AIDS: an international perspective.

The acquired immunodeficiency syndrome (AIDS) and infection with the human immunodeficiency virus type 1 (HIV-1) constitute a worldwide public health problem. Whereas in Europe and in most of the Americas transmission of HIV-1 has occurred predominantly among homosexual men and intravenous drug abusers, in Africa a distinct epidemiologic pattern has emerged that indicates that HIV-1 infection is mainly heterosexually acquired. Heterosexual transmission appears to be increasing in some parts of Latin America and the Caribbean, and possibly in the United States. In addition to HIV-1, at least one other human retrovirus, namely HIV-2, has been implicated as a cause of AIDS in Africa and Europe. Factors that influence heterosexual transmission of HIV-1 include genital ulcerations, early or late stages of HIV-1 infection in the index case, and possibly oral contraception and immune activation. The rate of perinatal transmission is enhanced when the mother's illness is more advanced. AIDS and HIV-1 infection may have a significant impact not only on public health, but also on the demography and socioeconomic conditions of some developing countries. Programs for the prevention and control of AIDS should be an immediate priority in all countries.

Integration of AIDS program activities into national health systems.

In this paper we have defined integration as being the health unit team acceptance of responsibility for all aspects of care at the health service/community interface level. The health unit functions within a system whose elements (hospitals, laboratory, pharmacy, etc.) function in complementarity with those of the FLHS. Vertical approaches are often adopted because of weaknesses in some elements of the NHS, thereby further undermining such an NHS. The development of innovative community-based approaches in some areas and countries has resulted from this type of situation. However, isolated from the NHS, such approaches cannot be expected to be sustainable or to have long-term impact. Integration is the best choice of approach; it offers a chance to influence the course of the AIDS epidemic and the response of health systems in each country. The basic structure of the NHS and the characteristics of a FLHS are analyzed. The challenge to AIDS programs is to define more exactly objectives and activities at the operational, interface levels. Based on this analysis, planning of operations should be delegated to the district. Weakness of some elements and aspects of the NHS which are relevant to AIDS control program implementation can be overcome, not by organizing the program vertically and independently from the NHS, but rather by sharing resources to strengthen the weak elements. Integration may be more difficult in the early stages of implementation, but in the long term it offers sustainable development of AIDS prevention and control activities.

PIP: This paper reviews the integration of AIDS program activities into national health systems as a possible way to make the activities more effective, efficient, and sustainable. For the purposes of this paper, integration is the health unit team acceptance of responsibility for all aspects of care at the health service/community interface level. Consideration is limited to the integration of AIDS control activities into national health systems, but the concept of integration is also applicable to other sectoral service systems such as education, religion, and rural development. The integration of activities will become a prerequisite for sustainability as the AIDS epidemic spreads. While such integration may be difficult in the early stages of implementation, it offers the sustainable development of AIDS prevention and control activities over the long term. Examples of the successful integration of AIDS activities into other health programs need to be studied in order to identify what is the most effective form of integration. The authors discuss integration and vertical approaches, and the structure of the national health service and characteristics of first-line health services.

From research to practice: use of short course zidovudine to prevent mother-to-child HIV transmission in the context of routine health care in Northern Thailand.

Thailand has made remarkable progress in battling the HIVepidemic, as the decreases in HIV prevalence and changes in sexual behavior attest. Yet, in Phayao, a northern province severely affected by HIV, approximately 280 HIV-infected women, or 5% of all pregnant women, gave birth to an estimated 70 infected children in 1997. As many of these infants die within their first year of life, the infant mortality rate is on the rise after years of decline. The province, however, responded quickly to this crisis. Since July 1997, the Ministry of Public Health (MOPH) offers through Phayao's seven public hospitals a short regimen of zidovudine to all consenting HIV-infected women to prevent mother-to-child transmission of the virus. The overall prophylactic coverage for the province reached 68% of all HIV-infected pregnant women in the fourth quarter of 1997, either through the MOPH program or through the North Thailand Perinatal HIV Prevention Trial, the parallel clinical trial conducted by the MOPH and the Ministry of University Affairs. Analysis of the data collected showed that compliance to the intervention was excellent, around 90%. This was achieved at an additional cost of US$ 0.13 per capita per year, affordable even in the context of the economic crisis, and represents less than 1% of public health expenditures in Thailand. The cost per Disability Adjusted Life Years saved is approximately US$35, making it highly cost-effective. In less than a year, the MOPH implemented this program on a large scale in this relatively poor province, with limited external support. Women receive pretest counseling at their first prenatal visit, are offered HIV testing and, if they accept, return for posttest counseling two weeks later. In the case of a positive test result, a confirmation test is performed at the provincial hospital. HIV-infected women are offered zidovudine the 34th week of pregnancy or as soon as possible thereafter. Before starting treatment, the women's hemoglobin, CBC and platelets are measured. Infants begin taking oral zidovudine shortly after birth and continue until they are one week old. Subsequently, health centers regularly follow the infants, and volunteers provide case management of childhood illness, nutrition problem solving, childhood immunizations and home visits. Mothers feed the infants breastmilk substitutes, and women with insufficient income receive the substitutes free of charge. The northern Thailand experience provides important insights into the feasibility of large scale interventions to prevent perinatal HIV, such as the need for the reorganization of the delivery of health care and quality counseling. On the basis of this experience, a simplified schedule of three intervention phases (Screen, Treat and Care), which can be incorporated into routine mother and child health care, is proposed. Follow-up of the child, however, will require more frequent and intensive contact with health care services than usual. At a time when many countries are reevaluating their health care systems, these insights should be considered, so as to additional better the needs of HIV-infected women during pregnancy and beyond.

Accuracy of two enzyme immunoassays and cell culture in the detection of Chlamydia trachomatis in low and high risk populations in Senegal.

Two enzyme immunoassays (EIAs), Chlamydiazyme (CZ; Abbott Laboratories) and Pathfinder (PF; Kallestadt), were compared with a cell culture technique in the detection of cervical Chlamydia trachomatis infection in 670 women in urban settings in Senegal (377 pregnant women and 293 prostitutes). Positive CZ and positive PF specimens were tested a second time using a monoclonal antibody blocking technique. True positive specimens were defined as those positive on culture or positive on EIA with confirmation of the result after blocking. Using this definition, the prevalence of genital chlamydial infection was 14.6% and 14.3% in pregnant women and prostitutes respectively. An important difference between the two populations was that the pregnant women were younger than the prostitutes, which might explain the fact that the prevalence of infection among the pregnant women was as high as that among the prostitutes, although the age-adjusted prevalence was higher among prostitutes than among pregnant women. The chlamydial detection rates of cell culture, CZ and PF were 62% (26/42), 69% (29/42) and 86% (36/42) respectively in prostitutes and 76% (42/55), 40% (22/55) and 53% (29/55) respectively in pregnant women. Agreement between the tests was 89%, 85% and 88% for culture/CZ, culture/PF and CZ/PF respectively. However, when data were adjusted for chance agreement, kappa coefficients were 0.40 for culture/CZ, 0.34 for culture/PF and 0.48 for CZ/PF. These results indicate that the accuracy of the EIAs and cell culture may vary greatly in different populations: both EIAs showed a distinctly higher detection rate than culture in prostitutes and a significantly lower detection rate in pregnant women.(ABSTRACT TRUNCATED AT 250 WORDS)