AIDS Surveillance in Africa

Surveillance of the AIDS pandemic in Africa has always posed formidable problems for epidemiologists. Diagnostic accuracy-according to the case definitions for AIDS used in industrialised countries-is impossible to achieve in all but a few places with the right diagnostic facilities. Responding to the urgent need for surveillance, the World Health Organisation drew up a clinical case definition (the WHO/Bangui definition), which depended on clinical criteria without the need for serological verification.'2 Judged by its use, the WHO/Bangui definition has been successful-52 African countries have reported cases ofAIDS using mainly this definition.3 Some countries have modified it to fit local circumstances, removing a defining symptom here, adding the need for an extra sign there, and many now accept or encourage a positive result of an HIV test as supportive evidence. (At least one, COte d'Ivoire, requires such a result.2) Inevitably the definition has its limitations, and two papers in this week's journal discuss these at length (p 11852, p 11894). Because of limited laboratory facilities published evaluations of the WHO/Bangui definition have been mainly restricted to groups of sick patients using HIV positivity as the reference standard. The definition's sensitivity and specificity have been calculated as being between 60% and 90%2 5- useful for purposes of surveillance, but leaving uncertainty over whether this surveillance tool is intended to monitor trends in cases of AIDS or HIV infection. Other problems exist with the WHO/Bangui definition. Because many doctors lack diagnostic facilities they use the definition for diagnosis. The title "clinical case definition" encourages this confusion. The misuse is disturbing as the probability that a patient who fulfils the WHO/Bangui definition tests positive for HIV may fall well below 50% when seroprevalence is low.5 Another problem of using the definition is the delayed and incomplete picture that it gives of the spread of infection.6 Far preferable for surveillance of infection is the unlinked anonymous testing for HIV of sentinel groups attending health services67 (such as pregnant women and people with sexually transmitted diseases), which has now begun in several African countries89 using the same methods as in industrialised countries.'° Where does this leave the WHO/Bangui definition? De Cock and colleagues rehearse the overwhelming case for AIDS reporting to continue and suggest a thoughtful redesign of the definition, which includes the requirement for a positive HIV test result.3 Insisting on positive test results in all circumstances, however, is impractical: HIV tests are already limited and are lioely to become more so as AIDS funding to Africa inevitably falls. As a provisional solution to the problem of surveillance the WHO/Bangui definition has been useful, but the time has come for its reappraisal

Comparison of Costs of Home and Facility-based Basic Obstetric Care in Rural Bangladesh

This study compared the costs of providing antenatal, delivery and postnatal care in the home and in a basic obstetric facility in rural Bangladesh. The average costs were estimated by interviewing midwives and from institutional records. The main determinants of cost in each setting were also assessed. The cost of basic obstetric care in the home and in a facility was very similar, although care in the home was cheaper. Deliveries in the home took more time but this was offset by the capital costs associated with facility-based care. As use-rates increase, deliveries in a facility will become cheaper. Antenatal and postnatal care was much cheaper to provide in the facility than in the home. Facility-based delivery care is likely to be a cheaper and more feasible method for the care provider as demand rises. In settings where skilled attendance rates are very low, home-based care will be cheaper

Perceived Delay in Healthcare-seeking for Episodes of Serious Illness and Its Implications for Safe Motherhood Interventions in Rural Bangladesh

