How common and frequent is heterosexual anal intercourse among South Africans? A systematic review and meta-analysis

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Abstract

Background: HIV is transmitted more effectively during anal intercourse (AI) than vaginal intercourse (VI). However, patterns of heterosexual AI practice and its contribution to South Africa’s generalized epidemic remain unclear. We aimed to determine how common and frequent heterosexual AI is in South Africa.

Methods: We searched for studies reporting the proportion practising heterosexual AI (prevalence) and/or the number of AI and unprotected AI (UAI) acts (frequency) in South Africa from 1990 to 2015. Stratified random-effects meta-analysis by sub-groups was used to produce pooled estimates and assess the influence of participant and study characteristics on AI prevalence. We also estimated the fraction of all sex acts which were AI or UAI and compared condom use during VI and AI.

Results: Of 41 included studies, 31 reported on AI prevalence and 14 on frequency, over various recall periods. AI prevalence was high across different recall periods for sexually active general-risk populations (e.g. lifetime = 18.4% [95%CI:9.4–27.5%], three-month = 20.3% [6.1–34.7%]), but tended to be even higher in higher-risk populations such as STI patients and female sex workers (e.g. lifetime = 23.2% [0.0–47.4%], recall period not stated = 40.1% [36.2–44.0%]). Prevalence was higher in studies using more confidential interview methods. Among general and higher-risk populations, 1.2–40.0% and 0.7–21.0% of all unprotected sex acts were UAI, respectively. AI acts were as likely to be condom protected as vaginal acts.

Discussion: Reported heterosexual AI is common but variable among South Africans. Nationally and regionally representative sexual behaviour studies that use standardized recall periods and confidential interview methods, to aid comparison across studies and minimize reporting bias, are needed. Such data could be used to estimate the extent to which AI contributes to South Africa’s HIV epidemic.

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Most cited references 73

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Meta-analysis and subgroups.

M Borenstein, Julian P. T. Higgins (2013)

Subgroup analysis is the process of comparing a treatment effect for two or more variants of an intervention-to ask, for example, if an intervention's impact is affected by the setting (school versus community), by the delivery agent (outside facilitator versus regular classroom teacher), by the quality of delivery, or if the long-term effect differs from the short-term effect. While large-scale studies often employ subgroup analyses, these analyses cannot generally be performed for small-scale studies, since these typically include a homogeneous population and only one variant of the intervention. This limitation can be bypassed by using meta-analysis. Meta-analysis allows the researcher to compare the treatment effect in different subgroups, even if these subgroups appear in separate studies. We discuss several statistical issues related to this procedure, including the selection of a statistical model and statistical power for the comparison. To illustrate these points, we use the example of a meta-analysis of obesity prevention.

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Advanced methods in meta-analysis: multivariate approach and meta-regression.

Lidia Arends, Paul A. C. Duijn, Theo Stijnen (2002)

This tutorial on advanced statistical methods for meta-analysis can be seen as a sequel to the recent Tutorial in Biostatistics on meta-analysis by Normand, which focused on elementary methods. Within the framework of the general linear mixed model using approximate likelihood, we discuss methods to analyse univariate as well as bivariate treatment effects in meta-analyses as well as meta-regression methods. Several extensions of the models are discussed, like exact likelihood, non-normal mixtures and multiple endpoints. We end with a discussion about the use of Bayesian methods in meta-analysis. All methods are illustrated by a meta-analysis concerning the efficacy of BCG vaccine against tuberculosis. All analyses that use approximate likelihood can be carried out by standard software. We demonstrate how the models can be fitted using SAS Proc Mixed. Copyright 2002 John Wiley & Sons, Ltd.

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Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomised controlled trial.

