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PubMed2001

Demographic surveillance and health equity in sub-Saharan Africa.

Accurate data are always needed to inform health policy, but are especially critical in tackling health inequities. The growing number of field research stations in sub-Saharan Africa are well-placed to generate relevant data and so support health policy action. Over the past 60 years, demographic surveillance systems have been crucial research tools for the evaluation of health interventions aimed at reducing socioeconomic differentials in mortality and morbidity in sub-Saharan Africa. The bulk of such work has been carried out by field research sites, often operating in remote, resource-constrained settings. The present paper reviews what we have learned since the pioneering work carried out in the field sites of Pholela (South Africa) and Niakhar (Senegal). It then focuses on current efforts to address health equity through INDEPTH, the international network of field sites with continuous demographic evaluation of population and their health in developing countries.

Africa South of the Sahara↗

PubMed2004

'You are a man because you have children': experiences, reproductive health knowledge and treatment-seeking behaviour among men suffering from couple infertility in South Africa.

BACKGROUND: In Africa, infertility traditionally has been viewed as a female problem. This study explores reproductive health knowledge, health-seeking behaviour and experiences related to involuntary childlessness in men suffering from couple infertility. METHODS: Twenty-seven men from a diverse cultural urban community in South Africa participated in in-depth interviews at the time of their first visit to an infertility clinic in a tertiary referral centre. RESULTS: Men had little knowledge about the physiology of human fertility, causes of infertility and modern treatment options. Awareness of male factor infertility was, however, high. Most men appeared involved in the health-seeking process. Men described their emotional reactions to childlessness and the impact of infertility on marital stability, and many reported that infertile men suffered from stigmatization, verbal abuse and loss of social status. CONCLUSIONS: These findings improve our understanding of the reproductive health needs of men suffering from couple infertility in Africa. This understanding is essential for the effective integration of male partners into modern infertility management. The need for appropriate counselling of men and, most particularly, for education of the community is recognized.

Community-Institutional Relations↗

PubMed2004

Childhood mortality among former Mozambican refugees and their hosts in rural South Africa.

BACKGROUND: It is important to monitor health differentials between population groups to understand how they are generated. Internationally displaced people represent one potentially disadvantaged group. We investigated differentials in mortality between children from former Mozambican refugee and host South African households in a rural sub-district in the north-east of South Africa. METHODS: Open prospective cohort of 30 276 children (80 462 person years of follow-up) followed from 1 January 1992 to 31 October 2000 in Limpopo Province, South Africa. Exposure and outcomes data came from the Agincourt Health and Demographic Surveillance System (DSS). RESULTS: There was no difference in infant mortality between children from former Mozambican refugee households and those from South African homes (adjusted rate ratio [RR] = 1.02, 95% CI: 0.79, 1.32), but mortality levels were higher among former Mozambican refugee children during the next 4 years (adjusted RR = 1.91, 95% CI: 1.50, 2.42). Increased mortality levels were also seen among children from larger households and whose mother died, while children born to mothers aged >40 years or with higher education were at lower risk. Measured maternal, household, and health service utilization characteristics could not explain the difference in mortality between children from former Mozambican refugee and South African households. Former Mozambican refugee children residing in refugee settlements had higher mortality rates than those residing in more established villages. CONCLUSIONS: This study demonstrates higher childhood, but not infant, mortality rates among children from former Mozambican refugee households compared with those from host South African households in rural South Africa. The lack of legal status and lower wealth of many former Mozambican refugees may partly explain this disparity.

Adolescent↗

PubMed1996

Phylogenetic analysis of GB virus C: comparison of isolates from Africa, North America, and Taiwan.

A group of flavi-like GB viruses (GBV-A, -B, and -C) has been discovered and partially characterized. Only GBV-C is found in humans. Nucleotide sequences of the putative helicase gene of the GBV-C genome were determined in 21 Taiwanese patients and compared with isolates from Africa and North America by phylogenetic analysis. The average similarities of Taiwanese isolates to those from West Africa, East Africa, Canada, and United States were 83%, 85%, 78%, and 82%, respectively. Phylogenetic analysis of the NS3 region showed that 81% of the Taiwanese isolates were more closely related to the East African isolate. GBV-C isolates from Taiwan could be classified into at least 3 groups. These data suggest that GBV-C isolates cloned from different geographic areas have genetic heterogeneity.

