Search

To determine whether HIV testing and counselling increased condom use and decreased heterosexual transmission of HIV in discordant couples.Prospective study.Kigali, the capital of Rwanda.Cohabiting couples with discordant HIV serology results.Condom use in the couple and HIV seroconversion in the negative partners.60 HIV discordant couples were identified, of whom 53 were followed for an average of 2.2 years. The proportion of discordant couples using condoms increased from 4% to 57% after one year of follow up. During follow up two of the 23 HIV negative men and six of the 30 HIV negative women seroconverted (seroconversion rates of 4 and 9 per 100 person years). The rate among women was less than half that estimated for similar women in discordant couples whose partners had not been serotested. Condom use was less common among those who seroconverted (100% v 5%, p = 0.01 in men; 67% v 25%, p = 0.14 in women).Roughly one in seven cohabiting couples in Kigali have discordant HIV serological results. Confidential HIV serotesting with counselling caused a large increase in condom use and was associated with a lower rate of new HIV infections. HIV testing is a promising intervention for preventing the spread of HIV in African cities.Approximately one in seven cohabiting couples in Kigali, Rwanda, have HIV-discordant serology. A study of prospective design was conducted in Kigali to determine whether HIV testing and counseling would increase condom use and decrease the heterosexual transmission of HIV among HIV-discordant couples. 60 HIV-discordant couples were identified of whom 53 were followed for an average of 2.2 years. The proportion of these couples using condoms increased from 4% to 57% after one year of follow-up. During follow-up, 2 of the 23 HIV-negative men and 6 of the 30 HIV-negative women seroconverted. The rate among women was less than half that estimated for similar women in discordant couples whose partners had not been serotested. Moreover, condom use was less common among those who seroconverted. HIV testing may therefore be considered a promising intervention for preventing the spread of HIV in African cities.

We examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 child-bearing urban women in Rwanda, central Africa. Although 68% of women reported only one lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Before receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the three primary routes of infection. However, only 16% of women reported taking any action to avoid AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of women had ever tried condoms, and many (68%) thought they could be dangerous to use. Women who perceived themselves at risk of AIDS (57%) were more likely to report changing behavior; they were also more likely to be infected with HIV. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partner, and believing that condoms are not dangerous. Future interventions should enhance perception of risk, encourage male sexual partners to reduce risky behavior, and increase familiarity with condoms.The authors examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 childbearing urban women in Rwanda, central Africa. Although 68% of them reported only 1 lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Prior to receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the 3 primary routes of infection. However, only 16% reported taking any action to prevent AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of the women has ever tried condoms, and many (68%) thought they could by dangerous to use. Those women who perceived themselves at risk for AIDS (57%0 were more likely to report changing behavior; they were also more likely to be HIV-infected. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partners, and believing that condoms are not dangerous. Future interventions should enhance the perception of risk, should encourage male sexual partners to reduce risktaking behavior, and should increase familiarity with condoms.

Our objective was to describe associations among male circumcision, behavioral and demographic variables, ulcerative and nonulcerative sexually transmitted disease (STD), and human immunodeficiency virus (HIV) infection via a cross-sectional study in Kigali, the capital of Rwanda. Our subjects were 837 married men who volunteered for HIV testing and counselling. Uncircumcised men had a relatively low-risk profile in that they reported fewer lifetime sexual partners and prostitute contacts than circumcised men and were more likely to live in rural areas with lower HIV prevalence rates. Uncircumcised men were also less likely to report a history of sexually transmitted disease (64% versus 73%, p = 0.01), although they were more likely to report genital ulceration (GUD) (24% versus 17%, p < 0.03) and to have inguinal adenopathy noted on physical exam (42% versus 29%, p = 0.009). Despite the low-risk profile, uncircumcised men had a higher prevalence of HIV infection than circumcised men (29% versus 21% HIV positive, p = 0.02), which was most marked in men reporting five or more lifetime sex partners (36% versus 23% HIV positive, p = 0.005) or contact with prostitutes (35% versus 23% HIV positive, p = 0.009). Circumcision remained a predictor of HIV infection in multivariate analyses (multivariate odds ratio 1.69, 95% confidence interval 1.16-2.47). Lack of circumcision is associated with a higher risk of HIV infection in Rwandan men. Further research is needed to determine whether this higher risk is due in part to poor hygiene or to complex mechanisms operating through the acquisition of other sexually transmitted diseases. Circumcision may be an appropriate risk reduction approach for men with known exposures to the virus when there are constraints to alternatives, such as condom use.

