Continuation with cotrimoxazole prophylaxis for the prevention of opportunistic infections in HIV-infected persons in rural Zimbabwe: feasibility, obstacles and opportunities.

We examined the outcomes of a World Health Organization (WHO) recommended programme offering cotrimoxazole (CTM) prophylaxis to 908 HIV-positive individuals in rural Zimbabwe, who accepted enrolment in the treatment programme. Outcomes included duration in programme, time between visits, relationship and marital status. Mean duration of participation in the programme was 224 days. The mean time between visits decreased from 11.2 weeks, between visit 1 and 2, to 4.3 weeks between visit 11 and 12. Statistical analysis showed significant positive correlations between duration in programme and participant age, participant relationship status and the partner's state of affairs. Statistical analysis showed no significant correlation between duration in programme and gender. Results indicate that if continuation is demonstrated for the first 4 to 6 months, participants will continue with the CTM programme. Results also reflect the constrained feasibility of CTM prophylaxis in rural Africa as well as the need to target subpopulations, such as young people, patients and their spouses for focused HIV/AIDS education initiatives.

Therapeutic feeding at a rural hospital in Zimbabwe.

OBJECTIVE: The purpose of this audit was to review treatment outcomes of participants in the Cooperazione e sviluppo/Cooperation and Development (CESVI), Therapeutic Feeding Programme (TFP) (i.e., death vs cure vs absconded) and to make recommendations for improving this and other similar programmes. DESIGN: This study was a retrospective chart review. The charts of all patients admitted to the TFP from 1 January 2005 to 31 December 2005 were analyzed. SETTING: The Salvation Army Howard Hospital is a district hospital in rural Zimbabwe. The hospital provides both inpatient and outpatient paediatric care. SUBJECTS: 132 consecutive children were enrolled in the TFP in 2005. INTERVENTION: The objectives of the TFP included identification of children with severe malnutrition; treating complications associated with severe malnutrition and prescribing appropriate dietary treatment. MAIN OUTCOME MEASURES: The main outcome of interest was whether TFP participants died, were cured, or absconded. We assessed factors that may be associated with these outcomes such as age, gender, comorbidities and length of stay. RESULTS: Female children and children with marasmus were more likely to abscond from the programme than male children and children with kwashiorkor (p = 0.041, 0.039 respectively). The majority of children who died while in the programme did so within the first week of their admission. The majority of children who were cured while in the programme achieved this goal after two weeks of hospitalization (p < 0.0001). CONCLUSION: Given the contextual factors in rural African settings that could potentially impede the healthy growth and development of children, this review has produced programmatic recommendations and suggestions for future research directions.

Acceptability of levonorgestrel subdermal implants versus tubal ligation for long-term contraception in a rural population of Zimbabwe.

This prospective cohort study of 257 rural Zimbabwean women was designed to compare patient satisfaction with levonorgestrel subdermal implants (Norplant and reg;) versus tubal ligation (TL) as a method of long-term contraception. Women were equally satisfied with both methods. At 1 year, 96% of Norplant users and 97% of the TL group reported being "satisfied" or "very satisfied," and 98% of Norplant users, and 99% of the TL cohort would recommend their chosen method to a friend or relative. Rating scores at both 6 months and 1 year were high and equal, with women in each cohort rating their method, on average, as 9 out of 10. Norplant users were significantly more likely to rate birth spacing as a reason for satisfaction with their method, whereas women in the TL cohort were more likely to select multiparity. The 1-year continuation rate with Norplant was 90%, with 4% discontinuing in order to have more children. Selecting the most appropriate method depends primarily on the potential desire of the woman to have more children.

A randomized control trial of an Ultra-Short zidovudine regimen in the prevention of perinatal HIV transmission in rural Zimbabwe.

