Comparison of key parameters of sexual behaviour in four African urban populations with different levels of HIV infection.

OBJECTIVE: To explore whether differences in sexual behaviour could explain differences in the rate of spread of HIV in four urban populations in Africa. METHODS: A cross-sectional, population-based study was conducted in two cities where the prevalence of HIV among adults exceeded 20% (Kisumu, Kenya and Ndola, Zambia) and two cities with a much lower HIV prevalence among adults (Cotonou, Benin and Yaoundé, Cameroon). In each of these cities, approximately 1000 men and 1000 women, aged 15-49 years, were randomly selected from the general population. Consenting men and women were interviewed about their sociodemographic characteristics and sexual behaviour, including characteristics of spouses and of non-spousal partners. Key parameters of sexual behaviour were compared between the four cities. RESULTS: On average, women in the high HIV prevalence cities had their sexual debut earlier than in the other cities. Men and women in Kisumu and Ndola got married earlier than men and women in Cotonou and Yaoundé. High rates of partner change, contacts with sex workers, concurrent partnerships and large age differences between partners were no more common in the two high HIV prevalence cities than in the two low HIV prevalence cities. CONCLUSIONS: In these four African populations, differences in reported sexual behaviour could not explain the differences in rate of spread of HIV. In all four cities, high-risk sexual behaviour patterns were identified.

Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia.

OBJECTIVE: To examine the factors responsible for the disparity in HIV prevalence between young men and women in two urban populations in Africa with high HIV prevalence. DESIGN: Cross-sectional survey, aiming to include 1000 men and 1000 women aged 15-49 years in Kisumu, Kenya and Ndola, Zambia. METHODS: Participants were interviewed and tested for HIV and other sexually transmitted infections. Analyses compared the marital and non-marital partnership patterns in young men and women, and estimated the likelihood of having an HIV-infected partner. RESULTS: Overall, 26% of individuals in Kisumu and 28% in Ndola were HIV-positive. In both sites, HIV prevalence in women was six times that in men among sexually active 1 5-19 year olds, three times that in men among 20-24 year olds, and equal to that in men among 25-49 year olds. Age at sexual debut was similar in men and women, and men had more partners than women. Women married younger than men and marriage was a risk factor for HIV, but the disparity in HIV prevalence was present in both married and unmarried individuals. Women often had older partners, and men rarely had partners much older than themselves. Nevertheless, the estimated prevalence of HIV in the partners of unmarried men aged under 20 was as high as that for unmarried women. HIV prevalence was very high even among women reporting one lifetime partner and few episodes of sexual intercourse. CONCLUSIONS: Behavioural factors could not fully explain the discrepancy in HIV prevalence between men and women. Despite the tendency for women to have older partners, young men were at least as likely to encounter an HIV-infected partner as young women. It is likely that the greater susceptibility of women to HIV infection is an important factor both in explaining the male-female discrepancy in HIV prevalence and in driving the epidemic. Herpes simplex virus type 2 infection, which is more prevalent in young women than in young men, is probably one of the factors that increases women's susceptibility to HIV infection.

Multicentre study on factors determining differences in rate of spread of HIV in sub-Saharan Africa: methods and prevalence of HIV infection.

