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Background: Treatment of sexually-transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. We aimed to assess the effect of these interventions on incidence of HIV-1 and other sexually-transmitted infections., Methods: We randomly allocated all adults living in 18 communities in rural Uganda to receive behavioural interventions alone (group A), behavioural and STI interventions (group B), or routine government health services and community development activities (group C). The primary outcome was HIV-1 incidence. Secondary outcomes were incidence of herpes simplex virus type 2 (HSV2) and active syphilis and prevalence of gonorrhoea, chlamydia, reported genital ulcers, reported genital discharge, and markers of behavioural change. Analysis was per protocol., Findings: Compared with group C, the incidence rate ratio of HIV-1 was 0.94 (0.60-1.45, p=0.72) in group A and 1.00 (0.63-1.58, p=0.98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1.12 (95% CI 0.99-1.25) in group A and 1.27 (1.02-1.56) in group B. Incidence of HSV2 was lower in group A than in group C (incidence rate ratio 0.65, 0.53-0.80) and incidence of active syphilis for high rapid plasma reagent test titre and prevalence of gonorrhoea were both lower in group B than in group C (active syphilis incidence rate ratio, 0.52, 0.27-0.98; gonorrhoea prevalence ratio, 0.25, 0.10-0.64)., Interpretation: The interventions we used were insufficient to reduce HIV-1 incidence in rural Uganda, where secular changes are occurring. More effective STI and behavioural interventions need to be developed for HIV control in mature epidemics.

Background: To evaluate HIV-1 incidence among adults and socio-demographic risk factors in a rural population in Uganda, a prospective cohort study was carried out., Methods: All consenting adult residents in a cluster of 15 neighbouring villages of the Masaka District of south-west Uganda have been participating in annual socio-demographic and serological surveys since November 1989. Those who had a negative serostatus when they were first tested and had at least one serostatus assessment during the 4 years of follow-up (1990-1994) have been evaluated for HIV-1 seroconversion. Incidence rates have been calculated per 1000 person-years of observation and socio-demographic characteristics assessed for association with recent seroconversion., Results: At the baseline survey, of 4175 adults with assessable serostatus (79% of all censused adults), 342 (8.2%) were seropositive. During 12588.2 person-years of follow-up 89 seroconversions were identified corresponding to an incidence rate of 7.1 (95% CI: 5.6-8.5). Overall rates were highest in females aged 20-24 years (15.2) and in males aged 20-44 years (11.6). There was a significant interaction between age and sex; the ratio of the rate in females to that in males decreased from 3.3:1 to 0.5:1 with increasing age. Rates for males aged > or = 20 years were four times higher than those for younger males. Other significant socio-demographic correlates with risk included not belonging to the majority tribe, non-Muslim religion and length of stay on compound of less than 10 years. Incidence rates did not show any clear trends with time., Conclusion: These findings further emphasize the need for targeted interventions.

All adult residents (aged 13 years or more) of 154 randomly selected households in 3 urban and one semi-rural ward of a town in South West Uganda on the trans-African highway were invited to participate in a socio-demographic, behavioural and medical survey. An unambiguous HIV-1 serostatus was obtained for 389 (80%) adults. The overall sero-prevalence rate was 40.4%; all age groups except males aged 13-19 years had infection rates in excess of 20%. Rates above 50% were found in females aged 20-34 years and males aged 35-44 years. For females seropositivity rates increased steeply with increasing numbers of lifetime sexual partners up to a maximum of 3; in contrast, for males rates continued to increase with increasing numbers of partners. The risk of infection amongst those with only one reported partner was 17%. A high proportion of males (14%) and females (18%) reported a history of genital ulcer disease within the previous 6 months; on examination genital lesions were observed in 12% of all participants. Interventions with a single focus are unlikely to have much impact in such a situation and a strategy is suggested which includes 3 components, namely improved STD control, a reduction in partner change and an increase in condom utilization.

We conducted a prospective cohort study to determine the post-natal incidence of and possible transmission routes for HIV-I infection in rural Ugandan children. The cohort consisted of the population of a cluster of 15 villages in Masaka District, south-west Uganda, and was enrolled in 1989-1990 through a demographic and serological survey. During the period 1991-1993 the population was resurveyed annually. A total of 5492 children aged 0-12 years were enrolled; of these, 41 (0.7%) were seropositive infants. A total of 3941 (72%) children were HIV-negative on enrolment and had at least one follow-up specimen. During 8596 person-years of observation only I seroconversion was observed, an incidence rate of 0.12 (95% CI 0.00-0.35) per 1000 years of observation. The transmission of HIV was most probably through breast milk. The case corresponds to a rate of 1.1 per 1000 in households with one or more HIV-positive adults (874 years of observation); no incident case was observed in households with only seronegative adults (6423 years of observation). Thus, HIV infection among children aged 0-12 years in this population is virtually exclusively the result of mother-to-child transmission. No infections were observed attributable to parenteral exposure, non-sexual casual or household contact, or insects.

