HIV incidence among non-migrating persons following a household migration event: a population-based, longitudinal study in Uganda

Background

The impact of migration on HIV risk among non-migrating household members is poorly understood. We measured HIV incidence among non-migrants living in households with and without migrants in Uganda.

Methods

We used four survey rounds of data collected from July 2011-May 2018 from non-migrant participants aged 15-49 years in the Rakai Community Cohort Study, an open, population-based cohort. Non-migrants were individuals with no evidence of migration between surveys or at the prior survey. The primary exposure, household migration, was assessed using census data and defined as ≥1 household member migrating in or out of the house from another community between surveys (∼18 months). Incident HIV cases tested positive following a negative result at the preceding visit. Incidence rate ratios (IRR) with 95% confidence intervals were estimated using Poisson regression with generalized estimating equations and robust standard errors. Analyses were stratified by gender, migration into or out of the household, and the relationship between non-migrants and migrants (i.e., any household migration, spouse, child).

Findings

Overall, 11,318 non-migrants (5,674 women) were followed for 37,320 person-years. 28% (6,059/21,370) of non-migrant person-visits had recent migration into or out of the household, and 240 HIV incident cases were identified in non-migrating household members. Overall, non-migrants in migrant households were not at greater risk of acquiring HIV. However, HIV incidence among men was significantly higher when the spouse had recently migrated in (adjIRR:2·12;95%CI:1·05-4·27) or out (adjIRR:4·01;95%CI:2·16-7·44) compared to men with no spousal migration. Women with in- and out-migrant spouses also had higher HIV incidence, but results were not statistically significant.

Interpretation

HIV incidence is higher among non-migrating persons with migrant spouses, especially men. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for those with migrant spouses.

Funding

National Institutes of Health, US Centers for Disease Control and Prevention.

Research in context

We searched PubMed for studies focused on HIV acquisition, prevalence or sexual behaviors among non-migrants who lived with migrants in sub-Saharan Africa (SSA) using search terms such as "HIV", "Emigration and Immigration", "family", "spouses", "household", "parents", and "children". Despite high levels of migration and an established association with HIV risk in SSA, there is limited data on the broader societal impacts of migration on HIV acquisition risk among non-migrant populations directly impacted by it.There has been only one published study that has previously evaluated impact of migration on HIV incidence among non-migrating persons in sub-Saharan Africa. This study, which exclusively assessed spousal migration, was conducted in Tanzania more than two decades earlier prior to HIV treatment availability and found that non-migrant men with long-term mobile partners were more than four times as likely to acquire HIV compared to men who had partners that were residents. To the best of our knowledge, this is the first study to examine the effect of non-spousal migration, including any household migration and child migration, on HIV incidence among non-migrants.

Added value of this study

In this study, we used data from the Rakai Community Cohort Study (RCCS), a population-based HIV surveillance cohort to measure the impact of migration on HIV incidence for non-migrant household members. The RCCS captures HIV incident events through regular, repeat HIV testing of participants and migration events through household censuses. Our study adds to the current literature by examining the general effect of migration in the household on HIV incidence in addition to child, and spousal migration. Using data from over 11,000 non-migrant individuals, we found that spousal, but not other types of household migration, substantially increased HIV risk among non-migrants, especially among men. Taken together, our results suggest that spousal migration may be associated with an increased risk of HIV acquisition in the period surrounding and immediately after spousal migration.

Implications of all the available evidence

Our findings suggest that spousal migration in or out of the household is associated with greater HIV incidence. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for men with migrant spouses.

How the 'HIV/TB co-epidemic-HIV stigma-TB stigma' syndemic impacts on the use of occupational health services for TB in South African hospitals: a structural equation modelling analysis of the baseline data from the HaTSaH Study (cluster RCT)

INTRODUCTION

Tuberculosis (TB) has become an occupational health hazard in South African hospitals where healthcare workers (HCWs) are additionally confronted daily with HIV and its associated stigma, causing a syndemic. Early TB diagnosis and treatment are vital, but the uptake of these services through occupational healthcare units (OHUs) is low. The current study hypothesises that (1) the link between HIV and TB and (2) the perceived HIV stigmatisation by colleagues create (3) a double HIV-TB stigma which increases (4) internalised TB stigma and leads to (5) a lower willingness to use OHU services for TB screening and treatment.

