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author:("crassa, Mark")
1.  Challenges with routine data sources for PMTCT programme monitoring in East Africa: insights from Tanzania 
Global Health Action  2015;8:10.3402/gha.v8.29987.
Routinely collected clinic data have the potential to provide much needed information on the uptake of services to prevent mother-to-child transmission (PMTCT) of HIV, and to measure HIV prevalence in pregnant women. This article describes the methodological challenges associated with using such data, based on the experiences of researchers and programme implementers in Tanzania and drawing from other examples from East Africa. PMTCT data are routinely collected in maternal and child health (MCH) clinics in East Africa using paper-based registers corresponding to distinct services within the PMTCT service continuum. This format has inherent limitations with respect to maintaining and accurately recording unique identifiers that can link patients across the different clinics (antenatal, delivery, child), and also poses challenges when compiling aggregate data. Recent improvements to recording systems include assigning unique identifiers to HIV-positive pregnant women in MCH clinics, although this should ideally be extended to all pregnant women, and recording mother and infant identifiers alongside each other in registers. The use of ‘health passports’, as in Malawi, which maintains the same antenatal clinic identifier over time, also holds promise. Routine data hold tremendous potential for clinic-level patient management, surveillance, and evaluating PMTCT/MCH programmes. Linking clinic data to community research datasets can also provide population-level estimates of coverage with PMTCT services, currently a problematic but vital statistic for monitoring programme performance and negotiating donor funding. Enhancements to indexing and recording of routine PMTCT/MCH data are needed if we are to capitalise on this rich data source.
PMCID: PMC4695617  PMID: 26715204
HIV; Africa; data collection; maternal health services; monitoring; evaluation; implementation research methods
2.  Factors associated with uptake of services to prevent mother-to-child transmission of HIV in a community cohort in rural Tanzania 
Sexually Transmitted Infections  2015;91(7):520-527.
This study aimed to identify factors associated with access to HIV care and antiretroviral (ARV) drugs for prevention of mother-to-child transmission (PMTCT) of HIV among HIV-positive pregnant women in a community cohort in rural Tanzania (Kisesa).
Kisesa-resident women who tested HIV-positive during HIV serosurveillance and were pregnant (while HIV-positive) between 2005 and 2012 were eligible. Community cohort records were linked to PMTCT and HIV clinic data from four facilities (PMTCT programme implemented in 2009; referrals to city-based hospitals since 2005) to ascertain service use. Factors associated with access to HIV care and ARVs during pregnancy were analysed using logistic regression.
Overall, 24% of women accessed HIV care and 12% accessed ARVs during pregnancy (n=756 pregnancies to 420 women); these proportions increased over time. In multivariate analyses for 2005–2012, being married, prior voluntary counselling and testing, increasing age, increasing year of pregnancy and increasing duration of infection were independently associated with access to care and ARVs. Residence in roadside areas was an independent predictor of access to care but not ARVs. There was no evidence of an interaction with time period.
Access to PMTCT services was low in this rural setting but improved markedly over time. There were fairly few sociodemographic differentials although support for young women and those without partners may be needed. Further decentralisation of HIV services to more remote areas, promotion of voluntary counselling and testing and implementation of Option B+ are likely to improve uptake and may bring women into care and treatment sooner after infection.
PMCID: PMC4680170  PMID: 26045467
3.  Associations between gestational anthropometry, maternal HIV, and fetal and early infancy growth in a prospective rural/semi-rural Tanzanian cohort, 2012-13 
Healthcare access and resources differ considerably between urban and rural settings making cross-setting generalizations difficult. In resource-restricted rural/semi-rural environments, identification of feasible screening tools is a priority. The objective of this study was to evaluate gestational anthropometry in relation to birth and infant growth in a rural/semi-rural Tanzanian prospective cohort of mothers and their infants.
