New insights into HIV epidemic in South Africa: key findings from the National HIV Prevalence,Incidence and Behaviour Survey, 2012

This article presents key findings from the 2012 HIV prevalence, incidence and behaviour survey conducted in South Africa and explores trends in the HIV epidemic. A representative household based survey collected behavioural and biomedical data among people of all ages. Chi-squared test for association and formal trend tests (2002, 2005, 2008 and 2012) were used to test for associations and trends in the HIV epidemic across the four surveys. In 2012 a total of 38 431 respondents were interviewed from 11 079 households; 28 997 (67.5%) of 42 950 eligible individuals provided blood specimens. HIV prevalence was 12.2% [95% CI: 11.4–13.1] in 2012 with prevalence higher among females 14.4% than males 9.9%. Adults aged 25–49 years were most affected, 25.2% [95% CI: 23.2–27.3]. HIV prevalence increased from 10.6% [95%CI: 9.8–11.6] in 2008 to 12.2% [95% CI: 11.4–13.1] in 2012 (p < 0.001). Antiretroviral treatment (ART) exposure doubled from 16.6% in 2008 to 31.2% in 2012 (p < 0.001). HIV incidence in 2012 among persons 2 years and older was 1.07% [95% CI: 0.87–1.27], with the highest incidence among Black African females aged 20–34 years at 4.5%. Sexual debut before 15 years was reported by 10.7% of respondents aged 15–24 years, and was significantly higher among male youth than female (16.7% vs. 5.0% respectively, p < 0.001). Reporting of multiple sexual partners in the previous 12 months increased from 11.5% in 2002 to 18.3% in 2012 (p < 0.001). Condom use at last sex dropped from 45.1% in 2008 to 36.2% in 2012 (p < 0.001). Levels of accurate HIV knowledge about transmission and prevention were low and had decreased between 2008 and 2012 from 31.5% to 26.8%. South Africa is on the right track with scaling up ART. However, there have been worrying increases in most HIV-related risk behaviours. These findings suggest that there is a need to scale up prevention methods that integrate biomedical, behavioural, social and structural prevention interventions to reverse the tide in the fight against HIV.     

The quantification of individual proteins in crevicular gingival fluid

The aim of the present study was the quantification of proteins present in crevicular fluid obtained from individual sulci, and to this effect simplified micromethods for the quantification of individual proteins were developed. Unstimulated, resting crevicular fluid from healthy crevicular spaces (i.e. in the absence of clinically detectable inflammation) of dogs and humans was collected for 3 minutes, either in microcapillary glass tubes or with the aid of filter paper strips. Quantification of proteins was done by radial immunodiffusion without the pooling of samples or by immunoelectrophoresis, without eluting from the papers. The concentrations of albumin and fibrinogen in crevicular fluid so determined proved to be significantly lower than plasma concentrations. These results strengthen the concept that capillary dynamics in healthy gingivae are similar to those in general tissue capillary beds and that gingival fluid is a plasma transudate. However, due to ever present sub-clinical inflammation and other factors, it is improbable that fluid from even healthy sulci is a true transudate.     

Endemic goitre among undernourished schoolchildren in eastern Caprivi, Namibia.

A cross-sectional study on a 20% random sample of 380 children, aged 6-18 years, from 8 primary schools in the Cuando River area of eastern Caprivi, Namibia, was done to determine the prevalence of goitre and to investigate related hormonal and nutritional factors. Of the children 34.5% had goitre. Reduced plasma free thyroxine concentrations in the more severely goitrous children, compared with matched non-goitrous children (P = 0.0007), implicated dietary iodine deficiency as the causative factor. Their diet was inadequate in energy and most nutrients according to World Health Organisation criteria. Retarded growth, indicated by their low body weight and height in relation to age, were observed in a large proportion (45.6-73%) of the children. These findings suggest that dietary iodine deficiency was the most likely cause for the endemic goitre in these children, who were predisposed to nutritional disorders by long-term undernourishment.     