OBJECTIVE: The objective of this study was to explore whether the differences in rate of spread of HIV in different regions in sub-Saharan Africa could be explained by differences in sexual behaviour and/or factors influencing the probability of HIV transmission during sexual intercourse. METHODS: A cross-sectional, population-based study was conducted in two cities with a high HIV prevalence (Kisumu in Kenya and Ndola in Zambia) and two cities with a relatively low HIV prevalence (Cotonou in Benin and Yaoundé in Cameroon). In each of these cities, approximately 1000 men and 1000 women, aged 15-49 years, were randomly selected from the general population. Consenting men and women were interviewed and were tested for HIV, syphilis, herpes simplex virus type 2 (HSV-2), gonorrhoea, chlamydial infection and trichomoniasis (the latter for women only). In addition, a survey was conducted on a random sample of 300 sex workers in each city. The research instruments, including the questionnaires and the laboratory procedures, were standardized to permit comparison of results. RESULTS: The numbers of men interviewed were 1021 in Cotonou, 973 in Yaoundé, 829 in Kisumu, and 720 in Ndola. The corresponding figures for women were 1095, 1116, 1060 and 1130. In Yaoundé, Kisumu and Ndola, the response rates for men were lower than for women due to failure to make contact with eligible men. The proportion of eligible women who were interviewed was 86% in Yaoundé, and 89% in Kisumu and Ndola. In Yaoundé, 76% of eligible men were interviewed, along with 82% in Kisumu and 75% in Ndola. The prevalence of HIV infection in men was 3.3% in Cotonou, 4.1% in Yaoundé, 19.8% in Kisumu and 23.2% in Ndola. For women, the respective figures were 3.4, 7.8, 30.1 and 31.9%. The prevalence of HIV infection among women aged 15-19 years was 23.0% in Kisumu and 15.4% in Ndola. Among women in Kisumu who had their sexual debut 5 years before the interview, the prevalence of HIV infection was 46%; in Ndola, it was 59%. Among sex workers, the prevalence of HIV infection was 57.5% in Cotonou, 34.4% in Yaoundé, 74.7% in Kisumu and 68.7% in Ndola. CONCLUSIONS: The HIV prevalence rates in the general population confirmed our preliminary assessment of the level of HIV infection in the four cities, which was based on estimates of HIV prevalence from sentinel surveillance among pregnant women. The very high prevalence of HIV infection among young women in Kisumu and Ndola calls for urgent intervention.

Commercial sex and the spread of HIV in four cities in sub-Saharan Africa.

OBJECTIVE: To examine whether commercial sex transactions were more common and/or transmission between sex workers and clients more efficient in two African cities with high HIV prevalence (Kisumu, Kenya and Ndola, Zambia) compared with two with relatively low HIV prevalence (Cotonou, Benin and Yaoundé, Cameroon). METHODS: Data on sexual behaviour, HIV and sexually transmitted infections were collected from representative samples of around 300 female sex workers in each city. Sexual behaviour data from a population-based study of around 1000 men aged 15-49 in each city were used to estimate the extent of contact with sex workers. RESULTS: The number of sex workers per 1000 males was highest in Kisumu and Ndola, but other estimates of the extent or characteristics of sex work contact showed no consistent differences between high or low prevalence cities. HIV prevalence among sex workers was 75% in Kisumu, 69% in Ndola, 55% in Cotonou and 34% in Yaoundé. The prevalence of genital ulceration and trichomoniasis was higher among sex workers in Kisumu and Ndola but no clear pattern was seen for the other sexually transmitted infections. Around 70% of sex workers in Cotonou reported use of a condom with the last client, markedly higher than in the other cities. CONCLUSIONS: Although sex work is likely to have played an important role in the spread of HIV in all four cities, differences in present patterns of sex work do not appear to explain the differential spread of HIV. However, high levels of condom use among sex workers may have slowed the spread from sex workers to the general population in Cotonou, highlighting the importance of interventions among sex workers and their clients.

Was there evidence of occupational exposure to human immunodeficiency virus (HIV) infection among nurse midwives ten years into the epidemic in Zambia?

A cross sectional study was conducted to determine occupational factors associated with the human immunodeficiency virus (HIV)) infection. The survey covered 30 health institutions throughout Zambia. A total of 370 consenting midwives took part in the study. The main outcome measures were percentage of midwives reporting adverse occupational exposures and HIV status. Out of 370 midwives, 146 (39.5%) were positive for HIV infection. Of the 370 respondents, 48 (13.0%) thought that they were HIV infected. None of these 48 midwives thought she became infected because of occupational exposure to HIV infected blood. A total of 324 (87.6%) said that they were concerned about becoming HIV positive at work. ;Needle stick injury' was reported by 321 (88.2%) midwives. The percentages of midwives reporting hand washing after every contact with a patient, using gloves all of the time and wearing aprons were 54.0%, 53.7% and 44.1% respectively. None of the occupational factors was associated with HIV infection. In conclusion, although there was no evidence to suggest occupational exposure to HIV among midwives, adherence to universal precautions was poor. Midwives should be educated about these precautions.

Adoption of safe water behaviors in Zambia: comparing educational and motivational approaches.

