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As part of a large IEC (Information, Education and Communication)/STD intervention trial, a 19-lesson, comprehensive school-based AIDS education programme was implemented and evaluated in 50 primary and 16 secondary schools in 12 parishes of Masaka District, Uganda. A series of three teacher-training and evaluation workshops spread over a year was held in each parish, between which teachers implemented the programme in the classroom. One hundred and forty-eight teachers were trained and about 3,500 students were subsequently exposed to the programme. Both teachers and students responded positively, which suggests that this type of programme has much to offer young people who attend school. However, some problems were encountered: language, programme content, community resistance to teaching about condoms, and several practical issues. Proposed solutions include flexibility with the English language policy, alternative approaches to role play activities, targeting influential individuals with information about the need for young people to learn about safer sex, and a parallel community-based IEC programme to facilitate community acceptance of the need for the programme. In addition, implementation may be incomplete unless comprehensive AIDS education is fully incorporated into the curriculum, and properly examined. These findings are placed in the context of other life skills/AIDS education programmes being introduced both in Uganda and elsewhere in Africa. [ABSTRACT FROM AUTHOR]

Kengeya-Kayondo J-F (MRC [UK] Programme on AIDS in Uganda, Uganda Virus Research Institute, PO Box 49, Entebbe, Uganda), Kamali A, Nunn A J, Ruberantwari A, Wagner H-U H and Mulder D W. Incidence of HIV-1 Infection in adults and sodo-demographic characteristics of seroconverters in a rural population in Uganda: 1990–1994. International Journal of Epidemiology 1996; 25: 1077–1082.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 seroJogical 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 seroposltive. During 12 588.2 person-years of follow-up 89 seroconversions were identified corresponding to an incidence rate of 7.1 (95% Ct : 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 ≥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. [ABSTRACT FROM PUBLISHER]

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]

Objective: The objective of this study is to estimate the annual costs of information, education, and communication (IEC), both community- and school-based; strengthened public and private sexually transmitted infections treatment; condom social marketing (CSM); and voluntary counseling and testing (VCT) implemented in Masaka, Uganda, over 4 years, and to explore how unit costs change with varying population use/uptake., Study: Total economic provider's costs and intervention outputs were collected annually to estimate annual unit costs between 1996 and 1999., Results: In early intervention years, uptake of all activities grew dramatically and continued to grow for public STI treatment, CSM, and VCT. Attendance at IEC performances started to drop in year 4. Unit costs dropped rapidly with increasing uptake of and participation in interventions., Conclusions: When implementing long-term community-based interventions, it is important to take into account that it takes time for communities to scale up their participation, since this can lead to large variations in unit costs.

Malaria claims over one million lives a year in some of the poorest countries of the world. Affected populations and governments cannot afford to pay for expensive new therapies. Most antimalarial treatments are purchased from local shops and administered in the home. These factors make for a complex set of requirements for any new treatment for malaria if a substantial reduction in mortality is ever to be achieved. Thankfully there are several treatments being developed, mostly within public-private partnerships. Typically, the goal of public-private partnerships is the granting of a product license, so work plans end after phase III trials. As these drugs will ultimately be used unsupervised, malaria control programme managers will require further data on safety and whether the drug is as efficacious when used outside of controlled clinical trials before allowing widespread use of these new products. These data need to be collected in highly specific phase IV programmes. We explain why public-private partnerships should extend their development plans well beyond drug registration, and set out the requirements of such a programme. We aim to generate debate and discussion so that guidelines that are internationally accepted and adhered to can be developed not only for antimalarials but for all drugs that are being developed specifically for use in resource-poor settings.

Objective: Few studies have described levels and determinants of perceived risk of HIV-1 among African adults for whom the sero-status is known. This study describes HIV risk perception obtained from a large rural population in south-west Uganda which also underwent serological testing for HIV., Design: Cross-sectional survey., Methods: Information on risk perception and sexual behaviour was collected by interview. Sera were obtained from all consenting adults (13 years and above) in order to assess HIV-1 prevalence., Results: Of 14,818 adults with a definitive sero-status, 9.7% were HIV-1 positive and 51% considered themselves to be at risk of infection. Risk perception showed similar patterns as age- and sex-specific sero-prevalence and there was correspondence between risk factors for perceived risk and known HIV risk factors. Partner's sexual behaviour was the commonest reason for risk perception in women whereas men cited their own sexual behaviour. Abstinence from sex was much more commonly mentioned as a protective practice than condom use in men and women., Conclusion: Half of the adults we have studied already see infection with HIV as a real possibility in their lives and are aware of HIV risk behaviours. More efforts should be made to implement sustainable control measures rather than simply raising awareness. In addition to recommending abstinence, these include mutual faithfulness, condom use and better treatment for STDs.

Objective: To study the association between change of residence and HIV-1 serostatus in a rural Ugandan population., Design: A longitudinal cohort study., Methods: As part of the annual surveillance of a population cohort of approximately 10,000 individuals in a rural subcounty of southwest Uganda, information has been collected for all adults on change of residence over a 3-year period and its association with HIV-1 serostatus. Sera were collected by a medical team during home visits. Antibody testing was performed at the Uganda Virus Research Institute using two independent enzyme immunoassay systems and Western blot when appropriate., Results: At the fourth survey-round, age and sex-standardized seroprevalence rates were 7.9% overall; the rate was 5.5% for 2,129 adults who had not changed address since the first survey, 8.2% for 336 who moved within the village, 12.4% for 128 who moved to a neighbouring village, 11.5% for 1,130 who had left the area and 16.3% for 541 who had joined the study area during the previous 3 years (P << 0.001, 4 degrees of freedom). We also observed an inverse relationship between years lived at the present house at the time of the first survey and both seroprevalence and subsequent seroincidence rates. The reported numbers of lifetime sexual partners were higher in those who changed residence., Conclusion: Change of residence is strongly associated with an increased risk of HIV-1 infection in this rural population and is likely to be the result of more risky sexual behaviour among those who move. These findings have important implications for the design of AIDS control programmes and intervention studies.

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.

Involvement of the study community in research on HIV/AIDS has presented the MRC/UVRI programme in rural Uganda with a multi-layered challenge. A typology developed in agricultural research which defines different levels of community participation in research is described where participation may be at 'contract', 'consultative', 'collaborative' and 'collegiate' level (each level indicating an increasing degree of community participation). Community involvement in the MRC/UVRI Programme is then outlined and the typology applied. It is shown that the majority of community participation in the Programme is at the contract level since the nature of the research programme as a 'foreign imposition' with 'foreign goals' has precluded the involvement of the community in much of the policy development and research planning. However, it is noted that as the Programme becomes more established in the area community influence grows and signs of community impact on policy and increased research inputs are beginning to be seen. The question is raised as to whether it is realistic to expect that externally imposed health research, particularly on sensitive topics, can ever be truly community participatory research.