A seroepidemiological study of pandemic A/H1N1(2009) influenza in a rural population of Mali.

The swine-origin H1N1 influenza A virus (pH1N1(2009)) started to circulate worldwide in 2009, and cases were notified in a number of sub-Saharan African countries. However, no epidemiological data allowing estimation of the epidemic burden were available in this region, preventing comprehensive comparisons with other parts of the world. The CoPanFlu-Mali programme studied a cohort of 202 individuals living in the rural commune of Dioro (southern central Mali). Pre-pandemic and post-pandemic paired sera (sampled in 2006 and April 2010, respectively) were tested by the haemagglutination inhibition (HI) method. Different estimates of pH1N1(2009) infection during the 2009 first epidemic wave were used (increased prevalence of HI titre of ≥1/40 or ≥1/80, seroconversions) and provided convergent attack rate values (12.4-14.9%), the highest values being observed in the 0-19-year age group (16.0-18.4%). In all age groups, pre-pandemic HI titres of ≥1/40 were associated with complete absence of seroconversion; and geometric mean titres were <15 in individuals who seroconverted and >20 in others. Important variations in seroconversion rate existed among the different villages investigated. Despite limitations resulting from the size and composition of the sample analysed, this study provides strong evidence that the impact of the pH1N1(2009) first wave was more important than previously believed, and that the determinants of the epidemic spread in sub-Saharan populations were quite different from those observed in developed countries.

Patterns and implications of medical pluralism among HIV/AIDS patients in rural South Africa.

In some societies, medical pluralism has been demonstrated to delay access to care. We identified sources of health care, and explored utilization patterns and triggers of care-seeking behavior among HIV/AIDS patients in rural South Africa. A longitudinal qualitative study consisting of in-depth interviews was conducted. We purposively sampled thirty-two adult HIV clinic attendees. A high degree of medical pluralism occurred among participants before initiation of antiretroviral treatment (ART). After ART initiation, participants predominantly used the HIV/ART clinic, and utilization of private and traditional facilities decreased. Patterns included both concurrent and sequential pathways to public, private and traditional health sectors. HIV diagnosis and treatment were delayed despite early contact with health systems. Therefore, use of multiple health care modalities before ART initiation can lead to delayed HIV testing and ART initiation. Integrated-care has the potential to mitigate the impact of medical pluralism on access to HIV-related services over the longer term.

The association between school attendance, HIV infection and sexual behaviour among young people in rural South Africa.

OBJECTIVES: To investigate whether the prevalence of HIV infection among young people, and sexual behaviours associated with increased HIV risk, are differentially distributed between students and those not attending school or college. DESIGN: A random population sample of unmarried young people (916 males, 1003 females) aged 14-25 years from rural South Africa in 2001. METHODS: Data on school attendance and HIV risk characteristics came from structured face-to-face interviews. HIV serostatus was assessed by oral fluid ELISA. Logistic regression models specified HIV serostatus and high-risk behaviours as outcome variables. The primary exposure was school attendance. Models were adjusted for potential confounders. RESULTS: HIV knowledge, communication about sex and HIV testing were similarly distributed among students and non-students. The lifetime number of partners was lower for students of both sexes (adjusted odds ratio (aOR) for more than three partners for men 0.67; 95% CI 0.44 to 1.00; aOR for more than two partners for women 0.69; 95% CI 0.46 to 1.04). Among young women, fewer students reported having partners more than three years older than themselves (aOR 0.58; 95% CI 0.37 to 0.92), having sex more than five times with a partner (aOR 0.57; 95% CI 0.37 to 0.87) and unprotected intercourse during the past year (aOR 0.60; 95% CI 0.40 to 0.91). Male students were less likely to be HIV positive than non-students (aOR 0.21; 95% CI 0.06 to 0.71). CONCLUSIONS: Attending school was associated with lower-risk sexual behaviours and, among young men, lower HIV prevalence. Secondary school attendance may influence the structure of sexual networks and reduce HIV risk. Maximising school attendance may reduce HIV transmission among young people.

Adherence to TB preventive therapy for HIV-positive patients in rural South Africa: implications for antiretroviral delivery in resource-poor settings?

