University of Zambia Medical Library


ZAMBIA HEALTH INFORMATION DIGEST

Volume 7 Number 4: October - December 2000

PUBLISHED BY:
THE UNIVERSITY OF ZAMBIA MEDICAL LIBRARY

IN ASSOCIATION WITH:
THE MINISTRY OF HEALTH, ZAMBIA
THE DREYFUS HEALTH FOUNDATION OF NEW YORK
A GRANT FROM THE IBM CORPORATION

[ZHID Table of Contents]

EDITORIAL BOARD:
Dr. J.C. L. Mwansa, Microbiologist: University Teaching Hospital
Dr. Oliver Bowa, Surgical Anatomist: University of Zambia Surgery Department
Dr. Andrew Mbewe, Consultant Paediatrician: Kitwe Central Hospital
Ms. Nora Mweemba, Consultant-Information: World Health Organisation-Zambia
Mr. Sikwanda Makono, Specialist, Health Education, Ministry of Health
Ms. Christine Kanyengo, Medical Librarian (Acting): University of Zambia Medical Library

ADDRESS:
Zambia Health Information Digest
Medical Library
University of Zambia
School of Medicine
P.O. Box 50110
Lusaka, Zambia
Telephone: 260-1-250801
Fax: 260-1-250753
Email: medlib@unza.zm

Production of Zambia Health Information Digest is funded by the DREYFUS HEALTH FOUNDATION of New York under the Communication For Better Health ( CBH ) Programme.

TECHNICAL Production:
University of Zambia Medical Library

Project Coordinator:
Christine Kanyengo
Data Input:
Charity Kaulule
Circulations:
Kenneth Chanda
Lovelee Mwengwe
Sepiso Iliamupu
Philip Banda
Irene Nachilobe

ACKNOWLEDGEMENTS:
The Zambia Health Digest is produced to provide current information to health workers who have little access to current health related publications and information.

The abstracts of journal articles published in this quarterly Digest are obtained from the Medline database provided by the Dreyfus Health Foundation of New York. Abstracts are also selected from a database of Zambian health articles, which is continually being compiled at the UNZA Medical Library. Readers are encouraged to send in their work for inclusion in this Zambian health information database.

Computer equipment has been supplied through a grant from the IBM Corporation.

The Health Sciences Centre of the University of Florida, our cooperating partners, supply photocopies of the full text articles to the University Medical library on request, which in turn will be supplied to readers on request. When available in the library, articles will be photocopied at a nominal cost.

Production costs are supported by The Dreyfus Health Foundation of New York.

CUSTOM SEARCHES:
Using the MEDLINE compact disc databases, custom searches can be done on any health issue to obtain the most up-to-date information available. Readers are encouraged to submit requests for searches on relevant health problems which they face. Requests should be sent to the Medical Library, attention Christine Kanyengo

TABLE OF CONTENTS:

EDITORIAL

 The choice of this issue’s theme – Sexual Health in Africa – highlights the problems that most Afircan countries face regarding the subject. The Importance of sexual health lies in the fact that it is the cornerstone of dealing with reproductive health, HIV/AIDs/STIs, and violence against women which are considered vital in tackling these problems.

This issue also sheds some light on Sexual and Reproductive Health in conflict situations, which has gained prominence since the International Conference on Population and Development in 1994. This conference held in Cairo defined reproductive health as a right and matter of choice for every individual and not in a demographic context. Refugees have the same reproductive health needs as people anywhere not affected by war. health wadefined reproductive health, not in a demographic context, but as a right and matter of choice for every individual.

Another area that has been discussed is Voluntary Counselling and HIV/AIDS testing in Zambia.This plays a crucial role in helping couples disclose their HIV status and make responsible choices to protect each other’s sexual and reproductive health and rights. And finally we thank our partners throughout Zambia and the world over for their unwavering support. We wish all all readers a festive season.

SEXUAL HEALTH IN AFRICA (Current Abstracts of Journal Articles -- MEDLINE)

Contemporary patterns of adolescent sexuality in urban Botswana.
Meekers D, Ahmed G
J Biosoc Sci 2000 Oct;32(4):467-85
In Botswana, as in other areas in southern Africa, there is a growing concern about the risks associated with adolescent sexuality. To facilitate the design of policies that can address these problems, it is necessary to gain a thorough understanding of contemporary patterns of adolescent sexual behaviour, and the factors that affect them. This paper examines these issues using data from the 1995 Botswana Adolescent reproductive Health Survey in conjunction with data from focus group discussions.

The results suggest that adolescents become sexually active at an early age, and that many of them, males and females alike, have multiple sex partners. This early sexual initiation implies that adolescent reproductive health programmes should target youths aged 13 or younger. For school-based programmes this implies starting no later than Grade 6 or Standard 1, and preferably earlier. Young males appear to be a particularly vulnerable group that needs further attention. Adolescents perceive that teachers, peers and parents have the largest influence on their reproductive health attitudes. Schools appear to have the most potential for providing reproductive health information, because they reach youths both directly and indirectly by educating their peers.

The results also show that male and female sexual behaviour is affected by different factors. Among males, having secondary education strongly increases the odds of being sexually active, presumably because such males make attractive partners. Among females, on the other hand, being in school significantly reduces the odds of being sexually active. This finding is consistent with the policy imposing a one-year school expulsion for pregnant schoolgirls, which was implemented as a deterrent to schoolgirl pregnancy

Perception and practice of emergency contraception by post-secondary school students in southwest Nigeria.
Arowojolu AO, Adekunle AO
Afr J Reprod Health 2000 Apr;4(1):56-65

A survey of 1500 students in post-secondary institutions in southwest Nigeria showed that the concept of emergency contraception (EC) was well known Respectively, 32.4%, 20.4% and 19.8% knew that combined pills, progesterone only pills and intrauterine contraceptive device (IUCD) were usable for EC, while 56.7% mentioned the use of traditional methods. Only 11.8% had ever used either pills or IUCD and 10.7% had used a traditional method. Few students (11.5% and 2.3% respectively) knew the correct timing of EC pills and IUCD.

The respondents reported varying circumstances under which EC was indicated but the majority cited condom breakage and sexual assault. The popular media represent the commonest source of information while hospitals/clinics were the commonest sources of procurement. About 37% of the respondents planned to use EC in future while 58% would not and 4.7% were uncertain. Reasons for these responses were explored.

Sexual activity and contraceptive use among female adolescents--a report from Port Harcourt, Nigeria.
Okpani AO, Okpani JU
Afr J Reprod Health 2000 Apr;4(1):40-7

Seven hundred and sixty-eight randomly selected single senior secondary school girls from Port Harcourt (mean age 16.32 years) were surveyed on aspects of sexual activity and contraceptive use. Two hundred and ten pregnancies (24 deliveries and 186 induced abortions) had occurred in 142 out of 605 girls (78.8%) who admitted being sexually exposed. The mean, modal and youngest ages of initiation into sexual activity were 15.04, 15 and 12 years respectively. At the time of the survey, 190 girls (24.7%) were sexually active and 74.2% of their male consorts were older working men, suggesting financial gains as a motive for the girls' sexual activity. Other findings were high awareness (72.4%) of the relationship between sexual activity and sexually transmitted diseases; a rather low level (56%) of knowledge of effective contraceptive methods, and limitation of contraceptive method use by sexually active girls, largely to the rhythm and withdrawal methods. Exposure to multiple sexual partners and a high level of parental approval of subjects' use of contraception were also present. In view of our findings, it is suggested that active efforts to promote sexuality education and contraceptive use should be intensified among Nigerian adolescents.

Confidentiality and HIV/AIDS in South Africa.
Uys LR
Nurs Ethics 2000 Mar;7(2):158-66

Keeping the diagnosis of a client confidential is one of the cornerstones of professional practice. In the case of a diagnosis such as HIV/AIDS, however, the ethics of this action may be challenged. Such a decision has a range of negative effects, for example, the blaming of others, supporting the denial of the client, and complicating the health education and care of the patient. It is suggested that the four ethical principles should be used to explore the ethics of such decisions, and that professional regulatory bodies and organizations should support professionals in situations where the client's sexual partner is informed against the wishes of the client.

Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania.
Sweat M, Gregorich S, Sangiwa G, Furlonge C, Balmer D, Kamenga C, Grinstead O, Coates T
Lancet 2000 Jul 8;356(9224):113-21

.

Report of sexually transmitted diseases by HIV infected men during follow up: time to target the HIV infected?
Machekano RN, Bassett MT, Zhou PS, Mbizvo MT, Latif AS, Katzenstein DA
Sex Transm Infect 2000 Jun;76(3):188-92

Factors affecting condom use among South African university students.
Peltzer K
East Afr Med J 2000 Jan;77(1):46-52

Specific psychiatric morbidity among diabetics at a Nigerian General Hospital.
Coker AO, Ohaeri JU, Lawal RA, Orija OB
East Afr Med J 2000 Jan;77(1):42-5

Factors influencing timing of seeking health care among patients with sexually transmitted diseases in Kampala, Uganda.
Nuwaha F
Cent Afr J Med 1999 Dec;45(12):320-3

  • OBJECTIVE:
    To identify predictors for timing of seeking health care among patients with sexually transmitted diseases (STDs).
  • DESIGN AND SETTING:
    A cross sectional study at the old Mulago hospital STD clinic in Kampala the capital city of Uganda.
  • SUBJECTS:
    A convenience sample of 138 patients with STDs were interviewed on social-demographic, STD symptoms, health seeking behaviour, condom use, sexual behaviour, and knowledge about STDs.
  • MAIN OUTCOME MEASURES:
    Early seekers (who sought care before 14 days) and late seekers (who sought care > or = 14 days of symptoms) were compared on the above variables using bivariate and multivariate logistic regression analyses.
  • RESULTS:
    On multivariate analysis, only two variables, having sex at least once during the period with symptoms (OR 7.27; 95% CI 3.02 to 17.51) and not having sex with a casual partner in the last three months (OR 3.23; 95% CI 1.14 to 9.09) predicted late seeking of health care.
  • CONCLUSIONS:
    Having sex at least once while symptomatic is a strong predictor of delay in seeking care and may be related to severity of symptoms. There is need to strengthen health education messages about the importance of seeking care immediately no matter how minor the symptoms. More research is needed to identify predictors for having sex while symptomatic.