Objective: To assess the trend in HIV-1 seroprevalence in an adult population in Uganda., Design: An observational cohort study with four year follow up., Setting: A cluster of 15 villages in rural Uganda., Subjects: All residents of the 15 villages--about 10,000 people., Main Outcome Measure: Prevalence of HIV-1 infection as assessed by enzyme immunoassay., Results: During the five year period the overall standardised seroprevalence of HIV-1 showed little change; 8.2% in 1990, 7.6% in 1994. Among males aged 13-24 years the prevalence decreased from 3.4% to 1.0% (P for trend < 0.001); among females of the same age the corresponding values were 9.9% and 7.3%. The decrease was greatest in males aged 20-24 years and females aged 13-19 years., Conclusion: This is the first report of a decline in HIV-1 prevalence among young adults in a general population in sub-Saharan Africa with high overall HIV-1 prevalence. It is too early to conclude that the epidemic in this population is in decline, but the results of this study should be reason for some cautious optimism and encourage the vigorous pursuit of AIDS control measures.

Serological studies on 7796 rural Ugandans showed 377 (4.8%) were HIV-1 antibody-positive, of whom 343 (8.2%) were adults, ten (0.4%) 5-12-year-olds and 24 (1.7%) under 5 years of age. Serological tests done on 18 mothers of the under-5s showed 17 to be HIV-1-positive. One mother was persistently negative. Her child had a history of multiple injections. Structured interviews with parents or guardians of the ten HIV-1-seropositive children aged 5-12 years to determine possible sources of exposure revealed that six were vertically infected and that blood transfusion, injections and sexual exposure each accounted for one case. It was not possible to identify a source of exposure in one instance. There was no evidence that casual household contact or scarifications played a role in the transmission of HIV-1 in children in this population. Our data show that in this rural population HIV-1 seropositivity in children is mainly associated with seropositivity in the mothers and that HIV-1 infection in children aged between 5 and 12 years is rare.

The mortality in 15 villages in South-West Uganda was studied in relation to HIV infection. After a population census, serum samples were tested for antibodies to HIV-1. Deaths were ascertained over 2 years. Unequivocal HIV-1 serology results were available for 9389 individuals. The prevalence of infection was 4.8% for all ages and 8.2% for adults (aged 13 or more). 198 deaths were recorded during 15,725 person years of observation. Mortality among seronegative adults was 7.7 per 1000 and among seropositive adults 115.9 per 1000. The excess annual death rate associated with HIV-1 infection was 5.3 per 1000 and in adults 7.9 per 1000. Highest excess mortality was 16.9 per 1000 in the age group 25-34. Among adults, half of all deaths and among those aged 13-44 over 80% of deaths were attributable to HIV-1 infection. These results show the strong impact that HIV-1 infection is having on mortality in a rural area of Uganda where the overall HIV-1 adult prevalence rate is below 10%--a rate lower than in many other parts of East Africa.

Objective: To study in depth sexual history and sexual behaviour variables as risk factors for HIV-1 infection in a rural Ugandan population., Methods: Following a socioeconomic and serological survey of a rural population in Masaka District, south-west Uganda, 233 randomly selected HIV-1-positive cases and 233 negative controls matched on age and village of residence, were invited in October 1990 to participate in a case-control study. A total of 132 cases and 161 controls attended for in-depth investigation including an interview about sexual behaviour., Results: The factor most strongly associated with increased risk of infection was a greater number of lifetime sexual partners, with odds ratios (OR) of 2.1 and 4.9 for those reporting 4-10 and 11 or more partners, respectively, compared with those reporting less than four partners. Having only one sexual partner did not provide complete protection, a total of seven (one male, six female) subjects reporting only one sexual partner were HIV-1-positive. Other significant factors were a history of genital ulcers [OR, 2.9; 95% confidence intervals (CI), 1.0-9.1) and not being a Muslim (OR, 5.4; 95% CI, 1.8-16.5) suggesting a possible protective effect of circumcision. There was a suggestion that those who married within the last 7 years (OR, 2.4; 95% CI, 0.9-6.1) and men exposed to menstrual blood (OR, 5.7; 95% CI, 0.7-49.8) were at an increased risk of HIV-1 infection., Conclusions: These results confirm the predominant role of sexual behaviour in the HIV-1 epidemic. Of particular concern is the observation of HIV-1 infection among those reporting only one partner. Where HIV-1 infection is widely distributed in the general population, risk reduction strategies should, in addition to the promotion of partner reduction, place strong emphasis on safe-sex techniques.

Objective: To determine the incidence of HIV-1 infection and HIV-1-associated mortality in a rural Ugandan population., Design: A prospective cohort study., Methods: A cohort consisting of the population (de jure census 9820) of a cluster of 15 villages in Masaka District, south-west Uganda was enrolled between 1989 and 1990 through a demographic and medical survey. The HIV-1 seroprevalence rate was 4.8% for all ages combined and 8.2% for those aged 13 years or more. The survey was repeated after 1 year., Results: The 1-year HIV-1 incidence rate among adults was 1% [9.2 per 1000 person-years of observation; 95% confidence interval (CI), 5.5-12.9). A total of 84 deaths were observed. In adults, half of all deaths (31 out of 60) were in HIV-1-seropositive individuals. The age-adjusted overall mortality rate ratio for HIV-positive adults compared with HIV-negatives was 20.8 (95% CI, 12.0-35.7). In the 13-44 age group the corresponding rate ratios for men, women and both sexes combined were 16.3, 108.9 and 58.7, respectively. The HIV-attributable mortality fractions, i.e., the proportion of deaths that would have been avoided in the absence of HIV, were 44, 50 and 89% for adult men, adult women and adults aged 25-34 years (both sexes combined), respectively. The 1-year progression to death among HIV-1-seropositive adults was 10.3%., Conclusion: These results demonstrate the profound impact that the HIV-1 epidemic has on adult mortality in a rural area of Uganda where the HIV-1 prevalence and incidence rates in adults are 8 and 1%, respectively.

