The role of testing and counselling for HIV prevention and care in the era of scaling-up antiretroviral therapy.

OBJECTIVE: HIV Testing and Counselling (TC) programmes are being scaled-up as part of efforts to provide universal access to antiretroviral treatment (ART). METHODS AND FINDINGS: Mathematical modelling of TC in Zimbabwe shows that if universal access is to be sustained, TC must include prevention counselling that enables behaviour change among infected and uninfected individuals. The predicted impact TC is modest, but improved programmes could generate substantial reductions in incidence, reducing need for ART in the long-term. CONCLUSIONS: TC programmes that focus only on identifying those in need of treatment will not be sufficient to bring the epidemic under control.

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.

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 clinical evaluation of children under the age of five years who are household contacts of adults with sputum positive tuberculosis in Harare, Zimbabwe.

OBJECTIVE: To determine the prevalence and risk factors for transmission of tuberculosis in children under five years of age who are household contact of sputum smear positive tuberculosis adults in Harare, Zimbabwe. DESIGN: Cross sectional study. SETTING: City Health Infectious Diseases Hospital Outpatient Department. SUBJECTS: 174 children in contact with 102 index cases. MAIN OUTCOME MEASURES: TB infection status in children according to modified WHO classification of tuberculosis. METHODS: Under five year old contacts of sputum smear positive TB adults were recruited over a three month period. A coded questionnaire was used to document the following: socio-demographic profile of caregivers, duration of stay with the index case and presenting complaints. Contacts were evaluated by clinical examination, Mantoux testing, HIV antibody testing and chest radiographs. RESULTS: Of the 174 children in contact with 102 index cases evaluated, 109 (62.6%) were Mantoux positive (> or = 10 mm), 42% had abnormal chest X-ray, with hilar lymphadenopathy being the commonest abnormality. Forty nine percent of the children evaluated had probable TB, 28% had suspected TB and 23% had no TB. High alcohol acid fast load (AAFB) in the index case was independently associated with probable and suspected TB (OR 2.27 95% CI (1.05 to 4.87). CONCLUSION: The documented high transmission rate among under five years contacts in the study justifies the need for strengthening contact tracing and appropriate therapeutic management of identified children.

Evaluation of the prototype Roche DNA amplification kit incorporating the new SSK145 and SKCC1B primers in detection of human immunodeficiency virus type 1 DNA in Zimbabwe.

We assessed the sensitivity and specificity of a newly developed DNA PCR kit (Roche Diagnostic Corporation, Indianapolis, Ind.) that incorporates primers for all the group M viruses for the detection of human immunodeficiency virus (HIV) type 1 (HIV-1) infection in Zimbabwe. A total of 202 whole-blood samples from adults whose HIV status was known were studied. This included 100 HIV-1-positive and 102 HIV-1-negative samples selected on the basis of concordant results obtained with two enzyme-linked immunosorbent assay kits. The prototype Roche DNA PCR assay had a 100% sensitivity for the detection of HIV-1 DNA and a specificity of 100%. We conclude that the new Roche DNA PCR kit is accurate for the detection of HIV DNA in Zimbabwean samples, in which HIV-1 subtype C dominates.

Evaluation of a measles vaccine efficacy during a measles outbreak in Mbare, City of Harare Zimbabwe.

OBJECTIVE: To determine measles vaccine efficacy. DESIGN: Between October and November 1996, during a measles outbreak in Mbare, a retrospective study through interviews with care givers was performed. Thirty clusters were randomly selected and seven or more, nine to 35 months old children in each cluster were selected. SETTING: Mbare suburb, City of Harare SUBJECTS: 294 children aged nine to 35 months. MAIN OUTCOME MEASURES: Cases were classified in a two by two contingency table based on their vaccination status and measles status during the outbreak. Vaccine coverage, attack rates and vaccine efficacy were then calculated. RESULTS: Of the 294 children selected, 83% (95% CI 78.7, 87.3) were vaccinated and 9.5% had measles. The attack rate for the vaccinated was 6.9% while that for the unvaccinated was 22%. Vaccine efficacy was 68%. CONCLUSION: Vaccine efficacy was found to be low. There is need for serological confirmation of measles cases during outbreaks; for a comprehensive evaluation of the measles vaccination programme in Mbare and for maintenance of high measles vaccine coverage rates to reduce morbidity.