    • Implementing the integration of component services for reproductive health.
    Mayhew SH, Lush L, Cleland J, Walt G
    Stud Fam Plann 2000 Jun;31(2):151-62

    In the wake of the 1994 International Conference on Population and Development in Cairo, considerable activity has occurred both in national policymaking for reproductive health and in research on the implementation of the Cairo Program of Action. This report considers how effectively a key component of the Cairo agenda--integration of the management of sexually transmitted infections, including human immunodeficiency virus, with maternal and child health-family planning services--has been implemented. Quantitative and qualitative data are used to illuminate the difficulties faced by implementers of reproductive health programs in Ghana, Kenya, South Africa, and Zambia. In these countries, clear evidence is found of a critical need to reexamine the continuing focus on family planning services and the nature of the processes by which managers implement reproductive health policies. Implications of findings for policy and program direction are discussed.

    Ethics in the practice of psychiatry in South Africa Population-based first-episode study..
    Szabo CP, Kohn R, Gordon A, Levav I, Hart GA
    S. Afr Med J 2000 May;90(5):498-503

    The impact of epilepsy on the quality of life of people with epilepsy in Zimbabwe: a pilot studyMielke J, Sebit M, Adamolekun B
    Seizure 2000 Jun;9(4):259-64

    . Epilepsy is a common cause of psychosocial disability and has been perceived to have a profound impact on the social functioning of individuals with epilepsy. In Zimbabwe a combination of developing world economic priorities (with provision of social and health services for disabled people not a major goal) and culturally mediated perceptions of epilepsy as a non-medical and feared stigma may further disadvantage people with epilepsy (PWE) in this respect. In order to assess both the level of psychosocial functioning of individuals with epilepsy and their own perception of it, three groups of people were sampled: attenders at a specialized epilepsy clinic and members of two community-based support groups. All completed a brief quality-of-life questionnaire with activities of daily living added. Those carers present completed the same questionnaire at the time of sampling. The results indicated that 36 of 38 people with epilepsy sampled, and their carers, did not perceive themselves to have sufficient cognitive impairment to interfere with social functioning, work performance or relationships with other as assessed by a subsection of the WHO SIDAM (objective evaluation of cognitive performance) interview.

    However, an adapted activities of daily Living Questionnaire (ADLQ) showed that three-quarters of careers (and two-thirds of PWE) felt that functioning was mildly to moderately reduced, particularly in the areas of solving daily problems and speed of thinking. One-quarter of PWE experienced problems with relationships to others, just less than one-fifth of PWE reported more than four areas of reduced functioning. Of special interest was the fact that 25 (66%) reported sexual functioning as not applicable, although only four of these were of an age group which is not sexually active (less than 15 years old). In addition one-third of the central Hospital Group reported difficulties with using public transport, but none of the Community Support Group members, implying that the use of Public transport becomes an issue when it is necessary to travel long distances and that PWE curtail their travel but do not necessarily view this as a restriction. The samples chosen were from groups which, compared with PWE as a whole, are likely to include more disabled individuals, because attenders at a specialized epilepsy clinic and members of support groups self-select for more symptomatic epilepsy and a visibility.

    Therefore the proportion of PWE perceived to have difficulties with ADL in this project is not representative for PWE as a whole. The implications of our study are firstly that there is a significant need for selected groups of PWE in Zimbabwe to receive attention to psychosocial abilities and secondly that there are certain specific areas such as sexual functioning and the use of transport which deserve special attention. A much more detailed inventory of neuro-psychological tests will be of value to plan treatment strategies for those selected by the crude screening instruments used in this project. An important future comparison will be a survey of ADL and psychosocial functioning amongst PWE in rural communities, because it is uncertain whether PWE in rural communities are generally more or less disabled than those in the city.

    Ethnicity and sexual behavior in Ghana.
    Addai I
    Soc Biol 1999 Spring-Summer;46(1-2):17-32

    Using data from the 1993 Ghana Demographic and Health Survey, this study explores the relationship between ethnicity and sexual behavior: having sex before age 17 and premarital sexual experience. All ethnic groups show substantial sexual experience before age 17 and premarital sexual engagement. Logistic regression analyses reveal that in general ethnicity influences the behaviors studied, especially for ever-married women. The data suggest that groups that practice matrilineal and patrilineal systems show differences in the likelihood of having sex before age 17. Contrary to expectation, there is an inverse relationship between education and sexual experience before age 17. The findings highlight the importance of group-specific programs in Africa.

    HIV-1 infection-associated risk factors among sexually transmitted disease
    Kyriakis KP, Hadjivassiliou M
    Sex Transm Dis 2000 May;27(5):259-65

    Child psychiatry in Johannesburg, South Africa. A descriptive account of cases presenting at two clinics in 1997.
    Vogel W, Holford L
    Eur Child Adolesc Psychiatry 1999 Sep;8(3):181-8

    Reproductive and sexual health and safe motherhood in the developing world. Eur J Contracept Reprod Health Care 1999 Dec;4(4):217-28 Shah D, Shroff S, Sheth S Nowrosjee Wadia Maternity Hospital, Mumbai, India. The aim of this paper is to discuss the main hurdles and possible solutions concerning reproductive and sexual health and safe motherhood in the developing countries. In response to the changing global situation, a broader new concept of reproductive health has emerged. The Programme of Action of The International Conference on Population and Development (ICPD) emphasizes and highlights various aspects of reproductive health. No population in the world has met the goals of the ICPD. The problems are particularly acute in developing countries: between 20 and 40% of births are unwanted or wrongly timed, posing hardships for families and jeopardizing the health of a million women and children. An estimated 50 million induced abortions are performed each year, with some 20 million of these performed under unsafe conditions or by untrained providers. Almost 600,000 women die every year due to pregnancy-related causes, 99% of them in developing countries. Approximately 7.6 million infant deaths occur during the perinatal period each year. There are more than 333 million new cases of curable sexually transmitted diseases world-wide each year. Nearly 22 million people are estimated to be infected with the human immunodeficiency virus, of whom 14 million are in sub-Saharan Africa, with rapidly increasing numbers of infected persons in South and South-East Asia. When compared to the developed world, these figures are staggering because of barriers operating at different levels and preventing women from receiving care that is timely and of good quality. United efforts of obstetricians, pediatricians, sociologists, and different governmental and non-governmental organizations are required to achieve our targets.

    Mental health in the Middle East: an Egyptian perspective.
    Okasha A
    Clin Psychol Rev 1999 Dec;19(8):917-33

    Sexually transmitted infections and HIV in a rural community in the Lesotho highlands. Sex Transm Infect 2000 Feb;76(1):39-42 Colvin M, Sharp B OBJECTIVES: To conduct a knowledge, attitude, and practice (KAP) study and to determine the prevalence of sexually transmitted diseases (STDs), including HIV, in a community residing in remote, rural Lesotho. METHODS: In 1995 a cross sectional, community based epidemiological study was conducted on a population of 7500 people living in 89 villages. A total of 29 villages were randomly selected and a systematic sample of houses within villages was obtained. Questionnaires were administered to subjects after written consent was obtained. Determination of N gonococcus and C trachomatis infection was done on urine using ligase chain reaction (LCR) technology. Using blood specimens, syphilis was diagnosed by RPR and TPHA tests and HIV by a single ELISA and confirmed with a western blot. RESULTS: Questionnaires were administered to 277 women, 100 men, and 149 youths (12-15 years). Chlamydia was diagnosed in 28.4% of adults, gonorrhoea in 5.9%, syphilis in 11.3%, and HIV infection in 6.3%. All cases of HIV occurred along the main road (p = 0.001) and 72% of individuals with gonorrhoea were co-infected with chlamydia (p = 0.0001). 11.6% of women and 38.0% of men had had sex with a non-regular partner in the past 3 months and none had used condoms. CONCLUSION: A high prevalence of STDs and HIV infection was found in a population characterised by low levels of knowledge about STD/HIV, high risk sexual behaviour, and evidence of inappropriate health seeking behaviour for STDs.

    Quality of life and treatment satisfaction after the addition of lamivudine or lamivudine plus loviride to zidovudine-containing regimens in treatment-experienced patients with HIV infection.
    Chatterton ML, Scott-Lennox J, Wu AW, Scott J
    Pharmacoeconomics 1999;15 Suppl 1:67-74

    Participatory diagramming as a means to improve communication about sex in rural Zimbabwe: a pilot study. Soc Sci Med 2000 Jun;50(12):1723-41 Kesby M School of Geography and Geosciences, University of St Andrews, Fife, Scotland, UK. mike.kesby@st-and.ac.uk It is increasingly recognised that unequal gender relations and poor communication between men and women about sexual matters, play a central role in the rapid transmission of HIV in sub-Saharan Africa. Analysis of how communication might practically be improved remains a critical area for investigation however. To this end a pilot study, conducted in January 1998 involving two all-female focus groups in two rural areas of Zimbabwe, explored the possibility of using 'participatory' methods and visual diagramming as a means to facilitate rural people's communication about issues of sexual health. While still provisional, the results hold considerable interest for future HIV/AIDS work in the region. As a research tool, diagramming provides richer, more nuanced data about sexual activity than wholly discursive focus groups. However, the technique also holds considerable potential for action research and positive interventions that seek to facilitate couples' more open communication and safer sexual decision making. The pilot established both that rural women were comfortable utilising the techniques and that they were prepared to use them to discuss the detail of their sex lives. The next and vital step, as participants themselves suggested, is to involve men in similar self-analytical activities.

