Resilience in emergency management: Learning from COVID-19 in oil and gas platforms

Emergency management, both in civilian and military context, is regarded as a complex socio-technical system, whose dynamic nature and complexity require a holistic approach. Over time, scholars developed diverse strategies and methods to capture such complexity and effectively design emergency plans for more or less severe disasters scenarios. Nonetheless, planning is not always an omni-comprehensive task, pushing organizations to stretch their adaptive capacities in dynamic and challenging settings. This manuscript explores such adaptive capacity as put in place by a leading Norwegian organization in providing emergency management solutions, facing unexpected challenges (at the time of the event): handling of Covid-19 infection episodes on offshore oil platforms. The study, conducted through the Functional Resonance Analysis Method (FRAM) highlights the relevance of organizational learning which allows to handle emergencies by adapting plans to the specific context and by renewing new emergency management procedures derived from lessons learned. The study focuses on three different Covid-19 infection management cases to understand the nuances of actions and emerging adaptations that led to the development of a revised emergency plan, seen again through the lens of FRAM. While the methodological approach refers to Covid-19 infection management, we believe it can be extended into larger crisis management, providing a use case for the applicability of FRAM into emergency management scenarios.

Differentiated prevention and care to reduce the risk of HIV acquisition and transmission among female sex workers in Zimbabwe: study protocol for the ‘AMETHIST’ cluster randomised trial

Background

Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and are critical to engage in HIV prevention, testing and care services. We describe the design of our evaluation of the ‘AMETHIST’ intervention, nested within a nationally-scaled programme for FSW in Zimbabwe. We hypothesise that the implementation of this intervention will result in a reduction in the risk of HIV transmission within sex work.

Methods

The AMETHIST intervention (Adapted Microplanning to Eliminate Transmission of HIV in Sex Transactions) is a risk-differentiated intervention for FSW, centred around the implementation of microplanning and self-help groups. It is designed to support uptake of, and adherence to, HIV prevention, testing and treatment behaviours among FSW. Twenty-two towns in Zimbabwe were randomised to receive either the Sisters programme (usual care) or the Sisters programme plus AMETHIST. The composite primary outcome is defined as the proportion of all FSW who are at risk of either HIV acquisition (HIV-negative and not fully protected by prevention interventions) or of HIV transmission (HIV-positive, not virally suppressed and not practicing consistent condom use). The outcome will be assessed after 2 years of intervention delivery in a respondent-driven sampling survey (total n = 4400; n = 200 FSW recruited at each site). Primary analysis will use the ‘RDS-II’ method to estimate cluster summaries and will adapt Hayes and Moulton’s ‘2-step’ method produce adjusted effect estimates. An in-depth process evaluation guided by our project trajectory will be undertaken.

Discussion

Innovative pragmatic trials are needed to generate evidence on effectiveness of combination interventions in HIV prevention and treatment in different contexts. We describe the design and analysis of such a study.

Trial registration

Pan African Clinical Trials Registry PACTR202007818077777. Registered on 2 July 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06119-w.

"It went through the roof": an observation study exploring the rise in PrEP uptake among Zimbabwean female sex workers in response to adaptations during Covid-19

Introduction

Sisters with a Voice (Sisters), a programme providing community‐led differentiated HIV prevention and treatment services, including condoms, HIV testing, pre‐exposure prophylaxis (PrEP) and antiretroviral therapy linkage for sex workers, reached over 26,000 female sex workers (FSW) across Zimbabwe in 2020. Zimbabwe's initial Covid “lockdown” in March 2020 and associated movement restrictions interrupted clinical service provision for 6 weeks, particularly in mobile clinics, triggering the adaptation of services for the Covid‐19 context and a scale up of differentiated service delivery (DSD) models. PrEP service delivery decentralized with shifts from clinical settings towards community/home‐based, peer‐led PrEP services to expand and maintain access. We hypothesize that peer‐led community‐based provision of PrEP services influenced both demand and supply‐side determinants of PrEP uptake. We observed the effect of these adaptations on PrEP uptake among FSW accessing services in Sisters in 2020.

Methods

New FSW PrEP initiations throughout 2020 were tracked by analysing routine Sisters programme data and comparing it with national PrEP initiation data for 2020. We mapped PrEP uptake among all negative FSW attending services in Sisters alongside Covid‐19 adaptations and shifts in the operating environment throughout 2020: prior to lockdown (January–March 2020), during severe restrictions (April–June 2020), subsequent easing (July–September 2020) and during drug stockouts that followed (October–December 2020).

Results and discussion

PrEP uptake in 2020 occurred at rates <25% (315 initiations or fewer) per month prior to the emergence of Covid‐19. In response to Covid‐19 restrictions, DSD models were scaled up in April 2020, including peer demand creation, community‐based delivery, multi‐month dispensing and the use of virtual platforms for appointment scheduling and post‐PrEP initiation support. Beginning May 2020, PrEP uptake increased monthly, peaking at an initiation rate of 51% (n = 1360) in September 2020. Unexpected rise in demand coincided with national commodity shortages between October and December 2020, resulting in restriction of new initiations with sites prioritizing refills.

Conclusions

Despite the impact of Covid‐19 on the Sisters Programme and FSW mobility, DSD adaptations led to a large increase in PrEP initiations compared to pre‐Covid levels demonstrating that a peer‐led, community‐based PrEP service delivery model is effective and can be adopted for long‐term use.

Control of sexually transmitted infections and global elimination targets, South-East Asia Region

The World Health Organization (WHO) set targets for a 90% reduction in the incidence of syphilis and gonorrhoea between 2018 and 2030. We review trends in sexually transmitted infections in the WHO South-East Asia Region to assess the feasibility of reaching these targets. Myanmar, Sri Lanka and Thailand reported 90% or greater reductions in the incidence or prevalence of syphilis and/or gonorrhoea between 1975 and 2005. Evidence suggests that smaller, more recent reductions in trends in sexually transmitted infections in India have driven regional declines. In other countries, sexually transmitted infections remain high or are increasing or data are not reliable enough to measure change. Sri Lanka and Thailand have strong control programmes for sexually transmitted infections that ensure universal access to services for these infections and targeted interventions in key populations. India and Myanmar have implemented targeted control efforts on a large scale. Other countries of the region have prioritized control of human immunodeficiency virus, and limited resources are available for other sexually transmitted infections. At national and subnational levels, data show rapid declines in sexually transmitted infections when targeted promotion of condom use and sexually transmitted infection services are scaled up to reach large numbers of sex workers. In contrast, recent outbreaks of sexually transmitted infections in underserved populations of men who have sex with men have been linked to rising trends in sexually transmitted infections in the region. A renewed and focused response to sexually transmitted infections in the region is needed to meet global elimination targets.

A rapid review of pre-exposure prophylaxis for HIV in the Asia-Pacific region: recommendations for scale up and future directions

Decline in new HIV infections in the Asia-Pacific region (APAC) continues to be slow, emphasising the importance of scaling up new HIV prevention strategies, such as pre-exposure prophylaxis (PrEP). To help inform PrEP rollout in APAC, we conducted a rapid review of published literature on PubMed from 2015 to 2020, to assess feasibility, implementation strategies, cost-effectiveness, and availability of national policies and guidelines; for the latter, we also did an expanded Internet search. This review focussed on nine countries contributing >95% of new infections in this region. A total of 36 PrEP-related studies conducted among men who have sex with men, female sex workers, and transgender women were included, of which 29 were quantitative, six were qualitative and one was a mixed-method study. Most of the studies have addressed the availability and acceptability of PrEP, whereas cost-effectiveness of any approach was assessed by limited studies. Limited published information was available about national PrEP policies and guidelines; of the selected nine countries, five have adopted the recommended World Health Organization PrEP policy of which four have integrated it in their national HIV response. HIV risk perception concerns about safety, side-effects, stigma, and affordability were major challenges to PrEP acceptance. Community-based implementation has the potential to address these. Limited evidence suggested merging PrEP implementation with ongoing targeted intervention and treatment programs could be a cost-effective approach. To stem the epidemic, newer effective prevention strategies, like PrEP, should be urgently adopted within the context of combination HIV prevention approaches.

