Estimates of the impact of HIV infection on fertility in a rural Ugandan population cohort

Fertility rates in a population-based cohort of over 3500 women aged 15-49 years living in rural southwest Uganda are described and examined in relation to infection with HIV. Over a six-year follow-up period (1989/90 to 1995/6) the average general fertility rate was estimated as 199 births per thousand woman-years of observation (95 % confidence interval 191 to 207) with a total fertility rate of 6.2 births per woman. The overall prevalence of infection with HIV was 12 per cent and remained relatively stable during follow-up. With the exception of women aged 15-19 years, women who were not infected with HIV had higher fertility than HIV-infected women. The overall age-adjusted fertility rate in HIV-infected women was 0.74 of that of uninfected women (95% confidence interval 0.63 to 0.87, P<0.001) and this result was unaffected by additional adjustment for marital status. When combined with an overall HIV prevalence rate of 12 per cent, this corresponds to a three per cent reduction in fertility rates in the whole population. The lower fertility in HIV-positive women is unlikely to be explained by increased use of contraception, as use of modern contraceptive methods in rural Uganda is low and fewer than ten per cent of women are aware of their HIV-serostatus. More likely explanations are reduced sexual activity due to clinical symptoms associated with HIV infection or lower fertility associated with coexisting infections with other sexually transmitted diseases, such as syphilis. A reduction in fertility caused by HIV infection itself cannot be excluded. The implications of these findings for the use of antenatal clinic data to provide population estimates of HIV prevalence are discussed

Evaluation of E-optotypes as a screening test and the prevalence and causes of visual loss in a rural population in SW Uganda.

BACKGROUND: Few population-based eye surveys have been conducted in sub-Saharan Africa, limiting the quality of epidemiological information on visual loss from Africa. In the present paper, we describe the prevalence of visual loss in rural Uganda and the screening accuracy of E-optotypes when used by non-medical staff. METHODS: Residents of 15 neighbouring villages were screened for visual loss (<6/18 in either eye) using Snellen's E-optotypes. Individuals who failed were initially referred to an ophthalmic clinical officer (OCO), who retested visual acuity and subsequently referred to an ophthalmologist to determine the cause of visual loss. Subjects from two villages (248 individuals) who passed visual acuity screening were re-examined by the OCO to estimate the accuracy of the screening procedure. RESULTS: Of the 4076 adults (aged 13 years and over, 69.3% of the censused population) who participated, 191 (4.7%) failed the vision screening criteria and 648 (15.9%) had non-vision impairing conditions. The prevalence of visual loss was at least 3.9%: 0.4% had bilateral blindness, 1.6% had bilateral visual impairment, 0.7% had unilateral blindness and 1.2% unilateral visual impairment. Cataract was the leading cause for all categories of visual loss except bilateral blindness, for which suspected glaucoma was most frequent. Refractive errors were the second leading cause of bilateral and unilateral visual impairment. Based on one subject (0.4%) in the validation sample who was found to have low vision, we estimated the sensitivity and specificity of E-optotypes for detecting visual loss to be 93% and 99%, respectively. CONCLUSIONS: Cataract and refractive errors were responsible for most of the visual loss in rural Uganda. Snellen's E-optotypes provide a suitable cost-saving tool for conducting population-based eye surveys in sub-Saharan Africa

Generalizability of population-based studies on AIDS: a comparison of newly and continuously surveyed villages in rural southwest Uganda.

BACKGROUND: Population-based studies are thought to provide generalizable epidemiological data on the human immunodeficiency virus type 1 (HIV-1) epidemic. However, longitudinal studies are susceptible to bias from added attention caused by study activities. We compare HIV-1 prevalence in previously and newly surveyed villages in rural southwest Uganda. METHODS: The study population resided in 25 neighbouring villages, of which 15 have been surveyed for 10 years. Respondents (>/=13 years) provided socio-demographic and sexual behaviour data and a blood sample for HIV-1 serology in private after informed consent. We tested the independent effect of residency: (1) original versus new villages; (2) proximity to main road; and (3) proximity to trading centre on HIV-1 serostatus of respondents using multivariate logistic regression. RESULTS: There were 8,990 adults censused, 68.3% were from the original villages, 48.2% were males and 6111 (68.0%) were interviewed and had definite HIV-1 serostatus. The HIV-1 prevalence was 6.1% overall, 5.7% in the new, and 6.4% in the original villages (P = 0.25). Residency in the new or original villages did not independently predict HIV-1 serostatus of respondents (P = 0.46). Independent predictors of HIV-1 serostatus were education (primary or higher, odds ratio [OR] = 1.7 and 1.4, respectively), being separated or widowed OR = 4.2, reported previous use of a condom OR = 1.8, or reported genital ulceration OR = 3.3, and age group 25-34 and 35-44 years OR = 5.8 and OR = 4.8 (all P </= 0.001). CONCLUSIONS: In the context of rural Uganda where there has been considerable health education about AIDS, the additional attention to HIV infection caused by this longitudinal study does not appear to have appreciably affected the prevalence of HIV-1 infection

