Does schooling protect sexual health? The association between three measures of education and STIs among adolescents in Malawi.

While multiple studies have documented shifting educational gradients in HIV prevalence, less attention has been given to the effect of school participation and academic skills on infection during adolescence. Using the Malawi Schooling and Adolescent Study, a longitudinal survey that followed 2,649 young people aged 14-17 at baseline from 2007 to 2013, we estimate the effect of three education variables: school enrolment, grade attainment, and academic skills-numeracy and Chichewa literacy-on herpes simplex virus type 2 (HSV-2) and HIV incidence using interval-censored survival analysis. We find that grade attainment is significantly associated with lower rates of both HSV-2 and HIV among girls, and is negatively associated with HSV-2 but not HIV among boys. School enrolment and academic skills are not significantly associated with sexually transmitted infections (STIs) for boys or girls in our final models. Efforts to encourage school progression in high-prevalence settings in sub-Saharan Africa could well reduce, or at least postpone, acquisition of STIs.

From kitchen to classroom: Assessing the impact of cleaner burning biomass-fuelled cookstoves on primary school attendance in Karonga district, northern Malawi.

Household air pollution from burning solid fuels is responsible for an estimated 2.9 million premature deaths worldwide each year and 4.5% of global disability-adjusted life years, while cooking and fuel collection pose a considerable time burden, particularly for women and children. Cleaner burning biomass-fuelled cookstoves have the potential to lower exposure to household air pollution as well as reduce fuelwood demand by increasing the combustion efficiency of cooking fires, which may in turn yield ancillary benefits in other domains. The present paper capitalises on opportunities offered by the Cooking and Pneumonia Study (CAPS), the largest randomised trial of biomass-fuelled cookstoves on health outcomes conducted to date, the design of which allows for the evaluation of additional outcomes at scale. This mixed methods study assesses the impact of cookstoves on primary school absenteeism in Karonga district, northern Malawi, in particular by conferring health and time and resource gains on young people aged 5-18. The analysis combines quantitative data from 6168 primary school students with in-depth interviews and focus group discussions carried out among 48 students in the same catchment area in 2016. Negative binomial regression models find no evidence that the cookstoves affected primary school absenteeism overall [IRR 0.92 (0.71-1.18), p = 0.51]. Qualitative analysis suggests that the cookstoves did not sufficiently improve household health to influence school attendance, while the time and resource burdens associated with cooking activities-although reduced in intervention households-were considered to be compatible with school attendance in both trial arms. More research is needed to assess whether the cookstoves influenced educational outcomes not captured by the attendance measure available, such as timely arrival to school or hours spent on homework.

Retention of Viability of Salmonella in Sucrose as Affected by Type of Inoculum, Water Activity, and Storage Temperature.

Outbreaks of salmonellosis have been associated with consumption of high-sugar, low-water activity (aw) foods. The study reported here was focused on determining the effect of storage temperature (5 and 25°C) on survival of initially high and low levels of Salmonella in dry-inoculated sucrose (aw 0.26 ± 0.01 to 0.54 ± 0.01) and wet-inoculated sucrose (aw 0.24 ± 0.01 to 0.44 ± 0.04) over a 52-week period. With the exception of dry-inoculated sucrose at aw 0.26, Salmonella survived for 52 weeks in dry- and wet-inoculated sucrose stored at 5 and 25°C. Retention of viability was clearly favored in sucrose stored at 5°C compared with 25°C, regardless of level or type of inoculum or aw. Survival at 5°C was not affected by aw. Initial high-inoculum counts of 5.18 and 5.25 log CFU/g of dry-inoculated sucrose (aw 0.26 and 0.54, respectively) stored for 52 weeks at 5°C decreased by 0.56 and 0.53 log CFU/g; counts decreased by >4.18 and >4.25 log CFU/g in samples stored at 25°C. Inactivation rates in wet-inoculated sucrose were similar to those in dry-inoculated sucrose; however, a trend toward higher persistence of Salmonella in dry- versus wet-inoculated sucrose suggests there was a higher proportion of cells in the wet inoculum with low tolerance to osmotic stress. Survival patterns were similar in sucrose initially containing a low level of Salmonella (2.26 to 2.91 log CFU/g). The pathogen was recovered from low-inoculated sucrose stored at 5°C for 52 weeks regardless of type of inoculum or aw and from dry-inoculated sucrose (aw 0.54) and wet-inoculated sucrose (aw 0.24) stored at 25°C for 12 and 26 weeks, respectively. Results emphasize the importance of preventing contamination of sucrose intended for use as an ingredient in foods not subjected to a treatment that would be lethal to Salmonella.

Women's Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia.

Women's perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women's health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men's risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman's HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women's misperception regarding MC. Programs should address women's informational needs and continue to emphasize that condoms remain critical, regardless of male partner's circumcision status.

To tell or not to tell: male partner engagement in a Phase 3 microbicide efficacy trial in South Africa.

