The reliability of mortality data in Johannesburg.

Information on deaths in Johannesburg is collected on a voluntary basis by the Johannesburg City Health Department from the Department of Home Affairs regional offices as well as state mortuaries in the area. The reliability of these routinely collected data was assessed. Records of deaths of Asians, coloureds and whites from 1 July 1989 to 31 December 1989 were included in the study. Burial orders obtained from the different cemeteries and crematoria in the area were compared with the routinely collected mortality data. Two thousand eight hundred and thirty-seven deaths were included in the study. One hundred and ninety (6%) deaths in the department's records could not be found among the corresponding burial orders while 1,019 (36%) burial order records were not found among the department's routinely collected mortality data. Underreporting of deaths was greatest among the aged (43%) and infants (39%). When this underreporting was taken into account, the corrected infant mortality rate was 19.1/1,000 live births as opposed to 14.1. Recommendations are made for the improvement of the quality of routinely collected mortality data.

The effect of a 6-month cardiac rehabilitation programme on serum lipoproteins and apoproteins A1 and B and lipoprotein a.

One hundred and forty-two cardiac rehabilitation patients were followed up over a period of 6 months and the percentage change over time was recorded for various lipid fractions including apoprotein AI (apo AI), apoprotein B (apo B) and lipoprotein a (Lp(a)). Data were analysed to see if improvement in peak oxygen consumption (VO2) or changes in body weight were related to any of the above. A significant percentage change was found for peak VO2, ventilatory threshold, high-density lipoprotein cholesterol (HDLC) and triglyceride levels, total cholesterol (TC)/HDL ratio, apo AI, apo A/apo B ratio and Lp(a). Multiple regression analysis showed that alterations in the lipid fractions were not related to changes in physical fitness except in the case of TC levels which dropped independently of other measures. On multivariate analysis, Lp(a) correlated positively with both the Broca index and the use of drugs of the fibrate series.

Perceptions and knowledge about AIDS among family planning clinic attenders in Johannesburg.

Many studies assessing the impact of national AIDS prevention programmes on knowledge, attitudes and practices have been published world-wide. Most have found that, while general knowledge increased, there was little change in behaviour. A survey of a random sample of 50 women attending a family planning clinic in Johannesburg determined the current knowledge, attitudes and practices of these sexually active women, aged 20-29 years. All selected respondents agreed to participate and a pretested structured questionnaire was completed. Most individuals had in excess of 7 years' schooling (78.0%), were single (58.0%) and domestic workers (28.6%). The majority were aware of AIDS (88.0%), but only 13.7% felt their knowledge was adequate. Fifty-two per cent knew sexual intercourse was a mode of transmission. Many misconceptions existed, 64.0% cited toilet seats, 47.1% sharing of utensils and 70.1% donating blood as routes by which HIV infection could be acquired. Only 47.1% and 34.1%, respectively, knew that the contraceptive pill and intra-uterine contraceptive device did not protect against HIV infection. Eighty-six per cent of the women were sexually active and 8.0% admitted to currently having more than one sexual partner. None used condoms and, generally, feelings regarding condom use were negative. Most (88.6%) believed AIDS patients should be hospitalised, 68.2% said in isolation wards, and 27.3% felt that AIDS patients should not be allowed to stay in the community. The implications of these findings are discussed and certain recommendations are made.

Evaluation of an AIDS awareness campaign using city buses in Johannesburg.

The Johannesburg City Health Department embarked on an AIDS awareness campaign using messages placed on the outside of 30 city buses. The selection of the message and the campaign are outlined briefly. An evaluation to assess the overall effectiveness and the cost-effectiveness of using buses as a "vehicle' for exposing the local community to AIDS awareness messages is described. Two cross-sectional studies using telephone interviews were done 2 1/2 and 6 months after the campaign began; 30.2% and 31.5%, respectively, of respondents had seen the message. Accurate recall of the message was generally poor. The overall cost of the campaign was R7 627. Various other aspects of the study are discussed. The study revealed that signs on buses are a cost-effective means of conveying simple and brief health-related messages.

'Birth to Ten'--pilot studies to test the feasibility of a birth cohort study investigating the effects of urbanisation in South Africa.

'Birth to Ten' is a birth cohort study currently being conducted in the Johannesburg-Soweto area. This paper describes the various pilot studies that were undertaken to investigate the feasibility of a cohort study in an urban area. These studies were designed to determine the monthly birth rate, the timing, frequency and duration of maternal antenatal visits, the timing and frequency of visits to well-baby clinics and the accuracy and reliability of routinely collected growth data. In addition, a birth data collection form was tested to ascertain the appropriateness of its use in clinics within the study area.

Perceptions and knowledge about the acquired immunodeficiency syndrome among students in university residences.

