Bioethics education in Democratic Republic of Congo: Experiences and challenges.

In regions marked by socio-economic turmoil, the task of teaching bioethics to health professionals and researchers can be more challenging than elsewhere. To demonstrate this, in this article we describe some of our teaching experiences in the Democratic Republic of Congo over the past decade. A first difficulty is linguistic. Anglo-Saxon language and culture largely dominates the field of bioethics, complicating teaching and education for those who do not master the language. A second obstacle is conceptual. Bioethics is often misunderstood as reflection on technological developments in medicine, which distorts its objectives and narrows its scope, particularly in resource-constrained settings. A third difficulty is cultural and political. Ethics in this setting is difficult to distinguish from common morality and the work of moralists, who comment on problems in medicine from a religious standpoint. Moreover, when interacting with communities and institutions that are strongly hierarchical, the critical stance of bioethics can give rise to resistance and rejection. These are among the array of difficulties that undoubtedly have given rise to sharp critiques of bioethics training initiatives in developing countries, where the introduction of bioethics has been depicted as a form of Western imperialism. While taking these criticisms seriously, our experiences in the field show how these seemingly insurmountable difficulties can be transformed into (more or less) manageable challenges.

Dans les régions marquées par un contexte socioéconomique difficile, les difficultés sont plus nombreuses qu'ailleurs pour ceux qui se donnent pour tâche de former à la réflexion éthique les professionnels de la santé et les chercheurs. Pour le montrer, nous évoquons dans cet article nos expériences en République Démocratique du Congo. Une première difficulté est à chercher du côté linguistique. En effet, la langue et la culture anglo-saxonnes dominent largement la discipline, compliquant la tâche de ceux qui maîtrisent mal l'anglais. Unedeuxième difficulté à surmonter est d'ordre conceptuel. Les objectifs et le champ d'application de la bioéthique sont souvent mal compris, ce qui peut conduire à confondre les spécialistesde la discipline tantôt avec des moralistes surtout préoccupés par le progrès biotechnologique, tantôt avec des référents religieux. La troisième difficulté évoquée est de nature politique et culturelle. Lorsqu'elle entre en interaction avec des communautés très hiérarchisées et conservatrices, la posture critique de la bioéthique peut susciter des réactions de rejet. Ce sont sans doute ces difficultés qui ont alimenté certaines critiques acerbes sur la pertinence des formations à l'éthique dans des zones marquées par les urgences sanitaires et alimentaires ou certaines accusations présentant ces démarches comme un avatar de plus de l'impérialisme occidental. Tout en prenant au sérieux ces difficultés, nous montrons par nos expériences qu'elles peuvent être transformées en défis à relever.

Sputum smear microscopy: evaluation of impact of training, microscope distribution, and use of external quality assessment guidelines for resource-poor settings.

Sputum smear microscopy is the main and often only laboratory technique used for the diagnosis of tuberculosis in resource-poor countries, making quality assurance (QA) of smear microscopy an important activity. We evaluated the effects of a 5-day refresher training course for laboratory technicians and the distribution of new microscopes on the quality of smear microscopy in 13 primary health care laboratories in Kinshasa, Democratic Republic of Congo. The 2002 external QA guidelines for acid-fast bacillus smear microscopy were implemented, and blinded rechecking of the slides was performed before and 9 months after the training course and microscope distribution. We observed that the on-site checklist was highly time-consuming but could be tailored to capture frequent problems. Random blinded rechecking by the lot QA system method decreased the number of slides to be reviewed. Most laboratories needed further investigation for possible unacceptable performance, even according to the least-stringent interpretation. We conclude that the 2002 external QA guidelines are feasible for implementation in resource-poor settings, that the efficiency of external QA can be increased by selecting sample size parameters and interpretation criteria that take into account the local working conditions, and that greater attention should be paid to the provision of timely feedback and correction of the causes of substandard performance at poorly performing laboratories.

Counseling and testing TB patients for HIV: evaluation of three implementation models in Kinshasa, Congo.

