Genital ulcers: etiology, clinical diagnosis, and associated human immunodeficiency virus infection in Kingston, Jamaica

Individuals presenting consecutively with genital ulcers in Kingston, Jamaica, underwent serological testing for human immunodeficiency virus (HIV) infection , chlamydial infection, and syphilis. Ulcer material was analyzed by the multiplex polymerase chain reaction (M-PCR) analysis DNA from herpes simplex virus (HSV), Haemophilus ducreyi, and Treponema pallidum was detected in 158 (52.0 percent), 72 (23.7 percent), and 31 (10.2 percent) of 304 ulcer specimens. Of the 304 subjects, 67 (22 percent) were HIV-seropositive and 64 (21 percent) were T. pallidum-seroactive. Granuloma inguinale was clinically diagnosed in nine (13.4 percent) of 67 ulcers negative by M-PCR analysis and in 12 (5.1 percent) of 237 ulcers positive by M-PCR analysis (P = .03). Lymphogranuloma venereum was clinically diagnosed in eight patients. Compared with M-PCR analysis, the sensitivity and specificity of a clinical diagnosis of syphilis, herpes, and chancroid were 67.7 percent, 53.8 percent, and 75 percent and 91.2 percent, 83.6 percent, and 75.4 percent, respectively. Reactive syphilis serology was 74 percent sensitive and 85 percent specific compared with M-PCR analysis. Reported contact with a prostitute in the preceding 3 months was associated with chancroid (P = .009), reactive syphilis serology (P = .011), and HIV infection (P = .007). The relatively poor pleads for syndromic management of genital ulcers in Jamaica. Prevention efforts should be intensified.(Au)

HIV infection and disturbances of vaginal flora during pregnancy.

Disturbances of vaginal flora are common among women of reproductive age. In areas of sub-Saharan Africa where the prevalence of HIV is high, the frequency of bacterial vaginosis (BV) is also high. In this study, we assessed the association of BV and other disturbances of vaginal flora with prevalent HIV infection in two cross-sectional studies among pregnant women in urban Malawi. The prevalence of HIV-1 was 23% in 1990 and 30% in 1993. Overall, 30% of the women had BV, 59% had mild or moderate disturbance of vaginal flora, and only 11% had normal vaginal flora. Increasing prevalence of HIV was significantly associated with increasing severity of disturbance of vaginal flora (p < .00001, chi2 trend test). This trend of increased prevalence persisted after controlling for concurrent sexually transmitted diseases (STDs), sexual activity, and socioeconomic factors. After multivariate adjustment for potential confounders, the odds ratio for the association of BV with prevalent HIV infection was 3.0 (95% confidence interval [CI], 2.4-3.8), that of moderate vaginal disturbance with HIV infection was 2.2 (95% CI, 1.7-2.8), and that of mild vaginal disturbance with HIV infection was 1.6 (95% CI, 1.3-2.1). Among women with BV, HIV infection was higher among younger women than older, implying more recent infection. Although these studies were cross-sectional, our data suggest that BV could be associated with increased susceptibility to HIV infection.

PIP: While ulcerative and nonulcerative STDs have been shown to be associated with HIV transmission, the potential association of HIV transmission with more frequent genital conditions which cause no inflammation of the vaginal or cervical mucosa have been inadequately studied. Bacterial vaginosis (BV) is characterized by disturbances in the vaginal flora resulting in the loss of lactobacilli, an increase in other mainly anaerobic flora, and an increased vaginal pH. Reproductive-age women commonly experience disturbances of vaginal flora, and in areas of sub-Saharan Africa in which HIV prevalence is high, there is also a high frequency of BV. The authors explored the association of BV and other disturbances of vaginal flora with prevalent HIV infection in 2 cross-sectional studies among pregnant women in urban Malawi. 23% of the 6684 women tested for HIV-1 infection in 1990 were seropositive, as well as 30% of 2464 women tested in 1993. Overall, 30% of the women had BV, 59% had mild or moderate disturbance of vaginal flora, and 11% had normal flora. An increasing prevalence of HIV was significantly associated with increasing severity of disturbance of vaginal flora, even after controlling for concurrent STDs, sexual activity, and socioeconomic factors. After multivariate adjustment for potential confounders, the odds ratio for the association of BV with prevalent HIV infection was 3.0, that of moderate vaginal disturbance with HIV infection was 2.2, and that of mild vaginal disturbance with HIV infection was 1.6. Among women with BV, HIV infection was higher among younger women than older, implying more recent infection. These findings suggest that BV could be associated with increased susceptibility to HIV infection.

