Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 23348-23351 411

followed to assess perinatal transmission of HIV. The diagnosis of disturbances
of vaginal flora was based on clinical criteria and varied from having none of the
clinical criteria (normal flora) to fulfilling three or more clinical criteria (BV).
Results: Among 9126 pregnant women screened in 1990 and 1993, the prevalence of BV was 29.0%. There was a strong significant association between
prevalent HIV and BV [adjusted OR (95% CI): 3.0 (2.2-4.0) in 1990 and 3.4
(2.4-4.9) in 1993], and a clear trend of increased HIV transmission with increased
disturbance of vaginal flora. Among 1196 women who had been followed for a
median of 2.5 years, BV was significantly associated with HIV seroconversion
(adjusted OR 3.7; 95% Cl 2.4-5.6 during pregnancy and adjusted RR = 2.3; 95%
Cl 1.8-3.0 postnatally). Of 343 babies tested for HIV, 92 (27%) were infected.
The MCT of HIV was 14% in women with normal vaginal flora during pregnancy
and increased to 28% in women with BV.
Conclusions: Screening and treating women with BV could restore normal
vaginal flora and decrease susceptibility to HIV, and reduce adverse reproductive
outcomes including perinatal transmission of HIV.
23348 1 Pelvic inflammatory disease among women in an
ambulatory setting with high HIV-1 seroprevalence
Elizabeth Bukusi1, C. Cohen2, S. Sinei3, M. Reilly4, K. Homes2, J. Bwayo3,
J. Kreiss2. University of Washington Box 359909, 325 Ninth Avenue, Seattle,
WIA. 98104; 2University of Washington, Seattle, WA., USA; 3University of
Nairobi, Nairobi, Kenya; 4University College of Dublin, Dublin, Ireland
Background: Both HIV-1 infection and pelvic inflammatory disease (PID) are
common in sub-Saharan Africa. The efficacy of out-patient therapy of HIV-1
infected women with PID has been disputed.
Methods: We recruited women aged 18-40 years presenting with complaints
of lower abdominal pain for less than one month at two public out-patient clinics
in Nairobi, Kenya. Participants underwent a standardized questionnaire, physical
examination, and assignment of a clinical severity score (CSS). HIV-1 serology, sexually transmitted disease screening, and endometrial biopsies to detect
plasma cell endometritis were performed. Patients were re-evaluated at one and
four weeks for response to therapy.
Results: PID was confirmed histologically in 63 (39%) of 162 women. Age,
marital status, and current commercial sex work were similar among women
with and without confirmed PID. Abdominal pain was more severe and CSS was
higher among women with confirmed PID. Women with confirmed PID were 3
times (95% Cl 1.5-5.9) more likely to be HIV-1 seropositive than women without
confirmed PID. Signs, symptoms and CSS were not statistically different between
the 31 HIV-1 infected and the 32 HIV-1 uninfected women with PID. N. gonorrhoeae and/or C. trachomatis infection was less commonly detected among the
HIV-1 infected women with PID (45 vs. 69%, OR = 0.4, 95% Cl 0.1-1.0), and
least commonly detected among HIV-1 seropositive women with low CD4 counts
(X2-trend, p <.04). Conversely, bacterial vaginosis was most commonly identified
among immunocompromised HIV-1 seropositive women with PID (X2-trend, p <.03). An equally high proportion of HIV-1 seropositive and seronegative women
were cured (81 vs. 85%), and no patient required hospitalization.
Conclusion: In this setting, HIV-1 infection is common and is associated with
an increased odds of confirmed PID among women with low abdominal pain,
and may be associated with an increased risk of non-gonococcal, non-chlamydial
PID. Out-patient treatment of PID was successful irrespective of HIV-1 serostatus
and degree of immunosuppression.
24*/23349 1Social-normative factors partially explain the
association between younger age and HIV risk in
gay/bisexual men in the US
Gordon Mansergh1, G. Marks1, D. McKirnan2, B. Bartholon1, S. Buchbinder3,
J. Douglas4, F. Judson4, K. Macqueen1. 1CDC, Division of HIV/AIDS Prevention,
1600 Clifton Rd NE, Mailstop E-45, Atlanta, GA; 2University of Illinois-Chicago,
Chicago, IL; 3San Francisco Dept. of Public Health, San Francisco, CA; 4Denver
Public Health Dept., Denver, CO, USA
Background: To test the hypothesis that the inverse association between age
and HIV sexual risk behavior and seroconversion in gay/bisexual men in North
America (not well documented in Europe or Australia) may be partially explained
by social-normative factors, including perceived peer norms for unsafe sex, importance of gay identity, pride in gay identity, self-homophobia, and an orientation
toward bars to meet and socialize with men.
Methods: Data from the CDC Collaborative HIV Seroincidence Study were
used to test the hypothesis. The sample consisted of HIV-negative gay and
bisexual men from Chicago, Denver, and San Francisco (N = 1629). Age and
social-normative factors were assessed at baseline, and sexual risk behavior,
HIV serostatus, and drug use were assessed at 6-month intervals over 2 years.
Regression analyses and other tests were conducted to examine the independent
mediational effects of the social-normative factors.
Results: The inverse associations between age and (a) HIV seroconversion,
(b) unprotected receptive anal (URA), and (c) unprotected insertive anal (UIA)

intercourse were confirmed in the sample. Social-normative factors of perceived
norms for unsafe sex and bar orientation were the strongest mediators of the
age-risk association: age was inversely associated with these two factors, which
in turn were associated with higher risk. Findings were independent of the influence of alcohol and drug use. Importance of gay identity was a mediator only
for URA (not UIA): age was inversely associated with gay identity importance,
and identity importance was associated with higher URA. These results were