Mothers (n = 114: 44 HIV-positive) attending antenatal clinic visits were recruited in their second or third trimester between March and November, 2012, and followed with their infants through 6-months post-partum. Demographic, clinical, and infant feeding data were obtained using questionnaires administered by a Swahili-speaking research nurse on demographic, socioeconomic, clinical, and infant feeding practices. Second or third trimester anthropometry (mid-upper arm circumference [MUAC], triceps skinfold thickness, weight, height), pregnancy outcomes, birth (weight, length, head circumference) and infant anthropometry (weight-for-age z-score [WAZ], length-for-age z-score [LAZ]) were obtained. Linear regression and mixed effect modeling were used to evaluate gestational factors in relation to pregnancy and infant outcomes.
Results and discussion
Gestational MUAC and maternal HIV status (HIV-positive mothers = 39 %) were associated with infant WAZ and LAZ from birth to 6-months in multivariate models, even after adjustment for infant feeding practices. The lowest gestational MUAC tertile was associated with lower WAZ throughout early infancy, as well as lower LAZ at 3 and 6-months. In linear mixed effects models through 6-months, each 1 cm increase in gestational MUAC was associated with a 0.11 increase in both WAZ (P < 0.001) and LAZ (P = 0.001). Infant HIV-exposure was negatively associated with WAZ (β = -0.65, P < 0.001) and LAZ (β = -0.49, P < 0.012) from birth to 6-months.
Lower gestational MUAC, evaluated using only a tape measure and minimal training that is feasible in non-urban clinic and community settings, was associated with lower infant anthropometric measurements. In this rural and semi-rural setting, HIV-exposure was associated with poorer anthropometry through 6-months despite maternal antiretroviral access. Routine assessment of MUAC has the potential to identify at-risk women in need of additional health interventions designed to optimize pregnancy outcomes and infant growth. Further research is needed to establish gestational MUAC reference ranges and to define interventions that successfully improve MUAC during pregnancy.
PMCID: PMC4625530  PMID: 26515916
Africa; HIV/AIDS; HIV-exposed; MUAC; Maternal; Nutrition; Point-of-care; Stunting; Triceps skinfold; Tanzania
5.  Updates to the Spectrum model to estimate key HIV indicators for adults and children 
AIDS (London, England)  2014;28(4):S427-S434.
The Spectrum program is used to estimate key HIV indicators for national programmes. The purpose of the study is to describe the key updates made to Spectrum in the last 2 years to produce the version used in the 2013 global estimates of HIV/AIDS.
The United Nations Programme on HIV/AIDS (UNAIDS) Reference Group on Estimates, Models and Projections regularly reviews new data and information needs and recommends updates to the methodology and assumptions used in Spectrum. The latest data from surveys, census and special studies are used to estimate key parameter values for countries and regions.
Country-specific life tables prepared by the United National Population Division (UNPD) have been incorporated into Spectrum's demographic projections replacing the model life tables used previously. This update includes revised estimates of non-AIDS life expectancy. Incidence among all adults 15–49 years generated from curve fitting to surveillance and survey data is now split by age using incidence rate ratios derived from Analysing Longitudinal Population-based HIV/AIDS data on Africa Network data for generalized epidemics. Methods for estimating the number of AIDS orphans have been updated to include the changing effects of PMTCT and antiretroviral therapy programmes. Procedures for estimating the number of adults eligible for treatment have been updated to reflect the 2013 WHO guidelines. Program data on AIDS mortality has been used to estimate prevalence trends in Argentina, Brazil and Mexico for the 2013 estimates.
Spectrum was updated for the 2013 round of HIV estimates in order to support national programmes with improved methods and data to estimating national indicators.
PMCID: PMC4247263  PMID: 25406748
AIDS; estimates; HIV; modeling
6.  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
7.  “It Is Like That, We Didn't Understand Each Other”: Exploring the Influence of Patient-Provider Interactions on Prevention of Mother-To-Child Transmission of HIV Service Use in Rural Tanzania 
PLoS ONE  2014;9(9):e106325.
