Radiological features of pulmonary tuberculosis in 963 HIV-infected adults at three Central African Hospitals.

Tuberculosis is one of the most important infectious complications in human immunodeficiency virus (HIV)-infected individuals in sub-Saharan Africa. In this radiological study, we detail the chest radiographic findings of Zairean and Zambian adults with a diagnosis of AIDS and tuberculosis as seen at three Central African Hospitals. Between 1992 and 1995, consecutive chest radiographs of 963 HIV-infected adults aged between 16 years and 56 years with microbiologically confirmed tuberculosis (TB) were reviewed: (1) 362 adults from Sendwe General Hospital, Lubumbashi, Zaire, (2) 175 from Mama Yemo Hospital, Kinshasa, Zaire, and (3) 426 adults from The University Teaching Hospital (UTH), Lusaka, Zambia. During the same period consecutive chest radiographs from 1000 age-matched HIV-negative adults with tuberculosis were collected for comparative purposes. Comparison of the two groups showed that the HIV-infected group of patients with tuberculosis had a significantly higher proportion of lymphadenopathy (26% vs 13%; P = 0.001), pleural effusions (16% vs 6.8%; P = 0.001), miliary shadowing (9.8% vs 5%; P = 0.001), an interstitial pattern (12% vs 7%; P = 0.01) and consolidation (10% vs 3%; P = 0.001). There was significantly less cavitation (33% vs 78%; P = 0.001) and atelectasis (12% vs 24%; P = 0.001) seen in the HIV-positive group compared to the HIV-negative group of patients. These patterns of radiographic changes were consistently seen across all three hospital sites. The radiographic appearances in HIV-infected individuals with TB is discussed.

Neopterin, beta 2-microglobulin, and acute phase proteins in HIV-1-seropositive and -seronegative Zambian patients with tuberculosis.

Neopterin is a biochemical marker for the activation of the cell-mediated immune system. We measured neopterin, beta 2-microglobulin, and acute phase proteins in 31 HIV-seropositive and -seronegative Zambian patients with tuberculosis, using stored sera that had been obtained at the beginning and at end of antituberculosis treatment. In both HIV-seropositive and -seronegative patients neopterin and acute phase proteins were elevated when tuberculosis was initially diagnosed and fell during treatment. In contrast, the mean beta 2-microglobulin level increased during antituberculous therapy in the HIV-seropositive group. Serum neopterin levels at diagnosis were correlated with other parameters of disease activity (fever, anemia, and weight loss). In both groups, patients with persistently elevated neopterin levels at the end of treatment were more likely to suffer relapse of tuberculosis or other adverse health events in the subsequent follow-up period. Neopterin can be used to monitor the response to antituberculous therapy in both HIV-seropositive and -seronegative patients and may have a prognostic value for the patients' wellbeing in the follow-up period.

Enteropathy in Zambians with HIV related diarrhoea: regression modelling of potential determinants of mucosal damage.

BACKGROUND: AIDS is characterised by small intestinal mucosal damage, but its aetiopathogenesis is poorly understood. Enteric infections in Africa differ from those in northern countries, where protozoan infections have been associated with severe enteropathy in AIDS patients. AIMS: To characterise enteropathy in Zambian AIDS patients compared with local controls, and to assess relative contributions of enteric infection, nutritional impairment, and immune dysfunction. METHODS: Computer aided mucosal morphometry of small intestinal biopsy specimens from 56 HIV infected Zambians with persistent diarrhoea and 26 diarrhoea free controls, followed by regression modelling. RESULTS: Patients with HIV related diarrhoea had reduced villous height and increased crypt depth compared with controls. There was no difference between HIV positive and negative controls. In regression models applied to AIDS mucosal measurements, villous height and crypt depth were related to nutritional parameters and to serum soluble tumour necrosis factor receptor p55 concentration. Crypt depth was also related to lamina propria plasma cell count. Intestinal infection was found in 79%, which consisted predominantly of microsporidia in 34%, Isospora belli in 24%, and Cryptosporidium parvum in 21%, but detection of these enteropathogens was not related to severity of enteropathy. CONCLUSIONS: Nutritional and immune disturbances were associated with enteropathy, accounting for over one third of the variation in mucosal morphometric parameters.

