Providing low-cost sexually transmitted diseases services in two semi-urban health centers in Central African Republic (CAR): characteristics of patients and patterns of health care-seeking behavior.

BACKGROUND: While treatment of symptomatic sexually transmitted diseases (STDs) has been shown to reduce the incidence of HIV infection, there are few published reports describing the delivery of high quality STD care in Africa. GOAL: To test the feasibility of providing comprehensive, affordable STD services through the existing primary care infrastructure. DESIGN: STD treatment services using a syndromic' approach were established in two semi-urban hospital outpatient departments (OPD) in Central African Republic (CAR). A dedicated paramedical provider took a clinical history, performed an examination, explained the diagnosis and the importance of referring partners, dispensed drugs, and offered partner referral vouchers. A fee-for-service system was used to resupply drugs initially purchased with project funds. RESULTS: Of 9,552 visits by index patients and partners over a 28-month period starting in October 1993, 60% were made by women; of these women, 90% were symptomatic, 77% had "vaginal discharge," 70% "lower abdominal pain," and 7% "genital ulcer." Among men, 64 % were symptomatic, 38 % had "urethral discharge," and 14% "genital ulcer." Half of all symptomatic patients presented within 1 week of the onset of symptoms; 44% of men compared to 18% of women had sought care elsewhere before the clinic visit. The average cost per STD treated with recommended drugs was $3.90. Etiologic data from subpopulations in both sites suggest that a high proportion of patients was infected with an STD. CONCLUSIONS: Comprehensive yet affordable care for STDs in persons (and their partners) who recognize symptoms is feasible and should be widely implemented in primary care systems to prevent the spread and complications of STDs and HIV in Africa.

PIP: This study examines the feasibility of providing comprehensive, low-cost sexually transmitted disease (STD) services through the existing primary care infrastructure in two semi-urban health centers in the Central African Republic. The results showed that out of the 9552 visits made by index patients and partners over a 28-month period, 60% were made by women. Among these women, 90% were symptomatic, 77% had vaginal discharge, 70% had lower abdominal pain, and 7% had genital ulcer. In addition, 44% of men, as compared to 18% of women, had looked for treatment elsewhere prior to the clinic visit. The average cost per STD treated with the recommended drugs was $3.90. Furthermore, condom use was low in both areas and etiologic data suggest that a large proportion of patients was infected with an STD. The findings suggest that a comprehensive and affordable model for STD control can be implemented in primary care systems to prevent the spread of STDs in Africa.

Patient-led partner referral enhances sexually transmitted disease service delivery in two towns in the Central African Republic.

In Bambari and Bria, 2 towns in the Central African Republic (CAR), we analysed a patient-led partner referral programme within enhanced sexually transmitted disease (STD) services. New (index) patients received syndromic management, counselling about notifying and treating contacts, and vouchers for distribution. From October 1993 to February 1996, 5232 and 4320 patient visits, of which 1814 (35%) and 4320 (30%) were contact referral visits, were logged in Bambari and Bria, respectively. Vouchers were distributed for at least 90% of contacts. Index and contact patients had similar age and sex distributions. In both towns, having a spouse (Bambari: odds ratio [OR] 1.5, 95% confidence interval [CI] 1.4-1.7; Bria: OR 1.9, 95% CI 1.5-2.3) was a factor associated with successful referral of a partner. Successful referral was accomplished by both male and female patients. Appropriate counselling techniques and vouchers facilitated partner referral. Further research on how to reach casual partners would enhance STD control efforts using patient-led partner referral.

Predictors of rape in the Central African Republic.

This is a study of women in the Central African Republic (CAR) whose first sexual encounter was the result of rape. The analyses presented here are based on a national HIV/AIDS survey conducted in 1989. Respondents were selected through multistage cluster sampling, where census districts and households within districts were randomly selected. A total of 1307 females responded to the question regarding the circumstances of their first intercourse. Nearly 22% of female respondents reported that their first experience with intercourse was rape. Bivariate analyses found that rape during first intercourse was significantly related to the following respondent characteristics at the time of the survey: age, marital status, having a child, education, occupation, urban versus rural living, ethnic group, age at first date, and consumption of alcohol. Rape was not significantly related to ability to read, religion, and years in current village or town. Rape during first intercourse was found in a stepwise logistic regression to be related to age, marital status, occupation, and ethnic group. These data indicate that the incidence of rape is higher than previously reported in Africa, there are specific risk factors, and there are serious negative consequences.

Multiple sexual partners: results of a national HIV/AIDS survey in the Central African Republic.

OBJECTIVES: To determine the prevalence and characteristics of individuals with more than one sexual partner in the Central African Republic during the previous 12 months. DESIGN: A national survey. METHODS: A stratified sample of 2589 individuals aged 15-50 years was interviewed in late 1989. The 157-question survey questionnaire was a modified version of a questionnaire developed by the World Health Organization Global Programme on AIDS. RESULTS: Thirty-four per cent of men and 17% of women reported having sex with more than one partner during the previous 12 months. For both men and women, logistic regression indicated that the risk of having multiple partners increased with being single compared with being married; being employed in a profession other than agriculture compared with being a farmer, unemployed, a housewife, or a student; living in an urban rather than a rural area; rape being part of their first sexual encounter; and combining sex with alcohol. Risk increased with increasing ability to read for men and with decreasing age and drinking alcohol for women. CONCLUSIONS: These findings can be used to develop and target HIV/AIDS prevention and control programmes and to improve mathematical models of the epidemic.

