One year after ART initiation: psychosocial factors associated with stigma among HIV-positive Mozambicans.

The pathways through which stigma is associated with psychological distress remains understudied in Africa. This study evaluates stigma among 277 Mozambicans who were on an antiretroviral therapy (ART) regimens for a full year. Using bivariate and multiple regression analyses, we examine psychosocial factors (disclosure decisions, perceived social support, and depression) associated with stigma, at ART initiation and 1 year later. We found 1 year after initiating ART, participants reported no change in stigma, a decrease in perceived social support, and an increase in depressive symptomology. Disclosing HIV status to friends (versus family or partner) was associated with lower levels of stigma. These findings suggest that HIV care in comparable settings should include counselling, support groups, and peer support, that includes stigma and disclosure concerns prior to and during the first year following diagnosis. Most importantly, assessment and treatment of depression should be incorporated into ongoing HIV care.

Treatment partners and adherence to HAART in Central Mozambique.

Adherence to highly active antiretroviral treatment (HAART) has been associated with increased survival rates and decreased drug resistance in various settings. There is growing concern that loss to follow-up will increase and adherence rates will decrease as HAART programs are expanded in resource-limited settings. In Central Mozambique, an innovative program was implemented, using community-based (trained community activists) and self-selected (family members or friends) "treatment partners" to provide psycho-social support to patients on HAART. We calculated adherence rates based on pharmacy records for all patients who refilled their medication for at least six consecutive months between September 2004 and June 2006. Medical charts were reviewed for a subset of 375 patients having high (> or =90%) adherence and 59 patients having low (<90%) adherence. Multivariate logistic regression analysis assessed the association between the type of treatment partner used and adherence to HAART. A total of 305 patients (70%) had self-selected treatment partners, 121 (28%) had community-based treatment partners, and 8 (2%) had no treatment partner. In adjusted analysis, patients who had no treatment partner were more likely to have low adherence (OR 9.47; 95% confidence interval 2.37-37.86 compared to self-selected treatment partner). Patients with community-based treatment partners did not have significantly lower adherence than patients with self-selected treatment partners. While it cannot be determined from these data which aspects or types of peer support are most effective in maintaining adherence, it appears that peer support was beneficial to this study population. While the study results are not directly applicable to other populations, other HAART programs should consider the potential benefit of providing treatment support to patients.

Effects of Xpert® MTB/RIF testing and GxAlert on MDR-TB diagnosis and linkage to care in Mozambique.

SETTING: The diagnosis of multidrug-resistant tuberculosis (MDR-TB) and gaps in linkage to care are the principal health challenges in Mozambique. Five GeneXpert machines and GxAlert, an eHealth platform, were installed in Sofala and Manica Provinces between 2012 and 2014. OBJECTIVE: To test the effects of Xpert® MTB/RIF testing and GxAlert on rifampin-resistant TB (RR-TB) diagnosis and second-line treatment initiation rates. DESIGN: We conducted a retrospective clinical review of patients with RR-TB from March 2012 to September 2015 at these five sites. Time-series analyses were conducted to investigate the impact of Xpert on case detection and treatment. Pre- and post- analyses were conducted to investigate the impact of GxAlert. RESULTS: A total of 32 182 Xpert tests were conducted: 4010 (12.5%) detected TB without rifampin resistance, and 306 (7.1%) had RR-TB. Of the RR-TB cases, 161 (52.6%) were started on MDR-TB treatment, 6.9% had documented culture results, and time from diagnosis to treatment initiation decreased over time. The absolute number of patients diagnosed and started on MDR-TB treatment increased by 0.26 (95%CI 0.15-0.38, P < 0.001) and 0.16 (95%CI 0.089-0.24, P < 0.001) every 6 months. GxAlert did not affect treatment initiation rates. CONCLUSION: Implementation of Xpert testing was associated with increases in the number of patients diagnosed and started on MDR-TB treatment.

Remote monitoring of Xpert® MTB/RIF testing in Mozambique: results of programmatic implementation of GxAlert.