PIP: Through the Zimbabwe Expanded Program of Immunization (ZEPI) introduced in Zimbabwe in 1982, children are vaccinated with the Schwarz-strain vaccine at age 9 months. Through the ZEPI, measles immunization coverage has increased from 56% in 1981 to 82% in 1995. Nonetheless, measles remains one of Zimbabwe's most important public health problems. The number of reported measles cases has declined, but there is still an unacceptably high level of cases and outbreaks continue to be reported regularly throughout the country. The efficacy of the measles vaccine used in the ZEPI was evaluated near the end of a measles outbreak which occurred between June and November 1996 in Mbare suburb, with an estimated 1995 population of 120,000. The retrospective study was conducted through interviews with caregivers of 7 or more children aged 9-35 months from each of 30 randomly selected neighborhood clusters. A total 294 children were considered from the clusters, of whom 83% were vaccinated and 9.5% had measles during the outbreak period. The attack rates for the vaccinated and unvaccinated were, respectively, 6.9% and 22%. Vaccine efficacy was therefore determined to be 68%. Clinical measles cases identified during outbreaks should be serologically confirmed to achieve a more accurate diagnosis. Moreover, the Mbare Health Team should conduct a comprehensive evaluation of its measles vaccination program.

Does an antimalarial drug history mean anything?

OBJECTIVE: To determine the validity of an antimalarial drug history. DESIGN: During a chloroquine sensitivity study carried out from 27 February to 13 April, 1995, an antimalarial drug history was obtained from the patients. A urine test was used as a gold standard to screen for antimalarial drugs in these patients. SETTING: Two Mutare district primary health care centres. SUBJECTS: Fifty clinical malaria cases were screened. MAIN OUTCOME MEASURES: Cases were classified in a two by two contingency table based on the reported antimalarial drug and the results of the urine test. Positive predictive value and negative predictive value were then examined.

Outcome of admitted malaria cases by treatment at Manicaland Provincial Hospital, Zimbabwe.

OBJECTIVE: To determine the outcome of admitted malaria cases according to age, late presentation, and antimalarial drug treatments received. DESIGN: We reviewed all March 1994 hospital and laboratory records of patients with a clinical diagnosis of malaria. SETTING: Manicaland Provincial Hospital. SUBJECTS: 319 clinical malaria cases. MAIN OUTCOME MEASURES: Cases were classified as uncomplicated, complicated and unconscious. RESULTS: Of the 319 cases reviewed, 213 slide examinations were done and 174 (82pc) were slide positive. Of slide positive admissions, 91 (52pc) were complicated and 37 (21pc) were unconscious; 22 (13pc) died. Case fatality was two pc in uncomplicated cases, six pc in complicated cases, and 46pc in unconscious cases. Uncomplicated and complicated cases did as well on chloroquine (none of the 53 died) as on other treatments (four of the 76 died), whereas unconscious patients did poorly regardless of therapy received. Twelve patients received no therapy on their first hospital day and four died. There was no significant association between young age (age < 5 years) and complications or death, nor between late presentation (illness onset > or = 3 days before hospital presentation) and complications or death.

Chloroquine resistant falciparum malaria in Mutare District, eastern Zimbabwe.

OBJECTIVE: From 1992 to 1994 malaria incidence and mortality increased in Manicaland province despite an intensified malaria control programme. This was perhaps due to chloroquine resistance. The magnitude of chloroquine resistance in unstable malaria transmission areas of Zimbabwe is unknown. DESIGN: A modified seven day prospective World Health Organization in vivo test for chloroquine resistance was carried out from February 27 to April 13, 1995. SETTING: Two Mutare district primary health care centres, in Manicaland Province. SUBJECTS: Thirty three patients were enrolled and 30 completed follow up. MAIN OUTCOME MEASURES: Cases were classified according to WHO classification for chloroquine resistances as S/R1, R2 or R3. RESULTS: The median age of the 30 cases was 12 years with a range of five to 60 years. Twenty cases (67 pc were S/R1, three (10pc) were R2 and seven (23 pc) were R3. By day 3 of chloroquine treatment there was a more than 50pc reduction in malaria related symptoms in all the three classifications. CONCLUSION: High level resistance (R2 and R3) of 33pc was demonstrated. Early symptom response did not give an indication of resistance. We recommend a re-assessment of the provincial malaria treatment policy with consideration of introduction of a second line antimalarial drug at the health centre level.