STD research in Africa

Training and capacity building in medical statistics in Sub-Saharan Africa: Impact of the London School of Hygiene & Tropical Medicine MSc in Medical Statistics, 1969 to 2021

Since its inception in 1969, the MSc in medical statistics program has placed a high priority on training students from Africa. In this article, we review how the program has shaped, and in turn been shaped by, two substantial capacity building initiatives: (a) a fellowship program, funded by the UK Medical Research Council, and run through the International Statistical Epidemiology Group at the LSHTM, and (b) the Sub-Saharan capacity building in Biostatistics (SSACAB) initiative, administered through the Developing Excellence in Leadership, Training and Science in Africa (DELTAS) program of the African Academy of Sciences. We reflect on the impact of both initiatives, and the implications for future work in this area.

Strategies for integrating primary health services in middle- and low-income countries: effects on performance, costs and patient outcomes

BACKGROUND

Integration of primary health care is change to bring together inputs, organisation, management and delivery of particular service functions. Integration has been promoted in the health sector to improve the efficiency of health care delivery. The need for integration arose from perceptions that services were fragmented when delivered through separate vertical programmes. Integration is relevant to the health system at various levels, and this review is concerned with integration at the point of delivery.

OBJECTIVES

To assess the effects of strategies to integrate primary health care services on producing a more coherent product and improving health care delivery and health status, in relation to service cost, outputs, impact and user acceptability.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (August 2000), MEDLINE (1966 to September 2000), EMBASE (1988 to September 2000), Socio Files (1974 to September 2000), Popline (1970 to September 2000), HealthStar (1975 to September 2000), Cinahl (1982 to September 2000); Cab Health (1972 to 1999), International Bibliography of the Social Sciences (1970 to 1999), and reference lists of articles. We also searched the Internet and World Health Organization (WHO) library database, hand searched relevant WHO publications and contacted experts in the field.

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of integration strategies in primary health care services. Health services in high-income countries were excluded. The primary outcomes were service outputs: productivity and coverage, impact, user acceptability and unit cost.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Four studies were included. There was no consistent pattern of benefit. Integration had a clear positive effect on the outputs in only one study; in another it had similar effects to vertical programme delivery but greater effect than the control group. In the other two studies integration resulted in negative outputs in comparison with vertical programmes, although in one of these integration performed better than the control group.

REVIEWER'S CONCLUSIONS

Few studies of good quality, large and with rigorous study design have been carried out to investigate the evidence to support integration as a style of service delivery. In fact, some studies found greater effects for vertical health care delivery. Policy makers and planners considering integration could introduce strategies, using rigorous study design, to allow further evaluation and increase the base of studies from which to draw evidence.

Pattern of sexually transmitted diseases among pregnant women in Burkina Faso, west Africa: potential for a clinical management based on simple approaches

OBJECTIVES

(1) To determine the prevalence of sexually transmitted diseases (STDs) in pregnant women in Burkina Faso. (2) To evaluate the potential of clinical management of STDs based on screening with clinical data and urine leucocyte esterase test (LET).

METHODS

Cross sectional study among antenatal clinic attendees was conducted in 1994 in Ouagadougou and Bobo-Dioulasso, the two largest urban centres in Burkina Faso, where more than 94% of the pregnant women benefit from antenatal care at least twice during their pregnancy. Each woman selected underwent an interview, general and gynaecological examination. Genital samples were collected to confirm the presence of STD pathogens. Logistic regression analysis was done to identify models that predict (a) gonorrhoea and/or chlamydia, (b) trichomoniasis and/or bacterial vaginosis, (c) candidiasis. Sensitivity, specificity and positive and negative predictive values of these models were assessed using standard methods.

