Patterns of partnership and condom use in two communities of female sex workers in Tanzania.

Two rapid ethnographic studies have found that commercial sex workers (CSWs) and other high-risk women in Tanzania have different categories of partners, ranging from single-time contacts to long and enduring relationships. Since the advent of HIV/AIDS prevention programs in Tanzania in the late 1980s, CSWs and their clients have been aware of the multiple benefits of condom use for the prevention of pregnancy and STDs including HIV. These women often use condoms for the single-time contact. However, since the HIV/AIDS epidemic, casual partners have decreased in number. These days, most of their sexual contacts occur within long-term partnerships, and within these relationships, condom use is rare. Although the message that condoms should be used during high-risk behavior has been largely accepted, the definition of a high-risk relationship needs to be extended from casual partnerships to include multiple long-term partnerships. In addition, men and women's empowerment through education, business, and equal rights needs to be addressed at all levels of society.

AVERT: a user-friendly model to estimate the impact of HIV/sexually transmitted disease prevention interventions on HIV transmission.

OBJECTIVE: To introduce the newly developed AVERT model by describing the purpose, logic, advantages and limitations of the model, to validate the model's estimates against seroconversion data from a large randomized controlled trial, and to provide practical examples of its applications. DESIGN: Static, deterministic spreadsheet-type model based on per sex act HIV-1 transmission probabilities. METHODS: Data from a recently completed trial carried out in Cameroon were used to validate the estimated number of new HIV infections generated by the AVERT model. A relatively limited set of biological and behavioral parameters was used to estimate the impact of a targeted HIV/sexually transmitted disease (STD) prevention intervention in a South African mining community. RESULTS: The comparison of AVERT estimates with actual seroincidence data from the Cameroon trial not only confirmed the validity of the model's outputs but also illustrated its potential to provide additional options in data analysis. Modeling the pre-and post-intervention scenarios for the South African mining community with AVERT provided estimates of the number of HIV infections averted due to targeted periodic presumptive STD treatment and community-based peer education. CONCLUSIONS: With a small number of accessible input variables, AVERT can provide plausible and defendable impact estimates of intervention effects on the reduction of HIV transmission. The AVERT model may be a helpful tool for decision-makers and planners in setting appropriate program priorities and analysing the cost-effectiveness of different intervention packages.

Measuring condom use among sex workers in the Dominican Republic.

The purpose of this paper is to assess the internal consistency of self-reported condom use among sex workers in Puerto Plata and Santo Domingo, Dominican Republic. We examined the responses to questions about condom use among 4 cross-sectional samples of sex workers. We compared measures based on: (1) questions using always-to-never scales; (2) questions about use with the past 5 clients; and (3) questions about use in the past week obtained from a retrospective coital log. In each sample, more women reported 'always' using condoms with clients than with each of the past 5 clients. In 3 of the 4 samples, only about half of the women who reported 'always' using condoms used condoms with the most recent 5 clients and with all clients in the past week. Internal consistency was significantly higher when the comparison was limited to use with the most recent 5 clients and use in the past week. Self-reported measures of condom use can be difficult to interpret. Assessing the internal consistency of several measures of use provides insight into the strengths and weaknesses of each measure.

PIP: Although evaluations of interventions to curtail the spread of HIV rely, to a large extent, on self-reported changes in behavior, the validity of self-reported condom use is difficult to assess. The internal consistency of self-reported condom use was investigated among four convenience samples of commercial sex workers in Puerto Plata (n = 408) and Santo Domingo (n = 604), Dominican Republic, interviewed before and after targeted HIV/AIDS educational programs. Three measures of condom use were assessed: 1) a measure based on reported frequency of use with new clients and regular clients using an always-to-never scale, 2) a measure of use with the most recent 5 clients, and 3) a measure based on a retrospective coital log of use with clients in the past 7 days. In each sample, more women reported "always" using condoms with clients than with each of the past 5 clients. The largest discrepancy was found in the second Puerto Plata sample, where 153 women (76%) reported always using condoms with clients, but only 96 women (47.5%) reported using condoms with each of the past 5 clients. "Sometimes" users were significantly more consistent in their responses than "always" users. Internal consistency was significantly improved (83-89%) when the comparison was limited to use with the most recent 5 clients and use in the past week.

