Access to and utilisation of healthcare services by sex workers at truck-stop clinics in South Africa: A case study.

BACKGROUND: Sex worker-specific health services aim to respond to the challenges that this key population faces in accessing healthcare. These services aim to integrate primary healthcare (PHC) interventions, yet most services tend to focus on prevention of HIV and sexually transmitted infections (STIs). North Star Alliance (North Star) is a public-private partnership providing a healthcare service package in roadside wellness clinics (RWCs) to at-risk populations along transport corridors in sub-Saharan Africa. OBJECTIVES: To inform future service development for sex workers and describe North Star's contribution to healthcare provision to this population in South Africa, we describe services provided to and utilised by sex workers, and their views of these services. METHODS: Using a mixed-methods approach, we present quantitative analyses of anonymised North Star routine data for sex workers for October 2013 - September 2015, covering nine sites in seven provinces. Clinic visits were disaggregated by type of service accessed. We performed thematic analysis of 25 semi-structured interviews conducted at five clinics. RESULTS: A total of 2 794 sex workers accessed RWCs during the 2 years. Sex workers attending clinics were almost exclusively female (98.2%) and aged <40 years (83.8%). The majority were South African (83.8%), except at Musina, where the majority of clients were Zimbabwean. On average, sex workers visited the clinics 1.5 times per person. However, in most cases only one service was accessed per visit. PHC services other than for HIV and STIs were accessed more commonly than HIV-specific services and STI treatment. There was an increase in the number of services accessed over time, the figure almost doubling from 1 489 during the first year to 2 936 during the second year. Although during recruitment participants reported having had sex in exchange for goods or money during the past 3 months, not all participants self-identified as sex workers during interviews; however, all reported feeling at higher risk of poor health than the general population owing to their involvement in sex work. Participants reported satisfaction with site accessibility, location and operating hours. Sex workers accessing sites described services as being suitable and accessible, with friendly staff. CONCLUSIONS: RWCs were highly appreciated by the users, as they are suitable and accessible. The sex workers who used the clinics visited them irregularly, mostly for PHC services other than HIV and STIs. Services other than the one for which the sex worker came to the clinic rarely appeared to be offered. We recommend areas for service expansion.

Cost effectiveness of expanded antenatal HIV testing in London.

BACKGROUND: Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing). OBJECTIVE: To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy. DESIGN: Incremental cost-effectiveness analysis. METHODS: Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies. RESULTS: Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40. CONCLUSION: Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.

Enough sterile syringes to prevent HIV transmission among injection drug users in Montreal?

The HIV epidemic among injection drugs users in Montreal continues unabated. We wished to know whether sufficient syringes were being distributed to provide for the needs of injection drug users (IDUs) in Montreal. Using data from several sources, including the estimated number of active IDUs in 1994 and the injection frequency according to the drug consumed, we calculated the number of syringes required by IDUs. The number of syringes estimated was compared with the number of syringes distributed by needle exchange programs or sold in private pharmacies. Overall, we estimated that in 1994 about 10,683,000 syringes were required by the 10,000 IDUs in Montreal. Because about 338,000 syringes were distributed, <5% of the need was being met. The parameters in our analysis, particularly the number of IDUs in Montreal, drug use, and the frequency of injection, are subject to uncertainty. Nevertheless, because of the disparity between the small proportion of syringes distributed and the number required, it is unlikely that sufficient syringes are available to ensure access to clean needles and prevent HIV transmission. Measures should be taken to expand syringe distribution to Montreal IDUs.

Syringe exchange in Canada: good but not enough to stem the HIV tide.

This article provides a historical perspective on the development of syringe exchange in Canada, the Canadian legal and policy context, evaluation and monitoring strategies, and current challenges facing HIV prevention efforts among injecting drug users. Despite the fact that it is legal to sell, exchange, or provide an IDU with a syringe and there are no laws in Canada requiring a physician's prescription to justify possession of a syringe, policy development and programming have not been adequate to hold HIV at bay in several cities across the country. Although there have been concerted efforts by syringe and needle exchange programs to increase the supply of injecting equipment, HIV prevalence continues to rise, provoking a rethinking of the role of syringe exchange. In a coordinated strategy for HIV prevention among drug users in Canada, needle and syringe exchange is not itself in question; however, ghettoization and needle quota systems may have had an adverse impact on prevention programming. A national action plan has been developed which aims to decentralize both methadone maintenance and syringe and needle exchange programs, increase access to detoxification and treatment modalities, and advocate for changes in the criminal justice system and law enforcement practices.

