Acceptability of voluntary HIV testing by pregnant women in developing countries: an international survey. Ghent International Working Group on Mother-to-Child Transmission of HIV.

OBJECTIVE: To evaluate acceptability of voluntary HIV counselling and testing (VCT) by pregnant women in the context of clinical trials assessing interventions to reduce mother-to-child transmission (MCT) of HIV in developing countries. METHODS: During September-October 1997, 13 studies located in West (Abidjan, Bobo Dioulasso), East (Nairobi, Mombasa, Dar Es Salaam, Blantyre, Lusaka, Harare) and South Africa (Soweto, Durban), and Thailand (Bangkok) were included in a cross-sectional mailing survey about the acceptability of VCT in antenatal clinics. Acceptance rate, return rate, overall acceptability of VCT (acceptance of both pre- and post-VCT sessions) were obtained using a standardized questionnaire. RESULTS: The median overall acceptability of VCT was 69% (range, 33-95%). Overall acceptability of VCT most frequently depended on return rates because acceptance rates were generally high. Where several studies were conducted in parallel in the same city or the same country, overall acceptability rates of HIV testing were generally comparable even if the intervention programmes differed. Overall acceptability rates of VCT were high in antenatal clinics where a particular effort in implementing VCT programmes had been made. CONCLUSIONS: This international survey shows that despite many obstacles, VCT is feasible and acceptable for pregnant women aiming to reduce their risk of transmitting HIV to their children.

Attitude of pregnant women towards HIV testing in Abidjan, Côte d'Ivoire and Bobo-Dioulasso, Burkina Faso. DITRAME Study Group (ANRS 049 Clinical Trial). Diminution de la Transmission Mère Enfant du VIH. Agence Nationale de Recherches sur le SIDA.

OBJECTIVE: To evaluate the attitude of pregnant women towards HIV testing in two cities of West Africa: Abidjan, Côte d'Ivoire and Bobo-Dioulasso, Burkina Faso. METHODS: In the context of a clinical trial to prevent HIV vertical transmission, HIV counselling and testing was offered systematically to women attending antenatal clinics. Informed consent was obtained and test results were given anonymously. Multiple logistic regression was performed to identify factors associated with refusal for testing and failure to return for test results. RESULTS: A total of 9724 pregnant women were interviewed from January 1995 to September 1996. In Abidjan (n=5766) and Bobo-Dioulasso (n=3958), 78 and 92.4% of the women consented to HIV testing, respectively, and 58.4 and 81.8% of them returned for the test results disclosure, respectively. In the two sites, the counsellors themselves and high educational level of the women appeared to be related to refusal of the test, whereas last trimester gestation was associated with failure to return for test results. In Abidjan, foreigners and employees were more likely to refuse testing, and HIV-infected women were three times less likely to return for results than uninfected women. CONCLUSION: Future implementation of interventions to reduce vertical transmission of HIV that require antenatal HIV testing and counselling will have to solve issue of acceptability of HIV testing by pregnant women.

Potential source of human exposure to Mycobacterium bovis in Burkina Faso, in the context of the HIV epidemic.

OBJECTIVE: To identify potential sources of human Mycobacterium bovis infection in Bobo-Dioulasso, Burkina Faso. METHODS: A tuberculin survey among 174 cattle was performed. Mycobacteriologic identification in 64 samples of pooled milk, and in 199 tissue samples collected from the slaughterhouse of Bobo-Dioulasso, Burkina Faso, was also done. We retrospectively analyzed the distribution of tuberculosis (TB) cases on 1140 clinical records according to professional occupation and to ethnic group. The frequency of pulmonary and extrapulmonary TB was related to potential exposure and route of transmission of M. bovis from animals. RESULTS: Out of six herds (total 170 bovines), only one was free of any positive tuberculin test. Among 199 bovines which had been slaughtered over four consecutive nights, 38 (19%) had morphologic lesions suggestive of TB; 17 (45%) of those were positive for acid-fast bacilli by microscopic examination on one of their lesions, and 20 samples (53%) presented a positive culture for a pathogenic mycobacterium, including M. bovis and M. tuberculosis. In the retrospective analysis, Peuls more frequently had a pulmonary form of disease. This may be related to the route of transmission. CONCLUSIONS: Attention has to be paid to human TB of bovine origin in Burkina Faso. The identification of M. tuberculosis in milk and in tissue samples raises the question of the transmission of TB from humans to cattle.

