Summaryobjectives To 1 determine (i) the prevalence and type of female genital cutting (FGC) in a rural multiethnic village in Tanzania, (ii) its associated demographic factors, (iii) its possible associations with HIV, sexually transmitted infections (STIs) and infertility and (iv) to assess the consistency between selfreported and clinically observed FGC.method The study was part of a larger community-based, cross-sectional survey with an eligible female population of 1993. All were human immunodeficiency virus (HIV)-tested and asked whether they were circumcised (n ¼ 1678; 84.2%). Participants aged 15-44 years were interviewed (n ¼ 636; 79.7%), and 399 (50.0%) were gynaecologically examined to screen for STIs and determine the FGC status.results At a mean age of 9.6 years, 45.2% reported being circumcised. In the age-group 15-44 years, 65.5% reported being cut, while FGC was observed in 72.5% and categorized as clitoridectomy or excision. The strongest predictors of FGC were ethnicity and religion, i.e. being a Protestant or a Muslim. FGC was not associated with HIV infection, other STIs or infertility. A positive, non-significant association between FGC and bacterial vaginosis was found with a crude odds ratio of 4.6. There was a significant decline of FGC over the last generation. An inconsistency between self-reported and clinically determined FGC status was observed in more than one-fifth of the women.conclusion The data indicate that both women and clinicians might incorrectly report women's circumcision status. This reveals methodological problems in determining women's circumcision status in populations practising the most common type of FGC. The positive association between FGC and bacterial vaginosis warrants further investigation.

Background: Chlamydia and gonorrhoea are major causes of morbidity among women in developing countries. Both infections have been associated with pregnancy-related complications, and case detection and treatment in pregnancy is essential. In countries without laboratory support, the diagnosis and treatment of cervical infections is based on the syndromic approach. In this study we measured the prevalence of chlamydia and gonorrhoea among antenatal care attendees in Botswana. We evaluated the syndromic approach for the detection of cervical infections in pregnancy, and determined if risk scores could improve the diagnostic accuracy.

BackgroundThough financial and policy level efforts are made to expand antiretroviral treatment (ART) service free of cost, survival outcome of ART program has not been systematically evaluated in Nepal. This study assesses the mortality rates and determinants among adult HIV-infected patients on ART in Far-western region of Nepal.MethodsThis retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15th 2006 and May 15th 2011 in five ART sites in the Far-western region, Nepal. Follow-up time was calculated from the date of ART initiation to date of death or censoring (loss to follow-up, transferred out, or 15 November 2011). Mortality rates (per 100 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore determinants of mortality.ResultsThe median follow-up time was 19.1 months. The crude mortality rate was 6.3 (95% confidence interval (CI) 5.3-7.6) but more than three-times higher in first 3 months after ART initiation (21.9 (95% CI 16.6- 28.8)). About 12% (83% men) of those newly initiated on ART died during follow-up. The independent determinants of mortality were male sex (hazard ratio (HR) 4.55, 95% CI 2.43-8.51), poor baseline performance scale (bedridden <50% of the day during the past month, HR 2.05, 95% CI 1.19-3.52; bedridden >50% of the day during the past month, HR 3.41, 95% CI 1.67-6.98 compared to normal activity), one standard deviation decrease in baseline bodyweight (HR 1.04, 95% CI 1.01-1.07), and poor WHO clinical stage (stage III, HR 2.96, 95% CI 1.31-6.69; stage IV, HR 3.28, 95% CI 1.30-8.29 compared to WHO clinical stage I or II).ConclusionsHigh mortality was observed within the first 3 months of ART initiation. Patients with poor baseline clinical characteristics had higher mortality, especially men. Earlier initiation of ART through expanded testing and counselling should be encouraged in HIV-infected patients.

