Sensitivity and specificity of HIV rapid tests used for research and voluntary counselling and testing.

BACKGROUND: HIV rapid tests (RT) are a quick and non-technically demanding means to perform HIV voluntary counselling and testing (VCT) but understanding their limitations is vital to delivering quality VCT. OBJECTIVE: To determine the sensitivity and specificity of HIV rapid tests used for research and voluntary counselling and testing at four sites in East Africa. DESIGN: Cross-sectional study. SETTING: Masaka District, Uganda; a sugar plantation in Kakira, Uganda; Coastal Villages in the Kilifi District of Kenya; and the Urban slum of Kangemi located West of Nairobi, Kenya. SUBJECTS: Six thousands two hundred and fifty five consenting volunteers were enrolled into the study, and 675 prevalent HIV infections were identified. RESULTS: The RT sensitivity tended to be high for all assays at all sites (97.63-100%) with the exception of the Uni-Gold assay (90.24% in Kangemi, 96.58% in Kilifi). Twenty four RT results were recorded as 'weak positives', 22 (92%) of which were negative by ELISA. There was a high rate of RT false positives in Uganda (positive predictive values ranging from 45.70% to 86.62%). CONCLUSIONS: The sensitivity and specificity of the RT varied significantly across sites. The rate of RT misclassification in Uganda suggests that a multiple test algorithm may be preferable to a single test as screener for HIV VCT.

Necrotizing enterocolitis: late surgical results after enterostomy without resection.

Between January 1985 and December 1992, 36 neonates were treated for necrotizing enterocolitis (NEC). 13/36 were treated conservatively and 2 (18%) died. 23/36 required surgical treatment at birth and 6/23 (26%) died; 14, out of 17 surviving initial surgery, underwent reintervention to restore intestinal continuity, 3 to 26 months later. In these 14 infants the acute necrotizing process involved the whole colon and ileum in 3 cases, the whole colon in 5, part of the colon in 3, part of the colon and ileum in 2 and was confined to the ileum in 1. 11 cases were perforated. During their first laparotomy all 14 cases had a decompressive enterostomy without resection. 21 reoperations were later needed in these 14 patients: simple enterostomy closure was performed in only 1 case, while resection of delayed strictures was required in 13. 12 cases underwent partial colectomy, 3 of these had multiple segmental resections for skip lesions and only 1 child had a total colectomy. The only postoperative complication was one anastomotic leak. Two children had short-gut syndrome but later outgrew their need for parenteral nutrition. Our experience does not support the need of resecting the gangrenous bowel in the acute phase. A simple diverting enterostomy seems to be effective treatment. Delaying the intestinal resection up to the time of recanalisation allows spontaneous healing and results in the sparing of a significant length of bowel.

Paratesticular rhabdomyosarcoma (RMS) and paraaortic lymphadenectomy.

This study is based on the experience of the Italian Cooperative Studies "AIEOP-RMS 79 and RMS 88". Between October 1979 and December 1989 299 children under 15 years of age with a histologically proven rhabdomyosarcoma (RMS) were examined. We analyzed the problem of the paratesticular localization paying particular attention to the role of surgery in dealing with paraaortic nodes. In the first study (RMS 79) the surgical exploration of retroperitoneal nodes was required: this procedure performed in 11 out of 14 patients affected by paratesticular RMS confirmed the negative data observed with diagnostic investigations. In RMS 88 study the sampling of retroperitoneal nodes was not required in cases with negative radiological findings but suggested in those cases with uncertain signs; two out of 8 patients underwent a laparotomy. In these two cases the results were negative. These 22 children were treated with an adjuvant chemotherapy after surgery and at present they show no evidence of disease.

Involving communities through feedback on evaluation.

PIP: In Uganda, the AIDS Support Organization (TASO) operating principle is community involvement in initiating and defining its own responses to the AIDS crisis. The community established objectives and strategies and selects TASO workers. In the communities of Muswangali (1500 people), Bbira (300 people), Biharwe (2500 people), and Nyeihanga (2500 people), TASO decided that community remobilization was needed. The idea was to involve the communities in the evaluation process. Training sessions were conducted in 1990 and 1991 among community leaders. The outcome were conducted in evaluation, the introduction of KAP surveys, and the initiation of Evaluation Presentation Feedback (EPF) sessions, which would inform the community on pertinent issues. The following topics were selected: self-reported numbers of sexual partners, personal risk perceptions, knowledge on the asymptomatic phase of HIV infections, and prevention strategies suitable to the community. THese topics and survey results were discussed with community members from a variety of age groups in half day workshops. There was a range of numbers of participants in each of the four community workshops, from 50 in Bbira to 500 in Muswangali. TASO trainers familiar with the communities conducted the sessions. EPF sessions used different methods of translating survey results. One way of showing how perceptions may be different from knowledge was to first ask the audience how many partners men had currently had on the average and then to supply the figures from the KAP survey. In one example, the community guessed 2.5 partners, but the actual figures were 1.2 partners. In another session, community partners were asked to interpret and discuss the data and its meaning. The aim of the EPF was to review the survey results and establish new objectives for AIDS programming. For example, in Biharwe and Nyeihanga, there was a need for identified increased condom distribution. The mobilization of these communities was accomplished due to these workshop sessions. Other mechanisms for developing culturally sensitive and appropriate feedback from the community are needed.^ieng