Objective: To determine sociodemographic risk factors associated with HIV-1 infection in a rural Ugandan population., Design: A population-based survey., Methods: All adult residents (aged > or = 13 years) in a cluster of 15 neighbouring villages of the Masaka District of south-west Uganda were invited to participate in a sociodemographic and serological survey. Questions relating to sexual behaviour were asked separately in an accompanying case-control study. Socioeconomic data and an unambiguous HIV-1 serostatus were obtained by house-to-house survey for 3809 (72%) of the adult population. The association between serostatus and the following variables were analysed: age, sex, marital status, tribe, religion, education, occupational group, place and frequency of travel and recent history of sexually transmitted disease., Results: Women aged 13-21 years were at a much higher risk than men of the same age [odds ratio (OR), 8.6; 95% confidence interval (CI), 3.0-24.5]. Married people aged < 25 years were twice as likely to be infected as those who were not currently married (OR, 2.3; 95% CI, 1.5-3.7). In contrast, in those aged > or = 25 years, women were at a lower risk than men (OR, 0.72; 95% CI, 0.52-0.98) as were those who were currently married compared with those who were not (OR, 0.47; 95% CI, 0.34-0.64). In both age groups those with a history of a recent genital ulcer were approximately three times more likely to be infected. Muslims had lower risks than non-Muslims (OR, 0.58 for both age groups)., Conclusions: The people most at risk of HIV-1 infection in this rural Ugandan population are young married women who had, presumably, commenced sexual activity recently.

Objectives: The AIDS epidemic in sub-Saharan Africa affects whole communities, adding to the already high burden of morbidity. Reports of AIDS cases are usually from hospital attenders, often diagnosed using the World Health Organization (WHO) clinical case definition. Little is known about the extent of HIV-associated morbidity in the general population. The objectives of this study were to describe the prevalence of (1) markers of general morbidity and (2) the criteria of the WHO clinical case definition for AIDS and (3) to determine the association between these markers and HIV-1 serostatus in a rural Ugandan community., Methods: A survey was conducted among the adult population (aged > or = 13 years) of 15 neighbouring villages in Masaka District, south-west Uganda. The survey included medical history, physical examination and testing for HIV-1 antibodies., Results: The HIV-1 seroprevalence among 4175 out of 5278 (79%) eligible adults was 8.2%. Current health problems were reported by 57.6% of adults, with increased rates in HIV-1-positive subjects, women and older people. Five of the 10 most common complaints showed significant associations with HIV-1 status, as did reported genital ulcer and vaginal discharge. The crude HIV-1 attributable disease burden in the population was 1.2% for current illness, 4.3% for previous serious illness and 9.9% for illness leading to hospital admission. Overall, 11 (3.3%) of the HIV-1-positive and nine (0.2%) of the HIV-1-negative subjects had AIDS as defined by the clinical case definition. The positive and negative predictive values and specificity were 55.0, 92.0%, and 99.8%, respectively., Conclusions: Against a background of high general morbidity, we observed a relatively small population attribution of HIV-1-associated morbidity. The results indicate that the clinical AIDS case definition may provide a useful tool for population surveys.

Background: In general, information on the causes of adult deaths in developing countries is scarce. More specifically, relatively little is known about the effect of HIV-1 associated disease on adult mortality in general populations. In this study we have used a verbal autopsy technique to ascertain whether adult deaths were associated with HIV-1 in a rural population with a prevalence of HIV-1 infection of 8%, and used HIV-1 antibody status to validate the verbal autopsy findings.Methods: All adult deaths in the population cohort that occurred between December 1990 and November 1993 were identified through a monthly death registration system. Approximately 2 months after death, a relative of the deceased was interviewed by a trained nurse, and questionnaires were assessed by at least two independent clinicians; all were unaware of the HIV serostatus of the deceased.Results: A total of 155 adult deaths was assessed, i.e. 53% of all recorded adult deaths. Of those assessed half were HIV-1 positive. In all 47% of deaths were classified as HIV-related. The overall specificity and positive predictive value of the verbal autopsy tool were both 92%; in those aged 13-44 years (83 adults) the corresponding values were 85% and 95% respectively. The verbal autopsy estimated HIV-1 attributable mortality fraction was similar to the calculated fraction based on prospective data.Conclusions: The results of this study suggest that verbal autopsy studies may assist in providing data on HIV-associated mortality in general populations and may be useful as surveillance tools. [ABSTRACT FROM AUTHOR]