PIP: The relative contributions of enteric infection, nutritional impairment, and immune dysfunction to AIDS-related enteropathy were investigated in a comparative study of small intestinal biopsy specimens from 56 HIV-positive patients from Lusaka, Zambia, with persistent diarrhea and 26 diarrhea-free controls. Compared with both HIV-positive and HIV-negative controls, patients with HIV-related diarrhea had a 40% reduction in mean villous height and a 19% increase in mean crypt depth. In regression models applied to AIDS mucosal measurements, villous height and crypt depth were related to nutritional parameters and to the serum soluble tumor necrosis factor receptor p55 concentration. Crypt depth also was related to lamina propria plasma cell count. Intestinal infection, primarily microsporidia, was detected in 79% of cases; however, the presence of enteropathogens was not related to the severity of enteropathy. These findings suggest that nutritional and immune disturbances account for more than 33% of the variation in mucosal morphometric parameters in AIDS-related enteropathy.

Systemic immune activation as a potential determinant of wasting in Zambians with HIV-related diarrhoea.

Wasting in African AIDS patients is severe, and its aetiology is probably multifactorial: persistent diarrhoea, poverty and tuberculosis may all contribute. We report a cross-sectional study of body composition measured anthropometrically in 75 adult patients with HIV-related persistent diarrhoea in Lusaka, and its relationship to gastrointestinal infection and systemic immune activation assessed using serum neopterin and soluble tumour necrosis factor receptor (sTNF-R55) concentrations. Patients as a group were generally severely wasted (mean body mass index (BMI) 15.8 kg/m2, range 11-22), but the severity of wasting was related neither to oesophageal candidiasis nor to intestinal infection. In men but not women, all measures of nutritional status were negatively related to serum sTNF-R55 concentration (fat-free mass in men, r = -0.64; 95% CI: -0.80, -0.41; p < 0.0001). Some wasted patients had cutaneous features of malnutrition, again associated with higher sTNF55 concentrations, and two had peripheral oedema. The diarrhoea-wasting syndrome in this part of Africa seems to be associated with evidence of high cytokine activity in men, rather than oesophageal candidiasis or any particular intestinal opportunistic infection. This immune activation requires further investigation in the context of the sex difference we have observed.

The impact of human immunodeficiency virus on response to treatment and recurrence rate in patients treated for tuberculosis: two-year follow-up of a cohort in Lusaka, Zambia.

To examine the effect of HIV on response to treatment and recurrence rate in patients with tuberculosis (TB), we have followed 239 previously untreated, adult, TB patients in a prospective cohort study in Lusaka, Zambia. One hundred and seventy-four (73%) were HIV-1 antibody positive. Patients with sputum smear positive, miliary, or meningeal TB were prescribed 2 months daily streptomycin, thiacetazone, isoniazid, rifampicin, pyrazinamide followed by 6 months thiacetazone and isoniazid; others, 2 months streptomycin, thiacetazone and isoniazid followed by 10 months thiacetazone and isoniazid. Thirty-five per cent of HIV-positive (HIV+ve) and 9% of HIV-negative (HIV-ve) patients were known to have died before the scheduled end of treatment. Surviving HIV+ve patients showed weight gain and improvement in symptoms and laboratory and radiological findings similar to HIV-ve patients. The risk of cutaneous drug reaction was 17% (95% CI: 12-25%) in HIV+ve, and 4% (1-13%) in HIV-ve patients. Severe rashes were attributed to thiacetazone. Recurrence of active TB was examined among 64 HIV+ve and 37 HIV-ve patients who successfully completed treatment, with mean follow-up after the end of treatment of 13.5 and 16.8 months, respectively. The rate of recurrence was 22/100 person years (pyr) for HIV+ve patients and 6/100 pyr for HIV-ve patients, giving a recurrence rate ratio of 4.0 (95% CI 1.2-13.8, P = 0.03).

