Melissa C Morgan
email: melissa.morgan@stx.oxon.org

Keywords: HIV, Mother-to-child transmission, Breastfeeding cessation, Prevention HIV, mother-to-child transmission, breastfeeding cessation, prevention mc.manuscriptcentral.com/ac-phm-vcy

Factors affecting breastfeeding cessation after discontinuation of antiretroviral therapy to prevent mother-to-child transmission of HIV

Almost all of these infections were the result of MTCT and 90% occurred in sub-Saharan Africa. In resource-poor settings, MTCT rates are 25-48% in breastfeeding populations in the absence of interventions [START_REF] De Cock | Prevention of mother-to-child HIV transmission in resource-poor countries -translating research into policy and practice[END_REF]. In Kenya, [START_REF] Nduati | Effect of breastfeeding and formula feeding on transmission of HIV-1 -a randomized clinical trial[END_REF] found that 44% of all transmission was due to breastfeeding, and 75% of all breastmilk transmission occurred in the first six months. Additionally, they showed that HIV transmission in breastfed infants was 16% higher than in formula-fed infants, and that HIV-free survival at 24 months was significantly higher in the formula-fed group [START_REF] Mbori-Ngacha | Morbidity and mortality in breastfed and formula-fed infants of HIV-1 infected women -a randomized clinical trial[END_REF][START_REF] Nduati | Effect of breastfeeding and formula feeding on transmission of HIV-1 -a randomized clinical trial[END_REF]. However, [START_REF] Thior | Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana -a randomized trial: the Mashi Study[END_REF] found that HIV-free survival at 18 months was similar in formula-fed and breastfed infants receiving zidovudine in Botswana and that cumulative infant mortality at 7 months was significantly higher in the formula-fed group, mainly due to diarrheal and respiratory diseases. These results demonstrate the importance of preventing postnatal transmission, as well as the conflicting evidence regarding the role that replacement feeding should play in prevention.

In developing countries, breastfeeding is considered essential to child survival. A pooled analysis (WHO Collaborative Study Team, 2000) found that non-breastfed infants have a sixfold increased risk of mortality due to infections in the first two months of life compared to breastfed infants. Further, it found that breastfeeding increased protection against diarrheal deaths and acute respiratory infections six-fold and two-fold, respectively, in the first six months. Benefits of breastfeeding are greatest in the first six months [START_REF] Fowler | Breastfeeding and HIV-1 transmission in resourcelimited settings[END_REF]WHO, 2000). Exclusive breastfeeding, defined as breastmilk only with no other liquids or solids [START_REF] Who | Indicators for assessing breastfeeding practices[END_REF], is associated with a significantly lower risk of HIV et al., 2005). For these reasons, the World Health Organization (WHO) recommends replacement feeding only when it is culturally acceptable, affordable, feasible, sustainable, and safe. If it is not, exclusive breastfeeding is recommended for the first six months followed by breastfeeding with complementary foods until an adequate diet can be provided without breastmilk (WHO, 2006).

In resource-poor settings, several problems may exist with replacement feeding.

Replacement feeding requires access to clean water, fuel, and feeding implements (UNAIDS, 1999). A South African study of 1253 HIV-infected women found that only 3% had access to clean water, fuel, refrigeration, and regular income [START_REF] Bland | Infant feeding counseling for HIV-infected and uninfected women: appropriateness of choice and practice[END_REF]. In Kenya, the median duration of breastfeeding is 20 months [START_REF] Owuor | Nutrition. In: Kenya Demographic and Health Survey 2003[END_REF]. Failure to breastfeed or early cessation may lead to unintentional disclosure of HIV status as it is contrary to common practice. In Zimbabwe, interviews revealed that women who do not breastfeed may face stigma because others believe they are promiscuous or HIV-positive [START_REF] Piwoz | An education and counseling program for preventing breastfeeding-associated HIV transmission in Zimbabwe: design and impact on maternal knowledge and behavior[END_REF]. Studies in South Africa [START_REF] Hilderbrand | The prevention of mother-to-child HIV transmission program and infant feeding practices[END_REF], Brazil [START_REF] Hebling | Feelings related to motherhood among women living with HIV in Brazil: a qualitative study[END_REF], and USA [START_REF] Chezem | Maternal feelings after cessation of breastfeeding: influence of factors related to employment and duration[END_REF] found that women experienced emotional pain, guilt, frustration, and sadness as a result of not breastfeeding or stopping earlier than intended. Despite the counseling they receive, some participants continue to breastfeed after stopping HAART. It is important to understand why this occurs. Although many studies have been conducted on factors affecting formula feeding [START_REF] Abiona | Acceptability, feasibility and affordability of infant feeding options for HIVinfected women: a qualitative study in south-west Nigeria[END_REF][START_REF] Bland | Infant feeding counseling for HIV-infected and uninfected women: appropriateness of choice and practice[END_REF][START_REF] Doherty | Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa[END_REF][START_REF] Doherty | A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa[END_REF][START_REF] Hilderbrand | The prevention of mother-to-child HIV transmission program and infant feeding practices[END_REF]Kiarie, Richardson, Mbori-Ngacha, Nduati, & John-Stewart, 2004;[START_REF] Leroy | Acceptability of formula-feeding to prevent HIV postnatal transmission, Abidjan, Cote d'Ivoire: ANRS 1201/1202 Ditrame Plus Study[END_REF][START_REF] Thairu | Sociocultural influences on infant feeding decisions among HIV-infected women in rural Kwa-Zulu Natal, South Africa[END_REF] and exclusive breastfeeding [START_REF] Abiona | Acceptability, feasibility and affordability of infant feeding options for HIVinfected women: a qualitative study in south-west Nigeria[END_REF][START_REF] Becquet | Acceptability of exclusive breastfeeding with early cessation to prevent HIV transmission through breast milk, ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d'Ivoire[END_REF][START_REF] Bland | Infant feeding counseling for HIV-infected and uninfected women: appropriateness of choice and practice[END_REF][START_REF] Bland | Breastfeeding practices in an area of high HIV prevalence in rural South Africa[END_REF][START_REF] Doherty | A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa[END_REF][START_REF] Piwoz | An education and counseling program for preventing breastfeeding-associated HIV transmission in Zimbabwe: design and impact on maternal knowledge and behavior[END_REF][START_REF] Poggensee | Infant feeding practices in western Tanzania and Uganda: implications for infant feeding recommendations for HIV-infected mothers[END_REF] among HIV-positive women, an extensive literature review indicates that few studies have examined factors affecting early breastfeeding cessation [START_REF] Abiona | Acceptability, feasibility and affordability of infant feeding options for HIVinfected women: a qualitative study in south-west Nigeria[END_REF][START_REF] Becquet | Acceptability of exclusive breastfeeding with early cessation to prevent HIV transmission through breast milk, ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d'Ivoire[END_REF] and no studies have explored this topic among HIV-positive women receiving a prolonged course of HAART for PMTCT.

Methods

This Eighteen participants, all aged 18 years or above, were selected based on their breastfeeding status. Ten participants stopped breastfeeding and eight continued breastfeeding beyond six months when HAART was discontinued. Participants in both groups were similar with regard to age and parity, and were evenly distributed in their duration in the study. No participants were receiving HAART at the time of this substudy. Women were recruited during routine KiBS clinic visits or were invited to come if they lived nearby. Women were compensated with a bar of soap and a fixed amount to cover transportation.

Data collection

The

Data analysis

Interviews were audiotaped, transcribed, and translated into English. Transcription was performed by interviewers. Quality control was enhanced by comparing a random sample of early transcripts to taped interviews to detect transcription errors and correct them. Using the framework approach [START_REF] Pope | Qualitative Research in Health Care[END_REF], data analysis consisted of five steps: (1) familiarization (listed recurrent themes by reading the translated transcripts);

(2) identifying a thematic framework (identified major themes by which data could be examined); (3) indexing (applied thematic framework to all data); ( 4) charting (created charts containing summaries);

(5) mapping and interpretation (used charts to find associations between themes). The statistical analysis was conducted using SPSS 13.0 (SPSS Inc., Chicago, IL). Interview transcripts were read multiple times by two authors to identify recurring themes. Analysis by two authors, one of whom was a member of the predominant local tribe, allowed minimization of subjective interpretations and ensured a high degree of inter-rater consensus.

The thematic framework was reviewed several times to ensure that all data was included.

Ethical approval

Ethical approval was obtained from the Kenya Medical Research Institute and the U.S.

Centers for Disease Control and Prevention. All women provided written informed consent.

