Does the consent of the patients have a role to play in formulating a treatment policy?

Zambia recently changed its treatment policy for malaria from the failing chloroquine to the more effective artemisinin combination therapy (ACT). A study was conducted to find out if the community accepted the new treatment policy, as a prediction of its success. Following high levels of acceptability, it was not surprising to see high levels of compliance and subsequent reduction in cases of severe malaria and deaths.

Bacteremia due to Mycobacterium tuberculosis or M. bovis, Bacille Calmette-Guérin (BCG) among HIV- positive children and adults in Zambia.

BACKGROUND: Among adults with advanced HIV infection in developing countries, bacteremia due to Mycobacterium tuberculosis (MTB) is common and bacteremia due to M. bovis (bacille Calmette-Guérin; BCG) is rare. Comparable data are not available for children with HIV. OBJECTIVE: To compare the prevalence of bacteremia due to M. tuberculosis or M. bovis BCG in hospitalized children and adults with HIV infection in a developing country with a high prevalence of tuberculosis and HIV and > 95% BCG immunization coverage. DESIGN: Descriptive cross-sectional study. METHODS: Prospectively hospitalized patients in Lusaka, Zambia who were suspected to have HIV infection underwent phlebotomy for HIV ELISA, HIV viral load, and lysis-centrifugation blood culture for mycobacteria. Histories were obtained and patients were examined for BCG scars. Mycobacterial isolates were identified using DNA probes for MTB complex (MTBC), multiplex PCR and IS6110 typing. RESULTS: The median age of 387 HIV-positive children was 15 months; 98% were BCG immunized. The median age of 344 HIV-positive adults was 32 years; 44% were BCG immunized. Blood cultures were positive for mycobacteria in six children (2%) and 38 adults(11%) (P < 0.001). The six pediatric isolates included five MTBC (40% clustered) and one BCG. The 38 adult isolates included 36 MTBC (16% clustered) and two M. avium complex. CONCLUSION: Bacteremia due to MTB is less common among children than adults with advanced HIV infection in Zambia. Bacteremia due to M. bovis BCG is rare even among children with recent BCG immunization and symptomatic HIV infection.

Safety and immunogenicity of a five-dose series of inactivated Mycobacterium vaccae vaccination for the prevention of HIV-associated tuberculosis.

Five doses of inactivated Mycobacterium vaccae vaccine were administered intradermally to 22 human immunodeficiency virus (HIV)-infected patients (11 bacille Calmette-Guérin [BCG]-positive and 11 BCG-negative) in Zambia whose CD4 lymphocyte counts were >/=200 cells/mm(3). HIV viral load and lymphocyte proliferation responses were compared for vaccine recipients and 22 HIV-infected control patients (11 BCG-positive and 11 BCG-negative). Immunization was safe and well tolerated in all patients, and induration at the vaccine site decreased from dose 1 to dose 5. A transient decrease in HIV viral load was observed in BCG-positive vaccine recipients after dose 3 but not after subsequent doses. Median lymphocyte stimulation indices to M. vaccae were 6.0 in vaccine recipients and 2.3 in control patients (P<.001). Stimulation indices were >/=3.0 in 19 vaccine recipients (86%) and 7 control patients (32%; P=.001). A 5-dose series of vaccination with inactivated M. vaccae is safe in HIV-infected patients and induces lymphocyte proliferation responses to the vaccine antigen. M. vaccae vaccine is a candidate for the prevention of tuberculosis in HIV infection.

The effects of BCG immunization and human immunodeficiency virus infection on dual skin test reactions to purified protein derivative and Mycobacterium avium sensitin among adults in Zambia.

SETTING: University hospital in Lusaka, Zambia. OBJECTIVE: To determine the effects of childhood bacille Calmette-Guerin (BCG) immunization and human immunodeficiency virus (HIV) infection on dual skin test reactions to purified protein derivative (PPD) and Mycobacterium avium sensitin (MAS) in a developing country. DESIGN: Descriptive cross-sectional study. RESULTS: Dual skin testing was performed on 112 adults, 58 HIV-positive and 54 HIV-negative. Forty-seven (42%) of 112 had PPD reactions > or =10 mm and 52 (46%) had MAS reactions > or =10 mm. PPD reactions > or =10 mm were present in 30 (63%) of 48 BCG-positive subjects compared to 17 (27%) of 64 BCG-negative subjects (P<0.001). Nineteen (33%) of 58 PPD or MAS skin test positive subjects were PPD dominant, 15 (26%) were MAS dominant, and 24 (41%) were non-dominant. MAS dominant and non-dominant reactions were significantly reduced in HIV-positive subjects, and non-dominant reactions were increased in BCG-positive subjects. CONCLUSIONS: Childhood BCG immunization is associated with PPD reactions > or =10 mm among adults. Reduced PPD reaction rates in HIV-positive adults appear to be due to a loss of BCG-induced PPD reactivity. Prior infection with M. avium complex is detectable in a significant proportion of adults in a developing country.

