Risk perception and HIV-1 prevalence in 15,000 adults in rural south-west Uganda.

OBJECTIVE: Few studies have described levels and determinants of perceived risk of HIV-1 among African adults for whom the sero-status is known. This study describes HIV risk perception obtained from a large rural population in south-west Uganda which also underwent serological testing for HIV. DESIGN: Cross-sectional survey. METHODS: Information on risk perception and sexual behaviour was collected by interview. Sera were obtained from all consenting adults (13 years and above) in order to assess HIV-1 prevalence. RESULTS: Of 14,818 adults with a definitive sero-status, 9.7% were HIV-1 positive and 51% considered themselves to be at risk of infection. Risk perception showed similar patterns as age- and sex-specific sero-prevalence and there was correspondence between risk factors for perceived risk and known HIV risk factors. Partner's sexual behaviour was the commonest reason for risk perception in women whereas men cited their own sexual behaviour. Abstinence from sex was much more commonly mentioned as a protective practice than condom use in men and women. CONCLUSION: Half of the adults we have studied already see infection with HIV as a real possibility in their lives and are aware of HIV risk behaviours. More efforts should be made to implement sustainable control measures rather than simply raising awareness. In addition to recommending abstinence, these include mutual faithfulness, condom use and better treatment for STDs.

Mortality associated with HIV-1 infection over five years in a rural Ugandan population: cohort study.

OBJECTIVE: To assess the impact of HIV-1 infection on mortality over five years in a rural Ugandan population. DESIGN: Longitudinal cohort study followed up annually by a house to house census and medical survey. SETTING: Rural population in south west Uganda. SUBJECTS: About 10,000 people from 15 villages who were enrolled in 1989-90 or later. MAIN OUTCOME MEASURES: Number of deaths from all causes, death rates, mortality fraction attributable to HIV-1 infection. RESULTS: Of 9777 people resident in the study area in 1989-90, 8833 (90%) had an unambiguous result on testing for HIV-1 antibody; throughout the period of follow up adult seroprevalence was about 8%. During 35,083 person years of follow up, 459 deaths occurred, 273 in seronegative subjects and 186 in seropositive subjects, corresponding to standardised death rates of 8.1 and 129.3 per 1000 person years. Standardised death rates for adults were 10.4 (95% confidence interval 9.0 to 11.8) and 114.0 (93.2 to 134.8) per 1000 person years respectively. The mortality fraction attributable to HIV-1 infection was 41% for adults and was in excess of 70% for men aged 25-44 and women aged 20-44 years. Median survival from time of enrollment was less than three years in subjects aged 55 years or more who were infected with HIV-1. Life expectancy from birth in the total population resident at any time was estimated to be 42.5 years (41.4 years in men; 43.5 years in women), which compares with 58.3 years (56.5 years in men; 60.5 years in women) in people known to be seronegative. CONCLUSIONS: These data confirm that in a rural African population HIV-1 infection is associated with high death rates and a substantial reduction in life expectancy.

PIP: The impact of HIV-1 infection on mortality in 15 villages in southwest Uganda was assessed in a 5-year (1990-95) longitudinal cohort study with an annual household census and serologic survey. HIV seroprevalence among the 4685 adults in the study area was 8.3%. During 35,083 person-years of follow up, 459 deaths occurred, 186 of which involved HIV-positive persons. Standardized mortality rates among HIV-positive and HIV-negative adults were 10.4 and 114.0 per 1000 person-years, respectively. The mortality fraction attributable to HIV was 41% for all adults and in excess of 70% for men 25-44 years of age and women 20-44 years of age. Median survival time from study enrollment was under 3 years in HIV-infected residents 55 years and older. Life expectancy from birth in the total population in any year of the study was 42.5 years compared with 58.3 years in HIV-negative persons. These findings confirm that HIV-1 is a significant determinant of mortality in rural African populations.

The orphan problem: experience of a sub-Saharan Africa rural population in the AIDS epidemic.