Interactions between patients and service providers frequently influence uptake of prevention of mother-to-child transmission (PMTCT) HIV services in sub-Saharan Africa, but this process has not been examined in depth. This study explores how patient-provider relations influence PMTCT service use in four government facilities in Kisesa, Tanzania. Qualitative data were collected in 2012 through participatory group activities with community members (3 male, 3 female groups), in-depth interviews with 21 women who delivered recently (16 HIV-positive), 9 health providers, and observations in antenatal clinics. Data were transcribed, translated into English and analysed with NVIVO9 using an adapted theoretical model of patient-centred care. Three themes emerged: decision-making processes, trust, and features of care. There were few examples of shared decision-making, with a power imbalance in favour of providers, although they offered substantial psycho-social support. Unclear communication by providers, and patients not asking questions, resulted in missed services. Omission of pre-HIV test counselling was often noted, influencing women's ability to opt-out of HIV testing. Trust in providers was limited by confidentiality concerns, and some HIV-positive women were anxious about referrals to other facilities after establishing trust in their original provider. Good care was recounted by some women, but many (HIV-positive and negative) described disrespectful staff including discrimination of HIV-positive patients and scolding, particularly during delivery; exacerbated by lack of materials (gloves, sheets) and associated costs, which frustrated staff. Experienced or anticipated negative staff behaviour influenced adherence to subsequent PMTCT components. Findings revealed a pivotal role for patient-provider relations in PMTCT service use. Disrespectful treatment and lack of informed consent for HIV testing require urgent attention by PMTCT programme managers. Strategies should address staff behaviour, emphasizing ethical standards and communication, and empower patients to seek information about available services. Optimising provider-patient relations can improve uptake of maternal health services more broadly, and ART adherence.
PMCID: PMC4152246  PMID: 25180575
8.  The INDEPTH standard population for low- and middle-income countries, 2013 
Global Health Action  2014;7:10.3402/gha.v7.23286.
Crude rates such as the crude death rate are functions of both the age-specific rates and the age composition of a population. However, differences in the age structure between two populations or two time periods can result in specious differences in the corresponding crude rates making direct comparisons between populations or across time inappropriate. Therefore, when comparing crude rates between populations, it is desirable to eliminate or minimize the influence of age composition. This task is accomplished by using a standard age structure yielding an age-standardized rate. This paper proposes an updated International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) standard for use in low- and middle-income countries (LMICs) based on newly available data from the health and demographic surveillance system site members of the INDEPTH network located throughout Africa and southern Asia. The updated INDEPTH standard should better reflect the age structure of LMICs and result in more accurate health indicators and demographic rates. We demonstrate use of the new INDEPTH standard along with several existing ‘world’ standards and show how resulting age-standardized crude deaths rates differ when using the various standard age compositions.
PMCID: PMC3969509  PMID: 24679543
crude death rate; age-specific mortality rate; age-standardized crude death rate; demography; standardized age structure; low- and middle-income countries
9.  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
10.  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
11.  Using vignettes in qualitative research to explore barriers and facilitating factors to the uptake of prevention of mother-to-child transmission services in rural Tanzania: a critical analysis 
Vignettes are short stories about a hypothetical person, traditionally used within research (quantitative or qualitative) on sensitive topics in the developed world. Studies using vignettes in the developing world are emerging, but with no critical examination of their usefulness in such settings. We describe the development and application of vignettes to a qualitative investigation of barriers to uptake of prevention of mother-to-child transmission (PMTCT) HIV services in rural Tanzania in 2012, and critique the successes and challenges of using the technique in this setting.
Participatory Learning and Action (PLA) group activities (3 male; 3 female groups from Kisesa, north-west Tanzania) were used to develop a vignette representing realistic experiences of an HIV-infected pregnant woman in the community. The vignette was discussed during in-depth interviews with 16 HIV-positive women, 3 partners/relatives, and 5 HIV-negative women who had given birth recently. A critical analysis was applied to assess the development, implementation and usefulness of the vignette.
The majority of in-depth interviewees understood the concept of the vignette and felt the story was realistic, although the story or questions needed repeating in some cases. In-depth interviewers generally applied the vignette as intended, though occasionally were unsure whether to steer the conversation back to the vignette character when participants segued into personal experiences. Interviewees were occasionally confused by questions and responded with what the character should do rather than would do; also confusing fieldworkers and presenting difficulties for researchers in interpretation. Use of the vignette achieved the main objectives, putting most participants at ease and generating data on barriers to PMTCT service uptake. Participants’ responses to the vignette often reflected their own experience (revealed later in the interviews).
