Household transmission of SARS-CoV-2 in a rural area in South Africa.

BACKGROUND: Patterns of SARS-CoV-2 spread have varied by geolocation, with differences in seroprevalence between urban and rural areas, and between waves. Household spread of SARS-CoV-2 is a known source of new COVID-19 infections, with rural areas in sub-Saharan Africa being more prone than urban areas to COVID-19 transmission because of limited access to water in some areas, delayed health- seeking behaviour and poor access to care. OBJECTIVES: To explore SARS-CoV-2 infection incidence and transmission in rural households in South Africa (SA). METHODS: We conducted a prospective household cluster investigation between 13 April and 21 July 2021 in the Matjhabeng subdistrict, a rural area in Free State Province, SA. Adults with SARS-CoV-2 confirmed by polymerase chain reaction (PCR) tests (index cases, ICs) and their household contacts (HCs) were enrolled. Household visits conducted at enrolment and on days 7, 14 and 28 included interviewer- administered questionnaires and respiratory and blood sample collection for SARS-CoV-2 PCR and SARS-CoV-2 immunoglobulin G serological testing, respectively. Co-primary cases were HCs with a positive SARS-CoV-2 PCR test at enrolment. The incidence rate (IR), using the Poisson distribution, was HCs with a new positive PCR and/or serological test per 1 000 person-days. Associations between outcomes and HC characteristics were adjusted for intra-cluster correlation using robust standard errors. The secondary infection rate (SIR) was the proportion of new COVID-19 infections among susceptible HCs. RESULTS: Among 23 ICs and 83 HCs enrolled, 10 SARS-CoV-2 incident cases were identified, giving an IR of 5.8 per 1 000 person-days (95% confidence interval (CI) 3.14 - 11.95). Households with a co-primary case had higher IRs than households without a co-primary case (crude IR 14.16 v. 1.75, respectively; p=0.054). HIV infection, obesity and the presence of chronic conditions did not materially alter the crude IR. The SIR was 15.9% (95% CI 7.90 - 29.32). Households with a lower household density (fewer household members per bedroom) had a higher IR (IR 9.58; 95% CI 4.67 - 21.71) than households with a higher density (IR 3.06; 95% CI 1.00 - 12.35). CONCLUSION: We found a high SARS-CoV-2 infection rate among HCs in a rural setting, with 48% of households having a co-primary case at the time of enrolment. Households with co-primary cases were associated with a higher seroprevalence and incidence of SARS-CoV-2. Sociodemographic and health characteristics were not associated with SARS-CoV-2 transmission in this study, and we did not identify any transmission risks inherent to a rural setting.

"Mothers get really exhausted!" The lived experience of pregnancy in extreme heat: Qualitative findings from Kilifi, Kenya.

Heat exposure in pregnancy is associated with a range of adverse health and wellbeing outcomes, yet research on the lived experience of pregnancy in high temperatures is lacking. We conducted qualitative research in 2021 in two communities in rural Kilifi County, Kenya, a tropical savannah area currently experiencing severe drought. Pregnant and postpartum women, their male spouses and mothers-in-law, community health volunteers, and local health and environment stakeholders were interviewed or participated in focus group discussions. Pregnant women described symptoms that are classically regarded as heat exhaustion, including dizziness, fatigue, dehydration, insomnia, and irritability. They interpreted heat-related tachycardia as signalling hypertension and reported observing more miscarriages and preterm births in the heat. Pregnancy is conceptualised locally as a 'normal' state of being, and women continue to perform physically demanding household chores in the heat, even when pregnant. Women reported little support from family members to reduce their workload at this time, reflecting their relative lack of autonomy within the household, but also potentially the 'normalisation' of heat in these communities. Climate change risk reduction strategies for pregnant women in low-resource settings need to be cognisant of local household gender dynamics that constrain women's capacity to avoid heat exposures.

Impact of vision impairment and self-reported barriers to vision care: The views of elders in Nuwara Eliya district, Sri Lanka.

