Estimating HCV prevalence at the state level: a call to increase and strengthen current surveillance systems.

The degree to which case surveillance captures persons ever infected with HCV is unknown. We determined the discrepancy between HCV seroprevalence, estimated from national survey data, among adults in New York State in 2008 (n = 286 262, or 1.95%) and the number of infected persons reported to the state's surveillance hepatitis registries (n = 144 015). Findings suggest the need to strengthen the existing surveillance system.

Community attitudes about discussing sexual health: assessing public opinion of local STD prevention campaigns.

OBJECTIVES: We assessed public views about the acceptability of and need for sexually transmitted disease (STD) and sexual health-related educational messaging in local campaigns. METHODS: A 28-item state-added module was included in the 2008 New York Behavioral Risk Factor Surveillance System survey (n=3,751). Respondents rated acceptability of venues/dissemination channels and messaging and agreement with attitudinal/need statements. Additional data were analyzed from a separate state survey with individual county samples (n=36,257). We conducted univariate, bivariate, and multivariable modeling analyses. RESULTS: Each venue was acceptable to more than three-quarters of respondents (range: 79% for billboards to 95% for teaching STD prevention in high school). All message areas were acceptable to at least 85% of respondents (acceptability rating range: 85% to 97%). More than 70% agreed that there is a need for more open discussion about STDs. Bivariate analyses identified areas where messaging tailored to specific subgroups may be helpful (e.g., 26% of white people, 44% of African Americans, and 45% of Hispanic people agreed with the statement, "I need ideas about how to talk to my partner about protection from STDs"). Little geographic variation was seen. Results of multivariable modeling on opposition showed limited interaction effects. CONCLUSION: These data provide key information about current community norms and reflect the public's approval for hearing and seeing more about sexual health and STDs in a range of public forums.

Pediatric influenza-associated deaths in new york state: death certificate coding and comparison to laboratory-confirmed deaths.

Introduction. Surveillance for laboratory-confirmed influenza-associated deaths in children is used to monitor the severity of influenza at the population level and to inform influenza prevention and control policies. The goal of this study was to better estimate pediatric influenza mortality in New York state (NYS). Methods. Death certificate data were requested for all passively reported deaths and any pneumonia and influenza (P&I) coded pediatric deaths occurring between October 2004 and April 2010, excluding New York City (NYC) residents. A matching algorithm and capture-recapture analysis were used to estimate the total number of influenza-associated deaths among NYS children. Results. Thirty-four laboratory-confirmed influenza-associated pediatric deaths were reported and 67 death certificates had a P&I coded death; 16 deaths matched. No laboratory-confirmed influenza-associated death had a pneumonia code and no pneumonia coded deaths had laboratory evidence of influenza infection in their medical record. The capture-recapture analysis estimated between 38 and 126 influenza-associated pediatric deaths occurred in NYS during the study period. Conclusion. Passive surveillance for influenza-associated deaths continues to be the gold standard methodology for characterizing influenza mortality in children. Review of death certificates can complement but not replace passive reporting, by providing better estimates and detecting any missed laboratory-confirmed deaths.

Local differences in human immunodeficiency virus prevalence: a comparison of social venue patrons, antenatal patients, and sexually transmitted infection patients in eastern kinshasa.

BACKGROUND: This study compares the sexual behavior and HIV prevalence of men and women at social venues where people meet new sexual partners in Eastern Kinshasa with that of sexually transmitted infection (STI) treatment and antenatal clinic (ANC) patients in the same area. METHODS: ANC patients, STI clinic patients, and social venue patrons were interviewed, asked to provide a blood sample on-site, and provided with information about obtaining test results. Every patron at identified social venues in the study area was invited to participate. RESULTS: One thousand one hundred sixteen pregnant women; 66 male and 229 female STI clinic patients; and 952 male and 247 female patrons of social venues were interviewed and tested for HIV. HIV prevalence differed by group: ANC patients (4%); female venue patrons (12%); female STI patients (16%); male venue patrons (2%); and male STI patients (23%). HIV prevalence among sex workers at social venues (29%) was higher than HIV prevalence among other female patrons with new or multiple partnerships in the past four weeks (19%) and higher than HIV prevalence among female patrons denying sex work (6%). However, the absolute number of infected women was higher among women reporting recent new or multiple partnerships than among the smaller group of sex workers (23 vs. 18). Two-thirds of the infected female STI patients (24/36) reported no more than one and no new sexual partner in the past year. CONCLUSION: Improving prevention programs in Kinshasa is essential. Prevention efforts should not neglect women at social venues who do not self-identify as sex workers but who have high rates of new sexual partnership formation.