Results

Demographic and socioeconomic factors

Demographic and socioeconomic characteristics of participants are shown in Table 1.

Seventy percent of participants who stopped breastfeeding and 75% who continued felt that the cost of replacement food did not affect their feeding decisions. Among those who continued breastfeeding, two mothers said cost played a role in their decisions.

Emotional aspects of breastfeeding

All mothers who continued breastfeeding and 80% of mothers who stopped felt that breastfeeding is important in developing an emotional bond with their baby.

"When you breastfeed, it's very important because the baby will be strong and that makes me feel that I'm a mother." (Age 23; one child; small business operator; continued breastfeeding)

Sadness and loneliness associated with breastfeeding cessation

Seventy percent of mothers who stopped breastfeeding did not feel sad or lonely about breastfeeding cessation. One mother was happy to stop breastfeeding so she could look for work. Another was embarrassed about breastfeeding and felt relieved to stop. In the group that continued breastfeeding, three mothers expressed sadness about breastfeeding cessation. Among those participants who expressed sadness, several said they felt better after successfully weaning their babies and two mentioned prayer as a way of coping with their sadness.

Benefits of breastfeeding and concerns about cessation

All mothers who continued breastfeeding and 70% of those who stopped believed that breastfeeding is beneficial. Several said breastfeeding protects the baby from other diseases and one mentioned that breastfeeding prevents pregnancy. Among those expressing concern about cessation, some were worried about their baby's health while others were apprehensive about the weaning process.

"Some people say that if you don't breastfeed, then the baby will be weak and other diseases will attack the baby, so breastfeeding protects these diseases that make the baby weak.

Knowledge about MTCT and consequences of continued breastfeeding

Participants received information about MTCT through KiBS, churches, clinics, traditional birth attendants, community members, and other HIV-positive mothers.

Knowledge about MTCT and the consequences of breastfeeding are shown in table 4.

Discussion

The results of this substudy demonstrate that many factors play a role in a mother's decision to stop or continue breastfeeding. Demographic and socioeconomic factors that appeared to increase compliance with recommendations included higher educational status, employment, and reliance on others for income. Education may increase awareness about MTCT and infant feeding options [START_REF] Bland | Breastfeeding practices in an area of high HIV prevalence in rural South Africa[END_REF]. In a related study in Côte d'Ivoire, [START_REF] Painter | Sociodemographic factors associated with participation by HIV-1-positive pregnant women in an intervention to prevent mother-to-child transmission of HIV in Cote d'Ivoire[END_REF] found that women who participated in a MTCT intervention were more educated and less dependent on others for income than those who did not participate. In this substudy, most participants in both groups did not feel that the cost of replacement food influenced infant feeding decisions. This finding conflicts with those of a previous Kenyan study, which reported the importance of cost in such decisions [START_REF] Kiarie | Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya[END_REF].

However, women in KiBS were encouraged to use locally available foods for replacement, which are considerably cheaper than formula.

Among the psychosocial factors, partner and family support were the most important in helping women stop breastfeeding. All mothers that stopped breastfeeding received support from their partner or other family members and all mothers who continued breastfeeding lacked partner or family support. In Côte d'Ivoire, [START_REF] Becquet | Acceptability of exclusive breastfeeding with early cessation to prevent HIV transmission through breast milk, ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d'Ivoire[END_REF] also found that women who failed to achieve early cessation were under pressure from the partner's family to continue breastfeeding. In Kenya, focus groups revealed that partner support is an important factor influencing infant feeding decisions [START_REF] Kiarie | Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya[END_REF]. Disclosure of HIV status was more common among those who stopped breastfeeding. However, in Kenya, [START_REF] Gaillard | Vulnerability of women in an African setting: lessons for mother-to-child transmission prevention programs[END_REF] found that only one third of HIV-positive, pregnant women in a stable relationship disclosed their status to their partner. Two studies in South Africa revealed the perceived importance of breastfeeding in developing an emotional bond with the baby (Hilderbrand et [START_REF] Hilderbrand | The prevention of mother-to-child HIV transmission program and infant feeding practices[END_REF][START_REF] Seidel | Experiences of breastfeeding and vulnerability among a group of HIV-positive women in Durban, South Africa[END_REF] and a Malawian study found that concerns regarding infant nutrition were a barrier to early cessation [START_REF] Piwoz | Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counselling messages of health workers in Lilongwe, Malawi[END_REF].

Cultural factors affecting compliance included the local custom of breastfeeding for approximately two years and fear of being stigmatized due to early cessation. These findings were similar to those found in a Zimbabwean study [START_REF] Piwoz | An education and counseling program for preventing breastfeeding-associated HIV transmission in Zimbabwe: design and impact on maternal knowledge and behavior[END_REF].

Limitations

This substudy has a few limitations. The small sample size and single site limits the generalizability of the results. Further, the study was conducted among clinical trial participants rather than the general population of HIV-positive breastfeeding women.

Conducting the interviews at the trial clinic and using tape recorders may have made participants feel vulnerable. Given the repeated counseling on breastfeeding cessation at six months, participants may have biased their responses in order to please interviewers.

Recommendations

The WHO recommends replacement feeding when it is culturally acceptable, affordable, feasible, sustainable, and safe. In many resource-poor settings, these criteria are not met and exclusive breastfeeding is therefore recommended for the first six months followed by breastfeeding with complementary foods until provision of an adequate diet without breastmilk is possible (WHO, 2006). In the context of limited resources and risk of HIV infection, the challenge is to determine the right age to transition to replacement feeding with Despite the counseling participants receive throughout KiBS, some continue to breastfeed after discontinuation of HAART. Because support of the male partner appears important in determining whether a mother will stop breastfeeding, couples counseling and testing may be an effective way to involve the partner in MTCT interventions and allow him to understand the importance of compliance. This recommendation is in agreement with those made by previous authors [START_REF] Eide | Social consequences of HIV-positive women's participation in prevention of mother-to-child transmission programs[END_REF][START_REF] Farquhar | Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission[END_REF][START_REF] Gaillard | Vulnerability of women in an African setting: lessons for mother-to-child transmission prevention programs[END_REF]. In Kisumu, men seldom accompany their partners to antenatal clinics. Involvement of the male partner in the antenatal process may also improve compliance. In order to promote safe disclosure of HIV status, counseling should address stigma and potential negative consequences of disclosure [START_REF] Eide | Social consequences of HIV-positive women's participation in prevention of mother-to-child transmission programs[END_REF][START_REF] Gaillard | Vulnerability of women in an African setting: lessons for mother-to-child transmission prevention programs[END_REF]. Counseling should continue into the postpartum period.

Outreach to community leaders and other influential persons may increase social support for HIV-positive mothers and could modify cultural norms for breastfeeding cessation (T.M. Painter, personal communication, June 22, 2006). Support groups with other HIV-positive mothers would allow women to share experiences. The involvement of churches and community groups may also increase awareness about MTCT, thereby increasing uptake and compliance with interventions.

Additional studies should be conducted to confirm these results. Studies are also needed to determine the optimal age to transition to replacement feeding in resource-poor settings and to establish appropriate counseling to help women comply with infant feeding recommendations. While this study was done among participants who received HAART for six months postpartum, the findings highlight some issues that may be important in

  Factors affecting breastfeeding cessation after discontinuation of antiretroviral therapy to prevent motherto-child transmission of HIV Introduction Mother-to-child transmission (MTCT) of HIV is a devastating problem. Worldwide, approximately 420,000 new pediatric HIV infections occurred in 2007 (UNAIDS, 2007).

  study utilized qualitative research methodology through semi-structured interviews with participants. All interviews were conducted in June and July 2006. The interview guide was developed in English and translated into Kiswahili and Dholuo. The interview guide employed open-ended questions about a broad range of potential factors while allowing the interviewers to ask additional questions on emerging themes. The mean interview length was 31 minutes. Three female interviewers conducted the interviews in a private setting in the language of the participant's choice. Data validity was supported by the fact that the interviewers were local women who spoke the predominant languages, Dholuo and Kiswahili. The interviewers were familiar with the techniques of field research and had previous interviewing experience. The protocol and interview guide were discussed in detail with the interviewers to ensure they understood the study objectives. Pilot interviews were and revise unclear interview questions and provide additional training to interviewers on areas of weakness.

  wean infants from breastmilk as soon as they are strong enough to withstand the risks of replacement feeding. It is also important to explore interventions that allow women to breastfeed without increasing their risk of MTCT.

