Review of policy and status of implementation of collaborative HIV-TB activities in 23 high-burden countries.

Issuance of national policy guidance is a critical step to ensure quality HIV-TB (human immunodeficiency virus-tuberculosis) coordination and programme implementation. From the database of the Joint United Nations Programme on HIV/AIDS (UNAIDS), we reviewed 62 national HIV and TB guidelines from 23 high-burden countries for recommendations on HIV testing for TB patients, criteria for initiating antiretroviral therapy (ART) and the Three I's for HIV/TB (isoniazid preventive treatment [IPT], intensified TB case finding and TB infection control). We used UNAIDS country-level programme data to determine the status of implementation of existing guidance. Of the 23 countries representing 89% of the global HIV-TB burden, Brazil recommends ART irrespective of CD4 count for all people living with HIV, and four (17%) countries recommend ART at the World Health Organization (WHO) 2013 guidelines level of CD4 count â©¿500 cells/mm(3) for asymptomatic persons. Nineteen (83%) countries are consistent with WHO 2013 guidelines and recommend ART for HIV-positive TB patients irrespective of CD4 count. IPT is recommended by 16 (70%) countries, representing 67% of the HIV-TB burden; 12 recommend symptom-based screening alone for IPT initiation. Guidelines from 15 (65%) countries with 79% of the world's HIV-TB burden include recommendations on HIV testing and counselling for TB patients. Although uptake of ART, HIV testing for TB patients, TB screening for people living with HIV and IPT have increased significantly, progress is still limited in many countries. There is considerable variance in the timing and content of national policies compared with WHO guidelines. Missed opportunities to implement new scientific evidence and delayed adaptation of existing WHO guidance remains a key challenge for many countries.

The epidemiology of HIV infection in Morocco: systematic review and data synthesis.

Morocco has made significant strides in building its HIV research capacity. Based on a wealth of empirical data, the objective of this study was to conduct a comprehensive and systematic literature review and analytical synthesis of HIV epidemiological evidence in this country. Data were retrieved using three major sources of literature and data. HIV transmission dynamics were found to be focused in high-risk populations, with female sex workers (FSWs) and clients contributing the largest share of new HIV infections. There is a pattern of emerging epidemics among some high-risk populations, and some epidemics, particularly among FSWs, appear to be established and stable. The scale of the local HIV epidemics and populations affected show highly heterogeneous geographical distribution. To optimize the national HIV response, surveillance and prevention efforts need to be expanded among high-risk populations and in geographic settings where low intensity and possibly concentrated HIV epidemics are emerging or are already endemic.

Intraspecific body size frequency distributions of insects.

Although interspecific body size frequency distributions are well documented for many taxa, including the insects, intraspecific body size frequency distributions (IaBSFDs) are more poorly known, and their variation among mass-based and linear estimates of size has not been widely explored. Here we provide IaBSFDs for 16 species of insects based on both mass and linear estimates and large sample sizes (n ≥ 100). In addition, we review the published IaBSFDs for insects, though doing so is complicated by their under-emphasis in the literature. The form of IaBSFDs can differ substantially between mass-based and linear measures. Nonetheless, in non-social insects they tend to be normally distributed (18 of 27 species) or in fewer instances positively skewed. Negatively skewed distributions are infrequently reported and log transformation readily removes the positive skew. Sexual size dimorphism does not generally cause bimodality in IaBSFDs. The available information on IaBSFDs in the social insects suggests that these distributions are usually positively skewed or bimodal (24 of 30 species). However, only c. 15% of ant genera are polymorphic, suggesting that normal distributions are probably more common, but less frequently investigated. Although only 57 species, representing seven of the 29 orders of insects, have been considered here, it appears that whilst IaBSFDs are usually normal, other distribution shapes can be found in several species, though most notably among the social insects. By contrast, the interspecific body size frequency distribution is typically right-skewed in insects and in most other taxa.

Has the quality of serosurveillance in low- and middle-income countries improved since the last HIV estimates round in 2007? Status and trends through 2009.