SETTING: Electronic diagnostic tests, such as the Xpert® MTB/RIF assay, are being implemented in low- and middle-income countries (LMICs). However, timely information from these tests available via remote monitoring is underutilized. The failure to transmit real-time, actionable data to key individuals such as clinicians, patients, and national monitoring and evaluation teams may negatively impact patient care. OBJECTIVE: To describe recently developed applications that allow for real-time, remote monitoring of Xpert results, and initial implementation of one of these products in central Mozambique. DESIGN: In partnership with the Mozambican National Tuberculosis Program, we compared three different remote monitoring tools for Xpert and selected one, GxAlert, to pilot and evaluate at five public health centers in Mozambique. RESULTS: GxAlert software was successfully installed on all five Xpert computers, and test results are now uploaded daily via a USB internet modem to a secure online database. A password-protected web-based interface allows real-time analysis of test results, and 1200 positive tests for tuberculosis generated 8000 SMS result notifications to key individuals. CONCLUSION: Remote monitoring of diagnostic platforms is feasible in LMICs. While promising, this effort needs to address issues around patient data ownership, confidentiality, interoperability, unique patient identifiers, and data security.

Treatment of acute childhood diarrhea with homeopathic medicine: a randomized clinical trial in Nicaragua.

OBJECTIVE: Acute diarrhea is the leading cause of pediatric morbidity and mortality worldwide. Oral rehydration treatment can prevent death from dehydration, but does not reduce the duration of individual episodes. Homeopathic treatment for acute diarrhea is used in many parts of the world. This study was performed to determine whether homeopathy is useful in the treatment of acute childhood diarrhea. METHODOLOGY: A randomized double-blind clinical trial comparing homeopathic medicine with placebo in the treatment of acute childhood diarrhea was conducted in León, Nicaragua, in July 1991. Eighty-one children aged 6 months to 5 years of age were included in the study. An individualized homeopathic medicine was prescribed for each child and daily follow-up was performed for 5 days. Standard treatment with oral rehydration treatment was also given. RESULTS: The treatment group had a statistically significant (P < .05) decrease in duration of diarrhea, defined as the number of days until there were less than three unformed stools daily for 2 consecutive days. There was also a significant difference (P < .05) in the number of stools per day between the two groups after 72 hours of treatment. CONCLUSIONS: The statistically significant decrease in the duration of diarrhea in the treatment group suggests that homeopathic treatment might be useful in acute childhood diarrhea. Further study of this treatment deserves consideration.

An evaluation of vital registers as sources of data for infant mortality rates in Cameroon.

BACKGROUND: Infant mortality rates have been widely used as indicators of health status and the availability, utilization and effectiveness of health services. Two principal sources of data for infant mortality rates are vital registers and censuses. This study was designed to evaluate the accuracy of vital registers as sources of data for infant mortality rates in Cameroon. METHODS: A household census of births and infant deaths that occurred in Buea Subdivision between 1 November 1991 and 31 October 1992 was conducted to determine the proportion that were registered and the reasons why the remainder were not registered. RESULTS: The registration coverage was found to be 62% for births and 4% for infant deaths. The most frequently reported reasons for not registering births were lack of money, lack of time and a complicated registration procedure. For infant deaths the reasons were lack of knowledge and no perceived benefits. CONCLUSIONS: Vital registers of birth and death are not an accurate source of data for infant mortality rates in Cameroon. Motivation for birth and death registration appear to be dependent on the perceived benefits. A mechanism of registration that uses medical institutions may substantially increase registration coverage for births and infant deaths.

