This study describes the sexual behaviour of men and women in a fishing village on the shores of Lake Victoria in southwest Uganda. The village is near a well known trading town-truckstop on the main trans-Africa highway with a high recorded prevalence of HIV infection. Data were obtained on the daily travel and sexual activities of 26 women and 54 men with particular attention paid to the rate of partner change and the proportion of sexual contacts with people outside the village. During a total of 587 person weeks the men made 1086 trips, mostly returning home the same day. They had a total of 1226 sexual contacts, most of which occurred either in their own village (83%) or a neighbouring fishing village (11%); 17 per cent of sexual contacts were with new partners. Fifteen of the women described themselves as married; 42 per cent of their sexual contacts were casual, paying partners. Of the eleven women who were single, between 80 and 100 per cent of contacts were with paying partners. Most of the women's partners were resident in the village. These data show a very high rate of sexual mixing within the village. Such communities should be targeted in future STD control programs.
Interview data were collected from 1749 men and 1976 women of mean age 36.0-39.7 years in Ado-Ekiti, Ondo State; Ibadan, Oyo State; Badagry, Lagos State; Ekiti West and Ekiti Southeast, Ondo State; and Egbeda Local Government Area, Oyo State. It is generally believed that men have a greater need for sex than do women, and that men should have unlimited sexual freedom while women are expected to have only one partner. Men's extramarital sexual activity is largely taken for granted. However, a growing number of men and women now believe that one woman is enough for one man at any given time and over a lifetime. Respondents often mentioned being afraid of sexually transmitted diseases and AIDS. Extramarital relations during a wife's postpartum abstinence are no longer important because of the rising level of contraception and the rapid decline in the duration of breastfeeding and postpartum abstinence. The double standards of male and female sex behavior will diminish with increased access to education and the move toward monogamous unions.
Patterns of migration do not simply arise out of chance. In South Africa, for example, migration patterns are a result of decades of legislation aimed at restricting the movements of the majority of the population and providing a steady flow of cheap black labour to the gold mines and other industries. In the new democratic South Africa, restrictive laws have been lifted, but circular migration remains a way of life for several million black South Africans. This paper examines the social and epidemiological implications of widespread circular migration from the perspective of a rural South African Health District. In particular, we report our findings on the patterns and prevalence of migration into and out of the Hlabisa Health District in rural KwaZulu/Natal, and the patterns of sexual networking of migrants and their rural partners. We conclude by examining the implications of these patterns of migration and sexual networking for the spread of HIV and other STDs.
Divorced or separated persons are more likely to be infected with HIV than those in marital unions: sexual partner instability appears to have significant implications in STD/HIV transmission. While this appears empirically true, most current STD/HIV preventive strategies do not seem to address partner instability as an important underlying factor in STD/HIV transmission and control. This paper describes reasons why young females may be motivated to change sexual partners or have more than one sexual partner. The problems appear to be dissatisfaction due to infidelity of the male partner, fear of getting STD from current partner, drunken or unattractive male partner, economic problems, lack of leisure time together, male partner's children with other women, and male partner's relatives' influence. STD/AIDS Control Programs should note that dissatisfaction with partner may be an underlying factor in HIV transmission.