Using an anonymous questionnaire to obtain baseline data on sexual behaviour and knowledge of the acquired immunodeficiency syndrome (AIDS) among students in university residences, the following information was obtained: Knowledge of AIDS was found to be high, although misconceptions regarding transmission of the virus were prevalent. Mosquito bites (15%) and the donating of blood (31%) were incorrectly identified as methods of transmission of the virus. Deep kissing was recognised by only 27% of the students as a possible method of transmission while 22% and 13% of the students, respectively, failed to identify the sharing of razor blades and blood transfusions as possible means of contracting HIV infection. The students' knowledge had not greatly affected sexual behaviour. Two-thirds of the respondents had previously had sexual contact; 38% were sexually active at the time of the study, and of these 74% had engaged in unprotected intercourse with casual partners in the previous 6 months. There was a negative attitude towards condom use and over 80% of sexually active students did not perceive themselves to be at risk of contracting AIDS. Campus Health (82%), State health services (51%), and public advertisements (60%) were preferred sources of AIDS information. Newspapers/magazines (80%) and leaflets (69%) were identified as the preferred media. In reality, significantly fewer students obtained their information from Campus Health (15%; P less than 0.05), State health services (19%, P less than 0.05) and leaflets (44%; P less than 0.05). It can be concluded that education programmes should be developed by credible organisations to ensure that an awareness of AIDS results in appropriate sexual behaviour.

The Johannesburg cardiac rehabilitation programme.

Cardiac rehabilitation has become a generally accepted mode of treatment for patients suffering from coronary artery disease. The Johannesburg cardiac rehabilitation programme was started in 1982 and has rapidly grown to become one of the largest programmes in southern Africa. This paper describes the 387 patients admitted to the unit between June 1986 and July 1988 and evaluates the effects of a combined exercise training and lifestyle modification programme. The mean age on admission was 55 years for males and 58 years for females. Most patients were from social classes I and II. Myocardial infarction, coronary artery bypass graft and a combination of both were the most common reasons for admission (35.4%, 23% and 21.2% respectively). On admission 72.9% of patients were smokers, 26.3% had hypertension and 34.3% had hypercholesterolaemia. A 50% drop-out rate within 12 months of starting the programme was noted. An increase in peak oxygen uptake, weight and skinfold thickness reduction, and improvement in the lipogram were seen after 6 months in patients who complied well with the programme. Cardiac rehabilitation is a secondary preventive strategy that can complement traditional medical and surgical therapies.

Exposure to hepatitis B virus among South African health care workers--implications for pre-immunisation screening.

Vaccination of health care workers is highly effective in preventing occupationally acquired hepatitis B virus (HBV) infection, but cost is a major factor impeding routine immunisation programmes. Pre-vaccination serological screening may be cost-beneficial if the prevalence of immunity is sufficiently high to offset its cost against the consequent reduction in vaccination needs. This critical population prevalence can be calculated given the cost of vaccination and testing. Samples of health care worker populations were examined for immunity and, using local present-day costs, it was calculated that pre-vaccination screening would be cost-beneficial in black nursing and laboratory personnel, but not their white counterparts or any student health care workers.

Knowledge, beliefs and practices among black goldminers relating to the transmission of human immunodeficiency virus and other sexually transmitted diseases.

The Chamber of Mines of South Africa employs approximately 750,000 miners from all over southern Africa. Sero-surveys in 1986 showed that, depending on geographical area of origin, between 0.02% and 3.76% of miners were positive for human immunodeficiency virus (HIV) antibodies. As a consequence, an intensive education campaign to stop the spread of HIV infection was launched. A study was undertaken to establish a valid baseline level of knowledge about black miners' beliefs, attitudes and practices related to HIV infection, acquired immunodeficiency syndrome (AIDS) and sexually transmitted diseases (STDs), and to recommend appropriate changes to the educational efforts of the Chamber of Mines. A structured, pre-tested questionnaire was used to interview in their home language 429 systematically sampled black miners from four different mines. The most relevant findings were that younger age, not being married and how general education predispose to contracting STDs, while a feeling of being at risk for contracting HIV infection is positively correlated with level of education. Close friends were the most important source of information on STDs, but the media and medical staff were the most important sources of information on AIDS/HIV infection. Condoms were used by 31% of respondents, while the main reasons for non-use were trust in the sexual partner and lack of availability. Promotion of a stable family life for miners may significantly impact on the transmission of HIV infection.

Qualitative evaluation of an AIDS health education poster. A rapid assessment method for health education materials.

In January 1989, the Johannesburg City Health Department developed an AIDS education poster. The poster was adapted from a cartoon in the Sowetan newspaper and was formally evaluated before its final production. As a result of this evaluation further editing and restructuring of the poster proved necessary. The methodology used in the evaluation is outlined, and some of the findings that emerged during the evaluation are discussed, since few formal evaluations of health education material seem to have been documented in South Africa. This study highlights the importance of formative evaluation of printed health educational media by a sample of the target audience before production and distribution.