Strengthening the scale-up and uptake of effective interventions for sex workers for population impact in Zimbabwe

Introduction

UNAIDS’ goal of ending AIDS by 2030 is unreachable without better targeting of testing, prevention and care. Female sex workers (FSW) in Zimbabwe are at high risk of HIV acquisition and transmission. Here, we report on collated programme and research data from Zimbabwe's national sex work programme. We also assess the potential for wider population impact of FSW programmes by modelling the impact on HIV incidence of eliminating transmission through FSW (i.e. calculate the population attributable fraction of incidence attributable to sex work).

Methods

Descriptive analyses of individual‐level programme data collected from FSW between 2009 and June 2018 are triangulated with data collected through 37 respondent driven sampling surveys from 19 sites in Zimbabwe 2011 to 2017. We describe programme coverage, uptake, retention and patterns of sex work behaviour and gaps in service provision. An individual‐level stochastic simulation model is used to reconstruct the epidemic and then the incidence compared with the counter‐factual trend in incidence from 2010 had transmission through sex work been eliminated from that date.

Results

Sisters has reached >67,000 FSW since 2009, increasing attendance as number of sites, programme staff and peer educators were increased. Over 57% of all FSW estimated to be working in Zimbabwe in 2017 (n = 40,000) attended the programme at least once. The proportion of young FSW reached has increased with introduction of the “Young Sisters programme.” There are no clear differences in pattern of sex work across settings. Almost all women report condom use with clients at last sex (95%); however, consistent condom use with clients in the last month varies from 52% to 95% by site. Knowledge of HIV‐positive status has increased from 48 to 78% between 2011 and 2016, as has prevalence of ART use among diagnosed women (29 to 67%). Although subject to uncertainty, modelling suggests that 70% (90% range: 32%, 93%) of all new infections in Zimbabwe from 2010 are directly or indirectly attributable to transmission via sex work.

Conclusions

It is feasible to increase coverage and impact of sex work programming through community‐led scale‐up of evidence‐based interventions. Eliminating transmission through commercial sex would likely have a substantial impact on new infections occurring more widely across Zimbabwe.

Mapping and characterising areas with high levels of HIV transmission in sub-Saharan Africa: A geospatial analysis of national survey data

BACKGROUND

In the generalised epidemics of sub-Saharan Africa (SSA), human immunodeficiency virus (HIV) prevalence shows patterns of clustered micro-epidemics. We mapped and characterised these high-prevalence areas for young adults (15-29 years of age), as a proxy for areas with high levels of transmission, for 7 countries in Eastern and Southern Africa: Kenya, Malawi, Mozambique, Tanzania, Uganda, Zambia, and Zimbabwe.

METHODS AND FINDINGS

We used geolocated survey data from the most recent United States Agency for International Development (USAID) demographic and health surveys (DHSs) and AIDS indicator surveys (AISs) (collected between 2008-2009 and 2015-2016), which included about 113,000 adults-of which there were about 53,000 young adults (27,000 women, 28,000 men)-from over 3,500 sample locations. First, ordinary kriging was applied to predict HIV prevalence at unmeasured locations. Second, we explored to what extent behavioural, socioeconomic, and environmental factors explain HIV prevalence at the individual- and sample-location level, by developing a series of multilevel multivariable logistic regression models and geospatially visualising unexplained model heterogeneity. National-level HIV prevalence for young adults ranged from 2.2% in Tanzania to 7.7% in Mozambique. However, at the subnational level, we found areas with prevalence among young adults as high as 11% or 15% alternating with areas with prevalence between 0% and 2%, suggesting the existence of areas with high levels of transmission Overall, 15.6% of heterogeneity could be explained by an interplay of known behavioural, socioeconomic, and environmental factors. Maps of the interpolated random effect estimates show that environmental variables, representing indicators of economic activity, were most powerful in explaining high-prevalence areas. Main study limitations were the inability to infer causality due to the cross-sectional nature of the surveys and the likely under-sampling of key populations in the surveys.

CONCLUSIONS

We found that, among young adults, micro-epidemics of relatively high HIV prevalence alternate with areas of very low prevalence, clearly illustrating the existence of areas with high levels of transmission. These areas are partially characterised by high economic activity, relatively high socioeconomic status, and risky sexual behaviour. Localised HIV prevention interventions specifically tailored to the populations at risk will be essential to curb transmission. More fine-scale geospatial mapping of key populations,-such as sex workers and migrant populations-could help us further understand the drivers of these areas with high levels of transmission and help us determine how they fuel the generalised epidemics in SSA.

The Ashodaya PrEP project: Lessons and implications for scaling up PrEP from a community-led demonstration project among female sex workers in Mysore, India

To inform PrEP roll out, Ashodaya Samithi, a sex workers' collective, conducted a community-led prospective demonstration project among female sex workers in Mysore and Mandya, India. Following a community preparedness phase and pre-screening, participants were recruited for clinical screening and enrolment, provided PrEP as part of combination HIV prevention, and followed for 16 months. Adherence was measured by self-reported pill intake and by tenofovir blood level testing among a subset of participants. Of the 647 participants enrolled, 640 completed follow-up. Condom use remained stable and no HIV seroconversions occurred. Self-reported daily PrEP intake over the last month was 97.97% at the end of the study. Tenofovir blood levels >40 ng/mL (consistent with steady state dosing) were detected among 80% (n = 68/85) and 90.48% (n = 76/84) of participants at month 3 and 6, respectively. Our study holds important insights for rolling out PrEP in community settings as part of targeted HIV prevention interventions.

Micro-planning at scale with key populations in Kenya: Optimising peer educator ratios for programme outreach and HIV/STI service utilisation

Peer education with micro-planning has been integral to scaling up key population (KP) HIV/STI programmes in Kenya since 2013. Micro-planning reinforces community cohesion within peer networks and standardizes programme inputs, processes and targets for outreach, including peer educator (PE) workloads. We assessed programme performance for outreach-in relation to the mean number of KPs for which one PE is responsible (KP:PE ratio)-and effects on HIV/STI service utilisation. Quarterly programmatic monitoring data were analysed from October 2013 to September 2016 from implementing partners working with female sex workers (FSWs) and men who have sex with men (MSM) across the country. All implementing partners are expected to follow national guidelines and receive micro-planning training for PEs with support from a Technical Support Unit for KP programmes. We examined correlations between KP:PE ratios and regular outreach contacts, condom distribution, risk reduction counselling, STI screening, HIV testing and violence reporting by KPs. Kenya conducted population size estimates (PSEs) of KPs in 2012. From 2013 to 2016, KP programmes were scaled up to reach 85% of FSWs (PSE 133,675) and 90% of MSM (PSE 18,460). Overall, mean KP:PE ratios decreased from 147 to 91 for FSWs, and from 79 to 58 for MSM. Lower KP:PE ratios, up to 90:1 for FSW and 60:1 for MSM, were significantly associated with more regular outreach contacts (p<0.001), as well as more frequent risk reduction counselling (p<0.001), STI screening (p<0.001) and HIV testing (p<0.001). Condom distribution and reporting of violence by KPs did not differ significantly between the two groups over all time periods. Micro-planning with adequate KP:PE ratios is an effective approach to scaling up HIV prevention programmes among KPs, resulting in high levels of programme uptake and service utilisation.