The growing burden of vision impairment (VI) among older people is a development challenge in Asian countries. This study aimed to understand older people's views and experiences about the impact of VI and barriers to eye care to inform policies to address this challenge. We conducted 12 focus group discussions in 2013 with retired Tamil and Sinhala elders in Nuwara Eliya district, Sri Lanka (n = 107). Data were analysed thematically. Older people described the broad impacts VI has on their lives. They worry about becoming dependent. VI restricts their ability to contribute to their families and communities, access information, socialise, maintain their health, and earn. Barriers to eye care services include transport difficulties, costs of treatment, fear, lack of knowledge, waiting times, and health staff attitudes. Older people experience and fear the impacts of VI on their health and well-being. Eye health promotion and care services need strengthening and integration with the primary health care system to address the backlog and growing need among older people in an equitable way. Older people should be consulted about how to overcome the economic, social, and cultural barriers to access to eye care and to minimise the impact of VI. ABBREVIATIONS: FGDs: focus group discussions; GBD: global burden of disease; NCDs: non-communicable diseases; VI: vision impairment.

Early childhood development: impact of national human development, family poverty, parenting practices and access to early childhood education.

BACKGROUND: This study was to describe and quantify the relationships among family poverty, parents' caregiving practices, access to education and the development of children living in low- and middle-income countries (LAMIC). METHODS: We conducted a secondary analysis of data collected in UNICEF's Multiple Indicator Cluster Surveys (MICS). Early childhood development was assessed in four domains: language-cognitive, physical, socio-emotional and approaches to learning. Countries were classified into three groups on the basis of the Human Development Index (HDI). RESULTS: Overall, data from 97 731 children aged 36 to 59 months from 35 LAMIC were included in the after analyses. The mean child development scale score was 4.93 out of a maximum score of 10 (95%CI 4.90 to 4.97) in low-HDI countries and 7.08 (95%CI 7.05 to 7.12) in high-HDI countries. Family poverty was associated with lower child development scores in all countries. The total indirect effect of family poverty on child development score via attending early childhood education, care for the child at home and use of harsh punishments at home was -0.13 SD (77.8% of the total effect) in low-HDI countries, -0.09 SD (23.8% of the total effect) in medium-HDI countries and -0.02 SD (6.9% of the total effect) in high-HDI countries. CONCLUSIONS: Children in the most disadvantaged position in their societies and children living in low-HDI countries are at the greatest risk of failing to reach their developmental potential. Optimizing care for child development at home is essential to reduce the adverse effects of poverty on children's early development and subsequent life.

Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries.

BACKGROUND: Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. South Africa (SA) offers a post-delivery Child Support Grant (CSG), which could encompass support during pregnancy, informed by lessons learnt from similar grants. OBJECTIVES: To review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA. METHODS: Systematic review of programmes providing cash or other support during pregnancy in low- and middle-income countries. RESULTS: Thirty-two programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support. CONCLUSIONS: Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-to-measure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health.

Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review.

BACKGROUND: High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care. METHODS: Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded. FINDINGS: Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients' attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being. CONCLUSIONS: The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.

Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa.

BACKGROUND: In South Africa, information on sex workers' characteristics, sexual behaviour and health needs is limited. Current social, legal and institutional factors impede a safe working environment for sex workers and their clients. OBJECTIVES: To describe characteristics and sexual behaviour of female, male and transgender sex workers, and assess their risk factors for unprotected sex. METHODS: Repeat cross-sectional surveys among sex workers were conducted in Hillbrow, Sandton, Rustenburg and Cape Town in 2010. Sex workers were interviewed once; any re-interviews were excluded from analysis. Unprotected sex was defined as any unprotected penetrative vaginal or anal sex with last two clients. RESULTS: Trained sex workers interviewed 1 799 sex workers. Sex work was a full-time profession for most participants. About 8% (126/1 594) of women, 33% (22/75) of men, and 25% (12/50) of transgender people had unprotected sex. A quarter of anal sex was unprotected. Unprotected sex was 2.1 times (adjusted odds ratio (AOR), 95% CI 1.2 - 3.7; p=0.011) more likely in participants reporting daily or weekly binge drinking than non-binge drinkers. Male sex workers were 2.9 times (AOR, 95%CI 1.6 - 5.3; p<0.001) more likely, and transgender people 2.4 times (AOR, 95% CI 1.1 - 4.9; p=0.021) more likely, than females to have unprotected sex. Sex workers in Hillbrow, where the only sex work-specific clinic was operational, were less likely to have unprotected sex than those in other sites. CONCLUSION: Tailored sex work interventions should explicitly include male and transgender sex workers, sex work-specific clinics, focus on the risks of unprotected anal sex, and include interventions to reduce alcohol harm.

