mothers appears to be lower. It is speculated that either intensive exposure to sexually transmitted pathogens or infection with several strains of HIV-1 may account for the rapid disease progression among female sex workers.
PMID:
7583442
[PubMed - indexed for MEDLINE]

Gayle H;, Ngugi E;, Berkley S;, Kimball AM. "International aspects of the AIDS/HIV epidemic." Annual review of public health ''.". 1995.
E.N. PN. "Rapid progression to disease in African sex workers with human immunodeficiency virus type 1 infection.". 1995. Abstract

J Infect Dis. 1995 Mar;171(3):686-9.
Rapid progression to disease in African sex workers with human immunodeficiency virus type 1 infection.
Anzala OA, Nagelkerke NJ, Bwayo JJ, Holton D, Moses S, Ngugi EN, Ndinya-Achola JO, Plummer FA.
Source
Department of Medical Microbiology, University of Nairobi, Kenya.
Erratum in
 J Infect Dis 1996 Jun;173(6):1529.
Abstract
From a cohort of female sex workers in Nairobi, Kenya, 163 women were observed to seroconvert to human immunodeficiency virus type 1 (HIV-1) and followed to study progression to HIV-1-related disease. The effect of several covariables on disease progression was studied using a Weibull proportional hazards model. The Weibull survival model was fitted to the observed incubation times. Estimates of the median duration to CDC stage IV-A and IV-C disease were 3.5 and 4.4 years, respectively. Condom use before seroconversion was associated with a reduced risk of CDC stage IV-A disease (relative risk = .64, P < .05). The incubation time of HIV-1-related disease is extremely short in this population.
Comment in
 The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface controlRapid progression to human immunodeficiency virus type 1 disease. [J Infect Dis. 1996]
PMID:
7876618
[PubMed - indexed for MEDLINE]

E.N. PN. "STD partner notification and referral in primary level health centers in Nairobi, Kenya.". 1995. Abstract

Sex Transm Dis. 1995 Jul-Aug;22(4):231-5.
STD partner notification and referral in primary level health centers in Nairobi, Kenya.
Njeru EK, Eldridge GD, Ngugi EN, Plummer FA, Moses S.
Source
University of Nairobi, Kenya.
Abstract
BACKGROUND:
Controlling sexually transmitted diseases requires that partners of patients with a sexually transmitted disease be notified and treated. However, many countries in the developing world lack the infrastructure and resources for effective partner referral.
GOAL OF THIS STUDY:
To provide information on rates of partner referral in primary-level health centers in Kenya, to identify characteristics of patients with sexually transmitted diseases who inform their partners about the need for treatment, and to evaluate the impact of a brief counseling intervention on rates of partner notification.
STUDY DESIGN:
Two-hundred-fifty-four patients presenting for treatment of a sexually transmitted disease were given 5 to 10 minutes of additional counseling on the importance of referring partners for sexually transmitted disease treatment. All patients who returned for follow-up 1 week later were interviewed to determine whether they had notified their sex partners.
RESULTS:
Sixty-eight percent of patients who returned for follow-up reported they had referred their partners for treatment of a sexually transmitted disease. The highest rates of partner notification occurred among women attending maternal child health/family planning clinics and married men and women attending general outpatient clinics.
CONCLUSION:
Strengthening and directing counseling toward women in maternal child health/family planning clinics and married men and women in general clinics may be an effective and inexpensive way to increase partner notification in the developing world.
PIP:
In developing countries, patient referral is a more feasible means of notifying partners of sexually transmitted disease (STD) clients than the costly, labor-intensive provider referral approach. However, enhancement strategies such as education and counseling, contact cards, educational materials, follow-up, and monetary incentives may be necessary. To assess the impact of brief counseling on patient referral rates, a study was conducted at five primary health care centers in low-income areas of Nairobi, Kenya. All 254 STD patients who attended the clinic in a two-week period in 1992 were enrolled in the study. Subjects were given 5-10 minutes of counseling, asked to identify their sexual partners, and given a return appointment for the following week. Of the 93 patients who returned to the clinic and provided partner referral data, 63 (68%) reported they informed their partner of the need for STD treatment and 54 (58%) claimed that their partners had been treated. Multivariate analysis indicated that partner notification rates were highest for females, married individuals or those with regular partners, and maternal-child health/family planning clinic patients. Although 84% of unmarried men, 66% of unmarried women, and 47% of married men were infected by a casual sex partner, only 35% of those in the casual partner group attempted notification. Before the study, only 15% of partners presented to the clinics for treatment as a result of partner referral. This provides some evidence of the effectiveness of the counseling strategy, at least for married men and women, although more detailed guidelines on methods of partner notification are recommended.
PMID:
7482106
[PubMed - indexed for MEDLINE