Evaluation of 2 techniques of HIV pre-test counselling for pregnant women in west Africa. DITRAME Study Group.

This study compares the effect of group and individual pre-test counselling on uptake of HIV voluntary counselling and testing (VCT) by African pregnant women and knowledge about HIV/AIDS in 2 antenatal clinics of Bobo-Dioulasso, Burkina Faso. Pre-test counselling was offered to 3958 pregnant women, 927 by group counselling and 3031 by individual counselling. Acceptance of the test improved with individual counselling, which was already high with group counselling (93.3% versus 89.4%). The return rate for results was independent of the pre-test counselling technique. At post-test session, knowledge about HIV/AIDS was better after group than individual counselling, except for reporting the existence of an asymptomatic stage of HIV infection. At a public health level, group pre-test counselling can be easily integrated into existing sessions of antenatal care counselling, routinely performed by the current clinic staff. Our findings may help programme managers in the field of maternal and child health to choose optimal options of pre-test counselling adapted to local circumstances in resource-poor settings.

HIV infection among pregnant women in Burkina Faso: a nationwide serosurvey.

To determine the prevalence of HIV infection among pregnant women in Burkina Faso and to identify factors associated with HIV infection in this population, we performed in 4 antenatal clinics in 4 urban centres located in the centre, the north, the east and the south-west of the country cross-sectional serological surveys between 7 October 1994 and 7 February 1995 using unlinked anonymous HIV screening method. In the towns included in the study more than 94% of pregnant women attend at least 2 antenatal consultations. In each centre all pregnant women attending an antenatal consultation during a 2-week period were invited to take part in a study to measure the prevalence of syphilis. Women with positive syphilis serology were offered treatment free of charge. A total of 1294 pregnant women were recruited into the study. There were no refusals. Thirty-two women (2.5%) had positive syphilis serology. The overall seroprevalence of HIV infection was 8% (95% confidence interval [CI]: 6.6-9.6). There was no evidence that the prevalence of syphilis or HIV infection varied between the 4 towns (P=0.12 and 0.52 respectively). In logistic regression analyses only the presence of syphilis infection was associated with risk of HIV (odds ratio=3.4; 95% CI: 1.4-7.9). The prevalence of syphilis among pregnant women in Burkina Faso is relatively low compared with that of HIV infection. These results suggest that HIV epidemic in Burkina Faso is important and that there is an urgent need to intensify HIV-prevention activities. The need for HIV surveillance in this sentinel population is urgent to follow the course of the epidemic and to measure the impact of interventions. One of the consequences of the high prevalence of HIV infection among pregnant women which requires greater attention in Burkina Faso is the increasing number of children who will be infected with HIV by vertical transmission.

HIV infection among pregnant women in Bobo-Dioulasso, Burkina Faso: comparison of voluntary and blinded seroprevalence estimates.

