Decline in prevalence of HIV-1 infection and syphilis among young women attending antenatal care clinics in Addis Ababa, Ethiopia: results from sentinel surveillance, 1995-2001

Systematic review and meta-analysis of seroprevalence of human immunodeficiency virus serological markers among pregnant women in Africa, 1984-2020

BACKGROUND

Human immunodeficiency virus (HIV) is a major public health concern, particularly in Africa where HIV rates remain substantial. Pregnant women are at an increased risk of acquiring HIV, which has a significant impact on both maternal and child health.

AIM

To review summarizes HIV seroprevalence among pregnant women in Africa. It also identifies regional and clinical characteristics that contribute to study-specific estimates variation.

METHODS

The study included pregnant women from any African country or region, irrespective of their symptoms, and any study design conducted in any setting. Using electronic literature searches, articles published until February 2023 were reviewed. The quality of the included studies was evaluated. The DerSimonian and Laird random-effects model was applied to determine HIV pooled seroprevalence among pregnant women in Africa. Subgroup and sensitivity analyses were conducted to identify potential sources of heterogeneity. Heterogeneity was assessed with Cochran's Q test and I2 statistics, and publication bias was assessed with Egger's test.

RESULTS

A total of 248 studies conducted between 1984 and 2020 were included in the quantitative synthesis (meta-analysis). Out of the total studies, 146 (58.9%) had a low risk of bias and 102 (41.1%) had a moderate risk of bias. No HIV-positive pregnant women died in the included studies. The overall HIV seroprevalence in pregnant women was estimated to be 9.3% [95% confidence interval (CI): 8.3-10.3]. The subgroup analysis showed statistically significant heterogeneity across subgroups (P < 0.001), with the highest seroprevalence observed in Southern Africa (29.4%, 95%CI: 26.5-32.4) and the lowest seroprevalence observed in Northern Africa (0.7%, 95%CI: 0.3-1.3).

CONCLUSION

The review found that HIV seroprevalence among pregnant women in African countries remains significant, particularly in Southern African countries. This review can inform the development of targeted public health interventions to address high HIV seroprevalence in pregnant women in African countries.

Molecular Epidemiology and Transmission Dynamics of the HIV-1 Epidemic in Ethiopia: Epidemic Decline Coincided With Behavioral Interventions Before ART Scale-Up

Background

Ethiopia is one of the sub-Saharan countries hit hard by the HIV epidemic. Previous studies have shown that subtype C dominates the Ethiopian HIV-1 epidemic, but the evolutionary and temporal dynamics of HIV-1 in Ethiopia have not been closely scrutinized. Understanding the evolutionary and epidemiological pattern of HIV is vital to monitor the spread, evaluate and implement HIV prevention strategies.

Methods

We analyzed 1,276 Ethiopian HIV-1 subtype C polymerase (pol sequences), including 144 newly generated sequences, collected from different parts of the country from 1986 to 2017. We employed state-of-art maximum likelihood and Bayesian phylodynamic analyses to comprehensively describe the evolutionary dynamics of the HIV-1 epidemic in Ethiopia. We used Bayesian phylodynamic models to estimate the dynamics of the effective population size (Ne) and reproductive numbers (Re) through time for the HIV epidemic in Ethiopia.

Results

Our analysis revealed that the Ethiopian HIV-1 epidemic originated from two independent introductions at the beginning of the 1970s and 1980s from eastern and southern African countries, respectively, followed by epidemic growth reaching its maximum in the early 1990s. We identified three large clusters with a majority of Ethiopian sequences. Phylodynamic analyses revealed that all three clusters were characterized by high transmission rates during the early epidemic, followed by a decline in HIV-1 transmissions after 1990. Re was high (4–6) during the earlier time of the epidemic but dropped significantly and remained low (Re &lt; 1) after the mid-1990. Similarly, with an expected shift in time, the effective population size (Ne) steadily increased until the beginning of 2000, followed by a decline and stabilization until recent years. The phylodynamic analyses corroborated the modeled UNAIDS incidence and prevalence estimates.

Conclusion

The rapid decline in the HIV epidemic took place a decade before introducing antiretroviral therapy in Ethiopia and coincided with early behavioral, preventive, and awareness interventions implemented in the country. Our findings highlight the importance of behavioral interventions and antiretroviral therapy scale-up to halt and maintain HIV transmissions at low levels (Re &lt; 1). The phylodynamic analyses provide epidemiological insights not directly available using standard surveillance and may inform the adjustment of public health strategies in HIV prevention in Ethiopia.