Participatory group research is an effective method for developing vignettes. A vignette was incorporated into qualitative interview discussion guides and used successfully in rural Africa to draw out barriers to PMTCT service use; vignettes may also be valuable in HIV, health service use and drug adherence research in this setting. Application of this technique can prove challenging for fieldworkers, so thorough training should be provided prior to its use.
PMCID: PMC3922981  PMID: 24512206
Vignette; Qualitative; Methodology; Africa; Vertical transmission; HIV
12.  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
13.  Is the Risk of HIV Acquisition Increased during and Immediately after Pregnancy? A Secondary Analysis of Pooled HIV Community-Based Studies from the ALPHA Network 
PLoS ONE  2013;8(12):e82219.
Previous studies of HIV acquisition in pregnancy have been in specific population groups, such as sero-discordant couples which have shown an increased risk of HIV acquisition during pregnancy and studies of sexually active women where the results have been ambiguous. However these studies are unable to tell us what the overall impact of pregnancy is on HIV acquisition in the general population.
Data from six community-based HIV cohorts were pooled to give 2,628 sero-conversions and a total of 178,000 person years of observation. Multiple imputation was used to allow for the uncertainty of exact sero-conversion date in surveillance intervals greater than the length of a pregnancy. Results were combined using Rubin’s rules to give appropriate error bounds. The analysis was stratified into two periods: pre- and post- widespread availability of prevention of mother-to-child HIV transmission services. This allows us to assess whether there is reporting bias relating to a person’s knowledge of their own HIV status which would become more widespread in the latter time period.
Results suggest that women while pregnant have a lower risk of acquiring HIV infection over all periods (HRR 0.79, 95%CI 0.70-0.89) than women who were not pregnant. There is no evidence for a difference in the rate of HIV acquisition between postpartum and non-pregnant women (HRR 0.92 95%CI 0.84-1.03).
Although there may be immunological reasons for increased risk of HIV acquisition during pregnancy, at a population level this study indicates a lower risk of HIV acquisition for pregnant women. Pregnant women may be more likely to be concordant with their current sexual partner than non-pregnant women, i.e. either already HIV positive prior to the pregnancy or if negative at the time of becoming pregnant more likely to have a negative partner.
PMCID: PMC3873249  PMID: 24386091
14.  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
15.  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
16.  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
17.  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
18.  The development and validation of dried blood spots for external quality assurance of syphilis serology 
BMC Infectious Diseases  2013;13:102.
Syphilis causes up to 1,500,000 congenital syphilis cases annually. These could be prevented if all pregnant women were screened, and those with syphilis treated with a single dose of penicillin before 28 weeks gestation. In recent years, rapid point-of-care tests have allowed greater access to syphilis screening, especially in rural or remote areas, but the lack of quality assurance of rapid testing has been a concern. We determined the feasibility of using dried blood spots (DBS) as specimens for quality assurance of syphilis serological assays.
We developed DBS extraction protocols for use with Treponema pallidum particle agglutination assay (TPPA), Treponema pallidum haemagglutination assay (TPHA) and an enzyme immunoassay (EIA) and compared the results with those using matching plasma samples from the same patient.
Since DBS samples showed poor performance with TPHA and EIA (TPHA sensitivity was 50.5% (95% confidence interval: 39.9–61.2%) and EIA specificity was 50.4% (95% CI: 43.7–57.1%), only the DBS TPPA was used in the final evaluation. DBS TPPA showed an sensitivity of 95.5% (95% CI: 91.3–98.0%) and a specificity of 99.0% (95% CI: 98.1–99.5%) compared to TPPA using plasma samples as a reference.
DBS samples can be recommended for use with TPPA, and may be of value for external quality assurance of point-of-care syphilis testing.