SETTING: Kinshasa, Democratic Republic of Congo. OBJECTIVES: To evaluate the implementation of three models of provider-initiated HIV counseling and testing (CT) for tuberculosis (TB) patients. METHODS: HIV CT was offered to all TB patients aged > or =18 months registered for treatment at three project clinics between August 2004 and June 2005. HIV CT was performed at the TB clinic, the health center or the freestanding voluntary counseling and testing (VCT) center. HIV-infected patients received cotrimoxazole prophylaxis. RESULTS: Uptake of HIV CT was high (95-98%) when performed at the TB clinic or primary health care center, but significantly lower (68.5%) among patients referred to a free-standing VCT center. The overall HIV prevalence among the 1088 patients tested for HIV was 18.8%. HIV was associated with female sex (aOR 1.91), recurrent TB (aOR 2.74), extra-pulmonary TB (aOR 1.97) and age. CONCLUSIONS: Implementation of provider-initiated routine HIV CT by the TB nurse or health care worker at the primary health care center results in a higher uptake compared to referral of patients with TB to freestanding VCT clinics. Provider-initiated HIV CT is only a first step and needs to be linked to access to HIV care, support and treatment.

Patient and provider perspectives on implementation models of HIV counseling and testing for patients with TB.

SETTING: TB clinics in Kinshasa, Democratic Republic of Congo. OBJECTIVES: To identify an acceptable approach to human immunodeficiency virus (HIV) counseling and testing (CT) for patients with tuberculosis (TB) from health care worker (HCWs) and patient perspectives. DESIGN: A qualitative evaluation was conducted of three models of routine provider-initiated HIV CT: off-site referral to a freestanding voluntary counseling and testing (VCT) center, on-site referral for HIV CT at the primary health care center to which the TB clinic belongs and HIV CT by the TB nurse. RESULTS: Incorporating HIV CT into routine TB care was supported by HCWs (96%) and patients (99%). The trusting patient-provider relationship was a primary reason why most HCWs (74%) and patients (68%) preferred the HIV CT by TB nurse model. Patients also cited continuity of care and potential optimisation of the management of HIV co-infected patients as reasons. Some patients and HCWs were concerned about confidentiality issues (HIV status documentation and privacy of counseling) and the potential difficulty of refusing routine HIV CT when it was offered by TB nurses. Some HCWs also expressed worry about the increased workload. CONCLUSION: Qualitative data provided insight into reasons for the high uptake observed of routine HIV CT offered by TB nurses and identified potential concerns when implementing this model.

The process of HIV status disclosure to HIV-positive youth in Kinshasa, Democratic Republic of the Congo.

As access to HIV/AIDS treatment increases in sub-Saharan Africa, greater attention is being paid to HIV-infected youth. Little is known about how HIV-positive youth are informed of their HIV infection. As part of a larger formative study informing a treatment program in Kinshasa, Democratic Republic of the Congo, semi-structured interviews were conducted with 19 youth (10-21 years) who had previously been told their HIV status and 21 caregivers who had disclosed the youth's HIV status to the youth. Questions explored youth's and caregivers' experiences of and immediate reactions to disclosure. Youth's median age at disclosure was 15 years old, with a range of 10-18 years based on caregiver reports (n=21) and from 10-19 years based on youth reports (n=18). The most common reasons spontaneously given for disclosing were the child's adherence to their treatment regimen (5/16), the need of the child to protect her/himself or stay healthy (5/16), the child's increasing age (4/16) and so that the child would know why they are suffering (3/16). Most youth (16/19) were surprised to learn of their diagnosis; 50% (8/16) wondered about the infection's origins. A large majority felt that it is better for them to know their HIV status (88%; 15/17). HIV care and treatment programs must be prepared to address the psychosocial needs of youth and their caregivers during the disclosure process.

Validity of self-reported 'safe sex' among female sex workers in Mombasa, Kenya--PSA analysis.

We assessed the validity of self-reported sex and condom use by comparing self-reports with prostate-specific antigen (PSA) detection in a prospective study of 210 female sex workers in Mombasa, Kenya. Participants were interviewed on recent sexual behaviours at baseline and 12-month follow-up visits. At both visits, a trained nurse instructed participants to self-swab to collect vaginal fluid specimens, which were tested for PSA using enzyme-linked immunosorbent assay (ELISA). Eleven percent of samples (n = 329) from women reporting no unprotected sex for the prior 48 hours tested positive for PSA. The proportions of women with this type of discordant self-reported and biological data did not differ between the enrolment and 12-month visit (odds ratio [OR] 1.1; 95% confidence interval [CI] 0.99, 1.2). The study found evidence that participants failed to report recent unprotected sex. Furthermore, because PSA begins to clear immediately after exposure, our measures of misreported semen exposure likely are underestimations.