CONTEXT: In the developing world, drinking water is an important route for transmission of diarrheal disease, a leading cause of morbidity and mortality in children. OBJECTIVES: In Field Trial 1 (FT1) and Field Trial 2 (FT2), the effectiveness of the behavior change approach known as motivational interviewing (MI) was compared to the standard practice of health education alone in initiating and sustaining safe water treatment and storage behavior among community residents. In Field Trial 3 (FT3), MI was compared with social marketing. DESIGN: Community surveys were conducted prior to local health promoter training and at follow-up. SETTING AND PARTICIPANTS: Low socioeconomic status peri-urban communities in Zambia were project sites. Local volunteer health promoters from communities were trained in an adaptation of MI for safe water treatment and storage. INTERVENTIONS: All health promoters received instruction in the causes and prevention of diarrhea. Health promoters in the experimental (MI) groups received MI training. MAIN OUTCOME MEASURES: FT1 and FT3 measured detectable disinfectant levels in stored household water. FT2 measured disinfectant sales. FINDINGS: No significant differences between the treatment groups were found in FT1. Subsequent MI training incorporated lessons learned from the previous trial and resulted in much higher purchase rates of the disinfectant (FT2) and levels of disinfectant in stored household water (FT3) in the MI group. CONCLUSION: MI appears promising for public health initiatives in the developing world. Further research to improve and refine the method is needed.

Utilisation of malarial drugs at a household level: results from a KAP study in Choma, southern province and Mporokoso, northern province of Zambia.

OBJECTIVES: To describe and document knowledge and use of anti-malarial drugs at household level in rural Zambia. DESIGN: Cross sectional study. SETTING: Community based. SUBJECTS: Data was collected from 392 male and 415 female respondents. MAIN OUTCOME MEASURES: Percentage of respondents knowing the cause of malaria and using modern health facilities. RESULTS: The median age of respondents in Choma was 37(Q1 = 27, Q3 = 52) while that for Mporokoso respondents was 34(Q1 = 26, Q3 = 47), (p < 0.001). There was no association between educational level and knowledge of causes of malaria (p = 0.674). Fever was significantly (p < 0.001) associated with malaria (20.4% in Choma, 80.6% in Mporokoso). However, only 1% in both areas mentioned the mosquito as a vector for malaria. The majority of residents (59.5%) went to the hospital when they suffered from malaria. Only 7% mentioned the use of traditional medicine. There was an association between the level of education and taking preventive measures against malaria in all the communities (p < 0.001). Respondents did not mention the use of treated mosquito nets. CONCLUSION: Residents in both Choma and Mporokoso did not know the cause of malaria. The use of treated mosquito nets is rare. Production of information, education, communication (IEC) health materials and recruitment of a village health educator is recommended.

Factors that determine utilization of modern contraceptives in East, Central and southern Africa.

A cross-sectional study to determine modern contraceptives utilization among women aged between 15 and 19 years was performed between September and October, 1991 in 5 countries of East Central and Southern Africa. The study involved both rural and urban area of Kenya, Uganda, Mauritius, Swaziland and Zambia. A total of 4513 women were interviewed of whom 2418 (53.6%) were from the urban areas while 2096 (46.4% were from the rural areas. The percentage distribution of contraceptive users was 33.2% in urban and 48.9% in rural areas. The proportion of users of traditional/natural contraception was 38.5%. Overall the prevalence of contraceptive use was 29.5%. Thus the natural/traditional methods were most popular in the region. The user rate of modern contraceptive methods ranged from 6.8% for Zambia to 60% for Mauritius. The study revealed that contraceptive prevalence rates were higher among women in urban areas (60%) than in rural areas (40%). The main factors influencing contraceptive use in order of importance included distance from residence to clinics, level of education attained, parity, marital status, approval by husbands/boyfriends and knowledge of family planning methods. Contraceptive use was highest in the age group of 20 to 34 years while it was lowest among young women aged 15-19 years.

