RESUMO
OBJECTIVES: Since contraception is an effective way of preventing the vertical transmission of HIV, we evaluated the impact of a family planning intervention on hormonal contraceptive use and incident pregnancy in a group of HIV-positive and HIV-negative urban Rwandan women. SUBJECTS AND METHODS: In a longitudinal cohort study, 502 women who were not pregnant or infertile and who had been previously HIV tested and counseled viewed an informational video about hormonal contraception followed by a facilitated discussion. They were given access to oral or injectable hormonal contraception and Norplant at the research clinic; those who used these methods were seen every 3 months. RESULTS: Of the 330 HIV-positive and 172 HIV-negative women who underwent the intervention, 120 either became new hormonal method users (n = 40), continued their previous use of a hormonal method (n = 64), or switched to another hormonal method (n = 16) following the intervention. There was a shift to use of longer lasting hormonal methods, and the annualized attrition rate was < 15%, compared to > 50% prior to the intervention. Rates of oral and injectable contraceptive use were similar among HIV-positive and HIV-negative women. Nine per cent of HIV-positive women became pregnant in the year after the intervention compared to 22% in a prior 12 month period when contraceptives were not provided at the study site. The corresponding proportions for HIV-negative women were 20% after the intervention versus 30% before the intervention. CONCLUSIONS: Access to and information about hormonal contraceptives resulted in increased use and reduced attrition among both HIV-positive and HIV-negative women in this study. The reduction in incident pregnancy was greatest among HIV-positive women, suggesting that factors other than access to hormonal contraceptives may have influenced fertility outcomes. Knowledge of HIV serostatus may have an important influence on family planning decisions.
Assuntos
Países em Desenvolvimento , Infecções por HIV/prevenção & controle , Complicações Infecciosas na Gravidez/prevenção & controle , Adolescente , Adulto , Comportamento Contraceptivo , Serviços de Planejamento Familiar , Feminino , Seguimentos , Infecções por HIV/transmissão , Educação em Saúde , Conhecimentos, Atitudes e Prática em Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Recém-Nascido , Transmissão Vertical de Doenças Infecciosas , Gravidez , Avaliação de Programas e Projetos de Saúde , Ruanda , População UrbanaRESUMO
OBJECTIVE: To describe sexual interaction and HIV-related communication in Rwandan couples and to examine their relationship to HIV testing and condom use. STUDY DESIGN: Cross-sectional survey of a longitudinal cohort. METHODS: In 1988, women recruited for an epidemiological study of HIV, and interested male partners, received confidential HIV testing and counseling. Two years after enrollment, 876 women reporting one steady partner in the past year completed a questionnaire addressing sexual and HIV-related communication, sexual motivation and violence in the partnership. RESULTS: Men control sexual decision making, and coercive sex and violence between partners is not uncommon. HIV-positive women were more likely to report coercive sex and less likely to have discussed their test results with their partner. Women with HIV-positive partners were more likely to report being physically abused. Condom use was more common if the man had been previously tested, and if women reported discussing or negotiating condom use. HIV-negative women with untested or seronegative partners were the least likely to use condoms or to discuss or attempt to negotiate condom use. CONCLUSIONS: Participation of the male partner is crucial for successful HIV risk reduction in couples. HIV testing and counseling of couples has beneficial long term effects on condom use and HIV-related communication. Couple communication is associated with condom use, but only when the discussion is specific (sexually transmitted disease risks and using condoms). Seronegative women with untested partners are at increased risk for HIV as they are the least likely to discuss or attempt to negotiate condom use.
PIP: The salience of couple communication to the prevention of human immunodeficiency virus (HIV) was demonstrated in a study of 876 Rwandan women with one steady sexual partner in the preceding year. These women were part of a longitudinal study of the natural history of HIV infection involving 1458 mothers recruited from prenatal and pediatric clinics at a Kigali Hospital in 1988. At study entry, 234 (27%) of the 876 monogamous women were HIV-positive; 45 additional women had seroconverted by the time of the two-year follow-up. Among the 855 sexually active subjects, only 196 (23%) were using condoms. Condom use was substantially higher among HIV-positive women (39%) than their HIV-negative counterparts (17%). In addition, condom use was significantly more likely if the woman had discussed condoms with her partner or if the male partner had agreed to an HIV test. Seronegative women with untested or HIV-negative partners were the least likely to discuss or use condoms. Notable was a pattern of male control of sexual decision making and female responsibility for condom provision, coercive sex, and domestic violence. 33% of women had been forced to have sex with their partner against their will and 21% had been beaten; these rates were even higher among HIV-positive women or HIV-negative women with infected partners. Given the disproportionate power of men in sexual relations in many African societies, efforts to strengthen women's condom negotiation skills may be counterproductive. Recommended, instead, are interventions that increase male involvement in HIV testing and counseling.
Assuntos
Coerção , Comunicação , Infecções por HIV/prevenção & controle , Comportamento Sexual , Estudos de Coortes , Preservativos , Aconselhamento , Estudos Transversais , Violência Doméstica , Feminino , Infecções por HIV/epidemiologia , Humanos , Masculino , Fatores de Risco , Ruanda/epidemiologia , Parceiros SexuaisRESUMO
We examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 child-bearing urban women in Rwanda, central Africa. Although 68% of women reported only one lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Before receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the three primary routes of infection. However, only 16% of women reported taking any action to avoid AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of women had ever tried condoms, and many (68%) thought they could be dangerous to use. Women who perceived themselves at risk of AIDS (57%) were more likely to report changing behavior; they were also more likely to be infected with HIV. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partner, and believing that condoms are not dangerous. Future interventions should enhance perception of risk, encourage male sexual partners to reduce risky behavior, and increase familiarity with condoms.