HIV-1 seroprevalence in Zambian patients with acute diarrhea: a community-based study.

The seroprevalence of HIV-1 in sub-Saharan African patients with diarrhea in the community remains largely unknown. We present the findings of a 2-month study that we undertook to ascertain the seroprevalence of HIV-1 in Zambian patients presenting with acute diarrhea in a community-based health center. A total of 256 patients with diarrhea and 140 apparently healthy controls was seen. Of the patients with diarrhea, 161 were < 16 years old and 95 were adults. Most children with diarrhea were < 6 years old (147 of 161; 91%). Overall, 81 of 256 (32%) patients with diarrhea were HIV-1-seropositive. When results from children < 18 months old and possibly having maternal anti-HIV-1 antibodies were excluded, 64 of 172 (37%) patients with diarrhea were HIV-seropositive. Rates of HIV-1 seropositivity for patients with diarrhea were significantly higher than were rates for diarrhea-free controls (p < .001 for both the total population; odds ratio [OR], 95% confidence interval [CI], 1.42 < 2.48 < 4.35) and population > 18 months old (OR, 95% CI, 1.54 < 2.90 < 5.49). Among children between 18 months and 5 years old, 14 of 63 (22%) were HIV-1-seropositive compared with 8 of 62 (13%) without diarrhea (p > .05, not significant). Moreover, 49 of 95 (52%) adults with acute diarrhea were HIV-1-seropositive compared with 10 of 44 (23%) healthy adult controls (p < .003; OR, 95% CI, 1.51 < 3.62 < 8.87). No significant differences were found in HIV-1 seroprevalence rates between males and females in all age groups. These data show a close association between acute diarrhea and HIV seropositivity in Zambian adults in the community.

PIP: Chronic diarrhea is a common clinical presentation of HIV infection worldwide and a major cause of mortality in cohorts of HIV-infected African children. Findings are presented from a study of HIV-1 seroprevalence among Zambian patients presenting to George Health Center, a community-based health center northwest of center Lusaka, with acute diarrhea during March-April 1994. 256 patients with diarrhea and 140 apparently healthy controls participated in the study. Of the patients with diarrhea, 161 were under 16 years old and 95 were adults. 147 (91%) of the children with diarrhea were under age 6 years. Overall, 81 of the 256 (32%) patients with diarrhea were HIV-1-seropositive. Excluding results from infants under age 18 months who may have had maternal anti-HIV-1 antibodies, 64 of 172 (37%) patients with diarrhea were HIV-seropositive. Among children aged 18 months to 5 years, 14 of 63 (22%) were HIV-1-seropositive compared with 8 of 62 (13%) without diarrhea. 49 of 95 adults with acute diarrhea were HIV-1-seropositive compared with 10 of 44 healthy adult controls. No significant differences were found in HIV-1 seroprevalence rates between males and females in all age groups. These data point to a close association between acute diarrhea and HIV seropositivity in this research setting.

Cryptosporidiosis in urban Zambian children: an analysis of risk factors.

In four crowded townships of Lusaka, Zambia, the prevalence of cryptosporidiosis in 222 children with diarrhea was 18%, with marked temporal and geographic variation over the course of one rainy season. Using data on the finding of oocysts of Cryptosporidium parvum in urban water supplies, the areas under study were categorized as high or low risk. Prevalence of cryptosporidiosis in children with diarrhea was higher in high risk areas after stratification by early/late stage of the rains (Mantel-Haenszel odds ratio [OR] = 2.9, 95% confidence interval [CI] = 1.3, 6.7; P = 0.008). Cryptosporidiosis was not associated with keeping animals, nutritional status, or parental education, but was apparently more common in breast fed children (OR = 2.7, 95% CI = 1.1, 6.9; P = 0.01), although the proportion of exclusively breast fed children was not measured. Since most of these infections were of short duration, we conclude that transmission of C. parvum can vary dynamically within one city and over short periods of time, and that water-borne contamination may be a substantial influence.