Bacterial vaginosis and disturbances of vaginal flora: association with increased acquisition of HIV.

BACKGROUND: Cross-sectional studies suggest an association between bacterial vaginosis (BV) and HIV-1 infection. However, an assessment of a temporal effect was not possible. OBJECTIVES: To determine the association of BV and other disturbances of vaginal flora with HIV seroconversion among pregnant and postnatal women in Malawi, Africa. DESIGN: Longitudinal follow-up of pregnant and postpartum women. METHODS: Women attending their first antenatal care visit were screened for HIV after counselling and obtaining informed consent. HIV-seronegative women were enrolled and followed during pregnancy and after delivery. These women were again tested for HIV at delivery and at 6-monthly visits postnatally. Clinical examinations and collection of laboratory specimens (for BV and sexually transmitted diseases) were conducted at screening and at the postnatal 6-monthly visits. The diagnosis of BV was based on clinical criteria. Associations of BV and other risk factors with HIV seroconversion, were examined using contingency tables and multiple logistic regression analyses on antenatal data, and Kaplan-Meier proportional hazards analyses on postnatal data. RESULTS: Among 1196 HIV-seronegative women who were followed antenatally for a median of 3.4 months, 27 women seroconverted by time of delivery. Postnatally, 97 seroconversions occurred among 1169 seronegative women who were followed for a median of 2.5 years. Bacterial vaginosis was significantly associated with antenatal HIV seroconversion (adjusted odds ratio = 3.7) and postnatal HIV seroconversion (adjusted rate ratio = 2.3). There was a significant trend of increased risk of HIV seroconversion with increasing severity of vaginal disturbance among both antenatal and postnatal women. The approximate attributable risk of BV alone was 23% for antenatal HIV seroconversions and 14% for postnatal seroconversions. CONCLUSIONS: This prospective study suggests that progressively greater disturbances of vaginal flora, increase HIV acquisition during pregnancy and postnatally. The screening and treating of women with BV could restore normal flora and reduce their susceptibility to HIV.

Approaches to control sexually transmitted diseases in Haiti, 1992-95.

Despite major obstacles, activities to control sexually transmitted diseases (STDs) were initiated in Haiti in 1992 in collaboration with local nongovernmental organizations. The approaches included review of available local data, assessment of STD case management practices and constraints, and development of specific STD control activities at the primary health care level, such as systematic screening of all pregnant women for syphilis and improved comprehensive syndrome-based STD case management. The activities included conduct of local studies, presentation and dissemination of results to key audiences, training of health care providers, improvement of local capacities, and consensus-building on implementation of STD control approaches. STD awareness and case management improved considerably; for example, 69% of the clinicians interviewed reported correct STD treatments in the north-eastern primary health care centres in 1995, compared with < 10% in 1992. At the end of the project, national STD case management guidelines were developed by consensus between the various organizations and the Ministry of Health. Lessons learned included the importance of local data generation and of communication and collaboration with various institutions for consensus-building, the need for continued training, and field supervision to ensure behaviour change among STD care providers. A national STD control programme should be implemented as soon as possible in both the public and private sector. External funding will remain critical to control this important public health problem in Haiti.

