VIGH Faculty Publications

Recent Publications by Vanderbilt Institute for Global Health faculty

Clinical and ultrasonographic features of abdominal tuberculosis in HIV-positive adults in Zambia
BMC Infectious Diseases
Edford Sinkala, Sylvia Gray, Isaac Zulu, Victor Mudenda, Lameck Zimba, Sten H. Vermund, Francis Drobniewski, Paul Kelly

• We estimated the prevalence and clinical features of abdominal (excluding genitourinary) TB in HIV-infected adults attending the University Teaching Hospital, Zambia.
  
• Of 140 HIV-seropositive patients with these features, 31 patients underwent full evaluation and 22 (71%) had definite or probable abdominal TB. Abdominal TB was associated with CD4 cell counts over a wide range though 76% had CD4 counts <100 cells/uL.
• The clinical manifestations of abdominal TB in our HIV-infected patients resembled the well-established pattern in HIV-uninfected adults. Patients with fever, weight loss, abdominal tenderness, abdominal lymphadenopathy, ascites and/or hepatomegaly in Zambia have a high probability of abdominal TB, irrespective of CD4 cell count.

 Willingness to be Circumcised for Preventing HIV among Chinese Men who have Sex with Men
AIDS Patient Care and STDs
Yuhua Ruan, Han-Zhu Qian, Dongliang Li, Wei Shi, Qingchun Li, Hongyuan Liang, Ye Yang, Fengji Luo, Sten H. Vermund, Yiming Shao

• This study evaluated the willingness to participate in a clinical trial of circumcision among 328 Chinese MSM. Of 284 uncircumcised MSM, 16.9% said they were absolutely willing to participate, 26.4% were probably, 28.9% were probably not, and 27.8% were absolutely not; 81% said male circumcision would help maintain genital hygiene.
• The major motivators for willingness to participate included contribution to AIDS scientific research and getting free medical service. Men also had concerns about ineffectiveness of circumcision in reducing HIV/sexually transmitted infection (STI) risks and side effects of the surgery.
• The study suggests that circumcision is uncommon among Chinese MSM. Considerable community education will be needed in circumcision advocacy among MSM in China. A clinical trial for efficacy among MSM should be considered.

Prevalence of HIV infection and predictors for syphilis infection among female sex workers in southern China
Southeast Asian Journal of Tropical Medicine and Public Health
Lu F, Jia Y, Sun X, Wang L, Liu W, Xiao Y, Zeng G, Li C, Liu J, Cassell H, Chen HT, Vermund SH

• The purpose of this study was to assess the prevalence and risk factors for syphilis infection among female sex workers (FSWs) in Liuzhou City, Guangxi Zhuang Autonomous Region, southern China.
• Of the 362 eligible participants, 81.7% were non-local residents (60.5% from other parts of Guangxi and 21.2% were non-Guangxi residents); 58.0% belonged to non-Han minority ethnic groups; 37.5% reported inconsistent condom use with their clients and 71.2% reported inconsistent condom use with their regular sex partners during the past month. Nearly 10% reported having had sex with drug users.
• The prevalence rates for HIV and syphilis infections were 2.3% and 11.0%, respectively. Almost half (46.6%) of participants reported having had STD symptoms.

Predictors for casual sex and/or infection among sexually transmitted disease clinic attendees in China
International Journal of STD and AIDS
Lu F, Jia Y, Bin S, Li C, Limei S, Kristensen S, Sun X, Xiao Y, Liu J, Li D, Qu S, Vermund SH

• To assess the risk factors for casual sex and infections among the sexually transmitted disease (STD) clinic attendees in two disparate Chinese cities, an STD clinic-based cross-sectional study was conducted to provide demographic and sexual behavior information.
  
• Of 536 participants, 22.5% reported having casual sex in the last three months, younger age, less education, unawareness of transmission routes and having had casual sex in the last three months were independent risk factors for acquisition of an STD.
• After decades of exceedingly low STD rates in China, a full panoply of STD diagnoses are now evident. Both for reproductive health concerns and for stemming the expansion of HIV spread, STD control and prevention must be revitalized as a priority for China's public health and medical institutions. Effective training is a priority, given the dearth of STD-experienced health-care workers.