1994
Piot PM, Kapita B, Ngugi EN, Mann JM, Colebunders R, Wabitsch R. "AIDS in Africa A Manual for Physicians, World Health Organization, Geneva.". 1994.Website
E.N. PN. "Health care-seeking behavior related to the transmission of sexually transmitted diseases in Kenya.". 1994. Abstract

Am J Public Health. 1994 Dec;84(12):1947-51.
Health care-seeking behavior related to the transmission of sexually transmitted diseases in Kenya.
Moses S, Ngugi EN, Bradley JE, Njeru EK, Eldridge G, Muia E, Olenja J, Plummer FA.
Source
Department of Community Health, University of Nairobi, Kenya.
Abstract
OBJECTIVES:
The purpose of this study was to identify health-care seeking and related behaviors relevant to controlling sexually transmitted diseases in Kenya.
METHODS:
A total of 380 patients with sexually transmitted diseases (n = 189 men and 191 women) at eight public clinics were questioned about their health-care seeking and sexual behaviors.
RESULTS:
Women waited longer than men to attend study clinics and were more likely to continue to have sex while symptomatic. A large proportion of patients had sought treatment previously in both the public and private sectors without relief of symptoms, resulting in delays in presenting to study clinics. For women, being married and giving a recent history of selling sex were both independently associated with continuing to have sex while symptomatic.
CONCLUSIONS:
Reducing the transmission of sexually transmitted diseases in Kenya will require improved access, particularly for women, to effective health services, preferably at the point of first contact with the health system. It is also critical to encourage people to reduce sexual activity while symptomatic, seek treatment promptly, and increase condom use.
Comment in
 The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface controlChallenges to the control of sexually transmitted diseases in Africa. [Am J Public Health. 1994]
PMID:
7998635
[PubMed - indexed for MEDLINE]
PMCID:
PMC1615368
Free PMC Article

E.N. PN. "Sexual behaviour in Kenya implications for sexually transmitted disease transmission and control.". 1994. Abstract

Sexually transmitted diseases have long been recognized as a major public health problem in Kenya. They are among the most common presenting complaints W ,Z!iji of adults at outpatient health facilities, ,Xid: representing 5% to 10% of the caseload at many clinics.' Gonorrhea, syphilis, chancroid, chlamydial infection, genital herpes infection, and human immunodeficiency virus type 1 (HIV-1) infection are the t, ;; most important sexually transmitted diseases in Kenya. The overall prevalence of these infections in the general population is unknown, but in antenatal populations in Nairobi, the prevalence of sexually transmitted diseases has recently been ..a shown to be in excess of 20%, with prevalence rates for gonorrhea, syphilis, and HIV-1 infection among pregnant women on the order of 5%, 8%, and 15%, respectively.2Sexually transmitted infections and their sequelae contribute significantly to morbidity and mortality. Syphilis in pregnancy is a major cause of spontaneous abortion, stillbirths, and neonatal morbidity and mortality. Gonorrhea and chlamydial infections in women are responsible for acute and chronic pelvic inflammatory disease, infertility, adverse p!!; pregnancy outcomes, and ophthalmia neonatorum.Perhaps even more important, treatable bacterial diseases, particularly those such as chancroid that cause genital ulceration, have been found to facilitate HIV-1 transmission.

1993
"Human immunodeficiency virus infection among high risk seronegative prostitutes in Nairobi.". 1993. Abstract

J Infect Dis. 1993 Jun;167(6):1414-7.
Human immunodeficiency virus infection among high-risk seronegative prostitutes in Nairobi.
Willerford DM, Bwayo JJ, Hensel M, Emonyi W, Plummer FA, Ngugi EN, Nagelkerke N, Gallatin WM, Kreiss J.
Source
Division of Basic Sciences, Fred Hutchinson Cancer Research Center, Seattle.
Abstract
To determine the frequency and duration of antibody-negative human immunodeficiency virus (HIV) infection among heterosexually exposed African women, 56 HIV-seronegative female prostitutes in Nairobi were studied. Polymerase chain reaction (PCR) was used to detect HIV DNA in peripheral blood at enrollment, and women were followed prospectively with serologic testing to determine HIV seroincidence. Six women (11%) were infected with HIV by PCR criteria at enrollment. Seroconversion occurred in 5 of these subjects within 1-12 months, while the sixth remained seronegative when last evaluated at 5 months. The cumulative annual seroconversion rate in the entire cohort was 38%. Using maximum likelihood analysis, the mean interval between HIV infection and seroconversion was estimated to be between 3 and 4 months, similar to that described for homosexual men and blood product recipients in the United States. Prolonged HIV infection in the absence of antibodies appears to be uncommon in this setting.
PMID:
8501333
[PubMed - indexed for MEDLINE]