OBJECTIVE: To assess the practicality and effectiveness of an Ultra-Short zidovudine regimen for prevention of perinatal HIV transmission in rural Zimbabwe. DESIGN: Double-blinded placebo-controlled randomized clinical trial. SETTING: The Salvation Army Howard Hospital, a district hospital in rural Zimbabwe. SUBJECTS: 222 HIV positive pregnant women presenting for antenatal care prior to 36 weeks were randomized. Twenty nine women were lost to follow up. INTERVENTION: In the Thai regimen, mothers received zidovudine (300 mg po bid) from 36 weeks gestation until labour, and zidovudine (300 mg po q3h) during labour, and the neonates received a placebo. In the Ultra-Short regimen, the mothers received a placebo from 36 weeks to labour, then zidovudine (300 mg po q3h) in labour. The neonates received zidovudine (2 mg/kg po qid) for the first three days of life. MAIN OUTCOME MEASURE: Infant HIV RNA status at six weeks of life. RESULTS: Results were available for 90 infants from the Thai group and 89 infants from the Ultra-Short group. Infant HIV seroconversion rates at six weeks of life were 18.9% (95%CI 10.8 to 27.0) with the Thai regimen, and 15.7% [95% Confidence Interval (CI) 8.1 to 23.4] with the Ultra-Short regimen. The upper bound of seroconversion in the Ultra-Short group was lower than the 25% seroconversion boundary that was specified to show equivalence. CONCLUSIONS: Although the Ultra-Short regimen has equivalent efficacy to the Thai regimen, it also has many practical advantages. Ultra-Short is thus a preferable protocol.

Cervical cancer screening in a rural population of Zimbabwe.

OBJECTIVE: To review cervical cancer screening since its introduction to a rural district hospital in Zimbabwe. DESIGN: Retrospective, descriptive. SETTING: Rural district hospital. SUBJECTS: Data from 419 cervical smears performed on women who had cervical cancer screening as part of a routine post partum visit from 1994 to 1996 was available for analysis. MAIN OUTCOME MEASURE: Rates of abnormal cervical smears. RESULTS: The majority of the patients were of age 20 to 29 years (47.2%) and of low gravidity (Zero to three children) 62.6%). A total of 173 slides (41.3%) were normal. Of the abnormal smears, 158 (37%) had inflammation, and 65 cases (15.5%) demonstrated abnormal cytology of which 50 (12%) were low grade squamous epithelial lesions (atypia/CINI), and the remaining 15 (3.6%) high grade squamous intra-epithelial lesions (CIN II/III and carcinoma in situ). CONCLUSION: There was a high frequency of abnormal smears at this rural district hospital. Furthermore, there were problems in sampling the population at highest risk, shortages of supplies, technical problems in sampling and interpretation, and difficulties in follow up of patients. These problems are discussed including the confounding effect of the Human Immunodeficiency Virus.

PIP: In Zimbabwe, where cervical cancer is the leading female malignancy, no systematic cervical screening program has been introduced. However, selective or opportunistic screening has been performed since the late 1980s at family planning clinics, various central and district government hospitals, and in private practice. The initial results of a cervical cancer screening program introduced in a district hospital (Salvation Army Howard Hospital) in the Chiweshe rural community in 1994 were investigated. The aim is for every mother to receive a Pap smear at her 6-week postpartum visit. By May 1996, a total of 419 Pap smears--representing less than 20% of the hospital's postnatal population--had been performed at this facility. If all postnatal visits included a Pap smear, there would have been 2500 screenings. 58.7% of smears were classified as inadequate, primarily because of the coexistence of sexually transmitted infections. A total of 173 slides (41.3%) were normal. Of the abnormal smears, 158 (37.7%) had inflammation. Abnormal cytology was reported in 65 cases (15.5%); 15 of these cases (3.6%) were high-grade squamous intraepithelial lesions. Factors contributing to the low number of Pap smears actually performed included a high default rate for the postpartum visit, shortages of test-related supplies, and the rapid turnover of trained staff. Cervical cancer screening efforts in Zimbabwe require physical resources to perform smears, well-trained personnel, transport and laboratory services, and adequate patient follow up and treatment. Finally, since cervical cancer primarily affects older women, young women of reproductive age may not be the most appropriate target population for screening efforts.