Susan Foster

Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh

BACKGROUNDnIn the control of reproductive-tract infections, including sexually transmitted infections (STIs), in low-income and middle-income countries, WHO recommends syndromic management for individuals with symptoms. This intervention was initially developed in areas where prevalence of such infections is high. We investigated the clinical effectiveness and cost of this approach among a group of women with a low prevalence of infection.nnnMETHODSnDuring a 5-month period, we investigated all women complaining of abnormal vaginal discharge and seeking care at maternal and child health/family-planning centres in Matlab, Bangladesh, for the presence of laboratory-diagnosed reproductive-tract infections and STIs. Syndromic diagnoses made by trained health-care workers were compared with laboratory diagnosis of infection. We then calculated the costs of treating women by means of the recommended WHO algorithm and an adapted algorithm incorporating use of a speculum and simple diagnostic tests.nnnFINDINGSnThe prevalence of endogenous infections among 320 women seen was 30%. Cervical infections (Neisseria gonorrhoeae and Chlamydia trachomatis) were found in only three women. The WHO algorithm had a high sensitivity (100%) but a low specificity (zero for bacterial vaginosis, candida, and Trichomonas vaginalis). The speculum-based algorithm had a low sensitivity (between zero and 59%) but a higher specificity (79-97%). Between 36% and 87% of costs would have been spent on uninfected women.nnnINTERPRETATIONnThe high rate of overtreatment in the population studied carries both financial and social costs--the latter in potentially exposing women misdiagnosed as having an STI to threats of domestic disruption or even violence. We make recommendations for management programmes in areas of low STI prevalence and low income.

Supply and use of essential drugs in sub-Saharan Africa: Some issues and possible solutions

The paper describes drug supply systems in Africa, both public and private, and concludes that the private sector may have serious drawbacks. Many opportunities exist for improving efficiency and reducing waste; the paper gives evidence for the savings to be made. Finally, there are several issues of specific importance to Africa, namely, geographic and spatial constraints to improving logistics, which are much more severe than elsewhere in the world; the problem of counterfeit drugs; financing of drug supplies and cost recovery; and the impact of the HIV/AIDS epidemic on supply and use of essential drugs.

Benefits of HIV screening of blood transfusions in Zambia

Blood transfusion continues to be an important route of transmission of HIV in developing countries, especially for young children following the perinatal period. Testing for HIV is costly and reliable donor support for the purchase of test kits is often essential, yet difficult to secure. The costs of screening transfusions for HIV and the financial benefits in terms of savings on treatment costs averted were calculated for a district hospital in Zambia where seroprevalence among donors was 15.9%. Financial benefits exceed costs by a factor of 2.7-3.5. In 1991, 1073 transfusions were given and an estimated 150 cases of transfusion-related AIDS were prevented by screening, of which 59% were in children aged 5 years or under and 31% were in women. The total cost of HIV screening was 3061 pounds (

Economic prospects for a new antimalarial drug

4745), and the cost per case of HIV infection prevented was 20.40 pounds (

Cutaneous reactions to thiacetazone in Zambia—implications for tuberculosis treatment strategies

31.62); the cost of this protection for the population served by the hospital was 0.02 pounds (

Maize production, drought and AIDS in Monze District Zambia

0.03) per person. An estimated 3625 undiscounted healthy years of life were saved, of which nearly 69% were in children under 6, at a cost of 0.85 pounds (

Economic evaluation of health interventions—some strengths and limitations

1.32) per year of life saved. It is essential that financial and political support for HIV screening of blood for transfusion is maintained.

Use of thiacetazone

The market for antimalarial drugs consists of the 2.8 billion (2.8 x 10(9) people living in malaria endemic areas and about 20-30 million people, mainly Europeans and North Americans, who travel or live in malarious areas, and the wealthy elite of malarious developing countries. Some of the largest markets include China, India, and Indonesia with a total of 1.9 billion people exposed; Latin America, with 119 million; and sub-Saharan Africa with 400 million. An estimated 200 million clinical cases occur each year, with around 2 million deaths annually, primarily in African children. Antimalarial drugs are distributed through several different networks and are purchased by governments and private individuals. At present the world market is dominated by chloroquine by virtue of its safety, wide availability and low price. Approximately 20% of the total production of chloroquine was distributed through national control programmes and 80% through other channels; chloroquine is probably the second or third most widely consumed drug in the world. The global market for antimalarial drugs is likely to be of the order of US

Carrying out a bed census at a district hospital in Zambia.

100-120 million, with chloroquine making up about US

Health-care reform: the issues and the role of donors

64-80 m, sulfadoxine/pyrimethamine about US