1991
E.N. PN. "Condom use prevents genital ulcers in women working as prostitutes Influence of human immunodeficiency virus infection.". 1991. Abstract

Sex Transm Dis. 1991 Jul-Sep;18(3):188-91.
Condom use prevents genital ulcers in women working as prostitutes. Influence of human immunodeficiency virus infection.
Cameron DW, Ngugi EN, Ronald AR, Simonsen JN, Braddick M, Bosire M, Kimata J, Kamala J, Ndinya-Achola JO, Waiyaki PG, et al.
Source
Department of Medical Microbiology, University of Nairobi, Kenya.
Abstract
Control of genital ulcer disease (GUD) is a proposed intervention to slow the dissemination of human immunodeficiency virus (HIV) infection. Programs for the control of sexually transmitted diseases (STD) should focus on groups of high-frequency transmitters, such as prostitutes and their clientele. This study illustrates the interaction between the prevalence of chancroid, use of barrier prophylaxis against STDs, and HIV infection in a population of female prostitutes in Nairobi. Four hundred and twenty three women were evaluated. Despite the increased use of condoms, the prevalence of genital ulcers remained constant between 1986-87 and 1987-88. Genital ulcer disease was simultaneously associated with HIV infection (adjusted odds ratio: 3.7, P less than .01) whereas it was independently and inversely associated with more consistent condom use (P less than .01). The authors conclude that genital ulcer disease can be controlled in these populations but concurrent HIV infection increases the difficulty of this intervention.
PIP:
Counselors at a Nairobi City Commission Maternal/Child Health Clinic interviewed prostitutes in a certain residential area every 6 months between 1986-1988 about sexual practices and condom use. In addition, every 6 months, health workers examined the women on a demand basis free of charge, promoted condom use, provided condoms, informed then about sexually transmitted diseases (STDs) and HIV infection, and took samples to test for STD and HIV status. Prostitutes were 3 times more likely to use condoms in 1987-1988 than 1986-1987, but the prevalence of genital ulcers remained basically the same (34% in 1986-1987 and 32% in 1987-1988). Hemophilus ducreyi was responsible for at least 80% of the genital ulcers. In 1987-1988, 35% of HIV-1 seropositive women had genital ulcers while only 14% of HIV-1 seronegative women did (p.01). In fact, genital ulcer prevalence increased significantly in HIV-1 seropositive women as the disease stage of HIV-1 advanced (27% of asymptomatic healthy women, 35% of women with generalized lymphadenopathy, and 46% of women with clinical HIV related disease; p.05). Thus this study suggested that the immunosuppressive traits of preexisting HIV infection negate any protective effect that condoms normally have against genital ulcers. Indeed
the researchers proposed that a complex bidirectional epidemiologic and biologic interaction of HIV and H. ducreyi infection to be the basis of the HIV-1 epidemic in these women. In conclusion, strategies to curtail the transmission of HIV among heterosexuals should consists of programs which understand and change sexual behavior resulting in a decline in the contribution of prostitutes or other core groups to the HIV epidemic, condom use to prevent STD and HIV transmission, and control of genital ulcers in high frequency transmitters including prostitutes and clients.
PMID:
1948518
[PubMed - indexed for MEDLINE

"Controlling HIV in Africa effectiveness and cost of an intervention in a high frequency STD transmitter core group.". 1991. Abstract

