Realities and Challenges of a Five Year Follow Up of Mother and Child Pairs on a PMTCT Program in Zimbabwe.

BACKGROUND: Complete follow up is an essential component of observational cohorts irrespective of the type of disease. OBJECTIVES: To describe five years follow up of mother and child pairs on a PMTCT program, highlighting loss to follow up (LTFU) and mortality (attrition). STUDY DESIGN: A cohort of pregnant women was enrolled from the national PMTCT program at 36 weeks gestational age attending three peri urban clinics around Harare offering maternal and child health services. Mother-infant pairs were followed up from birth and twice yearly for five years. RESULTS: A total of 479 HIV infected and 571 HIV negative pregnant women were enrolled, 445(92.9%) and 495(86.6%) were followed up whereas 14(3.0%) and 3(0.5%) died in the 1st year respectively; RR (95%CI) 5.3(1.5-18.7). At five years 227(56.7%) HIV infected and 239(41.0%) HIV negative mothers turned up, whereas mortality rates were 34 and 7 per 100 person years respectively. Birth information was recorded for 401(83.7%) HIV exposed and 441(77.2%) unexposed infants, 247(51.6%) and 232(40.6) turned up in the first year whilst mortality was 58(12.9%) and 22(4.4%) respectively, RR (95%CI) 3.2(2.0-5.4). At five years 210(57.5%) HIV exposed and 239(44.3%) unexposed infants were seen, whilst mortality rates were 53 per 1000 and 15 per 1 000 person years respectively. Mortality rate for HIV infected children was 112 compared to 21 per 1 000 person years for the exposed but uninfected. CONCLUSION: HIV infected mothers and their children succumbed to mortality whereas the HIV negatives were LTFU. Mortality rates and LTFU are high within PMTCT program.

Risk factors of HIV vertical transmission in a cohort of women under a PMTCT program at three peri-urban clinics in a resource-poor setting.

OBJECTIVE: To identify the risk factors of HIV vertical transmission in pregnant women. STUDY DESIGN: Observational cohort study. Between 2002 and 2003, 479 HIV-infected pregnant women in a PMTCT (prevention of the mother-to-child transmission) program were followed up with their infants at delivery, until 15 months with infant HIV testing. RESULTS: Of these 281 infants had a definitive HIV result by 15 months of age, and 31.7% of the infants become HIV infected. In univariate analysis the risk factor identified were presence of vaginal discharge, genital itchiness, genital ulcers, dysuria, abnormal breast and vaginal infections (Trichomonas, Bacteria vaginosis and Candida) in the mother at enrolment. In multivariate analysis vaginal infections risk ratio (RR) 1.72(1.03-2.88) and abnormal breast RR 4.36(2.89-6.58) were predictors of HIV vertical transmission. CONCLUSION: There is need to screen for vaginal infections (Trichomonas, Bacteria vaginosis and Candida) and examine pregnant women for mastitis to identify women at risk of HIV vertical transmission for prevention.

Effect of maternal HIV status on infant mortality: evidence from a 9-month follow-up of mothers and their infants in Zimbabwe.

OBJECTIVE: To describe infant mortality trends and associated factors among infants born to mothers enrolled in a prevention of mother-to-child transmission (PMTCT) program. STUDY DESIGN: A nested case-control study of human immunodeficiency virus (HIV)-positive and -negative pregnant women enrolled from the national PMTCT program at 36 weeks of gestation attending three peri-urban clinics in Zimbabwe offering maternal and child health care. Mother-infant pairs were followed up from delivery, and at 6 weeks, 4 months and 9 months. RESULTS: A total of 1045 mother and singleton infant pairs, 474 HIV-positive and 571 HIV-negative mothers, delivered 469 and 569 live infants, respectively. Differences in mortality were at 6 weeks and 4 months, RR (95% CI) 9.71 (1.22 to 77.32) and 21.84 (2.93 to 162.98), respectively. Overall, 9-month mortality rates were 150 and 47 per 1000 person-years for infants born to HIV-positive and HIV-negative mothers, respectively. Proportional hazard ratio of mortality for children born to HIV-positive mothers was 3.21 (1.91 to 5.38) when compared with that for children born to HIV-negative mothers. CONCLUSION: Maternal HIV exposure was associated with higher mortality in the first 4 months of life. Infant's HIV status was the strongest predictor of infant mortality. There is a need to screen infants for HIV from delivery and throughout breastfeeding.