Human immunodeficiency virus-associated diarrhea and wasting in Zambia: selected risk factors and clinical associations.

A significant association was observed among human immunodeficiency virus (HIV)-positive adult cases in Lusaka, Zambia compared with HIV-negative controls for chronic diarrhea (68% versus 22%; P < 0.05), weight loss (54% versus 30%; P < 0.05), lymphadenopathy (44% versus 15%; P < 0.05), and skin eruption (33% versus 7%; P < 0.05). Among the HIV-positive children, a higher proportion had clinical evidence of tuberculosis when compared with HIV-negative children (8% versus 1%; P < 0.05). The study demonstrated an association between weight loss in HIV-positive adults and children and chronic diarrhea (odds ratio [OR] = 12.7, 95% confidence interval [CI] = 6.4-25.5; P < 0.001), persistent cough (OR = 7.2, 95% CI = 2.9-14.5; P < 0.001), and an age of 31-45 years (OR = 3.8, 95% CI = 1.8-8.3; P < 0.01). The factors associated with mortality in HIV positive patients included chronic diarrhea (OR = 7.4, 95% CI = 1.6-34; P < 0.01), and lymphadenopathy (OR = 3.89, 95% CI = 1.2-12.2; P < 0.04).

Cryptosporidiosis in adults in Lusaka, Zambia, and its relationship to oocyst contamination of drinking water.

In Lusaka, where human immunodeficiency virus seroprevalence in young adults is approximately 25%, four townships were studied to establish the prevalence of persistent diarrhea in adults and the etiologic importance of cryptosporidiosis in adults with persistent diarrhea. Cryptosporidium parvum oocyst contamination of urban water supplies was measured and the results used to categorize these populations into high or low exposure. In total, 506 adults were reported as having had diarrhea in the 2 weeks prior to the survey; 101 of these episodes were persistent. Adults with persistent diarrhea in the high-exposure areas were more likely to have cryptosporidiosis (odds ratio, 5.14; 95% confidence interval, 1.57-17.2; risk ratio, 1.83; 95% confidence interval, 1.04-3.21; P = .003) although overall prevalence of persistent diarrhea was not greater in these areas. This association was not confounded by animal exposure, travel, or boiling water. Within these urban populations, water contamination with C. parvum was a major influence on the prevalence of infection.

HIV prevention among Zambian adolescents: developing a value utilization/norm change model.

Peer-led interventions are effective in reducing risk for HIV among adolescents. A pre-intervention study was conducted to determine how to successfully carry out a possible future intervention to reduce HIV risk among adolescents in urban Zambia. Ethnographic and sexual data were collected on 276 males and females both attending and not attending secondary school during a 14-month period in 1992-1993. Additionally, several focus groups were conducted. This paper reviews the cultural background of Zambian adolescents and presents an overview of the study results. Among the findings, it was learned that most of the male and female adolescents (average age of 17) are sexually active, very few routinely use condoms, less than half of sexually active adolescents have ever used a condom, AIDS is omnipresent in Zambia, the threat of HIV infection is a very real concern for most of the adolescents, there is a strong desire to protect themselves from HIV infection during sex (but condoms are often seen as ineffective and other forms of safer sex are not discussed), nearly all of the sexually active females and some of the males have received money or gifts for sex, and some of the out-of-school females are engaging in very risky sex (e.g., unprotected anal intercourse, and anilingus) with adult men. The ethnographic data, including a brief trial risk reduction workshop, suggests that the core values and social norms of the adolescents may shape behavioral change. A value utilization/norm change (VUNC) model is developed, which is intended to provide a conceptual framework for understanding how to utilize selected core values of the adolescents to strengthen or alter norms within the social networks in order to elicit desired HIV risk reduction.

Isolation of Campylobacter species from Zambian patients with acute diarrhoea.

Four hundred and one consecutive diarrhoea patients and 101 adult patients without diarrhoea were enrolled for this study from a health centre in Lusaka. Campylobacter was isolated from 6% of patients with acute diarrhoea. However, non of these were seen in control group. Further studies are being carried out to determine the importance of Campylobacter species with other bacterial pathogens. It will also be interesting to see its impact and association with human immuno deficiency virus in this region.