ACUTE DESTRUCTION BY HUMORAL ANTIBODY OF RAT SKIN GRAFTED TO MICE : THE ROLE OF COMPLEMENT AND POLYMORPHONUCLEAR LEUKOCYTES

A study has been made of the roles played by complement and polymorphonuclear leukocytes (PMN) in the acute destruction of xenografts of rat skin that follows injection of their hosts with antisera specifically reactive with graft antigens. The rat skin was grafted onto mice whose immune responses were suppressed by removal of the thymus and a brief course of treatment with rabbit antimouse lymphocyte serum. At about 2 wk after grafting the mice were injected intravenously or intraperitoneally with mouse antirat serum (MARS). This time interval was chosen because it avoided the complications that might be associated with either the process of healing in or with incipient rejection. Signs of graft damage were evident as early as 10 min after the injection of MARS, and in most animals so injected the grafts were completely destroyed within 24–48 h. The role of complement (C) in this acute destructive process is indicated by the results of three lines of experimentation. (a) Non-C-fixing antibodies or antibody fragments failed to cause damage to the grafts. Indeed, both chicken antirat serum and F(ab')₂ fragments from rabbit antirat serum completely protected the grafts against the effects of MARS that was administered 24 h later. (b) When mice were depleted of hemolytic C by treatment with cobra venom factor or heat-aggregated gamma globulin, the damage caused by MARS was greatly reduced or completely inhibited. (c) In mice with a genetically determined absence of C5 much greater quantities of MARS were required to cause graft damage; the tempo of the destructive process was consistently slower; and a greater number of grafts recovered from the initial inflammatory process than was the case for animals with an intact complement system. The participation of PMN in serum-mediated destruction of grafts was initially suggested by the results of microscope examination of fixed tissues. The essential role of these cells in the process is indicated by the failure of MARS to cause tissue damage in mice whose circulating PMN have been reduced to very low levels by treatment with nitrogen mustard or more specifically with an anti-PMN serum. The absence of tissue damage when circulating PMN are reduced but C levels are normal suggests that C-mediated cytolysis is unimportant in graft destruction and that the role of C lies in its ability to generate chemotactic factors. The latter may then attract the PMN that provide mediators of tissue damage.     

Sensation seeking and alcohol use predict HIV transmission risks: prospective study of sexually transmitted infection clinic patients, Cape Town, South Africa

Alcohol is related to HIV risk behaviors in southern Africa and these behaviors are correlated with sensation seeking personality and alcohol outcome expectancies. Here we report for the first time the associations among sensation seeking, substance use, and sexual risks in a prospective study in Africa. Sexually transmitted infection clinic patients in Cape Town South Africa (157 men and 64 women) completed (a) baseline measures of sensation seeking, sexual enhancement alcohol outcome expectancies, alcohol use in sexual contexts, and unprotected sexual behaviors and (b) 6-month follow-up measures of alcohol use in sexual contexts and unprotected sexual acts. Results confirmed that sensation seeking predicts HIV risk behavior and sensation seeking is related to alcohol outcome expectancies which in turn predict alcohol use in sexual contexts. HIV prevention counseling that addresses drinking in relation to sex is urgently needed in southern Africa.     

The vascular bed as the primary target in the destruction of skin grafts by antiserum. I. Resistance of freshly placed xenografts of skin to antiserum

Rat skin grafted onto immunosuppressed mice is resistant to mouse anti-rat serum during the first 7-10 d after transplantation. It gradually acquires susceptibility, reaching a peak of sensitivity at 14-16 d after grafting. The grafts remain sensitive to antiserum, though at decreasing levels for an additional 3 wk, and grafts that persist beyond that time are resistant to antiserum for as long as they survive. In the study reported here, it is shown that the initial period of resistance to antiserum is due to factors acting locally within the graft and is entirely uninfluenced by the regimen of immunosuppression or the protective dressings that are used. After administration of antiserum, deposits of the injected immunoglobulin and of endogenous C3 are found on the luminal surfaces of graft vessels, although no significant tissue damage is observed. Rat skin that has become highly sensitive to antiserum 14-16 d after transplantation loses that sensitivity if it is regrafted to a new recipient, and then regains it 8-10 d later. Thus, the resistance of freshly grafted skin to antisera is associated with the process of healing into place, a conclusion that is supported by the observation that the intracutaneous administration of antisera to rats causes intense local inflammation and necrosis. The skin is therefore sensitive just before it is removed for grafting, but temporarily loses sensitivity thereafter. Resistance to antiserum during the first 3 or 4 d after transplantation is probably attributable to the fact that at that time grafts are vascularized poorly if at all. The state of resistance extends for several days after vascularization of the graft takes place and is then only gradually lost, a phenomenon that seems to be associated with the resistance of newly formed and regenerating blood vessels to vasoactive substances. This view is in accord with and, indeed, supports the idea that the induction of vascular injury is an essential step in antisera-mediated damage to tissue grafts.     