DESIGN

A cross-sectional study using the baseline data from the HIV and TB Stigma among Healthcare workers Study (HaTSaH Study).

SETTING

Six hospitals in the Free State province of South Africa.

PARTICIPANTS

820 HCWs of the six selected hospitals.

RESULTS

The study results demonstrate that the co-epidemic (β=0.399 (screening model) and β=0.345 (treatment model)) combined (interaction effect: β=0.133 (screening) and β=0.132 (treatment)) with the persistent stigmatisation of HIV is altering the attitudes towards TB (β=0.345 (screening) and β=0.400 (treatment)), where the stigmatising views of HIV are transferred to TB-illustrating the syndemic impact. Our model demonstrated that this syndemic not only leads to higher levels of internal TB stigma (β=0.421 (screening) and β=0.426 (treatment)), but also to a lower willingness to use the OHU for TB screening (probit coefficient=-0.216) and treatment (probit coefficient=-0.160). Confidentiality consistently emerged as a contextual correlate of OHU use.

CONCLUSIONS

Theoretically, our results confirm HIV as a 'syndemic generator' which changes the social meaning of TB in the hospital context. Practically, the study demonstrated that the syndemic of TB and HIV in a highly endemic context with stigma impacts the intended use of occupational TB services.

TRIAL REGISTRATION NUMBER

Pre-results of the trial registered at the South African National Clinical Trials Register, registration ID: DOH-27-1115-5204.

ECG abnormalities and arterial function by HIV status among high-risk populations in Rakai, Uganda

Background

People living with HIV (PLHIV) are at increased risk for cardiovascular disease (CVD). In Sub-Saharan Africa, where a majority of PLHIV live, population-based data on major CVD events such as stroke and myocardial infarction are difficult and expensive to collect. The use of proxy measures of future CVD events that are easier to collect, could be a feasible way to better study CVD in such settings. This study aimed to determine the acceptability of incorporating ECG and arterial function measurements into a population-based cohort study and to assess the prevalence of ECG abnormalities and arterial stiffness.

Methods

A pilot study was conducted within the Rakai community cohort study in Uganda on two high-risk CVD groups; one determined by age (35-49) and Framingham CVD risk scores and the other by age alone (50+). Data on ECG, arterial function, blood pressure, and HIV status were collected. The acceptability of incorporating ECG and arterial function measurements was established as an acceptance rate difference of no more than 5% to blood pressure measurements.

Results

A total of 118 participants were enrolled, 57 PLHIV and 61 HIV negative. Both arterial function and ECG measurements were well accepted (2% difference), but the completeness of arterial function measurements captured was suboptimal (63%). Left ventricular hypertrophy (LVH) and arterial stiffness (> 10 m/s) were common in both PLHIV and HIV negative participants across the two high-risk populations. Prevalence rates ranged from 30% to 53% for LVH and 25% to 58% for arterial stiffness.

Conclusions

The incorporation of ECG and arterial function measurements into routine activities of a population-based cohort was acceptable. LVH and arterial stiffness were common in these high-risk for CVD populations, indicating the need for future research. The use of these proxy measures might be recommended when data on CVD events cannot be collected.

Key messages

It is acceptable to incorporate ECG and arterial function measurements into a population-based cohort in Uganda. High prevalence rates of LVH and arterial stiffness were found in people with high risk for CVD.

Stigma as a barrier to the use of occupational health units for tuberculosis services in South Africa

SETTING

Tuberculosis (TB) is the leading cause of death in South Africa, and health care workers (HCWs) are disproportionally affected. The resulting absenteeism strains the already overburdened health system. Although hospital occupational health care units (OHUs) are cost-effective and of crucial importance in tackling the TB epidemic, the fear of being stigmatised by other colleagues might lead HCWs to avoid using OHUs.

