HIV and fertility change in rural Zimbabwe

Fertility transition and HIV epidemics are currently running parallel in some sub-Saharan African populations. Interactions between the two at the individual and population levels could accentuate or moderate the resulting demographic trends. We review a number of mechanisms through which an HIV epidemic and responses to it can affect birth rates, through the biological and behavioural proximate determinants. Uninfected as well as infected people can be affected and many of the changes could have unintended consequences for fertility at the individual level. Results from a small-scale in-depth study in two rural areas of Zimbabwe are reviewed. These indicate that the local HIV epidemic has begun to influence the proximate determinants of fertility. If observed trends persist, a modest acceleration in the recent decline in birth rates seems plausible

Validity of oral mucosal transudate specimens for HIV testing using enzyme-linked immunosorbent assay in children in Chimanimani district, Zimbabwe

Objective. To assess the validity of oral mucosal transudate (OMT) specimens for HIV testing in children using enzyme-linked immunosorbent assay (ELISA). Methods. A cross-sectional descriptive study was conducted as part of a community-based behavioural and HIV sero-status survey of adults and children in the Chimanimani district of Zimbabwe. Dried blood spot (DBS) and OMT samples were collected from children aged between 2 and 14 years, inclusive. Both samples were tested for HIV using the Vironostika Uniform II plus O kits. The main study outcomes were the sensitivity and specificity of OMT samples, with DBS as the gold-standard specimen. Results. Paired DBS and OMT specimens were available from 1 274 (94.4%) of the 1 350 children enrolled. Using the DBS, HIV prevalence was 3.2%. Overall sensitivity of OMT was 48.8% (95% confidence interval (CI) 33.3 - 64.5), and specificity was 98.5% (95% CI 97.7 - 99.1). Conclusion. The overall sensitivity of OMT specimens for HIV testing in children using ELISA was low. Stratifying the analysis by sector showed that OMT samples are good specimens for HIV testing. It is important to note that factors such as the low HIV prevalence in our study population, quality of the OMT, diet and oral hygiene could have influenced the results

Impact and Process Evaluation of Integrated Community and Clinic-Based HIV-1 Control: A Cluster-Randomised Trial in Eastern Zimbabwe

BACKGROUND: HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels. METHODS AND FINDINGS: We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92–1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24–0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28–0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21–5.12). CONCLUSIONS: Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups

Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)

Community water-contact patterns and the transmission of schistosoma haematobium in the highveld region of Zimbabwe

The patterns of community water-contact, their relationships to Schistosoma haematobium infection in the human population and also in Bulinus globosus, snail host for S. haematobium and S. mattheei were carried out at 12 human water contact sites located in stream habitats in the temperate highveld region of Zimbabwe over a 27-month period during 1982-1984. It was shown that water contact was markedly heterogeneous with sex, age, type of activity and village location being the major variables affecting water-contact patterns. This heterogeneity in contact appears to be related to variations in levels of infection with S. haematobium among residents of the villages and by sex but in adults high water-contact was not associated with increased levels of infection and this discrepancy is attributed to the influence of acquired immunity in adults. An association was found between total body exposure indices and prevalence of S. haematobium in B. globosus in the cool dry and hot dry period of the year indicating that the level of input of schistosome eggs into water play an important role in determining snail infection rates, although the absence of clearcut relationships between the two parameters in the rainy and post-rainy periods suggest that other factors may be involved.community water-contact exposure index Schistosoma haematobium human beings Bulinus globosus transmission Zimbabwe