BACKGROUND: HIV surveillance systems aim to monitor trends of HIV infection, the geographical distribution and its magnitude, and the impact of HIV. The quality of HIV surveillance is a key element in determining the uncertainty ranges around HIV estimates. This paper aims to assess the quality of HIV surveillance systems in low- and middle-income countries in 2009 compared with 2007. METHODS: Four dimensions related to the quality of surveillance systems are assessed: frequency and timeliness of data; appropriateness of populations; consistency of locations and groups; and representativeness of the groups. An algorithm for scoring the quality of surveillance systems was used separately for low and concentrated epidemics and for generalised epidemics. RESULTS: The number of countries categorised as fully functioning in 2009 was 35, down from 40 in 2007. 47 countries were identified as partially functioning, while 56 were categorised as poorly functioning. When compared with 2007, the quality of HIV surveillance remains similar. The number of ANC sites in sub-Saharan Africa has increased over time. The number of countries with low and concentrated epidemics that do not have functioning HIV surveillance systems has increased from 53 to 56 between 2007 and 2009. CONCLUSION: Overall, the quality of surveillance in low- and middle-income countries has remained stable. Still too many countries have poorly functioning surveillance systems. Several countries with generalised epidemics have conducted more than one population-based survey which can be used to confirm trends. In countries with concentrated or low-level epidemics, the lack of data on high-risk populations remains a challenge.

Oral mucosal lesions and HIV status in a rural household survey in South Africa.

UNLABELLED: Several studies have documented the relevance of oral lesions in HIV populations. Oral HIV lesions are also considered useful indicators in HIV therapy. The objectives of the present study were to determine the prevalence of oral mucosal lesions (OML) in a rural population and to determine the differences, if any, in the prevalence of oral mucosal lesions of persons infected with HIV and persons not infected with HIV. The study was part of the Vaccine Preparedness Study (VPS) conducted by the Medical Research Council in Hlabisa, KwaZulu Natal, South Africa between 2000 and 2002. METHODS: A cross-sectional household survey examined adults aged 15 to 50 years. Oral mucosal lesions were determined by a presumptive diagnosis. Informed consent was obtained for the oral examination and separately for collecting a blood sample to determine HIV status by ELISA. RESULTS: A total of 2313 adults were interviewed for the VPS. Oral mucosal lesions were assessed in a sample comprising 537 adults. Of these, 185 consented to HIV testing and 22.7% (95% Confidence Interval (CI): 16.9-29.4%) were HIV positive. The prevalence of oral mucosal lesions in the total sample was 12.8% (95% CI: 10-16.3%). The prevalence of OML was 21.4% (9/42) among those who consented to a blood test and were HIV positive and 9.8% (n = 14/143) among those who were HIV negative. CONCLUSION: The prevalence of OML among HIV positive participants was significantly higher than among HIV negative participants.

Comparison of adult HIV prevalence from national population-based surveys and antenatal clinic surveillance in countries with generalised epidemics: implications for calibrating surveillance data.

BACKGROUND: Estimates of the impact of HIV in countries with generalised epidemics are generally based on antenatal clinic surveillance data collected over time. In an attempt to obtain geographically more representative estimates of HIV prevalence, many countries are now also conducting national population-based surveys in which HIV testing is included. We compare adult HIV prevalence estimates from antenatal clinic surveillance to those from national population-based surveys to assess the implications for calibrating surveillance data. METHODS: HIV prevalence estimates derived from fitting prevalence curves to antenatal clinic surveillance data are statistically compared to prevalence from national population-based surveys using data from 26 countries with generalised epidemics for the year in which the survey was conducted. Appropriate transformations are applied to inform the correction factors needed to adjust prevalence in countries where population-based surveys have not been conducted. RESULTS: HIV prevalence derived from antenatal clinic surveillance data generally overestimate population-based survey prevalence by about 20% (95% confidence interval: 10% to 30%) in both urban and rural areas. CONCLUSIONS: In countries where national population-based HIV surveys have been conducted, survey estimates of HIV prevalence (adjusted for potential survey biases as appropriate) can be used directly to calibrate antenatal clinic surveillance data. In countries where national HIV surveys have not been conducted, HIV prevalence derived from antenatal clinic surveillance data should be multiplied by about 0.8 to adjust for overestimation.

Progress and challenges in modelling country-level HIV/AIDS epidemics: the UNAIDS Estimation and Projection Package 2007.

