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1.  Mental distress in the general population in Zambia: Impact of HIV and social factors 
BMC Public Health  2009;9:298.
Background
Population level data on mental health from Africa are limited, but available data indicate mental problems to represent a substantial public health problem. The negative impact of HIV on mental health suggests that this could particularly be the case in high prevalence populations. We examined the prevalence of mental distress, distribution patterns and the ways HIV might influence mental health among men and women in a general population.
Methods
The relationship between HIV infection and mental distress was explored using a sample of 4466 participants in a population-based HIV survey conducted in selected rural and urban communities in Zambia in 2003. The Self-reporting questionnaire-10 (SRQ-10) was used to assess global mental distress. Weights were assigned to the SRQ-10 responses based on DSM IV criteria for depression and a cut off point set at 7/20 for probable cases of mental distress. A structural equation modeling (SEM) was established to assess the structural relationship between HIV infection and mental distress in the model, with maximum likelihood ratio as the method of estimation.
Results
The HIV prevalence was 13.6% vs. 18% in the rural and urban populations, respectively. The prevalence of mental distress was substantially higher among women than men and among groups with low educational attainment vs. high. The results of the SEM showed a close fit with the data. The final model revealed that self-rated health and self perceived HIV risk and worry of being HIV infected were important mediators between underlying factors, HIV infection and mental distress. The effect of HIV infection on mental distress was both direct and indirect, but was particularly strong through the indirect effects of health ratings and self perceived risk and worry of HIV infection.
Conclusion
These findings suggest a strong effect of HIV infection on mental distress. In this population where few knew their HIV status, this effect was mediated through self-perceptions of health status, found to capture changes in health perceptions related to HIV, and self-perceived risk and worry of actually being HIV infected.
doi:10.1186/1471-2458-9-298
PMCID: PMC2744699  PMID: 19689799
2.  Factors affecting voluntary HIV counselling and testing among men in Ethiopia: a cross-sectional survey 
BMC Public Health  2012;12:438.
Background
Voluntary HIV counselling and testing (VCT) is one of the key strategies in the HIV/AIDS prevention and control programmes in Ethiopia. However, utilization of this service among adults is very low. The aim of the present study was to investigate factors associated with VCT utilization among adult men since men are less likely than women to be offered and accept routine HIV testing.
Methods
The study utilized data from the Ethiopian Demographic Health Survey (EDHS) 2005, which is a cross-sectional survey conducted on a nationally representative sample. Using cluster sampling, 6,778 men aged 15–59 years were selected from all the eleven administrative regions in Ethiopia. Logistic regression was used to analyze potential factors associated with VCT utilization.
Results
Overall, 21.9% of urban men and 2.6% of rural men had ever tested for HIV through VCT and most of them had learned their HIV test result. Having no stigmatizing attitudes toward people living with HIV/AIDS was found to be strongly and positively associated with VCT utilization in both urban and rural strata. In rural areas HIV test rates were higher among younger men (aged ≤44 years) and those of higher socio-economic position (SEP). Among urban men, risky sexual behaviour was positively associated with VCT utilization whereas being Muslim was found to be inversely associated with utilization of VCT. Area of residence as well as SEP strongly affected men’s level of stigmatizing attitudes toward people living with HIV/AIDS.
Conclusions
VCT utilization among men in Ethiopia was low and affected by HIV/AIDS-related stigma and residence. In order to increase VCT acceptability, HIV/AIDS prevention and control programs in the country should focus on reducing HIV/AIDS-related stigma. Targeting rural men with low SEP should be given first priority when designing, expanding, and implementing VCT services in the country.
doi:10.1186/1471-2458-12-438
PMCID: PMC3538522  PMID: 22703550
HIV testing; VCT utilization; Stigma; Knowledge; Men; Ethiopia
3.  Risk factors, healthcare-seeking and sexual behaviour among patients with genital ulcers in Zambia 
BMC Public Health  2012;12:407.
Background
Genital ulcers (GU) are associated with an increased risk of HIV transmission. Understanding risk factors for genital ulcers and sexual behaviour patterns after onset of symptoms and health seeking behaviour among GU-patients can provide useful information to aid design effective prevention strategies for genital ulcers. We investigated risk factors of self-reported GUs and care-seeking in the general population, and assessed GU patients regarding past care-seeking, recent sexual behaviour and partner awareness of the disease.
