Maternal mortality in South Africa in 2001: From demographic census to epidemiological investigation

Background

Maternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS.

Methods

The 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes.

Results

After correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15–49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV/AIDS and external causes of deaths. Our regional estimates of MMR were found to be consistent with other findings in the Cape Town area, and with the Agincourt DSS. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. The effect of urbanization was small, and reversed in a multivariate analysis. Higher risks in provinces were not necessarily associated with lower income, lower education or higher proportions of home delivery, but correlated primarily with the prevalence of HIV/AIDS.

Conclusion

Demographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. In the case of South Africa, the level of MMR increased dramatically over the past 10 years, most likely because of HIV/AIDS. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.     

Global infant mortality trends and attributable determinants – an ecological study using data from 192 countries for the period 1990–2011

Background

Infant mortality rate (IMR) is regarded as an important indicator of population health. IMR rates vary substantially with the highest found in sub-Saharan Africa (SSA) compared to the lowest in Europe. Identifying spatial disparities in IMR and quantifying attributable risk factors is essential for policymakers when tailoring time-appropriate interventions at a global, regional, and country level.

Methods

Data for 192 countries were extracted from the World Bank Development Indicator database for the period 1990–2011. Spatial clustering was used to identify significant higher-risk IMR countries. A robust ecological generalized linear negative binomial regression model was used to quantify risk factors and associated decomposition values (Shapley).

Results

Significant reductions were observed in IMR for all of the World Health Organization regions for the period 1990–2011 except for SSA, which indicated a reversal of this trend in the 1990s due to HIV. Significant high-risk clustering of IMR is also indicated in SSA countries and parts of Asia. Maternal mortality (survival), lack of water and sanitation and female education were confirmed as prominent and high attributable risk factors for IMR. Distinct temporal changes in the attributability of these factors were observed, as well as significant heterogeneity with regards to the most attributable factor by region and country.

Conclusions

Our study suggests that maternal mortality is the most prominent attributable risk factor for infant mortality, followed by lack of access to sanitation, lack of access to water, and lower female education. Variation exists across regions and countries with regards to the most attributable factor. Our study also suggests significant underestimation of IMR in regions known for poorer data quality. The results will aid policymakers in re-tailoring time-appropriate interventions to more effectively reduce IMR in line with Millennium Development Goal 4.

     

Study of Women, Infant feeding, and Type 2 diabetes mellitus after GDM pregnancy (SWIFT), a prospective cohort study: methodology and design

Background

Although there are inequalities in child health and survival in the Democratic Republic of Congo (DRC), the influence of distal determinants such as geographic location on children's nutritional status is still unclear. We investigate the impact of geographic location on child nutritional status by mapping the residual net effect of malnutrition while accounting for important risk factors.

Methods

We examine spatial variation in under-five malnutrition with flexible geo-additive semi-parametric mixed model while simultaneously controlling for spatial dependence and possibly nonlinear effects of covariates within a simultaneous, coherent regression framework based on Markov Chain Monte Carlo techniques. Individual data records were constructed for children. Each record represents a child and consists of nutritional status information and a list of covariates. For the 8,992 children born within the last five years before the survey, 3,663 children have information on anthropometric measures. Our novel empirical approach is able to flexibly determine to what extent the substantial spatial pattern of malnutrition is driven by detectable factors such as socioeconomic factors and can be attributable to unmeasured factors such as conflicts, political, environmental and cultural factors.

Results

Although childhood malnutrition was more pronounced in all provinces of the DRC, after accounting for the location's effects, geographic differences were significant: malnutrition was significantly higher in rural areas compared to urban centres and this difference persisted after multiple adjustments. The findings suggest that models of nutritional intervention must be carefully specified with regard to residential location.