Feasible, Efficient and Necessary, without Exception - Working with Sex Workers Interrupts HIV/STI Transmission and Brings Treatment to Many in Need

BACKGROUND AND OVERVIEW

High rates of partner change in sex work-whether in professional, 'transactional' or other context-disproportionately drive transmission of HIV and other sexually transmitted infections. Several countries in Asia have demonstrated that reducing transmission in sex work can reverse established epidemics among sex workers, their clients and the general population. Experience and emerging research from Africa reaffirms unprotected sex work to be a key driver of sexual transmission in different contexts and regardless of stage or classification of HIV epidemic. This validation of the epidemiology behind sexual transmission carries an urgent imperative to realign prevention resources and scale up effective targeted interventions in sex work settings, and, given declining HIV resources, to do so efficiently. Eighteen articles in this issue highlight the importance and feasibility of such interventions under four themes: 1) epidemiology, data needs and modelling of sex work in generalised epidemics; 2) implementation science addressing practical aspects of intervention scale-up; 3) community mobilisation and 4) the treatment cascade for sex workers living with HIV.

CONCLUSION

Decades of empirical evidence, extended by analyses in this collection, argue that protecting sex work is, without exception, feasible and necessary for controlling HIV/STI epidemics. In addition, the disproportionate burden of HIV borne by sex workers calls for facilitated access to ART, care and support. The imperative for Africa is rapid scale-up of targeted prevention and treatment, facilitated by policies and action to improve conditions where sex work takes place. The opportunity is a wealth of accumulated experience working with sex workers in diverse settings, which can be tapped to make up for lost time. Elsewhere, even in countries with strong interventions and services for sex workers, an emerging challenge is to find ways to sustain them in the face of declining global resources.

Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review

Background

Female sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation.

Methods

In November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community.

Results

Of 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations.

Conclusions

Most FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.

Halting and reversing HIV epidemics in Asia by interrupting transmission in sex work: experience and outcomes from ten countries

HIV epidemics spread rapidly through Asian sex work networks two decades ago under conditions of high vulnerability, low condom use, intact male foreskins and ulcerative STIs. Experiences implementing interventions to prevent transmission in sex work in ten Asian countries were reviewed. All report increasing condom use trends in sex work. In the seven countries where condom use exceeds 80%, surveillance and other data indicate declining HIV trends or low and stable HIV prevalence with declining STI trends. All four countries with national-level HIV declines among sex workers have also documented significant HIV declines in the general population. While all interventions in sex work included outreach, condom programing and STI services, the largest declines were found in countries that implemented structural interventions on a large scale. Thailand and Cambodia, having controlled transmission early, are closest to providing universal access to HIV care, support and treatment and are exploring HIV elimination strategies.

Comparison of commercially available target enrichment methods for next-generation sequencing

Isolating high-priority segments of genomes greatly enhances the efficiency of next-generation sequencing (NGS) by allowing researchers to focus on their regions of interest. For the 2010-11 DNA Sequencing Research Group (DSRG) study, we compared outcomes from two leading companies, Agilent Technologies (Santa Clara, CA, USA) and Roche NimbleGen (Madison, WI, USA), which offer custom-targeted genomic enrichment methods. Both companies were provided with the same genomic sample and challenged to capture identical genomic locations for DNA NGS. The target region totaled 3.5 Mb and included 31 individual genes and a 2-Mb contiguous interval. Each company was asked to design its best assay, perform the capture in replicates, and return the captured material to the DSRG-participating laboratories. Sequencing was performed in two different laboratories on Genome Analyzer IIx systems (Illumina, San Diego, CA, USA). Sequencing data were analyzed for sensitivity, specificity, and coverage of the desired regions. The success of the enrichment was highly dependent on the design of the capture probes. Overall, coverage variability was higher for the Agilent samples. As variant discovery is the ultimate goal for a typical targeted sequencing project, we compared samples for their ability to sequence single-nucleotide polymorphisms (SNPs) as a test of the ability to capture both chromosomes from the sample. In the targeted regions, we detected 2546 SNPs with the NimbleGen samples and 2071 with Agilent's. When limited to the regions that both companies included as baits, the number of SNPs was ∼1000 for each, with Agilent and NimbleGen finding a small number of unique SNPs not found by the other.

Combating human trafficking in the sex trade: can sex workers do it better?

BACKGROUND

The dominant anti-trafficking paradigm conflates trafficking and sex work, denying evidence that most sex workers choose their profession and justifying police actions that disrupt communities, drive sex workers underground and increase vulnerability.

METHODS

We review an alternative response to combating human trafficking and child prostitution in the sex trade, the self-regulatory board (SRB) developed by Durbar Mahila Samanwaya Committee (DMSC, Sonagachi).

RESULTS

DMSC-led interventions to remove minors and unwilling women from sex work account for over 80% of successful 'rescues' reported in West Bengal. From 2009 through 2011, 2195 women and girls were screened by SRBs: 170 (7.7%) minors and 45 (2.1%) unwilling adult women were assisted and followed up. The remaining 90.2% received counselling, health care and the option to join savings schemes and other community programmes designed to reduce sex worker vulnerability. Between 1992 and 2011 the proportion of minors in sex work in Sonagachi declined from 25 to 2%.

CONCLUSIONS

With its universal surveillance of sex workers entering the profession, attention to rapid and confidential intervention and case management, and primary prevention of trafficking-including microcredit and educational programmes for children of sex workers-the SRB approach stands as a new model of success in anti-trafficking work.

Impact of high-risk sex and focused interventions in heterosexual HIV epidemics: a systematic review of mathematical models

Background

The core-group theory of sexually transmitted infections suggests that targeting prevention to high-risk groups (HRG) could be very effective. We aimed to quantify the contribution of heterosexual HRGs and the potential impact of focused interventions to HIV transmission in the wider community.

Methods

We systematically identified studies published between 1980 and 2011. Studies were included if they used dynamical models of heterosexual HIV transmission, incorporated behavioural heterogeneity in risk, and provided at least one of the following primary estimates in the wider community (a) the population attributable fraction (PAF) of HIV infections due to HRGs, or (b) the number per capita or fraction of HIV infections averted, or change in HIV prevalence/incidence due to focused interventions.

Findings

Of 267 selected articles, 22 were included. Four studies measured the PAF, and 20 studies measured intervention impact across 265 scenarios. In low-prevalence epidemics (≤5% HIV prevalence), the estimated impact of sex-worker interventions in the absence of risk compensation included: 6–100% infections averted; 0.9–6.2 HIV infections averted per 100,000 adults; 11–94% and 4–47% relative reduction in prevalence and incidence respectively. In high-prevalence epidemics (>5% HIV prevalence), sex-worker interventions were estimated to avert 6.8–40% of HIV infections and up to 564 HIV infections per 100,000 adults, and reduce HIV prevalence and incidence by 13–27% and 2–14% respectively. In both types of epidemics, greater heterogeneity in HIV risk was associated with a larger impact on the fraction of HIV infections averted and relative reduction in HIV incidence.

Conclusion

Focused interventions, as estimated by mathematical models, have the potential to reduce HIV transmission in the wider community across low- and high-prevalence regions. However, considerable variability exists in estimated impact, suggesting that a targeted approach to HIV prevention should be tailored to local epidemiological context.