PIP: Mid-1992 was a time of considerable political and socioeconomic instability in Haiti. Haiti's first democratically elected president had been ousted by a military junta and both political crimes and human rights abuses abounded. No national sexually transmitted disease (STD) control program was in place and almost no data were available on the magnitude and scope of STDs in the country. In this context, and despite many obstacles, STD control activities were planned with the hope of eventually developing a national STD control program. US Agency for International Development-funded AIDSCAP HIV/AIDS/STD prevention initiatives were first launched in Haiti in mid-1992 in collaboration with local nongovernmental organizations (NGOs). Direct collaboration with the de facto government was not allowed until democracy was restored in October 1994. The authors describe the STD control approaches and interventions initiated under these circumstances, with lessons learned for potential application outside of Haiti. Approaches included a review of available local data, an assessment of STD case management practices and constraints, and the development of specific STD control activities at the primary health care level, such as the systematic screening of all pregnant women for syphilis and improved comprehensive syndrome-based STD case management. Local studies were conducted, with the salient results presented to key audiences; health care providers were trained; local capacities improved; and consensus built upon the implementation of STD control approaches. STD awareness and case management improved considerably, with national STD case management guidelines developed at the end of the project through consensus between various organizations and the Ministry of Health.

Aetiology of genital ulcer disease in patients attending an STD clinic in Kingston, Jamaica

The purpose of this study was to determine the aetiology of genital ulcers (GUD) in STD clinic attenders, using state-of-the-art diagnostic tests, and to compare this with clinical diagnosis. Patients attending an STD clinic in Kingston, Jamaica for a new STD complaints were screened for GUD and clinically diagnosed. Swabs of ulcers were taken and tested for T. pallidum (TP), herpes simplex virus (HSV), and H. ducreyi (HD), using polymerase chain reaction (PCR). Sera were tested for syphilis and HIV infection. Of 4873 patients screened, 304 (6.2 percent) had GUD. In patients with ulcers, 158 (52 percent) were HSV (+), 73 (24 percent) were HD (+), and 31 (10 percent) were TP (+). Dual infections were identified in 20 (7 percent) ulcers. Clinically, herpes was diagnosed in 85/158 (54 percent) of HSV (+) ulcers, chancroid in 54/72 (75 percent) of HD (+) ulcers, and syphilis in 21/31 (68 percent) of TP (+) ulcers. Over three-quarters of GUD in Kingston had defined aetiology for herpes, chancroid or syphilis using PCR, with herpes being the commonest. Uniformly, clinical diagnosis performed poorly and Jamaican algorithms for the management of GUD will need to take into account the findings of this study, and should include counselling for herpes.(AU)

Trends of HIV-1 and sexually transmitted diseases among pregnant and postpartum women in urban Malawi.

OBJECTIVES: To examine rates of HIV-1 and sexually transmitted disease (STD) among pregnant and postpartum women in urban Malawi, Africa. DESIGN: Serial cross-sectional surveys and a prospective study. METHODS: Three major surveys were conducted in 1990, 1993 and 1994/1995. Consecutive first-visit antenatal women and women giving birth at the Queen Elizabeth Central Hospital were tested for HIV and STD after counseling and obtaining informed consent. Unlinked, anonymous HIV testing was also conducted on smaller samples of antenatal women in the same hospital to provide annual prevalence data. HIV-seronegative postpartum women from the 1990 and 1993 surveys were enrolled in a prospective study to determine HIV incidence. RESULTS: HIV seroprevalence rose from 2.0% in 1985 to 32.8% in 1996, a 16-fold increase. The highest age-specific HIV prevalence was in the following age-groups: 20-24 years during 1990, 25-29 years during 1993, and 30-34 years during 1996. Among 1173 women followed for a median of 30.9 months, HIV incidence was 5.98 per 100 person-years in women aged < 20 years and declined steadily in older women. The prevalence of STD significantly declined among both HIV-positive and negative women. This decline in STD prevalence, however, was not accompanied by increased condom use over time. CONCLUSIONS: Among urban childbearing women in Malawi, incidence of HIV is highest among young women while, currently, prevalence is highest among older women. Recent declines in STD prevalence suggest that HIV prevention programs are having an impact either through improved STD diagnosis and treatment or reduced risk behaviors. Sequential cross-sectional STD prevalence measures may be useful in monitoring effectiveness of STD and HIV prevention activities.