Prevalence and Trends of Major Transfusion Transmissible Infections among Blood Donors in Dire Dawa Blood bank, Eastern Ethiopia: Retrospective Study

Background

Acquisition of transfusion transmissible infections in the process of therapeutic blood transfusion is a major global health challenge in transfusion medicine. This study aimed to determine the prevalence and trends of major transfusion transmissible infections among blood donors.

Method

A retrospective analysis of consecutive blood donors' records covering the period between July 2010 and June 2013 was conducted at Dire Dawa Blood Bank, Eastern Ethiopia.

Result

A total of 6376 blood donors were tested, out of which 5647(88.57%) were replacement donors and 729(11.43%) were voluntary donors. The majority of them were male, 5430(85.16%), and aged between 18–32 years, 4492(70.45%). A total of 450(7.06%) donors had serological evidence of infection with at least one pathogen. The overall positivity rates of HBV, HIV, HCV and syphilis were 4.67%, 1.24%, 0.96%, and 0.44% respectively. Trends for transfusion-transmissible infections showed a significant decrease from 9.51% in 2010 to 6.95% in 2013 with the least prevalence in 2012 (5.90%) (P = 0.004). The prevalence of transfusion transmissible infections was significantly higher among male blood donors compared to female donors, among the age group of 25–32 years and 33–40 years compared to the age group of 18–24 years old, and among unemployed and private workers compared to students.

Conclusion

A significant percentage of the blood donors harbor transfusion-transmissible infections. Stringent donor selection using standard methods is highly recommended to ensure the safety of blood for the recipient. Furthermore, efforts on motivating and creating awareness in the community are required to increase voluntary blood donors.

Should All Pregnant Women be Screened for Syphilis?

In industrialized countries, the incidence of syphilis has decreased dramatically since the discovery of penicillin in the 1940s. However, syphilis and congenital syphilis are far from eradicated, especially in low- and middle-income countries. Syphilis in pregnant women is a cause of adverse pregnancy outcomes that can be prevented by screening for syphilis and early treatment in pregnancy. Several studies have found screening of pregnant women for syphilis to be a highly cost-effective intervention, even if the prevalence of syphilis is low. Obstacles to universal screening of pregnant women include low awareness of syphilis and low quality of antenatal care and healthcare in general in many low- and middle-income countries. For these settings, we need simpler and more reliable serological tests for syphilis, but we also need to strengthen health services in general to ensure sustainable antenatal care services to ensure sustainability of syphilis screening programmes.

Seroprevalence of Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus, and Syphilis among Blood Donors at Jigjiga Blood Bank, Eastern Ethiopia

BACKGROUND

Transfusion-transmissible infectious agents such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and Syphilis are among the greatest threats to blood safety for recipients. They are also the leading causes of death and chronic and life-threatening abnormalities.

METHODS

A retrospective analysis of consecutive blood donors' records covering the period between January 2010 and December 2014 was conducted to analyze for seroprevalence of HIV, HBV, HCV and syphilis among blood donors aged 17-65 years. The association of these infections with age group, blood group, their co-infection rate and year trends were analyzed. Linear regression analysis was used to determine trends of HIV, HBV, HCV and syphilis infections. Sterile venous anti-coagulated blood was collected from the donors and analyzed using highly sensitive and specific kits.

RESULT

From the total of 6827 consecutive blood donors, 963(14.1%) had serological evidence of infection with at least one pathogen and 73(1.07%) had multiple infections. The overall seroprevalence of HIV, HBV, HCV and syphilis was 3.16%, 9.48%, 0.73% and 0.73% respectively. Among those with multiple infections, the most common combinations were HIV-HBV 41/73(56.2%). Blood group "O positive" was the most common with 51.62% followed by "A positive". Moreover, significantly declining trends of HIV, HCV and syphilis seropositivity were observed over the study period.

CONCLUSION

A substantial percentage of the blood donors harbour HIV, HBV, HCV and syphilis infections. Strict selection of blood donors and comprehensive screening of donors' blood using standard methods are highly recommended to ensure the safety of blood for recipients.

A comparison of missing data procedures for addressing selection bias in HIV sentinel surveillance data

BACKGROUND

Selection bias is common in clinic-based HIV surveillance. Clinics located in HIV hotspots are often the first to be chosen and monitored, while clinics in less prevalent areas are added to the surveillance system later on. Consequently, the estimated HIV prevalence based on clinic data is substantially distorted, with markedly higher HIV prevalence in the earlier periods and trends that reveal much more dramatic declines than actually occur.