An assessment of the prevalence of orphans and the magnitude of their problems and the extent to which HIV-1 is contributing to this was done in a rural population in South-West Uganda with an HIV-1 seroprevalence of 8% among adults. Slightly over 10% of children aged less than 15 years were reported to have lost one or both parents. Loss of the father alone (6.3%) was more common than loss of the mother alone (2.8%). Generally orphans were living with their surviving parent or other relatives but it was also noted in this study that some children with both parents alive lived with relatives as part of the extended family system. HIV-1 seroprevalence rates were higher among orphans than among non-orphans and were up to 6 times higher in the 0-4 year age group. Seropositivity rates were also higher among surviving parents of orphans than among parents of non-orphans. No significant difference in mortality between orphans and non-orphans was observed. During a 3-year follow-up period a total of 169 children became orphans and 43% of these cases resulted from the death of an HIV-1 positive parent. There was a limited effect on school attendance by orphanhood. The HIV-1 epidemic has substantially increased the number of orphans in this community, a finding which is probably typical of many other sub-Saharan African countries. It appears that these orphans were generally well looked after within the community. This coping capacity may, however become overstretched if the epidemic evolves further.

PIP: During 1989-90 the Medical Research Programme on AIDS enrolled 4975 children younger than 15 living in a cluster of 15 villages in rural Masaka district, southwest Uganda, into a 3-year prospective study. It examined the data to assess the magnitude of the problem of orphans and the extent to which HIV-1 is contributing to their problems. In this area, it is common for children with both parents alive to live with other relatives (e.g., grandparents) to help with domestic work. 518 (10.4%) children had lost 1 or both parents. These orphans were more likely to have lost a father alone than a mother alone (6.3% vs. 2.8%). 67 (13%) of the 518 orphans (i.e., 1% of all children) had lost both parents. Orphans 0-4 years old and surviving parents of orphans were more likely to be HIV-1 infected than their counterparts (5.6% vs. 0.9% for non-orphans 0-4 years old; p = 0.01 and 15.4% vs. 6.2% for parents of non-orphans; p 0.001). During the follow-up period, 83 parents of previous non-orphans died, leaving 169 orphans. 42.6% of the newly registered orphans had an HIV-1 positive parent. 98 deaths occurred among HIV-1 negative children (7 orphans, 91 non-orphans). No significant difference in mortality rates among HIV-1 negative children existed. Yet, in the 0-4 year old age group, orphans had a higher, but insignificantly so, 3-year mortality rate than non-orphans (22.1 vs. 15.6/1000 person-years). School attendance in the previous 6 months was slightly lower among orphans than non-orphans (75.5% vs. 83.6%) but the difference was insignificant (p = 0.3). Census data indicate that orphanhood has increased by at least 50% in the last 20 years, probably due to the AIDS epidemic. These findings suggest that the community tends to care well for orphans, but if the HIV/AIDS epidemic continues this coping mechanism may be become overly burdened.

Incidence of HIV-1 infection in adults and socio-demographic characteristics of seroconverters in a rural population in Uganda: 1990-1994.

BACKGROUND: To evaluate HIV-1 incidence among adults and socio-demographic risk factors in a rural population in Uganda, a prospective cohort study was carried out. METHODS: All consenting adult residents in a cluster of 15 neighbouring villages of the Masaka District of south-west Uganda have been participating in annual socio-demographic and serological surveys since November 1989. Those who had a negative serostatus when they were first tested and had at least one serostatus assessment during the 4 years of follow-up (1990-1994) have been evaluated for HIV-1 seroconversion. Incidence rates have been calculated per 1000 person-years of observation and socio-demographic characteristics assessed for association with recent seroconversion. RESULTS: At the baseline survey, of 4175 adults with assessable serostatus (79% of all censused adults), 342 (8.2%) were seropositive. During 12588.2 person-years of follow-up 89 seroconversions were identified corresponding to an incidence rate of 7.1 (95% CI: 5.6-8.5). Overall rates were highest in females aged 20-24 years (15.2) and in males aged 20-44 years (11.6). There was a significant interaction between age and sex; the ratio of the rate in females to that in males decreased from 3.3:1 to 0.5:1 with increasing age. Rates for males aged > or = 20 years were four times higher than those for younger males. Other significant socio-demographic correlates with risk included not belonging to the majority tribe, non-Muslim religion and length of stay on compound of less than 10 years. Incidence rates did not show any clear trends with time. CONCLUSION: These findings further emphasize the need for targeted interventions.

