The effect of health care worker training on the use of intermittent preventive treatment for malaria in pregnancy in rural western Kenya.

BACKGROUND: In 1998, Kenya adopted intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) for malaria prevention during pregnancy. We conducted a survey in 2002 among women who had recently delivered in the rural neighbouring areas Asembo and Gem and reported coverage of 19% of at least one dose and 7% of two or more doses of SP. Health care workers (HCW) in Asembo were retrained on IPTp in 2003. OBJECTIVES: To evaluate if IPTp coverage increased and if the training in Asembo led to better coverage than in Gem, and to identify barriers to the effective implementation of IPTp. METHODS: Community-based cross-sectional survey among a simple random sample of women who had recently delivered in April 2005, interviews with HCW of antenatal clinics (ANC) in Asembo and Gem. RESULTS: Of the 724 women interviewed, 626 (86.5%) attended the ANC once and 516 (71.3%) attended two or more times. Overall IPTp coverage was 41% for at least one dose, and 21% for at least two doses of SP. In Asembo, coverage increased from 19% in 2002 to 61% in 2005 for at least one dose and from 7% to 17% for two doses of SP. In Gem, coverage increased from 17% to 28% and 7% to 11%, respectively. Interviews of HCW in both Asembo and Gem revealed confusion about appropriate timing, and lack of direct observation of IPTp. CONCLUSION: Training of HCW and use of simplified IPTp messages may be a key strategy in achieving Roll Back Malaria targets for malaria prevention in pregnancy in Kenya.

Risk factors for active syphilis and TPHA seroconversion in a rural African population.

OBJECTIVES: Syphilis is an important cause of morbidity in sub-Saharan Africa, and a cofactor for the sexual transmission of HIV. A better understanding of the prevalence and risk factors of syphilis in African populations would help to formulate effective interventions for its prevention and treatment. METHODS: The prevalence and incidence of syphilis were obtained from a cohort recruited in Mwanza, Tanzania. Two unmatched case-control studies nested within the cohort provide information on potential risk factors. RESULTS: The prevalence of active syphilis (TPHA positive and RPR positive any titre) was 7.5% in men and 9.1% in women, but in youths (aged 15-19 years) the prevalence was higher in women (6.6%) than in men (2.0%). The incidence of TPHA seroconversion was highest in women aged 15-19 at 3.4% per year, and around 2% per year at all ages among men. A higher prevalence of syphilis was found in those currently divorced or widowed (men: OR=1.61, women: OR=2.78), and those previously divorced or widowed (men: OR=1.51, women: OR=1.85). Among men, prevalence was associated with lack of circumcision (OR=1.89), traditional religion (OR=1.55), and reporting five or more partners during the past year (OR=1.81) while incidence was associated with no primary education (OR=2.17), farming (OR=3.85), and a self perceived high risk of STD (OR=3.56). In women, prevalence was associated with no primary education (OR=2.13), early sexual debut (OR=1.59), and a self perceived high risk of STD (OR=3.57), while incidence was associated with living away from the community (OR=2.72). CONCLUSION: The prevalence and incidence of syphilis remain high in this rural African population. More effort is needed to promote safer sexual behaviour, and to provide effective, accessible treatment. The high incidence of syphilis in young women calls for sexual health interventions targeted at adolescents.

Antibody to herpes simplex virus type 2 as a marker of sexual risk behavior in rural Tanzania.

A serosurvey was conducted in a random sample of 259 women and 231 men in 12 rural communities in Mwanza Region, Tanzania, using a type-specific ELISA for Herpes simplex virus type 2 (HSV-2) infection. Seroprevalence rose steeply with age to approximately 75% in women >=25 years old and 60% in men >=30. After adjusting for age and residence, HSV-2 prevalence was higher in women who were married, in a polygamous marriage, Treponema pallidum hemagglutination assay (TPHA)-positive, had more lifetime sex partners, or who had not traveled. Prevalence was higher in men who were married, had lived elsewhere, had more lifetime partners, had used condoms, or were TPHA-positive. HSV-2 infection was significantly associated with recent history of genital ulcer. The association between HSV-2 infection and lifetime sex partners was strongest in those <25 years old in both sexes. This association supports the use of HSV-2 serology as a marker of risk behavior in this population, particularly among young people.

Community perceptions and treatment seeking for malaria in Baringo district, Kenya: implications for disease control.

BACKGROUND: Malaria is one of the leading causes of morbidity and mortality in Kenya. Its control depends on many factors, some of which have not been studied at the level of rural community. OBJECTIVE: To identify what households in a Kenyan rural community perceive to be the cause and symptoms of malaria and their treatment behaviour for malaria. SETTING: Community-based study conducted in Marigat division of Baringo district. DESIGN: Cross-sectional study utilising qualitative ethnographic and semi-quantitative methods. Multi-stage cluster stratified procedure was used to select the villages, after which screening interviews were used to identify households. Finally, interviews and informal discussions were conducted with 463 heads of households with self-reported cases of malaria. The study was conducted between April and October 1992. RESULTS: The study findings indicate that the community has multiple aetiologies for malaria. Of the 463 heads of households interviewed, 258 (58.5%) associated the cause of the disease to the mosquito. Other aetiological beliefs included: wild vegetables (13.1%), water (11%) and milk (9.8%). Many of the respondents (90%) could identify malaria by several correct symptoms. In the treatment of malaria, various health resources such as public health facilities, over-the counter medications, private clinics and herbal medicines are used. For first choice of care, many households used public health facilities. However, if the malaria illness persisted, other forms of treatment especially private clinics and medicinal plants seem to have been preferred. CONCLUSION: Understanding community perceptions of aetiology, symptom identification and treatment of malaria is an important step towards the control of the disease.