METHODS

Using simulations, we compare and contrast the performance of the various approaches and models for handling selection bias in clinic-based HIV surveillance. In particular, we compare the application of complete-case analysis and multiple imputation (MI). Several models are considered for each of the approaches. We demonstrate the application of the methods through sentinel surveillance data collected between 2002 and 2008 from India.

RESULTS

Simulations suggested that selection bias, if not handled properly, can lead to biased estimates of HIV prevalence trends and inaccurate evaluation of program impact. Complete-case analysis and MI differed considerably in their ability to handle selection bias. In scenarios where HIV prevalence remained constant over time (i.e. β = 0), the estimated β^1 derived from MI tended to be biased downward. Depending on the imputation model used, the estimated bias ranged from -1.883 to -0.048 in logit prevalence. Furthermore, as the level of selection bias intensified, the extent of bias also increased. In contrast, the estimates yielded by complete-case analysis were relatively unbiased and stable across the various scenarios. The estimated bias ranged from -0.002 to 0.002 in logit prevalence.

CONCLUSIONS

Given that selection bias is common in clinic-based HIV surveillance, when analyzing data from such sources appropriate adjustment methods need to be applied. The results in this paper suggest that indiscriminant application of imputation models can lead to biased results.

Seroprevalence of HIV, HBV, HCV and syphilis infections among blood donors at Gondar University Teaching Hospital, Northwest Ethiopia: declining trends over a period of five years

Background

Transfusion-transmissible infectious agents such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis are among the greatest threats to blood safety for the recipient. This study aimed to determine the seroprevalence, risk factors and trends of HIV, HBV, HCV and syphilis infections among blood donors over a period of five years at Gondar University Teaching Hospital, Northwest Ethiopia.

Methods

A retrospective analysis of consecutive blood donors' records covering the period between January 2003 and December 2007 was conducted. Logistic regression analysis was used to determine risk factors associated with HIV, HBV, HCV and syphilis infections.

Results

From the total of 6361 consecutive blood donors, 607 (9.5%) had serological evidence of infection with at least one pathogen and 50 (0.8%) had multiple infections. The overall seroprevalence of HIV, HBV, HCV and syphilis was 3.8%, 4.7%, 0.7%, and 1.3% respectively. Among those with multiple infections, the most common combinations were HIV - syphilis 19 (38%) and HIV - HBV 17 (34%). The seropositivity of HIV was significantly increased among female blood donors, first time donors, housewives, merchants, soldiers, drivers and construction workers. Significantly increased HBV seropositivity was observed among farmers, first time donors and age groups of 26 - 35 and 36 - 45 years. Similarly, the seroprevalence of syphilis was significantly increased among daily labourers and construction workers. Statistically significant association was observed between syphilis and HIV infections, and HCV and HIV infections. Moreover, significantly declining trends of HIV, HCV and syphilis seropositivity were observed over the study period.

Conclusions

A substantial percentage of the blood donors harbour HIV, HBV, HCV and syphilis infections. Strict selection of blood donors and comprehensive screening of donors' blood using standard methods are highly recommended to ensure the safety of blood for recipient.

Heterogeneous and decreasing HIV prevalence among women seeking antenatal care in Kinshasa, Democratic Republic of Congo

BACKGROUND

We examined HIV prevalence trends over 4.5 years among women receiving antenatal care in Kinshasa, Democratic Republic of Congo, by geographic location, clinic management and urbanicity.

METHODS

Quarterly proportions and 95% confidence intervals (CIs) of pregnant women with HIV positive results were determined using aggregate service provision and uptake data from 22 maternity units that provided vertical HIV prevention services from October 2004 to March 2009. Assuming linearity, proportions were assessed for trend via the Cochran-Armitage test. Multivariable binomial regression was used to describe detailed prevalence trends.

RESULTS

HIV testing was offered to 220,006 pregnant women; 210,348 (95.6%) agreed to be tested and 191,216 (90.9%) received their results. A total of 3999 women were found to be HIV positive, a prevalence of 1.90% (95% CI: 1.84-1.96%). The median quarterly proportion of women testing positive for HIV was 1.94% (range: 1.44-2.44%). Prevalence was heterogeneous in terms of maternity management, urbanicity and geographic location. Modeling suggested that the overall prevalence dropped from 2.04% (95% CI: 1.92-2.16%) to 1.77% (95% CI: 1.66-1.88%) over 4.5 years, a relative decrease of 13.2% (95% CI: 3.53-22.9%). Trend testing corroborated this decline (P < 0.01).