The objective of our study was to estimate the prevalence of HIV infection among pregnant women in Bobo-Dioulasso (Burkina Faso) according to 2 survey methods. Unlinked anonymous HIV screening was performed among women attending 2 antenatal clinics. Voluntary and confidential HIV counselling and testing were offered to women attending 2 other antenatal clinics in the same time period, September-October 1996. Voluntary HIV testing was performed in the context of a clinical trial on mother-to-child transmission of HIV (ANRS 049 clinical trial) with an acceptance rate of HIV testing of 93%. The first survey recruited 200 women and the second, 424. The mean age (24.6 years vs 24.8 years) and the mean number of pregnancies (3.1 vs 3.3) of women were comparable, in the 2 studies (P=0.69 and P=0.26, respectively). Prevalence of HIV infection in the blinded survey was estimated at 10.0% (95% confidence interval (CI): 6.4-15.2), while it was 9.4% (95% CI: 6.9-12.7) in the voluntary HIV screening programme. These 2 estimates were not statistically different (P=0.82). In the voluntary screening study, the prevalence of HIV infection was significantly different between age groups 15-24 years and 25-49 years (13.9% vs 4.5%, P < 0.001). In the age group 25-49 years, the prevalence of HIV infection estimated in the blinded study and in the voluntary screening study were significantly different (10.5% vs 4.5%, P=0.04) suggesting a potential participation bias among pregnant women of older age in the voluntary, confidential HIV screening group. In conclusion, for the purpose of HIV surveillance, the most reliable method for HIV prevalence remains the unlinked, anonymous testing.

PIP: This study examines the prevalence of HIV infection among the pregnant women in Bobo-Dioulasso, Burkina Faso, through a comparison of voluntary and blinded seroprevalence estimates. Research methodology involves unlinked and anonymous HIV screening survey of 200 pregnant women attending two antenatal clinics from September 25 to October 1996. HIV serological tests were conducted and voluntary HIV screening were offered during the time period. Results showed that prevalence of HIV were statistically similar in both anonymous screening survey (10.0%) and confidential HIV counseling and testing study (9.4%). However, prevalence of HIV infection showed a difference between age groups 15-24 years and 25-49 years in the voluntary screening, suggestive of a possible participation bias with the method. The study concludes that unlinked anonymous HIV testing is the method of choice for HIV surveillance.

Stabilization of HIV infection rates in urban Burkina Faso, 1995-1999.

The objectives of this study were to monitor the trends of the HIV epidemic between 1995 and 1999 among pregnant women in Bobo-Dioulasso, the second largest town of Burkina Faso, and to discuss the possible effect of preventive interventions (condom availability) on sexual transmission of HIV in this context. Age-specific trends in HIV prevalence obtained from sentinel surveillance programme were analysed. Among antenatal clinic attendees, HIV prevalence was 7.5% (n=401) in 1995, 10% (n=200) in 1996, 7.6% (n=448) in 1997, 8.4% (n=642) in 1998 and 5.3% (n=716) in 1999 without demonstrated temporal trend (P=0.12). The average number of condoms available per person (aged 15-49 years) per year increased from 0.6 in 1992 to 5.7 in 1995 and 6.0 in 1999. Anonymous surveys are less subject to selection bias and suggest a stabilization of the HIV prevalence around 7.3% in Bobo-Dioulasso. Distribution of condoms could explain at least, partly, this stabilization of the HIV epidemic.

Prevalence and risk of HIV infection among female sex workers in Burkina Faso.

Little information is available regarding human immunodeficiency virus (HIV) infection among female sex workers (FSW) in Burkina Faso, West Africa. A cross-sectional study was conducted in Ouagadougou and Bobo-Dioulasso, the 2 largest cities of the country, to determine the prevalence of HIV infection and other sexually transmitted diseases (STDs) among FSWs, and to investigate the factors which were associated with HIV infection in this population. From October to November 1994, 426 FSWs were recruited. The method of anonymous and unlinked HIV screening recommended by the World Health Organization (WHO) was used. The overall HIV seroprevalence was 58.2% (95% confidence interval: 53.4-62.9) and 52.6% of FSWs had at least one STD agent. The most common STDs were trichomoniasis (23%), syphilis (15%) and gonorrhoea (13%). In a logistic regression analysis, risk factors for HIV infection were high gravidity (> or = 2 pregnancies), low perception of personal risk of HIV infection, syphilis and the presence of genital warts. These results suggest that FSWs in Burkina Faso need better information about HIV transmission and prevention and then need better access to STD detection and management services.

[The HIV epidemic in Burkina Faso: current status and the knowledge level of the population about AIDS, 1994-1995]. / L'épidémie à VIH au Burkina Faso: situation actuelle et niveau des connaissances de la population sur le SIDA, 1994-1995.

