Zena Stein

New York State Psychiatric Institute, New York, New York, United States

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Publications (204)1562.23 Total impact

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    ABSTRACT: The current Ebola outbreak is unique in its magnitude and its dispersion in dense, mobile populations. Physician and nurse responders face high mortality, and foreign aid in the form of medical supplies and staff continues to be unequal to the scope of the problem. Fear and loss have over-whelmed affected communities, already among the poorest in the world and still recovering from brutal civil wars. While the number of Ebola cases in Liberia appears to be on the decline, Ebola infections in Sierra Leone and Guinea continue to increase. 1 That the response to the epidemic be swift and massive is a matter of life and an unknown num-ber of deaths. Survivors of Ebola infection are valuable resources still largely overlooked in the struggle to contain the epidemic. With a case recovery rate of around 30% at the present time for the current West African epidemic, 2 survivors al-ready number thousands. There are several reasons why Ebola survivors may be critical to controlling the epidemic. First, and most importantly, the recovered have developed immunity to the current strain of Ebola and therefore are able to care for the sick with little to no risk of re-infection. In a sense, survivors are the only people in the world who are 'vaccinated' against further Ebola infec-tion with the strain in circulation. This uniquely positions them to mediate between the infected and uninfected and between local people and foreign responders. Second, survivors can donate their blood, as their anti-bodies might be protective and help those infected to survive the deadly virus. Although it has not yet been proven to be effective, passive immunotherapy with survivors' blood (convalescent plasma) could be an effective treatment for the tens of thousands of people projected to battle Ebola. Indeed, research into the biological and clinical progress in survivors is critical to a further understanding of Ebola. 3
    International Journal of Epidemiology 12/2014; 43(6). DOI:10.1093/ije/dyu233 · 9.20 Impact Factor
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    ABSTRACT: Sexual and reproductive health (SRH) services for HIV-positive women and men often neglect their fertility desires. We examined factors associated with pregnancy intent among recently diagnosed HIV-positive women (N = 106) and men (N = 91) who reported inconsistent condom use and were enrolled in an SRH intervention conducted in public sector HIV care clinics in Cape Town. Participants were recruited when receiving their first CD4 results at the clinic. All reported unprotected sex in the previous 3 months. Logistic regression identified predictors of pregnancy intent for the total sample and by gender. About three fifths of men and one fifth of women reported intent to conceive in the next 6 months. In the full-sample multiple regression analysis, men [adjusted odds ratio (AOR = 6.62)] and those whose main partner shared intent to conceive (AOR = 3.80) had significantly higher odds of pregnancy intent; those with more years of education (AOR = 0.81) and more biological children (AOR = 0.62) had lower odds of intending pregnancy. In gender-specific analyses, partner sharing pregnancy intent was positively associated with intent among both men (AOR = 3.53) and women (AOR = 13.24). Among men, odds were lower among those having more biological children (AOR = 0.71) and those unemployed (AOR = 0.30). Among women, relying on hormonal contraception was negatively associated with intent (AOR = 0.08), and main partner knowing her HIV status (AOR = 5.80) was positively associated with intent to conceive. Findings underscore the importance of providing integrated SRH services, and we discuss implications for clinical practice and care.
    Journal of acquired immune deficiency syndromes 12/2014; 67(Supplement 4):S205 - S212. DOI:10.1097/QAI.0000000000000369
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    Journal of acquired immune deficiency syndromes 12/2014; 67:S205–S212.
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    ABSTRACT: Relatively few interventions have tested the efficacy of female condom promotion either alone or in combination with other barrier methods. We evaluated the efficacy of a two-session (enhanced) cognitive-behavioral intervention (EI) (n = 147) against a one-session control (minimal) educational intervention (MI) (n = 149) to promote female condom (FC) use among female students aged 18-28 at a South African university. We assessed change from baseline to 2.5 and 5 months in number of vaginal intercourse occasions unprotected by male or female condoms in EI versus MI using generalized linear models with a log link function and GEE. Both groups reported significant reductions in number of unprotected vaginal intercourse occasions from baseline to each follow-up, with no significant difference between the two-session and single-session intervention. Introduction of a brief group-based MI FC promotion intervention with FC access holds promise for delivery in clinics and other community venues.