The paper examines the relationship between the lifetime risk of dying from AIDS and HIV prevalence, using a female stable population model in which the epidemic has stabilized. In addition to prevalence, lifetime risk is determined by various other factors, notably the level of mortality from causes other than AIDS, age at infection, and survival time between infection and death. Typically, the lifetime risk of dying from AIDS is between three and five times the HIV prevalence. Regression equations are developed for estimating lifetime risk from the prevalence and other parameters. The methods are applied to data for Kenya, and it is shown that the 1995 prevalence estimate of 7.5 per cent for the population aged 15 and over would be equivalent to a lifetime risk of about 30 per cent. HIV prevalence, or the proportion of the adult population which is HIV-positive, is the most commonly used index for measuring the scale of the epidemic. In African countries, national estimates of HIV prevalence are generally only available for females, as the main source of data is the anonymous testing of women who use antenatal services. More direct measures of the effect of HIV could be found from the annual death rate due to AIDS in the adult population, or the proportion of all adult deaths which are due to AIDS. These measures are rarely available in practice, as most African countries do not have death registration systems, and in any case, AIDS deaths are frequently perceived as due to other causes (Boerma et al. 1997). None of the above measures tells us about the overall risk of contracting HIV or dying from AIDS faced by an individual approaching adulthood and sexual maturity. But this last measure, which for a disease like AIDS is three or four times as large as the current prevalence measure, is one which would be very useful to planners and health educators alike. It would enable those who train skilled workers and professionals to judge what proportion of their cadres would be lost to this disease before the end of their working lives. It would allow insurance companies to set realistic premiums in countries affected by the epidemic. And it could provide a powerful advocacy tool for those trying to persuade young people not to follow the norm in terms of widely prevalent unsafe sexual behaviour. HIV prevalence, or the proportion of the adult population which is HIV-positive, is the most commonly used index for measuring the scale of the epidemic. In African countries, national estimates of HIV prevalence are generally only available for females, as the main source of data is the anonymous testing of women who use antenatal services. This paper investigates the relationship between HIV prevalence and lifetime risk, using models of age-specific incidence which have been tailored to reflect the type of sexual union formation patterns observed amongst females in a wide range of African populations. We focus on females because information on HIV prevalence, participation in sexual unions and fertility is widely available for females but not for males. The relationships which we discover
The AIDS epidemic has caused an increase in adult mortality and consequently an increase in the numbers of orphaned children. Data were used from the Kisesa Community Study in northwest Tanzania, to assess the prevalence and consequences of orphanhood in the context of existing child care practices in a rural area with moderately high HIV-prevalence. This study was carried out in a ward with about 20,000 people with HIV prevalence of 6.2 per cent among adults 15-44 years and slightly over one-third of adult deaths associated with HIV/AIDS. Seven point six per cent of children under 15 and 8.9 per cent of children under 18 had lost one or both parents. Child fostering was very common. Virtually all orphans and foster-children were cared for by members of the extended family, often the maternal grandparents: 14 per cent of households had at least one orphan. Such households did not have a lower economic status, but had a less favourable dependency ratio. Households with orphans were also more likely to be female-headed. Follow-up mortality rates were similar among orphans, foster-children and other children, for both sexes. Mobility was much higher among orphans and foster-children, and orphans and foster-children had somewhat lower school attendance rates: lower enrolment and higher dropout rates. The problem of rapidly increasing numbers of orphans needs to be considered in the context of previously high levels of adult mortality, child-fostering practices and general poverty. The extended family seems to be able to absorb the increase in orphans, because caring for children of other members of the family is widespread, whether the parents are alive or dead. This study yields no evidence that orphans as a group are disadvantaged, although certain subgroups of orphans or orphan households may be more vulnerable and in need of support.
Many health programs in developing countries share the common goals of reducing infant and child mortality. But there is no consensus on the most effective way to attain these goals. After regarding the historical evidence some contend that improvements in child survival are most strongly associated with a wide range of social and cultural changes such as changes in attitudes to child rearing in expectations regarding future support for parents from children and in womens expectations for themselves and for their children often stimulated as part of the literacy revolution. Of all the social factors associated with child mortality reductions maternal education specifically literacy has been singled out as one of the most important. In studies conducted in diverse locations such as Bangladesh India Mexico Nigeria and Zambia strong correlations have been found between maternal education and child mortality. From the findings of these researchers public health practitioners have advocated child health programs that are implemented in combination with a range of developmental interventions that will stimulate the kinds of social and cultural change believed to be the key to facilitating changes in health attitudes and behaviour. (excerpt)
This paper seeks to examine the linkage between mothers’ work and child health. The data are from a survey of 75 working and 75 non-working women in a village in Tamil Nadu, India. The results show that the working women spend on an average 1.7 hours less than the non-working women on child care. The duration of breastfeeding also is shorter among the working women. The morbidity rates were higher for the children of working women than for the children of nonworking women. Logistic regression analysis showed that the children of working women are at a significantly greater risk of morbidity even when socio-economic factors are controlled. The results, however, do not show a significant variation in morbidity by sex. Traditionally a woman's place has been at home and a generation ago, her employment outside the home was looked down upon by the society. This situation has now changed and women have started seeking employment outside their homes through gross economic necessity followed by the desire to raise economic status, to have an independent income, to make use of education, to pursue a career etc. In rural areas, however, poor women may go to work mainly out of sheer economic necessity. In the demographic literature, the discussion of the relationship between women's work and child mortality has almost always focused on paid employment outside the home. At low skills and in less developed economies, working women's additional income may be quite small. The mother's employment is seen as affecting the family through changes in care received by children. If the woman is working, she is likely to spend less time on feeding children, cleaning them, and playing with them. In the past, older siblings or grandparents were usually available to take care of young infants while the mother was employed; but because of social change and modernization, the extended family has become less common. All these factors may contribute to poor child health. On the basis of a review of literature, Ware (1984) observed that women's economic activities will have an adverse effect on child care only where the activity is incompatible with child rearing or where the mother lacks access to another person able to care for the child. There is a possibility of child neglect and malnutrition due to an early abandonment of breastfeeding. Very few studies in India have specifically investigated the effect of mothers’ work on child health. However, a few analyses of child mortality have examined mothers’ work
A 1991 serosurvey in a Ugandan trading town on the trans-African highway reported a 40 per cent HIV-1 prevalence in adults. Three years later in a repeat survey of the 531 adults resident in 1991, 279 (53%) were still present, 196 (37%) had left and 56 (11%) had died. There were 138 new residents and 46 children had become adults, making a total of 463 adults in 1994, 13 per cent less than 1991. Most immigrants (91%) came from the surrounding rural district whereas 38 per cent of emigrants went to an urban area. A significant inverse association between wealth and seropositivity was found for women but not men. Of the original residents 157 were known to be HIV-1 positive in 1991; 31 (20%) had died compared to 10 (4%) of the 232 known to be seronegative, representing an HIV-1 attributable mortality fraction of 60 per cent.