    Evaluating computerized health information systems: hardware, software and human ware: experiences from the Northern Province, South Africa.
    Herbst K, Littlejohns P, Rawlinson J, Collinson M, Wyatt JC
    J Public Health Med 1999 Sep;21(3):305-10

    Communication and sexuality in a Nigerian community. Adv Contracept 1999;15(1):61-8 Okonkwo JE, Uwakwe R, Obionu C, Okonkwo CV Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria. The traditional lack of interest in discussing sexuality creates a problem in doctor-patient communication, and this can affect patient management adversely. The dearth, ease or comfort in discussing sex was examined by a self-administered questionnaire to respondents, mainly medical students, nurses and paramedics, 20-70 years of age, who were not seeking treatment for sexual problems. The respondents were mainly of Igbo extraction from Eastern Nigeria. Factors considered include age, sex, religion, marital status, and education. The results show that 71.9% of all the respondents indicated that they would like to be able to discuss freely whereas 28.1% never really bothered; 40.9% of all the respondents could discuss sex with anybody whereas 59.1% could not; 75% in the married group discussed sex freely with their spouses or friends and 25% were unable to do so. Education showed a very significant influence on the ability to discuss sex freely. It is suggested that a systematic approach to education, especially sexual health education, may be a major way to combat the prevailing cultural inhibition.

    Training for transformation: reorientating primary health care nurses for the provision of mental health care in South Africa..
    Petersen I
    J Adv Nurs 1999 Oct;30(4):907-15

    Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.

    Traditional intravaginal practices and the heterosexual transmission of disease: a review.
    Brown JE, Brown RC
    Sex Transm Dis 2000 Apr;27(4):183-7

    Global distribution of the CCR2-64I/CCR5-59653T HIV-1 disease-protective haplotype.
    Martinson JJ, Hong L, Karanicolas R, Moore JP, Kostrikis LG
    AIDS 2000 Mar 31;14(5):483-9

    Generational differences in male sexuality that may affect Zimbabwean women's risk for sexually transmitted diseases and HIV/AIDS.
    Olayinka BA, Alexander L, Mbizvo MT, Gibney L
    East Afr Med J 2000 Feb;77(2):93-7

    Sildenafil (Viagra) in the treatment of male erectile dysfunction in Nairobi.
    Magoha GA
    East Afr Med J 2000 Feb;77(2):76-9

    Coitus, the proximate determinant of conception: inter-country variance in sub-Saharan Africa.
    Brown MS
    J Biosoc Sci 2000 Apr;32(2):145-59

    There is a general consensus in the literature that fertility differences between populations can be accounted for by differences in just four key proximate determinants: nuptiality, the postpartum non-susceptible period, contraception and abortion. Natural fecundibility is generally assumed to be constant between populations. This paper puts the theoretical and empirical case for a re-evaluation of that assumption, drawing on the under-utilized data on sexual activity collected in the Demographic Health Surveys (DHSs).

    Using data for married women in nine African countries, the analysis finds substantial population level differences in mean monthly coital frequency, which, if accurate, suggest an important demographic effect. There is a clear regional patterning to these differences, with levels of activity considerably lower among women in the West African populations included in the study than those from East and southern Africa. For West Africa in particular the data indicate the normality of exceptionally long periods of very infrequent or no intercourse by married women outside the period of postpartum abstinence. The findings challenge prevailing presumptions concerning susceptibility to pregnancy in marriage on which statistics for unmet need for family planning are derived.

    While doubts are raised over the precision of the sexual activity data used, the paper argues for the need for a greater effort to operationalize the 'proximate determinant of conception', not only for more accurate fertility modelling, but also as a planning tool for a more sensitive provision of family planning services in Africa.

    Family planning and sexual behavior in the era of HIV/AIDS: the case of Nakuru District, Kenya.
    Bauni EK, Jarabi BO
    Cent Stud Fam Plann 2000 Mar;31(1):69-80

    Recently, the prevalence of contraceptive use has increased in Kenya. The twin risks of unwanted pregnancy and HIV/AIDS infection remain central concerns of reproductive health programs. However, we do not know how sexually active men and women perceive these risks, nor the strategies they consider appropriate to cope with these risks, nor the difficulties they face in trying to adopt appropriate sexual behaviors to minimize them.

    This study seeks to provide insights into perceptions, coping strategies, and constraints in the changing behavior of sexually active people in Nakuru District, Kenya. Twelve focus-group discussions were conducted, the results of which show that people in the study area consider the two risks to be serious problems, but that they neither use condoms within marriage nor refuse their partners sex even if they perceive a risk of acquiring HIV. These findings call for serious efforts toward fostering behavioral change in this area.

    Perceptions of the risks of sexual activity and their consequences among Ugandan adolescents.
    Hulton LA, Cullen R, Khalokho SW
    Stud Fam Plann 2000 Mar;31(1):35-46

    The principal aim of this study of adolescents in Mbale District, Uganda, is to provide program-related information about their behavior, motivations, and perceptions of risk with regard to pregnancy and HIV transmission. Twelve single-sex focus-group discussions were conducted, six with young people aged 17-18 who were still attending school, and six with people of the same age who were not. The most important findings to emerge are that knowledge of safe-sex behavior and reported behavior have little in common and that the fundamental barriers to behavioral change lie within the economic and sociocultural context that molds the sexual politics of youth. Young males' lack of responsibility for the outcomes of their behavior is identified as an important barrier to improved sexual health.

    The imperative to explore ways by which young women might achieve status and identity and acquire material resources by means not related to their sexuality is highlighted.

    Is care and support associated with preventive behaviour among people with HIV?
    AIDS Care 1999 Oct;11(5):537-46
    AIDS Care 1999 Oct;11(5):537-46

    Care and support should play a critical role in assisting people who are HIV-positive to understand the need for prevention and to enable them to protect others. Differences in sexual risk reduction among 154 newly diagnosed HIV-positive individuals from semi-urban Tanzania were examined using a randomized control design, which assigned a control group to regular health services and an experimental group to enhanced care and support. Data were collected at baseline, three months and six months on self-reported sexual risk behaviours, disclosure of serostatus, reproductive health and psychosocial support. Over the six-month period, significant risk reduction occurred among both groups, with most of the behaviour change occurring during the first three months, e.g. 86 respondents (56%) reported condom use at last intercourse at 3 months compared with 24(16%) at baseline (p = 0.05).

    Extra care and support did not lead to increased risk reduction among the experimental group. The study population as a whole significantly changed their behaviour, suggesting that in the short term, learning one is HIV-positive has an impact on risk reduction. Often linked with problems such as tiredness and not being able to sleep. Headaches and bodily aches and pains were also mentioned by many of the women. In explaining the source of these problems, one of the strongest themes in women's accounts was the importance of their work roles. Women spoke of the gender division of labor, their heavy workloads, the 'compulsory' nature of their work, their financial insecurity and the considerable financial responsibility they assumed for their children. These contributed to the worry they experienced and led them into many different work activities. They also talked about specific links between the nature of their work and the health problems they experienced, in particular, the physical toll of their work. We suggest that it is important to document the content of women's work, both paid and unpaid, showing the ways in which it influences their physical and mental health. Women in developing countries have too long been defined as childbearers and their important roles as workers have too often been neglected.

    HIV prevention among male clients of female sex workers in Kaolack, Senegal: results of a peer education program. AIDS Educ Prev 2000:Feb;12(1):21-37
    Leonard L, Ndiaye I, Kapadia A, Eisen G, Diop O, Mboup S, Kanki P

    This article reports the results of a peer-led HIV prevention education and condom promotion program among transport workers in Kaolack, Senegal. As part of a 2-year longitudinal follow-up study, changes in men's AIDS-related knowledge, sexual behavior, condom use, and perceived barriers to condom use were evaluated by self-reports obtained from a systematic sample of transport workers interviewed before and after intervention. In addition to men's self-reports, preintervention and postintervention data on men's sexual and condom use behavior were gathered from a sample of licensed, commercial sex workers, who cited transport workers as their primary source of clients.

    Significant increases in men's HIV-related knowledge, previous use of condoms (from 30.4% to 53.5%), and consistent condom use with regular sex partners were documented over the study period, as were significant declines in perceived barriers to condom use. Though men reported significantly fewer sexual encounters with casual and commercial partners at follow-up compared to baseline, these data were unreliable.

    Women's post intervention reports indicate that a greater proportion of clients (including, but not limited to transport workers) "always" agree to use condoms (p < .01) compared with baseline and that fewer men offer more money for unprotected sex (p < .01). However, women also report taking greater initiative in the mechanics of condom use (supplying the condom, putting it on, and taking it off) than they did prior to the intervention, and significantly (p < .05) fewer women think that most of their clients know how to use a condom. The findings indicate that the peer-mediated intervention had a positive impact on several important outcomes measured and suggest that HIV prevention efforts need to focus on male client groups despite the logistical and methodological challenges.

    Heterosexual anal intercourse: prevalence, cultural factors, and HIV infection and other health risks, Part I.
    Halperin DT
    Aids Patient Care STDS 1999 Dec;13(12):717-30

    Studies of heterosexual HIV transmission have consistently found anal intercourse to be a highly predictive risk factor for seroconversion. Yet most AIDS prevention messages targeted at heterosexuals, presumably influenced by cultural taboos against acknowledging this sexual practice, continue to emphasize vaginal and, increasingly, oral sex transmission. The health risks of anal sex appear to be severely underestimated by a substantial proportion of sexually active women and men in North and Latin America as well as parts of South Asia, Africa, and other regions. Among heterosexuals reported rates of condom use are nearly universally lower for anal than for vaginal intercourse.