Methods
We analysed national data on genital ulcers from the 2007 Zambia Demographic and Health Survey, and data from a cross-sectional survey of genital ulcer patients from primary health care facilities in Lusaka, Zambia.
Results
The prevalence of GU in 2007 in the general population of Lusaka was 3.6%. Important predictors for genital ulcers were age 25–29 years, being widowed/separated/divorced and having a high number of life-time sexual partners. No differences in care-seeking were observed by residence, wealth and gender, and 60% of the respondents sought care from public health facilities. Among patients with GUs in Lusaka, 14% sought care >2 weeks after symptom onset. Forty-two percent were not aware of their HIV status, 57% reported sex after onset of symptoms and only 15% reported consistent condom use.
Conclusions
Low awareness of HIV status despite high probability of being infected and low condom use after onset of genital ulcer symptoms leads to a high potential for transmission to sexual partners. This, combined with the fact that many patients with GUs delayed seeking care, shows a need for awareness campaigns about GUs and the importance of abstinence or use of condoms when experiencing such symptoms.
doi:10.1186/1471-2458-12-407
PMCID: PMC3490779  PMID: 22672697
Genital ulcers (GUs); Inconsistent condom use; Care-seeking; Predictors; Zambia
4.  Targeting condom distribution at high risk places increases condom utilization-evidence from an intervention study in Livingstone, Zambia 
BMC Public Health  2012;12:10.
Background
The PLACE-method presumes that targeting HIV preventive activities at high risk places is effective in settings with major epidemics. Livingstone, Zambia, has a major HIV epidemic despite many preventive efforts in the city. A baseline survey conducted in 2005 in places where people meet new sexual partners found high partner turnover and unprotected sex to be common among guests. In addition, there were major gaps in on-site condom availability. This study aimed to assess the impact of a condom distribution and peer education intervention targeting places where people meet new sexual partners on condom use and sexual risk taking among people socializing there.
Methods
The 2005 baseline survey assessed the presence of HIV preventive activities and sexual risk taking in places where people meet new sexual partners in Livingstone. One township was selected for a non-randomised intervention study on condom distribution and peer education in high risk venues in 2009. The presence of HIV preventive activities in the venues during the intervention was monitored by an external person. The intervention was evaluated after one year with a follow-up survey in the intervention township and a comparison township. In addition, qualitative interviews and focus group discussions were conducted.
Results
Young people between 17-32 years of age were recruited as peer educators, and 40% were females. Out of 72 persons trained before the intervention, 38 quit, and another 11 had to be recruited. The percentage of venues where condoms were reported to always be available at least doubled in both townships, but was significantly higher in the intervention vs. the control venues in both surveys (84% vs. 33% in the follow-up). There was a reduction in reported sexual risk taking among guests socializing in the venues in both areas, but reporting of recent condom use increased more among people interviewed in the intervention (57% to 84%) than in the control community (55% to 68%).
Conclusions
It is likely that the substantial increase in reported condom use in the intervention venues was partially due to the condom distribution and peer education intervention targeting these places. However, substantial changes were observed also in the comparison community over the five year period, and this indicates that major changes had occurred in overall risk taking among people socializing in venues where people meet new sexual partners in Livingstone.
Trial registration
ClinicalTrials.gov NCT01423357.
doi:10.1186/1471-2458-12-10
PMCID: PMC3293038  PMID: 22221738
5.  Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities 
BMC Public Health  2010;10:347.
Background
Low uptake of voluntary HIV counselling and testing (VCT) in sub-Saharan Africa is raising acceptability concerns which might be associated with ways by which it is offered. We investigated the acceptability of home-based delivery of counselling and HIV testing in urban and rural populations in Zambia where VCT has been offered mostly from local clinics.
Methods
A population-based HIV survey was conducted in selected communities in 2003 (n = 5035). All participants stating willingness to be HIV tested were offered VCT at home and all counselling was conducted in the participants' homes. In the urban area post-test counselling and giving of results were done the following day whereas in rural areas this could take 1-3 weeks.
Results
Of those who indicated willingness to be HIV tested, 76.1% (95%CI 74.9-77.2) were counselled and received the test result. Overall, there was an increase in the proportion ever HIV tested from 18% before provision of home-based VCT to 38% after. The highest increase was in rural areas; among young rural men aged 15-24 years up from 14% to 42% vs. for urban men from 17% to 37%. Test rates by educational attainment changed from being positively associated to be evenly distributed after home-based VCT.