PIP: In 1989, researchers followed 239 newly diagnosed adult patients with tuberculosis (TB), never previously treated for TB, for two years to examine the response to TB treatment among patients with and without HIV infection and the TB recurrence rate. They were patients in the medical wards and the chest clinic outpatients' department of the University Teaching Hospital in Lusaka, Zambia. 174 (73%) tested positive for HIV. HIV-positive patients were more likely than HIV-negative patients to have extrapulmonary and both pulmonary and extrapulmonary TB (35% and 26% for both, respectively vs. 17% and 12%, respectively; p 0.001). They were less likely to have positive sputum tests than HIV-negative patients (36% vs. 57% for smear; p = 0.005 and 39% vs. 55% for culture; p = 0.03). HIV-positive patients were more likely to receive standard TB therapy (62% vs. 37%), while HIV-negative patients were more likely to receive short course therapy (62% vs. 37%; p = 0.001). HIV-positive patients were more likely than HIV-negative patients to die before completion of treatment (35% vs. 9%). Surviving HIV-positive patients gained weight and experienced improvement in symptoms at the same rate as did surviving HIV-negative patients. They also had similar laboratory and radiological findings. HIV-positive patients had a higher risk of cutaneous drug reaction than HIV-negative patients (17% vs. 4%; hazard ratio = 5.1; p = 0.03). One HIV-positive patient with a rash died. Thiacetazone was responsible for the rashes. Among the HIV-positive and HIV-negative patients who successfully completed treatment, the active TB recurrence rate was greatest for HIV-positive patients (22 vs. 6/100 person years; rate ratio = 4; p = 0.03). Yet, all but one of the HIV-positive cases with recurrent TB responded well to TB treatment. High recurrence rates pose renewed potential sources of infection and a high cost of renewed treatment.

Tuberculin sensitivity and HIV-1 status of patients attending a sexually transmitted diseases clinic in Lusaka, Zambia: a cross-sectional study.

A cross-sectional study to estimate the prevalence of latent tuberculosis (TB) in a group of Zambians at high risk of human immunodeficiency virus type 1 (HIV-1) infection and to examine the effect of HIV-1 infection on the tuberculin response was conducted in the University Teaching Hospital in Lusaka, Zambia during July to September 1990. Patients were selected from those presenting to the out-patient clinic for first referral with either sexually transmitted or skin disease. 268 adults were included in the study; 158 (59%; 95% confidence interval [CI] = 53-65%) were HIV-1 antibody positive. Of 82 HIV-1 negative participants who returned for Mantoux skin test reading, 51 (62%; 95% CI = 57-67%) had a positive test reaction (diameter > or = 10 mm) after receiving 2 units of RT-23 tuberculin. Of 106 HIV-1 positive participants who returned, only 32 (30%; 95% CI = 26-34%) had a diameter > or = 10 mm. Nine (28%) of the HIV-1 positive and Mantoux positive participants had large reactions > or = 30 mm, compared to 4 (8%) of the HIV-1 negative, Mantoux positive participants (P = 0.03). Results in the HIV-1 negative group indicated a prevalence of latent TB of 62% in this population. HIV-1 infection was associated with a much higher frequency of negative response to tuberculin and with a few large skin test responses. Thus, in populations where HIV seropositivity is high, Mantoux skin tests cannot be used to assess those with latent TB who might benefit from chemoprophylaxis.