Plasmodium Falciparum malaria and perinatally acquired human immunodeficiency virus type 1 infection in Kinshasa, Zaire. A prospective, longitudinal cohort study of 587 children.

BACKGROUND: It is uncertain whether Plasmodium falciparum malaria is more frequent or more severe in children with perinatally acquired human immunodeficiency virus type 1 (HIV-1) infection and whether P. falciparum infection accelerates the progression of HIV-related disease. METHODS: We conducted a prospective, longitudinal cohort study in Kinshasa, Zaire. Two hundred sixty children 5 to 9 months of age who had been born to HIV-1-seropositive mothers and 327 children of the same age who had been born to seronegative mothers were monitored intensively for malaria over a 13-month period. All episodes of fever were evaluated with blood smears for malaria, and children found to be infected with P. falciparum were treated with a standard regimen of oral quinine. RESULTS: A total of 2899 fevers were evaluated, with 271 cases of malaria identified. No statistically significant differences were found in the incidence, severity, or response to therapy of malaria among four well-defined groups of children: those with the acquired immunodeficiency syndrome (AIDS), those who were HIV-1-seropositive throughout the study, those who were born to HIV-1-seropositive mothers but reverted to seronegative, and those who were seronegative throughout the study. During the 13-month period the incidence of malaria in the 36 children with HIV infection in whom AIDS developed was lower, although not significantly so, than in the 37 in whom AIDS did not. CONCLUSIONS: In this study malaria was not more frequent or more severe in children with progressive HIV-1 infection and malaria did not appear to accelerate the rate of progression of HIV-1 disease.

HIV-1 seropositivity and mortality at University Hospital, Kinshasa, Zaire, 1987.

This study examines the impact of HIV-1 infection and AIDS on 500 of 563 consecutive deaths at University Hospital, Kinshasa, Zaire, in late 1987. HIV-1 seroprevalence was 31% for the entire population and 43% for the 247 adults. Forty-two (38%) of the 110 HIV-1-seropositive adult deaths occurred in those between the ages of 25 and 34 years. The mean age of death for seropositives was 36 years, 7.5 years less than seronegative deaths. AIDS and AIDS-associated diagnoses such as cryptococcal meningitis, chronic diarrhea and pneumonia accounted for 42% of all adult deaths and 74% of all HIV-1-seropositive adult deaths. Seventeen per cent of 50 sera initially negative by enzyme-linked immunosorbent assay (ELISA) were ultimately found to be HIV-1-seropositive by Western blot or p24 antigen testing. The data indicate that HIV-1 infection and AIDS contribute significantly to adult mortality in Kinshasa population and that sensitivity of ELISA tests decreases in terminal HIV-1 infection.

AIDS-related knowledge, sexual behavior, and condom use among men and women in Kinshasa, Zaire.

This study was conducted in 1988 among a random sample of 6,625 men and women of reproductive age in all 24 administrative zones of Kinshasa, the capital city of Zaire, to determine existing levels of knowledge regarding AIDS (acquired immunodeficiency syndrome), sexual behavior, knowledge and use of condoms in marital and extramarital relations; perceived risk of AIDS, and attitudes toward testing for the human immunodeficiency virus (HIV). Awareness of AIDS is almost universal, and the vast majority know the four main modes of transmission. Almost half believed in transmission by mosquitoes and in a vaccine or cure for AIDS. The majority of male respondents knew of condoms, but negative attitudes toward condom use are widespread, and few respondents perceived them to play a central role in combatting AIDS.

Duration and correlates of post-partum abstinence in four sites in Zaire.

Data on 2223 women with a child less than 25 months of age from four sites of two regions in Zaire were analyzed. The univariate correlates of current abstinence were determined on this population. A sub-sample of 778 women was then drawn for the development of multivariable model of predictors of the duration of abstinence. The median duration of abstinence in the two urban and two rural sites ranged from 4.5 to 8.8 months. The final multivariable model showed that low socio-economic status, rural residence, more living children, prolonged duration of breastfeeding and non-Zairian nationality were all important predictors of prolonged duration of abstinence. The relationship of duration of abstinence to that of amenorrhea is also important. While approx. 18% of the women included in this analysis continued to abstain for at least one month beyond the resumption of menses, the vast majority who did resume relations represent a target population for utilization of an alternate means of pregnancy prevention.