    This review examines anal sex among the general population, including its prevalence in various world regions, related sociocultural factors, and other associated health problems including anorectal STDs, Hepatitis B infection, and HPV-related anal cancer in women. U.S. survey and other data suggest that, in terms of absolute numbers, approximately seven times more women than homosexual men engage in unprotected receptive anal intercourse. Research among higher risk subpopulations, including bisexual men, injecting drug users, female sex workers, inner-city adolescents, and serodiscordant heterosexual couples, indicates that persons particularly at risk of being infected by or transmitting HIV are also more likely to practice anal sex. Considering this finding, along with the much greater efficiency for HIV infection as well as lower rates of condom usage, a significant proportion of heterosexual transmission in some populations is due to anal intercourse.

    This typically stigmatized and hidden sexual practice must be given greater emphasis in AIDS/STD prevention, women's care, and other health promotion programs.

    Community-perceived benefits of ivermectin treatment in northeastern Nigeria.
    Akogun OB, Akogun MK, Audu Z
    Soc Sci Med 2000 May;50(10):1451-6

    A 3-step approach involving focus group discussion, structured interviews and informal conversations with key individuals was used to investigate community usage and perceived benefits of ivermectin in nine Nigerian villages participating in a WHO-sponsored investigation of community-directed treatment with ivermectin (CDTI). Only 27% of 284 persons interviewed had received treatment. An under-estimation of the district's ivermectin needs led to inadequate supply of ivermectin to the communities, which was cited as the main reason (65%) for non-treatment. All those treated (N=76) were further interviewed using questionnaires. Worm expulsion (80%) and blindness s prevention (68%) were the most frequently stated benefits. Other perceived benefits were an increase in vitality (68%), sexual drive and performance (29%). The sudden relief from a heavy burden of worms, which had built up over a long period, may have indirect effect on all aspects of an individual's health and account for the diverse experiences. The feeling of vitality, good appetite and general health following ivermectin treatment is an animating experience to many communities. Health planners face the challenge of preparing communities for fewer 'sensational' experiences and preventing a possible feeling of disappointment that may result from frequent usage.

    Sexually transmitted diseases in Morocco: gender influences on prevention and health care seeking behavior.
    Soc Sci Med 2000 May;50(10):1369-83
    Manhart LE, Dialmy A, Ryan CA, Mahjour J

    Increased awareness of the medical and social costs of sexually transmitted diseases (STD) has resulted in greater attention to the control of these illnesses. STDs are responsible for a significant amount of morbidity in Morocco and have become a key target of the HIV control program. In 1996, the Ministry of Health conducted a qualitative study in order to enhance information, education and communication strategies in the national STD/HIV program. Data on the conceptualization and knowledge of STD, information sources and health-care-seeking behavior were gathered through 70 semidirected, in-depth interviews conducted with men and women in the general population and health care providers (HCPs).

    Two commonly applied health behavior theories in STD/HIV prevention, the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) served as a framework for data analysis. The most common name for STD is berd, which means "the cold" in Moroccan Arabic. Berd is caused either by cold striking the genital area or sexual intercourse and most often designates a syndrome of genital discharge. However, the term was also often used to indicate STD in general. The dual causality of berd maintains social stability by providing an honorable excuse for individuals who become infected, while warning against unsanctioned sexual behavior. Clear gender differences in understanding STDs and health-care-seeking behavior emerged through these interviews. STDs in Morocco are viewed as women's illnesses and men with STD often reported feeling victimized by women. Men appear to have more extensive informal information sources for STD than women. Consequences of STD, both physical and psychosocial, were viewed as more severe for women than men, and men had greater access to treatment, for both social and economic reasons.

    HIV incidence and HIV-associated mortality in a cohort of factory workers and their spouses in Tanzania, 1991 through 1996.
    Senkoro KP, Boerma JT, Klokke AH, Ng'weshemi JZ, Muro AS, Gabone R, Borgdorff MW
    J Acquir Immune Defic Syndr 2000 Feb 1;23(2):194-202

    n acceptability study of female-controlled methods of protection against HIV and STDs in south-western Uganda.
    Pool R, Whitworth JA, Green G, Mbonye AK, Harrison S, Wilkinson J, Hart GJ
    Int J STD AIDS 2000 Mar;11(3):162-7

    We aimed to assess the acceptability of a variety of formulations of female-controlled methods of protection against HIV and STDs among men and women in south-western Uganda. Pilot interviews were carried out with 50 men and 55 women and 25 focus group discussions (FGDs) were held with 138 women and 42 men. The female condom, foaming tablets, sponge, foam, gel and film were demonstrated to 146 women and 35 of their male partners, who then tried out 2 of the products. They were interviewed 7 times during the course of 5 months. At the end experiences were evaluated during a second series of FGDs. Sixty-five (45%) women completed the trial. The main reasons for non-completion were related to geographical mobility. Product preference after the initial demonstration was similar to that at the end of the trial.

    The most popular formulations were the sponge (25% of the women), foaming tablets (23%), and the female condom (19%). The foam was of medium popularity (16%). The gel (9%) and film (7%) were least popular. Ten per cent of the women and 14% of the men reported products interfering with sexual enjoyment; 24% of the women and 67% of the men said products increased enjoyment. 'Dry sex' is not popular in this area and increased lubrication was an important determinant of acceptability. Age, level of education and location did have some effect on preference. Although secrecy was a dominant theme in the FGDs, 87% of the women had informed their partners by the end of the trial.

    The products were generally well received. Female control was an important issue for both sexes. Male attitudes were ambivalent because female ownership of products increased women's control. Although they have clear preferences, women appear to accept the products generally and might use a single available product just as readily if choice was limited, as long as it conforms to general cultural preferences, such as those relating to wet/dry sex.

    Psychosocial determinants for sexual partner referral in Uganda: qualitative results.
    Nuwaha F, Faxelid E, Neema S, Eriksson C, Hojer B
    Int J STD AIDS 2000 Mar;11(3):156-61

    In order to understand and elicit the psychosocial factors influencing compliance with sexual partner referral, 10 focus group discussions (FGDs) and 40 individual interviews based on the attitude-social influence-self efficacy (ASE) model were held in Mbarara District of Uganda. The focus groups were derived from both rural and urban areas. Informal interviews were held with 20 men and 20 women presenting with symptoms of a sexually transmitted disease (STD) at the outpatient department of Mbarara Hospital. The emerging outcome of attitudinal beliefs regarding health consequences of partner referral were mainly positive. However, outcome beliefs relating to the relationship with the partners were mainly negative. Social influence for sexual partner referral was from health-care providers, partner(s), friends and relatives. The self-efficacy beliefs were mainly negative especially among women. Barriers hampering sexual partner referral were related to poor quality of health care, gender relations and type of sexual partners. There is a need to target these beliefs and self-efficacy expectations in health education and STD counselling and for more research to evaluate the psychosocial determinants of sexual partner referral quantitatively.

    reventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990-1993.
    Laukamm-Josten U, Mwizarubi BK, Outwater A, Mwaijonga CL, Valadez JJ, Nyamwaya D, Swai R, Saidel T, Nyamuryekung'e KP
    AIDS Care 2000 Feb;12(1):27-40

    HIV prevention through peer education and condom promotion among truck drivers and their sexual partners is described. Trends during an initial 18-month intensive phase, followed by a 24-month maintenance phase, were monitored with surveys. Trends for self-reported condom use were: increase among men (56 to 74%) during the first phase with a decrease (72%) during the maintenance phase. Respective figures for women were 51%, 91% and 70%. Multivariate analyses revealed that men most likely to report using condoms were unmarried, had children, were more educated, had previously reported a genital ulcer, and perceived themselves at risk for HIV infection (OR = 1.95-3.47).

    Women tending to use condoms were unmarried, aware of the limitations of condoms, not in denial as to the existence of HIV, harboured inaccurate information about HIV transmission and were afraid (OR = 1.35-2.52). Both sets of results suggest that the most sexually experienced men and women who did not have a permanent stable relationship and who perceived themselves at risk, were most likely to use a condom.

    Peer education was an effective tool for increasing knowledge and encouraging appropriate behaviour change. It was most effective as an intensive high-input intervention and sustainable with the relatively stable population of truck drivers.

    Women's attitudes to condoms and female-controlled means of protection against HIV and STDs in south-western Uganda.
    Hart GJ, Pool R, Green G, Harrison S, Nyanzi S, Whitworth JA
    AIDS Care 1999 Dec;11(6):687-98

    The consistent and correct use of the male condom makes it highly effective in both disease prevention and as a contraceptive method. However, it is also well recognized that its use is under men's control. Because of this vital limitation, there have been frequent calls for female-controlled methods of HIV prevention, particularly from women from sub-Saharan Africa. Here we report on data collected in focus-group discussions (FGDs) with women aged 17-54 inSouth-Western Uganda. A total of 138 women, from rural villages, urban family planning clinics and a truck-stop town, were recruited to participate in 18 FGDs on the male condom, the female condom and existing formulations of vaginal microbicidal products. Three themes emerged:

    We found that the female condom, while being perceived as an improvement over the male condom, was recognized as having limited value because of the need to agree its use prior to sex taking place. Other products were considered to be significantly better than the female condom; the sponge, in particular, was perceived as having advantages over every other product. Women like the fact that it could be inserted some time before, and left in place some time after, sexual intercourse, that it was effective for multiple instances of intercourse, and that men would be unaware that it was being employed. Female-controlled methods to prevent sexually transmitted infections, including HIV, and to increase reproductive choice, hold the promise of ceding some control over sexual and reproductive health to women.