PIP: Prevalence rates of HIV-1 and other sexually transmitted diseases (STDs) among pregnant and postpartum women were investigated in sequential, cross-sectional studies (1990, 1993, and 1994-95) conducted at Queen Elizabeth Central Hospital in Blantyre, Malawi. Annual anonymous, unlinked testing revealed a linear increase in HIV-1 prevalence among antenatal patients from 2.0% in 1985 to 32.8% in 1996. Analysis of demographic attributes of women enrolled in the 1990 and 1993 surveys of consecutive, first-visit antenatal women (n = 6603 and 2161, respectively) and the 1994-95 study of all women giving birth at the hospital during a 6-month period (n = 6964) indicated that HIV-infected women were most likely to be young, with fewer pregnancies, and be more educated. The highest age-specific HIV prevalence shifted from 20-24 years in 1990 to 30-34 years in 1996, indicating an aging cohort of women who became infected at a younger age. Reported lifetime use of condoms increased from 5.6% in 1990 to 17.5% in 1993, then declined to 4.9% in 1995; condom use was consistently higher among HIV-positive than HIV-negative women. The prevalence of all STDs (syphilis, trichomoniasis, gonorrhea, and genital warts and ulcers) declined significantly during 1990-96, with the most consistent decreases recorded among HIV-positive women. In a follow-up study of 1173 HIV-seronegative, postpartum women evaluated for 2302 person-years (average duration, 30.9 months), 97 seroconverted (4.21/100 person-years). The seroconversion rate declined steadily from 21.26/100 person-years in 1990 to 1.11/100 person-years in 1994-95. These findings are consistent with those from other sub-Saharan African countries, indicating a rapid increase in HIV prevalence followed by stabilization within about 10 years of the onset of the epidemic. The large decline in STD prevalence in the antenatal population suggests that Malawi's national AIDS prevention program is having an impact, either through improved STD diagnosis and treatment or reduced risk behaviors.

Validation of the WHO diagnostic algorithm and development of an alternative scoring system for the management of women presenting with vaginal discharge in Malawi.

OBJECTIVE: To evaluate the performance of the WHO algorithm for the detection of cervical infection in women presenting with vaginal discharge and modify the risk assessment score for optimum effectiveness in Malawi. METHODS: 550 consecutive women presenting with non-ulcerative genitourinary complaints were interviewed and examined. Cervical infection was defined as presence of Neisseria gonorrhoeae on culture and/or Chlamydia trachomatis by EIA. Other laboratory investigations included wet mount microscopy, serology for syphilis and HIV, LED testing of cervical and vaginal secretions, and pH testing of vaginal fluid. Sensitivity, specificity, and positive predictive values (PPV) of different algorithms were determined in the analysis. RESULTS: Cervical infection was identified in 19.5% of women (17.1% gonorrhoea, 3.7% chlamydial infection). The sensitivity/specificity/PPV of the WHO risk assessment were 43%/73%/28%, respectively by history and 62%/61%/27% with the addition of speculum examination. Using Malawi results to modify the risk assessment improved the performance to 61%/68%/31% respectively by history alone, which increased to 73%/64%/33% with bimanual examination and 72%/56%/29% with speculum examination. CONCLUSION: The sensitivity of the WHO risk assessment is low for the detection of cervical infection in Malawi. Although the Malawi risk assessment performed somewhat better on history alone, this study identified external and bimanual examination variables that improved the diagnostic performance of the algorithm in settings where speculum examination is not possible. Although the PPVs of the algorithms are low, country specific risk assessments can provide a framework for management until simple, affordable diagnostic tests for the definitive diagnosis of cervical infection are available.

Improving sexually transmitted disease management in the private sector: the Jamaica experience

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60 percent of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4 month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluted with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre-versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3 percent; P > 0.05); diagnostics/screening (57.2-71.0 percent; P = 0.042); treatment (68.3-74.5 percent; P > 0.05)l and knowledge (66.4-83.2 percent; P = 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8 percent (P = 0.001), and providing effective treatment for gonorrhea rose form 57.8 to 81.1 percent (P = 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4 percent. CONCLUSION: The introduction of contiuing medical education for improved STD care targetting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services. continuing education programs that target the private sector can be successful and should be included as standard activity to improve care and providee a public/private link to STD/HIV control.(Au)

The decentralization of syphilis screening for improved care in Jamaican public clinics. Collaborative Working Group on Decentralized Syphilis Screening.