CONCLUSIONS

The decreasing HIV prevalence among Kinshasa antenatal care seekers is robust and encouraging. The relatively low prevalence and the weak existing healthcare system require prevention of mother-to-child transmission interventions that strengthen maternal and child healthcare service delivery. Complacency would be unwarranted: assuming a uniform national crude birth rate of 50/1000 and 1.8% antenatal HIV prevalence, approximately 7000 pregnant HIV infected women in Kinshasa, and 60,000 nationwide, are in need of care and prevention services yearly.

Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations

Background: Women who work commercially in sex work (female sex workers [FSW]) are considered a high-risk group for sexually transmissible infections (STI), yet the level of reported pathogens varies in studies around the world. This study reviewed STI rates reported in 42 studies of FSW around the world published between 1995 and 2006 and analysed the trends and types of populations surveyed, emphasising difficult to access FSW populations. Methods:Studies were retrieved by PUBMED and other search engines and were included if two or more pathogens were studied and valid laboratory methods were reported. Results: The five most commonly assessed pathogens were Neisseria gonorrhea (prevalence 0.5–41.3), Chlamydia trachomatis (0.61–46.2), Treponema pallidum (syphilis; 1.5–60.5), HIV (0–76.6), and Trichomonas vaginalis (trichmoniasis; 0.11–51.0). Neisseria gonorrhea and C. trachomatis were the most commonly tested pathogens and high prevalence levels were found in diverse areas of the world. HIV was highly prevalent mostly in African countries. Although human papillomavirus infection was surveyed in few studies, prevalence rates were very high and its aetiological role in cervical cancer warrant its inclusion in future FSW monitoring. Hard-to-access FSW groups tended to have higher rates of STI. Conclusions: The five most commonly detected pathogens correspond to those that are highly prevalent in the general population, however there is an urgent need to develop rapid testing diagnostics for all five pathogens to increase prevention and treatment, especially in outreach programs to the most vulnerable groups among FSW.

HIV-1 Subtype C gag-specific T-cell responses in relation to human leukocyte antigens in a diverse population of HIV-infected Ethiopians

Knowledge of the most dominant T-cell epitopes in the context of the local human leukocyte antigen (HLA) background is a prerequisite for the development of an effective HIV vaccine. In 100 Ethiopian subjects, 16 different HLA-A, 23 HLA-B, and 12 HLA-C specificities were observed. Ninety-four percent of the population carried at least 1 of the 5 most common HLA-A and/or HLA-B specificities. HIV-specific T-cell responses were measured in 48 HIV-infected Ethiopian subjects representing a wide range of ethnicities in Ethiopia using the interferon (IFN)-gamma enzyme-linked immunospot (Elispot) assay and 49 clade C-specific synthetic Gag peptides. Fifty-eight percent of the HIV-positive study subjects showed T-cell responses directed to 1 or more HIV Gag peptides. Most Gag-specific responses were directed against the subset of peptides spanning Gag p24. The breadth of response ranged from 1 to 9 peptides, with most (78%) individuals showing detectable responses to <3 Gag peptides. The magnitude of HIV-specific T-cell responses was not associated with HIV viral load but correlated positively with CD4 T-cell counts. The most frequently targeted Gag peptides overlapped with those previously described for HIV-1 subtype C-infected southern Africans, and therefore can be used in a multiethnic vaccine.

Neurological evaluation of untreated human immunodeficiency virus infected adults in Ethiopia

