Vinod Mishra

HIV infection does not disproportionately affect the poorer in sub-Saharan Africa.

Background:Wealthier populations do better than poorer ones on most measures of health status, including nutrition, morbidity and mortality, and healthcare utilization. Objectives:This study examines the association between household wealth status and HIV serostatus to identify what characteristics and behaviours are associated with HIV infection, and the role of confounding factors such as place of residence and other risk factors. Methods:Data are from eight national surveys in sub-Saharan Africa (Kenya, Ghana, Burkina Faso, Cameroon, Tanzania, Lesotho, Malawi, and Uganda) conducted during 2003–2005. Dried blood spot samples were collected and tested for HIV, following internationally accepted ethical standards and laboratory procedures. The association between household wealth (measured by an index based on household ownership of durable assets and other amenities) and HIV serostatus is examined using both descriptive and multivariate statistical methods. Results:In all eight countries, adults in the wealthiest quintiles have a higher prevalence of HIV than those in the poorer quintiles. Prevalence increases monotonically with wealth in most cases. Similarly for cohabiting couples, the likelihood that one or both partners is HIV infected increases with wealth. The positive association between wealth and HIV prevalence is only partly explained by an association of wealth with other underlying factors, such as place of residence and education, and by differences in sexual behaviour, such as multiple sex partners, condom use, and male circumcision. Conclusion:In sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of association with poverty as most other diseases. HIV programmes should also focus on the wealthier segments of the population.

HIV transmission risk behavior among HIV-infected adults in Uganda: results of a nationally representative survey.

Objective:Evaluate factors associated with HIV transmission risk behavior among HIV-infected adults in Uganda. Design:Cross-sectional and nationally representative study (2004–2005 Uganda HIV/AIDS Sero-Behavioral Survey) tested 18 525 adults (15–59 years old) for HIV and herpes simplex virus type 2 (HSV-2). Methods:Data were weighted to obtain nationally representative results. Sexual-risk behavior by HIV-infected individuals was defined as unprotected sex at last encounter. Using multivariate analysis, we identified factors associated with being sexually active, knowing HIV status, and using contraception and condoms. Results:Of 1092 HIV-infected respondents, 64% were female (median age was 33 years), 84% had HSV-2, and 13% reported one lifetime partner (1% of men and 23% of women). Twenty-one percent of adults knew their HIV status and 9% knew their partners. Seventy-seven percent were sexually active, of whom 27% reported condom use at last sex. Of last unprotected sexual encounters, 84% were with spouses and 13% with steady partners. Of cohabitating persons, 40% had an HIV-negative spouse. Those who knew their HIV status were three times more likely to use a condom at last sex encounter [adjusted odds ratio (AOR), 3.0; 95% confidence intervals (CI), 1.9–4.7] and those who knew their partners HIV status were 2.3 times more likely to use condoms (AOR, 2.3; 95% CI, 1.2–4.3). Conclusions:A minority of HIV-infected adults in Uganda knew they had HIV infection; nearly half were in an HIV-discordant relationship, and few used condoms. Knowledge of HIV status, both ones own and ones partners, was associated with increased condom use. Interventions to support HIV-infected persons and their partners to be tested are urgently needed.

Evaluation of bias in HIV seroprevalence estimates from national household surveys

Objectives: To evaluate HIV seroprevalence estimates from demographic and health surveys (DHS) and AIDS indicator surveys (AIS) for potential bias because of non-response and exclusion of non-household population groups. Methods: Data are from 14 DHS/AIS surveys with HIV testing, conducted during 2003–6. Blood samples were collected and analysed for HIV using standard laboratory and quality control procedures. HIV prevalence among non-tested adults was predicted based on multivariate statistical models of HIV for those who were interviewed and tested, using a common set of predictor variables. Estimates of the size of non-household populations in national censuses were used to assess potential bias because of their exclusion in the household surveys under different assumptions about proportion of adults and HIV prevalence in non-household populations. Results: Non-tested men had significantly higher predicted HIV prevalence than those tested in eight of the 14 countries, while non-tested women had significantly higher predicted prevalence than those tested in seven of the 14 countries. Effects of non-response were somewhat stronger in lower-prevalence countries. The overall effect of non-response on observed national HIV estimates was small and insignificant in all countries. Estimated effects of exclusion of non-household population groups were generally small, even in concentrated epidemics in India and Cambodia under the scenario that 75% of the non-household population was adults having 20 times greater HIV prevalence than adults in household surveys. Conclusions: Non-response and the exclusion of non-household population groups tend to have small, insignificant effects on national HIV seroprevalence estimates obtained from household surveys.