PMCID: PMC3586363  PMID: 23442198
Dried blood spots; Syphilis; Treponema pallidum; DBS; Sensitivity; Evaluation
19.  Evaluation of knowledge levels amongst village AIDS committees after undergoing HIV educational sessions: results from a pilot study in rural Tanzania 
Village AIDS committees (VAC) were formed by the Tanzanian government in 2003 to provide HIV education to their communities. However, their potential has not been realised due to their limited knowledge and misconceptions surrounding HIV, which could be addressed through training of VAC members. In an attempt to increase HIV knowledge levels and address common misconceptions amongst the VACs, an HIV curriculum was delivered to members in rural north western Tanzania.
An evaluation of HIV knowledge was conducted prior to and post-delivery of HIV training sessions, within members of three VACs in Kisesa ward. Quantitative surveys were used with several open-ended questions to identify local misconceptions and evaluate HIV knowledge levels. Short educational training sessions covering HIV transmission, prevention and treatment were conducted, with each VAC using quizzes, role-plays and participatory learning and action tools. Post-training surveys occurred up to seven days after the final training session.
Before the training, "good" HIV knowledge was higher amongst men than women (p = 0.041), and among those with previous HIV education (p = 0.002). The trade-centre had a faster turn-over of VAC members, and proximity to the trade-centre was associated with a shorter time on the committee.
Training improved HIV knowledge levels with more members achieving a "good" score in the post-training survey compared with the baseline survey (p = < 0.001). The training programme was popular, with 100% of participants requesting further HIV training in the future and 51.7% requesting training at three-monthly intervals.
In this setting, a series of HIV training sessions for VACs demonstrated encouraging results, with increased HIV knowledge levels following short educational sessions. Further work is required to assess the success of VAC members in disseminating this HIV education to their communities, as well as up-scaling this pilot study to other regions in Tanzania with different misconceptions.
PMCID: PMC3262745  PMID: 22165999
20.  Parental control and monitoring of young people's sexual behaviour in rural North-Western Tanzania: Implications for sexual and reproductive health interventions 
BMC Public Health  2011;11:106.
Parenting through control and monitoring has been found to have an effect on young people's sexual behaviour. There is a dearth of literature from sub-Saharan Africa on this subject. This paper examines parental control and monitoring and the implications of this on young people's sexual decision making in a rural setting in North-Western Tanzania.
This study employed an ethnographic research design. Data collection involved 17 focus group discussions and 46 in-depth interviews conducted with young people aged 14-24 years and parents/carers of young people within this age-group. Thematic analysis was conducted with the aid of NVIVO 7 software.
Parents were motivated to control and monitor their children's behaviour for reasons such as social respectability and protecting them from undesirable sexual and reproductive health (SRH) outcomes. Parental control and monitoring varied by family structure, gender, schooling status, a young person's contribution to the economic running of the family and previous experience of a SRH outcome such as unplanned pregnancy. Children from single parent families reported that they received less control compared to those from both parent families. While a father's presence in the family seemed important in controlling the activities of young people, a mother's did not have a similar effect. Girls especially those still schooling received more supervision compared to boys. Young women who had already had unplanned pregnancy were not supervised as closely as those who hadn't. Parents employed various techniques to control and monitor their children's sexual activities.
Despite parents making efforts to control and monitor their young people's sexual behaviour, they are faced with several challenges (e.g. little time spent with their children) which make it difficult for them to effectively monitor them. There is a need for interventions such as parenting skills building that might enable parents to improve their relationships with children. This would equip parents with the appropriate skills for positive guidance and monitoring of their children and avoid inappropriate parenting behaviour. As much as parents focus their attention on their school going daughters, there is a need to also remember the out-of-school young people as they are also vulnerable to adverse SRH outcomes.
PMCID: PMC3045945  PMID: 21324171
21.  Trends in HIV & syphilis prevalence and correlates of HIV infection: results from cross-sectional surveys among women attending ante-natal clinics in Northern Tanzania 
BMC Public Health  2010;10:553.
Sentinel surveillance for HIV in ante-natal clinics (ANC) remains the primary method for collecting timely trend data on HIV prevalence in most of sub-Saharan Africa. We describe prevalence of HIV and syphilis infection and trends over time in HIV prevalence among women attending ante-natal clinics (ANC) in Magu district and Mwanza city, part of Mwanza region in Northern Tanzania. HIV prevalence from ANC surveys in 2000 and 2002 was 10.5% and 10.8% respectively. In previous rounds urban residence, residential mobility, the length of time sexually active before marriage, time since marriage and age of the partner were associated with HIV infection.