Use of image analysis in determining masticatory efficiency in patients presenting for immediate dentures.

Image analysis was used to determine masticatory efficiency and performance before and after placement of immediate dentures. Sections of cored carrot were used as the test food and the particle size of chewed expectorated food was measured using image analysis. Measurements were shown to be accurate and reproducible. Masticatory function of immediate-denture patients was also compared with a similar number of dentate individuals and experienced complete-denture wearers. Dentate subjects were significantly (P less than .01) more efficient at masticating the test food than were the complete- or immediate-denture wearers. The new method of measurement removes the necessity for the unpleasant and unhygienic sieving process previously used in this type of study.

Oral rehydration therapy in Malawi: impact on the severity of disease and on hospital admissions, treatment practices, and recurrent costs.

In the first 2 years following refresher training of paediatric staff in oral rehydration therapy (ORT) and the establishment of an oral rehydration unit at the Kamuzu Central Hospital, Lilongwe, Malawi, there was a 50% decrease in the number of children admitted to the paediatric ward with the diagnosis of diarrhoeal diseases, a 56% decrease in the use of intravenous fluid to rehydrate such children, a threefold increase in the use of oral rehydration salts (ORS) exclusively to rehydrate children with mild or moderate dehydration, and a 39% decrease in the number of paediatric deaths associated with diarrhoeal diseases. Over the same period, there was a 32% decrease in recurrent hospital costs attributable to paediatric diarrhoeal diseases. As use of ORT continues to increase in Malawi, where diarrhoeal diseases account for 9% of paediatric hospital admissions, there should be considerable decreases in mortality from such diseases and concomitant increases in cost savings attributable to them.

PIP: In the 1st 2 years following refresher training of pediatric staff in oral rehydration therapy (ORT) and the establishment of an oral rehydration unit at the Kamuzu Central Hospital, Lilongwe, Malawi, there was a 50% decrease in the number of children admitted to the pediatric ward with the diagnosis of diarrheal diseases, a 56% decrease in the use of intravenous fluid to rehydrate such children, a 3-fold increase in the use of oral rehydration salts exclusively to rehydrate children with mild or moderate dehydration, and a 39% decrease in the number of pediatric deaths associated with diarrheal diseases. Over the same period, there was a 32% decrease in recurrent hospital costs attributable to pediatric diarrheal diseases. As use of ORT continues to increase in Malawi, where diarrheal diseases account for 9% of pediatric hospital admissions, there should be considerable decreases in mortality from such diseases and concomitant increases in cost savings attributable to them. (author's)

Oral rehydration therapy in Malawi: impact on the severity of disease and on hospital admissions; treatment practices; and recurrent costs

In the first 2 years following refresher training of paediatric staff in oral rehydration therapy (ORT) and the establishment of an oral rehydration unit at the Kamuzu Central Hospital; Lilongwe; Malawi; there was a 50 percent decrease in the number of children admitted to the paediatric ward with the diagnosis of diarrhoeal diseases; a 56 percent decrease in the use of intravenous fluid to rehydrate such children; a threefold increase in the use of oral rehydration salts (ORS) exclusively to rehydrate children with mild or moderate dehydration; and a 39 percent decrease in the number of paediatric deaths associated with diarrhoeal diseases. Over the same period; there was a 32 percent decrease in recurrent hospital costs attributable to paediatric diarrhoeal diseases. As use of ORT continues to increase in Malawi; where diarrhoeal diseases account for 9 percent of paediatric hospital admissions; there should be considerable decreases in mortality from such diseases and concomitant increases in cost savings attributable to them

Estimating health service utilization, immunization coverage, and childhood mortality: a new approach in Uganda.

PIP: Interviews were conducted in the 75 households nearest to each of the 36 rural health facilities in Uganda's Mbale District in order to estimate childhood morbidity/mortality and the utilization of health services. Data were obtained on 2596 children under 5 years of age. There were 50 deaths in the 527 live births in the 12 months preceding the survey, giving an infant mortality rate of 95/1000. There were an additional 51 deaths among the 2069 children 1-4 years of age (25/1000). 34% of deaths among infants and 69% of deaths among children 1-4 years of age were associated with diarrhea. Of the 2495 children 0-4 years of age who were alive at the time of the survey, 506 (20%) had diarrhea in the 2 weeks preceding the survey and there was a diarrhea morbidity rate of 3.2 episodes/year/child. Only 60 (12%) of the children with diarrhea were treated with some form of oral rehydration; 314 (62%) were given drugs obtained from local pharmacies. Finally, only 38% of children 1-4 years of age and 21% of infants under 1 year of age were fully immunized for their age. These findings suggest high rates of childhood mortality and underutilization of preventive health services among households in the immediate vicinity of health facilities. This research approach can be used to facilitate program evaluation, even though the results cannot be generalized to the entire population of the district. It provides local health workers with an opportunity to assess their community's health needs and motivates them to improve health care delivery.^ieng

Oral rehydration therapy in Malawi: impact on hospital admissions; hospital treatment practices and severity of disease

After the first two years after refresher training of pediatric staff in oral rehydration therapy [ORT] and the establishment of an oral rehydration unit at Kamuzu Central Hospital [KCH]; Lilongwe; there was a 50 percent decrease in the number of children admitted to the pediatric ward with the diagnosis of diarrheal disease; a 56 percent decrease in the use of intravenous fluid for rehydration of children hospitalized with diarrheal disease and a 70 percent increase in the use of oral rehydration salts [ORS] exclusively to rehydrate children with mild or moderate dehydration