Estimates of HIV burden in emergencies.

OBJECTIVE: To quantify the proportion of people living with HIV who are being affected by emergencies. METHODS: Emergencies were defined as conflict, natural disaster and/or displacement. Country-specific estimates of populations affected by emergencies were developed based on eight publicly available databases and sources. These estimates were calculated as proportions and then combined with updated country-level HIV estimates for the years 2003, 2005 and 2006 to obtain estimates of the number of men, women and children living with HIV who were also affected by emergencies. RESULTS: In 2006, 1.8 (range 1.3-2.5) million people living with HIV (PLHIV) were also affected by conflict, disaster or displacement, representing 5.4% (range 4.0-7.6%) of the global number of PLHIV. In the same year, an estimated 930 000 (range 660 000-1.3 million) women and 150 000 (range 110 000-230 000) children under 15 years living with HIV were affected by emergencies. In emergency settings, the estimated numbers of PLHIV in 2003 and 2005 were 2.6 million (range 2.0-3.4 million) and 1.7 million (range 1.4-2.1 million), respectively, representing 7.9% and 5.1% of the global number of PLHIV). CONCLUSIONS: These estimates provide a rationale to ensure that HIV interventions are integrated into rapid assessment of all emergency and preparedness and response plans to prevent HIV infections and address excess suffering, morbidity and mortality among these often overlooked vulnerable groups.

Estimates of HIV burden in emegencies

Objective: To quantify the proportion of people living with HIV who being infected by emergencies. Methods: Emergencies were defined as conflict, natural disaster and/or displacement. Country-specific estimates of populations affected by emergencies were developed based on eight publicly available databases and sources. These estimates were calculated as proportions and then combined with updated country-level HIV estimates for the years 2003, 2005 and 2006 to obtain estimated of hte number of men, women and children living with HIV who were also affected by emergencies. Results: In 2006, 1.8 (range 1.3-2.5) million people living with HIV (PLHIV) were also affected by conflict, disaster or displacement, representing 5.4% (range 4.0-7.6%) of the global number of PLHIV. In the same year, an estimated 930 000 (range 660 000-1.3 million) women and 150 000 (range 110 000-230 000) children under 15 years living wiht HIV were affected by emergencies . In emergency settings, the estimated numbers of PLHIV in 2003 and 2005 were 2.6 million (range 2.0-3.4 million) and 1.7 million (range 1.4-2.1 million), respectively, representing 7.9% abd 5.1% of the global number of PLHIV. Conclusions: These estimates provide a rationale to ensure that HIV interventions are integrated into rapid assessment of all emergency and preparedness and response plans to prevent HIV infections and address excess suffering, morbity and mortality among these often overlooled vulnerable groups. (AU)

HIV prevalence and trends from data in Zimbabwe, 1997-2004.

BACKGROUND: This paper brings together data from a variety of reports to provide a basis for assessing future steps for responding to and monitoring the HIV epidemic in Zimbabwe. METHOD: Data reported from four antenatal clinic (ANC) surveys conducted between 2000 and 2004, two small local studies in Zimbabwe conducted from 1997 through 2003, four general population surveys from 1999 through 2003, and service statistics covering 1990 through 2004 were used to describe recent trends in HIV prevalence and incidence, behaviour change, and programme provision. RESULTS: HIV prevalence among pregnant women attending ANCs declined substantially from 32.1% in 2000 to 23.9% in 2004. The local studies confirmed the decline in prevalence. However, prevalence continued to be high. Sexual behaviour data from surveys suggests a reduction in sexual experience before age 15 years among both males and females age 15-19 years, and in the proportions of males and females aged 15-29 years reporting non-regular sexual partners in the past 12 months. Reported condom use with non-regular partners has been high since 1999. Condom distribution and HIV counseling and testing increased from 2000 to 2004. DISCUSSION: On the basis of examination of data from a variety of sources, the recent decrease in HIV prevalence may be related to recent reductions in early-age sexual activity and non-regular sexual partnerships and increases in condom use. Comparison of data from sentinel surveillance systems, population based serosurveys, local studies, and service statistics provide increased confidence that a decline in HIV prevalence in Zimbabwe is actually happening in the population.

A survey of STI policies and programmes in Europe: preliminary results.