Objective To measure the prevalence of Trichomonas vaginalis (TV) infection and bacterial vaginosis (BV) among pregnant women in Botswana, and to evaluate the syndromic approach and alternative management strategies for these conditions in pregnancy. Methods In a cross-sectional study, 703 antenatal care attendees were interviewed and examined, and specimens were collected to identify TV, BV, Candida species, Chlamydia trachomatis and Neisseria gonorrhoeae. Information on reproductive tract infections earlier in pregnancy was obtained from a structured interview and the antenatal record. Findings TV was found in 19% and BV in 38% of the attendees. Three-fourths of women with TV or BV were asymptomatic. Syndromic management according to the vaginal discharge algorithm would lead to substantial under-diagnosis and over-treatment of TV and BV. Signs of vaginal discharge were more predictive of the presence of these conditions than were symptoms. Among the 546 attendees on a repeat antenatal visit, 142 (26%) had been diagnosed with vaginal discharge earlier in their pregnancy -14 of them twice. In 143 cases, an attendee was diagnosed with vaginal discharge in the second or third trimester; however, metronidazole had been prescribed only 17 times (12%). Conclusion Diagnosis and treatment of TV and BV among pregnant women in sub-Saharan Africa presents major challenges. Half the pregnant women in this study were diagnosed with TV or BV, but these conditions were not detected and treated during antenatal care with syndromic management. Also, health workers did not adhere to treatment guidelines. These results indicate that management guidelines for TV and BV in antenatal care should be revised.

The aim of this study was to determine the prevalence of HIV infection, other sexually transmitted diseases (STDs), and biological risk factors associated with HIV infection in a rural population in Tanzania. A population-based study of a village population was carried out from July 1991 through January 1992. A total of 3,239 people (83.7%) participated in an HIV serosurvey. The total HIV prevalence was 0.7 and 1.9% among males and females, respectively (odds ratio, OR = 2.5; 95% confidence interval, CI: 1.2-5.1), and 4.3% in women and 1.6% in men in participants aged 15 to 44 (OR = 2.6; CI: 1.2-5.8). The same age group was interviewed and offered screening for STDs. Trichomonas vaginalis vaginitis (24.7%) was the most common reproductive tract infection (RTI); 10.3% of women were infertile and 10.6% suffered from pelvic inflammatory disease (PID). Comparing women and men, we found that 2.2 versus 20.4% had been treated for genital discharge (OR = 12.6; CI: 7.1-22.5); 2.6 versus 1.2% suffered from active syphilis (OR = 1.5; CI: 0.9-2.3); 6.9 versus 9.6% had chlamydial infection; and 46.9 versus 14.6% had an ongoing RTI/STD (OR = 5.0; CI: 3.6-6.9). A significant association was found between HIV infection and STD cases (in women) and between HIV infection and a history of STDs (in men). The heavy burden of untreated RTIs in females calls for a more gender-specific approach to HIV and STD prevention.

PurposeThere are a high number of HIV-infected patients receiving antiretroviral therapy (ART) in the Kathmandu District of Nepal, but information on adherence and factors influencing it are scarce in this population. The present study aimed to estimate ART adherence among HIV-infected patients in the Kathmandu District of Nepal, and to determine the factors associated with ART adherence.Patients and methodsThis study included 316 HIV-infected patients attending three ART centers in the Kathmandu District. Information on sociodemographic characteristics, socioeconomic status, and ART use for the previous 7 days was collected via interview. Participants were considered adherent if they reported taking ≥95% of their ART as prescribed. The association between explanatory variables and ART adherence was measured using logistic regression and reported as odds ratios (OR) with 95% confidence intervals (CI).ResultsMale participants accounted for 64.6% (n=204). Overall ART adherence was 86.7%. ART adherence in men and women were 84.3% and 91.1%, respectively. Age (OR 1.04; 95% CI 1.00–1.09), travel time to ART centers (OR 1.38; 95% CI 1.12–1.71), history of illegal drug use (OR 3.98; 95% CI 1.71–9.24), and adverse effects (OR 4.88; 95% CI 1.09–21.8), were all independently and negatively associated with ART adherence. Use of reminder tools (OR 3.45; 95% CI 1.33–8.91) was independently and positively associated with ART adherence.ConclusionThe observed ART adherence in this study is encouraging. Travel time to ART centers, self-reported adverse effects, illegal drug use, and not using reminder tools were the major determinants of ART adherence. Interventions that take these factors into account could further improve ART adherence.

