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C F Gilks

Publications and source records attributed to C F Gilks.

At least 19 recordsLinked to original sources
PubMed2002

Are intestinal helminths a risk factor for non-typhoidal Salmonella bacteraemia in adults in Africa who are seropositive for HIV? A case-control study.

In Africa, invasive, non-typhoidal Salmonella (NTS) infections are a common but life-threatening complication in adults who are seropositive for HIV. The high prevalence of human infection with intestinal helminths which penetrate the gut could explain the greater importance of NTS bacteraemia in Africa compared with that in industrialized countries. If helminth infection is a major risk factor for NTS it would provide a locally relevant, public-health target. Intestinal helminth carriage in 57 HIV-positive patients with NTS bacteraemia (the cases) was compared with that in 162 HIV-positive controls who were similar to the cases in terms of age, sex, urban dwelling and socio-economic factors. The prevalence of helminth infection, 29% overall, was lower among the cases (18%) than among the controls (33%), giving a crude odds ratio of 0.40 [with a 95% confidence interval (CI) of 0.21-0.9] and an adjusted odds ratio (aOR) of 0.79 (CI = 0.4-1.8). Five (9%) of the cases and 12 (7%) of the controls were infected with nematodes which penetrate the gut (Ascaris lumbricoides and/or Strongyloides stercoralis). The aOR for infection with these penetrating worms, corrected for age, sex, urban dwelling and phase of study, was 1.40 (CI = 0.4-4.5). The present results do not exclude the possibility that helminths play a role in invasive NTS infections, but are not consistent with helminths being a sufficient risk factor in this population to be a public-health target. Anthelmintics are unlikely to have a major impact on preventing NTS bacteraemia in patients diagnosed HIV-positive in Africa.

AIDS-Related Opportunistic Infections↗
PubMed2002

Quality assessment of sputum transportation, smear preparation and AFB microscopy in a rural district in Malawi.

SETTING: Ntcheu District, Central Region of Malawi. OBJECTIVES: To assess 1) the feasibility of introducing simple internal quality control procedures for acid-fast bacilli (AFB) microscopy, and 2) the quality of the district sputum smear microscopy service. DESIGN: A simple internal quality control system was piloted in which district laboratory staff assessed: 1) specimen suitability, 2) time between sputum submission and smear examination, 3) smear preparation and staining, and 4) microscopy. Actual times for processing specimens were compared with recommended times. External quality validation was carried out. RESULTS: Of 4805 sputum specimens: 1) documentation was complete in 95%, 2) 93% reached the laboratory within 7 days of collection, 3) 96% of smears were well prepared and stained, and 4) 97% concordance (96.4% smear-positive and 97.6% smear-negative) was demonstrated when 208 smears were re-examined by a second technician. The aggregate index of reliability was 86%. The mean time spent on microscopic examination was 3.8 minutes, compared with the recommended time of 10 minutes. When all smears from 164 patients were assessed externally, 98.2% concordance (98.1% smear-positive and 98.2% smear-negative) was demonstrated. False smear-negative and smear-positive rates were less than 2% each. CONCLUSION: District laboratory staff were able to incorporate simple quality control procedures for AFB microscopy into their routine practice, resulting in a reliable service. The lessons learnt are widely relevant and potentially useful for implementation of a national quality assurance scheme.

Chi-Square Distribution↗
PubMed2001

Trends in bloodstream infections among human immunodeficiency virus-infected adults admitted to a hospital in Nairobi, Kenya, during the last decade.