Human immunodeficiency virus (HIV) has been implicated in neurological complications in developed countries. Developing countries have different viral clades and potentially different genetic and social risks for these complications. Baseline neurological performance measures associated with HIV infection have rarely been available from developing countries. The authors carried our a cross-sectional neurological evaluation of a cohort of community-dwelling treatment-naïve HIV-infected patients and similar control subjects from the same communities in Ethiopia. Blinded evaluation using standardized structured questionnaires and a neurological examination was performed by neurologists and treating physicians trained by an HIV neurology specialist. Quantitative performance measures for cognitive and motor function were employed. Data were analyzed with descriptive statistical methods, standard contingency table methods, and nonparametric methods. HIV-positive and control groups were similar by age, gender, and job site. Participants included 73 HIV-positive and 87 HIV-negative controls. Fingertapping speed in the dominant hand was more poorly performed in HIV positives than negatives (P = .01) and was significantly associated with HIV viral load levels (P = .03). Other quantitative neuropsychiatric tests including timed gait, grooved pegboard, task learning, and animal naming did not show significant differences between the two groups. The overall prevalence of central nervous system (CNS) and/or peripheral nervous system (PNS) disease did not significantly differ in the two populations. HIV patients had slowed fingertapping speed correlating with viral load. Other measures of CNS and/or peripheral nervous performance did not differ from controls. The unanticipated minor evidence of HIV-associated neurocognitive and peripheral nerve deficits in this untreated HIV-positive population invite further investigation.

Temporal trends in the incidence of HIV infection in antenatal clinic attendees in Addis Ababa, Ethiopia, 1995-2003

BACKGROUND

The HIV incidence data are relevant in depicting the current dynamics and trend of the epidemic. Using a new laboratory method for HIV-1 incidence, we aimed at estimating a 10-year trend in HIV-1 incidence in Addis Ababa, Ethiopia.

METHODS

We determined the temporal trends in HIV incidence based on a total of 7744 serum specimens from pregnant women who attended antenatal clinics in Addis Ababa between 1995 and 2003. HIV incidence was determined by IgG-capture HIV-1 BED incidence enzyme immunoassay following a validation using a well-characterized panel of serial serum specimens from subtype C-infected seroconverters.

FINDINGS

Of the 1350 HIV+ specimens tested as part of the annual sentinel survey between 1995 and 2003, a total of 1332 (98.7%) were tested by BED HIV-1 incidence assay. The incidence rate of HIV-1 infection declined significantly from 7.7% (95% CI, 3.9-11.5%) in 1995 to 2.0% (95% CI, 0.7-3.3%) in 2003. Although there was a trend, amongst the age group of 15-29 years, in age-specific decline in incidence, it was not statistically significant. No change in HIV incidence rate was observed for the group aged above 30 years.

INTERPRETATION

A corresponding decline in the incidence of HIV infection was observed with the decline in the prevalence of HIV infection between 1995 and 2003 in Addis Ababa City. Whether the declines were because of changes in sexual behaviours or other reasons needs to be explored. The BED HIV-1 incidence assay provides a valuable tool in obtaining information on recent HIV-1 infection.

Evidence of a substantial decline in prevalence of HIV-1 infection among pregnant women: data from 1995 to 2003 in Dar es Salaam, Tanzania

OBJECTIVE

To determine the prevalence trends of HIV-1 infection among pregnant women seen between 1995 and 2003 at public antenatal clinics (ANC) in the city of Dar es Salaam.

DESIGN AND SETTINGS

Cross-sectional studies among pregnant women at selected antenatal clinics who were offered HIV testing as part of research and service programmes to prevent vertical transmission of HIV infection and improve pregnancy outcomes.

SUBJECTS AND METHODS

Consenting women gave blood for HIV antibody testing using a sequential ELISA protocol. Sociodemographic information was collected using structured interviews.

RESULTS

In total, 62% of women attending the antenatal clinics gave informed consent for HIV testing and 51,076 had final confirmed results available for this analysis. Women below 20 years of age had the lowest HIV seroprevalence. The HIV-1 prevalence declined from 14.2% in 1995 to 10.6% in 2003.

CONCLUSION

There is a definite substantial decline in prevalence of HIV-1 infection among pregnant women in Dar es Salaam following ongoing interventions, which have been carried out in Tanzania. There is a need to further strengthen these interventions.

HIV/AIDS in Ethiopia: where is the epidemic heading?

OBJECTIVES

A possible decline in prevalence of HIV in some sub-Saharan African countries has been reported recently. The present study aimed to evaluate the prevalence and incidence of HIV and behavioural data to investigate trends in HIV/AIDS in Ethiopia.

METHODS

A review was conducted of published reports and literature, raw and modelled (using Epidemic Projection Package and Spectrum software) surveillance data and estimates from antenatal clinics (ANCs) and data from voluntary counselling and testing centres. Observations were restricted to the adult population.