Sex worker-led structural interventions in India: a case study on addressing violence in HIV prevention through the Ashodaya Samithi collective in Mysore

Background & objectives:

Structural interventions have the capacity to improve the outcomes of HIV/AIDS interventions by changing the social, economic, political or environmental factors that determine risk and vulnerability. Marginalized groups face disproportionate barriers to health, and sex workers are among those at highest risk of HIV in India. Evidence in India and globally has shown that sex workers face violence in many forms ranging from verbal, psychological and emotional abuse to economic extortion, physical and sexual violence and this is directly linked to lower levels of condom use and higher levels of sexually transmitted infections (STIs), the most critical determinants of HIV risk. We present here a case study of an intervention that mobilized sex workers to lead an HIV prevention response that addresses violence in their daily lives.

Methods:

This study draws on ethnographic research and project monitoring data from a community-led structural intervention in Mysore, India, implemented by Ashodaya Samithi. Qualitative and quantitative data were used to characterize baseline conditions, community responses and subsequent outcomes related to violence.

Results:

In 2004, the incidence of reported violence by sex workers was extremely high (> 8 incidents per sex worker, per year) but decreased by 84 per cent over 5 years. Violence by police and anti-social elements, initially most common, decreased substantially after a safe space was established for sex workers to meet and crisis management and advocacy were initiated with different stakeholders. Violence by clients, decreased after working with lodge owners to improve safety. However, initial increases in intimate partner violence were reported, and may be explained by two factors: (i) increased willingness to report such incidents; and (ii) increased violence as a reaction to sex workers’ growing empowerment. Trafficking was addressed through the establishment of a self-regulatory board (SRB). The community's progressive response to violence was enabled by advancing community mobilization, ensuring community ownership of the intervention, and shifting structural vulnerabilities, whereby sex workers increasingly engaged key actors in support of a more enabling environment.

Interpretation & conclusions:

Ashodaya's community-led response to violence at multiple levels proved highly synergistic and effective in reducing structural violence.

Quality assurance and quality improvement using supportive supervision in a large-scale STI intervention with sex workers, men who have sex with men/transgenders and injecting-drug users in India

Background

Documentation of the long-term impact of supportive supervision using a monitoring tool in STI intervention with sex workers, men who have sex with men and injection-drug users is limited. The authors report methods and results of continued quality monitoring in a large-scale STI services provided as a part of a broader HIV-prevention package in six Indian states under Avahan, the India AIDS Initiative.

Methodology

Guidelines and standards for STI services, and a supportive supervisory tool to monitor the quality were developed for providing technical support to STI component of large-scale HIV-prevention intervention through 372 project-supported STI clinics. The tool contained 80 questions to track the quality of STI services provided on a five-point scoring scale in five performance areas: coverage, quality of clinic and services, referral networks, community involvement and technical support.

Results

The tool was applied to different STI clinics during supportive supervision visits conducted once in every 3 months to assess quality, give immediate feedback and develop a quality score. A total of 292 clinics managed by seven lead implementing partners in six Indian states were covered in 15 quarters over 45 months. Overall quality indicators for the five performance areas showed a three- to sevenfold improvement over the period.

Conclusion

It was possible to improve quality over the long-term in STI interventions for sex workers, men who have sex with men and injection-drug users using an interactive and comprehensive supportive supervision tool which gives on-the-spot feedback. However, such an effort is time-consuming and resource-intensive, and needs a structured approach.

Control of sexually transmitted infections and prevention of HIV transmission: mending a fractured paradigm

Control of sexually transmitted infections (STIs) is feasible, leads to improved sexual and reproductive health and contributes to preventing HIV transmission. The most advanced HIV epidemics have developed under conditions of poor STI control, particularly where ulcerative STIs were prevalent. Several countries that have successfully controlled STIs have documented stabilization or reversal of their HIV epidemics. STI control is a public health outcome measured by reduced incidence and prevalence. The means to achieve this include: (i) targeting and outreach to populations at greatest risk; (ii) promoting and providing condoms and other means of prevention; (iii) effective clinical interventions; (iv) an enabling environment; and (v) reliable data. Clinical services include STI case management, screening and management of STIs in sex partners. Syndromic case management is effective for most symptomatic curable STIs and screening strategies exist to detect some asymptomatic infections. Presumptive epidemiologic treatment of sex partners and sex workers complement efforts to interrupt transmission and reduce prevalence. Clinical services alone are insufficient for control since many people with STIs do not attend clinics. Outreach and peer education have been effectively used to reach such populations. STI control requires effective interventions with core populations whose rates of partner change are high enough to sustain transmission. Effective, appropriate targeting is thus necessary and often sufficient to reduce prevalence in the general population. Such efforts are most effective when combined with structural interventions to ensure an enabling environment for prevention. Reliable surveillance and related data are critical for designing and evaluating interventions and for assessing control efforts.

Sex work and the 2010 FIFA World Cup: time for public health imperatives to prevail

Background

Sex work is receiving increased attention in southern Africa. In the context of South Africa's intense preparation for hosting the 2010 FIFA World Cup, anxiety over HIV transmission in the context of sex work has sparked debate on the most appropriate legal response to this industry.

Discussion

Drawing on existing literature, the authors highlight the increased vulnerability of sex workers in the context of the HIV pandemic in southern Africa. They argue that laws that criminalise sex work not only compound sex workers' individual risk for HIV, but also compromise broader public health goals. International sporting events are thought to increase demand for paid sex and, particularly in countries with hyper-endemic HIV such as South Africa, likely to foster increased HIV transmission through unprotected sex.

Summary

The 2010 FIFA World Cup presents a strategic opportunity for South Africa to respond to the challenges that the sex industry poses in a strategic and rights-based manner. Public health goals and growing evidence on HIV prevention suggest that sex work is best approached in a context where it is decriminalised and where sex workers are empowered. In short, the authors argue for a moratorium on the enforcement of laws that persecute and victimise sex workers during the World Cup period.

Using mathematical modelling to estimate the impact of periodic presumptive treatment on the transmission of sexually transmitted infections and HIV among female sex workers

BACKGROUND

In settings with poor sexually transmitted infection (STI) control in high-risk groups, periodic presumptive treatment (PPT) can quickly reduce the prevalence of genital ulcers, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). However, few studies have assessed the impact on HIV. Mathematical modelling is used to quantify the likely HIV impact of different PPT interventions.

METHODS

A mathematical model was developed to project the impact of PPT on STI/HIV transmission amongst a homogeneous population of female sex workers (FSWs) and their clients. Using data from Johannesburg, the impact of PPT interventions with different coverages and PPT frequencies was estimated. A sensitivity analysis explored how the projections were affected by different model parameters or if the intervention was undertaken elsewhere.

RESULTS

Substantial decreases in NG/CT prevalence are achieved among FSWs receiving PPT. Although less impact is achieved among all FSWs, large decreases in NG/CT prevalence (>50%) are possible with >30% coverage and supplying PPT every month. Higher PPT frequencies achieve little additional impact, whereas improving coverage increases impact until NG/CT becomes negligible. The impact on HIV incidence is smaller, longer to achieve, and depends heavily on the assumed NG/CT cofactors, whether they are additive, the assumed STI/HIV transmission probabilities and STI durations. Greater HIV impact can be achieved in settings with lower sexual activity (except at high coverage), less STI treatment or high prevalences of Haemophilus ducreyi.

CONCLUSIONS

Despite the model's assumption of homogeneous risk behaviour probably resulting in optimistic projections, and uncertainty in STI cofactors and transmission probabilities, projections suggest PPT interventions with sufficient coverage (> or = 40%) and follow-up (> or = 2 years) could noticeably decrease the HIV incidence (>20%) among FSW populations with inadequate STI treatment.