BACKGROUND: It is important for HIV/AIDS control programmes to determine population knowledge on AIDS in order to develop appropriate Information, Education and Communication (IEC) messages. The objectives of our study were to determine the seroprevalence of HIV and syphilis among pregnant women, female prostitutes and long-distance truck drivers and to evaluate knowledge, attitudes, beliefs, and practice (KABP) with respect to the HIV/AIDS epidemic in these three groups in Burkina Faso. METHODS: We performed three cross-sectional serosurveys including face-to-face interviews on KABP between October 1994 and February 1995 in three population groups. RESULTS: Overall, 1,294 pregnant women, 236 long-distance truck drivers and 426 female prostitutes were recruited. HIV seroprevalence was 8% (95% Confidence Interval (CI): 6.6-9.6) among pregnant women, 18.6% (95% CI: 13.9-24.2) among long-distance truck drivers and 58.2% (95% CI: 53.4-62.9) in female prostitutes. The prevalence of syphilis was 2.5%, 9.3% and 15%, respectively. Most pregnant women (98%), long-distance truck drivers (96%) and female prostitutes (98%) had already heard of AIDS. However, the level of knowledge of HIV transmission routes, of risk factors for HIV transmission and of available preventive measures was very low. Consequently, 41% of pregnant women, 40% of long-distance truck drivers and an alarming 61% of female prostitutes reported that they did not feel themselves at risk for HIV. In each group, high levels of knowledge on AIDS were associated with increased awareness of AIDS risk and the adoption of preventive behaviours. Level of education was associated with knowledge of AIDS and condom use. However, in the 12 months preceding the surveys, condom use was very low among pregnant women (0.1%), long-distance truck drivers (18%) and among female prostitutes (42%). CONCLUSIONS: These results indicate that HIV is widespread in Burkina Faso and that there is an urgent need to develop and evaluate HIV prevention strategies in the general population and among core groups such as female prostitutes and long-distance truck drivers. Interventions must include information campaigns, condom promotion and distribution, and sexually transmitted diseases control.

[Impaired fertility in women infected with HIV-1. Implications for sentinel serosurveillance]. / Réduction de la fertilité chez les femmes infectées par le VIH-1. Implications pour la sérosurveillance sentinelle.

BACKGROUND: Given the relationship between HIV infection and fertility, antenatal clinic-based HIV prevalence may not provide a good estimate of the community HIV prevalence. The objective of this work was to evaluate the impact of HIV infection on fertility among women attending antenatal clinics in Bobo-Dioulasso (Burkina Faso), and to discuss possible implications on HIV sentinel surveillance. METHODS: In the context of a phase II/III clinical trial of a short course of Zidovudine during pregnancy (DITRAME - ANRS 049 trial) we consecutively proposed voluntary counselling and HIV testing (VCT) to 1349 women aged at least 18 years, carrying a pregnancy of 7 months or less and living in Bobo-Dioulasso. During pre-test counselling session, a standardised questionnaire was administered to collect detailed information regarding socio-demographic characteristics and obstetrical history. Blood samples were then taken and tested for HIV after written informed consent. RESULTS: Mean age (+/- standard deviation) at first sexual intercourse was similar among HIV-infected (HIV+) (16.7+/- 2; n=83) and HIV-negative (HIV-) women (16.9+/- 2; n=1336). However, HIV+ women aged 25 years and above had, on the average fewer pregnancies (3.8+/- 1.5; n=37) than HIV- women (5.0+/- 2.3; n=567), p<0.01. Similarly, these HIV+ women had, on average, less live births (2.8+/- 1.3; n=35) than HIV- ones (3.7+/- 2.1; n=555), p=0.02. Other sexual and obstetrical characteristics such as maternal age, proportion of primigravidae, stillbirths or spontaneous abortions were comparable between HIV+ and HIV- women. CONCLUSIONS: Our data suggest that the level of fertility of HIV+ women aged 25 years and above is significantly lower than for HIV- women. Therefore, HIV+ women in this age group are likely to be under-represented among antenatal clinic attendees. These findings suggest adjusting antenatal clinic-based HIV sentinel surveillance data for age and fertility in order to derive a good estimate of the community HIV prevalence.