PIP: The aim was to evaluate the accuracy of vital registers in reporting of infant mortality in Cameroon. Vital registration in Cameroon is dependent on parents filing the papers with the district attorney and paying 600 francs. Birth certificates are required for family allowance claims by employees, tax deductions, school attendance, applications for employment, national identity cards, and proof of paternity. Death certificates are required for insurance claims, inheritance, transportation only of the deceased, and cessation of family allowances. Data were obtained from the Buea Subdivision of the southwest province of Cameroon in November and December, 1992, from interviews from 30 high school and university students, and a household census of 6178 households in the 23 villages. All births and deaths were recorded that occurred between November 1, 1991, and October 21, 1992. Registration data from the councils was also obtained for the same period. The results indicated 1569 births and 106 infant deaths. 98% of births were in health institutions. 1% of urban births occurred at home and 4% of rural births occurred at home. 53% of infant deaths occurred in health institutions and 47% occurred at home. 44% of urban deaths occurred at home and 40% of rural deaths occurred at home. 62% of all reported births were registered: 69% in urban areas and 52% in rural areas. 80% of births were registered within a month after births. Only 33% of reported births could be confirmed by a birth certificate since they were kept by the father. 84% of births were registered by fathers or male relatives. 4% of infant deaths were reported to have been registered. 32% occurred prior to discharge from the health institution. Cross checking of reported and registered births was not possible, since anonymity was protected. The council had registered 1716 births, who ranged in age at time of registration, from 1 day to 59 years. 52% were under 1 year old at registration. Registration increased at aged 4, 10-13, and 17-20 years. 59 deaths were registered by the council, of which 90% were registered by the end of the 4th month following the death, but only 7% were infant deaths. Family allowance was found to be significantly associated with birth registration. Coverage and timeliness would be substantially improved by registration in medical institutions; elimination of registration fees would also increase coverage.

Characteristics of drug resistance and HIV among tuberculosis patients in Mozambique.

SETTING: The rate of human immunodeficiency virus (HIV) seroprevalence among tuberculosis patients varies between 2% and 53% in Mozambique, depending on the region. Drug resistance surveillance has been performed in only a few cities in Mozambique. OBJECTIVES: To establish the extent of drug resistance in areas of Mozambique with different levels of HIV prevalence, to estimate the prevalence of HIV among tuberculosis (TB) patients, and to examine the association between drug resistance and HIV infection. DESIGN: All tuberculosis patients diagnosed at randomly selected health facilities over 9 months (September 1998 to June 1999) were enrolled in the study. Sputum was collected, smeared and cultured, and drug susceptibility tests were performed. Blood was tested for HIV in the respective provinces, and patients received pre-test and post-test counselling. RESULTS: Of 709 culture-positive cases, 25.5% were HIV-positive. HIV-positive patients were significantly more likely to have a prior history of treatment (OR 2.2; 95% CI 1.9-3.6) and resistance to both isoniazid and streptomycin (OR 2.3; 95% CI 1.3, 4.5). In patients with no history of prior tuberculosis treatment, the multidrug resistance rate was 3.4% and resistance to isoniazid and streptomycin (HS) was 5.2%. Any drug resistance was significantly more common among those with a history of prior treatment (OR 3.1; 95% CI 2.1-4.7), particularly resistance to HS (OR 4.5; 95% CI 2.6-7.9). CONCLUSIONS: This study demonstrates substantial levels of drug resistance in Mozambique. Differences in drug resistance between high and low HIV prevalence areas may be related to prior treatment.

Intrahousehold resource allocation and child growth in Mozambique: an ethnographic case-control study.

This study examines the effect of intrahousehold cash income control and decision-making patterns on child growth in the rural town of Sussundenga in Manica Province, Mozambique. A case-control study design was used to examine the influence of men's and women's disaggregated cash incomes on child growth. The research tested whether greater maternal share of household cash income was associated with (1) increased maternal decision-making and bargaining power in the household, and (2) better child growth. Fifty case households, with children 1-4 years old exhibiting poor growth, were matched with 50 control households of similar socioeconomic status in which all children under five demonstrated healthy growth. Data were gathered on gender-specific income generation and expenditure, specific intrahousehold allocation processes, diet, and sociodemographic variables using a formal survey. Key informant interviews, focus groups, and observation over one year provided ethnographic context for the case-control findings. Case-control differences were analyzed using McNemar's test, paired t-test, and conditional logistic regression. In spite of matching households for socioeconomic status, control household incomes were still slightly greater than cases. Male spouse income was also higher among controls while maternal income, and maternal proportion of household income, were not significantly different. Household meat, fish and poultry consumption, and maternal education were significantly greater among control households than cases. Greater maternal share of household income was not associated with greater maternal decision-making around cash. However, mothers must spend what little cash they earn on daily food supplies and usually request additional cash from spouses to cover these costs. There is evidence that if mothers earn enough to cover these socially prescribed costs, they can spend cash for other needs. Above this threshold, women's earnings may confer more bargaining power. The research also revealed a nuclearization of households, attenuation of community bonds of mutual aid, and increasing importance of cash for survival.