Bloodstream infections are a frequent complication in human immunodeficiency virus (HIV)-infected adults in Africa and usually associated with a poor prognosis. We evaluated bloodstream infections across a decade in 3 prospective cross-sectional surveys of consecutive medical admissions to the Kenyatta National Hospital, Nairobi, Kenya. Participants received standard clinical care throughout. In 1988-1989, 29.5% (28 of 95) of HIV-positive patients had bloodstream infections, compared with 31.9% (46 of 144) in 1992 and 21.3% (43 of 197) in 1997. Bacteremia and mycobacteremia were significantly associated with HIV infection. Infections with Mycobacterium tuberculosis, non-typhi species of Salmonella (NTS), and Streptococcus pneumoniae predominated. Fungemia exclusively due to Cryptococcus neoformans was uncommon. Clinical features at presentation remained similar. Significant improvements in the survival rate were recorded among patients with NTS bacteremia (20%-83%; P<.01) and mycobacteremia (0%-73%; P<.01). Standard clinical management can improve outcomes in resource-poor settings.

AIDS-Related Opportunistic Infections↗
PubMed2001

Increasing rates of malarial fever with deteriorating immune status in HIV-1-infected Ugandan adults.

BACKGROUND: Falciparum malaria and HIV-1 infection are two of the most important health problems facing sub-Saharan Africa. No convincing evidence of an association between symptomatic malaria and HIV-1 infection has been found. OBJECTIVE: To investigate the effect of HIV-associated immunosuppression on malarial fever rates. DESIGN: An observational cohort study in HIV-specific, primary healthcare clinics in Entebbe, Uganda, on 1371 HIV-1-infected adults participating in a randomized trial of 23-valent pneumococcal vaccine. METHODS: Cohort members underwent routine 6 monthly surveillance and had open clinic access when sick. Episodes of fever were assessed according to standardized protocols. Rates of malaria are described according to HIV immune status determined by CD4 T cell counts. RESULTS: Incidence rates of Plasmodium falciparum malarial fever showed a marked inverse relationship with CD4 T cell count; 140, 93 and 57 cases per 1000 pyo for CD4 T cell groups < 200, 200--499 and > 500 respectively, P < 0.001. Malarial fever definitions incorporating parasite density criteria (derived from asymptomatic surveillance) to correct for chance findings of fever and P. falciparum parasitaemia, did not affect the association of incidence rates with immunosuppression. CONCLUSION: These data support an interaction between symptomatic P. falciparum and HIV. Emphasis on mosquito avoidance measures should be an important component of education and counselling of HIV/AIDS patients in malaria-endemic areas, and suggests an additional HIV-related public health problem in Africa.

AIDS-Related Opportunistic Infections↗
PubMed2001

HIV care in non-industrialised countries.

The HIV/AIDS epidemic is now most rapidly expanding in the non-industrialised world. As more and more poor people fall sick and die prematurely, the issue of care for the HIV-infected person living in a resource-poor country is of paramount importance. Rational and comprehensive care packages need to be based on proper understanding of the natural history of infection and accurate measurement of the HIV/AIDS disease burden. In the early stages of infection, disease progression is the same in non-industrialised nations as it is in industrialised countries. Once virulent diseases start, survival is short largely because of limited access to inadequate health care. Therefore, early HIV-related disease, as well as AIDS, are targets for care. Needs are diverse but can be considered as more of the same (e.g. to cope with additional cases of TB generated by HIV) and those new services such as voluntary counselling and testing and palliative care. Budgets are limited everywhere, but prioritisation can be promoted through drawing up a hierarchy of care needs. Specific HIV/AIDS services and the provision of anti-retroviral therapy come after basic services are implemented. Affordable ways to use disease-modifying drugs need to be pursued that are relevant to non-industrialised countries and which do not promote AIDS exceptionalism.

Developing Countries↗
PubMed2001

Pulmonary disease in HIV-infected African children.