"

  My husband refused that I should not stop breastfeeding the baby. Anytime I wanted to remove or stop the baby from breastfeeding, my husband could make a lot of noise… He didn't allow me to stop breastfeeding, so I decided to continue breastfeeding to be at peace."

	All mothers that stopped breastfeeding received support from their partner or other family
	members to stop breastfeeding.
	"My mom, when she got the news, she just told me to be free because it's something that (Age 24; two children; small business operator; continued breastfeeding)
	happened, something people have, so she just told me not to be stressed, not to be afraid.
	She'd be there in case of any problem." (Age 25; one child; unemployed housewife; stopped
	F o r breastfeeding) However, several faced questions from family members regarding their decision to stop F o r
	P breastfeeding. They responded with excuses for breastfeeding cessation, such as working or P
	looking for a job.	e e r e e r
		R R
		e e
		v i e v i e
		w w
	Psychosocial factors Psychosocial factors affecting compliance with breastfeeding recommendations are O n l O n l
	shown in table 2.	y y
	"My husband saw that I have never stopped breastfeeding a baby with those months and he
	didn't like the baby being stopped like that. So he was saying that the baby needs to be
	breastfed until he leaves (stops) on his own." (Age 25; three children; unemployed
	Partner and family support housewife; continued breastfeeding)
		9 10

"When the baby was able to take porridge, the follow-up staff told me to mix soya beans and finger millet for the baby's porridge, but this was not available unless you buy them, and these things were affecting my decision to stop breastfeeding the baby." (Age 37; four children; small business operator; continued breastfeeding) "It's only my uncle who was against it because he felt I was to breastfeed the baby up to around three years. But I told him I could not breastfeed to that extent because I'm somebody who stays alone and must look for how the baby can eat. So I had to leave breastfeeding because I wanted to go and look for a job." (Age 25; one child; unemployed housewife; stopped breastfeeding) Among mothers who continued breastfeeding, all lacked support from either the partner or other family members to stop breastfeeding. Most lacked support from both.

Table 1 .

 1 Demographic and socioeconomic factors

	determining if women meet WHO criteria for replacement feeding. If interventions such as
	those used in KiBS are implemented on a wider scale, then the findings are of additional
	significance for the future.
	F o r
	P
	e
	e r
	R
	e
	v i e
	w
	O n l
	y
	17

*Melissa C. Morgan. Email: Melissa.Morgan@stx.oxon.org

Table 4 .

 4 Knowledge about MTCT and consequences of continued breastfeeding

	Factor	Discontinued breastfeeding	Continued breastfeeding
		(N=10)	(N=8)
	Knew infant could become	9 (90%)	6 (75%)
	HIV-infected if breastfeeding
	continued
	Learned about MTCT from	4 (40%)	3 (38%)
	persons in the community
	Shared knowledge gained	9 (90%)	5 (63%)
	from the study with others
	Person with whom they	9/9 (100%)	1/5 (20%)
	shared knowledge was
	supportive

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Acknowledgements

We would like to thank the mothers who were interviewed for this study. We wish to acknowledge Phoebe Okola, Jane Omanga, and Mary Othanya at the Kenya Medical Research Institute and Centers for Disease Control and Prevention in Kisumu for conducting the interviews and assisting with transcription and translation. We would also like to acknowledge the following staff at the Kenya Medical Research Institute and Centers for Disease Control and Prevention in Kisumu: John Okanda, Richard Ndivo, and Vitalis Sewe. We also thank Dr. Michael Thigpen and Dr. Thomas Painter at the Centers for Disease Control and Prevention in Atlanta for commenting on the study protocol. Finally, we thank Dr. Harold Jaffe and Dr. Premila Webster at the Department of Public Health, University of Oxford for commenting on the study protocol and manuscript. This study was supported by the Department of Public Health at the University of Oxford. This paper is published with approval of the Acting Director of the Kenya Medical Research Institute.


Mogens Bernsdorf

Christian Ingvar

Leif Jörgensen

Malgorzata K Tuxen

Erik H Jakobsen

Anna Saetersdal

Marie Louise Kimper-Karl

Niels Kroman

Eva Balslev

Bent Ejlertsen

Mogens Bernsdorf¹

Effect of adding gefitinib to neoadjuvant chemotherapy in estrogen receptor negative early breast cancer in a randomized phase II trial

à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction

The long term outcome of NAC has been investigated in large randomized trials, which neither have been able to detect a difference in disease free survial (DFS) or overall survival (OS), when compared to adjuvant chemotherapy [START_REF] Rastogi | Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27[END_REF][START_REF] Kaufmann | Recommendations from an international expert panel on the use of neoadjuvant (primary) systemic treatment of operable breast cancer: new perspectives 2006[END_REF][START_REF] Mauri | Neoadjuvant versus adjuvant systemic treatment in breast cancer: a meta-analysis[END_REF][START_REF] Mieog | Preoperative chemotherapy for women with operable breast cancer[END_REF].

Systemic NAC may result in local tumor regression or even pathologic complete response (pCR). The complete eradication of detectable tumor is a prognostic marker, associated with improved outcome [2;5-7]. Tumors with absence of estrogen (ER) and progesterone (PgR) receptors have higher response rates to NAC and are more likely to achieve a pCR [5;6;8;9]. Epidermal growth factor receptor (EGFR) is a transmembrane receptor with tyrosine kinase activity, which stimulates a series of intracellular pathways responsible for cell proliferation, downregulating apoptosis, invasion, metastasis and angiogenesis [10;11]. Although studies have demonstrated an inverse relationship between the expression of ER and EGFR [START_REF] Kaufmann | Recommendations from an international expert panel on the use of neoadjuvant (primary) systemic treatment of operable breast cancer: new perspectives 2006[END_REF][START_REF] Mauri | Neoadjuvant versus adjuvant systemic treatment in breast cancer: a meta-analysis[END_REF][START_REF] Mieog | Preoperative chemotherapy for women with operable breast cancer[END_REF][START_REF] Dieras | Randomized parallel study of doxorubicin plus paclitaxel and doxorubicin plus cyclophosphamide as neoadjuvant treatment of patients with breast cancer[END_REF][START_REF] Bear | Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer:National Surgical Adjuvant Breast and Bowel Project Protocol B-27[END_REF][START_REF] Ciardiello | Antitumor effect and potentiation of cytotoxic drugs activity in human cancer cells by ZD-1839 (Iressa), an epidermal growth factor receptor-selective tyrosine kinase inhibitor[END_REF][START_REF] Colleoni | Chemotherapy is more effective in patients with breast cancer not expressing steroid hormone receptors: a study of preoperative treatment[END_REF][START_REF] Von | Doxorubicin with cyclophosphamide followed by docetaxel every 21 days compared with doxorubicin and docetaxel every 14 days as preoperative treatment in operable breast cancer: the GEPARDUO study of the German Breast Group[END_REF][START_REF] Mendelsohn | Status of epidermal growth factor receptor antagonists in the biology and treatment of cancer[END_REF][START_REF] Ciardiello | EGFR antagonists in cancer treatment[END_REF][START_REF] Faratian | Predictive markers in breast cancer--the future[END_REF][START_REF] Mcclelland | Enhanced epidermal growth factor receptor signaling in MCF7 breast cancer cells after long-term culture in the presence of the pure antiestrogen ICI 182,780 (Faslodex)[END_REF][START_REF] Sainsbury | Epidermal-growth-factor receptors and oestrogen receptors in human breast cancer[END_REF], and suggested a connection between EGFR and the basal-like phenotype [12;15;16], the function and clinical significance of EGFR in breast cancer are still poorly understood. Preclinical in vivo [7;17] and in vitro [7;13] studies have shown that gefitinib (Iressa , Astra Zeneca), a selective EGFR tyrosine kinase inhibitor, exhibits anti-proliferative and anti-tumor activity in breast cancer. Although anti-EGFR agents, like gefitinib, excert their effect through the EGF receptor, a connection between EGFR expression and the clinical activity of the EGFR directed drugs has not clearly been demonstrated [11;17;18]. Amplifications and mutations of EGFR are rarely seen in breast cancer [11;12;19;20] thus limiting their clinical utility as predictive markers. Furthermore it is hypothesized that gefitinib can both potentiate the effect [7;17] and cause a reversal of resistance to anthracyclines [START_REF] Yang | Gefitinib reverses chemotherapy resistance in gefitinib-insensitive multidrug resistant cancer cells expressing ATP-binding cassette family protein[END_REF].

Triple-negative breast cancer (TNBC) is characterized by the lack of expression of ER, PgR and human epidermal growth factor receptor 2 (HER2) and has been associated with an increased pCR rate compared to non-TNBC [START_REF] Liedtke | Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer[END_REF].