Conclusion

Childhood malnutrition is spatially structured and rates remain very high in the provinces that rely on the mining industry and comparable to the level seen in Eastern provinces under conflicts. Even in provinces such as Bas-Congo that produce foods, childhood malnutrition is higher probably because of the economic decision to sell more than the population consumes. Improving maternal and child nutritional status is a prerequisite for achieving MDG 4, to reduce child mortality rate in the DRC.     

Determinants of self rated health and mortality in Russia – are they the same?

Background

Research into Russia's health crisis during the 1990s includes studies of both mortality and self-rated health, assuming that the determinants of the two are the same. In this paper, we tested this assumption, using data from a single study on both outcomes and socioeconomic, lifestyle and psychological predictor variables.

Methods

We analysed data from 7 rounds (1994–2001) of the Russia Longitudinal Monitoring Survey, a panel study of a general population sample (11,482 adults aged over 18 living in households of 2 or more people). Self-rated health was measured on a 5 point scale and dichotomised by combining responses "very poor" and "poor" into poor health. Deaths (n = 782) during a mean follow up of 4.1 years were reported by another household member. Associations between several predictor variables and poor or very poor self-rated health and mortality were measured using logistic regression and Cox proportional hazards analysis respectively.

Results

Poor self-rated health was significantly associated with mortality; hazard ratios, compared with very good, good or average health, were 1.69 (1.36-2.10) in men and 1.74 (1.38-2.20) in women. Low education predicted both mortality and poor self-rated health, but income predicted subjective health more strongly. Smoking doubled the risk of death but was unrelated to subjective wellbeing. Frequent drinkers experienced greater mortality than occasional drinkers, despite reporting better health. In contrast, dissatisfaction with life predicted poor self-rated health, but not mortality.

Conclusion

Differences between the predictors of subjective health and mortality, even though these outcomes were strongly associated, suggest that influences on subjective health are not restricted to serious disease. These findings also suggest the presence of risk factors for relatively sudden deaths in apparently well people, although further research is required. Meanwhile, caution is required when using studies of self-rated health in Russia to understand the determinants of mortality.     

Information systems on human resources for health: a global review

Background

Although access to life-saving treatment for patients infected with HIV in South Africa has improved substantially since 2004, treating all eligible patients (universal access) remains elusive. As the prices of antiretroviral drugs have dropped over the past years, availability of human resources may now be the most important barrier to achieving universal access to HIV treatment in Africa. We quantify the number of HIV health workers (HHWs) required to be added to the current HIV workforce to achieve universal access to HIV treatment in South Africa, under different eligibility criteria.

Methods

We performed a time and motion study in three HIV clinics in a rural, primary care-based HIV treatment program in KwaZulu-Natal, South Africa, to estimate the average time per patient visit for doctors, nurses, and counselors. We estimated the additional number of HHWs needed to achieve universal access to HIV treatment within one year.

Results

For universal access to HIV treatment for all patients with a CD4 cell count of ≤350 cells/μl, an additional 2,200 nurses, 3,800 counselors, and 300 doctors would be required, at additional annual salary cost of 929 million South African rand (ZAR), equivalent to US$ 141 million. For universal treatment (‘treatment as prevention’), an additional 6,000 nurses, 11,000 counselors, and 800 doctors would be required, at an additional annual salary cost of ZAR 2.6 billion (US$ 400 million).

Conclusions

Universal access to HIV treatment for patients with a CD4 cell count of ≤350 cells/μl in South Africa may be affordable, but the number of HHWs available for HIV treatment will need to be substantially increased. Treatment as prevention strategies will require considerable additional financial and human resources commitments.     

Where they live, how they play: Neighborhood greenness and outdoor physical activity among preschoolers

Background

Drug-resistant tuberculosis (DR-TB) is a major public health problem caused by various factors. It is essential to systematically investigate the epidemiological and, in particular, the ecological factors of DR-TB for its prevention and control. Studies of the ecological factors can provide information on etiology, and assist in the effective prevention and control of disease. So it is of great significance for public health to explore the ecological factors of DR-TB, which can provide guidance for formulating regional prevention and control strategies.

