A survey of STI policies and programmes in Europe: preliminary results.

OBJECTIVES: A survey was conducted to assess the adequacy of sexually transmitted infections (STI) prevention and control policies and programmes in the European region (including the central Asian republics). METHODS: An adapted World Health Organization (WHO) model questionnaire was sent to ministry of health officials in all 45 countries of Europe and central Asia. The questionnaire included questions on STI programme structure; STI case management; the different types and levels of services, including public and private service providers; partner notification and screening policies; services for vulnerable populations; monitoring and supervision; surveillance and research. RESULTS: Western European countries largely leave STI prevention and care to individual practitioners. Licensed providers exist at all levels of care, and access to consultations and treatment is usually free of charge. In the newly independent states (NIS), by contrast, programme efforts emphasise state guidance and supervision of local providers rather than individual practitioners. Access to services is limited in that in several NIS, only public sector specialists are licensed to treat STI. Formerly free of charge policies have been severely eroded. While in western Europe access to condoms appears to be good, in the NIS there are many fewer condom outlets. Regionwide, in 40% of countries the distribution of condoms is part of STI consultations. CONCLUSIONS: Non-availability of affordable high quality STI services, including STI treatment and condoms, may be one of the causes for the much higher STI prevalence in parts of eastern Europe and NIS than in western Europe.

Patterns of partnership and condom use in two communities of female sex workers in Tanzania.

Two rapid ethnographic studies have found that commercial sex workers (CSWs) and other high-risk women in Tanzania have different categories of partners, ranging from single-time contacts to long and enduring relationships. Since the advent of HIV/AIDS prevention programs in Tanzania in the late 1980s, CSWs and their clients have been aware of the multiple benefits of condom use for the prevention of pregnancy and STDs including HIV. These women often use condoms for the single-time contact. However, since the HIV/AIDS epidemic, casual partners have decreased in number. These days, most of their sexual contacts occur within long-term partnerships, and within these relationships, condom use is rare. Although the message that condoms should be used during high-risk behavior has been largely accepted, the definition of a high-risk relationship needs to be extended from casual partnerships to include multiple long-term partnerships. In addition, men and women's empowerment through education, business, and equal rights needs to be addressed at all levels of society.

Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990-1993.

HIV prevention through peer education and condom promotion among truck drivers and their sexual partners is described. Trends during an initial 18-month intensive phase, followed by a 24-month maintenance phase, were monitored with surveys. Trends for self-reported condom use were: increase among men (56 to 74%) during the first phase with a decrease (72%) during the maintenance phase. Respective figures for women were 51%, 91% and 70%. Multivariate analyses revealed that men most likely to report using condoms were unmarried, had children, were more educated, had previously reported a genital ulcer, and perceived themselves at risk for HIV infection (OR = 1.95-3.47). Women tending to use condoms were unmarried, aware of the limitations of condoms, not in denial as to the existence of HIV, harboured inaccurate information about HIV transmission and were afraid (OR = 1.35-2.52). Both sets of results suggest that the most sexually experienced men and women who did not have a permanent stable relationship and who perceived themselves at risk, were most likely to use a condom. Peer education was an effective tool for increasing knowledge and encouraging appropriate behaviour change. It was most effective as an intensive high-input intervention and sustainable with the relatively stable population of truck drivers.

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.

