While antiretroviral therapy (ART) reduces AIDS-related morbidity and mortality, it is unclear if prolonged ART use among people living with HIV (PLHIV) increases the risk of hypertension. We assessed the association between the duration of ART use and hypertension in the Rakai Community Cohort Study (RCCS). We conducted a cross-sectional study among PLHIV (35–49 years old) on ART in the RCCS who were surveyed between August 2016 and May 2018. Systolic and diastolic blood pressure (BP) was measured twice, averaged, and classified as any hypertension (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg), severe or worse hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg), or hypertensive crisis (systolic BP ≥ 180 mmHg or diastolic BP ≥ 110 mmHg). ART duration was categorized as short (0–2 years), moderate (> 2–5 years), or prolonged (> 5 years). We used log-binomial regression to estimate the adjusted prevalence ratio (adjPR) of hypertension associated with ART duration. A total of 1,144 PLHIV on ART with documented BP information were identified in the RCCS, of whom 173 (15.1

Introduction Voluntary medical male circumcision (VMMC) reduces the risk of heterosexual acquisition of HIV by 50%–60%. The Uganda Ministry of Health recommends abstinence for 42 days after VMMC to allow complete wound healing. However, some men resume sex early before the recommended period. We estimated trends in prevalence and risk factors of early sex resumption (ESR) among VMMC clients in Rakai, Uganda, from 2013-2020. Methods Data from the Rakai Community Cohort Study, a cross-sectional study were analyzed. Data included consenting men aged 15–49 years in who self-reported having received VMMC in one of four successive surveys, (June 2013 to January 2015), (February 2015 to September 2016), (October 2016 to May 2018), and (June 2018 to October 2020). ESR prevalence and associated risk factors using modified Poisson regression to estimate adjusted prevalence ratios (aPR) were estimated. Results Overall, 1,832 men participated in the study. ESR decreased from 45.1% in 2013 to 14.9% in 2020 (p<0.001). Across the three surveys, ESR prevalence was consistently higher among married than never married men, aPR=1.83, 95% CI: [1.30,2.57]; aPR=2.46, 95% CI: [1.50,4.06]; aPR=2.22, 95% CI: [1.22,4.03]. ESR prevalence was higher among men who reported more than one sexual partner than men with one partner, aPR=1.59, 95% CI: [1.16,2.20]. In the fourth survey (2018-2020), ESR prevalence was significantly higher among men with primary education than men with post-primary, aPR=2.38, 95% CI: [1.31, 4.30] while ESR prevalence was lower among men aged at least 45 men with no sexual relationship in the past 12 months but self-reported to have resumed sex activities, aPR= 0, 95% CI: [1.86-07, 2.69-06] and aPR=0, 95% CI: [3.61e-07, 2.12e-06], respectively. Overall, men who reported primary school as their highest level of education reported ESR more often than those with post-primary education aPR=2.38, 95% CI: [1.31, 4.30]. Occupation and known HIV status were not associated with ESR. Conclusions Self-reported ESR after VMMC declined between 2013 and 2020. Targeted efforts for counseling focusing on married men, men who had multiple sex partners, and men with lower levels of education can help decrease post-VMMC ESR. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The RCCS is approved by the Uganda Virus Research Institute (UVRI) Research and Ethics Committee (REC), the Western IRB, and the Uganda National Council Science & Technology. All data were de-identified and participants had provided written informed consent I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data files will be available upon request.

