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Summary The study investigates the relationships of demographic indicators (fertility, mortality, marriage, education) with modern and traditional wealth in rural Senegal. Data were based on rural households interviewed in the 2011 DHS survey. An Absolute Wealth Index was computed from a list of 15 modern goods. A Traditional Wealth Index was computed from data on land and livestock per capita. Modern wealth was always associated with modern demographic behavior (lower fertility, lower mortality, higher age at marriage, higher level of education), whereas traditional wealth was not associated with fertility and mortality, and was negatively associated with marriage and education.

Background The HIV seroprevalence among women aged 15–24 years was compared according to their pattern of contraceptive use in four African countries: Kenya, Lesotho, Malawi and Zimbabwe. Study Design Data were derived from Demographic and Health Surveys (DHS) conducted between 2003 and 2006 on representative samples, totaling 4549 women. Results It is indicated that users of depo-medroxyprogesterone acetate (DMPA) have a significantly higher seroprevalence than nonusers [odds ratio (OR)=1.82, 95% CI=1.63–2.03] and higher than users of oral contraceptives and users of traditional methods. The results were confirmed in a multivariate analysis including as controls, age, duration since first intercourse, urban residence, education, number of sexual partners in the last 12 months and marital status. A somewhat smaller net effect (OR=1.34, 95% CI=1.10–1.63) was found. In contrast, oral contraceptives and traditional methods did not show any risk for HIV (OR=0.96 and 0.92, respectively). Conclusion The increased risk of DMPA was present in three of the four countries investigated, and significant in Zimbabwe and Lesotho, the countries with the highest HIV seroprevalence. The HIV risk attributable to DMPA remained small altogether and was estimated as 6% in the four countries combined.

The recommendations for clinical research in developing countries were published in 2007 and the present article deals with issues which were not initially raised or discussed in depth. In particular, we discuss specific questions linked to trials conducted in developing countries with regard to informed consent, research project review by two ethics committees, standards of care, management of biological samples, study follow-up committees, notification of Serious Adverse Events, paediatric trials, and Contract Research Organizations.

Les recommandations pour la recherche clinique dans les pays en developpement (PED) ont fait l'objet d'une publication en 2007 et le present article aborde des sujets qui n'avaient pas pu etre abordes ou approfondis initialement. Ont ete particulierement discutes les questions particulieres aux essais menes dans les PED autour du consentement eclaire, la revue des projets par deux comites d'ethique, la question du standard de soins, la gestion des prelevements biologiques, les comites de suivi des etudes, la notification des Evenements Indesirables Graves, les essais en pediatrie et les Organismes de Recherche sous Contrat (CRO).

To the Editor: The comments made by Gisselquist on our paper focus on the risk associated with unsafe injections rather than with DMPA per se. Our study was not designed to separate the effects of unsafe injections from the effects of using DMPA in an HIV environment. Note however that similar effects were found in Thailand where injections are assumed to be safe and that the biological plausibility for an effect of hormonal contraception is quite strong. This leads us to think that in this case the effect is more likely to be due to the interactions with hormones than to the injection per se. What we showed is that in real life of an African population injectable contraception was associated with a minor increase in risk of HIV infection whatever the reason. Of course for the individual woman the issue is whether she is at risk of Ivory not. If her partner is infected with HIV she should be using condoms and not any other form of contraception. Even if she is not exposed to HIV she should use only safe injections whether for contraception or for other purpose and be protected from any type of contamination such as HIV HBV HCV or other germs. Gisselquist is right in emphasizing the need for safe injections in Africa for any type of therapy or prevention. For us recommending DMPA still appears legitimate for women who are not exposed to HIV and assuming that injections are safe. The control of HIV is likely to be efficient if such policies are followed and unlikely to be enough by just shifting from injectable contraceptives to other types beyond condoms. (full text)

Sunil Sazawal and colleagues did a large randomised controlled trial of zinc supplementation in a malaria holoendemic area of east Africa which showed no significant effect on mortality among children younger than 5 years. However in subgroup analyses Sazawal and colleagues showed a significant effect of the intervention on mortality in children older than 12 months and this effect was significant for boys (relative risk 0.71) but not for girls (0.95). We did a similar study on the effects of zinc supplementation in a malaria holoendemic area of west Africa. Here zinc supplementation had no effect on malaria morbidity but significantly reduced diarrhoea morbidity in children younger than 3 years. A subgroup analysis showed that this effect was also significant for boys (relative risk 0.67) but not for girls (1.03) a finding that needs further explanation. Finally we showed a significant association between malnutrition and mortality but not between malnutrition and malaria in this cohort. (excerpt)