Delay in accessing emergency obstetric-care facilities during life-threatening obstetric complications is a significant determinant of high maternal mortality in developing countries. To examine the factors associated with delays in seeking care for episodes of serious illness and their possible implications for safe motherhood interventions in rural Bangladesh, a cross-sectional study was initiated in Matlab sub-district on the perceptions of household heads regarding delays in seeking care for episodes of serious illness among household members. Of 2,177 households in the study, 881 (40.5%) reported at least one household member who experienced an illness perceived to be serious enough to warrant care-seeking either from health facilities or from providers. Of these, 775 (88.0%) actually visited some providers for treatment, of whom 79.1% used transport. Overall, 69.3% perceived a delay in deciding to seek care, while 12.1% and 24.6% perceived a delay in accessing transport and in reaching the provider respectively. The median time required to make a decision to seek care was 72 minutes, while the same was 10 minutes to get transport and 80 minutes to reach a facility or a provider. Time to decide to seek care was shortest for pregnancy-related conditions and longest for illnesses classified as chronic, while time to reach a facility was longest for pregnancy-related illnesses and shortest for illnesses classified as acute. However, the perceived delay in seeking care did not differ significantly across socioeconomic levels or gender categories but differed significantly between those seeking care from informal providers compared to formal providers. Reasons for the delay included waiting time for results of informal treatment, inability to judge the graveness of disease, and lack of money. For pregnancy-related morbidities, 45% reported ‘inability to judge the graveness of the situation’ as a reason for delay in making decision. After controlling for possible confounders in multivariate analysis, type of illness and facility visited were the strongest determinants of delay in making decision to seek care. To reduce delays in making decision to seek care in rural Bangladesh, safe motherhood interventions should intensify behaviour change-communication efforts to educate communities to recognize pregnancy-danger signs for which a prompt action must be taken to save life. This strategy should be combined with efforts to train community-based skilled birth attendants, upgrading public facilities to provide emergency obstetric care, introduce voucher schemes to improve access by the poorest of the poor, and improve the quality of care at all levels

Comparison of costs of home and facility-based basic obstetric care in rural Bangladesh

This study compared the costs of providing antenatal, delivery and postnatal care in the home and in a basic obstetric facility in rural Bangladesh. The average costs were estimated by interviewing midwives and from institutional records. The main determinants of cost in each setting were also assessed. The cost of basic obstetric care in the home and in a facility was very similar, although care in the home was cheaper. Deliveries in the home took more time but this was offset by the capital costs associated with facility-based care. As use-rates increase, deliveries in a facility will become cheaper. Antenatal and postnatal care was much cheaper to provide in the facility than in the home. Facility-based delivery care is likely to be a cheaper and more feasible method for the care provider as demand rises. In settings where skilled at-tendance rates are very low, home-based care will be cheaper

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

Background: It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania. Methods: This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses.ResultsStudy findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities. Conclusions: We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.USAID through the Health Research Challenge for Impact (HRC) [GHS-A-00-09-00004-00]Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Perceived Delay in Healthcare-seeking for Episodes of Serious Illness and Its Implications for Safe Motherhood Interventions in Rural Bangladesh

Delay in accessing emergency obstetric-care facilities during life-threatening obstetric complications is a significant determinant of high maternal mortality in developing countries. To examine the factors associated with delays in seeking care for episodes of serious illness and their possible implications for safe motherhood interventions in rural Bangladesh, a cross-sectional study was initiated in Mat\uadlab sub-district on the perceptions of household heads regarding delays in seeking care for episodes of serious illness among household members. Of 2,177 households in the study, 881 (40.5%) reported at least one household member who experienced an illness perceived to be serious enough to warrant care-seeking either from health facilities or from providers. Of these, 775 (88.0%) actually visited some providers for treatment, of whom 79.1% used transport. Overall, 69.3% perceived a delay in deciding to seek care, while 12.1% and 24.6% perceived a delay in accessing transport and in reaching the provider respectively. The median time required to make a decision to seek care was 72 minutes, while the same was 10 minutes to get transport and 80 minutes to reach a facility or a provider. Time to decide to seek care was shortest for pregnancy-related conditions and longest for illnesses classified as chronic, while time to reach a facility was longest for pregnancy-related illnesses and shortest for illnesses classified as acute. However, the perceived delay in seeking care did not differ significantly across socioeconomic levels or gender categories but differed significantly between those seeking care from informal providers compared to formal providers. Reasons for the delay included waiting time for results of informal treatment, inability to judge the graveness of disease, and lack of money. For pregnancy-related morbidities, 45% reported \u2018inability to judge the graveness of the situation\u2019 as a reason for delay in making decision. After controlling for possible confounders in multivariate analysis, type of illness and facility visited were the strongest determinants of delay in making decision to seek care. To reduce delays in making decision to seek care in rural Bangladesh, safe motherhood interven\uadtions should intensify behaviour change-communication efforts to educate communities to recognize pregnancy-danger signs for which a prompt action must be taken to save life. This strategy should be combined with efforts to train community-based skilled birth attendants, upgrading public facilities to provide emergency obstetric care, introduce voucher schemes to improve access by the poorest of the poor, and improve the quality of care at all levels