INTRODUCTION:Voluntary medical male circumcision (VMMC) reduces the risk of heterosexual acquisition of HIV by 50%-60%. The Uganda Ministry of Health recommends abstinence of sex for 42 days after VMMC to allow complete wound healing. However, some men resume sex early before the recommended period. We estimated trends in prevalence and risk factors of early sex resumption (ESR) among VMMC clients in Rakai, Uganda, from 2013-2020. METHODS:Data from the Rakai Community Cohort Study (RCCS), a cross-sectional study, were analyzed. Data included consenting males aged 15-49 years in RCCS who self-reported having received VMMC between the period of 2013 to 2020. ESR prevalence and associated risk factors were assessed using modified Poisson regression to estimate adjusted prevalence ratios (aPR). RESULTS:Overall, 1,832 participants were included in this study. ESR decreased from 45.1% in 2013 to 14.9% in 2020 (p<0.001). Across the first three surveys, ESR prevalence was consistently higher among the married participants than the never married participants, aPR = 1.83, 95% CI: [1.30,2.57]; aPR = 2.46, 95% CI: [1.50,4.06]; aPR = 2.22, 95% CI: [1.22,4.03]. ESR prevalence was higher among participants who reported to have more than one sexual partner than participants with one partner, aPR = 1.59, 95% CI: [1.16,2.20]. In the fourth survey from 2018-2020, ESR prevalence was significantly higher among participants with primary education than participants with post-primary, aPR = 2.38, 95% CI: [1.31, 4.30]. However, ESR prevalence was lower among participants aged at least 45 years than participants aged 15-19 years, aPR = 0.0, 95% CI: [1.86e-07, 2.69e-06]. Overall, participants who reported primary school as their highest level of education reported ESR more often than those with post-primary education aPR = 2.38, 95% CI: [1.31, 4.30]. Occupation and known HIV status were not associated with ESR. CONCLUSIONS:Self-reported ESR after VMMC declined between 2013 and 2020. Targeted efforts for counseling focusing on married men, men who had multiple sex partners, and men with lower levels of education may decrease ESR.

INTRODUCTION:Pre-exposure prophylaxis (PrEP) programmes have been initiated in sub-Saharan Africa to prevent HIV acquisition in key populations at increased risk. However, data on PrEP uptake and retention in high-risk African communities are limited. We evaluated PrEP uptake and retention in HIV hyperendemic fishing villages and trading centres in south-central Uganda between April 2018 and March 2019. METHODS:PrEP eligibility was assessed using a national risk screening tool. Programme data were used to evaluate uptake and retention over 12 months. Multivariable modified Poisson regression estimated adjusted prevalence ratios (aPR) and 95% Confidence intervals (CIs) of uptake associated with covariates. We used Kaplan-Meier analysis to estimate retention and multivariable Cox regression to estimate adjusted relative hazards (aRH) and 95% CIs of discontinuation associated with covariates. RESULTS AND DISCUSSION:Of the 2985 HIV-negative individuals screened; 2750 (92.1 %) were eligible; of whom 2,536 (92.2%) accepted PrEP. Male (aPR = 0.91, 95% CI = 0.85 to 0.97) and female (aPR = 0.85, 95% CI = 0.77 to 0.94) fisher folk were less likely to accept compared to HIV-discordant couples. Median retention was 45.4 days for both men and women, whereas retention was higher among women (log rank, p < 0.001) overall. PrEP discontinuation was higher among female sex workers (aRH = 1.42, 95% CI = 1.09 to 1.83) and female fisher folk (aRH = 1.99, 95% CI = 1.46 to 2.72), compared to women in discordant couples. Male fisher folk (aRH = 1.37, 95% CI = 1.07 to 1.76) and male truck drivers (aRH = 1.49, 95% CI = 1.14 to 1.94) were more likely to discontinue compared to men in discordant couples. Women 30 to 34 years tended to have lower discontinuation rates compared to adolescents 15 to 19 years (RH = 0.78 [95% CI = 0.63 to 0.96]). CONCLUSIONS:PrEP uptake was high, but retention was very low especially among those at the highest risk of HIV: fisher folk, sex workers and truck drivers and adolescent girls. Research on reasons for PrEP discontinuation could help optimize retention.

There are limited data on the impact of antiretroviral therapy (ART) on population-level adult mortality in sub-Saharan Africa. We analysed data for 2000-14 from the Rakai Community Cohort Study (RCCS) in Uganda, where free ART was scaled up after 2004. Using non-parametric and parametric (Weibull) survival analysis, we estimated trends in average person-years lived between exact ages 15 and 50, per capita life-years lost to HIV, and the mortality hazards of people living with HIV (PLHIV). Between 2000 and 2014, average adult life-years lived before age 50 increased significantly, from 26.4 to 33.5 years for all women and from 28.6 to 33.8 years for all men. As of 2014, life-years lost to HIV had declined significantly, to 1.3 years among women and 0.4 years among men. Following the roll-out of ART, mortality reductions among PLHIV were initially larger in women than men, but this is no longer the case.

