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1.  Inpatient child mortality by travel time to hospital in a rural area of Tanzania 
To investigate the association, if any, between child mortality and distance to the nearest hospital.
The study was based on data from a 1-year study of the cause of illness in febrile paediatric admissions to a district hospital in north-east Tanzania. All villages in the catchment population were geolocated, and travel times were estimated from availability of local transport. Using bands of travel time to hospital, we compared admission rates, inpatient case fatality rates and child mortality rates in the catchment population using inpatient deaths as the numerator.
Three thousand hundred and eleven children under the age of 5 years were included of whom 4.6% died; 2307 were admitted from <3 h away of whom 3.4% died and 804 were admitted from ≥3 h away of whom 8.0% died. The admission rate declined from 125/1000 catchment population at <3 h away to 25/1000 at ≥3 h away, and the corresponding hospital deaths/catchment population were 4.3/1000 and 2.0/1000, respectively. Children admitted from more than 3 h away were more likely to be male, had a longer pre-admission duration of illness and a shorter time between admission and death. Assuming uniform mortality in the catchment population, the predicted number of deaths not benefiting from hospital admission prior to death increased by 21.4% per hour of travel time to hospital. If the same admission and death rates that were found at <3 h from the hospital applied to the whole catchment population and if hospital care conferred a 30% survival benefit compared to home care, then 10.3% of childhood deaths due to febrile illness in the catchment population would have been averted.
The mortality impact of poor access to hospital care in areas of high paediatric mortality is likely to be substantial although uncertainty over the mortality benefit of inpatient care is the largest constraint in making an accurate estimate.
PMCID: PMC4269975  PMID: 24661618
access; hospital; mortality; child; Africa
2.  Cryptosporidium Prevalence and Risk Factors among Mothers and Infants 0 to 6 Months in Rural and Semi-Rural Northwest Tanzania: A Prospective Cohort Study 
Cryptosporidium epidemiology is poorly understood, but infection is suspected of contributing to childhood malnutrition and diarrhea-related mortality worldwide.
A prospective cohort of 108 women and their infants in rural/semi-rural Tanzania were followed from delivery through six months. Cryptosporidium infection was determined in feces using modified Ziehl-Neelsen staining. Breastfeeding/infant feeding practices were queried and anthropometry measured. Maternal Cryptosporidium infection remained high throughout the study (monthly proportion = 44 to 63%). Infection did not differ during lactation or by HIV-serostatus, except that a greater proportion of HIV-positive mothers were infected at Month 1. Infant Cryptosporidium infection remained undetected until Month 2 and uncommon through Month 3 however, by Month 6, 33% of infants were infected. There were no differences in infant infection by HIV-exposure. Overall, exclusive breastfeeding (EBF) was limited, but as the proportion of infants exclusively breastfed declined from 32% at Month 1 to 4% at Month 6, infant infection increased from 0% at Month 1 to 33% at Month 6. Maternal Cryptosporidium infection was associated with increased odds of infant infection (unadjusted OR = 3.18, 95% CI 1.01 to 9.99), while maternal hand washing prior to infant feeding was counterintuitively also associated with increased odds of infant infection (adjusted OR = 5.02, 95% CI = 1.11 to 22.78).
Both mothers and infants living in this setting suffer a high burden of Cryptosporidium infection, and the timing of first infant infection coincides with changes in breastfeeding practices. It is unknown whether this is due to breastfeeding practices reducing pathogen exposure through avoidance of contaminated food/water consumption; and/or breast milk providing important protective immune factors. Without a Cryptosporidium vaccine, and facing considerable diagnostic challenges and ineffective treatment in young infants, minimizing the overall environmental burden (e.g. contaminated water) and particularly, maternal Cryptosporidium infection burden as a means to protect against early infant infection needs prioritization.
Author Summary
Early infancy and childhood Cryptosporidium infection is associated with poor nutritional status, stunted growth, and cognitive deficits, yet minimal research is available regarding the burden and risk factors worldwide. Since there is no vaccine available, and because diagnostic challenges exist and treatment for children younger than one year is ineffective, prevention of early infancy infection through a better understanding of basic epidemiology is critical. This study was designed to investigate symptomatic and clinically silent infection amongst HIV-seropositive and HIV-seronegative mothers and their infants in a longitudinal cohort, and to indentify potential risk factors. Findings indicate that infants are living in a Cryptosporidium environment as demonstrated by the chronically high level of maternal infection throughout the 6-month post-partum period. Despite this, infant infection prevalence remains low until six months of age when it dramatically rises. The increase in infant infection corresponds to a reduction in exclusive breastfeeding. As expected, maternal infection is associated with increased infant infection, but unexpectedly, so is maternal hand washing prior to infant feeding. Since prevention may indeed be the “best medicine” for infants, investigation of beneficial breastfeeding practices, protective correlates in breast milk, and ways to reduce the maternal and environmental Cryptosporidium burden are needed.
PMCID: PMC4183438  PMID: 25275519
3.  “Men are always scared to test with their partners … it is like taking them to the Police”: Motivations for and barriers to couples’ HIV counselling and testing in Rakai, Uganda: a qualitative study 
Uptake of couples’ HIV counselling and testing (couples’ HCT) can positively influence sexual risk behaviours and improve linkage to HIV care among HIV-positive couples. However, less than 30% of married couples have ever tested for HIV together with their partners. We explored the motivations for and barriers to couples’ HCT among married couples in Rakai, Uganda.
This was a qualitative study conducted among married individuals and selected key informants between August and October 2013. Married individuals were categorized by prior HCT status as: 1) both partners never tested; 2) only one or both partners ever tested separately; and 3) both partners ever tested together. Data were collected on the motivations for and barriers to couples’ HCT, decision-making processes from tested couples and suggestions for improving couples’ HCT uptake. Eighteen focus group discussions with married individuals, nine key informant interviews with selected key informants and six in-depth interviews with married individuals that had ever tested together were conducted. All interviews were audio-recorded, translated and transcribed verbatim and analyzed using Nvivo (version 9), following a thematic framework approach.
