Understanding the reasons for decline of HIV prevalence in Haiti.

OBJECTIVES: HIV sero-surveillance rounds and projection estimates suggest a decline of HIV prevalence among pregnant women and the general population in Haiti. This study aimed to evaluate the decline of HIV prevalence and understand the reasons for the decline. METHODS: Following an epidemiological analysis, three mathematical models were used to re-create the national epidemic, calculate HIV incidence, and confirm the decline of HIV prevalence. Declining trends in prevalence data were compared with observed trends in behavioural data. RESULTS: HIV progressed rapidly from initial infection to AIDS and death, with people dying twice as fast as in developed countries. With the rapid progression of the disease and the early intervention efforts in securing the blood supply, prevalence among commercial sex workers and blood donors peaked in the late 1980s followed by a decline in the mid-1990s in the general population. The observed decline among pregnant women and in the general population was confirmed after controlling for confounding variables. The Haitians are well informed: there is an increase in condom use with occasional partners at last contact and in abstinence and fidelity, and a decrease in the number of occasional partners. However, the age of sexual debut is lower and the proportion of sexually active youth has increased. CONCLUSIONS: There is evidence of decline in HIV prevalence among pregnant women, specifically among pregnant women living in urban areas and pregnant women 25 years and older, but not among pregnant women living in rural areas and pregnant women 24 years and younger. Although many factors have acted in synergy to halt the AIDS epidemic in Haiti, the main reasons for decline seem to point to mortality and blood safety intervention efforts in the early stages of the epidemic.

Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti.

OBJECTIVE: To determine whether observed changes in HIV prevalence in countries with generalised HIV epidemics are associated with changes in sexual risk behaviour. METHODS: A mathematical model was developed to explore the relation between prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of infection throughout the population. To create a null model a range of assumptions about sexual behaviour, natural history of infection, and sampling biases in ANC populations were explored to determine which factors maximised declines in prevalence in the absence of behaviour change. Modelled prevalence, where possible based on locally collected behavioural data, was compared with the observed prevalence data in urban Haiti, urban Kenya, urban Cote d'Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia. RESULTS: Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and urban Haiti, like Uganda before them, could only be replicated in the model through reductions in risk associated with changes in behaviour. In contrast, prevalence trends in urban Cote d'Ivoire, Malawi, urban Ethiopia, and Rwanda show no signs of changed sexual behaviour. CONCLUSIONS: Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are quite recent and caution is required because of doubts over the accuracy and representativeness of these estimates. Nonetheless, the observed changes are consistent with behaviour change and not the natural course of the HIV epidemic.

[Survey of infant mortality in Mirebalais, Haiti]. / Enquête sur la mortalité infantile à Mirebalais, Haïti.

Infant mortality remains high in Haiti, at 74 deaths per 1,000 live births. In this study, we aimed to assess infant mortality in Mirebalais and to identify the associated risk factors. We carried out a census of pregnant women in Mirebalais, at the beginning of the study, over a three-week period. Twelve researchers visited the homes of the newborns to enroll the families in the study and to collect demographic data. Further visits were scheduled for two, four, six, nine and twelve months after birth. If the child died during this time, the investigator asked the mother about all the steps taken to prevent the death of the child, and an autopsy was carried out. The survey began on July 12 1994 and ended on December 31 1995. During that time, about 2,151 pregnant women were enrolled. Seven of these women died and 16 had abortions. In total, 2,069 children were born to the enrolled women. We enrolled 515 other children after birth or following referral by health workers or midwives. We therefore followed 2,584 children. We found that 10% of the mothers were aged between 15 and 19 years, 66.3% had had one to three pregnancies and 73% were entirely uneducated. The early neonatal mortality rate was 4.64 per 1,000 live births, late neonatal mortality was 6.96 per thousand and post-neonatal mortality was 45.6 per thousand live births. Diarrhea was responsible for 60% of the deaths and acute respiratory infections for 11%, these two causes accounting for 71% of the deaths of children aged 1 to 12 months. Thus, although infant mortality has decreased it remains high in Mirebalais, largely due to diarrhea and acute respiratory infections in the post-neonatal period.

Arrested pregnancy syndrome in Haiti: findings from a national survey.

