Conflict and HIV: A framework for risk assessment to prevent HIV in conflict-affected settings in Africa.

In sub-Saharan Africa, HIV/AIDS and violent conflict interact to shape population health and development in dramatic ways. HIV/AIDS can create conditions conducive to conflict. Conflict can affect the epidemiology of HIV/AIDS. Conflict is generally understood to accelerate HIV transmission, but this view is simplistic and disregards complex interrelationships between factors that can inhibit and accelerate the spread of HIV in conflict and post conflict settings, respectively. This paper provides a framework for understanding these factors and discusses their implications for policy formulation and program planning in conflict-affected settings.

Lessons from successful micronutrient programs. Part I: program initiation.

Internationally recognized research findings on the potential health benefits of preventing micronutrient deficiencies--especially reduced child mortality from vitamin A deficiency and prevention of in utero developmental damage and mental retardation from iodine deficiency--have contributed to raising the awareness of deficiencies and the commitment of many governments to their reduction or near-elimination. The procedures undertaken to decide on large-scale programs followed conventional patterns in the 12 countries included in this study (11 Asian countries plus South Africa). Thus, a sequence of national surveys, institutional arrangements through intersectoral technical committees, legislation, incorporation of programs into national plans, and resource mobilization, including external assistance, was similar for all three micronutrients. Vitamin A supplementation twice yearly to children, then to women postpartum, has reached the national level. Iodized salt is universally adopted at the national level in most countries, with a need for continuing efforts to reach underserved populations and to implement legislation and quality control. Iron programs, usually aiming at daily supplementation during pregnancy, have been pursued, but with less intensity. However, it is clear that these procedures have succeeded in creating a rapid expansion of large-scale deficiency-control programs, which while evolving are generally being maintained.

Lessons from successful micronutrient programs. Part II: program implementation.

National programs for vitamin A supplementation and iodization of the salt supply were launched and sustained with high (but not universal) coverage in most of the countries studied. Iron programs (requiring daily or weekly supplementation, in contrast to vitamin A), which were distributed mainly through antenatal care, had lower coverage and acceptance. Constraints to supplementation were supply, awareness of health staff and communities, and (for vitamin A) insecurity with phasing out of the national immunization days, which have been a major vehicle for distribution. Administration to women postpartum becomes even more important and needs greater coverage. Iodized salt programs have expanded well, with good interagency collaboration and local management, supported by legislation (which may need strengthening); constraints remain in terms of too many salt producers, inadequate quality, import issues, and prices. More integrated, multifaceted programs are needed, with priority to developing and implementing fortification--especially in finding effective ways to iron-fortify rice. Data are lacking, with fewer surveys once programs start, constraining monitoring and program control and adaptation. Nonetheless, interventions appear to have gone to scale remarkably successfully.

Lessons from successful micronutrient programs. Part III: program impact.

Micronutrient-deficiency control programs have been greatly extended at the national level in the last 10 to 15 years. However, rigorous evaluations of these are scarce, so that conclusions on impact are tentative and based mainly on indirect evidence. The coverage of vitamin A capsule distribution programs has exceeded 70% in most study countries. In countries implementing national iodized salt programs, the coverage reaches 60% to 90% of households with adequately iodized salt. Of the three micronutrients, coverage of iron tablet supplementation is the least well documented due to inadequate program monitoring systems and population survey data. Supplementation of preschool children 6 to 59 months of age with vitamin A capsules has plausibly contributed to the reduction in clinical vitamin A deficiency and its near-elimination in many countries. The impact of vitamin A capsule supplementation on children's biochemical vitamin A status (serum retinol) in national programs may be less. National data on salt iodization show a consistent relation to reduced prevalence of iodine-deficiency disorder symptoms (goiter); the rates of cretinism and other results of iodine deficiency are almost certainly falling too. The evaluation of the impact of salt iodization programs on biochemical iodine status is limited by a lack of data. Although trials have demonstrated the efficacy of iron supplementation in reducing the prevalence of anemia, the interpretation of national-level data is not so clear. Given the substantial financial and technical commitment required to implement national micronutrient-deficiency control programs, it is vital that investment enable the evaluation of the impact of these programs. It is becoming increasingly important to collect data on subclinical deficiency (e.g., biochemical data) to assess program impact.