Asli Kulane

The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda

CONTEXT Contraceptive discontinuation is a common event that may be associated with low motivation to avoid pregnancy. If this is the case, a substantial proportion of pregnancies that follow discontinuation will be reported as intended. METHODS Demographic and Health Survey data from six countries (Bangladesh, the Dominican Republic, Kazakhstan, Kenya, the Philippines and Zimbabwe) over the period 1999-2003 were used to explore the proportions of pregnancies women reported as intended or unintended following various contraceptive behaviors. Multivariate logistic regression analysis was used to examine the characteristics of women who reported births as intended when they followed contraceptive failure or discontinuation for reasons other than a desire for pregnancy. RESULTS The proportion of births reported as intended following contraceptive failure ranged from 16% in Bangladesh to 54% in Kazakhstan, and the proportion reported as intended following discontinuation for reasons other than a desire for pregnancy ranged from 37% in Kenya to 51% in Kazakhstan. In at least half the countries, associations were found between selected womens characteristics and their reports that births following either contraceptive failure or discontinuation were intended: Factors that were positively associated were womens age and the time elapsed between contraceptive discontinuation and the index conception; factors that were negatively associated were increasing number of living children and reporting method failure as opposed to method discontinuation. CONCLUSION These findings suggest that underlying variation in the motivation to avoid pregnancy is an important factor in contraceptive discontinuation.BACKGROUND Sixty percent of new HIV infections in Uganda occur in stable relationships between HIV discordant couples. Given the importance of fertility in Uganda, we hypothesized that unsafe sexual practices may be used to found a family/replace a dead child. Thus, we explored sexual practices to understand to what extent these are influenced by the desire to have children and the implications for HIV transmission among discordant couples. METHODS A cross-sectional survey of 114 HIV discordant couples in Kampala, and in-depth interviews with 15 purposively selected couples. Quantitative data were analysed using STATA. Multivariate logistic regression analysis done to identify factors associated with consistent condom use. Thematic content analysis of qualitative data was done using NVIVO 2. RESULTS Participants wanting children and those with multiple sexual partners were less likely to use condoms (Adj OR 0.51, and 0.36 respectively). Three of the five types of sexual practices used by couples do not allow pregnancy to occur. Main reasons for wanting a child included: ensuring lineage continuity and posterity, securing relationships and pressure from relatives to reproduce. Challenges included: risk of HIV transmission to partner and child, lack of negotiating power for safer sex, failure of health systems to offer safe methods of reproduction CONCLUSIONS HIV sero-discordant couples with strong desire for childbearing have a dilemma of risking HIV infection or infecting their spouse. Some risk transmission of HIV infection to reproduce. We need to address gender issues, risky behaviour and reproductive health services for HIV sero-discordant couples.

To use or not to use a condom: a prospective cohort study comparing contraceptive practices among HIV-infected and HIV-negative youth in Uganda.

BackgroundUnwanted pregnancy and HIV infection are issues of significant concern to young people. Limited data exists on contraceptive decision-making and practices among HIV-infected and HIV-negative young people in low resource settings with generalized HIV epidemics.MethodsFrom July 2007 until April 2009, we recruited, and followed up over a one year period, a cohort of 501 HIV-negative and 276 HIV-infected young women and men aged 15-24 years residing in Kampala and Wakiso districts. We compared contraceptive use among HIV-infected and HIV-negative young people and assessed factors associated with contraceptive decision-making and use, using multivariate logistic regression modelling to estimate odds ratios (OR) and 95% confidence intervals (CI).ResultsContraceptive use among sexually active HIV-infected young people was 34% while it was 59% among the HIV-negative group. The condom was the most frequently used method of contraception. Only 24% of the HIV-infected used condoms consistently compared to 38% among the negative group OR 0.56 (95% CI 0.38, 0.82). HIV-infected young people were more likely to discuss safe sex behaviour with health workers OR 1.70 (95% CI 1.13, 2.57), though its effect on fertility decision-making was not significant. Throughout the years follow-up, only 24% among the HIV-negative and 18% among the HIV-infected continued to use contraception while 12% and 28% among the HIV-negative and infected respectively did not use contraception at all. At multivariate analysis, the HIV-infected young people were less likely to maintain contraceptive use. Other factors independently associated with sustained contraceptive use were age of the respondent, marital status and being a male. Conversely, HIV-infected young people were less likely to initiate use of contraception. Being married or in a relationship was associated with higher odds of initiating contraceptive use.ConclusionCompared to the HIV-negative group, sexually active HIV-infected young people are less likely to use contraception and condoms. Initiating or sustaining contraceptive use was also significantly less among the HIV-infected group. Strengthening family planning services and developing new innovative ideas to re-market condom use are needed. Policy and guidelines that empower health workers to help young people (especially the HIV infected) express their sexuality and reproduction should urgently be developed.