Predictors of recurrence of prolapse after procedure for prolapse and haemorrhoids.

AIM: The procedure for prolapse and haemorrhoids (PPH) is an effective surgical therapy for symptomatic haemorrhoids. Compared with haemorrhoidectomy, meta-analysis has shown PPH to be less painful, with higher patient satisfaction and a quicker return to work, but at the cost of higher prolapse recurrence rates. This is the first report describing predictors of prolapse recurrence after PPH. METHOD: A cohort of patients with symptomatic haemorrhoids, treated with PPH in our hospital between 2002 and 2009, was retrospectively analysed. Multivariate analysis was performed to identify patient-related and perioperative predictors associated with persisting prolapse and prolapse recurrence. RESULTS: In total, 159 consecutively enrolled patients were analysed. Persistence and recurrence of prolapse was observed in 16% of the patients. Increased surgical experience showed a trend towards lower recurrence rates. Multivariate analysis identified female gender, long duration of PPH surgery and the absence of muscle tissue in the resected specimen as independent predictors of postoperative persistence of prolapse of haemorrhoids. The absence of prior treatment with rubber band ligation (RBL) as well as increased PPH experience at the hospital showed a trend towards a higher rate of prolapse recurrence. CONCLUSION: In order to reduce recurrence of prolapse, PPH should be performed by a surgeon with adequate PPH experience, patients should be treated with RBL prior to PPH and a resection of mucosa with underlying muscle fibres should be strived for.

Sexual violence, HSV-2 and HIV are important predictors for infertility in Rwanda.

BACKGROUND: In order to formulate cost-effective health interventions aimed at preventing infertility it is necessary to identify modifiable risk factors for infertility in sub-Saharan Africa. This case-control study examined potential predictors and their population attributable fraction (PAF%) for various infertility types including lifestyle factors, sexual behaviour and reproductive tract infections (RTIs). METHODS: Sexually active women aged 21-45 year presenting with infertility problems at the infertility clinic of the Kigali University Teaching Hospital (n = 312), and fertile controls who recently delivered (n = 283) were surveyed together with their male partners. Participants were interviewed about socio-demographic characteristics, sexual behaviours and lifestyle factors, and were tested for HIV and RTIs. RESULTS: Variables significantly associated with tubal infertility were history of sexual violence [adjusted odds ratio (AOR) 2.41; 95% CI 1.36-4.25]; positive HIV (AOR 2.41; 95% CI 1.36-4.25), herpes simplex virus type 2 (HSV-2; AOR 1.67; 95% CI 1.03-2.71) and Chlamydia trachomatis serology (AOR 1.78; 95% CI 0.99-3.21), and current bacterial vaginosis by Amsel criteria (AOR 1.97; 95% CI 1.12-3.47). Among men, male factor infertility was associated with positive HIV (AOR 2.43; 95% CI 1.31-5.23) and HSV-2 serology (AOR 1.71; 95% CI 1.02-2.87) and current urologic abnormalities (AOR 2.38; 95% CI 1.01-5.31). Positive HSV-2 serostatus carried the greatest PAF% (26%) for tubal infertility, followed by positive HIV serostatus (20%) and history of sexual violence (17%). CONCLUSIONS: Although temporal relationships are difficult to ascertain, history of sexual violence, HSV-2 infection and HIV infection are important predictors of infertility in Rwanda.

