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Objectives: To develop and implement a method to identify and characterize places where people meet new sexual partners and to assess HIV prevention program coverage in those places., Methods: In three townships (populations 60 000-100 000 each) and one business district (population < 20 000) in South Africa, interviewers asked over 250 informants per area to identify public sites where people meet new sexual partners. All reported sites were visited and mapped. A knowledgeable person onsite was interviewed about the site and its patrons. Individuals socializing at sites were interviewed about their sexual behavior., Results: More than 200 sites in each township and 64 sites in the central business district were identified and visited. The male to female ratio among site patrons was approximately 2:1. In each area, men and women socializing at sites reported high rates of new sexual partner acquisition and low condom use. Almost half of the 3085 men and 1564 women interviewed while socializing reported having a new sexual partner in the last 4 weeks. A third reported meeting a new partner at the site of the interview. Commercial sex was rare in the townships but available at 31% of central business district sites. Fewer than 15% of township and only 20% of business district sites had condoms., Conclusion: The PLACE method successfully identified sites where people with high rates of new sexual partnerships can be reached for prevention programs. Sexual networks in these areas are extensive, diffuse, and characterized by high rates of new partnership formation and concurrency with little acknowledged commercial sex.

Aim: To assess the quality of integrated sexually transmitted infection (STI) services in primary health care., Method: A two-page questionnaire, in collaboration with district health service supervisors, was developed to assess the quality of care and health services for STIs in individual clinics., Results: The data suggest that the quality-assessment instrument used has the potential to promote the improvement of STI care delivery at district and clinic levels., Conclusion: The quality-assessment instrument proved easy to use, can be adapted to local requirements and is appropriate for use in developing countries. The authors maintain that using this instrument in various district clinics could help supervisors identify the main impediments to the delivery of high quality services, and give them a platform from which to set priorities in training, infrastructure, equipment and supplies.

Objective(s): To evaluate the feasibility and acceptability of the Micralax applicator and of methyl cellulose placebo gel for use in vaginal microbicide clinical trials., Design: A two-centre prospective study following women for 2 months., Setting: Two primary health care clinics in South Africa., Patients, Participants: Female volunteers (n = 28) 18 years or older who were HIV negative and had no clinically detectable genital tract abnormalities or reproductive tract infections., Interventions: Participants used pre-filled Micralax applicators to apply methyl cellulose gel every other day, as well as up to 1 h before to every episode of vaginal sex., Main Outcome Measure(s): Consistency in the weight of gel dispensed per application; side-effects attributed to applicator or gel use; and acceptability of the applicator and of the gel., Results: Over a 2 month follow-up period the 22 women completing the study reported no adverse events related to gel or applicator use. The Micralax applicator proved acceptable. The gel was not too messy and did not reduce sexual frequency or pleasure. On average, the applicator dispensed 4.7 ml per use (close to the 4 ml planned)., Conclusions: The Micralax applicator performs well as a delivery system for potential vaginal microbicides; and methyl cellulose is an appropriate placebo for future microbicide trials.

Objective: Short-course antiretroviral therapy (ART) has been shown to be effective in reducing mother-to-child transmission (MTCT) of HIV-1. This article details the public health lessons learnt from a district-based pilot programme where a short-course zidovudine (ZDV) regimen has been used in a typical South African peri-urban setting., Methods: The pilot programme was initiated at two midwife obstetric units in January 1999. Lay counsellors conducted pre- and post-test counselling and nurses took blood for HIV enzyme-linked immunosorbent assay (ELISA) testing. Short-course ZDV was administered antenatally (from 36 weeks' gestation) and during labour. Mother-infant pairs were followed up at eight child health clinics where free formula feed was dispensed weekly. Infants received co-trimoxazole prophylaxis and were ELISA tested for HIV at 9 and 18 months. After 17 months protocol changes aimed at eliminating weaknesses included initiation of ZDV at 34 weeks, self-administration of the first dose of ZDV with the onset of labour, and rapid HIV testing for both mothers and infants., Results: Voluntary counselling and testing was shown to be highly acceptable, with individual counselling more effective than group counselling. Based on less than optimal availability of records, ZDV utilisation was encouraging with up to 59% of subjects initiating treatment, 3 weeks' median duration of ZDV use, and up to 88% receiving at least one intrapartum ZDV dose. Self-administration of the intrapartum dose reached 41%., Conclusions: Short-course antenatal and intrapartum ART to prevent MTCT of HIV1 was shown to be feasible.