Pursuing scale and quality in STI interventions with sex workers: initial results from Avahan India AIDS Initiative

BACKGROUND

Migration, population mobility, and sex work continue to drive sexually transmitted epidemics in India. Yet interventions targeting high incidence networks are rarely implemented at sufficient scale to have impact. India AIDS Initiative (Avahan), funded by the Bill and Melinda Gates Foundation, is scaling up interventions with sex workers (SWs) and other high risk populations in India's six highest HIV prevalence states.

METHODS

Avahan resources are channelled through state level partners (SLPs) to local level non-governmental organisations (NGOs) who organise outreach, community mobilisation, and dedicated clinics for SWs. These clinics provide services for sexually transmitted infections (STIs) including Condom Promotion, syndromic case management, regular check-ups, and treatment of asymptomatic infections. SWs take an active role in service delivery. STI capacity building support functions on three levels. A central capacity building team developed guidelines and standards, trains state level STI coordinators, monitors outcomes, and conducts operations research. Standards are documented in an Avahan-wide manual. State level STI coordinators train NGO clinic staff and conduct supervision of clinics based on these standards and related quality monitoring tools. Clinic and outreach staff report on indicators that guide additional capacity building inputs.

RESULTS

In 2 years, clinics with community outreach for SWs have been established in 274 settings covering 77 districts. Mapping and size estimation have identified 187,000 SWs. In a subset of four large states covered by six SLPs (183,000 estimated SWs, 65 districts), 128,326 (70%) of the SWs have been contacted through peer outreach and 74,265 (41%) have attended the clinic at least once. A total of 127,630 clinic visits have been reported, an increasing proportion for recommended routine check ups. Supervision and monitoring facilitate standardisation of services across sites.

CONCLUSION

Targeted HIV/STI interventions can be brought to scale and standardised given adequate capacity building support. Intervention coverage, service utilisation, and quality are key parameters that should be monitored and progressively improved with active involvement of SWs themselves.

STI declines among sex workers and clients following outreach, one time presumptive treatment, and regular screening of sex workers in the Philippines

OBJECTIVES

This intervention linked research aimed to reduce prevalence of Neisseria gonorrhoeae (Ng) and Chlamydia trachomatis (Ct) among female sex workers by means of one round of presumptive treatment (PT), and improved prevention and screening services.

METHODS

A single round of PT (azithromycin 1 g) was given to all female sex workers reached during a 1 month period of enhanced outreach activity. Routine sexually transmitted infection (STI) screening services were successfully introduced for two groups of unregistered sex workers who work in brothels (BSWs) and on the street (SSWs). No changes were made to existing screening methods for registered sex workers (RSWs) or lower risk guest relations officers (GROs). Cross sectional prevalence of Ng and Ct was measured by PCR on three occasions, and stratified by type of sex work. Ng/Ct prevalence was assessed twice in clients of BSWs.

RESULTS

Prevalence of Ng and/or Ct at baseline, 1 month post-PT, and 7 months post-PT was BSWs: 52%, 27%, 23%; SSWs: 41%, 25%, 28%; RSWs: 36%, 26%, 34%; GROs: 20%, 6%, 24%, respectively. Ng/Ct declines 1 month post-PT were significant for all groups. 6 months later prevalence remained low for BSWs (p<0.001), and SSWs (p = 0.05), but had returned to pre-intervention levels for the other groups. Prevalence of Ng/Ct among clients of BSWs declined from 28% early in the intervention to 15% (p = 0.03) 6 months later.

CONCLUSIONS

In this commercial sex setting, one round of PT had a short term impact on Ng/Ct prevalence. Longer term maintenance of STI control requires ongoing access to effective preventive and curative services.

The prevention and management of congenital syphilis: an overview and recommendations

The continued occurrence of congenital syphilis is an indictment of the inadequate antenatal care services and poor quality of programmes to control sexually transmitted infections. More than 1 million infants are born with congenital syphilis each year. Despite national policies on antenatal testing and the widespread use of antenatal services, syphilis screening is still implemented only sporadically in many countries, leaving the disease undetected and untreated among many pregnant women. The weak organization of services and the costs of screening are the principal obstacles facing programmes. Decentralization of antenatal syphilis screening programmes, on-site testing and immediate treatment can reduce the number of cases of congenital syphilis. Antenatal syphilis screening and treatment programmes are as cost effective as many existing public health programmes, e.g. measles immunization. Diagnosis of congenital syphilis is problematic since more than half of all infants are asymptomatic, and signs in symptomatic infants may be subtle and nonspecific. Newer diagnostic tests such as enzyme immunoassays, polymerase chain reaction and immunoblotting have made diagnosis more sensitive and specific but are largely unavailable in the settings where they are most needed. Guidelines developed for better-resourced settings are conservative and err on the side of overtreatment. They are difficult to implement in, or inappropriate for, poorly-resourced settings because of the lack of investigative ability and the pressure on health facilities to discharge infants early. This paper offers recommendations for treating infants, including an approach based solely on maternal serological status and clinical signs of syphilis in the infant.

Intrauterine Contraceptive Devices and Risk of Pelvic Inflammatory Disease

The intrauterine contraceptive device (IUD) is highly effective and cost-effective. IUD use is limited in some regions, however, due to concerns about increased risk of pelvic inflammatory disease (PID) and subsequent complications such as infertility and ectopic pregnancy. Recent reviews suggest that the overall risk of PID with modern IUDs is lower than previously thought, at least in regions with a low prevalence of sexually transmitted infections (STIs). Risk of PID may be higher, however, in places where gonorrhoea and chlamydia are prevalent, where screening for STIs is limited and where aseptic conditions for insertion are difficult to ensure. A World Health Organization multi-centre study and other studies have confirmed regional differences in STI prevalence, and the WHO study established that PID risk is temporally related to IUD insertion procedures. Studies of the effectiveness of antibiotic prophylaxis to prevent infectious complications are inconclusive due at least in part to use of sub-therapeutic regimens for pathogens commonly implicated in PID. In summary, the IUD can be safe and effective if inserted under aseptic conditions in women free of cervical infection. Further study is needed to define appropriate standards of care for IUD insertion where STI prevalence is high and ability to rule out infection is limited. Even with safe insertion, IUD promotion in areas of high STI/HIV prevalence must address women's needs for dual protection from infection and unwanted pregnancy.

Sexually transmitted infections: prevention and management

In the early 21st century, STI and HIV have been linked inextricably. Although the focus of this article is STI, some discussion on the diagnosis and management of individuals with HIV infection is necessary. The history of HIV diagnosis in the workplace is checkered. The authors have seen cases of prospective workers being subjected to HIV testing without their knowledge as part of a pre-employment medical examination. If the test came back positive, the men were told that they would not be employed without explanation. This approach is a breech of the human rights of the individual being tested and cannot be condoned. Any HIV testing must be done with the full and informed consent of the individual, with counseling given before and after testing to enable individuals with HIV infection to seek care and protect their families and to give individuals without HIV infection counseling on risk reduction. Men and women who present with an STI are at risk for HIV infection. With increasing options for management and secondary prevention, it is important to recognize people who are at risk. This identification should be done through HIV VCT. The location, funding, and supervision of VCT sites related to workplace populations should be a subject for serious debate. Although fears of mass layoffs after HIV testing largely have been unfounded, it is natural for workers to be fearful, unless there is a clearly articulated policy stating that the company observes and enforces nondiscriminatory practices. The workplace examples show that syndromic STI management, allied to comprehensive prevention programs, can have a genuine and measurable impact on STI prevalence. The potential interventions and partners are listed in Table 2. A community-based, randomized study in Tanzania showed that the institution of a well-managed STI syndromic management program can reduce HIV incidence by up to 40%, in the context of a rising HIV epidemic. Presumptive STI treatment for female sex workers (see Box 1) may prove useful as a short-term measure to reduce high STI prevalence rates while more sustainable preventive and curative services are established. The laboratory diagnosis of STIs remains problematic in the face of commonly available technologies of limited sensitivity and specificity and often substandard quality-assurance practices. For these and other reasons, syndromic management became the recommended strategy for treating STIs. The availability of rapid, accurate, and inexpensive diagnostics, especially for cervical infections for women, would alter management recommendations. Work is being done by the WHO and others to develop and assess low-cost diagnostics. Managing STIs and altering the behavior that leads to STIs are essential elements of any HIV prevention and management program. The issues surrounding a practical, compassionate, and comprehensive HIV program can be difficult. Numerous publications exist to help program managers navigate these issues and appropriately tailor a program to the needs of individual organizations. Some of these publications are listed in the next section.