PIP: A cross-sectional study of the Mantoux response and HIV-1 status of a sample of patients with sexually transmitted diseases and skin diseases in Lusaka, Zambia, sought to estimate the prevalence of latent tuberculous infection. The sample was selected from patients attending the sexually transmitted diseases/dermatology section at the University Teaching Hospital, Lusaka, Zambia, between July and September 1990. A questionnaire regarding socioeconomic factors, history of TB, contact with TB, location and documentation of bacillus Calmette-Guerin (BCG) scar(s) and history of BCG vaccination was completed, and a physical examination for acquired immune deficiency syndrome (AIDS) was carried out. The Mantoux result was recorded as the average diameter of induration, measured in 2 perpendicular directions by the pen and palpation method. A total of 158 patients (59%) were HIV-1 positive. Of the 66 women who took part, 46 (70%) were HIV-1 positive; of the 201 men, 112 (56%) were HIV-1 positive (p = 0.06). 232 patients had sexually transmitted diseases, the commonest being genital ulceration; 123/231 (53%) were HIV-1 positive. The remaining 36 patients had skin diseases, the commonest being herpes zoster; 32/36 (89%) were HIV-1 positive. Of the 267 patients remaining in the study, 193 (72%) returned to have their Mantoux test read, 188 within 48-72 h. 106 (67%) HIV-1 positive patients and 82 (75%) HIV-1 negative patients returned. Of the 82 HIV-1 negative patients, 51 (62%) had a Mantoux reaction or= 10 mm; 55 (67%) had a reaction or= 5 mm. Of the 106 HIV-1 positive patients, only 32 (30%) had a Mantoux reaction or= 10 mm; 35 (33%) had a response or= 5 mm. Comparing HIV-1 negative and HIV-1 positive participants gave a significant odds ratio of 3.85 for a Mantoux response or= 10 mm. Among the individuals with a Mantoux reaction or= 10 mm, 9/32 (28%) of HIV-1 positive participants had a megareaction or= 30 mm, while megareactions occurred in 4/51 (8%) of HIV-1 negative participants (odds ratio 4.6).

The impact of human immunodeficiency virus on mortality of patients treated for tuberculosis in a cohort study in Zambia.

We have examined the impact of human immunodeficiency virus (HIV) on mortality of patients treated for tuberculosis in a prospective study in Lusaka, Zambia. Patients with sputum smear-positive, miliary, or meningeal tuberculosis were prescribed 2 months' daily streptomycin, thiacetazone, isoniazid, rifampicin, and pyrazinamide followed by 6 months thiacetazone and isoniazid; others, 2 months streptomycin, thiacetazone and isoniazid followed by 10 months thiacetazone and isoniazid. 239 patients (65 HIV-negative and 174 HIV-positive) were followed to 2 years from start of treatment. The crude mortality rate ratio for HIV-positive compared with HIV-negative patients over 2 years was 5.00 (95% confidence interval 2.30-10.86). Median survival for HIV-positive patients from the start of treatment was 22 months. At least 34% of HIV-positive patients for whom cause of death was known died from tuberculosis, three-quarters of these during the first month of treatment. Risk factors for death in HIV-positive patients included multi-site tuberculosis, history of prolonged diarrhoea or fever, oral thrush, splenomegaly, anergy to tuberculin, low weight, anaemia or lymphopenia, and poor compliance with regimens containing rifampicin and pyrazinamide. Tuberculosis, even treated, was a major cause of death in patients with HIV infection.

PIP: The impact of HIV on mortality is described in a prospective study of tuberculosis patients in Lusaka, Zambia, where more than 70% of newly diagnosed tuberculosis patients have concurrent HIV infection. Patients attending the University Teaching Hospital in Lusaka, Zambia, were recruited to a prospective cohort study from April to December 1989. Of the 239 patients included in the follow-up study, 174 (73%) were HIV-1 positive by ELISA. A higher proportion of HIV-positive patients were 25-34 years old, and they more often had a negative tuberculin response, anemia, or lymphopenia at recruitment. The probability of survival for HIV-negative and HIV-positive patients was, respectively: at 2 months 95% and 89%; at 6 months 95% and 76%; at 12 months 91% and 66%; at 18 months 87% and 55%; and at 24 months 87% and 48%. The median survival of HIV-positive patients was 22 months. The crude, 2-year mortality rate ratio for HIV-positive compared with HIV-negative patients was 5 (p 0.001). Mortality was higher for patients with both pulmonary and extrapulmonary disease than for those with either pulmonary or extrapulmonary disease alone; for individual sites, only lymph node disease was associated with a significantly higher mortality than other sites (p = 0.01). At presentation prolonged fever, prolonged diarrhea, oral Candida or splenomegaly, negative tuberculin response, anemia or lymphopenia and low weight were associated with higher mortality. Among the 39 patients seen at 2 months who had been prescribed short-course chemotherapy, subsequent mortality was lower in the group who reported receiving all 60 doses of either rifampicin or pyrazinamide or both (20 patients) than among those who had not (19 patients¿ (rate ratio 0.24, p = 0.02). 47 of the 81 patients died within 24 months of the start of treatment, 5 HIV-negative and 42 HIV-positive. 3 of 5 HIV-negative patients for whom information was available died of active tuberculosis. Among HIV-positive patients, 14 of 42 died of active tuberculosis and 2 more of complications of tuberculosis.

