Practising obstetrics and gynaecology in areas with a high prevalence of HIV infection

What is it like to practise obstetrics and gynaecology in a country with a high prevalence of HIV infection? My experience relates especially to Zimbabwe, but the same factors apply equally well to Zambia, Zaire, Uganda, Kenya, Tanzania, Malawi, and Mozambique. Within a population of 11 million in Zimbabwe, at least 1 million are HIV positive according to the official figures. AIDS often means "home-based care"; the nearest clinic or hospital, which has very little to offer, may be 3 hours away by wheelbarrow. Many patients who die with chronic diarrhoea lack a piped water supply nearby, an indoor toilet, or even a waterproof sheet. Every year in Zimbabwe there are 120,000 confinements of HIV-positive women compared with 7000 HIV-positive pregnancies in the USA. Transmission of the virus in Africa is mainly heterosexual and vertical, although blood transfusion still plays a part. Intravenous drug use is not a problem but alcohol is, by way of promoting risky behaviour. A secondary epidemic of tuberculosis (TB) (also among HIV-negative persons) adds to the difficulties in sub-Saharan Africa.

[African histoplasmosis due to Histoplasma capsulatum var. duboisii: relationship with AIDS in recent Congolese cases]

Six new cases are described for African histoplasmosis, Histoplasma capsulatum var. duboisii, from Congo. The first was an HIV sero-negative child who has been monitored for the last three years. While under treatment with ketoconazole, amphotericin B, and finally itraconazole, the development of the infection was accompanied by purulent lesions, mainly cutaneous, but also superficial and deep lymphadenopathies. As a last option, itraconazole gave very satisfactory results both during the acute phase and during long-term treatment. However, eight months after treatment had ceased, there was a relapse and the long-term treatment had to be restarted. The other cases concerned HIV sero-positive patients with disseminated infections that had all been mistaken for tuberculosis. After diagnosis of the infection in two cases, the following two years of treatment could not prevent death. A fourth case, diagnosed in December 1994, is currently undergoing treatment. The fifth subject was lost after diagnosis during follow-up, but inquires made after the discovery of the patient's death strongly indicated acquired immunodeficiency as the cause. The last of these six cases, determined as HIV sero-negative, showed large bony lesions of the spinal column associated with a sore on the thorax. Thus, in a short period of time, three or four cases of African histoplasmosis occurred which were associated with HIV infection. Only seven identical observations have previously been reported in the literature. Therefore, we believe that this mycosis should now be included in the criteria for the diagnosis and definition of AIDS in the tropics.

A role for a new herpes virus (KSHV) in different forms of Kaposi's sarcoma

Kaposi's sarcoma (KS) is a previously rare, tumour-like lesion of controversial biological nature. KS has since the early 1980s become frequent in patients with AIDS, particularly in homosexuals. KS is also endemic in Central Africa predominantly in otherwise healthy men but also in women and children. Recently, evidence for the presence of novel, herpes virus DNA sequences in more than 90% of AIDS Kaposi lesions (AKS) was presented. This DNA was identified using representational difference analysis (RDA) generating short, unique sequences with variable homology to several herpes virus, but no intact virus was recovered. If these DNA-sequences are also present in other, non-HIV-associated forms of Kaposi's sarcoma this would strongly suggest a specific, aetiopathological involvement of this putative new herpes virus in the pathogenesis of Kaposi's sarcoma, rather than a contamination of yet another opportunistic virus in immunosuppressed AIDS patients.

AIDS knowledge, risk behaviors, and factors related to condom use among male commercial sex workers and male tourist clients in Bali, Indonesia

OBJECTIVES

To describe the AIDS/sexually transmitted diseases (STD) knowledge and risk behaviors, and to determine factors related to condom use among male commercial sex workers (CSW) and male tourist clients in Bali, Indonesia.

DESIGN

Individual survey interviews were conducted with a sample of 80 male CSW and 100 tourist clients in the Kuta area of Bali.

METHODS

Survey interviews included detailed questions on AIDS/STD knowledge, sexual behavior, and psychosocial measures related to risk taking.

RESULTS

Most of the male CSW had heard about AIDS and other STD, although some misconceptions about transmission and risks of different sexual practices remained. Both oral and anal intercourse with tourists were common and condom use was far from consistent. Factors related to condom use for anal intercourse with tourist clients were condom beliefs, self efficacy, susceptibility to STD infection, and STD knowledge. Tourist clients were mainly from Australia and Europe and many had paid for sex in other parts of Indonesia as well as in high prevalence countries. Knowledge of AIDS/STD was very good among the tourists and previous experience with STD was common. Factors related to condom use with male CSW were condom beliefs and self efficacy.

CONCLUSION

There is a very active and mobile group of male CSW and tourist clients present in Bali. Interventions with these men are needed due to the low level of knowledge about AIDS among CSW, their experience with STD and STD symptoms, and their level of risky sexual behavior.