The orphan problem: Experience of a sub-Saharan Africa rural population in the AIDS epidemic

During 1989-90 the Medical Research Programme on AIDS enrolled 4975 children younger than 15 living in a cluster of 15 villages in rural Masaka district, southwest Uganda, into a 3-year prospective study. It examined the data to assess the magnitude of the problem of orphans and the extent to which HIV-1 is contributing to their problems. In this area, it is common for children with both parents alive to live with other relatives (e.g., grandparents) to help with domestic work. 518 (10.4%) children had lost 1 or both parents. These orphans were more likely to have lost a father alone than a mother alone (6.3% vs. 2.8%). 67 (13%) of the 518 orphans (i.e., 1% of all children) had lost both parents. Orphans 0-4 years old and surviving parents of orphans were more likely to be HIV-1 infected than their counterparts (5.6% vs. 0.9% for non-orphans 0-4 years old; p = 0.01 and 15.4% vs. 6.2% for parents of non-orphans; p 0.001). During the follow-up period, 83 parents of previous non-orphans died, leaving 169 orphans. 42.6% of the newly registered orphans had an HIV-1 positive parent. 98 deaths occurred among HIV-1 negative children (7 orphans, 91 non-orphans). No significant difference in mortality rates among HIV-1 negative children existed. Yet, in the 0-4 year old age group, orphans had a higher, but insignificantly so, 3-year mortality rate than non-orphans (22.1 vs. 15.6/1000 person-years). School attendance in the previous 6 months was slightly lower among orphans than non-orphans (75.5% vs. 83.6%) but the difference was insignificant (p = 0.3). Census data indicate that orphanhood has increased by at least 50% in the last 20 years, probably due to the AIDS epidemic. These findings suggest that the community tends to care well for orphans, but if the HIV/AIDS epidemic continues this coping mechanism may be become overly burdened

Declining HIV-1 incidence and associated prevalence over 10 years in a rural population in south-west Uganda: a cohort study.

BACKGROUND: In Uganda, there have been encouraging reports of reductions in HIV-1 prevalence but not in incidence, which is the most reliable measure of epidemic trends. We describe HIV-1 incidence and prevalence trends in a rural population-based cohort between 1989 and 1999. METHODS: We surveyed the adult population of 15 neighbouring villages for HIV-1 infection using annual censuses, questionnaires, and serological surveys. We report crude annual incidence rates by calendar year and prevalence by survey round. FINDINGS: 6566 HIV-1 seronegative adults were bled two or more times between January, 1990, and December, 1999, contributing 31984 person years at risk (PYAR) and 190 seroconversions. HIV-1 incidence fell from 8.0 to 5.2 per 1000 PYAR between 1990 and 1999 (p=0.002, chi(2) for trend). Significant sex-specific and age-group-specific reductions in incidence were evident. Incidence was 37% lower for 1995-99 than for 1990-94 (p=0.002, t-test). On average, 4642 adult residents had a definite HIV-1 serostatus at each yearly survey round. HIV-1 prevalence fell significantly between the first and tenth annual survey rounds (p=0.03, chi(2) for trend), especially among men aged 20-24 years (6.5% to 2.2%) and 25-29 years (15.2% to 10.9%) and women aged 13-19 years (2.8% to 0.9%) and 20-24 years (19.3% to 10.1%) (all p<0.001, chi(2) for trend). INTERPRETATION: Our findings of a significant drop in adult HIV-1 incidence in rural Ugandans give hope to AIDS control programmes elsewhere in sub-Saharan Africa where rates of HIV-1 infection remain high

Child survival in relation to mother's HIV infection and survival: evidence from a Ugandan cohort study.

OBJECTIVE: To analyse the contribution of maternal survival and HIV status to child (under-5 years) mortality in a rural population cohort in South-west Uganda. METHODS: Approximately 10 000 people residing in 15 neighbouring villages were followed between 1989 and 2000 using annual censuses and serological surveys to collect data on births, deaths, and adult HIV serostatus. Mother-child records were linked, child mortality risks (per 1000 births) and hazard ratios (HRs) for child mortality according to maternal HIV serostatus were computed, allowing for time-varying covariates. RESULTS: A total of 3727 children were born, of whom 415 died during 14 110 child years of follow-up. Mother's HIV status at birth was ascertained unambiguously for 3004 children, of whom 218 were born to HIV-positive mothers. Infant mortality risk was higher for HIV seropositive than seronegative mothers (225 versus 53) as was child mortality risk (313 versus 114). Child mortality risk was also higher for mothers who died (571) than for surviving mothers (128). After controlling for child's age and sex, independent predictors of mortality in children were: mother's terminal illness or death (HR = 3.8); mother being HIV positive (HR = 3.2); child being a twin (HR = 2.0); teenage motherhood (HR = 1.7) and maternal absence (HR = 1.7). CONCLUSION: Maternal survival and HIV status are strong predictors of child survival. The higher mortality in HIV-infected women compounds mortality risks for their children, regardless of children's HIV status. Programmes aimed at the welfare of children should take into account the independent effect of mothers' HIV and vital status