Tuberculosis and HIV: current status in Africa.

PIP: Having radically and permanently altered the face of tuberculosis (TB) in Africa, HIV/AIDS is the major threat to TB control programs in Africa. As HIV prevalence rises, so will TB rates. TB rates will plateau once HIV infection does. The control of TB therefore partly depends upon the control of HIV transmission. The current epidemiological situation is described with regard to TB case notification, incidence estimates, and projections; TB and HIV co-infection; and evidence of the interaction between TB and HIV. The impact of HIV upon the clinical management of TB with regard to diagnostic obstacles and treatment complications is considered, followed by an examination of the threats and opportunities for National Tuberculosis Program activities in Africa in the context of HIV/AIDS. Community-based TB care approaches and the role of isoniazid preventive therapy in HIV-infected people are also considered.^ieng

Recruitment to a trial of tuberculosis preventive therapy from a voluntary HIV testing centre in Lusaka: relevance to implementation.

To determine the number of clients attending for voluntary human immunodeficiency virus (HIV) testing who are able to enter a trial of preventive therapy for tuberculosis, and the factors that determine who receives therapy, we studied 475 consecutive people attending for an HIV test at Lusaka's first voluntary HIV testing centre and the preventive therapy study clinic at the University Teaching Hospital, Lusaka, Zambia. Semi-structured interviews were conducted by counsellors and collated with recruitment data from the trial. Two hundred and twenty-five people were seropositive, of whom 201 returned to collect their results; 77 (38%) of these (16% of the total number screened) entered the trial. Reasons for not entering the trial included exclusion by trial protocol (30), including 18 who had active tuberculosis; psychological adjustment to a positive result (27); death (6); worries about confidentiality (3); the experimental nature of the trial (12); attitudes of staff in the hospital (5); and cost of transport (7). Targeting preventive therapy at those who are already choosing to be tested for HIV seems appropriate and may be cost-effective. Although visiting a hospital may deter some people, the prevalence of active tuberculosis among this group emphasized the importance of arranging adequate screening facilities.

Impact of HIV infection on Zambian businesses.

PIP: In Zambia, an assessment was made of mortality and morbidity trends from 1987 to 1993 with data collected from the records of 33 companies. Death rates were calculated by dividing the annual number of deaths by the total number of employees at the end of each year. The average total number of employees during the study period was 10,204. The crude death rate among this population increased sequentially (P 0.001) from 0.25 per 100 person years in 1987 to 1.83 in 1993. (Average annual mortality between ages 15 and 60 years old in developing countries is 0.5 per 100 person years.) Most companies do not record cause of death, so this increase can not be absolutely attributable to AIDS. However, there was an increase in reporting death from AIDS and from tuberculosis and diarrhea, which are strongly associated with the disease. Since unemployment is a major problem in Zambia, there are many residents with less income and poorer nutrition than these workers. None of the company managers commented on possible demographic causes for this striking increase. Some managers had noticed increased mortality in their companies, but the aggregate figures really tell the tale.^ieng

Building an effective response. International cooperation.

PIP: The response to the AIDS epidemic in Zambia in 1985 was constrained by 1) a downturn in the economy and 2) denial on the part of government. Finally in 1986 the government recognized AIDS was a major public health problem, but it concentrated on mobilizing support from international organizations. During 1988-89 one local nongovernmental organization (NGO) in Zambia recognized that care for people with AIDS was a necessary condition of modifying sexual ritual cleansing. They have been particularly successful in organizing preventive measures as well as taking care of people with AIDS in the community. The concerns expressed by Zambian NGOs encompass guaranteed donor and government funding for NGOs and for the future; the benefit of innovative strategies for all Zambians; and agreement on the best strategies. The Zambian government since 1990 has moved to develop a health reform policy to ensure leadership by government; accountability towards Zambia's people; and the building of partnership with the public, NGOs, and donors. The government, in collaboration with major donors and NGOs, has articulated a Strategic Health Plan. The major items of the Plan are: a) a coordinator for donors and NGOs has been appointed within the Ministry of Health, b) donors have agreed to standardize the reporting and evaluation of donor-supported programs, c) in order to improve the financial accounting system and consequently accountability at the district level, one major donor has funded a training program for accounts assistants, d) the government has agreed to guarantee the Ministry of Health's funding under an agreement reached with the World Bank, and to implement a multisectoral plan in the fight against AIDS, and e) NGOs are moving to establish an administrative secretariat to assist in coordination of their activities.^ieng

Understanding lay perspectives: care options for STD treatment in Lusaka, Zambia.

