• Acceptability and technical problems of the female condom amongst commercial sex workers in a rural district of Malawi.

      Zachariah, R; Harries, A D; Buhendwa, L; Spielmann, M P; Chantulo, A; Bakali, E; Médecins Sans Frontières - Luxembourg, Thyolo district, Thyolo, Malawi. zachariah@internet.lu (2003-10)
      A study was conducted among commercial sex workers (CSWs) in rural southern Malawi, in order to (a) assess the acceptability of the female condom and (b) identify common technical problems and discomforts associated with its use. There were 88 CSWs who were entered into the study with a total of 272 female condom utilizations. Eighty-six (98%) were satisfied with the female condom, 80% preferred it to the male condom and 92% were ready to use the device routinely. Of all the utilizations, the most common technical problem was reuse of the device with consecutive clients, 6% after having washed it, and 2% without any washing or rinsing. The most common discomfort that were reported included too much lubrication (32%), device being too large (16%), and noise during sex (11%). This study would be useful in preparing the introduction of the female condom within known commercial sex establishments in Malawi.
    • Adherence to a Six-Dose Regimen of Artemether-Lumefantrine for Treatment of Uncomplicated Plasmodium Falciparum Malaria in Uganda.

      Fogg, C; Bajunirwe, F; Piola, P; Biraro, S; Checchi, F; Kiguli, J; Namiiro, P; Musabe, J; Kyomugisha, A; Guthmann, J P; et al. (Published by: American Society of Tropical Medicine and Hygiene, 2004-11)
      Measuring baseline levels of adherence and identifying risk factors for non-adherence are important steps before the introduction of new antimalarials. In Mbarara in southwestern Uganda, we assessed adherence to artemether-lumefantrine (Coartem) in its latest World Health Organization blister formulation. Patients with uncomplicated Plasmodium falciparum malaria were prescribed artemether-lumefantrine and received an explanation of how to take the following five doses at home. A tablet count was made and a questionnaire was completed during a home visit. Among 210 analyzable patients, 21 (10.0%) were definitely or probably non-adherent, whereas 189 (90.0%) were probably adherent. Age group was not associated with adherence. Lack of formal education was the only factor associated with non-adherence after controlling for confounders (odds ratio = 3.1, 95% confidence interval [CI] = 1.1-9.7). Mean lumefantrine blood levels were lower among non-adherent (n = 16) (2.76 microg/mL, 95% CI = 1.06-4.45) than among adherent (n = 171) (3.19 microg/mL, 95% CI = 2.84-3.54) patients, but this difference was not statistically significant. The high adherence to artemether-lumefantrine found in our study suggest that this drug is likely to be very effective in Mbarara provided that patients receive clear dosage explanations.
    • Adherence to the combination of sulphadoxine-pyrimethamine and artesunate in the Maheba refugee settlement, Zambia.

      Depoortere, E; Guthmann, J P; Sipilanyambe, N; Nkandu, E; Fermon, F; Balkan, S; Legros, D; Epicentre, Paris, France. evelyn.depoortere@msf.be (Wiley-Blackwell, 2004-01)
      Artemisinin-based combination therapy (ACT) is one strategy recommended to increase cure rates in malaria and to contain resistance to Plasmodium falciparum. In the Maheba refugee settlement, children aged 5 years or younger with a confirmed diagnosis of uncomplicated falciparum malaria are treated with the combination of sulphadoxine-pyrimethamine (1 day) and artesunate (3 days). To measure treatment adherence, home visits were carried out the day after the last treatment dose. Patients who had any treatment dose left were considered certainly non-adherent. Other patients' classification was based on the answers to the questionnaire: patients whose caretakers stated the child had received the treatment regimen exactly as prescribed were considered probably adherent; all other patients were considered probably non-adherent. Reasons for non-adherence were assessed. We found 21.2% (95% CI [15.0-28.4]) of the patients to be certainly non-adherent, 39.4% (95% CI [31.6-47.6]) probably non-adherent, and 39.4% (95% CI [31.6-47.6]) probably adherent. Insufficient explanation by the dispenser was identified as an important reason for non-adherence. When considering the use of ACT, the issue of patient adherence remains challenging. However, it should not be used as an argument against the introduction of ACT. For these treatment regimens to remain efficacious on a long-term basis, specific and locally adapted strategies need to be implemented to ensure completion of the treatment.
    • Clinical screening for HIV in a health centre setting in urban Kenya: an entry point for voluntary counselling, HIV testing and early diagnosis of HIV infection?