The UNAIDS Estimation and Projection Package (EPP) was developed to aid in country-level estimation and short-term projection of HIV/AIDS epidemics. This paper describes advances reflected in the most recent update of this tool (EPP 2007), and identifies key issues that remain to be addressed in future versions. The major change to EPP 2007 is the addition of uncertainty estimation for generalised epidemics using the technique of Bayesian melding, but many additional changes have been made to improve the user interface and efficiency of the package. This paper describes the interface for uncertainty analysis, changes to the user interface for calibration procedures and other user interface changes to improve EPP's utility in different settings. While formal uncertainty assessment remains an unresolved challenge in low-level and concentrated epidemics, the Bayesian melding approach has been applied to provide analysts in these settings with a visual depiction of the range of models that may be consistent with their data. In fitting the model to countries with longer-running epidemics in sub-Saharan Africa, a number of limitations have been identified in the current model with respect to accommodating behaviour change and accurately replicating certain observed epidemic patterns. This paper discusses these issues along with their implications for future changes to EPP and to the underlying UNAIDS Reference Group model.

The quality of sero-surveillance in low- and middle-income countries: status and trends through 2007.

OBJECTIVE: To examine the quality of HIV sero-surveillance systems in 127 low-income and middle-income countries by 2007, as well as gaps in data needed for reliable estimates of HIV prevalence and size of populations at risk for infection. METHODS: The quality of countries' surveillance systems was scored using information from 2001 through 2007. Sero-surveillance data were compiled from the US Census Bureau's HIV/AIDS Surveillance Database, from countries' national HIV surveillance reports available to UNAIDS, from demographic and health survey (DHS) data, from the scientific literature and from countries' Estimation and Projection Programme (EPP) data files. The quality of systems was scored according to the classification of the epidemic in each country (generalised, concentrated or low-level). RESULT: The number of countries categorised as fully functioning in 2007 was 40. 43 countries were identified as partially functioning while 44 were categorised as poorly functioning. Low scores were most often attributed to a lack of recent data or data from appropriate risk groups. CONCLUSION: Many countries still have poorly functioning surveillance systems. The inclusion of HIV testing in national population-based surveys in recent years has resulted in some countries with generalised epidemics receiving higher coverage scores, but many countries with concentrated or low-level epidemics continue to lack data on high-risk populations.

The 2005 Workbook: an improved tool for estimating HIV prevalence in countries with low level and concentrated epidemics.

OBJECTIVE: This paper describes improvements and updates to an established approach to making epidemiological estimates of HIV prevalence in countries with low level and concentrated epidemics. METHODS: The structure of the software used to make estimates is briefly described, with particular attention to changes and improvements. DISCUSSION: The approach focuses on identifying populations which, through their behaviour, are at high risk of infection with HIV or who are exposed through the risk behaviour of their sexual partners. Estimates of size and HIV prevalence of these populations allow the total number of HIV infected people in a country or region to be estimated. Major changes in the software focus on the move away from short term projections and towards developing an epidemiological curve that more accurately represents the change in prevalence of HIV over time. The software continues to provide an output file for use in the Spectrum software so as to estimate the demographic impact of HIV infection at country level.

Short term estimates of adult HIV incidence by mode of transmission: Kenya and Thailand as examples.

OBJECTIVE: Patterns of transmission of HIV are different among different regions of the world and change over time within regions. In order to adapt prevention strategies to changing patterns of risk, we need to understand the behaviours that put people at risk of infection and how new infections are distributed among risk groups. METHODS: A model is described to calculate the expected incidence of HIV infections in the adult population by mode of exposure using the current distribution of prevalent infections and the patterns of risk within different populations. For illustration the model is applied to Thailand and Kenya. RESULTS: New infections in Kenya were mainly transmitted through heterosexual contact (90%), while a small but significant number were related to injecting drug use (4.8%) and men who have sex with men (4.5%). In Thailand, the epidemic has spread over time to the sexual partners of vulnerable groups and in 2005 the majority of new infections occurred among the low risk heterosexual population (43%). Men having sex with men accounted for 21% and sex work (including sex workers, clients, and partners of clients) for 18% of new infections. Medical interventions did not contribute significantly to new infections in either Kenya or Thailand. CONCLUSIONS: The model provides a simple tool to inform the planning of effective, appropriately targeted, country specific intervention programmes. However, better surveillance systems are needed in countries to obtain more reliable biological and behavioural data in order to improve the estimates of incidence by risk group.

National population based HIV prevalence surveys in sub-Saharan Africa: results and implications for HIV and AIDS estimates.

