Prioritising prevention strategies for patients in antiretroviral treatment programmes in resource-limited settings.

Expanded access to antiretroviral therapy (ART) offers opportunities to strengthen HIV prevention in resource-limited settings. We invited 27 ART programmes from urban settings in Africa, Asia and South America to participate in a survey, with the aim to examine what preventive services had been integrated in ART programmes. Twenty-two programmes participated; eight (36%) from South Africa, two from Brazil, two from Zambia and one each from Argentina, India, Thailand, Botswana, Ivory Coast, Malawi, Morocco, Uganda and Zimbabwe and one occupational programme of a brewery company included five countries (Nigeria, Republic of Congo, Democratic Republic of Congo, Rwanda and Burundi). Twenty-one sites (96%) provided health education and social support, and 18 (82%) provided HIV testing and counselling. All sites encouraged disclosure of HIV infection to spouses and partners, but only 11 (50%) had a protocol for partner notification. Twenty-one sites (96%) supplied male condoms, seven (32%) female condoms and 20 (91%) provided prophylactic ART for the prevention of mother-to child transmission. Seven sites (33%) regularly screened for sexually transmitted infections (STI). Twelve sites (55%) were involved in activities aimed at women or adolescents, and 10 sites (46%) in activities aimed at serodiscordant couples. Stigma and discrimination, gender roles and funding constraints were perceived as the main obstacles to effective prevention in ART programmes. We conclude that preventive services in ART programmes in lower income countries focus on health education and the provision of social support and male condoms. Strategies that might be equally or more important in this setting, including partner notification, prompt diagnosis and treatment of STI and reduction of stigma in the community, have not been implemented widely.

HIV prevention in Latin America: reaching youth in Colombia.

The aim of this paper is to describe and evaluate a school-based peer education programme on HIV primary prevention implemented in urban marginal districts of three cities of Colombia from 1997 to 1999. Its main objective was to promote risk awareness and safe sexual behaviours among urban youth populations. Methodology included the collection of baseline information through qualitative methods (focus groups and in-depth interviews), a knowledge, attitudes and practices (KAP) survey, a health education intervention, and post-intervention data collection. Direct beneficiaries were adolescents 10 to 19 years of age, and secondary school teachers of 6th to 9th grades. Main strategies used were peer education and classroom sessions conducted by trained teachers. Short-term results suggest that the programme had a positive effect on knowledge and attitudes related to HIV/AIDS (as the mean knowledge summary indicator among adolescents and secondary school teachers increased 24% and 21%, respectively). The main outcome has been the development of a sex education programme, emphasizing the role of schools in the promotion of sexual and reproductive health. Mass education by a combination of interventions and events at school level, backed up by effective interpersonal communication such as peer education, classroom teaching and community actions are effective primary prevention strategies for HIV sexual transmission and should be more extensively considered.

HIV/AIDS epidemic in French Guiana: 1979-1997. Groupe d'Etude Clinique de l'Infection VIH en Guyane Française.

The incidence of AIDS in French Guiana remains one of the highest in Latin America and the Caribbean. The annual AIDS incidence rate increased continually from the start of the epidemic until 1995, when it reached 59.3/100,000 population declining thereafter to 26.6 in 1997. The prevalence of HIV in pregnant women was 0.9% in 1993, increasing to 1.3% in 1995, and that in individuals attending sexually transmitted disease (STD) clinics was 2.1% in 1996. We included 224 patients in a study of survival after AIDS diagnosis. The principal AIDS-defining diagnosis was tuberculosis in 20.5% of reported cases. The median duration of survival was 10.2 months. Multivariate analysis showed that, patients > or = 45 years at entry progressed more rapidly to AIDS than younger patients. HIV prevention and access to health care should be developed in the various ethnic communities and adapted to cultural status. The progressive implementation of multiple antiretroviral therapies since 1996 may further reduce progression of the disease but early HIV diagnosis is required to improve the overall prognosis of HIV-infected patients.

[Primary chemoprevention of tuberculosis in HIV-infected patients in non-industrialized countries]. / Chimioprophylaxie primaire de la tuberculose chez les personnes infectées par le VIH dans les pays non industrialisés.

In randomized placebo-controlled trials in Haïti, Zambia and Uganda, prophylactic use of isoniazid (INH) for 6 to 12 months reduced the annual incidence of tuberculosis in HIV-infected patients by more than 50 per cent. For several years, WHO, IUTATLD and CDC have recommended that HIV-positive patients testing positive in a PPD test should be treated with INH as a form of anti-tuberculosis chemoprophylaxis (ATC). Whilst these recommendations are easy to follow in industrialized countries, widespread use of ATC in developing countries remains problematic because: (i) It is unknown what proportion of patients are likely to be re-infected at the end of ATC in countries where TB is endemic; (ii) It is possible that resistant bacilli may be selected due to the incomplete exclusion from the ATC program of patients with active TB at enrollment; (iii) It is difficult to identify asymptomatic carriers of M. tuberculosis at enrollment; (iv) It is doubtful that all patients will comply with a treatment regime which lasts several months; (v) The cost of a widespread ATC program, whose full benefit remains to be evaluated, may be difficult to justify. This paper attempts to review these issues and demonstrates the need for more population-based clinical trials in the field.

