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Background: More than half of malaria cases in Zimbabwe are concentrated in Manicaland Province, where seasonal malaria epidemics occur despite intensified control strategies. Recently, high levels of pyrethroid and carbamate resistance were detected in Anopheles funestus, the major malaria vector in eastern Zimbabwe. In response, a single round of indoor residual spraying (IRS) using pirimiphos-methyl (an organophosphate) was implemented in four high burden districts of Manicaland Province from November 1, 2014 to December 19, 2014. The objective of this study was to evaluate the effect of this programmatic switch in insecticides on malaria morbidity reported from health care facilities in Mutasa District, one of the worst affected districts in Manicaland Province. Methods: The number of weekly malaria cases for each health facility 24 months prior to the 2014 IRS campaign and in the subsequent high transmission season were obtained from passive case surveillance. Environmental variables were extracted from remote-sensing data sources and linked to each health care facility. Negative binomial regression was used to model the weekly number of malaria cases, adjusted for seasonality and environmental variables. Results: From December 2012 to May 2015, 124,206 malaria cases were reported from 42 health care facilities in Mutasa District. Based on a higher burden of malaria, 20 out of 31 municipal wards were sprayed in the district. Overall, 87.3% of target structures were sprayed and 92.1% of the target population protected. During the 6 months after the 2014 IRS campaign, a period when transmission would have otherwise peaked, the incidence of malaria was 38% lower than the preceding 24 months at health facilities in the sprayed wards. Conclusions: Pirimiphos-methyl had a measurable impact on malaria incidence and is an effective insecticide for the control of An. funestus in eastern Zimbabwe. [ABSTRACT FROM AUTHOR]

Background: To better understand trends in the burden of malaria and their temporal relationship to control activities, a survey was conducted to assess reported cases of malaria and malaria control activities in Mutasa District, Zimbabwe. Methods: Data on reported malaria cases were abstracted from available records at all three district hospitals, three rural hospitals and 25 rural health clinics in Mutasa District from 2003 to 2011. Results: Malaria control interventions were scaled up through the support of the Roll Back Malaria Partnership, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and The President's Malaria Initiative. The recommended first-line treatment regimen changed from chloroquine or a combination of chloroquine plus sulphadoxine/ pyrimethamine to artemisinin-based combination therapy, the latter adopted by 70%, 95% and 100% of health clinics by 2008, 2009 and 2010, respectively. Diagnostic capacity improved, with rapid diagnostic tests (RDTs) available in all health clinics by 2008. Vector control consisted of indoor residual spraying and distribution of longlasting insecticidal nets. The number of reported malaria cases initially increased from levels in 2003 to a peak in 2008 but then declined 39% from 2008 to 2010. The proportion of suspected cases of malaria in older children and adults remained high, ranging from 75% to 80%. From 2008 to 2010, the number of RDT positive cases of malaria decreased 35% but the decrease was greater for children younger than five years of age (60%) compared to older children and adults (26%). Conclusions: The burden of malaria in Mutasa District decreased following the scale up of malaria control interventions. However, the persistent high number of cases in older children and adults highlights the need for strategies to identify locally effective control measures that target all age groups. [ABSTRACT FROM AUTHOR]

Background: In highly populated African urban areas where access to clean water is a challenge, water source contamination is one of the most cited risk factors in a cholera epidemic. During the rainy season, where there is either no sewage disposal or working sewer system, runoff of rains follows the slopes and gets into the lower parts of towns where shallow wells could easily become contaminated by excretes. In cholera endemic areas, spatial information about topographical elevation could help to guide preventive interventions. This study aims to analyze the association between topographic elevation and the distribution of cholera cases in Harare during the cholera epidemic in 2008 and 2009. Methods: We developed an ecological study using secondary data. First, we described attack rates by suburb and then calculated rate ratios using whole Harare as reference. We illustrated the average elevation and cholera cases by suburbs using geographical information. Finally, we estimated a generalized linear mixed model (under the assumption of a Poisson distribution) with an Empirical Bayesian approach to model the relation between the risk of cholera and the elevation in meters in Harare. We used a random intercept to allow for spatial correlation of neighboring suburbs. Results: This study identifies a spatial pattern of the distribution of cholera cases in the Harare epidemic, characterized by a lower cholera risk in the highest elevation suburbs of Harare. The generalized linear mixed model showed that for each 100 meters of increase in the topographical elevation, the cholera risk was 30% lower with a rate ratio of 0.70 (95% confidence interval=0.66-0.76). Sensitivity analysis confirmed the risk reduction with an overall estimate of the rate ratio between 20% and 40%. Conclusion: This study highlights the importance of considering topographical elevation as a geographical and environmental risk factor in order to plan cholera preventive activities linked with water and sanitation in endemic areas. Furthermore, elevation information, among other risk factors, could help to spatially orientate cholera control interventions during an epidemic. [ABSTRACT FROM AUTHOR]

