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HIV/AIDS/STD in Africa a
D. Wilson & S. Lavelle
a
a
Department of Psychology , University of Zimbabwe , PO Box MP 167, Mount Pleasant, Harare, Zimbabwe Published online: 25 Sep 2007.
To cite this article: D. Wilson & S. Lavelle (1992) HIV/AIDS/STD in Africa, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:4, 438-443, DOI: 10.1080/09540129208253117 To link to this article: http://dx.doi.org/10.1080/09540129208253117
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
438 AMSTERDAM SUMMARIES
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Conclusion HIV and AIDS in Asia are characterized by common threads on the one hand and considerable diversity on the other. Weniger et al. (PoC4087) suggested that the four epidemic waves seen in Thailand may spread to nearby Asian countries, particularly India. Burma and parts of China. In Thailand, a first wave of HIV infection among male injecting drug users was quickly followed by a second among female prostitutes. The third wave occurred in the male clients of the prostitutes and the final, fourth wave in their wives. Potential factors that might explain this pattern are a high degree of needlesharing among injecting drug users, a high frequency of men going to prostitutes and the absence of premarital or extramarital sex among most women. Injecting drug use, on the other hand, accounted for a relatively small proportion of HIV diagnoses in Japan, Hong Kong, Singapore and Taiwan. Consequently, injecting drug use appears to have played a minor role in the spread of HIV infection in these countries to date. While HIV incidence and prevalence varied widely across the Asian region, nearly all countries reported an increasing number of diagnoses as a result of heterosexual contact. Although some successful interventions were reported, there were many communities where AIDS awareness appeared to be low, condom use was infrequent and needle sharing among drug users widespread. Clearly epidemiological surveillance needs to be strengthened in a number of countries and appropriate interventions for HIV prevention must be initiated urgently. Concerted action is required, with international support, to meet the challenge presented by HIV and AIDS in Asia. If the challenge is not taken up soon will we look back in years to come and ask whether too little was done, too late? J. ELFORD Senior Lecturer in Epidemiology, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia
HIV/AIDS/STD in Africa Introduction The deepening global economic crisis and worldwide contraction in health services, civil wars and other disasters, rampant HIV levels in eastern and southern Africa and unfolding epidemics in parts of West Africa, Asia and Latin America, contributed to a mood of gloom and resignation at the VIIIth International AIDS Conference/IIIrd World STD Congress. In this atmosphere, it would have been all too easy to disregard numerous incremental, but solid, advances, particularly in STD prevention. The AIDS and STD meetings merged felicitously: indeed, the entire conference underscored the importance of STD control as a firm, unifying foundation for coherent AIDS prevention activities.
Prevention A recent World Health Organization review of strategies for effective intervention emphasized the importance of community-level, interpersonal initiatives in AIDS prevention. Evidence presented from disparate regions strongly upheld this conclusion. Hays et al. (PoD5183) found that peer norms best predicted risk reduction among gay Californian men. Waibale et al. (PoC4836) monitored condom uptake in Ugandan bars during a four month mass media campaign, followed by interpersonal education. During the mass media campaign, 91% of supplied condoms were not taken. Within weeks of the interpersonal intervention, condom demand exceeded supply.
AMSTERDAM SUMMARIES
439
The case for interventions targeting individuals at heightened risk for STD was put forcibly by Over
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& Piot (PoD5405). When the effects over 10 years of preventing a single case of STD amongst the
most sexually active subset of the population and the larger population are compared, the former is estimated to prevent from 8.5 to 55 times as many subsequent infections. Such models support targeted interventions. However, Potts, Anderson & Boily (1 99 1) caution that targeted interventions are most effective early in an epidemic and that overemphasis on targeting in an established epidemic would omit large secondary risk groups. Moreover, comprehensive targeting of the most sexually active requires that they constitute identifiable, accessible and clearly delineated groups, a premise which may only be true for such conspicuous sub-groups as, say, prostitutes or truckers. The diverse concomitants of vulnerability were illustrated in Uganda by Konde-Lule et el. (PoC4019), who found that women, anyone aged 20-29, trading town residents, those with secondary education, ‘bargirls’, vendors and drivers, were at heightened risk for HIV. Thus, in highly affected areas, Wilson et al. (PoC4527, PoC4789, PoC4522, PoD5328, PoD5389, PoD5436) described programmes combining targeted with community-wide intervention, by training vulnerable individuals as educators and condom providers, initially to their immediate peers, then to the larger community. They presented evidence of the coverage, impact and economy of such combined interventions. For US$85,000, a multi-site intervention in six Zimbabwean sites inhabited by 1.5-2 million people, held 12,865 community meetings, attended by 1.03 million people and distributed 5.74 million condoms. This averages US$6.61 per meeting, US$0.08 per attenders reached face-to-face and US$O.Ol per condom distributed. These costs compared favourably to mass media or other public health interventions. In a random sample of 705 prostitutes in Bulawayo (population 1 million), 91% reported having seen peer educator’s uniforms, 80% had attended community AIDS meetings and 83% had been taught by a peer educator. Of these, over 90%1had received condoms from the project. The percentage reporting condom use with the last client rose from 18% before the program to 73% after 2 years. Reported condom use was strongly related to program exposure: 27% of those who had attended no meetings, 46% of those who had attended 1 meeting, 74% of those who had attended 2-4 meetings and 80% of those who had attended 5 or more meetings reported condom use with their last client. Condom social marketing, which relies on both media and interpersonal promotion and combines widespread coverage with some targeting (since most consumers tend to be men planning to have sex with casual partners), stands