Africa↗

PubMed1998

Introducing quality assurance to health service delivery--some approaches from South Africa, Ghana and Kenya.

The following report combines the contributions of four health care professionals engaged in quality improvement activities in three different areas of Africa--Ghana in West Africa, Kenya in the East, and the Republic of South Africa. These reports provide current and vivid accounts of the impact of quality assurance and quality improvement activities on areas of change in each country's rapidly expanding health care system.

Delivery of Health Care↗

PubMed2005

Patient satisfaction with health care providers in South Africa: the influences of race and socioeconomic status.

OBJECTIVE: The first democratic government elected in South Africa in 1994 inherited huge inequalities in health status and health provision across all sections of the population. This study set out to assess, 4 years later, the influence of race and socioeconomic status (SES) on perceived quality of care from health care providers. DESIGN: A 1998 countrywide survey of 3820 households assessed many aspects of health care delivery, including levels of satisfaction with health care providers among different segments of South African society. RESULTS: Fifty-one percent (n = 1953) of the respondents had attended a primary care facility in the year preceding the interview and were retained in the analysis. Both race and SES were significant predictors of levels of satisfaction with the services of the health care provider, after adjusting for gender, age, and type of facility visited. White and high SES respondents were about 1.5 times more likely to report excellent service compared with Black and low SES respondents, respectively. CONCLUSION: In South Africa, race and SES are not synonymous and can no longer be considered reliable proxy indicators of one another. Each has distinct and significant but different degrees of association with client satisfaction. Any assessment of equity-driven health policy in South Africa should consider the impacts of both race and SES on client satisfaction as one of the indicators of success.

Adult↗

PubMed2003

Organophosphorus insecticides synergize pyrethroids in the resistant strain of cotton bollworm, Helicoverpa armigera (Hübner) (Lepidoptera: Noctuidae) from West Africa.

Helicoverpa armigera (Hübner) populations from West Africa recently developed resistance to pyrethroid insecticides through enhanced metabolism by mixed-function oxidases. The combination index method was used to study the synergism of pyrethroids by organophosphorus insecticides. Several mixtures of insecticides currently registered to control cotton pest complex in West Africa were tested, including: cypermethrin/ethion, cypermethrin/profenofos, deltamethrin/ triazophos, deltamethrin/chlorpyriphos, cyfluthrin/chlorpyriphos, and betacyfluthrin/chlorpyriphos. In the resistant strain, the organophosphorus insecticides significantly increased the toxicity of pyrethroids suppressing the resistance effect, either by additive or synergistic effects. Significant synergism was shown for the following mixtures: cypermethrin/ethion, deltamethrin/triazophos, and deltamethrin/chlorpyriphos. The use of synergism from these insecticide mixtures should prove to be an additional tool in the overall resistance management strategy because the pyrethroid resistance in H. armigera from West Africa is not yet stable, decreasing between cotton seasons and increasing with treatments. In absence of selection, the susceptibility of H. armigera to insecticides should be restored.

Africa, Western↗

PubMed2002

Africa: addressing growing threats to food security.

Africa remains the only region in the world where the number of hungry people will still be on the increase in 2020, and the number of malnourished children will have increased correspondingly. In this report I have acknowledged the general public policy trends across Africa in terms of macroeconomic policy reforms and political transitions. These welcome trends have to still produce stable nations and economies. Although economic development is the long-term solution to Africa's challenge on hunger and poverty, this will take time. And it follows therefore that African nations have to pursue policies and strategies that promote long-term growth while at the same time offering short-term safety nets for the poorest of the poor. The growth and development strategy will have at its core the need to increase significantly the levels of public-sector investment in agriculture and rural development and to give top priority to the commercialization of smallholder agriculture so as to increase productivity and competitiveness. But food security at the household level is ultimately a balance between availability and access, and in this regard governments need complementary food security policies that increase the probability of food access by the vulnerable groups.