Hearing loss prevalence and risk factors among Sierra Leonean children.

OBJECTIVES: To determine hearing loss prevalence among a group of Third World children, to describe the physical examination and audiometric findings in the hearing-impaired children, and to assess the association of hearing loss with several known risk factors. It was hypothesized that chronic otorrhea would be the risk factor most strongly associated with hearing loss. DESIGN: Community screening program to identify and evaluate hearing-impaired children. Case-control analysis of hearing loss risk factors. A survey taker, blinded to the children's hearing status, ascertained risk factors. SETTING: Rural community in eastern province of Sierra Leone, West Africa. PATIENTS: Population-based sample of 2015 children aged 5 to 15 years. Risk factor analysis was performed in 184 children and an equal number of matched controls. MAIN OUTCOME MEASURE: Hearing loss determined according to World Health Organization, Geneva, Switzerland, definition. RESULTS: A total of 184 (9.1%) of 2015 children were found to have mild or greater hearing loss. The prevalence of bilateral profound hearing impairment was 4.0 per 1000. We assessed physical examination and audiometric findings. The risk factor most strongly associated with hearing loss was a history of otorrhea persisting longer than 1 month (odds ratio, 23.3; 95% confidence limits, 12.11, 45.40). CONCLUSIONS: A high prevalence of hearing loss was identified. Much of this impairment may result from chronic untreated or unrecognized ear infections. Further community-based studies of hearing-impaired children are necessary for planning preventive and curative programs.

The effects of peer education on STD and AIDS knowledge among prisoners in Mozambique.

The study was designed to evaluate the impact of education on AIDS knowledge among prison inmates in Maputo, Mozambique. A 6-month follow-up study was carried out in 1993 among 300 prisoners. A knowledge, attitudes, and practices questionnaire regarding AIDS and STD was administered to each subject as part of the intake medical examination and after an educational intervention provided by 30 prisoner 'activists'. A large proportion of prisoners had high risk behaviours (65% had 2 or more sexual partners per month and 39% had a history of STD) and low AIDS knowledge at incarceration. Statistically significant increases in knowledge occurred after the intervention. Prisoners with less formal education had a poorer performance on the initial questionnaire (43% vs 69% P < 0.00001) and had a greater improvement after the intervention (41% vs 24%, P < 0.00001). The results demonstrate that educational interventions involving peer health educators contribute positively to the acquisition of knowledge among prisoners.

Syphilis and HIV infection among prisoners in Maputo, Mozambique.

A cross-sectional study was carried out among 1284 male and 54 female prisoners to assess the prevalence of and risk factors for sexually transmitted diseases (STD) in 4 correctional institutions of Maputo, Mozambique. Among the men, 32% reported a history of prostitute contact and 41% reported a history of STD. Only 9% reported having ever used condoms. Seventy (5.5%) men reported having had sexual intercourse while in prison, in all but one instance this involved sex with another man. There was no reported intravenous drug use. One hundred and four (7.8%) inmates had positive serological tests for syphilis and 8 (0.6%) had antibodies to HIV. Among men, syphilis was associated with a history of genital ulcer [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 1.4, 6.4] and uncircumcised status (OR = 1.5, 95% CI = 1.0, 2.5). This study demonstrates that syphilis is common among inmates in Maputo and that risk behaviours for STD transmission exist within Maputo prisons. There is a need for STD screening and treatment programmes within prisons in Mozambique and the introduction of educational interventions, including condom promotion.