Gender norms that privilege men's sexual power and pleasure, and distrust of condom use in intimate relationships, leave women vulnerable to HIV and other sexually transmitted infections. Vaginal microbicides allow women to exert a degree of control over their sexual health, through responsibility for product insertion as well as the possibility of covert use. In practice, however, the uptake of new HIV-prevention products is heavily influenced by partnership dynamics. This paper presents a secondary analysis of data from two qualitative sub-studies conducted during a Phase 3 microbicide efficacy trial in South Africa. Using transcripts from in-depth interviews and focus group discussions with 278 female trial participants and 27 male partners, we investigated the extent to which women disclosed microbicide use to their partners, and the level and types of male engagement with microbicide use. Most women chose to communicate with their partners about the trial, but the timing and content of associated discussions differed according to their motivation for disclosure. Men provided their partners with both moral and practical support, but reported a desire for greater involvement in decision-making surrounding microbicide uptake and use. The findings inform recommendations for constructive male participation in future trials and, ultimately, introduction of a marketed product.

Using a 2-stage strategy with respondent-driven sampling to recruit a hard-to-reach population for a placebo microbicide gel clinical trial in Nellore, Andhra Pradesh (India).

Traditional recruitment methods for microbicide efficacy trials are labor intensive and may fail to reach high-risk hard-to-reach populations. We report duration of recruitment and lessons learned from a two-stage process to recruit female sex workers (FSWs) into a placebo microbicide trial, and examined characteristics associated with successful recruitment of peers who screened for and enrolled in the trial. FSWs were first recruited via respondent-driven sampling (RDS) to complete a survey and subsequently invited to screen for enrollment into a placebo microbicide trial taking place at a local clinic. It took 6 months to enroll 267 participants into the trial. Successful recruiters of peers who enrolled were more likely to have enrolled themselves (AOR 2.0, CI 1.3-2.9) and less likely to visit Nellore city (AOR 0.5, CI 0.3-0.9). Recruitment of FSWs via a two-stage recruitment strategy with RDS can be a good option for future clinical trials.

Using biomarkers to assess the validity of sexual behavior reporting across interview modes among young women in Kampala, Uganda.

Understanding the transmission dynamics of HIV and other sexually transmitted infections is critically dependent on accurate behavioral data. This study investigates the effect of the mode of questionnaire delivery on the quality of sexual behavior reporting in a 2010 survey conducted in Kampala, Uganda, among 18-24-year-old women. We compare the reported prevalence of five sexual outcomes across three interview modes: traditional face-to-face interviewing (FTFI) in which question rewording was permitted, FTFI administered via computer-assisted personal interviewing (CAPI) in which questions were read as written, and audio computer-assisted self-interviewing (ACASI) in which participants listened to prerecorded questions and entered responses using a computer touchscreen. We then assess the validity of the data by evaluating the reporting of sexual experience against three biological markers. Results suggest that ACASI elicits higher reporting of some key indicators than FTFI does, but self-reports from all interview modes were subject to validity concerns when compared with biomarker data. The study highlights the important role that biomarkers can play in sexual behavior research.

Challenges in measuring the sequencing of life events among adolescents in Malawi: a cautionary note.

Using data from two rounds of the Malawi Schooling and Adolescent Survey, this research note examines consistency of retrospective reporting on the timing and sequencing of sexual initiation, school leaving, and marriage. The analysis, which compares reporting of events both within and between rounds, indicates substantial inconsistency in reporting of event sequences and highlights difficulties in measuring transitions to adulthood in sub-Saharan Africa with survey data.

Herpes simplex virus type 2 cross-sectional seroprevalence and the estimated rate of neonatal infections among a cohort of rural Malawian female adolescents.

OBJECTIVE: To assess herpes simplex virus type 2 (HSV-2) seroprevalence among rural Malawian adolescent women and estimate the number of neonatal herpes infections among infants of these adolescents. METHODS: A longitudinal cohort study of adolescents (14-16 years at entry) residing in rural Malawi was initiated in 2007 with annual observation. HSV-2 testing was introduced in 2010. In this study, we (1) determined, using cross-sectional analysis, risk factors for positive serostatus, (2) adjusted for non-response bias with imputation methods and (3) estimated the incidence of neonatal herpes infection using mathematical models. RESULTS: A total of 1195 female adolescents (age 17-20 years) were interviewed in 2010, with an observed HSV-2 seroprevalence of 15.2% among the 955 women tested. From a multivariate analysis, risk factors for HSV-2 seropositivity include older age (p=0.037), moving from the baseline village (p=0.020) and report of sexual activity with increasing number of partners (p<0.021). Adjusting for non-response bias, the estimated HSV-2 seroprevalence among the total female cohort (composed of all women interviewed in 2007) was 18.0% (95% CI 16.0% to 20.2%). HSV-2 seropositivity was estimated to be 25.6% (95% CI 19.6% to 32.5%) for women who refused to provide a blood sample. The estimated number of neonatal herpes infections among the total female cohort was 71.8 (95% CI 57.3 to 86.3) per 100 000 live births. CONCLUSIONS: The risk of HSV-2 seroconversion is high during adolescence, when childbearing is beginning, among rural Malawian women. Research on interventions to reduce horizontal and vertical HSV-2 transmission during adolescence in resource-limited settings is needed.