Methods

Anti-TB drug resistance data were obtained from the World Health Organization/International Union Against Tuberculosis and Lung Disease (WHO/UNION) Global Project on Anti-Tuberculosis Drug Resistance Surveillance, and data on ecological factors were collected to explore the ecological factors for DR-TB. Partial least square path modeling (PLS-PM), in combination with ordinary least squares (OLS) regression, as well as geographically weighted regression (GWR), were used to build a global and local spatial regression model between the latent synthetic DR-TB factor ("DR-TB") and latent synthetic risk factors.

Results

OLS regression and PLS-PM indicated a significant globally linear spatial association between "DR-TB" and its latent synthetic risk factors. However, the GWR model showed marked spatial variability across the study regions. The "TB Epidemic", "Health Service" and "DOTS (directly-observed treatment strategy) Effect" factors were all positively related to "DR-TB" in most regions of the world, while "Health Expenditure" and "Temperature" factors were negatively related in most areas of the world, and the "Humidity" factor had a negative influence on "DR-TB" in all regions of the world.

Conclusions

In summary, the influences of the latent synthetic risk factors on DR-TB presented spatial variability. We should formulate regional DR-TB monitoring planning and prevention and control strategies, based on the spatial characteristics of the latent synthetic risk factors and spatial variability of the local relationship between DR-TB and latent synthetic risk factors.     

Space-time confounding adjusted determinants of child HIV/TB mortality for large zero-inflated data in rural South Africa

South Africa is experiencing a major burden of HIV/TB. We used longitudinal data from the Agincourt sub-district in rural northeast South Africa over the years 2000 to 2005. A total of 187 HIV/TB deaths were observed among 16,844 children aged 1-5 years coming from 8,863 households. In this paper we used Bayesian models to assess risk factors for child HIV/TB mortality taking into account the presence of spatial correlation. Bayesian zero inflated spatiotemporal models were able to detect hidden patterns within the data. Our main finding was that maternal orphans experienced a threefold greater risk of HIV/TB death compared to those with living mothers (AHR=2.93, 95% CI[1.29;6.93]). Risk factor analyses which adjust for person, place and time provide evidence for policy makers that includes a spatial distribution of risk. Child survival is dependent on the mother's survival; hence programs that promote maternal survival are critical.     

Identifying covariates of population health using extreme bound analysis

Background

The literature is full of lively discussion on the determinants of population health outcomes. However, different papers focus on small and different sets of variables according to their research agenda. Because many of these variables are measures of different aspects of development and are thus correlated, the results for one variable can be sensitive to the inclusion/exclusion of others.

Method

We tested for the robustness of potential predictors of population health using the extreme bounds analysis. Population health was measured by life expectancy at birth and infant mortality rate.

Results

We found that only about half a dozen variables are robust predictors for life expectancy and infant mortality rate. Among them, adolescent fertility rate, improved water sources, and gender equality are the most robust. All institutional variables and environment variables are systematically non-robust predictors of population health.

Conclusion

The results highlight the importance of robustness tests in identifying predictors or potential determinants of population health, and cast doubts on the findings of previous studies that fail to do so.     

Exposing misclassified HIV/AIDS deaths in South Africa

Objective

To quantify the deaths from human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) that are misattributed to other causes in South Africa’s death registration data and to adjust for this bias.

Methods

Deaths in the World Health Organization’s mortality database were distributed among 48 mutually exclusive causes. For each cause, age- and sex-specific global death rates were compared with the average rate among people aged 65–69, 70–74 and 75–79 years to generate “relative” global death rates. Relative rates were also computed for South Africa alone. Differences between global and South African relative death rates were used to identify the causes to which deaths from HIV/AIDS were misattributed in South Africa and quantify the HIV/AIDS deaths misattributed to each. These deaths were then reattributed to HIV/AIDS.