OBJECTIVE

To investigate whether the perception of TB stigma among colleagues has a negative effect on the willingness to use OHUs for TB services.

DESIGN

In the Free State Province, South Africa, a representative sample of 804 HCWs from six hospitals were surveyed on workplace stigma as a predictor for the use of OHUs for TB services. Applying structural equation modelling, we also controlled for exogenous variables.

RESULTS

There was a significant negative relationship between the perception of stigmatising attitudes and behaviours among co-workers and the use of OHUs for TB screening (β -0.21, P = 0.000), treatment (β -0.16, P = 0.001) and isoniazid preventive therapy (β -0.17, P = 0.000).

CONCLUSION

The negative effect of TB stigma on OHU use among HCWs can impact upon their health and increase hospital costs. This needs to be addressed by interventions combating TB stigma among HCWs in the workplace.

Measuring HIV- and TB-related stigma among health care workers in South Africa: a validation and reliability study

SETTING

Recent evidence indicates that human immunodeficiency virus (HIV) and tuberculosis (TB) related stigma act as a key barrier to the utilisation of associated occupational health services by South African health care workers (HCWs). It also highlights a dearth of appropriate tools to measure HIV and TB stigma among HCWs.

OBJECTIVE

To test four scales measuring different aspects of stigma: respondent's external stigma (RES) and others' external stigma (OES) towards TB as well as HIV across different professional categories of HCWs.

DESIGN

The current study employs data from a study on HIV and TB stigma among HCWs, a cluster randomised controlled trial for the collection of data among 882 HCWs in the Free State Province of South Africa. Confirmatory factor analyses and structural equation modelling were used to assess the validity and reliability of the scales.

RESULTS

All four scales displayed adequate internal construct validity. Subsequent analysis demonstrated that all four scales were metric-invariant, and that the OES scales were even scalar-invariant across patient and support staff groups. The scales displayed good reliability and external construct validity.

CONCLUSION

Our results support the use of the scales developed to measure TB and HIV stigma among HCWs. Further research is, however, needed to fine tune the instruments and test them across different resource-limited countries.

Factors influencing treatment default among tuberculosis patients in a high burden province of South Africa

OBJECTIVE

To determine and describe the factors influencing treatment default of tuberculosis (TB) patients in the Free State Province of South Africa.

METHODS

A retrospective records review of pulmonary TB cases captured in the ETR.Net electronic TB register between 2003 and 2012 was performed. Subjects were >15 years of age and had a recorded pre-treatment smear result. The demographic and clinical characteristics of defaulters were described. Multivariate logistic regression analysis was used to determine factors associated with treatment default. The odds ratios (OR) together with their corresponding 95% confidence intervals (CI) were estimated. Statistical significance was considered at 0.05.

RESULTS

A total of 7980 out of 110 349 (7.2%) cases defaulted treatment. Significantly higher proportions of cases were male (8.3% vs. female: 5.8%; p<0.001), <25 years old (9.1% vs. 25-34 years: 8.7%; 35-44 years: 7.0%; 45-54 years: 5.2%; 55-64 years: 4.4%; >64 years: 3.9%; p<0.001), undergoing TB retreatment (11.0% vs. new cases: 6.3%; p<0.001), had a negative pre-treatment sputum smear result (7.8% vs. positive smear results: 7.1%; p<0.001), were in the first 2 months of treatment (95.5% vs. >2 months: 4.8%; p<0.001), and had unknown HIV status (7.8% vs. HIV-positive: 7.0% and HIV-negative: 5.7%; p<0.001). After controlling for potential confounders, multivariate analysis revealed a two-fold increased risk of defaulting treatment when being retreated compared to being treated for the first time for TB (adjusted OR (AOR) 2.0, 95% CI 1.85-2.25). Female cases were 40% less likely to default treatment compared to their male counterparts (AOR 0.6, 95% CI 0.51-0.71). Treatment default was less likely among cases >24 years old compared to younger cases (25-34 years: AOR 0.8, 95% CI 0.77-0.87; 35-44 years: AOR 0.6, 95% CI 0.50-0.64; 45-54 years: AOR 0.4, 95% CI 0.32-0.49; 55-64 years: AOR 0.3, 95% CI 0.21-0.43; >64 years: AOR 0.3, 95% CI 0.19-0.35). Co-infected cases receiving antiretroviral therapy (ART) were 40% less likely to default TB treatment relative to those whose ART status was unknown (AOR 0.6, 95% CI 0.46-0.57).