Surveillance of HIV and syphilis infections among antenatal clinic attendees in Tanzania-2003/2004

BACKGROUND: This paper presents the prevalence of human immunodeficiency virus (HIV) and syphilis infections among women attending antenatal clinics (ANC) in Tanzania obtained during the 2003/2004 ANC surveillance. METHODS: Ten geographical regions; six of them were involved in a previous survey, while the remaining four were freshly selected on the basis of having the largest population among the remaining 20 regions. For each region, six ANC were selected, two from each of three strata (urban, peri-urban and rural). Three of the sites did not participate, resulting into 57 surveyed clinics. 17,813 women who were attending the chosen clinics for the first time for any pregnancy between October 2003 and January 2004. Patient particulars were obtained by interview and blood specimens were drawn for HIV and syphilis testing. HIV testing was done anonymously and the results were unlinked. RESULTS: Of the 17,813 women screened for HIV, 1,545 (8.7% (95% CI = 8.3–9.1)) tested positive with the highest prevalence in women aged 25–34 years (11%), being higher among single women (9.7%) than married women (8.6%) (p < 0.07), and increased with level of education from 5.2% among women with no education to 9.3% among those at least primary education (p < 0.001). Prevalence ranged from 4.8% (95% CI = 3.8% – 9.8%) in Kagera to 15.3% (95% CI = 13.9% – 16.8%) in Mbeya and was; 3.7%, 4.7%, 9.1%, 11.2% and 15.3% for rural, semi-urban, road side, urban and 15.3% border clinics, respectively (p < 0.001). Of the 17,323 women screened for syphilis, 1265 (7.3% (95%CI = 6.9–7.7)) were positive, with highest prevalence in the age group 35–49 yrs (10.4%) (p < 0.001), and being higher among women with no education than those with some education (9.8% versus 6.8%) (p < 0.0001), but marital status had no influence. Prevalence ranged from 2.1% (95% CI = 1.4% – 3.0%) in Kigoma to 14.9% (95% CI = 13.3%-16.6%) in Kagera and was 16.0% (95% CI = 13.3–18.9), 10.5% (95% CI = 9.5–11.5) and 5.8% (95% CI = 5.4–6.3) for roadside, rural and urban clinics, respectively. Syphilis and HIV co-infection was seen in 130/17813 (0.7%). CONCLUSION: The high HIV prevalence observed among the ANC clinic attendees in Tanzania call for expansion of current voluntary counselling and testing (VCT) services and access to antiretroviral drugs (ARV) in the clinics. There is also a need for modification of obstetric practices and infant feeding options in HIV infection in order to prevent mother to child transmission of HIV. To increase uptake to HIV testing the opt-out strategy in which all clients are offered HIV testing is recommended in order to meet the needs of as many pregnant women as possible

Estimating the Capacity for ART Provision in Tanzania with the Use of Data on Staff Productivity and Patient Losses

BACKGROUND: International targets for access to antiretroviral therapy (ART) have over-estimated the capacity of health systems in low-income countries in Sub-Saharan Africa. The WHO target for number on treatment by end 2005 for Tanzania was 10 times higher than actually achieved. The target of the national Care and Treatment Plan (CTP) was also not reached. We aimed at estimating the capacity for ART provision and created five scenarios for ART production given existing resource limitations. METHODS: A situation analysis including scrutiny of staff factors, such as available data on staff and patient factors including access to ART and patient losses, made us conclude that the lack of clinical staff is the main limiting factor for ART scale-up, assuming that sufficient drugs and supplies are provided by donors. We created a simple formula to estimate the number of patients on ART based on availability and productivity of clinical staff, time needed to initiate vs maintain a patient on ART and patient losses using five different scenarios with varying levels of these parameters. FINDINGS: Our scenario assuming medium productivity (40% higher than that observed in 2002) and medium loss of patients (20% in addition to 15% first-year mortality) coincides with the actual reported number of patients initiated on ART up to 2008, but is considerably below the national CTP target of 90% coverage for 2009, corresponding to 420,000 on ART and 710,000 life-years saved (LY's). Our analysis suggests that a coverage of 40% or 175,000 on treatment and 350,000 LY's saved is more achievable. CONCLUSION: A comparison of our scenario estimations and actual output 2006-2008 indicates that a simple user-friendly dynamic model can estimate the capacity for ART scale-up in resource-poor settings based on identification of a limiting staff factor and information on availability of this staff and patient losses. Thus, it is possible to set more achievable targets