Serum lipids and lipoprotein in adult Ghanaians.

OBJECTIVES: To date, no measurement of serum lipid levels in healthy adult Ghanaians have been carried out. This study was undertaken with the objective of providing reference values for serum lipid levels in the Ghanaian population. DESIGN/SETTING: Fasting serum lipid levels were measured in 79 adult Ghanaians living in an urban setting. Volunteers were randomly selected from the work force of the University of Ghana in Accra. There were 54 males and 25 females in the study population. RESULTS: The mean serum cholesterol (SC) for Ghanaian males was 4.27 +/- 1.00 mmol L-1. A value of 4.34 +/- 1.12 mmol L-1 was obtained for the females in this study. High-density lipoprotein cholesterol (HDL-C) in Ghanaian males averaged 1.37 +/- 0.44 mmol L-1 and 1.47 +/- 0.50 mmol L-1 in females. There was no statistically significant difference in low-density-lipoprotein cholesterol (LDL-C) and very-low-density-lipoprotein cholesterol (VLDL-C) levels between the females and males in this study. CONCLUSIONS: Compared to other studies, our results show that populations in Europe and North America have higher levels of total cholesterol and LDL cholesterol than Ghanaians. The levels of HDL cholesterol as well as VLDL cholesterol are higher in Ghanaians than in Europeans and Americans. Further work needs to be done to compare lipid levels in urban and rural Ghanaians as well as in those with cardiovascular disorders.

The impact of HIV on infectiousness of pulmonary tuberculosis: a community study in Zambia.

OBJECTIVE: To examine the impact of HIV on infectiousness of pulmonary tuberculosis (TB). DESIGN: A cross-sectional tuberculin survey carried out among household contacts of HIV-1-positive and negative patients with bacteriologically confirmed pulmonary TB. Contacts were also examined for active TB. SETTING: Index cases were recruited from patients attending the University Teaching Hospital in Lusaka, Zambia and household contacts were examined during visits to their homes within Lusaka. PATIENTS, PARTICIPANTS: A total of 207 contacts of 43 HIV-positive patients, and 141 contacts of 28 HIV-negative patients with pulmonary TB were examined. MAIN OUTCOME MEASURES: Proportion of contacts of HIV-positive and negative index cases with a positive tuberculin response (diameter of induration > or = 5 mm to a dose of 2 tuberculin units). RESULTS: Fifty-two per cent of contacts of HIV-positive pulmonary TB patients had a positive tuberculin response compared with 71% of contacts of HIV-negative patients (odds ratio, 0.43; 95% CI, 0.26-0.72; P < 0.001). This difference persisted after allowing for between-household variations in the tuberculin response. Tuberculin response in the contact was related to age of contact, intimacy with the index case and crowding in the household. However, the effect of HIV status of the index case was not confounded by these variables. Tuberculin response in the contact was also related to the number of bacilli seen in the sputum smear of the index case which partially explained the effect of HIV status of the index case. Active TB was diagnosed in 4% of contacts of HIV-positive and 3% of contacts of HIV-negative cases, respectively (P = 0.8). CONCLUSIONS: HIV-positive patients with pulmonary TB may be less infectious than their HIV-negative counterparts and this may partly be explained by lower bacillary load in the sputum.