Understanding lay persons' perceptions of STD care is critical in the design and implementation of appropriate health services. Using 20 unstructured group interviews, 10 focus group discussions and 4 STD case simulations in selected sub-populations in Lusaka, we investigated lay person perspectives of STD services. The study revealed a large diversity of care options for STD in the communities, including self-care, traditional healers, medicine sold in the markets and streets, injections administered in the compounds, private clinics, health centres and hospital. The factors identified as influencing care seeking behaviour are: lay referral mechanisms, social cost, availability of care options, economics, beliefs, stigma and quality of care as perceived by the users.

PIP: Lusaka's health system is comprised of 4 hospitals, 22 government urban health centers, 144 private for-profit clinics, and more than 1000 traditional healers and traditional birth attendants. The authors explored laypeople's perspectives of sexually transmitted disease (STD) care services using 20 unstructured group interviews, 10 focus group discussions, and 4 STD case simulations in selected subpopulations of the city. People of differing age and sex were sampled. A large diversity of care options for STD was found in the communities, including self-care, traditional healers, medicine sold in the markets and streets, and injections administered in the compounds, private clinics, health centers, and hospitals. Lay referral mechanisms, social cost, the availability of care options, economics, beliefs, stigma, and the quality of care as perceived by users influence care-seeking behavior in this population.

How have Zambian businesses reacted to the HIV epidemic?

OBJECTIVES: To evaluate the impact of HIV on businesses in Zambia and to assess attitudes towards HIV and HIV education in the workplace. METHODS: The personnel managers of 33 companies with a total workforce of 10,204 in Lusaka and in towns in the Copperbelt were visited by two members of the study team. The study was discussed and a questionnaire about the impact of HIV on their company was explained and left for completion from company records. RESULTS: All 33 questionnaires were returned. HIV was recognised to be a problem by 30 companies questioned. Seven said that it had affected recruitment and 11 production. 23 companies carried out pre-employment medicals. 17 companies demanded that some or all of their employees had an HIV test before employment. Nine companies were sure that a positive HIV test would prevent employment, 15 were unsure saying that there was no particular company policy. Two companies had recently changed their policy and had stopped discriminating against those with HIV. 12 companies had some HIV educational material available for their employees and five had someone (or an organisation that they used) to whom they could refer employees for HIV information and advice. Condoms were provided free to staff by five of the companies. All thought that HIV education in the workplace was an appropriate intervention. Mortality data showed a sevenfold increase in the crude mortality from 0.25-1.8 per 100 person-years from 1987-93, and an increasing trend in reported deaths from AIDS and HIV related conditions. CONCLUSIONS: HIV is having an important impact in the workplace in urban Zambia. Although many companies insist on pre-employment medicals, often including HIV testing, few have developed policies relating to test results. Some companies have instituted HIV education but there is a demand for this service to be available more widely. There has been a striking increase in mortalities in this working population, which seems likely to be related to HIV, although the cause of most deaths was not recorded.

PIP: The Kara Counselling and Training Trust (KCTT), a Zambian nongovernmental organization, launched an investigation of the impact of HIV on businesses in the country. 33 companies were visited by two members of the study team between June and August 1993. 25 of the companies were located in Lusaka and 8 were based in the Copperbelt mining region. The profile of the companies consisted of accountancy, vehicles sales and assembly, food and beverage manufacturing, and farming. A questionnaire was left with the personnel managers to be filled out. The total number of employees was 10,204 (79% men and 21% women). 30 managers thought that HIV had affected their companies in some way. 11 said that productivity was affected and 7 cited recruitment. The main worry was the loss of trained and highly skilled staff who were difficult to replace. 7 managers made changes about company policy regarding funeral leave because increasing numbers of employees were attending funerals. Holiday leave was required for attending funerals. In 32 companies the crude death rate increased sequentially (p .001) from .25/100 person years in 1987 to 1.83/100 person years in 1993. There were 26 deaths among 10,319 employees in 1987 vs. 187 deaths among 10,204 in 1993. 23 companies carried out medical tests on some or all employees before hiring them. 9 companies asked some of their employees to have an HIV test before employment. 2 companies, which had previously carried out such tests, changed their policy. Only 7 companies were certain that a positive test would not prevent employment, 15 firms were unsure, and 9 said that a positive test would preclude employment. 12 firms had some form of HIV education at the workplace (posters in locker rooms, but not formal education). 5 companies had HIV counseling available mainly by referral to a counseling service. 5 companies provided condoms to their employees. All companies recognized that HIV education was indispensable and were interested in HIV outreach education.