at the confluence of mass and focused approaches. It is an extraordinarily robust intervention, which has proven itself in the most diverse cultures and economies, irrespective of infrastructural considerations. Yoda et al. (PoD5 152) described a condom social marketing programme in Burkino Faso, one of the world’s poorest countries, in which 2.7 million condoms were sold in just four months, through 68 wholesalers and 800 retailers. Youth interventions, which are clearly a global priority, are frequently beset by objections that informing youth about sex and condoms encourages sexual activity. Yet a study of the Swiss Stop AIDS campaign reported that condom promotion had no effect upon sexual activity (Hausser, TuD0575). Barriers to HIV transmission other than the male condom are urgently needed. Among discordant couples in Zambia, Feldblum al. (WeC1085) reported that spermicide substantially reduced female HIV seroconversion. Several studies explored the possible protective effect of male circumcision. Salebe et al. (PoC4715) found no association between circumcision and HIV status in Tanzania. However, based on a study of gay US men, Kreiss et al. (PoC4091) estimated that up to 40% of homosexual HIV infections could be averted by circumcision. Among truckers in Kenya, uncircumcised men were 3.8 times as likely to be HIV+ (Bwayo et al., ThC1514). In a study of STD patients in Kenya, uncircumcised men were 5.4 times as likely to be H I V S 011 enrollment and 5.3 times as likely to become HIV+ during follow-up. This effect was independent of GUD history or positive chancroid culture (Tyndall et al., PoC4308). In Uganda, circumcised Muslims were 3.3 times and non-Muslims 1.9 times less likely to be HIV+. Islamic affiliation was unrelated to HIV status after controlling for circumcision. The effect of circumcision was independent of a history of genital sores (Hellmann et al., PoC4299). These data suggest that the biological effect of an inact foreskin is not expressed simply through increased ulceration susceptibility, but also through other mechanisms, including retention of HIV-infected
440
AMSTERDAM SUMMARIES
vaginal secretions in the nurturant milieu of the preputial sac. They also suggest that the behavioural characteristics of circumcised groups modify, but do not fully account for, the protective effect of circumcision. While widespread adult circumcision is daunting, several less intimidating strategies present themselves. Groups who practice circumcision after males become sexually active could be encouraged to begin circumcision earlier. Societies who practised circumcision until recently, including most South African groups, could be encouraged to revive the practice. Infant circumcision could be promoted. Circumcision could be offered to HIV-men in discordant relationships.
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Other STD Important work was presented in the broader domain of STD control. Hayes et al. (MoC0029) estimated, albeit controversially, that 20-40% of female HIV infection and 75-95% of male HIV infection in Africa was attributable to GUD. The pillars of comprehensive STD control include understanding of STD transmission dynamics in each context, intensified education to promote symptom suspicion, recognition nd treatment seeking, especially among women, improved case finding through, inter alia, screening in antenatal settings and partner notification, strengthened case management and improved STD counselling. Bradley et al. (ThC1557) interviewed 382 STD Kenyan STD patients and 380 controls. Seventynine percent of married male STD patients and 16% of married controls reported having extramarital sex in the past 3 months. Only 7% of married female STD patients and nearly 4% of married controls reported extramarital sex over the same period. Only 7% of married men, but almost 80% of married women believed they had contracted STD from their spouse. Thus, while Kenyan men and their casual partners acquire STD from each other, married women seem to contract STD from their spouses. Serological data from Zimbabwe tell a similar story. Latif et al. (1989) followed discordant couples for 18 months at a Zimbabwean referral hospital: in only two cases was a woman the index (in both cases, the women had received unscreened transfusions; moreover, one woman’s earlier husband had died of an unspecified viral illness). Several barriers to optimal health seeking behaviour were documented. In a study of STD patients in Kenya, Wanjala et al. (Poc4310) reported that 42% of men with GUD had sought treatment elsewhere (48% from other doctors, 46% from primary clinics and 6% from pharmacists, friends or vendors) before presenting at an STD clinic and that this treatment was almost entirely inappropriate. The mean period from symptom expression to presentation at an STD clinic was 17 days and 8% reported having sex while symptomatic. Moses et al. (PoC4295) reported that 30% of female STD patients at Kenyan health centres waited 2 or more weeks after symptom onset before presenting at a clinic and 24% reported having sex while symptomatic. Pattullo et al. (PoC4365) reported that 33% of Kenyan women presenting with GUD reported having had sex since the onset of symptoms. In these studies, reasons for delayed presentation included long waits (up to four hours for a 2 minute consultation), hostile treatment by health personnel, low confidence in the quality of care and, at times, unaffordability of transport or treatment. These studies illustrate how neglected STD education has been in AIDS and other health campaigns and underscore the importance of increasing symptom suspicion and treatment seeking on the part of patients and prompt, courteous, appropriate care on the part of the public, private and informal health sectors. Even without AIDS, S T D screening for antenatal women would be desirable. Hira et al. (PoC4323) described a Zambian syphilis screening programme, which began in 1983 and has been extended to 100% of urban and 40% of rural maternity centres, at an estimated cost of US$12 per adverse outcome averted. From 1983 to 1991, prenatal syphilis prevalence has approximately halved in selected centres. Holmes (session 83) described a case management package for developing countries combining behavioural risk assessment and algorithms for primarily syndromic management. Behavioural risk assessments warrant further examination, provided they an accommodate circumstances where women’s risk profile largely reflects their spouses’ behaviour. Grosskurth et al. (PoC4525) described a comprehensive, integrated S T D programme-encompassing training of health personnel, provision of drugs and STD education-in Mwanza, a region of 2 million people in Tanzania.