High-risk sexual behavior at social venues in Madagascar.

BACKGROUND: Persistent high levels of sexually transmitted infection (STI) in Madagascar indicate current prevention strategies are inadequate. STI/HIV prevention based in social venues may play an important role in reaching individuals at risk of infection. We identified venues where people meet sexual partners and measured the need and potential for venue-based prevention. METHODS: Interviews were conducted in 7 Madagascar towns with 1) community informants to identify social venues, 2) individuals socializing at a sample of venues to assess sexual behavior among venue patrons, and 3) venue representatives to assess the potential for venue-based intervention. RESULTS: Community informants identified numerous venues (range: 67-211 venues, depending on the town); streets, bars, and hotels were most commonly reported. Among 2982 individuals socializing at venues, 78% of men and 74% of women reported new sexual partnership or sex trade for money, goods, or services in the past 4 weeks and 19% of men and 18% of women reported symptoms suggestive of STI in the past 4 weeks. STI symptom levels were disproportionately high among respondents reporting either sex trade or new sexual partnership in the past 4 weeks. Twenty-eight percent of men and 41% of women reported condom use during the last sex act with a new partner. Although 24% to 45% of venues had hosted STI/HIV interventions, interventions were deemed possible at 73% to 90% venues according to 644 interviews with venue representatives. CONCLUSIONS: Venue-based intervention is possible and would reach a spectrum of populations vulnerable to STI/HIV including sex workers, their clients, and other high-risk populations.

A formal decision analysis identifies an optimal treatment strategy in a resource-poor setting.

OBJECTIVE: Decision analytic techniques use formal specifications of utility for the four fundamental decision events: true positives, false positives, true negatives, and false negatives. An optimal policy is the one with the lowest expected net cost. In this paper, decision analytic techniques for treatment selection based on patient characteristics are applied to a resource-poor setting. STUDY DESIGN AND SETTING: A cohort of 986 female sex workers in Antananarivo and Tamatave, Madagascar were tested for cervical infection at baseline and again 2 months later after presumptive treatment for gonorrhea and chlamydia. RESULTS: Three equivalent approaches to identify the optimal policy based on patient characteristic subgroups are demonstrated. Two of them require exhaustive searches of all possible alternatives. The third identifies the optimal policy as an analytic expression that compares a decision function with a threshold and leads to a closed-form solution. With this approach, the optimal policy can be expressed in four equivalent forms using basic epidemiological measures: likelihood ratio, predicted probability of disease, logistic regression parameters, and total risk score. CONCLUSION: These methods illustrate the application of a decision analysis to clinical epidemiology. Management of cervical infection for sex workers in Madagascar occurs under severe resource constraints, and therefore requires an algorithm for identifying optimal treatment regimens.

Cost-effectiveness of treatment strategies for cervical infection among women at high risk in Madagascar.

BACKGROUND: According to the national guidelines developed in 2001, a woman at high risk of gonorrhea and chlamydia in Madagascar is treated presumptively at her first sexually transmitted infection clinic visit; risk-based treatment (RB) is subsequently used at 3-month visits. OBJECTIVES: To compare health and economic outcomes for a 2-stage Markov process with the following 3 cervical infection treatment policies at baseline and at 3-month follow-up visit: presumptive treatment (PT), RB, and an interim laboratory/risk-based policy. STUDY DESIGN: Cost-effectiveness analysis was used to compare the 9 treatment strategies. RESULTS: When 3-month incidence of cervical infection is <20%, the national guidelines are less costly and less effective than both RB followed by PT, and PT at both visits. CONCLUSIONS: The national guidelines are a reasonable strategy, especially in the context of resource constraints, relatively low reinfection rates, and local preferences.

Socio-demographic and behavioural factors associated with high incidence of sexually transmitted infections in female sex workers in Madagascar following presumptive therapy.