Xpert(®) MTB/RIF for smear-negative presumptive TB: impact on case notification in DR Congo.

SETTING: The impact of Xpert(®) MTB/RIF as a follow-on diagnostic test after smear microscopy on tuberculosis (TB) notification has not yet been well defined. DESIGN: Quasi-experimental design with 86 evaluation and 49 control clinics in Kinshasa, Democratic Republic of Congo. Smear microscopy was supported at all 135 clinics, Xpert was placed in 15 evaluation clinics and a sputum transport system was implemented for 25 satellite clinics. The number of cases notified before and during the project (July 2012-June 2013) was obtained from the National TB Program. RESULTS: Of 27,147 presumptive TB cases presenting in clinics with access to Xpert, 5922 (21.8%) were smear-positive. Of 18,636 individuals with ⩾ 3 negative microscopy results, 6920 (37.1%) underwent Xpert testing, 991 (14.3%) of whom tested positive. The number of bacteriologically positive cases increased equally in evaluation clinics (15.1%, 95%CI -2.3 to 32.6) and control clinics (13.6%, 95%CI 2.6-29.3), for a difference in increase of 1.5% (95%CI -28.8 to 31.8). There was no difference in the change in smear-negative cases (-42.4%, 95%CI -111.5 to 26.6), nor in all types of TB notified (-6.1%, 95%CI -32.5 to 20.4) between the evaluation and control clinics. CONCLUSION: In part due to a restrictive algorithm, Xpert as follow-on to smear microscopy did not increase the overall number of TB notifications, nor the number of bacteriologically positive cases.

Reasons for the wide variation in reported rates of mother-to-child transmission of HIV-1.

PIP: The explanation of marked global variation (between 12 and 65%) in the rate of mother-to-child transmission (MCT) of HIV-1 both in developed and developing countries is inadequate. The risk of MCT ranges from one in eight to one in 1.5 pregnancies. There are marked methodological differences in the case definitions, study designs and diagnostic criteria in the various MCT investigations. Although most HIV-1 MCT appears to occur in the peripartum period, it can also occur in the intrauterine phase or immediately postpartum requiring diagnostic techniques that are not often available. Polymerase chain reaction or in situ hybridization tests for early diagnosis of MCT have been found to lack specificity for both HIV-infected and uninfected infants who are born to HIV-infected mothers and who remain HIV-seropositive during their first year of life. A second explanation for the wide variability derives from the varying case mix of any given maternal cohort. HIV infection during pregnancy and pregnant women with advanced HIV-induced immunosuppression are particularly infectious to their children. A third source of MCT variation results from selection bias in many MCT studies. It is not known whether the only mechanism of transmission in the perinatal period is transplacental or transmission occurs during delivery. Data suggest that delivery via Caesarean section halves the risk of MCT. Antiretroviral treatment (zidovudine) for HIV-infected mothers in the immediate prepartum and intrapartum period, followed by postpartum administration to their infants has reduced these infants' chance of MCT by as much as 50%. A recent study from Malawi demonstrated that HIV-1-seropositive women with vitamin A deficiency had a twofold greater risk of transmitting HIV-1 infection to their infants. The many biologic reasons for the wide variation in MCT make it unlikely that prevention will be possible through a single biologic and/or pharmacologic approach.^ieng

Successful use of pooled sera to determine HIV-1 seroprevalence in Zaire with development of cost-efficiency models.

To determine the accuracy and cost efficiency of pooling sera prior to HIV-1 testing, sera from 8,000 Kinshasa factory workers and their spouses were screened individually (2.44% seropositive) and in 800 pools of 10 sera each. There were no false-negative or false-positive pools, resulting in a calculated seroprevalence estimate of 2.42%. Further testing of all sera in positive pools can identify HIV-positive individuals. These applications were modeled to compare the cost-efficiency of pooling with individual testing under different conditions. The results suggest that pooling provides an alternative test format for use in both developing and industrialized countries when the seroprevalence and/or the marginal cost of obtaining a sample are sufficiently low. For our cohort, testing only the pools for seroprevalence estimation resulted in a 78% cost saving compared with individual testing; pooling with subsequent identification of individual seropositives represented a 56% cost reduction.

Evidence of marked sexual behavior change associated with low HIV-1 seroconversion in 149 married couples with discordant HIV-1 serostatus: experience at an HIV counselling center in Zaire.