Findings

In South Africa, deaths from HIV/AIDS are often misclassified as being caused by 14 other conditions. Whereas in 1996–2006 deaths attributed to HIV/AIDS accounted for 2.0–2.5% of all registered deaths in South Africa, our analysis shows that the true cause-specific mortality fraction rose from 19% (uncertainty range: 7–28%) to 48% (uncertainty range: 38–50%) over that period. More than 90% of HIV/AIDS deaths were found to have been misattributed to other causes during 1996–2006.

Conclusion

Adjusting for cause of death misclassification, a simple procedure that can be carried out in any country, can improve death registration data and provide empirical estimates of HIV/AIDS deaths that may be useful in assessing estimates from demographic models.     

Interpersonal violence: an important risk factor for disease and injury in South Africa

Background  

Burden of disease estimates for South Africa have highlighted the particularly high rates of injuries related to interpersonal violence compared with other regions of the world, but these figures tell only part of the story. In addition to direct physical injury, violence survivors are at an increased risk of a wide range of psychological and behavioral problems. This study aimed to comprehensively quantify the excess disease burden attributable to exposure to interpersonal violence as a risk factor for disease and injury in South Africa.     

'The girl with her period is the one to hang her head' Reflections on menstrual management among schoolgirls in rural Kenya

Background

Village AIDS committees (VAC) were formed by the Tanzanian government in 2003 to provide HIV education to their communities. However, their potential has not been realised due to their limited knowledge and misconceptions surrounding HIV, which could be addressed through training of VAC members. In an attempt to increase HIV knowledge levels and address common misconceptions amongst the VACs, an HIV curriculum was delivered to members in rural north western Tanzania.

Methods

An evaluation of HIV knowledge was conducted prior to and post-delivery of HIV training sessions, within members of three VACs in Kisesa ward. Quantitative surveys were used with several open-ended questions to identify local misconceptions and evaluate HIV knowledge levels. Short educational training sessions covering HIV transmission, prevention and treatment were conducted, with each VAC using quizzes, role-plays and participatory learning and action tools. Post-training surveys occurred up to seven days after the final training session.

Results

Before the training, "good" HIV knowledge was higher amongst men than women (p = 0.041), and among those with previous HIV education (p = 0.002). The trade-centre had a faster turn-over of VAC members, and proximity to the trade-centre was associated with a shorter time on the committee. Training improved HIV knowledge levels with more members achieving a "good" score in the post-training survey compared with the baseline survey (p = < 0.001). The training programme was popular, with 100% of participants requesting further HIV training in the future and 51.7% requesting training at three-monthly intervals.

Conclusions

In this setting, a series of HIV training sessions for VACs demonstrated encouraging results, with increased HIV knowledge levels following short educational sessions. Further work is required to assess the success of VAC members in disseminating this HIV education to their communities, as well as up-scaling this pilot study to other regions in Tanzania with different misconceptions.     

Global burden of injuries attributable to alcohol consumption in 2004: a novel way of calculating the burden of injuries attributable to alcohol consumption

Background

Alcohol consumption is a major risk factor for injuries; however, international data on this burden are limited. This article presents new methods to quantify the burden of injuries attributable to alcohol consumption and quantifies the number of deaths, potential years of life lost (PYLL), and disability-adjusted life years (DALYs) lost from injuries attributable to alcohol consumption for 2004.

Methods

Data on drinking indicators were obtained from the Comparative Risk Assessment study. Data on mortality, PYLL, and DALYs for injuries were obtained from the World Health Organization. Alcohol-attributable fractions were calculated based on a new risk modeling methodology, which accounts for average and heavy drinking occasions. 95% confidence intervals (CIs) were calculated using a Monte Carlo simulation method.