Sexually transmitted infection control with sex workers: regular screening and presumptive treatment augment efforts to reduce risk and vulnerability

Sex workers have high rates of sexually transmitted infections (STIs), many of them easily curable with antibiotics. STIs as co-factors and frequent unprotected exposure put sex workers at high risk of acquiring HIV and transmitting STIs and HIV to clients and other partners. Eliminating STIs reduces the efficiency of HIV transmission in the highest-risk commercial sex contacts--those where condoms are not used. This paper reviews two STI treatment strategies that have proven effective with female sex workers and their clients. 1) Clinical services with regular screening have reported increases in condom use and reductions in STI and HIV prevalence. Such services include a strong peer education and empowerment component, emphasize consistent condom use, provide effective treatment for both symptomatic and asymptomatic STIs, and begin to address larger social, economic and human rights issues that increase vulnerability and risk. 2) Presumptive treatment of sex workers, a form of epidemiologic treatment, can be an effective short-term measure to rapidly reduce STI rates. Once prevalence rates are brought down, however, other longer-term strategies are required. Effective preventive and curative STI services for sex workers are key to the control of sexually transmitted infections, including HIV, and are highly synergistic with other HIV prevention efforts.

Eradicating chancroid

Genital ulcers are important cofactors of HIV transmission in the countries most severely affected by HIV/AIDS. Chancroid is a common cause of genital ulcer in all 18 countries where adult HIV prevalence surpasses 8% and is rare in countries with low-level HIV epidemics. Haemophilus ducreyi, the causative organism of chancroid, is biologically vulnerable and occupies a precarious epidemiological niche. Both simple, topical hygiene and male circumcision greatly reduce risk of infection and several classes of antibiotics--some of which can be administered in single-dose treatment regimens--provide rapid cure. H. ducreyi depends on sexual networks with high rates of partner change for its survival, thriving in environments characterized by male mobility and intensive commercial sex activity. Elimination of H. ducreyi infection from vulnerable groups results in disappearance of chancroid from the larger community. Once endemic in Europe and North America, chancroid began a steady decline early in the twentieth century, well before the discovery of antibiotics. Social changes--resulting in changing patterns of commercial sex--probably disrupted the conditions needed to sustain chancroid as an endemic disease. Sporadic outbreaks are now easily controlled when effective curative and preventive services are made available to sex workers and their clients. More recently, chancroid prevalence has declined markedly in countries such as the Philippines. Senegal, and Thailand, a development that may contribute to stabilization of the HIV epidemics in these countries. Eradication of chancroid is a feasible public health objective. Protecting sex workers and their clients from exposure to sexually transmitted diseases (STDs) and improving curative services for STDs are among the proven strategies that could be employed.

A randomised study of allogeneic transplantation with stem cells from blood or bone marrow

Sixty-one consecutive adult patients with leukaemia, primary myelofibrosis or myelodysplastic syndrome with an HLA-identical or one antigen mismatched family donor were randomised to allogeneic transplantation with PBPC or BM. Progenitor cells were mobilised into the blood by giving the donors 10 microg/kg/day G-CSF subcutaneously for 5-7 days. G-CSF was not given to patients after transplantation. The time to neutrophil counts >0.5 x 109/l was 17 days (95% CI 15.2-18.8 days) in the PBPC group compared to 23 (95% CI 20.3-25.7 days) in the BM group (P = 0.0005). The time to platelet counts >20 x 109/l was 13 days (95% CI 11.7-14.3 days) in the PBPC group and 21 days (95% CI 18.7-23.3 days) in the BM group (P = 0.0005). Acute GVHD of grades II-IV developed in six patients transplanted with PBPC and three patients transplanted with BM. The numbers of patients with chronic GVHD were 15 and 8, respectively. Transplant-related mortality and leukaemia-free survival showed no significant differences. Transplantation with PBPC appears preferable for the recipient due to faster neutrophil and platelet recovery. However, the final conclusion can not be drawn before long-term results on chronic GVHD and relapse incidence in longer randomised trials are available.

Characteristics of haemopoietic progenitor cells related to CD34 epitope class expression

Haemopoietic progenitor cells (HPCs) express the CD34 molecule, a heavily glycosylated transmembrane protein displaying three main classes of epitopes. The CD34 epitope class expression may vary between different subsets of HPCs. The aim of this study was to characterise the subsets of HPCs expressing CD34 class II and III epitopes. The cells were studied for coexpression of activation-, lineage- and adhesion-associated molecules, and their clonogenic ability and morphological features were examined. CD34+ HPCs expressing class III epitopes outnumbered those expressing class II. Class III expressing HPCs were enriched for CFU-GM and BFU-E and cells coexpressing CD13, CD33, c-kit and CD71 compared to class II expressing HPCs. CD34+ cells exclusively expressing class III epitopes uniformly displayed CD13 and CD33; they had a high clonogenic capacity and morphological characteristics of promyelocytes and myelocytes. The data show that class III epitopes are distributed more broadly on CD34+ HPCs than are class II epitopes, and that lack of class II epitopes is confined to CD34+ HPCs at a late stage of myeloid differentiation. The higher number of class III expressing HPCs coexpressing c-kit and CD71 suggests that these cells exhibit a higher proliferative or differential potential than do HPCs expressing class II epitopes.

Evidence of declining STD prevalence in a South African mining community following a core-group intervention

OBJECTIVES

To reduce the prevalence of curable sexually transmitted diseases (STDs) in a South African mining community through provision of STD treatment services, including periodic presumptive treatment and prevention education to a core group of high-risk women living in areas around the mines.

METHODS

Women at high risk for STDs attended a mobile clinic monthly for examination and counseling, and were treated presumptively for bacterial STDs with a directly observed 1-g dose of azithromycin. Gonococcal and chlamydial infection rates were measured by urine ligase chain reaction, and genital ulcers were assessed by clinical examination. Changes in STD prevalence among local miners were assessed through comparison of prevalence in two cross-sectional samples of miners taken 9 months apart, and through routine disease surveillance at mine health facilities.

RESULTS

During the first 9 months of the intervention, 407 women used the services. Baseline prevalence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in women was 24.9%; 9.7% of these women had clinical evidence of genital ulcer disease (GUD). The proportion of women with incident gonococcal or chlamydial infections at the first monthly return visit (69% follow-up rate) was 12.3%, and genital ulcers were found in 4.4% of these women. In the miner population, the prevalence of N gonorrhoeae and/or C trachomatis was 10.9% at baseline and 6.2% at the 9-month follow-up examination (P<0.001). The prevalence of GUD by clinical examination was 5.8% at baseline and 1.3% at follow-up examination (P< 0.001). Rates of symptomatic STDs seen at mine health facilities decreased among miners in the intervention area compared with miners living farther from the site and with less exposure to the project.