Conclusions
A high uptake was achieved by delivering HIV counselling and testing at home. The highest uptakes were seen in rural areas, in young people and groups with low educational attainment, resulting in substantial reductions in existing inequalities in accessing VCT services.
doi:10.1186/1471-2458-10-347
PMCID: PMC2902437  PMID: 20553631
6.  Effects of neighbourhood-level educational attainment on HIV prevalence among young women in Zambia 
BMC Public Health  2009;9:310.
Background
Investigations of the association between socio-economic position indicators and HIV in East, Central and Southern Africa have chiefly focused on factors that pertain to individual-level characteristics. This study investigated the effect of neighbourhood educational attainment on HIV prevalence among young women in selected urban and rural areas in Zambia.
Methods
This study re-analysed data from a cross-sectional population survey conducted in Zambia in 2003. The analyses were restricted to women aged 15–24 years (n = 1295). Stratified random cluster sampling was used to select 10 urban and 10 rural clusters. A measure for neighbourhood-level educational attainment was constructed by aggregating individual-level years-in-school. Multi-level mixed effects regression models were run to examine the neighbourhood-level educational effect on HIV prevalence after adjusting for individual-level underlying variables (education, currently a student, marital status) and selected proximate determinants (ever given birth, sexual activity, lifetime sexual partners).
Results
HIV prevalence among young women aged 15–24 years was 12.5% in the urban and 6.8% in the rural clusters. Neighbourhood educational attainment was found to be a strong determinant of HIV infection in both urban and rural population, i.e. HIV prevalence decreased substantially by increasing level of neighbourhood education. The likelihood of infection in low vs. high educational attainment of neighbourhoods was 3.4 times among rural women and 1.8 times higher among the urban women after adjusting for age and other individual-level underlying variables, including education. However, the association was not significant for urban young women after this adjustment. After adjusting for level of education in the neighbourhood, the effect of the individual-level education differed by residence, i.e. a strong protective effect among urban women whereas tending to be a risk factor among rural women.
Conclusion
The findings suggested structural effects on HIV prevalence. Future research should include more detailed mapping of neighbourhood factors of relevance to HIV transmission as part of the effort to better understand the causal mechanisms involved.
doi:10.1186/1471-2458-9-310
PMCID: PMC2753350  PMID: 19706189
7.  The context of HIV risk behaviours among HIV-positive injection drug users in Viet Nam: Moving toward effective harm reduction 
BMC Public Health  2009;9:98.
Background
Injection drug users represent the largest proportion of all HIV reported cases in Viet Nam. This study aimed to explore the perceptions of risk and risk behaviours among HIV-positive injection drug users, and their experiences related to safe injection and safe sex practices.
Methods
This study used multiple qualitative methods in data collection including in-depth interviews, focus group discussions and participant observation with HIV-positive injection drug users.
Results
The informants described a change in the sharing practices among injection drug users towards more precautions and what was considered 'low risk sharing', like sharing among seroconcordant partners and borrowing rather than lending. However risky practices like re-use of injection equipment and 'syringe pulling' i.e. the use of left-over drugs in particular, were frequently described and observed. Needle and syringe distribution programmes were in place but carrying needles and syringes and particularly drugs could result in being arrested and fined. Fear of rejection and of loss of intimacy made disclosure difficult and was perceived as a major obstacle for condom use among recently diagnosed HIV infected individuals.
Conclusion
HIV-positive injection drug users continue to practice HIV risk behaviours. The anti-drug law and the police crack-down policy appeared as critical factors hampering ongoing prevention efforts with needle and syringe distribution programmes in Viet Nam. Drastic policy measures are needed to reduce the very high HIV prevalence among injection drug users.
doi:10.1186/1471-2458-9-98
PMCID: PMC2676271  PMID: 19348681
8.  Lost opportunities in HIV prevention: programmes miss places where exposures are highest 
BMC Public Health  2008;8:31.
Background
Efforts at HIV prevention that focus on high risk places might be more effective and less stigmatizing than those targeting high risk groups. The objective of the present study was to assess risk behaviour patterns, signs of current preventive interventions and apparent gaps in places where the risk of HIV transmission is high and in communities with high HIV prevalence.
