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The Maternity in Migori and AIDS Stigma Study (MAMAS Study) aims to understand the effects of HIV/AIDS stigma on service use by pregnant women in rural Kenya, and to use the knowledge gained to develop stigma reduction interventions for this vulnerable group. The research plan includes a prospective study of women who use antenatal care (ANC) services at clinics in Migori and Rongo Districts in Nyanza Province, Kenya, as well as qualitative research to elucidate the potential role of HIV/AIDS stigma as a barrier to health service use among women in the community who do not use ANC services. The MAMAS prospective study includes interviews with childbearing women at their first ANC visit, during late pregnancy, and after the birth. Around 1800 pregnant women who come to ten clinics for their first ANC visit and do not yet know their HIV status are being interviewed before their first visit to assess their perceptions of HIV/AIDS stigma, uptake of HIV testing, and other variables. A subsample of these women (n=900) are re-interviewed during their last month of pregnancy and then again at six weeks postpartum to assess changes in perceptions and experiences of stigma, number of ANC visits completed, place of delivery, postpartum checkups, and enrollment in HIV care and treatment. The qualitative research component will consist of in-depth interviews with:

• Women who did not use maternity services for a recent pregnancy
• Traditional birth attendants
• Community health workers
• Male partners of women who did not use maternity services

The final step will be to integrate the findings from the quantitative and qualitative data and use them to guide the development of an intervention to reduce HIV/AIDS stigma that adversely affects pregnant women in Kenya.

Facilitated by The Twinning Center, the UCSF School of Nursing has partnered with the Ministry of Health in Mozambique in order to adapt, pilot, and implement an US evidence-based Positive Prevention (PP) intervention within rural Mozambique. The purpose of this project is to develop a PP intervention that will effectively address the needs of people living with HIV (PLHIV) in Mozambique through advancing understanding among healthcare providers, counseling and testing staff, and peer educators. Beginning in 2006, this intervention is taking place in two sites in Maputo Province in Mozambique. The first site focuses on building healthcare provider skills around effective risk assessment and prevention messages for their HIV-infected patients. The second site focuses on implementing similar needs assessment and prevention messages within one community–based Voluntary counseling and testing center and an accompanying peer support group. Collaboration among US and Mozambican partners (including healthcare providers, counseling and testing counselors, and PLHIV peer counselors) has guided the development of this PP intervention. The intervention currently includes case studies developed by Mozambican partners and a peer-led support group with enhanced one-to-one risk reduction counseling by counselors and PLHIV peers. Case studies are used in each setting to illustrate concepts such as assessment of transmission risk, behavioral risk reduction approaches, encouragement of partner testing and disclosure, prevention of mother-to-child transmission, and family planning.

UCSF is one site of an NIMH-funded multi-site, international efficacy trial of a behavioral intervention to reduce the incidence of HIV infection. Collaborating international sites teamed with US sites are: Zimbabwe (S. Morin, UCSF PI), South Africa (T. Coates, UCLA PI), Tanzania (M. Sweat, Johns Hopkins University PI) and Thailand (D. Celantano, Johns Hopkins University PI). In this prevention trial, 34 communities in Africa (Tanzania, Zimbabwe, and South Africa) and 14 communities in Thailand will be randomized to either a community-based HIV voluntary counseling and testing (CBVCT) intervention or clinic-based standard VCT (SVCT). The intervention has three major strategies:

1. To make VCT more available in community settings
2. To engage the community through outreach and community mobilization
3. To provide post-test support services

These strategies are designed to change community norms and reduce risk for HIV among all community members, irrespective of whether they participated directly in the intervention. Thus, we plan a community-level sampling approach as opposed to a cohort design to evaluate outcomes.

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.

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.