AMSTE~M
SUMMARIES 441
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Care and support
There were surprisingly few studies on care and support in Africa. Shepard et al. (PoD5505) costed AIDS care in 3 Rwandan hospitals. On averge, an AIDS patient would be hospitalized for 41 days, at a cost of US$358. In 1990, hospitalization of Rwanda’s 1849 confirmed hospitalized cases cost US$600,00, or 4.6% of Rwanda’s public sector hospital budget. This figure may exceed 11% by 1994. They concluded that improved care in district health centres and at home was urgently needed to reduce the burden on referral hospitals. In a study of the costs of caring for Ugandan AID patients, Kezaala et al. (PoD5498) estimated that each home care visits costs half as much as a hospital admission (US$5-7 versus US$12-13, respectively). They also noted that outreach care reinforced community prevention effots. Foster et al. (PoD5769) costed inpatient care at Monze District Hospital in Zambia. Mean treatment costs were US$41 for HIV- patients, US$22 for asymptomatic HIV+ patients and US$66 for AIDS patients. However, when treatment costs for AIDS patients were differentiated by T B status, they averaged US$132 for T B patients and US$39 for non-TB patients. T B accounted for 58% of the costs of treating AIDS in the hospital. They concluded that prevention, earlier diagnosis and better treatment of T B could substantially reduce the financial burden of AIDS in the hospital. Cost analyses provide support for community care, but sharply different evidence of the quality of community care emerged. Ankrah et al. (PoD5009) studied 24 rural Ugandan families of adults with AIDSs. They reported that families willingly absorbed infected members and provided devoted care. They noted, however, that the burden of care fell disproportionately on female family members. In contrast, Seeley et al. (MoD0071) noted that family support for AIDS patients in Uganda was frequently a myth. Of 17 women with AIDS, the mother was the only carer in 8 cases and a daughter the sole carer in 2 cases. In 6 cases, siblings and and parents shared care and in one case, the patient died alone. Of 13 men, 4 were cared for by a wife, 3 were cared for by their mother or a sister and 6 received care from other relatives. Of the 17 who died during the study, there were 7 cases where relatives refused to give help, citing poverty or other duties. However, in only one case did relatives withhold help for the funeral. Three patients’ medical records cited poverty or neglect as contributory to death. They concluded that the burden of care fell disproportionately on immediate relatives and strongly questioned the supposition that the extended family provides adequate support for AIDS patients.
Orphans
Mitigating the impact of AIDS on orphans in severely affected African countries is of the utmost importance. However, most orphan studies were descriptive and convincing models and mechanisms for ameliorative interventions are lacking. Several studies highlighted the scope of the problem. Mutembei et al. (PoD5162) reported that there were 49,000 orphans in the Kagera region of Tanzania. Kamali et al. (PoD5159) reported that 10% of a sample of 5,022 children in Masaka district in Uganda had lost one or both parents. During a one year cohort follow-up, the researchers identified 24 children orphaned after the death of a HIV+ parent and only two orphaned after the death of a HIV- parent, suggesting that HIV is largely responsible for the orphan problem. Foster et al. (PoD5158) surveyed 1781 children from 586 randomly selected households in Manicaland province, Zimbabwe. Nearly 7% of children under 15 had lost at least one parent and 53% of these deaths had occurred in the past 20 months, thus substantially implicating AIDS as the cause of death. There were no controlled comparisons of the nutritional, health, socioeconomic and psychological status of orphans, but impressionistic data suggested reduced quality of care. Three seems to be considerable agreement that extended families and communities should care for orphans, with support from social welfare organizations, but whether communities are able to do so, and what forms of support are needed, remains unclear. More than further descriptive studies, we urgently need multiple intervention models to guide our responses to the orphan crisis.
442
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NGOs Campbell et al. (PoD5565) described a Salvation Army international technical assistance team which has completed field-level programme design in 5 countries (Congo, Brazil, India, Nigeria, Zimbabwe) in 12 months. In their assistance, they seek to combine internationally transferable programmatic concepts, regionally specific influences and local conditions and initiatives. Their experience suggests that capacity building through networking can work, provided the organizations share a common philosophy, vision and goal. However, Mannemplavan (PoD5272) presented a shocking vignette of a major AIDS Service Organization in Africa, widely acclaimed as pivotal to AIDS activities in that country, which received approximately US$500,000 in government and donor funds over 3 years, yet only managed to train 15 people and counsel another 27 individuals, at an average cost of US$12,000 per beneficiary. He ascribed much blame to the government and donors, for continuing to providing funding without rudimentary monitoring and noted that such examples unjustly tarnish the reputation of many dedicated NGOs.