PIP: Long-distance truck drivers and their sexual partners have a disproportionate effect on the transmission dynamics of sexually transmitted diseases (STDs), including HIV infections, in Tanzania. In 1993, the African Medical and Research Foundation added an STD component (peer education and condom distribution) to its HIV/AIDS prevention program along the Tanzania-Zambia highway. The present study of 1330 women (mean age, 27.3 years) recruited from 7 highway truckstops assessed the acceptability and feasibility of 4 approaches to the prevention of STDs: special STD services offered twice a week at a site and hours chosen by women, special clinic-based outreach services for women once every 3 months, integration of STD services into the nearest primary health care clinic, and provision of STD drugs. Most study participants were local brew sellers (47.2%), bar/guest house attendants (27%), and petty traders (21.1%). The overall HIV prevalence was 50%. Attendance per woman was higher when services were offered outside a health facility (1.23) or at times other than normal clinic hours (1.43) than when STD services were integrated with primary health care (1.0). The total cost per patient was US$11 when the clinic did not provide STD drugs, $12 for special clinic-based services for women, $11.50 for non-clinic-based services, and $11 for the integrated STD/primary health care approach. Women were equally satisfied with the 3 service delivery strategies, but highly dissatisfied when STD-specific drugs were not provided and their infection was not cured.

Sentinel surveillance for HIV-1 among pregnant women in a developing country: 3 years' experience and comparison with a population serosurvey.

OBJECTIVES: To establish unlinked, anonymous sentinel surveillance for HIV-1 among pregnant women attending an antenatal clinic, to determine age-specific seroprevalences, to monitor trends and to compare seroprevalence with that detected by a population serosurvey. To establish the sustainability and costs of surveillance. DESIGN: Sentinel surveillance for HIV through serial collection of unlinked, anonymous seroprevalence data from antenatal care; comparison of sentinel data with those from a population serosurvey; financial and general audit of the sentinel surveillance. SETTING: A community antenatal clinic in a large urban centre, Mwanza Municipality, Tanzania, eastern Africa, between October 1988 and September 1991. PATIENTS: Pregnant women attending for antenatal care. MAIN OUTCOME MEASURE: Age-specific HIV-1 seroprevalences, trends over time, difference from age-specific population seroprevalences, sustainability and costs. RESULTS: Overall HIV-1 seroprevalence was 11.5% (95% confidence interval, 10.5-12.4); differences in age-specific prevalences were not significant. There was no clear evidence of change in seroprevalence over the study period in any age group, although there was some indication of a rise in some age groups in 1988-1989. Sentinel surveillance among pregnant women may have significantly underestimated population HIV-1 seroprevalence for women under the age of 35 years. HIV-1 surveillance proved feasible and sustainable. Additional recurrent costs were US$1.7 per specimen for unlinked anonymous testing and US$0.57 per woman for syphilis screening. CONCLUSIONS: HIV-1 seroprevalence did not change significantly over 3 years, probably implying a substantial incidence of HIV-1 infection. In this setting seroprevalence in pregnant women may have underestimated population seroprevalence in women aged under 35 years. With modest inputs and good organization unlinked anonymous HIV-1 sentinel surveillance of pregnant women can be introduced and sustained in an African setting. This may usefully be carried out in conjunction with syphilis screening.

PIP: Between October 1989 and September 1991, health workers took blood samples from pregnant women attending Makongoro Clinic in Mwanza, Tanzania, to determine age-specific HIV-1 seroprevalence in pregnant women, trends over 3 years, and the feasibility, sustainability, and costs of HIV monitoring and to compare age-specific seroprevalences in pregnant women with those of all women. Overall, HIV prevalence among pregnant women stood at 11.5%. Even though the younger and older age groups had lower seroprevalence than the other age groups (10% for those under 20 years old, 11% for 30-34 year olds, and 8.3% for = or 35 year olds vs. 12.8% for 25-29 year olds and 12.3% for 20-24 year olds), the differences were not significant. HIV seroprevalence appeared to increase in 1988-89 in most age groups, but no significant evidence of a linear trend occurred during the study period for any age group. This absence of significant change in HIV seroprevalence over 3 years likely indicated a considerable HIV incidence. The population serosurvey revealed an HIV seroprevalence of 15.1% among the general adult female population, suggesting that the sentinel surveillance among pregnant women could have greatly underestimated population HIV seroprevalence for women under 35 years old (p = .02). Sentinel surveillance improved the clinic's ability to detect anemia and reintroduced syphilis screening. Unlinked anonymous testing resulted in additional recurrent costs of S$1.7/specimen. Syphilis screening added recurrent costs of US$0.57/woman. These findings indicated that health workers in Africa can successfully introduce and maintain anonymous HIV-1 sentinel surveillance of pregnant women and this can be accomplished with concurrent syphilis screening.