Childhood human immunodeficiency virus (HIV) infection is common in most regions of sub-Saharan Africa. Acute and chronic respiratory diseases are major causes of morbidity and mortality in HIV-infected children. They represent a significant added burden in a region where diagnostic capabilities are limited and management decisions are often made on the basis of clinical guidelines alone. Pneumocystis carinii pneumonia is now recognised as an important cause of acute severe pneumonia and death in HIV-infected infants. However, there are few data on incidence and aetiology for more treatable conditions such as bacterial pneumonia. The association of pulmonary tuberculosis and HIV infection is uncertain, and the diagnosis is further confused by the presence of lymphoid interstitial pneumonitis and other chronic HIV-related pulmonary disease. This article reviews the literature and highlights the urgent need for further research in order to improve clinical management and appropriate interventions.

AIDS-Related Opportunistic Infections↗
PubMed2000

The changing impact of HIV/AIDS on Kenyatta National Hospital, Nairobi from 1988/89 through 1992 to 1997.

OBJECTIVE: Consequences of the growing HIV/AIDS epidemic for health services in sub-Saharan Africa remain poorly defined. Longitudinal data from the same centre are scarce. We aimed to describe the impact of a rapidly rising HIV/AIDS disease burden on an urban hospital over the last decade. DESIGN AND SETTING: Cross-sectional observational study in 1997, compared to similar data from 1988/89 and 1992. The study was carried out in the Kenyatta National Hospital, Nairobi, Kenya. METHOD: Consecutive adult medical patients were enrolled on admission and then followed up until death or discharge. The main outcome measures were clinical stage, HIV status, bacteraemia, length of stay, bed occupancy, final diagnosis and outcome of hospital admission. RESULTS: In 1997, 518 patients, 493 with HIV serology, were enrolled: HIV prevalence was 40.0%, bed occupancy 190%, the mean length of stay 9.5 days (SD 12) and overall mortality 18.5%. The mean number of HIV-positive admissions per day steadily rose from 4.3 [95% confidence interval (CI), 0.6] patients in 1988/89, through 9.6 (95% CI, 1.4) in 1992, to 13.1 (95% CI, 2.8) or 13.9 adjusted for those enrolled without HIV serology in 1997. In contrast the mean number admitted with clinical AIDS, 1.7 in 1988/89 and 3.3 in 1992, fell to 2.6 cases per day in 1997. With HIV-negative admissions increasing by 37% and bed occupancy nearly doubling in 1997, HIV prevalence appeared to be stabilizing (19 then 39 and 40% respectively). Over time fewer HIV-infected patients were bacteraemic (26, 24 and 14%; P < 0.01); had clinical AIDS (39, 34 and 24% respectively; P < 0.01); or died (36, 35 and 22.6%; P < 0.02). HIV-negative mortality, 14% in 1988/89, rose to 23% in 1992 but fell to 15% in 1997. The mean length of hospital stay (9.5-10 days) did not differ according to HIV status nor did it change across the decade. CONCLUSION: The HIV/AIDS disease burden in Kenyatta National Hospital medical wards has risen inexorably over the last decade. Most recently, the number of HIV-uninfected patients has also risen, leading to bed occupancy figures of 190%. Despite overcrowding and irrespective of HIV status, in-patient mortality has fallen. Time trends suggest fewer clinical AIDS patients are presenting for hospital care, implying a rising community burden of chronic HIV/AIDS disease. Although widely predicted, it is not inevitable that medical services in urban African hospitals dealing with large volumes of HIV/AIDS disease, will collapse or become overwhelmed with chronic, end-stage disease and death.

Adult↗
PubMed2000

23-valent pneumococcal polysaccharide vaccine in HIV-1-infected Ugandan adults: double-blind, randomised and placebo controlled trial.