CONCLUSIONS

Salient factors influence TB patient treatment default in the Free State Province. Therefore, the strengthening of clinical and programmatic interventions for patients at high risk of treatment default is recommended. In particular, ART provision to co-infected cases facilitates TB treatment adherence and outcomes.

Integration of TB-HIV services at an ANC facility in Frances Baard District, Northern Cape, South Africa

BACKGROUND

Integrated tuberculosis-human immunodeficiency virus (TB-HIV) service delivery as part of maternal health services, including antenatal care (ANC), is widely recommended. This study assessed the implementation of collaborative TB-HIV service delivery at a hospital-based ANC service unit.

METHODS

A record review of a random sample of 308 pregnant women attending the ANC service between April 2011 and February 2012 was conducted. Data were extracted from registers and patient case notes. Outcomes included the proportion of women who underwent HIV counselling and testing (HCT), CD4 count testing, antiretroviral treatment (ART), cotrimoxazole preventive treatment (CPT), TB screening and isoniazid preventive treatment (IPT). Analysis measured variations in patient characteristics associated with service delivery.

RESULTS

All women underwent HCT; 80% of those who tested HIV-positive were screened for TB. Most (85.9%) of the HIV-positive women received a CD4 count. However, only 12.9% of eligible women received ART prophylaxis onsite, only 35.7% were referred for initiation of ART, only 42.3% commenced IPT and none received CPT or further investigations for TB. HIV-negative women had 2.6 higher odds (95%CI 1.3-5.3) of receiving TB screening than their HIV-positive counterparts.

CONCLUSIONS

Although the identification of HIV-positive women and TB suspects was adequate, implementation of other TB-HIV collaborative activities was sub-optimal.

Foreskin T-cell subsets differ substantially from blood with respect to HIV co-receptor expression, inflammatory profile, and memory status

The foreskin is the main site of heterosexual human immunodeficiency virus (HIV) acquisition in uncircumcised men, but functional data regarding T-cell subsets present at this site are lacking. Foreskin tissue and blood were obtained from Ugandan men undergoing elective adult circumcision. Tissue was treated by mechanical and enzymatic digestion followed by T-cell subset identification and assessment of cytokine production using flow cytometry. Foreskin CD4(+) T cells were predominantly an effector memory phenotype, and compared with blood they displayed a higher frequency of CCR5 expression (42.0% vs. 9.9%) and interleukin-17 production. There was no difference in T-regulatory cell frequency, but interferon-γ and tumor necrosis factor-α production were increased in foreskin CD8(+) T cells. These novel techniques demonstrate that the foreskin represents a proinflammatory milieu that is enriched for HIV-susceptible T-cell subsets. Further characterization of foreskin T-cell subsets may help to define the correlates of HIV susceptibility in the foreskin.

Measuring quality of life among HIV-infected women using a culturally adapted questionnaire in Rakai district, Uganda

To examine self-reported quality of life and health status of HIV-infected women and a comparison sample of HIV-uninfected women in rural Uganda, we culturally adapted a Lugandan version of the Medical Outcomes Survey-HIV (MOS-HIV). We administered a cross-sectional survey among 803 women (239 HIV-positive and 564 HIV-negative) enrolled in a community study to evaluate maternal and child health in Rakai District, Uganda. The interview took 20 minutes and was generally well-accepted. Reliability coefficients were >0.70, except for role functioning, energy and cognitive function. MOS-HIV scores for HIV-positive women were correlated with increasing number of physical symptoms and higher HIV viral load. Compared to HIV-negative women, HIV-positive women reported lower scores than HIV-negative women for general health perceptions, physical functioning, pain, energy, role functioning, social functioning, mental health and overall quality of life (p all <0.01). Substantial impairment was noted among women reporting >/=4 symptoms. In summary, HIV-positive women reported significantly poorer functioning and well-being than HIV-negative women. We conclude that patient-reported measures of health status and related concepts may provide a feasible, reliable and valid method to assess the impact of HIV/AIDS and future therapeutic interventions to improve patient outcomes in rural Africa.