BackgroundThe aims of this study were to estimate the prevalence and severity of MSCs in the adult general population of Northern Norway, and to study associations between MSCs and various demographic and lifestyle variables.MethodsData from the Tromsø 6 survey (2007–2008) of the population-based Tromsø Study were used (12,984 participants, 65.7% participation rate). We included 8,439 participants aged 30–79 years in the analyses. Associations between demographic and lifestyle variables and chronic MSCs (i.e., those lasting for at least 3 consecutive months, hereafter referred to as simply MSCs) was examined using logistic regression analysis.ResultsThe total age-adjusted prevalence of both mild and severe MSCs was 63.4% and 52.9% in women and men, respectively. In women, the age-adjusted prevalence was 44.0% and 19.4% for mild and severe MSCs, respectively; the corresponding values in men were 40.8% and 12.1%. The highest prevalence was found in the neck/shoulder region (34.2% and 8.9% for mild and severe MSCs, respectively). The prevalence of MSCs in ≥5 body regions was three times higher in women than in men (14.9% vs 5.6%). Current smoking was significantly associated with MSCs (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.22-1.62), but showed a stronger effect in women (OR: 1.60, 95% CI: 1.30-1.96) than in men (OR: 1.25, 95% CI: 1.02-1.52). Self-perceived poor health was strongly associated with MSC (OR: 3.73, 95% CI: 3.27-4.24). Moderate vs low level of physical activity was associated with MSCs only in women (OR: 1.37, 95% CI: 1.12-1.67). Other demographic and lifestyle variables associated with MSCs were age (OR: 1.04, 95% CI: 1.01-1.06), body mass index (BMI) >30 kg/m2 (OR: 1.42, 95% CI: 1.23-1.66), low education level (OR: 1.78, 95% CI: 1.53-2.08) and former smoking (OR: 1.21, 95% CI: 1.09-1.35). Marital status, BMI <18.5 kg/m2, high and very high level of physical activity was not associated with MSCs.ConclusionChronic MSCs are highly prevalent in this Northern Norwegian population, and are strongly related to self-perceived poor health. Women have a higher burden of MSCs than men. Most demographic and lifestyle variables associated with MSCs showed stronger associations in women than in men.

BackgroundThe incidences of reportable sexually transmitted infections (STI) among men who have sex with men (MSM) have increased since the late 1990 s in Norway. The objectives of our study were to assess factors, associated with recent selected STI among MSM, living in Norway in order to guide prevention measures.MethodsWe conducted a cross-sectional Internet-based survey during 1-19 October 2007 among members of a MSM-oriented Norwegian website using an anonymous questionnaire on demographics, sexual behaviour, drug and alcohol use, and STI. The studied outcomes were gonorrhoea, syphilis, HIV or Chlamydia infection in the previous 12 months. Associations between self-reported selected STI and their correlates were analysed by multivariable Poisson regression. P value for trend (p-trend), adjusted prevalence ratios (PR) with 95% confidence intervals [] were calculated.ResultsAmong 2430 eligible 16-74 years old respondents, 184 (8%) reported having had one of the following: syphilis (n = 17), gonorrhoea (n = 35), HIV (n = 42) or Chlamydia (n = 126) diagnosed in the past 12 months. Reporting Chlamydia was associated with non-western background (PR 2.8 [1.4-5.7]), number of lifetime male partners (p-trend < 0.001), unsafe sex under the influence of alcohol (PR 1.8 [1.1-2.9]) and with younger age (p-trend = 0.002). Reporting gonorrhoea was associated with unrevealed background (PR 5.9 [1.3-26.3]), having more than 50 lifetime male partners (PR 4.5 [1.3-15.6]) and more than 5 partners in the past 6 months (PR 3.1 [1.1-8.8]), while mid-range income was protective (PR 0.1 [0.0-0.6]). Reporting HIV was associated with residing in Oslo or Akershus county (PR 2.3 [1.2-4.6]), non-western background (PR 5.4 [1.9-15.3]), unrevealed income (PR 10.4 [1.5-71.4]), number of lifetime male partners (p-trend < 0.001) and being under the influence of selected drugs during sex in the past 12 months (PR 5.2 [2.7-11.4]). In addition, the frequency of feeling drunk was reversibly associated with HIV.ConclusionsOur study demonstrates different associations of demographic and behavioural factors with different STI outcomes in the study population. Number of lifetime male partners was the most important potential predictor for Chlamydia and HIV. The STI prevention efforts among MSM should focus on Oslo and Akershus, promote safe sex practices and tackle sex-related drug and alcohol use.