Prevention of HIV and other STIs in rural Senegal: a study of prevention-related events collected by sentinel observers

We conducted a study of AIDS/STI prevention-related events based on a network of sentinel observers over a 35-month period in three rural communities of Senegal (May 2000 - March 2003). In one of these communities we also conducted a population-based study on self-reported prevention events and attitudes towards AIDS. Sentinel observers recorded 1 590 AIDS/STI prevention-related events. More than half of the reported events were radio programmes. The proportion of events on the occasion of which therapies was addressed increased significantly between 2000 and 2001, from less than 3% to about 10%, while sharp decreases in the proportion of events dealing with condoms and STIs, both from around 25% to less than 15%, were observed at the same time. The population-based survey indicated that men were more influenced by individual events like informal discussions or radio programmes while women seemed to be more influenced by collective events such as public meetings and school education.

Qualitative changes in AIDS preventative attitudes in a rural Senegalese population

Recent changes in knowledge and attitudes towards AIDS in a rural population of Senegal were assessed comparing two cross-sectional studies conducted six years apart (1997 and 2003). Random samples of 866 and 709 adults aged 15-59 were included. Sociodemographic characteristics of the two population samples were very similar. The proportion of those who estimated their personal risk of being infected by HIV as high or very high fell from 49.1% in 1997 to 17.2% in 2003. The proportion of those who reported having already changed their behaviour to protect themselves from AIDS fell from 56.3% to 24.9%. Methods cited as protection against HIV changed over the period. Fidelity and/or partner selection was cited by 93% of respondents in 1997 and 58% in 2003 when suspicion of potentially soiled materials appeared. Finally, attitudes towards persons living with HIV or AIDS (PLWHA) in 2003 were ambivalent: while 73.9% thought that a PLWHA should not be allowed to mix with other villagers, 65.1% would be ready to provide care to a PLWHA. Drastic changes in attitudes towards the AIDS threat could be identified over the period. AIDS preventive attitudes measured in 1997 were not sustained in 2003, while stigmatization of PLWHA was very widespread.

Mobility and the spread of human immunodeficiency virus into rural areas of West Africa

BACKGROUND

In eastern and southern Africa, the human immunodeficiency virus (HIV) epidemic appeared first in urban centres and then spread to rural areas. Its overall prevalence is lower in West Africa, with the highest levels still found in cities. Rural areas are also threatened, however, because of the population's high mobility. We conducted a study in three different communities with contrasting infection levels to understand the epidemiology of HIV infection in rural West Africa.

METHOD

A comparative cross-sectional study using a standardized questionnaire and biological tests was conducted among samples in two rural communities of Senegal (Niakhar and Bandafassi, 866 and 952 adults, respectively) and a rural community of Guinea-Bissau (Caio, 1416 adults). We compared the distribution of population characteristics and analysed risk factors for HIV infection in Caio at the individual level.

RESULTS

The level of HIV infection was very low in Niakhar (0.3%) and Bandafassi (0.0%), but 10.5% of the adults in Caio were infected, mostly with HIV type 2 (HIV-2). Mobility was very prevalent in all sites. Short-term mobility was found to be a risk factor for HIV infection among men in Caio (adjusted odds ratio (aOR) = 2.06; 95% CI: 1.06-3.99). Women from Caio who reported casual sex in a city during the past 12 months were much more likely to be infected with HIV (aOR = 5.61 95% CI: 1.56-20.15). Short-term mobility was associated with risk behaviours at all sites.

CONCLUSIONS

Mobility appears to be a key factor for HIV spread in rural areas of West Africa, because population movement enables the virus to disseminate and also because of the particularly risky behaviours of those who are mobile. More prevention efforts should be directed at migrants from rural areas who travel to cities with substantial levels of HIV infection.