Results

In 2004, 851,900 (95% CI: 419,400 to 1,282,500) deaths, 19,051,000 (95% CI: 9,767,000 to 28,243,000) PYLL, and 21,688,000 (95% CI: 11,097,000 to 32,385,000) DALYs for people 15?years and older were due to injuries attributable to alcohol consumption. With respect to the total number of deaths, harms to others were responsible for 15.1% of alcohol-attributable injury deaths, 14.5% of alcohol-attributable injury PYLL, and 11.35% of alcohol-attributable injury DALYs. The overall burden of injuries attributable to alcohol consumption corresponds to 17.3% of all injury deaths, 16.7% of all PYLL, and 13.6% of all DALYs caused by injuries, or 1.4% of all deaths, 2.0% of all PYLL, and 1.4% of all DALYs in 2004.

Conclusions

The novel methodology described in this article to calculate the burden of injuries attributable to alcohol consumption improves on previous methodology by more accurately calculating the burden of injuries attributable to one??s own drinking, and for the first time, calculates the burden of injuries attributable to the alcohol consumption of others. The burden of injuries attributable to alcohol consumption is large and is entirely avoidable, and policies and strategies to reduce it are recommended.     

Does the Type of Provider and the Place of Residence Matter in the Utilization of Prenatal Ultrasonography? Evidence from Canada

Background

There has been a proliferation of repeat prenatal ultrasound examinations per pregnancy in many developed countries over the past 20 years, yet few studies have examined the main determinants of the utilization of prenatal ultrasonography.

Objective

The objective of this study was to examine the influence of the type of provider, place of residence and a wide range of socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles.

Methods

The study utilized the data set of the Maternity Experience Survey (MES) conducted by Statistics Canada in 2006. Using an appropriate count data regression model, the study assessed the influence of a wide range of socioeconomic, demographic, maternal risk factors and types of provider on the number of prenatal ultrasounds. The regression model was further extended by interacting providers with provinces to assess the differential influence of types of provider on the number of ultrasounds both across and within provinces.

Results

The results suggested that, in addition to maternal risk factors, the number of ultrasounds was also influenced by the type of healthcare provider and geographic regions. Obstetricians/gynaecologists were likely to recommend more ultrasounds than family physicians, midwives and nurse practitioners. Similarly, birthing women who received their care in Ontario were likely to have more ultrasounds than women who received their prenatal care in other provinces/territories. Additional analysis involving interactions between providers and provinces suggested that the inter-provincial variations were particularly more pronounced for family physicians/general practitioners than for obstetricians/gynaecologists. Similarly, the results for intra-provincial variations suggested that compared with obstetricians/gynaecologists, family physicians/GPs ordered fewer ultrasound examinations in Prince Edward Island, British Columbia, Nova Scotia, Alberta and Newfoundland.

Conclusion

After controlling for a number of socioeconomic and demographic factors, as well as maternal risk factors, it was found that the type of provider and the province of prenatal care were statistically significant determinants of the frequency of use of ultrasounds. Additional analysis involving interactions between providers and provinces indicated wide intra- and inter-provincial variations in the use of prenatal ultrasounds. New policy measures are needed at the provincial and federal government levels to achieve more appropriate use of prenatal ultrasonography.     

HIV in the Middle East and North Africa: priority, culture, and control

Objectives

This study aimed to assess the priority of HIV/AIDS in the Middle East and North Africa region and compare it with other regions. This review examines the social, cultural and religious features of HIV in the region, and considers their influence on perception of risk and approaches to control, such as condom use and antiretroviral therapy.

Methods

We screened a wide range of sources for comprehensive and reliable data; the search of PubMed, ISI Web of Science, ScienceDirect, and grey literature databases were unrestricted by language and year of publication.

Results

Studies of HIV/AIDS in the region are limited, especially studies of social aspects of HIV/AIDS and their relevance for control. Findings suggest low condom use across the region among high-risk groups, and the general population, and low antiretroviral therapy uptake among people with HIV/AIDS.

Conclusions

The review indicates gaps in the literature and needs for more academic engagement and political commitment. Cultural norms have notable implications for HIV control, which are discussed, considering implications for the priority, prevention, treatment, and control of HIV/AIDS.     