A third round of HIV sentinel surveillance was conducted at ante-natal clinics in Mwanza region, Tanzania during 2006. We interviewed women attending 27 ante-natal clinics. In 15 clinics we also anonymously tested women for syphilis and HIV infection and linked these results to the questionnaire data.
HIV prevalence was 7.6% overall in 2006 and 7.4% at the 11 clinics used in previous rounds. Geographical variations in HIV prevalence, apparent in previous rounds, have largely disappeared but syphilis prevalence is still higher in rural clinics. HIV prevalence has declined in urban clinics and is stable in rural clinics. The correlates of HIV infection have changed over time. In this round older age, lower gravidity, remarriage, duration of marriage, sexual activity before marriage, long interval between last birth and pregnancy and child death were all associated with infection.
HIV prevalence trends concur with results from a community-based cohort in the region. Correlates of HIV infection have also changed and more proximate, individual level factors are now more important, in line with the changing epidemiology of infection in this population.
PMCID: PMC2946298  PMID: 20836872
22.  "Driving the devil away": qualitative insights into miraculous cures for AIDS in a rural Tanzanian ward 
BMC Public Health  2010;10:427.
The role of religious beliefs in the prevention of HIV and attitudes towards the infected has received considerable attention. However, little research has been conducted on Faith Leaders' (FLs) perceptions of antiretroviral therapy (ART) in the developing world. This study investigated FLs' attitudes towards different HIV treatment options (traditional, medical and spiritual) available in a rural Tanzanian ward.
Qualitative interviews were conducted with 25 FLs purposively selected to account for all the denominations present in the area. Data was organised into themes using the software package NVIVO-7. The field work guidelines were tailored as new topics emerged and additional codes progressively added to the coding frame.
Traditional healers (THs) and FLs were often reported as antagonists but duality prevailed and many FLs simultaneously believed in traditional healing. Inter-denomination mobility was high and guided by pragmatism.
Praying for the sick was a common practice and over one third of respondents said that prayer could cure HIV. Being HIV-positive was often seen as "a punishment from God" and a consequence of sin. As sinning could result from "the work of Satan", forgiveness was possible, and a "reconciliation with God" deemed as essential for a favourable remission of the disease. Several FLs believed that "evil spirits" inflicted through witchcraft could cause the disease and claimed that they could cast "demons" away.
While prayers could potentially cure HIV "completely", ART use was generally not discouraged because God had "only a part to play". The perceived potential superiority of spiritual options could however lead some users to interrupt treatment.
The roll-out of ART is taking place in a context in which the new drugs are competing with a diversity of existing options. As long as the complementarities of prayers and ART are not clearly and explicitly stated by FLs, spiritual options may be interpreted as a superior alternative and contribute to hampering adherence to ART. In contexts where ambivalent attitudes towards the new drugs prevail, enhancing FLs understanding of ART's strengths and pitfalls is an essential step to engage them as active partners in ART scale-up programs.
PMCID: PMC2916904  PMID: 20646300
23.  Parent-child communication about sexual and reproductive health in rural Tanzania: Implications for young people's sexual health interventions 
Many programmes on young people and HIV/AIDS prevention have focused on the in-school and channeled sexual and reproductive health messages through schools with limited activities for the young people's families. The assumption has been that parents in African families do not talk about sexual and reproductive health (SRH) with their children. These approach has had limited success because of failure to factor in the young person's family context, and the influence of parents. This paper explores parent-child communication about SRH in families, content, timing and reasons for their communication with their children aged 14-24 years in rural Tanzania.
This study employed an ethnographic research design. Data collection involved eight weeks of participant observation, 17 focus group discussions and 46 in-depth interviews conducted with young people aged 14-24 years and parents of young people in this age group. Thematic analysis was conducted with the aid of NVIVO 7 software.