    AIDS and Behavior 08/2014; DOI:10.1007/s10461-014-0860-6 · 3.49 Impact Factor
  • Erica L Gollub, Zena Stein
    The Lancet 01/2014; 383(9914):304-5. DOI:10.1016/S0140-6736(14)60098-2 · 39.21 Impact Factor
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    ABSTRACT: Background: Medical male circumcision (MMC) reduces the risk of HIV acquisition for men in heterosexual encounters by 50-60%. However, there is no evidence that a circumcised man with HIV poses any less risk of infecting his female partner than an uncircumcised man. There may be an additional risk of HIV transmission to female partners during the 6-week healing period and if condoms are used less often after circumcision. The aim was to explore young women's perspectives on MMC, with a view to developing clear messages about the limitations of MMC in reducing women's HIV risk. Methods: We explored women's perspectives on MMC in KwaZulu-Natal, South Africa, with a sample of 30 female tertiary students via four focus groups (two for women only; two mixed gender). Results: In all groups, women communicated a thorough understanding of the partial efficacy of MMC, but believed that others would not understand this concept. Participants noted that MMC affords no direct benefit to women. Most thought that MMC would increase females' risk of contracting HIV, that circumcised men may engage in risky behaviours and that men would increase their number of sexual partners after circumcision. Participants believed that condom use would decrease after MMC and speculated that men would have sex during the healing period, which could further compromise women's sexual health. Conclusion: The concerns expressed by women regarding MMC highlight the need for including women in the dialogue about MMC and for clarifying the impact of MMC on HIV risk for women.
    Sexual Health 03/2013; 10(2). DOI:10.1071/SH12067 · 1.58 Impact Factor
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    Erica Gollub, Zena Stein
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    ABSTRACT: A recent multi-country study on hormonal contraceptives (HC) and HIV acquisition and transmission among African HIV-serodiscordant couples reported a statistically significant doubling of risk for HIV acquisition among women as well as transmission from women to men for injectable contraceptives. Together with a prior cohort study on African women seeking health services, these data are the strongest yet to appear on the HC-HIV risk. This paper will briefly review the Heffron study strengths and relevant biological and epidemiologic evidence; address the futility of further trials; and propose instead an alternative framework for next steps. The weight of the evidence calls for a discontinuation of progestin-dominant methods. We propose here five types of productive activities: (1) scaling injectable hormones down and out of the contraceptive mix; (2) strengthening and introducing public health strategies with proven potential to reduce HIV spread; (3) providing maximal choice to reduce unplanned pregnancy, starting with quality sexuality education through to safe abortion access; (4) expanding provider training, end-user counseling and access to male and female barriers, with a special renewed focus on female condom; (5) initiating a serious research agenda to determine anti-STI/HIV potential of the contraceptive cervical cap. Trusting women to make informed choices is critical to achieve real progress in dual protection.
    AIDS research and treatment 11/2012; 2012:524936. DOI:10.1155/2012/524936
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    ABSTRACT: In preparation for a school-based intervention in KwaZulu-Natal, South Africa, a cross-sectional survey of potential HIV risk factors in youth aged 14-17 (n=983) was conducted. Boys were significantly more likely than girls to report lifetime sexual activity (37.7% v. 13.8%, P<0.01). Among boys and girls, 46.1% reported condom use at last sex. Discussion of condom use with a partner was the strongest predictor of condom use (boys, odds ratio (OR)=7.39; girls, OR=5.58, P<0.0001). Age was independently associated with sexual activity for boys (OR=1.49, P<0.0001) and girls (OR=1.74, P=0.02). For boys, perceptions of male peer behaviour were associated with both ever having participated in sexual activity (OR=1.48, P<0.01) and condom use at last sex (OR=1.79, P<0.01). Girls who equated condom use with having numerous partners were more likely to use them. Among boys, results challenged some expected gender beliefs: support for girls' initiative in relationship formation and refusal of sex were significant predictors of sexual activity. Among girls, higher pregnancy risk perception (OR=1.32, P=0.02) and knowledge (OR=4.85, P=0.055) were associated with sexual activity. Creating more gender equitable norms can reduce HIV risk behaviours. HIV prevention interventions should build on existing gender equitable beliefs, and work to promote others, including sexual communication and negotiation skills, and modelling of positive peer norms.