Preventive attitudes towards the threat of AIDS: process and determinants in rural Senegal

This report is intended to identify the determinants of preventive attitudes and thereby enable the further elaboration of effective prevention programs in a country where the HIV epidemic has remained controlled. Across-sectional survey using a standardized questionnaire was conducted among a sample of 866 adults of the general population of the rural area of Niakhar, Senegal. The analysis identified psychosocial determinants related to preventive attitudes and the influence of sociodemographic characteristics and of sources of AIDS information on these determinants. Psychosocial determinants of preventive attitudes differed according to gender: Among men, personal risk perception was associated with preventive attitudes. Among women, level of AIDS-related knowledge, communication about AIDS, and optimism about the future were associated with preventive attitudes. Sociodemographic factors and sources of information were similar for men and women: Preventive attitudes were adopted primarily by young, educated subjects who had been exposed to urban life. Religion appeared to be a major obstacle to preventive attitudes. Preventive messages broadcast on radio or television may be determinative. Our results call for a strengthened collaboration with religious leaders and a focus on risk perception to rationalize preventive actions. We also encourage the targeting of vulnerable populations, such as women in rural areas, by developing preventive messages to be delivered through national media (radio, television) and by staff from health centers, which most women visit, at least for prenatal care.

Religion and protective behaviours towards AIDS in rural Senegal

OBJECTIVES

To describe the association between religion and factors related to sexually transmitted diseases (STD)/AIDS in a country where religious leaders were involved early in prevention.

DESIGN

A cross-sectional study conducted in a rural area in central Senegal.

METHODS

Questionnaire-based interviews of a random sample of 858 adults from the general population aged 15-59 years and in-depth interviews of four religious leaders and 50 people.

RESULTS

Seventy-six per cent of the respondents were Muslim, 24% Catholic, 1% Animist and 0.2% Protestant. A total of 86% of men and 87% of women reported religion to be very important to them. Important prevention-related variables were inversely associated with the importance of religion. Men who considered religion to be very important were less likely to cite AIDS as a major health problem [odds ratio (OR) 0.4, P = 0.008] and were less likely to feel at risk of getting HIV (OR 0.5, P = 0.0005). Women who considered religion to be very important were less likely to report an intention to change to protect themselves from AIDS (OR 0.2, P = 0.0001), less likely to report having discussed AIDS with others (OR 0.4, P = 0.01) and much more likely to feel at risk of getting HIV (OR 9.3, P = 10(-4)). Individuals who considered religion to be very important were not more likely to report intending to or actually having become faithful to protect themselves from AIDS.

CONCLUSION

These findings stress the need to intensify the involvement of religious authorities in HIV/STD prevention at the local level.

Risk behaviours and AIDS knowledge in a rural community of Senegal: relationship with sources of AIDS information

BACKGROUND

The objective of this paper is to describe sources of information on HIV/AIDS and their relationship with AIDS-related knowledge and sexual behaviour in a rural area of south Senegal.

METHODS

A cross-sectional study using a standardized questionnaire was administered in 1994 by local interviewers to 240 men and 242 women aged 15-59 years, randomly selected from the general population.

RESULTS

Sources of HIV/AIDS information most frequently cited were radio for men (61% of men) and the local health centre for women (52% of women). Among men, citing radio as a source of information was associated with an improved overall AIDS-related knowledge (a seven-questions based average score was 4.30 for men citing radio acquired information and 5.90 for men not citing radio acquired information; P < 10(-4)) and was associated with a smaller number of casual sexual partners in the 12 months preceding the interview (1.94 versus 1.48; P = 0.04). Women citing the local health centre as a source of HIV/AIDS information had a better perception of condom use and more often felt threatened by HIV/AIDS, but did not declare a significantly different number of casual sex partners in the 12 months preceding the interview. Television as a source was cited by 42% of men and 33% of women and was associated with an increased AIDS-knowledge score for men, with a smaller number of casual sex partners for women and with better perception of condoms for men.

CONCLUSION

Because of its large spread and impact, radio appears to be an efficient way to reduce risk-taking behaviour among men. In addition, it is a very convenient way to reach people with high mobility such as male seasonal migrants. For women, attendance at health centres for maternity purposes is an opportunity to receive prevention messages. Finally, numerous men and women have had the opportunity to watch television when they are in towns during the migration period. This method seems to deliver effective messages.

Impact of chloroquine resistance on malaria mortality

Over 12 years, from 1984 to 1995, we conducted a prospective study of overall and malaria specific mortality among three rural populations in the Sahel, savanna and forest areas of Senegal. The emergence of chloroquine resistance has been associated with a dramatic increase in malaria mortality in each of the studied populations. After the emergence of chloroquine resistance, the risk of malaria death among children 0-9 years old in the three populations was multiplied by 2.1, 2.5 and 5.5, respectively. This is the first study to document malaria mortality at the community level in Africa before and after the emergence of chloroquine resistance. Findings suggest that the spread of chloroquine resistance has had a dramatic impact on the level of malaria mortality in most epidemiological contexts in tropical Africa.