The value of effective public tuberculosis treatment: an analysis of opportunity costs associated with multidrug resistant tuberculosis in Latvia

Background

We determine efficient, equitable and mixed efficient-equitable allocations of a male circumcision (MC) intervention reducing female to male HIV transmission in South Africa (SA), as a case study of an efficiency-equity framework for resource allocation in HIV prevention.

Methods

We present a mathematical model developed with epidemiological and cost data from the nine provinces of SA. The hypothetical one-year-long MC intervention with a budget of US$ 10 million targeted adult men 15–49 years of age in SA. The intervention was evaluated according to two criteria: an efficiency criterion, which focused on maximizing the number of HIV infections averted by the intervention, and an equity criterion (defined geographically), which focused on maximizing the chance that each male adult individual had access to the intervention regardless of his province.

Results

A purely efficient intervention would prevent 4,008 HIV infections over a year. In the meantime, a purely equitable intervention would avert 3,198 infections, which represents a 20% reduction in infection outcome as compared to the purely efficient scenario. A half efficient-half equitable scenario would prevent 3,749 infections, that is, a 6% reduction in infection outcome as compared to the purely efficient scenario.

Conclusions

This paper provides a framework for resource allocation in the health sector which incorporates a simple equity metric in addition to efficiency. In the specific context of SA with a MC intervention for the prevention of HIV, incorporation of geographical equity only slightly reduces the overall efficiency of the intervention.     

Rapid assessment response (RAR) study: drug use and health risk - Pretoria, South Africa

Background

Within a ten year period South Africa has developed a substantial illicit drug market. Data on HIV risk among drug using populations clearly indicate high levels of HIV risk behaviour due to the sharing of injecting equipment and/or drug-related unprotected sex. While there is international evidence on and experience with adequate responses, limited responses addressing drug use and drug-use-related HIV and other health risks are witnessed in South Africa. This study aimed to explore the emerging problem of drug-related HIV transmission and to stimulate the development of adequate health services for the drug users, by linking international expertise and local research.

Methods

A Rapid Assessment and Response (RAR) methodology was adopted for the study. For individual and focus group interviews a semi-structured questionnaire was utilised that addressed key issues. Interviews were conducted with a total of 84 key informant (KI) participants, 63 drug user KI participants (49 males, 14 females) and 21 KI service providers (8 male, 13 female).

Results and Discussion

Adverse living conditions and poor education levels were cited as making access to treatment harder, especially for those living in disadvantaged areas. Heroin was found to be the substance most available and used in a problematic way within the Pretoria area. Participants were not fully aware of the concrete health risks involved in drug use, and the vague ideas held appear not to allow for concrete measures to protect themselves. Knowledge with regards to substance related HIV/AIDS transmission is not yet widespread, with some information sources disseminating incorrect or unspecific information.

Conclusions

The implementation of pragmatic harm-reduction and other evidence-based public health care policies that are designed to reduce the harmful consequences associated with substance use and HIV/AIDS should be considered. HIV testing and treatment services also need to be made available in places accessed by drug users.     

Critically examining diversity in end-of-life family caregiving: implications for equitable caregiver support and Canada’s Compassionate Care Benefit

Background

Mental health is of special importance regarding socioeconomic inequalities in health. On the one hand, mental health status mediates the relationship between economic inequality and health; on the other hand, mental health as an "end state" is affected by social factors and socioeconomic inequality. In spite of this, in examining socioeconomic inequalities in health, mental health has attracted less attention than physical health. As a first attempt in Iran, the objectives of this paper were to measure socioeconomic inequality in mental health, and then to untangle and quantify the contributions of potential determinants of mental health to the measured socioeconomic inequality.