Abstract: This ecological study describes the cholera epidemic in Harare during 2008-2009 and identifies patterns that may explain transmission. Rates ratios of cholera cases by suburb were calculated by a univariate regression Poisson model and then, through an Empirical Bayes modelling, smoothed rate ratios were estimated and represented geographically. Mbare and southwest suburbs of Harare presented higher rate ratios. Suburbs attack rates ranged from 1.2 (95% Cl=0.7–1.6) cases per 1000 people in Tynwald to 90.3 (95% Cl=82.8–98.2) in Hopley. The identification of this spatial pattern in the spread, characterised by low risk in low density residential housing, and a higher risk in high density south west suburbs and Mbare, could be used to advocate for improving water and sanitation conditions and specific preparedness measures in the most affected areas. [ABSTRACT FROM AUTHOR]

Background: Cases of smear-negative TB have increased dramatically in high prevalence HIV settings and pose considerable diagnostic and management challenges. Methods and Findings: Between February 2006 and July 2007, a cohort study nested within a cluster-randomised trial of community-based case finding strategies for TB in Harare, Zimbabwe was undertaken. Participants who had negative sputum smears and remained symptomatic of TB were follow-up for one year with standardised investigations including HIV testing, repeat sputum smears, TB culture and chest radiography. Defaulters were actively traced to the community. The objectives were to investigate the incidence and risk factors for TB. TB was diagnosed in 218 (18.2%) participants, of which 39.4% was bacteriologically confirmed. Most cases (84.2%) were diagnosed within 3 months, but TB incidence remained high thereafter (111.3 per 1000 person-years, 95% CI: 86.6 to 146.3). HIV prevalence was 63.3%, and HIV-infected individuals had a 3.5-fold higher risk of tuberculosis than HIV-negative individuals. Conclusion: We found that diagnosis of TB was insensitive and slow, even with early radiography and culture. Until more sensitive and rapid diagnostic tests become widely available, a much more proactive and integrated approach towards prompt initiation of ART, ideally from within TB clinics and without waiting for TB to be excluded, is needed to minimise the risk and consequences of diagnostic delay. [ABSTRACT FROM AUTHOR]

A severe outbreak of cholera has been reported in Zimbabwe since mid 2008, with so far over 92,000 cases and over 4,000 deaths. This outbreak has differed from previous outbreaks in being mainly urban and with a high case-fatality rate. Breakdown in the supply of clean water has been the main underlying cause but breakdown in health service delivery in Zimbabwe has also contributed to the magnitude and severity of the outbreak. [ABSTRACT FROM AUTHOR]

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Background HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels. Methods and Findings We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92-1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24-0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28-0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21-5.12). Conclusions Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population subgroups. [ABSTRACT FROM AUTHOR]

Background. African hospitals have experienced major increases in admissions for tuberculosis, but they are ill-equipped to prevent institutional transmission. We compared institutional rates and community rates of tuberculin skin test (TST) conversion in Harare, Zimbabwe Methods. We conducted a cohort study of TST conversion 6, 12, and 18 months into training among 159 nursing and 195 polytechnic school students in Harare. Students had negative TST results (induration diameter, ⩽9 mm) with 2-step testing at the start of training. Results. Nursing students experienced 19.3 TST conversions (increase in induration diameter, ⩾10 mm) per 100 person-years (95% confidence interval [CI], 14.2–26.2 conversions per 100 person-years), and polytechnic school students experienced 6.0 (95% CI, 3.5–10.4) conversions per 100 person-years. The rate of difference was 13.2 conversions (95% CI, 6.5–20.0) per 100 person-years. With a more stringent definition of conversion (increase in the induration diameter of ⩾10 mm to at least 15 mm), which is likely to increase specificity but decrease sensitivity, conversion rates were 12.5 and 2.8 conversions per 100 person-years in nursing and polytechnic school students, respectively (rate difference, 9.7 conversions per 100 person-years; 95% CI, 4.5–14.8 conversions per 100 person-years). Nursing students reportedly nursed 20,868 inpatients with tuberculosis during 315 person-years of training. Conclusions. Both groups had high TST conversion rates, but the extremely high rates among nursing students imply high occupational exposure to Mycobacterium tuberculosis. Intense exposure to inpatients with tuberculosis was reported during training. Better prevention, surveillance, and management of institutional M. tuberculosis transmission need to be supported as part of the international response to the severe human immunodeficiency virus infection epidemic and health care worker crisis in Africa. [ABSTRACT FROM AUTHOR]