Improvement in AIDS knowledge, perceptions and risk behaviours over a short period in a rural community of Senegal

The objective of this paper is to assess knowledge, perceptions and behavioural changes in response to AIDS in a rural community in the south of Senegal, comparing 2 cross-sectional surveys using standardized questionnaires and performed in 1990-1992 and 1994. An AIDS-related knowledge score was built using 4 questions about routes of HIV transmission, ranging from 0 to 4. The score increased between the 2 surveys from 1.6 to 2.1 for men (P = 0.006) and from 0.8 to 2.6 for women (P < 10(-4)). The proportion of those who responded 'I don't know' to the 4 questions dealing with routes of AIDS transmission decreased from 24% to 14% on the average for men and from 66% to 20% on the average for women. The proportion of men who declared casual sex partners in the past 12 months decreased from 39% to 21% (P = 0.01). However, the proportion remained stable for women (from 15% to 18%). These results show that despite a relatively low level of HIV infection (0.8% of all adults), AIDS-related knowledge increased and at-risk behaviour decreased in a rural area of west Africa.

[Results of a preliminary study on the various factors of HIV infection and sexually transmitted disease in rural west Africa]

A pilot study has been carried out in two Senegalese rural communities in January-February 1996 in order to evaluate the feasibility of a study that is being launched in several rural sites in West Africa. This study aims to shed light on the factors of HIV infection and other sexually transmitted diseases. A sample of 100 adults were asked to answer a questionnaire on at risk behaviors for these infections. Few of them have refused to answer the questionnaire: 9% (6/66) in a first site and 3% (1/34) in the other site. Interviewers', remarks made after this pilot study showed that sex and age of interviewer and interviewee must be matched and that they must know each other so as to establish a relation of confidence. Participation to the biological part of the study may prove to be poor since, in each two communities, 27% and 40% of the interviewees declared they would refuse to provide a blood sample if asked. Finally, preliminary results suggest that at risk sexual behaviors and motivation of casual sex may be different between the two communities. The present pilot study shows that the use of our questionnaire is possible among rural communities in sub-Saharan Africa. However, it will be necessary to further explain the importance of the biological part of the study to achieve a satisfactory participation rate.

Knowledge, attitudes and perception of AIDS in rural Senegal: relationship to sexual behaviour and behaviour change

OBJECTIVES

To describe the determinants of 'at risk' sexual behaviour and perception of AIDS-related prevention messages in rural Africa.

SETTING

A rural area in Southern Senegal.

DESIGN

Cross-sectional study using a standardized questionnaire administered by local interviewers to 240 men and 242 women aged 15-59 years, randomly selected among the general population.

RESULTS

Twenty-eight per cent of the sexually active men and 27% of the sexually active women declared at least one casual sexual partner in the 12 months preceding the interview. Among these, 27% of men and 30% of women declared having used a condom in most acts of casual intercourse. Seasonal migrants and divorced or widowed women were more likely to declare casual sex. Causal sex was motivated by material needs for 66% of the women who experienced it, and those of the women who reported casual sexual intercourse were less likely to feel at risk of AIDS [odds ratio (OR), 3.9; P = 0.01] and were more optimistic about their future (OR, 3.6; P = 0.03). For men, the motivations explaining a change in sexual behaviour in order to avoid HIV infection included the perception of AIDS as a health problem (OR, 11; P = 0.004), the perception of the disease as serious (OR, 5.4; P = 0.001) and the feeling of personal risk of becoming HIV-infected (OR, 3.2; P = 0.02). Perceived skill in changing one's behaviour was strongly associated with declaration of past behaviour change for both men and women (men: OR, 3.4; P = 0.02; women: OR, 6.3; P = 0.0001).

CONCLUSION

Men and women exhibit two different patterns regarding their behaviour and perception towards AIDS. Material needs appear to be of importance for women, whereas perception of a real threat lead men to adopt protective behaviours. In the very area of this study, widowed and divorced women as well as male seasonal migrants are particularly exposed to HIV infection. They are characterized by a higher risk behaviour, a low rate of condom use and seldom declared any protective measures to avoid HIV infection.