Tuberculosis knowledge, attitudes and health-seeking behaviour in rural Uganda

OBJECTIVES To assess tuberculosis (TB) knowledge, attitudes and health-seeking behaviour to inform the design of communication and social mobilisation interventions. SETTING Iganga/Mayuge Demographic Surveillance Site, Uganda. DESIGN Between June and July 2008, 18 focus group discussions and 12 key informant interviews were conducted, including parents of infants and adolescents and key informant interviews with community leaders, traditional healers and patients with TB. RESULTS People viewed TB as contagious, but not necessarily an airborne pathogen. Popular TB aetiologies included sharing utensils, heavy labour, smoking, bewitchment and hereditary transmission. TB patients were perceived to seek care late or to avoid care. Combining care from traditional healers and the biomedical system was common. Poverty, drug stock-outs, fear of human immunodeficiency virus (HIV) testing and length of TB treatment negatively affect health-seeking behaviour. Stigma and avoidance of persons with TB often reflects an assumption of HIV co-infection. CONCLUSION The communitys concerns about pill burden, quality of care, financial barriers, TB aetiology, stigma and preference for pluralistic care need to be addressed to improve early detection. Health education messages should emphasise the curability of TB, the feasibility of treatment and the engagement of traditional healers as partners in identifying cases and facilitating adherence to treatment.

It is more than the issue of taking tablets: the interplay between migration policies and TB control in Sweden.

OBJECTIVES Tuberculosis is re-emerging as a critical public health concern in Sweden among the immigrants. The aim of this study was to explore the experiences of the Somali community of TB care in the Stockholm area. METHODS Focus group discussions were conducted with 34 adult women and men by a Somali speaking moderator. Each group consisted of 6-9 participants-men and women separately. The audio taped discussions were transcribed, translated and read many times and in the process patterns and codes were identified and migration emerged as important theme in the context of TB control. RESULTS Fear of being deported emerged as barrier to sharing of complete health information with the doctor. The routine contact tracing and follow-up of infected cases in TB control was expressed as a source of concern since it was feared the health care providers could share the information with the immigration authorities. Interpreter use was expressed as barrier particularly if of same female gender. CONCLUSION It is important to be aware of how a countrys immigration policies impact on TB control activities among immigrants The existing TB control measures, such as contact tracing, assume new meanings for immigrants. Further research is therefore needed to understand this emerging complexity in order to make TB control more effective.

Reasons for declining to enroll in a phase I and II HIV vaccine trial after randomization among eligible volunteers in Dar es Salaam, Tanzania.