Verbal autopsy as a tool for diagnosing HIV-related adult deaths in rural Uganda.

BACKGROUND: In general, information on the causes of adult deaths in developing countries is scarce. More specifically, relatively little is known about the effect of HIV-1 associated disease on adult mortality in general populations. In this study we have used a verbal autopsy technique to ascertain whether adult deaths were associated with HIV-1 in a rural population with a prevalence of HIV-1 infection of 8%, and used HIV-1 antibody status to validate the verbal autopsy findings. METHODS: All adult deaths in the population cohort that occurred between December 1990 and November 1993 were identified through a monthly death registration system. Approximately 2 months after death, a relative of the deceased was interviewed by a trained nurse, and questionnaires were assessed by at least two independent clinicians; all were unaware of the HIV serostatus of the deceased. RESULTS: A total of 155 adult deaths was assessed, i.e. 53% of all recorded adult deaths. Of those assessed half were HIV-1 positive. In all 47% of deaths were classified as HIV-related. The overall specificity and positive predictive value of the verbal autopsy tool were both 92%; in those aged 13-44 years (83 adults) the corresponding values were 85% and 95% respectively. The verbal autopsy estimated HIV-1 attributable mortality fraction was similar to the calculated fraction based on prospective data. CONCLUSIONS: The results of this study suggest that verbal autopsy studies may assist in providing data on HIV-associated mortality in general populations and may be useful as surveillance tools.

PIP: The verbal autopsy technique represents a means for increasing the accuracy of acquired immunodeficiency syndrome (AIDS)-related mortality statistics in sub-Saharan Africa, where many deaths occur at home. A structured interview, adapted to local disease perceptions, is administered by lay personnel to relatives or friends of the deceased. This technique was evaluated in a rural area of Uganda's Masaka district with a human immunodeficiency virus (HIV)-1 seroprevalence rate of 8%. All adult deaths occurring in the 15 index villages from December 1990 to November 1993 were identified through a monthly village-based death registration system. A nurse paid an initial condolence visit to the bereaved family and returned about two months later with the questionnaire. Interviews were conducted with families or friends of 155 (53%) of the 293 adult deaths for which HIV serostatus was known. At least two clinicians unaware of serostatus results assessed each questionnaire and indicated the likely causes of death. There was agreement on whether the death was or was not HIV-related in 141 (91%) of these deaths. The 14 cases with discordant assessments were reviewed by a third clinician. Overall, 73 (47%) of deaths were attributed to HIV-related causes. Using HIV serostatus as a standard of comparison, the overall specificity and predictive value of the verbal autopsy were both 92%. These findings suggest that the method can be relied upon to estimate HIV-associated mortality in populations with a relatively high HIV prevalence.

HIV-1 infection in a Ugandan town on the trans-African highway: prevalence and risk factors.