PIP: Syphilis is a major public health problem in Mozambique, with 603 of 14,036 blood donations made at the central hospital in Maputo during 1990 being positive on VDRL testing. There were approximately 2340 prisoners held at Machava, Mutatele, and Hanhane prisons, and Cadeia civil jail between September 1990 and February 1991, the period during which a cross-sectional study was conducted to determine the prevalence of and risk factors for sexually transmitted diseases (STDs) among inmates in the 4 facilities. 1284 male and 54 female inmates voluntarily agreed to participate in the study. The men were of mean age 26.2 years (range, 15-70 years) and had been in jail an average of 5.5 months. 36% of the men reported having been imprisoned on at least one previous occasion. The men and women reported having a mean 1.6 and 1.2 sex partners per week, respectively, before their detention. 32% of men reported having a history of sexual relations with prostitutes; 41% and 17% of men and women, respectively, reported a history of STDs; and 9% of men and no woman reported ever having used condoms. 7.9% of men and 3.7% of women had syphilis. 70 men reported having sexual intercourse in jail, 69 of whom reported such intercourse as being with other men. 0.6% of men and no woman had antibodies to HIV. There was no reported IV drug use among respondents. Among men, syphilis infection was significantly associated with a history of genital ulcers and being uncircumcised. 64% of the men were uncircumcised. STD screening and treatment programs, educational interventions, and condom promotion are needed in Mozambique's prisons.

Syphilis and HIV infection among displaced pregnant women in rural Mozambique.

A cross-sectional study was conducted among displaced pregnant women in Mozambique to determine the prevalence and correlates of HIV infection and syphilis. Between September 1992 and February 1993, 1728 consecutive antenatal attendees of 14 rural clinics in Zambézia were interviewed, examined, and tested for HIV and syphilis antibodies. The seroprevalence of syphilis and HIV were 12.2% and 2.9%, respectively. Reported sexual abuse was frequent (8.4%) but sex for money was uncommon. A positive MHA-TP result was significantly associated with unmarried status, history of past STD, HIV infection, and current genital ulcers, vaginal discharge, or genital warts. Significant correlates of HIV seropositivity included anal intercourse, history of past STD, and syphilis. In summary, displaced pregnant women had a high prevalence of syphilis but a relatively low HIV seroprevalence suggesting recent introduction of HIV infection in this area or slow spread of the epidemic. A syphilis screening and treatment programme is warranted to prevent perinatal transmission and to reduce the incidence of chancres as a cofactor for HIV transmission.

Impact of traditional birth attendant training in Mozambique: a controlled study.

This study was designed to assess the utility and impact on perinatal mortality of a model traditional birth attendant (TBA) training program in rural Mozambique by comparing birth attendance and outcomes in similar communities with and without trained TBAs. Birth attendants and pregnancy outcomes were compared in 1) communities with good access to trained TBAs, 2) randomly selected, comparable communities with no access to trained TBAs, and 3) communities with good access to functioning maternities. Information was collected by interviews with women in randomly selected households. A total of 4,169 women were interviewed who reported on 3,616 completed pregnancies, which resulted in a birth or fetal death. Among women with good access to trained TBAs, 33% reported giving birth attended by a trained TBA, 43% reported giving birth at a health facility, and 24% reported giving birth attended by an untrained person. Among women without access to trained TBAs, 58% reported giving birth at health facilities, and 42% reported attendance by untrained persons. Among women with access to functioning maternity centers, 77% reported giving birth at a health facility and 22% said their birth was attended by an untrained person. There was no significant difference in perinatal or infant mortality among the groups. This study demonstrated a preference for health facility deliveries among rural Mozambican women with good access to trained TBAs. It also failed to demonstrate a reduction in perinatal or infant mortality associated with TBA training. Women said they preferred to deliver in health facilities because conditions were considered better and interventions could be performed if needed. The preference for health facility birth over home birth with a TBA may have been related to difficulties with TBA neighbors and their families or fear of potential witchcraft. Efforts to promote TBA training should be balanced with support for birthing services based in health facilities.