NAC containing anthracycline has by far been the most extensively studied cytotoxic combination and the combination of epirubicin and cyclophosphamide (EC) for a duration of 4-6 cycles is an effective regimen and remains a standard in neoadjuvant treatment of breast cancer patients [2;23;24]. The anthracyclines, epirubicin and doxorubicin, have similar cytotoxic effect and have been combined with and compared to other cytotoxic drugs, with no combination clearly being superior to the other [23;24]. With the introduction of molecular targeted drugs into cancer treatment, there are a great number of agents for evaluation in combination with anthracycline and taxane based therapy, with the objective of increasing the pCR rate. This randomized phase II trial (NCT 00239343) was designed to compare pCR after four cycles of EC plus gefitinib to four cycles of EC plus placebo in patients with ER negative breast cancer.

Patients and Methods

Study Design

NICE was a Nordic phase II, multicenter, two-armed double-blind randomized trial involving 12 centers in Denmark, Norway and Sweden examining the effect of adding gefitinib to EC. In addition, a correlative science study was conducted including blood samples and tumor biopsies taken before and after four cycles of EC and gefitinib or placebo. Results from the correlative science studies will be reported elsewhere.

Ethical committees approved the study protocol and the study was conducted according to the Helsinki declaration. All study participants provided written informed consent. This trial is registered on the ClinicalTrials.gov website, NCT 00239343.

Patients

Eligible patients were women with unilateral, primary operable, ER negative invasive breast cancer 2 cm. Exclusion criteria included inflammatory breast cancer, involvement of skin or muscle, involvement of supraclavicular lymph nodes or evidence of distant metastases, a history of unstable or uncompensated respiratory, cardiac, hepatic or renal disease.

Patients were randomized sequentially in a 1:1 ratio when eligibility had been established.

Treatment

Patients were randomly assigned to either four cycles of EC (epirubicin 90 mg/m 2 and cyclophosphamide 600 mg/m 2 ) plus 12 weeks of daily treatment with gefitinib 250 mg or EC plus 12 weeks treatment with placebo. Chemotherapy was administered every 3 weeks.

Gefitinib and placebo tablets were of identical appearance and package and no personnel with direct connecion to the study had acces to randomization code or unblinded data until database had been unlocked.

Treatment with chemotherapy was postponed, if blood counts on day 1 showed leukocytes below 2.5 x 10 9 /l or platelets below 50 x 10 9 /l, until these values were again reached.

Unless reached within two weeks or following febrile neutropenia grade 4 or leucopenia grade 4, epirubicin was reduced by 15 mg/m² and cyclophosphamide by 100 mg/m² in subsequent courses. Other toxicities related to epirubicin and/or cyclophosphamide was handled at the investigators discretion. Dose interruptions for up to maximum 14 days were the first approach to managing toxicity related to gefitinib. Dose reduction for gefitinib was not allowed.

After four cycles of EC and placebo or gefitinib, patients underwent mastectomy or breast conserving surgery, including surgical removal of residual tumor and surrounding tissue.

Postoperatively, patients received additional chemotherapy, trastuzumab and radiotherapy, according to local guidelines.

Assessments

Upon study entry and prior to surgery, tumor assessment consisting of breast palpation, mammography and breast ultrasonography was performed. In case of disagreement regarding tumor size, the ultrasonography prevailed. Blood samples and core biopsies were taken before initiation of trial medication. Breast palpation was also performed before each series of chemotherapy. A medical history including assessment of adverse events (AE) and a clinical examination were recorded at each 3-week visit.

Endpoints

The primary endpoint was pCR defined as no evidence of invasive cancer in the breast.

A central review of pathologic tumor response in all patients, was conducted on tumor sections or blocks by one independent pathologist (EB) at Department of Pathology, Herlev Hospital, Copenhagen. The independent pathologist's decision on pathologic response was used as final assessment.

Secondary endpoints were complete (CR) and overall objective tumor (OR) response as assessed by the response evaluation criteria in solid tumors (RECIST) criteria. CR was defined as complete disappearance of tumor. A tumor regression of >30% was defined as a partial response (PR) whereas tumor progression >20% was considered progression of disease (PD). A tumor that neither fulfilled the criterion for PR or PD was considered stable disease (SD).

All secondary endpoints was reported by the investigators.

The severities of AEs were graded according to the National Cancer Institute Common Toxicity Criteria (NCI CTC vs. 2.0).

Immunohistochemistry and Flouroscence In Situ Hybridization

ER and PgR immunostaining was carried out according to local guidelines prior to inclusion, and classified as negative if less than 10% of cells were stained. Frozen and formalin fixed paraffin-embedded (FFPE) tumor tissue was collected at baseline and at the time of definitive surgery.

All FISH analyses were performed at the Department of Pathology, Herlev Hospital, Copenhagen. HER2 copy number was visualized by FISH (HER2 pharm Dx , Dako, Glostrup, Denmark) according to the manufacturer's instructions. Tumors were scored as HER2 positive or amplified when the gene to centromere 17 ratio was 2.

Statistical analysis

This trial was designed to demonstrate that the addition of gefitinib to an EC regime would increase the pCR rate. We estimated that 77 patients per arm would be needed in order for the study to have a 90% power to detect a standardized difference of 0.526 at a 2sided 5% significance level in a given parameter.

All patients that were enrolled, randomized and received study treatment were considered the intention to treat population (ITT). The analysis population for all efficacy endpoints was the per protocol population (PP) and for the safety endpoints the ITT population was used for analysis. The PP consisted of those subjects from the ITT population that were not major protocol deviators, and subjects included in the PP were to be fully evaluable; adequate tumor sample for histological analysis at baseline and at surgery. Patients who completed treatment but had poor compliance, defined as number of missed doses exceeding 20% and/or less than 10 consecutive days of treatment immediately prior to surgery at 12 weeks, were considered major protocol deviators and excluded from the PP.

Prior to unblinding, protocol deviators, major and minor, were identified to ascertain the PP population.

The primary and secondary variables were analysed by a Chi-square test to find the percentage of patients responding in the two groups and a p-value for the difference. The Fisher´s exact test was used in subgroup analysis, to evaluate differences in pCR between triple negative and non-triple negative tumors.

Results

A total of 181 patients were randomized from October 2004 to May 2007 into this study (figure 1). One patient randomized to the placebo group discontinued the study before receiving any treatment, leaving 180 patients in the ITT population; comprising 94 patients assigned to the gefitinib group and 86 assigned to the placebo group. Baseline characteristics were well balanced in the two groups, but HER2 amplification was more common in the placebo (37.2%) than in the gefitinib (23.4%) group (table 1).

In all 158 patients completed treatment, while the remaining 23 (12.7%) patients discontinued treatment due to adverse events (AE) (11 patients), progression of disease (3 patients), non-eligible (5 patients) and other reasons (4 patients). Another 14 patients, who completed treatment, were retrospectively identified as major protocol deviators and excluded from the PP leaving 144 subjects in the PP, comprising 71 patients in the gefitinib group and 73 in the placebo group. Major protocol deviations leading to exclusions included primary tumor under 2.0 cm (8 patients), primary tumor being ER positive (5 patients) and safety reasons (12 patients) (table 2). Patients with primary tumor being either < 2.0 cm or ER postive were erroneously included.

Tumor parameters

The mean tumor size, measured by palpation, mammography and ultrasonography, was comparable between the two treatment groups, with ultrasonography showing a mean diameter of 3.0 cm (range 2-8 cm) in gefitinib treated patients and 3.3 cm (range 2-12 cm) in the placebo group. Table 4 summarizes baseline target tumor evaluation (RECIST criteria) for the PP.

Tumor Response

All tumor response data has been reviewed centrally, showing only minor deviations compared to investigators' data. All tumor response data presented are investigators. No significant differences in response across the evaluation parameters were recorded at the time of surgery between the treatment groups. Table 5 summarizes pathologic and clinical tumor responses in the PP population. Pathologic complete response was observed in 17% of patients treated with gefitinib (12/71) and in 12% of patients treated with placebo (9/73) with a difference of 4.57% (95% CI, -7.19 -16.33; p= 0.44). There was no difference in CR as this was observed in 10% of patients in both the gefitinib (7/71) and placebo group (7/73) with a difference of 0.27% (95% CI, -9.61 -10.2; p=0.96). The ITT population showed similar results (p=0.86).