All adult residents (aged 13 years or more) of 154 randomly selected households in 3 urban and one semi-rural ward of a town in South West Uganda on the trans-African highway were invited to participate in a socio-demographic, behavioural and medical survey. An unambiguous HIV-1 serostatus was obtained for 389 (80%) adults. The overall sero-prevalence rate was 40.4%; all age groups except males aged 13-19 years had infection rates in excess of 20%. Rates above 50% were found in females aged 20-34 years and males aged 35-44 years. For females seropositivity rates increased steeply with increasing numbers of lifetime sexual partners up to a maximum of 3; in contrast, for males rates continued to increase with increasing numbers of partners. The risk of infection amongst those with only one reported partner was 17%. A high proportion of males (14%) and females (18%) reported a history of genital ulcer disease within the previous 6 months; on examination genital lesions were observed in 12% of all participants. Interventions with a single focus are unlikely to have much impact in such a situation and a strategy is suggested which includes 3 components, namely improved STD control, a reduction in partner change and an increase in condom utilization.

PIP: In mid-1991, in a Ugandan town on the trans-African highway, interviews were conducted with and blood specimens taken from 389 persons aged 13 to more than 45 years from 154 households to assess the prevalence of HIV-1 infection and to identify its risk factors. The overall HIV-1 prevalence rate stood at 40.4% (35.6% for men and 43.7% for women). The highest HIV-1 prevalence rates were among men aged 35-44 (56.7%) and women aged 20-24 and aged 25-34 (52.9% and 50.6%, respectively). The urban rate was higher than the semi-rural rate (44.1% vs. 25.6%; p 0.005). 65% of all households had at least one HIV-1 seropositive adult. Single adults had a lower HIV-1 seroprevalence rate than ever married adults (e.g., among men, 10.3% vs. 30.8-62.5%) (relative risk [RR] = 2.8; p 0.005). The Baganda ethnic group had the lowest rate, while the Rwandese group had the highest rate (35.8% vs. 59.2%; RR = 1.4). Education did not affect the prevalence rate. Employed persons were more likely to have HIV-1 infection than the unemployed (44.4% vs. 32.6%; p 0.05). The occupations with the highest HIV-1 infection rates were business person (56.2%) and bar attendant (50%). History of blood transfusion did not appear to be a risk factor for HIV-1 infection (28% vs. 41.3% for no history). 33 HIV-1 seropositive adults had never had sexual intercourse. Men were more likely to have had multiple sex partners than women (e.g., having at least 10 lifetime partners, 61% vs. 11%). Seropositivity rates increased greatly with rising numbers of lifetime sexual partners to a maximum of 3 for females, but it continued to rise for men. It increased for men as the number of contacts in the last month increased (p = 0.05 for trend). 14% of men and 18% of women had a genital ulcer disease in the last 6 months. These findings suggest a need for a three-pronged AIDS prevention strategy: improved sexually transmitted disease control, a reduction in partner change, and an increase in condom use.

Post-natal incidence of HIV-I infection among children in a rural Ugandan population: no evidence for transmission other than mother to child.

We conducted a prospective cohort study to determine the post-natal incidence of and possible transmission routes for HIV-I infection in rural Ugandan children. The cohort consisted of the population of a cluster of 15 villages in Masaka District, south-west Uganda, and was enrolled in 1989-1990 through a demographic and serological survey. During the period 1991-1993 the population was resurveyed annually. A total of 5492 children aged 0-12 years were enrolled; of these, 41 (0.7%) were seropositive infants. A total of 3941 (72%) children were HIV-negative on enrolment and had at least one follow-up specimen. During 8596 person-years of observation only I seroconversion was observed, an incidence rate of 0.12 (95% CI 0.00-0.35) per 1000 years of observation. The transmission of HIV was most probably through breast milk. The case corresponds to a rate of 1.1 per 1000 in households with one or more HIV-positive adults (874 years of observation); no incident case was observed in households with only seronegative adults (6423 years of observation). Thus, HIV infection among children aged 0-12 years in this population is virtually exclusively the result of mother-to-child transmission. No infections were observed attributable to parenteral exposure, non-sexual casual or household contact, or insects.

Human immunodeficiency virus (HIV-1) seropositivity among children in a rural population of south-west Uganda: probable routes of exposure.