Aetiology of genital ulcer disease in female partners of male participants in a circumcision trial in Uganda

HIV acquisition is associated with herpes simplex virus type 2 (HSV-2) infection and genital ulcer disease (GUD). Three randomized control trials demonstrated that male circumcision significantly decreases HIV, HSV-2, human papillomavirus and self-reported GUD among men. GUD is also decreased among female partners of circumcised men, but it is unknown whether male circumcision status affects GUD pathogens in female partners. For the evaluation of GUD aetiology, two separate multiplex assays were performed to detect Haemophilus ducreyi, Treponema pallidum, HSV-1 and HSV-2. Of all the female GUD swabs evaluated, 67.5% had an aetiology identified, and HSV-2 was the primary pathogen detected (96.3%). However, there was no difference in the proportion of ulcers due to HSV-2 or other pathogens between female partners of circumcised men (11/15, 73.3%) compared with uncircumcised men (15/25, 60.0%, P = 0.39). The seroprevalence of HSV-2 is high in this population and therefore most of the detected HSV-2 infections represent reactivation. Since GUD is associated with HIV acquisition and one-third of GUD in this study did not have an aetiological agent identified, further research is needed to better understand the aetiology of GUD in Africa, and its relationship to circumcision and HIV infection.

Immunisation coverage among children born to HIV-infected women in Rakai district, Uganda: effect of voluntary testing and counselling (VCT)

To evaluate the impact of maternal HIV-infection on routine childhood Immunisation coverage, we compared the Immunisation status of children born to HIV-infected and HIV-uninfected women in rural Uganda. The study population was 214 HIV(+) and 578 HIV(-) women with children aged 6 to 35 months previously enrolled in a community study to evaluate maternal and child health in Rakai District, Uganda. Sampling of subjects for interview was stratified by the use of voluntary counselling and testing (VCT) service so that the final sample was four groups: HIV + /VCT+ (n = 98); HIV + /VCT- (n = 116); HIV - /VCT+ (n= 348); HIV - /VCT- (n = 230). The main outcome measure was the percent of complete routine childhood Immunisations recommended by the WHO as assessed from Immunisation cards or maternal recall during household interviews. We found that Immunisation coverage in the overall sample was 26.1%. For all vaccines, children born to HIV-infected mothers had lower Immunisation coverage than children born to HIV-negative mothers (21.3 vs. 27.7%). There was a statistically significant interaction between maternal HIV-infection and maternal knowledge of HIV-infection (p = 0.034). The children of mothers who were HIV-infected and knew their serostatus (HIV + /VCT + ) had a more than two-fold odds of underImmunisation (OR = 2.21, 95% CI: 1.14, 4.29) compared to children of mothers who were HIV - /VCT-. We conclude that maternal HIV-infection was associated with childhood underImmunisation and this was mediated by a mother's knowledge of her HIV status. HIV VCT programmes should encourage HIV-infected mothers to complete childhood Immunisation. Improving access to Immunisation services could benefit vulnerable populations such as children born to HIV-infected mothers.

Burden of infection among heads and non-head of rural households in Rakai, Uganda