AIDS awareness among nursing students

Nursing students are being identified as a potential risk group for the AIDS spread. Awareness regarding AIDS in this group is crucial for AIDS management and prevention. This cross-sectional study was planned and carried out to assess the awareness of nursing students regarding AIDS and to identify the areas of confusion that might serve as an important target of educational intervention. The study consisted of 204 nursing students selected from Nursing school, Govt. Medical College, Nagpur. The overall knowledge regarding etiology, risk factors, transmission, treatment and prevention of AIDS was confusing among the students. The average knowledge score was estimated to be 17.6 of 28. However, more knowledge was found to be correlated with more positive and fearless attitude towards AIDS patients.

Female partners of AIDS patients in Uganda: reported knowledge, perceptions and plans

OBJECTIVE

To assess reported knowledge of a partner's AIDS diagnosis, perceived risk of HIV infection, need for HIV testing and future support plans among women partners of male Ugandan AIDS patients.

SUBJECTS AND METHODS

A cross-sectional descriptive survey was conducted at New Mulago Hospital, Kampala, Uganda. The subjects were women partners of consecutive male AIDS patients admitted to medical wards.

RESULTS

Only 12% reported their partner's AIDS diagnosis; women who reported knowing were less likely to be financially dependent on the partner. Most women (76%) reported being at risk of HIV; in general, these women were older, in a newer relationship, had less children and were in customary rather than civil or cohabiting marriages. More than half (56%) of the women reported a need for HIV testing, though few (5%) had been tested. Those who stated the need for HIV testing were in a newer relationship, had less children and were more financially independent of their husbands; women in a cohabiting type marriage were less likely to report their need for testing than those in a civil or customary marriage. About half (56%) reported plans for future support if their husbands did not recover; these women were more likely to be in an older relationship and to have more children.

CONCLUSIONS

Most women partners of AIDS patients in New Mulago Hospital reported no knowledge of their husbands' diagnosis. Over half perceived a need to be tested but very few reported having been tested, and only half reported having planned for the future of their families. Interventions are urgently needed to address barriers to knowledge and to acknowledgement of a partner's AIDS diagnosis, to HIV testing and to planning for the future.

Prevalence of skin disease in patients infected with human immunodeficiency virus in Bangkok, Thailand

A detailed study of the skin lesions of 248 patients infected with the human immunodeficiency virus (HIV) in Bangkok, Thailand, is reported. The study population consisted of 140 patients with asymptomatic disease (stage I), 27 patients with symptomatic disease (stage II), and 81 patients with advanced stage of the disease (stage III). Ninety-five percent of all patients were observed to have one or more skin disorders. Conditions with prevalence higher than 5% included oral candidiasis (34.3%), pruritic papular eruption (32.7%), seborrhoeic dermatitis (21.0%), herpes zoster (16.1%), oral hairy leucoplakia (14.9%), herpes simplex (10.9%), onychomycosis (9.3%), cutaneous ringworm (7.7%), psoriasis (6.5%), and folliculitis (5.6%). Patients in the stage II and III subgroups were found to have a significantly more number of skin disorders than patients in stage I. The prevalence pattern of skin disorders in this study are generally similar to previous studies in the literature. Three notable differences, however, emerge from this study: (1) the high prevalence of pruritic papular eruption in all subgroups, (2) the high prevalence of Penicillium maneffei infection in patients with advanced disease, and (3) the absence of Kaposi's sarcoma in the study population. Knowledge about the cutaneous disease pattern in the locals will be more clinically relevant for proper care of the patients.

HIV-preventive cognitions amongst secondary school students in Uganda

A self-completion questionnaire was used to survey HIV-preventive cognitions among secondary school students in Kabarole district, Uganda. An encouraging pattern of HIV-preventive beliefs was observed, suggesting that health education efforts have been effective in establishing basic transmission knowledge, accurate risk perception and an understanding of effective precautions. Further analysis explored the prerequisites of men and women's HIV-preventive self-efficacy, and intentions and tolerance of people with AIDS. Approximately a third of variance in men and women's condom use self-efficacy, half the variance in women's condom use intentions and a quarter of the variance in men's condom use intentions was accounted for by specified variables. Results offered support for psychological relationships proposed by social cognition models and suggested specific health education targets for young Ugandan men and women.

Clinical features of HIV seropositive Zambian subjects

Data was collected from 1595 anti-HIV positive patients out of which 90% of the patients were from the Copperbelt province, and the rest from five out of the eight other provinces of Zambia. One-hundred and one positive HIV patients were less than 2 years of age, 69 were aged 2 to 14 years and 1418 were aged above 15 years. The male to female ratio was about 1:1 at all ages, except that there was an excess of males below 5 years. Of the four most frequent symptoms or signs, loss of weight or malnutrition was regarded in about 50% of seropositive patients at all ages; generalized lymphadenopathy was seen in at least 35% of all age groups and most frequently at 2-14 (60%); chronic watery diarrhoea was most common at less than 2 years (44%) and least common in older children (17%); chronic chest infections had highest frequency in children 2-14 years (59%) and lowest in adults (32%). Intensive education of children before they are sexually active is the best hope for controlling the epidemic.