Randomized clinical trial of brief risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa

Objectives. We examined the effects of a brief counseling intervention designed to reduce HIV risk behaviors and sexually transmitted infections (STIs) among patients receiving STI services in Cape Town, South Africa.Methods. After randomization to either a 60-minute risk reduction counseling session or a 20-minute HIV–STI educational session, patients completed computerized sexual behavior assessments. More than 85% of the participants were retained at the 12-month follow-up.Results. There were 24% fewer incident STIs and significant reductions in unprotected vaginal and anal intercourse among participants who received risk reduction counseling relative to members of the control condition. Moderator analyses showed shorter lived outcomes for heavy alcohol drinkers than for lighter drinkers. The results were not moderated by gender.Conclusions. Brief single-session HIV prevention counseling delivered to STI clinic patients has the potential to reduce HIV infections. Counseling should be enhanced for heavier drinkers, and sustained outcomes will require relapse prevention techniques. Disseminating effective, brief, and feasible behavioral interventions to those at highest risk for HIV infection should remain a public health priority.Although South Africa has less than 1% of the world''s population, it accounts for nearly 10% of the global burden of AIDS. It is estimated that currently 5.5 million South Africans (12.3% of the country''s total population of 44.8 million) are infected with HIV.¹ A number of different factors probably account for the high incidence of HIV in South Africa, including sexual mixing patterns, social migration, high rates of alcohol abuse, sexual coercion in relationships characterized by gender power imbalances, and delayed rollout of HIV prevention programs.^2–5Perhaps most critical in driving HIV infections are other co-occurring sexually transmitted infections (STIs), which increase susceptibility to HIV by degrading naturally protective mucosal immunological mechanisms, migrating vulnerable cells to the genital tract, and affording HIV a portal of entry into the bloodstream. STIs also facilitate transmission of the virus from HIV-infected partners by increasing their HIV infectiousness.⁶ As a result of these factors, in combination with high HIV prevalence rates, South Africans who contract STIs are among the highest-risk populations for HIV infection in the world.²Although behavioral interventions have been shown to be effective in reducing sexual risks among STI clinic patients,⁷ several of these interventions have relied on multiple group sessions that have proven difficult to implement.^8,9 In response to the urgent need for effective, feasible, and affordable interventions designed to prevent HIV among STI clinic patients, researchers have developed brief single-session HIV risk reduction counseling interventions intended for use in both resource-rich^10–13 and resource-poor STI clinics.¹⁴ When performed in conjunction with HIV testing, brief prevention counseling has shown promise in reducing sexual risk behaviors and decreasing STIs.^15,16Brief risk reduction counseling has also demonstrated promising outcomes when delivered outside of HIV testing. For example, Crosby et al.¹⁷ examined a single-session personalized counseling intervention for men receiving STI clinic services in the United States. The intervention led to increases in condom use, reductions in unprotected sex, reductions in sexual partners, and 38% fewer new STI diagnoses relative to a standard of care control group. Overall, single-session sexual risk reduction counseling can be as effective as interventions that require multiple sessions and consume far greater resources.^7,18The brief risk reduction counseling intervention reported here is grounded in cognitive–behavioral theories of health behavior change and is designed for use with all STI patients, including those who refuse HIV testing. We previously tested this intervention in a small trial conducted in Cape Town, South Africa. We observed a 63% reduction in unprotected vaginal and anal intercourse over a 6-month follow-up period, compared with the 30% reduction observed in an HIV education control condition.¹⁹ In addition, condom use among participants increased from 65% to 88%. The overall findings were promising and suggested that a brief single-session counseling intervention may be effective in reducing the risk of HIV and other STIs in South Africa.We report the outcomes of a randomized clinical trial designed to test the effects of a brief single-session risk reduction counseling session intended for use in resource-poor STI clinics. We hypothesized that brief theory-based risk reduction counseling sessions would reduce unprotected vaginal and anal intercourse and prevent STIs during 12 months of observation. We also examined potential moderators of the intervention effects. We included participant gender as a factor in the analyses because there are differences in STI risks between men and women, especially given the gender dynamics in sexual relationships and that men ultimately control the use of condoms. We also tested alcohol use and use of other drugs as moderators of risk reduction outcomes because they are known cofactors for HIV transmission risk behaviors in South Africa.^20,21