Summary: Urinary schistosomiasis is known to be associated with lesions in the female genital organs, particularly with the presence of ‘sandy patches’ in the lower genital tract. This study sought to determine the effect of treatment with praziquantel on gynaecological schistosomiasis in residents of an area endemic for Schistosoma haematobium. A cohort study was conducted among women aged 20–49 years in rural Zimbabwe. The shape and size of lesions were mapped pre treatment and 3 and 12 months following treatment. Ova of S. haematobium were looked for in cytology smears, wet mounts, biopsies, urine and stool. Specimens were collected for detection of sexually transmitted diseases and cancer. At baseline, almost half of the 527 women included in the study had sandy patches. Although urinary ova excretion decreased following treatment (odds ratio 10.3, 95% CI 3.8–27.8, P <0.001), praziquantel treatment was not associated with a significant reduction in genital lesions or contact bleeding (P =0.31–0.94). Sandy patches remained strongly associated with contact bleeding and vessel abnormalities even after treatment. Findings were independent of HIV status. Such lesions, which are common and apparently refractory to treatment for at least 12 months, may be an important risk factor for both the acquisition and transmission of HIV. [Copyright &y& Elsevier]

Background. Cough lasting for ≧3 weeks (i.e., chronic cough) indicates that a patient has suspected tuberculosis (TB). At the primary health care level, the spectrum of disease that causes chronic cough has not been previously investigated in a setting with a high prevalence of human immunodeficiency virus (HIV) infection. Methods. A total of 544 adults with chronic cough were recruited systematically from 2 primary health care clinics, and they were evaluated using preset first- and second-line investigations and diagnostic case definitions. Results. The overall prevalence of HIV infection among the study cohort was 83%. TB was the most common diagnosis, with 207 HI V-positive patients (46%) and 27 HIV-negative patients (3 0%) having confirmed or probable TB. Of these, 145 HIV-positive patients with TB (70%) and 20 HIV-negative patients with TB (74%) had smear- positive cases of TB. Only 17 HIV-positive and 2 HIV-negative patients had smear-negative but culture-positive cases of TB. Lower respiratory tract infections (n = 178; HIV prevalence, 79%) and pneumonia (n = 87; HIV prevalence, 89%) were the next most common diagnoses. Asthma (n = 26; HIV prevalence, 46%), posttuberculous disease and other fibrotic lung disease (n = 34; HIV prevalence, 88%), and cardiac disease (n = 15; HIV prevalence, 93%) were more common than were Pneumocystis jiroveci pneumonia and cryptococcosis (n = 8 and n = 5, respectively; HIV prevalence, 100%), and we found no cases of nocardiosis or histoplasmosis. Conclusions. TB was diagnosed for 43% of patients who presented with chronic cough to primary health care clinics in Harare, with 71% having smear-positive disease. The findings of TB culture added relatively little to the findings of fluorescent microscopy of concentrated sputum specimens. The prevalence of HIV infection was high across a range of diagnoses, suggesting that an HIV test should be recommended in the initial investigation of chronic cough. [ABSTRACT FROM AUTHOR]

Background It has recently been argued that unsafe medical injections are a major transmission route of HIV infection in the generalised epidemics of sub-Saharan Africa. Methods and Findings We have analysed the pattern of injections in relation to HIV incidence in a population cohort in Manicaland in a rural area of Zimbabwe. In Poisson regression models, injections were not found to be associated with HIV in males (rate ratio = 0.33; 95% confidence interval: 0.07 to 1.46) or females (rate ratio = 1.04; 95% confidence interval: 0.59 to 1.85). Conclusion It is important that unsafe medical injections can be confidently excluded as a major source of HIV infection. In rural Zimbabwe the evidence is that they can. [ABSTRACT FROM AUTHOR]

HIV-related sub-fertility has been reported for those populations in sub-Saharan Africa in which contraceptive use is low. We use data from a retrospective survey in rural Zimbabwe and multivariate logistic regression models to show that recent birth rates and current pregnancy rates are also lower among HIV-positive women than among HIV-negative women in those African populations where contraceptive use is high. The fertility reduction is smaller than where contraceptive use is low because age at first sexual intercourse is later and birth rates at older ages are already low. Nevertheless, total fertility is approximately 8.5 per cent lower and HIV-associated sub-fertility may account for as much as one-quarter of fertility decline in Zimbabwe since the late 1980s. Mechanisms for HIV-associated sub-fertility in rural Zimbabwe include more frequent widowhood and divorce, reduced coital frequency, increased amenorrhoea, and possibly, pelvic inflammatory disease. Miscarriage appears to be a less important factor than elsewhere possibly because syphilis is rare. [ABSTRACT FROM AUTHOR]