    Sexual Health 05/2012; 9(2):178-86. DOI:10.1071/SH10150 · 1.58 Impact Factor
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    ABSTRACT: Women comprise one-half of people infected with the human immunodeficiency virus in the world, and about 70% of them live in sub-Saharan Africa. Advancing, untreated HIV disease in women has resulted in substantial declines in fertility rates, life expectancy and infant mortality rates, and an increased burden of tuberculosis. Three decades into the pandemic, our knowledge of HIV acquisition in women remains sparse, as are options of what women can use to reduce their risk of acquiring HIV. Here, we describe the role of pre-HIV responses to venereal diseases and then discuss unwanted pregnancies, early perceptions of the HIV epidemic in setting prevention priorities, and the history of microbicide development. Opportunities to reduce HIV risk in women through sexual reproductive health services are highlighted. Women are key to turning the tide of the HIV pandemic. Microbicides provide an opportunity to ensure survival of women while addressing the power disparities that underpin women's vulnerability to HIV.
    Best practice & research. Clinical obstetrics & gynaecology 02/2012; 26(4):487-93. DOI:10.1016/j.bpobgyn.2012.01.006 · 1.87 Impact Factor
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    ABSTRACT: We surveyed 111 male clients of an HIV/AIDS service organization in New York City in 2008 and 2009. Seventeen percent had used the female condom for anal intercourse; of these, 89.3% had used the female condom with male partners, 21.4% with female partners, and 10.7% with both. Users of the female condom for vaginal intercourse were more likely to use it for anal intercourse (odds ratio = 12.7; 95% confidence interval = 2.5, 64.9; P = .002). The safety and efficacy of the female condom for anal intercourse are unknown and should be evaluated.
    American Journal of Public Health 12/2011; 101(12):2241-4. DOI:10.2105/AJPH.2011.300260 · 3.93 Impact Factor
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    ABSTRACT: Objectives  To assess the uptake of HIV testing among preschool children with HIV-positive mothers in a peri-urban population-based study in KwaZulu-Natal, South Africa, an area of high HIV prevalence. Methods  All children 4-6 years old and their primary caregivers from the area were invited to participate. All participants were asked about prior HIV testing and were offered counselling and voluntary HIV testing irrespective of previous testing. Twenty-seven HIV-infected mothers were interviewed to identify barriers to testing their children. Results  One thousand five hundred and eighty-three children (88% of eligible children) and their caregivers participated. Of the biological mothers, 86% were previously tested for HIV (27% tested positive). Among the surviving 244 children born to an infected mother, only 41% had been tested for HIV (23% tested positive). Subsequently, 90% of previously untested children of infected mothers underwent HIV testing (9.3% were positive). Overall seroprevalence among study children was 4.9%. All infected mothers interviewed endorsed the belief that children of HIV-infected women should be tested for HIV. Women who missed opportunities for antenatal HIV testing reported no systematic testing of their children at later ages. Conclusions  In this community with high HIV prevalence, HIV testing of children is infrequent despite high testing coverage among caregivers. The low proportion of children tested for HIV, particularly those of infected mothers, is of great concern as they are at high risk for morbidity and mortality associated with untreated childhood HIV infection. HIV testing programs should strengthen protocols to include children, especially for those who missed PMTCT opportunities in infancy.
    Tropical Medicine & International Health 08/2011; 16(12):1490-4. DOI:10.1111/j.1365-3156.2011.02872.x · 2.30 Impact Factor
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    ABSTRACT: Religious and secular institutions advocate strategies that represent all points on the continuum to reduce the spread of HIV/AIDS. Drawing on an extensive literature review of studies conducted in sub-Saharan Africa, we focus on those secular institutions that support all effective methods of reducing HIV/AIDS transmission and those conservative religious institutions that support a limited set of prevention methods. We conclude by identifying topics for dialogue between these viewpoints that should facilitate cooperation by expanding the generally acceptable HIV/AIDS prevention methods, especially the use of condoms.