Methods

In a cross-sectional observational study, mental health data were taken from an Urban Health Equity Assessment and Response Tool (Urban HEART) survey, conducted on 22 300 Tehran households in 2007 and covering people aged 15 and above. Principal component analysis was used to measure the economic status of households. As a measure of socioeconomic inequality, a concentration index of mental health was applied and decomposed into its determinants.

Results

The overall concentration index of mental health in Tehran was -0.0673 (95% CI = -0.070 - -0.057). Decomposition of the concentration index revealed that economic status made the largest contribution (44.7%) to socioeconomic inequality in mental health. Educational status (13.4%), age group (13.1%), district of residence (12.5%) and employment status (6.5%) also proved further important contributors to the inequality.

Conclusions

Socioeconomic inequalities exist in mental health status in Iran's capital, Tehran. Since the root of this avoidable inequality is in sectors outside the health system, a holistic mental health policy approach which includes social and economic determinants should be adopted to redress the inequitable distribution of mental health.     

Geoadditive models to assess spatial variation of HIV infections among women in Local communities of Durban,South Africa

Background  

The severity of the HIV/AIDS epidemic in South Africa varies between and within provinces, with differences noted even at the suburban scale. We investigated the geographical variability of HIV infection in rural areas of the eThekwini Metropolitan Municipality in KwaZulu-Natal province, South Africa.     

Wealth status and risky sexual behaviour in Ghana and Kenya

Background

Emerging evidence seems to suggest that there is some association between individual socioeconomic status and sexual risk-taking behaviour in sub-Saharan Africa. A number of broad associations have emerged, among them, positive, neutral and negative relationships between wealth status and sexual risk-taking behaviour. Reduction in the number of sex partners as a behavioural change has been advocated as an important tool in HIV prevention, and affecting such a change requires an understanding of some of the factors that can influence social behaviour, interactions and activities of subpopulations.

Objectives

To further explore the determinants of sexual risk-taking behaviour (individuals having multiple sex partners), especially the effects that variations in household wealth status, gender and different subpopulation groups have on this behaviour.

Methods

The relationship between wealth status and sexual risk-taking behaviour in the context of HIV/AIDS infection in Ghana and Kenya was assessed using raw data from the 2003 Demographic and Health Surveys of each country. Wealth quintiles were used as a proxy for economic status, while non-marital and non-cohabiting sexual partnerships were considered indicators for risky sexual behaviour.

Results

For females, there appears to be an increasing probability of sexual risk taking by wealth status in Kenya, while, in Ghana, an inverted J-shaped relationship is shown between wealth status and sexual risk taking. When controlled for other variables, the relationship between wealth status and sexual risk-taking behaviour disappears for females in the two countries. For males, there is no clearly discernable pattern between wealth status and sexual risk-taking behaviour in Ghana, while there is a general trend towards increasing sexual risk-taking behaviour by wealth status in Kenya. For Ghana, the highest probabilities are among the highest and the middle wealth quintiles; in Kenya, high probabilities were found for the two highest wealth quintiles. Controlling for the effects of other factors, the pattern for Ghana is further blurred (not statistically significant), but the relationship continues to show in the case of Kenya, and is significant for the highest quintile. In general, for both Ghana and Kenya, men in the highest wealth quintile were found to be more likely to have multiple sexual partners than the other groups.

Conclusion

The changing phases of HIV infection indicate that it is no longer poverty that drives the epidemic. Rather, it is wealth and a number of other sociodemographic factors that explain sexual risk-taking behaviour that puts people at risk. Understanding local specific factors that predispose individuals towards sexual risk taking could help to expand the range of information and services needed to combat the HIV pandemic.     

Low haemoglobin predicts early mortality among adults starting antiretroviral therapy in an HIV care programme in South Africa: a cohort study

Background  

Antiretroviral therapy (ART) has dramatically reduced morbidity and mortality among people with HIV infection; however, mortality after the start of ART is high in resource-limited settings. We investigated risk factors for mortality among adults starting ART in a multi-clinic community programme in South Africa.