The aim of the study was to use population-based data from 689 adults to describe the socio-demographic, behavioural and biomedical correlates of HIV infection and aid identification of effective HIV control strategies for rural Zimbabwe. Dried blood spot and urine samples were collected for HIV and sexually transmitted disease (STD) testing and participants were interviewed on socio-demographic characteristics, sexual behaviour and experience of STD symptoms. HIV seroprevalence was 23.3% and was higher in females, divorcees, widows, working men, estate residents, and respondents reporting histories of STD symptoms. Female HIV seroprevalence rises sharply at ages 16-25. A third of sexually-active adults had experienced STD-associated symptoms but there were delays in seeking treatment. Herpes simplex virus type 2 (HSV-2) and Trichomonas vaginalis are more common causes than syphilis, gonorrhoea, and chlamydia, and are strongly associated with HIV infection. Local programmes promoting safer sexual behaviour and fast and effective STD treatment among young women, divorcees and working men could reduce the extensive HIV transmission in rural communities. [ABSTRACT FROM AUTHOR]

Presents a study that evaluated the effect on health care of HIV testing of patients routinely admitted to medical wards in the two major city hospitals in Harare, Zimbabwe. Reasons for the reluctance to perform HIV testing; Common diseases among patients in medical wards; Features of hospital care for HIV patients in Zimbabwe.

Three hundred eighty-eight human immuno deficiency virus (HIV)-negative clients in Zimbabwe were retested at 3 months using 2 parallel rapid tests. One operator error (risk, 0.26%; 95% confidence interval, 0.0065%-1.4%) and no "true" seroconversions (upper 95% confidence limit, 0.96%) were detected. High-risk behavior was not significantly reduced. Policies recommending routine retesting need to be reconsidered. [ABSTRACT FROM AUTHOR]

The article discusses a study which compared the effectiveness of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe. The cluster-randomised trial involved neighborhoods in the high-density residential suburbs of Harare. It was concluded that wide implementation of active case finding could have significant effects on the transmission of tuberculosis.

Objective To assess the diagnostic value of provider-initiated symptom screening for tuberculosis (TB) and how HIV status affects it. Methods We performed a secondary analysis of randomly selected participants in a community-based TB-HIV prevalence survey in Harare, Zimbabwe. All completed a five-symptom questionnaire and underwent sputum TB culture and HIV testing. We calculated the sensitivity, specificity, and positive and negative predictive values of various symptoms and used regression analysis to investigate the relationship between symptoms and TB disease. Findings We found one or more symptoms of TB in 21.2% of 1858 HIV-positive (HIV+) and 9.9% of 7121 HIV-negative (HIV-) participants (P< 0.001 ). TB was subsequently diagnosed in 48 HIV+ and 31 HIV- participants. TB was asymptomatic in 18 culture-positive individuals, 8 of whom (4 in each HIV status group) had positive sputum smears. Cough of any duration, weight loss and, for HIV+ participants only, drenching night sweats were independent predictors of TB. In HIV+- participants, cough of a 2 weeks' duration, any symptom and a positive sputum culture had sensitivities of 48%, 81% and 65%, respectively; in HIV- participants, the sensitivities were 45%, 71 % and 74%, respectively. Symptoms had a similar sensitivity and specificity in HIV+ and HIV- participants, but in HIV+ participants they had a higher positive and a lower negative predictive value. Conclusion Even smear-positive TB may be missed by provider-initiated symptom screening, especially in HIV+ individuals. Symptom screening is useful for ruling out TB, but better TB diagnostics are urgently needed for resource-poor settings. [ABSTRACT FROM AUTHOR]