Motivations for couples’ HCT included the need to know each other's HIV status, to get a treatment companion or seek HIV treatment together – if one or both partners were HIV-positive – and to reduce mistrust between partners. Barriers to couples’ HCT included fears of the negative consequences associated with couples’ HCT (e.g. fear of marital dissolution), mistrust between partners and conflicting work schedules. Couples’ HCT was negotiated through a process that started off with one of the partners testing alone initially and then convincing the other partner to test together. Suggestions for improving couples’ HCT uptake included the need for couple- and male-partner-specific sensitization, and the use of testimonies from tested couples.
Couples’ HCT is largely driven by individual and relationship-based factors while fear of the negative consequences associated with couples’ HCT appears to be the main barrier to couples’ HCT uptake in this setting. Interventions to increase the uptake of couples’ HCT should build on the motivations for couples’ HCT while dealing with the negative consequences associated with couples’ HCT.
PMCID: PMC4169647  PMID: 25239379
Motivations; barriers couples; counselling; testing; Rakai; Uganda
4.  Hypertension, kidney disease, HIV and antiretroviral therapy among Tanzanian adults: a cross-sectional study 
BMC Medicine  2014;12(1):125.
The epidemics of HIV and hypertension are converging in sub-Saharan Africa. Due to antiretroviral therapy (ART), more HIV-infected adults are living longer and gaining weight, putting them at greater risk for hypertension and kidney disease. The relationship between hypertension, kidney disease and long-term ART among African adults, though, remains poorly defined. Therefore, we determined the prevalences of hypertension and kidney disease in HIV-infected adults (ART-naive and on ART >2 years) compared to HIV-negative adults. We hypothesized that there would be a higher hypertension prevalence among HIV-infected adults on ART, even after adjusting for age and adiposity.
In this cross-sectional study conducted between October 2012 and April 2013, consecutive adults (>18 years old) attending an HIV clinic in Tanzania were enrolled in three groups: 1) HIV-negative controls, 2) HIV-infected, ART-naive, and 3) HIV-infected on ART for >2 years. The main study outcomes were hypertension and kidney disease (both defined by international guidelines). We compared hypertension prevalence between each HIV group versus the control group by Fisher’s exact test. Logistic regression was used to determine if differences in hypertension prevalence were fully explained by confounding.
Among HIV-negative adults, 25/153 (16.3%) had hypertension (similar to recent community survey data). HIV-infected adults on ART had a higher prevalence of hypertension (43/150 (28.7%), P = 0.01) and a higher odds of hypertension even after adjustment (odds ratio (OR) = 2.19 (1.18 to 4.05), P = 0.01 in the best model). HIV-infected, ART-naive adults had a lower prevalence of hypertension (8/151 (5.3%), P = 0.003) and a lower odds of hypertension after adjustment (OR = 0.35 (0.15 to 0.84), P = 0.02 in the best model). Awareness of hypertension was ≤25% among hypertensive adults in all three groups. Kidney disease was common in all three groups (25.6% to 41.3%) and strongly associated with hypertension (P <0.001 for trend); among hypertensive participants, 50/76 (65.8%) had microalbuminuria and 20/76 (26.3%) had an estimated glomerular filtration rate (eGFR) <60 versus 33/184 (17.9%) and 16/184 (8.7%) participants with normal blood pressure.
HIV-infected adults on ART >2 years had two-fold greater odds of hypertension than HIV-negative controls. HIV-infected adults with hypertension were rarely aware of their diagnosis but often have evidence of kidney disease. Intensive hypertension screening and education are needed in HIV-clinics in sub-Saharan Africa. Further studies should determine if chronic, dysregulated inflammation may accelerate hypertension in this population.
PMCID: PMC4243281  PMID: 25070128
Hypertension; Blood pressure; HIV; Antiretroviral therapy; Sub-Saharan Africa; Kidney disease
5.  Assessment of paediatric inpatient care during a multifaceted quality improvement intervention in Kenyan District Hospitals – use of prospectively collected case record data 
In assessing quality of care in developing countries, retrospectively collected data are usually used given their availability. Retrospective data however suffer from such biases as recall bias and non-response bias. Comparing results obtained using prospectively and retrospectively collected data will help validate the use of the easily available retrospective data in assessing quality of care in past and future studies.
Prospective and retrospective datasets were obtained from a cluster randomized trial of a multifaceted intervention aimed at improving paediatric inpatient care conducted in eight rural Kenyan district hospitals by improving management of children admitted with pneumonia, malaria and diarrhea and/or dehydration. Four hospitals received a full intervention and four a partial intervention. Data were collected through 3 two weeks surveys conducted at baseline, after 6 and 18 months. Retrospective data was sampled from paediatric medical records of patients discharged in the preceding six months of the survey while prospective data was collected from patients discharged during the two week period of each survey. Risk Differences during post-intervention period of16 quality of care indicators were analyzed separately for prospective and retrospective datasets and later plotted side by side for comparison.
For the prospective data there was strong evidence of an intervention effect for 8 of the indicators and weaker evidence of an effect for one indicator, with magnitude of effect sizes varying from 23% to 60% difference. For the retrospective data, 10 process (these include the 8 indicators found to be statistically significant in prospective data analysis) indicators had statistically significant differences with magnitude of effects varying from 10% to 42%. The bar-graph comparing results from the prospective and retrospective datasets showed similarity in terms of magnitude of effects and statistical significance for all except two indicators.
Multifaceted interventions can help improve adoption of clinical guidelines and hence improve the quality of care. The similar inference reached after analyses based on prospective assessment of case management is a useful finding as it supports the utility of work based on examination of retrospectively assembled case records allowing longer time periods to be studied while constraining costs.
