Unprotected intercourse for extra money among commercial sex workers in Kinshasa, Democratic Republic of Congo.

This study assessed the extent and correlates of the practice of engaging in unprotected intercourse for extra money among commercial sex workers (CSWs) in Kinshasa, Democratic Republic of the Congo. We conducted a cross-sectional survey using a structured, interviewer-administered questionnaire among a convenience sample of 136 CSWs. More than one-quarter of CSWs (26.5%) engaged in unprotected intercourse for extra money. These CSWs charged about 3.5 times more for unprotected intercourse than for protected intercourse. Multivariate logistic regression showed that CSWs who engaged in unprotected intercourse for extra money were significantly more likely to live or work in non-downtown (lower socioeconomic) areas of Kinshasa (odds ratio [OR] = 3.07), to have at least one child less than six years of age (OR = 2.95), and to know other CSWs who engaged in the same practice (OR = 9.38). We hypothesize that desperate socioeconomic conditions combined with peer/social norms drive the practice of engaging in unprotected intercourse for extra money. Additional circumstances under which Kinshasa CSWs engaged in unprotected intercourse included intercourse with clients who tore their condoms to increase sexual pleasure (58.8% of CSWs), episodes of condom failure (56.8% of CSWs), and unprotected intercourse with regular noncommercial partners (only 5.3% of CSWs with noncommercial partners always used condoms with these partners).

Effectiveness of HIV prevention interventions in developing countries.

OBJECTIVE: To review the effectiveness of projects and programs in developing countries that aim to reduce sexual transmission of HIV infection or transmission related to injection drug use. DESIGN: We identified 34 published studies undertaken in 18 developing countries that met rigorous inclusion criteria. These criteria included the length of follow-up, use of statistical analysis, the inclusion of a comparison group, and type of outcomes measured. RESULTS: We found that behavioral change interventions are effective when targeted to populations at high risk, particularly female sex workers and their clients. Few studies have evaluated harm reduction interventions in injecting drug users (IDUs). Evidence on the effectiveness of voluntary counseling and testing programs was promising, and VCT was most effective when directed at discordant couples. Treatment of sexually transmitted diseases (STD) appears highly effective in reducing HIV/STD transmission, particularly in the earlier stages of the epidemic. CONCLUSIONS: This review demonstrates that HIV prevention interventions can be effective in changing risk behaviors and preventing transmission in low and middle-income countries. When the appropriate mix of interventions is applied, they can lead to significant reductions in the prevalence of HIV at the national level. Additional research is needed to identify effective interventions, particularly in men who have sex with men, youth, IDUs and HIV-infected persons. Structural and environmental interventions show great promise, although more evaluation is needed.

Structural interventions in public health.

OBJECTIVE: To review structural interventions in public health, identify distinct approaches to structural interventions, and assess their implications for HIV-prevention interventions. METHOD: The MEDLINE, HealthStar, PsychInfo and Sociofile databases were searched on specific health issues, types of public health interventions, and conceptual topics (e.g. empowerment, social structure, and inequality) to compile a list of public health interventions in the United States. We excluded interventions focused on testing and surveillance unless they specifically facilitated prevention, and educational or media campaigns focused on increasing individuals' level of knowledge about a particular health problem. RESULTS: The term 'structural' is used to refer to interventions that work by altering the context within which health is produced or reproduced. Structural interventions locate the source of public-health problems in factors in the social, economic and political environments that shape and constrain individual, community, and societal health outcomes. We identified two dimensions along which structural interventions can vary. They may locate the source of health problems in factors relating to availability, acceptability, or accessibility; and they may be targeted at the individual, organizational, or environmental levels. All together, this framework suggests nine kinds of structural interventions, and it is possible to identify examples of each kind of intervention across a range of public health issues. CONCLUSIONS: The relevance of this framework for developing HIV prevention interventions is considered.

Global dimensions of the AIDS epidemic: implications for prevention and care.

The appropriate balance of HIV prevention and care activities depends on the specific epidemiology of HIV, including the stage of the epidemic; information about the cost-effectiveness of specific prevention interventions and treatment regimens; and the level of public resources available. In all countries, it is far less costly to prevent HIV than to treat people with AIDS. Once prevention needs are met, governments facing a severe epidemic who have additional resources should consider cost-effective treatment for people living with AIDS. The epidemiology of HIV provides two clear messages for prevention. First, it is imperative to act early in the epidemic, when HIV spreads exponentially. Viral load is highest during the first few months of infection, so that early in the epidemic a large proportion of those infected may be highly infectious. Second, it is crucial to target interventions initially to those with the highest-risk behavior. This will have the greatest impact on the number of new HIV infections prevented, as individuals with large numbers of sexual and needle-sharing partners who do not use condoms or clean injecting equipment are those most likely to become infected and then spread HIV. Changing the behavior of these individuals, even if only a relatively few members of society, is essential to curbing the epidemic.

Making AIDS prevention a national priority.