Sexually transmitted infections and reproductive health morbidity in a cohort of female sex workers screened for a microbicide feasibility study in Nellore, India.

UNLABELLED: Women constitute 38% of India's 2.4 million HIV-infected persons. Microbicides are potential HIV-prevention products currently undergoing clinical trials for efficacy. A four-month placebo vaginal gel trial was conducted in Nellore, India to determine the feasibility of recruiting a suitable cohort of female sex workers (FSWs) for a future vaginal microbicide efficacy trial. We report on the HIV and STI prevalence and reproductive health (RH) morbidity of FSWs screened for the trial.   RESULTS: 529 FSWs completed screening procedures; of those 33.6% were found ineligible.  The mean age was 30.9 years; 68.6% women were married and 57.5% were home-based FSWs.  Self-reported symptoms included abnormal vaginal discharge (31.6%), genital itching (3.4%), uterine mass/prolapse (3%) and painful intercourse (2.6%).  Gynecological surgery was reported by 73.2% of participants; of those 10.5% had undergone a hysterectomy. Female sterilization was the most commonly reported contraceptive method. Pelvic examination showed vaginal discharge (50.7%), cervical discharge (5.3%), uterine/vaginal wall prolapse (2.6%), and cervical mass/nodule/vesicles/genital warts (4.2%). Common epithelial findings included erythema (79.1%) and vesicles/bullae (6%); 46% of participants had Papanicolaou tests graded as inflammatory and 1.1% as malignant. HSV-2 was the mostly commonly detected STI (60.7%) followed by HIV (5.3%), syphilis (2.8%), chlamydia (2.2%), gonorrhoea (0.7%) and trichomoniasis (15.5%).  RTIs were more common: bacterial vaginosis (27.8%) and candidiasis (18.9%). CONCLUSIONS:  The low HIV prevalence and high RH morbidity in the population makes this site unsuitable for a future phase 2 or 3 microbicide efficacy trial.  HIV prevention programs targeting this population should include access to RH services.

Social desirability bias in sexual behavior reporting: evidence from an interview mode experiment in rural Malawi.

CONTEXT: Social desirability bias is problematic in studies that rely on self-reported sexual behavior data. Where gender norms create different expectations about socially acceptable behavior, males and females face distinct pressures in reporting certain outcomes, which can distort assessments of risk for HIV and STIs. METHODS: In 2009, relationship and sexual behavior data were collected from 1,750 never-married males and females aged 16-18 via audio computer-assisted self-interviewing (audio-CASI) during the third round of the Malawi Schooling and Adolescent Study. A comparison group of 311 youth completed an identical questionnaire in face-to-face interviews. To assess whether interview mode may have influenced participants' reporting of sensitive behavior, reports of sexual experience in the two groups were compared. Multiple logistic regression analysis was used to identify associations between interview mode and reports of these behaviors, by gender. RESULTS: In adjusted regression models, males were less likely to report ever having had a girlfriend in audio-CASI than in face-to-face interviews (odds ratio, 0.4), but they were more likely to report having had sex with a relative or teacher (3.5). For females, reports of ever having had a boyfriend or having had sex did not differ between modes. A small proportion of females reported ever having had sex with a relative or teacher in audio-CASI, while none did so in face-to-face interviews. CONCLUSIONS: The method used for collecting relationship and sexual behavior data may influence the reported prevalence of some key behaviors, particularly among males. Further research is needed to improve methods of collecting sensitive data.

An evaluation of methods to improve the reporting of adherence in a placebo gel trial in Andhra Pradesh, India.

Female sex workers (FSWs) were recruited for a 4-month placebo vaginal gel trial in Nellore, India. Two experiments explored if prior knowledge of biomarkers for unprotected sex and insertion of gel applicators would yield more accurate self-reports. A third experiment compared self-reports of gel use and adherence levels between FSWs randomly assigned to interactive voice response survey (IVRS) and those assigned to paper diaries. Prior knowledge of biomarkers did not improve accuracy of self-reported condom or gel use, nor did it affect actual adherence. Of those who tested positive for the presence of semenogelin in the vagina, 76% reported no unprotected sex in the previous 48 h. Overall, women reported using gel on 90% of days whereas the biomarker indicated gel use on fewer than 50% of days. Compliance to IVRS was low, despite familiarity with mobile phone technology. Additional explorations with other populations are needed.

Characteristics of female sex workers in southern India willing and unwilling to participate in a placebo gel trial.

Respondent-driven sampling was used to recruit female sex workers (FSWs) for a community survey conducted in southern India. After survey completion, participants were given a brochure describing a clinical trial that entailed daily use of a placebo vaginal gel for four months. This study assessed predictors of screening among survey respondents, predictors of enrollment among those eligible for the trial, and predictors of visit attendance and retention among those enrolled. FSWs who reported having symptoms of sexually transmitted infections (STI), engaging in sex work in the past month, and living in a subdistrict easily accessible by public transportation with a high concentration of FSWs, were more likely to screen. FSWs who had never been tested for HIV were more likely to enroll. This analysis suggests that the primary reason FSWs participated in the trial was a desire for health care-not other factors hypothesized to be important, e.g., HIV risk perception and poverty status.