To estimate the seroincidence of HIV-1 infection among women of reproductive age in Kigali, Rwanda.Fixed prospective cohort followed for 36 months between November 1988 and June 1992, as part of an ongoing study of mother-to-child transmission of HIV-1.Centre Hospitalier, Kigali, Rwanda.A total of 216 HIV-seronegative women were enrolled at delivery between November 1988 and June 1989.A blood sample was obtained at delivery to test for HIV antibodies (by enzyme-linked immunosorbent assay and Western blot). Serum was tested every 3 months during follow-up. Incidence density rates of HIV seroconversion were estimated.The follow-up rate after 3 years was 89%, assessed by the maximum person-years method. The seroincidence density rate was 3.5 per 100 women-years (95% confidence interval, 1.9-5.0). It decreased linearly from 7.6 during the first 6-months postpartum to 2.5 per 100 women-years during the last 6 months of the third year of follow-up. Maternal age did not affect HIV incidence rates. We examined the role of the cohort, counselling, and the first 6-month postpartum effects on this estimate.This fixed cohort provided an overall estimation of the HIV infection incidence rate and its dynamics. These figures could be used for programming future HIV preventive vaccine efficacy trials in Rwanda.The objective was to estimate the seroincidence of HIV-1 infection among women of reproductive age in Kigali, Rwanda. A fixed prospective cohort followed a total of 216 HIV-seronegative women for 36 months between November 1988 and June 1992 at Centre Hospitalier, Kigali, Rwanda. A study of mother-to-child transmission of HIV-1 has been going on at the Centre Hospitalier de Kigali since November 1988. A group of HIV-seronegative women matched by maternal age and parity was consecutively selected as a comparison group. The mean maternal age was 25.1 years (SD, 4.5 years), and the total number of pregnancies was 2.7 (SD, 1.8). A blood sample was obtained at delivery to test for HIV antibodies (by enzyme-linked immunosorbent assay and Western blot). Serum was tested every 3 months during follow-up. The follow-up rate after 3 years was 89.2% (577/646.75), assessed by the maximum person-years method. 20 seroconversions were documented during the first 36 months of follow-up among the 216 women seronegative at inclusion, yielding a cumulative incidence of 11.2%. The largest number of seroconversions (8/20; 40%) was observed in the first 6 months of the postpartum period. The seroincidence density rate was 3.5/100 women-years (95% confidence interval, 1.9-5.0). It decreased linearly from 7.6 during the first 6-months postpartum to 2.5 per 100 women-years during the last 6 months of the third year of follow-up (P = 0.01). Maternal age did not affect HIV incidence rates. We examined the role of the cohort, counseling, and the first 6-month postpartum effects on this estimate. The study confirms that pregnant women may represent a population in which the HIV seroincidence is high and concentrated in the immediate postpartum period. Pregnant women should become a potential target group for future large scale vaccination trials and programs with adequate follow-up. These figures could be used for programming future HIV preventive vaccine efficacy trials in Rwanda.

• Sixteen human immunodeficiency virus type 1 (HIV-1 )—seropositive children aged 5 to 12 years (nine girls and seven boys), born to HIV-1—infected mothers, were diagnosed between 1984 and 1987 in Kigali, Rwanda. They were compared with a group of age- and sex-matched HIV-1—sero-negative children consecutively selected from the outpatient department. Two subjects were asymptomatic. Chronic cough was the most frequent symptom (seven of 16 patients). The most common signs were short stature (12 of 16 patients), low weight for age (seven of 16 patients), chronic parotitis (eight of 16 patients), persistent generalized lymphadenopathy (seven of 16 patients), and pulmonary tuberculosis (four of 16 patients). Lymphoid interstitial pneumonitis was diagnosed on radiologic grounds in five of 16 patients. Evidence of perivasculitis in the fundus was noted in three of 16 patients. Two children died during the study period (mean duration of follow-up, 40 months; range, 27 to 62 months); none of the other children had life-threatening infection or loss of developmental milestones. Immunologic assessment in the 16 children revealed high levels of IgG, decreased CD4 + /CD8 + ratio, and skin test anergy. Endocrinologic investigations revealed normal thyroid function and normal basal human growth hormone levels but low basal insulinlike growth factor I levels (0.21±0.07 vs 0.44±0.20 U/mL for controls). In Kigali, perinatally HIV-1—infected children surviving beyond 5 years of age often present with moderate signs and symptoms, principally pulmonary involvement, chronic parotitis, and persistent generalized lymphadenopathy. Short stature is the major clinical manifestation in these patients and may be due, in part, to low growth hormone secretion rather than to malnutrition. ( AJDC . 1991;145:1248-1251)