    Global Public Health 08/2011; 6 Suppl 2:S192-209. DOI:10.1080/17441692.2011.604039 · 0.92 Impact Factor
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    Louise Kuhn, Ida Susser, Zena Stein
    The Lancet 07/2011; 378(9787):285-7. DOI:10.1016/S0140-6736(11)60134-7 · 39.21 Impact Factor
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    ABSTRACT: Young men in South Africa can play a critical role in preventing new human immunodeficiency virus (HIV) infections, yet are seldom targeted for HIV prevention. While reported condom use at last sex has increased considerably among young people, consistent condom use remains a challenge. In this study, 74 male higher education students gave their perspectives on male and female condoms in 10 focus group discussions. All believed that condoms should be used when wanting to prevent conception and protect against HIV, although many indicated that consistent condom use was seldom attained, if at all. Three possible situations for not using condoms were noted: (i) when sex happens in the heat of the moment and condoms are unavailable, (ii) when sexual partnerships have matured and (iii) when female partners implicitly accept unprotected sex. Men viewed it as their responsibility to have male condoms available, but attitudes about whose decision it was to initiate condom use were mixed. Almost all sexually active men had male condom experience; however, very few had used female condoms. Prevention initiatives should challenge traditional gendered norms that underpin poor condom uptake and continued use and build on the apparent shifts in these norms that are allowing women greater sexual agency.
    Health Education Research 06/2011; 26(5):859-71. DOI:10.1093/her/cyr041 · 1.66 Impact Factor
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    ABSTRACT: As the focal science for public health, epidemiology has been a large tent supporting diverse activities. The hospital epidemiologist, the cancer trialist, the researcher studying teenage dating violence, and the theorist elaborating epidemic curves all work on different topics using disparate methods, but all of them could and should be comfortable under that one tent. Epidemiology certainly has seen its share of internecine squabbles. These quarrels have generic causes that include noble attempts to differentiate new work directions, to shake up priorities or to motivate constituencies toward new conceptualizations. Some rifts grow from the sincere attempt by some to correct what they see as past mistakes in research direction or problem framing, which may spur defense of long-standing efforts in which considerable time and effort has been invested. A fractious crowd is sometimes encouraged to patch things over and get along, but it is not entirely clear that such an approach is necessary or right when it comes to disagreements among scientists. According to one school of thought, to which we subscribe, the more active the dialogue and criticism between scientists, the more vibrant the field. Nevertheless, no matter how much one believes in the merits of reasoned debate, one must lament the energy expended on disagreements that stem from nothing other than miscommunication of ideas. At one time or another we have all seen reasonable people talk past each other because they use the same terms with different definitions attached, or because they do not stand willingly in their opposite’s shoes to view the other side of the discussion with intellectual empathy. We support reasoned debate, but we wish to avoid the unproductive debate that characterizes conversations that slide past each other without meaningful discourse. One specific debate, the one that prompts this comment, has focused on the role of social class in disease. It has simmered for years while its participants have unproductively talked past one another. The debate has ranged wide, but we focus on three of the actors who could have done better, and whom we now wish to hold to account. We are happy to name names: we refer to ourselves. The origin of the miscommunication was a statement in the 1986 text of one of us:
    European Journal of Epidemiology 06/2011; 26(6):431-2. DOI:10.1007/s10654-011-9579-0 · 5.15 Impact Factor
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    ABSTRACT: High rates of unintended pregnancies and sexually transmitted infection (STI), including HIV, highlight the importance of promoting dual protection (DP) - i.e., methods that offer concurrent protection against unintended pregnancies and STI - during contraceptive counseling. Using a Phase II quasi-experimental design, this study compared an individualized, clinic-based, nurse-delivered intervention designed to increase DP against standard of care among 101 HIV negative women accessing contraceptive services in medically under-served areas of New York City. Participants were evaluated at baseline, post-counseling, and six months later. Findings indicated that the intervention has possible benefit. At six-month follow-up, there was greater perceived susceptibility to STI and fewer condom-unprotected vaginal sex occasions in the intervention arm. Women in the intervention also had five times the odds of reporting female condom use. Results suggest that this intervention has the potential for a larger population impact and should be more rigorously evaluated in a Phase III trial.
