HIV/AIDS • CID 2008:46 (15 June) • 1913
H I V / A I D SM A J O R A R T I C L E
Natural History and Risk Factors Associated
with Early and Established HIV Type 1 Infection
among Reproductive-Age Women in Malawi
Johnstone J. Kumwenda,1Bonus Makanani,1Frank Taulo,1Chiwawa Nkhoma,2George Kafulafula,1Qing Li,3
Newton Kumwenda,3and Taha E. Taha3
1College of Medicine, University of Malawi, Chichiri, and
Blantyre, Malawi; and
2Johns Hopkins University–University of Malawi College of Medicine Research Project,
3Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
type 1 (HIV-1) infection are limited in sub-Saharan Africa. We examined plasma viral levels and trends during
early and established HIV-1 infection among reproductive-age women who participated in a randomized trial to
treat genital tract infection in Malawi. We also assessed the association of injectable hormonal contraceptive use
with HIV-1 infection.
We studied 3 groups of women who were infected or uninfected with HIV-1: seroconverters, se-
roprevalent women, and seronegative women. Questionnaires and blood samples were collected at baseline and
every 3 months for 1 year. The virus set point in seroconverters and levels and trends of viral load over time were
determined. The associations of injectable hormonal contraceptive use with HIV-1 infection and viral load were
assessed using conditional logistic regression and mixed-effect models, respectively.
In the original clinical trial, 844 women infected with HIV-1 and 842 women not infected with HIV-
1 were enrolled. Of 31 women who experienced seroconversion during 12 months, 27 were matched with 54
seroprevalent and 54 seronegative women. The estimated median plasma virus set point was 4.45 log10copies/mL
(interquartile range, 4.32–5.14 log10copies/mL). Injectable hormonal contraceptive use was significantly associated
with HIV-1 seroconversion (adjusted odds ratio, 10.42;P p .03
the seroconverters, a statistically significant interaction was found between the linear association of viral load and
time of injectable hormonal contraceptive use (regression coefficient, ?0.14;
Knowledge of virus set point and trends of viral load in HIV-1 seroincident and seroprevalent
asymptomatic women could assist in antiretroviral treatment management.
Data evaluating the biological events and determinants of early human immunodeficiency virus
) but not with established HIV-1 infection. Among
).P p .02
Natural history data from sub-Saharan Africa describ-
ing the trends of plasma viremia in women after se-
roconversion are scarce. The plasma viral loads aregen-
erally high in southern Africa, possibly because of
HIV-1 subtype C—the most dominant clade in the
southern region of Africa—and other factors, such as
intercurrent infections. This sustained elevation of the
viral level may lead to faster disease progression . It
is important to study these populations to understand
Received 26 September 2007; accepted 23 January 2008; electronically
published 5 May 2008.
Reprints or correspondence: Dr. Taha E. Taha, Bloomberg School ofPublicHealth,
Johns Hopkins University, 615 N. Wolfe St., Rm. E7138, Baltimore, MD 21205
Clinical Infectious Diseases2008;46:1913–20
? 2008 by the Infectious Diseases Society of America. All rights reserved.
determinants of infection and, consequently,todevelop
During primary HIV-1 infection, high levels of virus
replication are demonstrated by a steep increase in
plasma HIV-1 RNA levels that often reach a peak of
[2–4]. Although virologic and immunologic responses
vary in HIV-1–infected individuals, mobilization of
host defenses against the virus results in decreases in
virus levels that reach a steady state or set point 2–6
months after infection [4, 5]. It is suggested that high
steady-state levels of plasma HIV-1 RNA at 4–12
months after infection result in faster progression to
AIDS [5–7]. On the basis of these initial events, HIV-
1 becomes permanently established, and infected cells
are constantly present in viral reservoirs in all pa-
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