The snout and palmomental reflexes in HIV disease in Tanzania

Following earlier observations on the snout (SR) and palmomental(PMR) reflexes in AIDS in Tanzania, a series of 1127 adults, 649 HIV-positive and 478 HIV-negative, from 4 groups at different risk of HIV infection were examined neurologically between 1987 and 1992. The prevalence of SR and PMR was calculated according to HIV status, HIV stage, demographic factors and neurologic findings. In the total series of HIV positives the prevalence ranged from SR 39.3% and PMR 22.6% in asymptomatic HIV disease to SR 87% and PMR 69% in terminal AIDS. In HIV negatives the prevalence of SR was 19.2% and PMR 15.3%, and increased with age. There was no relationship with age in the HIV positives and no gender differences. SR and PMR were also associated with neuropathy, myelopathy and AIDS dementia complex independent of HIV stage. This study shows a strong association between SR and PMR and HIV disease in Africa. The prevalence increased with HIV stage and related neurological disorders.

The proportion of tuberculosis cases in Tanzania attributable to human immunodeficiency virus

BACKGROUND

Routine data obtained from the National Tuberculosis and Leprosy Programme (NTLP) of Tanzania have shown a constant increase in the notified number of tuberculosis (TB) cases since 1982. Possible causes include an improved reporting system, improvement in health services after the introduction of short course chemotherapy (SCC), and human immunodeficiency virus (HIV) infection. This paper examines to what extent the increased TB case detection rate can be attributed to HIV infection, by calculating the population attributable risk for various years.

METHOD

The prevalence of HIV infection was obtained from data of the National AIDS Control Programme and the relative risk of HIV for developing TB from a case-control study and the literature.

RESULTS

Between 1985 and 1989 the increase was the highest among women aged 15-24 years and men aged 25-34 years; age groups in which HIV prevalence is highest. In the case-control study HIV prevalence among blood donors was 9.4% and among smear-positive pulmonary TB patients 51.6%, giving an odds ratio (OR) of 8.1 (95% confidence interval (CI): 4.4-16.3). For all TB cases the OR was 11.8. In a population with an HIV prevalence of 10%, about 40% of the smear-positive TB patients are attributable to HIV. The excess of TB cases in the entire country between 1982 and 1989 can be attributable to HIV infection. This has implications for TB control and socioeconomic consequences in the country.

Is under-reporting of AIDS a problem in Jamaica?

A survey of physicians in Jamaica was conducted between March and September, 1993 in order to estimate the level of reporting of HIV and AIDS. A questionnaire was delivered to nearly all of approximately 1,200 physicians practising in Jamaica. Completed questionnaires were received from 418, a response rate of 35%. Of the physicians responding, 46% were in private practice only, 22% in the public sector only and 32% in both. Two-thirds (66%) of the physicians in private practice had not diagnosed a case of AIDS and 65% had not had a patient with a positive HIV test result. Half (54%) of the private physicians had reported all their AIDS cases, 8% had reported some and 38% (45 doctors) had reported none. The main reasons for not reporting were: "thought someone else had reported" (15 doctors), concern for confidentiality (11) and not knowing where to report (8). Only 9% of private practitioners were currently seeing an AIDS patient and 12% were seeing an HIV-infected person. Of physicians with current AIDS patients 16% preferred not to report, 21% intended to report and 63% had reported. Nearly one-third (29%) of private practitioners expressed reservations about treating persons with HIV/AIDS. Most (75%) public sector physicians had seen one or more AIDS patients. Sixty-four per cent of these physicians said that all of their AIDS cases were reported, 4% said some, 4% said none and 28% didn't know. Reporting of AIDS cases is better in the public sector than among private physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

Knowledge, attitude and beliefs amongst inhabitants of high density informal settlements with regard to sexuality and AIDS in Alexandra township

OBJECTIVE

The main purpose of this study was to gain information on the knowledge that people living in squatter conditions have about AIDS, their attitude towards this disease and their sexual practices.

METHOD

The study had two parts, in-depth interviews and a survey. The in-depth interviews were held with 68 male informal settlement dwellers to obtain information on the type of questions to ask in the quantitative part of the study, taking into account the sensitivity of the information we were seeking, and how best to phrase these questions. For the survey, the 300 male informal settlement residents who were interviewed, were located by means of systematic sampling techniques.

RESULTS

The results of the survey showed that most of the respondents were living in squalid conditions, without recreation facilities. They were also likely to have had more than one partner (54%). Most of the respondents (90%) had heard about AIDS as a disease. Even though they were aware of AIDS as an epidemic in the country as a whole, they were not convinced that the disease exists in their community, the main reason being that they have never heard about nor seen a person with AIDS in the township.

CONCLUSION

There is an urgent need for AIDS education. But this education cannot take place as a separate activity from other upliftment activities in squatter areas.