Africa↗

PubMed2001

The acceptability of the female condom: perspectives of family planning providers in New York City, South Africa, and Nigeria.

This article seeks to fill the gap in female condom acceptability research by examining family planning (FP) providers' attitudes and experiences regarding the female condom in three countries (South Africa, the US, and Nigeria) to highlight providers' potential integral role in the introduction of the female condom. The case studies used data drawn from three independent projects, each of which was designed to study or to change FP providers' attitudes and practices in relation to the female condom. The case study for New York City used data from semistructured interviews with providers in one FP consortium in which no special female condom training had been undertaken. The data from South Africa were drawn from transcripts and observations of a female condom training program and from interviews conducted in preparation for the training. The Nigerian study used observations of client visits before and after providers were trained concerning the female condom. In New York City, providers were skeptical about the contraceptive efficacy of the female condom, with only 8 of 22 providers (36%) reporting they would recommend it as a primary contraceptive. In South Africa, providers who had practiced insertion of the female condom as part of their training expressed concern about its physical appearance and effects on sexual pleasure. However, they also saw the female condom as a tool to empower clients to increase their capacity for self-protection. Structured observations of providers' counseling interactions with clients following training indicated that Nigerian providers discussed the female condom with clients in 80% of the visits observed. Despite the lack of a uniform methodology, the three case studies illuminate various dimensions of FP providers' perceptions of the acceptability of the female condom. FP providers must be viewed as a critical factor in female condom acceptability, uptake, and continued use. Designing training programs and other interventions that address sources of provider resistance and enhance providers' skills in teaching female condom negotiation strategies may help to increase clients' use of the female condom.

Attitude of Health Personnel↗

PubMed2001

Kaposi's sarcoma in South Africa.

Kaposi's sarcoma was endemic in South Africa even before the advent of the human immunodeficiency virus (HIV). Between 1988 and 1996, the incidence of Kaposi's sarcoma in South Africa has risen at least threefold and continues to increase as the HIV epidemic grows. Research from South Africa has shown that infection with human herpesvirus 8 (HHV8) is associated with Kaposi's sarcoma but not with any other major cancer site or type. In addition, the risk of Kaposi's sarcoma increases with increasing antibody titer to HHV8, but, for a given titer, the risk is greater in HIV-seropositive compared with HIV-seronegative individuals. The age- and sex-standardized seroprevalence of HHV8 in black South African hospital patients was found to be slightly more than 30%; the seroprevalence of HHV8 increased with age and was similar in men and in women. The modes of transmission of HHV8 are yet to be fully elucidated. Limited evidence exists for sexual transmission in black South African adults, but mother-to-child and person-to-person transmission in childhood is also likely. Furthermore, the seroprevalence of HHV8 decreases with increasing levels of education and is lower in whites than in blacks, suggesting that factors associated with poverty may be important determinants of transmission. Future research should focus on risk factors for Kaposi's sarcoma in HHV8-infected individuals, on determinants and mode of transmission of HHV8, and on the elucidation of the effect of primary HHV8 infection in adults and in children.

Adult↗

PubMed1999

Variability and evolution of Kaposi's sarcoma-associated herpesvirus in Europe and Africa. International Collaborative Group.

OBJECTIVE: To study the evolution of Kaposi's sarcoma-associated herpesvirus (KSHV) or human herpesvirus type 8 in Europe and Africa. DESIGN AND METHODS: PCR and sequence analysis of the variable viral membrane glycoprotein gene K1 in 58 tumour and peripheral blood samples from patients with AIDS-related Kaposi's sarcoma (KS), 'classic' (HIV-negative) KS, transplant KS, Multicentric Castleman's Disease, other lymphoproliferative disorders, and healthy KSHV-infected individuals from the UK, Denmark, Sweden, Italy, Spain, Iceland, The Faroe Islands, Greece, The Gambia and Uganda. RESULTS: Three major groups of K1 sequences were found: A, B and C, as defined previously. The K1 gene has evolved, both within and between these three groups, under positive selection. KSHV group B strains predominate in Africa and are more distant from groups A and C, found in Europe, than A and C are from each other. Within group C two subgroups, C' and C", can be identified. Subgroup C" is more closely related to group A in a region of the K1 protein and appears to be phylogenetically close to the branchpoint between A and C. Group A and C strains are currently found in both HIV-1-infected and -uninfected Europeans, and were already present in Europe before the start of the AIDS epidemic. We found some examples of closely related K1 sequences in Italy and Denmark, but in general KSHV strains in Europe did not cluster geographically. CONCLUSION: KSHV strains in East and West Africa are closely related but phylogenetically distant from those in Europe. The two major KSHV groups in Europe are more closely related, with some strains adopting an intermediate phylogenetic position. In Europe, KSHV strains may have been disseminated at least several decades ago. Variability in the K1 region is driven by selection and does not correlate with different KSHV-related pathologies or geographic regions where clinically more aggressive HIV-negative KS ('endemic' KS) is more common.