The contemporary AIDS epidemic can be compared with the other major visitations of pestilence. In Europe 20 million or more people probably died during the Black Death in 1347-1351, and globally perhaps 20 million died during the 1917-1919 influenza epidemic. By the end of 1996 the world estimates for the AIDS epidemic were over 6 million dead and a further 23 million seropositive and nearly all certain of death. In numbers dying, the AIDS epidemic will certainly far exceed both other historic epidemics, although no-one knows the total mortality in Europe and Asia for the Black Death. The reason for the inevitability of greater mortality from AIDS is the open-endedness of the present epidemic. Both the previous epidemics just cited were over in three or four years, and it is this relatively short duration which was thought to characterize epidemics. In contrast, the first AIDS cases were identified in 1981, the result of infection mostly over the previous decade. Thus, the AIDS epidemic is already a quarter of a century old, and the level of infection is still climbing both globally and in the Third World. There is no evidence as yet about its likely duration or even whether it will become endemic in some parts of the world. There are, however, contrasting aspects of the disease. World population is now three times its level in the early twentieth century and ten times that of the fourteenth century. Population growth rates in most of the Third World are now so high that even a huge rise in mortality may not cancel them out, and we are not yet certain that any country will experience a decline in population size because of AIDS. In comparison, the Black Death ravaged a nearstationary population, reducing Europe’s numbers by perhaps one-third. The high population growth rates of the developing world have come about because of continuing high fertility together with declining mortality which has raised life expectancy even in sub-Saharan Africa to almost 50 years. Thus, the most pessimistic projection of the present epidemic does not show the expectation of life at birth falling to as low a level as 30 years in any sub-Saharan African country, while the influenza epidemic reduced India’s expectation of life for the whole intercensal decade, 1911-1921, to 18.5 years. Nevertheless, there is in Africa a contemporary AIDS epidemic which in its intensity and in its impact on the population can be likened to the plague. In its intensity it is quite unlike anything experienced by national populations outside sub-Saharan Africa, although some sectors of other populations, such as homosexuals in the United States, may have comparable experiences. This severe epidemic is identified in Table 1 and Map 1. The affected population is found in a long belt stretching from the Central African Republic and southern Sudan through Uganda, Rwanda, Burundi, Kenya and Tanzania to Malawi, Zambia, Zimbabwe, Botswana, South Africa and Namibia. The map, but not the table, identifies southern Sudan, which has been omitted from the table both because it is not a national population and because HIV testing is so poor as to be suggestive rather than definitive. In South Africa, KwaZuluNatal has been disproportionately affected (and the major city in the table is not Johannesburg * In this concluding chapter, other chapters are referenced by providing only the author’s name and no date. All other publications are referenced with the year of publication. Assistance has been provided by Jeff Marck, Wendy Cosford and Pat Goodall of the Australian National University’s Health Transition Centre.
Antibody screening for HIV has reduced transmission of AIDS by blood transfusion. Of the 12,768 units of blood donated to the Mbarara Regional Blood Bank between January 1992 and December 1994, 577 were found to be HIVI-positive using the ELISA technique. Percentage of positivity decreased from 5.4 in 1992 to 3.9 in 1994. Replacement donors had a higher positivity rate than volunteer donors. The females had more positives than the males. Distribution of the blood groups O and AB was similar between the Ugandan and English samples. There were differences in the blood groups A and B. The AB blood group which was only 4 per cent of the total had a higher percentage of HIV I positives. This preliminary finding should be confirmed by a more organized study.