Methods
The PLACE method was used to collect data. Inhabitants of selected communities in Lusaka and Livingstone were interviewed about where people met new sexual partners. Signs of HIV preventive activities in these places were recorded. At selected venues, people were interviewed about their sexual behaviour. Peer educators and staff of NGOs were also interviewed.
Results
The places identified were mostly bars, restaurants or sherbeens, and fewer than 20% reported any HIV preventive activity such as meetings, pamphlets or posters. In 43% of places in Livingstone and 26% in Lusaka, condoms were never available. There were few active peer educators. Among the 432 persons in Lusaka and 676 in Livingstone who were invited for interview about sexual behaviour, consistent condom use was relatively high in Lusaka (77%) but low in Livingstone (44% of men and 34% of women). Having no condom available was the most common reason for not using one. Condom use in Livingstone was higher among individuals socializing in places where condoms always were available.
Conclusion
In the places studied we found a high prevalence of behaviours with a high potential for HIV transmission but few signs of HIV preventive interventions. Covering the gaps in prevention in these high exposure places should be given the highest priority.
doi:10.1186/1471-2458-8-31
PMCID: PMC2270817  PMID: 18218124
9.  High potential of escalating HIV transmission in a low prevalence setting in rural Tanzania 
BMC Public Health  2007;7:103.
Background
Previous surveillance among antenatal clinic (ANC) attendees within the remote rural Manyara and Singida regions in Tanzania identified an imminent but still, relatively low HIV epidemic. We conducted a population-based HIV study to identify risk factors and validate the representativeness of ANC-based estimates.
Methods
Using a two-stage cluster sampling approach, we enrolled and then interviewed and collected saliva samples from 1,698 adults aged 15–49 years between December 2003 and May 2004. We anonymously tested saliva samples for IgG antibodies against HIV using Bionor HIV-1&2 assays ®. Risk factors for HIV infection were analysed by multivariate logistic regression using the rural population of the two regions as a standard.
Results
The prevalence of HIV in the general population was 1.8% (95%CI: 1.1–2.4), closely matching the ANC-based estimate (2.0%, 95% CI: 1.3–3.0). The female to male prevalence ratio was 0.8 (95%CI 0.4–1.7). HIV was associated with being a resident in a fishing community, and having recently moved into the area. Multiple sexual partners increased likelihood of HIV infection by 4.2 times (95% CI; 1.2–15.4) for men. In women, use of contraceptives other than condoms was associated with HIV infection (OR 6.5, 95% CI; 1.7–25.5), while most of the population (78%) have never used condoms.
Conclusion
The HIV prevalence from the general population was comparable to that of pregnant women attending antenatal clinics. The revealed patterns of sexual risk behaviours, for example, close to 50% of men having multiple partners and 78% of the population have never used a condom; it is likely that HIV infection will rapidly escalate. Immediate and effective preventive efforts that consider the socio-cultural contexts are necessary to reduce the spread of the infection.
doi:10.1186/1471-2458-7-103
PMCID: PMC1904444  PMID: 17559683
10.  Associations between sexual behaviour change in young people and decline in HIV prevalence in Zambia 
BMC Public Health  2007;7:60.
Background
Evidence suggests that HIV prevalence amongst young Zambians has declined recently, especially in higher-education groups. We studied trends in key sexual behaviour indicators among 15–24 year-olds from 1995 to 2003, including the associations between sexual behaviour change and education.
Methods
The data stem from a series of three population-based surveys conducted in 1995 (n = 1720), 1999 (n = 1946) and 2003 (n = 2637). Logistic regression and Extended Mantel Haenszel Chi Square for linear trends were used to compare the three surveys.
Results
Men and lower-education groups reported more than one sexual partner in the year immediately prior to the survey more frequently than did women and higher-education groups (p < 0.01), but these proportions declined regardless of sex and residence. Substantial delays in child-bearing were observed, particularly among higher-education and urban respondents. Condom use at least for casual sexual intercourse increased from 1995 to 2003; the level was highest among urban and higher-education groups. The number of women reporting frequent dry sex using traditional agents fell during the period. Participants from the rural area and those with less education reported more sexual experience than urban and higher-education participants in 2003. The reported number of sexual partners during the year immediately prior to the survey was a factor that reduced the association between HIV and survey times among sexually active young urban men and women.