      Arendt, V; Mossong, J; Zachariah, R; Inwani, C; Farah, B; Robert, I; Waelbrouck, A; Fonck, K; Médecins Sans Frontières, Mission Kenya, Brussels Operational Centre, Brussels, Belgium. (2007-01)
      A study was conducted among patients attending a public health centre in Nairobi, Kenya in order to (a) verify the prevalence of HIV, (b) identify clinical risk factors associated with HIV and (c) determine clinical markers for clinical screening of HIV infection at the health centre level. Of 304 individuals involved in the study,107(35%) were HIV positive. A clinical screening algorithm based on four clinical markers, namely oral thrush, past or present TB, past or present herpes zoster and prurigo would pick out 61 (57%) of the 107 HIV-positive individuals. In a resource-poor setting, introducing a clinical screening algorithm for HIV at the health centre level could provide an opportunity for targeting voluntary counselling and HIV testing, and early access to a range of prevention and care interventions.
    • A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement.

      Neuner, F; Schauer, M; Klaschik, C; Karunakara, U; Elbert, T; Department of Clinical Psychology, University of Konstanz, Konstanz, Germany. frank.neuner@uni-konstanz.de (2004-08)
      Little is known about the usefulness of psychotherapeutic approaches for traumatized refugees who continue to live in dangerous conditions. Narrative exposure therapy (NET) is a short-term approach based on cognitive-behavioral therapy and testimony therapy. The efficacy of narrative exposure therapy was evaluated in a randomized controlled trial. Sudanese refugees living in a Ugandan refugee settlement (N = 43) who were diagnosed as suffering from posttraumatic stress disorder (PTSD) either received 4 sessions of NET, 4 sessions of supportive counseling (SC), or psychoeducation (PE) completed in 1 session. One year after treatment, only 29% of the NET participants but 79% of the SC group and 80% of the PE group still fulfilled PTSD criteria. These results indicate that NET is a promising approach for the treatment of PTSD for refugees living in unsafe conditions.
    • Effectiveness of a health education intervention in a war environment.

      Blair, A; Shiels, C; Médecins Sans Frontières, London, UK. alistair.blair@virgin.net (2002-04)
    • The efficacy of a mental health program in Bosnia-Herzegovina: impact on coping and general health.

      Mooren, T T M; de Jong, K; Kleber, R J; Ruvic, J; De Vonk, Centrum '45, Noordwijkerhout, The Netherlands. T.Mooren@Centrum45.nl (Wiley-Blackwell, 2003-01)
      The efficacy of a community-based psychosocial program in Bosnia-Herzegovina during the war and immediate postwar years (1994-1999) was described in this article. Ten centers provided various kinds of psychological help in the besieged city of Sarajevo and the towns of Zenica, Travnik, and Vitez. Since 1994, an intensive monitoring system has documented data on clients, interventions, and outcomes. This study focused on the systematic evaluation of counseling interventions aimed to alleviate the distress in wartime. The sample consisted of 3,283 and 1,785 inhabitants of Sarajevo, Zenica, Travnik, and Vitez who filled out the GHQ-28 and IES respectively. Pre- and post-assessments were compared throughout consecutive years (1994-1999) and across age groups and both sexes. Outcomes of these scales reflected very high scores, especially among people between 30 and 40 years of age. Furthermore, intake scores increased in time rather than decreased. Differences between pre- and postmeasurements are highly significant--throughout the years. Analyses revealed substantial proportions of clinically recovered or generally improved individual functioning, although some clients revealed no improvement.
    • Factors associated with Condom Use Problems during Vaginal Sex with main and non-main partners

      DʼAnna, L H; Korosteleva, O; Warner, L; Douglas, J; Paul, S; Metcalf, C; McIlvaine, E; Malotte, C K; California State University, Long Beach, Center for Health Care Innovation, and Department of Math and Statistics, LongBeach, CA 90840, USA. laura.d’anna@csulb.edu (2012-09-01)
      Incorrect condom use is a common problem that can undermine their prevention impact. We assessed the prevalence of 2 condom use problems, breakage/slippage and partial use, compared problems by partnership type, and examined associations with respondent, partner, and partnership characteristics.
    • Field research in humanitarian medical programmes. Treatment of neuropathic pain in Sierra Leone.

      Lacoux, P A; Lassalle, X; McGoldrick, P M; Crombie, I K; Macrae, W A; Médecins Sans Frontières, Paris, France. phil@lacoux.u-net.com (Elsevier, 2008-01-31)
      A pilot study was carried out among 223 war wounded and amputees in Sierra Leone in 2001 to investigate whether an intervention using proven medication for clinically diagnosed neuropathic pain would work in a developing country with limited health services. Compliance with medication was assessed in 79 patients and their pain and mood scores were assessed by questionnaire before medication and 6-10 months later. The pain and mood scores of 33 patients who stopped taking medication were compared for the initial and follow-up assessments indicating that, although the scores showed an improvement at follow-up, there was no significant improvement. Compliance was reasonable in 46 patients who continued with their medication, with 86.5% of possible doses collected although many had difficulty understanding how to take the drugs properly. Their pain and mood scores showed significant improvement at reassessment indicating that pain will be reduced with a longer duration of treatment. This study showed that it is possible to run an effective intervention for neuropathic pain in Sierra Leone with intermittent expert involvement and MSF have been able to develop a protocol for the assessment and treatment of neuropathic pain that may be useful in other difficult settings in which they work.
    • An investigation into the health-related quality of life of individuals living with HIV who are receiving HAART.