Communities The views of communities are often considered sacrosanct, notwithstanding, for example, feminist and gay protestations that communities are often repressive. Those who consider community views inviolate should ponder Nabauitu et al. s’ (PoD5508) observation that Ugandan community elders believed that only coercive legislation and condign punishment would change sexual behaviour.
Development perspectives The larger social factors underlying the AIDS pandemic were undoubtedly accorded greater recognition at this meeting. Mann (plenary address) grasped the very heart of the epidemic when he described male dominated societies as the greatest possible threat to public health. Mann has consistently argued that, for example, changing land tenure, inheritance or divorce laws in, say, Uganda would contribute more to AIDS prevention than, say, condom distribution. He also noted perceptively that AIDS thrived in contexts where governments were stood or fell by exchange or interest rate fluctuations, but were impervious to changes in infant mortality, access to health care or life expectancy. DeCosas (session 115) described AIDS as a disease of unbalanced development, of colonially oriented, extractive, “anti-community’’ economies, based on strategic translocation of large male labour forces. He and Mann advocate subjecting future development projects to an AIDS audit, to ensure projects are designed to minimize potential HIV transmission. T o sceptics who consider this farfetched, they advert to the environmental movement, whose capacity to impose environmental-impact audits seemed equally slender a decade or two ago. Without detracting a mote from the validity of their perspective, it is vital to combine intensified emphasis on the long-term, structural and developmental roots of AIDS with redoubled emphasis on short-term strategies, including eradication of barriers to effective prevention, comprehensive STD control judged primarily by accessibility and acceptability to women, community interventions to promote STD awareness and treatment seeking, partner reduction and condom use and ubiquitous condom promotion.
Conclusions Severely affected countries have gained many insights needed to prevent HIV transmission, but, tragically, too late to decisively alter their own epidemics. If only countries with time to act, including South Africa, Nigeria, other west African countries and much of Asia and Latin America would apply, with sufficient resolution, the insights gained at such cost. This means stripping away the unessential and using common sense and basic, sound management to develop community interventions on the largest scale. Yet, in Amsterdam, this vision receded still further. There was simply insufficient commitment from above and insufficient resolve from within to pare the many-tentacled AIDS industry to an essential core-what contributes most directly, demonstrably, effectively and economically to prevention, care and SUPPOR.
AMSTERDAM SUMMARIES
443
References LATIP,A.S., KATZENSTEIN, D.A., Bmm, M.T. et al. (1989) Genital ulcers and transmission of HIV among couples in Zimbabwe, AiDS, 3:, pp. 519-523. P o r n , M., ANDERSON,R. & BOILY, M.C. (1991) Slowing the spread of human immunodeficiency virus in developing countries, Lancer, 338, pp. 608-61 3.
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D. WILSON& S . LAVELLE Depamnent of Psychology, University of Zimbabwe, PO Box MP 167, Mount Pleasant, Harare, Zimbabwe
Sex workers, AIDS & HIV Introduction If it is true that the nature of the international AIDS conference reflects something of the host city then this is probably reason enough for the mushrooming of papers on prostitution at the Amsterdam meeting. At the San Francisco conference there were 77 entries on prostitution, in Florence this had increased slightly to 80, but in Amsterdam the figure had nearly tripled to 205. In addition to up-dates in such areas of long standing interest as the extent of HIV infection amongst sex workers and the use of condoms, there were also reports of work in the rather newer areas of male prostitution, clients and the various interventions aimed at reducing HIV spread associated with the sex industry. Given the amount of material presented at the meeting it is possible only to provide an edited selection of the areas covered.
(1) The prevalence of HIV infection
One of the most striking differences at the conference was the contrast between HIV prevalences amongst sex workers in the developed and the developing world. Nkya (PoD5645) reported on 212 female prostitutes from northern Tanzania enrolled into an HIV cohort study. On first examination 73% of cases were found to be HIV positive. On follow up of the original 58 HIV negative women 21% had seroconverted by 1991. Thirty per cent of the HIV positive women were continuing to work as prostitutes, 25% had retired from prostitution, and 26% had died. Geeta (Poc4623) reported on an HIV prevalence study of female prostitutes in Bombay. Out of 451 blood samples taken, 36% were found to be HIV positive. These figures parallel earlier reports of the rapid increase in prevalence of HIV amongst sex workers in Thailand and give some idea of the magnitude of the problem as HIV penetrates new geographical areas. Throughout Europe, north America and parts of central and southern America, the HIV prevalence figures amongst sex workers are on the whole much lower. Kanouse (PoC4192) tested 638 female sex workers in Los Angeles county between September 1990 and February 1991, only 2.5% of samples were positive for HIV. Ward (PoC4186) found only 0.9% of women (2 out of 223) tested in her London study between 1986 and 1991. In Mexico Valdespino (PoC4052) reported sentinel surveillance study results of female prostitution of between 0% to 5% though there is some evidence of HIV increasing. Zapiola (PoC4661) tested 237 female prostitutes in Buenos Aires and identified 6.3% as positive for HIV. Many of these studies stressed the importance of the overlap between injecting drug use and sex work. Estabanez (PoC4189) reported HIV results from 1665 female prostitutes in Spain from 1989 to 1992. Although overall prevalence of HIV was 12.5% this figure masked significance differences depending on whether the women were injecting drug users. HIV seroprevalence amongst women
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV/AIDS/STD in Africa a
D. Wilson & S. Lavelle
a
a
Department of Psychology , University of Zimbabwe , PO Box MP 167, Mount Pleasant, Harare, Zimbabwe Published online: 25 Sep 2007.