Conclusion
High risk behaviours clearly decreased, especially in higher-educated and urban groups, and there is a probable association here with the decline in HIV prevalence in the study population. Fewer sexual partners and condom use were among the core factors involved for both sexes; and for women a further factor was delayed child-bearing.
doi:10.1186/1471-2458-7-60
PMCID: PMC1868719  PMID: 17448256
11.  Steep HIV prevalence declines among young people in selected Zambian communities: population-based observations (1995–2003) 
BMC Public Health  2006;6:279.
Background
Understanding the epidemiological HIV context is critical in building effective setting-specific preventive strategies. We examined HIV prevalence patterns in selected communities of men and women aged 15–59 years in Zambia.
Methods
Population-based HIV surveys in 1995 (n = 3158), 1999 (n = 3731) and 2003 (n = 4751) were conducted in selected communities using probability proportional to size stratified random-cluster sampling. Multivariate logistic regression and trend analyses were stratified by residence, sex and age group. Absence, <30% in men and <15% in women in all rounds, was the most important cause of non-response. Saliva was used for HIV testing, and refusal was <10%.
Results
Among rural groups aged 15–24 years, prevalence declined by 59.2% (15.7% to 6.4%, P < 0.001) in females and by 44.6% (5.6% to 3.1%, P < 0.001) in males. In age-group 15–49 years, declines were less than 25%. In the urban groups aged 15–24, prevalence declined by 47% (23.4% to 12.4%, P < 0.001) among females and 57.3% (7.5% to 3.2%, P = 0.001) among males but were 32% and 27% in men and women aged 15–49, respectively. Higher educated young people in 2003 had lower odds of infection than in 1995 in both urban [men: AOR 0.29(95%CI 0.14–0.60); women: AOR 0.38(95%CI 0.19–0.79)] and rural groups [men: AOR 0.16(95%CI 0.11–0.25), women: AOR 0.10(95%CI 0.01–7.34)]. Although higher mobility was associated with increased likelihood of infection in men overall, AOR, 1.71(95%CI 1.34–2.19), prevalence declined in mobile groups also (OR 0.52 95%CI 0.31–0.88). In parallel, urban young people with ≥11 school years were more likely to use condoms during the last casual sex (OR 2.96 95%CI 1.93–4.52) and report less number of casual sexual partners (AOR 0.33 95%CI 0.19–0.56) in the last twelve months than lower educated groups.
Conclusion
Steep HIV prevalence declines in young people, suggesting continuing declining incidence, were masked by modest overall declines. The concentration of declines in higher educated groups suggests a plausible association with behavioural change.
doi:10.1186/1471-2458-6-279
PMCID: PMC1660545  PMID: 17096833
12.  Reducing uncertainties in global HIV prevalence estimates: the case of Zambia 
BMC Public Health  2006;6:83.
Background
The premise for using antenatal care (ANC) clinic data for estimating HIV prevalence in the general population is the finding from community studies in sub-Saharan Africa that total HIV prevalence in pregnant women attending ANC clinics closely approximate levels in the total general population of both women and men aged 15–49 years. In this study, the validity of national level HIV prevalence estimates for the total general population 15–49 years made from ANC clinic and population survey data was assessed.
Methods
In 2001–2002, a national population HIV prevalence survey for women 15–49 years and men 15–59 years was conducted in Zambia. In the same period, a national HIV sentinel surveillance survey among pregnant women attending ANC clinics was carried out.
Results
The ANC HIV prevalence estimates for age-group 15–49 years (rural: 11.5%; 95% CI, 11.2–11.8; urban: 25.4%; 95% CI, 24.8–26.0; adjusted national: 16.9%; 95% CI, 16.6–17.2) were similar to the population survey estimates (rural: 10.8%; 95% CI, 9.6–12.1; urban: 23.2%; 95% CI 20.7–25.6; national: 15.6%; 95% CI, 14.4–16.9). The HIV prevalence urban to rural ratio was 2.2 in ANC and 2.1 in population survey estimates.
Conclusion
The HIV prevalence estimate for the total general population 15–49 years derived from testing both women and men in the population survey was similar to the estimate derived from testing women attending ANC clinics. It shows that national HIV prevalence estimates for adults aged 15–49 years can also be obtained from ANC HIV sentinel surveillance surveys with good coverage when ANC attendance and fertility are high.
doi:10.1186/1471-2458-6-83
PMCID: PMC1552066  PMID: 16579863

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