    Evaluation of a drama-in-education programme to increase AIDS awareness in South African high schools: a randomized community intervention trial.
    Med Trop (Mars) 44: Int J STD AIDS 2000 Feb;11(2):105-11
    J. Psychosom Res 1998 Oct;45(4):353-60

    A community intervention trial was undertaken in KwaZulu Natal, South Africa to evaluate the effectiveness of a high school drama-in-education programme. Seven pairs of secondary schools were randomized to receive either written information about HIV/AIDS or the drama programme. Questionnaire surveys of knowledge, attitude and behaviour were compared before and 6 months after the interventions. One thousand and eighty students participated in the first survey and 699 in the second. Improvements in knowledge (P=0.0002) and attitudes (P < 0.00001) about HIV/AIDS were demonstrated in pupils at schools receiving the drama programme when compared to pupils receiving written information alone. These changes were independent of age, gender, school or previous sexual experience. In schools receiving the drama programme, sexually active pupils reported an increase in condom use (P < 0.01). It is important to provide resources to sustain such programmes and to obtain stronger evidence of effect on behaviour by measuring changes in HIV incidence.

    Beliefs about sexual relationships and behaviour among commercial farm residents in Zimbabwe.
    Bhagwanjee A, Parekh A, Paruk Z, Petersen I, Subedar H
    Cent Afr J Med 1999 Jul;45(7):178-82

    Predictors of women's decision to ask new partners to use condoms to avoid HIV/AIDS in South Africa.
    Kirigia JM, Muthuri LH
    East Afr Med J 1999 Sep;76(9):484-9

    Social aspects of AIDS-related stigma in rural Uganda.
    Muyinda H, Seeley J, Pickering H, Barton T
    Health Place 1997 Sept;3(3):143-7

    In the process of collecting sexual behaviour data through in-depth interviews, 24 respondents offered information on stigma related to HIV-1 infection. Observations of social relations in public places and families of infected individuals were made. The findings suggest that although HIV/AIDS-related stigma has had adverse effects on treatment seeking behaviour of PWAs and coping mechanisms of their families, a more tolerant attitude is starting to emerge in this area. Probably, due to improvements in counselling services and home care schemes for those with AIDS. This supports the call for increased investments in counselling and community development aimed at caring for people with AIDS (PWAs).

    Posttraumatic stress symptoms in a population of rural children in South Africa.Peltzer K
    Psychol Rep 1999 Oct;85(2):646-50

    The purpose of the study was to identify exposure to experiences such as violence and the consequences for health in children in a rural South African community. The stratified random sample included 148 children below 17 yr., which comprised 68 (46%) boys and 80 (54%) girls in the age range of 6 to 16 years (M = 12.1 yr., SD = 3.1). Their ethnicity was Northern Sotho. The interviews included the Children's Posttraumatic Stress Disorder Inventory and the Reporting Questionnaire for Children. The experiences could be grouped into either traumatic or other events. 99 (67%) had directly or vicariously experienced a traumatic event which included witnessing someone killed or seriously injured, serious accident, violent or very unexpected death or suicide of loved one, sexual abuse or rape of relative or friend, violent crime, child abuse, and other life-threatening situations. Scores on the Children's Posttraumatic Stress Disorder Inventory of 17 (8.4%) fulfilled the criterion for posttraumatic stress disorder. 71% had more than one score and 53% had more than four scores on the Reporting Questionnaire for Children. Posttraumatic stress symptoms were significantly related to age and experiences such as thosementioned above.

    Socio-demographic characteristics and sexual behaviour of adolescents attending the STC, UCH, Ibadan: a 5 year review.
    Fawole OI, Ajayi IO, Babalola TD, Oni AA, Asuzu MC
    West Afr J Med 1999 Jul-Sep;18(3):165-9

    As a continuation of the on-going efforts to prevent and control the spread ofsexually transmitted diseases (STDs) and the Acquired Immunodeficiency syndrome (AIDS) in adolescents, this retrospective clinic-based study identifies the socio- demographic characteristics, describes the sexual practices, identifies the common STDs, including drug utilization patterns in this risk group at the special treatment clinic of the University College Hospital, Ibadan.

    Results reveal that adolescents constituted between 3.3% and 4.8% of the total number of patients seen each year. The characteristics of the subjects were as follows: 54 (38.3%) were aged 19 years, 133 (94.3%) were single, 79 (53.2%) were females and 103 (73.0%) were students.

    As regards sexual behaviour, 22 (15.71%) denied previous history of sexual intercourse. Vaginal intercourse was reported in all the sexually active youth, 2(1.71%) reported oral sex, while 10 (8.41%) admitted that they had multiple sexual partners. Gonorrhoea was diagnosed in 23 (21.51%) of sexually active youths. Among those who had used drugs before presentation ampicillin was the common drug used for treatment by 14 (26.4%).

    The importance of encouraging adolescents to present at STD clinics is highlighted. Health workers need to have a sympathetic attitude and assure them of confidentiality. The need for more community-based education is shown, including the importance of proper and complete documentation of hospital records.

    Reduced fertility associated with HIV: the contribution of pre-existing subfertility.
    Ross A, Morgan D, Lubega R, Carpenter LM, Mayanja B, Whitworth JA
    AIDS 1999 Oct 22;13(15):2133-41

    Lymphatic filariasis related perceptions and practices on the coast of Ghana: implications for prevention and control.
    Ahorlu CK, Dunyo SK, Koram KA, Nkrumah FK, Aagaard-Hansen J, Simonsen PE
    Acta Trop 1999 Oct 15;73(3):251-61

    A qualitative study to investigate lymphatic filariasis related perceptions and practices that may be relevant for the design of appropriate health education and control programmes was conducted in four endemic villages in coastal Ghana. The villagers were aware of the common manifestations of filariasis, such as adenolymphangitis (ADL), lymphoedema, elephantiasis and hydrocele, which were specifically described with local terminology. ADL attacks were identified as the most dreaded health problem in the communities, and elephantiasis and hydrocele also ranked high in importance among reported diseases. Generally the respondents did not accept the mosquito theory of transmission, but they believed in other physical, and in spiritual and hereditary causes. Hydrocele was considered to have no link to the other disease manifestations. The manifestations were most often treated with herbal preparations which were used orally, smeared on affected parts or given as enema. In some cases the affected parts were scarified before herbal preparations were applied.

    The manifestations affected the work output of its victims and subjected them to hardships such as teasing, unsuitability for marriage, sexual dysfunction and divorce. Although the etiology was seen as different, the local perception of the developmental process of elephantiasis closely paralleled that of the biomedical understanding. It is suggested that this coincidence is used as an entry point for health education, to advance a broader biomedical knowledge on etiology, transmission and treatment options, and thereby to ensure co-operation of the target populations in the control of this complex disease.

    Increased sexual abstinence among in-school adolescents as a result of school health education in Soroti district, Uganda.
    Shuey DA, Babishangire BB, Omiat S, Bagarukayo H
    Health Educ Res 1999 Jun;14(3):411-9

    A school health education programme in primary schools aimed at AIDS prevention in Soroti district of Uganda emphasized improved access to information, improved peer interaction and improved quality of performance of the existing school health education system. A cross-sectional sample of students, average age 14 years, in their final year of primary school was surveyed before and after 2 years of interventions. The percentage of students who stated they had been sexually active fell from 42.9% (123 of 287) to 11.1% (31 of 280) in the intervention group, while no significant change was recorded in a control group. The changes remained significant when segregated by gender or rural and urban location. Students in the intervention group tended to speak to peers and teachers more often about sexual matters. Increases in reasons given by students for abstaining from sex over the study period occurred in those reasons associated with a rational decision-making model rather than a punishment model.

    A primary school health education programme which emphasizes social interaction methods can be effective in increasing sexual abstinence among school-going adolescents in Uganda. The programme does not have to be expensive and can be implemented with staff present in most districts in the region.

    Predictors of condom use among patients with sexually transmitted diseases in Uganda.
    Nuwaha F, Faxelid E, Hojer B
    Sex Transm Dis 1999 Oct;26(9):491-5

    A school-based AIDS education programme for secondary school students in Nigeria: a review of effectiveness.
    Fawole IO, Asuzu MC, Oduntan SO, Brieger WR
    Health Educ Res 1999 Oct;14(5):675-83

    Nigerian secondary school students are becoming sexually active at an increasing earlier age. Sexually active students are at risk of contacting STDs, including HIV infection. As a result, health education initiatives to increase level of knowledge, influence attitudes and encourage safe sexual practices are being implemented in schools, but the effectiveness of these programmes have not been evaluated.

    In this study, the knowledge, attitude and sexual risk behaviors of223 students who received a comprehensive health education intervention were compared with 217 controls. At post-test, intervention students exhibited greater knowledge about HIV/AIDS transmission and prevention (P < 0.05). Intervention students were less likely to feel AIDS is a white man's disease and were more likely to be tolerant of people living with the disease (P < 0.05). After the intervention, the mean number of reported sexual partners among the experimental students significantly decreased from 1.51 to 1.06, while it increased from 1.3 to 1.39 among the controls.

    Among the intervention students there was also an increase in consistent use of the condom and the use of the condom at last sexual intercourse. We conclude that students can benefit from specific education programmes that transmit important information necessary to prevent risky behavior, and improve knowledge and attitudes on HIV/AIDS.

    FACT SHEET: THE EVIDENCE LINKING HIV TO AIDS

    Global Issues An Electronic Journal of the U.S. Department of State Volume 5, Number 2, July 2000

     The following fact sheet, prepared by the U.S. National Institute of Allergy and Infectious Diseases (NIAID), a component of the National Institutes of Health, refutes many of the myths surrounding the AIDS epidemic.

    MYTH:
    HIV antibody testing is unreliable.
    FACT:
    Diagnosis of infection using antibody testing is one of the best- established concepts in medicine. HIV antibody tests exceed the performance of most other infectious disease tests in both sensitivity (the ability of the screening test to give a positive finding when the person tested truly has the disease) and specificity (the ability of the test to give a negative finding when the subjects tested are free of the disease under study). Current HIV antibody tests have sensitivity and specificity in excess of 98 percent and are therefore extremely reliable (W.H.O, 1998; Sloand et al. JAMA 1991;266:2861).