    AIDS Care 04/2011; 23(4):467-75. DOI:10.1080/09540121.2010.516335 · 1.60 Impact Factor
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    ABSTRACT: Health care providers can play a key role in influencing clients to initiate and maintain use of the female condom, an underused method for HIV/STI and pregnancy prevention. In 2001-2002, based on semistructured interviews with 78 health care providers from four types of settings in New York City, we found that most providers had seen the female condom, but they had not used it and did not propose the method to clients. They lacked details about the method-when to insert it, where it can be obtained, and its cost. Gender of provider, provider level of training, and setting appeared to influence their attitudes. Unless and until provider training on the female condom is greatly improved, broader acceptance of this significant public health contribution to preventing HIV/AIDS and unwanted pregnancy will not be achieved.
    AIDS education and prevention: official publication of the International Society for AIDS Education 02/2011; 23(1):65-77. DOI:10.1521/aeap.2011.23.1.65 · 1.51 Impact Factor
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    International Journal of Epidemiology 12/2010; 39(6):1417-25. DOI:10.1093/ije/dyq222 · 9.20 Impact Factor
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    ABSTRACT: As life expectancy for HIV-infected persons improves, studies in sub-Saharan Africa show that a considerable proportion of HIV-positive women and men desire to have children. Integrating sexual and reproductive health care into HIV services has until now emphasized the right of women to make informed choices about their reproductive lives and the right of self-determination to reproduce, but this is often equated with avoidance of pregnancy. Here, we explore guidance and attention to safer conception for HIV-infected women and men. We find this right lacking. Current sexual and reproductive health guidelines are not proactive in supporting HIV-positive people desiring children, and are particularly silent about the fertility needs of HIV-infected men and uninfected men in discordant partnerships. Public health policymakers and providers need to engage the HIV-infected and uninfected to determine both the demand for and how best to address the need for safer conception services.
    Journal of Public Health Policy 12/2009; 30(4):367-78. DOI:10.1057/jphp.2009.35 · 1.48 Impact Factor
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    Zena Stein, Louise Kuhn
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    ABSTRACT: New studies of breastfeeding have discovered or confirmed the benefits to mother and child. They reinforce an emphasis on exclusive breastfeeding - no other food or fluids - during the first 6 months. Studies include findings from across the world, in well-resourced and poorly resourced settings. They also emphasize longer duration of breastfeeding, into the second year of life, and gradual rather than abrupt weaning. For HIV-infected mothers, the dangers of non-exclusive feeding in the first half year of life have been well documented in recent publications. Other studies open up the possibilities for antiretroviral treatment to accompany breastfeeding, whether given to the mother, or child, or both. To be effective, implementation of any recommendations must consider individual, family, and community resources.
    Journal of Public Health Policy 09/2009; 30(3):300-10. DOI:10.1057/jphp.2009.23 · 1.75 Impact Factor

Publication Stats

5k Citations
1,562.23 Total Impact Points


  • 1977–2014
    • New York State Psychiatric Institute
      • Anxiety Disorders Clinic
      New York, New York, United States
  • 1967–2014
    • Columbia University
      • • Department of Epidemiology
      • • Department of Psychiatry
      • • Gertrude H. Sergievsky Center
      • • Department of Genetics and Development
      • • Department of Pediatrics
      New York, New York, United States
    • Manchester University
      North Manchester, Indiana, United States
  • 2011
    • RTI International
      Durham, North Carolina, United States
  • 1960–2008
    • The University of Manchester
      Manchester, England, United Kingdom
  • 2003
    • Philadelphia University
      Philadelphia, Pennsylvania, United States
  • 2000
    • City University of New York - Hunter College
      • Department of Anthropology
      Manhattan, NY, United States
  • 1999
    • South African Medical Research Council
      Kaapstad, Western Cape, South Africa
  • 1995
    • University of California, Berkeley
      • School of Public Health
      Berkeley, MO, United States
    • University of KwaZulu-Natal
      • Department of Paediatrics and Child Health
      Durban, KwaZulu-Natal, South Africa
  • 1972
    • Institute of Food Research
      Norwich, England, United Kingdom