BACKGROUND: Infection with Streptococcus pneumoniae is a frequent and serious problem for HIV-immunosuppressed adults. Vaccination is recommended in the USA and Europe, but there are no prospective data that show vaccine efficacy. METHODS: 1392 (937 female) HIV-1-infected adults in Entebbe, Uganda, were enrolled. 697 received 23-valent pneumococcal polysaccharide vaccine and 695 received placebo. The primary endpoint was first event invasive pneumococcal disease. Secondary endpoints included vaccine serogroup-specific invasive disease, all (probable and definite) pneumococcal events, all-cause pneumonia, and death. FINDINGS: First invasive events occurred in 25 individuals (24 bacteraemias, one pyomyositis), 15 in the vaccine arm and ten in the placebo arm (hazard ratio [HR] 1.47; 95% CI 0.7-3.3). 22 isolates (88%) were of vaccine-specific serogroups with 15 events in the vaccine arm compared with seven in the placebo arm (HR 2.10; 0.9-5.2). All pneumococcal events had a similar distribution (20 vs 14; HR 1.41; 0.7-2.8) though all-cause pneumonia was significantly more frequent in the vaccine arm (40 vs 21; HR 1.89; 1.1-3.2). Mortality was unaffected by vaccination. INTERPRETATION: 23-valent pneumococcal polysaccharide vaccination is ineffective in HIV-1-infected Ugandan adults and probably has little, or no, public health value elsewhere in sub-Saharan Africa. Increased rates of pneumococcal disease in vaccine recipients may necessitate a reappraisal of this intervention in other settings.

AIDS-Related Opportunistic Infections↗
PubMed2000

Rhodococcus equi and HIV-1 infection in Uganda.

OBJECTIVES: To describe three cases of Rhodococcus equi infection in a cohort of HIV-1 infected adults in Entebbe, Uganda and to compare this to the rates and presentation of tuberculosis in this cohort. METHODS: Consecutive HIV-1 infected adults registering with a community HIV/AIDS clinic in Entebbe were enrolled in a cohort between October 1995 and June 1998 as part of an intervention trial of pneumococcal polysaccharide vaccine. Participants were routinely reviewed every 6 months and had open access to the clinic when unwell. Standard protocols were followed for investigation and management of illness. Microbiological investigations followed standard procedures. RESULTS: 1372 (71% female) study participants were followed for 2141 person years of observation (pyo). Rhodococcus equi was isolated from three study participants from blood, a lymph node aspirate and stool. The individuals were undergoing investigation of acute pneumonia, acute cough with cervical lymphadenopathy and chronic fever with wasting, respectively. The clinical features of these cases are described. All had a CD4 T-cell count of <300/ml. The rate of R. equi infection in the cohort was 1.4/1000 pyo. There were 132 cases of pulmonary and extrapulmonary tuberculosis in the cohort which were diagnosed either microbiologically or clinically. The rate of laboratory confirmed mycobacterial disease was 50.1/1000 pyo. The ratio of mycobacterial disease to R. equi disease was 36:1 (95% CI 11-113:1). CONCLUSIONS: Rhodococcus equi infection occurs in HIV-1 infected adults in Africa. The infection is clinically indistinguishable from pulmonary and extra-pulmonary tuberculosis in the cohort described here. Although the rate of R. equi disease is much less than that of tuberculosis, it is important to consider it in the differential diagnosis of tuberculous infection in cases which are smear negative. Rhodococcus equi infection is probably underdiagnosed in Africa due to a lack of microbiological facilities and its resemblance to common commensal organisms.

AIDS-Related Opportunistic Infections↗
PubMed2000

Paediatric HIV infection in a rural South African district hospital.

The objective of this study was to determine the prevalence, clinical spectrum, and outcome of paediatric HIV infection in 281 consecutive children admitted to hospital in rural South Africa between October 1996 and January 1997. HIV infection was defined as two positive ELISAs in those aged > 12 months; a positive ELISA plus a positive IgG3 in those aged 6-12 months; and a positive ELISA plus positive p24 antigen or PCR in those aged 0-5 months. In all, 72 (26 per cent) children were HIV infected. Age-specific HIV prevalence was at least 25 per cent in all 1-5 year age groups. HIV-infected children were more likely to have been previously admitted (46 per cent vs. 23 per cent; p = 0.0002), and were more likely to have severe malnutrition (52 per cent vs. 17 per cent; p < 0.0001). Both HIV-infected and HIV-uninfected most frequently presented with diarrhoeal disease (51 per cent vs. 32 per cent), acute respiratory infection (13 per cent vs. 23 per cent), and malnutrition (18 per cent vs. 11 per cent). Satisfactory response to antibiotic therapy was less likely among the HIV-infected (56 per cent vs. 73 per cent; p = 0.02), and mortality was higher among the HIV-infected (21 per cent vs. 7 per cent; p = 0.005). It is concluded that HIV-infected children present with disease syndromes common to this setting, but do so more frequently and with worse outcome than their uninfected counterparts. The high burden of paediatric HIV disease in this setting poses a substantial challenge for health resources.