Gender differences and factors associated with treatment-seeking behaviour for infertility in Rwanda.

BACKGROUND: This study examines perceptions of infertility causes, treatment-seeking behaviour and factors associated with seeking medical care in an urban infertile population in Rwanda, as well as the response of health providers. METHODS: Between November 2007 and May 2009 a hospital based survey was conducted among 312 women and 254 male partners in an infertile relationship. RESULTS: Infertility causes based on a medical diagnosis were mentioned by 24% of women and 17% of men. Male infertility awareness was low in both sexes with 28% of men and 10% of women reporting male-related causes. Seventy-four per cent of women and 22% of men had sought care for their infertility in the past. Seeking treatment in the formal medical sector was associated with higher income, being married and infertility duration of more than 5 years in both sexes. In women, higher education and being nulliparous and in men blaming oneself for the infertility was also associated with seeking formal medical care. Participants reported a wide array of treatments they received in the past, often including ineffective or even harmful interventions. CONCLUSION: Health authorities should invest in improving information, education and counselling on issues pertaining to causes and treatments of infertility, and in drawing up guidelines for the management of infertility at all levels of health care.

A Safe Motherhood project in Kenya: assessment of antenatal attendance, service provision and implications for PMTCT.

OBJECTIVES: To investigate uptake and provision of antenatal care (ANC) services in the Uzazi Bora project: a demonstration-intervention project for Safe Motherhood and prevention of mother-to-child transmission of HIV in Kenya. METHODS: Data were extracted from antenatal clinic, laboratory and maternity ward registers of all pregnant women attending ANC from January 2004 until September 2006 at three antenatal clinics in Mombasa and two in rural Kwale district of Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds logistic regression analyses assessed changes over time, and determinants of the frequency and timing of ANC visits, uptake of HIV testing, and provision of iron sulphate, folate and single-dose nevirapine (sd-NVP). RESULTS: About half of women in rural and urban settings (52.2% and 49.2%, respectively) attended antenatal clinics only once. Lower parity, urban setting, older age and having received iron sulphate and folate supplements during the first ANC visit were independent predictors of more frequent visits. The first ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5% and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally marked improvements were observed in the uptake of HIV testing and the provision of iron sulphate and folate. CONCLUSION: Provision of ANC services, including sd-NVP, increased markedly over time. While further improvements in quality are necessary, particular attention is needed to implement evidence-based interventions to alter ANC utilization patterns. Encouragingly, improved provision of basic essential obstetric care may increase attendance.

Concurrent sexual and substance-use risk behaviours among female sex workers in Kenya's Coast Province: findings from a behavioural monitoring survey.

While many studies confirm the association between HIV, alcohol and injecting drug use by female sex workers (FSWs), little is known about their use of marijuana, khat and other substances and the association of these substances with HIV, risky sexual behaviour, and sexual violence. To better understand this association, data were analysed from a cross-sectional, behavioural survey of 297 FSWs in Mombasa, a well-known tourist destination and the second largest port in Africa and capital city of the Coast Province in Kenya. Among the FSWs, lifetime use of different substances was reported by 91% for alcohol, 71% for khat, 34% for marijuana, and 6% for heroin, cocaine, glue or petrol. The majority (79%) used more than one substance, and multiple-substance use was reported by all respondents who ever used marijuana, heroin, cocaine, glue and petrol. The risk of HIV acquisition was perceived as medium to high by 41% of respondents, 75% of whom attributed this risk to multiple partners. Sexual violence was reported by 48% of respondents, and 30% indicated that this happened several times. Despite HIV prevention programmes targeting FSWs in Mombasa, most of them continue to engage in risky sexual behaviours. This suggests that harm reduction strategies for substance use should be coupled with efforts to promote consistent condom use and partner reduction.