A study of sexual behavior change in rural Senegal

This study describes recent sociodemographic and behavioral changes in a rural community in Senegal and investigates how these changes may have modified the risk of HIV/STD transmission. The authors combine findings from two surveys: (a) a marriage survey among all adults of a rural community of approximately 7,000 inhabitants; and (b) a sexual practices survey conducted among a sample of the same population (165 men and 165 women) between 1989 and 1994. During the last 30 years--between 1955-64 and 1985-92--age at first marriage increased in the study area from 25 to 32 years for men and from 21 to 24 years for women. At the same time, age at first sexual intercourse decreased by approximately 10 years on average for men. As expected, this has led to an increase in premarital sexual activity, and we have documented both an increase in the percentage of individuals declaring sexual relations before marriage and, for men, an increase in the number of sexual partners before marriage. Multipartnership is more frequent among men than women (OR=4.4), among those who had their first intercourse at an early age (OR=3.3), among rural migrants (OR=2.7), and among those who had a good knowledge of AIDS. These findings show how recent changes in marriage, sexual behaviors, and seasonal migration have combined to increase the risk of HIV/STD infection within the community. Male rural migrants and their partners are particularly exposed.

Reliability of reports of sexual behavior: a study of married couples in rural west Africa

A heterosexual partners survey in rural Senegal, Africa, was carried out in 1992 to evaluate the reliability of self-reported answers about sexual practices. The authors followed 62 married couples weekly during a 5-week period to assess the level of agreement 1) between answers made by members of the same couple but collected separately, 2) between retrospective reporting of sexual activity during the last 4 weeks versus weekly reporting of sexual activity during 4 weeks, and 3) between answers to a set of identical retrospective questions asked 5 weeks apart. Reports over recent and short periods of time such as 7 days are reliable: The dates of sexual acts with spouse reported during the weekly interviews were concordant between members of a couple at 0-day or 1-day intervals in 72% of cases. The concordance of weeks reported with or without intercourse was also high. Reports over longer periods of time are less reliable: The comparison of retrospective reports versus weekly reports regarding mean number of sexual acts during the last 4 weeks shows a clear overreporting that was higher among men (4.5 vs. 2.7 sexual acts) than among women (3.7 vs. 2.7).

The evaluation of surveys of sexual behaviour: a study of couples in rural Senegal

The reliability of self-reported answers about sexual behaviour is assessed by means of a survey of couples in rural Senegal, Africa, carried out in 1992. A total of 51 married couples were followed weekly over a five-week period. Reports for a recall period of seven days are reliable: dates of sexual acts differed by no more than a day in 73 per cent of cases. Reports over longer periods are less reliable. Retrospective recall of coital frequency for a four-week period yields much higher estimates than those obtained with a seven-day recall, particularly for men.

Rapid decline in child mortality in a rural area of Senegal

Retrospective and prospective demographic and health data collected on the population of Mlomp (6352 people in 1985), a rural area of Senegal, show that the probability of dying before the age of 5 years declined from 350 to 81 deaths per hundred livebirths in the last 25 years. This decline is greater and faster than ever observed in Senegal. The drop in mortality mainly results from improved access to new and efficient health services--a dispensary and a maternity clinic--and from growth surveillance, health education, vaccination and malaria programmes initiated in the 1960s and 1970s. Although socioeconomic conditions have changed in the area, the influence of classical factors such as women's educational level and improvement in transportation has probably been limited. Deaths from diseases that can be prevented by immunization (such as neonatal tetanus, measles, whooping cough) are now very rare (3% of the deaths of children under 5 years during the period 1985-1989). Although the risks of dying from diarrhoea or acute respiratory infections are much lower than in other rural areas of Senegal, these are still the main causes of deaths (33% and 19% of deaths after 1 month of age). Malaria, despite its high morbidity during the rainy season, causes few deaths (4%). This reflects the success of the health education programme promoting chemoprophylaxis and early treatment of fever cases. Mlomp is one example of an African rural area where the provision of well-organized health services at a reasonable cost has produced a dramatic decline in child mortality.

