Mary T. Bassett

Genital ulcers and transmission of HIV among couples in Zimbabwe.

Seventy-five married men found to be positive for HIV-1 in Harare, Zimbabwe, were interviewed in order to define behaviours associated with acquisition of infection and to determine factors associated with transmission of infection to their wives. The majority of infected men reported sexual intercourse with multiple heterosexual partners and female prostitutes, and gave a history of sexually transmitted diseases (STDs). All subjects denied homosexual activity and parenteral drug abuse. Serological testing of the wives of seropositive men showed that 45 (60%) were HIV-antibody-positive. Wives of men with AIDS and AIDS-related complex (ARC) and wives of men who gave a history of genital ulcer disease were more likely to be seropositive. The study demonstrates that HIV-1 infection in Zimbabwe occurs through heterosexual intercourse and is associated with other STDs. In addition, the study shows that male to female transmission of HIV-1 is facilitated by the presence of genital ulcers in infected men.

Uptake of workplace HIV counselling and testing: a cluster-randomised trial in Zimbabwe.

Background HIV counselling and testing is a key component of both HIV care and HIV prevention, but uptake is currently low. We investigated the impact of rapid HIV testing at the workplace on uptake of voluntary counselling and testing (VCT). Methods and Findings The study was a cluster-randomised trial of two VCT strategies, with business occupational health clinics as the unit of randomisation. VCT was directly offered to all employees, followed by 2 y of open access to VCT and basic HIV care. Businesses were randomised to either on-site rapid HIV testing at their occupational clinic (11 businesses) or to vouchers for off-site VCT at a chain of free-standing centres also using rapid tests (11 businesses). Baseline anonymised HIV serology was requested from all employees. HIV prevalence was 19.8% and 18.4%, respectively, at businesses randomised to on-site and off-site VCT. In total, 1,957 of 3,950 employees at clinics randomised to on-site testing had VCT (mean uptake by site 51.1%) compared to 586 of 3,532 employees taking vouchers at clinics randomised to off-site testing (mean uptake by site 19.2%). The risk ratio for on-site VCT compared to voucher uptake was 2.8 (95% confidence interval 1.8 to 3.8) after adjustment for potential confounders. Only 125 employees (mean uptake by site 4.3%) reported using their voucher, so that the true adjusted risk ratio for on-site compared to off-site VCT may have been as high as 12.5 (95% confidence interval 8.2 to 16.8). Conclusions High-impact VCT strategies are urgently needed to maximise HIV prevention and access to care in Africa. VCT at the workplace offers the potential for high uptake when offered on-site and linked to basic HIV care. Convenience and accessibility appear to have critical roles in the acceptability of community-based VCT.

The Association Between Alcohol Use, Sexual Risk Behavior, and HIV Infection Among Men Attending Beerhalls in Harare, Zimbabwe

HIV testing and a behavioral survey were conducted with a cross-sectional sample of 324 men recruited at beerhalls in Harare, Zimbabwe, to examine the relationship among alcohol use, high-risk sexual behavior, and HIV infection among male beerhall patrons and to evaluate the feasibility of using beerhalls as venues for male-centered HIV prevention activities. Recent HIV seroconversions were identified using the less-sensitive enzyme immunoassay. HIV education activities were provided inside beerhalls and qualitative methods were used to assess the acceptability of conducting HIV prevention activities and research at beerhalls. The prevalence of HIV infection was 30%; the prevalence of recent seroconversion was 3.4%. Having sex while intoxicated in the previous 6 months was reported by 31% of men and was strongly associated with recent HIV seroconversion as well as unprotected sex with casual partners and paying for sex. Acceptability of prevention and research activities was high among beerhall patrons, managers, and owners. Beerhalls present an environment associated with high-risk sexual behavior and concomitantly high rates of HIV seroconversion. Beerhalls are appropriate and feasible venues for delivering HIV prevention programs targeted at men in many regions of sub-Saharan Africa and the world.

Prevalence and Incidence of Herpes Simplex Virus Type 2 Infection among Male Zimbabwean Factory Workers

Stored sera from a cohort of 2397 male factory workers in Harare, Zimbabwe, were screened for herpes simplex virus type 2 (HSV-2)-specific antibodies, to estimate the prevalence and incidence of genital herpes infection and to assess the relation between HSV-2 and human immunodeficiency virus (HIV) acquisition. The prevalence of HSV-2 at enrollment was 39.8%. Correlates of HSV-2 seropositivity were HIV seropositivity, marital status, history of sexually transmitted disease (STD), older age, and higher income. The incidence of HSV-2 seroconversion during follow-up was 6.2/100 person-years. Correlates of HSV-2 seroconversion were enrollment while HIV-positive or seroconversion during follow-up, reported genital ulcer, history of STD, and number of sex partners. No evidence was found that HSV-2 infection was more likely to precede HIV or vice versa. HSV-2 and HIV seropositivity are strong markers for high-risk sexual behavior. Improved interventions targeted to populations in which the incidence of either viral infection is high are needed.