generally consistent for outcomes of cross-sectional and cumulative behavior
scores, and they were confirmed by HIV seroconversion as the outcome.
Conclusions: The North American finding that younger age is associated with
HIV risk may be partially explained by social-normative factors, namely perceived
norms for unsafe sex and social aspects of bar settings. Results suggest that
sexual mixing patterns of young men, especially in relation to bar settings, may be
an important area for future research and risk-reduction efforts. Investigations in
North America and elsewhere are needed to identify other psychosocial variables
that may be important to address when targeting younger gay/bisexual men.
23350 1 Risk factors for HIV seroconversion in a contemporary
cohort of of high risk men who have sex with men (MSM)
Susan Buchfinder', P. Heagerty2, K. Mayer3, J. Douglas4, C. Celum5,
G. Seage6, B. Koblin7. 125 Vanness Avenue Suite 500, San Francisco, CA;
2FHCRC-HIVNET Statitical Center, Seattle, WA; 3Memorial Hospital/NEBHS,
Pawtucket, RI; 4Denver Department of Public Health, Denver, CO; 5Seattle
HIVNET Site, Seattle HIVNET Site, Seattle, WA; 6ABT Association Inc.
Cambrigde, MA; 7New York Blood Center, New York, NY, USA
Background: To evaluate risk factors associated with HIV seroconversion among
high risk MSM.
Methods: The HIVNET Vaccine Preparedness Study enrolled 3257 HIV negative MSM from 6 US cities. Risk behavior interviews and HIV testing and
counseling occurred semiannually for 18 months. Seroincidence was calculated
using person-year (py) methods. Repeated measures logistic regression was
used to estimate and test associations of serostatus at each 6-month visit with
both time-independent and -dependent covariates.
Results: HIV seroincidence was 1.54/100 py (95% C.I. 1.22-1.94), with pairwise differences by city (lowest 0.8/100 py; highest 2.2/100 py) but not over time.
On bivariate analysis, men <35 years at enrollment (1.9/100 py) were significantly more likely than men >35 (1.1/100 py) to seroconvert. African-American
(2.0/100 py) and Latino (1.9/100 py) MSM were somewhat but not significantly
more likely than white MSM (1.3/100 py) to sero-convert. Independent predictors
in the multivariable model controlling for city, age, and race were:
Risk behaviors, any 6-month period % Cohort % Seroconverters Adjusted OR (95% CI)
Unprotected receptive anal sex w/HIV+ 2% 18% 4.75 (2.17-10.39)
Unprot receptive anal w/HIV unknown 7% 25% 2.42 (1.35-4.33)
Total male partners 5-10 22% 28% 2.66 (1.11-6.40)
Total male partners >10 21% 41% 3.53 (1.45-8.55)
Uncircumcised 13% 21% 2.15(1.15-4.01)
Amyl nitrate use 27% 52% 1.88 (1.12-3.15)
Conclusions: These data suggest that risk reduction counseling for MSM
should focus on reducing unprotected anal sex with unknown serostatus as well
as HIV+ partners and address the total number of sex partners. Lack of circumcision appears associated with seroconversion in this US population; whether
this suggests the insertive route as a portal of entry is unclear. Amyl nitrate
may enhance infection via behavioral or biological routes (e.g. increased trauma,
increased blood flow). Seroincidence in this cohort is not declining over time.
236*/23351 1 Sexual coercion and HIV risk perception in rural
Uganda
Lynn Paxton1, R. Ssengonzi2, F. Nalugoda1, N. Sewankambo3, M. Wawer4.
1Rakai Project/Uganda Virus Research Entebbe PO. Box 49; 2Pennsylvania
State University, University Park PA; 3Makerere University, Kampala; 4Columbia
University, New York, NY Uganda
Background: A woman's risk of HIV infection through heterosexual contact may
be increased when intercourse occurs as a result of coercion. We examined the
prevalence of sexual coercion in a rural Ugandan cohort and its association with
both beliefs about seropositivity and actual infection.
Methods: Participants in a community-based STD control trial were interviewed about coercion in their relationships, their beliefs about their own and
their partner's likelihood of being HIV infected and asked to provide blood for HIV
serology.
Results: Data from 3111 women and 2743 men have been analyzed to date.
Coercion within the prior 12 months was reported by 26.4% of women and 10.2%
of men: most was between spouses. Frequency of coercion as reported by women
was classified as occasional (69.2%), frequent (18.4%) and constant (0.4%). The
most common forms were physical restraint (77.4%), verbal threats (21.2%),
slaps (5.2%), threatening gestures (3.3%), and beating (1.6%). Coerced women
were more likely to believe both their partners (RR = 2.8; 95% Cl = 2.3-3.5)
and themselves (RR = 2.0; 95% Cl = 1.6-2.4) to be seropositive. Coercive men
were twice as, likely to believe themselves infected. Condom use was low in
both coercive and non-coercive relationships. Only 20.4% of men who believed
themselves infected actually were as compared to 6% of men who believed themselves to be seronegative. The comparable figures for women were 21.2% vs.
9.4%. HIV seroprevalence among coerced women was not significantly elevated

except in the youngest age group (<19 years) (RR = 1.9; 95% CI = 1.1-5.2).
Fifteen percent of women who did not initially report sexual coercion did so in
subsequent interviews.
Conclusion: Sexual coercion occurs frequently in this rural African society and
is significantly associated with perceptions about self and partner HIV seropositivity. It is less associated with prevalent HIV infection except among the youngest
women who have had the least cumulative exposure to coercion.