To cite this article: D. Wilson & S. Lavelle (1992) HIV/AIDS/STD in Africa, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:4, 438-443, DOI: 10.1080/09540129208253117 To link to this article: http://dx.doi.org/10.1080/09540129208253117
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
438 AMSTERDAM SUMMARIES
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Conclusion HIV and AIDS in Asia are characterized by common threads on the one hand and considerable diversity on the other. Weniger et al. (PoC4087) suggested that the four epidemic waves seen in Thailand may spread to nearby Asian countries, particularly India. Burma and parts of China. In Thailand, a first wave of HIV infection among male injecting drug users was quickly followed by a second among female prostitutes. The third wave occurred in the male clients of the prostitutes and the final, fourth wave in their wives. Potential factors that might explain this pattern are a high degree of needlesharing among injecting drug users, a high frequency of men going to prostitutes and the absence of premarital or extramarital sex among most women. Injecting drug use, on the other hand, accounted for a relatively small proportion of HIV diagnoses in Japan, Hong Kong, Singapore and Taiwan. Consequently, injecting drug use appears to have played a minor role in the spread of HIV infection in these countries to date. While HIV incidence and prevalence varied widely across the Asian region, nearly all countries reported an increasing number of diagnoses as a result of heterosexual contact. Although some successful interventions were reported, there were many communities where AIDS awareness appeared to be low, condom use was infrequent and needle sharing among drug users widespread. Clearly epidemiological surveillance needs to be strengthened in a number of countries and appropriate interventions for HIV prevention must be initiated urgently. Concerted action is required, with international support, to meet the challenge presented by HIV and AIDS in Asia. If the challenge is not taken up soon will we look back in years to come and ask whether too little was done, too late? J. ELFORD Senior Lecturer in Epidemiology, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia
HIV/AIDS/STD in Africa Introduction The deepening global economic crisis and worldwide contraction in health services, civil wars and other disasters, rampant HIV levels in eastern and southern Africa and unfolding epidemics in parts of West Africa, Asia and Latin America, contributed to a mood of gloom and resignation at the VIIIth International AIDS Conference/IIIrd World STD Congress. In this atmosphere, it would have been all too easy to disregard numerous incremental, but solid, advances, particularly in STD prevention. The AIDS and STD meetings merged felicitously: indeed, the entire conference underscored the importance of STD control as a firm, unifying foundation for coherent AIDS prevention activities.
Prevention A recent World Health Organization review of strategies for effective intervention emphasized the importance of community-level, interpersonal initiatives in AIDS prevention. Evidence presented from disparate regions strongly upheld this conclusion. Hays et al. (PoD5183) found that peer norms best predicted risk reduction among gay Californian men. Waibale et al. (PoC4836) monitored condom uptake in Ugandan bars during a four month mass media campaign, followed by interpersonal education. During the mass media campaign, 91% of supplied condoms were not taken. Within weeks of the interpersonal intervention, condom demand exceeded supply.
AMSTERDAM SUMMARIES
439
The case for interventions targeting individuals at heightened risk for STD was put forcibly by Over
Downloaded by [Universitaetsbibliothek Giessen] at 04:36 06 March 2015
& Piot (PoD5405). When the effects over 10 years of preventing a single case of STD amongst the
most sexually active subset of the population and the larger population are compared, the former is estimated to prevent from 8.5 to 55 times as many subsequent infections. Such models support targeted interventions. However, Potts, Anderson & Boily (1 99 1) caution that targeted interventions are most effective early in an epidemic and that overemphasis on targeting in an established epidemic would omit large secondary risk groups. Moreover, comprehensive targeting of the most sexually active requires that they constitute identifiable, accessible and clearly delineated groups, a premise which may only be true for such conspicuous sub-groups as, say, prostitutes or truckers. The diverse concomitants of vulnerability were illustrated in Uganda by Konde-Lule et el. (PoC4019), who found that women, anyone aged 20-29, trading town residents, those with secondary education, ‘bargirls’, vendors and drivers, were at heightened risk for HIV. Thus, in highly affected areas, Wilson et al. (PoC4527, PoC4789, PoC4522, PoD5328, PoD5389, PoD5436) described programmes combining targeted with community-wide intervention, by training vulnerable individuals as educators and condom providers, initially to their immediate peers, then to the larger community. They presented evidence of the coverage, impact and economy of such combined interventions. For US$85,000, a multi-site intervention in six Zimbabwean sites inhabited by 1.5-2 million people, held 12,865 community meetings, attended by 1.03 million people and distributed 5.74 million condoms. This averages US$6.61 per meeting, US$0.08 per attenders reached face-to-face and US$O.Ol per condom distributed. These costs compared favourably to mass media or other public health interventions. In a random sample of 705 prostitutes in Bulawayo (population 1 million), 91% reported having seen peer educator’s uniforms, 80% had attended community AIDS meetings and 83% had been taught by a peer educator. Of these, over 90%1had received condoms from the project. The percentage reporting condom use with the last client rose from 18% before the program to 73% after 2 years. Reported condom use was strongly related to program exposure: 27% of those who had attended no meetings, 46% of those who had attended 1 meeting, 74% of those who had attended 2-4 meetings and 80% of those who had attended 5 or more meetings reported condom use with their last client. Condom social marketing, which relies on both media and interpersonal promotion and combines widespread coverage with some targeting (since most consumers tend to be men planning to have sex with casual partners), stands at the confluence of mass and focused approaches. It is an extraordinarily robust intervention, which has proven itself in