HIV seroincidence and correlates of seroconversion in a cohort of male factory workers in Harare, Zimbabwe.

OBJECTIVES Given that health promotion messages on transmission of HIV and other sexually transmitted diseases (STD) have been widely publicized in Zimbabwe and elsewhere in the late 1980s, it is vital to analyse which risk events still expose individuals to infection. A cohort was established with the objectives of estimating HIV seroincidence, behavioural and biological determinants of infection, and ultimately, evaluating the impact of AIDS prevention interventions in the workplace. METHODS HIV seroincidence was estimated in a prospectively followed cohort of male factory workers recruited in Harare, Zimbabwe during the period prior to a workplace AIDS prevention intervention. Correlates of HIV seroconversion were identified using Cox regression analysis. RESULTS There were 51 seroconversions among 1607 HIV-negative participants following 1738 person-years (PY) of observation [seroincidence, 2.93 per 100 PY; 95% confidence interval (CI), 2.18-3.86]. The prevalence of HIV in the cohort was 19.1%. HIV seroincidence was significantly increased among men who were younger [hazard ratio (HR) per year, 0.96; 95% CI, 0.93-0.99], were single (HR, 3.29; 95% CI, 1.56-6.96), were married but resided separately from their wives (HR, 2.18; 95% CI, 0.99-4.80), reported having any STD (HR, 3.00; 95% CI, 1.53-5.86), reported having a genital ulcer (HR, 4.87; 95% CI, 2.18-10.91), and reported paying for sex (HR, 2.01; 95% CI, 1.06-3.77). Seroincidence also increased with the number of sex partners reported in the year preceding enrolment (HR per partner, 1.10; 95% CI, 1.01-1.21). In multiple Cox regression analysis, three independent associations with HIV seroconversion were reporting a genital ulcer (adjusted HR, 3.55; 95% CI, 1.52-8.29), number of sex partners (adjusted HR, 1.10; 95% CI, 1.01-1.21), and being married but residing separately from ones wife (adjusted HR, 2.21; 95% CI, 1.00-4.89). CONCLUSIONS Innovative and sustained workplace-based interventions are needed to address the high risk of HIV infection in this economically productive population. The predictors of HIV seroconversion described in this study underscore the need for public health efforts to simultaneously address the biological, socioeconomic and behavioural factors that continue to place individuals at risk of HIV in general populations of Africa.

Breast-milk shedding of drug-resistant HIV-1 subtype C in women exposed to single-dose nevirapine.

Single-dose nevirapine reduces intrapartum human immunodeficiency virus 1 type (HIV-1) transmission but may also select for nonnucleoside reverse-transcriptase inhibitor (NNRTI) resistance in breast milk (BM) and plasma. Among 32 Zimbabwean women, median 8-week postpartum plasma and BM HIV-1 RNA levels were 4.57 and 2.13 log(10) copies/mL, respectively. BM samples from women with laboratory-diagnosed mastitis (defined as elevated BM Na(+) levels) were 5.4-fold more likely to have HIV-1 RNA levels above the median. BM RT sequences were not obtained for 12 women with BM HIV-1 RNA levels below the lower limit of detection of the assay used. In 20 paired BM and plasma samples, 65% of BM and 50% of plasma RT sequences had NNRTI-resistance mutations, with divergent mutation patterns.

Professionalism, patient satisfaction and quality of health care: Experience during Zimbabwe's structural adjustment programme

In 1991, Zimbabwe embarked on a structural adjustment programme. In the health sector, collection of fees was enforced and fees were later increased. Utilisation subsequently declined. This paper examines the perceptions of both government nurses and health care consumers regarding the impact of adjustment on overall quality of care, including nurse professionalism, the nurse-client relationship and patient satisfaction with care. These issues were explored in a series of focus group discussions held in December 1993, about three years after policy reforms. The discussions suggested many areas of shared concern (fees, drug availability, waiting times), but divergent views regarding the process of care. Nurses were concerned mainly with overwork and patient ingratitude, and failed to recognise nurse behaviour as a major source of patient dissatisfaction. Community women saw nurses as hardened and indifferent, especially in urban areas. These differences are rooted in the perceived class differences between nurses and the communities they serve, but appear to have sharpened during the period of structural adjustment.

Safety and trough concentrations of nevirapine prophylaxis given daily, twice weekly, or weekly in breast-feeding infants from birth to 6 months.