BACKGROUND:After scale-up of antiretroviral therapy (ART), routine annual viral load monitoring has been adopted by most countries, but reduced frequency of viral load monitoring may offer cost savings in resource-limited settings. We investigated if viral load monitoring frequency could be reduced while maintaining detection of treatment failure.METHODS:The Rakai Health Sciences Program performed routine, biannual viral load monitoring on 2489 people living with human immunodeficiency virus (age ≥15 years). On the basis of these data, we built a 2-stage simulation model to compare different viral load monitoring schemes. We fit Weibull regression models for time to viral load >1000 copies/mL (treatment failure), and simulated data for 10 000 individuals over 5 years to compare 5 monitoring schemes to the current viral load testing every 6 months and every 12 months.RESULTS:Among 7 monitoring schemes tested, monitoring every 6 months for all subjects had the fewest months of undetected failure but also had the highest number of viral load tests. Adaptive schemes using previous viral load measurements to inform future monitoring significantly decreased the number of viral load tests without markedly increasing the number of months of undetected failure. The best adaptive monitoring scheme resulted in a 67% reduction in viral load measurements, while increasing the months of undetected failure by <20%.CONCLUSIONS:Adaptive viral load monitoring based on previous viral load measurements may be optimal for maintaining patient care while reducing costs, allowing more patients to be treated and monitored. Future empirical studies to evaluate differentiated monitoring are warranted.

BACKGROUND:Longitudinal data from a rural Ugandan cohort was used to estimate rates of unfulfilled need for contraception, defined as having unmet need and intent to use contraception at baseline but having an unintended pregnancy or with persistent unmet need for contraception at follow up. METHODS:Between 2002 and 2009 (5 survey rounds), a total of 2610 sexually active non-pregnant women with unmet need for contraception at the start of an inter-survey period were asked whether they intended to use any method of contraception until they desired a child. Modified Poisson multivariate regression was used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% CI of unfulfilled need for contraception. RESULTS:The proportion of women with unmet need at the start of an interval who intended to use contraception significantly increased from 61 to 69.1% (p < 0.05). However the majority of women who said they intended to use contraception had unfulfilled need for contraception at the subsequent survey (64.8 to 56.8%). In the adjusted analysis, significant predictors of unfulfilled need for contraception included age 40-49 years (PR = 1.34; 95% CI 1.04-1.74) and those with unknown HIV status (PR = 1.16; 95% CI 1.06-1.26). CONCLUSIONS:There is a significant discrepancy between women's intent to use contraception (> 60%) and subsequent initiation of use (< 30%) with many having unintended pregnancies which might explain the persistent high fertility in Uganda. Future research needs to address unfulfilled need for contraception among women at risk of unintended pregnancies.

ABSTRACT Assessment of an individual’s functional status, as measured by activities of daily living (ADL), is an essential element in the diagnosis of HIV-associated neurocognitive disorders (HAND) but individuals with cognitive impairment may not accurately report ADL. We assessed agreement between self- and caregiver-reported ADL in HIV-positive persons. Antiretroviral therapy (ART)-naïve HIV-positive persons (n = 321) and HIV-negative controls (n = 134) in Rakai, Uganda, completed neurocognitive tests and an ADL questionnaire. Co-resident relatives (“caregivers”) were independently administered the ADL questionnaire to determine their perception of the participant’s ADL. The relationship between neurocognitive impairment and participant-caregiver agreement was assessed using kappa statistics. Regression was used to estimate adjusted prevalence ratios (AdjPR) of participant-caregiver agreement on disability scores. Relative to HIV-negative adults, HIV-positive participants scoring at least 1 standard deviation (SD) below the norm on 2 or more neurocognitive tests were classified as having mild neurocognitive impairment and those scoring at least 2 SD below the norm on 2 or more neurocognitive tests were classified as having moderate-to-severe. Mean age was 36 years (SD 8.9), and 53% of participants were male. The rate of ADL agreement between participants and caregivers was 77% for HIV-positive and 87% for HIV-negative participants (AdjPR = 0.89, 95% CI 0.81–0.97, p = .01). Among HIV-positive participants, 41% had moderate neurocognitive impairment, 15% had severe neurocognitive impairment, and 44% were normal. For moderate neurocognitive impairment, the rate of ADL agreement was 69% and for severe neurocognitive impairment, it was 66%. Compared to non-impaired HIV-positive participants (86% ADL agreement), ADL agreement was lower with moderate impairment (AdjPR = 0.89, 95%CI 0.81–0.98, p = .023) and severe impairment (AdjPR = 0.77, 95%CI 0.63–0.95, p = .014). Gender, education and CD4 count were not associated with ADL agreement. HIV-positive persons with neurocognitive impairment have lower agreement with caregivers’ reports of ADL than HIV-positive persons without cognitive impairment.