Background: Partner notification has been practiced for decades, with substantial resources directed towards it, and with little evidence on whether it has made a public health impact on disease transmission. Most of the evaluations were not randomized controlled trials, and were conducted in the United States, prior to the HIV/AIDS epidemic. There are reasons to question whether partner notification for gonorrhoea and chlamydia is applicable to HIV. It is also questionable whether interventions for the developed world are applicable to the developing world., Objectives: This review aims to compare the effects of various sexually transmitted disease (STD) partner notification strategies, including to compare provider referral with contract and patient referral, and to compare different patient referral strategies to each other. In addition to updating previous reviews, it addresses partner notification in developing countries as well as in developed countries, with particular consideration for HIV/AIDS. It attempts to address some of the methodological limitations of earlier reviews., Search Strategy: The search strategy included MEDLINE, EMBASE, Psychological Abstracts, Sociological Abstracts, the Cochrane Controlled Trials register, the proceedings of the International AIDS Conferences and the International Society for STD Research meetings., Selection Criteria: The review includes published or unpublished randomised controlled trials (RCTs) comparing two or more partner notification strategies for people diagnosed with STDs., Data Collection and Analysis: For each comparison within each study, the difference in the rate of partners elicited, notified, medically evaluated, harmed, etc, the 95% confidence interval, and if significant, the numbers needed to treat (NNT) were calculated., Main Results: We found 11 RCTs, including 8014 participants. Only two trials were conducted in developing countries, and only two trials were conducted among HIV positive patients. There was some risk of bias in all the included trials. The review found moderately strong evidence that: 1. provider referral alone, or the choice between patient and provider referral, when compared with patient referral among patients with HIV or any STD, increases the rate of partners presenting for medical evaluation; 2. contract referral, when compared with patient referral among patients with gonorrhoea, results in more partners presenting for medical evaluation; 3. verbal, nurse-given health education together with patient-centred counselling by lay workers, when compared with standard care among patients with any STD, results in small increases in the rate of partners treated., Reviewer's Conclusions: There is a need for evaluations of interventions combining provider training and patient education, and for evaluations conducted in developing countries. All partner notification evaluations, but especially those among HIV positive patients, need to measure potential harmful effects, such as domestic violence, to ensure that partner notification does more good than harm.

Objective: To evaluate a recently developed low-dose, large-field, direct digital X-ray scanning system for medical use., Method: Radiation dose, image quality, diagnostic capability and clinical utility of the unit were compared with those of conventional radiography., Results: Radiation doses ranged from 3% to 5% of conventional radiographic values, and a mean of 1 line-pair per millimetre could be detected. Ease of use, anatomical coverage and tolerance to patient motion were advantages. However, image quality was inferior to that of conventional radiographs, with limited fine detail visibility and penetration. Only 67 of 156 (42.9%) pathological features seen on conventional radiographs were detected, including 13 of 41 fractures (31.7%) and 11 of 18 pneumothoraces (61.1%)., Conclusion: Although image quality and diagnostic performance were not ideal, potential roles in triage, foreign body detection and possibly screening were promising. Radiographic factors may have affected sensitivity. This machine demonstrated useful attributes that may, with improvement, be beneficial in the imaging of trauma and other patients.

Objective: To determine the risk factors associated with meningococcal disease among children living in Cape Town., Design: A case-control study was conducted from October 1993 to January 1995., Setting: The study population consisted of all children under the age of 14 years who were resident in the Cape Town metropolitan region. Cases and controls were selected from Red Cross War Memorial Children's Hospital., Results: A total of 70 cases and 210 controls were interviewed. Significant risk factors for meningococcal disease included being breast-fed for less than 3 months (adjusted odds ratio (OR) 2.4); overcrowding (adjusted OR 2.3); and age less than 4 years (adjusted OR 2.3). Exposure to two or more household members who smoked was also a risk factor, but only in the presence of a recent upper respiratory tract infection (adjusted OR 5.0)., Conclusion: This is the first case-control study in South Africa examining risk factors for meningococcal disease. It provides further evidence for reduction of smoking, reduction of overcrowding and promotion of breast-feeding as important public health measures.

In developing countries without access to laboratory testing, the syndromic management of cervicitis in women with lower genital tract symptoms results in overtreatment. We evaluated the validity of using different age cut-offs to predict the risk of cervical infection in women attending a clinic for sexually transmitted diseases in Cape Town. Specimens from 161 women with lower genital tract symptoms were examined microbiologically for evidence of cervicitis (gonorrhoea and/or chlamydial infection). Women with cervicitis (median 21 years) were significantly younger than those not infected (median 23 years). Retrospective simulation using the age cut-offs (< 45 years (current approach), < 30 years, and < 25 years) to predict cervicitis showed that specificity could be increased (overtreatment reduced) from 17% to 50% if presumptive diagnoses of cervicitis were restricted to women aged under 25 years. Lowering the age cut-off would severely limit sensitivity, however, and as many as 9% and 20%, respectively, of infected women would go untreated if the age cut-offs < 30 and < 25 years were used. The use of a lower age cut-off would therefore serve neither individual nor public health in the presumptive diagnosis and treatment of cervicitis in a high risk population, and would result in a substantially lower detection rate.