Factors that Determine Utilisation of Mordern Contraceptives in East; Central and Southern Africa

A cross-sectional study to determine modern contraceptives utilization among women aged between 15 and 19 years was performed between September and October; 1991 in 5 countries of East Central and Southern Africa. The study involved both rural and urban area of Kenya; Uganda; Mauritius; Swaziland and Zambia. A total of 4513 women were interviewed of whom 2418 (53.6) were from the urban areas while 2096 (46.4were from the rural areas. The percentage distribution of contraceptive users was 33.2in urban and 48.9in rural areas. The proportion of users of traditional/natural contraception was 38.5. Overall the prevalence of contraceptive use was 29.5. Thus the natural/traditional methods were most popular in the region. The user rate of modern contraceptive methods ranged from 6.8for Zambia to 60for Mauritius. The study revealed that contraceptive prevalence rates were higher among women in urban areas (60) than in rural areas (40). The main factors influencing contraceptive use in order of importance included distance from residence to clinics; level of education attained; parity; marital status; approval by husbands/boyfriends and knowledge of family planning methods. Contraceptive use was highest in the age group of 20 to 34 years while it was lowest among young women aged 15-19 years

Sleeping sickness and tsetse awareness: a sociological study among the Tambo and Lambya of the northern Luangwa Valley, Zambia.

Data on awareness of tsetse flies and knowledge of trypanosomiasis were collected in May, 1988, in the Luangwa Valley of Isoka District in the Northern Province of Zambia. One thousand and nine hundred adult males and females were interviewed. There was a high level of fly awareness among all the respondents, regardless of duration of residence and age groups. Malaria was considered as the most serious illness in the community, and hence overshadowed the impact of trypanosomiasis in the community. Disease awareness gravity cannot be attributed to individual's socio-economic levels.

PIP: In May 1988, tropical disease researchers interviewed 1940 Tambo and Lambya men and women living in 2 chiefs' areas (Katyetye and Mweniwisi) of the Luangwa Valley of Isoka District in the Northern Province of Zambia to determine their knowledge of trypanosomiasis (sleeping sickness) and tsetse flies. 98.4% of the respondents who had lived in the area for at least one month knew that tsetse fly bites transmitted trypanosomiasis. 94.2% of those who lived in the area for 1 month also knew this. Only people who lived in the area for 1 month believed that witchcraft and bad water transmitted sleeping sickness (0.9% and 0.1% respectively). Approximately 73% reported tsetse flies to be uncommon in their villages. Just 2% believed trypanosomiasis to be a leading disease because its treatment often requires a long hospitalization. Most people (74%) thought malaria to be the most serious disease, because it occurs frequently and kills many people. Tsetse flies become ubiquitous during the rainy season. Further the Tropical Disease Research Centre in Ndola, Zambia has found extremely high tsetse densities along access roads and paths connecting villages. The researchers planned to use these results in developing a parasite control project in the area. Community health workers trained under the Primary Health Care project could conduct health education sessions about sleeping sickness in the area to increase awareness of the seriousness of the disease.

The problems of a social survey in epidemiology: an experience from a Zambian rural community.

A socio-economic study of 1097 people was carried out between November and December 1979. Demographic data and other health characteristics were obtained by census of the entire study population. Interviews covered disease awareness, perceived morbidity, health-care utilization, knowledge, attitudes and practices; all adults aged 15 years and above were interviewed 2 weeks before physical examinations were made. Age and literacy level were found to have no effect on the people's health-seeking behaviour in Kabinga. The results of this social survey failed to reveal the real practices of the community's use of both ethno-medicine and biomedicine.

PIP: A population segment was investigated in Kabinga, northern Zambia, in order to explore the use of biomedical ethnomedical health services and assess the knowledge of disease vectors. In this community schistosomiasis, malaria, anemia, and hookworm infestation was widespread. The population of 11 villages numbered 1097 people (545 males and 552 females) including 220 adults aged 15049. A WHO standardized questionnaire containing demographic and sociological questions was administered. The subjects were asked what action they would take when afflicted by malaria. The majority of 218 responders were women. The mean age for females was 35.2 years and for males it was 37.5 years. 4 responders did not know what to do if struck with malaria. Only .9% of both literate and illiterate adults indicated the use of African medicine in case of malaria. 62% of them went to the clinic or hospital for treatment during the last sickness episode. 29.2% of both genders did nothing, and only 2.4% of women turned to traditional medicine. 1 female could not recall what she did. 81% of the adult population attended either a clinic or a hospital for treatment during the previous 8 months. Most remembered using these facilities at least one (14 could not remember it). There was a significant correlation between refraining from the use of traditional medicine and utilization of the services of a clinic or hospital. Despite these findings, the answers were probably biased, because most women depend on their male counterparts for making decisions. Anthropologically oriented research methods could ensure reliability of data and reveal epidemiological problems in this community.