Concurrent Sexual and Substance-Use Risk Behaviours Among Female Sex Workers in Kenya's Coast Province: Findings from a Behavioural Monitoring Survey

While many studies confirm the association between HIV; alcohol and injecting drug use by female sex workers (FSWs); little is known about their use of marijuana; khat and other substances and the association of these substances with HIV; risky sexual behaviour; and sexual violence. To better understand this association; data were analysed from a cross-sectional; behavioural survey of 297 FSWs in Mombasa; a well-known tourist destination and the second largest port in Africa and capital city of the Coast Province in Kenya. Among the FSWs; lifetime use of different substances was reported by 91 for alcohol; 71 for khat; 34 for marijuana; and 6 for heroin; cocaine; glue or petrol. The majority (79) used more than one substance; and multiple-substance use was reported by all respondents who ever used marijuana; heroin; cocaine; glue and petrol. The risk of HIV acquisition was perceived as medium to high by 41 of respondents; 75 of whom attributed this risk to multiple partners. Sexual violence was reported by 48 of respondents; and 30 indicated that this happened several times. Despite HIV prevention programmes targeting FSWs in Mombasa; most of them continue to engage in risky sexual behaviours. This suggests that harm reduction strategies for substance use should be coupled with efforts to promote consistent condom use and partner reduction

Sexual risk behaviour and HAART: a comparative study of HIV-infected persons on HAART and on preventive therapy in Kenya.

Unprotected sex (UPS) among persons receiving highly active antiretroviral therapy (HAART) remains a concern because of the risk of HIV-transmission. A cross-sectional study comparing the sexual risk behaviour of 179 people living with HIV/AIDS (PLHA) receiving HAART with that of 143 PLHA receiving preventive therapy (PT) with cotrimoxazole/isoniazid was conducted in Mombasa, Kenya. Forty-five percent of all participants were sexually active in the last six months. Participants receiving PT were more likely to report > or =2 partners (13% vs.1%; P = 0.006). Participants receiving PT reported more UPS with regular partners (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 1.8-8.4) and also more sexually transmitted infections (STI) symptoms (OR: 1.7; 95% CI: 1.0-2.8; P = 0.059). More than 40% of all participants did not know the HIV-status of regular partners. Therefore, HAART was not associated with increased sexual risk behaviours though considerable risk of HIV-transmission remains. HIV-care services need to emphasize partner testing and consistent condom use with all partners.

HIV testing and counselling for women attending child health clinics: an opportunity for entry to prevent mother-to-child transmission and HIV treatment.

This study assessed the potential for HIV testing at child health clinics to increase knowledge of HIV status, and entry to infant feeding counselling and HIV treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and counselling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing (95% confidence interval = 1.4-5.1; P = 0.003). Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is acceptable. This could optimize entry into HIV treatment, infant feeding counselling and family planning services.

Morbidity in the first year postpartum among HIV-infected women in Kenya.

OBJECTIVE: To assess the effects of HIV infection on morbidity and the needs of infected women for services in the first year postpartum. METHODS: A cross-sectional study with 500 women attending a child-health clinic in Mombasa, Kenya. RESULTS: Postpartum duration was a median of 3.3 months (interquartile range, 1.9-6.1 months). The 54 HIV-infected women had a lower income and less financial support than the uninfected women, and they were more likely to experience fever, dyspnea, and dysuria, and to have genital warts (odds ratio [OR], 9.6; 95% confidence interval [CI], 2.6-35.6; P<0.001), candidiasis (OR, 2.9; 95% CI, 1.2-6.8; P=0.012), and bacterial vaginosis (OR, 1.8; 95% CI, 0.95-3.3; P=0.066). Six (nearly 15%) of the HIV-infected women had low- or high-grade squamous intraepithelial lesions, and 21 (42%) had an unmet need for contraception. More than half of all women were anemic, and normocytic anemia was predominant among the HIV infected. CONCLUSION: Compared with uninfected women, morbidity was increased for HIV-infected women during the year following delivery. This period could be used to offer these, and all-women, family planning services, cervical cancer screening, and treatment for anemia and reproductive tract infections.

Heavy episodic drinking among Kenyan female sex workers is associated with unsafe sex, sexual violence and sexually transmitted infections.