OBJECTIVES: A survey was conducted to assess the adequacy of sexually transmitted infections (STI) prevention and control policies and programmes in the European region (including the central Asian republics). METHODS: An adapted World Health Organization (WHO) model questionnaire was sent to ministry of health officials in all 45 countries of Europe and central Asia. The questionnaire included questions on STI programme structure; STI case management; the different types and levels of services, including public and private service providers; partner notification and screening policies; services for vulnerable populations; monitoring and supervision; surveillance and research. RESULTS: Western European countries largely leave STI prevention and care to individual practitioners. Licensed providers exist at all levels of care, and access to consultations and treatment is usually free of charge. In the newly independent states (NIS), by contrast, programme efforts emphasise state guidance and supervision of local providers rather than individual practitioners. Access to services is limited in that in several NIS, only public sector specialists are licensed to treat STI. Formerly free of charge policies have been severely eroded. While in western Europe access to condoms appears to be good, in the NIS there are many fewer condom outlets. Regionwide, in 40% of countries the distribution of condoms is part of STI consultations. CONCLUSIONS: Non-availability of affordable high quality STI services, including STI treatment and condoms, may be one of the causes for the much higher STI prevalence in parts of eastern Europe and NIS than in western Europe.

Adolescence--a dynamic concept.

The World Health Organization (WHO) defines adolescents as persons between 10 and 19 years of age. (WHO 1998) Although adolescents make up about 20 per cent of the world's population (of whom 85 per cent live in developing countries), they have traditionally been neglected as a distinct target group and subsumed under the promotion of family, women's and child welfare and health. This has at least partially been because adolescents were seen as a relatively healthy age group, one that did not have a heavy 'burden of disease', at least as compared with young infants or older adults. However, there is increasing recognition that adolescents have special health-related vulnerabilities. Among the major causes of morbidity and mortality in young people are suicide, road accidents, tobacco use and sexual and reproductive ill-health. (WHO 1998) Furthermore, adolescents are increasingly seen as 'gateways to health' because behavioural patterns acquired during this period tend to last throughout adult life--roughly 70 per cent of premature deaths among adults are due to behaviours initiated in adolescence. (WHO 1998) This paper describes the social, economic, cultural, legal and health issues which affect the experience of adolescence. It shows that while young people around the world may experience the same physical changes and sensations during adolescence, the manner in which these are interpreted and give rise to social and legal prescriptions varies tremendously.

Sexually transmitted infections among adolescents: the need for adequate health services.

The World Health Organization (WHO) estimates that two-thirds of all STIs worldwide occur in young people--teenagers and those in their early twenties (WHO 1993, WHO 1995). The provision of STI services to these age groups should therefore be high on the agenda of STI programme planners and adolescent/young people's health programmers alike. However, attempts to promote the sexual health of young people have so far tended to focus on prevention, education and counselling, while the provision of services to those who have already faced the consequences of unprotected sexual activity, including pregnancy and STI, or sexual violence, has lagged behind. In 1999-2000 a review was commissioned by GTZ of the characteristics of adolescent sexuality, evidence of STI risk in adolescents, the profile of adolescents in need of STI care, types and evidence of success of different STI service delivery models for adolescents and the advantages and disadvantages of each of these, and to what extent a youth-specific approach to STI services or an STI-specific approach to adolescent health service delivery, is warranted. This review will be published jointly by GTZ and WHO with the title Sexually Transmitted Infections among Adolescents: The Need for Adequate Health Services. This is a shortened form of the Summary and Conclusions of this book.

Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for public health benefits?

It has been widely believed that, by combining the services for preventing and treating sexually transmitted infections (STI) with those for family planning (FP), STI coverage would increase and the combined service would be of higher quality and more responsive to the needs of women. So far, there is little concrete evidence that integration has had such an impact. Besides the absence of documentation, a clear definition of integration is lacking. We therefore carried out a comprehensive review of concrete experiences with integrated services, and present a summary of our findings in this article. The results indicate that the tasks of STI prevention, such as education for risk reduction and counselling, have been integrated into family planning services much more frequently than the tasks of STI diagnosis and treatment. Some STI/FP integration efforts appear to have been beneficial, for instance when the integration of STI/HIV prevention had a positive impact on client satisfaction, and on the acceptance of family planning. Less clear is whether STI prevention, when concentrated among traditional FP clients, is having a positive impact on STI risk behaviours or condom use. A few projects have reported increases in STI caseloads following integration. In some projects, FP providers were trained in STI case management, but few clients were subsequently treated.

Recent declines in reported syphilis rates in eastern Europe and central Asia: are the epidemics over?

