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BackgroundA randomized controlled trial (RCT) has shown that male circumcision (MC) reduces sexual transmission of HIV from women to men by 60% (32%-76%; 95% CI) offering an intervention of proven efficacy for reducing the sexual spread of HIV. We explore the implications of this finding for the promotion of MC as a public health intervention to control HIV in sub-Saharan Africa.Methods and findingsUsing dynamical simulation models we consider the impact of MC on the relative prevalence of HIV in men and women and in circumcised and uncircumcised men. Using country level data on HIV prevalence and MC, we estimate the impact of increasing MC coverage on HIV incidence, HIV prevalence, and HIV-related deaths over the next ten, twenty, and thirty years in sub-Saharan Africa. Assuming that full coverage of MC is achieved over the next ten years, we consider three scenarios in which the reduction in transmission is given by the best estimate and the upper and lower 95% confidence limits of the reduction in transmission observed in the RCT. MC could avert 2.0 (1.1-3.8) million new HIV infections and 0.3 (0.1-0.5) million deaths over the next ten years in sub-Saharan Africa. In the ten years after that, it could avert a further 3.7 (1.9-7.5) million new HIV infections and 2.7 (1.5-5.3) million deaths, with about one quarter of all the incident cases prevented and the deaths averted occurring in South Africa. We show that a) MC will increase the proportion of infected people who are women from about 52% to 58%; b) where there is homogenous mixing but not all men are circumcised, the prevalence of infection in circumcised men is likely to be about 80% of that in uncircumcised men; c) MC is equivalent to an intervention, such as a vaccine or increased condom use, that reduces transmission in both directions by 37%.ConclusionsThis analysis is based on the result of just one RCT, but if the results of that trial are confirmed we suggest that MC could substantially reduce the burden of HIV in Africa, especially in southern Africa where the prevalence of MC is low and the prevalence of HIV is high. While the protective benefit to HIV-negative men will be immediate, the full impact of MC on HIV-related illness and death will only be apparent in ten to twenty years.

User fees are used to recover costs and discourage unnecessary attendance at primary care clinics in many developing countries. In South Africa, user fees for children aged under 6 years and pregnant women were removed in 1994, and in 1997 all user fees at all primary health care clinics were abolished. The intention of these policy changes was to improve access to health services for previously disadvantaged communities. We investigated the impact of these changes on clinic attendance patterns in Hlabisa health district. Average quarterly new registrations and total attendances for preventive services (antenatal care, immunization, growth monitoring) and curative services (treatment of ailments) at a mobile primary health care unit were studied from 1992 to 1998. Regression analysis was undertaken to assess whether trends were statistically significant. There was a sustained increase in new registrations (P = 0.0001) and total attendances (P = 0.0001) for curative services, and a fall in new registrations (P = 0.01) and total attendances for immunization and growth monitoring (P = 0.0002) over the study period. The upturn in demand for curative services started at the time of the first policy change. The decreases in antenatal registrations (P = 0.07) and attendances (P = 0.09) were not statistically significant. The number of new registrations for immunization and growth monitoring increased following the first policy change but declined thereafter. We found no evidence that the second policy change influenced underlying trends. The removal of user fees improved access to curative services but this may have happened at the expense of some preventive services. Governments should remain vigilant about the effects of new health policies in order to ensure that objectives are being met.