PIP: The authors examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 childbearing urban women in Rwanda, central Africa. Although 68% of them reported only 1 lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Prior to receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the 3 primary routes of infection. However, only 16% reported taking any action to prevent AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of the women has ever tried condoms, and many (68%) thought they could by dangerous to use. Those women who perceived themselves at risk for AIDS (57%0 were more likely to report changing behavior; they were also more likely to be HIV-infected. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partners, and believing that condoms are not dangerous. Future interventions should enhance the perception of risk, should encourage male sexual partners to reduce risktaking behavior, and should increase familiarity with condoms.
Assuntos
Infecções por HIV/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Adolescente , Adulto , Dispositivos Anticoncepcionais Masculinos , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/transmissão , Soroprevalência de HIV , Educação em Saúde , Humanos , Assunção de Riscos , Ruanda/epidemiologia , Comportamento Sexual , Inquéritos e Questionários , População UrbanaRESUMO
We present the baseline results of a prospective cohort study on the perinatal transmission of HIV-1 in Kigali, Rwanda. HIV-1-antibody testing was offered to all women of urban origin delivering a live newborn at the maternity ward of the Centre Hospitalier de Kigali from November 1988 to June 1989; 218 newborns of 215 HIV-positive mothers were matched to 218 newborns of 216 HIV-negative mothers. The matching criteria were maternal age and parity. No differences in socioeconomic characteristics were observed between HIV-positive and HIV-negative women. HIV-positive mothers more frequently reported a history of at least one death of a previously born child (P less than 0.01) and a history of abortion (P less than 0.001). Most of the HIV-positive women were asymptomatic, but 72.4% of them had a CD4; CD8 ratio less than 1 versus 10.1% in the HIV-negative group (P less than 0.001). The frequency of signs and symptoms was not statistically different in the two groups, except for a history of herpes zoster or chronic cough, which was more frequent among HIV-positive women. The rates of prematurity, low birth weight, congenital malformations and neonatal mortality were comparable in the two groups. However, infants of HIV-positive mothers had a mean birth weight 130 g lower than the infants of HIV-negative mothers (P less than 0.01). The impact of maternal HIV-1 infection on the infant seems limited during the neonatal period.
Assuntos
Infecções por HIV/epidemiologia , Soroprevalência de HIV , HIV-1 , Mortalidade Infantil , Complicações Infecciosas na Gravidez/epidemiologia , Aborto Espontâneo/complicações , Aborto Espontâneo/epidemiologia , Peso ao Nascer , Estudos de Coortes , Feminino , Infecções por HIV/complicações , Infecções por HIV/congênito , Infecções por HIV/transmissão , Herpes Zoster/complicações , Herpes Zoster/epidemiologia , Humanos , Recém-Nascido , Masculino , Troca Materno-Fetal , Gravidez , Estudos Prospectivos , Ruanda/epidemiologia , Fatores SocioeconômicosRESUMO
OBJECTIVE: To determine if beta 2-microglobulin (beta 2M) predicts death among HIV-infected African women. DESIGN: Nested case-control study. SETTING: Kigali, Rwanda. PARTICIPANTS: Two hundred and five seroprevalent women known to be HIV-infected since 1986-1987; 67 of whom died of HIV disease (cases) and 138 were alive (controls) as of November 1991. In addition, 128 women who seroconverted between 1986 and 1991. MAIN OUTCOME MEASURES: HIV serology, clinical signs and symptoms of HIV disease, hematology variables, and beta 2M concentration. RESULTS: beta 2M concentration increased over time (P < 0.001) in the seroprevalent women and seroconvertors. The average rate of beta 2M increase in women who died was 0.5 compared with 0.3 mg/l/year in the vital, seroprevalent women (P = 0.07). The strongest independent predictors of death were the rate of change of beta 2M (mg/l/year) [odds ratio (OR), 3.4; 95% confidence interval (CI), 1.7-6.8] and baseline beta 2M concentration (mg/l) [OR, 1.6; 95% CI, 1.2-2.1]. The rate of death for women with beta 2M concentration > or = 7.0 mg/l and a rate of change of beta 2M > or = 0.4 mg/l/year was 7.3 times higher than for women with beta 2M concentration < 7.0 mg/l and a rate of change of beta 2M of < 0.4 mg/l/year (95% CI, 3.1-17.2). The estimated median time from seroconversion to death assuming a constant rate of change of beta 2M was 10.6 years (95% CI, 9.9-11.2) for this cohort of HIV-infected women. CONCLUSIONS: Elevated beta 2M and a high rate of beta 2M increase were strongly associated with mortality among HIV-infected African women. Based on survival estimates using the rate of change of beta 2M, HIV-infected African women have similar survival compared with HIV-infected adults in the United States.