A non-significant difference in OR (5.96%; 95% CI, -9.94 -21.86; p=0.45) was observed between the two groups, with a tumor response observed in 68% (48/71) of patients treated with gefitinib, 62% (45/73) in the placebo group and 65% (93/144) combined.

At the time of surgery a PD was observed in two patients in the placebo group (2/73, 2.7%) and in 5 (7.0%, p=0.23) patients treated with gefitinib.

Post-hoc subgroup analysis showed a significant difference (p=0.03) in pCR between TNBC and tumors that were either HER2 and/or PgR positive independent of treatment.

12 of 82 TNBC (gefitinib: 7/41, placebo: 5/41) achieved a pCR (15%) compared to 1 of 48 that were non-TNBC (2%). TNBC-status could be established on 130/144 tumors. A pCR was seen in 8 of the 14 tumors, where TNBC-status could not be established.

Toxicity

The addition of gefitinib was associated with a higher incidence of AEs and the most frequently reported in both groups were nausea, alopecia and fatigue. The incidence of diarrhoea and rash/acne/dermatitis were more frequent in the gefitinib group (49, 52%), than in the placebo group (17, 20%), and were the most common reported AEs leading to discontinuation and they were reported only in the gefitinib group. More patients from the gefitinib group (9/94) discontinued treatment, than in the placebo group (2/86), due to AEs.

The patients in the gefitinib group suffered more serious adverse events (SAE) than patients in the placebo group. Febrile neutropenia was observed in 17 out of 94 patients (18.1%) in the gefitinib group and in 8 out of 87 patients (9.2%) from the placebo group.

No deaths were reported. The most frequent SAE´s and their distribution across the treatment groups are listed in table 3.

Discussion

The addition of gefitinib to EC in a neoadjuvant setting was expected to increase the rate of pCR. This expectation, was based on preclinical studies showing that gefitinib had both anti-proliferative and anti-tumor activity, as well as indicating a synergy between gefitinib and anthracycline [7;13;17]. Our results demonstrate, that the EGFR inhibitor gefitinib does not increase pCR rate in a neoadjuvant setting among ER negative breast cancer patients.

Furthermore, the addition of gefitinib to an EC regimen did not result in an increase of CR or OR rates, therefore not supporting a possible synergy between gefitinib and anthracycline.

The addition of gefitinib to EC resulted in an increase in toxicity, and discontinuations of treatment due to AEs were more frequent in the gefitinib group (9/94) than in the placebo group (2/84). More importantly, the incidence of SAE's was higher in the gefitinib group, due to more episodes of febrile neutropenia. Other studies, that have reported on adverse events with gefitinib, have not observed a higher incidence in hematologic toxicities in the gefitinib arm, but otherwise reported similar adverse events [10;25].

With no other antineoplastic treatment than the study drug, administered before or during the study, the results are without influence from other therapeutics, and therefore resemble the direct effect of EC with and without gefitinib on both primary and secondary endpoints. This trial had a biological hypothesis and the outcome is a strong indicator for no further evaluation of gefitinib in this setting. Amplification of HER2 has been associated with sensitivity to anthracycline [26;27] and a higher proportion of HER2 amplified tumors in the placebo group, could indicate a randomization problem and have concealed an effect of gefitinib. The latter though, seems unlikely since only 2 patients, in both the geftinib group (17%) and the placebo group (22%), that obtained a pCR were HER2 amplified. Molecular profiling methods have been used to identify clinically relevant subtypes and propose a new classification of breast cancer. The subtypes are defined by their genetic expression profiles and include: normal breast-like, luminal-like A, luminal-like B, HER2 positive and basal-like subtypes. Studies have suggested a connection between the basallike subgroup and overexpression of EGFR [START_REF] Nielsen | Immunohistochemical and clinical characterization of the basal-like subtype of invasive breast carcinoma[END_REF]. Although, no connection between EGFR expression and response to anti-EGFR therapy [10;11;17] has been demonstrated, choosing a different subgroup of patients, other than ER negative, might have been more appropriate, but remains unclear and needs further scientific investigation. As of now, there is no clear way to select patients that would benefit from anti-EGFR treatment in breast cancer [START_REF] Faratian | Predictive markers in breast cancer--the future[END_REF]. However, post-hoc subgroup analysis of our data showed that TNBC were more likely to achieve a pCR than non-TNBC, which is in line with a previously published study [START_REF] Liedtke | Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer[END_REF]. Additional biomarker studies, which might add information on how to select appropriate patients, are in the progress.

The results of our study are similar to other neoadjuvant studies with regards to both clinical response and pCR. Others have previously reported similar pCR rates between ER positive and ER negative tumors in a prospective neoadjuvant trial [START_REF] Buzdar | Significantly higher pathologic complete remission rate after neoadjuvant therapy with trastuzumab, paclitaxel, and epirubicin chemotherapy: results of a randomized trial in Mean[END_REF], but a higher OR in an ER negative based patient group was expected, since several studies [5;6;8;9], in subgroup analysis, have showed that ER negative tumors are more sensitive to chemotherapy than ER positive tumors. We did not observe an improved combined OR in our trial, as a OR of 65% is in accordance with studies [5;6;8;9] that included patients with mixed ER status.

Whether or not, as indicated by others [START_REF] Faratian | Predictive markers in breast cancer--the future[END_REF][START_REF] Mcclelland | Enhanced epidermal growth factor receptor signaling in MCF7 breast cancer cells after long-term culture in the presence of the pure antiestrogen ICI 182,780 (Faslodex)[END_REF][START_REF] Sainsbury | Epidermal-growth-factor receptors and oestrogen receptors in human breast cancer[END_REF], an inverse relationship between EGFR and ER expression exists, awaits conduction of further gene expression analysis. If such an inverse relationship exists, the mechanism of action of gefitinib may be, as anticipated by others [10;11;17;18], more than simple inhibition of the EGFR tyrosine kinase.

A combination regimen, consisting of anthracycline and taxane-based chemotherapy is now the treatment of choice for neoadjuvant treatment of breast cancer, since both the NSABP-B27 and the Gerparduo trials showed increased pCR rates with the addition of a taxane [6;9]. Whether this increase in pCR will improve long-term patient outcome is still unknown. In our study, patients were given postoperative chemotherapy by investigators choice.

Molecular targeted treatment provides opportunities for these agents to be added to chemotherapeutic regimens, but still requires assessment and monitoring of molecular, pathologic and genetic markers that may or may not predict response to a specific regimen. So far, anti-HER2 treatment is the only molecular targeted drug that has demonstrated effect in randomized neoadjuvant breast cancer trials [START_REF] Buzdar | Significantly higher pathologic complete remission rate after neoadjuvant therapy with trastuzumab, paclitaxel, and epirubicin chemotherapy: results of a randomized trial in Mean[END_REF] and since a clinical benefit of treatment with EGFR inhibitors in breast cancer patients has not been established, there is a need for identification and clinical validation of useful criteria for selecting patients that potentially could benefit from such treatment.

Acknowledgment

The study was sponsered by Astra Zeneca. We would like to thank the following centers for provision of

  study material: Sweden: Malmö Hospital and Lund University Hospital. Norway: Trondheim Hospital and Rikshospitalet-Radiumhospitalet Oslo. Denmark: Herlev Hospital, Aarhus University Hospital, Odense University Hospital, Vejle Hospital, Roskilde Hospital, Naestved Hospital and Ringsted Hospital. Contribution of Charlotte Levin Tykjaer Jörgensen is gratefully acknowledged. human epidermal growth factor receptor 2-positive operable breast cancer. J Clin Oncol 23:3676-85.

Table 1 .

 1 Pretreatment patient and tumor characteristics (ITT population)

		Gefitinib (n=94)	Placebo (n=86)
	Characteristics	Number (n)	Percent (%)	Number (n)	Percent (%)
	Age, years
	Mean	53		53,1
	SD	10.2		10.5
	Range	32, 74		31, 74
	Histology
	Ductal	84	94.4	76	95
	Lobular	3	3.4	2	2.5
	Other	2	2.2	2	2.5
	Missing	5		6
	Histologic grade
	I	1	1.1	1	1.2
	II	40	45.0	36	44.5
	III	48	53.9	44	54.3
	Missing	5		5
	Tumor status
	< 30 mm	52	55.3	41	47.7
	31 -50 mm	36	38.3	37	43.0
	> 51 mm	6	6.4	8	9.3
	HER2
	Normal	56	59.6	46	53.4
	Amplified	22	23.4	32	37.2
	Unsuitable	16	17.0	8	9.3
	SD: Standard deviation.
	ITT: Intention to treat.

Table 2 .