Fertility rates in a population-based cohort of over 3500 women aged 15-49 years living in rural southwest Uganda are described and examined in relation to infection with HIV. Over a six-year follow-up period (1989/90 to 1995/6) the average general fertility rate was estimated as 199 births per thousand woman-years of observation (95 % confidence interval 191 to 207) with a total fertility rate of 6.2 births per woman. The overall prevalence of infection with HIV was 12 per cent and remained relatively stable during follow-up. With the exception of women aged 15-19 years, women who were not infected with HIV had higher fertility than HIV-infected women. The overall age-adjusted fertility rate in HIV-infected women was 0.74 of that of uninfected women (95% confidence interval 0.63 to 0.87, P<0.001) and this result was unaffected by additional adjustment for marital status. When combined with an overall HIV prevalence rate of 12 per cent, this corresponds to a three per cent reduction in fertility rates in the whole population. The lower fertility in HIV-positive women is unlikely to be explained by increased use of contraception, as use of modern contraceptive methods in rural Uganda is low and fewer than ten per cent of women are aware of their HIV-serostatus. More likely explanations are reduced sexual activity due to clinical symptoms associated with HIV infection or lower fertility associated with coexisting infections with other sexually transmitted diseases, such as syphilis. A reduction in fertility caused by HIV infection itself cannot be excluded. The implications of these findings for the use of antenatal clinic data to provide population estimates of HIV prevalence are discussed. Understanding the effect of HIV 1 infection on fertility in populations in sub-Saharan Africa is vital for predicting the likely demographic impact of the epidemic and for predicting the future socio-demographic burden on communities of increased numbers of children infected by vertical transmission of HIV or subsequently orphaned by the death of their HIV-infected
This paper examines the psychological effect of orphanhood in a case study of 193 children in Rakai district of Uganda. Studies on orphaned children have not examined the psychological impact. Adopting parents and schools have not provided the emotional support these children often need. Most adopting parents lack information on the problem and are therefore unable to offer emotional support; and school teachers do not know how to identify psychological and social problems and consequently fail to offer individual and group attention. The concept of the locus of control is used to show the relationship between the environment and individuals' assessment of their ability to deal with it and to adjust behaviour. Most orphans risk powerful cumulative and often negative effects as a result of parents' death, thus becoming vulnerable and predisposed to physical and psychological risks. The children were capable of distinguishing between their quality of life when their parents were alive and well, when they became sick, and when they eventually died. Most children lost hope when it became clear that their parents were sick, they also felt sad and helpless. When they were adopted, many of them felt angry and depressed. Children living with widowed fathers and those living on their own were significantly more depressed. These children were also more externally oriented than those who lived with their widowed mothers. Teachers need to be retrained in diagnosing psycho-social problems and given skills to deal with them. Short courses should be organized for guardians and community development workers in problem identification and counselling.
The World Development Report 1993 announced that global life expectancy was then 65. Experience in the developed world suggests that the World Health Organization's dictum, 'health is a state of complete physical, mental and social well-being', is simply not attainable for the foreseeable future. As physical health has improved, mental problems have become more prominent and a sense of well-being has declined. Furthermore, as the population ages and medical technology improves, the cost of health care grows almost exponentially. Since the population of the developed world is continuing to age and aging is spreading rapidly throughout the developing world, knowledge is the principal way of dealing with this seemingly intractable problem: we must know, quantitatively, the age-specific causes of ill health, and we must know which means of prevention and treatment are effective. Finally, we must apply that knowledge rationally.
The Rakai Project conducted a population-based cohort study in rural Rakai District, Uganda, a region with high rates of HIV prevalence. The cohort population described here was followed between 1990 and 1992 and consisted of all residents aged 15 years or more living in 1945 households in 31 community clusters. A detailed census was conducted at baseline in every study household. Census data were updated annually, and all inter-survey deaths, births, and migrations were recorded. Immediately following each annual census, all consenting adults were administered a socio-demograp hic, behavioural and health survey, and provided a blood sample for HIV testing.
