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Bulletin of the World Health Organization. 2003; 81(4):307.Three recent studies challenge the assumption that the main cause of the spread of HIV in Africa is unprotected sex. They argue that it is unsafe injections, which transmit the infection on a far larger scale than has previously been thought. Most experts assume that unsafe sex between men and women is responsible for 90% of HIV infections in sub-Saharan Africa. The medical reuse of contaminated needles and syringes is thought to account for another 5%. The authors of the controversial trio of papers recently published in the International Journal of STD and AIDS (2003;14;144-73) take a radically different view. (excerpt)
[Estimation of the rate of mother-to-child HIV transmission: methodological problems and current estimates. Report of 2 study workshops (Ghent, Belgium, 17-20 February 1992 and 3-5 September 1993)] Estimation du taux de transmission du VIH de la mere a l'enfant: problemes methodologiques et estimations actuelles. Rapport de deux ateliers de travail (Gand, Belgique, 17-20 fevrier 1992 et 3-5 septembre 1993).
SANTE. 1994 Mar-Apr; 4(2):73-86.Many cohort studies since 1985-1989 have estimated the rate of mother-to-child transmission of HIV. Data collection and analysis problems in many of these studies made it hard to compare transmission rates between studies. The AIDS Task Force/European Community and WHO/Global Program on AIDS held workshops on methodological problems and actual estimations of mother-to-child transmission of HIV in February 1992 and September 1993 in Belgium. Researchers who have conducted studies in Central and Eastern Africa, Europe, Haiti, and the US participated. They examined enrollment and follow-up methods, diagnostic criteria and case definitions, measurement and comparison of mother-to-child transmission rates, and determinants of transmission. The reported transmission ranges varied from 13% to 32% in developed countries and from 25% to 48% in developing countries. Since the estimation methods differed, the participants could not make direct comparisons, so they developed a common methodology at the 1992 workshop. They agreed on definitions of HIV-related signs and symptoms, AIDS in children, and HIV-related deaths. They developed a classification system of children born to HIV-1 infected women based on probable HIV infection status during the first 15 months of life. This system let them define a direct method of computation of the transmission rate and an indirect method for studies with a comparison group of children born to HIV negative women. At the 1993 workshop, participants applied some data sets to these standardized methods to revise earlier estimates and to compare mother-to-child HIV-1 transmission rates in 13 different locations. The transmission rates, determined by the direct and indirect methods, ranged from 12.7% to 42.1% and from 20.7% to 42.8%, respectively. Using the direct method, those in industrialized countries and developed countries ranged from 14% to 25% and from 13% to 42%, respectively. Both methods attain a reasonable estimate of the true rate. Application of these methods to all studies would help researchers design and implement trials assessing interventions trying to reduce or prevent mother-to-child transmission of HIV.
Estimating the rate of mother-to-child transmission of HIV. Report of a workshop on methodological issues, Ghent (Belgium), 17-20 February 1992.
AIDS. 1993 Aug; 7(8):1139-48.A meeting was held in 1992 in Ghent, Belgium, under the auspices of the European Economic Community AIDS Task Force in collaboration with the WHO Global program on AIDS and UNICEF. THe objective were: 1) to address methodological issues in the estimation of the rate of mother-to-child (MTCT) transmission of HIV-1, with special reference to developing countries, and 2) to present a critical evaluation of selected perinatal studies using a standardized methodological approach. The discussions and recommendations made during the workshop are summarized. In the previous 8 years, numerous studies had been conducted to estimate the rate of MTCT of HIV. Many of these had encountered problems in data collection and analysis, making it difficult to compare transmission rates between studies. 14 teams of investigators participated, representing studies from central (5) and eastern Africa (3), Europe (2), Haiti (1), and the US (3). A critical evaluation of the projects was carried out under 4 headings: 1) enrollment and follow-up procedures, 2) diagnostic criteria and case definitions, 3) measurement and comparison of MTCT rats, and 4) determinants of transmission. The different estimations of the rate of HIV MTCT reported ranged from 13-32% in industrialized countries and from 26-48% in developing countries. For the purpose of calculating the rate of HIV MTCT, it is important to establish whether a child who dies before 15 months is HIV-infected. 3 definitions were proposed for children who died before their infection status could be determined by serology. Factors identified as possible risk factors for HIV MTCT included impaired maternal clinical and immunological status, HIV-seroconversion during pregnancy, shortened duration of pregnancy, choriamnionitis, vaginal delivery, prolonged and/or complicated labor, and breast-feeding. Maternal age and parity did not appear to be associated with MTCT in most studies.