Prevalence of HIV-1, HIV-2 and HTLV antibody, in Fortaleza, Ceara, Brazil, 1993-1994.

To evaluate the respective part of HIV-1, HIV-2, and human T lymphotropic virus (HTLV) infection in Fortaleza, the principal city of the Ceara state (Northeast of Brazil), a cross-sectional seroepidemiological survey was conducted from July 1993 to February 1994 in 6 selected groups: pregnant women, tuberculosis (Tb) patients, sexually transmitted disease (STD) patients, female and male commercial sex workers (CSWs) and prisoners. Sera were screened by Mixt HIV-1/HIV-2 commercial enzyme immunoassay and ELISA HTLV I/II. Each serum found positive by ELISA was confirmed by Western blot. A total of 2917 persons were interviewed, of whom 2754 (94.4%) agreed to participate and gave a blood sample. Twenty-eight were found to be HIV-1 antibody positive. The prevalence ranged from 0.25% in pregnant women to 2.9% in male CSWs. The prevalence was 1% in STD patients and 0.44% in Tb patients. None of the sera was found positive for HIV-2. The prevalence of antibodies to HTLV-1 varied from 0.12% in pregnant women to 1.21% in female CSWs. Five sera were positive for HTLV-II. These results confirm the hypothesis that the HIV epidemic in Northeastern Brazil is still limited to high risk groups. Repeated cross-sectional surveys of this type should be performed as a surveillance tool to study the dynamics of this epidemic in low prevalence areas. Defining risk factors should allow targeting of intervention strategies.

PIP: During July 1993 to February 1994, in Ceara state, Brazil, researchers conducted a cross-sectional seroepidemiological survey of 814 pregnant women, 451 tuberculosis patients, 395 sexually transmitted disease (STD) patients, 496 female and 171 male commercial sex workers (CSWs), and 427 prisoners. They aimed to determine the prevalence of HIV-1, HIV-2, and human T lymphotropic virus (HTLV). All subjects lived in Fortaleza, where the HIV epidemic is recent. They tended to be poorly educated, poor, and not married. 28 persons were positive for HIV-1. The HIV-1 prevalence rate ranged from 0.25% in pregnant women to 2.92% in male CSWs. It was 0.44% for tuberculosis patients, 1.01% for STD patients, 1.61% for female CSWs, and 1.64% for prisoners. Indeterminate results occurred in 0.4% of all subjects. They were more common in tuberculosis patients than in other groups (1.1% vs. 0.3%; p = 0.023). No one tested positive for HIV-2. The prevalence of HTLV-I ranged from 0.12% in pregnant women to 1.21% in female CSWs. It was 0.44% for tuberculosis patients, 0.51% for STD patients, 0.58% for male CSWs, and 0.47% for prisoners. Five people (1 pregnant woman, 1 tuberculosis patient, 1 female CSW, and 2 prisoners) tested positive for HTLV-II. A 45-year-old, homosexual CSW, intravenous drug user who had tuberculosis was coinfected with HIV-1 and HTLV-I. The most common risk factor for HIV-1 infection was never used condoms (48% for female CSWs to 89% for STD patients). These findings indicate that Fortaleza has a low endemicity for HIV-1 infection and that HIV-1 is still limited to high risk groups (e.g., CSWs). The authors recommend that periodic cross-sectional surveys be conducted to study the dynamics of HIV-1 infection in this low prevalence area.

Shigellosis at a Caribbean resort. Hamburger and North American origin as risk factors.

During a three-week period in 1984, 339 tourists and expatriate employees with diarrhea visited the infirmary at a Caribbean resort club. Epidemiologic studies suggested that over 60% of the 1,893 tourists at the resort club during that time may have been ill. Shigella flexneri 4a was isolated from seven of 18 stool specimens. A few cases of diarrheal illness occurred at the resort club before the onset of the outbreak, which was temporally related to illness in a butcher. North American residence, eating raw or very rare hamburger, having a roommate who was ill and younger age were significantly associated with acquiring disease. Control measures, principally elimination of ill food handlers from the kitchens, were followed by a prompt and marked reduction in new cases. Isolated resorts pose problems in disease control similar to those on cruise ships, with hundreds of foods available, large numbers of short-stay visitors with few outside exposures, and many food handlers in whom pathogens can persist between groups of visitors. Resort clubs can reduce the risk of traveler's diarrhea, without using mass prophylaxis against pathogenic bacteria, by appropriate handling and preparation of food and by surveillance for diarrheal illnesses.