Trial registration
Current Controlled Trials ISRCTN42996612. Trial registration date: 20/11/2008
PMCID: PMC4110369  PMID: 25035114
Quality improvement; Prospective; Retrospective; Paediatrics; Health services research; Kenya
6.  Using health worker opinions to assess changes in structural components of quality in a Cluster Randomized Trial 
The ‘resource readiness’ of health facilities to provide effective services is captured in the structure component of the classical Donabedian paradigm often used for assessment of the quality of care in the health sector. Periodic inventories are commonly used to confirm the presence (or absence) of equipment or drugs by physical observation or by asking those in charge to indicate whether an item is present or not. It is then assumed that this point observation is representative of the everyday status. However the availability of an item (consumables) may vary. Arguably therefore a more useful assessment for resources would be one that captures this fluctuation in time. Here we report an approach that may circumvent these difficulties.
We used self-administered questionnaires (SAQ) to seek health worker views of availability of key resources supporting paediatric care linked to a cluster randomized trial of a multifaceted intervention aimed at improving this care conducted in eight rural Kenyan district hospitals. Four hospitals received a full intervention and four a partial intervention. Data were collected pre-intervention and after 6 and 18 months from health workers in three clinical areas asked to score item availability using an 11-point scale. Mean scores for items common to all 3 areas and mean scores for items allocated to domains identified using exploratory factor analysis (EFA) were used to describe availability and explore changes over time.
SAQ were collected from 1,156 health workers. EFA identified 11 item domains across the three departments. Mean availability scores for these domains were often <5/10 at baseline reflecting lack of basic resources such as oxygen, nutrition and second line drugs. An improvement in mean scores occurred in 8 out of 11 domains in both control and intervention groups. A calculation of difference in difference of means for intervention vs. control suggested an intervention effect resulting in greater changes in 5 out of 11 domains.
Using SAQ data to assess resource availability experienced by health workers provides an alternative to direct observations that provide point prevalence estimates. Further the approach was able to demonstrate poor access to resources, change over time and variability across place.
PMCID: PMC4082497  PMID: 24974166
Quality improvement; Child health; Paediatrics; Health services research
7.  Coming home to die? The association between migration and mortality in rural Tanzania before and after ART scale-up 
Global Health Action  2014;7:10.3402/gha.v7.22956.
Prior to the scale-up of antiretroviral therapy (ART), demographic surveillance cohort studies showed higher mortality among migrants than residents in many rural areas.
This study quantifies the overall and AIDS-specific mortality between migrants and residents prior to ART, during ART scale-up, and after widespread availability of ART in Rufiji district in Tanzania.
In Health and Demographic Surveillance System (HDSS), the follow-up of individuals aged 15–59 years was categorized into three periods: before ART (1998–2003), during ART scale-up (2004–2007), and after widespread availability of ART (2008–2011). Residents were those who never migrated within and beyond HDSS, internal migrants were those who moved within the HDSS, and external migrants were those who moved into the HDSS from outside. Mortality rates were estimated from deaths and person-years of observations calculated in each time period. Hazard ratios were estimated to compare mortality between migrants and residents. AIDS deaths were identified from verbal autopsy, and the odds ratio of dying from AIDS between migrants and residents was estimated using the multivariate logistic regression model.
Internal and external migrants experienced higher overall mortality than residents before the introduction of ART. After widespread availability of ART overall mortality were similar for internal and external migrants. These overall mortality experiences observed were similar for males and females. In the multivariate logistic regression model, adjusting for age, sex, education, and social economic status, internal migrants had similar likelihood of dying from AIDS as residents (adjusted odds ratio [AOR]=1.14, 95% confidence interval [CI]: 0.70–1.87) while external migrants were 70% more likely to die from AIDS compared to residents prior to the introduction of ART (AOR=1.70, 95% CI: 1.06–2.73). After widespread availability of ART with the same adjustment factors, the odds of dying from AIDS were similar for internal migrants and residents (AOR=1.56, 95% CI: 0.80–3.04) and external migrants and residents (AOR=1.42, 95% CI: 0.76–2.66).
Availability of ART has reduced the number of HIV-infected migrants who would otherwise return home to die. This has reduced the burden on rural communities who had cared for the return external migrants.
PMCID: PMC4032507  PMID: 24857612
residents; internal migration; external migration; rural-urban migrants; mortality; HIV; ART; ARV; Tanzania
9.  How have ART treatment programmes changed the patterns of excess mortality in people living with HIV? Estimates from four countries in East and Southern Africa 
Global Health Action  2014;7:10.3402/gha.v7.22789.
Substantial falls in the mortality of people living with HIV (PLWH) have been observed since the introduction of antiretroviral therapy (ART) in sub-Saharan Africa. However, access and uptake of ART have been variable in many countries. We report the excess deaths observed in PLWH before and after the introduction of ART. We use data from five longitudinal studies in Malawi, South Africa, Tanzania, and Uganda, members of the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA).
Individual data from five demographic surveillance sites that conduct HIV testing were used to estimate mortality attributable to HIV, calculated as the difference between the mortality rates in PLWH and HIV-negative people. Excess deaths in PLWH were standardized for age and sex differences and summarized over periods before and after ART became generally available. An exponential regression model was used to explore differences in the impact of ART over the different sites.
127,585 adults across the five sites contributed a total of 487,242 person years. Before the introduction of ART, HIV-attributable mortality ranged from 45 to 88 deaths per 1,000 person years. Following ART availability, this reduced to 14–46 deaths per 1,000 person years. Exponential regression modeling showed a reduction of more than 50% (HR =0.43, 95% CI: 0.32–0.58), compared to the period before ART was available, in mortality at ages 15–54 across all five sites.
Excess mortality in adults living with HIV has reduced by over 50% in five communities in sub-Saharan Africa since the advent of ART. However, mortality rates in adults living with HIV are still 10 times higher than in HIV-negative people, indicating that substantial improvements can be made to reduce mortality further. This analysis shows differences in the impact across the sites, and contrasts with developed countries where mortality among PLWH on ART can be similar to that of the general population. Further research is urgently needed to establish why the different impacts on mortality were observed and how the care and treatment programmes in these countries can be more effective in reducing mortality further.