The prevalence and aetiology of persistent diarrhoea in adults in urban Zambia.

As the AIDS pandemic has spread, diarrhoea in adults has become a major burden on health care institutions in central Africa and on the families of sufferers. In order to assess the magnitude of the problem, we carried out a survey of households in a high population density township of Lusaka to determine the prevalence of persistent diarrhoea in adults. We also carried out a study of the causes of persistent diarrhoea in patients attending the University Teaching Hospital, Lusaka. The community survey assessed 460 households, representing a sample of 1440 adults. 94 adults were reported as having had diarrhoea in the 2 weeks prior to the survey, implying an attack rate of 1.74 per adult per year. Of these 94 cases, six had diarrhoea of between 2 and 4 weeks duration, and ten had diarrhoea of over 4 weeks duration. In the hospital study, 75 (97%) out of 77 patients with diarrhoea of over 1 months' duration were HIV seropositive; potentially pathogenic parasites were found in 61/75 (81%) of seropositives. This information indicates that persistent diarrhoea in adults, mostly related to HIV infection, is likely to be an important and growing reservoir of enteric pathogens and represents a significant burden on hospitals and relatives. This emerging problem in sub-Saharan Africa may foreshadow developments in other continents.

PIP: This study assesses the prevalence of diarrheal diseases in adults in urban Zambia as it relates to HIV infection in order to develop possible strategies for the management of AIDS patients. The study was conducted in a community via a house-to-house survey. In addition, the causes for persistent diarrhea in patients at the University Teaching Hospital were also investigated. The community sample consisted of 1440 adults, of which 94 (6.5%) had had diarrhea in the previous 2 weeks, which translates into an attack rate of 1.74 episodes/adult/year. Of these cases, 6 (6.4%) had diarrhea lasting between 2 and 4 weeks; 10 (10.6%) had diarrhea lasting over 4 weeks. In the hospital setting, 75 (97.4%) out of 77 patients with diarrhea lasting over 4 weeks were also HIV seropositive. Pathogenic parasites were found in 61 (81.3%) of the seropositive patients. The authors conclude that persistent diarrhea in adults, mostly related to HIV infection, is likely to represent an important and growing reservoir of enteric pathogens; furthermore, it presents a significant burden on hospitals and families.

Plasmodium falciparum malaria in vivo drug sensitivity in Lusaka, Zambia.

In most of sub-Saharan African, drug resistant falciparum malaria has become a major health care concern. Drug sensitivity was evaluated in vivo in Lusaka, Zambia, in 71 episodes in 61 patients with uncomplicated falciparum malaria, for Chloroquin (CQ), Pyrimethamine/sulfadoxine (PS) and halofantrine (HF). CQ resistance was found at R2 (16 pc) and R3 (24.5 pc) level in 37 patients, R3 (10.5 pc) resistance to PS was found among 19 subjects studied. The drug resistance to CQ was inversely related to age.

Gut parasites in HIV-seropositive Zambian adults with diarrhoea.