An assessment of rural women's knowledge, constraints and perceptions on cervical cancer screening: the case of two districts in Zimbabwe.

This paper gives a sociological and anthropological insight into the rural women's perceptions and understanding of cervical symptomatology, screening and cancer. Qualitative data was collected through in-depth interviews and focus group discussions with women and health personnel. Quantitative data was obtained through questionnaires administered to 356 women from Mutoko and Shurugwi districts. The study revealed that cervical cancer is a disease that is of concern among health practitioners and women. 95.78% of the interviewed women had never gone for screening and had little knowledge about the various aspects of the disease in terms of causes, prevention and treatment. The study made four recommendations: the need for national screening policy and programme to be put in place, health education to women about cervical cancer, use of VIA in low resource settings and sensitisation of women about the availability of screening facilities in the districts where programmes are in place.

Cervical dyskaryosis among women with and without HIV: prevalence and risk factors.

Women in developing countries often present for medical care with advanced cervical cancer, although this condition is preventable through regular screening and early treatment. This study sought to identify the prevalence and risk factors for cervical dyskaryosis among women in Zimbabwe with and without HIV. In a cross-sectional study, 200 consenting women were screened for cervical dyskaryosis and sexually transmitted infections (STI). The relationship between various risk factors for cervical dyskaryosis was examined. The overall prevalence of cervical dyskaryosis was high (19%), and significantly higher among HIV-infected women at 30% compared with 13% among seronegative women, with a peak at a younger age among seropositive women. Use of intravaginal herbs, practising intravaginal cleansing, being single, a history of three or more lifetime sexual partners and a history of previous STI were associated with cervical dysplasia. The high frequency of cervical abnormality lends weight to the demand for implementation of regular screening programmes and health education.

HIV prevalence in Zimbabwean women: 54-67% knowledge and perceived risk.

This study examined the level of knowledge of sexually transmitted infections (STI) and HIV, knowledge of symptoms and potential sequelae of STI and perceived personal risks of infection among urban women in Zimbabwe. The women consented to being interviewed, examined, tested and treated for curable diagnosed STIs. Prevalence of both STI and HIV was high 11.4% and 54.5% among women aged 15-19 years, 28.5% and 62.4% among those 20-29 years and was highest among the age group >/=30 years 39.0% and 67.0% respectively. Women aged 15-19 years least perceived their risk of infection. Of the women with the highest rates of STI/HIV infection, less than 30% were aware of their vulnerability to such infections. Knowledge of specific STIs, their symptoms and sequelae was generally low. Women who did not know about syphilis, gonorrhoea, chancroid or warts were more likely to perceive themselves at no risk of infection. Condom use was very low (16.5%). There is an urgent need to improve current education programmes to raise awareness of STIs and the dangers of their long-term sequelae along with behavioural skills building interventions that include equipping women with negotiating skills, making female condoms available at affordable prices and motivating condom use.

Association of herpes simplex virus type 2 with the human immunodeficiency virus among urban women in Zimbabwe.

A cross-sectional study at two urban primary health care clinics in Zimbabwe was conducted among 393 consecutive women. The purpose was to determine the seroprevalence of herpes simplex virus type 2 (HSV-2), to identify coinfections and to determine the association between HSV-2, HIV and other sexually transmitted infections (STIs). Sera were tested for HSV-2, HIV and syphilis. Genital specimens were tested for the other STIs. The seroprevalence of ulcerative STIs tested was 42.2% for HSV-2 and 3.9% for syphilis. HSV-2 seropositive women had twice the risk of being HIV infected compared to HSV-2 seronegative women, adjusted OR=2.05 (95% CI=1.29-3.23). HSV-2 seropositivity was also associated with older age, a lower level of education, increase in the number of lifetime sexual partners and history of genital ulcers in the past six or more months. Our data suggest that in this population HSV-2 may contribute more to HIV infection than syphilis because of its high frequency. There is an urgent need for development of an effective HSV-2 vaccine.