HIV infection among women in prison: an assessment of risk factors using a nonnominal methodology.

The relative contributions of needle use practices and sexual behaviors to human immunodeficiency virus (HIV) antibody seropositivity among 394 women incarcerated in Quebec were determined by risk factor assessment and serology with a nonnominal methodology. HIV positivity was found in 6.9% (95% confidence interval [CI] = 4.6, 9.9) of all participants and in 13% (95% CI = 8.6, 18.6) of women with a history of injection drug use. HIV seropositivity among women with a history of injection drug use was predicted by sexual or needle contact with a seropositive person, self-reported genital herpes, and having had a regular sexual partner who injected drugs, but it was not predicted by prostitution. Nonnominal testing is an ethical alternative to mandatory and anonymous unlinked testing among correctional populations.

Cervicovaginal screening in women with HIV infection: a need for increased vigilance?

OBJECTIVE: To review the current literature on cervical disease (dysplasia, cervical intraepithelial neoplasia [CIN] or carcinoma) in women with HIV infection and to assess recommendations for cervicovaginal screening in these patients. DATA SOURCES: MEDLINE and AIDSLINE were searched for relevant articles published in English or French between January 1987 and February 1993, abstracts presented at international AIDS conferences from 1989 to 1993 were evaluated, and pertinent agencies and organizations were consulted. STUDY SELECTION: A total of 92 reports of gynecologic disease in women with HIV infection were examined; 32 studies were retained that reported pertinent findings on cervical dysplasia, CIN or cervical carcinoma. DATA EXTRACTION: The following criteria were used to extract data: study design (descriptive v. comparative), sample size, heterogeneity of the study population, presence of immunodeficiency indicators (i.e., absolute CD4+ lymphocyte count) and presence of concomitant vaginal infections. Recommendations were assessed for their specific application to women with HIV infection. DATA SYNTHESIS: Data on the associations between stage of cervical disease and response to treatment at varying levels of CD4+ lymphocyte depletion were incomplete. Recommendations by official bodies for cervicovaginal screening in women with HIV infection differed little from recommendations for standard care of all women of reproductive age. CONCLUSIONS: The consequences of a missed or delayed diagnosis of cervical disease for women with HIV infection can be severe. Pending further research, more frequent cervicovaginal screening through Papanicolaou testing and colposcopy in women with HIV infection is warranted.

HIV disease and AIDS in women: current knowledge and a research agenda.

The study of the clinical manifestations, progression, and outcome of human immunodeficiency virus (HIV) infection in women has begun in earnest. AIDS-defining diseases that are more common in women than in men include wasting syndrome, esophageal candidiasis, and herpes simplex virus disease, whereas Kaposi's sarcoma is rare. Non-AIDS-defining gynecological conditions such as vaginal candida infections and cervical pathology are prevalent among women at all stages of HIV infection. Associations have been documented between the presence of human papillomavirus, lower genital tract neoplasia, and HIV-related immunosuppression. Pregnancy has not been confirmed to have an effect on the clinical progression of HIV disease in women incremental to the effect of time. Differential access and utilization of therapeutic interventions appear to account for much of the reported gender discrepancy in survival. Well designed epidemiological and clinical studies will help further scientific knowledge leading to early diagnosis, appropriate treatment, and timely prevention of the manifestations of HIV disease in women.

HIV infection among Quebec women giving birth to live infants.

This is the first anonymous unlinked seroprevalence study in Canada to use serum samples from newborns to determine the seroprevalence rate of human immunodeficiency virus (HIV) infection among childbearing women. Of the 68,808 samples tested 42 were confirmed as positive, for an overall crude seroprevalence rate of 6.1 per 10,000 live births (95% confidence interval [CI] 4.4 to 8.3), or 1 woman in 1638. Women who lived on Montreal island had an overall rate of 17.9 per 10,000 live births (95% CI 12.2 to 25.4), or 1 woman in 559. We observed a significant association between revenue index and seroprevalence; the rates were as high as 46.4 per 10,000 live births (95% CI 18.7 to 95.3), or 1 woman in 216, for Montreal island postal code areas with revenue indexes 20% or more below the provincial median. Extrapolation of the data suggested that 56 women with HIV infection gave birth to a live infant during 1989 in Quebec. Even though attempts to generalize the data from childbearing women to women of childbearing age have an inherent conservative bias, the results of our study suggest that 988 women (95% CI 713 to 1336) aged 15 to 44 years in Quebec had HIV infection in 1989. The actual number is likely substantially higher. The need for well-designed, creative interventions to prevent further HIV transmission to women is evident. Planning for the provision of medical and psychosocial services sensitive to specific needs of women who are already infected should start immediately.