This report describes findings from a national survey of pregnant women in Haiti regarding the social epidemiology of pedisyon (perdition), or "arrested pregnancy syndrome," a condition believed to be associated with infertility. Data collected on mortality of respondents' sisters were used to indirectly measure the prevalence of this culture-bound syndrome in the adult female population and to compare its distribution in urban and rural areas. Perdition appears to be a fairly common event that affects a large proportion of Haitian women. Reported cases of pedisyon were significantly higher in urban areas, which also differed from rural areas on respondent education, economic status, use of prenatal care, and fertility. No differences were found on sociodemographic, health, or fertility variables when women reporting perdition deaths were compared with women who reported other sister deaths. The utility and limitations of the proxy respondent method are discussed. Possible explanations for the higher rate of pedisyon among urban Haitian women are discussed, and suggestions are made for future research on arrested pregnancy syndrome.

An AIDS test that travels well.

PIP: A new dipstick test will enable health workers in remote Third World communities to screen blood for human immunodeficiency virus (HIV) and monitor the spread of HIV infection. The test, developed by the Program for Appropriate Technology in Health (PATH), works without electricity, instrumentation, or cold chain and is locally manufacturable. Results are available in 20 minutes, and the cost is 25 cents per sample. Antibodies to both HIV-1 and HIV-2 are detectable. In the test, a plastic dipstick shaped like a comb with 8 test strips is dipped into blood samples, rinsed, and soaked in a reagent solution. The appearance of a red dot on a dipstick tooth indicates a positive finding. Field trials in Uganda, Kenya, Brazil, China, Indonesia, India, and Thailand indicate the dipstick is as reliable as screening tests already on the market; the false-positive rate was under 2%. India and Indonesia are already manufacturing the new test, and Kenya, Uganda, Cameroon, China, and Thailand have expressed interest. The low cost of the dipstick may enable its use in seroprevalence surveys in previously unstudied regions of the Third World. Such a survey was just conducted among a randomly selected group of pregnant women from across Haiti. Blood samples from simple finger pricks collected on filter paper yielded highly reliable results.^ieng

AIDS-related knowledge, attitudes, beliefs, and practices in Haiti.

AIDS constitutes an important public health problem in Haiti, where it appears to be spread mainly through heterosexual encounters. The study reported here employed in-depth interviews, focus group discussions, and a national cross-sectional survey of 1,300 men and 1,300 women 15 to 49 years old to assess AIDS-related knowledge, attitudes, beliefs, and practices in Haiti. According to criteria established for the study, 38.1% of the 1,118 sexually active male survey respondents were found to engage in high-risk behavior. In general, the women were found to have better knowledge of AIDS than the men. Significant obstacles to condom use included the inability of women to choose whether condoms would be used and a belief that condom lubricant could cause health problems. The study also found a tendency to ostracize people with AIDS, especially in areas outside Port-au-Prince, and a belief that AIDS was imposed on people by fate--which could partially explain the tendency to persist in high-risk behavior.

PIP: AIDS constitutes a major health problem in Haiti which continues to grow through what seems to be mainly heterosexual relations. Over 1989-90, 8.9% of 1720 pregnant women attending a prenatal clinic in a suburban slum were identified as HIV-seropositive. Among initial blood donors in 1990, 5.8% of 1199 males and 1.9% of 15 female donors were seropositive for HIV. In-depth interviews, focus groups, and a national cross-sectional survey of 1300 men and 1300 women aged 15-49 years were conducted in an effort to assess participants' AIDS-related knowledge, attitudes, beliefs, and practices. 38.1% of the 1118 sexually active male survey respondents engaged in high-risk behavior. Men were considered to be at high risk for infection/transmission if they had ever visited a prostitute or had more than 1 sex partner in the month preceding the interview. Most in Haiti have heard of AIDS, but many misconceptions remain about how HIV is transmitted. Women did, however, tend to better informed than men. Even though the women may be comparatively better informed about HIV transmission, their lack of ability to negotiate condom use still impedes the more widespread use of condoms. The belief that condom lubricant may cause health problems also impedes condom use. Finally, the study found a tendency to ostracize people with AIDS, especially outside of Port-au-Prince, and the belief that individuals acquire AIDS deterministically according to fate. A coordinated national effort is needed to correct these misconceptions and increase the prevalence of condom usage.