Assuntos
Infecções por HIV/sangue , Infecções por HIV/mortalidade , Microglobulina beta-2/análise , Adolescente , Adulto , Biomarcadores/sangue , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Soropositividade para HIV/sangue , Humanos , Modelos Logísticos , Prognóstico , Ruanda/epidemiologia , Análise de SobrevidaRESUMO
To investigate nutritional status and heterosexual human immunodeficiency virus (HIV) transmission, we performed a nested case-control study of sexually active, adult women in Kigali, Rwanda. Forty-five women who seroconverted during the 24-month study period were compared to 74 women who remained seronegative throughout the study. Seroconvertors and nonseroconvertors did not differ in preseroconversion serum levels of vitamin A, carotenoids, vitamin E, selenium, albumin, ferritin, or cholesterol. Weight loss, however, was a significant predictor of eventual HIV seroconversion. Subsequent seroconvertors lost an average of 1.5 kg during the first 6 months of the study compared with a 1.0-kg gain (p = 0.001) for nonconvertors. Nine of 27 (33%) seroconvertors, compared with one of 44 (2%) controls, lost at least 5 kg in the 6-month period beginning 1 year before their seroconversion (odds ratio, 21.5, 95% confidence interval 4.1-112). The association between weight loss and seroconversion was independent of other potential risk factors such as socioeconomic status, pregnancy, and genital ulcer disease. In addition to these findings for measured weight loss during follow-up, reported weight loss before enrollment was also a risk factor for subsequent seroconversion. Additional studies of heterosexual HIV transmission are needed to determine whether or not weight loss is causally related to susceptibility for HIV infection.
Assuntos
Soropositividade para HIV/imunologia , Estado Nutricional , Adolescente , Adulto , Estudos de Casos e Controles , Ensaio de Imunoadsorção Enzimática , Feminino , Anticorpos Anti-HIV/imunologia , Infecções por HIV/transmissão , Soropositividade para HIV/epidemiologia , Soropositividade para HIV/transmissão , HIV-1/imunologia , Humanos , Fatores de Risco , Ruanda , Comportamento Sexual , Redução de PesoRESUMO
Data were collected on 6709 singleton livebirths occurring in the hospital of Kigali, Rwanda. An analysis of birthweights was carried out by socioeconomic status, parity and age of the mother. The mean birthweight was highest in the high socioeconomic group. An effect of maternal age and parity on birthweight was observed. Because of the strong association between socioeconomic status and birthweight, the incidence of low birthweight can be used as an indicator of socioeconomic development.
PIP: The association between birthweight and socioeconomic status was investigated in the 6707 singleton births that occurred in the hospital in Kigali, Rwanda, in a 2-year period. Socioeconomic status was defined according to whether the mother delivered at the fee-paying clinic (high group) or at the free public clinic (low group). To evaluate the effect of parity, the birthweight data were given separately for 1st-born children and 4th-born children. In addition, primiparae were divided into 2 groups: mothers younger than 20 years of age and those age 20 years and older. Overall, the incidence of low birthweight (under 2500 grams) was 17.5% in this survey. Before analyzing for socioeconomic status, the percentage of low birthweight infants in the 3 age/parity categories was: para 1, under 20 years, 28.9%; para 1, 20 years or over, 21.9%; and para 4, 12.0%. Women of the higher socioeconomic group delivered heavier infants than women of the lower group. The difference between the 2 socioeconomic groups was significant at the p0.001 level for the study group as a whole as for the different subgroups. Mean birthweight was 3.12 + or - 0.50 in the high socioeconomic group compared with 2.95 + or - 0.49 in the low socioeconomic group; the percentage of low birthweight infants was 11.5% in the former group and 18.9% in the latter group. Given the strong association observed in this study, it is suggested that the incidence of low birthweight can be used as an indicator of socioeconomic development.
Assuntos
Peso ao Nascer , Fatores Socioeconômicos , Adolescente , Adulto , Feminino , Humanos , Recém-Nascido , Idade Materna , Paridade , Gravidez , RuandaRESUMO
OBJECTIVE: To determine whether HIV testing and counselling increased condom use and decreased heterosexual transmission of HIV in discordant couples. DESIGN: Prospective study. SETTING: Kigali, the capital of Rwanda. SUBJECTS: Cohabiting couples with discordant HIV serology results. MAIN OUTCOME MEASURES: Condom use in the couple and HIV seroconversion in the negative partners. RESULTS: 60 HIV discordant couples were identified, of whom 53 were followed for an average of 2.2 years. The proportion of discordant couples using condoms increased from 4% to 57% after one year of follow up. During follow up two of the 23 HIV negative men and six of the 30 HIV negative women seroconverted (seroconversion rates of 4 and 9 per 100 person years). The rate among women was less than half that estimated for similar women in discordant couples whose partners had not been serotested. Condom use was less common among those who seroconverted (100% v 5%, p = 0.01 in men; 67% v 25%, p = 0.14 in women). CONCLUSIONS: Roughly one in seven cohabiting couples in Kigali have discordant HIV serological results. Confidential HIV serotesting with counselling caused a large increase in condom use and was associated with a lower rate of new HIV infections. HIV testing is a promising intervention for preventing the spread of HIV in African cities.
PIP: Approximately one in seven cohabiting couples in Kigali, Rwanda, have HIV-discordant serology. A study of prospective design was conducted in Kigali to determine whether HIV testing and counseling would increase condom use and decrease the heterosexual transmission of HIV among HIV-discordant couples. 60 HIV-discordant couples were identified of whom 53 were followed for an average of 2.2 years. The proportion of these couples using condoms increased from 4% to 57% after one year of follow-up. During follow-up, 2 of the 23 HIV-negative men and 6 of the 30 HIV-negative women seroconverted. The rate among women was less than half that estimated for similar women in discordant couples whose partners had not been serotested. Moreover, condom use was less common among those who seroconverted. HIV testing may therefore be considered a promising intervention for preventing the spread of HIV in African cities.