Human immunodeficiency virus (HIV) antigens and RNA in HIV-seronegative women with cervical intraepithelial neoplasia
AIDS Research and Human Retroviruses
Jayasri Basu, Seymour L. Romney, Ruth H. Angeletti, Sten H. Vermund, Edward Nieves, Anna S. Kadish, Magdy S. Mikhail, George A. Orr

• While investigating whether proteins retrieved by cervicovaginal lavages (CVL) from women with cervical intraepithelial neoplasia (CIN) might correlate with risk of progression to invasive cervical cancer, we unexpectedly identified HIV gag and env glycoprotein in CVL from women with HIV-negative serology.
• To validate the unexpected MS findings we performed Western blot (WB) and immunoaffinity chromatography (IC) analysis of CVL for HIV proteins, viral load assays of paired CVL and blood samples, and immunohistochemical HIV p24 expression in cervical biopsy specimens.
• All 20 subjects remained HIV-seronegative throughout the study. Women with HIV proteins and RNA were comparatively older. Our findings suggest that CVL HIV proteins in women with CIN could be markers for unrecognized HIV exposure or subclinical infection. Proteomic screening of cervical secretions may be useful in identifying seronegative women exposed to HIV and/or at risk for AIDS.

Implementation of 'see-and-treat' cervical cancer prevention services linked to HIV care in Zambia
AIDS
Mulindi H. Mwanahamuntu, Vikrant V. Sahasrabuddhe, Krista S. Pfaendler, Victor Mudenda, Michael L. Hicks, Sten H. Vermund, Jeffrey S.A. Stringer, Groesbeck P. Parham

• HIV infection is associated with higher incidence, more rapid progression, and increased recurrence rates of human papillomavirus (HPV)-associated cervical intraepithelial neoplasia (CIN) and invasive cervical cancer, an AIDS-defining disease. The last decade has seen a global push for increasing access to affordable antiretroviral therapy (ART) for HIV-infected individuals in the developing world.
• Over the past 2½ years, our program has screened over 20,000 women through services offered in 15 primary care clinics and one referral Gynecologic Cancer Prevention Clinic. Our experience has shown that linking cervical cancer prevention services with HIV care and treatment services has potentiated the impact of initiatives such as PEPFAR by preventing cervical cancer in women living longer on ART and who have never been screened.
• We believe that HIV-targeted funds can and should address closely allied health concerns whose neglect may reduce the long-term success of HIV programs. This holds the promise of both saving lives and ensuring the strengthening of the broader primary care context so essential for sustaining HIV programs beyond the PEPFAR/Global Fund era.

HIV Incidence Rates and Risk Factors for Urban Women in Zambia: Preparing for a Microbicide Clinical Trial
Sexually Transmitted Diseases
Muzala Kapina, Cheri Reid, Karisse Roman, Elena Cyrus-Cameron, Antonia Kwiecien, Stephen Weiss, Sten H. Vermund

• A preparedness study was conducted to evaluate the suitability of sites and populations following the same study procedures intended for a larger scale microbicide efficacy trial. In the process the study evaluated human immunodeficiency virus (HIV) incidence, prevalence, and risk profiles for HIV-acquisition among young women in urban Zambia.
• Women aged 16 to 49 years were screened for participation in the study that involved HIV/sexually transmitted infection testing and the assessment of sexual behavioral characteristics. Two hundred thirty-nine eligible women were enrolled and followed up for 12 months.
• It was concluded that our general population sample, characterized by high HIV prevalence and ongoing incidence rates despite receiving regular risk reduction counseling and free condoms qualifies for future microbicide studies.

Risk Factors for Syphilis and Prevalence of HIV, Hepatitis B and C among Men Who Have Sex with Men in Beijing, China: Implications for HIV Prevention
AIDS Behavior
Yuhua Ruan, Fengji Luo, Yujiang Jia, Xinxu Li, Qingchun Li, Hongyuan Liang, Xiaoxi Zhang, Dongliang Li, Wei Shi, Jennifer M. Freeman, Sten H. Vermund, Yiming Shao

• To examine the correlates for syphilis and the prevalence for HIV, hepatitis B, hepatitis C among men-who-have-sex-with-men (MSM) in Beijing, China. A total of 541 MSM was recruited using peer-referral, community outreach, and Internet.
• HIV prevalence was 4.8%, syphilis 19.8%, HCV 0.4% and HBsAg 6.5%. The median number of lifetime male sex partners was ten. In the past 3 months, 20.7% drank alcohol ≥1 times per week. In the past month, 21.3 and 14.6% had unprotected anal intercourse with regular and casual male sex partners, respectively. Syphilis is now epidemic among Beijing’s MSM.
• Prevention efforts are urgent as HIV prevalence is already near 5%. Education, condom promotion, STD control, and alcohol-related intervention are needed urgently.