BACKGROUND: Too little is known about the many women who generate income in Madagascar by trading sex. METHODS: Clinical and laboratory exams were offered to 493 non-care seeking female sex workers (SWs) in Antananarivo and 493 in Tamatave. SWs were recruited by peers in their community; they were interviewed, counselled and treated for sexually transmitted infections (STIs) at recruitment and re-evaluated 2 months later. RESULTS: One hundred and eighty six (38%) of the SWs in Antananarivo and 113 (23%) in Tamatave did not complete primary school (P < 0.0001). The incidence rates per person per month in Antananarivo and Tamatave, respectively, were 0.09 and 0.08 for gonorrhoea; 0.05 and 0.03 for chlamydia; 0.24 and 0.15 for trichomoniasis; 0.07 and 0.05 for syphilis. At follow-up, consistent condom use with clients was reported by 56 (12%) SWs in Antananarivo and 137 (29%) in Tamatave (P < 0.0001); 320 (70%) SWs in Antananarivo and 11 (2%) in Tamatave reported sex with a non-paying partner in the past month (P < 0.0001). In Antananarivo, 422 (92%) of the SWs thought they were at no or low risk of having an STI compared to 100 (21%) in Tamatave (P = 0.02). At follow-up, 277 (61%) SWs reported no birth control for their last sex act in Antananarivo, compared to 26 (5%) in Tamatave (P < 0.0001). Socio-demographic and behavioural risk factors for incident gonorrhoea, chlamydia and trichomoniasis varied by city. CONCLUSIONS: Strategies to address the needs of women who trade sex should include educational and economic opportunities; should tackle male partners of SWs; promote dual protection against unintended pregnancy and STIs, while taking into account local socio-demographic and behavioural characteristics.

[Prenatal care in Kinshasa: Knowledge, beliefs, and barriers to timely care]. / Soins prénatals à Kinshasa (République démocratique du Congo): croyances, connaissances et obstacles à la programmation appropriée.

According to the international medical community, adequate antenatal care, beginning by the end of the fourth month of pregnancy, is beneficial to maternal and perinatal outcomes. However, there is little research on timing of antenatal care and factors that influence it, including external barriers and women's beliefs. This research was conducted at antenatal clinics in the Democratic Republic of Congo where rates of infant and maternal mortality are among the highest in sub-Saharan Africa and where antenatal care begins later than in other countries in the region; the goal was to assess knowledge, beliefs and barriers to timely antenatal care. In this paper we present data collected in structured interviews at the women's first antenatal visit (N = 206). Although 75% of women believed antenatal care should start before the end of the fourth month, as recommended by WHO, only 22% presented by this time. Important barriers were financial (37%) and lack of knowledge about appropriate timing (35%). Gravidity was associated with gestational age at first visit (p < 0.001). Average gestational age at first visit was 4.7 months in primigravidae and 5.9 months in women with > or = 2 previous pregnancies. Most women in Kinshasa begin antenatal care later than recommended by WHO. Educating women on the importance of timely antenatal care and improving its financial accessibility should be priorities for maternal and child health programs in the DRC.

Evidence-based treatment guidelines for sexually transmitted infections developed with and for female sex workers.

BACKGROUND: Sex work is frequently one of the few options women in low-income countries have to generate income for themselves and their families. Treating and preventing sexually transmitted infections (STIs) among sex workers (SWs) is critical to protect the health of the women and their communities; it is also a cost-effective way to slow the spread of HIV. Outside occasional research settings however, SWs in low-income countries rarely have access to effective STI diagnosis. OBJECTIVES: To develop adequate, affordable, and acceptable STI control strategies for SWs. METHODS: In collaboration with SWs we evaluated STIs and associated demographic, behavioural, and clinical characteristics in SWs living in two cities in Madagascar. Two months post-treatment and counselling, incident STIs and associated factors were determined. Evidence-based STI management guidelines were developed with SW representatives. RESULTS: At baseline, two of 986 SWs were HIV+; 77.5% of the SWs in Antananarivo and 73.5% in Tamatave had at least one curable STI. Two months post-treatment, 64.9% of 458 SWs in Antananarivo and 57.4% of 481 women in Tamatave had at least one STI. The selected guidelines include speculum exams; syphilis treatment based on serologic screening; presumptive treatment for gonorrhoea, chlamydia, and trichomoniasis during initial visits, and individual risk-based treatment during 3-monthly follow-up visits. SWs were enthusiastic, productive partners. CONCLUSIONS: A major HIV epidemic can still be averted in Madagascar but effective STI control is needed nationwide. SWs and health professionals valued the participatory research and decision-making process. Similar approaches should be pursued in other resource-poor settings where sex work and STIs are common and appropriate STI diagnostics lacking.