AIDS-Related Opportunistic Infections↗

PubMed2000

Immune activation in africa is environmentally-driven and is associated with upregulation of CCR5. Italian-Ugandan AIDS Project.

BACKGROUND: HIV infection in Africa is associated with immune activation and a cytokine profile that stimulates CCR5 expression. We investigated whether this immune activation is environmentally driven; if a dominant expression of CCR5 could indeed be detected in African individuals; and if R5 HIV strains would be prevalent in this population. METHODS: Freshly drawn peripheral blood mononuclear cells from HIV-uninfected African and Italian individuals living in rural Africa, from HIV-uninfected Africans and Italians living in Italy, and from HIV-infected African and Italian patients were analysed. Determinations of HIV coreceptor-specific mRNAs and immunophenotype analyses were performed in all samples. Virological analyses included virus isolation and characterization of plasma neutralizing activity. FINDINGS: Results showed that: immune activation is detected both in Italian and African HIV-uninfected individuals living in Africa but not in African subjects living in Italy; CCR5-specific mRNA is augmented and the surface expression of CCR5 is increased in African compared with Italian residents (CXCR4-specific mRNA is comparable); R5-HIV strains are isolated prevalently from lymphocytes of African HIV-infected patients; and plasma neutralizing activity in HIV-infected African patients is mostly specific for R5 strains. CONCLUSIONS: Immune activation in African residents is environmentally driven and not genetically predetermined. This immune activation results in a skewing of the CCR5 : CXCR4 ratio which is associated with a prevalent isolation of R5 viruses. These data suggest that the selection of the predominant virus strain within the population could be influenced by an immunologically driven pattern of HIV co receptor expression.

Africa↗

PubMed2001

The fate of free male condoms distributed to the public in South Africa.

OBJECTIVES: Public sector male condom distribution in South Africa rose from six million in 1994 to 198 million in 1999 as part of the government's condom promotion efforts for HIV/AIDS prevention. This study investigates what happens to the condoms which are distributed free of charge by the South African Department of Health. METHODS: A prospective study was undertaken during 1998-1999 at 12 representative public health facilities. Five-hundred and fifty-four consecutive subjects leaving the facilities were recruited and followed-up for 5 weeks to ascertain the fate of the 8164 condoms they had procured. RESULTS: A total of 384 participants (69.3%) and their 5528 condoms (67.7%) were followed successfully. After 5 weeks, 43.7% of the condoms had been used or broken in sex, 21.8% had been given away, 8.5% had been lost or discarded, and 26.0% were still available for use. Increased rates of condom use by participants were associated with active (compared to passive) condom procurement. CONCLUSIONS: In light of the rapidly increasing number of free condoms being distributed by the public health service in South Africa, it is reassuring to note that wastage at 5 weeks is less than 10%. Extrapolating these data to the 198 million public sector condoms distributed in South Africa in 1999, at least 87 million condoms were used in sex. This methodology may be used to help evaluate the impact of existing condom distribution systems and the effectiveness of various condom promotion strategies.

Adolescent↗

PubMed2001

Initiating co-trimoxazole prophylaxis in HIV-infected patients in Africa: an evaluation of the provisional WHO/UNAIDS recommendations.