    Progress in testing methodology has also enabled detection of viral genetic material, antigens, and the virus itself in body fluids and cells. While not widely used for routine testing due to high cost and requirements in laboratory equipment, these direct testing techniques have confirmed the validity of the antibody tests (Jackson et al. J Clin Microbiol 1990;28:16; Busch et al. NEJM 1991;325:1; Silvester et al. J Acquir Immune Defic Syndr Hum Retrovirol 1995;8:411; Urassa et al. J Clin Virol 1999;14:25; Nkengasong et al. AIDS 1999;13:109; Samdal et al. Clin Diagn Virol 1996;7:55).

    MYTH:
    There is no AIDS in Africa. AIDS is nothing more than a new name for old diseases.
    FACT:
    The diseases that have come to be associated with AIDS in Africa -- such as wasting syndrome, diarrhoeal diseases, and tuberculosis (TB) -- have long been severe burdens there. However, high rates ofmortality from these diseases, formerly confined to the elderly and malnourished, are now common among HIV-infected young and middle-aged people (UNAIDS, 1999).

    For example, in a study in Cote d'Ivoire, HIV-seropositive individuals with pulmonary tuberculosis (TB) were 17 times more likely to die within six months than HIV-seronegative individuals with pulmonary TB (Ackah et al. Lancet 1995; 345:607). In Malawi, mortality over three years among children who had received recommended childhood immunizations and who survived the first year of life was 9.5 times higher among HIV-seropositive children than among HIV-seronegative children. The leading causes of death were wasting and respiratory conditions (Taha et al. Pediatr Infect Dis J 1999;18:689). Elsewhere in Africa, findings are similar.

    MYTH:
    HIV cannot be the cause of AIDS because researchers are unable to explain precisely how HIV destroys the immune system.
    FACT:
    A great deal is known about the pathogenesis of HIV disease, even though important details remain to be elucidated. However, a complete understanding of the pathogenesis of a disease is not a prerequisite to knowing its cause. Most infectious agents have been associated with the disease they cause long before their pathogenic mechanisms have been discovered. Because research in pathogenesis is difficult when precise animal models are unavailable, the disease-causing mechanisms in many diseases, including tuberculosis and hepatitis B, are poorly understood. The critics' reasoning would lead to the conclusion that M. tuberculosis is not the cause of tuberculosis or that hepatitis B virus is not a cause of liver disease (Evans. Yale J Biol Med 1982;55:193).

    MYTH:
    AZT and other antiretroviral drugs, not HIV, cause AIDS.
    FACT:
    The vast majority of people with AIDS never received antiretroviral drugs, including those in developed countries prior to the licensure of AZT in 1987, and people in developing countries today where very few individuals have access to these medication (UNAIDS, 1999).

    As with medications for any serious diseases, antiretroviral drugs can have toxic side effects. However, there is no evidence that antiretroviral drugs cause the severe immunosuppression that typifies AIDS, and abundant evidence that antiretroviral therapy, when used according to established guidelines, can improve the length and quality of life of HIV-infected individuals (Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, 2000).

    In the 1980s, clinical trials enrolling patients with AIDS found that AZT given as single-drug therapy conferred a modest (and short-lived) survival advantage compared to placebo. Among HIV-infected patients who had not yet developed AIDS, placebo-controlled trials found that AZT given as single-drug therapy delayed, for a year or two, the onset of AIDS-related illnesses. Significantly, long-term follow-up of these trials did not show a prolonged benefit of AZT, but also never indicated that the drug increased disease progression or mortality. The lack of excess AIDS cases and death in the AZT arms of these placebo-controlled trials effectively counters the argument that AZT causes AIDS (NIAID, 1995).

    Subsequent clinical trials found that patients receiving two-drug combinations had up to 50 percent increases in time to progression to AIDS and in survival when compared to people receiving single-drug therapy. In more recent years, three-drug combination therapies have produced another 50 percent to 80 percent improvement in progression to AIDS and in survival when compared to two-drug regimens in clinical trials (Deeks, Volberding, 1999). Use of potent anti-HIV combination therapies has contributed to dramatic reductions in the incidence of AIDS and AIDS-related deaths in populations where these drugs are widely available, an effect which clearly would not be seen if antiretroviral drugs caused AIDS (Figure 1; CDC. HIV AIDS Surveillance Report 1999;1 [2]:1; CDC MMWR 1999; 48:1; Palella et al. NEJM 1998;338:853; Mocroft et al. Lancet 1998; 352:1725; Vittinghoff et al. J Infect Dis 1999;179:717; Detels et al. JAMA 1998;280:1497).

    MYTH:
    Behavioural factors such as recreational drug use and multiple sexual partners account for AIDS.
    FACT:
    The proposed behavioural causes of AIDS, such as multiple sexual partners and long-term recreational drug use, have existed for many years. The epidemic of AIDS, characterized by the occurrence of formerly rare opportunistic infections such as Pneumocystis carinii pneumonia (PCP), did not occur in the United States until a previously unknown human retrovirus -- HIV --spread through certain communities (NIAID, 1995a; NIAID, 1995b).

    Compelling evidence against the hypothesis that behavioural factors cause AIDS comes from recent studies that have followed cohorts of homosexual men for long periods of time and found that only HIV-seropositive men develop AIDS.

    For example, in a prospectively studied cohort in Vancouver, 715 homosexual men were followed for a median of 8.6 years. Among 365 HIV-positive individuals, 136 developed AIDS. No AIDS-defining illnesses occurred among 350 seronegative men despite the fact that these men reported appreciable use of inhalable nitrites ("poppers") and other recreational drugs, and frequent receptive anal intercourse (Schechter et al. Lancet 1993;341:658).

    Other studies show that among homosexual men and injection-drug users, the specific immune deficit that leads to AIDS - a progressive and sustained loss of CD4+ T cells -- is extremely rare in the absence of other immunosuppressive conditions. For example, in the Multicenter AIDS Cohort Study, more than 22,000 T-cell determinations in 2,713 HIV-seronegative homosexual men revealed only one individual with a CD4+ T-cell count persistently lower than 300 cells per cubic millimeter (mm3) of blood, and this individual was receiving immunosuppressive therapy (Vermund et al. NEJM 1993;328:442).

    In a survey of 229 HIV-seronegative injection-drug users in New York City, mean CD4+ T-cell counts of the group were consistently more than 1000 cells/mm3 of blood. Only two individuals had two CD4+ T-cell measurements of less than 300/mm3 of blood, one of whom died with cardiac disease and non-Hodgkin's lymphoma listed as the cause of death (Des Jarlais et al. J Acquir Immune Defic Syndr 1993;6:820).

    MYTH:
    AIDS among transfusion recipients is due to underlying diseases that necessitated the transfusion, rather than to HIV.
    FACT:
    This notion is contradicted by a report by the U.S. Transfusion Safety Study Group (TSSG), which compared HIV-negative and HIV- positive blood recipients who had been given transfusions for similar diseases. Approximately three years after the transfusion, the mean CD4+ T-cell count in 64 HIV-negative recipients was 850/mm3 of blood, while 111 HIV-seropositive individuals had average CD4+ T-cell counts of 375/mm3 of blood. By 1993, there were 37 cases of AIDS in the HIV- infected group, but not a single AIDS-defining illness in the HIV- seronegative transfusion recipients (Donegan et al. Ann Intern Med 1990;113:733; Cohen. Science 1994;266:1645).

    MYTH:
    High usage of clotting factor concentrate, not HIV, leads to CD4+ T- cell depletion and AIDS in hemophiliacs.
    FACT:
    This view is contradicted by many studies. For example, among HIV- seronegative patients with hemophilia A enrolled in the Transfusion Safety Study, no significant differences in CD4+ T-cell counts were noted between 79 patients with no or minimal factor treatment and 52 with the largest amount of lifetime treatments. Patients in both groups had CD4+ T cell-counts within the normal range (Hasset et al. Blood 1993;82:1351). In another report from the Transfusion Safety Study, no instances of AIDS-defining illnesses were seen among 402 HIV-seronegative hemophiliacs who had received factor therapy (Aledort et al. NEJM 1993;328:1128).

    In a cohort in the United Kingdom, researchers matched 17 HIV- seropositive hemophiliacs with 17 HIV-seronegative hemophiliacs with regard to clotting factor concentrate usage over a 10-year period. During this time, 16 AIDS-defining clinical events occurred in nine patients, all of whom were HIV-seropositive. No AIDS-defining illnesses occurred among the HIV-negative patients. In each pair, the mean CD4+ T cell count during follow-up was, on average, 500 cells/mm3 lower in the HIV-seropositive patient (Sabin et al. BMJ 1996;312:207).

    Among HIV-infected hemophiliacs, Transfusion Safety Study investigators found that neither the purity nor the amount of Factor VIII therapy had a deleterious effect on CD4+ T cell counts (Gjerset et al., Blood 1994;84:1666). Similarly, the Multicenter Hemophilia Cohort Study found no association between the cumulative dose of plasma concentrate and incidence of AIDS among HIV-infected hemophiliacs (Goedert et al. NEJM 1989;321:1141).

    MYTH:
    The distribution of AIDS cases casts doubt on HIV as the cause. Viruses are not gender-specific, yet only a small proportion of AIDS cases are among women.
    FACT:
    The distribution of AIDS cases, whether in the United States or elsewhere in the world, invariably mirrors the prevalence of HIV in a population. In the United States, HIV first appeared in populations of homosexual men and injection-drug users, a majority of whom are male. Because HIV is spread primarily through sex or by the exchange of HIV-contaminated needles during injection-drug use, it is not surprising that a majority of U.S. AIDS cases have occurred in men (U.S. Census Bureau, 1999; UNAIDS, 1999).