the most diverse cultures and economies, irrespective of infrastructural considerations. Yoda et al. (PoD5 152) described a condom social marketing programme in Burkino Faso, one of the world’s poorest countries, in which 2.7 million condoms were sold in just four months, through 68 wholesalers and 800 retailers. Youth interventions, which are clearly a global priority, are frequently beset by objections that informing youth about sex and condoms encourages sexual activity. Yet a study of the Swiss Stop AIDS campaign reported that condom promotion had no effect upon sexual activity (Hausser, TuD0575). Barriers to HIV transmission other than the male condom are urgently needed. Among discordant couples in Zambia, Feldblum al. (WeC1085) reported that spermicide substantially reduced female HIV seroconversion. Several studies explored the possible protective effect of male circumcision. Salebe et al. (PoC4715) found no association between circumcision and HIV status in Tanzania. However, based on a study of gay US men, Kreiss et al. (PoC4091) estimated that up to 40% of homosexual HIV infections could be averted by circumcision. Among truckers in Kenya, uncircumcised men were 3.8 times as likely to be HIV+ (Bwayo et al., ThC1514). In a study of STD patients in Kenya, uncircumcised men were 5.4 times as likely to be H I V S 011 enrollment and 5.3 times as likely to become HIV+ during follow-up. This effect was independent of GUD history or positive chancroid culture (Tyndall et al., PoC4308). In Uganda, circumcised Muslims were 3.3 times and non-Muslims 1.9 times less likely to be HIV+. Islamic affiliation was unrelated to HIV status after controlling for circumcision. The effect of circumcision was independent of a history of genital sores (Hellmann et al., PoC4299). These data suggest that the biological effect of an inact foreskin is not expressed simply through increased ulceration susceptibility, but also through other mechanisms, including retention of HIV-infected
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vaginal secretions in the nurturant milieu of the preputial sac. They also suggest that the behavioural characteristics of circumcised groups modify, but do not fully account for, the protective effect of circumcision. While widespread adult circumcision is daunting, several less intimidating strategies present themselves. Groups who practice circumcision after males become sexually active could be encouraged to begin circumcision earlier. Societies who practised circumcision until recently, including most South African groups, could be encouraged to revive the practice. Infant circumcision could be promoted. Circumcision could be offered to HIV-men in discordant relationships.
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Other STD Important work was presented in the broader domain of STD control. Hayes et al. (MoC0029) estimated, albeit controversially, that 20-40% of female HIV infection and 75-95% of male HIV infection in Africa was attributable to GUD. The pillars of comprehensive STD control include understanding of STD transmission dynamics in each context, intensified education to promote symptom suspicion, recognition nd treatment seeking, especially among women, improved case finding through, inter alia, screening in antenatal settings and partner notification, strengthened case management and improved STD counselling. Bradley et al. (ThC1557) interviewed 382 STD Kenyan STD patients and 380 controls. Seventynine percent of married male STD patients and 16% of married controls reported having extramarital sex in the past 3 months. Only 7% of married female STD patients and nearly 4% of married controls reported extramarital sex over the same period. Only 7% of married men, but almost 80% of married women believed they had contracted STD from their spouse. Thus, while Kenyan men and their casual partners acquire STD from each other, married women seem to contract STD from their spouses. Serological data from Zimbabwe tell a similar story. Latif et al. (1989) followed discordant couples for 18 months at a Zimbabwean referral hospital: in only two cases was a woman the index (in both cases, the women had received unscreened transfusions; moreover, one woman’s earlier husband had died of an unspecified viral illness). Several barriers to optimal health seeking behaviour were documented. In a study of STD patients in Kenya, Wanjala et al. (Poc4310) reported that 42% of men with GUD had sought treatment elsewhere (48% from other doctors, 46% from primary clinics and 6% from pharmacists, friends or vendors) before presenting at an STD clinic and that this treatment was almost entirely inappropriate. The mean period from symptom expression to presentation at an STD clinic was 17 days and 8% reported having sex while symptomatic. Moses et al. (PoC4295) reported that 30% of female STD patients at Kenyan health centres waited 2 or more weeks after symptom onset before presenting at a clinic and 24% reported having sex while symptomatic. Pattullo et al. (PoC4365) reported that 33% of Kenyan women presenting with GUD reported having had sex since the onset of symptoms. In these studies, reasons for delayed presentation included long waits (up to four hours for a 2 minute consultation), hostile treatment by health personnel, low confidence in the quality of care and, at times, unaffordability of transport or treatment. These studies illustrate how neglected STD education has been in AIDS and other health campaigns and underscore the importance of increasing symptom suspicion and treatment seeking on the part of patients and prompt, courteous, appropriate care on the part of the public, private and informal health sectors. Even without AIDS, S T D screening for antenatal women would be desirable. Hira et al. (PoC4323) described a Zambian syphilis screening programme, which began in 1983 and has been extended to 100% of urban and 40% of rural maternity centres, at an estimated cost of US$12 per adverse outcome averted. From 1983 to 1991, prenatal syphilis prevalence has approximately halved in selected centres. Holmes (session 83) described a case management package for developing countries combining behavioural risk assessment and algorithms for primarily syndromic management. Behavioural risk assessments warrant further examination, provided they an accommodate circumstances where women’s risk profile largely reflects their spouses’ behaviour. Grosskurth et al. (PoC4525) described a comprehensive, integrated S T D programme-encompassing training of health personnel, provision of drugs and STD education-in Mwanza, a region of 2 million people in Tanzania.