OBJECTIVE: To evaluate the proposed WHO/UNAIDS criteria for initiating co-trimoxazole prophylaxis in adult HIV-infected patients in Africa [WHO clinical stages 2--4 or CD4 count < 500 x 10(6) /l or total lymphocyte count (TLC) equivalent]. DESIGN: Observational cohort study of 5-year follow-up. SETTING: Adult HIV clinics, University of Cape Town, South Africa. METHODS: Effect of prophylactic low dose co-trimoxazole (480 mg per day or 960 mg three times per week) on survival and morbidity was assessed in patients stratified by WHO clinical stage, CD4 T-lymphocyte count or TLC. Patients receiving antiretroviral therapy were excluded. RESULTS: Co-trimoxazole reduced mortality [adjusted hazard ratio (AHR), 0.56; 95% confidence interval (CI), 0.33--0.85; P > 0.001] and the incidence of severe HIV-related illnesses (AHR, 0.52; 95% CI, 0.38--0.68; P < 0.001) in patients with evidence of advanced immune suppression on clinical (WHO stages 3 and 4) or laboratory assessment (TLC < 1250 x 10(6)/l or CD4 count < 200 x 10(6)/l). No significant evidence of efficacy was found in patients with WHO stage 2 or CD4 count 200--500 x 10(6)/l/TLC 1250--2000 x 10(6)/l. If we had applied the WHO/UNAIDS recommendations 88.3% of our patients would have received co-trimoxazole prophylaxis at their initial clinic visit. CONCLUSION: Co-trimoxazole in HIV-infected adults from an area in which Pneumocystis carinii pneumonia is uncommon demonstrated a survival benefit consistent with previous randomized trials. Further studies are needed to assess the optimal time of commencement of prophylaxis, as widespread co-trimoxazole use will lead to increasing antimicrobial resistance to other major pathogens in Africa.

AIDS-Related Opportunistic Infections↗

PubMed2004

The cost of HIV/AIDS to businesses in southern Africa.

BACKGROUND: Information on the potential costs of HIV/AIDS to the private sector is needed if companies are to be given a financial incentive to invest in prevention and treatment interventions. OBJECTIVES: To estimate the cost of HIV/AIDS to businesses in southern Africa using company-specific data on employees, costs, and HIV prevalence. METHODS: : Six formal sector enterprises in South Africa and Botswana provided detailed human resource, financial, and medical data and carried out voluntary, anonymous HIV seroprevalence surveys. The present value of incident HIV infections with a 9-year median survival and 7% real discount rate was estimated. Costs included were sick leave; productivity loss; supervisory time; retirement, death, disability, and medical benefits; and recruitment and training of replacement workers. RESULTS: HIV prevalence in the workforces studied ranged from 7.9 to 25.0%. HIV/AIDS among employees added 0.4-5.9% to the companies' annual salary and wage bills. The present value of an incident HIV infection ranged from 0.5 to 3.6 times the annual salary of the affected worker. Costs varied widely across firms and among job levels within firms. Key reasons for the differences included HIV prevalence, levels and stability of employee benefits, and the contractual status of unskilled workers. Some costs were omitted from the analysis because of lack of data, and results should be regarded as quite conservative. CONCLUSIONS: AIDS is causing labor costs for businesses in southern Africa to rise and threatens the competitiveness of African industry. Research on the effectiveness of workplace interventions is urgently needed.

Botswana↗

PubMed2000

Spondyloarthropathies in sub-Saharan Africa.