Despite the success of antiretroviral prophylaxis in reducing mother-to-child HIV-1 transmission, postpartum transmission through breast milk remains a problem. Antiretroviral administration to the infant during the period of breast-feeding could protect against postnatal transmission. An open-label phase 1/2 study was designed to assess the safety and trough concentrations of nevirapine (NVP) given once weekly (OW), twice weekly (TW), or once daily (OD) to HIV-exposed breast-feeding infants for 24 weeks. Following maternal dosing with 200 mg NVP orally at onset of labor, breast-feeding infants were randomized within 48 hours of birth to 1 of 3 regimens: arm 1, NVP given OW (4 mg/kg from birth to 14 days, ↑ to 8 mg/kg from 15 days to 24 weeks), arm 2, NVP given TW (4 mg/kg from birth to 14 days, ↑ to 8 mg/kg from 15 days to 24 weeks), and arm 3, NVP given OD (2 mg/kg from birth to 14 days, ↑ to 4 mg/kg from 15 days to 24 weeks). Trough NVP concentrations and clinical and laboratory abnormalities were monitored. Of the 75 infants randomized (26 to OW, 25 to TW, and 24 to OD dosing), 63 completed the 32-week follow-up visit. No severe skin, hepatic, or renal toxicity related to NVP was observed. Neutropenia occurred in 8 infants. Trough NVP levels were lower than the therapeutic target (100 ng/mL) in 48 of 75 (64.0%) samples from infants in the OW arm, 3 of 65 (4.6%) samples in the TW arm, and 0 of 72 samples in the OD arm. Median (range) trough NVP concentrations were 64 ng/mL (range: <25–1519 ng/mL) with OW dosing; 459 (range: <25–1386 ng/mL) with TW dosing; and 1348 (range: 108–4843 ng/ml) with OD dosing. Our data indicate that NVP prophylaxis for 6 months was safe and well tolerated in infants. OD NVP dosing resulted in all infants with trough concentration greater than the therapeutic target and maintenance of high drug concentrations. A phase 3 study is planned to assess the efficacy of OD infant NVP regimen to prevent breast-feeding HIV-1 transmission.

Relationship between bladder cancer incidence, Schistosoma haematobium infection, and geographical region in Zimbabwe

Bladder cancer is common in Zimbabwe, possibly due to the high prevalence of Schistosoma haematobium infection in some areas. We undertook a correlational study based on retrospective medical record review to see whether the number of bladder cancers could be related to geographical region and prevalence of S. haematobium infection. We also determined patient demographic characteristics and tumour histology. Of 483 patients identified (1984-1987), 69% with available histology had squamous cell carcinomas. The remainder had transitional cell carcinomas. Patients with squamous cell carcinoma were younger than patients with transitional cell carcinomas (50% vs 20% under 50 years old, P less than 0.05) and had a sex ratio of one. There was a positive geographical relationship between S. haematobium prevalence and the incidence of squamous cell carcinoma of the bladder: provinces with high prevalence of S. haematobium had more bladder cancer cases with a predominance of squamous cell carcinoma (r = 0.87, P less than 0.01). These data support a casual relationship between S. haematobium infection and squamous cell carcinoma of the bladder.

School based HIV prevention in Zimbabwe: feasibility and acceptability of evaluation trials using biological outcomes

ObjectiveTo determine the feasibility and acceptability of conducting a community randomized trial (CRT) of an adolescent reproductive health intervention (ARHI) using biological measures of effectiveness. SettingFour secondary schools and surrounding communities in rural Zimbabwe. MethodsDiscussions were held with pupils, parents, teachers and community leaders to determine acceptability. A questionnaire and urine sampling survey was undertaken among Form 1 and 2 pupils. Studies were undertaken to inform likely participation and follow up in a future CRT. A community survey of 16–19-year-olds was conducted to determine levels of secondary school attendance and likely HIV prevalence at final follow up in the event of a trial. ResultsForm 1 and 2 pupils aged 12–18 years (n = 723; median age, 15 years) participated in the research. Prevalences of HIV, Chlamydia and gonorrhoea were 3.6% [95% confidence interval (CI), 2.3–5.3%], 0.4% (95% CI, 0.1–1.3%) and 1.9% (95% CI, 1.0–3.3%) respectively. There was poor correlation between biological evidence of sexual experience and questionnaire responses, due to concerns about confidentiality. Only 13% (95% CI, 4–27%) of those infected with HIV and/or a sexually transmitted disease admitted to having had sex. In the community survey of 573 adolescents aged 16–19 years, 6.6% (95% CI, 3.9–10.3%) of females and 5.1% (95% CI, 2.9–8.2%) of males were HIV positive. High participation and retention rates are achievable within a trial in this setting. ConclusionsIt is acceptable and feasible to conduct randomized trials to establish the effectiveness of ARHIs. However, self-reported behavioural outcomes will probably be biased, emphasizing the importance of using externally validated biological outcome measures to determine effectiveness.