Summary: Background: HIV-1 prevalence typically rises more rapidly at young ages in women than in men in sub-Saharan Africa. Greater susceptibility to infection on exposure in women is believed to be a contributory factor as is greater exposure to previously infected sexual partners of the opposite sex. We investigated the latter hypothesis using data from a field study in rural Manicaland, Zimbabwe. Methods: Quantitative data on onset and degree of sexual activity, numbers of partners, concurrent partnerships, condom use, and partner characteristics were used in conjunction with epidemiological data on age and sex specific prevalence of HIV infection to do statistical analyses of association between key variables. Mathematical models and qualitative data were used to aid analysis and interpretation. Findings: Older age of sexual partner was associated with increased risk of HIV-1 infection in men (odds ratio 1.13 [95% CI 1.02-1.25]) and women (1.04 [1.01-1.07]). Young women form partnerships with men 5-10 years older than themselves, whereas young men have relationships with women of a similar age or slightly younger. Greater number of lifetime partners is also associated with increased risk of HIV (1.03 [1.00-1.05]). Young men report more partners than do women but infrequent coital acts and greater use of condoms. These behaviour patterns are underpinned by cultural factors including the expectation that women should marry earlier than men. A strong gender effect remains after factors that affect exposure to infected partners are controlled for (6.04 [1.49-24.47]). Interpretation: The substantial age difference between female and male sexual partners in Manicaland is the major behavioural determinant of the more rapid rise in HIV prevalence in young women than in men. Theoretical studies have suggested that this difference is an important determinant of observed epidemiological patterns but the study reported in this paper provides clear empirical evidence... [ABSTRACT FROM AUTHOR]

Few sub-Saharan African countries have witnessed declines in HIV prevalence, and only Uganda has compelling evidence for a decline founded on sexual behavior change. We report a decline in HIV prevalence in eastern Zimbabwe between 1998 and 2003 associated with sexual behavior change in four distinct socioeconomic strata. HIV prevalence fell most steeply at young ages — by 23 and 49%, respectively, among men aged 17 to 29 years and women aged 15 to 24 years — and in more educated groups. Sexually experienced men and women reported reductions in casual sex of 49 and 22%, respectively, whereas recent cohorts reported delayed sexual debut. Selective AIDS-induced mortality contributed to the decline in HIV prevalence. [ABSTRACT FROM AUTHOR]

Recent data from the Manicaland HIV/STD Prevention Project, a general-population open HIV cohort study, suggested that between 2004 and 2007 HIV prevalence amongst males aged 15-17 years in eastern Zimbabwe increased from 1.20% to 2.23%, and in females remained unchanged at 2.23% to 2.39%, while prevalence continued to decline in the rest of the adult population. We assess whether the more likely source of the increase in adolescent HIV prevalence is recent sexual HIV acquisition, or the aging of long-term survivors of perinatal HIV acquisition that occurred during the early growth of the epidemic. Using data collected between August 2006 and November 2008, we investigated associations between adolescent HIV and (1) maternal orphanhood and maternal HIV status, (2) reported sexual behaviour, and (3) reporting recurring sickness or chronic illness, suggesting infected adolescents might be in a late stage of HIV infection. HIV-infected adolescent males were more likely to be maternal orphans (RR = 2.97, p<0.001) and both HIV-infected adolescent males and females were more likely to be maternal orphans or have an HIV-infected mother (male RR = 1.83, p<0.001; female RR = 16.6, p<0.001). None of 22 HIV-infected adolescent males and only three of 23 HIV-infected females reported ever having had sex. HIV-infected adolescents were 60% more likely to report illness than HIV-infected young adults. Taken together, all three hypotheses suggest that recent increases in adolescent HIV prevalence in eastern Zimbabwe are more likely attributable to long-term survival of mother-to-child transmission rather than increases in risky sexual behaviour. HIV prevalence in adolescents and young adults cannot be used as a surrogate for recent HIV incidence, and health systems should prepare for increasing numbers of long-term infected adolescents.

Background: To contain ongoing cholera outbreaks, the World Health Organization has suggested that reactive vaccination should be considered in addition to its previous control measures., Objectives: To explore the potential impact of a hypothetical reactive oral cholera vaccination using the example of the recent large-scale cholera outbreak in Zimbabwe., Methods: This was a retrospective cost-effectiveness analysis calculating the health and economic burden of the cholera outbreak in Zimbabwe with and without reactive vaccination. The primary outcome measure was incremental cost per disability-adjusted life year (DALY) averted., Results: Under the base-case assumptions (assuming 50% coverage among individuals aged ≥2 years), reactive vaccination could have averted 1 320 deaths and 23 650 DALYs. Considering herd immunity, the corresponding values would have been 2 920 deaths and 52 360 DALYs averted. The total vaccination costs would have been ~$74 million and ~$21 million, respectively, with per-dose vaccine price of US$5 and $1. The incremental costs per DALY averted of reactive vaccination were $2 770 and $370, respectively, for vaccine price set at $5 and $1. Assuming herd immunity, the corresponding cost was $980 with vaccine price of $5, and the programme was cost-saving with a vaccine price of $1. Results were most sensitive to case-fatality rate, per-dose vaccine price, and the size of the outbreak., Conclusions: Reactive vaccination has the potential to be a cost-effective measure to contain cholera outbreaks in countries at high risk. However, the feasibility of implementation should be further evaluated, and caution is warranted in extrapolating the findings to different settings in the absence of other in-depth studies.