HIV seroprevalence and its associations with the other reproductive tract infections in asymptomatic women in Harare, Zimbabwe.

The objective was to determine the magnitude of HIV as well as the associations between HIV seropositivity with reproductive tract infections (RTIs) among healthy women in Harare, Zimbabwe. In a cross-sectional study, 393 informed consenting women aged 15--49 years, attending 2 primary healthcare clinics, were interviewed and screened for HIV and RTIs. HIV seroprevalence was 29.3%. Seropositivity was significantly associated with bacterial vaginosis, syphilis, gonorrhoea and/or Chlamydia trachomatis infection, warts and genital ulcers. Risk factors for HIV were absence of lactobacilli in vaginal fluid, vaginal pH >4.5, age >20 years, being unmarried, having had more than one lifetime sexual partner, having used a condom at least once in their lifetime, having experienced an infant mortality, and a partner who was non-monogamous or a frequent traveller. In view of the very high seroprevalence and concomitant RTIs in this population, we recommend promotion of women-controlled prevention methods along with proactive detection and treatment of RTIs.

Perinatal practices in two rural districts of Zimbabwe: a community perspective.

OBJECTIVE: To describe perinatal practices from a community perspective and identify factors associated with perinatal death. DESIGN: Cross sectional community based survey. SETTING: Murewa and Madziwa rural areas, Zimbabwe. SUBJECTS: Women aged 15 to 50 years who had been pregnant within the 24 months preceding the survey. MAIN OUTCOME MEASURES: Where delivered, where preferred to deliver, model of delivery, use of herbs in labour, duration of labour, assistant at delivery, time of delivery, condition of baby at birth, resuscitation methods, birth weight, initiation of breast feeding, illness in the first week and outcome of pregnancy. RESULTS: 644 women were interviewed; 581/644 stated where they would have liked to deliver and 505/644 stated where they actually delivered their last baby. The majority 369/581 (62.4%) preferred to delivery at a government hospital and 240/505 (47.5%) actually delivered at a government hospital. Of the home deliveries only 27/581 (4.6%) preferred to deliver at home and yet 123/505 (24.4%) actually delivered at home. Primary care clinics were less preferred 151/581 (25.5%) as a place for delivery and 89/505 (17.6%) actually delivered there. Labour lasting more than 12 hours occurred in 20.4% of deliveries. Nurses were the commonest attendants at delivery 309/508 (60.4%) and morbidity following delivery was noted in 72/495 (14.5%). Resuscitation was carried out in 61/72 infants. Beating/shaking 36/61 (58.0%) and pouring cold water over the baby 11/61 (18.0%) were the commonest methods of resuscitation. Being delivered by a doctor compared to a nurse and being in Murewa district were statistically significant risk factors for mortality with Odds Ratio (OR) 5.21 (95% CI 2.86 to 9.51) and 3.90 (95% CI 1.51 to 10.09) respectively. The odds of dying when delivered by breech extraction were high, but not statistically significant OR 3.73 (95% CI 0.92 to 13.97) when compared to being delivered by vertex delivery. Labour more than 12 hours, use of herbs in pregnancy and time of delivery were not significantly associated with mortality with OR (95% CI) of 1.02 (0.40 to 2.19), 0.92 (0.00 to 4.38), 1.05 (0.56 to 1.97) respectively. On logistic regression analysis only being delivered in Murewa district remained significant. CONCLUSION: The utilisation of primary health care centres for delivery was unexpectedly low and home deliveries were unacceptably high. Increased mortality when delivered by a doctor and high early neonatal morbidity suggest poor monitoring and delayed intervention in labour. Infant morbidity following delivery was high and methods for neonatal resuscitation inappropriate. There is a need for more studies looking into health worker skills particularly in the areas of partogram use and neonatal resuscitation in these districts.

