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.

Decline of infant and child mortality rates in rural Senegal over a 37-year period (1963-1999)

BACKGROUND

In spite of an improving trend, childhood mortality in rural sub-Saharan Africa remains high and has recently risen in some countries. The factors associated with the long-term decline in childhood mortality are poorly known, due to a lack of data.

METHODS

A Senegalese rural population has been under demographic surveillance since 1963. Infant and under-5 mortality rates were calculated for different periods to generate a long-term trend in childhood mortality. Evolution of age and seasonal patterns of mortality were observed.

FINDINGS

During the observation period (1963-1999), infant and under-5 mortality rates decreased from 223 per thousand to 80 per thousand and 485 per thousand to 213 per thousand , respectively, with a constant annual rate of decline in the probability of dying since the 1960s (-3.7% and -3.1%, respectively). The age pattern of the under-5 mortality changed drastically, with a large decrease in the death rate between 6 and 24 months of age (from 321 per thousand to 87 per thousand ). This change took place during the 1970s. The seasonal variation, characterized by a greater proportion of deaths during the rainy season, was very marked during the 1960s, then decreased during the 1980s but it has tended to increase again in the 1990s, particularly among children 1-4 years old.

CONCLUSION

This study confirms the long-term trend of decrease in child mortality in rural West Africa. Historical knowledge on healthcare developments suggests that immunizations have contributed to the decrease and the change in the age pattern. The re-emergence of malaria seems the most likely explanation for the recent rebound in seasonal variation. Attention to immunization and malaria should continue to be a priority.

Children's height, health and appetite influence mothers' weaning decisions in rural Senegal

BACKGROUND

In many developing countries, breastfed children have a lower nutritional status than those weaned from 12 months of age. Reverse causality, that is, earlier weaning of healthy and well-nourished children, is a possible explanation.

METHODS

Maternal reasons for early and late weaning were investigated in a cohort of 485 rural Senegalese children using structured interviews during two rounds at the ages of 18--28 and 23--33 months, respectively. Length, weight and height were assessed, and dates of weaning were monitored.

RESULTS

The mean duration of breastfeeding was 24.1 months (quartiles 21.9 and 26.3). Two-thirds of mothers of breastfed children under 2 stated that they would wean at the age of 2, while for breastfed children aged 2 years, a 'tall and strong' child was the most prevalent criterion. The main reasons for weaning prior to 2 years (N = 244) were that the child ate well from the family plate (60%), that the child was 'tall and strong' (46%) and maternal pregnancy (35%). The main reasons for weaning later than the age of 2 were: a 'little, weak' child (33%), food shortage (25%), illness of the child (24%) and refusal of family food (14%, N = 120). Children breastfed above the age of 2 because they were 'small and weak' had lower mean height-for-age and a greater prevalence of stunting than children breastfed late for other reasons (P < 0.0001).

CONCLUSION

The habit of postponing weaning of stunted children very likely explains why breastfed children have lower height-for-age than weaned children in this setting.

Breast-feeding is associated with improved growth in length, but not weight, in rural Senegalese toddlers

BACKGROUND

Prolonged breast-feeding is frequently associated with malnutrition in less-developed countries, even after adjustment for socioeconomic confounders. However, in rural Senegal, breast-feeding is prolonged when the child is stunted.

OBJECTIVE

We aimed to test whether the lower height-for-age of children weaned late is explained by their height before weaning or whether prolonged breast-feeding is associated with impaired growth.

DESIGN

A cohort of 443 Senegalese children recruited from dispensaries at 2 mo of age were visited in their homes at 6-mo intervals when they were approximately 1.5 to 3 y of age. Weight, length, arm circumference, and triceps skinfold thickness were measured. Six-month increments were analyzed in relation to breast-feeding (breast-fed compared with weaned children or breast-feeding duration), season, and maternal housing with use of multiple linear regression.

RESULTS

The mean duration of breast-feeding was 24.1 mo (quartiles 1 and 3: 21.9 and 26.4). Height-for-age at the age of 3 y was negatively associated with age at weaning (P < 0.01), but this association disappeared after adjustment for height-for-age in infancy. Length increments were significantly greater in both the second and third years of life in children breast-fed for longer durations (P < 0.05) and tended to be greater in breast-fed than in weaned children in the second year of life (P = 0.05). In the third year of life, breast-fed children had greater length increments than did weaned children in the subgroup with poor housing (P for interaction < 0.05). Growth in weight did not differ significantly according to breast-feeding.

CONCLUSION

Prolonged breast-feeding improved linear growth, and the negative relation between height-for-age and duration of breast-feeding was due to reverse causality.

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.

Real-time monitoring of the hybridization reaction: application to the quantification of oligonucleotides in biological samples

We describe here a competitive hybridization assay using TRACE technology which can be used for real-time monitoring of oligonucleotide hybridization. This assay quantifies all kinds of oligonucleotides in biological fluids without extraction. The assay makes use of two different probes and involves a fluorescent transfer process. As fluorescence measurements are not destructive, they can be sequentially repeated, thereby allowing comparison of the hybridization kinetics and binding strength of chemically modified backbone oligonucleotides (>0.5 nM) in biological media. The assay was validated for pharmacokinetic analysis of phosphodiester and phosphorothioate oligonucleotides in plasma and in different organs (liver, kidneys, lungs, spleen) at low concentrations (0.4 mg/kg, corresponding to clinical doses). Respective sensitivities for phosphodiester and phosphorothioate were 0.2 and 0.8 pmol/ml in plasma and 2 and 8 pmol/g in tissues, which allow to recover intact phosphorothioate sequences in some organs even after 24 h.

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.

[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.