Analysis of Variance↗
PubMed2000

Trial-of-antibiotic algorithm for the diagnosis of tuberculosis in a district hospital in a developing country with high HIV prevalence.

OBJECTIVE: To evaluate a diagnostic algorithm for pulmonary tuberculosis based on smear microscopy and objective response to trial of antibiotics. SETTING: Adult medical wards, Hlabisa Hospital, South Africa, 1996-1997. METHODS: Adults with chronic chest symptoms and abnormal chest X-ray had sputum examined for Ziehl-Neelsen stained acid-fast bacilli by light microscopy. Those with negative smears were treated with amoxycillin for 5 days and assessed. Those who had not improved were treated with erythromycin for 5 days and reassessed. Response was compared with mycobacterial culture. RESULTS: Of 280 suspects who completed the diagnostic pathway, 160 (57%) had a positive smear, 46 (17%) responded to amoxycillin, 34 (12%) responded to erythromycin and 40 (14%) were treated as smear-negative tuberculosis. The sensitivity (89%) and specificity (84%) of the full algorithm for culture-positive tuberculosis were high. However, 11 patients (positive predictive value [PPV] 95%) were incorrectly diagnosed with tuberculosis, and 24 cases of tuberculosis (negative predictive value [NPV] 70%) were not identified. NPV improved to 75% when anaemia was included as a predictor. Algorithm performance was independent of human immunodeficiency virus status. CONCLUSION: Sputum smear microscopy plus trial of antibiotic algorithm among a selected group of tuberculosis suspects may increase diagnostic accuracy in district hospitals in developing countries.

AIDS-Related Opportunistic Infections↗
PubMed2000

National and provincial estimated costs and cost effectiveness of a programme to reduce mother-to-child HIV transmission in South Africa.

OBJECTIVE: To estimate the cost and cost effectiveness nationally and for each province of a programme to reduce mother-to-child transmission (MTCT) of HIV in South Africa. METHODS: A model developed to estimate cost and cost effectiveness of interventions in Hlabisa, KwaZulu-Natal, was modified and applied to each province. This model predicts a 37% reduction in paediatric HIV infections if short-course oral zidovudine (ZDV) plus infant formula feed for 4 months is provided within a strengthened health system. Estimates of the number of pregnancies and HIV prevalence among pregnant women per province in 1997 were combined with an estimated 30% MTCT rate. Costs were calculated from a health system perspective, and effectiveness was estimated as cost per infection averted and cost per disability-adjusted life year (DALY) gained. RESULTS: In 1997, 63,397 paediatric HIV infections were estimated to have occurred in South Africa, mainly in KwaZulu-Natal (18,513, 29%) and Gauteng (10,417, 16%). The cost of a national programme is estimated at R155.9 million (1997 rand costs, 0.94% of the national health budget). Major cost items are drugs (R46.4 m, 30%), staff salaries (R45.8 m, 29%), and formula feed (R37.1 m, 24%). Most money would need to be spent in KwaZulu-Natal (R37.6 m, 24% of national cost), Gauteng (R25.2 m, 16%) and the Eastern Cape (R24 m, 15%). National cost per infection averted is R6,724, and R213 per DALY gained. Provincial DALY costs range from R176 to R369. CONCLUSIONS: A national programme preventing 37% of expected paediatric HIV infections would cost a small fraction of the national health budget, at a cost equivalent to R3.89 per capita total population. The cost per DALY gained compares well with established public health and clinical interventions in middle-income countries, even without factoring in the care costs that would be saved through a successful programme. Cost effectiveness is greatest where HIV prevalence is highest.