To determine the effect of an HIV-1 counselling program on 149 married Zairian couples with discordant HIV-1 serology, the rates of HIV-1 seroconversion and reported condom utilization have been observed during 382.4 person-years of follow-up (minimum follow-up time per couple of 6 months). Before determination of HIV-1 serostatus and counselling, less than 5% of these couples had ever used a condom. One month after notification of HIV-1 serostatus and counselling, 70.7% of couples reported using condoms during all episodes of sexual intercourse. At 18 months follow-up, 77.4% of the 140 couples still being followed reported continued use of condoms during all episodes of sexual intercourse. At the time of notification of HIV-1 serostatus, 18 couples experienced acute psychological distress. Home-based counselling by trained nurses resolved these difficulties in all but three couples who subsequently divorced. Intensive counselling following notification of HIV-1 serostatus led to low rates of HIV-1 seroconversion (3.1% per 100 person-years of observation) in Zairian married couples with discordant HIV-1 serostatus who voluntarily attended an HIV counselling center.

Heterosexual transmission of HIV-1 among employees and their spouses at two large businesses in Zaire.

To better understand the reasons why up to 80% of all HIV-1 infections in Zaire, but less than 5% in North America and Europe, are acquired through heterosexual transmission, and to assess the impact of HIV-1 infection on a large urban African workforce, we enrolled 7068 male employees, 416 female employees and 4548 female spouses of employees at two large Kinshasa businesses (a textile factory and a commercial bank) in a prospective study of HIV-1 infection. The HIV-1 seroprevalence rate was higher in male employees (5.8%) and their spouses (5.7%) at the bank than among male employees (2.8%) and their spouses (3.3%) at the textile factory. At both businesses HIV-1 seroprevalence was higher among employees in managerial positions (5.0%) than among workers in lower-level positions (3.0%; P less than 0.0001). In a multivariate analysis of male employees, receipt of a transfusion, a history of genital ulcer disease, working at the bank, urethritis, or being divorced or separated were independently associated with HIV-1 infection. During 1987 and 1988, AIDS was the most common cause of death among recently employed workers, accounting for 20 and 24% of all deaths at the textile factory and the commercial bank, respectively. The HIV-1 seroprevalence rate was higher among female workers (7.7%) than among the spouses of male workers (3.9%; P = 0.001). In multivariate analysis of the wives of workers, having an HIV-1-seropositive spouse, receipt of a blood transfusion, or a history of genital ulcer disease were independently associated with HIV-1 infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Trends and risk factors for HIV-1 seropositivity among outpatient children, Kinshasa, Zaire.

To investigate recent trends in pediatric HIV-1 infection and the early impact of a blood screening program begun in one hospital in 1987 in Kinshasa, Zaire, we evaluated 1110 consecutive children seen in the pediatric emergency ward of the city's largest hospital in November 1988. The HIV-1 seroprevalence was 5.0%, not significantly higher than the rate of 3.8% found in 1986 (P = 0.2). The seropositivity rate was bimodally distributed; children less than 6 months of age had a higher rate (12.6%) than children 6-11 months old (1.9%; OR = 7.6; P less than 0.0001) and children 1-13 years old (4.1%; OR = 3.4; P less than 0.0001). Seropositive children greater than or equal to 1 year of age were more likely than seronegative children to be anemic and to have signs of malnutrition. A previous blood transfusion was associated with HIV-1 seropositivity among children greater than or equal to 1 year of age (OR = 5.4, P less than 0.0005), but not among younger children. Fifty-two per cent of seropositive children greater than or equal to 1 year of age received a transfusion (etiological fraction = 42%). The association with seropositivity was higher for those who had received a transfusion before 1987 than for those who had received a transfusion since 1987 (OR = 4.8, P = 0.01). These findings suggest a relatively stable, high pediatric HIV-1 seroprevalence in Kinshasa and a decreased but continued risk of transfusions. Expansion of currently limited blood transfusion screening programs, and the development of new strategies for limiting transfusions and preventing severe anemia, are needed.