Comparison of HIV prevalence estimates from antenatal care surveillance and population-based surveys in sub-Saharan Africa

Objective: To compare HIV seroprevalence estimates obtained from antenatal care (ANC) sentinel surveillance surveys in Ethiopia, Kenya, Malawi, Tanzania and Uganda with those from population-based demographic and health surveys (DHS) and AIDS indicator surveys (AIS). Methods: Geographical information system methods were used to map ANC surveillance sites and DHS/AIS survey clusters within a 15-km radius of the ANC sites. National DHS/AIS HIV prevalence estimates for women and men were compared with national prevalence estimates from ANC surveillance. DHS/AIS HIV prevalence estimates for women and men residing within 15 km of ANC sites were compared with those from ANC surveillance. For women, these comparisons were also stratified by current pregnancy status, experience of recent childbirth and receiving ANC for the last birth. Results: In four of the five countries, national DHS/AIS estimates of HIV prevalence were lower than the ANC surveillance estimates. Comparing women and men in the catchment areas of the ANC sites, the DHS/AIS estimates were similar to ANC surveillance estimates. DHS/AIS estimates for men residing in the catchment areas of ANC sites were much lower than ANC surveillance estimates for women in all cases. ANC estimates were higher for younger women than DHS/AIS estimates for women in ANC catchment areas, but lower at older ages. In all cases, urban prevalence was higher than rural prevalence but there were no consistent patterns by education. Conclusions: ANC surveillance surveys tend to overestimate HIV prevalence compared to prevalence among women in the general population in DHS/AIS surveys. However, the ANC and DHS/AIS estimates are similar when restricted to women and men, or to women only, residing in catchment areas of ANC sites. Patterns by age and urban/rural residence suggest possible bias in the ANC estimates.

The relationship of family size and composition to fertility desires contraceptive adoption and method choice in South Asia.

CONTEXTnMany countries in South Asia, including Nepal, India and Bangladesh, demonstrate a strong cultural preference for sons, which may influence fertility desires and contraceptive use.nnnMETHODSnDemographic and Health Survey data from married, nonpregnant women aged 15-49 who had at least one child were used to examine the relationship of parity and number of sons to reproductive outcomes in Nepal, India and Bangladesh. Outcomes of interest were desire for another child, contraceptive use and type of contraceptive (modern vs. traditional, temporary vs. permanent). Odds ratios and relative risk ratios were calculated using binary and multinomial logistic regression.nnnRESULTSnIn general, desire for another child decreased and contraceptive use increased as the number of children and number of sons increased. These associations were more prominent in Nepal and India than in Bangladesh. For example, compared with women who had three daughters and no sons, the odds of contraceptive use among women with two sons and one daughter were 4.8 in Nepal, 3.5 in India and 2.0 in Bangladesh. Within India, the associations of parity and number of sons with reproductive outcomes were generally stronger in northern states than in South India or West Bengal.nnnCONCLUSIONSnSon preference remains widespread in all three countries and has a major influence on reproductive behavior. Reducing such preference would require a change in social norms and attitudes of the people and an improvement of the status of women.