OBJECTIVES: This study examined the decentralization of syphilis screening for improved care in Jamaican public clinics. METHODS: One of every five serum samples tested at the six peripheral sites was frozen and retested at the central laboratory in Kingston. Patient files and laboratory logbooks were compared over a 3-month period. RESULTS: Between May 1993 and December 1994, 15.5% of 32913 patients with sexually transmitted diseases and 8.3% of 8914 women seeking prenatal care were found syphilis seroreactive. Of 2001 samples evaluated, 1933 (96.6%) had been correctly reported at the peripheral sites. Of 129 syphilis seroreactors detected at the peripheral sites, 88 (68%) were treated the same day and 21 (16%) more within 3 days after testing. CONCLUSIONS: Syphilis seroreactors were accurately detected and quickly treated at the peripheral sites. If these efforts can be sustained, Jamaican syphilis rates should decrease.

The decentralization of syphilis screening for improved care in Jamaican public clinics: Collaborative Working Group on Decentralization Syphilis Screening

OBJECTIVES: This study examined the decentralization of syphilis screening for improved care in Jamaican public clinics. METHODS: One of every five serum samples tested at the six peripheral sites was frozen and retested at the central laboratory in Kingston. Patient files and laboratory logbooks were compared over a 3-month period. RESULTS: Between May 1993 and December 1994, 15.5 percent of 32913 patients with sexually transmitted disease and 8.3 percent of 8914 women seeking prenatal care were found syphilis seroreactive. Of 2001 samples evaluated, 1933 (96.6 percent) had been correctly reported at the peripheral sites. Of 129 syphilis seroreactors detected at the peripheral sites, 88 (68 percent) were treated the same day and 21 (16 percent) more within 3 days after testing. CONCLUSIONS: Syphilis seroreactors were accurately detected and quickly treated at the peripheral sites. If these efforts can be sustained, Jamaican syphilis rates should decrease.(AU)

Cervical abnormalities, human papillomavirus, and human immunodeficiency virus infections in women in Malawi.

Cervical lavage samples and Pap smears were obtained from 284 women in Malawi to evaluate the association between human papillomavirus (HPV) and human immunodeficiency virus (HIV) infections. Squamous intraepithelial lesions were present in 15% (17/16) of HIV-seropositive and 7% (11/152) of HIV-seronegative women (P=.05) and in 23% (19/83) of HPV polymerase chain reaction (PCR)-positive and 4% (6/156) of HPV PCR-negative women (P<.001). HPV DNA was detected in 23% of HIV-uninfected women but in 60% of HIV-infected women with <300 CD4 cells/mm(3) (P<.002). High-risk HPV types 16 and 18 constituted half of the identified types. HPV DNA in previously HPV-positive women was detected more often than in HIV-seropositive abnormal cervical cytology than uninfected ones and were more likely to have persistent HPV infections. Early detection of HPV and regular monitoring of HIV-related cervical lesions may be important in HIV-infected women.

Reported condom use is not associated with incidence of sexually transmitted diseases in Malawi.

OBJECTIVES: To establish frequency of reported condom use and validate reliability of self-reporting among urban women in Malawi. DESIGN: Cross-sectional survey in antenatal women in 1989 and 1993. Prospective study in cohort first surveyed in 1989. METHODS: A total of 6561 women in 1989 and 2460 women in 1993 answered questions about condom use and sexual activity, had a physical examination and were screened for HIV. A subset of women from the 1989 screening were administered a questionnaire and tested for syphilis, Neisseria gonorrhoeae and Trichomonas vaginalis infections every 6 months. RESULTS: Although between the two cross-sectional studies intermittent condom use increased from 6 to 15% (P < 0.001) with no difference according to HIV infection, consistent use was reported by less than 1%. In the prospective study, women reported a higher condom use at any visit than either group assessed cross-sectionally. Consistent condom use peaked at 62% in the first 6 months, but declined to as low as 8% in the second year of follow-up. Condom use at each visit, either intermittent or consistent, was higher in HIV-seropositive than HIV-seronegative women. Overall, the incidence of gonorrhea, trichomoniasis and syphilis did not decline in women reporting consistent condom use. CONCLUSIONS: In prospectively followed women reports of consistent condom use was substantially higher than in cross-sectional surveys, but rapidly decreased over time, irrespective of HIV status. The presence of new sexually transmitted diseases suggests that this population of urban women overreports condom use or underreports sexual activity, or both. Intensive and sustained education is needed to achieve consistent condom use. Biologic markers of sexual activity are useful in interpreting reported condom use.