Switch from first to second-line ART is recommended by WHO for patients with virologic failure. Delays in switching may contribute to accumulated drug resistance, advanced immunosuppression, increased morbidity and mortality. The 3rd 90′ of UNAIDS 90:90:90 targets 90% viral suppression for persons on ART. We evaluated the rate of switching to second-line antiretroviral therapy (ART), and the impact of delayed switching on immunologic, virologic, and mortality outcomes in the Rakai Health Sciences Program (RHSP) Clinical Cohort Study which started providing ART in 2004 and implemented 6 monthly routine virologic monitoring beginning in 2005.

Most societies in Sub Saharan Africa are patriarchal with major decisions made by men. However studies on family planning mostly focus on women and ignore power dynamics within relationships. Here we use data collected between 2013 and 2015 from 2636 couples, part of a community based cohort, with the aim of assessing how women’s perception of their spouse’s fertility desires affects her use of modern contraception. We used mediation analysis for this. We also used Chisquare tests to assess how accurate women’s perception of her spouse’s fertility desires was by comparing it with her partner’s reported fertility desires. We found that in 53.9% of the couples there was concordance between the female’s perception of their male spouse’s fertility desires and the reported fertility desires of the male spouse. However is 28.9% of couples females thought the man desired a child while the male did not desire a child. We also found that female’s fertility desires were indirectly influenced by their perceptions of the male spouse’s fertility desires which affected their use of modern contraception. This indirect effect was statistically significant (11%; p<0.001). There is a need to promote increased spousal communication which would help merge perceptions and actual desires within a couple in this setting. This would help reduce the high rates of unmet need for contraception observed in similar settings. Correspondence to: Tom Lutalo, Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda. Emailtlutalo@rhsp.org Received: September 17, 2017; Accepted: October 06, 2017; Published: October 09, 2017 Introduction Many Sub Saharan Africa (SSA) societies are patriarchal with social power held by men [1,2]. However family planning (FP) programs generally do not recognize the role of male attitudes and attributes in fertility-related decision making [3,4,5,6,7]. There is a need to explore how power dynamics within relationships affect women’s reproductive aspirations and behaviors and how women’s contraceptive behaviors are affected by the perceived fertility desires of their male partners. This information can be used by programs to help women control their fertility [9]. Men tend to have the dominant influence in household decision-making, including fertility and family planning, but surveys in Africa suggest that men and women do not necessarily have similar fertility attitudes, perceived roles, and goals [3,4,8,9]. Exploration of couple’s fertility dynamics is urgently needed for program strategies to reduce unmet need, unintended pregnancies and expand family planning use. Although current literature on fertility decision making in SSA strongly suggests that men play an important and often dominant role in couples’ adoption of contraception [10,11], there is limited empirical data on whether male attitudes are either perceived or true barriers to use of contraception by women. We know little about how women reconcile the desire for children within patriarchal families where they are less empowered to make important fertility and contraceptive decisions for themselves. Uganda, is a patriarchal society, with one of the highest annual population growth rates in the world (3% per annum), the highest Total Fertility Rate (TFR) in East Africa of 5.4 children per woman, and a modern contraceptive prevalence among married women of 35% [12,13]. The aim of this analysis was to conduct a prospective assessment on couples to understand how the women’s perception of their spouse’s fertility desires affects her use of female controlled modern contraception. The strength of our couple’s analyses is that we were able to assess how accurate a woman’s perception of her spouse’s fertility desires was, by examining her partner’s fertility desires. This study fills an important gap in our understanding of the role of male desires and decision making around fertility decisions and to assess to what extent women’s perceptions of their spouse’s attitude is a barrier to use of contraception.