Antenatal care patterns and factors associated with perinatal outcome in two rural districts in Zimbabwe.

OBJECTIVE: To study antenatal care (ANC) patterns, to identify factors associated with poor perinatal outcome and quality of ANC. DESIGN: Cross sectional community based survey. SETTING: Murewa and Madziwa rural Districts. SUBJECTS: 644 women aged between 15 to 50 years who had been pregnant in the immediate 24 months preceding the survey. MAIN OUTCOME MEASURES: Perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of ANC. RESULTS: A total of 644 women were interviewed. Overall perinatal mortality was 115 per 1,000 births. 511/644 (79.3%) visited a health centre for ANC. The woman herself (41.8%) as well as husbands (41.8%) were commonly the decision makers regarding starting ANC. Only 298/510 (58.4%) of women used primary health care facilities for ANC. 211/629 (35.1%) of women lived more than 5 kms from the health care centre. 153/629 (24.3%) were not able to pay for ANC. Only 110/509 (21.6%) started ANC in the first trimester. 307/495 (62.0%) made five or less ANC visits. Pregnancy related morbidity was high 209/644 (32.5%) and use of traditional herbs was common 158/644 (24.%). There were significant differences between districts as far as perinatal outcome, ANC attendance, distance from health centre, ability to pay for ANC, gestation at first booking, frequency of ANC visits, use of herbs in pregnancy, pregnancy related morbidity and quality of care all having p values of 0.001 or less. On further analysis using logistic regression, having problems with pregnancy and vaginal bleeding were significant predictors of poor perinatal outcome with odds ratio (95% CI) of 2.8 (1.4 to 5.9) and 3.0 (1.1 to 8.6) respectively. Quality of ANC was rated as sub-optimal. CONCLUSION: Majority of rural women attended clinics for ANC. Perinatal mortality rate and pregnancy related morbidity were high. Vaginal bleeding was the strongest predictor for mortality. There is need to improve quality of antenatal care as this was found to be suboptimal. More objective oriented antenatal care visits and waiting mother's shelters form part of the solutions. Further studies are called for.

Aids and cancer in Africa: the evolving epidemic in Zimbabwe.

BACKGROUND: Zimbabwe is severely affected by the AIDS epidemic, and many cancers in African populations are related to infectious agents. OBJECTIVE: To study the current pattern, and short-term changes in incidence, of cancers related to infectious agents (and especially to HIV), with respect to the evolving epidemic of AIDS. METHODS: Analysis of data on the African population of Harare, Zimbabwe, from the Zimbabwe Cancer Registry, for the period 1990-1995. Comparison with data on prevalence of HIV seropositivity, and notifications of AIDS. RESULTS: Comparing results from 1993-1995 with those for 1990-1992 shows a continuing increase in the incidence of Kaposi's sarcoma with a doubling of the rates in both men and women. A dramatic increase in the incidence of squamous cell tumours of the conjunctiva was also observed, as well as a significant increase in the incidence of non-Hodgkin's lymphoma in women. There was no apparent increase in risk for Hodgkin's disease, myeloma, liver cancer, or cancer of the cervix. CONCLUSIONS: The AIDS epidemic has had a dramatic effect on the profile of cancer. The changes in incidence involve several cancers previously linked to AIDS in North America and Europe.

The effects of established and gestational diabetes on pregnancy outcome at Harare Maternity Hospital.

A study was carried out to determine the effect of established and gestational diabetes on pregnancy outcome over a period of two years at Harare Maternity Hospital, Harare, Zimbabwe. During the period, 51 patients with established diabetes mellitus and 70 patients with gestational diabetes were treated. The perinatal mortality was higher among this group (124 per 1,000) compared with the rest of the total hospital population (44 per 1,000) who delivered during the same period.