BACKGROUND: Sentinel surveillance among pregnant women attending antenatal clinics (ANCs) has been the main source of information on HIV trends in sub-Saharan Africa. These data have also been used to generate national HIV and AIDS estimates. New technologies and resources have allowed many countries to conduct national population based surveys that include HIV prevalence measurement, as an additional source of information on the AIDS epidemic. METHODS: The authors reviewed the reports of 20 national population based surveys from 19 countries carried out in sub-Saharan Africa since 2001. They examined the sampling methodology, HIV testing and response rates, and female:male and urban:rural prevalence ratios. They also constructed adjusted prevalence scenarios assuming different relative risks for survey non-responders. RESULTS: The national population based surveys vary considerably in quality, as reflected in the household response rate (ranging from 75.4% to 99.7%), women's testing rate (ranging from 68.2% to 97.3%), and men's testing rate (ranging from 62.2% to 95.4%), while for some surveys detailed response information is lacking. While 95% confidence intervals around the female:male and urban:rural prevalence ratios in individual countries are large, the median female:male ratio of the combined set of surveys results is 1.5 and the median urban:rural ratio 1.7. A scenario assuming that non-responders have twice the HIV prevalence of those who fully participated in the survey suggests that individual non-response could result in an adjusted HIV prevalence 1.03 to 1.34 times higher than the observed prevalence. CONCLUSIONS: Population based surveys can provide useful information on HIV prevalence levels and distribution. This information is being used to improve national HIV and AIDS estimates. Further refinements in data collection, analysis, and reporting, combined with high participation rates, can further improve HIV and AIDS estimates at national and regional level.

Improved plausibility bounds about the 2005 HIV and AIDS estimates.

BACKGROUND: Since 1998 the Joint United Nations Programme on HIV/AIDS and the World Health Organization has provided estimates on the magnitude of the HIV epidemic for individual countries. Starting with the 2003 estimates, plausibility bounds about the estimates were also reported. The bounds are intended to serve as a guide as to what reasonable or plausible ranges are for the uncertainty in HIV incidence, prevalence, and mortality. METHODS: Plausibility bounds were developed for three situations: for countries with generalised epidemics, for countries with low level or concentrated epidemics (LLC), and for regions. The techniques used build on those developed for the previous reporting round. However the current bounds are based on the available surveillance and survey data from each individual country rather than on data from a few prototypical countries. RESULTS: The uncertainty around the HIV estimates depends on the quality of the surveillance system in the country. Countries with population based HIV seroprevalence surveys have the tightest plausibility bounds (average relative range about the adult HIV prevalence (ARR) of -18% to +19%.) Generalised epidemic countries without a survey have the next tightest ranges (average ARR of -46% to +59%). Those LLC countries which have conducted multiple surveys over time for HIV among the populations most at risk have the bounds similar to those in generalised epidemic countries (ARR -40% to +67%). As the number and quality of the studies in LLC countries goes down, the plausibility bounds increase (ARR of -38% to +102% for countries with medium quality data and ARR of -53% to +183% for countries with poor quality data). The plausibility bounds for regions directly reflect the bounds for the countries in those regions. CONCLUSIONS: Although scientific, the plausibility bounds do not represent and should not be interpreted as formal statistical confidence intervals. However in order to make the bounds as meaningful as possible the authors have tried to apply reasonable statistical approaches and assumptions to their derivation. An understanding of the uncertainty in the HIV estimates may help policy makers take better informed decisions to address the epidemic in their respective countries.