      Jelsma, J; Maclean, E; Hughes, J; Tinise, X; Darder, M; Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. jjelsma@uctgsh1.uct.ac.za (2005-07)
      The health authorities have recently accepted the routine provision of highly active antiretroviral therapy to persons living with AIDS in South Africa. There is a need to investigate the impact of HAART on the health-related quality of life of people living with HIV/AIDS (PLWHA) in a resource-poor environment, as this will have an influence on compliance and treatment outcome. The aim of this study was to explore whether HAART is efficacious in improving the self-reported health-related quality of life (HRQoL) in a group of PWLA in WHO Stages 3 and 4 living in a resource-poor community. A quasi-experimental, prospective repeated measures design was used to monitor the HRQoL over time in participants recruited to an existing HAART programme. The HRQoL of 117 participants was determined through the use of the Xhosa version of the EQ-5D and measurements were taken at baseline, one, six and 12 months. At the time of the 12-month questionnaire, 95 participants had been on HAART for 12 months. Not all participants attended all follow-up visits, but only two participants had withdrawn from the HAART programme, after two or three months. At baseline, the rank order of problems reported in all domains of the EQ-5D was significantly greater than at 12 months. The mean score on the global rating of health status increased significantly (p < 0.001) from a mean of 61.7 (SD = 22.7) at baseline to 76.1 at 12 months (SD = 18.5) It is concluded that, even in a resource-poor environment, HRQoL can be greatly improved by HAART, and that the possible side effects of the drugs seem to have a negligible impact on the wellbeing of the subjects. This bodes well for the anticipated roll-out of HAART within the public health sector in South Africa.
    • Kala-azar outbreak in Libo Kemkem, Ethiopia: epidemiologic and parasitologic assessment.

      Alvar, J; Bashaye, S; Argaw, D; Cruz, I; Aparicio, P; Kassa, A; Orfanos, G; Parreño, F; Babaniyi, O; Gudeta, N; et al. (2007-08)
      In May 2005, visceral leishmaniasis (VL) was recognized for the first time in Libo Kemkem, Ethiopia. In October 2005, a rapid assessment was conducted using data from 492 patients with VL treated in the district health center and a household survey of 584 residents of four villages. One subdistrict accounted for 71% of early cases, but the incidence and number of affected subdistricts increased progressively throughout 2004-2005. In household-based data, we identified 9 treated VL cases, 12 current untreated cases, and 19 deaths attributable to VL (cumulative incidence, 7%). Thirty percent of participants were leishmanin skin test positive (men, 34%; women, 26%; P = 0.06). VL was more common in men than women (9.7% versus 4.5%, P < 0.05), possibly reflecting male outdoor sleeping habits. Molecular typing in splenic aspirates showed L. infantum (six) and L. donovani (one). Local transmission resulted from multiple introductions, is now well established, and will be difficult to eradicate.
    • The Prevalence of Mental Health Problems in Rwandan and Burundese Refugee Camps

      de Jong, J; Scholte, W F; Koeter, M W; Hart, A A; Médecins Sans Frontières, Holland, Amsterdam, The Netherlands. (2000-09)
      OBJECTIVE: We examined the prevalence of mental health problems in refugees living in camps that emerged in Tanzania during the Rwanda crisis that started in 1994. METHOD: Using the 28-item version of the General Health Questionnaire (GHQ-28), we examined two samples: a random sample (n = 854) and a sample of clients of a psychosocial support programme in these camps (n = 23). Sensitivity, specificity and positive- and negative predictive values were estimated for several cut-off scores of the GHQ-28. RESULTS: The prevalence of serious mental health problems was estimated at 50% (SE 12%). When using the GHQ-28 as a screener, a cut-off score of 14 is recommended. CONCLUSION: Given the high prevalence of mental health problems, psychosocial programmes for large refugee populations should aim at strengthening community structures and supporting groups instead of focusing at individuals. The screening capacity of the GHQ-28 could be used to identify mentally vulnerable groups.
    • The prevention of mother-to-child HIV transmission programme and infant feeding practices.