We investigated the rate of transmitted drug resistance (TDR) among HIV-1 seroconverters identified from the Rakai Community Cohort Study (RCCS) survey, a population-based cohort in Rakai District, Uganda. Participants aged 15-49 are interviewed at study visits approximately every 12-18 months and provided a serological sample. Antiretroviral therapy (ART) has been provided free of charge since 2004. RCCS participants with documented negative HIV-1 serology between January 2011 and August 2012 and confirmed seroconversion between November 2012 and October 2013 were included in this analysis. Serum was genotyped for HIV drug resistance mutations in reverse transcriptase and protease genes. Mutations were classified according to the 2009 World Health Organization surveillance of transmitted HIV-1 drug resistance update. Seventy-five (75) seroconverters were identified and genotyped. The mean age was 28 years (range 18-49) and the majority were male, n = 44 (58%). The HIV-1 subtype frequencies were A = 19 (25%), D = 44 (59%), C = 4 (5%), A/D recombinant = 5 (7%), and C/D recombinant = 3 (4%). The majority (72/75, 96%) of individuals were infected with wild-type virus with no evidence of TDR. Two individuals had a single non-nucleoside reverse transcriptase inhibitor mutation each, K101E and K103N, and one had a single protease inhibitor mutation, M46I. No mutations were identified involving nucleoside reverse transcriptase inhibitors. In conclusion, almost 10 years after the introduction of ART in rural Uganda, rates of TDR remain low. Ongoing surveillance for TDR remains an important public health priority and should be conducted among known seroconverters to estimate TDR.

Objective: Uganda has an unmet need for family planning of 34% and a total fertility rate of 6.2. We assessed the desire for female sterilization among sexually active women who wanted to stop childbearing in rural Rakai district, Uganda.Study design: 7192 sexually active women enrolled in a community cohort between 2002 and 2008 were asked about fertility intentions. Those stating that they did not want another child (limiters) were asked whether they would be willing to accept female sterilization, if available. Trends in desire for sterilization were determined by chi-square test for trend, and Modified Poisson regression was used to estimate prevalence rate ratios and 95% confidence intervals of the associations between desire for sterilization and socio-demographic characteristics and HIV status.Results: From 2002 to 2008, the proportion of limiters dropped (from 47.2% to 43.7%; p<.01). Use of pills and injectables among limiters significantly increased, 38.9% to 50.3% (p<.0001), while use of intrauterine devices and implants declined from 3.3% to 1.7% (p<0.001). The desire for sterilization significantly increased from 54.2% to 63.1% (p<0.0001), and this was consistently higher among the HIV-positive (63.6-70.9%, p<0.01) than HIV-negative women (53.3-61.2%, p<0.0001). Factors significantly associated with the desire for sterilization included higher number of living children (> = 3), being HIV-infected and having received HIV counseling and testing.Conclusion: There is latent and growing desire for sterilization in this population. Our findings suggest a need to increase permanent contraception services for women who want to limit childbearing in this setting. (C) 2015 Elsevier Inc. All rights reserved.

Poverty, family stability, and social policies influence the ability of adolescents to attend school. Likewise, being enrolled in school may shape an adolescent’s risk for HIV and pregnancy. We identified trends in school enrollment, factors predicting school enrollment (antecedents), and health risks associated with staying in or leaving school (consequences).

OBJECTIVE:The objective of this study is to understand how trends in HIV acquisition among youth can be influenced by change in HIV risk factors, social factors and prevention and treatment programmes. DESIGN:Trends in HIV incidence (per 1000 person-years), by sex and age group, were estimated using data from youth (15-24 years: n = 22,164) in the Rakai Community Cohort Study. Trends in HIV incidence were compared with trends in previously identified HIV risk factors, social factors and programmes. METHODS:Poisson and linear regression were used to test for statistical significance and decomposition was used to calculate attribution of risk factors to HIV incidence. RESULTS:Substantial declines between 1999 and 2011 occurred in sexual experience, multiple partners and sexual concurrency among adolescents and young adults. HIV acquisition declined substantially (86%, P = 0.006) among adolescent women (15-19 years) but not among men or young adult women. Changes in HIV incidence and risk behaviours coincided with increases in school enrolment, decline in adolescent marriage, availability of antiretroviral therapy (ART) and increases in male medical circumcision (MMC). Much of the decline in HIV incidence among adolescent women (71%) was attributable to reduced sexual experience; the decline in sexual experience was primarily attributable to increasing levels of school enrolment. CONCLUSION:Dramatic decreases in HIV incidence occurred among adolescent women in Rakai. Changes in school enrolment and sexual experience were primarily responsible for declining HIV acquisition over time among adolescent women. Given limited improvement among young men and young adult women, the need for effective HIV prevention for young people remains critical.