Estimating and projecting HIV prevalence and AIDS deaths in Tanzania using antenatal surveillance data

BACKGROUND: The Estimations and Projections Package (EPP 2005) for HIV/AIDS estimates and projects HIV prevalence, number of people living with HIV and new HIV infections and AIDS cases using antenatal clinic (ANC) surveillance data. The prevalence projection produced by EPP can be transferred to SPECTRUM, a demographic projectionmodel, to calculate the number of AIDS deaths. This paper presents estimates and projections of HIV prevalence, new cases of HIV infections and AIDS deaths in Tanzania between 2001 and 2010 using the EPP 2005 and SPECTRUM soft-wares on ANC data. METHODS: For this study we used; the 1985 – 2004 ANC data set, the 2005 UN population estimates for urban and rural adults, which is based on the 2002 population census, and results of the 2003 Tanzania HIV Indicator Survey. The ANC surveillance sites were categorized into urban and rural areas on the basis of the standard national definitions of urban and rural areas, which led to 40 urban and 35 rural clinic sites. The rural and urban epidemics were run independently by fitting the model to all data and on level fits. RESULTS: The national HIV prevalence increased from 0% in 1981 to a peak of 8.1% in 1995, and gradually decreased to 6.5% in 2004 which stabilized until 2010. The urban HIV epidemic increased from 0% in 1981 peaking at 12.6% in 1992 and leveled to between 10.9% and 11.8% from 2003 to 2010. The rural epidemic peaked in 1995 at 7.0% and gradually declined to 5.2% in 2004, and then stabilized at between 5.1% and 5.3% from 2005 to 2010. New infections are projected to rise steadily, resulting in 250,000 new cases in 2010. Deaths due to AIDS started in 1985 and rose steadily to reach 120,000 deaths in 2010, with more females dying than men. CONCLUSION: The fact that the number of new infections is projected to increase steadily to reach 250,000 per year in 2010 calls for more concerted efforts to combat the spread of HIV infection particularly in the rural areas where the infrastructure needed for prevention programmes such as counseling and testing, condom accessibility and AIDS information is less developed

Men’s roles in care seeking for maternal and newborn health: a qualitative study applying the three delays model to male involvement in Morogoro Region, Tanzania

Background: Increasing the utilization of facility-based care for women and newborns in low-resource settings can reduce maternal and newborn morbidity and mortality. Men influence whether women and newborns receive care because they often control financial resources and household decisions. This influence can have negative effects if men misjudge or ignore danger signs or are unwilling or unable to pay for care. Men can also positively affect their families’ health by helping plan for delivery, supplementing women’s knowledge about danger signs, and supporting the use of facility-based care. Because of these positive implications, researchers have called for increased male involvement in maternal and newborn health. However, data gathered directly from men to inform programs are lacking. Methods: This study draws on in-depth interviews with 27 men in Morogoro Region, Tanzania whose partners delivered in the previous 14 months. Debriefings took place throughout data collection. Interview transcripts were analyzed inductively to identify relevant themes and devise an analysis questionnaire, subsequently applied deductively to all transcripts. Results: Study findings add a partner-focused dimension to the three delays model of maternal care seeking. Men in the study often, though not universally, described facilitating access to care for women and newborns at each point along this care-seeking continuum (deciding to seek care, reaching a facility, and receiving care). Specifically, men reported taking ownership of their role as decision makers and described themselves as supportive of facility-based care. Men described arranging transport and accompanying their partners to facilities, especially for non-routine care. Men also discussed purchasing supplies and medications, acting as patient advocates, and registering complaints about health services. In addition, men described barriers to their involvement including a lack of knowledge, the need to focus on income-generating activities, the cost of care, and policies limiting male involvement at facilities. Conclusion: Men can leverage their influence over household resources and decision making to facilitate care seeking and navigate challenges accessing care for women and newborns. Examining these findings from men and understanding the barriers they face can help inform interventions that encourage men to be positively and proactively involved in maternal and newborn health