BACKGROUND: Since the early 1990s, major syphilis epidemics have occurred in the Newly Independent States (NIS) of the former Soviet Union. The new and rapidly changing societal and economic conditions in these countries challenge their traditional approaches to the control of sexually transmitted infections (STI). Nevertheless, following a steady increase until 1997, reported syphilis incidence has declined during the past 3 years in most parts of the region. We examine these trends against a background of ongoing changes in service delivery, care seeking behaviour, and case finding practices. METHODS: National syphilis surveillance data reported to the WHO Regional Office for Europe were compiled and analysed, and supplemented with information presented at recent expert meetings and with results from ongoing research. RESULTS: Since 1997, reported syphilis incidence either stabilised or declined in many locations in the NIS, but further increased in others, especially in rural areas. Congenital syphilis continued to increase in all countries, except Latvia. The proportion of self presenting cases versus cases detected through screening declined, and so did notifications of early compared with late forms of syphilis. Patients increasingly seek care in the private formal and informal healthcare sectors which hardly participate in case reporting. CONCLUSIONS: Recent declines in syphilis notifications in the NIS are at least partially a reflection of a reduced intensity of active case finding and of changes in reporting completeness because of a shift in service utilisation from the public to the private/informal sectors. Syphilis rates are still high, indicating that both public and private sectors have to respond more efficiently to the needs of many people at risk of STI. The collection of serial STI prevalence data is recommended to be able to validate trends in notifications.

The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making.

OBJECTIVE: To describe recent patterns and trends in the HIV epidemic in eastern Europe. METHODS: AIDS programme managers and epidemiologists of 23 countries were contacted and requested to provide national HIV surveillance data. Joint United Nations Programme on HIV/AIDS/World Health Organisation country fact sheets were reviewed and analysed, and this information was supplemented with published HIV prevalence and sexually transmitted disease case reporting information, unpublished travel reports and expert evaluations. RESULTS: The cumulative number of HIV cases reported in the region increased more than fivefold between 1995 and 1997, from 9111 to 46573; Ukraine, Russia and Belarus accounted for about 90% of all new cases. Dramatic increases in the number of HIV-infected injecting drug users (IDU) were reported from these countries, and a similar pattern was emerging in Moldova, the Baltic States, the Caucasus and Kazakstan. In central Europe, the increase in the number of cases was much lower, and (with the exception of Poland) homosexual transmission was most common, whereas in the Balkan countries, cases due to heterosexual transmission were reported relatively more frequently. At the end of 1997, more than 50% of all cases region-wide had been reported from IDU. HIV prevalence data were inconclusive. The number of reported syphilis cases had risen significantly in the countries of the former Soviet Union. CONCLUSION: Our data confirm that HIV must have been rapidly spreading among IDU in several countries of the former Soviet Union, whereas central and southeast Europe have so far escaped a more extensive spread of HIV. Factors that might have fuelled a massive spread among IDU include changes in drug demand and supply, migration and specific local drug production and consumption patterns. High rates of syphilis reported in the countries of the former Soviet Union highlight that subregion's increased vulnerability with regards to a further spread of the epidemic, via heterosexual intercourse, into the general population.

HIV prevention among injecting drug users: responses in developing and transitional countries.

OBJECTIVE: Human immunodeficiency virus (HIV) infection associated with injecting drug use has been reported in at least 98 countries and territories worldwide. There is evidence that new epidemics are emerging in different regions, including Eastern Europe, Latin American, and the eastern Mediterranean. The authors provide a global overview of the situation of HIV infection associated with injecting drug use and responses that have been implemented in various developing and transitional countries. METHODS: Although there has been extensive documentation of the extent and nature of of HIV infection associated with injecting drug use in many developed countries and the various interventions implemented in those countries, there is very limited information on the situation in developing and transitional countries. This chapter brings together information from a broad range of sources, including published literature; "gray" or "fugitive" literature; data collected by the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations International Drug Control Programme (UNDCP); personal communications; and direct observation by the authors. The authors have traveled extensively to a wide range of developing and transitional countries and have accessed information not readily available to the international research community. RESULTS: A wide range of HIV prevention strategies targeting injecting drug users (IDUs) has been implemented in developing countries and countries in transition. Interventions include opioid substitution pharmacotherapy, needle syringe exchange and distribution, condom and bleach distribution, outreach to IDUs, peer education programs, and social network interventions. In some communities, completely new models of intervention and service delivery have developed in response to specific local needs and limitations. CONCLUSIONS: Although empirical data may currently be lacking to demonstrate the effectiveness of may HIV prevention programs targeting IDUs in developing and transitional countries, there is evidence that innovative HIV prevention initiatives are being implemented and sustained in a wide range of sociocultural settings.

