SummaryOBJECTIVES To understand the reasons for poor cataract surgery uptake in people with blindness or severe visual impairment in rural South Africa. METHODSMETHODS A qualitative analysis of detailed, domiciliary interviews with a community-based random sample of elderly Zulus who were blind or severely visually impaired as a result of operable cataract, who had previously been invited for surgery but had failed to attend. RESULTS RESULTSFear of surgery and a fatalistic attitude to the inevitability and irreversibility of blindness in old age were the main reasons for failure to attend for surgery. There was a lower level of disability and perceived need than had been assumed for people with such poor visual acuity. Non-surgical western style health care for systemic illness was common but few patients had sought any form of assistance for their poor vision. Issues of cost and accessibility were relatively unimportant.CONCLUSIO N CONCLUSION Provision of affordable and accessible cataract surgery for the blind and severely visually impaired members of a community does not guarantee that it will be taken up. Other barriers to surgery may be revealed when practical issues such as cost and accessibility are addressed. Perceptions of visual disability among subjects with cataract may differ from simple objective clinical standards.

Background: Syphilis remains a significant cause of preventable perinatal death in developing countries, with many women remaining untested and thus untreated. Syphilis testing in the clinic (on-site testing) may be a useful strategy to overcome this. We studied the impact of on-site syphilis testing on treatment delays and rates, and perinatal mortality. Methods: We conducted a cluster randomised controlled trial among seven pairs of primary healthcare clinics in rural South Africa, comparing on-site testing complemented by laboratory confirmation versus laboratory testing alone. Intervention clinics used the on-site test conducted by primary care nurses, with results and treatment available within an hour. Control clinics sent blood samples to the provincial laboratory, with results returned 2 weeks later. Results: Of 7134 women seeking antenatal care with available test results, 793 (11.1%) tested positive for syphilis. Women at intervention clinics completed treatment 16 days sooner on average (95% confidence interval: 11 to 21), though there was no significant difference in the proportion receiving adequate treatment at intervention (64%) and control (69%) clinics. There was also no significant difference in the proportion experiencing perinatal loss (3.3% v 5.1%; adjusted risk difference: −0.9%; 95% CI −4.4 to 2.7). Conclusions: Despite reducing treatment delays, the addition of on-site syphilis testing to existing laboratory testing services did not lead to higher treatment rates or reduce perinatal mortality. However on-site testing for syphilis may remain an important option for improving antenatal care in settings where laboratory facilities are not available.

Few high-quality studies were found. HIV is detected moderately more frequently in genital secretions of men and women with a STD, and HIV load is substantially increased among men with urethritis. Successful STD treatment reduces both of these parameters, but not to control levels. More high-quality studies are needed to explore this important relationship further.

Summaryobjective To demonstrate the impact on perinatal mortality of inadequate treatment for maternal syphilis despite adequate screening. method In 12 clinics providing antenatal care in Hlabisa, South Africa 1783 pregnant women were screened for syphilis at their first antenatal visit between June and October 1998. Pregnancy outcome was determined among those with syphilis. results A total of 158 women were diagnosed with syphilis: prevalence 9% (95% CI 8-10%). Mean gestation at first antenatal visit was 24 weeks. Thirty women (19%) received no treatment and 96 (61%) received all three recommended doses of penicillin. Among those receiving at least one dose, mean delay to the first dose was 20 days. Among those fully treated mean delay to treatment completion was 34 days. Pregnancy outcome was known for 142 women (90%) and there were 17 perinatal deaths among 15 women (11%). Eleven of 43 women (26%) who received one or fewer doses of penicillin experienced a perinatal death whilst only four of 99 women (4%) who received two or more doses of penicillin did so (P ϭ 0.0001). Protection from perinatal death increased with the number of doses of penicillin: linear modelling suggests that one dose reduced the risk by 41%, two doses by 65% and three doses by 79%, compared with no doses. A dose-specific, categorical model confirmed reduction in risk by 79% for all three doses. conclusion Despite effective screening, many pregnant women with syphilis remain inadequately treated, resulting in avoidable perinatal mortality. Delays in starting and finishing treatment, as well as incomplete treatment occur. Near-patient syphilis testing in the antenatal clinic with early treatment could improve treatment of syphilis and reduce perinatal mortality, and a randomized trial to test this is underway. keywords perinatal mortality, syphilis, Africa correspondence Professor

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