PMCID: PMC3999950  PMID: 24762982
HIV; sub-Saharan Africa; mortality; ALPHA network; antiretroviral therapy
10.  The impact of voluntary counselling and testing services on sexual behaviour change and HIV incidence: observations from a cohort study in rural Tanzania 
BMC Infectious Diseases  2014;14:159.
It is widely assumed that voluntary counselling and testing (VCT) services contribute to HIV prevention by motivating clients to reduce sexual risk-taking. However, findings from sub-Saharan Africa have been mixed, particularly among HIV-negative persons. We explored associations between VCT use and changes in sexual risk behaviours and HIV incidence using data from a community HIV cohort study in northwest Tanzania.
Data on VCT use, sexual behaviour and HIV status were available from three HIV serological surveillance rounds undertaken in 2003–4 (Sero4), 2006–7 (Sero5) and 2010 (Sero6). We used multinomial logistic regression to assess changes in sexual risk behaviours between rounds, and Poisson regression to estimate HIV incidence.
The analyses included 3,613 participants attending Sero4 and Sero5 (3,474 HIV-negative and 139 HIV-positive at earlier round) and 2,998 attending Sero5 and Sero6 (2,858 HIV-negative and 140 HIV-positive at earlier round). Among HIV-negative individuals VCT use was associated with reductions in the number of sexual partners in the last year (aRR Seros 4–5: 1.42, 95% CI 1.07-1.88; aRR Seros 5–6: 1.68, 95% CI 1.25-2.26) and in the likelihood of having a non-cohabiting partner in the last year (aRR Seros 4–5: 1.57, 95% CI 1.10-2.25; aRR Seros 5–6: 1.48, 95% CI 1.07-2.04) or a high-risk partner in the last year (aRR Seros 5–6 1.57, 95% CI 1.06-2.31). However, VCT was also associated with stopping using condoms with non-cohabiting partners between Seros 4–5 (aRR 4.88, 95% CI 1.39-17.16). There were no statistically significant associations between VCT use and changes in HIV incidence, nor changes in sexual behaviour among HIV-positive individuals, possibly due to small sample sizes.
We found moderate associations between VCT use and reductions in some sexual risk behaviours among HIV-negative participants, but no impacts among HIV-positive individuals in the context of low overall VCT uptake. Furthermore, there were no significant changes in HIV incidence associated with VCT use, although declining background incidence and small sample sizes may have prevented us from detecting this. The impact of VCT services will ultimately depend upon rates of uptake, with further research required to better understand processes of behaviour change following VCT use.
PMCID: PMC3994406  PMID: 24655360
Voluntary counselling and testing; HIV; Sexual behaviour; Tanzania; Cohort study
11.  Using HIV-attributable mortality to assess the impact of antiretroviral therapy on adult mortality in rural Tanzania 
Global Health Action  2014;7:10.3402/gha.v7.21865.
The Tanzanian national HIV care and treatment programme has provided free antiretroviral therapy (ART) to HIV-positive persons since 2004. ART has been available to participants of the Kisesa open cohort study since 2005, but data to 2007 showed a slow uptake of ART and a modest impact on mortality. Additional data from the 2010 HIV serological survey provide an opportunity to update the estimated impact of ART in this setting.
The Kisesa Health and Demographic Surveillance Site (HDSS) has collected HIV serological data and demographic data, including verbal autopsy (VA) interviews since 1994. Serological data to the end of 2010 were used to make two estimates of HIV-attributable mortality, the first among HIV positives using the difference in mortality between HIV positives and HIV negatives, and the second in the population using the difference between the observed mortality rate in the whole population and the mortality rate among the HIV negatives. Four time periods (1994–1999, 2000–2004, 2005–2007, and 2008–2010) were used and HIV-attributable mortality estimates were analysed in detail for trends over time. A computer algorithm, InterVA-4, was applied to VA data to estimate the HIV-attributable mortality for the population, and this was compared to the estimates from the serological survey data.
Among HIV-positive adults aged 45–59 years, high mortality rates were observed across all time periods in both males and females. In HIV-positive men, the HIV-attributable mortality was 91.6% (95% confidence interval (CI): 84.6%–95.3%) in 2000–2004 and 86.3% (95% CI: 71.1%–93.3%) in 2008–2010, while among women, the HIV-attributable mortality was 87.8% (95% CI: 71.1%–94.3%) in 2000–2004 and 85.8% (95% CI: 59.6%–94.4%) in 2008–2010. In the whole population, using the serological data, the HIV-attributable mortality among men aged 30–44 years decreased from 57.2% (95% CI: 46.9%–65.3%) in 2000–2004 to 36.5% (95% CI: 18.8%–50.1%) in 2008–2010, while among women the corresponding decrease was from 57.3% (95% CI: 49.7%–63.6%) to 38.7% (95% CI: 27.4%–48.2%). The HIV-attributable mortality in the population using estimates from the InterVA model was lower than that from HIV sero-status data in the period prior to ART, but slightly higher once ART became available.
In the Kisesa HDSS, ART availability corresponds with a decline in adult overall mortality, although not as large as expected. Using InterVA to estimate HIV-attributable mortality showed smaller changes in HIV-related mortality following ART availability than the serological results.
PMCID: PMC3962553  PMID: 24656167
HIV-attributable mortality; ART; HDSS; InterVA model; serological survey; verbal autopsy
12.  Explaining the uptake of paediatric guidelines in a Kenyan tertiary hospital – mixed methods research 
Evidence-based standards for management of the seriously sick child have existed for decades, yet their translation in clinical practice is a challenge. The context and organization of institutions are known determinants of successful translation, however, research using adequate methodologies to explain the dynamic nature of these determinants in the quality-of-care improvement process is rarely performed.