    Increasingly, however, women in the United States are becoming HIV- infected, usually through the exchange of HIV-contaminated needles or sex with an HIV-infected male. The Centers for Disease Control (CDC) estimates that 30 percent of new HIV infections in the United States in 1998 were in women. As the number of HIV-infected women has risen, so too has the number of female AIDS patients in the United States. Approximately 23 percent of U.S. adult/adolescent AIDS cases reported to the CDC in 1998 were among women. In 1998, AIDS was the fifth leading cause of death among women aged 25 to 44 in the United States, and the third leading cause of death among African-American women in that age group (NIAID Fact Sheet: HIV/AIDS Statistics).

    In Africa, HIV was first recognized in sexually active heterosexuals, and AIDS cases in Africa have occurred at least as frequently in women as in men. Overall, the worldwide distribution of HIV infection and AIDS between men and women is approximately one to one (U.S.Census Bureau, 1999; UNAIDS, 1999).

    MYTH:
    HIV cannot be the cause of AIDS because the body develops a vigorous antibody response to the virus.
    FACT:
    This reasoning ignores numerous examples of viruses other than HIV that can be pathogenic after evidence of immunity appears. Measles virus may persist for years in brain cells, eventually causing a chronic neurologic disease despite the presence of antibodies. Viruses such as cytomegalovirus, herpes simplex, and varicella zoster may be activated after years of latency even in the presence of abundant antibodies. In animals, viral relatives of HIV with long and variable latency periods, such as visna virus in sheep, cause central nervous system damage even after the production of antibodies (NIAID, 1995). Also, HIV is well recognized as being able to mutate to avoid the ongoing immune response of the host (Levy. Microbiol Rev 1993;57:183).

    MYTH:
    Only a small number of CD4+ T cells are infected by HIV, not enough to damage the immune system.
    FACT:
    New techniques such as the polymerase chain reaction (PCR) have enabled scientists to demonstrate that a much larger proportion of CD4+ T cells are infected than previously realized, particularly in lymphoid tissues. Macrophages and other cell types are also infected with HIV and serve as reservoirs for the virus. Although the fraction of CD4+ T cells that is infected with HIV at any given time is never extremely high (only a small subset of activated cells serve as ideal targets of infection), several groups have shown that rapid cycles of death of infected cells and infection of new target cells occur throughout the course of disease (Richman J Clin Invest 2000;105:565).
    MYTH:
    HIV is not the cause of AIDS because many individuals with HIV have not developed AIDS.
    FACT:
    HIV disease has a prolonged and variable course. The median period of time between infection with HIV and the onset of clinically apparent disease is approximately 10 years in industrialized countries, according to prospective studies of homosexual men in which dates of seroconversion are known. Similar estimates of asymptomatic periods have been made for HIV-infected blood-transfusion recipients, injection-drug users, and adult hemophiliacs (Alcabes et al. Epidemiol Rev 1993;15:303).

    As with many diseases, a number of factors can influence the course of HIV disease. Factors such as age or genetic differences between individuals, the level of virulence of the individual strain of virus, as well as exogenous influences such as co-infection with other microbes may determine the rate and severity of HIV disease expression. Similarly, some people infected with hepatitis B, for example, show no symptoms or only jaundice and clear their infection, while others suffer disease ranging from chronic liver inflammation to cirrhosis and hepatocellular carcinoma. Co-factors probably also determine why some smokers develop lung cancer while others do not (Evans. Yale J Biol Med 1982;55:193; Levy. Microbiol Rev 1993;57:183; Fauci. Nature 1996;384:529).

    MYTH:
    Some people have many symptoms associated with AIDS but do not have HIV infection.
    FACT:
    Most AIDS symptoms result from the development of opportunistic infections and cancers associated with severe immunosuppression secondary to HIV. However, immunosuppression has many other potential causes. Individuals who take glucocorticoids and/or immunosuppressive drugs to prevent transplant rejection or for autoimmune diseases can have increased susceptibility to unusual infections, as do individuals with certain genetic conditions, severe malnutrition, and certain kinds of cancers. There is no evidence suggesting that the numbers of such cases have risen, while abundant epidemiologic evidence shows a staggering rise in cases of immunosuppression among individuals who share one characteristic: HIV infection (NIAID, 1995; UNAIDS, 1999).

    MYTH:
    The spectrum of AIDS-related infections seen in different populations proves that AIDS is actually many diseases not caused by HIV.
    FACT:
    The diseases associated with AIDS, such as PCP and Mycobacterium avium complex (MAC), are not caused by HIV but rather result from the immunosuppression caused by HIV disease. As the immune system of an HIV-infected individual weakens, he or she becomes susceptible to the particular viral, fungal, and bacterial infections common in the community. For example, HIV-infected people in certain Midwestern and mid-Atlantic regions are much more likely than people in New York City to develop histoplasmosis, which is caused by a fungus. A person in Africa is exposed to different pathogens than is an individual in an American city. Children may be exposed to different infectious agents than adults (AIDS Knowledge Base, 1999a; 1999b).

    An expanded version of this fact sheet is available on the NIAID website

    SEXUAL AND REPRODUCTIVE HEALTH IN CONFLICT SITUATIONS

    By: Wilma Doedens (Sexual Health Exchange, 2000 - no.2 )

     During the International Conference on Population and Development in 1994, the international community for the first time defined reproductive health, not in a demographic context, but as a right and matter of choice for every individual. In the years that followed, other international conferences, such as the 1995 Fourth World Conference on Women reinforced this consensus. Governments agreed that, in crisis situations, they and the rest of the international community should honour all relevant llegal obligations and live up to international commitments to protect and promote the rights of refugees and displaced persons, including reproductive rights.

    Human rights relevant to reproductive health include

    Refugees of course have the same reproductive health needs as people unaffected by displacement. Moreover, the factors that influence the involuntary movement of populations across and within national frontiers render them extremely vulnerable, including to reproductive health problems. This increases their needs for preventive and curative care, including services related to safe motherhood, family planning, prevention of unsafe abortion and treatment of complicated abortions, prevention and treatment of HIV/AIDS and other sexually transmitted infections (STIs), prevention and management of the consequences of sexual violence, and sex education. Forcibly-displaced persons have left behind the support of traditional values, extended families, friends and familiar ways of life. They have often lost their loved ones, their possessions, their jobs and income, their social status, and even their human dignity. Provision of adequate reproductive health services in these situations is always very difficult. Refugees have often lost their loved ones, their possessions, their jobs and income, their social status, and even their human dignity. (Steve Dupont/CARE)

    Sexual and gender-based violence
    At every stage of a conflict, women and adolescent girls and boys are vulnerable to sexual violence. While rape and other forms of violent sexual assault have always been used as weapons of war, this problem seems to be worsening. Many women and girls are forced to offer sex in exchange for food, shelter or protection. Emergency contraception and other medical and psychological support are rarely available. Sexual violence has a disastrous effect on people's physical and mental health, leading to unwanted pregnancies, unsafe and complicated abortions, abandoned babies, HIV/STI transmission, sexual dysfunction, rejection by family and community and even suicide. Programmes aimed at preventing sexual violence have to involve the community as well as the police and military.

    STIs and HIV/AIDS
    Poverty, powerlessness and social instability promote the spread of both HIV and other STIs. Populations may be forced to migrate into areas with a higher incidence of HIV/STIs. An influx of armed forces or peace keepers consisting of young, sexually active men can also lead to increased HIV/STI transmission. Rape and sexual abuse often increase and people may be forced to exchange sexual favours for money or basic resources as a survival strategy. Soldiers may have minimal knowledge of HIV/STI prevention and can be victim and vehicle of transmission at the same time. Fighting leads to more surgical interventions and an increased demand for blood transfusions. In addition, HIV transmission through contaminated blood transfusions may be high if there is a breakdown in the normal system of blood screening and universal precautions. The impact of an increased HIV/STI prevalence on the public health of a community is very serious. A high prevalence of STIs is known to increase HIV transmission. There are physical sequelae, such as the debilitating chronic complications of AIDS like tuberculosis and diarrhoea. STIs can lead to long-term pain, infertility and complications during pregnancy and childbirth. Children may also be affected with increased risk of morbidity and mortality.

    Having to support a high number of people living with HIV/AIDS affects the economic and emotional well-being of the refugee community. HIV/AIDS can lead to social rejection, isolation and loss of income, poverty and economic dependence. The community may have to support an increasing number of orphans.

    Fertility and family planning
    Data on the fertility of displaced persons are not readily available and there is no conclusive evidence to support that their fertility is higher than before the crisis. In general, however, women in refugee settings seem to have higher fertility rates than they would in ordinary circumstances. As the situation stabilises, fertility rates can go up for several reasons: couples may want to replace lost children; mother and child health (MCH) programmes in the camps increase infants' chance of survival; and there may be political pressure to rebuild the community. Nevertheless, given the choice, many refugee couples would prefer to limit their family size and space their children.

    Maternal mortality and morbidity
    Most conflict situations affect populations from poor countries, where women already have an increased risk of maternal mortality and morbidity. Their flight aggravates this issue. Of the women of reproductive age in the refugee population, an estimated 20% is pregnant at any one time. During the exodus and emergency phases of a conflict situation, pregnant women may become malnourished and anaemic and are at high risk of serious infectious diseases. They are exposed to psychological and physical violence. They are often alone, living in temporary shelters and may have to give birth under hazardous conditions. Skilled help and surgical referral services are usually not available for the estimated 15% of deliveries that will develop complications. All these factors greatly increase the risk of maternal morbidity and mortality: after the emergency phase, the main causes of death among women refugees of childbearing age are pregnancy-related complications.

