Urban-rural and sex differentials in tuberculosis mortality in Bangladesh: results from a population-based survey.

OBJECTIVE: To assess tuberculosis mortality in Bangladesh through a population-based survey using a Verbal Autopsy tool. METHODS: Nationwide mortality survey employing the WHO-recommended Verbal Autopsy (VA) tool, and using InsilicoVA, a data-driven method, to assign the cause of death. Using a three-stage cluster sampling method, 3997 VA interviews were conducted in both urban and rural areas of Bangladesh. Cause-specific mortality fractions (CSMF) were estimated using Bayesian probabilistic models. RESULTS: 6.8% of total deaths in the population were due to TB [95% CI: (5.1, 8.9)], comprising 12.0% [95% CI: (11.1, 12.8)] and 6.42% [95% CI: (5.4, 7.3)] of total male and female deaths, respectively. This proportion was highest among adults age 15-49 years [12.2%, 95% CI: (9.4, 14.6)]. The urban population is more likely to die from TB, and urban males have highest CSMF [13.6%, 95% CI: (9.1, 16.9)]. CONCLUSION: Our survey results show that TB is the fifth major cause of death in the general population and that sex and place of residence (urban/rural) have a significant effect on TB mortality in Bangladesh. The underlying causes of higher rates of TB-related deaths in urban areas and particularly among urban males, who have better knowledge and higher enrollment in the DOTS Program, need to be explored.

Periodical antibiotic treatment for the control of gonococcal and chlamydial infections among sex workers in Benin and Ghana: a cluster-randomized placebo-controlled trial.

BACKGROUND: In resource-poor settings, control of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) among female sex workers (FSWs) is difficult. We sought to determine whether periodical antibiotic treatment (PAT) might be effective in controlling these infections among West African FSWs. Secondary objectives were to determine the impact of PAT on human immunodeficiency virus (HIV) incidence among FSWs and on NG/CT prevalence among their clients. METHODS: Cluster-randomized, double-blind, placebo-controlled trial among FSW communities in Benin and Ghana. Within each of 9 pairs of clusters of FSW communities, one was allocated to receive, during 9 months, a monthly antibiotic (alternatively ciprofloxacin or azithromycin, n = 296 FSWs) and the other a placebo (n = 340 FSWs). Prevalence of NG/CT infections was measured at 3-month intervals using the polymerase chain reaction. HIV status was determined at the beginning and at the end of the study. RESULTS: After adjusting for age, HIV status, duration of prostitution, price per intercourse and condom use, and accounting for prevalence at enrollment and cluster-pairing effect, prevalence ratios (intervention vs. placebo) of NG infection were 0.77 (P = NS), 1.07 (P = NS), and 0.49 (P = 0.05) at the first, second, and third follow-up visits, respectively. PAT neither reduced significantly CT prevalence or HIV incidence among FSWs nor NG/CT prevalence among their clients. CONCLUSION: The only beneficial impact of PAT was on the prevalence of gonococcal infections among FSWs 9 months after the beginning of the intervention. Although PAT could be more effective in other circumstances, for instance, in the early stages of a program for FSWs, it can not be recommended at present as a routine strategy to control cervical infections among FSWs.

Transactional sex is the driving force in the dynamics of HIV in Accra, Ghana.

OBJECTIVE: To delineate the population attributable fraction (PAF) of transactional sex in prevalent cases of HIV infection in the male adult population of Accra, Ghana. DESIGN AND METHODS: Cross-sectional study of clients who visited a sex worker (SW), of boyfriends of SW and of male personnel in prostitution venues. A questionnaire was administered and urine obtained for detection of anti-HIV antibodies. The PAF of prevalent HIV acquired from SW was calculated using a combination of data from this survey of clients, from on-going SW surveys, the national HIV surveillance system and the national census. RESULTS: HIV prevalence was 4.9% (8/162) among clients of mobile SW, 15.8% (53/335) among clients of home-based SW, 17.5% (10/57) among personnel and 32.1% (9/28) among boyfriends. A condom was used in 90% of intercourses, according to clients. Non-use of a condom was clustered in selected locations and independently associated with older age of client, frequency of intercourse with SW in the last year and current urethritis. Among the male population of Accra aged 15-59 years, 84% of prevalent cases of HIV were attributable to transactional sex. A sensitivity analysis showed that under various assumptions PAF varied between 47% and 100%. CONCLUSIONS: In Accra, approximately four-fifths of prevalent cases of HIV in adult males were acquired from SW. Comprehensive interventions providing education, condoms and treatment for sexually transmitted diseases for SW and their clients should be approached as other public health priorities and provided in all cities, large and small, of West Africa.

The price of development: HIV infection in a semiurban community of Ghana.

OBJECTIVE: To describe the epidemiology of HIV infection in the Manya Krobo District, Ghana, and its potential link to the building of the Akosombo dam. METHODS: A questionnaire and a blood sample were collected among 1228 consecutive pregnant women seen at the prenatal clinics of the two major hospitals of the district. RESULTS: Overall, prevalence of HIV and of serologically confirmed syphilis were 14.9% and 0.7%, respectively. HIV infection was more prevalent among the Krobo ethnic group (137 of 742 [18.5%]) than among other ethnic groups (46 of 486 [9.5%]; p <.001). Two distinct patterns of HIV distribution were identified. Among the Krobos, HIV was common among all age groups, reached a plateau (21.9%) in the 30- to 34-year-old group and was associated strongly with having lived in Côte d'Ivoire and with having received only primary school education. Among the other ethnic groups, prevalence decreased with age, from 17.2% in the 13- to 19-year-old age group to 1.4% among women aged 35 years or older, and HIV infection was associated with having had first sexual intercourse before the age of 17 years. In logistic regression analysis, the independent risk factors for HIV infection were age, schooling, age at first sexual intercourse; having lived in Côte d'Ivoire; age and schooling showed significant interactions with ethnic group. CONCLUSIONS: The high HIV prevalence documented in this part of Ghana seems to be, to some extent, a consequence of construction of the Akosombo dam in the 1960s. The flooding of the land, the failures of the resettlement program and the ensuing poverty prompted economically driven migration, specially to Côte d'Ivoire, where many migrants became infected with HIV. Local transmission followed. This illustrates that HIV can disseminate widely in a society where most men are circumcised and where genital ulcerative diseases are uncommon and should be an indication for less complacency about HIV control in West Africa.