BACKGROUND Recruitment, enrollment and retention of volunteers in an HIV vaccine trial is important in the efforts to ultimately develop a vaccine that can prevent new HIV infections. Following recruitment, some randomized individuals decline to be enrolled in an HIV vaccine trial. The reasons for such a decision are not well known. This article describes why individuals who were randomized in a phase I and II HIV vaccine trial in Dar es Salaam, Tanzania declined to be enrolled. METHODS Face-to-face interviews were conducted with 14 individuals (7 men and 7 women). Repeated readings of the 14 interview transcripts to look for reasons for declining to enroll in the trial were performed. Data was analyzed using the content analysis approach. RESULTS Informants expressed fear of the outcome of an experimental HIV vaccine in their lives. Unlike women, some men were concerned over the effect of the vaccine on their reproduction intentions. Women were concerned about the unknown effects of the vaccine in their bodies. Also, to a large extent, informants faced resistance from significant others such as fiancées, parents, relatives, and friends. Women were influenced by their potential intimate sexual partners; men were forbidden by their parents, and mothers had the most influential opinion. CONCLUSIONS Fear of the negative outcome of an experimental vaccine and resistance from significant others are the main reasons for declining to enroll in the HIV vaccine trial among eligible volunteers after randomization. The resistance from the significant others provides valuable guidance for designing future trials in Tanzania; for example, expanding the HIV vaccine trial education to the general population from the onset of the trial design.

Willingness to volunteer in a Phase I/II HIV vaccine trial: a study among police officers in Dar es Salaam, Tanzania

Background: As HIV infection continues to devastate low-income countries, efforts to search for an effective HIV vaccine are crucial. Therefore, participation in HIV vaccine trials will be useful for the development of a preventive vaccine that will work and thus reduce the global HIV epidemic. Objective: The objective of this study was to analyse the willingness to volunteer (WTV) in a Phase I/II HIV vaccine trial among police officers in Dar es Salaam, Tanzania. Design: We included a convenience sample of 329 participants (79% males) from sensitisation workshops that were held once at each of the 32 police stations. Participants were recruited from 23 stations which were included according to availability. Data about personal characteristics, general HIV and AIDS knowledge and sexual behaviour, attitudes towards vaccines and willingness to participate in the HIV vaccine trial were obtained through an interview-administered questionnaire with both closed and open-ended questions. Results: Overall, 61% of the participants expressed WTV in HIV vaccine trials. WTV was significantly associated with: positive attitude towards use of effective vaccine, Odds ratio (OR), 36.48 (95% CI: 15.07–88.28); the intention to tell others about ones decision to participate in the trial, OR, 6.61 (95% CI: 3.89–11.24); Tanzania becoming a partner in developing the vaccine, OR, 4.28 (95% CI: 2.28–8.03); having an extra sexual partner, OR, 3.05 (95% CI: 1.63–5.69); perceived higher risk of getting HIV infection, OR, 2.11 (95% CI: 1.34–3.33); and high knowledge about HIV and AIDS, OR, 1.92 (95% CI: 1.22–3.01). Conclusion: The results indicated that a majority of police officers in this study were willing to participate in HIV vaccine trials. However, there is a need to provide the respondents with precise information about the purpose of a Phase I/II HIV vaccine trial and the fact that it does not protect against HIV infection, in order to avoid increasing risky behaviour.

T- and B-cell responses of malaria immune individuals to synthetic peptides corresponding to non-repeat sequences in the N-terminal region of the Plasmodium falciparum antigen Pf155/RESA.