An analysis of the economic impact of HIV infection among patients at Mama Yemo Hospital, Kinshasa, Zaire.

In a prospective study of adult admissions to the Department of Internal Medicine at Mama Yemo Hospital, Kinshasa, Zaire in late 1988, 129 women and 122 men were screened for HIV infection. Fifty per cent were found to be seropositive, with half of the seropositives meeting the World Health Organization (WHO) clinical AIDS definition. The HIV seropositives had a mortality rate of 50%, which was significantly higher (P = 0.004) than the 30% mortality rate seen in the seronegative group. Direct costs during hospitalization did not differ ($60.30 for HIV seropositives, $56.50 for HIV seronegatives), but pre-hospitalization expenses were significantly higher in the HIV-seropositive group ($170 for HIV seropositives, $110 for HIV seronegatives). Years of productive life lost due to death were also significantly higher for HIV seropositives versus HIV seronegatives (30.6 versus 21.3 years; P = 0.0007), and 73% of the premature mortality in the study population was attributable to HIV infection.

Prevention of perinatal HIV transmission: are there alternatives to pre-pregnancy serological screening in Kinshasa, Zaire?

Complete obstetrical and medical histories were obtained from 6312 women between the ages of 15 and 45 years who had undergone HIV serological tests. Individual factors were examined for sensitivity, specificity and positive predictive value of HIV infection. No individual risk factors for HIV infection were identified which had sensitivities greater than 60%. Combinations of factors were modelled by logistic regression. Only a model which included indicators of present illness with AIDS/HIV-related symptoms (i.e., chronic fever, diarrhea or profound weight loss) was predictive of HIV serostatus. These results suggest that identification of healthy women at high risk of HIV infection using non-serological information is not feasible. Thus, since the yearly cost of universal serological screening is prohibitively expensive in the Zairean context, HIV/AIDS education and prevention campaigns may in fact be a more cost-effective means of preventing perinatal transmission of HIV.

PIP: Complete obstetrical and medical histories were obtained from 6312 women between ages 15-45 who had undergone HIV serological tests. Individual factors were examined for sensitivity, specificity, and positive predictive value of HIV infection. No individual risk factors for HIV infection were identified which had sensitivities 60%. Combinations of factors were modelled by logistic regression. Only a model which included indicators of present illness with AIDS/HIV-related symptoms (chronic fever, diarrhea, or profound weight loss) was predictive of HIV serostatus. These results suggest that identification of healthy women at high risk of HIV infection using nonserological information is not feasible. Thus, since the yearly cost of universal serological screening is prohibitively expensive in Zaire, HIV/AIDS education and prevention campaigns may be a more cost-effective means of preventing perinatal HIV transmission.

Heterosexual transmission of HIV-1 among employees and their spouses at two large businesses in Zaire.

To better understand the reasons why up to 80% of all HIV-1 infections in Zaire, but less than 5% in North America and Europe, are acquired through heterosexual transmission, and to assess the impact of HIV-1 infection on a large urban African workforce, we enrolled 7068 male employees, 416 female employees and 4548 female spouses of employees at two large Kinshasa businesses (a textile factory and a commercial bank) in a prospective study of HIV-1 infection. The HIV-1 seroprevalence rate was higher in male employees (5.8%) and their spouses (5.7%) at the bank than among male employees (2.8%) and their spouses (3.3%) at the textile factory. At both businesses HIV-1 seroprevalence was higher among employees in managerial positions (5.0%) than among workers in lower-level positions (3.0%; P less than 0.0001). In a multivariate analysis of male employees, receipt of a transfusion, a history of genital ulcer disease, working at the bank, urethritis, or being divorced or separated were independently associated with HIV-1 infection. During 1987 and 1988, AIDS was the most common cause of death among recently employed workers, accounting for 20 and 24% of all deaths at the textile factory and the commercial bank, respectively. The HIV-1 seroprevalence rate was higher among female workers (7.7%) than among the spouses of male workers (3.9%; P = 0.001). In multivariate analysis of the wives of workers, having an HIV-1-seropositive spouse, receipt of a blood transfusion, or a history of genital ulcer disease were independently associated with HIV-1 infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Perinatal transmission of the human immunodeficiency virus type 1 to infants of seropositive women in Zaire.