    Complications of abortion
    Spontaneous and induced abortions are common among forcibly-displaced persons. Refugee women are vulnerable to rape and coercive sex, especially in the early stages of the emergency. The breakdown in family ties often leads to increased unprotected sexual activity among young persons. As men lose their traditional roles and status and have little work to do, excessive drinking and violence may result. Methods of family planning and emergency contraception are not always provided or information about the availability of these methods may be lacking. All this may lead to an increased number of unwanted pregnancies. When abortion is not legally available, women may resort to dangerous procedures.

    Complications from abortions constitute a major cause of death and of morbidity such as haemorrhage, sepsis, chronic pelvic infections and infertility. Management of these complications is time-consuming and expensive and diverts scarce resources from other health services. Providing protection against sexual violence (e.g. through extra security in camps), family planning methods --including emergency contraception-- and safe abortion services is the only way to decrease the number of unsafe abortions.

    Harmful traditional practices
    There is anecdotal evidence that in stabilised refugee situations and in the returnee phase, the traditional practice of female genital cutting (FGC) is sometimes revived as communities attempt to reassert their cultural identity. However, FGC frequently results in serious, life-long health consequences, including complications during and after pregnancy and delivery. Therefore, FGC should never be "medicalised" by health services in refugee camps, or carried out by professional health workers.

    Adolescent sexual health
    Like adults, refugee adolescents are at serious risk for HIV/STIs, unintended pregnancy and unsafe abortion, sexual and gender violence or pregnancy-related morbidity and mortality. The refugee situation creates instability in the sexual and reproductive development of teenagers, with often severe, even life-threatening consequences. They are at increased risk of suffering sexual and physical violence, especially because adolescents live unaccompanied in many camps. Older teenagers may have increased responsibilities for younger siblings. Schooling or training has been interrupted and career opportunities are lost, resulting in feelings of disempowerment. Adolescents' removal from traditional guidance, their own culture and the uncertainties of their present lives can result in confusion about sexual behaviour. Boredom may lead to increased drug and alcohol use and an earlier onset of unprotected sexual activity. Their precarious economic situation increases the chances that adolescents will engage in prostitution to feed themselves or their families. Teenagers are often not able to access reproductive health services as youth-friendly health services are rarely available.

    International responses
    In response to these problems, a number of organisations have adapted their policies to include reproductive health and rights for people living in conflict or post-conflict situations. In 1995, an Inter-Agency Working Group (IAWG) for Reproductive Health in Refugee Situations was established under the co-ordination of UNHCR. Its members include some 30 UN and governmental agencies, NGOs, academic and donor institutions. The group has a guidance role in strengthening reproductive health services in refugee situations. The IAWG produced a field manual that describes a Minimum Initial Service Package (MISP) of reproductive health interventions to be put in place as soon as possible in a refugee situation. The MISP incorporates all that is needed to provide basic reproductive health services during the emergency phase of a crisis situation. Its aim is to reduce mortality. As soon as the situation stabilises, comprehensive reproductive health service provision should follow. The field manual advises on how to put the MISP into practice. Today, many agencies working in the field implement only one element of reproductive health-care in their projects. Very few comprehensively address the reproductive health needs of forcibly displaced people; e.g. many programmes place insufficient emphasis on involving men and boys in reproductive health. Much more effort needs to be put into translating policies and resolutions into practical measures that will give these people access to comprehensive reproductive health services of their choice. After all, the total worldwide yearly cost of better reproductive health-care is less than one week of world expenditures on armaments. The article is based on an earlier publication for UNFPA.

    Wilma Doedens,
    Médecins Sans Frontières Swiss,
    12, Rue du Lac, Geneva, 1211 Switzerland;
    Tel: +41-22-849.8484;
    Fax: +41-22-300.4414;
    Email: Wilma Doedens
    Website:     Medecins Sans Frontieres

    SHARING HIV TEST RESULTS WITH FUTURE AND CURRENT MARRIAGE PARTNERS IN ZAMBIA

    By: Stanley Chama and Ignatius Kayawe (Sexual Health Exchange no. 2000-1)

    Kara Counselling and Training Trust (Kara) began offering voluntary counselling and testing (VCT) for HIV to the Zambian public in 1992. In the first years, clients came for testing because they were sick. These days however, more and more healthy young people are requesting tests for other reasons: they may be planning to get married, to have children or to engage in unprotected sex after being in an intimate relationship for some time. More than 20% of the clients now come for marriage-related reasons -- as individuals or as couples. People want to know their HIV status so they can share it with their current or future spouse in order to make informed choices and protect each other's sexual and reproductive health.

    Reasons for testing
    About one third of VCT clients come as couples; of these, about 60-70% intend to get married. Most of the couples suspect that one or both partners are infected with HIV. Couples also want tests because they plan to have a child. Married persons who come for VCT as individuals have different motives. Suspicion of infidelity is common in women: they believe their husbands have other sexual partners and want to protect themselves. In other cases, where HIV testing has been discussed openly with the spouse and s/he is reluctant to take the test, people come to be tested individually. This is common among women who may be planning to conceive but want to ascertain their HIV status before they do so. Overall, women are becoming increasingly assertive in coming for testing without their husband's approval, although men tend to react negatively when their partner does a test without consulting them.

    Clients also come for testing when they have had an extramarital affair and want to avoid passing the infection to their partner. Others come for testing when they suspect HIV infection in the family and want to protect themselves or improve their quality of life in case they are already infected. Most unmarried individuals who think they have been exposed to HIV, come for VCT secretly. The decision to inform others often depends on the test result. A minority comes for testing to confirm they are HIV-negative. These clients usually discuss their plans to go for an HIV test with friends, family and spouse-to-be.

    Disclosing HIV status: the importance of counselling
    Pre-test counselling is crucial for preparing individuals and couples for the HIV test because it gives clients the opportunity to think through issues. When clients are not ready, the test is postponed. But pre-test counselling also prepares them for accepting the test results and sharing them with their sexual partner(s).

    Yet, many people are overwhelmed by a positive HIV test. They may rush to inform others before they have really absorbed the news themselves. This may have negative consequences and counsellors therefore pay special attention to the issue of disclosure, stressing the client's full responsibility and control over whom to inform, when and in what manner. Though there are certain immediate reactions to positive test results like anger, shock, denial or doubts about the result, clients usually overcome these through subsequent follow-up counselling, which focuses on their feelings and the anticipated negative consequences of the test results. Follow-up also includes repeat HIV testing for those who are negative after three months, followed by regular appointments on a 4-6 monthly basis. About 99% of HIV-negative clients continue to be negative on subsequent repeat tests. Kara's VCT centres also offer regular condom supply and appointments on a quarterly basis for discordant couples.

    Consequences of disclosing HIV status
    One issue that discourages married individuals from disclosing their HIV-positive status to their spouses --especially when they did not tell their partners they were having an HIV test-- is the fact that the person tested first, will be considered guilty of having brought the infection into the household. Especially women who test HIV-positive first are often perceived guilty of infidelity and marriage usually breaks. Therefore, these individuals often prefer to keep quiet or arrange to have a test taken together, pretending they have never taken one before. Even revealing a negative HIV test result triggers suspicion, because it is thought that only people who are not sure of themselves go for testing.

    When couples show strong suspicions of one another, they are helped to re-establish communication and understanding before tackling the issues of HIV testing. They are offered the option of having the test and getting the results together, or being tested individually and sharing the results afterwards. With appropriate counselling, most couples prefer the first option. When both partners are negative, they usually readily accept the results. When both are positive, their common HIV status usually allows them to accept each other as life partners.

    About 20% of couples that come for HIV testing are discordant couples. Among couples preparing for marriage, two thirds decide to cancel the marriage arrangements after learning their discordant status. In couples already married, HIV-negative women tend to accept their seropositive husbands. Married women who are economically empowered usually stand firm on not having any form of sex with their HIV-positive husband, though they continue living together. On the other hand, HIV-negative men need more time to accept the situation. Nevertheless, the majority of married discordant couples stay together.

    Thus, voluntary counselling and testing plays a crucial role in helping couples disclose and share their HIV status with each other and make responsible choices to protect each other's sexual and reproductive health and rights.

    Stanley Chama and Ignatius Kayawe,
    Kara Counselling and Training Trust;
    Plot 20427, Kutwa Road
    P.O. Box 37559, Lusaka, Zambia;
    Tel: +260-1-229847/222776;
    Fax: +260-1-229848;
    e-mail: Kara Counselling

    REQUEST FORM FOR FULL LENGTH TEXT OF ARTICLES:

    1) ABSTRACT TITLES FOR DESIRED ARTICLES:
    a)---------------------------------------------------------------------------------
    b)---------------------------------------------------------------------------------
    c)---------------------------------------------------------------------------------
    d)---------------------------------------------------------------------------------

    2) COMMENTS: (Send us your thoughts and letters about this digest or any health related issue facing Zambia today and we may even print them!)

    3) ADDRESS YOU WOULD LIKE US TO SEND ARTICLES TO:
    Name-------------------------------------------------------------------
    Title--------------------------------------------------------------------
    P.O Box----------------------------------------------------------------
    Street Address-------------------------------------------------------
    City/Town-------------------------------------------------------------

    4) SEND THIS FORM (OR A COPY) AND YOUR LETTERS TO THE FOLLOWING ADDRESS:
    Zambia Health Information Digest
    Medical Library
    University of Zambia, School of Medicine
    Tel: 01-250801
    Fax: 01-250753
    P.O. Box 50110
    Lusaka, Zambia
    medlib@unza.zm

    [ZHID Table of Contents] [Medical Guide Table of Contents] [Zamnet][UNZA][UNZA Library]

    Send comments and/or suggestions to: medlib@unza.zm or lenny@library.health.ufl.edu
    Copyright © 1996-2001, The University of Zambia Medical Library and Lenny Rhine
    Guide to Medical Resources WWW site: http://www.medguide.org.zm/

    Last updated January 24, 2001