The objective was to determine HIV prevalence, symptomatology and mortality among adult heads and non-heads of households, in order to assess the burden of HIV on households. It was a community study of 11,536 adults aged 15-59, residing in 4,962 households in 56 villages, Rakai district, Uganda. First, 4,962 heads and 6,574 non-heads of households were identified from censuses. Interviews were then used to determine socio-demographic/behavioural characteristics. HIV seroprevalence was diagnosed by two EIAs with Western blot confirmation. The adjusted odds ratio (OR) and 95% confidence intervals (CI) of HIV infection in household heads and non-heads were estimated by multivariate logistic regression. Age-adjusted mortality was also assessed. HIV prevalence was 16.9% in the population, and 21.5% of households had at least one HIV-infected person (<0.0001). HIV prevalence was higher among heads than non-heads of households (21.5 and 13.3%, respectively, OR=1.79; CI 1.62-1.97). Most household heads were males (70.5%), and HIV prevalence was 17.8% among male heads compared with 6.6% in male non-heads of households (OR=2.31; CI 1.65-2.52). Women heading households were predominantly widowed, separated or divorced (64.4%). HIV prevalence was 30.5% among female heads, compared with 15.6% in female non-household heads (OR=1.42; CI 1.15-1.63). Age-adjusted mortality was significantly lower among male household heads than non-heads, both for the HIV-positive (RR=0.68) and HIV-negative men (RR=0.63). Among women, HIV-negative female household heads had significantly higher mortality than HIV-uninfected female non-heads (RR=1.72). HIV disproportionately affects heads of households, particularly males. Mortality due to AIDS is likely to increase the proportion of female-headed households, and adversely affect the welfare of domestic units.

HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda

OBJECTIVE

Evidence of condom effectiveness for HIV and sexually transmitted disease (STD) prevention is based primarily on high-risk populations. We examined condom effectiveness in a general population with high HIV prevalence in rural Africa.

METHODS

Data were from a randomized community trial in Rakai, Uganda. Condom usage information was obtained prospectively from 17,264 sexually active individuals aged 15-59 years over a period of 30 months. HIV incidence and STD prevalence was determined for consistent and irregular condom users, compared to non-users. Adjusted rate ratios (RR) of HIV acquisition were estimated by Poisson multivariate regression, and odds ratios of STDs estimated by logistic regression.

RESULTS

Only 4.4% reported consistent condom use and 16.5% reported inconsistent use during the prior year. Condom use was higher among males, and younger, unmarried and better educated individuals, and those reporting multiple sex partners or extramarital relationships. Consistent condom use significantly reduced HIV incidence [RR, 0.37; 95% confidence interval (CI), 0.15-0.88], syphilis [odds ratio (OR), 0.71; 95% CI, 0.53-0.94] and gonorrhea/Chlamydia (OR, 0.50; 95% CI, 0.25-0.97) after adjustment for socio-demographic and behavioral characteristics. Irregular condom use was not protective against HIV or STD and was associated with increased gonorrhea/Chlamydia risk (OR, 1.44; 95% CI, 1.06-1.99). The population attributable fraction of consistent use for prevention of HIV was -4.5% (95% CI, -8.3 to 0.0), due to the low prevalence of consistent use in the population.

CONCLUSIONS

Consistent condom use provides protection from HIV and STDs, whereas inconsistent use is not protective. Programs must emphasize consistent condom use for HIV and STD prevention.

Randomized trial of presumptive sexually transmitted disease therapy during pregnancy in Rakai, Uganda

OBJECTIVE

The purpose of this study was to assess presumptive sexually transmitted disease treatment on pregnancy outcome and HIV transmission.

STUDY DESIGN

In a randomized trial in Rakai District, Uganda, 2070 pregnant women received presumptive sexually transmitted disease treatment 1 time during pregnancy at varying gestations, and 1963 control mothers received iron/folate and referral for syphilis. Maternal-infant sexually transmitted disease/HIV and infant outcomes were assessed. Intent-to-treat analyses estimated adjusted rate ratios and 95% confidence intervals.

RESULTS

Sexually transmitted diseases were reduced: Trichomonas vaginalis (rate ratio, 0.28; 95% CI, 0.18%-0.49%), bacterial vaginosis (rate ratio, 0.78; 95% CI, 0.69-0.87), Neisseria gonorrhoeae /Chlamydia trachomatis (rate ratio, 0.43; 95% CI, 0.27-0.68), and infant ophthalmia (rate ratio, 0.37; 95% CI, 0.20-0.70). There were reduced rates of neonatal death (rate ratio, 0.83; 95% CI, 0.71-0.97), low birth weight (rate ratio, 0.68; 95% CI, 0.53-0.86), and preterm delivery (rate ratio, 0.77; 95% CI, 0.56-1.05); but there were no effects on maternal HIV acquisition or perinatal HIV transmission.