We conducted mixed methods research in a tertiary hospital in a low-income country to explore the uptake of locally adapted paediatric guidelines. The quantitative component was an uncontrolled before and after intervention study that included an exploration of the intervention dose-effect relationship. The qualitative component was an ethnographic research based on the theoretical perspective of participatory action research. Interpretive integration was employed to derive meta-inferences that provided a more complete picture of the overall study results that reflect the complexity and the multifaceted ontology of the phenomenon studied.
The improvement in health workers’ performance in relation to the intensity of the intervention was not linear and was characterized by improved and occasionally declining performance. Possible root causes of this performance variability included challenges in keeping knowledge and clinical skills updated, inadequate commitment of the staff to continued improvement, limited exposure to positive professional role models, poor teamwork, failure to maintain professional integrity and mal-adaptation to institutional pressures.
Implementation of best-practices is a complex process that is largely unpredictable, attributed to the complexity of contextual factors operating predominantly at professional and organizational levels. There is no simple solution to implementation of best-practices. Tackling root causes of inadequate knowledge translation in this tertiary care setting will require long-term planning, with emphasis on promotion of professional ethics and values and establishing an organizational framework that enhances positive aspects of professionalism. This study has significant implications for the quality of training in medical institutions and the development of hospital leadership.
PMCID: PMC3975593  PMID: 24613001
ETAT+; Ethnographic; Guidelines; Implementation; Performance; Mixed methods research; Hospital leadership; Complex adaptive system
13.  The public sector nursing workforce in Kenya: a county-level analysis 
Kenya’s human resources for health shortage is well documented, yet in line with the new constitution, responsibility for health service delivery will be devolved to 47 new county administrations. This work describes the public sector nursing workforce likely to be inherited by the counties, and examines the relationships between nursing workforce density and key indicators.
National nursing deployment data linked to nursing supply data were used and analyzed using statistical and geographical analysis software. Data on nurses deployed in national referral hospitals and on nurses deployed in non-public sector facilities were excluded from main analyses. The densities and characteristics of the public sector nurses across the counties were obtained and examined against an index of county remoteness, and the nursing densities were correlated with five key indicators.
Of the 16,371 nurses in the public non-tertiary sector, 76% are women and 53% are registered nurses, with 35% of the nurses aged 40 to 49 years. The nursing densities across counties range from 1.2 to 0.08 per 1,000 population. There are statistically significant associations of the nursing densities with a measure of health spending per capita (P value = 0.0028) and immunization rates (P value = 0.0018). A higher county remoteness index is associated with explaining lower female to male ratio of public sector nurses across counties (P value <0.0001).
An overall shortage of nurses (range of 1.2 to 0.08 per 1,000) in the public sector countrywide is complicated by mal-distribution and varying workforce characteristics (for example, age profile) across counties. All stakeholders should support improvements in human resources information systems and help address personnel shortages and mal-distribution if equitable, quality health-care delivery in the counties is to be achieved.
PMCID: PMC3913960  PMID: 24467776
Nurses; Public sector; Human resources for health; County; Kenya
14.  Does the Spectrum model accurately predict trends in adult mortality? Evaluation of model estimates using empirical data from a rural HIV community cohort study in north-western Tanzania 
Global Health Action  2014;7:10.3402/gha.v7.21783.
Spectrum epidemiological models are used by UNAIDS to provide global, regional and national HIV estimates and projections, which are then used for evidence-based health planning for HIV services. However, there are no validations of the Spectrum model against empirical serological and mortality data from populations in sub-Saharan Africa.
Serologic, demographic and verbal autopsy data have been regularly collected among over 30,000 residents in north-western Tanzania since 1994. Five-year age-specific mortality rates (ASMRs) per 1,000 person years and the probability of dying between 15 and 60 years of age (45Q15,) were calculated and compared with the Spectrum model outputs. Mortality trends by HIV status are shown for periods before the introduction of antiretroviral therapy (1994–1999, 2000–2005) and the first 5 years afterwards (2005–2009).
Among 30–34 year olds of both sexes, observed ASMRs per 1,000 person years were 13.33 (95% CI: 10.75–16.52) in the period 1994–1999, 11.03 (95% CI: 8.84–13.77) in 2000–2004, and 6.22 (95% CI; 4.75–8.15) in 2005–2009. Among the same age group, the ASMRs estimated by the Spectrum model were 10.55, 11.13 and 8.15 for the periods 1994–1999, 2000–2004 and 2005–2009, respectively. The cohort data, for both sexes combined, showed that the 45Q15 declined from 39% (95% CI: 27–55%) in 1994 to 22% (95% CI: 17–29%) in 2009, whereas the Spectrum model predicted a decline from 43% in 1994 to 37% in 2009.
From 1994 to 2009, the observed decrease in ASMRs was steeper in younger age groups than that predicted by the Spectrum model, perhaps because the Spectrum model under-estimated the ASMRs in 30–34 year olds in 1994–99. However, the Spectrum model predicted a greater decrease in 45Q15 mortality than observed in the cohort, although the reasons for this over-estimate are unclear.
PMCID: PMC3895202  PMID: 24438873
HIV; adult mortality; Spectrum model; cohort
15.  Deciphering the Complex Distribution of Human Immunodeficiency Virus Type 1 Subtypes among Different Cohorts in Northern Tanzania 
PLoS ONE  2013;8(12):e81848.
Increased understanding of the genetic diversity of HIV-1 is challenging but important in the development of an effective vaccine. We aimed to describe the distribution of HIV-1 subtypes in northern Tanzania among women enrolled in studies preparing for HIV-1 prevention trials (hospitality facility-worker cohorts), and among men and women in an open cohort demographic surveillance system (Kisesa cohort).
The polymerase encompassing partial reverse transcriptase was sequenced and phylogenetic analysis performed and subtype determined. Questionnaires documented demographic data. We examined factors associated with subtype using multinomial logistic regression, adjusted for study, age, and sex.