      Hilderbrand, K; Goemaere, E; Coetzee, D; Infectious Diseases and HIV/AIDS Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town. (2003-10)
      Since the first cases of HIV transmission through breast-feeding were documented, a fierce debate has raged on appropriate guidelines for infant feeding in resource-poor settings. A major problem is determining when it is safe and feasible to formula-feed, as breast-milk protects against other diseases. A cross-sectional survey of 113 women attending the programme for the prevention of mother-to-child transmission in Khayelitsha, Cape Town, was conducted. Over 95% of women on the programme formula-fed their infants and did not breast-feed at all. Seventy per cent of women said that their infant had never had diarrhoea, and only 3% of children had had two episodes of diarrhoea. Focus groups identified the main reasons for not breast-feeding given by women to their families and those around them. Formula feeding is safe and feasible in an urban environment where sufficient potable water is available.
    • A qualitative investigation of adherence to nutritional therapy in malnourished adult AIDS patients in Kenya

      Dibari, Filippo; Bahwere, Paluku; Le Gall, Isabelle; Guerrero, Saul; Mwaniki, David; Seal, Andrew; Valid International, Oxford, UK; UCL Centre for International Health and Development, Institute of Child Health, London, UK; MSF-France, Nairobi, Kenya/Paris, France; Centre for Public Health, Kenya Medical Research Institute, KEMRI/CPHR, Nairobi, Kenya; Academy for Educational Development/Regional Office for Eastern and Central Africa, Nairobi, Kenya (Cambridge University Press, 2011-02-04)
      To understand factors affecting the compliance of malnourished, HIV-positive adults with a nutritional protocol using ready-to-use therapeutic food (RUTF; Plumpy'nut®).
    • Risk factors for buruli ulcer: a case control study in Cameroon

      Pouillot, Régis; Matias, Gonçalo; Wondje, Christelle Mbondji; Portaels, Françoise; Valin, Nadia; Ngos, François; Njikap, Adelaïde; Marsollier, Laurent; Fontanet, Arnaud; Eyangoh, Sara; et al. (2007-12-19)
      BACKGROUND: Buruli ulcer is an infectious disease involving the skin, caused by Mycobacterium ulcerans. This disease is associated with areas where the water is slow-flowing or stagnant. However, the exact mechanism of transmission of the bacillus and the development of the disease through human activities is unknown. METHODOLOGY/PRINCIPAL FINDINGS: A case-control study to identify Buruli ulcer risk factors in Cameroon compared case-patients with community-matched controls on one hand and family-matched controls on the other hand. Risk factors identified by the community-matched study (including 163 pairs) were: having a low level of education, swamp wading, wearing short, lower-body clothing while farming, living near a cocoa plantation or woods, using adhesive bandages when hurt, and using mosquito coils. Protective factors were: using bed nets, washing clothes, and using leaves as traditional treatment or rubbing alcohol when hurt. The family-matched study (including 118 pairs) corroborated the significance of education level, use of bed nets, and treatment with leaves. CONCLUSIONS/SIGNIFICANCE: Covering limbs during farming activities is confirmed as a protective factor guarding against Buruli ulcer disease, but newly identified factors including wound treatment and use of bed nets may provide new insight into the unknown mode of transmission of M. ulcerans or the development of the disease.
    • Risk factors for death in hospitalized dysentery patients in Rwanda.

      Legros, D; Paquet, C; Dorlencourt, F; Saoult, E; EPICENTRE, Paris, France. (Wiley-Blackwell, 1999-06)
      To evaluate the management of severe dysentery cases in in-patient facilities during an epidemic of Shigella dysenteriae type 1 (Sd1), and to identify the factors associated with the risk of death, we conducted a prospective cohort study in 10 Rwandese hospitals between September and December 1994. Data were obtained from 849 cases admitted to hospitals with diarrhoea and visible blood in stools. The proportion of patients with persistent bloody diarrhoea was 51.0% at treatment day 3 and 27.9% at treatment day 5. At discharge, 79.9% had improved or were cured. The case fatality ratio was 13.2%, higher for patients treated with nalidixic acid than for those treated with ciprofloxacin (12.2% vs. 2.2%, RR = 5.80, 95% CI = 0.83-40.72). In a logistic regression model three risk factors were significantly associated with an increased risk of death during hospitalization: severe dehydration on admission (adjusted OR = 2.79, 95% CI = 1.46-5.33), age over 50 (adjusted OR vs. 5-49 age group = 3.22, 95% CI = 1.70-6.11) and prescription of nalidixic acid (adjusted OR vs. ciprofloxacin = 8.66, 95% CI = 1.08-69.67). Those results were consistent with reported high levels of resistance of Sd1 to the commonest antibiotics, including nalidixic acid. Patients belonging to groups with a higher risk of dying should be given special medical attention and supportive care. In areas of high resistance to nalidixic acid, severe cases of dysentery should be treated with fluoroquinolones in order to reduce the mortality associated with these epidemics.