Objectives: To evaluate the sensitivity of a syndromic diagnostic procedure in detecting and treating sexually transmitted diseases (STDs) and genital tract infections (GTIs)., Methods: All new patients presenting at an STD clinic were sampled systematically by gender over a 6-week period. After the patient's clinical consultation, the clinical records were reviewed. Thereafter all patients were given a thorough genital examination by the research physician, and specimens were collected for laboratory investigations. In a retrospective simulation clinicians' syndromic diagnoses were validated against the laboratory findings, or for genital ulcer syndrome against the findings of the research physician., Results: 170 men and 161 women were included in the sample. Ninety-five per cent of patients were black and the median age was 22 years for women and 26 years for men. In this setting, the Western Cape syndromic diagnostic procedure achieved reasonable levels of sensitivity in detecting Neisseria gonorrhoeae and Chlamydia trachomatis in men and women, and in detecting Trichomonas vaginalis and bacterial vaginosis in women. However, it was estimated to be only 36.4% sensitive in detecting genital ulcers in women, and between 0% and 12.3% sensitive in detecting Candida albicans. With syndromic management 8.2% of men and 32.9% of women would leave the clinic with at least one infection inadequately treated., Conclusions: Despite the introduction of syndromic protocols, it is likely that a proportion of STDs and GTIs are not being detected and treated owing to the high prevalence of multiple syndromes and mixed infections, both symptomatic and asymptomatic.

Over the last 6 years there has been a decline in the incidence of measles in Cape Town. However, during August 1992 an outbreak occurred, with cases reported at many schools in children presumably immunised. The objectives of this study were to characterise the epidemic in Cape Town and to determine possible reasons for the outbreak. The investigation consisted of two components--a description of the epidemic and an investigation of an outbreak at one primary school. Results indicate that during the last 4 months of the year, 757 cases were notified in Cape Town, compared with 144 in the first 8 months. The epidemic affected mainly white and coloured children over 5 years of age (P < 0.001). In contrast, during the period before the epidemic most cases occurred in black children and in those aged less than 1 year (P < 0.001). There was no significant increase in hospitalised cases. Investigation of the outbreak at one school revealed that the attack rate was 7.6% (25/329 children). Immunisation coverage (at least one dose of any measles vaccine) was 91% and vaccine efficacy was estimated to be 79% (95% CI 55-90); it was highest for monovalent measles (100%) and lowest for measles-mumps-rubella (74%). The epidemiology of measles in Cape Town has thus changed as evinced in this epidemic, with an increase in the number of cases occurring in older, previously vaccinated children. The possible reasons for this include both primary and secondary vaccine failure.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between urbanisation and measles control is examined. In urban settings in developing regions measles is a disease of particular importance, since it tends to affect children at a younger age and with greater severity than in rural settings. A further finding in urban areas, especially peri-urban slums, is the lower measles vaccination coverage rates compared with rural regions. Factors identified as determinants of measles vaccination coverage among children under 2 years of age in urban areas include: home delivery; being born outside the urban setting; and length of stay in the city. These factors are probably related to the low socioeconomic status and lack of social integration experienced by new urban immigrants. A number of additional obstacles, such as distance, economic and cultural barriers, and inconvenient clinic hours all prevent parents from gaining easy access to vaccination services. In order to address the problems of measles control in expanding urban settings, a regional approach--with full integration of curative and preventive services--is called for. A more effective use of existing services will probably go a long way towards improving urban vaccination coverage with resultant measles control.

A study was undertaken to ascertain the vaccination coverage of children aged 12-23 months living in Khayelitsha, a peri-urban township outside Cape Town, and to identify factors associated with measles vaccination coverage. A stratified proportional cluster sampling technique was used to select 46 clusters of 10 children each. Three strata were defined according to area of residence. The vaccination status of each child was determined from the preschool card. Usable information was obtained for 432 children; in 75.4% of cases the respondent was the child's mother, and 69.4% of children possessed a preschool card. Measles vaccination coverage was 63.5% (95% confidence interval 58-67%). Three factors had a significant association with incomplete measles vaccination: less than 6 months' residence in the area (odds ratio (OR) 3.1), having been born outside Cape Town (OR 2.5), and home delivery (OR 2.0). The mothers' level of education and children's age were not associated with measles vaccination status. Children in the New Shanty area were identified as a high-risk group. Carers of children in the New Shanty area were the least likely to know of the need for measles vaccination and to be visited by a community health worker. Greater efforts are required to identify high-risk children and areas.

As part of a community health programme, a population-based case-control study was undertaken to determine whether crowding and alcohol are risk factors for tuberculosis in Mamre. Forty notified cases of tuberculosis were compared with 84 randomly selected controls. Cases and controls were group-matched for age and sex. Seventy-six per cent of dwellings had a housing density ratio greater than 100%. There was no association between crowding and tuberculosis, but cases lived in houses that were significantly older than those of controls (odds ratio, 4,8, 95% confidence interval 1,5-15,6). There was an association between alcohol problems in the household and tuberculosis (odds ratio adjusted for employment status 2,2, 95% confidence interval 1,3-3,8). Further studies using refined methods are needed to evaluate the role of crowding in tuberculosis. The need for alcohol intervention campaigns in conjunction with tuberculosis control programmes directed at high-risk groups should be considered.