Among 140 individuals (125 women and 15 men), subtype A1 predominated (54, 39%), followed by C (46, 33%), D (25, 18%) and unique recombinant forms (URFs) (15, 11%). There was weak evidence to suggest different subtype frequencies by study (for example, 18% URFs in the Kisesa cohort versus 5–9% in the hospitality facility-worker cohorts; adjusted relative-risk ratio (aRR) = 2.35 [95% CI 0.59,9.32]; global p = 0.09). Compared to men, women were less likely to have subtype D versus A (aRR = 0.12 [95% CI 0.02,0.76]; global p = 0.05). There was a trend to suggest lower relative risk of subtype D compared to A with older age (aRR = 0.44 [95% CI 0.23,0.85] per 10 years; global p = 0.05).
We observed multiple subtypes, confirming the complex genetic diversity of HIV-1 strains circulating in northern Tanzania, and found some differences between cohorts and by age and sex. This has important implications for vaccine design and development, providing opportunity to determine vaccine efficacy in diverse HIV-1 strains.
PMCID: PMC3859540  PMID: 24349139
16.  The implementation of an external quality assurance method for point- of- care tests for HIV and syphilis in Tanzania 
BMC Infectious Diseases  2013;13:530.
External quality assurance (EQA) programmes, which are routinely used in laboratories, have not been widely implemented for point-of- care tests (POCTs). A study was performed in ten health centres in Tanzania, to implement the use of dried blood spots (DBS) as an EQA method for HIV and syphilis (POCTs).
DBS samples were collected for retesting at a reference laboratory and the results compared to the POCT results obtained at the clinic. In total, 2341 DBS samples were collected from 10 rural health facilities over a period of nine months, of which 92.5% were correctly collected and spotted.
The EQA method was easily implemented by healthcare workers under routine conditions in Northern Tanzania. For HIV, 967 out of 972 samples (99.5%) were concordant between DBS and POCT results. For syphilis, the sensitivity of syphilis tests varied between clinics with a median of 96% (25th and 75th quartile; 95-98%). The specificity of syphilis POCT was consistent compared to laboratory based test using DBS, with a median of 96% (25th and 75th quartiles; 95-98%).
Overall, the quality of testing varied at clinics and EQA results can be used to identify clinics where healthcare workers require remedial training, suggesting the necessity for stringent quality assurance programmes for POC testing. As Tanzania embarks on scaling up HIV and syphilis testing, DBS can be a useful and robust tool to monitor the quality of testing performed by healthcare workers and trigger corrective action to ensure accuracy of test results.
PMCID: PMC3830510  PMID: 24206624
17.  InterVA-4 as a public health tool for measuring HIV/AIDS mortality: a validation study from five African countries 
Global Health Action  2013;6:10.3402/gha.v6i0.22448.
Reliable population-based data on HIV infection and AIDS mortality in sub-Saharan Africa are scanty, even though that is the region where most of the world’s AIDS deaths occur. There is therefore a great need for reliable and valid public health tools for assessing AIDS mortality.
The aim of this article is to validate the InterVA-4 verbal autopsy (VA) interpretative model within African populations where HIV sero-status is recorded on a prospective basis, and examine the distribution of cause-specific mortality among HIV-positive and HIV-negative people.
Data from six sites of the Alpha Network, including HIV sero-status and VA interviews, were pooled. VA data according to the 2012 WHO format were extracted, and processed using the InterVA-4 model into likely causes of death. The model was blinded to the sero-status data. Cases with known pre-mortem HIV infection status were used to determine the specificity with which InterVA-4 could attribute HIV/AIDS as a cause of death. Cause-specific mortality fractions by HIV infection status were calculated, and a person-time model was built to analyse adjusted cause-specific mortality rate ratios.
The InterVA-4 model identified HIV/AIDS-related deaths with a specificity of 90.1% (95% CI 88.7–91.4%). Overall sensitivity could not be calculated, because HIV-positive people die from a range of causes. In a person-time model including 1,739 deaths in 1,161,688 HIV-negative person-years observed and 2,890 deaths in 75,110 HIV-positive person-years observed, the mortality ratio HIV-positive:negative was 29.0 (95% CI 27.1–31.0), after adjustment for age, sex, and study site. Cause-specific HIV-positive:negative mortality ratios for acute respiratory infections, HIV/AIDS-related deaths, meningitis, tuberculosis, and malnutrition were higher than the all-cause ratio; all causes had HIV-positive:negative mortality ratios significantly higher than unity.
These results were generally consistent with relatively small post-mortem and hospital-based diagnosis studies in the literature. The high specificity in cause of death attribution achieved in relation to HIV status, and large differences between specific causes by HIV status, show that InterVA-4 is an effective and valid tool for assessing HIV-related mortality.
PMCID: PMC3800746  PMID: 24138838
HIV/AIDS; mortality; Africa; verbal autopsy; InterVA; Alpha Network
18.  The Trade-Off between Accuracy and Accessibility of Syphilis Screening Assays 
PLoS ONE  2013;8(9):e75327.
The availability of rapid and sensitive methods to diagnose syphilis facilitates screening of pregnant women, which is one of the most cost-effective health interventions available. We have evaluated two screening methods in Tanzania: an enzyme immunoassay (EIA), and a point-of-care test (POCT). We evaluated the performance of each test against the Treponema pallidum particle agglutination assay (TPPA) as the reference method, and the accessibility of testing in a rural district of Tanzania. The POCT was performed in the clinic on whole blood, while the other assays were performed on plasma in the laboratory. Samples were also tested by the rapid plasma Reagin (RPR) test. With TPPA as reference assay, the sensitivity and specificity of EIA were 95.3% and 97.8%, and of the POCT were 59.6% and 99.4% respectively. The sensitivity of the POCT and EIA for active syphilis cases (TPPA positive and RPR titer ≥1/8) were 82% and 100% respectively. Only 15% of antenatal clinic attenders in this district visited a health facility with a laboratory capable of performing the EIA. Although it is less sensitive than EIA, its greater accessibility, and the fact that treatment can be given on the same day, means that the use of POCT would result in a higher proportion of women with syphilis receiving treatment than with the EIA in this district of Tanzania.