Assuntos
Sorodiagnóstico da AIDS , Dispositivos Anticoncepcionais Masculinos/estatística & dados numéricos , Aconselhamento , Infecções por HIV/prevenção & controle , Adulto , Feminino , Infecções por HIV/psicologia , Soropositividade para HIV/epidemiologia , Humanos , Masculino , Estudos Prospectivos , Ruanda/epidemiologia , Fatores Sexuais , Comportamento SexualRESUMO
OBJECTIVES: This study examined hormonal contraceptive use and pregnancy in urban Rwandan women, following human immunodeficiency virus (HIV) antibody testing and counseling. METHODS: A sample of 1458 childbearing urban Rwandan women aged 18 to 35 years was tested and followed for 2 years. RESULTS: At enrollment, 17% of 998 HIV-negative women and 11% of 460 HIV-positive women were pregnant, and 17% vs 23%, respectively, were using hormonal contraceptives. One year later, half of the HIV-positive and one third of the HIV-negative hormonal-contraceptive users had discontinued use. The 2-year incidence of pregnancy was 43% in HIV-positive and 58% in HIV-negative women. HIV-positive women with fewer than four children were more likely to become pregnant than those with four or more; this association persisted in multivariate analyses but was not noted among HIV-negative women. At the end of the study, over 40% of non-users said that they would use hormonal contraception if it was provided at the study clinic, but 40% of HIV-positive women desired more children. CONCLUSIONS: Research is needed to identify the practical and psychosocial obstacles to effective long-term contraception among HIV-positive women. HIV counseling programs must specifically address the issue of childbearing.
Assuntos
Sorodiagnóstico da AIDS , Comportamento Contraceptivo , Aconselhamento , Gravidez , Adolescente , Adulto , Atitude , Feminino , Soropositividade para HIV , Humanos , Análise Multivariada , Ruanda , Estudos de AmostragemRESUMO
In 1986-1987 a consecutive sample of 3702 women presenting to prenatal and pediatric clinics at the only hospital in Kigali, Rwanda, was screened for human immunodeficiency virus (HIV) and malaria infection. The prevalence of HIV antibodies was 29%, and that of malaria parasites was 9%. HIV antibodies were more prevalent in women from the urban center than in those from the outskirts (31% vs. 20%, P less than .001), and malaria parasites showed the opposite prevalence pattern (8% vs. 15%, P less than .001); after stratifying by location, there was no association between HIV and the presence or degree of malaria parasitemia. HIV prevalence was 45% in women who had received a blood transfusion between 1980-1985 (before screening of donated blood began), and 28% among the great majority (94%) who had never been transfused. HIV prevalence was 44% in single mothers. 34% in women in common law unions, and 20% in those in legal marriages. These high rates of infection in the general population of Kigali highlight the need to develop effective programs for preventing further spread of sexually transmitted HIV.
Assuntos
Anticorpos Anti-HIV/sangue , Infecções por HIV/complicações , Malária/complicações , Plasmodium falciparum/isolamento & purificação , Complicações Infecciosas na Gravidez/epidemiologia , Adulto , Fatores Etários , Animais , Transfusão de Sangue , Feminino , Infecções por HIV/epidemiologia , Humanos , Malária/sangue , Malária/epidemiologia , Casamento , Gravidez , Prevalência , População Rural , Ruanda/epidemiologia , Pais Solteiros , População UrbanaRESUMO
During a 3-month period, 131 cases of herpes zoster were diagnosed in Kigali, Rwanda. There were 46 female and 85 male patients. Mean age was 29 years (range 1-66). An unusually high proportion of patients presented with cranial and sacral nerve localisation of their cutaneous lesions. 55/131 patients (42%) had involvement of more than one dermatome. None of the patients had an underlying condition known to favour herpes zoster. 120/131 (92%) had antibodies to HIV detected by an immunoenzymatic assay (EIA) and indirect immunofluorescence. 92/125 adult patients (74%) had no sign or symptom related to HIV infection other than herpes zoster. This study suggests that herpes zoster in Central Africa is an early and readily detectable manifestation of HIV-induced immunosuppression.
Assuntos
Soropositividade para HIV/complicações , Herpes Zoster/etiologia , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Doenças dos Nervos Cranianos/etiologia , Feminino , Herpes Zoster/diagnóstico , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , RuandaRESUMO
OBJECTIVE: We evaluated the impact of human immunodeficiency virus (HIV) testing and counseling on self-reported condom and spermicide use and on corresponding HIV seroconversion and gonorrhea rates in urban Rwandan women. DESIGN: Prospective cohort study with 2 years of follow-up, comparison of outcome variables before and after an intervention, and condom use measured in a control group that did not receive the intervention. SETTING: Outpatient research clinic in Kigali, the capital of Rwanda. PARTICIPANTS: One thousand four hundred fifty-eight childbearing women, 32% of whom were infected with HIV, were enrolled in a prospective study in 1988, and followed at 3- to 6-month intervals for 2 years. Follow-up was available for 95% of subjects at year 1 and 92% at year 2. INTERVENTIONS: An acquired immunodeficiency syndrome (AIDS) educational videotape, HIV testing and counseling, and free condoms and spermicide were provided to all participants and interested sexual partners. MAIN OUTCOME MEASURES: Self-report of compliance with condom-spermicide use and observed incidence of HIV and gonorrhea. RESULTS: Only 7% of women reported ever trying condoms before the intervention, but 22% reported condom use with good compliance 1 year later. Women who were HIV-positive were more likely to adopt condom use than HIV-negative women (36% vs 16%; P < .05). Independent predictors of condom use, both in HIV-positive and in HIV-negative women, included HIV testing and counseling of the male partner, having a nonmonogamous relationship, and believing condoms were not dangerous. Human immunodeficiency virus seroconversion rates decreased significantly (from 4.1 to 1.8 per 100 person-years; P < .04) in women whose partners were tested and counseled. The prevalence of gonorrhea decreased substantially (13% to 6%; P < .05) among HIV-positive women, with the greatest reduction among condom users (16% to 4%; P < .05). CONCLUSION: A confidential HIV testing and counseling program was associated with increased use of condoms and reduced rates of gonorrhea and HIV in urban Rwandan women. The lack of risk reduction in HIV-negative women whose partner's serostatus was unknown was of concern. Interventions that promote HIV testing and counseling for both members of a couple should be considered in other high-prevalence areas.