Objective: Under Millennium Development Goal 4, countries are required to reduce child mortality by two-thirds between 1990 and 2015. In countries with generalized epidemics of human immunodeficiency virus (HIV) infection, standard statistics based on fertility history may misrepresent progress towards this target owing to the correlation between deaths among mothers and early childhood deaths from acquired immunodeficiency syndrome., Methods: To empirically estimate this bias, child mortality data and fertility history, including births to deceased women, were collected through prospective household surveys in eastern Zimbabwe during 1998-2005. A mathematical model was then used to investigate the determinants and temporal dynamics of the bias, first in Zimbabwe and then in other countries with different background mortality rates and HIV-related epidemic profiles., Findings: According to the empirical data, standard cross-sectional survey statistics underestimated true infant and under-5 mortality by 6.7% and 9.8%, respectively. These estimates were in agreement with the output from the model, in which the bias varied according to the magnitude and stage of the epidemic of HIV infection and background mortality rates. The bias was greater the longer the period elapsed before the survey and in later stages of the epidemic. Bias could substantially distort the measured effect of interventions to reduce non-HIV-related mortality and of programmes to prevent mother-to-child transmission, especially when trends are based on data from a single survey., Conclusion: The correlation between the HIV-related deaths of mothers and their children can bias survey estimates of early child mortality. A mathematical model with a user-friendly interface is available to correct for this bias when measuring progress towards Millennium Development Goal 4 in countries with generalized epidemics of HIV infection.

Background: Accurate diagnosis of latent tuberculosis infection (LTBI) in recently exposed HIV-infected tuberculosis (TB) contacts is a public health priority because of the high risk of progression to active TB but is hampered by the high background prevalence of LTBI in high-burden populations and poor sensitivity of tuberculin skin testing (TST) in HIV co-infection., Methods: The prevalence of LTBI in 222 recent household contacts of TB cases and 176 household contacts of community controls without TB in Harare, Zimbabwe were compared using TST and interferon gamma enzyme-linked immunospot (ELISpot) responses to ESAT-6 (early secretory antigenic target-6) and CFP-10 (culture filtrate protein-10). TST and ELISpot results were correlated with markers of recent TB exposure and the impact of HIV co-infection was assessed., Results: In this high-incidence population, the proportion of ELISpot-positive contacts was not significantly different from community controls. However, ELISpot, unlike TST, revealed a higher prevalence of LTBI in recent contacts of sputum smear-positive cases than in contacts of controls. ELISpot results correlated significantly with positive sputum smear and culture status of the index case (adjusted OR 2.40, CI 1.12 to 5.14), even in the subgroup of HIV-infected contacts (adjusted OR 5.36, CI 1.11 to 25.93). and were independent of contacts' HIV status. TST results were also associated with positive smear and culture status of the index case (adjusted OR 4.41, CI 1.82 to 10.67) but were negatively associated with contacts' HIV status (adjusted OR 0.25, CI 0.10 to 0.60)., Conclusions: Contact investigations in high-burden populations should focus on contacts of sputum smear-positive cases in whom recent infection can be detected by ELISpot, even in the presence of HIV co-infection.

Objective: To investigate HIV incidence during a trial of two voluntary counselling and testing (VCT) strategies. Counselling may promote beneficial behavioural change, although knowledge of negative status does not appear to contribute further benefit., Design: The parent cluster-randomized trial demonstrated much greater uptake of VCT when counselling and rapid testing were available on-site (intensive VCT) than through pre-paid vouchers to an external provider (standard VCT). Anonymous HIV tests had been requested from all employees at enrolment and after 2 years intervention., Methods: The study setting was 22 businesses in Harare, Zimbabwe. Participants were 3146 HIV-negative individuals remaining in employment at the end of intervention, of whom 2966 (94.3%) consented to repeat testing. VCT linked to basic HIV care was provided and the main outcome measures were HIV incidence under each study arm, as a retrospective secondary analysis., Results: Mean VCT uptake in this cohort was 70.7 and 5.2%, respectively, in the intensive and standard arms. Crude HIV incidence was 1.21 per 100 person-years, with non-significantly higher rates in the intensive VCT arm [mean site incidence 1.37 and 0.95 per 100 person-years, respectively; adjusted rate ratio 1.49 (95% confidence interval 0.79-2.80)., Conclusions: Highly acceptable VCT did not reduce HIV incidence in this predominantly male cohort. HIV incidence was highest in the high uptake VCT arm, lending support to a US trial in which rapid testing appeared to have adverse behavioural consequences in some HIV-negative clients. Careful comparison of outcomes under different counselling and testing strategies is needed to maximize HIV prevention from global scale-up of VCT.