Breastfeeding and weaning practices in rural Mexico.

This report describes the breastfeeding and weaning practices of rural women in two Mexican towns and the cultural beliefs upon which these practices are based. Interviews and focus group discussions were used to collect information. Women thought breastfeeding preferable to bottle-feeding. Eighty percent initiated breastfeeding and 69% gave colostrum. Breastfeeding was discontinued early (mean age 4 months). The mean age at which children were introduced to other liquids was 2 months (range 0-5 months) and to solids, 4 months (range 1-8 months). Women's decisions regarding infant feeding were influenced most by custom and advice from doctors and family members. In some instances medical advice conflicted with traditional practices. These findings suggest important avenues for intervention in hospital practices, education for health care workers, and in the development of health promotion services.

PIP: The impact of culture and community factors on breast feeding and weaning practices is examined by means of interviews among 35 rural women aged 16-43 years from Jalisco, Mexico, and by means of focus group discussions. Breast feeding practices are gleaned from information provided by mothers on their youngest child aged 2 weeks to 17 months for a 24 hour period prior to the interview. All study infants were given breast milk, supplements of water, and other liquids from birth. Fresh or powdered cow's milk was the usual supplement, except for 5 infants who received commercial formula. Boiled water was used in rehydrating powdered milk. Breast milk substitution was a bottle or cup given 2-4 times daily. The introduction of solid foods was made at 1 month to 8 months of age. Foods ranged from beans, tortillas, bread, pasta, fruit, chicken soup, flavored gelatin, to soft drinks. Between 9 months and 23 months, toddlers were fed the same foods in addition to vegetables, beef, fish, egg, cookies, and prepackaged cold cereal. The reasons given for not breast feeding were illness of the mother, a breast problem, insufficient milk, or an ill child. Colostrum was given for the following reasons: doctor's advice, the best interests of the baby, a woman's preference, custom, and no reason. Colostrum was not given for a variety of reasons including, for example, when the doctor advised against it or when a woman was ill or had a breast problem. In the three focus groups (27 persons), breast feeding was mentioned as preferable because of the added protection given the baby, the convenience of the mother, and the exchange between mother and infant. Other important factors were the improved health of the baby, the absence of cleanliness problems, and the milk was the right temperature. Exclusive breast feeding was recommended for a duration of 3-9 months. Breast feeding was withheld for 4-5 hours if a child had vomiting or diarrhea, or had been in the sun too long. Weaning was considered appropriate anytime between 2 months and 12 months of age. Weaning occurred when the mother was unable to continue or the child wanted to stop or had teeth. There was disagreement about how quickly to complete the process of weaning. Food was introduced at 2 to 6 months of age when milk was not enough to satisfy the child's hunger.

Nutritional status of rural Bolivian children.

While providing health care in rural Bolivia, 349 children under 4 years old were seen. Height and weight were measured and demographic data obtained. The purpose was to describe the prevalence of malnutrition and its associated socioeconomic factors. The sample included Mataco Indians and Bolivians of European or of mixed descent. Using international standards, 21% of the children had weight below the fifth percentile for age; 27% had height below the fifth percentage for age; 17% were below the fifth percentile for weight/height. Malnutrition was more common in younger children (peak prevalence in 1-2 year olds). Malnutrition was associated with race and water source, but not with family size, literacy, immunizations, meals per day, or deaths in family. Attempts to improve nutrition should focus on the youngest children.