While the C-terminal repeat region of Pf155/RESA, a Plasmodium falciparum vaccine candidate has been extensively studied for B- and T-cell reactivities, little is so far known about the non-repeat region in this respect. The present study aimed at investigating the non-repeat sequence 171-227 of Pf155/RESA for T- and B-cell epitopes. Eight overlapping peptides were synthesised and assayed for their ability to stimulate peripheral blood mononuclear cells obtained from P. falciparum-immune donors to proliferate and to induce secretion of interferon-gamma (IFN-gamma) and/or interleukin 4 (IL-4) using the ELISPOT assay. The plasmas of the corresponding donors were tested for antibody reactivity with the same peptides in ELISA. The individual cellular responses to the different peptides varied and in general they were not correlated, emphasising the importance of including several parameters for T-cell activation. The most frequent T-cell responses (proliferation, IFN-gamma and/or IL-4) were seen with two partially overlapping peptides corresponding to the sequences 171-185 and 181-195 that induced responses in 71 and 62% of the donors, respectively. Although, the frequency of responders was high, the magnitude of the responses was generally low. Two overlapping peptides corresponding to the sequence 186-206 bound antibodies from a large number of plasma samples. IL-4 producing cells were frequently found in donors whose sera contained antibodies to the corresponding peptide. However, there was no absolute correlation and many donors having anti-peptide antibodies could also be induced to produce IFN-gamma. In conclusion, the non-repeat region of Pf155/RESA contains several epitopes inducing functionally distinct T-cell responses. The sequence 171-206 was found to contain both B- and T-cell epitopes recognised by almost all individuals naturally primed to malaria. Thus, this sequence should be a useful tool in future immuno-epidemiological studies and/or for inclusion into a subunit vaccine against the asexual blood stages of the P. falciparum parasite.

Health system capacity: maternal health policy implementation in the state of Gujarat, India

Introduction : The Government of Gujarat has for the past couple of decades continuously initiated several interventions to improve access to care for pregnant and delivering women within the state. Data from the last District Family Heath survey in Gujarat in 2007–2008 show that 56.4% of women had institutional deliveries and 71.5% had at least one antenatal check-up, indicating that challenges remain in increasing use of and access to maternal health care services. Objective : To explore the perceptions of high-level stakeholders on the process of implementing maternal health interventions in Gujarat. Method : Using the policy triangle framework developed by Walt and Gilson, the process of implementation was approached using in-depth interviews and qualitative content analysis. Result : Based on the analysis, three themes were developed: lack of continuity; the complexity of coordination; and lack of confidence and underutilization of the monitoring system. The findings suggest that decisions made and actions advocated and taken are more dependent on individual actors than on sustainable structures. The findings also indicate that the context in which interventions are implemented is challenged in terms of weak coordination and monitoring systems that are not used to evaluate and develop interventions on maternal health. Conclusions : The implementation of interventions on maternal health is dependent on the capacity of the health system to implement evidence-based policies. The capacity of the health system in Gujarat to facilitate implementation of maternal health interventions needs to be improved, both in terms of the role of actors and in terms of structures and processes.INTRODUCTION The Government of Gujarat has for the past couple of decades continuously initiated several interventions to improve access to care for pregnant and delivering women within the state. Data from the last District Family Heath survey in Gujarat in 2007-2008 show that 56.4% of women had institutional deliveries and 71.5% had at least one antenatal check-up, indicating that challenges remain in increasing use of and access to maternal health care services. OBJECTIVE To explore the perceptions of high-level stakeholders on the process of implementing maternal health interventions in Gujarat. METHOD Using the policy triangle framework developed by Walt and Gilson, the process of implementation was approached using in-depth interviews and qualitative content analysis. RESULT Based on the analysis, three themes were developed: lack of continuity; the complexity of coordination; and lack of confidence and underutilization of the monitoring system. The findings suggest that decisions made and actions advocated and taken are more dependent on individual actors than on sustainable structures. The findings also indicate that the context in which interventions are implemented is challenged in terms of weak coordination and monitoring systems that are not used to evaluate and develop interventions on maternal health. CONCLUSIONS The implementation of interventions on maternal health is dependent on the capacity of the health system to implement evidence-based policies. The capacity of the health system in Gujarat to facilitate implementation of maternal health interventions needs to be improved, both in terms of the role of actors and in terms of structures and processes.