Objective: To determine the association between female genital Schistosoma haematobium infection and HIV., Design and Methods: A cross-sectional study with a 1-year follow-up. Gynecological and laboratory investigations were performed for S. haematobium and HIV. Sexually transmitted infections, demographic and urogenital history were analysed as confounders. The participants were 527 sexually active, non-pregnant, non-menopausal women between the ages of 20 and 49 years. The setting was a rural Zimbabwean community where S. haematobium related lesions were found in 46% of the women, HIV in 29% and herpes simplex type- 2 (HSV-2) in 65%., Results: In permanent residents (>3 years residency), HIV was found in 41% (29/70) of women with laboratory proven genital schistosomiasis as opposed to 26% HIV positive (96/375) in the schistosomal ova negative group [odds ratio (OR), 2.1; 95% confidence interval (CI), 1.2-3.5; P = 0.008. In multivariate analysis S. haematobium infection of the genital mucosa was significantly associated with HIV seropositivity (adjusted OR, 2.9; 95% CI, 1.11-7.5; P = 0.030). All seven women who became HIV positive during the study period (seroincidence 3.1%) had signs of S. haematobium at baseline. In accordance with other studies HIV was significantly associated with HSV-2 (OR, 3.0; 95% CI, 1.7-5.3; P < 0.001), syphilis and human papillomavirus. The highest HIV prevalence (45%) was found in the 25-29 years age group., Conclusion: Women with genital schistosomiasis had an almost three-fold risk of having HIV in this rural Zimbabwean community. Prospective studies are needed to confirm the association.

Introduction: Syndromic management of sexually transmitted infections (STIs) is one important strategy in human immunodeficiency virus (HIV) prevention in developing countries, but there is a scarcity of rural community-based data on the relative prevalences of the STIs. We sought to determine the prevalences of the STIs and their clinical correlates in rural Zimbabwean women., Methods: A cross-sectional study was conducted among 527 sexually active, non-pregnant, non-menopausal women between the ages of 20 and 49 years., Results: The seroprevalence for herpes simplex virus type 2 (HSV-2), HIV, trichomoniasis and syphilis were 64.5, 29.3, 24.7 and 6.2% respectively. HSV-2 seropositivity was significantly associated with current non-syphilitic ulcers (adjusted odds ratio [OR] 4.91, 95% confidence interval [CI] 1.08-22.34, p = 0.040). HSV-2 seroprevalence peaked at the age of 35 whereas HIV peaked at 25. The two diseases were strongly associated (OR 2.92, 95% CI 1.85-4.65, p < 0.001)., Conclusion: There is evidence of rural epidemics of both HSV-2 and HIV, and a change in the aetiology of genital ulcers in rural Zimbabwe.

Serological assays using dried blood spots from 5221 women in rural areas of eastern Zimbabwe were used to assess the epidemiology of Trichomonas vaginalis infection, and its association with HIV. Antibodies to T. vaginalis and to HIV were detected by enzyme immunoassays. Behavioural and demographic data were collected by confidential questionnaires. In total, 516 (9.9%) women were seropositive for T. vaginalis and seroprevalence increased with age among younger women. Divorced, widowed and single women were more likely to be seropositive. After controlling for age, seropositivity was significantly associated with being sexually active, having multiple sex partners, having a partner who had multiple sex partners, and having a new sex partner in the past year. Seropositivity was associated with a recent history of genital discharge. Overall, 208 (40.3%) T. vaginalis-positive samples were also positive for HIV, compared with 1106 (23.5%) T. vaginalis-negative samples (age and sex adjusted OR 2.11, 95% CI 1.74-2.55, P < 0.001). There was increased risk for being HIV-positive amongst T. vaginalis-seropositive women regardless of residence, employment or education. In a logistic regression controlling for common risk factors, the association remained significant. T. vaginalis-seropositive young women with a history of genital discharge were much more likely to be HIV-positive than women who were T. vaginalis-seronegative and had no history of discharge (OR 6.08, 95 % CI 2.95-12.53). Although a causal relationship cannot be assumed, detection and treatment of trichomoniasis may be important in strategies to reduce HIV transmission through sexually transmitted infection control.