The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa

Background: A randomized controlled trial (RCT) has shown that male circumcision (MC) reduces sexual transmission of HIV from women to men by 60(32?76; 95CI) offering an intervention of proven efficacy for reducing the sexual spread of HIV. We explore the implications of this finding for the promotion of MC as a public health intervention to control HIV in sub-Saharan Africa. Methods and Findings :Using dynamical simulation models we consider the impact of MC on the relative prevalence of HIV in men and women and in circumcised and uncircumcised men. Using country level data on HIV prevalence and MC; we estimate the impact of increasing MC coverage on HIV incidence; HIV prevalence; and HIV-related deaths over the next ten; twenty; and thirty years in sub-Saharan Africa. Assuming that full coverage of MC is achieved over the next ten years; we consider three scenarios in which the reduction in transmission is given by the best estimate and the upper and lower 95confidence limits of the reduction in transmission observed in the RCT. MC could avert 2.0 (1.1?3.8) million new HIV infections and 0.3 (0.1?0.5) million deaths over the next ten years in sub-Saharan Africa. In the ten years after that; it could avert a further 3.7 (1.9?7.5) million new HIV infections and 2.7 (1.5?5.3) million deaths; with about one quarter of all the incident cases prevented and the deaths averted occurring in South Africa. We show that a) MC will increase the proportion of infected people who are women from about 52to 58; b) where there is homogenous mixing but not all men are circumcised; the prevalence of infection in circumcised men is likely to be about 80of that in uncircumcised men; c) MC is equivalent to an intervention; such as a vaccine or increased condom use; that reduces transmission in both directions by 37. Conclusions: This analysis is based on the result of just one RCT; but if the results of that trial are confirmed we suggest that MC could substantially reduce the burden of HIV in Africa; especially in southern Africa where the prevalence of MC is low and the prevalence of HIV is high. While the protective benefit to HIV-negative men will be immediate; the full impact of MC on HIV-related illness and death will only be apparent in ten to twenty years

Early sexual debut among young men in rural South Africa: heightened vulnerability to sexual risk?

OBJECTIVE: This report examines early sexual debut ( or = 3 partners in the past 3 years (OR = 10.26, p<0.01). CONCLUSIONS: Men who initiate sex before age 15 form a distinct risk group in this setting. Specific interventions are needed for young men in the pre-teen years, before sexual debut.

Quality of care for under-fives in first-level health facilities in one district of Bangladesh.

OBJECTIVE: The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. MCE studies are under way in Bangladesh, Brazil, Peru, Uganda and the United Republic of Tanzania. The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children under 5 years old in first-level government health facilities, to inform government planning of child health programmes. METHODS: Generic MCE Health Facility Survey tools were adapted, translated and pre-tested. Medical doctors trained in IMCI and these tools conducted the survey in all 19 health facilities in the study areas. The data were collected using observations, exit interviews, inventories and interviews with facility providers. FINDINGS: Few of the sick children seeking care at these facilities were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home. Over one-third of the sick children whose care was observed were managed by lower-level workers who were significantly more likely than higher-level workers to classify the sick child correctly and to provide correct information on home care to the caregiver. CONCLUSION: These results demonstrate an urgent need for interventions to improve the quality of care provided for sick children in first-level facilities in Bangladesh, and suggest that including lower-level workers as targets for IMCI case-management training may be beneficial. The findings suggest that the IMCI strategy offers a promising set of interventions to address the child health service problems in Bangladesh.

Hookworm (Necator americanus) transmission in inland areas of sandy soils in KwaZulu-Natal, South Africa.

This study extended the association between hookworm transmission in KwaZulu-Natal and the sandy coastal plain by investigating the parasite's occurrence in isolated areas of sandy soils further inland. A school-based prevalence survey was carried out in selected inland sandy areas and in surrounding areas dominated by clay soils within a narrow altitudinal range of between 500 and 700 m to reduce the effect of altitude on climate-related factors (rainfall and temperature). Sandy areas situated on the coastal plain were included in the analysis for comparative purposes. Soil samples (0-50 mm depth) were collected from each locality to assess their nematode loadings and to analyse selected physical and chemical properties. Significant differences were found between the moderate prevalence of hookworm infection among children living in inland areas with sandy soils (17.3%) and the low prevalence in surrounding non-sandy areas (5.3%, P < 0.001), and between infection among children living in all inland areas (9.3%) and the high prevalence on the coastal plain (62.5%, P < 0.001). Amounts of fine and medium sand were highest in both the coastal plain soils and in inland sandy areas and these fractions showed a significant positive correlation with hookworm prevalence and nematode loadings. Clay, coarse sand and organic matter contents were highest in surrounding non-sandy soils and showed a significant negative correlation with the nematode variables. No statistically significant correlations were found with soil pH at study localities. We conclude that properties of inland sandy soils, particularly particle size distribution, correlate well with hookworm prevalence and nematode loadings and therefore provide a more suitable habitat for nematodes than surrounding non-sandy areas. These results suggest that particle size distribution of sand fractions, organic matter and clay content in the soil influence the survival of hookworm larvae and hence the parasite's transmission.

Risk factors for HIV infection among women in Carletonville, South Africa: migration, demography and sexually transmitted diseases.