Assuntos
Sorodiagnóstico da AIDS , Preservativos , Gonorreia/epidemiologia , Infecções por HIV/epidemiologia , Promoção da Saúde , Adulto , Confidencialidade , Aconselhamento , Feminino , Seguimentos , Gonorreia/prevenção & controle , Infecções por HIV/prevenção & controle , Soropositividade para HIV , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Análise Multivariada , Cooperação do Paciente , Prevalência , Estudos Prospectivos , Fatores de Risco , Ruanda/epidemiologia , Parceiros Sexuais , Espermicidas/uso terapêuticoRESUMO
OBJECTIVE: To better characterize the natural history of disease due to human immunodeficiency virus (HIV) infection in African women. DESIGN: Prospective cohort study over a 2-year follow-up period. PARTICIPANTS: A total of 460 HIV-seropositive women and a comparison cohort of HIV-seronegative women recruited from prenatal and pediatric clinics in Kigali, Rwanda in 1988. MEASUREMENTS: Clinical signs and symptoms of HIV disease, AIDS, and mortality. MAIN RESULTS: Follow-up data at 2 years were available for 93% of women who were still alive. At enrollment, many seropositive women reported symptoms listed in the World Health Organization (WHO) clinical case definition of AIDS, but these were nonspecific and often improved over time. The 2-year mortality among HIV-infected women by Kaplan-Meier survival analysis was 7% (95% CI, 5% to 10%) overall, and 21% (CI, 8% to 34%) for the 40 women who fulfilled the WHO case definition of AIDS at entry. In comparison, the 2-year mortality in women not infected with HIV was only 0.3% (CI, 0% to 7%). Independent baseline predictors of mortality in seropositive women by Cox proportional hazards modeling were, in order of descending risk factor prevalence: a body mass index of 21 kg/m2 or less (relative hazard, 2.3; CI, 1.1 to 4.8), low income (relative hazard, 2.3; CI, 1.1 to 4.5), an erythrocyte sedimentation rate exceeding 60 mm/h (relative hazard, 4.9; CI, 2.2 to 10.9), chronic diarrhea (relative hazard, 2.6; CI, 1.1 to 5.7), a history of herpes zoster (relative hazard 5.3; CI, 2.5 to 11.4), and oral candida (relative hazard, 7.3; CI, 1.6 to 33.3). Human immunodeficiency virus disease was the cause of death in 38 of the 39 HIV-positive women who died, but only 25 met the WHO definition of AIDS before death. CONCLUSIONS: Human immunodeficiency virus disease now accounts for 90% of all deaths among child-bearing urban Rwandan women. Many symptomatic seropositive patients may show some clinical improvement and should not be denied routine medical care. Easily diagnosed signs and symptoms and inexpensive laboratory tests can be used in Africa to identify those patients with a particularly good or bad prognosis.
PIP: In 1988, researchers recruited 18-35 year old women from pediatric and prenatal care clinics at the Centre Hospitalier de Kigali in Rwanda to observe HIV disease progression. They compared probability of survival of the 460 HIV-positive women with that of the 998 HIV-negative women. They used simple clinical and laboratory variables as predictors of mortality from AIDS. The researchers did not use the WHO clinical case definition of AIDS as the outcome measure since 40 and 30 women from each group, respectively, met the criteria for AIDS at entry. Only 66% (25) of the HIV=infected women who died met the criteria for AIDS during the study. After 2 years, mortality among HIV-infected women stood at 7% (39) which was more than 20 times higher than that among women not HIV infected (0.3%; p .001). Mortality was 21% for those who met the WHO criteria for AIDS. The wasting syndrome was the cause of the death in 51% of HIV-infected death cases. The baseline predictors of mortality in HIV-infected women in descending order of prevalence of predictor included an at most body mass index of 21 kg.sq. (48%; relative hazard [RH] 2.3), low income (46%; RH=2.6), mm/hour erythrocyte sedimentation rate (39%; rh = 4.9), chronic diarrhea (10%; RH = 2.6), a history of herpes zoster (9%; RH 5.3), and oral candidiasis (1%; RH 7.3). The erythrocyte sedimentation rate was a better predictor than lymphocyte counts (p .001) and p .11, respectively). Of the 40 HIV-infected women who met the criteria for AIDS, the health of 32 women improved so the physicians no longer considered them to have AIDS. Thus health workers should treat symptomatic HIV-positive cases. AIDS was responsible for 90% of all deaths among reproductive age women living in Kigali. Health workers in Africa can use the simpler erythrocyte sedimentation rate instead of the more costly CD4 counts as a predictor of progression to AIDS.