AIDS. 1991 Apr;5(4):407-11.
Controlling HIV in Africa: effectiveness and cost of an intervention in a high-frequency STD transmitter core group.
Moses S, Plummer FA, Ngugi EN, Nagelkerke NJ, Anzala AO, Ndinya-Achola JO.
Source
Department of Community Health, University of Nairobi, Kenya.
Abstract
Since 1985, a population of over 1,000 predominantly HIV-positive female prostitutes residing in a low-income area of Nairobi, has been enrolled in a sexually transmitted disease (STD)/HIV control programme. The major elements of the programme include the diagnosis and treatment of conventional STD, and the promotion of condom use to prevent the transmission of HIV and other sexually transmitted infections. Using estimates of numbers of HIV-seropositive prostitutes, numbers of sexual contacts, susceptibility of clients to HIV, HIV transmission efficiency, rates of condom use and the basic reproductive rate of HIV infection in Kenya, we estimate that the programme is responsible for preventing between 6,000 and 10,000 new cases of HIV infection per year among clients and contacts of clients. The total annual operating cost of the programme is approximately US$77,000 or between US$8.00 and US$12.00 for each case of HIV infection prevented. Programmes to reduce the transmission of HIV and other sexually transmitted infections which are targeted at high-frequency STD transmitters, such as prostitutes, can be effective and relatively inexpensive to undertake. More such programmes should be developed and evaluated in different settings.
PMID:
1905555
[PubMed - indexed for MEDLINE]

Plummer, FA; Nagelkerke NJ; MN-AJO; BJJ; NES; N. "The importance of core groups in the epidemiology and control of HIV-1 infection.". 1991. Abstract

In Africa, HIV transmission occurs mainly through heterosexual intercourse. High-frequency transmitter core groups are key to the epidemiology of HIV-1 and STD on the continent. The rapid growth of the HIV-1 epidemic in Africa appears to have resulted, in part, from social and economic factors which result in individuals' frequent engagement in sexual intercourse with members of HIV-infected core groups. Understanding the importance of core groups in HIV-1 transmission is therefore key to developing more effective programs for the control of HIV-1. Sections explore the core groups concept and the sexual transmission of infection, social and economic forces creating core groups in Africa, the interaction of STD and HIV-1 in core groups, the effect of STD on HIV-1 disease progression in core groups in accelerating the HIV-1 epidemic, the role of core group interventions in control programs, balancing disease control with the potential for victimization, and research needs

E.N. PN. "Social epidemiology in Africa slowing the heterosexual transmission of AIDS.". 1991. Abstract

AIDS Soc. 1991 Jan-Feb;2(2):7-8.
Social epidemiology in Africa: slowing the heterosexual transmission of AIDS.
Ronald A, Ndinya-achola JO, Ngugi EN, Moses S, Brunham R, Plummer FA.
Abstract
PIP:
Analyzing why the rate of transmission of AIDS varies widely in Africa is the basis for designing strategies for intervention. Promiscuity, i.e. high rates of sex partner change, is not the only reason for rapid transmission, but it is a prerequisite for the explosive spread seen in certain groups. High frequency groups include mobile single men and prostitutes. Research and strategies must focus on sex practices, concepts of personal vulnerability, and possibility of behavioral change. The sexually transmitted diseases that are thought to increase susceptibility to HIV, i.e., genital ulcer diseases, can be controlled with appropriate strategies. Male circumcision is associated with lower HIV seroprevalence. Thus strategies must be concentrate on sustained prevention among high STD transmitters, providing early, effective care for STDs, increasing economic alternatives for women, and offering voluntary circumcision where culturally acceptable.
PMID:
12343101
[PubMed - indexed for MEDLINE]

1990
"HIV infection among lower socioeconomic strata prostitutes in Nairobi.". 1990. Abstract

AIDS. 1990 Feb;4(2):139-44.
HIV infection among lower socioeconomic strata prostitutes in Nairobi.
Simonsen JN, Plummer FA, Ngugi EN, Black C, Kreiss JK, Gakinya MN, Waiyaki P, D'Costa LJ, Ndinya-Achola JO, Piot P, et al.
Source
Centre for Microbiologic Research, Kenya Medical Research Institute.
Abstract
A cohort of 418 lower socioeconomic strata prostitutes were enrolled in a study of the epidemiology of sexually transmitted diseases (STDs) between January and April 1985. Sixty-two per cent of the women were seropositive for HIV infection at enrollment. Significant associations were found between HIV seropositivity and Tanzanian origin (OR = 2.12, CI 95% = 1.18-3.81, P less than 0.03), younger age, a shorter duration of prostitution, reduced fecundity, use of oral contraceptives (OR = 1.8, CI 95% = 1.1-2.9, P less than 0.05) and genital ulcer disease (OR = 3.32, P less than 0.00001). No associations were noted with other STD. Stepwise logistic regression analysis confirmed independent associations between HIV infection and Tanzanian origin (OR = 2.27, CI 95% = 1.25-4.14, P less than 0.007), reduced fecundity (OR = 0.83, CI 95% = 0.74-0.94, P less than 0.003), oral contraceptive use (OR = 2.02, CI 95% = 1.22-3.35, P less than 0.006) and duration of prostitution (OR = 0.39, CI 95% = 0.23-0.65, P less than 0.004). Oral contraceptives may increase susceptibility to HIV or may be a marker for other factors which increase risk of acquisition. Further studies are necessary to confirm this association.
PMID:
2328096
[PubMed - indexed for MEDLINE]