Children with multiresistant Salmonella typhimurium (MRST) systemic infections, in total 246, were diagnosed during the study period. Of these, 220 had MRST without metastatic focal infections and 26 had metastatic focal infections (including 12 patients with meningitis). The median age of the children was 10 months. Diarrhoeal disease, measles and severe malnutrition were the most frequent causes of admission. Fever was found in 99% and diarrhoea in 72% of the patients, with respiratory symptoms in 72%. In 199 (81%) of the patients, the MRST infection was considered to be hospital-acquired. Of the 246 children, 159 were treated with cefotaxime. In this group, 16 of 152 patients died (10.5%). However, of the 87 children who did not receive cefotaxime, 64 died (74%). Relapses occurred in 4% of the patients with bacteraemia treated with cefotaxime. Our study confirms the high efficiency of cefotaxime in treating severe systemic infections with MRST.

To better characterize the natural history of disease due to human immunodeficiency virus (HIV) infection in African women.Prospective cohort study over a 2-year follow-up period.A total of 460 HIV-seropositive women and a comparison cohort of HIV-seronegative women recruited from prenatal and pediatric clinics in Kigali, Rwanda in 1988.Clinical signs and symptoms of HIV disease, AIDS, and mortality.Follow-up data at 2 years were available for 93% of women who were still alive. At enrollment, many seropositive women reported symptoms listed in the World Health Organization (WHO) clinical case definition of AIDS, but these were nonspecific and often improved over time. The 2-year mortality among HIV-infected women by Kaplan-Meier survival analysis was 7% (95% CI, 5% to 10%) overall, and 21% (CI, 8% to 34%) for the 40 women who fulfilled the WHO case definition of AIDS at entry. In comparison, the 2-year mortality in women not infected with HIV was only 0.3% (CI, 0% to 7%). Independent baseline predictors of mortality in seropositive women by Cox proportional hazards modeling were, in order of descending risk factor prevalence: a body mass index of 21 kg/m2 or less (relative hazard, 2.3; CI, 1.1 to 4.8), low income (relative hazard, 2.3; CI, 1.1 to 4.5), an erythrocyte sedimentation rate exceeding 60 mm/h (relative hazard, 4.9; CI, 2.2 to 10.9), chronic diarrhea (relative hazard, 2.6; CI, 1.1 to 5.7), a history of herpes zoster (relative hazard 5.3; CI, 2.5 to 11.4), and oral candida (relative hazard, 7.3; CI, 1.6 to 33.3). Human immunodeficiency virus disease was the cause of death in 38 of the 39 HIV-positive women who died, but only 25 met the WHO definition of AIDS before death.Human immunodeficiency virus disease now accounts for 90% of all deaths among child-bearing urban Rwandan women. Many symptomatic seropositive patients may show some clinical improvement and should not be denied routine medical care. Easily diagnosed signs and symptoms and inexpensive laboratory tests can be used in Africa to identify those patients with a particularly good or bad prognosis.In 1988, researchers recruited 18-35 year old women from pediatric and prenatal care clinics at the Centre Hospitalier de Kigali in Rwanda to observe HIV disease progression. They compared probability of survival of the 460 HIV-positive women with that of the 998 HIV-negative women. They used simple clinical and laboratory variables as predictors of mortality from AIDS. The researchers did not use the WHO clinical case definition of AIDS as the outcome measure since 40 and 30 women from each group, respectively, met the criteria for AIDS at entry. Only 66% (25) of the HIV=infected women who died met the criteria for AIDS during the study. After 2 years, mortality among HIV-infected women stood at 7% (39) which was more than 20 times higher than that among women not HIV infected (0.3%; p .001). Mortality was 21% for those who met the WHO criteria for AIDS. The wasting syndrome was the cause of the death in 51% of HIV-infected death cases. The baseline predictors of mortality in HIV-infected women in descending order of prevalence of predictor included an at most body mass index of 21 kg.sq. (48%; relative hazard [RH] 2.3), low income (46%; RH=2.6), mm/hour erythrocyte sedimentation rate (39%; rh = 4.9), chronic diarrhea (10%; RH = 2.6), a history of herpes zoster (9%; RH 5.3), and oral candidiasis (1%; RH 7.3). The erythrocyte sedimentation rate was a better predictor than lymphocyte counts (p .001) and p .11, respectively). Of the 40 HIV-infected women who met the criteria for AIDS, the health of 32 women improved so the physicians no longer considered them to have AIDS. Thus health workers should treat symptomatic HIV-positive cases. AIDS was responsible for 90% of all deaths among reproductive age women living in Kigali. Health workers in Africa can use the simpler erythrocyte sedimentation rate instead of the more costly CD4 counts as a predictor of progression to AIDS.