PMCID: PMC3774815  PMID: 24066175
19.  Do accurate HIV and antiretroviral therapy knowledge, and previous testing experiences increase the uptake of HIV voluntary counselling and testing? Results from a cohort study in rural Tanzania 
BMC Public Health  2013;13:802.
Despite the introduction of free antiretroviral therapy (ART), the use of voluntary counselling and testing (VCT) services remains persistently low in many African countries. This study investigates how prior experience of HIV and VCT, and knowledge about HIV and ART influence VCT use in rural Tanzania.
In 2006–7, VCT was offered to study participants during the fifth survey round of an HIV community cohort study that includes HIV testing for research purposes without results disclosure, and a questionnaire covering knowledge, attitudes and practices around HIV infection and HIV services. Categorical variables were created for HIV knowledge and ART knowledge, with “good” HIV and ART knowledge defined as correctly answering at least 4/6 and 5/7 questions about HIV and ART respectively. Experience of HIV was defined as knowing people living with HIV, or having died from AIDS. Logistic regression methods were used to assess how HIV and ART knowledge, and prior experiences of HIV and VCT were associated with VCT uptake, with adjustment for HIV status and socio-demographic confounders.
2,695/3,886 (69%) men and 2,708/5,575 women (49%) had “good” HIV knowledge, while 613/3,886 (16%) men and 585/5575 (10%) women had “good” ART knowledge. Misconceptions about HIV transmission were common, including through kissing (55% of women, 43% of men), or mosquito bites (42% of women, 34% of men).
19% of men and 16% of women used VCT during the survey. After controlling for HIV status and socio-demographic factors, the odds of VCT use were lower among those with poor HIV knowledge (aOR = 0.5; p = 0.01 for men and aOR = 0.6; p < 0.01 for women) and poor ART knowledge (aOR = 0.8; p = 0.06 for men, aOR = 0.8; p < 0.01 for women), and higher among those with HIV experience (aOR = 1.3 for men and aOR = 1.6 for women, p < 0.01) and positive prior VCT experience (aOR = 2.0 for all men and aOR = 2.0 for HIV-negative women only, p < 0.001).
Two years after the introduction of free ART in this setting, misconceptions regarding HIV transmission remain rife and knowledge regarding treatment is worryingly poor, especially among women and HIV-positive people. Further HIV-related information, education and communication activities are urgently needed to improve VCT uptake in rural Tanzania.
PMCID: PMC3844310  PMID: 24007326
HIV; VCT; HIV testing; Tanzania; Cohort study
20.  Dynamic logistic regression model and population attributable fraction to investigate the association between adherence, missed visits and mortality: a study of HIV-infected adults surviving the first year of ART 
BMC Infectious Diseases  2013;13:395.
Adherence is one of the most important determinants of viral suppression and drug resistance in HIV-infected people receiving antiretroviral therapy (ART).
We examined the association between long-term mortality and poor adherence to ART in DART trial participants in Uganda and Zimbabwe randomly assigned to receive laboratory and clinical monitoring (LCM), or clinically driven monitoring (CDM). Since over 50% of all deaths in the DART trial occurred during the first year on ART, we focussed on participants continuing ART for 12 months to investigate the implications of longer-term adherence to treatment on mortality. Participants’ ART adherence was assessed by pill counts and structured questionnaires at 4-weekly clinic visits. We studied the effect of recent adherence history on the risk of death at the individual level (odds ratios from dynamic logistic regression model), and on mortality at the population level (population attributable fraction based on this model). Analyses were conducted separately for both randomization groups, adjusted for relevant confounding factors. Adherence behaviour was also confounded by a partial factorial randomization comparing structured treatment interruptions (STI) with continuous ART (CT).
In the CDM arm a significant association was found between poor adherence to ART in the previous 3-9 months with increased mortality risk. In the LCM arm the association was not significant. The odds ratios for mortality in participants with poor adherence against those with optimal adherence was 1.30 (95% CI 0.78,2.10) in the LCM arm and 2.18 (1.47,3.22) in the CDM arm. The estimated proportions of deaths that could have been avoided with optimal adherence (population attributable fraction) in the LCM and CDM groups during the 5 years follow-up period were 16.0% (95% CI 0.7%,31.6%) and 33.1% (20.5%,44.8%), correspondingly.
Recurrent poor adherence determined even through simple measures is associated with high mortality both at individual level as well as at the ART programme level. The number of lives saved through effective interventions to improve adherence could be considerable particularly for individuals monitored without using CD4 cell counts. The findings have important implications for clinical practice and for developing interventions to enhance adherence.
PMCID: PMC3847061  PMID: 24060199
Dynamic logistic regression model; Population attributable fraction; ART; Adherence; Mortality; HIV
21.  Blood Glucose as a Predictor of Mortality in Children Admitted to the Hospital with Febrile Illness in Tanzania 
Data from a prospective study of 3,319 children ages 2 months to 5 years admitted with febrile illness to a Tanzanian district hospital were analyzed to determine the relationship of blood glucose and mortality. Hypoglycemia (blood sugar < 2.5 mmol/L and < 45 mg/dL) was found in 105 of 3,319 (3.2%) children at admission, and low-normal blood glucose (2.5–5 mmol/L and 45–90 mg/dL) was found in 773 of 3,319 (23.3%) children. Mortality was inversely related to admission blood sugar; compared with children with an admission blood glucose of > 5 mmol/L, the adjusted odds of dying were 3.3 (95% confidence interval = 2.1–5.2) and 9.8 (95% confidence interval = 5.1–19.0) among children with admission blood glucose 2.5–5 and < 2.5 mmol/L, respectively. Receiver operating characteristic (ROC) analysis suggested an optimal cutoff for admission blood sugar of < 5 mmol/L in predicting mortality (sensitivity = 57.7%, specificity = 75.2%). A cutoff for admission blood glucose of < 5 mmol/L represents a simple and clinically useful predictor of mortality in children admitted with severe febrile illness to hospital in resource-poor settings.