E.N. PN. "Transition dynamics of HIV disease in a cohort of African prostitutes: a Markov model approach.". 1990. Abstract

AIDS. 1990 Aug;4(8):743-7.
Transition dynamics of HIV disease in a cohort of African prostitutes: a Markov model approach.
Nagelkerke NJ, Plummer FA, Holton D, Anzala AO, Manji F, Ngugi EN, Moses S.
Source
Kenya Medical Research Institute, Nairobi.
Abstract
The progression of HIV-related disease from infection to death is represented as a staged Markov model. Transitions between stages are considered reversible. The model is fitted to data from a cohort of African prostitutes by means of maximum likelihood. It appears that the progression to symptomatic disease (Centers for Disease Control stage IV) in this population is considerably more rapid than that reported from studies in Western countries.
PIP:
Identifying the incubation period of HIV infection is important for individual prognoses, for developing and testing intervention strategies, for determining the reproductive rate of the disease, and for prevalence of the disease. Mathematical modeling of HIV infection in Africa is necessitated because the disease is more widespread and the immune system is constantly active due to the exposure to diseases such as malaria and tuberculosis. The Markov model for this analysis was selected because parametric estimation is not based on the time a stage is entered, but on the duration between observations and the stages at the time of observation. The HIV infected female prostitutes in the Pumwani area of Nairobi, Kenya (a population primarily of Tanzanian origin) have been identified as a study population since 1985, and seen every 6 months in clinic, or as needed. Data are constricted by the movement out of the area in the end stage of disease, which is only partially solved by tracking with community health workers. The stages identified in incubation estimation are stage 1: seropositive but symptom free (CDC stage II); stage 2: generalized lymphadenopathy (CDC stage III); stage 3: symptomatic disease (CDC stage IV); and stage 4: death. Data reflect the movement back and forth between stage 1 and 2, between 2 and 3, so the model is not a pure Longini model but rather a timed homogeneous staged model with reversible stages called transition parameters computed in a numerical differentiation. The Fortran computer program for the analyses is available from the authors. The results suggest a quick transition between seroconversion and lymphadenopathy (2.4 months) and unlikely reversal, with the mean waiting time until passage to stage 3 is approximately 2.6 years and conversions are common. Since opportunistic infections are treatable, this makes sense. Assuming a correct model, the estimation of the transition time of 20 months of h34 value
of .01 and .05, the mean passage time from stage 1, 2, 3 to 4 (death) is 9.1, 8.9, and 6.2 years 12.9, 12.7, and 10.1 years respectively. The implications are that 1) when infectiousness is hypothesized to be not uniform, peak infectivity occurs earlier in Africa than in the West at least among prostitutes, or 2) if infectivity is constant throughout the incubation period, then HIV transmission must be higher in Africa to explain the high rate of infection.
PMID:
2175619
[PubMed - indexed for MEDLINE]

1989
"Epidemiologic evidence for the development of serovar specific immunity after gonococcal infection.". 1989. Abstract

lin Invest. 1989 May;83(5):1472-6.
Epidemiologic evidence for the development of serovar-specific immunity after gonococcal infection.
Plummer FA, Simonsen JN, Chubb H, Slaney L, Kimata J, Bosire M, Ndinya-Achola JO, Ngugi EN.
Source
Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada.
Abstract
We tested the hypothesis that strain-specific immunity occurs after gonococcal infection in a longitudinal study of 227 prostitutes resident in one small community who experienced frequent gonococcal infections. Women were examined and cultured for Neisseria gonorrhoeae at 2-wk intervals. Gonococcal isolates were typed according to protein 1 serovar, auxotype, and beta-lactamase plasmid type, and classified as to serovar and strain. The hypothesis was tested by comparing the predictions of the hypothesis with the observations of the study. Over the 14-mo period of the study, major changes in the prevalence of specific serovars were observed in the gonococcal population infecting these women. Women with HIV infection experienced a higher rate of gonococcal infection (0.56 +/- 0.03 vs. 0.46 +/- 0.04, P less than 0.05, t test) compared with HIV-negative women and were more likely to experience multiple infections with the same strain. The duration of prostitution was inversely related to the frequency of gonococcal infection. Women experiencing an infection with a specific gonococcal serovar were at a 2- to 10-fold reduced risk of reinfection with the same serovar, except for the 1B-1 serovar. The results of the study were consistent with all four predictions of the hypothesis. Infection with a specific gonococcal serovar results in specific but incomplete protection against subsequent infection with the homologous serovar. The mechanism of this protection remains to be determined.
PMID:
2496142
[PubMed - indexed for MEDLINE]
PMCID:
PMC303849
Free PMC Article