One year surveillance of HIV-1 infection in Johannesburg, South Africa.

A sero-epidemiological surveillance study to monitor the prevalence of HIV-1 infection in Johannesburg, South Africa, was commenced in February 1988. The population selected for study were attenders at clinics for sexually transmitted diseases (STD) and at family planning (FP) clinics. In the 12 months of the study 6631 sera were tested. Of the STD attenders, 15 of 1224 black females (1.2%) and 21 of 2482 black males (0.8%) were positive. Of the 449 white males tested 49 were homosexual, amongst whom 10 (20.4%) were positive; in the heterosexual white male group 4 of 400 (1.0%) were positive. Of the FP clinic attenders, 4 of 1459 black females (0.3%) were positive. 68 of the 6631 sera tested were indeterminate for infection. No attenders were positive for HIV-2 infection. These data confirmed the entry of HIV infection into the black population in South Africa.

Considerations on the further expansion of the AIDS epidemic in South Africa--1990.

An epidemiological composite of the human immunodeficiency virus (HIV) epidemic in South Africa was constructed from reported acquired immunodeficiency syndrome (AIDS) figures, blood donor seroprevalence data and a family of active surveillance studies in the Johannesburg area. Of great concern is the extensive and continuing silent spread of HIV in the urban black population, manifested by doubling times in male and female sexually transmitted disease (STD) clinic attenders of 10.67 and 9.78 months respectively, a doubling time in female family planning (FP) attenders of 6.55 months, and HIV infection rates of 1:56, 1:37 and 1:91, respectively. These data suggest a spread of infection far more extensive than the relatively lower AIDS figures. However, seroprevalence figures in municipal employees of mainly rural origin were considerably lower, only 1:1,250 in black men and none in women, but regular movements between urban and rural areas could well introduce and amplify infection in rural areas. A complete epidemiological picture of HIV can only be attained by employing both the above approach of the family of surveys complemented by a nationwide seroprevalence study to assess HIV penetration into the general 'background' population. Educational interventions should now be particularly targeted to the major risk groups in the urban black heterosexual community.

Short-term predictions of the prevalence of human immunodeficiency virus infection among the black population in South Africa.

After a brief methodological review of acquired immunodeficiency syndrome/human immunodeficiency virus (AIDS/HIV) forecasting methods, some of these methods were applied to the South African situation and short-term predictions of the prevalence of HIV infection among the black population in South Africa were obtained. At present, the prevalence of HIV infection increases exponentially, with a doubling time of 8,5 months (95% confidence interval 7,6-9,6 months). By the end of 1989 the number of HIV-infected black South Africans aged 15-49 years was estimated to be between 45,000 and 63,000, and it is predicted that these numbers will rise to between 119,000 and 168,000 by the end of 1990, and to between 317,000 and 446,000 by the end of 1991. Because of the lack of basic data, these forecasts are tentative, but they nevertheless indicate the great seriousness of the HIV epidemic in South Africa.

Epidemiological considerations of the present status and future growth of the acquired immunodeficiency syndrome epidemic in South Africa.

Limited epidemiological data on acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) infection have been assembled by voluntarily reported AIDS figures, blood donor serum prevalence and high-risk sentinel population and random background population sero-prevalence studies. The HIV epidemic in South Africa can thus be shown to consist of four separate epidemics of which the heterosexual epidemic will undoubtedly constitute the major growth in this country. Intervention must be directed to shrinking the promiscuous core which sustains this epidemic by directing attention at female prostitution and limiting the reproductive rate of the epidemic by energetic and professionally directed education at an early stage of a child's school career. Sexually transmitted diseases will play a major role in the determination of the extent of the heterosexual epidemic.

AIDS and South Africa--towards a comprehensive strategy. Part I. The world-wide experience.

In this, the first of a three-part series of articles in which we propose steps towards a comprehensive strategy for the control of HIV infection, we consider briefly the world-wide experience with the HIV epidemic. Our objective is to highlight the problems and controversial issues which are pertinent to strategies for the control of HIV infection. We focus on problems of case-definition, differences between 'African' and 'Western' AIDS and the implications for South Africa, and problems with sensitivity and specificity of tests used at present, particularly in the context of false positivity in a community with a low prevalence of HIV infection. We consider some of the ethical issues, including the need for adequate counselling, the need for informed consent before testing, and the centrality of confidentiality, particularly in the context of possible victimisation and neglect of HIV-positive individuals. Differences between 'notification' and 'reporting' are emphasised. Recommendations are made regarding these problems.