PIP: To determine the frequency of reported condom use and validate the reliability of self-reporting among urban women in Malawi, 6561 women in 1989 and 2460 women in 1993 answered survey questions about condom use and sexual activity, had a physical examination, and were screened for HIV. A subset of women from the 1989 screening were administered a questionnaire and tested for syphilis, gonorrhea, and Trichomonas vaginalis infections every six months. The study populations consisted of consecutive women presenting for their first antenatal visit to Queen Elizabeth Hospital in Blantyre, Malawi. Intermittent condom use increased from 6% to 15% between the two cross-sectional studies, with no difference according to HIV infection; consistent condom use was reported by less than 1%. In the prospective study, women reported higher condom use at any visit than either group assessed cross-sectionally. Consistent condom use peaked at 62% in the first six months, but declined to as low as 8% during the second year of follow-up. Condom use at each visit, either intermittent or consistent, was higher among HIV-seropositive than HIV-seronegative women. Overall, the incidence of syphilis, gonorrhea, and trichomoniasis did not decline in women reporting consistent condom use. This incidence of new sexually transmitted diseases suggests that the studied population either overreports condom use or underreports sexual activity, or both.

Infant mortality and maternal vitamin A deficiency during human immunodeficiency virus infection.

The maternal factors that contribute to high mortality rates among infants born to women with human immunodeficiency virus (HIV) are unclear. We followed 474 HIV-infected mothers and their infants in Malawi from pregnancy through the infants' 12th month of life. Of the 474 HIV-infected pregnant women, 300 (63.3%) were deficient in vitamin A (serum level of vitamin A, <1.05 micromol/L). Mean serum vitamin A levels among mothers whose infants died were 0.78 +/- 0.03 micromol/L compared with 1.02 +/- 0.02 micromol/L among mothers whose infants had survived for the first 12 months of life (P <.0001). The overall infant mortality rate was 28.7%. We divided HIV-positive mothers into six groups according to serum vitamin A levels (micromol/L) as follows: group 1, <0.35; group 2, between 0.35 and 0.70; group 3, between 0.70 and 1.05; group 4, between 1.05 and 1.40; group 5, between 1.40 and 1.75; and group 6, >1.75. Infant mortality rates for each group were 93.3%, 41.6%, 23.4%, 18.5%, 17.7%, and 14.2%, respectively (P < .0001). Maternal vitamin A deficiency during HIV infection may contribute to increased infant mortality.

The effect of human immunodeficiency virus infection on birthweight, and infant and child mortality in urban Malawi.

BACKGROUND: Low birthweight, prematurity and intra-uterine growth retardation (IUGR) are major determinants of child survival. Therefore, it is important to assess excess mortality due to human immunodeficiency virus (HIV) infection in populations where low birthweight is common. METHODS: A prospective study was conducted on 1385 children born to seropositive and seronegative women in urban Malawi. Children were regularly examined and tested for HIV. RESULTS: The mortality rate of children of HIV seropositive mothers was substantially higher (223/1000 at 12 months, 317/1000 at 24 months and 360/1000 at 30 months) than that of children of seronegative mothers (68/1000 at 12 months, 106/1000 at 24 months and 118/1000 at 30 months). The incidence of prematurity and IUGR was also higher in infants of HIV seropositive mothers than in infants of seronegative mothers (12.7% versus 3.8%, P < 0.001 for premature and 7.7% versus 4.4%, P = 0.02 for IUGR infants). The mother-to-infant HIV-1 transmission rate was 35.1%. After 12 months of age, HIV infected children showed the highest mortality; however, uninfected children of HIV seropositive and children of HIV seronegative mothers had similar mortality. The mean birthweight of HIV infected and uninfected children was not significantly different. In HIV infected children the most frequent causes of death were diarrhoea, pneumonia and failure to thrive. Less common risk factors for child mortality included active maternal syphilis and cervicitis/vaginitis. CONCLUSION: The substantial difference in survival among children of HIV infected and uninfected mothers suggests that mortality could be reduced if HIV infection were not a risk factor. To decrease childhood mortality, a combination of interventions such as treatment of sexually transmitted infections during pregnancy and measures to reduce mother-to-infant transmission should be adopted.