BACKGROUND:HIV risk is influenced by multiple factors including the behaviors and characteristics of sexual partners. We examined the association between partner characteristics and HIV acquisition among young people in rural Uganda, controlling for individual-level risk factors.METHODS:We used self-reported data from 15- to 24-year-olds (n = 1969 male participants and n = 2826 female participants) from a population-based cohort (2005-2011) in Rakai, Uganda. Respondents could report characteristics for up to 4 sexual partners in the last year. Poisson regression was used to estimate HIV incidence rate ratios (IRRs).RESULTS:In regression analyses controlling for marital status, young women's risk of HIV acquisition increased if their partner was a truck driver, drank alcohol before sex, and used condoms inconsistently. In young men, the risk of HIV acquisition increased with partners who were not enrolled in school, in partnerships with higher coital frequency, and in partnerships where respondents were unable to assess the HIV risk of their partner. Mixed-model regressions adjusting for respondent's individual-level risk factors showed that young women's risk of HIV acquisition increased with each nonmarital sexual partner [IRR: 1.54 (1.20 to 1.98)], each partner who drank alcohol before sex [IRR: 1.60 (1.11 to 2.32)], and each partner who used condoms inconsistently [IRR: 1.99 (1.33 to 2.98)]. Among young men, having nonmarital partnerships increased HIV acquisition [IRR for each partner: 1.54 (1.20 to 1.98)].IMPLICATIONS:Partner characteristics predicted HIV acquisition among youth. HIV prevention programs should emphasize awareness of partner's risk characteristics to avoid high-risk relationships.

It is unclear whether ongoing CD4 monitoring is needed following immunologic and virologic response to antiretroviral therapy (ART). We investigated the proportion of clients who achieved a virologic and immunologic response and then had a subsequent CD4 count <200 cells/μL despite continued virologic suppression. Included in this analysis were clients receiving ART through the Rakai Health Sciences Program between June 2004-May 2013 who achieved a CD4 ≥200 cells/μL and VL ≤400 copies/mL and who had three sets of CD4 and VL measurements (defined as a sequence) within a 390 day period. A CD4 decline was defined as any drop in CD4 count to <200 cells/μL during a period of viral suppression. A total of 1553 clients were included, 68% females, mean age of 35.5 years (SD 8.3), median baseline CD4 count 183 cells/μL (IQR 106-224). 43 (2.8%) clients developed CD4 declines, the majority, 32/43 (74%), among individuals whose initial CD4 was <300 cells/μL. Of the 43 clients with CD4 declines, 24 had an additional CD4 measurement and 20/24 (83%) achieved a CD4 ≥200 cell/μL on their next measurement (median 285 cells/μL; IQR 220-365). CD4 declines were significantly greater among those with lower CD4 at sequence initiation [adjusted hazard ratio (AHR) 4.3 (95% CI 2.1, 9.0) CD4 200-249 versus ≥350 cells/μL]. Clients who achieved an immunologic and virologic response to ART were unlikely to experience a subsequent CD4 count decline to <200 cells/μL, and among those experiencing a decline, the majority were transient in nature. Thus, ongoing CD4 monitoring could be omitted.