PIP: Between April and December 1989, the chest clinic of the University Teaching Hospital in Lusaka, Zambia, confirmed pulmonary tuberculosis (TB) in 141 adults, 95 (67%) of whom were HIV-1 seropositive. Health workers made home visits to 71 of the index cases (43 HIV-1 positive and 28 HIV-1 negative) to learn whether the 348 household members would also develop TB, thus allowing researchers to determine the effect of HIV on infectiousness of TB. Contacts of HIV-1 positive patients developed TB at a lower rate than did those of HIV-1 negative patients (52% vs. 71%; odds ratio [OR] = 0.43; p .001). This difference continued even after controlling for between-household variations, indicating that confounding variables did not account for the difference. Age of contact, intimacy with the index case, and crowding in the household were associated with the tuberculin response in the contact, but they did not confound the effect of HIV status. Tuberculin response in the contact was associated with the number of bacilli in the sputum smear (crude OR = 3.13; p = .013, and adjusted OR =1.84; p = .28), suggesting that the number of bacilli somewhat explained the difference in infectiousness between HIV-1 positive and HIV-1 negative patients. 12 contacts (8 of HIV-positive cases and 4 of HIV-negative cases) developed active TB after the TB diagnosis in the index case. These findings clearly demonstrated that infection with Mycobacterium tuberculosis was less likely in household members of HIV-1 positive cases than in those of HIV-1 negative cases. The lower bacillary load in the sputum in HIV- 1 cases may have accounted somewhat for the lower infectiousness of pulmonary TB.

Negative sputum smear results in HIV-positive patients with pulmonary tuberculosis in Lusaka, Zambia.

During recruitment to a prospective study of tuberculosis patients in Lusaka, Zambia, 109 had pulmonary disease proven by sputum culture for Mycobacterium tuberculosis, of whom 72 were HIV-1 antibody-positive and 37 were HIV-negative. Among these culture-proven cases, 43% of the HIV-positive patients had a negative sputum smear, compared with 24% of the HIV-negative cases. There was a strong trend towards lower grade or negative sputum smear in the HIV-positive group (P = 0.003). HIV-positive cases also had lower colony counts on culture and colonies took longer to appear. The findings imply that cases of HIV-associated pulmonary tuberculosis may frequently be missed and emphasise the need for new diagnostic methods.

The impact of human immunodeficiency virus on presentation and diagnosis of tuberculosis in a cohort study in Zambia.

Two hundred and forty-nine patients with tuberculosis were recruited to a cohort study to investigate the interaction between tuberculosis and HIV in Lusaka, Zambia; findings at presentation are presented here. One hundred and eighty-two (73%; 95% confidence interval 67-79%) of the cases were HIV-1 antibody positive. The diagnosis of tuberculosis was confirmed by microscopy for acid-alcohol fast bacilli, culture of Mycobacterium tuberculosis, or histology in 74% of all cases. HIV negative and positive cases differed in site of disease: among HIV negative patients 72% had pulmonary disease alone, 16% extrapulmonary disease alone and 12% had both, whereas among HIV positive patients 40% had pulmonary disease alone, 34% extrapulmonary disease alone and 26% both (P < 0.001). HIV negative and positive cases were compared with regard to outcome of diagnostic procedures: 55% of HIV negative cases could be diagnosed at enrollment by sputum smear, but only 35% of HIV positive cases (P < 0.01). Among pulmonary cases confirmed by sputum culture, 76% of HIV negative patients had a positive sputum smear, compared with 57% of HIV positive patients (P = 0.09). Pleural and pericardial disease were difficult to confirm, but culture of pleural fluid was positive in 12/46 HIV positive patients, compared with 0/11 HIV negative patients. Lymph node disease was readily confirmed by biopsy. The tuberculin test was positive in only 30/110 (27%) of HIV positive cases, but in 21/38 (55%) of HIV negative cases (P < 0.01). Mycobacterium tuberculosis was cultured in 57% of HIV negative cases and 54% of HIV positive cases; no atypical mycobacteria were isolated. Initial resistance to isoniazid was present in isolates from 5% of cases with a positive culture.

Community-based high blood pressure programs in sub-Saharan Africa.