Kreiss JK;, Coombs R;, Plummer F;, Holmes KK;, Nikora B;, Cameron W;, Ngugi EN;, Ndinya-Achola JO;, Corey L. "Isolation of human immunodeficiency virus from genital ulcers in Nairobi prostitutes.". 1989. Abstract

Recent epidemiologic studies have implicated genital/anorectal ulcer disease as an important cofactor for acquisition and transmission of human immunodeficiency virus (HIV) during sexual intercourse. To better understand the mechanism for the association between genital ulcers and HIV, exudates from 62 genital ulcers of 56 HIV-seropositive prostitutes in Nairobi (Kenya) were cultured for HIV. Twenty-six ulcer cultures could not be evaluated for the presence of HIV because of bacterial or fungal contamination. HIV was isolated from 4 (11%) of the 36 remaining uncontaminated ulcer cultures (2 introital, 1 vaginal, and 1 cervical) from 4 separate women. HIV was isolated from the cervical os from only 2 of the 4 women. HIV p24 antigen was detected in exudate from 1 of the 4 culture-positive ulcers and 0 of 32 culture-negative ulcers. Genital ulcers in seropositive patients should be regarded as potential sources of HIV, which could be important in transmission of HIV during intercourse. Public health measures aimed at controlling sexually transmitted genital ulcer diseases should be an integral part of acquired immunodeficiency syndrome (AIDS) prevention programs

1988
E.N. PN. "Health outreach and control of HIV infection in Kenya.". 1988. Abstract

J Acquir Immune Defic Syndr. 1988;1(6):566-70.
Health outreach and control of HIV infection in Kenya.
Ngugi EN, Plummer FA.
Source
Department of Community Health, College of Health Sciences, University of Nairobi, Kenya.
Abstract
This paper highlights the role of mobilization of individuals and community groups and health professionals in prevention of HIV transmission. It traces the educational strategy employed to reach the general population and selected groups at risk. In Kenya, the general awareness about AIDS started to grow in late 1985 and increased in 1986-87. This has resulted in reduction of the incidence of some sexually transmitted diseases (STDs). The importance of pretesting education material as well as monitoring and evaluation of educational efforts to lay the ground for culturally appropriate and more effective health education messages to combat HIV transmission is presented. The paper concludes by emphasizing the importance of developing the HIV infection programs with the people and for the people.
PMID:
3225743
[PubMed - indexed for MEDLINE]
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"Prevention of transmission of human immunodeficiency virus in Africa effectiveness of condom promotion and health education among prostitutes.". 1988. Abstract