Serological studies on 7796 rural Ugandans showed 377 (4.8%) were HIV-1 antibody-positive, of whom 343 (8.2%) were adults, ten (0.4%) 5-12-year-olds and 24 (1.7%) under 5 years of age. Serological tests done on 18 mothers of the under-5s showed 17 to be HIV-1-positive. One mother was persistently negative. Her child had a history of multiple injections. Structured interviews with parents or guardians of the ten HIV-1-seropositive children aged 5-12 years to determine possible sources of exposure revealed that six were vertically infected and that blood transfusion, injections and sexual exposure each accounted for one case. It was not possible to identify a source of exposure in one instance. There was no evidence that casual household contact or scarifications played a role in the transmission of HIV-1 in children in this population. Our data show that in this rural population HIV-1 seropositivity in children is mainly associated with seropositivity in the mothers and that HIV-1 infection in children aged between 5 and 12 years is rare.

Migration and HIV-1 seroprevalence in a rural Ugandan population.

OBJECTIVE: To study the association between change of residence and HIV-1 serostatus in a rural Ugandan population. DESIGN: A longitudinal cohort study. METHODS: As part of the annual surveillance of a population cohort of approximately 10,000 individuals in a rural subcounty of southwest Uganda, information has been collected for all adults on change of residence over a 3-year period and its association with HIV-1 serostatus. Sera were collected by a medical team during home visits. Antibody testing was performed at the Uganda Virus Research Institute using two independent enzyme immunoassay systems and Western blot when appropriate. RESULTS: At the fourth survey-round, age and sex-standardized seroprevalence rates were 7.9% overall; the rate was 5.5% for 2,129 adults who had not changed address since the first survey, 8.2% for 336 who moved within the village, 12.4% for 128 who moved to a neighbouring village, 11.5% for 1,130 who had left the area and 16.3% for 541 who had joined the study area during the previous 3 years (P << 0.001, 4 degrees of freedom). We also observed an inverse relationship between years lived at the present house at the time of the first survey and both seroprevalence and subsequent seroincidence rates. The reported numbers of lifetime sexual partners were higher in those who changed residence. CONCLUSION: Change of residence is strongly associated with an increased risk of HIV-1 infection in this rural population and is likely to be the result of more risky sexual behaviour among those who move. These findings have important implications for the design of AIDS control programmes and intervention studies.

PIP: A longitudinal cohort study was conducted in a rural subcounty of Masaka district, Uganda, to study the association between change of residence and HIV-1 serostatus. Information was collected for all adults with regard to change of residence over a three-year period. The association of change of residence was assessed through the analysis of blood sera collected by a medical team during home visits. At the fourth survey round, age and sex-standardized seroprevalence rates were 7.9% overall; 5.5% for 2129 adults who had not changed address since the first survey, 8.2% for 336 who moved within the village, 12.4% for 128 who moved to a neighboring village, 11.5% for 1130 who had left the area, and 16.3% for 541 who had joined the study area during the previous three years. An inverse relationship was observed between the years lived at the present house at the time of the first survey and both seroprevalence and subsequent seroincidence rates. The reported numbers of lifetime sexual partners were higher among individuals who changed residence.

Recognition, treatment seeking behaviour and perception of cause of malaria among rural women in Uganda.