We studied residents of urban and rural areas of Ghana from 1972 through 1987 to evaluate the health burden of cardiovascular diseases, especially high blood pressure, in these African communities. Among urban adults, the prevalence of hypertension was 8% to 13%, compared to only 4.5% among rural adults. Overall, rates were higher among men than among women. However, the rate of hypertension was the same for men and women over 40 years old. The prevalence of hypertension was 29% for persons aged 35 and older, compared to 3.9% for persons under 35 years of age. Of the 24% of the study participants who were aware of their hypertension status, only a third were undergoing treatment, and only half of those were receiving adequate treatment. The determinants of hypertension include age, family history, body mass index, parity, and alcohol use. On a continent where over 80% of the health budget is spent on communicable diseases such as malaria, this study represents one of the few early attempts to understand the magnitude of the health burden of noncommunicable diseases in Africa.

Use of prednisolone in the treatment of HIV-positive tuberculosis patients.

Corticosteroids are beneficial in the treatment of some forms of tuberculosis, but their role in TB affecting HIV-positive patients is not clear. During a cohort study of tuberculosis patients in Lusaka, Zambia, prednisolone was prescribed for specific indications. Six of 47 (13 per cent) of patients who received prednisolone early in treatment developed herpes zoster, compared with 2 of 118 (2 per cent) of those who did not. Three patients who received prednisolone developed Kaposi's sarcoma, compared with none who did not. At 2 months patients who had received prednisolone showed a greater improvement in generalized lymphadenopathy and cough. Controlled studies of the risks and benefits of administration of corticosteroids to HIV-positive TB patients are urgently needed.

The profile of the African smoker: the Ghana smoking studies.

PIP: The prevalence of cigarette smoking in Ghana was assessed by examining the data on smoking from 2 World Health Organization sponsored studies of blood pressure and cardiovascular disease. The 2 studies were the Civil Servants Hypertension Project, which surveyed a sample of approximately 20% of all civil servants and included 486 male and 202 female respondents, and the Mamprobi Survey, which sampled the general population and included 3745 respondents, aged 14-64 years. Additional data from 2 other studies was also examined. Overall, the studies found that the proportion of smokers in Ghana was small and that most of those who smoked were not heavy smokers. The smoking prevalence rate among civil servants was 32% for males and 5.9% for females. Among the respondents in the Mamprobi Survey, the respective rates were 24% and 0.8%. For those aged 15-19 years, the prevalence rates in the 2 studies ranged from 4.6%-7.8% for males and was 0.0% for females. In another recent study of 2493 respondents from the general population, the proportion of smokers was only 15.1%. The proportion of smokers was similar among those who earned low and high salaries. In the Civil Servants Study the mean number of cigaretters smoked/day among the civil servants was 7 for the males and 4.7 for the females. In the Mamprobi Survey, the respective mean numbers were 8.4 and 3.0. Among civil servants, professional and administratie personnel smoked an average of 12 cigarettes/day while lower salaried workers smoked an average of 7 cigarettes/day. Only 3.7% of all the smokers in the 2 studies combined smoked 20 or more cigarettes/day. All of the studies indicate that 97%-99% of those who smoked/used cigarettes. Among civil servants, 91% of the smokers and 60% of the nonsmokers used alcohol. The studies indicate that the typical smoker in Ghana is an urban male, between 20-29 years of age, who began smoking as an adolescent. He is just as likely to belong to a high income group as a low income group; however, if he belongs to the former group, he is more likely to smoke more than the average number of cigarettes/day. Available information on smoking should be used to launch a public health campaign to reduce smoking in Ghana. At the present time, only a minority of the population smokes, few individuals are heavy smokers, and teachers and educators are showing considerable interest in combating smoking. Currently, educated and professional groups have a relatively high proportion of smokers. If these groups can be motivated to stop smoking, they might serve as effective role models for other segments of the population. Factors which may increase the smoking problem in Ghana are the growing number of young people who smoke and the ambivalence of the government toward smoking. Voluntary organizations and health professionals should assume more active roles in educating the public about the hazards of smoking.^ieng