To examine perinatal transmission of the human immunodeficiency virus type 1 (HIV-1) in Zaire, we screened 8108 women who gave birth at one of two Kinshasa hospitals that serve populations of markedly different socioeconomic status. For up to one year, we followed the 475 infants of the 466 seropositive women (5.8 percent of those screened) and the 616 infants of 606 seronegative women matched for age, parity, and hospital. On the basis of clinical criteria, 85 of the seropositive women (18 percent) had the acquired immunodeficiency syndrome (AIDS). The infants of seropositive mothers, as compared with those of seronegative mothers, were more frequently premature, had lower birth weights, and had a higher death rate in the first 28 days (6.2 vs. 1.2 percent; P less than 0.0001). The patterns were similar at the two hospitals. Twenty-one percent of the cultures for HIV-1 of 92 randomly selected cord-blood samples from infants of seropositive women were positive. T4-cell counts were performed in 37 seropositive women, and cord blood from their infants was cultured. The cultures were positive in the infants of 6 of the 18 women with antepartum T4 counts of 400 or fewer cells per cubic millimeter, as compared with none of the infants of the 19 women with more than 400 T4 cells per cubic millimeter (P = 0.02). One year later, 21 percent of the infants of the seropositive mothers had died as compared with 3.8 percent of the control infants (P less than 0.001), and 7.9 percent of their surviving infants had AIDS. We conclude that the mortality rates among children of seropositive mothers are high regardless of socioeconomic status, and that perinatal transmission of HIV-1 has a major adverse effect on infant survival in Kinshasa.

Homicide victims in New Orleans: recent trends.

Data are presented on 694 criminal homicide victims killed in the city of New Orleans during four years; 1979, 1982, 1985, and 1986. The homicide rate for black males was 6.5 times higher than that for white males for the years studied. Over 70% of victims were killed by handguns. When victims were assigned to one of five socioeconomic strata, homicide rates for blacks exceeded those for whites by a factor of at least 2.5 times for each socioeconomic stratum. White victims were more likely than were black victims to be legally intoxicated at the time of death, but black victims were nearly four times more likely to have illicit drugs other than alcohol detected. During the time period investigated, there was a marked decrease in the number of victims with pentazocine and tripelennamine ("Ts and blues") detected and an abrupt increase in the number of victims with detectable phencyclidine and cocaine levels. Further studies are needed to investigate risk factors for homicide victimization so that effective intervention strategies can be employed.

The epidemiology of perinatal transmission of HIV.

PIP: The range of issues in the epidemiology of perinatal infection with HIV covers prevalence of HIV in women, types of HIV transmission to the fetus and newborn, problems with testing for HIV infections in neonates, variations in effectiveness of transmission to infants, maternal, fetal and perinatal mortality. In the U.S. 75% of all pediatric AIDS cases are traceable to HIV-positive mothers, but numbers are small. In Central Africa, seroprevalence in women is about 5%, and perinatal HIV is significant. HIV has been demonstrated in fetal tissues and cord blood, indicating transmission in utero. Transmission at birth has not yet been documented. Transmission of HIV after birth, presumably via breastfeeding, has been shown in at least 8 cases. No information is available on HIV titers in breast milk. Diagnosis of HIV infection in newborns is problematic. Cord blood cultures, the p24 antigen test, and the in situ hybridization method are feasible but impractical in most clinics. The Western blot test for IgM-specific antibodies is not specific or sensitive enough for infants. A new method called [DNA] polymerase chain reaction (PCR) is capable of detecting acquired HIV infection, and may be useful in clinics, since it does not require radionuclides. In 11 studies the incidence of HIV infection in infants of seropositive mothers ranged from 8-65%. There is some indication that the stage of the HIV disease, and possibly socioeconomic status, of the mother affect the transmission of the virus. There is no indication that pregnancy worsens maternal HIV status, although there is a suggestion that mothers may worsen in the postpartum period. Several studies show increased incidence of low birth weight and prematurity, associated with higher infant mortality, in newborns of HIV-positive mothers. No effective programs of screening or counseling women at risk of HIV infection and pregnancy have been reported.^ieng