AIDS Serodiagnosis↗
PubMed1999

Immunologic and clinical stages in HIV-1-infected Ugandan adults are comparable and provide no evidence of rapid progression but poor survival with advanced disease.

Clear understanding of the natural history of HIV-1 disease is critical for planning and developing appropriate therapeutic strategies for HIV-1-infected populations in the developing world. Present knowledge about Africa is based on very limited data that largely use clinical staging as the prognostic marker; this approach has not been prospectively validated. Our objectives were to compare clinical staging and CD4+ T-cell counts as prognostic tools and to describe survival and cause of death in seroprevalent HIV-1-infected Ugandan adults by means of a prospective cohort study. Consecutive HIV-1-infected adults registering with a community HIV/AIDS clinic in Entebbe, Uganda were enrolled between October 1994 to January 1995 and observed during follow-up until the end of December 1997. Baseline CD4+ T-cell count distribution showed clear and appropriate associations with clinical stage in the 201 participants. Both provided equivalent prognostic information: median survival with CD4+ T-cell count <200 cells/microl was 9 months (95% confidence interval [CI], 7-15 months) compared with 19 and 7 months (95% CI, 10-28 and 0-8 months, respectively) in clinical stages 3 and 4, respectively; survival at 3 years with CD4+ T-cell count > or =200 cells/microl was 68% and for clinical stage 1 and 2, 80% and 60%, respectively. Clinical stage 3 and 4 were 76% sensitive and 65% specific for predicting a CD4+ T-cell count <200 cells/microl, positive predictive value of 56%, negative predictive value 78%. In all, 82 participants died (41%; mortality rate 216 of 1000 person-years) and was strongly associated with low CD4+ T-cell counts. In conclusion, clinical staging is valid and comparable with staging by CD4 T-cell counts for epidemiologic measurements. Mortality with early disease in Entebbe appears equivalent to that found in the developed world but there is poor survival with advanced disease.

Adolescent↗
PubMed1999

Admission trends in a rural South African hospital during the early years of the HIV epidemic.

CONTEXT: Few studies have attempted to quantify the effect of the epidemic of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) on demand for health care in developing countries. More data are required to improve understanding of its impact and to guide development of appropriate response strategies. OBJECTIVE: To assess the HIV/AIDS epidemic's impact on demand for inpatient hospital care in a rural area of South Africa. DESIGN: Retrospective analysis of data from general hospital and individual ward admission registers, a tuberculosis program database, and patient case notes. SETTING AND PATIENTS: Patients admitted between 1991 and 1998 to a 450-bed hospital that serves Hlabisa District, South Africa (population approximately 200000), where HIV seroprevalence among antenatal clinic attendees increased from 4% in 1992 to 29% in 1998. MAIN OUTCOME MEASURES: Number of admissions to 9 hospital wards, number of clinical AIDS and general medical admissions (both excluding tuberculosis), and number of tuberculosis admissions to adult medical wards during the study period. RESULTS: Total hospital admissions increased by 81%, from 6562 in 1991 to 11, 872 in 1998. Adult tuberculosis ward admissions increased by 360%, from 303 to 1393. In 1998, tuberculosis patients accounted for 47% and 30% of adult male and female medical ward admissions, respectively, and for 11 % of total hospital admissions. Nontuberculosis clinical AIDS cases increased 43-fold, accounting for 4% of adult medical admissions in 1997 vs 0.2% in 1991. Tuberculosis and nontuberculosis clinical AIDS cases were the only types of admission to show a clear and consistent upward trend over the period studied. Patterns in other types of admissions varied more and changes were smaller. CONCLUSIONS: The HIV/AIDS epidemic has had an important impact on demand for adult tuberculosis and general medical care in a rural South African district hospital. If this impact is shown to extend to other rural South African areas, response strategies are urgently needed.