CONCLUSION

Reductions of maternal sexually transmitted disease improved pregnancy outcome but not maternal HIV acquisition or perinatal HIV transmission.

Mortality associated with HIV infection in rural Rakai District, Uganda

OBJECTIVE

To assess mortality impact of HIV in rural Uganda.

METHODS

An open cohort of 19983 adults aged 15-59 years, in Rakai district was followed at 10 month intervals for four surveys. Sociodemographic characteristics and symptomatology/disease conditions were assessed by interview. Deaths among residents and out-migrants were identified household census. Mortality rates were computed per 1000 person years (py) and the rate ratio (RR) of death in HIV-positive/HIV-negative subjects, and the population attributable fraction (PAF) of death were estimated according to sociodemographic characteristics. Mortality associated with potential AIDS defining symptoms and signs was assessed.

RESULTS

HIV prevalence was 16.1%. Mortality was 132.6 per 1000 py in HIV-infected versus 6.7 per 1000 py in uninfected subjects, and 73.5% of adult deaths were attributable to HIV infection. Mortality increased with age, but the highest attributable risk of HIV associated deaths were observed in persons aged 20-39 years (PAF > 80%) and in women. HIV associated mortality was highest in the better educated (PAF > or = 75%) and among government employees (PAF > or = 82%). Of the HIV-positive subjects 40.5% reported no illness < 10 months preceding death, symptoms were poor predictors of death (sensitivity 1.6-38.8%), and only 9.1% met the World Health Organization clinical definition of AIDS. Infant mortality rates in babies of HIV-infected and uninfected mothers were 209.4 and 97.7 per 1000, respectively.

CONCLUSION

HIV is taking substantial toll in this population, particularly among the younger better educated adults, and infants. Symptomatology or the World Health Organization definition of AIDS are poor predictors of death.

Population-based study of fertility in women with HIV-1 infection in Uganda

BACKGROUND

To assess the effects of HIV-1 and other sexually transmitted infections on pregnancy, we undertook cross-sectional and prospective studies of a rural population in Rakai district, Uganda.

METHODS

4813 sexually active women aged 15-49 years were surveyed to find out the prevalence of pregnancy by interview and selective urinary human chorionic gonadotropin tests. The incidence of recognised conception and frequency of pregnancy loss were assessed by follow-up. Samples were taken to test for HIV-1 infection, syphilis, and other sexually transmitted diseases.

FINDINGS

At time of survey 757 (21.4%) of 3544 women without HIV-1 infection or syphilis were pregnant, compared with 46 (14.6%) of 316 HIV-1-negative women with active syphilis, 117 (14.2%) of 823 HIV-1-positive women with no concurrent syphilis, and 11 (8.5%) of 130 women with both syphilis and HIV-1 infection. The multivariate adjusted odds ratio of pregnancy in HIV-1-infected women was 0.45 (95% CI 0.35-0.57); the odds of pregnancy were low both in HIV-1-infected women without symptoms (0.49 [0.39-0.62]) and in women with symptoms of HIV-1-associated disease (0.23 [0.11-0.48]). In women with concurrent HIV-1 infection and syphilis the odds ratio was 0.28 (0.14-0.55). The incidence rate of recognised pregnancy during the prospective follow-up study was lower in HIV-1-positive than in HIV-1-negative women (23.5 vs 30.1 per 100 woman-years; adjusted risk ratio 0.73 [0.57-0.93]). Rates of pregnancy loss were higher among HIV-1-infected than uninfected women (18.5 vs 12.2%; odds ratio 1.50 [1.01-2.27]). The prevalence of HIV-1 infection was significantly lower in pregnant than in non-pregnant women (13.9 vs 21.3%).

INTERPRETATION

Pregnancy prevalence is greatly reduced in HIV-1-infected women, owing to lower rates of conception and increased rates of pregnancy loss. HIV-1 surveillance confined to pregnant women underestimates the magnitude of the HIV-1 epidemic in the general population.