The rational use of antischistosomal drugs in schistosomiasis control

The paper examines the available antischistosomal drugs in Zimbabwe and the use of population-based chemotherapy as an effective strategy of morbidity reduction in schistosomiasis control. The problems of poor drug efficacy and side-effects that were associated with earlier antischistosomal drugs have largely been overcome with the advent of recent, safe and effective oral drugs. The main constraints of population-based chemotherapy are the costs of drug procurement, transport and the logistics of delivery. In highly endemic areas, screening for infection may not be necessary and following pilot surveys mass chemotherapy can be carried out. Nevertheless, anecdotal and unverified reports suggest that mass chemotherapy may result in lightly infected individuals losing their residual immunity and risk heavy reinfection. To lower costs of the drugs and reduce organizational problems of delivery it may be preferable to target treatment at high risk groups. These groups include certain age classes with peak prevalence and intensity of infection and those predisposed to get heavy infections. Treatment prevents the development of overt disease in these high risk groups and also significantly reduces contamination and consequently transmission. However, chemotherapy only results in temporary relief and its impact requires to be sustained by parallel and long-lasting interventions that include improved sanitation, better water supplies and health education. Suggestions are made on how to train and utilize community and public health workers for such control programmes.epidemiology antischistosomal drugs control Zimbabwe

Is there evidence for behaviour change in response to AIDS in rural Zimbabwe?

This article reports on evidence for behaviour change in response to AIDS among women in two rural areas of Manicaland Province, Zimbabwe. It examines self-reported data on two overlapping areas of behaviour: (1) actions taken to avoid HIV-1 infection; and (2) fertility practices. The latter were used to assess the validity of the former, given that self-reported behaviour data are notoriously problematic. It is concluded that while self-reported behaviour change is exaggerated, the true level of change has nonetheless been significant and includes delayed onset of sexual relations, increased use of condoms and, possibly, increased monogamy. Reported actions taken to avoid HIV-1 infection and differentials in fertility practices were correlated with data on demographic, social and psychological factors. Differentials in fertility practices were associated with heightened risk perception--particularly when based on personal acquaintance with AIDS patients--but not with greater knowledge of HIV-1/AIDS. Results from the study suggest that effective behaviour change in Manicaland is facilitated by greater knowledge, experience and personal risk perception but obstructed by low female autonomy, marital status and economic status, and by male labour migration and alcohol consumption. Gaps in knowledge included misconceptions about the distinction between HIV-1 and AIDS, the influence of STDs, perinatal transmission, and incorrect modes of transmission. Better knowledge was associated with education, religion, travel and media exposure. Personal risk perception was quite high (42%) and correlated with non-marriage, media exposure and contact with medical services. Few respondents knew close relatives with HIV/AIDS (4%) but nearly a quarter of those who felt in danger of infection said this was because friends and relatives were dying of AIDS. Many reported credible behavioural responses, some of which would only be effective given their partner's co-operation. Intensified behaviour interventions are needed which should include peer-education initiatives targeting men and individuals without access to modern media. The epidemic may accelerate fertility decline in rural Zimbabwe through behavioural as well as biological change.HIV/AIDS KABP behaviour change fertility Zimbabwe

HIV decline associated with behavior change in eastern Zimbabwe.

Few sub-Saharan African countries have witnessed declines in HIV prevalence, and only Uganda has compelling evidence for a decline founded on sexual behavior change. We report a decline in HIV prevalence in eastern Zimbabwe between 1998 and 2003 associated with sexual behavior change in four distinct socioeconomic strata. HIV prevalence fell most steeply at young ages-by 23 and 49%, respectively, among men aged 17 to 29 years and women aged 15 to 24 years-and in more educated groups. Sexually experienced men and women reported reductions in casual sex of 49 and 22%, respectively, whereas recent cohorts reported delayed sexual debut. Selective AIDS-induced mortality contributed to the decline in HIV prevalence

HIV decline associated with behavior change in Eastern Zimbabwe

Few sub-Saharan African countries have witnessed declines in HIV prevalence, and only Uganda has compelling evidence for a decline founded on sexual behavior change. We report a decline in HIV prevalence in eastern Zimbabwe between 1998 and 2003 associated with sexual behavior change in four distinct socioeconomic strata. HIV prevalence fell most steeply at young ages—by 23 and 49%, respectively, among men aged 17 to 29 years and women aged 15 to 24 years—and in more educated groups. Sexually experienced men and women reported reductions in casual sex of 49 and 22%, respectively, whereas recent cohorts reported delayed sexual debut. Selective AIDS-induced mortality contributed to the decline in HIV prevalence