Up to 75% of women with urinary schistosomiasis have Schistosoma haematobium ova in the genitals. This study aimed to describe the prevalence of gynecologic S. haematobium infection and to differentiate the disease from sexually transmitted infections (STIs). Gynecologic and laboratory investigations for S. haematobium and STIs were performed in 527 women between the ages of 20 and 49 in rural Zimbabwe. Genital homogenous yellow and/or grainy sandy patches, the commonest type of genital pathology, were identified in 243 (46%) women. Grainy sandy patches were significantly associated with S. haematobium ova only. Genital S. haematobium ova was also significantly associated with homogenous yellow sandy patches, mucosal bleeding, and abnormal blood vessels. The presence of ova was not a predictor for ulcers, papillomata, leukoplakia, polyps, or cell atypia. Mucosal sandy patches seem to be pathognomonic for S. haematobium infection in the female genitals. Coexistence of ova and other lesions may not be causal.

Cervical cancer is a leading cause of cancer-related deaths in developing countries, and the human papillomavirus (HPV) is linked etiologically to cervical cancer. Hence, a vaccine which prevents HPV-associated cervical cancer would have the most impact in developing countries, including the African continent. The type-specific immune response towards HPV virus-like particles, in combination with geographical variation in the prevalence of HPV, necessitates the presence of multiple HPV type antigens in a single vaccine cocktail in order to provide relevant protection. We aimed to investigate whether co-infection with HIV, which is highly prevalent in Africa, plays a role in HPV genotype distribution. After informed consent, HPV detection by GP5+/6+ PCR and HIV detection by serology was carried out on 236 women from the rural north-western part of Zimbabwe. The prevalence of HPV was higher in HIV positive women (54%) than in HIV negative women (27%). Certain HPV types (HPV types 11, 39, 43, 51, and 59, P-values ranging from 0.017 to 0.067) occurred more frequently in HIV positive women. Only high-risk HPV, and not HIV, was associated significantly with cervical intraepithelial neoplasia in multiple regression analysis. In conclusion, a high prevalence of HPV was found in a rural community, where regular Papanicolaou (Pap) smears would be a logistic and economic impossibility, but where free vaccination programmes against other infections are already established. The results suggest that HIV co-infection may have an impact on HPV genotype distribution., (Copyright 2004 Wiley-Liss, Inc.)

Pneumococcal pneumonia and meningitis are common infectious disease problems in people who are HIV seropositive in southern Africa. For many years two inexpensive antibiotics, penicillin and trimethoprim-sulphamethoxazole (TMP-SMX) had been effective in treatment, but recently resistance to these agents has been reported from many parts of the world. This study was designed to determine the antimicrobial resistance patterns in invasive pneumococci from hospital patients in Harare, Zimbabwe. A total of 160 isolates of Streptococcus pneumoniae from blood cultures and CSF cultures were examined. The isolates came from adults and children in hospital in Harare between 1994 and 2000. The majority of isolates came from HIV positive adults (74%) and children (75%). Isolates of pneumococci with an MIC of 1.0 mg/l or more were first seen in 1997 and by 2000 they made up 35% of all isolates. Significantly more isolates from HIV seropositive patients (50%) showed reduced susceptibility to penicillin compared with isolates from HIV seronegative patients (16%), and high level resistance (MIC 1.0 mg/l or higher) was found in 16% isolates from HIV positive patients compared with 6% isolates from HIV seronegative patients. Resistance to TMP-SMX was common, with more than 50% isolates from HIV positive and HIV negative patients having reduced susceptibility to this antibiotic combination.

HIV-1 mRNA levels (virus load) were quantified for 191 pulmonary tuberculosis (TB) patients and 132 HIV-1 seropositive controls. Human leukocyte antigen (HLA) class I and II genes were typed for 188 patients and 121 HIV-1 seropositive controls. The mean log virus load was higher among cases than HIV-1 seropositive controls (p < 0.0001). Among the controls, mean log virus load was higher among males than females (p = 0.04). There was no association between virus load and homozygosity at HLA class I and II among the controls. In contrast, among the cases, HLA-DRB1 homozygosity was associated with high virus load (p = 0.008), conferring risk for rapid progression to AIDS, thus lending support to the heterozygote advantage hypothesis. The observed decreased virus load in HLA-DRB-1 heterozygotes may be due to a better control of M. tb. infection in the context of HIV-1 disease.