Summary:In Thyolo District, Malawi, a study was conducted among commercial sex workers (CSWs) attending mobile clinics in order to; determine the prevalence and pattern of sexually transmitted infections (STIs), describe sexual behaviour among those who have an STI and identify risk factors associated with`no condom use' .There were 1817 CSWs, of whom 448 (25%) had an STI. Of these, the commonest infections included 237 (53%) cases of abnormal vaginal discharge, 109 (24%) cases of pelvic in¯ammatory disease and 95 (21%) cases of genital ulcer disease (GUD). Eightyseven per cent had sex while symptomatic, 17% without condoms. Having unprotected sex was associated with being married, being involved with commercial sex outside a known rest-house or bar, having a GUD, having fewer than two clients/day, alcohol intake and having had no prior medication for STI.The high levels of STIs, particularly GUDs, and unprotected sex underlines the importance of developing targeted interventions for CSWs and their clients.

Laboratory services are run down in many low-income countries, severely constraining their input to patient care and disease surveillance. There are few data about the quality and cost of individual components of the laboratory service in poorer countries, yet this information is essential if optimal use is to be made of scarce resources. Staff time, range of tests, workload, and safety procedures were monitored over 12 months (1997-98) in a typical district hospital laboratory in Malawi. Data were collected to calculate the total economic cost of these services. Of the 31203 tests performed, 84% were to support blood transfusion and diagnosis of malaria and tuberculosis (TB). Test quality was reasonable for malaria and TB microscopy and blood transfusion, but poor for haemoglobin estimation. The cost per test ranged from US dollars 0.35 for haemoglobin to US dollars 11.7 per unit of blood issued and the total annual cost of the laboratory service was US dollars 32618. Blood transfusion and microscopy for malaria and TB comprised the majority of tests. Ensuring that these tests are of the highest quality will therefore have the most impact in reducing wastage of laboratory resources. Inadequate quality of haemoglobin estimations is a particular problem. The findings of this study are likely to be relevant to other low-income countries with similar disease burdens.

The prevalence of antibodies to human immunodeficiency virus type 1 (HIV-1), hepatitis C virus (HCV), human T lymphotropic virus I (HTLV-I), and hepatitis B (HBV) surface antigen (HBsAg) was determined in blood donors from Ntcheu, Malawi. Each donation was also screened for HIV-1 RNA and HCV RNA. Among 159 blood donations, the prevalence of HIV-1 infection was 10.7%, 8.1% for HBV carriage, 6.8% for anti-HCV, and 2.5% for anti-HTLV-I. HIV-1/HTLV-I and HIV-1/HCV dual infections were observed in 1.2% of the donations. Consequently, 13% of blood donors from Ntcheu should be deferred for retroviral infections and 15% for hepatitis viral infections. Sequence analyses of the HIV-1 strains revealed a relatively homogeneous circulation of subtype C viruses in Malawi. These findings confirm the high endemicity of blood-borne viruses in Malawi and the need for a sensitive viral screening of blood donations to improve blood safety.

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Objectives: To describe health seeking and sexual behaviour including condom use among patients presenting with sexually transmitted infections (STIs) and, to identify sociodemographic and behavioural risk factors associated with "no condom use" during the symptomatic period. Methods: A cross sectional study of consecutive new STI cases presenting at the district STI clinic in Thyolo, Malawi. They were interviewed by STI counsellors after obtaining informed consent. All patients were treated according to national guidelines. Results: Out of 498 new STI clients, 53% had taken some form of medication before coming to the STI clinic, the most frequent alternative source being the traditional healer (37%). 46% of all clients reported sex during the symptomatic period (median 14 days), the majority (74%) not using condoms. 90% of all those who had not used condoms resided in villages and had seen only the traditional healer. Significant risk factors associated with "no condom use" included visiting a traditional healer, being female, having less than 8 years of school education, and being resident in villages. Genital ulcer disease (GUD) was the most common STI in males (49%) while in females this comprised 27% of STIs. Conclusions: These findings, and especially the extremely high GUD prevalence is of particular concern, considering the high national HIV prevalence in Malawi (9%) and the implications for STI and HIV transmission. There is an urgent need to integrate traditional healers in control activities, encourage their role in promoting safer sexual behaviour, and to reorient or even change existing strategies on condom promotion and STI control. S exually transmitted infections (STIs) are known to facilitate the sexual transmission of HIV 1 2 and effective STI case management is known to reduce the incidence of HIV.3 Malawi has both high HIV and high STI rates. The national HIV prevalence in Malawi is 9%, while among antenatal women the syphilis seroprevalence is estimated at 2-10%. 4 In 1990, 42% of antenatal clinic attendees were diagnosed with at least one STI and HIV infection rates among patients with STIs range from 53-83%.5 STI control in Malawi is therefore of major public health importance.An important determinant of effective STI control is the health seeking behaviour of people with STIs who may seek care from alternative sources (outside an official STI clinic) such as traditional healers, private clinics, pharmacists, and market vendors.Traditional healers in particular are well reputed in African rural communities and are often considered to be the most appropriate initial point of contact for help when symptoms of STIs are thought to be linked to traditional beliefs and related perceptions. 6 Knowledge about the relative importance of these alternative providers in STI control could encourage better collaboration with some of these groups, encourage early referral for effective antibiotic treatment, and help remove or reduce potential barriers to STI control.Control of STIs involves not only pro...