Effect of iron chelation therapy on recovery from deep coma in children with cerebral malaria.

BACKGROUND: Cerebral malaria is a severe complication of Plasmodium falciparum infection in children, with a mortality rate of 15 to 50 percent despite antimalarial therapy. METHODS: To determine whether combining iron chelation with quinine therapy speeds the recovery of consciousness, we conducted a randomized, double-blind, placebo-controlled trial of the iron chelator deferoxamine in 83 Zambian children with cerebral malaria. To be enrolled, patients had to be less than six years old, have P. falciparum parasitemia, have normal cerebrospinal fluid without evidence of bacterial infection, and be in a coma from which they could not be aroused. Deferoxamine (100 mg per kilogram of body weight per day, infused intravenously for 72 hours) or placebo was added to standard therapy with quinine and sulfadoxine-pyrimethamine. The time to the recovery of full consciousness, time to parasite clearance, and mortality were examined with Cox proportional-hazards regression analysis. RESULTS: The rate of recovery of full consciousness among the 42 patients given deferoxamine was 1.3 times that among the 41 given placebo (95 percent confidence interval, 0.7 to 2.3); the median time to recovery was 20.2 hours in the deferoxamine group and 43.1 hours in the placebo group (P = 0.38). Among 50 patients with deep coma, the rate of recovery of full consciousness was increased 2.2-fold with deferoxamine (95 percent confidence interval, 1.1 to 4.7), decreasing the median recovery time from 68.2 to 24.1 hours (P = 0.03). Among 69 patients for whom data on parasite clearance were available, the rate of clearance with deferoxamine was 2.0 times that with placebo (95 percent confidence interval, 1.2 to 3.6). Among all 83 patients, mortality was 17 percent in the deferoxamine group and 22 percent in the placebo group (P = 0.52). CONCLUSIONS: Iron chelation therapy may hasten the clearance of parasitemia and enhance recovery from deep coma in cerebral malaria.

PIP: Cerebral malaria is a severe complication of Plasmodium falciparum infection in children, with a mortality rate of 15-50% despite antimalarial therapy. In order to determine whether combining iron chelation with quinine therapy speeds recovery of consciousness, the authors conducted a randomized, double-blind, placebo-controlled trial of the iron chelator deferoxamine in 83 Zambian children with cerebral malaria. To be enrolled, patients had to be under age 6, have P. falciparum parasitemia, have normal cerebrospinal fluid without evidence of bacterial infection, and be in a coma from which they cannot be aroused. Deferoxamine (100 mg/kg of body weight/day, infused intravenously for 72 hours) or placebo was added to standard therapy with quinine and sulfadoxine-pryimethamine. The time to recovery of full consciousness, time to parasite clearance, and mortality were examined with Cox proportional-hazards regression analysis. The rate of recovery of full consciousness among the 42 patients given deferoxamine was 1.3 time that among the 41 who received the placebo (95% confidence interval [CI], 0.7-2.3; the median time to recovery was 20.2 hours in the deferoxamine group, and 43.1 hours in the placebo group (p=0.38). Among 50 patients in deep coma, the rate of recovery of full consciousness was increased 2.2-fold with deferoxamine (95% CI, 1.1-4-7), decreasing the median recovery time from 68.2 to 24.1 hours (p=0.03). Among 69 patients for whom data on parasite clearance were available, the rate of clearance with deferoxamine was 2.0 times that with placebo (95% CI, 1.2-3.6). Among all 83 patients, mortality was 17% in the deferoxamine group and 22% in the placebo group (p=0.52). It is concluded that iron chelation therapy may speed the clearance of parasitemia and enhance recovery from deep coma in cerebral malaria.