We undertook a nine month study to define the frequency of parasitic infections in adults with diarrhoea presenting at the medical filter clinic and the Dermatovenereology clinic of the University Teaching Hospital in Lusaka, Zambia. A total of 287 patients with diarrhoea were enrolled in the study; 130 from the adult medicine filter clinic recruitment consulting room and 157 patients from the Dermatovenereology clinic. Of 130 patients from the adult filter clinic, 85 (65%) were HIV-seropositive and 45 (35%) were seronegative for HIV. Out of 85 HIV-seropositive patients, 58 (68.2%) had acute diarrhoea and 27 (31.8%) had chronic diarrhoea. Of the 45 HIV-seronegative patients, 35 (77%) had acute diarrhoea and 10 (23%) had chronic diarrhoea. All of the 157 patients recruited from the Dermatovenereology clinic were HIV-seropositive. Of these, 97 (62%) had chronic diarrhoea; 7 (4%) had acute diarrhoea, and 53 (34%) patients had no diarrhoea. The common parasites detected were Ascaris lumbricoides, hookworm, Entamoeba coli, and Cryptosporidium spp. Isospora belli and Cryptosporidium spp were seen only in the HIV-seropositive group. In the Dermatovenereology clinic there was a statistically significant difference between parasite detection rate of Isospora belli and Cryptosporidium spp in HIV-seropositive patients with chronic diarrhoea compared to asymptomatic HIV-seropositive individuals P < 0.01 and p = 0.05, respectively). A significant difference in detection rates of Entamoeba coli was seen between the HIV-seropositive group in the Dermatovenereology clinic [17 (10.8%) out of 157] compared to 1 (1.5%) out of 85 in the adult medicine filter clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Over a period of 9 months (June 1, 1992-February 25, 1993), a total of 287 patients with diarrhea presenting at the adult medicine filter clinic (130) and the dermatovenereology clinic (157) of the University Teaching Hospital in Lusaka, Zambia, were enrolled in a study of the frequency of parasitic infections in adults with diarrhea. All of the 157 patients recruited from the dermatovenereology clinic were HIV-seropositive. Of these, 97 (62%) had chronic diarrhea; 7 (4%) had acute diarrhea, and 53 (34%) had no diarrhea. Out of 130 patients recruited from the adult medicine filter clinic, 85 (65.4%) were HIV-seropositive and 45 (34.6%) were seronegative. Of the HIV-seropositive patients, 58 (68%) had acute diarrhea and 27 (32%) had chronic diarrhea. 10 (23%) of the HIV-seronegative patients had chronic diarrhea. The common parasites detected in stools of all HIV-seropositive adults were Ascaris lumbricoides, hookworm, Entamoeba coli, and Cryptosporidium spp. The coccidian parasites Isospora belli and Cryptosporidium spp were seen only in the HIV-seropositive group. In the dermatovenereology clinic there was a statistically significant difference between parasite detection rate of Isospora belli and Cryptosporidium spp in HIV-seropositive patients with chronic diarrhea compared to asymptomatic HIV-seropositive individuals (p = 0.01 and p 0.05, respectively). Cryptosporidium was detected in 4 (4.7%) HIV-seropositive adults in the adult medicine filter clinic and in 4 (4%) seropositive patients with diarrhea in the dermatovenereology clinic. Isospora belli was detected in 5 (6%) HIV-seropositive adult medicine filter clinic patients, while 9 (9%) HIV-seropositive patients from the dermatovenereology clinic had this parasite. A significant difference in detection rates of Entamoeba coli was seen between the HIV-seropositive group in the dermatovenereology clinic: 17 (10.8%), compared to patients in the adult medicine filter clinic: 1 (1.5%).

Characteristics of women terminating pregnancies at the University Teaching Hospital, Lusaka, Zambia.

Abortion in Zambia is liberalized. A hospital based study to determine characteristics of women having legal abortion was conducted at the University Teaching Hospital, Lusaka, Zambia. A total of 200 participants attending a Gynaecological clinic were interviewed from March to May 1993. The clients' five year age groups between 15 and 45 years were about equally represented in the study and 113 (56.5 pc) clients were of single status, out of which 10 (15.9 pc) were students. The respondents were fairly educated with 140 (70.0 pc) having attained secondary education. The mean gestation was 8.3 (standard deviation 2.2) weeks. About one half (52.5 pc) of the clients had used no contraception method. We conclude that use of contraceptives was low and hence there was a need for expanded family planning education and making contraceptives available to all concerned, including students, in order to reduce the abortion rate.

Anti-bovine viral diarrhoea virus antibodies in adult Zambian patients infected with the human immunodeficiency virus.

Bovine viral diarrhoea (BVD) virus is a cosmopolitan pestivirus of animals which is associated with diarrhoea, immunosuppression and synergy with other pathogens. This study was conducted to establish the prevalence of anti-BVD virus antibodies in healthy Zambian adults and those with asymptomatic and symptomatic HIV disease. Sera from 1159 adults were tested for anti-BVD virus antibodies using the indirect immunofluorescence test and the confirmatory Western blot. Of the 1159 sera examined, 180 (15.5%) showed significantly elevated titres of anti-BVD antibodies. These included 70 out of 477 (14.7%) HIV-negative healthy adults; 73 out of 480 (15.2%) of HIV-positive asymptomatic individuals; 23 out of 129 (17.8%) HIV-seropositive patients with associated illnesses excluding diarrhoea; and 14 out of 73 (19.2%) of HIV-seropositive patients with chronic diarrhoea. HIV-seropositive patients with chronic diarrhoea or associated illnesses appear to have significantly increased seroprevalence of anti-BVD virus antibodies (P = > 0.01). The mechanism of interaction between BVD virus and HIV infections and the synergistic effects with other opportunistic pathogens in humans requires definition.