Training birth attendants in the Sahel.

A small-scale training programme for birth attendants in a remote area of Burkina Faso was evaluated two years after it had been started. The evaluation methods included interviews with trained birth attendants and the analysis of health service statistics and survey data. The findings showed that the programme had been moderately successful in imparting knowledge and overcoming cultural inhibitions about assisted deliveries. However, the effectiveness of the programme was severely curtailed by structural deficits in the health system, especially lack of skilled staff, supervision and transport. In deprived areas such as the Sahel, it is probably the health centre, the hospital and the referral system that should be the first priority for improvement, rather than grass-roots practices.

PIP: This program evaluation pertains to a program initiated in 1990 for training of 18 traditional birth attendants (TBAs) from Fulani or Rimaibe villages in the department of Sebba in northern Burkina Faso. All were illiterate and most were another ethnic minority. Training was directed to performing safe birth procedures and the detection of high risk pregnancies. Techniques were taught for massaging the uterus in order to induce contractions, putting the baby to the breast immediately after delivery, and referral. Methods involved group discussions, practical demonstrations, and role playing. Pictorial cards were used for recording pregnancy information. TBAs received simple maternity kits. An ambulance was made available for emergency referral to the regional hospital. The area is served by two clinics and one medical center. Program evaluation occurred in 1992. Interviews were conducted among 17 TBAs, health service statistics were collected, and a health survey was conducted in the department (296 women of childbearing age from 21 villages). 397 deliveries occurred in the five years preceding the survey. 92% of deliveries were at either of the two clinics or at the Sebba medical center. 12% delivered without assistance. 39% had the assistance of a friend or relative. 24% had assistance from an older neighbor. 19% had assistance from untrained TBAs. 7% had health personnel assistance. TBAs were found to have retained most of the childbirth information, and 11 could correctly identify signs of high risk pregnancy. 14 correctly described hygienic practices. All 17 recognized chloroquine as an anti-malaria drug, and 12 knew the proper dosage of 3 tablets per week. Knowledge of postpartum hemorrhage was weak. The trained TBAs were seldom used in the two year period. Seven villages regularly used their services. Three correctly attended 35-50% of all births in their villages. 13 TBAs made a total of 36 referrals. Program success was not related to training activities or cultural obstacles. The entire health delivery system at the clinic level, the referral system, and health staff training rather than grass roots changes, were suggested improvements. Candidates for training should be selected more appropriately.

Herpes zoster as an indicator of HIV infection in Africa.

In areas where resources for health information are limited, the incidence of herpes zoster can usefully be monitored as an indicator of HIV infection. A sudden parallel rise of the number of symptomatic HIV cases and herpes zoster cases was observed in a northern district of Zimbabwe. Herpes zoster was made locally reportable. Three years later the incidence of herpes zoster and HIV in the hospital and of herpes zoster in the surrounding rural health centres was analysed. The herpes zoster attack rate and the HIV seropositivity rate of herpes zoster patients resembled those elsewhere in Africa. The distribution of cases of zoster was comparable with that of HIV infection.

PIP: In 1987, Karoi district in northern Zimbabwe made herpes zoster a reportable disease because of an unusual increase in the number of cases in the district. Health workers at the hospital had seen an increase in the number of patients with HIV associated symptoms between June 1986 and March 1989. Herpes zoster cases rose from 0 to 100 between 1986 and 1987. HIV cases increased from 10 to 300 between 1986 and 1987. By 1988, these numbers increased to 500 and 450, respectively. 89% of herpes zoster cases at the hospital in 1988-89 were HIV positive. About 66% of these HIV positive cases had no sign or symptom of HIV infection other than herpes zoster. The percentage of confirmed HIV cases with a current or previous history of herpes zoster was 15% in 1987, 32% in 1988, and 17% in 1989. The decrease after 1988 was due to hospital staff telling health centers' staff that they no longer needed to refer all herpes zoster cases to the hospital since almost all young herpes zoster cases were HIV positive. Based on a herpes zoster attack rate of 15%, a positive predictive value of 90%, and the cumulative herpes zoster incidence for 1986-89 of 250/1200 inhabitants, the researchers calculated that there were about 1500 HIV positive cases or 12.5% of the total population living in the area. This would bring the number of HIV positive cases in the district to 3600 or 4 times the number who came to the hospital with HIV associated symptoms and were indeed HIV positive. Health workers can monitor expansion of the HIV epidemic in northern Zimbabwe based on the number of herpes zoster cases.