To examine the frequency of community acquired bacteraemia in children in Kigali, Rwanda, blood cultures were obtained from 900 consecutive febrile children (T degrees greater than or equal to 39 degrees C) seen at an outpatient clinic over the course of a year. A pathogen was isolated from 112 children (12.4%): Salmonella typhi from 47, S enteritidis from 23, S typhimurium from 13, Streptococcus pneumoniae from 14, Staphylococcus aureus from 9, and Haemophilus influenzae from 3. Salmonella species represented 74% of the isolates. The children with S typhi bacteraemia were older (mean age 75 months) than those with bacteraemia due to other organisms. Controls consisted of febrile, nonbacteraemic children without (group I) or with (group II) Plasmodium falciparum parasitaemia. Bacteraemic children were older and presented more frequently with diarrhoea, vomiting, and dehydration, but less frequently with convulsions than controls. The rate of hospital admission was higher among bacteraemic children (61%) than among group I (39%) or group II (46%) controls. The case-fatality rate was similar in the three groups (9.3% versus 2.9% and 7.3%). Community-acquired bacteraemia in Rwandese children is common and is mainly caused by Salmonella species.

During a 21-month period, we observed an outbreak of severe systemic infections due to multiresistant Salmonella typhimurium among 66 children in the in-patient Department of Paediatrics of Kigali, Rwanda. These infections were more likely to occur in subjects who had stayed for a long time in the hospital for severe illness and/or malnutrition. The children usually presented first with mild to moderate diarrhoea and fever. Later, sever pulmonary involvement was often noted (rales: 58%; respiratory distress: 42%). Moreover, there were four cases of abscess, three arthritis and one meningitis. Of the 66 children, 48 were treated with cefotaxime. The fatality-rate among this group was 10.4%. The fatality-rate among the 18 other untreated patients was 77.9%, suggesting a high efficiency of cefotaxime against these strains of multiresistant Salm. typhimurium.

Nineteen out of 139 children with severe systemic disease due to multiresistant Salmonella typhimurium observed during a 34-month period in an in-patient department in Rwanda had focal metastatic infections. More than 80% of the invasive Salmonella infections were acquired in the hospital. Focal metastatic infections occurred after longer hospital stays than bacteremia (29.1 +/- 17.4 days as against 13.5 +/- 9.0 days, p less than 0.01) and were diagnosed more time after the first sign of infection (3.28 +/- 1.41 days as against 1.86 +/- 1.10 days, p less than 0.01). Bacteremia was documented in 13 of the 17 children with focal infection from whom blood cultures were obtained. Seven of 12 had positive stool cultures. The sites of metastatic focal infection were meninges (7 cases), soft tissue (5 cases), joint or bone (4 cases), pleura (2 cases), eye (1 case). The clinical course of meningitis was fulminant and 6/7 patients died before receiving adequate antimicrobial therapy. One child with meningitis and 9 patients with focal infections at other sites were treated with cefotaxime and were cured or improved.