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Care and support
There were surprisingly few studies on care and support in Africa. Shepard et al. (PoD5505) costed AIDS care in 3 Rwandan hospitals. On averge, an AIDS patient would be hospitalized for 41 days, at a cost of US$358. In 1990, hospitalization of Rwanda’s 1849 confirmed hospitalized cases cost US$600,00, or 4.6% of Rwanda’s public sector hospital budget. This figure may exceed 11% by 1994. They concluded that improved care in district health centres and at home was urgently needed to reduce the burden on referral hospitals. In a study of the costs of caring for Ugandan AID patients, Kezaala et al. (PoD5498) estimated that each home care visits costs half as much as a hospital admission (US$5-7 versus US$12-13, respectively). They also noted that outreach care reinforced community prevention effots. Foster et al. (PoD5769) costed inpatient care at Monze District Hospital in Zambia. Mean treatment costs were US$41 for HIV- patients, US$22 for asymptomatic HIV+ patients and US$66 for AIDS patients. However, when treatment costs for AIDS patients were differentiated by T B status, they averaged US$132 for T B patients and US$39 for non-TB patients. T B accounted for 58% of the costs of treating AIDS in the hospital. They concluded that prevention, earlier diagnosis and better treatment of T B could substantially reduce the financial burden of AIDS in the hospital. Cost analyses provide support for community care, but sharply different evidence of the quality of community care emerged. Ankrah et al. (PoD5009) studied 24 rural Ugandan families of adults with AIDSs. They reported that families willingly absorbed infected members and provided devoted care. They noted, however, that the burden of care fell disproportionately on female family members. In contrast, Seeley et al. (MoD0071) noted that family support for AIDS patients in Uganda was frequently a myth. Of 17 women with AIDS, the mother was the only carer in 8 cases and a daughter the sole carer in 2 cases. In 6 cases, siblings and and parents shared care and in one case, the patient died alone. Of 13 men, 4 were cared for by a wife, 3 were cared for by their mother or a sister and 6 received care from other relatives. Of the 17 who died during the study, there were 7 cases where relatives refused to give help, citing poverty or other duties. However, in only one case did relatives withhold help for the funeral. Three patients’ medical records cited poverty or neglect as contributory to death. They concluded that the burden of care fell disproportionately on immediate relatives and strongly questioned the supposition that the extended family provides adequate support for AIDS patients.
Orphans
Mitigating the impact of AIDS on orphans in severely affected African countries is of the utmost importance. However, most orphan studies were descriptive and convincing models and mechanisms for ameliorative interventions are lacking. Several studies highlighted the scope of the problem. Mutembei et al. (PoD5162) reported that there were 49,000 orphans in the Kagera region of Tanzania. Kamali et al. (PoD5159) reported that 10% of a sample of 5,022 children in Masaka district in Uganda had lost one or both parents. During a one year cohort follow-up, the researchers identified 24 children orphaned after the death of a HIV+ parent and only two orphaned after the death of a HIV- parent, suggesting that HIV is largely responsible for the orphan problem. Foster et al. (PoD5158) surveyed 1781 children from 586 randomly selected households in Manicaland province, Zimbabwe. Nearly 7% of children under 15 had lost at least one parent and 53% of these deaths had occurred in the past 20 months, thus substantially implicating AIDS as the cause of death. There were no controlled comparisons of the nutritional, health, socioeconomic and psychological status of orphans, but impressionistic data suggested reduced quality of care. Three seems to be considerable agreement that extended families and communities should care for orphans, with support from social welfare organizations, but whether communities are able to do so, and what forms of support are needed, remains unclear. More than further descriptive studies, we urgently need multiple intervention models to guide our responses to the orphan crisis.
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NGOs Campbell et al. (PoD5565) described a Salvation Army international technical assistance team which has completed field-level programme design in 5 countries (Congo, Brazil, India, Nigeria, Zimbabwe) in 12 months. In their assistance, they seek to combine internationally transferable programmatic concepts, regionally specific influences and local conditions and initiatives. Their experience suggests that capacity building through networking can work, provided the organizations share a common philosophy, vision and goal. However, Mannemplavan (PoD5272) presented a shocking vignette of a major AIDS Service Organization in Africa, widely acclaimed as pivotal to AIDS activities in that country, which received approximately US$500,000 in government and donor funds over 3 years, yet only managed to train 15 people and counsel another 27 individuals, at an average cost of US$12,000 per beneficiary. He ascribed much blame to the government and donors, for continuing to providing funding without rudimentary monitoring and noted that such examples unjustly tarnish the reputation of many dedicated NGOs.