PMCID: PMC3741242  PMID: 23817332
22.  Co-morbidity of epilepsy in Tanzanian children: a community-based case-control study 
To define the prevalence and associations of co-morbidity and school attendance in older children with epilepsy (CWE) from a rural district of Tanzania by conducting a community-based case-control study.
Children aged 6 -14 years old with active epilepsy (at least two unprovoked seizures in the last five years) were identified in a cross-sectional survey in Tanzania. Co-morbidities were assessed and cases were compared with age-matched controls.
Co-morbidity was very common amongst cases (95/112, 85%), with 62/112 (55%) having multiple co-morbidities. Co-morbidities consisted of cognitive impairment (72/112, 64%), behaviour disorder 68/112 (61%), motor difficulties 29/112 (26%), burns and other previous injuries (29/112, 26%). These complications were significantly more common in cases than in controls (Odds Ratio 14.8, 95%CI 7.6–28.6, p<0.001). Co-morbidity in CWE was associated with structural cause, abnormal electroencephalogram and early onset seizures. Cognitive impairment was very common in CWE (64%) and was not associated with Phenobarbital use but was associated with motor difficulties, early onset and recurrent seizures. Poor school attendance was found in 56/112 (50%) of CWE, but not in the controls: it was associated with the presence of multiple co-morbidities, especially with motor difficulties in CWE.
Children with epilepsy in a rural area of sub-Saharan Africa had a high level of co-morbidity. Cognitive impairment and poor school attendance were very common. These associated difficulties in CWE in the region need to be addressed to reduce the negative impact of epilepsy on these children.
PMCID: PMC3672980  PMID: 22130004
epilepsy; Africa; children; co-morbidity; cognitive impairment; education
23.  Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) 
Lancet  2013;381(9879):1763-1771.
Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa.
The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum.
138 074 women aged 15–49 years contributed 636 213 person-years of observation. 49 568 women had 86 963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17·2% (95% CI 17·0–17·3), but 60 of 118 (50·8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20·5 (18·9–22·4) in women who were not pregnant or post partum and 8·2 (5·7–11·8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51·8 (47·8–53·8) per 1000 person-years in women who were not pregnant or post partum and 11·8 (8·4–15·3) per 1000 person-years in pregnant or post-partum women.
HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women.
Wellcome Trust, Health Metrics Network (WHO).
PMCID: PMC4325135  PMID: 23683643
24.  Low Rates of Repeat HIV Testing Despite Increased Availability of Antiretroviral Therapy in Rural Tanzania: Findings from 2003–2010 
PLoS ONE  2013;8(4):e62212.
HIV counselling and testing (HCT) services can play an important role in HIV prevention by encouraging safe sexual behaviours and linking HIV-infected clients to antiretroviral therapy (ART). However, regular repeat testing by high-risk HIV-negative individuals is important for timely initiation of ART as part of the ‘treatment as prevention’ approach.
To investigate HCT use during a round of HIV serological surveillance in northwest Tanzania in 2010, and to explore rates of repeat testing between 2003 and 2010.
HCT services were provided during the fourth, fifth and sixth rounds of serological surveillance in 2003–2004 (Sero-4), 2006–2007 (Sero-5) and 2010 (Sero-6). HCT services have also been available at a government-run health centre and at other clinics in the study area since 2005. Questionnaires administered during sero-surveys collected information on socio-demographic characteristics, sexual behaviour and reported previous use of HCT services.
The proportion of participants using HCT increased from 9.4% at Sero-4 to 16.6% at Sero-5 and 25.5% at Sero-6. Among participants attending all three sero-survey rounds (n = 2,010), the proportions using HCT twice or more were low, with 11.1% using the HCT service offered at sero-surveys twice or more, and 25.3% having tested twice or more if reported use of HCT outside of sero-surveys was taken into account. In multivariable analyses, individuals testing HIV-positive were less likely to repeat test than individuals testing HIV-negative (aOR 0.17, 95% CI 0.006–0.52).
Although HCT service use increased over time, it was disappointing that the proportions ever testing and ever repeat-testing were not even larger, considering the increasing availability of HCT and ART in the study area. There was some evidence that HIV-negative people with higher risk sexual behaviours were most likely to repeat test, which was encouraging in terms of the potential to pick-up those at greatest risk of HIV-infection.
PMCID: PMC3633850  PMID: 23626791
25.  Predictors of Tuberculosis in the? First Six Months after Initiation of Antiretroviral Therapy: a Case-Control Study 
Adult HIV clinic in Tanzania.
In Africa, 10% of HIV infected adults starting antiretroviral therapy (ART) die within the first year, and tuberculosis (TB) is the leading cause of death. In this study, we investigated the predictors of ART-associated TB.
In this nested case-control study, adults starting ART were screened for TB according to the WHO protocol and those not diagnosed with TB were observed for six months. Patients diagnosed with tuberculosis were defined as cases, and controls were selected from among patients who did not develop tuberculosis using incidence density matching.
Among the 2514 HIV positive adults in our cohort, 72 (3%) were diagnosed with TB during the first six months of ART. By multivariate analysis, baseline characteristics predictive of TB were cough, fever, and night sweats and 76% (55/72) of cases had at least one of these symptoms at the time of starting ART.
75% of patients who developed TB during the first six months of ART had symptoms of TB at time of starting ART but the symptoms were sub-diagnostic. Improved TB diagnostics and/or better strategies for empirical anti-TB are needed for patients with symptoms of TB at ART initiation.
PMCID: PMC3631349  PMID: 22691942
HIV; mortality; cohort

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