Assuntos
Infecções por HIV/mortalidade , Síndrome da Imunodeficiência Adquirida/epidemiologia , Adolescente , Adulto , Fatores Etários , Causas de Morte , Feminino , Seguimentos , Infecções por HIV/sangue , Humanos , Incidência , Contagem de Leucócitos , Linfócitos , Análise Multivariada , Probabilidade , Modelos de Riscos Proporcionais , Fatores de Risco , Ruanda/epidemiologia , Fatores Socioeconômicos , Taxa de Sobrevida , Saúde da População UrbanaRESUMO
To determine the prevalence of Mycobacterium tuberculosis infection and the incidence of tuberculosis in HIV-infected and uninfected urban Rwandan women, 460 HIV-positive and 998 HIV-negative childbearing women were recruited from pediatric and prenatal care clinics and were enrolled in a prospective study in 1988 and followed for 2 yr. Tuberculin testing was administered 12 to 18 months after enrollment. Fifty-three percent of HIV-negative women had positive tuberculin tests (induration > or = 10 mm), with higher rates among older women and among women who had received BCG vaccine. Only 21% of HIV-positive women had positive tuberculin tests, with no relationship to BCG vaccine. Follow-up was available for 93% of subjects. Tuberculosis was diagnosed in 20 HIV-positive women and in two HIV-negative women. Features associated with an increased risk of tuberculosis among HIV-positive women included: age > or = 30, body mass index in the lowest quartile, low income, erythrocyte sedimentation rate > 75, positive tuberculin test, and chronic cough, chronic fever, and weight loss. Among Rwandan women who are infected with HIV, approximately half of those who are infected with M. tuberculosis do not have positive tuberculin tests. The rate ratio for development of tuberculosis among HIV-positive women was 22 (95% CI, 5 to 92). New algorithms are needed to improve the early detection of tuberculosis among HIV-positive patients in Africa.
PIP: This study determines the prevalence of Mycobacterium tuberculosis (TB) infection and the incidence among HIV infected and uninfected women in urban Rwanda. The sample population includes 460 HIV-positive women and 998 HIV-negative women who were recruited from pediatric and prenatal care clinics at the Centre Hospitalier de Kigali. The sample is considered representative of childbearing women from the capital city. Initial interviews were conducted in 1988 and followed-up in 1990. HIV-1 diagnosis was determined on the basis of enzyme immunoassay and western blot tests or indirect immunofluorescence that showed reactivity to both a core protein and an envelope protein. A positive tuberculin test was defined as induration of 10 mm or more. Routine visits were made every 6 months. Comparisons were made between women who were HIV positive at their first HIV test (250 women), women who were negative at their first test but seroconverted between the first HIV test and the TB test 3 years later (80 women), and women who were HIV negative at the time of TB testing (687). 55% of HIV-negative women had positive tests with induration of more than 10 mm. 25% of HIV-positive women and 66% of HIV-negative women had TB tests with over 5 mm induration. 31% of HIV-positive women and 70% of HIV-negative women had induration of over 2 mm. 77% of women had TB vaccine scars. Prevalence of a positive test was significantly higher in the HIV-negative vaccinated group than in the nonvaccinated group. The proportion with low white cell counts, low lymphocyte counts, and high sedimentation rates was higher among HIV-positive women than HIV-negative women. During the 2-year follow-up period, 20 of the 401 HIV-positive women and 2 of the 917 HIV-negative women were diagnosed with TB. The risk ratio was 22.9. The incidence of TB was 3 times higher among women who had been infected with HIV at least 18 months than among women who had been infected less than 18 months. Low income and low body mass were associated with an increased risk of TB. 9 out of 17 HIV-infected women with TB had negative TB tests.
Assuntos
Infecções por HIV/complicações , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/epidemiologia , Sorodiagnóstico da AIDS , Adolescente , Adulto , Vacina BCG , Feminino , Seguimentos , Humanos , Incidência , Estudos Prospectivos , Ruanda/epidemiologia , Teste Tuberculínico , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/prevenção & controleRESUMO
OBJECTIVE: --To determine behavioral and demographic risk factors for human immunodeficiency virus (HIV) infection in central Africa. DESIGN: --Cross-sectional survey. SETTING: --Kigali, Rwanda. PARTICIPANTS: --A representative sample of 1458 childbearing women aged 19 to 37 years who were recruited from outpatient prenatal and pediatric clinics at the only community hospital in the city. MAIN OUTCOME MEASURE: --Antibodies to HIV assessed by enzyme immunoassay and confirmed by Western blot or indirect immunofluorescence. RESULTS: --The HIV seroprevalence was 32% overall. Infection rates were higher in women who were single, in those in steady relationships that began after 1981, and in the 33% of women reporting more than one lifetime sexual partner. Women in legal marriages or monogamous partnerships had lower rates of infection, but even low-risk women had prevalences on the order of 20%. History of venereal disease in the past 5 years, although the strongest risk factor in a multiple logistic analysis (odds ratio, 2.7; 95% confidence interval, 2.0 to 3.7), was reported by only 30% of those infected. Having a male sexual partner who drank alcohol or who had higher income were significant risk factors for HIV infection in the multivariate analysis, but use of oral contraceptives and having an uncircumcised partner were not. CONCLUSIONS: --The epidemic of the acquired immunodeficiency syndrome in Rwanda has spread beyond high-risk groups to the general population of women without known risk factors. For most of these women, a steady male partner is the source of their HIV risk and therefore a vital target for intervention efforts.
