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Author Notes:

Corresponding author. 1518 Clifton Road NE, Atlanta, GA 30322, USA. E-mail: kmwall@emory.edu

See publication for full list of author contributions.

We would like to acknowledge the study couples and staff in Zambia who made this study possible.

The corresponding author had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

The authors do not have a commercial or other association that might pose a conflict of interest.


Research Funding:

This work was supported by: the National Institute of Child Health and Development (NICHD R01 HD40125); the National Institute of Mental Health (NIMH R01 66767); the AIDS International Training and Research Program Fogarty International Center (D43 TW001042); the Emory Center for AIDS Research (P30 AI050409); the National Institute of Allergy and Infectious Diseases (NIAID R01 AI51231; NIAID R01 AI040951; NIAID R01 AI023980; NIAID R01 AI64060; NIAID R37 AI51231); the US Centers for Disease Control and Prevention (5U2GPS000758); and the International AIDS Vaccine Initiative.

This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID).

The contents do not necessarily reflect the views of USAID or the United States Government.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


  • Science & Technology
  • Life Sciences & Biomedicine
  • Public, Environmental & Occupational Health
  • Couples' voluntary HIV counselling and testing
  • discordant couples
  • HIV risk
  • genital ulceration and inflammation
  • longitudinal cohort
  • Zambia

Risk of heterosexual HIV transmission attributable to sexually transmitted infections and non-specific genital inflammation in Zambian discordant couples, 1994-2012

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Journal Title:

International Journal of Epidemiology


Volume 46, Number 5


, Pages 1593-1606

Type of Work:

Article | Final Publisher PDF


Background: Studies have demonstrated the role of ulcerative and non-ulcerative sexually transmitted infections (STI) in HIV transmission/acquisition risk; less is understood about the role of non-specific inflammatory genital abnormalities. Methods: HIV-discordant heterosexual Zambian couples were enrolled into longitudinal follow-up (1994-2012). Multivariable models estimated the effect of genital ulcers and inflammation in both partners on time-to-HIV transmission within the couple. Population-attributable fractions (PAFs) were calculated. Results: A total of 207 linked infections in women occurred over 2756 couple-years (7.5/100 CY) and 171 in men over 3216 CY (5.3/100 CY). Incident HIV among women was associated with a woman's non-STI genital inflammation (adjusted hazard ratio (aHR) = 1.55; PAF = 8%), bilateral inguinal adenopathy (BIA; aHR = 2.33; PAF = 8%), genital ulceration (aHR = 2.08; PAF = 7%) and the man's STI genital inflammation (aHR = 3.33; PAF = 5%), BIA (aHR = 3.35; PAF = 33%) and genital ulceration (aHR = 1.49; PAF = 9%). Infection among men was associated with a man's BIA (aHR = 4.11; PAF = 22%) and genital ulceration (aHR = 3.44; PAF = 15%) as well as with the woman's non-STI genital inflammation (aHR = 1.92; PAF = 13%) and BIA (aHR = 2.76; PAF = 14%). In HIV-M+F- couples, the man being uncircumcised. with foreskin smegma. was associated with the woman's seroconversion (aHR = 3.16) relative to being circumcised. In F+M- couples, uncircumcised men with BIA had an increased hazard of seroconversion (aHR = 13.03 with smegma and 4.95 without) relative to being circumcised. Self-reporting of symptoms was low for ulcerative and non-ulcerative STIs. Conclusions: Our findings confirm the role of STIs and highlight the contribution of non-specific genital inflammation to both male-to-female and female-to-male HIV transmission/acquisition risk. Studies are needed to characterize pathogenesis of non-specific inflammation including inguinal adenopathy. A better understanding of genital practices could inform interventions.

Copyright information:

© The Author 2017. Published by Oxford University Press on behalf of the International Epidemiological Association.

This is an Open Access work distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/).

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