We investigate the prevalence of, and risk factors for, HIV infection among women in an urban South African setting. A random sample of 834 women was recruited into a community-based cross-sectional study. HIV prevalence was 37.1% with higher prevalence among migrant women (46.0%) than non-migrant women (34.7%), (odds ratio [OR]=1.61, 95% confidence interval [CI]: 1.11-2.31). The highest HIV prevalence (50.9%) was between ages 26 and 35 years. Having two or more lifetime partners increased the risk of HIV infection (OR=4.88, 95% CI: 3.01-7.89). Migration, age, marital status, alcohol use, syphilis and gonorrhoea were independently associated with HIV infection. Migration increases the risk of HIV infection. Provision of services to treat sexually transmitted diseases and educational empowerment programmes that will promote safer sex among migrant women are urgently needed.

The effect of soil type and climate on hookworm (Necator americanus) distribution in KwaZulu-Natal, South Africa.

We investigated environmental factors influencing the distribution of hookworm infection in KwaZulu-Natal, South Africa. Prevalence data were sourced from previous studies and additional surveys carried out to supplement the database. When geo-referenced the data revealed that higher prevalences are limited to areas below 150 m above sea level, and low prevalences to areas above this altitude. Using univariate analysis we investigated the differences in environmental factors in the two areas. The relationship between hookworm prevalence, altitude and climate-derived variables was assessed using Pearson correlation coefficient, and that of soil type using the t-test. Multivariate analysis was used to determine environmental factors that combine best to provide favourable conditions for hookworm distribution. The results revealed that areas 150 m above sea level, i.e. inland, supported low mean hookworm prevalences (x = 6, n = 21), and were characterized by soils with a clay content of more than 45%, variable temperatures and moderate rainfall. Hookworm prevalence also decreased southwards as temperatures became slightly cooler, rainfall remained more-or-less constant and the coastal plain narrowed. In the multivariate model prevalence was most significantly correlated with the mean daily minimum temperature for January followed by the mean number of rainy days for January. This indicates the importance of summer conditions in the transmission of hookworm infection in KwaZulu-Natal and suggests that transmission may be seasonal.

High incidence of Type 2 diabetes mellitus in South African Indians: a 10-year follow-up study.

AIMS: Previous cross-sectional studies have established that South African Indians have a high prevalence of Type 2 diabetes mellitus. A prospective community study was undertaken to determine the incidence of Type 2 diabetes and the risk factors associated with its development in a cohort of South African Indians who had been studied 10 years previously. METHODS: This is a report on 563 subjects who participated both at baseline and at the 10-year follow-up study. In the baseline study, 2479 subjects (> 15 years) were studied; using 1985 World Health Organization criteria for glucose tolerance based on 75 g oral glucose tolerance tests (OGTT), the crude prevalence of diabetes mellitus (Diabetes) was 9.8% and of impaired glucose tolerance (IGT) 5.8% (age and sex-adjusted prevalence 13% and 6.9%, respectively). RESULTS: At the 10-year follow-up study, 563 of the subjects who could be traced consented to a repeat OGTT; of these, 91 (16.2%) were classified as Diabetes and 41 (7.3%) as IGT. Of the subjects who did not have diabetes at baseline (n = 517), 49 (9.5%) progressed to diabetes (PTD) and 40 (7.7%) had IGT. The crude cumulative incidence of diabetes was 9.5% (rate of progression 0.95% per annum; incidence density 9.5/1000 person years) with an age and sex-adjusted cumulative incidence of 8.3% (rate of progression 0.95% per annum; incidence density 8.3/1000 person years). Examination of risk factors predictive of subsequent diabetes development was undertaken by analysis of baseline (year 0) variables in the 517 subjects who did not have diabetes at baseline. In multivariate analysis using a logistic regression model, the significant predictive risk factors for future diabetes included 2-h post load plasma glucose (2 PG) (P < 0.0001, odds ratio (OR) 1.7, 95% confidence interval (CI) 1.4-2.1), body mass index (BMI) (P < 0.006, OR 1.1, 95% CI 1.0-1.3) and obesity (P < 0.01, OR 4.6, 95% CI 1.4-14.7). CONCLUSIONS: This long-term study has shown that in South African Indians there is a high incidence of Type 2 diabetes, and in this population significant predictors include higher baseline blood glucose, BMI and obesity.