Universal prevention is associated with lower prevalence of fetal alcohol spectrum disorders in Northern Cape, South Africa: a multicentre before-after study.

AIMS: Prevalence of fetal alcohol spectrum disorders (FASDs) is remarkably high in several provinces of South Africa; yet population-level knowledge of the harms of maternal drinking remains low. In two heavily affected areas, we assessed effectiveness of interventions to heighten awareness of these harms and to alter social norms about drinking in pregnancy. METHODS: FASD prevalence, maternal knowledge and drinking behaviours were investigated in two Northern Cape Province towns, before and after interventions which included highlighting FASD using local media and health promotion talks at health facilities. Independently, two dysmorphologists and a neuropsychometrist examined children at 9 and 18 months. RESULTS: Pre-intervention maternal knowledge of alcohol harms was low and FASD prevalence 8.9% (72/809). Interventions reached high coverage and knowledge levels increased substantially. FASD prevalence was 5.7% post-intervention (43/751; P = 0.02); 0.73 lower odds, controlling for maternal age and ethnicity (95% confidence interval = 0.58-0.90). No change was detected in more severe FASD forms, but in the whole population, median dysmorphology scores reduced from 4 [inter-quartile range (IQR) = 2-7] to 3 (IQR = 1-6; P = 0.002). CONCLUSION: This, the first prevention study using FASD outcomes, suggests that universal prevention might reduce FASD by ∼30% and have population-level effects. This supports intensifying universal interventions where knowledge of harms of maternal drinking is low. These efforts need to be accompanied by alcohol-dependence treatment to lower more severe FASD forms.

HIV incidence and prevalence among cohorts of women with higher risk behaviour in Bloemfontein and Rustenburg, South Africa: a prospective study.

OBJECTIVES: The primary objective was to measure HIV incidence in two prospective cohorts of HIV-negative women. Secondary objectives included measuring pregnancy rates and participant retention rates. DESIGN: Cross-sectional HIV screening of women selected for higher risk behaviours, with a subsequent prospective study of uninfected women, followed monthly for up to 6 months. SETTING: Clinics established for research purposes in Bloemfontein and Rustenburg, South Africa. PARTICIPANTS: The authors enrolled women 18-35 years old and presumed at higher risk of sexual acquisition of HIV as indicated by self-reported sexual behaviour or recent sexually transmitted infection symptoms. In Bloemfontein, 1364 women were screened, 1154 were eligible for HIV testing and 1145 agreed to be tested. The prospective study enrolled 401 HIV-negative women. In Rustenburg, 946 women were screened, 540 were eligible and underwent HIV testing and 223 HIV-negative women entered the prospective study. PRIMARY AND SECONDARY OUTCOMES: Baseline prevalences of HIV infection and HIV incidence rates in the prospective cohorts, according to a double rapid test algorithm with a third rapid test for discrepant or indeterminate results. Pregnancy prevalences and pregnancy incidence rate in Bloemfontein. Participant retention rates in the prospective cohort until the study end. RESULTS: In Bloemfontein, 1145 women were tested, 391 entered follow-up and 92.3% of participants completed six study visits. In Rustenburg, 540 women were tested, 194 entered follow-up and retention up to the point of early study termination was 88.6%. Overall HIV prevalence was 21.2% (95% CI 18.9% to 23.6%) in Bloemfontein and 23.5% (95% CI 19.9% to 27.1%) in Rustenburg. Overall HIV incidence was 5.5/100 person-years (95% CI 2.5 to 10.4) in Bloemfontein and 3.0/100 person-years (95% CI 0.4 to 10.8) in Rustenburg. Cross-sectional pregnancy prevalences were 6.5% in Bloemfontein and 8.6% in Rustenburg. CONCLUSIONS: The authors observed substantial HIV incidence rates in both cohorts. Vigorous prevention efforts are needed in these smaller cities.

Fetal alcohol syndrome among grade 1 schoolchildren in Northern Cape Province: prevalence and risk factors.

OBJECTIVE: To describe the prevalence, characteristics and risk factors for fetal alcohol syndrome (FAS) and partial FAS among schoolgoing children in Grade 1 in Northern Cape Province, South Africa. DESIGN: A cross-sectional study using a two-tiered method for ascertainment of FAS/partial FAS cases, comprising: screening of growth parameters, diagnostic assessment for screen-positive children using clinical and neurocognitive assessments, and maternal history of drinking during pregnancy. Mothers or caregivers of FAS children and matched controls were interviewed. SETTING: Primary schools in De Aar (8) and Upington (15). Subjects. Grade 1 pupils in 2001 (De Aar, N=536) and 2002 (Upington, N=1299). OUTCOME MEASURES: FAS or partial FAS. RESULTS: The prevalence of FAS/partial FAS was high: 64/536 (119.4/1000, 95% CI 93.2-149.9) in De Aar, and 97/1299 (74.7/1 000, 95% CI 61.0-90.3) in Upington. Overall, 67.2 per 1000 children (95% CI 56.2-79.7) had full FAS features. Growth retardation was also common in this population: 66.6% (1181/1774) were underweight, 48.3% (858/1776) stunted, and 15.1% had a head circumference <2 SD for age. Mothers of children with FAS were less likely to have full-time employment or have attended secondary school and had lower body mass index, and about 80% currently smoked. Over two-thirds of all pregnancies had been unplanned. CONCLUSIONS: A very high proportion of pupils (nearly 1 in 10) had FAS/partial FAS, the rate in De Aar being the highest yet described in South Africa. FAS/partial FAS may contribute to the extremely high rate of growth retardation in South Africa as a whole and is a major cause of learning disability. These epidemiological features are important in designing preventive interventions.