The modes of transmission model has been widely used to help decision-makers target measures for preventing human immunodeficiency virus (HIV) infection. The model estimates the number of new HIV infections that will be acquired over the ensuing year by individuals in identified risk groups in a given population using data on the size of the groups, the aggregate risk behaviour in each group, the current prevalence of HIV infection among the sexual or injecting drug partners of individuals in each group, and the probability of HIV transmission associated with different risk behaviours. The strength of the model is its simplicity, which enables data from a variety of sources to be synthesized, resulting in better characterization of HIV epidemics in some settings. However, concerns have been raised about the assumptions underlying the model structure, about limitations in the data available for deriving input parameters and about interpretation and communication of the model results. The aim of this review was to improve the use of the model by reassessing its paradigm, structure and data requirements. We identified key questions to be asked when conducting an analysis and when interpreting the model results and make recommendations for strengthening the model's application in the future. Le modele de modes de transmission a ete largement utilise pour aider les decideurs a cibler les mesures empechant l'infection par le virus d'immunodeficience humaine (VIH). Le modete estime le nombre de nouvelles infections par leVIH au cours de l'annee suivante, contractees par des individus appartenant aux groupes a risque identifies d'une population donnee, en utilisant des donnees sur la taille des groupes, le comportement a risque global de chaque groupe, la prevalence actuelle de l'infection par le VIH entre partenaires sexuels ou d'injection de drogues de chaque groupe, et la probabilite de transmission du VIH associee aux divers comportements a risque. La force du modele reside dans sa simplicite, permettant de synthetiser des donnees provenant d'une variete de sources, ce qui donne une meilleure caracterisation de I'epidemie du VIH dans certains contextes. Toutefois, des problemes ont ete releves concernant les hypotheses qui sous-tendent la structure du modele, les limites des donnees disponibles pour obtenir les parametres d'entree, ainsi que l'interpretation et la communication des resultats du modele. L'objectif de la presente etude etait d'ameliorer l'utilisation du modele en reevaluant son paradigme, sa structure et ses exigences en termes de donnees. Nous avons identifie les principales questions a poser lors de l'analyse et de l'interpretation des resultats du modele, et nous faisons des recommandations visant a renforcer l'application du modele a l'avenir. El modelo de los modos de transmision se ha empteado de manera cjeneralizada para ayudar a los responsables de la toma de decisiones a dirigir las medidas para la prevencion de la infeccion por el virus de la inmunodehciencia humana (VIH). El modelo calcula el numero de infecciones porVIH nuevas adquiridas durante el ano subsiguiente por individuos en grupos de riesgo identificados en una poblacion dada empleando datos acerca del tamano de los grupos, el comportamiento de riescjo conjunto en cada grupo, la prevalencia actual de la infeccion por VIH entre las parejas sexuales o personas que comparten jeringuillas para el consumo de drogas de los individuos de cada grupo y la probabilidad de trasmitir elVIH asociada a los diferentes comportamientos de riesgo. El punto fuerte del modelo es su sencillez, que permite sintetizar datos de fuentes variadas, de lo que resulta una caracterizacion mas exacta de la epidemia del VIM en algunos entornos. No obstante, han surgido dudas acerca de las suposiciones que subyacen a la estructura del modelo, las limitaciones de los datos disponibles para derivar de ellos parametros de entrada y la interpretacion y comunicacion de los resultados dei modelo. El objeto de este examen fue el de mejorar el uso del modelo volviendo a examinar su paradigma, su estructura y los requisitos de los datos. Identificamos los puntos clave que deben cuestionarse durante la realizacion de un analisis y la interpretacion de los resultados dei modelo y formulamos recomendaciones para consolidar la aplicacion del modelo en el futuro., Introduction In the current global financial climate, it is more important than ever that effective resource allocation for the control of human immunodeficiency virus (HIV) infection is based on informed, [...]

We assessed the impact of HIV-1 on malaria in the sub-Saharan African population. Relative risks for malaria in HIV-infected persons, derived from literature review, were applied to the HIV-infected population [...]

Sound policy and program decisions require timely information based on valid and relevant measures. Recent findings suggest that despite the availability of effective and affordable guidelines for the management of sick children in first-level health facilities in developing countries, the quality and coverage of these services remains low. We report on the development and evaluation of a set of summary indices reflecting the quality of care received by sick children in first-level facilities. The indices were first developed through a consultative process to achieve face validity by involving technical experts and policymakers. The definition of evaluation measures for many public health programs stops at this point. We added a second phase in which standard statistical techniques were used to evaluate the content and construct validity of the indices and their reliability, drawing on data sets from the multi-country evaluation of integrated management of childhood illness (MCE) in Brazil, Tanzania and Uganda. The statistical evaluation identified important conceptual errors in the indices arising from the theory-driven expert review. The experts had combined items into inappropriate indicators resulting in summary indices that were difficult to interpret and had limited validity for program decision making. We propose a revised set of summary indices for the measurement of child health care in developing countries that is supported by both expert and statistical reviews and that led to similar programmatic insights across the three countries. We advocate increased cross-disciplinary research within public health to improve measurement approaches. Child survival policymakers, program planners and implementers can use these tools to improve their monitoring and so increase the health impact of investments in health facility care. Keywords: Child health care; Integrated management of childhood illnesses (IMCI); Measurement; Brazil; Tanzania; Uganda