PIP: Low birth weight, prematurity, and intra-uterine growth retardation (IUGR) are major determinants of child survival. Therefore, it is important to assess excess mortality due to human immunodeficiency virus (HIV) infection in populations where low birth weight is common. A prospective study was conducted on a total of 1385 children born to 679 HIV-seropositive and 687 seronegative women in urban Malawi. Children were regularly examined and tested for HIV. The mortality rate of children of HIV-seropositive mothers was substantiality higher (223/1000 at 12 months, 317/1000 at 24 months, and 360/1000 at 30 months, p 0.0001) than that of children of seronegative mothers (68/1000 at 12 months, 106/1000 at 24 months, and 118/1000 at 30 months). The incidence of prematurity and IUGR was also higher in infants of HIV-seropositive mothers than in infants of seronegative mothers (12.5% versus 3.8%, p 0.001 for premature and 7.7% versus 4.4%, p = 0.02 for IUGR infants). The mother-to-infant HIV-1 transmission rate was 35.1%. The overall incidence of low birth weight was 14.1%, but the incidence was 20.1% among children of seropositive mothers and 8.3% among those of seronegative mothers (p 0.001). After 12 months of age, HIV-infected children showed the highest mortality; however, uninfected children of HIV-seropositive and children of HIV-seronegative mothers had similar mortality. The mean birth weight of HIV-infected and uninfected children was not significantly different. In HIV-infected children the most frequent causes of death were diarrhea, pneumonia, and failure to thrive. Less common risk factors for child mortality included active maternal syphilis and cervicitis/vaginitis. A possible enrolment bias could have resulted in lower mortality estimates among babies of HIV-seronegative mothers. To decrease childhood mortality, a combination of interventions such as treatment of sexually transmitted infections during pregnancy and measures to reduce mother-to-infant transmission should be adopted.

Traditional vaginal agents: use and association with HIV infection in Malawian women.

OBJECTIVES: To assess the prevalence of traditional vaginal agent use in Malawian women and its association with HIV infection. METHODS: Consenting, consecutive antenatal women were administered a questionnaire and screened for sexually transmitted diseases (STD) including HIV. RESULTS: Of the 6603 consenting women, 886 (13%) reported using intravaginal agents for tightening and 2222 (34%) for self-treatment of vaginal discharge and itching. A higher proportion of HIV-infected than uninfected women (17% versus 14%) reported use of intravaginal agents for treatment (odds ratio, 1.29; 95% confidence interval, 1.05-1.57), but no difference in HIV status was found when these agents were used for tightening. In multivariate analysis, vaginal agent use for treatment was independently associated with HIV seropositivity. CONCLUSIONS: The association of HIV infection with vaginal agents for self-treatment, but not for tightening, suggests that STD may play a role or that vaginal agents are used differently for the two purposes. In addition to a small increased risk of HIV infection associated with vaginal agent use, these agents may interfere with condom effectiveness or acceptability of vaginal microbicides.

