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This project has two primary aims: 1. Identify barriers and facilitators for heterosexual couples pertaining to utilizing couples-based voluntary counseling and testing (CBVCT) in Soweto, South Africa 2. Identify relationship-based predictors of HIV risk behavior in couples (e.g., communication, intimacy, commitment, etc.). The study is comprised of two phases. The first phase was qualitative in nature, and focused on obtaining information from men and women regarding their relationships and their perceptions and attitudes about couples-based testing for HIV. Both individual interviews and focus groups were conducted (N=48, 16 couples in individual interviews and eight couples in focus groups). Data collection was completed for this phase in February of 2006. The second phase was a cross-sectional quantitative study of predictors of HIV risk behavior and of utilizing couples-based testing among a sample of 220 couples. The survey included questions about relationship dynamics, such as trust and communication, as well as social norms regarding HIV testing. This project finished data collection in December of 2008. The research is based at the Chris Hani Baragwanath Hospital and the Perinatal HIV Research Unit at the University of the Witwatersrand in Johannesburg, South Africa.

This project conducted in-depth qualitative interviews with couples (n=20) key informants (n=12), and focus groups (n=4) regarding the feasibility and acceptability of a comprehensive couples-based intervention. Key issues were explored to determine potential interest for intervention content. The research is based at the Chris Hani Baragwanath Hospital and the Perinatal HIV Research Unit at the University of the Witwatersrand in Johannesburg, South Africa. The primary aims of the project were to:

• Determine the ideal components of an integrated package delivering comprehensive HIV and reproductive health services to heterosexual couples in Soweto, South Africa.
• Explore the feasibility and acceptability of such a program via in-depth interviews with potential target audience members and key informants.

This study tests the efficacy of an intervention utilizing HIV rapid testing and integration of HIV Voluntary Counseling and Testing (VCT) into Tuberculosis (TB) evaluation and home-based VCT for family members, to overcome identified logistical and psychological barriers to HIV VCT among new TB patients and their family members. The specific aims of the study are:

1. To determine the uptake of and barriers to HIV VCT among a cross-sectional sample of 2,000 TB evaluation patients offered same-day results HIV counseling and testing at the Uganda National TB and Leprosy Programme outpatient TB clinic at Old Mulago Hospital in Kampala, Uganda
2. To conduct a randomized trial of HIV VCT among 600 households comparing VCT uptake between home-based VCT and TB clinic-based VCT for family and household members of TB evaluation patients
3. To investigate the effectiveness of home-based and TB clinic-based VCT in linking HIV+ persons to HIV medical care and social support

Through this study’s dissemination plan and the proposed policy and community forums, information on a successful model could be made rapidly available to key stakeholders responsible for setting national policy and local HIV/AIDS control programs.

The HIV and malaria epidemics inflict the greatest harm in sub-Saharan Africa and overlap significantly. We have recently identified an interaction between acute malaria and false positive HIV EIA test results. This project will investigate this interaction in three of the most common rapid EIA HIV tests used in sub-Saharan Africa among a cohort of 450 HIV-uninfected children aged 2-17 years being followed longitudinally for malaria in Kampala, Uganda as part of a larger, parent study. Children will be HIV counseled and tested once at baseline. For those who test HIV-negative we will retest blood samples at the time of first new malaria diagnosis using samples already being collected for the parent study, and again as blood is collected for the parent study for a period of up to 180 days. The study will be conducted at the MU/UCSF Malaria Clinic in Kampala, Uganda. The study clinic is located within the Mulago Hospital Complex, the primary referral hospital in Uganda. The aims of the study are to:

• Determine the prevalence of false positive HIV EIA test results in children with uncomplicated malaria.
• Estimate the duration of false positive HIV EIA test results in children with uncomplicated malaria.
• Compare the positive predictive value, sensitivity and specificity of serial rapid HIV testing algorithms to parallel rapid HIV testing algorithms in children with uncomplicated malaria.
• Identify risk factors and predictors of false positive HIV EIA test results in children with malaria.

The overarching goal of this program project (P01) is to evaluate novel and strategic interventions to reduce the burden of malaria and improve HIV outcomes among children and pregnant women, the populations most affected by the overlap of these diseases. We hypothesize that treatment with HIV protease inhibitors (PIs) will lower the incidence of malaria and consequent morbidity in HIV+ children and pregnant women compared to those treated with standard antiretroviral treatment. This hypothesis is based on the appreciation that malaria parasites and HIV express biochemically similar proteases and the observation that HIV PIs exert potent in vitro antimalarial activity. We hypothesize that in HIV- children, chemopreventive therapy will offer strong protection against malaria without increased malarial morbidity after discontinuation of the intervention. We hypothesize that intermittent or chronic antimalarial and PI-based antiretroviral therapy will select for drug resistant parasites, and that different drugs will offer different selective pressures. Four interlinked studies to test these three hypotheses comprise our P01 projects:

1. Protease inhibitors for the prevention of malaria in HIV-infected children
2. Protease inhibitors to reduce malaria morbidity in HIV-infected pregnant women
3. Chemopreventive therapy for malaria in HIV-uninfected infants and children
4. Selection of drug resistant malaria parasites by antimalarial and HIV therapies

The projects will enroll a total of 1600 participants and be implemented by a multidisciplinary, multinational team in Tororo, Uganda, a site of high malaria transmission. The Administrative and Data and Statistics Cores will support the four projects. CAPS will spearhead the Data and Statistics Core for this P01.