Family planning services quality as a determinant of use of IUD in Egypt

BackgroundBoth availability and quality of family planning services are believed to have contributed to increasing contraceptive use and declining fertility rates in developing countries. Yet, there is limited empirical evidence to show the relationship between the quality of family planning services and the population based prevalence of contraceptive methods. This study examined the relationship between quality of family planning services and use of intrauterine devices (IUD) in Egypt.MethodsThe analysis used data from the 2003 Egypt Interim Demographic and Health Survey (EIDHS) that included 8,445 married women aged 15–49, and the 2002 Egypt Service Provision Assessment (ESPA) survey that included 602 facilities offering family planning services. The EIDHS collected latitude and longitude coordinates of all sampled clusters, and the ESPA collected these coordinates for all sampled facilities. Using Geographic Information System (GIS) methods, individual women were linked to a facility located within 10 km of their community. A facility-level index was constructed to reflect the quality of family planning services. Four dimensions of quality of care were examined: counseling, examination room, supply of contraceptive methods, and management. Effects of quality of family planning services on the use of IUD and other contraceptive methods were estimated using multinomial logistic regression. Results are presented as relative risk ratios (RRR) with significance levels (p-values).ResultsIUD use among women who obtained their method from public sources was significantly positively associated with quality of family planning services (RRR = 1.36, p < 0.01), independent of distance to the facility, facility type, age, number of living children, education level, household wealth status, and residence. Quality of services related to counseling and examination room had strong positive effects on use of IUD (RRR = 1.61 for counseling and RRR = 1.46 for examination room). Obtaining IUD from a private source or using other contraceptive methods was not associated with quality of services.ConclusionThis study is one among the few that used geographic information to link data from a population-based survey with an independently sampled health facility survey. The findings demonstrate that service quality is an important determinant of use of clinical contraceptive methods in Egypt. Improving quality of family planning services may help further increase use of clinical contraceptive methods and reduce fertility.

Trends in HIV-related behaviors and knowledge in Uganda 1989-2005: evidence of a shift toward more risk-taking behaviors.

Objective(s):To describe recent trends in HIV-related behaviors and knowledge in Uganda between 1989 and 2005. Design:Population-based, cross-sectional national surveys of adult women and men. Methods:Trend analysis of selected HIV-related behavior and knowledge indicators, using data from the 2004-2005 Uganda HIV/AIDS Sero-Behavioral Survey and the 2000-2001, 1995, and 1988-1989 Uganda Demographic and Health Surveys. Responses to similar questions across the different surveys were compared to determine trends in indicators. Results:HIV/AIDS knowledge increased to a high level by 2001 and remained stable thereafter. Some self-reported risk behaviors improved, whereas others deteriorated. Among 15- to 24-year-old women and men, primary abstinence increased, from 23% in 1989 to 32% in 2005 and from 32% in 1995 to 42% in 2005, respectively. In men, there were increases in sex with multiple partners and sex with nonspousal partners, although reported condom use during nonspousal sex declined. Of men aged 15-49 years, self-reported multiple sex partnership increased from 24% in 2001 to 29% in 2005 and nonspousal sex increased from 28% in 2001 to 37% in 2005. Between 2001 and 2005, condom use during last nonspousal sex declined from 65% to 55% in men aged 15-24 years. Conclusions:Although substantial improvements in HIV-related risk behaviors and knowledge occurred since 1989, recent increases in some HIV-related risk behaviors were observed, indicating a shift toward more risk-taking behaviors. Prevention efforts should be reinvigorated to address this, otherwise the past success in the HIV fight will be reversed. Monitoring of HIV-related indicators should be continued.

Comparison of HIV prevalence estimates from sentinel surveillance and a national population-based survey in Uganda, 2004-2005.

Objective:HIV programs in generalized epidemics have traditionally relied on antenatal clinic (ANC) sentinel surveillance data to guide prevention and to model epidemic trends. ANC data, however, come from a subset of the population, and their representativeness of the population has been debated. Methods:Data from a national population-based Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) were compared with those from ANC sentinel surveillance. Using geographic information system, UHSBS clusters within a 30 km radius of the ANC sites were mapped. Estimates of HIV prevalence from ANC surveillance were compared with those from UHSBS. Results:The ANC-based HIV prevalence, 6.0% [confidence interval (CI) 5.5% to 6.5%], was similar to that from UHSBS, 5.9% (CI 5.4% to 6.4%). The ANC-based estimate correlated with that of UHSBS catchment area women who were pregnant and those who had given birth in the 2 years preceding the survey. ANC data overestimated prevalence in the 15-year to 19-year age group, were similar to UHSBS for ages 20-29 years, and underestimated prevalence in older respondents. ANC data underestimated HIV prevalence among women (6.0% vs. 7.4%; CI 6.6% to 8.2%) and urban women (7.6% vs. 12.7%) but was similar for rural women (5.3% vs. 4.9%). Conclusions:ANC-based surveillance remains an important tool for monitoring HIV/AIDS programs. ANC and UHSBS data were similar overall and for 15-year to 29-year olds, women who were pregnant, and women who had a birth in the 2 years before the survey. ANC estimates were lower in those ≥30 years and in urban areas. Periodic serosurveys to adjust ANC-based estimates are needed.