Lay health beliefs concerning HIV and AIDS--a barrier for control programmes.

Work in AIDS control in East Africa revealed widespread lay health beliefs concerning HIV infection and AIDS amongst health workers and members of the general population at both lower and higher risk of infection. The beliefs were often factually incorrect and undermining to AIDS control in the field of information, education and communication (IEC). The beliefs were conveyed informally but their origins could often be traced. Local media were important sources. The beliefs were powerful, persistent and resistant to conventional educational methods. Their prevalence and type changed with time in different groups. A model of how the beliefs came to be generated is proposed and reasons suggested for their persistence and strength. A current programme for countering the beliefs is described. An additional important group of policy and scientific beliefs were also identified amongst policy makers and scientists. It is noted that these phenomenon are international and not confined to Africa.

Behavioral characteristics and laboratory parameters in homo- and bisexual men in West Berlin: an evaluation of five years of testing and counselling on AIDS.

Sera of 1980 homo- and bisexual men who visited the Landesinstitut für Tropenmedizin Berlin (West) between April 1983 and December 1987 were tested for HIV antibodies; 24.3% were positive. Of HIV-antibody-positive men, 78.9% reported both active and passive anal intercourse, 58.8%, rectal enemas, and 53.3%, use of butyl nitrite. There was a sexual partner with known positive HIV-antibody status or AIDS in 33.9%, and in 32.4% there was a history of sexual activity in the USA. In the year before the test, 18.8% had had more than 50 partners. All these behavioral characteristics were found to be significantly correlated to HIV antibodies. We noted a substantial reduction of high-risk behavior from 1983 to 1987. The most important behavioral factor for HIV infection in 1983 and 1984 was sexual activity in the USA, and from 1984 to 1987, the numbers of lifetime partners. Persons infected with HIV were significantly more often carriers of antibodies against HAV, HBV, CMV, EBV, and syphilis. Prevalence of antibodies against HIV, HAV, HBV, and syphilis increased with age, duration of homosexual practice, and the number of partners. Overall crude prevalence rates of HIV antibodies, anti-HBc, anti-HAV, and antibodies to syphilis declined during the observation period. Clinical findings such as fever, oral lesions, and lymphadenopathy syndrome (LAS) were found to be highly indicative of HIV infection. Lower hemoglobin values, a reduced white cell count, and hyperimmunoglobulinemia were significantly more frequent in subjects with HIV antibodies.

Time trends of HIV-I antibody prevalence in homosexual men.

1840 homosexual and bisexual men were tested for human immunodeficiency virus type I (HIV) infection at the Landesinstitut für Tropenmedizin, Berlin between April 1983 and December 1987. A total of 25.1% were seropositive for HIV, but the percentage was seemingly declining. During the study period we observed also a steady decrease in the prevalence of lymphadenopathy syndrome (LAS), antibodies to hepatitis B and syphilis, and high-risk sexual behaviour in the study population. By adjusting for these changes of population characteristics we assessed the odds of HIV infection which had more than doubled between 1983 and 1986 (prevalence odds ratio 2.43, 95% confidence interval 1.58 to 3.76). In 1987 the HIV prevalence odds showed a drop which, however, was not significant (p = 0.34) when compared with the odds in 1986. Methodological aspects of time trend estimation based on data of voluntary HIV testing are discussed.

Prevalence of Borrelia burgdorferi in Ixodes ricinus ticks in Berlin (West).