Assuntos
Soroprevalência de HIV , Complicações Infecciosas na Gravidez/epidemiologia , Comportamento Sexual/estatística & dados numéricos , Adulto , Estudos Transversais , Feminino , Anticorpos Anti-HIV/análise , Infecções por HIV/epidemiologia , Infecções por HIV/imunologia , Humanos , Incidência , Masculino , Casamento , Gravidez , Complicações Infecciosas na Gravidez/imunologia , Prevalência , Estudos Prospectivos , Análise de Regressão , Fatores de Risco , Ruanda/epidemiologia , Fatores Socioeconômicos , População UrbanaRESUMO
Our objective was to describe associations among male circumcision, behavioral and demographic variables, ulcerative and nonulcerative sexually transmitted disease (STD), and human immunodeficiency virus (HIV) infection via a cross-sectional study in Kigali, the capital of Rwanda. Our subjects were 837 married men who volunteered for HIV testing and counselling. Uncircumcised men had a relatively low-risk profile in that they reported fewer lifetime sexual partners and prostitute contacts than circumcised men and were more likely to live in rural areas with lower HIV prevalence rates. Uncircumcised men were also less likely to report a history of sexually transmitted disease (64% versus 73%, p = 0.01), although they were more likely to report genital ulceration (GUD) (24% versus 17%, p < 0.03) and to have inguinal adenopathy noted on physical exam (42% versus 29%, p = 0.009). Despite the low-risk profile, uncircumcised men had a higher prevalence of HIV infection than circumcised men (29% versus 21% HIV positive, p = 0.02), which was most marked in men reporting five or more lifetime sex partners (36% versus 23% HIV positive, p = 0.005) or contact with prostitutes (35% versus 23% HIV positive, p = 0.009). Circumcision remained a predictor of HIV infection in multivariate analyses (multivariate odds ratio 1.69, 95% confidence interval 1.16-2.47). Lack of circumcision is associated with a higher risk of HIV infection in Rwandan men. Further research is needed to determine whether this higher risk is due in part to poor hygiene or to complex mechanisms operating through the acquisition of other sexually transmitted diseases. Circumcision may be an appropriate risk reduction approach for men with known exposures to the virus when there are constraints to alternatives, such as condom use.
Assuntos
Circuncisão Masculina , Infecções por HIV/epidemiologia , Infecções Sexualmente Transmissíveis/epidemiologia , Adulto , Estudos Transversais , Demografia , Doenças dos Genitais Masculinos/epidemiologia , Humanos , Masculino , Análise Multivariada , Prevalência , Estudos Prospectivos , Fatores de Risco , Ruanda/epidemiologia , Comportamento Sexual/estatística & dados numéricosRESUMO
Few studies have addressed the relation between serum vitamin A level and HIV disease progression. Thirty HIV-infected women in Rwanda were studied over a time span of 26 to 99 months. Fourteen subjects seroconverted and died of HIV-related disease at a mean of 44 months (range, 26-69 months) after their first HIV-positive test and were termed "rapid progressors," (RPs). A comparison group of 16 "slow progressors" (SPs) were HIV-positive at the time of their first HIV serology and had asymptomatic HIV infections at a mean of 96 months (range, 93-99 months) after their first HIV serology. Baseline mean serum retinol values were the same in RPs and SPs: 0.65 + 0.08 mmol/L versus 0.67 + 0.09 micromol/L (p = .7). Lower serum retinol levels were observed in RPs compared with SPs for the second and third measurements, obtained at a median of 12 and 24 months past baseline: 0.51 + 0.07 mmol/L versus 0.76 + 0.14 mmol/L (p = .3) and 0.44 + 0.09 mmol/L versus 0.64 + 0.08 mmol/L (p = .08), respectively. Median retinol levels for the third sample measurement were similar in RPs with lower viral load (LVL) and SPs (0.49 mmol/L and 0.52 mmol/L, respectively) compared with only 0.19 mmol/L in RPs with higher viral load (HVL; p = .02). A trend toward decreasing serum retinol levels and increasing HIV-1 RNA viral load was observed at the third sample measurement (p = .04). Subjects with LVL, higher serum retinol levels (> or =0.70 mmol/L), or both had more favorable rates of survival than subjects with HVL, low serum retinol levels (<0.70 mmol/L), or both. Although sample size does not permit definitive conclusions, this study demonstrates an association of high HIV load, rapid progression, and low serum retinol late but not early in disease progression.