Spatial modeling of HIV prevalence in Kenya.

BackgroundIn 2003, artesunate-amodiaquine (AS+AQ) was introduced as the new first-line treatment for uncomplicated malaria in Burundi. After confirmed diagnosis, treatment was delivered at subsidized prices in public health centres. Nine months after its implementation a study was carried out to assess whether children below five years of age with uncomplicated malaria were actually receiving AS+AQ.MethodsA community-based study was conducted in Makamba province. Randomly selected households containing one or more children under five with reported fever onset within fourteen days before the study date were eligible. Case-management information was collected based on caregiver recall. A case definition of symptomatic malaria from observations of children presenting a confirmed malaria episode on the day of the survey was developed. Based on this definition, those children who had probable malaria among those with fever onset in the 14 days prior to the study were identified retrospectively. Treatment coverage with AS+AQ was then estimated among these probable malaria cases.ResultsOut of 195 children with fever on the day of the study, 92 were confirmed as true malaria cases and 103 tested negative. The combination of loss of appetite, sweating, shivering and intermittent fever yielded the highest possible positive predictive value, and was chosen as the case definition of malaria. Out of 526 children who had had fever 14 days prior to the survey, 165 (31.4%) were defined as probable malaria cases using this definition. Among them, 20 (14.1%) had been treated with AS+AQ, 10 with quinine (5%), 68 (41%) received non-malaria treatments, and 67 got traditional treatment or nothing (39.9%). Most people sought treatment from public health centres (23/99) followed by private clinics (15/99, 14.1%). The median price paid for AS+AQ was 0.5 US

A global database of abortion laws, policies, health standards and guidelines

.ConclusionAS+AQ was the most common treatment for patients with probable malaria at public health centres, but coverage was low due to low health centre utilisation and apparently inappropriate prescribing. In addition, AS+AQ was given to patients at a price ten times higher than the subsidized price. The availability and proper use of ACTs should be monitored and maximized after their introduction in order to have a significant impact on the burden of malaria.A clear understanding of geographic distribution of HIV-infected people and maintaining up-to-date lists and locations of facilities providing HIV-related services are essential for monitoring the epidemic and for providing treatment care and support services to the infected and their families. In this study we model and map human immunodeficiency virus (HIV) prevalence in Kenya in relation to its spatial and behavioral determinants using data from the 2003 Kenya Demographic and Health Survey (DHS). The 2003 Kenya DHS is one of the first population-based national surveys to link individual HIV test results for both males (age 15-54) and females (age 15-49) with the full set of behavioral social and demographic indicators included in the survey. The survey also collected spatial coordinates of the communities where survey respondents lived. These coordinates have been used to estimate spatial indicators such as distance to roads distance to Lake Victoria and population density. Using these spatial social demographic and behavioral indicators we developed a model to predict HIV prevalence. We apply this model to map HIV concentration areas at sub-provincial level and we assess the existing HIV service coverage in relation to the spatial distribution of HIV prevalence. The study finds large subregional variations in the prevalence of HIV in Kenya. Areas of high concentration of HIV-infected people have a disproportionately low density of HIV-related services. (authors)The dramatic changes in the earths landscape have prompted increased interest in the links between population land use and land cover. Previous research emphasized the notion of population pressure (population pressure increases demands on natural resources causing changes in land use) overlooking the potentially important effects of changes in land use on humans. Using multiple data sets from the Chitwan Valley Family Study in Nepal we test competing hypotheses about the impact of land use on first birth timing. We argue that while agricultural land should encourage early childbearing land area devoted to public infrastructure should discourage it. The results show that individuals from neighborhoods with larger proportions of land under agriculture experienced first birth at rates higher than those from neighborhoods with smaller proportions. On the other hand individuals from neighborhoods with larger proportions of land under public infrastructure experienced first birth at rates lower than those from neighborhoods with smaller proportions. (authors)