To the Editors: We read with some concern the recent article by Kanyago et al,1 entitled “Shang Ring versus forceps-guided adult male circumcision: a randomized controlled effectiveness study in southwestern Uganda.” Our Shang Ring study groups strongly believe in the need for high-quality surgical training to decrease the number of postoperative complications, particularly with a new surgical device.2 It seems that although the surgeon in the study had performed more than 100 forceps-guided circumcisions, the article does not report any hands-on surgical training with the Shang Ring. Moreover, it is unclear why all ring sizes were not available for the study. The authors neither reference nor compare their experience with previous trials in Africa that demonstrated the safety of the Shang Ring. None of these trials observed the relatively high complication rates reported in this study.3–6 Also, the small study was underpowered to show differences in the primary end point. We note that there was a 25% loss to follow-up in the group of patients undergoing forceps-guided circumcision, versus 0% for the Shang Ring group, which raises the possibility of significant selection bias. The authors assumed that the 25% of patients lost to follow-up in the conventional circumcision group were “healed on the day of their next scheduled follow-up appointment,” for example, a patient presenting for a day 3 visit but not for subsequent appointments was considered healed on study day 7, an unlikely scenario for conventional circumcision. The authors in addition assumed that no complications occurred in this group of patients, which is surprising given that their complication rate in the forceps-guided group was a relatively high 18% in the intention-to-treat analysis. This for example is in contrast to the 0.8% moderate/severe complication rate for dorsal slit circumcision versus 1.8% for Shang Ring circumcision (P = 0.697) as reported by Kigozi et al.6 The 32% infection rate reported with Shang Ring circumcision in this study far exceeds the rates in all other Shang Ring studies and suggests (1) inappropriate surgical technique, (2) inaccurate diagnosis, or (3) lack of experience with Shang Ring wound healing.3,4,6 We are also puzzled by the 12.3% of men classified as “healed” at the 7-day visit for Shang Ring removal and the 34.3% healed by day 14. This is inconsistent with the detailed study by Barone et al,3 which reported the earliest complete wound healing was 21 days. We also question the definition of “persistent wound” as a complication of the procedure. Indeed, it is unclear how 30% patients undergoing Shang Ring circumcision could be listed as having a persistent wound versus 8% in the forceps-guided group, when the time to complete healing was similar in both groups (P = 0.08). Despite these concerns, it is gratifying to see that Shang Ring circumcision was nevertheless faster to perform and allowed patients to resume normal activity more quickly compared with the forceps-guided group, while maintaining at least an equivalent major complication rate and greater patient satisfaction. This article highlights the need for proper surgical training and an understanding of the wound healing process so as to avoid misclassification of complications for a device that could potentially increase the efficiency of surgery essential to the scale up of adult circumcision services in Africa.

Objectives:To quantify the association between intimate partner violence (IPV) and incident HIV infection in women in the Rakai Community Cohort Study between 2000 and 2009. Design and methods:Data were from the Rakai Community Cohort Study annual surveys between 2000 and 2009. Longitudinal data analysis was used to estimate the adjusted incidence rate ratio (IRR) of incident HIV associated with IPV in sexually active women aged 15–49 years, using a multivariable Poisson regression model with random effects. The population attributable fraction was calculated. Putative mediators were assessed using Baron and Kenny's criteria and the Sobel–Goodman test. Results:Women who had ever experienced IPV had an adjusted IRR of incident HIV infection of 1.55 (95% CI 1.25–1.94, P = 0.000), compared with women who had never experienced IPV. Risk of HIV infection tended to be greater for longer duration of IPV exposure and for women exposed to more severe and more frequent IPV. The adjusted population attributable fraction of incident HIV attributable to IPV was 22.2% (95% CI 12.5–30.4). There was no evidence that either condom use or number of sex partners in the past year mediated the relationship between IPV and HIV. Conclusion:IPV is associated with incident HIV infection in a population-based cohort in Uganda, although the adjusted population attributable fraction is modest. The prevention of IPV should be a public health priority, and could contribute to HIV prevention.

CONTEXT:Sexually active young women bear the brunt of the HIV epidemic in Sub-Saharan Africa. Information is needed on risk and protective correlates at the family, partner and individual level for the design of programs to encourage safer sexual behaviors and reduce HIV risk among young women.METHODS:The study was conducted among 1,675 sexually experienced women aged 15-24 living in Rakai, Uganda. The sample was taken from an ongoing community cohort study initiated in 1994 in 56 villages by the Rakai Health Sciences Program. Contextual variabless at the family, partner and individual levels were analyzed in relation to three outcome variables: sex before the age of 15, coerced first sex and condom use at first sex.RESULTS:At the family level, young females who did not live with both parents were more likely than those who did to have had sex before the age of 15 and to have experienced sexual coercion at first sex. Those whose mothers had some secondary education and whose female caregiver did not consume alcohol had elevated odds of using a condom at first sex. Having initiated sex at age 15 or older was the strongest individual-level characteristic associated with having used a condom at first sex.CONCLUSIONS:Reproductive health interventions should target adolescents and their parents to delay the onset of sexual activity, prevent sexual coercion and encourage condom use. Both adolescents and their parents should be educated about the risks associated with different types of sexual partnerships.