This study was conducted in order to understand how women in rural Uganda recognise malaria, their treatment-seeking behaviour when malaria is suspected and how the perception of cause may influence this behaviour. Focus group discussions and semi-structured interviews were held with women selected from the general population and from women attending health clinics for both preventive and curative services. The main finding of this study was that the word used for malaria in the local language, omusujja, covered a broad symptom complex which did not consistently correspond to the clinical case definition of malaria. Since there was no specific word for 'malaria', the study was broadened to encompass omusujja. The women reported that omusujja was an important health problem which had various causes, including poor diet, environmental conditions, and the bites of mosquitoes. The symptoms associated with omusujja were quite varied and ranged from generally 'feeling unwell' to a specific fever diagnosis (usually in children) of 'a rise in body temperature'. Women recognised that omusujja posed a particular threat to pregnant women. Preventive actions recommended by the women were in line with their perceptions of cause. The respondents usually mentioned the use of herbs as the first treatment action, followed by the purchase of tablets from shops, with the final recourse being the formal health sector if the previous actions had not effected a cure.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: To facilitate the design of malaria prevention and control programs in tropical Africa, a qualitative investigation of treatment seeking behaviors and perceptions of the causes and symptoms of malaria was conducted in a rural area in South Western Uganda's Masaka District. Components of the investigation included focus group discussions involving 42 participants recruited from women's clubs and prenatal and child health clinics, semi-structured interviews with 395 female outpatients 13 years of age and above and adult women escorting young children to government subdispensaries for treatment of a new malaria episode, and household interviews with 64 mothers. In this rural community, there is no specific word for malaria; rather, the word "omusujja" is used to refer to malarial symptoms as well as any kind of fever. Respondents consistently identified omusujja as the most prevalent, serious disease in their community. They linked its causation to food and drink, environmental conditions, vectors such as mosquitoes, and other illnesses. There was widespread awareness that omusujja presents differently according to age group, e.g. fever, refusal to suck, crying, vomiting, and mouth sores in infants as compared to miscarriage, vomiting, weakness, chills, and joint pain in pregnant women. Treatment is initiated promptly, although it mainly consists of use of local herbs; if the herbs fail to reduce the fever, hospital care is sought. Preventive methods cited included boiling water, cleaning cooking utensils, avoiding raw mangoes and roasted maize, and keeping mosquitoes out of the home. Recommended is a health education campaign emphasizing the role of mosquitoes in malaria transmission and the need for prompt medical intervention.

Transdisciplinary research: research capacity building in developing countries at low cost.

Transdisciplinary research within the context of The Medical Research Council Programme on AIDS (MRCPA) has proven to be a way of research capacity building requiring relatively few additional costs. In developing countries where funds for specialised training are not always or easily available, encouraging multidisciplinary research teams is worthwhile, particularly for grooming into research relatively junior national researchers by providing them with opportunities to work with more senior international scientists.

Two-year HIV-1-associated mortality in a Ugandan rural population.

The mortality in 15 villages in South-West Uganda was studied in relation to HIV infection. After a population census, serum samples were tested for antibodies to HIV-1. Deaths were ascertained over 2 years. Unequivocal HIV-1 serology results were available for 9389 individuals. The prevalence of infection was 4.8% for all ages and 8.2% for adults (aged 13 or more). 198 deaths were recorded during 15,725 person years of observation. Mortality among seronegative adults was 7.7 per 1000 and among seropositive adults 115.9 per 1000. The excess annual death rate associated with HIV-1 infection was 5.3 per 1000 and in adults 7.9 per 1000. Highest excess mortality was 16.9 per 1000 in the age group 25-34. Among adults, half of all deaths and among those aged 13-44 over 80% of deaths were attributable to HIV-1 infection. These results show the strong impact that HIV-1 infection is having on mortality in a rural area of Uganda where the overall HIV-1 adult prevalence rate is below 10%--a rate lower than in many other parts of East Africa.

Risk factors for HIV-1 infection in adults in a rural Ugandan community: a case-control study.