RESULTS

Between 2001 and 2003, more ANC sites showed a decline than a rise in HIV prevalence, but most lacked statistical significance. Modelled data suggested a rise in prevalence of HIV in rural areas (2003: 2.6%) and in all Ethiopia (2003: 4.4%), but a stable or declining prevalence in Addis Ababa (2003: 14.6%) and other urban areas (2003: 11.8%). Modelled HIV incidence, inferred from prevalence changes, showed a slowly rising trend in Addis Ababa (2003: 2.0%), other urban areas (2003: 1.7%), and rural Ethiopia (2003: 0.46%). The total burden of HIV/AIDS is expected also to rise substantially due to population growth. In Addis Ababa, crude data on HIV prevalence from ANCs too suggested a falling trend. Voluntary counselling and testing data from 2002 to 2004 supported this trend but indicated a mixed trend pattern for high risk behaviour. No other serial behavioural trend data were available.

CONCLUSIONS

Lack of quality data on behavioural trends impedes the interpretation of prevalence and incidence data in Ethiopia. Modelled data suggest an expanding HIV epidemic in rural and all Ethiopia, but a possible decline in some urban areas. Crude site prevalence values may be more sensitive to acute changes, possibly indicating a slowing/reversal of the epidemic's expansion.

Changes in the Etiology of Sexually Transmitted Diseases in Botswana between 1993 and 2002: Implications for the Clinical Management of Genital Ulcer Disease

BACKGROUND

In recent years, increasing evidence has accumulated that suggests the majority of cases of genital ulcer disease in sub-Saharan Africa are due to viral and not bacterial infections. Although many cross-sectional studies support such a trend, few serial cross-sectional data are available to show the evolution of genital ulcer disease over time.

METHODS

We surveyed the prevalence of sexually transmitted diseases (STDs) among patients with STD symptoms and women recruited from family planning clinics in 3 cities in Botswana in 2002 and compared our findings with those from a survey of a similar population conducted in 1993.

RESULTS

The observed proportion of cases of genital ulcer disease due to chancroid decreased from 25% in 1993 to 1% in 2002, whereas the proportion of ulcers due to herpes simplex virus increased from 23% in 1993 to 58% in 2002. Although the proportion of ulcers due to syphilis was similar for both surveys, the rate of positive serologic test results for syphilis among patients with genital ulcer disease decreased from 52% in 1993 to 5% in 2002. During this period, decreases in the prevalence of gonorrhea, syphilis-reactive serologic findings, chlamydial infection, and trichomoniasis were also detected among patients with STDs and women from family planning clinics. These changes remained significant after estimates were adjusted for the sensitivity and specificity of diagnostic tests.

CONCLUSIONS

Our findings suggest a decrease in the prevalence of bacterial STDs and trichomoniasis, a reduction in the proportion of ulcers due to bacterial causes, and an increase in the proportion of ulcers due to herpes simplex virus during the period 1993-2002. These changes should be taken into consideration when defining new guidelines for the syndromic management of genital ulcer disease.

Lay diagnosis of causes of death for monitoring AIDS mortality in Addis Ababa, Ethiopia

Lay diagnoses of death collected at burial sites were validated against two 'gold standards': the hospital discharge diagnosis of causes of death obtained by a surveillance of hospital deaths (including autopsy results) and the physician review of verbal autopsies (VAs) that were carried out for a sample of cemetery records. The diagnostic indicators of the lay diagnoses were then used to provide estimates of the share of AIDS-attribuTable mortality. The verbal autopsy results provide an independent estimate of the percentage of AIDS deaths. From a total of 21,274 burial records, 2546 hospital discharge diagnoses, 1480 outcomes of autopsies and 200 adult verbal autopsies were gathered over a period of 1 year starting from February 2001. Independent of the gold standard, lay diagnoses such as lung disease and cold have a specificity of about 90% and a combined sensitivity of about 55% in determining AIDS mortality. Without a significant loss in specificity, the sensitivity increases to 60-65% when diarrhoea, TB, herpes zoster and mental or nerve problem are included. We thus conclude that even in the presence of a reluctance to talk of HIV/AIDS, lay diagnosis of causes of death can be used for monitoring AIDS mortality. Lung disease and cold, in particular, have become well-known euphemisms for AIDS in the community. The share of AIDS deaths in the adult population (20-54) is estimated at 68%, without noticeable differences between men and women. Our results confirm the high impact of HIV/AIDS on mortality as was estimated by epidemiological projections for Addis Ababa.