Maternal and fetal angiotensin-converting enzyme gene insertion/deletion polymorphism not associated with pregnancy-induced hypertension in Chinese women

Objective. The study aimed to investigate whether maternal and fetal angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphisms and the incompatibility of maternal and fetal ACE genotype are associated with the risk of pregnancy-induced hypertension (PIH) in Chinese Han women. Methods. Using a case-control mother-baby dyads study, a total of 226 maternal/offspring pairs were selected at Anyang Maternal and Child Health Hospital from January 2008 to December 2009. Maternal venous and cord bloods were obtained for DNA extraction. A polymerase chain reaction was performed on the genomic DNA samples to obtain the ACE gene I/D polymorphism. Results. In the present sample, there is no difference in maternal and fetal ACE genotype or allele frequency between PIH patients and control group (p > 0.05). Furthermore, no significant association was found between the genotype incompatibility of fetal and maternal ACE gene and the risk of PIH (p > 0.05). Conclusion. We did not find fetus ACE gene I/D polymorphism to be associated with the risk of PIH. Nor is there any evidence that the incompatibility of fetal and maternal ACE genotype is associated with PIH in the studied population.

Factors that influence the willingness of young adults in Dar es Salaam, Tanzania, to participate in phase I/II HIV vaccine trials.

Background HIV/AIDS continues to destroy the lives of young people especially in low-income countries. The inclusion of youths in HIV vaccine trials is of utmost importance in obtaining an effective vaccine that is acceptable to them. Objective To characterize the willingness of young adults in Tanzania to participate in an HIV vaccine trial and the factors that influence this willingness. Design Four hundred and fifty young adults who visited a youth-friendly Infectious Diseases Clinic (IDC) from February 2012 to September 2012 completed a self-administered questionnaire concerning sociodemographic information, their knowledge about and perception of HIV vaccine studies, and the availability of social support. Results Of our participants, 50.6% expressed willingness to participate in HIV vaccine trials, and this willingness was positively correlated with having some knowledge about HIV vaccine studies (AOR, 2.2; 95% CI: 1.4–3.4), a positive perception toward such studies (AOR, 2.3; 95% CI: 1.5–3.6), having a relationship with someone who could help them make a decision (AOR, 2.5; 95% CI: 1.3–4.9), and age at the time of sexual debut (AOR, 2.6; 95% CI 1.0–6.7) for 15- to 19-year-olds and (AOR, 2.7; 95% CI 1.0–7.1) for older participants. Conclusions The participants exhibited a moderate willingness to participate in HIV vaccine trials, which was associated with a positive perception of and some knowledge about such trials, having a relationship with someone who might influence their decision as well as age at time of sexual debut. More efforts should be made to inform the youths about specific HIV vaccine trials and related matters, as well as to engage significant others in the decision-making process.Background HIV/AIDS continues to destroy the lives of young people especially in low-income countries. The inclusion of youths in HIV vaccine trials is of utmost importance in obtaining an effective vaccine that is acceptable to them. Objective To characterize the willingness of young adults in Tanzania to participate in an HIV vaccine trial and the factors that influence this willingness. Design Four hundred and fifty young adults who visited a youth-friendly Infectious Diseases Clinic (IDC) from February 2012 to September 2012 completed a self-administered questionnaire concerning sociodemographic information, their knowledge about and perception of HIV vaccine studies, and the availability of social support. Results Of our participants, 50.6% expressed willingness to participate in HIV vaccine trials, and this willingness was positively correlated with having some knowledge about HIV vaccine studies (AOR, 2.2; 95% CI: 1.4-3.4), a positive perception toward such studies (AOR, 2.3; 95% CI: 1.5-3.6), having a relationship with someone who could help them make a decision (AOR, 2.5; 95% CI: 1.3-4.9), and age at the time of sexual debut (AOR, 2.6; 95% CI 1.0-6.7) for 15- to 19-year-olds and (AOR, 2.7; 95% CI 1.0-7.1) for older participants. Conclusions The participants exhibited a moderate willingness to participate in HIV vaccine trials, which was associated with a positive perception of and some knowledge about such trials, having a relationship with someone who might influence their decision as well as age at time of sexual debut. More efforts should be made to inform the youths about specific HIV vaccine trials and related matters, as well as to engage significant others in the decision-making process.