PIP: An exploratory study was conducted in Malawi to determine whether a correlation exists between human immunodeficiency virus (HIV) and traditional practices involving the intravaginal application of substances such as herbs and pulverized stone. Included in the survey were 6603 consecutive consenting volunteers who presented at the prenatal clinic of an urban hospital from October 1989-October 1990. The median age of study participants was 24 years. Although only 11% reported having had a sexually transmitted disease (STD) in the three years preceding the interview, laboratory analysis revealed the presence of such an infection in 46%. HIV infection was found in 1502 (23%). A total of 2953 (45%) of these pregnant women reported use of vaginal agents or vaginal incision, either for the treatment of discharge or itching or for the enhancement of sexual pleasure through vaginal tightening. Concerns have been raised that the placement of desiccants, irritants, and astringents in the vagina can induce certain physiological changes that increase the risk of HIV infection. Demonstrated in this survey was a slight association between HIV seropositivity and the use of vaginal agents for self-medication but not for vaginal tightening. In the univariate analysis, this finding persisted only for pregnant women without past or current STD infection. In the multivariate analysis, users of vaginal agents for treatment had a small increased risk of HIV in addition to--and independently of--the risk conferred by an STD history. It is possible, however, that the use of vaginal agents for self-medication is a marker for the presence of genital tract inflammation--a co-factor for HIV transmission. Given the extent of this traditional practice and its potential risk, more research is urged on the type of vaginal agents used and their effects on vaginal tissue.

Maternal vitamin A deficiency and mother-to-child transmission of HIV-1.

Studies show that around 10-40% HIV-positive women will give birth to children who are also infected. However, the risk factors for transmission from mother to child are not well understood and the effects of maternal nutritional status are unknown. We conducted a study of vitamin A status in pregnant women as a risk factor for mother-to-child transmission of HIV in Malawi. Serum vitamin A, height, weight, CD4 T-cell counts, and duration of breastfeeding were measured in 338 HIV-positive mothers whose infant's HIV serostatus was known. Mother-to-child transmission of HIV was 21.9% among mothers whose infants survived to 12 months of age. Mean vitamin A concentration in 74 mothers who transmitted HIV to their infants was lower than that in 264 mothers who did not transmit HIV to their infants (0.86 [0.03] vs 1.07 [0.02], p < 0.0001). We divided HIV positive mothers to 4 groups, those with vitamin A concentrations of less than 0.70, between 0.70 and 1.05, between 1.05 and 1.40, and greater than or equal to 1.40 mumol/L. The mother-to-child transmission rates for each group were 32.4%, 26.2%, 16.0%, and 7.2%, respectively (p < 0.0001). Maternal CD4 cell counts, CD4%, and CD4/CD8 ratio were also associated with increased mother-to-child transmission of HIV. Maternal age, body-mass index, and breastfeeding practices were not significantly associated with higher mother-to-child transmission. Our study suggests that maternal vitamin A deficiency contributes to mother-to-child transmission of HIV.

Childhood malaria parasitaemia and human immunodeficiency virus infection in Malawi.

PIP: Malaria and human immunodeficiency virus (HIV) infection are major health problems in many areas in Sub-Saharan Africa. An interaction between malaria and HIV infection has been postulated, since both produce similar cellular immune responses, with a lowering of the CD4/CD8 lymphocyte ratio. The frequency of malaria parasitemia was examined in children born to HIV-seropositive and seronegative mothers attending regular postnatal visits. A prospective study on mother-to-infant transmission of HIV had been underway since 1989 in Queen Elizabeth Central Hospital, Blantyre, a major hospital in urban Malawi. Standard HIV serology was performed on pregnant women, after obtaining consent. To reduce the effect of selection bias and seasonality, HIV seropositive (case) and seronegative (control) mothers and their infants were enrolled at delivery. Children included in the study were 503 born to 494 HIV-seropositive mothers and 540 born to 536 HIV-seronegative mothers. At each 3-monthly postpartum visit a Giemsa-stained thick blood film from the child was examined for malaria parasites. Children born to HIV-seropositive mothers were tested for HIV antibodies at 12 and 18 months of age. Of the 353 children born to HIV-seropositive mothers, 82 children (23.2%) were found to be HIV seropositive by enzyme-linked immunosorbent assay and Western blotting at 12 and 18 months. No statistically significant difference was found in frequency of malaria parasitemia by maternal or infant HIV serostatus after controlling for child's age. There was, however, a significant trend of increase in high parasitemia with age, irrespective of the HIV serostatus of the mother or the child. The frequency of parasitemia was higher in the wet season than in the dry season. This study suggests that maternal or infant HIV infection does not alter susceptibility to, or the clinical course of, malaria in infants.^ieng