OBJECTIVES: To explore patient and health worker perspectives on adherence to tuberculosis preventive therapy (TBPT), and to derive lessons for improving access to care amongst human immunodeficiency virus (HIV) infected individuals in resource-poor settings. DESIGN: Both quantitative and qualitative methods were employed. Patient records were reviewed for HIV-positive individuals attending a hospital-based HIV clinic between January 2000 and March 2002. Eighteen patients and two health care workers underwent in-depth interviews exploring perspectives around adherence. RESULTS: Of 229 HIV-positive clinic attendees, 94 (41.0%) were eligible for TBPT. Of 87 patients initiating a 6-month TBPT course of isoniazid 300 mg daily, 41 (47.1%) completed TBPT. Of the 46 interrupters, 16 (34.7%) did not return to the clinic after receiving their first dose of TBPT. Barriers to adherence included fear of stigmatization, lack of money for food and transport, the belief that HIV is incurable, competition between Western and traditional medicine, and a reluctance to take medication in the absence of symptoms. Disclosure of HIV status, social and family support, and a supportive clinic environment positively influenced adherence. CONCLUSION: Interventions to improve the accessibility and quality of the care delivery system have the potential to support adherence to TBPT and other HIV care regimens, including antiretroviral therapy.

Undiagnosed pulmonary tuberculosis deaths in rural South Africa.

This research explores death from pulmonary tuberculosis (PTB) using a verbal autopsy (VA) tool within the established Agincourt Health and Demographic Surveillance System site in South Africa's rural northeast. Previous work on active case finding in the area highlighted a modest burden of undiagnosed PTB in the community. This VA research confirms the existence of undiagnosed PTB deaths, with 13 (46%) of 28 PTB deaths among the permanent adult population (n = 38,251) going undetected by the health service. There was a median duration of coughing in the community of 16 weeks among these undiagnosed PTB deaths. As most undiagnosed cases present to the health service at some point during their illness, intervention strategies to support early diagnosis at this level can only be re-emphasised by this work.

Introduction of voluntary counselling and rapid testing for HIV in rural South Africa: from theory to practice.

Expanding access to voluntary counselling and testing (VCT) for HIV is an important first step in the development of a comprehensive package of HIV services. This article describes the introduction of VCT among five primary health care (PHC) facilities in a rural South African setting, alongside a multidimensional impact assessment as part of a national pilot programme. A baseline review of services demonstrated low levels of VCT, which were predominantly hospital-based. Twenty health workers in five PHC facilities were trained to provide VCT using rapid-testing assays. The feasibility of VCT introduction and its overall acceptability to clients and providers were evaluated using clinic testing registers, semi-structured interviews with counsellors and mock client encounters. One year after its introduction, a major increase in the quantity of HIV testing, the proportion of clients who receive their results, and the proportion who present voluntarily was observed. The majority of those presenting were women, and 20-40 year olds predominated. There was a high level of acceptance among health workers, and the quality of VCT was rated very good in mock client encounters. This work demonstrates one effective model for improving access to VCT through existing primary health care services in a rural South African context.

Active case finding: understanding the burden of tuberculosis in rural South Africa.

SETTING: The Agincourt demographic and health surveillance site in South Africa's rural Northern Province. OBJECTIVES: To accurately assess the true burden of tuberculosis in a rural sub-district with a known high prevalence of human immunodeficiency virus. DESIGN: Data on hospital registrations of tuberculosis were combined with data from an ongoing demographic health and surveillance system to accurately describe the burden of tuberculosis in a well-defined community. Undiagnosed active cases of sputum-positive disease in the community were detected among chronic coughers identified by heads of household during a single-pass census interview. RESULTS: The incidence of hospitalised tuberculosis among the permanently resident population (n = 56 566) was 212/100,000 person-years during 1999. The average point prevalence of detected tuberculosis (all forms) among patients aged over 10 years was 133/100,000, and 81/100,000 for sputum-positive pulmonary disease. This compares with a point prevalence of 16/100,000 cases of sputum-positive disease detected through active case finding. CONCLUSION: For every nine cases of sputum positive pulmonary tuberculosis being treated at any one time, there are two cases of undiagnosed disease in the community. This study demonstrates a modest burden of undiagnosed tuberculosis among residents in a rural sub-district in South Africa.

Infectious disease policy: towards the production of health.

This paper reflects on current infectious disease control methods, their biomedical history and the management structures they are driven by. It asks whether a broader concept of 'infectious disease policy', with an emphasis on 'process' rather than outcomes, will help to re-frame the control discourse to ensure that infectious disease control is not only a method for preventing and treating infectious diseases, but is also a path for the creation of healthy communities.

PIP: This paper reflects on current infectious disease control methods, their biomedical history and the management structures they are driven by. It focuses on the broader concept of "infectious disease policy" as a method for preventing and treating infectious diseases, and as a path for the creation of healthy communities. Infectious disease policy broadens the biological perspective of infectious disease control and highlights the common obstacles to policy and intervention, obstacles, which include poverty, inequity, environmental factors, access, and the interrelationship between individuals and communities with health structures. Developing such a policy will encourage a change in focus from purely biomedical program approach to a process-oriented policy approach, which will enable infectious disease control to be integrated, flexible, sensitive to global, national and local contexts, and directly involved in the creation of healthy communities.