PIP: The authors measured height and weight and obtained demographic data for 349 children under 4 years of age in rural Bolivia for the purpose of describing the prevalence of malnutrition and its associated socioeconomic factor. The sample included Mataco Indians and Bolivians of European or of mixed descent. On the basis of international standards, 21% had weight below the 5th percentile for age; 27% had height below the 5th percentile for age; and 17% were below the 5th percentile for weight/height. Malnutrition was most common in younger children, with a peak prevalence among 1-2 year olds. Malnutrition was associated with race and water source, but not with family size, literacy, immunizations, meals per day, or deaths in the family. These findings suggest that attempts to improve nutrition should focus on the youngest children.

Modeling HIV transmission risk among Mozambicans prior to their initiating highly active antiretroviral therapy.

Understanding sexual behavior and assessing transmission risk among people living with HIV-1 is crucial for effective HIV-1 prevention. We describe sexual behavior among HIV-positive persons initiating highly active antiretroviral therapy (HAART) in Beira, Mozambique. We present a Bernoulli process model (tool available online) to estimate the number of sexual partners who would acquire HIV-1 as a consequence of sexual contact with study participants within the prior three months. Baseline data were collected on 350 HAART-naive individuals 18-70 years of age from October 2004 to February 2005. In the three months prior to initiating HAART, 45% (n = 157) of participants had sexual relationships with 191 partners. Unprotected sex occurred in 70% of partnerships, with evidence suggesting unprotected sex was less likely with partners believed to be HIV-negative. Only 26% of the participants disclosed their serostatus to partners with a negative or unknown serostatus. Women were less likely to report concurrent relationships than were men (21 versus 66%; OR 0.13; 95%CI: 0.06, 0.26). Given baseline behaviors, the model estimated 23.2 infections/1,000 HIV-positive persons per year. The model demonstrated HAART along with syphilis and herpes simplex virus type 2 (HSV-2) treatment combined could reduce HIV-1 transmission by 87%; increasing condom use could reduce HIV-1 transmission by 67%.

Condom use after voluntary counselling and testing in central Mozambique.

OBJECTIVE: To evaluate the efficacy of voluntary counselling and testing (VCT) for HIV/AIDS in changing risky sexual behaviour in central Mozambique. METHOD: Longitudinal cohort study of men and women aged at least 18 years from October 2002 to June 2003. We interviewed 622 participants in VCT groups and 598 in non-VCT groups. The interviews occurred before counselling and 4 and 6 months afterwards. RESULTS: Reported use of condoms while having sex with a friends/prostitute increased over each time period in the VCT group and between baseline and first visit in the non-VCT group. Both men and women in the VCT group increased their condom use over time, but the women in the non-VCT group did not. Reported always/sometimes use of condoms for both literate and illiterate subjects was higher and rose over time in the VCT group. CONCLUSION: People who undergo voluntary counselling and testing fro HIV/AIDS change their behaviour, presumably as a result of their counselling.

Evaluation of vision services delivered by a mobile eye clinic in Costa Rica.

A number of private voluntary organizations provide mobile eye services to underserved populations in the developing world. This paper seeks to determine what segment of the population makes use of mobile vision clinics and whether the clinics are identifying significant eye conditions previously undetected by local eye care providers. The population studied were those attending the 1989 vision screening project conducted in rural Costa Rica by members of Volunteer Optometric Services to Humanity (VOSH). Sources of data include patient records of clinic attendees (N = 1530), patient interviews, and Costa Rican census data. Most of the clinic attendees were female (56.9%), over 35 years of age, and literate (71.1%). The three most commonly stated occupation categories were (1) housewife; (2) agriculture, forestry, or fishery worker; and (3) student. Over one-half reported having had a previous eye examination. Presbyopia and low hyperopia were the predominant refractive conditions encountered. Over one-third of patients presented with visual acuities 6/15 (20/50) or worse, and one-third of this group had never had an eye examination. Three-quarters of the patients required prescription lenses and over 20% had cataract. The dispensing of presbyopic corrections to first time patients is clearly the most valuable service provided by the clinics. Teaming up with mobile cataract camps may improve the access to surgical care for patients with cataract. It is important that mobile vision projects target future efforts toward those likely to be missed by conventional screenings.