Hiv testing and counselling for women attending child health clinics: An opportunity for entry to prevent mother-to-child transmission and hiv treatment. Author

Variables for input into a simple model of HIV prevention, AVERT, were derived from a study of hot spots of transactional sex on the trans-Africa highway. Diaries were completed by a sample of sex workers at selected sites of transactional sex for a period of 28 consecutive days. Key information elicited included numbers, types and occupations of clients, numbers of liaisons, sexual acts in each liaison, and condom use. 857 diaries were distributed and 578 received and usable in 30 sites. A sexual patterning matrix was completed by 202 truckers at the Malaba border point as part of a health seeking behaviour survey. Two methods were employed to estimate female sex worker (FSW) numbers on the highway. FSW focus group discussions (FGDs) at 15 sites were carried out and included questioning on the number of sex workers at the site. As most transactional sex on the highway is centred on bars and lodgings, a patron census and survey of 1007 bars and lodgings was carried out which included questions on the presence and proportions of FSWs among the clientele.

There are an estimated 8000 FSWs on the trans-Africa highway from Mombasa to Kampala. Annual numbers of different sexual partners per FSW were 129, annual numbers of sexual acts per FSW were 634, percentage of sexual acts protected by condom use was 77.7%. Using these input data an estimated 3200-4148 new HIV infections occur on this portion of the trans-Africa highway in 1 year. Having a 90% condom use programme in place could prevent almost two thirds of these infections and cumulative incidence would decline from 1.29% to 0.42%.

In generalised epidemics there has been a debate as to the place of targeted interventions. In the current east African epidemic we show that a targeted intervention could have significant impact in averting HIV infections related to the trans-Africa highway.

To investigate the sexual and treatment-seeking behaviour for sexually transmitted infection (STI) in long-distance transport workers of East Africa.

A health-seeking behaviour survey was carried out at four sites on the Mombasa-Kampala trans-Africa highway (n = 381). The questionnaires probed details of STI knowledge, symptoms and care-seeking behaviour. In one site at the Kenya-Uganda border, a sexual patterning matrix was used (n = 202) to measure sexual behaviour in truck drivers and their assistants over the 12-month period before the interview.

Over half of the sexual acts of long-distance transport workers over 12 months were with female sex workers, with an annual average of 2.8 sexual partners. Condom use was reported at 70% for liaisons with casual partners. 15% of truckers had had a self-reported STI and one-third exhibited high-risk sexual behaviour in the previous year. Of those with an STI, 85% had symptoms when on the road and 77.2% sought treatment within 1 week of onset of symptoms. 94% of drivers and 56% of assistants sought treatment for STI in a private health facility or pharmacy. The cost of private facilities and pharmacies was not significantly higher than in the public sector. Waiting times were three times longer in the public sector. Only 28.9% of patients completed their medication courses as prescribed.

Truck drivers and their assistants in East Africa have high rates of reported STIs and many continue to exhibit high-risk sexual behaviour. The transport workers studied here favoured private health facilities because of convenience and shorter waiting times.

Although several clinical prediction rules exist for lower respiratory tract infection (LRTI), few are for acute bronchitis (acute bronchitis) and most have not been validated in high human immunodeficiency virus (HIV) prevalence settings.

An Acute Bronchitis Severity Score (ABSS) was developed and validated during a randomized trial of antibiotic treatment for acute bronchitis. Ambulatory adults with productive cough of < or =2 weeks at out-patient respiratory disease clinics in Nairobi, Kenya, were recruited and assessed for clinical response to therapy. The ABSS quantitative ratings of LRTI-associated symptoms, physical signs and sputum Gram stain purulence were assessed using standard psychometric tests.

The ABSS was evaluated among 649 cases of acute bronchitis; 129 (20%) were HIV-seropositive. The ABSS had small floor and ceiling effects (1.8/0.2) and demonstrated high internal consistency (alpha-coefficient of 0.66) and internal validity, with a mean inter item total correlation of > or =0.25. Effect sizes from baseline to subsequent follow-up visits were large (>0.5). Wheezing and chest pain were associated with higher ABSS values, whereas irrelevant clinical variables were not.

The ABSS demonstrated good responsiveness, high internal consistency, good correlation with common respiratory signs and symptoms and high discriminatory validity among patients with acute bronchitis in a high HIV-seroprevalence setting.

Recent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-to-male transmission risk by 60% or more. However, the public health impact of large-scale male circumcision programs for HIV prevention is unclear.

Two mathematical models were examined to explore this issue: a random mixing model and a compartmental model that distinguishes risk groups associated with sex work. In the compartmental model, two scenarios were developed, one calculating HIV transmission and prevalence in a context similar to the country of Botswana, and one similar to Nyanza Province, in western Kenya.

In both models, male circumcision programs resulted in large and sustained declines in HIV prevalence over time among both men and women. Men benefited somewhat more than women, but prevalence among women was also reduced substantially. With 80% male circumcision uptake, the reductions in prevalence ranged from 45% to 67% in the two "countries", and with 50% uptake, from 25% to 41%. It would take over a decade for the intervention to reach its full effect.