[HIV infection in truck drivers in Burkina Faso: a seroprevalence survey]. / L'infection á VIH chez les chauffeurs routiers au Burkina Faso: une enquête de séroprévalence.

Truck drivers are a well recognized high risk population for sexually transmitted diseases. Prior to start-up of a health care program and an information/education campaign, a cross-sectional study using the unlinked, anonymous screening method was carried out to assess seroprevalence of HIV and syphilis infections in truck drivers in Bobo Dioulasso, Burkina Faso. During the month of November 1994, 236 truck drivers were recruited at a cotton-producing factory. The prevalence of HIV infection was 18.6% and the prevalence of syphilis was 9.3%. Multivariate logistic regression analysis showed a statistically significant association between HIV infection and the following factors: age under 30 years, claimed systematic use of condoms, and previous genital ulcers. These findings suggest that truck drivers are highly exposed to the risk of contracting and disseminating HIV infection due to their high mobility and the high incidence of sexually transmitted diseases among their ranks. Prevention of HIV infection in truck drivers in Burkina Faso will require education to promote systematic use of condoms at each sexual contact as well as screening and treatment of sexually transmitted diseases at truck stops.

[Attitudes to counseling related to HIV infection screening in Bobo-Dioulasso, Burkina Faso]. / Le point sur le conseil lié au dépistage de l'infection par le VIH á Bobo-Dioulasso, Burkina Faso.

Two approaches, a questionnaire administered to pregnant women and interviews independently with selected individuals in posts of responsibility, were used to assess (i) the perception of HIV screening among patients attending a Maternal and Child Health Clinic and (ii) the attitudes of health staff and local authorities. One hundred and thirty five pregnant women were individually interviewed in their native language at the Farakan Maternal and Child Health Clinic, Bobo Dioulasso. Ninety six percent accepted the principle of being screened for HIV, and 91% wanted to be given the result, 46% in the presence of a family member. The person most often chosen to share the announcement of the result was the regular partner. Three physicians, two midwives, a hospital director, a parish priest and a politician were interviewed. One midwife did not approve of offering screening tests in the absence of available treatment. Four of these individuals suggested that the presence of a member of the family during counselling would be valuable to promote a sense of partnership. Many reasons were given to explain the difficulties associated with announcing the results of tests. They included: the absence of treatment; the cost of the test; the lack of confidentiality; psychosocial consequences; the reaction, particularly fear, of the patient; difficulties associated with communication and with changing behavior. These observations contribute to a basis for analysis to develop a local and national consensus about HIV testing and counselling for pregnant woman.

PIP: In April 1994, in Burkina Faso, 135 pregnant women aged 15-41 attending the Farakan Maternal and Child Health Center in Bobo-Dioulasso were interviewed in their native language. In-depth interviews were also conducted with three physicians, two midwives, a hospital director, a parish priest, and a politician. Researchers aimed to learn from these interviews the perception of the prenatal clients and the attitudes of health staff and local authorities toward HIV screening. 96% of the pregnant women accepted in principle being screened for HIV. 91% of these women would want to know the results of the screening. 46.5% preferred being informed of the results in the presence of a family member. 64% of the women wanting a family member to be present did not want the family member to be their husband, partner, or the child's father. 60% of the women who wanted the family member to be their partner were not sure he could keep the secret. 68% thought that their partner would reject them. Seven of the eight key informants perceived HIV screening as achieving assurance of clinical management of HIV-infected patients and limiting HIV transmission. Four key informants were in favor of HIV screening only as long as there the patients has given informed consent. One of the midwives opposed HIV screening in the absence of available treatment. Four key informants thought that the presence of a family member during counseling would be worthwhile and would promote a sense of partnership. Difficulties associated with informing patients of the results of the HIV test included absence of treatment, cost of the test, lack of confidentiality, psychosocial consequences, the reaction (e.g., fear) of the patient, and difficulties related to communication and with changing behavior. These findings serve as a basis for developing a local and national consensus about HIV testing and counseling for pregnant women.