Assuntos
Infecções por HIV/etiologia , HIV-1/fisiologia , RNA Viral/sangue , Carga Viral , Vitamina A/sangue , Adulto , Progressão da Doença , Feminino , Infecções por HIV/mortalidade , Infecções por HIV/virologia , HIV-1/genética , Humanos , Ruanda/epidemiologia , Análise de Sobrevida , Fatores de Tempo , Deficiência de Vitamina A/complicaçõesRESUMO
OBJECTIVE: To develop a human immunodeficiency virus (HIV) staging system for sub-Saharan Africa on the basis of an evaluation of the World Health Organization (WHO) system and predictors of mortality. DESIGN: Prospective cohort study with 4 years of follow-up. SETTING: Kigali, Rwanda. PATIENTS: 412 HIV-infected women recruited from prenatal and pediatric clinics. MEASUREMENTS: Clinical signs and symptoms of HIV disease, laboratory assays (including complete blood count and erythrocyte sedimentation rate), and cumulative mortality. RESULTS: The WHO staging system includes a clinical and a laboratory axis. The clinical axis was revised by inclusion of oral candidiasis, chronic oral or genital ulcers, and pulmonary tuberculosis as "severe" disease (clinical stage IV); in addition, body mass index was substituted for weight loss in the definition for the wasting syndrome. The 36-month cumulative mortality was 7% for women in modified clinical stage I ("asymptomatic"), 15% for those in stage II, 19% for those in stage III, and 36% for those in stage IV (P < 0.001). The laboratory axis was revised by replacing lymphocyte count with hematocrit and erythrocyte sedimentation rate. The 36-month mortality was 10% for women in modified stage A ("normal" laboratory results) and 33% for those in stage B (erythrocyte sedimentation rate > 65 mm/h or hematocrit < 0.38) (P < 0.001). A single staging system combining clinical and laboratory criteria is proposed, with a 36-month mortality of 7% for women in combined stage I, 10% for those in stage II, 29% for those in stage III, and 62% for those in stage IV (P < 0.001). CONCLUSIONS: On the basis of this analysis, a staging system relevant for sub-Saharan Africa is proposed that reflects the range of HIV-related outcomes, has strong prognostic significance, includes inexpensive and available laboratory tests, and can be used by both clinicians and researchers.
PIP: In Rwanda, health workers followed 412 HIV infected women attending prenatal and pediatric outpatient clinics in Kigali for 4 years. Researchers used these findings to evaluate WHO's HIV Staging System and predictors of mortality and to produce an HIV staging system for sub-Saharan Africa. The 36-month cumulative mortality was 9% for women originally in stage I, 15% for those in stage II, and 25% for those in stage III, and 27% for those in stage IV (p = 0.001). Significant predictors of mortality at 36 months were oral candidiasis, a low body mass index (=or 19 kg/sq. m), a history of oral or genital ulcers (especially chronic ulcers), a low hematocrit (0.38), and a high erythrocyte sedimentation rate (65 mm/h) (p 0.001). 12 of the 96 women who died by 36 months had developed pulmonary or extrapulmonary tuberculosis (TB). The researchers revised the WHO system by adding oral candidiasis, chronic oral or genital ulcers, and pulmonary TB to clinical stage IV (severe HIV disease). In the laboratory axis of the system, they replaced lymphocyte count with hematocrit and erythrocyte sedimentation rate. Using the modified laboratory axis, the 36-month mortality rate was 10% for women with normal laboratory results (stage A) and 33% for those with low hematocrit and a high erythrocyte sedimentation rate (stage B). Based on the proposed single staging system, the 36-month mortality rate was 7% for women in stage I, 10% for those in stage II, 29% for those in stage III, and 62% for those in stage IV (p 0.001). The researchers used these results to propose a staging system that is relevant for sub-Saharan Africa, considers the extent of HIV-related outcomes, requires only inexpensive and available laboratory tests, and has clear prognostic significance. Both clinicians and researchers can use this modified staging system.
Assuntos
Países em Desenvolvimento , Infecções por HIV/classificação , Infecções por HIV/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS , Adolescente , Adulto , Estudos de Avaliação como Assunto , Feminino , Seguimentos , Infecções por HIV/complicações , Infecções por HIV/mortalidade , Humanos , Neoplasias/complicações , Estudos Prospectivos , Ruanda/epidemiologia , Organização Mundial da SaúdeRESUMO
Few studies have addressed the relation between serum vitamin A levels and HIV disease progression. Thirty HIV-infected women in Rwanda were studied over a time span of 26 to 99 months. Fourteen subjects seroconverted and died of HIV-related disease at a mean of 44 months (range, 26-69 months) after their first HIV-positive test and were termed "rapid progressors," (RPs). A comparison group of 16 "slow progressors" (SPs) were HIV-positive at the time of their first HIV serology and had asymptomatic HIV infections at a mean of 96 months (range, 93-99 months) after their first HIV serology. Baseline mean serum retinol values were the same in RPs and SPs: 0.65 + 0.08 micromol/L versus 0.67 + 0.09 micromol/L (p = .7). Lower serum retinol levels were observed in RPs compared with SPs for the second and third measurements, obtained at a median of 12 and 24 months past baseline: 0.51 + 0.07 micromol/L versus 0.76 + 0.14 micromol/L (p = .3) and 0.44 + 0.09 micromol/L versus 0.64 + 0.08 micromol/L (p = .08), respectively. Median retinol levels for the third sample measurement were similar in RPs with lower viral load (LVL) and SPs (0.49 micromol/L and 0.52 micromol/L, respectively) compared with only 0.19 micromol/L in RPs with higher viral load (HVL; p = .02). A trend toward decreasing serum retinol levels and increasing HIV-1 RNA viral load was observed at the third sample measurement (p = .04). Subjects with LVL, higher serum retinol levels (> or =0.70 micromol/L), or both had more favorable rates of survival than subjects with HVL, low serum retinol levels (<0.70 micromol/L), or both. Although sample size does not permit definitive conclusions, this study demonstrates an association of high HIV load, rapid progression, and low serum retinol late but not early in disease progression.