Patterns of sexual behaviour in a rural population in north-western Tanzania.

The HIV epidemic in sub-Saharan Africa has been characterised by the predominance of heterosexual transmission. Patterns of sexual behaviour have been implicated in the spread of the epidemic, but few quantitative data are available on sexual behaviour in rural populations in Africa. This paper reports data from a survey of 1117 adults aged 15-54 years selected randomly from twelve rural communities in Mwanza Region, Tanzania. Sexual debut occurred early, 50% of women and 46% of men reporting first sex before age 16. On average, women married 1.8 years and men 6.1 years after their sexual debut. In women, age at sexual debut appears to have increased over time, in parallel with an increase in age at first marriage. Men were generally married later, to women around five to ten years younger than themselves. Marital dissolution and remarriage were common in both sexes. Reported numbers of sexual partners were compared with those recorded in a population survey in Britain. More men reported 10 or more lifetime partners, or three or more partners in the past year, in rural Mwanza (48% and 29%) than in Britain (24% and 6%). Women reported fewer partners, and results were broadly similar to British data. Casual sex during the past year was reported by 53% of the men and 15% of the women, but only 2% of men reported sexual contact with bar girls or commercial sex workers. Only 20% of men and 3% of women had ever used a condom. Interventions are needed to reduce the high levels of sexual partner change and casual sex, and low levels of condom use, recorded in this rural population. Targeting of interventions to traditional "core groups" may be of limited value in rural areas, and additional strategies are needed, focusing particularly on teenagers who are at high risk of HIV and other sexually transmitted diseases.

Sexual behaviour patterns and other risk factors for HIV infection in rural Tanzania: a case-control study.

OBJECTIVE: To examine the association between HIV infection and patterns of sexual behaviour and other risk factors in a rural Tanzanian population in a case-control study, nested within a randomized trial of improved sexually transmitted disease treatment. METHODS: All HIV-positive patients from the baseline survey of the randomized trial were eligible as cases. Cases (n = 338) and controls (a random sample of one in eight HIV-negative persons; n = 1078) were interviewed about risk factors for HIV infection using a structured questionnaire. RESULTS: A significantly higher HIV prevalence was found among men and women not currently employed in farming [men: odds ratio (OR), 2.08; women: OR, 3.65], women who had travelled (OR, 3.27), educated women (OR, 4.51), and widowed/ divorced people compared with those currently married (men: OR, 3.10; women: OR, 3.54). Two spouse-related factors were significantly associated with HIV, even after adjustment for the sexual behaviour of the index case: HIV was more prevalent in men with younger spouses (P = 0.020 for trend) and in women married to men currently employed in manual work, office work or business (OR, 2.20). In women only, blood transfusions were associated with a higher HIV prevalence (OR, 2.40), but only a small population attributable fraction (4%). There was an increased HIV prevalence associated with increasing numbers of injections. Reported number of lifetime sexual partners was significantly associated with HIV infection (women: OR, 7.33 if > or = 10 lifetime partners compared with < or = 1; men: OR, 4.35 for > or = 50 compared with < or = 1). After adjustment for confounders, male circumcision was associated with a lower HIV prevalence (OR, 0.65; P = 0.11). CONCLUSIONS: In these rural communities, many HIV infections occur through sexual transmission. Some people are at high risk of HIV infection through large numbers of sex partners, whereas some are at risk through their spouse or regular partner. The role of circumcision in HIV transmission is unclear. Commercial sex seems to play a negligible role in HIV transmission in these communities. Our results confirm marked heterogeneity in HIV risk, indicating the scope for risk reduction strategies.

PIP: In a baseline survey a cohort of 12,537 adults was enrolled, interviewed, and examined between November 1991 and December 1992 in the Mwanza Region of Tanzania using random cluster sampling. The study itself took place in May and June of 1993, and it consisted of 338 cases (149 men and 189 women) and 1078 controls (504 men and 574 women). The remainder of the analysis of men was restricted to the 149 cases and 394 controls 20-54 years old. The blood samples from consenting adults were tested for HIV antibodies by enzyme-linked immunosorbent assay (ELISA). A significantly higher HIV prevalence was found among men and women not currently employed in farming (men: odds ratio [OR] 2.08; women: OR 3.65), women who had traveled (OR 3.27), educated women (OR 4.51), and widowed/divorced people compared with those currently married (men: OR 3.10; women: OR 3.54). Two spouse-related factors were significantly associated with HIV even after adjustment for the sexual behavior of the index case: HIV was more prevalent in men with younger spouses (p = 0.020 for trend) and in women married to men currently employed in manual work, office work, or business (OR 2.20). In women only blood transfusions were associated with a 2-fold increased prevalence of HIV (OR 2.40), but only a small population-attributable fraction (4%). There was an increased HIV prevalence associated with increasing numbers of injections, even after adjustment for confounders. The reported number of lifetime sexual partners was significantly associated with HIV infection (women: OR 7.33 if or= 10 lifetime partners compared with or= 1; men: OR 4.35 for or= 50 compared with or= 1). After adjustment for confounders, male circumcision was associated with a lower HIV prevalence (OR 0.65; p = 0.11). Most HIV infections occurred through sexual transmission, although some were attributable to nonsterile injections. Since the large number of sexual partners was a major risk factor, intervention strategies should promote the reduction of partners and the use of condoms.