PIP: To investigate recent trends in pediatric HIV-1 infection and the early impact of a blood screening program begun in 1 hospital in Kinshasa, Zaire, the authors evaluated 1110 consecutive children seen in the pediatric emergency ward of the city's largest hospital in November 1988. The HIV-1 seroprevalence was 5.0%, not significantly higher than the 3.8% rate found in 1986 (p=0.2). The seropositivity rate was bimodally distributed; children 6 months of age had a higher rate (12.6%) than children 6-11 months old (1.9%; OR+7.6; p0.0001) and children 1-13 years old (4.1%; OR+3.4; p0.0001). Seropositive children or= 1 year of age were more likely than seronegative children to be anemic and to have signs of malnutrition. A previous blood transfusion was associated with HIV-1 seropositivity among children or= 1 year of age (OR=5.4, p0.0005), but not among younger children. 52% of seropositive children or= 1 year of age had received a transfusion (etiological fraction=42%). The association with seropositivity was higher for those who had received a transfusion before 1987 than for those who received 1 since that time (OR=4.8, p=0.01). These findings suggest a relatively stable, high pediatric HIV-1 seroprevalence in Kinshasa and a decreased but continuous risk of transfusions. Expansion of currently limited blood transfusion screening programs and the development of new strategies for limiting transfusions and anemia prevention are necessary.

Evidence from Zaire that breast-feeding by HIV-1-seropositive mothers is not a major route for perinatal HIV-1 transmission but does decrease morbidity.

Breast-feeding as a route of HIV-1 transmission during infancy but also as a protective measure against early childhood morbidity has been investigated prospectively in children born to HIV-1-seropositive mothers and control children born to age- and parity-matched HIV-1-seronegative women. The mothers of all study children had been enrolled antenatally at a maternity hospital in Kinshasa, Zaire, which served a relatively affluent group of women who sometimes chose not to breast-feed their infants. In 106 children born to HIV-1-seropositive women, the rate of HIV-1 transmission was 21% in 28 infants exclusively breast-fed, 19% in 68 infants both breast- and bottle-fed and 0% in 10 infants who were bottle-fed only (P = 0.35). In contrast, non-HIV-1-infected children of both HIV-1-seropositive and HIV-1-seronegative mothers who were exclusively breast-fed compared with uninfected children who were not exclusively breast-fed had significantly lower incidence rates of acute diarrhea, fever and lower respiratory tract infection. The lack of a dose-response effect between breast-feeding and perinatal HIV-1 transmission and the presence of a protective effect of breast-feeding against common causes of early childhood morbidity and mortality support the current World Health Organization recommendation that breast-feeding should continue to be promoted in all developing countries, including those with high HIV-1 prevalence rates in women of childbearing age.

HIV and other sexually transmitted diseases among female prostitutes in Kinshasa.

In 1988, 1233 prostitutes from different geographic areas of Kinshasa participated in a cross-sectional survey on HIV infection and other sexually transmitted diseases (STDs). Despite relatively good knowledge about AIDS and STDs, the reported preventive behaviour was poor. Only 12% of the women reported regular use of condoms, while greater than 50% of the women reported regular use of antibiotics and 38% reported doing nothing specific to prevent STDs. Thirty-five per cent of the women were HIV-positive compared with 27% in a similar survey in Kinshasa in 1986. The prevalence of other STDs was very high, ranging from 5% for genital ulcer disease (GUD) to 23% for gonococcal infection. HIV-positive women were older than HIV-negative women (26.9 versus 25.4 years; P less than 0.001), had a significantly lower level of reported condom use (9 versus 14%, P = 0.009), and reported more frequent use of antibiotics to prevent STDs (55 versus 42%, P = less than 0.001). The prevalence of syphilis, gonorrhoea, chlamydial infection and trichomoniasis was not higher in HIV-positive women compared with HIV-negative women. However, HIV-positive women had a higher prevalence of GUD (9 versus 3%, P less than 0.001), antibodies against Haemophilus ducreyi (82 versus 57%, P less than 0.001), antibodies against herpes simplex virus type 2 (96 versus 76%, P less than 0.001), condylomata accuminata (5 versus 1%, P = 0.003) and cytologic evidence of human papilloma virus on Papaniclaou cervical smear (11 versus 5%, P = 0.006). This study confirms the high incidence of HIV and other STDs among prostitutes in Africa.(ABSTRACT TRUNCATED AT 250 WORDS)

High HIV-1 incidence in young women masked by stable overall seroprevalence among childbearing women in Kinshasa, Zaïre: estimating incidence from serial seroprevalence data.