[The reduction of mother-child transmission of HIV infection in developing countries: potential intervention strategies, obstacles to implementation and perspectives. The Reduction of Mother-Child Transmission of HIV Infection in Africa Group]. / Réduction de la transmission mère-enfant du VIH dans les pays en développement: stratégies d'intervention disponsibles, obstacles à leur mise en oeuvre et perspectives. Groupe DITRAME.

Mother to child transmission (MCT) of Human Immunodeficiency Virus (HIV) is the main cause of the spread of the HIV epidemic in the pediatric population. It is estimated that to date, three million children worldwide have been infected by HIV. The epidemic burden in developing countries is dramatic. Ninety-five percent of the world's HIV-infected women are living in developing countries. In industrialized countries, antiretroviral treatment of pregnant women and newborns with azidothymidine (AZT, ACTG 076 regimen) and discouraging breast feeding by HIV-infected mothers are effectively reducing MCT of HIV. However, there are three major obstacles to the systematic application of these strategies in developing countries: (a) difficulties in implementing the complex AZT administration and its corollary the avoidance of breast feeding; (b) the complexity of the logistics of the ACTG 076 regimen; (c) cost. Indeed, in developing countries the socioeconomic situation of the populations are precarious and health structures and services are underdeveloped. In addition, the anxiety and the reluctance of general population in the face of the HIV problem and the high prevalence of maternal anemia reduce the acceptability and safety of AZT treatment for pregnant women in developing regions. Only interventions that are applicable, acceptable, safe, affordable, of low cost and integrated into health system will be able to reduce HIV MCT. We now know that MCT occurs mostly during the perinatal period and the maternal viral load in blood, in cervical secretions and in breast milk appears to be the main determinant of transmission. Maternal vitamin A deficiency may also favor MCT of HIV. It is however possible that this association is confounded by the relationship between advanced maternal HIV disease (a known risk factor for transmission) and vitamin A deficiency. In spite of these uncertainties concerning determinants of MCT of HIV, several interventions have been designed. The first involves treating the mother with antiretroviral drugs for the perinatal period. The second is vaginal disinfection by application of virucidal antiseptics during the perinatal period. The third is to give vitamin A supplements to pregnant women and children. Finally, passive immunotherapy with anti-HIV antibodies applied to pregnant women and/or new born, may be beneficial. The feasibility, safety and efficacy of these potential interventions have not yet been demonstrated in developing countries. In view of the dramatic spread of HIV infection in these countries, the evaluation of these interventions is of utmost priority. These trials are necessary because of the public health emergency but should be performed in strict respect of human rights and medical ethics.

[Maternal HIV infection and the anthropometric characteristics of children at birth in Burkina Faso. DITRAME Study Group]. / Infection maternelle par le VIH et paramètres anthropométriques de l'enfant à la naissance au Burkina Faso.

The aim of this study was to investigate the relationship between maternal HIV status and the anthropometric characteristics of children at birth. A cross-sectional study was conducted in Bobo-Dioulasso from January 1995 to May 1996. We included all mother-child pairs seen postpartum for whom the HIV status of the mother had been determined at an antenatal visit and anthropometric measurements had been taken for the child at birth. Birth weights below 2,500 g were classed as "low", body lengths of less than 47 cm at birth were described as "small birth size" and head circumferences of less than 33 cm were classed as "small". We included 956 mothers and 956 children in the survey. Low birth-weights were recorded more frequently among children born to HIV-infected mothers than among those born to uninfected mothers (23. 37% versus 15.6%; p = 0.006). Mean birth-weight, birth size and head circumference did not differ significantly between the children of HIV-infected and uninfected mothers. In multivariate analysis, HIV infection and primiparity were independently associated with low birth-weight. Maternal HIV infection was the only factor associated with small birth size. There was no relationship between head circumference and maternal HIV status. Thus, maternal HIV infection appears to be associated with low birth-weight and small birth size.