Large-scale uptake of male circumcision services in African countries with high HIV prevalence, and where male circumcision is not now routinely practised, could lead to substantial reductions in HIV transmission and prevalence over time among both men and women.

Behavioral interventions in female sex workers (FSWs) are associated with changes in sexual behavior and reduced rates of sexually transmitted infections (STIs) and HIV We examined the sustainability of such interventions.

HIV-uninfected Kenyan FSWs were enrolled in a clinical trial that provided free male condoms, community and clinic-based counseling, and STI management. After trial completion, scaled-back community-based resources remained in place. More than a year later, women were invited to complete a follow-up behavioral questionnaire and to undergo STI/HIV counseling and testing. Individual changes in sexual behavior were assessed by paired analysis.

One hundred seventy-two women participated in the resurvey 1.2 years after trial termination. Client numbers had risen (paired t test, P < 0.001), but condom use had also increased (P < 0.001); both remained substantially lower than at enrollment. Regular partners accounted for a greater proportion of unprotected FSW sexual encounters (35% vs. 10%; P < 0.001). Only 9 (5.2%) of 172 women had a conventional STI, and the follow-up HIV incidence of 1.6 per 100 person-years (PYs) was similar to that during the trial period (3.7 per 100 PYs). Incident STIs and HIV were associated with the frequency of unprotected sex and younger age.

Less intensive community-based risk reduction services after clinical trial termination may support ongoing reductions in STIs and HIV among high-risk FSWs.

To determine the prevalence and correlates of herpes simplex virus type 2 (HSV-2) seropositivity among fishermen along the shores of Lake Victoria in Kisumu district, Kenya.

Sera from a random sample of 250 fishermen from 18 beaches were collected after a detailed sociodemographic interview. HSV-2 infection was tested by Kalon HSV-2 ELISA.

The HSV-2 seroprevalence was 63.9%. In multivariate analysis, fishermen were more likely to be infected with HSV-2 if they were HIV positive (prevalence ratio (PR) 1.27; 95% CI 1.06 to 1.52) compared with those testing HIV negative, were aged 18-20 (PR 0.49; 95% CI 0.24 to 0.99) and older than 40 (PR 1.66; 95% CI 1.30 to 2.14) years compared with those aged 21-25 years, perceived their last two sexual partners to have a sexually transmitted infection (STI; PR 1.27; 95% CI 1.06 to 1.52) compared with those who did not and were more likely to be circumcised (PR 1.49; 95% CI 1.19 to 1.86).

HSV-2 seroprevalence is high among this population and is associated with HIV serostatus, age, perception about partner's STI status and circumcision.

There are limited reports on HIV-1 RNA load, CD4+ T-lymphocytes and antibody responses in relation to disease progression in HIV-1 infected untreated children in Africa.

To describe the relationships between these parameters, we conducted a longitudinal cohort study involving 51 perinatally HIV-1 infected children aged between 1 and 13 years. HIV status was determined by ELISA and confirmed by western blot and PCR. Antibodies were quantified by limiting dilution ELISA, plasma HIV-1 RNA load by RT-PCR and CD4+ T-lymphocytes by FACSCount.

Asymptomatic and symptomatic disease had, respectively, a rise in median HIV-1 RNA load from 1,195 to 132,543 and from 42,962 to 1,109,281 copies/ml in children below 6 years. The increase in viral load was 10-fold higher for asymptomatic compared to other categories and 2-fold faster for children less than 6 years than those above. Similarly, symptomatic children below 6 years had initial median CD4+ T-lymphocyte counts of 647 (22%) cells/muL, declining to 378 (20%) while those above 6 years had initial values of below 335 (15%) but which increased to 428 (17%). Median viral load correlated significantly with median CD4+ T-lymphocyte percentage in children above 6 years (p=0.026) but not below.

Viral load is lower in older than younger children and correlates significantly with percentage CD4+ T-lymphocytes. Survival by HIV-1 infected children requires a competent immune response early in infection to counter the rapidly replicating virus. Interventions aimed at boosting the naive immune system may prolong survival in these children.

To determine the pattern of opportunistic infections such as TB and Candida species in HIV infected patients in Northern Kenya.

Cross-sectional study. SETTING: Five health facilities in Moyale (n=224), Mandera (n=121) and Turkana Kakuma; (n=83), Lopiding; (n=94) districts during different periods in 2003. SUBJECTS: Five hundred and fifty two patients.

In total 94 (18%) patients were found to be HIV positive (Moyale=42, Mandera=13, Turkana; Kakuma=8, Lopiding=31). Only 65 of 94 HIV positive patients provided saliva samples. Of these, 11 (17%) were TB smear positive and 19 (29.2%) were colonized by oral Candida species. The Candida isolates were as follows; Co-infection of Candida species and TB (n=4), C. albicans only (n=12), C. tropicalis only (n=1), C. albicans and C. glabarata (n=1) and C. albicans, C. glabarata and C. tropicalis. co-infection (n=1).