OBJECTIVE: To study in depth sexual history and sexual behaviour variables as risk factors for HIV-1 infection in a rural Ugandan population. METHODS: Following a socioeconomic and serological survey of a rural population in Masaka District, south-west Uganda, 233 randomly selected HIV-1-positive cases and 233 negative controls matched on age and village of residence, were invited in October 1990 to participate in a case-control study. A total of 132 cases and 161 controls attended for in-depth investigation including an interview about sexual behaviour. RESULTS: The factor most strongly associated with increased risk of infection was a greater number of lifetime sexual partners, with odds ratios (OR) of 2.1 and 4.9 for those reporting 4-10 and 11 or more partners, respectively, compared with those reporting less than four partners. Having only one sexual partner did not provide complete protection, a total of seven (one male, six female) subjects reporting only one sexual partner were HIV-1-positive. Other significant factors were a history of genital ulcers [OR, 2.9; 95% confidence intervals (CI), 1.0-9.1) and not being a Muslim (OR, 5.4; 95% CI, 1.8-16.5) suggesting a possible protective effect of circumcision. There was a suggestion that those who married within the last 7 years (OR, 2.4; 95% CI, 0.9-6.1) and men exposed to menstrual blood (OR, 5.7; 95% CI, 0.7-49.8) were at an increased risk of HIV-1 infection. CONCLUSIONS: These results confirm the predominant role of sexual behaviour in the HIV-1 epidemic. Of particular concern is the observation of HIV-1 infection among those reporting only one partner. Where HIV-1 infection is widely distributed in the general population, risk reduction strategies should, in addition to the promotion of partner reduction, place strong emphasis on safe-sex techniques.

Risk factors for HIV-1 infection in adults in a rural Ugandan community: a population study.

OBJECTIVE: To determine sociodemographic risk factors associated with HIV-1 infection in a rural Ugandan population. DESIGN: A population-based survey. METHODS: All adult residents (aged > or = 13 years) in a cluster of 15 neighbouring villages of the Masaka District of south-west Uganda were invited to participate in a sociodemographic and serological survey. Questions relating to sexual behaviour were asked separately in an accompanying case-control study. Socioeconomic data and an unambiguous HIV-1 serostatus were obtained by house-to-house survey for 3809 (72%) of the adult population. The association between serostatus and the following variables were analysed: age, sex, marital status, tribe, religion, education, occupational group, place and frequency of travel and recent history of sexually transmitted disease. RESULTS: Women aged 13-21 years were at a much higher risk than men of the same age [odds ratio (OR), 8.6; 95% confidence interval (CI), 3.0-24.5]. Married people aged < 25 years were twice as likely to be infected as those who were not currently married (OR, 2.3; 95% CI, 1.5-3.7). In contrast, in those aged > or = 25 years, women were at a lower risk than men (OR, 0.72; 95% CI, 0.52-0.98) as were those who were currently married compared with those who were not (OR, 0.47; 95% CI, 0.34-0.64). In both age groups those with a history of a recent genital ulcer were approximately three times more likely to be infected. Muslims had lower risks than non-Muslims (OR, 0.58 for both age groups). CONCLUSIONS: The people most at risk of HIV-1 infection in this rural Ugandan population are young married women who had, presumably, commenced sexual activity recently.

HIV-1 incidence and HIV-1-associated mortality in a rural Ugandan population cohort.

OBJECTIVE: To determine the incidence of HIV-1 infection and HIV-1-associated mortality in a rural Ugandan population. DESIGN: A prospective cohort study. METHODS: A cohort consisting of the population (de jure census 9820) of a cluster of 15 villages in Masaka District, south-west Uganda was enrolled between 1989 and 1990 through a demographic and medical survey. The HIV-1 seroprevalence rate was 4.8% for all ages combined and 8.2% for those aged 13 years or more. The survey was repeated after 1 year. RESULTS: The 1-year HIV-1 incidence rate among adults was 1% [9.2 per 1000 person-years of observation; 95% confidence interval (CI), 5.5-12.9). A total of 84 deaths were observed. In adults, half of all deaths (31 out of 60) were in HIV-1-seropositive individuals. The age-adjusted overall mortality rate ratio for HIV-positive adults compared with HIV-negatives was 20.8 (95% CI, 12.0-35.7). In the 13-44 age group the corresponding rate ratios for men, women and both sexes combined were 16.3, 108.9 and 58.7, respectively. The HIV-attributable mortality fractions, i.e., the proportion of deaths that would have been avoided in the absence of HIV, were 44, 50 and 89% for adult men, adult women and adults aged 25-34 years (both sexes combined), respectively. The 1-year progression to death among HIV-1-seropositive adults was 10.3%. CONCLUSION: These results demonstrate the profound impact that the HIV-1 epidemic has on adult mortality in a rural area of Uganda where the HIV-1 prevalence and incidence rates in adults are 8 and 1%, respectively.