[HBs antigen carrier state in pregnant women in Bobo Dioulasso (Burkina Faso)]. / Portage de l'antigène HBs chez les femmes enceintes a Bobo-Dioulasso (Burkina Faso).

The aim of this study was to evaluate the prevalence rate and the risk factors for the carriage of hepatitis B markers in pregnant women in Bobo Dioulasso, Burkina Faso. Out of 917 pregnant women recruited during antenatal care, 98 (10.7%) were HBs antigen positive. Among these ones, 18.2% carded HBe antigen, 66.7% antiHBe antibodies and 95.6% antiHBc antibodies. Two risk factors were identified: maternal age of 23 and 28 (RR = 2.33, chi2 =12.21, p = 0.005) and widowage (Fisher test RR = 6.43, p = 0.0016). This high prevalence of HBs antigen calls for systematic screening for hepatitis B during antenatal care along with an immunization policy toward women of reproductive age and newborns.

Anaemia during pregnancy in Burkina Faso, west Africa, 1995-96: prevalence and associated factors. DITRAME Study Group.

We report the results of a cross-sectional study carried out in 1995-96 on anaemia in pregnant women who were attending two antenatal clinics in Bobo-Dioulasso, Burkina Faso, as part of a research programme including a clinical trial of zidovudine (ZDV) in pregnancy (ANRS 049 Clinical Trial). For women infected with human immunodeficiency virus (HIV) in Africa, anaemia is of particular concern when considering the use of ZDV to decrease mother-to-child transmission of HIV. The objectives were to determine the prevalence of and risk factors for maternal anaemia in the study population, and the effect of HIV infection on the severity of maternal anaemia. HIV counselling and testing were offered to all women, and haemograms were determined for those women who consented to serological testing. Haemoglobin (Hb) levels were available for 2308 of the 2667 women who accepted HIV testing. The prevalence of HIV infection was 9.7% (95% confidence interval (CI): 8.6-10.8%). The overall prevalence of anaemia during pregnancy (Hb level < 11 g/dl) was 66% (95% CI: 64-68%). The prevalence of mild (10 g/dl < or = Hb < 11 g/dl), moderate (7 g/dl < or = Hb < 10 g/dl) and severe (Hb < 7 g/dl) anaemia was 30.8%, 33.5% and 1.7%, respectively. The prevalence of anaemia was 78.4% in HIV-infected women versus 64.7% in HIV-seronegative women (P < 0.001). Although the relative risk of HIV-seropositivity increased with the severity of anaemia, no significant association was found between degree of anaemia and HIV serostatus among the study women with anaemia. Logistic regression analysis showed that anaemia was significantly and independently related to HIV infection, advanced gestational age, and low socioeconomic status. This study confirms the high prevalence of anaemia during pregnancy in Burkina Faso. Antenatal care in this population must include iron supplementation. Although HIV-infected women had a higher prevalence of anaemia, severe anaemia was infrequent, possibly because few women were in the advanced stage of HIV disease. A short course regimen of ZDV should be well tolerated in this population.

Living with HIV: women's experience in Burkina Faso, West Africa.

Our study aimed at studying HIV-infected women's experience with sharing serostatus with their partner and their group support. A survey was carried out among 79 seropositive women involved in a therapeutic trial in Bobo-Dioulasso, following freely consented prenatal HIV testing. The study revealed that women are reluctant to inform their partners and fear being stigmatized by relatives and friends. The major concern reported was health consequences and most women wished to receive care. The non-governmental organizations supporting people living with HIV were not known by these women, but providing this information raised a high interest and many women considered joining them soon and getting themselves involved. These community-based organizations, lead by qualified and highly motivated volunteers, could facilitate a better social integration of HIV infected women in Burkina Faso.