Parent-child communication about SRH happened in most families. The communication was mainly on same sex basis (mother-daughter and rarely father-son or father-daughter) and took the form of warnings, threats and physical discipline. Communication was triggered by seeing or hearing something a parent perceived negative and would not like their child to experience (such as a death attributable to HIV and unmarried young person's pregnancy). Although most young people were relaxed with their mothers than fathers, there is lack of trust as to what they can tell their parents for fear of punishment. Parents were limited as to what they could communicate about SRH because of lack of appropriate knowledge and cultural norms that restricted interactions between opposite sex.
Due to the consequences of the HIV pandemic, parents are making attempts to communicate with their children about SRH. They are however, limited by cultural barriers, and lack of appropriate knowledge. With some skills training on communication and SRH, parents may be a natural avenue for channeling and reinforcing HIV/AIDS prevention messages to their children.
PMCID: PMC2875205  PMID: 20462413
24.  Barriers to Sustaining Antiretroviral Treatment in Kisesa, Tanzania 
AIDS patient care and STDs  2009;23(3):203-210.
Two years after the introduction of free antiretroviral therapy (ART) in Tanzania and in spite of the logistical support provided to facilitate clinic attendance, a considerable level of attrition from the program was identified among clients from a semi-rural ward. Qualitative research on ART patients’ health-seeking behavior identified factors affecting sustained attendance at treatment clinics. A mix of methods was used for data collection including semi-structured interviews with 42 clients and 11 service providers and 4 participatory group activities conducted with members of a post-test group between October and December 2006. A socio-ecological framework guided data analysis to categorize facilitators and barriers into individual, social, programmatic, and structural level influences, and subsequently explored their interaction and relative significance in shaping ART clients’ behavior. Our findings suggest that personal motivation and self-efficacy contribute to program retention, and are affected by other individual-level experiences such as perceived health benefits or disease severity. However, these determinants are influenced by others’ opinions and beliefs in the community, and constrained by programmatic and structural barriers. Individuals can develop the requisite willingness to sustain strict treatment requirements in a challenging context, but are more likely to do so within supportive family and community environments. Effectiveness and sustainability of ART roll-out could be strengthened by strategic intervention at different levels, with particular attention to community-level factors such as social networks’ influence and support.
PMCID: PMC2776987  PMID: 19866538
25.  From HIV diagnosis to treatment: evaluation of a referral system to promote and monitor access to antiretroviral therapy in rural Tanzania 
Individuals diagnosed with HIV in developing countries are not always successfully linked to onward treatment services, resulting in missed opportunities for timely initiation of antiretroviral therapy, or prophylaxis for opportunistic infections. In collaboration with local stakeholders, we designed and assessed a referral system to link persons diagnosed at a voluntary counselling and testing (VCT) clinic in a rural district in northern Tanzania with a government-run HIV treatment clinic in a nearby city.
Two-part referral forms, with unique matching numbers on each side were implemented to facilitate access to the HIV clinic, and were subsequently reconciled to monitor the proportion of diagnosed clients who registered for these services, stratified by sex and referral period. Delays between referral and registration at the HIV clinic were calculated, and lists of non-attendees were generated to facilitate tracing among those who had given prior consent for follow up.
Transportation allowances and a "community escort" from a local home-based care organization were introduced for patients attending the HIV clinic, with supportive counselling services provided by the VCT counsellors and home-based care volunteers. Focus group discussions and in-depth interviews were conducted with health care workers and patients to assess the acceptability of the referral procedures.
Referral uptake at the HIV clinic averaged 72% among men and 66% among women during the first three years of the national antiretroviral therapy (ART) programme, and gradually increased following the introduction of the transportation allowances and community escorts, but declined following a national VCT campaign. Most patients reported that the referral system facilitated their arrival at the HIV clinic, but expressed a desire for HIV treatment services to be in closer proximity to their homes. The referral forms proved to be an efficient and accepted method for assessing the effectiveness of the VCT clinic as an entry point for ART.
The referral system reduced delays in seeking care, and enabled the monitoring of access to HIV treatment among diagnosed persons. Similar systems to monitor referral uptake and linkages between HIV services could be readily implemented in other settings.
PMCID: PMC2788344  PMID: 19906291

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