DISCUSSION

Provision of STD treatment services to a core group of high-risk women may significantly reduce their burden of disease, and may contribute to a reduction in community STD prevalence. In the absence of sensitive and affordable screening tests for STDs in women, periodic presumptive treatment coupled with prevention education is a feasible approach to providing STD services in this population.

Thrombopoietin combined with early-acting growth factors effectively expands human hematopoietic progenitor cells in vitro

Thrombopoietin (TPO) is established as a powerful stimulant of megakaryocyte differentiation and platelet production both in vivo and in vitro. In preparation for future transplantation of ex vivo expanded CD34+ hematopoietic progenitor cells (HPCs), we have examined the in vitro effect of TPO on cultures of HPC when combined with other early-acting hematopoietic growth factors (GFs) in an attempt to decrease post-transplant thrombocytopenia and accelerate engraftment. By adding TPO to all possible combinations of GM-CSF, IL-3, and c-kit ligand (CKL) in a suspension culture system, we found a significant increase in both relative and absolute numbers of cells in cultures containing TPO of the megakaryocytic lineage and CD34+ cells after 14 days of culture. The most efficient GF combinations for expansion of cell populations of the megakaryocytic lineage and HPCs were TPO, GM-CSF, and CKL, which increased the number of cells of the megakaryocytic lineage 78 fold and the number of CD34+ cells 1.8 fold. The number of CD34+ cells decreased in the cultures containing GM-CSF and CKL with no TPO present, and the number of cells of the megakaryocytic lineage was increased merely 27 fold. Based on our findings, we suggest adding cells from HPCs expanded in cultures containing TPO, GM-CSF, and CKL to unexpanded stem cells for stem cell transplantation.

The use of epidemiologic mass treatment and syndrome management for sexually transmitted disease control

BACKGROUND

Epidemiologic mass treatment and syndrome management are two sexually transmitted disease (STD) control strategies that are receiving increased attention internationally. The former is a population-based intervention, whereas the latter attempts to improve the quality and efficiency of clinic-based STD case management.

METHODS

The published literature on these subjects was reviewed.

RESULTS

Epidemiologic mass treatment refers to treatment of whole communities (mass treatment) or high-risk subgroups within communities (targeted presumptive treatment) based on high STD prevalence rates. Syndrome management overcomes many obstacles to provision of quality STD case management by basing treatment decisions on recognition of easily identifiable syndromes. Experience with application of these strategies is summarized, and their possible use as STD control measures in communities with similar conditions is discussed.

CONCLUSIONS

Epidemiologic mass treatment may be an effective approach to rapidly reduce STD transmission in high prevalence communities, especially when high-risk core groups are effectively reached. Once high prevalence rates are brought down, however, longer term strategies, including improved STD case management, are essential to maintain reduced rates.

Indicators and the measurement of STD case management in developing countries. STD PI6&7 Working Group

The paper reviews methodologies for measuring quality of sexually transmitted disease (STD) case management through facility based assessments. These include observations and interviews of providers, as promoted by the World Health Organization's Global Programme on AIDS, and some of the viable alternatives including patient exit interviews, mystery patients, record review and patient encounter forms with supervisory visits. The paper concludes that the alternative approaches are feasible in resource poor settings and that they provide crucial data for evaluation and continued program development.

CD34 molecule epitope distribution on cells of haematopoietic origin

The CD34 molecule belongs to the mucin membrane molecule family and is expressed on virtually all normal haematopoietic progenitor cells (HPC). Due to its heavy glycosylation, several different epitopes exist on the molecule. Based on the sensitivity of the glycosylated molecule to degradation with a glycoprotease from Pasteurella haemolytica and neuraminidase, three classes of epitopes have been identified. The class I and II epitopes are probably related to the glycosylated part of the molecule while class III epitopes are core protein related. It has been known for some time that CD34 class I epitopes are absent on CD34 molecules expressed on high endothelial venules. Here we review recent observations that expression of both class I and II epitopes, but not class III epitopes, is impaired on mature myeloid CD34-pos. HPC while no diverse class epitope expression was observed on immature HPC. In addition, cells from patients with CD34-pos. acute myeloid leukaemia of FAB classification M4-M5, i.e., leukaemic blast cells of relatively mature morphologic phenotype, also express less class I and II epitopes than class III epitopes. It therefore seems that HPC maturation and class I and II epitope deprivation are concomitant events and that CD34 class I and II epitopes are lost prior to downregulation of the CD34 molecule per se. The biological significance of this observation is discussed as well as the need to carefully select CD34-specific monoclonal antibodies for research and clinical purposes.

Notes from the field: practical issues in upgrading STD services based on experience from primary healthcare facilities in two Rwandan towns

OBJECTIVE

In order to assess the feasibility of upgrading STD management at the primary healthcare level in Rwanda, a project was piloted in a health centre and a hospital dispensary in two up country towns.

METHODS

Nurses trained in syndrome based management treated all patients with genitourinary complaints at first visit without laboratory results. They provided condom demonstration and risk reduction advice, and gave coupons for partner referral. Principal findings and decisions were recorded on individual patient records. Partners presenting referral coupons were treated presumptively and their records linked to the index case.

RESULTS

Three quarters of symptomatic patients seen at the two primary healthcare facilities were women. With training and supervision, nurses applied the syndromic STD management guidelines correctly in over 90% of cases. Symptomatic treatment failure at first follow up visit varied from 0% for male urethritis to 27% for genital ulcer, the one condition that was not treated syndromically. Four fifths of women presenting with vaginal discharge had clinical signs of cervicitis, and the presence of cervical signs was 86% sensitive for presence of leucocytes on cervical Gram stain.

CONCLUSIONS

With adequate post-training supervision, nurses were able to apply the syndromic STD management guidelines and a high degree of clinical improvement was achieved. Syndromic algorithms that recommend treatment for all common pathogens at the first visit had higher rates of symptomatic cure at follow up than the algorithm employing a sequential treatment approach. Clinical and laboratory evidence suggests a high prevalence of cervicitis in this population of women seeking care.

Efflux of CD34+ cells from bone marrow to peripheral blood is selective in steady-state hematopoiesis and during G-CSF administration

Comparative studies of the CD34+ cell population in peripheral blood (PB) and bone marrow (BM) may contribute to understanding the mechanisms involved in mobilization of hematopoietic progenitor cells (HPCs) from BM to PB. PB-CD34+ and BM-CD34+ cells in steady-state hematopoiesis and during granulocyte colony-stimulating factor (G-CSF) administration were studied for the expression of activation-associated, lineage-associated and adhesion-associated molecules and for their cloning capacity [granulocyte-macrophage colony-forming cells (CFU-GM) and burst-forming unit-erythrocytes (BFU-E)]. G-CSF increased significantly the number of CD34+ cells in PB as well as in BM and resulted in a reduction of CD34+ cells coexpressing the adhesion-related molecule CD49d. Further, G-CSF reduced the relative number of lymphoid progenitors (CD34+ cells coexpressing CD10, CD19, CD20, CD2, or CD7) in both compartments. However, G-CSF had no major impact on the observed differences between PB-CD34+ and BM-CD34+ cells seen during steady-state hematopoiesis despite a relative decrease in PB and increase in BM of certain immature progenitors (CD34+DR- cells). Circulating CD34+ cells, even in steady-state, were enriched for colony-forming cells, and individual colonies appeared larger compared with their BM counterparts. PB-CD34+ cells contained relatively more myeloid progenitors (CD34+CD13+ cells) and fewer B lymphoid progenitors (CD10, CD19, and CD20 cells) than BM-CD34+ cells. CD34+DR-cells were present in a higher proportion of the CD34+ cells in PB than in BM. There were lower numbers of CD34+ cells expressing CD49d and c-kit in PB than in BM. To summarize, the differences between PB-CD34+ and BM-CD34+ cells observed during steady-state hematopoiesis were largely conserved during G-CSF administration. G-CSF, therefore, mainly has an effect on the quantity not the composition of the circulating CD34+ cell pool. Our data also suggest that the egress of HPCs from BM during steady-state hematopoiesis, as well as during G-CSF administration, is a selective process; that is, certain subsets are more prone to enter into circulation than others, and this release may be mediated via common pathway possibly involving downregulation of c-kit and VLA-4 (CD49d).