Lancet. 1988 Oct 15;2(8616):887-90.
Prevention of transmission of human immunodeficiency virus in Africa: effectiveness of condom promotion and health education among prostitutes.
Ngugi EN, Plummer FA, Simonsen JN, Cameron DW, Bosire M, Waiyaki P, Ronald AR, Ndinya-Achola JO.
Source
Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi.
Abstract
Condom use was assessed after a programme of education about the acquired immunodeficiency syndrome and a condom distribution programme in a well-characterised prostitute population in Nairobi. Women received their education at group meetings (barazas) and at individual counselling sessions during which they were given the results of serological tests for the human immunodeficiency virus (group 1) or at barazas only (group 2), or through very little of either (group 3). During the counselling sessions free condoms were distributed. Before either of the programmes started, 10%, 9%, and 7% of groups 1, 2, and 3 women, respectively, reported occasional use of condoms. By November 1986, 80%, 70%, and 58% of groups 1, 2, and 3 women, respectively, reported at least some condom use. The mean frequency of condom use was 38.7 (SD 31.8)%, 34.6 (34.5)%, and 25.6 (29.5)% of sexual encounters in groups 1, 2, and 3 women. 20 of 28 women who were non-condom-users seroconverted compared with 23 of 50 women who reported some use of condoms.
PIP:
In some parts of Africa, prostitutes and their clients represent the groups at greatest risk of human immunodeficiency virus (HIV) infection and the major disseminators of the virus. As part of a cohort study of the epidemiology of sexually transmitted diseases in Nairobi, 595 prostitutes have been followed since 1985. At the start of the study, 61% of these prostitutes were infected with HIV. Health education, initially about conventional sexually transmitted diseases and subsequently about acquired immunodeficiency syndrome (AIDS), was a major component of this project. Health education was provided at barazas (general community meetings including lectures, skits, role playing, and discussion) and individual counseling sessions. To evaluate the effectiveness of such health promotion efforts on the prevention of HIV infection, specifically on adoption of condom use, the prostitutes were divided into 3 groups: 1) those who received their health education through both barazas and individual sessions at which the results of serological tests for HIV infection were discussed; 2) those who attended barazas only; and 3) prostitutes who received neither intervention. Condoms were distributed free of charge to all prostitutes who requested them. At the start of the project, only 10%, 7%, and 7% of prostitutes in Groups 1, 2, and 3, respectively, reported some use of condoms. After 6 months in the program, this statistic had increased to 80%, 70%, and 58%, respectively. The mean frequency of condom use was 38.7%, 34.6%, and 25.6% of sexual encounters in Group 1, 2, and 3 women. Any condom use
resulted in a 3-fold reduction in risk of seroconversion. 20 of 28 women who were not condom users seroconverted compared with 23 of 50 condom users. Stepwise logistic regression confirmed that group discussion was the factor most significantly associated with condom use.
PMID:
2902326
[PubMed - indexed for MEDLINE]

Kinyari TN, White E, Sharma A, Morris M, Bukusi EA, Meier AS, Farqhuar C, Ngugi EN, Cohen CR. "The relationship between sexual partnerships characteristics and condom use among young female sex workers in Nairobi , Kenya (Manuscript under.". 1988.
E.N. PN. "A review of HIV-1 in Africa.". 1988. Abstract

Bull N Y Acad Med. 1988 Jul-Aug;64(6):480-90.
A review of HIV-1 in Africa.
Ronald AR, Ndinya-Achola JO, Plummer FA, Simonsen JN, Cameron DW, Ngugi EN, Pamba H.
Abstract
PIP:
As the AIDS epidemic reaches a dramatic stage of development, the time for African countries to establish effective control programs has come. The history of AIDS in Africa is different from that other regions of the world. The disease developed among heterosexual communities. By 1987, over 8,000 cases of AIDS had been reported from 37 of the 47 nations of Africa. Over 2,000 of these cases were found in Uganda. However, under-reporting and under-representation of the number of actual cases is still a problem. In many cases, there has been a failure to recognize the disease. The demographic and geographic distribution of seroprevalence is discussed. Because of the inaccuracies in AIDS reporting in Africa, epidemic forecasting is difficult. If 5 million are currently infected, a potential 50 million Africans may be infected by 1993. A further discussion of the risk factors for HIV-1 holds that promiscuity is the major problem. Cures and inexpensive treatments for the infection are years away. Energy, resources, and national committees in Africa and the world must be coordinated to combat the ultimate crisis of this century.
PMID:
3069166
[PubMed - indexed for MEDLINE]
PMCID:
PMC1630576
Free PMC Article

1987
"Retrospective seroepidemiology of AIDS virus infection in Nairobi populations.". 1987. Abstract

J Infect Dis. 1987 Jun;155(6):1108-12.
Retrospective seroepidemiology of AIDS virus infection in Nairobi populations.
Piot P, Plummer FA, Rey MA, Ngugi EN, Rouzioux C, Ndinya-Achola JO, Veracauteren G, D'Costa LJ, Laga M, Nsanze H, et al.
Abstract
Among 446 sera from prostitutes in Nairobi, the prevalence of antibody to human immunodeficiency virus (HIV) rose from 4% in 1981 to 61% in 1985. None of 118 men with chancroid seen in 1980 had antibody to HIV compared with 15% of 107 such men in 1985. Among pregnant women, 2.0% were seropositive in 1985 versus none of 111 in 1981. Seropositive prostitutes and women with sexually transmitted diseases (STDs) tended to have more sex partners and had a higher prevalence of gonorrhoea, and in women with STDs, significantly more seropositive women practiced prostitution. Pregnant women and men with STDs who were born in the most-western region of Kenya were more likely to have antibody to HIV than were such groups from other geographic areas. Our results indicate that the AIDS virus was recently introduced into Kenya, that HIV can rapidly disseminate in a high-risk group of heterosexuals, and that prostitutes may have significantly contributed to the spread of the virus.
PMID:
3471817
[PubMed - indexed for MEDLINE]