PIP: During the period from August 1993 through August 1994, it was estimated that another 3 million persons had been infected with HIV, with the global total exceeding 17 million then. In Asia infections increased from 12% to 16% with a corresponding decrease in North America and Europe. Over 60% of all infections had occurred in Sub-Saharan Africa. In south and southeast Asia, HIV infections were estimated at over 2.5 million in mid-1994. Estimated infections in Thailand had risen 10-fold since early 1990, with rates of 4% among young men and 1.5% among pregnant women. Yet in Thailand reported cases of sexually transmitted diseases (STDs) fell by 77% between 1986 and 1993, which was attributed to media promotion of condom use. In east Asia and the Pacific, the estimated number of infections had reached 50,000 in mid-1994, a doubling in one year. There had been a steep rise in the rate of reported STDs in China. The countries of eastern Europe and central Asia in mid-1994 had over 50,000 infections, but many of the factors associated with rapid HIV spread were present: economic crisis, rising unemployment, armed conflicts, and major population movements. To date (mid-1994), there have been an estimated 100,000 infections in north Africa and the Middle East. As of mid-1994, 190 countries worldwide had reported close to 1 million AIDS cases to the World Health Organization. But an estimated 4 million adults and children had developed AIDS since the start of the pandemic. By 2000, the cumulative case total is projected to reach nearly 10 million. A retrospective analysis of the epidemic in Uganda, Tanzania, Rwanda, and Zambia showed that by the 12th year of the epidemic, youth under 25 accounted for up to 3/4 of all new infections. Implementing basic prevention programs in Asia would cost between 0.75 and 1.5 billion US dollars a year to avert an estimated 5 million infections by the year 2000 alone.^ieng

Alpha-tocopheryl succinate protects hepatocytes from chemical-induced toxicity under physiological calcium conditions.

Rat and canine hepatocyte suspensions were exposed to toxic concentrations of ethyl methanesulfonate (EMS) and ionophore A-23187 in the presence and absence of extracellular calcium (Ca2+) and alpha-tocopheryl succinate (alpha-TS). The exogenous administration of alpha-TS (25 microM) completely protected hepatocytes from chemically-induced toxicity when exposed to 'physiological' free extracellular calcium concentrations (0.8-1.5 mM). Under these protective conditions the cellular accumulation of both alpha-TS (2.8 nmol/10(6) cells) and alpha-T (0.91 nmol/10(6) cells) were observed. Hepatocytes exposed to unesterified alpha-tocopherol (alpha-T, 25 microM) or alpha-tocopheryl acetate (alpha-TA, 25 microM), however, were not protected from the toxic effect of chemicals even though these treatments resulted in the marked accumulation of cellular alpha-T (2.65 nmol/10(6) cells) and alpha-TA (2.3 nmol/10(6) cells), respectively. Our findings suggest that the supplementation of endogenous stores of alpha-T or alpha-TA does not promote protection against chemical toxicity and that alpha-TS cytoprotection results not from the accumulation of alpha-T but rather from the cellular presence of the intact alpha-TS molecule. Thus alpha-TS appears to possess cytoprotective properties that differ from other vitamin E congeners.

Control of diarrhoeal diseases.

During its early years, WHO was primarily concerned with epidemic control, standardization and quality control of vaccines, and administration of the International Sanitary Regulations. Among the acute enteric infections, cholera received the greatest attention because of its propensity for rapid epidemic spread. When the seventh pandemic of cholera began in 1961, WHO responded with a greatly expanded programme of activities which included cooperation with countries in training and control efforts, and research on treatment and prevention, especially vaccine development. At the same time, numerous training courses were held on enteric infections and a series of controlled field trials established the degree of protection conferred by existing typhoid and paratyphoid vaccines. In 1970, when the cholera pandemic spread to Africa, the emergency assistance programme was reactivated, with increasing attention to the provision of appropriate treatment, especially oral rehydration therapy, rather than the supply of ineffective vaccines. The requirement of cholera vaccination for international travel in the International Health Regulations was abolished in 1973 by the World Health Assembly. Another public health problem of importance during the 1970s was the increase in antibiotic resistance of enteric bacteria, especially Shigella dysenteriae 1 and Salmonella typhi, first in Central America and Mexico and later in Asia. There was a notable acceleration in research on diarrhoeal disease and especially on cholera during this period, with the discovery of several new viral and bacterial agents of diarrhoea, advances in knowledge of intestinal immunity indicating that better protection might be achieved with oral vaccines, and the demonstration of the effectiveness of a single formulation of oral rehydration salts (ORS) in the treatment of all diarrhoeas including cholera.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: This article traces the history of the worldwide struggle to control diarrheal diseases. When the 7th pandemic of cholera began in 1961, WHO responded with a greatly expanded program of activities which included cooperation with countries in training and control efforts, and research on treatment and prevention. In 1970, when the cholera pandemic spread to Africa, the emergency assistance program was reactivated, with increasing attention to the provision of appropriate treatment, especially oral rehydration therapy. Another public health problem of importance during the 1970s was the increase in antibiotic resistance of enteric bacteria. The demonstration of the effectiveness of a single formulation of oral rehydration salts (ORS) in the treatment of all diarrheas was instrumental in convincing public health administrators that diarrheal diseases control should become an essential component of primary health care and led to the creation of a global Diarrheal Diseases Control program. The Program, which has the objective of reducing childhood mortality and morbidity due to diarrheal diseases and their associated ill effects, especially malnutrition, consists of 2 main components: a health services and control component and research component. If the targets set by the Program for 1989 can be attained, it is expected that by then at least 1.5 million childhood deaths due to diarrhea will be prevented annually.