General and HIV-1-associated morbidity in a rural Ugandan community.

OBJECTIVES: The AIDS epidemic in sub-Saharan Africa affects whole communities, adding to the already high burden of morbidity. Reports of AIDS cases are usually from hospital attenders, often diagnosed using the World Health Organization (WHO) clinical case definition. Little is known about the extent of HIV-associated morbidity in the general population. The objectives of this study were to describe the prevalence of (1) markers of general morbidity and (2) the criteria of the WHO clinical case definition for AIDS and (3) to determine the association between these markers and HIV-1 serostatus in a rural Ugandan community. METHODS: A survey was conducted among the adult population (aged > or = 13 years) of 15 neighbouring villages in Masaka District, south-west Uganda. The survey included medical history, physical examination and testing for HIV-1 antibodies. RESULTS: The HIV-1 seroprevalence among 4175 out of 5278 (79%) eligible adults was 8.2%. Current health problems were reported by 57.6% of adults, with increased rates in HIV-1-positive subjects, women and older people. Five of the 10 most common complaints showed significant associations with HIV-1 status, as did reported genital ulcer and vaginal discharge. The crude HIV-1 attributable disease burden in the population was 1.2% for current illness, 4.3% for previous serious illness and 9.9% for illness leading to hospital admission. Overall, 11 (3.3%) of the HIV-1-positive and nine (0.2%) of the HIV-1-negative subjects had AIDS as defined by the clinical case definition. The positive and negative predictive values and specificity were 55.0, 92.0%, and 99.8%, respectively. CONCLUSIONS: Against a background of high general morbidity, we observed a relatively small population attribution of HIV-1-associated morbidity. The results indicate that the clinical AIDS case definition may provide a useful tool for population surveys.

Community-based HIV/AIDS research--whither community participation? Unsolved problems in a research programme in rural Uganda.

Involvement of the study community in research on HIV/AIDS has presented the MRC/UVRI programme in rural Uganda with a multi-layered challenge. A typology developed in agricultural research which defines different levels of community participation in research is described where participation may be at 'contract', 'consultative', 'collaborative' and 'collegiate' level (each level indicating an increasing degree of community participation). Community involvement in the MRC/UVRI Programme is then outlined and the typology applied. It is shown that the majority of community participation in the Programme is at the contract level since the nature of the research programme as a 'foreign imposition' with 'foreign goals' has precluded the involvement of the community in much of the policy development and research planning. However, it is noted that as the Programme becomes more established in the area community influence grows and signs of community impact on policy and increased research inputs are beginning to be seen. The question is raised as to whether it is realistic to expect that externally imposed health research, particularly on sensitive topics, can ever be truly community participatory research.

Community-based HIV/AIDS research--whither community participation? Unsolved problems in a research programme in rural Uganda

Involvement of the study community in research on HIV/AIDS has presented the MRC/UVRI programme in rural Uganda with a multi-layered challenge. A typology developed in agricultural research which defines different levels of community participation in research is described where participation may be at 'contract'; 'consultative'; 'collaborative' and 'collegiate' level (each level indicating an increasing degree of community participation). Community involvement in the MRC/UVRI Programme is then outlined and the typology applied. It is shown that the majority of community participation in the Programme is at the contract level since the nature of the research programme as a 'foreign imposition' with 'foreign goals' has precluded the involvement of the community in much of the policy development and research planning. However; it is noted that as the Programme becomes more established in the area community influence grows and signs of community impact on policy and increased research inputs are beginning to be seen. The question is raised as to whether it is realistic to expect that externally imposed health research; particularly on sensitive topics; can ever be truly community participatory research