STD services for women at truck stop in Tanzania: evaluation of acceptable approaches

AIDS continues to be the commonest cause of death in Tanzania among those aged between 15 and 45 years. Both ulcerative and non-ulcerative sexually transmitted diseases have been identified as major co-factors in HIV transmission. Certain groups including long distance truck drivers and their sexual partners have been reported as having a disporportionate effect on the transmission dynamics of STD including HIV, in a population. In 1993 African Medical and Research Foundation decided to add an STD component to their HIV/AIDS prevention programme along the Tanzania-Zambia highway which had been targeting truck drivers and their sexual partners through peer education and condom distribution since 1989. A study to evaluate the acceptability and feasibility of four different approaches of delivering STD services, was conducted over a period of one year. The approaches for delivering STD services were: special STD services offered twice a week at a site and at hours of the women's choice, special outreach services once every three months, or STD services integrated into the nearest Primary Health Clinic. Drugs were provided at three of the four interventions. 1,330 women at seven truckstops, participated in the evaluation study. The women were generally satisfied with all approaches that included the provision of drugs. The most expensive and ineffective way of treating STD was by not providing drugs. These findings confirm the fact that it is feasible to provide STD services to women at high risk in HIV high transmission areas. These women would utilise STD services provided in a manner that suits them if mobilised and encouraged by their peer educators.

Differences in the distribution of CD34 epitopes on normal haemopoietic progenitor cells and leukaemic blast cells

The CD34 molecule expressed on haemopoietic progenitor cells contains a large number of epitopes whose expression may be related to the maturation or function of the cells. Monoclonal antibodies specific for different epitopes have been reported to detect different numbers of CD34+ leukaemic blast cells. We wanted to confirm this observation and study whether parallel findings could be observed for normal haemopoietic progenitor cells. The cells were immunophenotyped by flow cytometry with a series of monoclonal antibodies reactive with different CD34 epitopes. Class III epitopes (resistant to enzymatic cleavage with neuraminidase, chymopapain and a glycoprotease from Pasteurella haemolytica) showed a broader distribution on normal haemopoietic progenitor cells and leukaemic blast cells than class I epitopes (sensitive to cleavage with all three enzymes) and class II epitopes (sensitive to degradation with glycoprotease and chymopapain, and resistant to neuraminidase). The subpopulation of normal progenitor cells which exclusively expressed class III epitopes had flow cytometric characteristics compatible with mature myeloid progenitor cells whereas class I, II and III epitopes were equally expressed on cells enriched for immature subsets. No discordant epitope expression could be observed for the more immature leukaemias (AML-M0/1) and a higher percentage of the more mature leukaemic blast cells (AML-M3 and AML-M4/5) expressed class III epitopes compared to the percentage expressing class I and II epitopes. These data indicate that CD34 class III epitopes are more broadly distributed on normal haemopoietic progenitor cells and leukaemic blast cells than class I and II epitopes, and that class I and II epitopes may be down-regulated prior to class III epitopes during normal haemopoietic progenitor cell differentiation. These findings should be considered when selecting CD34 mabs for quantification and positive selection of haemopoietic progenitor cells for research and clinical purposes.

Lineage commitment of CD34+ human hematopoietic progenitor cells

Hematopoietic cells occur in a continuum of many different stages of functional differentiation, from totipotential stem cells to terminally differentiated lineage-specific cells. At some point during differentiation, progenitor cells become committed to a particular lineage. Little is known about the surface molecules that distinguish lineage-committed progenitor cells from multipotential progenitor cells; this study was undertaken to address this issue. Exploiting a thymic stromal cell co-culture system, we show that CD34+ bone marrow cells expressing the T lymphocyte-associated CD2 and CD7 molecules, the B lymphocyte-associated CD10 and CD19, or the myeloid-associated CD33, contain progenitor cells that can generate T lymphocytes, granulocytes, and monocytes, indicating that the expression of any of these molecules on progenitor cells does not imply lineage commitment. CD34+CD13bright, CD34+CD14+, and CD34+CD15+ cells generated myeloid progeny, and CD34+CD20+ cells failed to differentiate along the T lymphoid and myeloid lineages. Thus expression of CD13, which precedes that of CD14 and CD15 during early hematopoiesis, appears to coincide with commitment to myeloid development. Our findings also indicate that expression of CD20 is restricted to progenitor cells committed to B lymphocyte development.

A comprehensive genetic map of the mouse genome

The availability of dense genetic linkage maps of mammalian genomes makes feasible a wide range of studies, including positional cloning of monogenic traits, genetic dissection of polygenic traits, construction of genome-wide physical maps, rapid marker-assisted construction of congenic strains, and evolutionary comparisons. We have been engaged for the past five years in a concerted effort to produce a dense genetic map of the laboratory mouse. Here we present the final report of this project. The map contains 7,377 genetic markers, consisting of 6,580 highly informative simple sequence length polymorphisms integrated with 797 restriction fragment length polymorphisms in mouse genes. The average spacing between markers is about 0.2 centimorgans or 400 kilobases.

Partner referral as a component of integrated sexually transmitted disease services in two Rwandan towns

OBJECTIVE

To document partner referral rates at health centres with improved STD services, and to determine factors contributing to successful referral.

METHODS

Partner referral was initiated as part of the upgrading of STD services in primary care health facilities in two semi-urban Rwanda towns. After syndromic management of the presenting complaint, index patients received prevention education and condom demonstration, and were urged to refer sexual partners to the health centre for a free examination. Partner referral coupons linked by code number to the symptomatic index patient were given to facilitate referral; no identifying information was collected on partners from the index patients.

RESULTS

Three quarters of the symptomatic patients seen at the two primary health care facilities were women. Overall, the ratio of referred partners to index patients was 26%. Only 58% of index patients accepted partner referral coupons. The referral rate for those who did accept coupons was 45%. Partner referral worked best for regular partners. Most index patients and partners were married and only four index patients referred more than one partner. Women index patients, especially when pregnant, were more successful in referring partners than men. Index patients who referred partners tended to be older than those who did not. Awareness of STD symptoms in the partner, and diagnosis of cervicitis were associated with a higher rate of STD symptoms in the partner, and diagnosis of cervicitis were associated with a higher rate of partner referral.

CONCLUSIONS

Efforts to improve rates of partner referral should begin at the clinic level with improved counselling to convince more index patients of the importance of partner referral. Partner symptom recognition may be useful for increasing rates of partner referral. Supplementary strategies are needed to reach non-regular partners. When syndromic management is used, counselling should take into account the lower predictive values of identifying STD in women in order to avoid partner accusation. Despite limitations, patient referral of sexual partners can be an effective strategy for reaching a population at high risk for STD with minimal additional investment in health worker staff time.