Seasonal migration: a risk factor for HIV infection in rural Senegal

Sociodemographic and epidemiological data collected on a rural population of the Ziguinchor region of Senegal showed that a large part of the adult population, 80% of women between 15 and 24 years old and 82% of men between 20 and 40 years old, move each year on seasonal labor migrations to the main cities of Senegal or the Gambia or their proximity. In October 1990, an exhaustive seroprevalence survey of the population aged 20 years or older (3,230 persons tested) showed that 0.8% was HIV-2 and 0.1% HIV-1 seropositive. Interviews of 91 persons (24 seropositive persons and 67 seronegative controls) revealed that seropositivity was associated with a history of blood transfusions, injections, sexually transmitted diseases, and seasonal migration. Our findings suggest that in the rural area under study, beside a few cases of transmission by blood transfusion or injection, HIV-2 and HIV-1 are mainly transmitted first to adult men through sexual contacts with infected women met during their seasonal migration and second to their wives or regular partners once they are back home.

HIV-2 infections in a rural Senegalese community

In a community study in rural Senegal, 22 human immunodeficiency virus type-2 (HIV-2) seropositive cases and 64 matched controls were examined clinically and evaluated immunologically. The presence of clinical signs was highly correlated with HIV-2 seropositivity: 9 anti-HIV-2 positive patients and 5 controls presented with clinical signs (odd ratio [OR] = 8.2, confidence limits [CL] 2-35). The main symptom associated with HIV-2 seropositivity was a chronic cough (OR = 18.5, CL 1.8-899). The presence of diarrhoea was not significant (OR = 3.1, CL 0.3-3.5). The total number of CD8 cells, CD4/CD8 ratio, beta 2 microglobulin, and IgG level discriminated between seropositive and seronegative individuals (P less than 0.05). When the anti-HIV-2 positives were grouped as 13 healthy and 9 sick people, red blood cells, lymphocytes, T lymphocytes, CD4 cells, and beta 2 microglobulin differed significantly. Clinical symptoms were associated with immunodepression: 5 of 14 sick people had less than 500 CD4/microliters vs. 1 of 72 healthy persons. This study at the community level emphasizes the clinical and immunological impact of HIV-2 infection. Even if it presents with a longer incubation period than HIV-1, this virus is a major threat to public health.

Antibiotic treatment of venereal disease and Reiter's syndrome in a Greenland population

OBJECTIVE

To assess the effects of antibiotic treatment of urethritis or cervicitis on the incidence of recurrences of articular symptoms in Reiter's syndrome patients.

METHODS

Retrospective evaluation of the medical charts of 109 patients living in Greenland.

RESULTS

Thirty-seven percent of the episodes of genitourinary tract inflammation that were not treated or were treated with penicillin were followed by arthritis, compared with 10% of those treated with tetracycline or erythromycin.

CONCLUSION

Antibiotics active against Chlamydia trachomatis reduced the risk of postvenereal arthritis in the population studied.

[Fiessinger-Leroy-Reiter syndrome in Greenland. Clinical and epidemiological aspects]

A clinical and epidemiological study of the Fiessinger Leroy Reiter syndrome was undertaken in Inuits from four Greenland cities, because of the frequency of HLA B27 antigen and venereal diseases in this population. A mean prevalence of 0.67 p. cent was found in Inuits from the west coast, of which 27.5 p. cent are carriers of the HLA B27 antigen. In Amassalik, on Greenland's east coast, where the frequency of B27 was estimated at 6.5 p. cent, the prevalence of the syndrome is 0.32 p. cent. Immunogenetic and preliminary familial data show that HLA B27 is present in 87.5 p. cent of the patients and that 34 p. cent have a close relative with the disease. Clinical data are comparable to those reported in the literature. Evolution is marred by frequent recurrences: 85 p. cent of the patients followed for more than ten (10) years present at least one recurrence. The total frequency of ankylosing spondylarthritis is 16.7 p. cent. It increases, in retrospect, to reach 45 p. cent in 22 patients followed for more than 15 years.

Reiter's syndrome in Greenland. A clinical and epidermiological study of two communities

Patients with post-venereal Reiter's syndrome, living in the districts of Egedesminde and Jakobshavn in Greenland, were ascertained from medical records and patient examinations. Fifty-one patients were found to have definite Reiter's syndrome according to the ARA proposed criteria. The prevalence of the disease is 1.08% in Egedesminde and 0.34% in Jakobshavn. Annual incidences and prevalences show a marked increase between 1960 and 1983. Retrospective follow-up data on all patients show that the disease recurs in over 85% of cases for which the follow-up period is 10 years or longer.