The impact of prevalent and incident HSV-2 infection on the incidence of HIV-1 infection in a cohort of female commercial sex workers in KwaZulu-Natal, South Africa is investigated. The incident HSV-2 infection increases the risk of HIV-1 infection, the effect wanes with time since infection and the effect is significantly greater for men than it is for women.

Objective The objective of this study was to assess the effect of Integrated Management of Childhood Illness (IMCI) case management training on the use of antimicrobial drugs among health-care workers treating young children at first-level facilities. Antimicrobial drugs are an essential child-survival intervention. Ensuring that children younger than five who need these drugs receive them promptly and correctly can save their lives. Prescribing these drugs only when necessary and ensuring that those who receive them complete the full course can slow the development of antimicrobial resistance. Methods Data collected through observation-based surveys in randomly selected first-level health facilities in Brazil, Uganda and the United Republic of Tanzania were statistically analysed. The surveys were carried out as part of the multi-country evaluation of IMCI effectiveness, cost and impact (MCE). Findings Results from three MCE sites show that children receiving care from health workers trained in IMCI are significantly more likely to receive correct prescriptions for antimicrobial drugs than those receiving care from workers not trained in IMCI. They are also more likely to receive the first dose of the drug before leaving the health facility, to have their caregiver advised how to administer the drug, and to have caregivers who are able to describe correctly how to give the drug at home as they leave the health facility. Conclusions IMCI case management training is an effective intervention to improve the rational use of antimicrobial drugs for sick children visiting first-level health facilities in low-income and middle-income countries. Keywords Anti-bacterial agents/administration and dosage; Antimalarials/administration and dosage; Prescriptions, Drug/standards: Child; Caregivers/education Community health aides/education; Delivery of health care, Integrated/utilization; Primary health care; Ambulatory care facilities; Guidelines; Brazil; United Republic of Tanzania; Uganda (source: MESH, NLM). Mots cles Antibi otiques/administration et posologie; Antipaludique/administration et posologie; Ordonnance medicale medicament/normes; Enfant; Soignant/enseignement; Auxiliaire sante publique/enseignement; Distribution integree soins/utilisation; Programme soins courants; Services soins ambulatoires; Lignes directrices; Bresil; Republique-Unie de Tanzanie; Ouganda (source: MeSH, INSERM). Palabras clave Antibioticos/administracion y dosificacion; Antimalaricos/administracion y dosificacion; Prescripcion de medicamentos/normas; Nino; Cuidadores/educacion; Auxiliares de salud comunitaria/educacion; Entrega integrada de atencion de salud/utilizacion; Atencion primaria de salud; Instituciones de atencion ambulatoria; Pautas; Brasil; Republica Unida de Tanzania; Uganda (fuente: DeCS, BIREME). [TEXT NOT REPRODUCIBLE IN ASCII.] Bulletin of the World Health Organization 2004;82:509-515., Voir page 513 le resume en francais. En la pagina 514 figura un resumen en espanol. [TEXT NOT REPRODUCIBLE IN ASCII.] Introduction Despite advances over the past few decades made [...]

In 1999, 17% of adult women in Hlabisa, KwaZulu-Natal, South Africa, tested positive for HIV. Among 22-year-old women, 24% tested positive. This indicates that the HIV epidemic is still growing in South Africa.

About one-fourth of the women living in some rural parts of South Africa may be HIV-positive, according to a study of 2,013 pregnant women who visited a prenatal clinic in Hlabisa in 1997. Twenty-six percent were HIV-positive, and among women between 20 and 24 years old, 34% were HIV-positive.