 2 Major protocol deviations leading to exclusions from PP population

	Gefitinib (n=94)	Placebo (n=86)
	(n, percent)	(n, percent)

Number of patients with at least 1 major deviation

	Objective progression of disease during study period	1 (1.1)	2 (2.3)
	Premature discontinuation for other reasons	2 (2.1)	1 (1.2)
	No adequate tumor sample	-	2 (2.3)
	Patients may have more than one major protocol deviation
	PP: Per protocol.
		23 (24.5)	13 (15.1)
	Deviation
	Tumor 2cm	6 (6.4)	2 (2.3)
	Estrogen receptor positive	3 (3.2)	2 (2.3)
	Distant metastases or bilateral breast cancer	-	1 (1.2)
	Discontinuation because of safety reasons	10 (10.6)	2 (2.3)
	Compliance	4 (4.3)	2 (2.3)
	Less than 10 consecutive days of treatment prior to surgery at 12 weeks	17 (18.1)	6 (7.0)

Table 3 .

 3 The most frequent SAE's (ITT population)

		Gefitinib (n=94)	Placebo (n=86)
		(n, percent)	(n, percent)
	Febrile Neutropenia	17 (18.1)	8 (9.3)
	Fever	3 (3.2)	4 (4.7)
	Leukopenia	1 (1.1)	2 (2.3)
	Total patients with SAE	25 (26.6)	14 (16.3)
	Total number of SAE's	43 (45.7)	24 (27.9)
	SAE: Severe adverse event
	ITT: Intention to treat.

Table 4 .

 4 Baseline target tumor evaluation, PP

		Gefitinib	Placebo	Total
		(n=71)	(n=73)	(n=144)
	Longest diameter-physical (cm)
	n	67	72	139
	Mean (SD)	4.1 (1.7)	4.6 (2.2)	4.3 (2.0)
	Median	4.0	4.0	4.0
	Range	1, 9	0, 14	0, 14
	Longest diameter -x-ray (cm)
	n	62	59	121
	Mean (SD)	3.4 (1.7)	3.6 (1.5)	3.5 (1.6)
	Median	3.0	3.0	3.0
	Range	1, 12	1, 8	1, 12
	Longest diameter-ultrasound (cm)
	n	66	67	133

The study was sponsered by Astra Zeneca. We would like to thank

Gefitinib (n=71)

(n, percent)

Placebo (n=73)

(n, percent)


Workneh Gebeyehu

Henk Bogale

Erwin Boer

Ronald

Condom use among low-literate, rural females in Ethiopia: The role of vulnerability to HIV infection, condom attitude, and self-efficacy

Keywords: illiterate females, condom use, Ethiopia, psychosocial determinants condom use, psychosocial determinants, low-literate, females, Ethiopia * p < .05;

Condom use among low-literate, rural females in Ethiopia:

The role of vulnerability to HIV infection, condom attitude, and self-efficacy

(UNAIDS, 2007), with a large difference in HIV prevalence rate between urban and rural areas (Ethiopian Federal Ministry of Health, 2006). However, exact HIV prevalence figures are not known for all rural regions [START_REF] Kebede | The HIV epidemic and the state of its surveillance in Ethiopia[END_REF] and a

wide geographical variation has been found in HIV prevalence rates in rural areas with higher rates of HIV infection in the Amhara region [START_REF] Abebe | HIV prevalence in 72,000 urban and rural male army recruits in Ethiopia, 1999-2000[END_REF]Ethiopian Federal Ministry of Health, 2006). In 2005, an estimated 1.32 million people in Ethiopia were living with HIV/AIDS, about 686.000 in urban areas and 634.000 in rural areas, where 85% of the population lives (Ethiopian Federal Ministry of Health, 2006).

In Ethiopia, the most important route of transmission is unprotected heterosexual intercourse among adolescents. Sexual activities start around the age of fifteen [START_REF] Adamu | Patterns and correlates of sexual initiation, sexual risk behaviors and condom use among secondary school students in Ethiopia[END_REF] and studies among adolescents aged 17 -19 years indicate that about 40% is sexually active [START_REF] Alene | Adolescent reproductive health and awareness of HIV among rural high school students, North Western Ethiopia[END_REF][START_REF] Taffa | Reproductive health perceptions, beliefs and sexual risk-taking among youth in Addis Ababa, Ethiopia[END_REF].

About 50% of the adolescents in urban areas reported not to use condoms or to use condoms inconsistently [START_REF] Wouhabe | Sexual behaviour, knowledge and awareness of related reproductive health issues among single youth in Ethiopia[END_REF][START_REF] Adamu | Patterns and correlates of sexual initiation, sexual risk behaviors and condom use among secondary school students in Ethiopia[END_REF][START_REF] Taffa | Psychosocial determinants of sexual activity and condom use intention among youth in Addis Ababa, Ethiopia[END_REF][START_REF] Taffa | Reproductive health perceptions, beliefs and sexual risk-taking among youth in Addis Ababa, Ethiopia[END_REF]. In Ethiopia, an urban to rural spread of HIV infection has been reported [START_REF] Shabbir | Urban to rural routes of HIV infection spread in Ethiopia[END_REF] and an important route of infection is through rural males, such as farmers, merchants and students, which have unprotected sexual contacts with urban sex workers [START_REF] Shabbir | Urban to rural routes of HIV infection spread in Ethiopia[END_REF][START_REF] Adamu | Patterns and correlates of sexual initiation, sexual risk behaviors and condom use among secondary school students in Ethiopia[END_REF]. Like in many countries in Sub-Saharan Africa, young females in Ethiopia are more vulnerable for HIV infection than males [START_REF] Gregson | Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe[END_REF]Central Statistics Agency, 2006). Despite this vulnerability, level of condom use among females in rural Ethiopia is reported to be extremely low. One study found that only one percent of rural females, aged 15-24, used a condom during their first sexual intercourse (Central Statistics Agency, 2006), but detailed knowledge about levels of condom use among rural females in Ethiopia is currently lacking.

Also, little is known about the psychosocial determinants of condom use among rural females in Ethiopia, who often are low-literate. By low-literate we mean functional illiteracy, which refers to reading and writing skills that are inadequate to cope with the demands of daily life. Available studies have mainly focused on the determinants of condom use among urban youth, who are more literate [START_REF] Taffa | Psychosocial determinants of sexual activity and condom use intention among youth in Addis Ababa, Ethiopia[END_REF][START_REF] Taffa | Reproductive health perceptions, beliefs and sexual risk-taking among youth in Addis Ababa, Ethiopia[END_REF]. Efforts to develop effective interventions to promote condom use among low-literate rural females in Ethiopia require an understanding of the current level of condom use and of the main psychosocial determinants of condom use.

To date, some controversy exists on the usefulness of fear-based (or riskperception-arousing) approaches in promoting condom use in Africa [START_REF] Green | Can fear arousal in public health campaigns contribute to the decline of HIV prevalence[END_REF][START_REF] Kirby | Can fear arousal in public health campaigns contribute to the decline of HIV prevalence[END_REF][START_REF] Halparin | The controversy over fear arousal in AIDS prevention and lessons from Uganda[END_REF]. The controversy seems to focus on the role of perceived vulnerability as a main determinant of HIV preventive behaviour among young people in Africa. According to Protection Motivation Theory [START_REF] Norman | Protection motivation theory[END_REF] and the Extended Parallel Process Model [START_REF] Witte | Addressing underlying mechanisms to HIV/AIDS preventive behaviors in Ethiopia[END_REF], an awareness of perceived vulnerability to HIV infection is important to adolescents [START_REF] Witte | Addressing underlying mechanisms to HIV/AIDS preventive behaviors in Ethiopia[END_REF]. Also condom related self-efficacy is an important determinant of intended condom use among adolescents in Africa, especially among females [START_REF] Boer | Gender power imbalance and differential psychosocial correlates of intended condom use among male and female adolescents from Venda, South Africa[END_REF][START_REF] Heeren | Theory-based predictors of condom use among university students in the United States and South Africa[END_REF][START_REF] Heeren | Theory-based predictors of condom use among university students in the United States and South Africa[END_REF].

However, this does not exclude that other cognitive determinants may also be important in shaping condom use behavior among African adolescents.