Over 30,000 ever-married women in 13 (out of 25) Indian states where HIV is thought to be highly prevalent-Maharashtra, West Bengal, Tamil Nadu, and ten other less populous states-were surveyed about their awareness and knowledge of AIDS. Only one in six women had heard of AIDS. Among those, knowledge about transmission and prevention is poor. Multivariate analyses reveal that rural, poorly educated, and poor women are the least likely to be AIDS-aware and if aware, have the poorest understanding of the syndrome. Despite low levels of awareness and knowledge, we find a strong positive association between AIDS awareness and knowledge and condom use.
This paper describes the general cultural background of male circumcision for the Bantu speaking peoples of sub-equatorial Africa. Where the contemporary cultural context of male circumcision is now variable and often transformed amongst groups who continue the practice, traditional practices were commonly of a particular and rather narrow profile linked to the toughening, training and initiation of male adolescents into warrior status. For those groups the normal social context of circumcision was in the adolescent rites of passage typically called 'initiation schools' in the ethnographic literature. These in turn were highly associated with 'age-grades', age ranked male cohorts whose membership was defined by participation in the same initiation schools in the same year. Linguistic evidence suggests the schools and circumcision are very ancient and typological arguments suggest that those Bantu groups which do not circumcise males have abandoned a once more widespread practice. In the main, the Bantu groups which do not circumcise males belong to certain contiguous linguistic groups and their neighbours from amongst bordering Bantu subgroups. Almost all groups which have abandoned male circumcision have also abandoned initiation schools and age-grades. This constitutes a culture area in terms of those dimensions of those societies. Circumcising and non-circumcising groups are suggested to have their distribution due to diffusion of loss and it cannot be expected that differential risk behaviours in relation to HIV infection will be found to sort similarly amongst Bantu-speaking or other African peoples. But such mapping, for those who would do it, can now take place with the knowledge that a cluster of cultural traits typify the non-circumcising Bantu groups.
We use data from an anonymous self-administered 1991 survey of military personnel in northern Thailand to estimate overall levels of and socio-demographic differentials in same-sex sexual behaviour in this population. Additionally, we examine the relationship between sexual experience with another male and a variety of outcomes relevant to HIV prevention and policy. Overall, 16.3 per cent of the sexually active soldiers report ever having had anal or oral sex with other males. Same-sex sexual behaviour in this sample is positively associated with several indicators of higher socio-economic status. All of the men who report having had sex with other men report having had vaginal intercourse with females as well. Comparison of our estimate of same-sex sexual behaviour with those obtained from two similar samples drawn in 1991 suggests that the lower estimates observed in the other two studies are largely due to differences in data collection methods. Regarding the HIV/AIDS-related outcomes we examined, men who have had sex with other men are significantly more likely than those who have not to have ever injected drugs, to personally know someone with HIV/AIDS, to have had sex with a female prostitute in the last six months, and to have had a sexually transmitted disease in the last six months. In this sample, men who have had sex with other men are also less knowledgeable about HIV/AIDS than are men who have not. These results are discussed in terms of their implications for HIV-prevention policy in Thailand.
Extended families and clans in African societies have extensive systems of treatment and patient management which can be used with AIDS sufferers. This paper used data from a baseline survey of six districts to study patient care in Uganda. The levels of AIDS illness are high, and highest in the sexually active age groups of 20-49 years. Of the nuclear family, parents, siblings, spouses and children are the dominant AIDS patients' primary carers in that order. Other relatives in the extended family also contribute much primary care. The contribution of neighbours and friends to primary caring and of other relatives as secondary carers is small. This is perhaps because of the financial burden of caring for the patients. However, there are indications that households and families are coping with the effects of the disease.
The consensus achieved at the 1994 International Conference on Population and Development (ICPD) signaled a move away from discussing population issues in the context of demographic targets, toward global recognition that the problems associated with rapidly growing human populations are part of a broader human development agenda. Devoid of demographic targets, the ICPD program of action instead challenges countries to change their approach to population programs, family planning, and reproductive health. World Fertility Survey and Demographic and Health Survey data indicate a high level of unwanted fertility in almost all countries covered. The lack of availability or inaccessibility of family planning services is but one reason why there is so much unmet need. There would be greater uptake of family planning if services were planned with community involvement and oriented toward clients, offering them real choices and paying more attention to them as individuals and their overall circumstances. That expansion in concept and of services is at the core of the Cairo agenda. A number of countries around the world have started taking steps to broaden existing family planning and related programs to include other reproductive health information and services. Mexico and India are examples of two developing countries which are making program and structural changes in order to implement the ICPD recommendations, while most African countries have welcomed the approach and are looking for technical and resource help for implementation.