RESULTS

All 645 consecutive pregnant women were enrolled in the two sites. Among these women 32.4% presented at least one STD. The major STDs were: trichomoniasis (14%), bacterial vaginosis (13%), recent syphilis (3.6%), chlamydial infection (3.1%), genital warts (3%), gonococcal infection (1.6%) and genital ulcer (0.8%). Prevalence of vaginal candidiasis was 14%. The use of a risk marker (length of relationship with regular sexual partner < 3 years), and the positivity +3 of the urine LET provided a sensitivity of 80% and a positive predictive value of 7% for the screening of gonococcal and/or chlamydial infection. If clinical signs and positivity of the urine LET were taken into account sensitivity and positive predictive value of trichomoniasis and/or bacterial vaginosis screening were 77% and 37%, respectively. Clinical signs and positivity of the urine LET showed a low sensitivity (23%) for screening vaginal candidiasis.

CONCLUSIONS

The prevalence of STDs in pregnant women is high in urban Burkina Faso. Systematic screening combined with effective treatment should be included in antenatal care in the future. Urine LET, if associated with interview and clinical examination offers a simple, rapid and affordable tool for systematic screening of STDs in pregnant women. However, the proportion of overtreatments with proposed strategies will be high. Further studies are needed to develop and validate better algorithms with probably cheap laboratory tests.

Contact tracing and sexually transmitted disease among aboriginal men on the Anangu Pitjantjatjara lands

Sexually transmitted diseases (STDs) are a major health problem for Pitjantjatjara Aboriginal people, causing considerable morbidity and being implicated in the potential rapid transmission of human immunodeficiency virus (HIV) infection. This paper presents data in relation to STD contact tracing on the Anangu Pitjantjatjara lands. In-depth interviews were conducted with Aboriginal men and non-Aboriginal clinic staff to ascertain their attitudes to and perceptions of contact tracing. The interviews with Aboriginal men also sought more general information in relation to health-seeking behaviour and knowledge of STDs. While contact tracing has proven an effective method of case detection on the Anangu Pitjantjatjara lands (most named contacts are able to be located and a high proportion are found to be infected), the data suggest that important constraining issues are the reluctance of Aboriginal men to consult with particular health workers because of moiety group considerations, concerns about confidentiality, and the low level of knowledge of STDs, particularly of largely asymptomatic infections such as chlamydia, syphilis and HIV.

STD/HIV control in Malawi and the search for affordable and effective urethritis therapy: a first field evaluation

OBJECTIVES

To evaluate gonococcal (GU) and nongonococcal urethritis (NGU), chlamydia antigen, and serostatus for syphilis and human immunodeficiency virus (HIV) among males attending a Malawian STD clinic with complaints of urethral discharge and/or dysuria. To collect demographic and behavioural data and to determine the effectiveness of five treatments for urethritis.

METHODS

Urethritis was diagnosed using microscopy and culture for Neisseria gonorrhoeae. Sera were screened with rapid plasma reagin (RPR) and if reactive, with microhaemagglutination for Treponema pallidum (MHA-TP). HIV antibodies and chlamydia antigen were detected using enzyme immunoassay. Patients were randomised for treatment, cure was assessed 8-10 days later.

RESULTS

At enrolment, GU was diagnosed in 415 (80.3%) and NGU in 59 (11.2%) of 517 males. Chlamydia antigen was found in 26 (5.2%) of 497 specimens tested. Syphilis seropositivity rate (RPR and MHA-TP reactive) was 10.7%. Overall HIV seroprevalence was 44.2%; 71.7% of men with reactive syphilis serology were HIV(+) compared with 40.9% of syphilis seronegatives (OR: 3.6, p < 0.001). Trimethoprim 320 mg/sulphamethoxazole 1600 mg by mouth for 2 days (TMPSMX), or the combination of amoxicillin 3 gm, probenicid 1 gm, and clavulanate 125 mg by mouth once (APC), failed to cure gonorrhoea effectively. Amoxicillin 3 gm, probenicid 1 gm, and clavulanate 125 mg, by mouth once with doxycycline 100 mg BID for 7 days (APC-D), gentamicin 240 mg IM once (GENT), ciprofloxacin 250 mg by mouth once (CIPRO) cured 92.9% to 95% of gonorrhoea. APC-D treatment did not generate less NGU at follow-up. HIV serostatus did not affect cure of urethritis.

CONCLUSION

All patients presenting with urethritis should be treated syndromically using a simple algorithm and screened for syphilis seroreactivity for appropriate treatment and counselling.