According to the Theory of Planned Behaviour, attitude and subjective norm are important determinants of intended condom use [START_REF] Albarracín | Theories of reasoned action and planned behavior as models of condom use: a meta-analysis[END_REF]. Attitude refers to the association of condom use with negative hedonistic and social consequences [START_REF] Sutton | A comparative test of the Theory of Reasoned Action and the Theory of Planned Behavior in the prediction of condom use intentions in a national sample of English young people[END_REF]. Many studies among African adolescents have shown that attitude toward condom use positively relates to condom use [START_REF] Heeren | Theory-based predictors of condom use among university students in the United States and South Africa[END_REF][START_REF] Boer | Gender power imbalance and differential psychosocial correlates of intended condom use among male and female adolescents from Venda, South Africa[END_REF][START_REF] Bryan | Condom use among South African adolescents: developing and testing theoretical models of intentions and behavior[END_REF].

Subjective norm refers to the perception of approval or disapproval from significant others with regard to using condoms. Subjective norm has been found

to be an important determinant of contraception and condom use among African adolescents [START_REF] Bryan | Condom use among South African adolescents: developing and testing theoretical models of intentions and behavior[END_REF][START_REF] Boer | Social correlates of HIV protection among black adolescents in Venda, South Africa[END_REF][START_REF] Giles | Condom use in African adolescents: the role of individual and group factors[END_REF][START_REF] Fekadu | Expanding the Theory of Planned Behavior: the role of social norms and group identification[END_REF].

F

Methods

Setting and sample

This study was conducted in January 2007 in two rural Kebeles (communities), Koncher Sasaberay and Borebor Sencha, 250 km North West of Addis Ababa. The females in the communities are typical for the rural Amhara highland and were located in a remote area, five to ten kilometers away from main roads. There are no roads there and means of transportation are on foot or by horseback. Each

Kebele has ten sub-Kebeles, located at different places in the area. From each sub-Kebele ten women aged between 13 and 24 were randomly selected, in cooperation with Kebele women coordinator, based on the location of their home.

Measures

To collect the data, we used a structured questionnaire. The questionnaire was translated from English into Amharic by the first author and four native speakers of Amharic checked the translation for appropriateness of the language to the rural females. Social cognitions were assessed with 5-point Likert-items (1 = completely disagree, 5 = completely agree), derived from [START_REF] Boer | Social correlates of HIV protection among black adolescents in Venda, South Africa[END_REF][START_REF] Wouhabe | Sexual behaviour, knowledge and awareness of related reproductive health issues among single youth in Ethiopia[END_REF], and for each social cognition mean scores were computed.

Vulnerability to HIV infection was measured with one item: 'If I do not use condoms, I run a high risk of HIV/AIDS'. Response efficacy was measured with a three item scale (Cronbach's α = .98). An example of response efficacy item is:

'Using condoms will protect me against being infected with HIV'. Self-efficacy

was measured with a six item scale (α = .98). Examples of self-efficacy items are:

'I am able to talk about safe sex with my partner' and 'It will be difficult for me to interrupt sex by putting on condom'. If necessary, answers on questions were recoded such that a higher number indicates a higher score on self-efficacy. Mean score were computed. We also assessed attitude to condoms, subjective norm and intended condom use, variables from the Theory of Planned Behavior. Attitude to condoms was measured with five items (α = .79), such as 'Using condoms will make sex less enjoyable'. All items were recoded such that a higher number

Statistical analysis

All statistical analysis was performed using SPSS 16. Differences between average scale scores were tested using F tests. Relationships between variables were

Results

Table 1 shows the demographic characteristics, separately for condom users (n = 88, 44%) non-condom users (n = 112, 56%) and the total group.

---Table 1 about 2 shows that there are significant differences on psychosocial determinants between females that use condoms and females that do not use condoms.

---

Determinants of intended and actual condom use

Table 3 shows the Spearman correlations between the social cognitive variables and intended condom and actual condom use.

---Table 3 about here ---Intended condom use was significantly correlated to perceived vulnerability to HIV infection, response efficacy of condom use and condom related self-efficacy. psychosocial determinants. To identify the relative importance of psychosocial determinants in the explanation of condom use intention, we performed a hierarchical multiple regression analysis (Table 4).

---Table 4 about here ---

The psychosocial determinants were significantly related to intended condom use (F(5, 194) = 245.75, p < .001; R 2 = .86), with significant contributions of selfefficacy (β = .63, p < .001), vulnerability (β = .14, p = .001), and attitude (β = -.23, p = .002).

To identify the relative importance of predictors of actual condom use (1 = no; 2 = yes), we performed logistic regression analyses.

---Table 5 about here ---Demographic characteristics, were significantly related to condom use, but the level of explained variance was limited (Nagelkerke's R 2 = .24). The psychosocial determinants (Table 5) were significantly related to actual condom use

Discussion

The aim of this study was to investigate the level of condom use and the psychosocial determinants of condom use among low-literate females from the rural Amhara region in Ethiopia. About half of the respondents reported to use condoms, which is a higher estimate then reported by [START_REF] Wouhabe | Sexual behaviour, knowledge and awareness of related reproductive health issues among single youth in Ethiopia[END_REF]. It may well be that we overestimated condom use, due to the global nature of our assessment of condom use, which should not be interpreted as an assessment of current end consistent condom use. However, we can conclude that level of condom use among rural females in Ethiopia is low, especially among illiterate women aged 20-24, despite the wide availability of condoms in markets and shops at a very low price (1 Birr, .01 Euro).

There were consistent and clear differences in mean scores on psychosocial determinants between females that used condoms and the females that did not use condoms. In comparison to the females that did not use condoms, females that used condoms had a significantly higher attitude, perceived a significantly higher subjective norm, had a significantly higher level of self-efficacy, felt more vulnerable to HIV infection and perceived condoms to be more effective in preventing infection with HIV. As may be expected, intention to use condoms was also significantly higher among the users of condoms, than among the females that did not use condoms. These clear and consistent differences in psychosocial To disentangle the relative importance of psychosocial determinants of intended and actual condom use, regression analyses were calculated. Self-efficacy to use condoms was the primary determinant of intended condom use, with also significant contribution for vulnerability and attitude toward condoms. The finding that among females, self-efficacy is related to intended condom use has also been reported in other studies among African females [START_REF] Heeren | Theory-based predictors of condom use among university students in the United States and South Africa[END_REF][START_REF] Heeren | Theory-based predictors of condom use among university students in the United States and South Africa[END_REF][START_REF] Boer | Gender power imbalance and differential psychosocial correlates of intended condom use among male and female adolescents from Venda, South Africa[END_REF]. Intended condom use among these females was not related to social norms on condom use, a finding that also has been reported among other females in Africa [START_REF] Boer | Social correlates of HIV protection among black adolescents in Venda, South Africa[END_REF]. Since in the Amhara culture it is not appropriate to discuss sexual matters with parents, adolescents may have little idea about the appropriate social norms. With regard to actual condom use, a different picture merged with a significant contribution to actual condom use of condom attitude and perceived vulnerability to HIV infection. Response efficacy was to a lesser extent related to actual condom use.

In this study, perceived vulnerability to HIV infection was significantly related to intended condom use and to actual condom use. In view of the recent discussion on the use of fear appeals in AIDS prevention education in Africa [START_REF] Green | Can fear arousal in public health campaigns contribute to the decline of HIV prevalence[END_REF][START_REF] Kirby | Can fear arousal in public health campaigns contribute to the decline of HIV prevalence[END_REF], the results indicate that programs that shape accurate perceptions of vulnerability to HIV may be effective to promote condom use. Especially among these low-literate females, a lack of awareness of the risks of unprotected sex may contribute to HIV risk behaviors. However, this does not 15 mean that the risk should be exaggerated, since exaggeration may lead to fear and, with low levels of condom related self-efficacy, may promote maladaptive coping behaviours, as predicted by Protection Motivation Theory (Norman et al., 2006) and the Extended Parallel Process Model [START_REF] Witte | Addressing underlying mechanisms to HIV/AIDS preventive behaviors in Ethiopia[END_REF]. One has to realize that cultural values on the role and position of women in society, such as early marriage practices (Pathfinder International, 2006), and female subservience and unequal gender relations [START_REF] Boer | Gender power imbalance and differential psychosocial correlates of intended condom use among male and female adolescents from Venda, South Africa[END_REF][START_REF] Dunkle | Effective HIV prevention requires gender transformative work with men[END_REF]) also have bearing on whether women can protect themselves from HIV infection.

Therefore, perceptions of vulnerability to HIV infection should not only be promoted among females, but also among males.