Circumcision and HIV prevention among men who have sex with men: no final word
JAMA
Sten H. Vermund, Han-Zhu Qian

• A meta-analysis of epidemiological studies published prior to 2000 suggested a statistically significant protective association between circumcision and HIV infection among African heterosexual men. A causal relationship between HIV risk reduction and male circumcision seemed likely; there was biological plausibility and consistency between studies.
• The studies, however, did not confirm that circumcision predated HIV risk reduction or that confounding factors might not explain the association.
• Infant and adult circumcision are recommended in regions with high HIV prevalence as in sub-Saharan Africa. But the question as to whether MSM should be circumcised to reduce their HIV risk, particularly men who preferentially practice insertive sex, is one that only future research can answer.

Hepatitis B and hepatitis C in Pakistan: prevalence and risk factors
International Journal of Infectious Diseases
Syed Asad Ali, Rafe M.J. Donahue, Huma Qureshi, Sten H. Vermund

• We reviewed the medical and public health literature over a 13-year period (January 1994-September 2007) to estimate the prevalence of active hepatitis B and chronic hepatitis C in Pakistan, analyzing data separately for the general and high-risk populations and for each of the four provinces.
• A weighted average of hepatitis B antigen prevalence in pediatric populations was 2.4% (range 1.7-5.5%) and for hepatitis C antibody was 2.1% (range 0.4-5.4%). A weighted average of hepatitis B antigen prevalence among healthy adults (blood donors and non-donors) was 2.4% (range 1.4-11.0%) and for hepatitis C antibody was 3.0% (range 0.3-31.9%). Rates in the high-risk subgroups were far higher.
• Data suggest a moderate to high prevalence of hepatitis B and hepatitis C in different areas of Pakistan. The published literature on the modes of transmission of hepatitis B and hepatitis C in Pakistan implicate contaminated needle use in medical care and drug abuse and unsafe blood and blood product transfusion as the major causal factors.

Use of oral contraceptives, intrauterine devices and tubal sterilization and cancer risk in a large prospective study, from 1996 to 2006
International Journal of Cancer
Tsogzolmaa Dorjgochoo, Xiao-Ou Shu, Hong-Lan Li, Han-Zhu Qian, Gong Yang, Hui Cai, Yu-Tang Gao, Wei Zheng

• The association of contraceptive methods, including oral contraceptives (OC), intrauterine devices (IUD) and tubal sterilization (TS), with overall and site-specific cancer were prospectively investigated in a cohort of 66,661 Chinese women in Shanghai, 76.7% of whom used contraception.
• During a median follow-up time of 7.5 years, 2,250 women were diagnosed with cancer. Ever-use of any contraceptive method was not associated with overall cancer risk [adjusted hazard ratio (HR(adj)) = 1.02, 95% CI, 0.92-1.12]. Use of any contraceptive method was associated with increased risk of rectal cancer (HR(adj) = 1.68, 95% CI, 1.08-2.62) and reduced risk of thyroid cancer (HR(adj) = 0.63, 95% CI, 0.38-1.04).
• We did not find any contraceptive method to be related to the risk of ovarian cancer but the analyses were based on few events. Although chance findings are a likely explanation for some of the associations found in our study, these findings suggest that various contraceptive methods or reproductive patterns may play a role in the etiology of cancer.

Which helminth coinfections really affect HIV disease progression?
AIDS
Kayvon Modjarrad

• The study by Walson et al. published in the recent issue of AIDS describes the results of the first randomized, placebo-controlled trial to evaluate the impact of soil-transmitted helminth infection on CD4+ cell count and viral load among HIV-1, geohelminth coinfected adults.
• The study by Walson et al. contains multiple ambiguities, beginning with its analytic plan. It is unclear whether the authors compared the time-dependent trends in CD4+ cell counts and viral load between the two study arms or whether they evaluated cross-sectional differences in serial fashion.
• Ultimately, the results of the current study suggest that the story of HIV-helminth interactions is far from over. Additional, well designed studies must be conducted to more definitively address the issues raised, focusing not just on helminth infections as a whole, but species-specific effects as well.