OBJECTIVE: To describe the dynamics of the HIV-1 epidemic in childbearing women in Kinshasa, Zaïre, by estimating incidence from serial seroprevalence studies. METHODS: In 1986 and 1989, 5937 and 4623 pregnant women, respectively, were screened for HIV-1 in Kinshasa. We estimated age-specific incidence from two seroprevalence surveys by using a birth-year cohort analysis and adjusting for differences in mortality and fertility between HIV-1-infected and uninfected women. Mortality and fertility data were measured in a cohort of women recruited from the survey in 1986 and followed until 1989. RESULTS: While the overall HIV-1 seroprevalence changed little (5.8% in 1986 and 6.5% in 1989; P = 0.17), the prevalence increased in birth-year cohorts of women under 25 years of age in 1989 from 3.2 to 6.2% (P < 0.001), but decreased for women above 25 years of age from 6.9 to 6.7% (P = 0.7). In addition, new HIV infections between 1986 and 1989 were balanced by a higher mortality and lower fertility observed in HIV-infected women. After adjusting for these effects, we estimated an overall 3-year cumulative HIV-1 incidence of 2.8 per 100 uninfected women [95% confidence interval (CI), 1.4-4.2]. The highest incidence, 5.7 per 100 (95% CI, 3.5-8.0), was in women aged 20-24 years in 1989. CONCLUSION: Despite an overall relatively stable HIV-1 prevalence in childbearing women in Kinshasa between 1986 and 1989, approximately 40% of all HIV-1 infections detected in the 1989 survey occurred between 1986 and 1989, and 60% occurred in women under 25 years of age in 1989.

Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study.

OBJECTIVES: The heterosexual spread of HIV-1 is occurring at different rates in different parts of the world. The transmission probability of HIV-1 per sexual contact is low, but may be greatly enhanced by several cofactors. Sexually transmitted diseases (STD), especially genital ulcers, may be such factors. So far, epidemiological evidence that other STD facilitate HIV-1 transmission is weak. The objective of this study was to determine whether treatable STD enhanced sexual transmission of HIV-1 in a cohort of female prostitutes in Kinshasa, Zaire. METHODS: We conducted a nested case-control study of 431 initially HIV-1-negative women followed prospectively for a mean duration of 2 years (with monthly STD check-ups and 3-monthly HIV-1 serology). Cases (seroconverters, n = 68) were compared with controls (women who remained HIV-1-negative, n = 126) for incidence of STD and sexual exposure during the presumed period of HIV-1 acquisition. RESULTS: The annual incidence of HIV-1 in this cohort was 9.8%. Seroconverters were younger than HIV-1-negative women (mean age, 24.6 versus 26.8 years; P = 0.04). During the period of HIV-1 acquisition, cases had a much higher incidence of gonorrhoea, chlamydial infection and trichomoniasis, and engaged in unprotected sex with clients and partners more frequently than controls. After controlling for sexual exposure by multivariate analysis, adjusted odds ratios for seroconversion were 4.8 [95% confidence interval (CI), 2.4-9.8] for gonorrhoea, 3.6 (95% CI, 1.4-9.1) for chlamydial infection and 1.9 (95% CI, 0.9-4.1) for trichomoniasis. Genital ulcers were more frequent in cases than controls, but much less common than other STD. CONCLUSION: Non-ulcerative STD were risk factors for sexual transmission of HIV-1 in women, after controlling for sexual exposure. Because of their high prevalence in some populations, non-ulcerative STD may represent a considerable population-attributable risk in the transmission of HIV-1 worldwide. The identification of treatable STD as risk factors for HIV-1 transmission offers an important additional strategy for the prevention of HIV/AIDS.