In this study, local data collectors used an interview with structured questionnaires to asses the scores of the low-literate females on psychosocial determinants. The reliabilities of the scales in this study were very high, ranging from α = .79 to α = .98. It can be concluded that the use of structured questionnaires, in combination with the oral explanation of data collectors, allows for a reliable assessment of psychosocial determinants of low-literates. In this study level of explained variance was very high, both in the prediction of intended condoms use (R 2 = .86) and in the prediction of condom use (R 2 = .75). This indicates that the studied psychosocial determinants do indeed significantly relate to intended and actual condom use.

There are some limitations to this study.

  Condom use among low-literate, rural females in Ethiopia:The role of vulnerability to HIV infection, condom attitude, and self-efficacy the estimated HIV prevalence rate in Ethiopia was 2.1% [1.8-2.2%]

  behaviour. According to these theories, an awareness of perceived vulnerability, in combination with the belief that condom use is effective to avoid infection (response-efficacy), and the belief that one is able to execute the recommended behaviour (self-efficacy) are vital in the adoption of condom use behavior. Some studies have shown, that perceived vulnerability to HIV infection is indeed important to promote HIV preventive behaviour among African

  aged 13-24 years, education level from illiterate to grade 8, and regardless of marital status and religion(N = 200). The local HIV/AIDS prevention coordinator asked selected females for participation. Permission for the research was obtained from appropriate officials from the region and central government officials. The research was explained clearly to the females and it was stressed that participation was voluntary. Response rate was 100%.ProcedureSince most participants in this study were illiterates or low literates, we used female data collectors to read or help the participants reading the structured questionnaires and to write down the responses of the participants. The data collectors received a one day training, which emphasized how to communicate politely with rural females and their family members, like the parents or the husband, which in the Amhara culture had to approve the interview. In the training, the data collectors also received information on the culture, religion, and educational level of the rural females. The data collectors and the participants made appointments on the appropriate time for the interview, since all participants were farmers and were busy with their daily duties on the field. The questionnaires were administered on individual basis. The data collectors went to the house of the participants and approached the participants politely and respectfully and explained them the procedure during the interview. The data collector and the participant sat together alone, in the absence of children or any body else to make the participant feel free to answers questions on sexual matters, which is a taboo Amhara region. The data collectors stressed to the participants, that they would keep secret all the information provided by the participants. For their participation, the participants received ten Ethiopian Birr, around one Euro.

  positive attitude to condoms. Subjective norm was assessed by means of normative beliefs of significant others, namely current sexual partner, new sexual partner, friends, parents, and motivation to comply with these normative beliefs. An example of a normative belief item is: 'My friends think that I should use condoms' ( -2 = completely disagree, 2 = completely agree ) and an example of a motivation to comply item is: ' I care about the opinion of my friends' ( 1= completely disagree, 5 = completely agree). Subjective norm was established by computing the mean of the products of normative beliefs and motivation to comply (α = .79). Intention to use condom was measured with a four item scale (α = .93). An example of an intention item was: 'In the future I will always use condoms'. We assessed actual condom use with a single item on whether they used condoms to prevent themselves from HIV infection (1 = no, 2 = yes). We further assessed marital status (1 = unmarried, 2 = married, 3 = divorced) and current education levels (1 = no school education and cannot read and write, 2 = no school education, but can read and write a little, 3 = 1 or 2 years of school education, 4 = 3 or 4 years of school education, 5 = 5 or 6 years of school education, 6 = 7 or 8 years of school education). Since it is impolite in the Ethiopian culture to directly ask for the age of a person, we used three age categories(1 = 13-16, 2 = 17-20, 3 = 21-24) to assess age.

  correlation coefficients. Hierarchical multiple regression analysis was used in the regression of psychosocial determinants on intention to use condoms. Logistic regression analysis was used in the regression of psychosocial determinants on actual condom use.

  here ---Of the 200 participants, 165 (44%) were aged below 21 years, most were not married or divorced (166, 83%) and level of education was low with 54 illiterate women (27%) en 53 women (27%) with only basic literacy skills. Almost all participants (183; 91.5%) were members of the Ethiopian Orthodox Church. Age was significantly related to condom use (χ 2 (2, N = 200) = 10.9, p = .004) with more condom use in the lower age group. Marital status was significantly related to condom use (χ 2 (2, N = 200) = 30.2, p < .001) with more condom use among the unmarried and less condom use among the married and divorced. Educational status was significantly related to condom use (χ 2 (2, N = 200) = 24.9, p < .001) with less condom use among the low-literate women and more condoms use among women with primary grade. Also religion was significantly related to condom use (χ 2 (1, N = 200) = 7.8, p = .005) with more condom use among the Muslim women.

  condom use was also significantly related to attitude to condoms and subjective norm, variables that were derived from the Theory of Planned Behavior. Actual condom use was significantly correlated with all

(

  Nagelkerke's R 2 = .75), with significant contributions of attitude to condoms (B = 2.58, p < .001; OR = 13.1 [3.7 -47.3]), vulnerability (B = 1.41, p < .001; OR = 4.1 [2.3 -7.4]) and response efficacy (B = .70, p = .02; OR = 2.0 [1.1 -3.5]) and.

  , self-efficacy and intended condom use were not significantly related to actual condom use.

  importance of psychosocial determinants in shaping condom use behavior among low-literate, rural females in Ethiopia.

Table 2

 2

	about here ---

= 196.00, p < .001), perceived a significantly higher response efficacy of condoms (F(1, 198) = 158.30, p < .001) and had a significantly higher self-efficacy in using condoms (F(1, 198) = 111.68, p < .001). Moreover, females that had used condoms had a significantly more positive attitude to condoms (F(1, 198) = 109.33, p < .001), perceived a significantly more positive subjective norm to the use of condoms (F(1, 198) = 23.27, p < .001) and reported a significantly higher intention to use condoms (F(1, 198) = 133.53, p < .001).

Table 1 :

 1 Secondly, the study used a cross sectional study design, which limits the making of causal inferences. This study focused on females. Given the male dominance in sexual matters, it is important to also investigate intention to condom use and condom use among males. Mean scores (SD) on demographic characteristics for females that use condoms (n = 112) and females that do not use condoms (n = 88) in Amhara, Ethiopia.

	First, the study investigated

Table 2 :

 2 Mean scores (SD) on social cognitions for females that use condoms (n = 112) and females that do not use condoms (n = 88) in Amhara, Ethiopia.

	Social cognition	Condom users	Non-condom users
	Vulnerability	4.44 (0.80)	2.47 (1.18) *
	Response efficacy	3.80 (1.24)	1.89 (0.80) *
	Self-efficacy	3.42 (1.42)	1.66 (0.76) *
	Attitude	3.65 (0.88)	2.52 (0.55) *
	Subjective norm	.25 (5.31)	-2.97 (3.77) *
	Intention to use condoms	3.56 (1.17)	1.90 (0.78) *
	* p < . 001

Table 3 :

 3 Correlations between the social cognition variables and intended and actual use of condoms.

	* p < .001
		VUL	RES	EFF	ATT	SOC	INT	CON
	Vulnerability (VUL)	--
	Response efficacy (RES)	.70 *	--
	Self-efficacy (EFF)	.60 *	.84 *	--
	Attitude (ATT)	.52 *	.69 *	.83 *	--
	Social norms (SOC)	.29 *	.50 *	.58 *	.48 *	--
	Intended condom use (INT) .66 *	.81 *	.92 *	.81 *	.55 *	--
	Actual condom use (CON)	.71 *	.67 *	.60 *	.60 *	.32 *	.64 *	--

Table 4 :

 4 Hierarchical multiple regression analysis of psychosocial variables on intended use of condoms of females in Amhara, Ethiopia.

	Variables	B	SE B	β
	Vulnerability	.14	.04	.15 ***
	Response efficacy	.05	.05	.05
	Self-efficacy	.57	.06	.64 **
	Attitude	.22	.07	.15 **
	Social norms	.01	.01	.04
	R 2			.86
	* p < .01; ** p < .001

Table 5 :

 5 Logistic regression analysis of psychosocial variables on actual use of condoms among rural females in Amhara, Ethiopia

		B	SE B
	Vulnerability	1.41 ***	.30
	Response efficacy	.70 *	.29
	Self-efficacy	-.63	.53
	Attitude	2.58 ***	.65
	Social norms	.03	.08
	Intention	-.06	.59
	Nagelkerke R 2	.75

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Acknowledgements:

This study was financially supported by an educational grant to the first author by the Netherlands Fellowship Programmes of Nuffic, the Netherlands organization for international cooperation in higher education. The authors thank Alemneh Yitayew, HIV prevention secretariat officer in Dejen, Amhara, Ethiopia and the data collectors for their assistance during the field research and Asegedech Tadesse for assisting during data analysis.