Seroprevalence of syphilis among women attending urban antenatal clinics in Burkina Faso, 1995-8. The DITRAME Study Group. DIminunation de la TRAnsmission Mère-Enfant.

OBJECTIVES: To describe annual trends in syphilis seroprevalence and to identify risk factors of syphilis among pregnant women receiving antenatal care in Bobo-Dioulasso, Burkina Faso. METHODS: Women were recruited between January 1995 and July 1998 in three antenatal clinics where counselling and HIV testing services had been established in the context of a trial evaluating a short course of zidovudine to reduce mother to child transmission of HIV (ANRS 049 trial). Sociodemographic variables were collected during HIV pretest counselling sessions. Syphilis diagnosis was considered when serum was positive with both rapid plasma reagin and Treponema pallidum haemagglutination assay (TPHA) tests. RESULTS: Overall, 10,980 pregnant women were screened. Syphilis seroprevalence was 0.24% (95% confidence interval (CI): 0.15-0.35) without changes over time. HIV prevalence was 8.8% (CI: 8.3-9.3). In a multivariable analysis, having casual sex partners (odds ratio (OR) = 4.48; CI: 1.62-12.38), being HIV seropositive (OR = 2.62; CI: 1.02-6.74), and being illiterate (OR = 3.78; CI: 1.24-11.48) were independent risk factors for syphilis infection. CONCLUSIONS: This study suggests low syphilis seroprevalence in this city of Burkina Faso. Sexually transmitted disease programmes should be reinforced to offer free access to syphilis screening and treatment in order to eliminate this disease, in coordination with HIV prevention and care.

Pattern of sexually transmitted diseases among pregnant women in Burkina Faso, west Africa: potential for a clinical management based on simple approaches.

OBJECTIVES: (1) To determine the prevalence of sexually transmitted diseases (STDs) in pregnant women in Burkina Faso. (2) To evaluate the potential of clinical management of STDs based on screening with clinical data and urine leucocyte esterase test (LET). METHODS: Cross sectional study among antenatal clinic attendees was conducted in 1994 in Ouagadougou and Bobo-Dioulasso, the two largest urban centres in Burkina Faso, where more than 94% of the pregnant women benefit from antenatal care at least twice during their pregnancy. Each woman selected underwent an interview, general and gynaecological examination. Genital samples were collected to confirm the presence of STD pathogens. Logistic regression analysis was done to identify models that predict (a) gonorrhoea and/or chlamydia, (b) trichomoniasis and/or bacterial vaginosis, (c) candidiasis. Sensitivity, specificity and positive and negative predictive values of these models were assessed using standard methods. RESULTS: All 645 consecutive pregnant women were enrolled in the two sites. Among these women 32.4% presented at least one STD. The major STDs were: trichomoniasis (14%), bacterial vaginosis (13%), recent syphilis (3.6%), chlamydial infection (3.1%), genital warts (3%), gonococcal infection (1.6%) and genital ulcer (0.8%). Prevalence of vaginal candidiasis was 14%. The use of a risk marker (length of relationship with regular sexual partner < 3 years), and the positivity +3 of the urine LET provided a sensitivity of 80% and a positive predictive value of 7% for the screening of gonococcal and/or chlamydial infection. If clinical signs and positivity of the urine LET were taken into account sensitivity and positive predictive value of trichomoniasis and/or bacterial vaginosis screening were 77% and 37%, respectively. Clinical signs and positivity of the urine LET showed a low sensitivity (23%) for screening vaginal candidiasis. CONCLUSIONS: The prevalence of STDs in pregnant women is high in urban Burkina Faso. Systematic screening combined with effective treatment should be included in antenatal care in the future. Urine LET, if associated with interview and clinical examination offers a simple, rapid and affordable tool for systematic screening of STDs in pregnant women. However, the proportion of overtreatments with proposed strategies will be high. Further studies are needed to develop and validate better algorithms with probably cheap laboratory tests.