HIV prevalence in 72 000 urban and rural male army recruits, Ethiopia

BACKGROUND

The recent estimate of around 2 million HIV-infected people in Ethiopia derives from data that are sparse, especially in the rural areas where the majority (> 85%) of the population lives. We assessed HIV prevalence in almost 72 000 army recruits who resided in urban and rural areas prior to recruitment.

METHODS

Rapid HIV tests, HIVSPOT and Determine, were conducted on blood samples drawn at enrolment from almost 10 000 urban recruits, in 1999, and 62 000 rural recruits, in 2000. Socio-demographic data from recruits were available.

RESULTS

In urban recruits, overall HIV prevalence was 7.2%, ranging from 4.3 to 10.5% depending on region. In rural recruits, overall HIV prevalence was 3.8%, but the majority were farmers (57%) and students (18%) with an HIV prevalence of 2.7% and 2.6%, respectively. (Higher) level of education in rural recruits was associated with HIV infection. Rural recruits of the Muslim religion were less likely to be HIV infected than recruits of the Orthodox Christian religion (odds ratio: 0.7; 95% confidence interval, 0.65-0.84). Urban and rural residents of Amhara region were at higher risk of HIV infection.

CONCLUSION

Prevalence in both rural and urban army recruits is below previous estimates. Geographic distribution of HIV is uneven. The impact of religion, education, and region on HIV prevalence suggests avenues for targeting HIV prevention efforts in Ethiopia.

Mortality impact of AIDS in Addis Ababa, Ethiopia

OBJECTIVE

To measure the impact of HIV on mortality in Addis Ababa, Ethiopia.

DESIGN

A retrospective review of burials at three cemeteries, 1987-2001 and a prospective surveillance of burials at all (n = 70) cemeteries, February-May, 2001.

METHODS

The age, sex, and date of burial were recorded; in the absence of denominators, we compared the ratio of deaths of persons 25-49 versus 5-14 years of age per calendar year, using logistic regression, adjusting for sex and site. The age- and sex- specific mortality were calculated and compared with pre-HIV mortality in 1984.

RESULTS

Of 17,519 deaths, retrospectively reviewed, complete data were available for 6342 (47%) females and 7269 (53%) males. During 1987-2001, the '25-49' versus '5-14' group all-cause mortality ratio increased by 8.5% per calendar year (P < 0.05). A total of 5101 deaths were recorded in the prospective surveillance. Crude mortality rates were 9.5/1000 per year (men) and 7.1/1000 per year (women). In comparison with 1984, 5.0-times as many men and 5.3-times as many women died in the age group 35-39 years. Attributing the increase in mortality in ages 15-60 to HIV in the period 1984-2001, Ethiopian men and women have a probability of 18.8 and 17.8%, respectively, of dying of HIV before age 60.

CONCLUSION

Burials increased significantly among the '25-49', versus the '5-14' group, during the period 1987-2001. This trend, and a five-times higher mortality in 2001 than in 1984 in those aged 35-39 years demonstrate a severe impact of HIV on mortality. Continuing surveillance of burials is recommended.

Evidence of changes in sexual behaviours among male factory workers in Ethiopia

OBJECTIVE

To assess changes in sexual behaviours among male factory workers in Ethiopia.

DESIGN

Open cohort studies in two factories near Addis Ababa.

DATA AND METHODS

At intake and biannual follow-up visits, data were collected on sexual behaviours including casual sex, sex with commercial sex workers (CSW), condom use, and history of sexually transmitted diseases (STDs) as indicated by genital discharge and genital ulcer. Health education, HIV testing, and counselling were offered to all participants.

RESULTS

Between February 1997 and December 1999, 1124 males were enrolled in the two cohort studies. At intake, the prevalence of casual sex in the past year, sex with CSWs, condom use with the last casual partner, history of genital discharge in the past 5 years, and history of genital ulcer in the past 5 years were 9.7, 43.4, 38.8 (Akaki site only), 10.6 and 2.1%, respectively. At the Wonji site, the intake prevalence of casual sex, sex with CSW, and history of genital discharge decreased significantly by calendar year between 1997 and 1999. At both sites combined, between the first and the fourth follow-up visits, there was a decline in the proportion of males reporting recent casual sex (from 17.5 to 3.5%, < 0.001), sex with CSWs (from 11.2 to 0.75%, < 0.001), and genital discharge (from 2.1 to 0.6%, = 0.004).

CONCLUSION

There was a decline over time in risky sexual behaviours reported by cohort participants. Part of this decline occurred independently of cohort interventions.