Highlights from the Canada youth and AIDS study.

The identification of Acquired Immunodeficiency Syndrome (AIDS) in 1981, and the subsequent isolation of the human immunodeficiency virus (HIV) in 1983, signaled the beginning of worldwide concern over the potential impact of the disease. As the global incidence of AIDS and HIV infection increased, Canadians expressed growing apprehension about the epidemic's affect on themselves. Because adolescents potentially are at risk for HIV infection, a special need existed to determine how Canadian youth were responding to the AIDS epidemic. During the summer of 1987, the Federal Centre for AIDS, in conjunction with the National Health Research and Development Program and the Canadian Public Health Association, commissioned a nationwide study. A national sample of more than 38,000 youth in grades 7, 9, 11, and the first year of college and university were surveyed about their knowledge, attitudes, and behavior concerning AIDS and other sexually transmitted diseases (STDs). Also included in the total sample were youth who had recently dropped out of school and those who lived on the streets of large cities. In this article, the authors summarize findings from the study and offer conclusions and recommendations for action.

PIP: The Federal Center for AIDS, the National Health Research and Development Program, and the Canadian Public Health Association commissioned a study in 1987 on 38,000 adolescents 11-21 years old. The questions focused on knowledge of AIDS and attitudes and behavior about AIDS. The youth know how AIDS is transmitted but do not know how to practice prevention. Mass media has been the major purveyor of AIDS information, but are suspected of capitalizing on the situation to sell their products. Schools and physicians are regarded as reliable information sources, but these sources have not been providing the desired AIDS information on a regular basis. Education about AIDS is currently the most important preventative measure that can be implemented. Knowledge will help modify behavior only if people believe that everyone, including themselves, are at risk of contracting AIDS. Unfortunately, adolescents tend to believe in their own invincibility so they continue to be at risk for sexually transmitted infections. Surveys were conducted on adolescent attitudes toward homosexuals, AIDS infected people, and sexual intercourse in order to understand their associated behaviors. Only 14% of college students polled said they always used condoms. This type of attitude needs to be changed. Street youths are in a high risk AIDS category because they take more chances. Somehow these youths must be reached. Recommendations to improve the situation include: providing clear frank information about AIDS in Canada; educational programs for adolescents; education for parents about AIDS; counselling for college students through university health services; and an increase in AIDS survey research.

Prolactinomas. Clinical presentation, radiologic assessment, and therapeutic options.

Of the pituitary tumors, the prolactinoma is the most common, characteristically causing amenorrhea/galactorrhea in women and symptoms secondary to mass effect in men. Direct coronal CT scanning with rapid infusion contrast enhancement is now considered the most sensitive and specific method for evaluating the pituitary. Normally the gland is either homogeneous or heterogeneous in a repetitive fashion, and measures up to 9-10 mm in height. Adenomas typically are hypodense lesions in the anterior lobe associated with mass effect--superior surface convexity, gland enlargement, bony erosion, infundibulum displacement, or vascular "tuft" shift. High field superconductive MRI is thought to be superior to CT for evaluation of macroadenomas and may soon surpass CT in the evaluation of microadenomas. Treatment remains controversial. Perhaps surgery is the best alternative for women 15 to 30 years of age with microadenomas producing prolactin less than 100 ng/ml. Patients who are either beyond the child-bearing years, present with tumors greater than 10 mm in diameter, or have microadenomas producing prolactin greater than 100 ng/ml may be better served by medical therapy using bromocriptine or pergolide mesylate.

The prevalence of breast feeding in Calgary, 1979-1980.

PIP: The breastfeeding practices of infants in Calgary, Alberta in 1979 and 1980 were studied using annual cohorts. Approximately 63% of infants were breastfed during the 1st week and the proportion did not change significantly during the 1st month. This proportion is higher than in an earlier study in Calgary and surveys in Canada several years ago. Most infants not breastfed during the 1st month were given commercially available infants' formula, and only a small percentage of infants were given cow's milk. The proportion of breastfed infants fell significantly after 3 months, suggesting that encouragement of breast feeding should continue for several months after delivery.^ieng