Adult↗
PubMed1999

Prevalence of infection with human herpesvirus 8/Kaposi's sarcoma herpesvirus in rural South Africa.

OBJECTIVE: To determine prevalence of infection with human herpesvirus 8 (HHV-8)/Kaposi's sarcoma herpesvirus (KSHV) and to gain some insight into possible transmission dynamics of this novel virus in South Africa. METHODS: Stored, anonymous serum from 50 patients with a sexually transmitted disease (STD), 50 adult medical ward patients (25 male, 25 female), and 36 paediatric ward patients in Hlabisa Hospital, KwaZulu-Natal, was screened by enzyme-linked immunosorbent assay (ELISA) for antibodies to the small capsid-related protein encoded by HHV-8/KSHV orf65. Antibodies to the latency-associated nuclear antigen (LANA) were measured by immunofluorescence, and sera that were reactive in the ELISA but negative by immunofluorescence were re-tested by Western blot against the recombinant orf65 protein to exclude nonspecific reactivity. RESULTS: Overall, 47 patients tested positive (34.6%), 76 tested negative (55.9%) and 13 (9.5%) had indeterminate results. Among those with a definite result, prevalence was similar among males (47.2%) and females (52.8%) and increased in later adulthood (< 18 months 37.5%, 19-120 months 38.5%, 15-34 years 32.1%, 35-69 years 62.8%). Prevalence was highest among medical patients (58.1%); among those with an STD it was 31.1% (P = 0.01), and among children it was 22.8% (P = 0.001). When age-adjusted, prevalence among medical patients (23.7%) was similar to that among patients with an STD. CONCLUSION: Prevalence of HHV-8/KSHV is high in this setting and transmission appears to be occurring in childhood as well as among adults. Larger population-based studies are required to detail the transmission dynamics of HHSV-8/KSHV.

Adult↗
PubMed1998

Antiretroviral drugs as a public health intervention for pregnant HIV-infected women in rural South Africa: an issue of cost-effectiveness and capacity.

OBJECTIVE: To estimate cost-effectiveness and capacity requirements for providing antiretroviral drugs to pregnant HIV-infected women in rural South Africa. SETTING: Hlabisa health district, where HIV prevalence among pregnant women was 26.0% in 1997. METHODS: Calculation of the number of paediatric HIV infections averted under three scenarios, and their cost. No intervention was compared with scenario A (zidovudine delivered within current infrastructure), scenario B (zidovudine delivered through enhanced infrastructure), and scenario C (short-course zidovudine plus lamivudine delivered through enhanced infrastructure). Cost-effectiveness was defined as cost per infection averted and cost per potential life-year gained. Capacity was determined in terms of staff and infrastructure required to effectively implement the scenarios. RESULTS: With no intervention, 657 paediatric HIV infections were projected for 1997. In scenario A this could be reduced by 15% at a cost of US$ 574 825, in scenario B by 42% at US$ 1520770, and in scenario C by 47% at US$ 764901. In scenario C, drugs accounted for 76% of costs, whereas additional staff accounted for 18%. Cost per infection averted was US$ 2492 and cost per potential life-year gained (discounted at 3%) was US$ 88. Cost of scenario C was equivalent to 14% of the 1997 district health budget. At least 12 extra counsellors and nurses and one laboratory technician, together with substantial logistical and managerial support, would be needed to deliver an effective intervention. CONCLUSION: Although antiretrovirals may be relatively cost-effective in this setting, the budget required is currently unaffordable. Developing the capacity required to deliver the intervention would pose both a major challenge, and an opportunity, to improve health services.

Adult↗