PIP: There is only a small probability that HIV-1 will be transmitted via any single sexual contact. The risk of transmission, however, during such an act may be greatly increased by the presence of ulcerative genital sexually transmitted disease (STD). Little evidence is published on whether infection with non-ulcerative STD facilitates the transmission of HIV-1. The authors therefore investigated whether treatable STD enhanced the sexual transmission of HIV-1 in a cohort of female prostitutes in Kinshasa, Zaire. 431 initially HIV-1-seronegative women were followed prospectively in this nested case-control study for a mean duration of two years in monthly STD check-ups and three-monthly HIV-1 serology. The 68 women who seroconverted were compared against the 126 women who remained HIV-1-seronegative for the incidence of STD and sexual exposure during the presumed period of HIV-1 acquisition. There was a 9.8% annual incidence of HIV-1 in this cohort of subjects. Seroconverters were of mean age 24.6 years compared to 26.8 years for the HIV-seronegative women. During the period of HIV-1 acquisition, cases had a much higher incidence of gonorrhea, chlamydial infection, and trichomoniasis, and engaged in unprotected sex with clients and partners more frequently than controls. After controlling for sexual exposure by multivariate analysis, adjusted odds ratio for seroconversion were 4.8 for gonorrhea, 3.6 for chlamydial infection, and 1.9 for trichomoniasis. Genital ulcers were more frequent in cases than controls, but much less common than other STD. These findings therefore suggest that non-ulcerative STDs were risk factors for the sexual transmission of HIV-1 in these women. Such STD may be a considerable population-attributable risk in the transmission of HIV-1 worldwide given the high prevalence of non-ulcerative STDs in some populations.

Accurate detection of maternal antibodies to HIV in newborn whole blood dried on filter paper.

OBJECTIVE: The testing of neonatal blood specimens dried on filter paper for maternal HIV antibodies, using an enzyme immunoassay (EIA) with confirmation of repeatedly reactive specimens by immunoblot (IB), was first described in 1987. It has been used to conduct large, unlinked, anonymous HIV seroprevalence surveys for surveillance of HIV in child-bearing women in several countries. We directly assessed the sensitivity and specificity of this combination of tests to detect maternal HIV antibodies. SETTING: Serum samples obtained from mothers delivering at a major hospital in Kinshasa, Zaire were screened for HIV antibody using the rapid assay HIVCHEK. DESIGN: Plasma from HIVCHEK-positive women and age-matched negative controls were tested by enzyme-linked immunosorbent assay (ELISA); repeatedly reactive specimens were confirmed by Western blot (WB). Two days after delivery, whole blood was obtained from each newborn by heel-stick, dried on filter paper, and tested by EIA. Repeatedly reactive specimens were confirmed by IB. MAIN OUTCOME MEASURE: The serologic status of neonatal filter-paper specimens was compared with that of corresponding maternal plasma. RESULTS: The testing of neonatal filter-paper specimens using EIA, with confirmatory testing of repeatedly reactive specimens using IB, was 100.0% sensitive [of the 192 ELISA-positive and WB-positive maternal plasma specimens, 192 of the corresponding newborn filter-paper specimens were EIA-positive and IB-positive; 95% confidence interval (CI), 98.1-100]. The detection of maternal HIV antibodies was 99.6% specific using this combination of tests (of the 281 ELISA-negative or ELISA-positive but WB-negative maternal plasma samples, 280 of the corresponding newborn filter-paper specimens were EIA-negative or EIA-positive but IB-negative; 95% CI, 98.0-100). CONCLUSIONS: Maternal HIV antibodies can be detected accurately by testing neonatal blood dried on filter paper, using EIA with confirmation of repeatedly reactive specimens by IB. This approach can facilitate the determination of HIV seroprevalence in child-bearing women in countries with neonatal screening programs, or where serum or plasma is difficult to obtain.

PIP: Neonatal blood specimens dried on filter paper have been tested for maternal HIV antibodies in large, unlinked, anonymous HIV seroprevalence surveys toward the surveillance of HIV in child-bearing women in several countries. This study assesses the sensitivity and specificity of this combination of tests. The standard approach involves first testing the sample via an enzyme immunoassay (EIA), then confirming repeatedly reactive specimens through immunoblot (IB). To test this methodology, serum samples were obtained from mothers delivering at a major hospital in Kinshasa, Zaire, and screened with rapid assay HIVCHEK for antibody to HIV. Plasma from HIVCHEK-positive women and age-matched negative controls were then subjected to ELISA, with repeatedly reactive samples confirmed with Western blot. Whole blood was later obtained by heel-stick from each newborn 2 days after delivery, dried on filter paper, and tested by EIA and IB for confirmation. The serologic statuses of neonatal filter-paper specimens were then compared with those of corresponding maternal plasma. 100% sensitivity was achieved by testing neonatal filter-paper specimens with EIA and confirming with IB. The combination of tests also proved 99.6% specific for detecting maternal HIV antibodies; both results are at 95% confidence intervals. These results demonstrate that maternal HIV antibodies can therefore be detected accurately by testing neonatal blood dried on filter paper, using EIA, then confirming repeatedly reactive specimens via IB. This approach may help determine HIV seroprevalence in childbearing women in countries with neonatal screening programs or where serum or plasma is difficult to obtain.