E.N. PN. "Retrospective seroepidemiology of AIDS virus infection in Nairobi populations.". 1987. Abstract

J Infect Dis. 1987 Jun;155(6):1108-12.
Retrospective seroepidemiology of AIDS virus infection in Nairobi populations.
Piot P, Plummer FA, Rey MA, Ngugi EN, Rouzioux C, Ndinya-Achola JO, Veracauteren G, D'Costa LJ, Laga M, Nsanze H, et al.
Abstract
Among 446 sera from prostitutes in Nairobi, the prevalence of antibody to human immunodeficiency virus (HIV) rose from 4% in 1981 to 61% in 1985. None of 118 men with chancroid seen in 1980 had antibody to HIV compared with 15% of 107 such men in 1985. Among pregnant women, 2.0% were seropositive in 1985 versus none of 111 in 1981. Seropositive prostitutes and women with sexually transmitted diseases (STDs) tended to have more sex partners and had a higher prevalence of gonorrhoea, and in women with STDs, significantly more seropositive women practiced prostitution. Pregnant women and men with STDs who were born in the most-western region of Kenya were more likely to have antibody to HIV than were such groups from other geographic areas. Our results indicate that the AIDS virus was recently introduced into Kenya, that HIV can rapidly disseminate in a high-risk group of heterosexuals, and that prostitutes may have significantly contributed to the spread of the virus.
PMID:
3471817
[PubMed - indexed for MEDLINE]

1986
Ngugi EN;, Plummer FA. "Health Outreach and Control of HIV Infection in Kenya.". 1986. Abstract

This paper highlights the role of mobilization of individuals and community groups and health professionals in prevention of HIV transmission. It traces the educational strategy employed to reach the general population and selected groups at risk. In Kenya, the general awareness about AIDS started to grow in late 1985 and increased in 1986--87. This has resulted in reduction ofthe incidence of some sexually transmitted diseases (STDs). The importance of pretesting education material as well as monitoring and evaluation of educational efforts to lay the ground for culturally appropriate and more effective health education messages to combat HIV transmission is presented. The paper concludes by emphasizing the importance of developing the HIV infection programs with the people and for the people. Key Words: Human immunodeficiency rvirus-Prevention-Kenya-Sexually transmitted diseases.

1985
E.N. PN. "Sexually transmitted diseases in Kenya.". 1985. Abstract

Kenya Nurs J. 1985 Dec;13(2):5-9.
Sexually transmitted diseases in Kenya.
Ronald AR, Ngugi EN, Da Costa.
PMID:
3854890
[PubMed - indexed for MEDLINE]

1983
E.N. PN. "The Council of National Representatives Brasilia, 6th-10th June 1983.". In: Kenya Nurs J. 1983 Dec;11(2):.; 1983:. Abstract

Kenya Nurs J. 1983 Dec;11(2):23-7.
The Council of National Representatives Brasilia, 6th-10th June 1983.
Ngugi EN.

PMID:
6564282
[PubMed - indexed for MEDLINE]

1982
1981
E.N. PN. "Opening speech to Coast Branch N.N.A.K. AGM on team work and nurses welfare.". In: Opening speech to Coast Branch N.N.A.K. AGM on team work and nurses welfare.; 1981. Abstract

Kenya Nurs J. 1981 Jun;10(1):21-2.
Opening speech to Coast Branch N.N.A.K. AGM on team work and nurses welfare.
Ngugi EN.

PMID:
6913629
[PubMed - indexed for MEDLINE]

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E.N. PN. "Setting the pace: new approaches in nursing practice: paper presented to the International Council of Nurses Congress at the 17th ICN Quadrennial Congress held in Los Angeles in June, 1981.". In: International Council of Nurses Congress at the 17th ICN Quadrennial Congress held in Los Angeles in June, 1981. Los Angeles; 1981. Abstract

Kenya Nurs J. 1981 Dec;10(2):13-5.
Setting the pace: new approaches in nursing practice: paper presented to the International Council of Nurses Congress at the 17th ICN Quadrennial Congress held in Los Angeles in June, 1981.
Ngugi EN.
PMID:
6921385
[PubMed - indexed for MEDLINE]

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