Communities The views of communities are often considered sacrosanct, notwithstanding, for example, feminist and gay protestations that communities are often repressive. Those who consider community views inviolate should ponder Nabauitu et al. s’ (PoD5508) observation that Ugandan community elders believed that only coercive legislation and condign punishment would change sexual behaviour.
Development perspectives The larger social factors underlying the AIDS pandemic were undoubtedly accorded greater recognition at this meeting. Mann (plenary address) grasped the very heart of the epidemic when he described male dominated societies as the greatest possible threat to public health. Mann has consistently argued that, for example, changing land tenure, inheritance or divorce laws in, say, Uganda would contribute more to AIDS prevention than, say, condom distribution. He also noted perceptively that AIDS thrived in contexts where governments were stood or fell by exchange or interest rate fluctuations, but were impervious to changes in infant mortality, access to health care or life expectancy. DeCosas (session 115) described AIDS as a disease of unbalanced development, of colonially oriented, extractive, “anti-community’’ economies, based on strategic translocation of large male labour forces. He and Mann advocate subjecting future development projects to an AIDS audit, to ensure projects are designed to minimize potential HIV transmission. T o sceptics who consider this farfetched, they advert to the environmental movement, whose capacity to impose environmental-impact audits seemed equally slender a decade or two ago. Without detracting a mote from the validity of their perspective, it is vital to combine intensified emphasis on the long-term, structural and developmental roots of AIDS with redoubled emphasis on short-term strategies, including eradication of barriers to effective prevention, comprehensive STD control judged primarily by accessibility and acceptability to women, community interventions to promote STD awareness and treatment seeking, partner reduction and condom use and ubiquitous condom promotion.
Conclusions Severely affected countries have gained many insights needed to prevent HIV transmission, but, tragically, too late to decisively alter their own epidemics. If only countries with time to act, including South Africa, Nigeria, other west African countries and much of Asia and Latin America would apply, with sufficient resolution, the insights gained at such cost. This means stripping away the unessential and using common sense and basic, sound management to develop community interventions on the largest scale. Yet, in Amsterdam, this vision receded still further. There was simply insufficient commitment from above and insufficient resolve from within to pare the many-tentacled AIDS industry to an essential core-what contributes most directly, demonstrably, effectively and economically to prevention, care and SUPPOR.
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References LATIP,A.S., KATZENSTEIN, D.A., Bmm, M.T. et al. (1989) Genital ulcers and transmission of HIV among couples in Zimbabwe, AiDS, 3:, pp. 519-523. P o r n , M., ANDERSON,R. & BOILY, M.C. (1991) Slowing the spread of human immunodeficiency virus in developing countries, Lancer, 338, pp. 608-61 3.
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D. WILSON& S . LAVELLE Depamnent of Psychology, University of Zimbabwe, PO Box MP 167, Mount Pleasant, Harare, Zimbabwe
Sex workers, AIDS & HIV Introduction If it is true that the nature of the international AIDS conference reflects something of the host city then this is probably reason enough for the mushrooming of papers on prostitution at the Amsterdam meeting. At the San Francisco conference there were 77 entries on prostitution, in Florence this had increased slightly to 80, but in Amsterdam the figure had nearly tripled to 205. In addition to up-dates in such areas of long standing interest as the extent of HIV infection amongst sex workers and the use of condoms, there were also reports of work in the rather newer areas of male prostitution, clients and the various interventions aimed at reducing HIV spread associated with the sex industry. Given the amount of material presented at the meeting it is possible only to provide an edited selection of the areas covered.
(1) The prevalence of HIV infection
One of the most striking differences at the conference was the contrast between HIV prevalences amongst sex workers in the developed and the developing world. Nkya (PoD5645) reported on 212 female prostitutes from northern Tanzania enrolled into an HIV cohort study. On first examination 73% of cases were found to be HIV positive. On follow up of the original 58 HIV negative women 21% had seroconverted by 1991. Thirty per cent of the HIV positive women were continuing to work as prostitutes, 25% had retired from prostitution, and 26% had died. Geeta (Poc4623) reported on an HIV prevalence study of female prostitutes in Bombay. Out of 451 blood samples taken, 36% were found to be HIV positive. These figures parallel earlier reports of the rapid increase in prevalence of HIV amongst sex workers in Thailand and give some idea of the magnitude of the problem as HIV penetrates new geographical areas. Throughout Europe, north America and parts of central and southern America, the HIV prevalence figures amongst sex workers are on the whole much lower. Kanouse (PoC4192) tested 638 female sex workers in Los Angeles county between September 1990 and February 1991, only 2.5% of samples were positive for HIV. Ward (PoC4186) found only 0.9% of women (2 out of 223) tested in her London study between 1986 and 1991. In Mexico Valdespino (PoC4052) reported sentinel surveillance study results of female prostitution of between 0% to 5% though there is some evidence of HIV increasing. Zapiola (PoC4661) tested 237 female prostitutes in Buenos Aires and identified 6.3% as positive for HIV. Many of these studies stressed the importance of the overlap between injecting drug use and sex work. Estabanez (PoC4189) reported HIV results from 1665 female prostitutes in Spain from 1989 to 1992. Although overall prevalence of HIV was 12.5% this figure masked significance differences depending on whether the women were injecting drug users. HIV seroprevalence amongst women