Lut Van Damme, Gita Ramjee, Michel Alary … (2002)

Nonoxynol-9 (rINN, nonoxinol-9) is an over-the-counter spermicide that has in-vitro anti-HIV-1 activity. Results of studies of its effectiveness in prevention of HIV-1 infection in women have been inconclusive. We aimed to assess effectiveness of this vaginal gel. We did a randomised, placebo-controlled, triple-blinded, phase 2/3 trial with COL-1492, a nonoxynol-9 vaginal gel, in 892 female sex workers in four countries: Benin, Côte d'Ivoire, South Africa, and Thailand. 449 women were randomly allocated nonoxynol-9 and 443 placebo. Primary endpoint was incident HIV-1 infection. Secondary endpoints included Neisseria gonorrhoeae and Chlamydia trachomatis infections. Analysis was by intention to treat. 765 women were included in the primary analysis. HIV-1 frequency in nonoxynol-9 users was 59 (16%) of 376 compared with 45 (12%) [corrected] of 389 in placebo users (402.5 vs 435.0 woman-years; hazard ratio adjusted for centre 1.5; 95% CI 1.0-2.2; p=0.047). 239 (32%) women reported use of a mean of more than 3.5 applicators per working day, and in these women, risk of HIV-1 infection in nonoxynol-9 users was almost twice that in placebo users (hazard ratio 1.8; 95% CI 1.0-3.2). 516 (68%) women used the gel less frequently than 3.5 times a day, and in these, risk did not differ between the two treatments. No significant effect of nonoxynol-9 on N gonorrhoeae (1.2; 0.9-1.6) or C trachomatis (1.2; 0.8-1.6) infections was reported. This study did not show a protective effect of COL-1492 on HIV-1 transmission in high-risk women. Multiple use of nonoxynol-9 could cause toxic effects enhancing HIV-1 infection. This drug can no longer be deemed a potential HIV-1-prevention method. Assessment of other microbicides should continue.

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Author and article information

Journal

Journal ID (nlm-ta): J Int AIDS Soc

Journal ID (iso-abbrev): J Int AIDS Soc

Journal ID (archive): ZIAS

Journal ID (publisher-id): zias20

Title: Journal of the International AIDS Society

Publisher: Taylor & Francis

ISSN (Electronic): 1758-2652

Publication date Collection: 2017

Publication date (Electronic): 11 January 2017

Volume: 20

Issue: 1

Electronic Location Identifier: 21162

Affiliations

[ ^a ]Department of Infectious Disease Epidemiology, Imperial College London , London, UK

[ ^b ]Vaccine Clinical Research Branch, Division of AIDS, National Institutes of Allergy and Infectious Diseases, US National Institutes of Health , Bethesda, MD, USA

[ ^c ]Department of Medicine, University of Pittsburgh School of Medicine , Pennsylvania, UK

[ ^d ]Department of Medical Microbiology and Immunology, University of California , Davis, CA, USA

[ ^e ]Women’s Global Health Imperative Program, RTI International , San Francisco, CA, USA

[ ^f ]Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine , London, UK

Author notes

[ ^§ ] Corresponding author: Branwen N. Owen, Department of Infectious Disease Epidemiology, Norfolk Place , London W2 1PG, UK, Tel: ++43 650 2628 292. ( b.owen11@ 123456imperial.ac.uk )

[*]

These authors have contributed equally to the work.

Article

Publisher ID: 1274530

DOI: 10.7448/IAS.20.1.21162

PMC ID: 5461120

PubMed ID: 28364565

SO-VID: 76d32ebf-4e6f-45ef-9a4a-fe9b66165877

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License ( http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 14 April 2016

Date accepted : 15 December 2016

Page count

Figures: 4, Tables: 1, References: 94, Pages: 14

Funding

Funded by: National Institute of Allergy and Infectious Diseases of the National Institutes of Health

Award ID: R01AI057020

Research reported in this publication was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health Award [Grant Number R01AI057020]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

How common and frequent is heterosexual anal intercourse among South Africans? A systematic review and meta-analysis

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SciELO South Africa

Most cited references 73

Meta-analysis and subgroups.

Advanced methods in meta-analysis: multivariate approach and meta-regression.

Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomised controlled trial.

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