This study examined patterns of alcohol use and its association with unsafe sex and related sequelae among female sex workers in Mombasa, Kenya. A community-based cross-sectional study was conducted using snowball sampling. Binge drinkers (> or =5 alcoholic drinks on > or =1 occasion in the previous month) were compared with non-binge drinkers. Of 719 participants, 22.4% were lifetime-alcohol abstainers, 44.7% non-binge and 33.0% binge drinkers. Compared with non-binge drinkers, binge drinkers were more likely to report unprotected sex (adjusted odds ratio (AOR)=1.59, 95% confidence interval [CI]=1.00-2.53; P=0.047) and sexual violence (AOR=1.85, 95% CI=1.27-2.71; P=0.001) and to have either syphilis, Neisseria gonorrhoeae or Trichomonas vaginalis infection (AOR=1.56, 95% CI=1.00-2.41; P=0.048). HIV prevalence was higher among women having ever drunk (39.9%) than lifetime abstainers (23.2%; P<0.001), but was not associated with drinking patterns. Interventions are needed to assist female sex workers adopt safer drinking patterns. Investigation is needed for the effectiveness of such interventions in reducing unprotected sex, sexual violence and sexually transmitted infections.

Use of self home-made diaphragm for protection against pregnancy and sexually-transmitted infections: case report.

This is a case report of a 44-year-old woman who used a home-made diaphragm for 16 years to protect herself from pregnancy and sexually-transmitted infections. The woman stitched a piece of cloth with folded polythene inside. This case report provides a vivid illustration of the limitations of available methods of protection for women. It consists of an introduction to the topic, a description of her experiences using her home-made diaphragm and a discussion of the significance of the case. This report supports the need for additional research on female-controlled methods of protection against sexually-transmitted infections, methods that can be used without male knowledge and co-operation, such as vaginal microbicides and cervical barriers against infection, including the diaphragm.

The Pap smear for detection of bacterial vaginosis.

OBJECTIVE: To assess validity of Pap smears in diagnosing bacterial vaginosis. METHOD: A prospective diagnostic accuracy study with 533 women in Mombasa, Kenya. Diagnosis of bacterial vaginosis using clinical observations scored with simplified Amsel's criteria and Bethesda system for Pap smears was compared with a reference standard (Nugent criteria for gram stains). Both laboratory tests were interpreted blindly. RESULT: Bacterial vaginosis prevalence was 36.7% (191/521) with Nugent criteria. Pap smear sensitivity and specificity were 59.4% (111/187) and 83.3% (270/324), with corresponding figures for simplified Amsel's criteria of 44.8% (81/181) and 84.8% (263/310). For Pap smear and simplified Amsel's criteria, positive predictive values were 67.3 and 63.3%, and negative predictive values 78.0% and 72.5%. CONCLUSION: In diagnosing bacterial vaginosis, Pap smears have moderate sensitivity (though higher than simplified Amsel's criteria). Specificity of Pap smears is adequate. Including bacterial vaginosis assessment as a standard component of Pap smears warrants consideration.

Validity of self-reported 'safe sex' among female sex workers in Mombasa, Kenya--PSA analysis.

We assessed the validity of self-reported sex and condom use by comparing self-reports with prostate-specific antigen (PSA) detection in a prospective study of 210 female sex workers in Mombasa, Kenya. Participants were interviewed on recent sexual behaviours at baseline and 12-month follow-up visits. At both visits, a trained nurse instructed participants to self-swab to collect vaginal fluid specimens, which were tested for PSA using enzyme-linked immunosorbent assay (ELISA). Eleven percent of samples (n = 329) from women reporting no unprotected sex for the prior 48 hours tested positive for PSA. The proportions of women with this type of discordant self-reported and biological data did not differ between the enrolment and 12-month visit (odds ratio [OR] 1.1; 95% confidence interval [CI] 0.99, 1.2). The study found evidence that participants failed to report recent unprotected sex. Furthermore, because PSA begins to clear immediately after exposure, our measures of misreported semen exposure likely are underestimations.