Indicators and the measurement of STD case management in developing countries. STD PI6&7 Working Group.

The paper reviews methodologies for measuring quality of sexually transmitted disease (STD) case management through facility based assessments. These include observations and interviews of providers, as promoted by the World Health Organization's Global Programme on AIDS, and some of the viable alternatives including patient exit interviews, mystery patients, record review and patient encounter forms with supervisory visits. The paper concludes that the alternative approaches are feasible in resource poor settings and that they provide crucial data for evaluation and continued program development.

Improving sexually transmitted disease management in the private sector: the Jamaica experience.

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60% of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4-month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluated with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre- versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3%; P > 0.05); diagnostics/screening (57.2-71.0%; P= 0.042); treatment (68.3-74.5%; P> 0.05); and knowledge (66.4-83.2%; P= 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8% (P= 0.001), and providing effective treatment for gonorrhea rose from 57.8 to 81.1 % (P= 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4%. CONCLUSION: The introduction of continuing medical education for improved STD care targeting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services, continuing education programs that target the private sector can be successful and should be included as a standard activity to improve care and provide a public/private link to STD/HIV control.

PIP: The Jamaican Ministry of Health has estimated that over 60% of all sexually transmitted diseases (STDs) are managed within the private sector, where 800 (66%) of the country's 1200 registered physicians practice. To improve the quality of STD case management provided by these practitioners, the Medical Association of Jamaica organized a series of 6 half-day seminars repeated at 3-4 month intervals in three geographic locations between December 1993 and July 1995. Topics addressed included urethritis, genital ulcer disease, HIV/AIDS, vaginal discharge, pelvic inflammatory disease, and STDs in children and adolescents. A total of 628 private practitioners attended at least one seminar and almost half the physicians attended two or more. Comparisons of scores on a written pretest completed before the seminar and those from a post-test conducted by telephone after the seminar revealed significant improvements in all four general STD management categories: counseling/education, diagnostics/screening, treatment, and knowledge. The proportion of practitioners who obtained syphilis serologies during pregnancy rose from 38.3% to 83.8% and those providing effective treatment for gonorrhea increased from 57.8% to 81.1%. Overall, 96% of practitioners were providing some level of risk-reduction counseling at the time of the post-test and 74% were prescribing correct treatment regimens. Ongoing education and motivation by the national STD control program or the Medical Association are recommended to improve STD case management even further.

Diagnosis of HIV infection with instrument-free assays as an alternative to the ELISA and western blot testing strategy: an evaluation in Central Africa.

The efficiency of an alternative instrument-free testing strategy was evaluated using a membrane-based rapid screening assay (HIVCHEK and its new version HIVCHEK1 + 2) in serial combination with a particle agglutination assay (SERODIA-HIV). Among 1,054 Zairian individuals at high risk of HIV infection, 573 were Western blot-positive for HIV-1 (54.4%) and none were Western blot-positive for HIV-2. In this group, the sensitivities of the serial combination HIVCHEK plus SERODIA-HIV and HIVCHEK1 + 2 plus SERODIA-HIV were 98.1 and 98.2%, respectively, and the specificities were 99.6 and 99.5% compared with HIV-1 Western blot. The positive predictive values were 99.6% for HIVCHEK plus SERODIA-HIV and 99.5% for HIVCHEK1 + 2 plus SERODIA-HIV; the negative predictive values were 97.8 and 97.9%, respectively. Among 1,495 pregnant women, 90 were Western blot-positive for HIV-1 (6.0%), and 54 of 1,510 blood donors were HIV-1 Western blot-positive (3.6%). None were positive for HIV-2. The sensitivities of HIVCHEK plus SERODIA-HIV and HIVCHEK1 + 2 plus SERODIA-HIV in these groups were 98.6 and 99.3%, respectively, and the specificities were 99.8 and 99.7%. The positive and negative predictive values of HIVCHEK plus SERODIA-HIV were 96.6 and 99.9%, respectively, and they were 94.1 and 99.9%, respectively, for HIVCHEK1 + 2 plus SERODIA-HIV. These instrument-free testing strategies are efficient alternatives for serodiagnosis of HIV-1 infection, although their cost should be further reduced.