In 1986, 1711 nymphal and adult Ixodes ricinus orginating from Berlin (West) forests were examined individually or in pools of up to 10 ticks for the presence of Borrelia burgdorferi, the etiologic agent of Lyme borreliosis. Detection of borreliae was carried out by means of a culture method using modified Barbour-Stoenner-Kelly-Medium (BSK II). Tick populations from 14 out of 15 locations contained positive specimens. The calculated minimal infection rate of pooled ticks was 2.5% in nymphs (n = 1365), 10.2% in females (n = 59), and 5.3% in males (n = 114). Among those ticks examined individually, none of the nymphs (n = 49) proved to be positive but B. burgdorferi was isolated from 8.2% of the females (n = 73) and 7.8% of the males (n = 51). Fifty-five out of 56 isolates were identified as B. burgdorferi by means of an indirect immunofluorescence test (IFT) using monoclonal antibody H 5332. From these results B. burgdorferi must be considered as being present in the Berlin area.

The skin-dwelling microfilariae of Monanema martini in Lemniscomys striatus as potential drug screening model for onchocerciasis: midazolam effect in vitro.

The murid model of Monanema martini in Lemniscomys striatus was used to evaluate its potential as drug screening model in onchocerciasis. It had been described that the histopathology and the reaction to diethylcarbamazine treatment of this model closely resemble human onchocerciasis. To study further similarities the in vitro effect of midazolam was examined. Skin-dwelling microfilariae (mf) of M. martini were taken by skin snips and placed in either plain phosphat buffered saline or midazolam. Concentrations of 50 micrograms/ml midazolam significantly reduced motility within 15 min. The percentage of fully motile mf dropped to 9.2 and 1.4 after 15 and 30 min, respectively. In contrast to this finding fully motile mf were obtained after intraperitoneal injection of 60 mg/kg BW; but the technique used did not allow to evaluate the in vivo effect of midazolam. The similarities with the human disease and the finding that midazolam paralyses mf of M. martini like mf of O. volvulus in vitro indicate the potential of the model for simulating human onchocerciasis.

The paralyzing effect of midazolam on Onchocerca volvulus microfilariae in vitro.

Midazolam, a water soluble benzodiazepine derivative, inhibited the motility of Onchocerca volvulus microfilariae in vitro at concentrations of 25, 50, and 100 micrograms/ml. The effect was proportional to the concentrations used. Microfilariae regained motility after elimination of midazolam by washing. Diethylcarbamazine did not alter the midazolam effect. It is suggested that the Mazzotti reaction as the sequelae of diethylcarbamazine is caused by transient increased microfilarial migration. Combining midazolam with the diethylcarbamazine medication may prevent the Mazzotti reaction.

Risk factors for HIV infection in German i.v. drug abusers. Clinical, serological and epidemiological features.

A series of 320 German i.v. drug abusers (32.2% female, 67.8% male) were tested in a cross-sectional study for antibodies against HIV. Seroprevalence increased from 0 in those who discontinued i.v. drug abuse before 1982 to 37.2% in those who stopped injecting drugs in 1985/1986 or who were still addicted. Antibodies to HIV were significantly associated with lymphadenopathy and clinical symptoms (fever, weight loss, diarrhea, fatigue, night sweat, dermal lesions) and with markers of hepatitis A and hepatitis B virus infection. Participants of the study admitted in 92.5% of cases to "needle sharing" and in 83.1% of cases to sexual contacts among drug abusers. Prostitution and drug abuse in prison were significantly correlated with seropositivity. No antibodies to HIV infection were detected in 131 subjects of a control group of household contacts.

Active immunization against hepatitis B: immunogenicity of a recombinant DNA vaccine in females, heterosexual and homosexual males.

Three groups of subjects (58 females, 54 heterosexual males, and 50 homosexual males) received three doses of a recombinant DNA yeast-derived hepatitis B vaccine according to a 0, 1, and 6 month vaccination schedule. Local and general side effects were mild. Seroconversion rates after three injections were not significantly different between the groups. Females showed a significantly higher anti-HBs response than both groups of males, and heterosexual males had higher antibody titres than homosexual males. Among the four homosexual non-responders, three were carriers of the human immunodeficiency virus.