HLA-B27 is virtually absent in most of the sub-Saharan Africa populations, and ankylosing spondylitis is rare; only a few patients have been reported from central and southern Africa. HLA-B27 was present in only one of 17 patients (6%). The disease shows clinical features that are similar to those observed in white HLA-B27-negative patients with ankylosing spondylitis; ie, the disease onset is later compared with HLAB27-positive patients, the patients rarely get acute anterior uveitis as one of the extra-articular manifestations, and familial occurrence of ankylosing spondylitis is rarely observed. There is a virtual absence of ankylosing spondylitis even in the west African countries of Gambia and Senegal, where 3% to 6% of the general population has HLA-B27. The epidemic of HIV infection in sub-Saharan Africa in recent years, however, has been associated with a dramatic upsurge in the prevalence of spondyloarthropathies other than ankylosing spondylitis, primarily reactive arthritis and undifferentiated forms of the disease, and less often psoriatic arthritis. HLA-B27, because of its rarity and virtual lack of association with the observed cases of spondyloarthropathy in this population, cannot be used as an aid to diagnosis of spondyloarthropathy in black Africans. Conversely, HIV infection is increasingly showing such a strong association with reactive arthritis, psoriatic arthritis, and undifferentiated spondyloarthropathies in sub-Saharan African populations that any patient with acute or chronic inflammatory arthritis may need to be tested for possible HIV infection. More research is needed on the evaluation of risk and protective factors in sub-Saharan African populations to better delineate the relative importance of genetic and environmental factors in the pathogenesis of spondyloarthropathies.

AIDS-Related Opportunistic Infections↗

PubMed2000

Effect of human immunodeficiency virus infection on episodes of diarrhea among children in South Africa.

BACKGROUND: Infection with HIV is increasing among children in South Africa. Diarrhea is a common cause of morbidity and mortality in Africa, and some studies have shown that HIV-infected children have episodes of severe diarrhea with higher mortality than HIV-uninfected children. OBJECTIVES: To compare the severity, pathogens and outcome of diarrhea in HIV-infected and uninfected children. METHODS: We studied 181 children ages 3 months to 4 years admitted for gastroenteritis to the Chris Hani Baragwanath Hospital in Soweto, South Africa. Demographic details of the children were recorded, as were the details of the episode of diarrhea. Stools specimens were collected and sent for microbiologic evaluation. The clinical course of the child's admission was recorded. Children were diagnosed as being infected with HIV if they tested positive by HIV enzyme-linked immunosorbent assay (ELISA) and were >15 months of age, or if they were ELISA-positive, were < 15 months of age and had clinical signs of HIV infection. RESULTS: Of the 176 children with an HIV ELISA result, 31 (17.6%) were classified as HIV-infected. More HIV-infected children were malnourished (80.6% vs. 39.5%, P < 0.001) and more likely to have had prolonged diarrhea (16.1% vs. 5.9%, P = 0.07) compared with HIV-uninfected children. HIV-infected children had a higher rate of a codiagnosis of pneumonia (43.3% vs. 9.2%, P < 0.0001) and were more likely to require a hospital stay of >4 days (prevalence odds ratio, 5.11; 95% confidence interval, CI 1.49 to 17.52). There were no significant differences in stool pathogens or in the level of dehydration on admission between the HIV-infected and uninfected children. CONCLUSION: HIV-infected children have the same spectrum of enteric pathogens as uninfected children but require more attention because of malnutrition and comorbidity.

Breast Feeding↗

PubMed2002

Prevalence of HIV among truck drivers visiting sex workers in KwaZulu-Natal, South Africa.

BACKGROUND: Although the role of mobile populations in the spread of HIV has been documented in several countries, there are few data on HIV among truck drivers in South Africa and the sex workers with whom they interact. GOAL: To determine HIV prevalence and risk behavior in a sample of truck drivers visiting commercial sex workers at truck stops. STUDY DESIGN: Two sex workers from each of five truck stops were trained to obtain informed consent, administer questionnaires to obtain data on demographic and migration patterns, and collect saliva samples for HIV testing from their clients. Data on HIV prevalence and demographic characteristics of sex workers operating at the truck stops were obtained from an ongoing vaginal microbicide trial. RESULTS: The mean age of the truck drivers (all men) was 37 years (range, 18-71 years), and that of the sex workers (all females) was 25 years (range, 15-49 years). Sixty-six percent of the men reported having a sexually transmitted infection in the previous six months, and 37% always stopped for sex along the route. Twenty-nine percent reported never using condoms with sex workers, whereas 13% had used condoms with their wives. All men traveled to more than one province in South Africa, and 65% traveled to neighboring countries. Anal sex was practiced by 42% of the men. The overall HIV prevalence (in the two groups combined) was 56%. CONCLUSION: Truck drivers may have facilitated the spread of HIV infection throughout southern Africa.

Adolescent↗