Socio-geographical patterns of HIV-1 transmission in Kagera Region, Tanzania

Social and structural factors related to HIV risk among truck drivers passing through the Iringa region of Tanzania

Truck drivers and their assistants have been identified as groups at higher risk for HIV infection. We sought to identify and describe the social and structural factors that may contribute to HIV risk among truck drivers who visit rest stops in Iringa, Tanzania, a region characterized by high levels of migration and mobility. This analysis was part of a comprehensive strategic assessment to examine HIV risk factors in Iringa. This analysis focuses on 11 in-depth interviews with truck drivers and a transport owner. A semi-structured interview guide was developed to elicit open-ended responses and enable probing. Interviews were conducted in Swahili, transcribed, and translated into English. Data analysis followed thematic analysis procedures that included initial reading of transcripts, development of a codebook and identification of themes through in-depth reading of transcripts. Drivers described structural risk factors for HIV including work conditions, the power imbalance between male drivers and their sexual partners and minimal perceived HIV risk with certain partners (e.g., regular partners and women selling sex). Multiple and inter-related social norms associated with truck stop environments influenced HIV risk, including peer influence and expectations, presence of sex workers, ability to purchase sex throughout their travel and alcohol consumption. These distinct social norms in truck stops and other rest points facilitated behavior that many participants said they would not engage in elsewhere. HIV prevention strategies with truck drivers should address individual, social and structural barriers to HIV prevention through partnerships with the health and transportation sectors, local government and local communities. HIV prevention services should be adapted to drivers' times and places of availability, for example, condom provision where/when drivers make decisions about or have sex. A focus on positive messaging and addressing specific challenges including the continual challenge of re-choosing and reinforcing decisions to engage in safer sexual behaviors is important.

USING PARTICIPATORY METHODS AND GEOGRAPHIC INFORMATION SYSTEMS (GIS) TO PREPARE FOR AN HIV COMMUNITY-BASED TRIAL IN VULINDLELA, SOUTH AFRICA (Project Accept-HPTN 043)

Recent attempts to integrate geographic information systems (GIS) and participatory techniques, have given rise to terminologies such as participatory GIS and community-integrated GIS. Although GIS was initially developed for physical geographic application, it can be used for the management and analysis of health and health care data. Geographic information systems, combined with participatory methodology, have facilitated the analysis of access to health facilities and disease risk in different populations. Little has been published about the usefulness of combining participatory methodologies and GIS technology in an effort to understand and inform community-based intervention studies, especially in the context of HIV. This article attempts to address this perceived gap in the literature. The authors describe the application of participatory research methods with GIS in the formative phase of a multisite community-based social mobilization trial, using voluntary counseling and testing and post-test support as the intervention.

Place matters: multilevel investigation of HIV distribution in Tanzania

OBJECTIVE

To examine the extent to which the regional and neighborhood distribution of HIV in Tanzania is caused by the differential distribution of individual correlates and risk factors.

METHODS

Nationally representative, cross-sectional data on 12,522 women and men aged 15-49 years from the 2003-2004 Tanzanian AIDS Indicator Survey. Three-level multilevel binary logistic regression models were specified to estimate the relative contribution of regions and neighborhoods to the variation in HIV seroprevalence.

RESULTS

Spatial distribution of individual correlates (and risk factors) of HIV do not explain the neighborhood and regional variation in HIV seroprevalence. Neighborhoods and regions accounted for approximately 14 and 6% of the total variation in HIV. HIV prevalence ranged from 1.8% (Kigoma) to 6.7% (Iringa) even after adjusting for the compositional make-up of these regions. An inverse association was observed between log odds of being HIV positive and neighborhood poverty [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.09-0.61] and regional poverty (OR 0.97, 95% CI 0.95-0.99).

CONCLUSION

Our study provides evidence for independent contextual variations in HIV, above and beyond that which can be ascribed to geographical variations in individual-level correlates and risk factors. We emphasize the need to adopt both a group-based and a place-based approach, as opposed to the dominant high-risk group approach, for understanding the epidemiology of HIV as well as for developing HIV intervention activities.

Mapping transactional sex on the Northern Corridor highway in Kenya

Even in generalized HIV/AIDS epidemics, vulnerable populations such as sex workers and truckers require special attention in programming. Combining a number of elicitation methods, centred on Geographical Information Systems (GIS) mapping, the Kenyan section of the Northern Corridor highway was studied to characterize the 'hot spots' where transactional sex is concentrated and to provide estimates of numbers of truckers and sex workers and the volumes of transactional sex taking place on the highway. An average of 2400 trucks park overnight at the 39 hot spots identified. These spots have an estimated sex worker population of 5600 women. Analysis of 403 sex worker diaries shows an average of 13.6 different clients and 54.2 sex acts in a month. Condom use is 69% in liaisons with regular clients and 90% with casual clients. The use of GIS is demonstrated at regional and local scales. The 'bridge population' of clients of sex workers, containing a wide rage of occupations, supports the concept of programming for 'vulnerable places' as well as vulnerable groups.

Estimating and projecting HIV prevalence and AIDS deaths in Tanzania using antenatal surveillance data

Background

The Estimations and Projections Package (EPP 2005) for HIV/AIDS estimates and projects HIV prevalence, number of people living with HIV and new HIV infections and AIDS cases using antenatal clinic (ANC) surveillance data. The prevalence projection produced by EPP can be transferred to SPECTRUM, a demographic projectionmodel, to calculate the number of AIDS deaths. This paper presents estimates and projections of HIV prevalence, new cases of HIV infections and AIDS deaths in Tanzania between 2001 and 2010 using the EPP 2005 and SPECTRUM soft-wares on ANC data.

Methods

For this study we used; the 1985 – 2004 ANC data set, the 2005 UN population estimates for urban and rural adults, which is based on the 2002 population census, and results of the 2003 Tanzania HIV Indicator Survey. The ANC surveillance sites were categorized into urban and rural areas on the basis of the standard national definitions of urban and rural areas, which led to 40 urban and 35 rural clinic sites. The rural and urban epidemics were run independently by fitting the model to all data and on level fits.

Results

The national HIV prevalence increased from 0% in 1981 to a peak of 8.1% in 1995, and gradually decreased to 6.5% in 2004 which stabilized until 2010. The urban HIV epidemic increased from 0% in 1981 peaking at 12.6% in 1992 and leveled to between 10.9% and 11.8% from 2003 to 2010. The rural epidemic peaked in 1995 at 7.0% and gradually declined to 5.2% in 2004, and then stabilized at between 5.1% and 5.3% from 2005 to 2010. New infections are projected to rise steadily, resulting in 250,000 new cases in 2010. Deaths due to AIDS started in 1985 and rose steadily to reach 120,000 deaths in 2010, with more females dying than men.

Conclusion

The fact that the number of new infections is projected to increase steadily to reach 250,000 per year in 2010 calls for more concerted efforts to combat the spread of HIV infection particularly in the rural areas where the infrastructure needed for prevention programmes such as counseling and testing, condom accessibility and AIDS information is less developed.

Surveillance of HIV and syphilis infections among antenatal clinic attendees in Tanzania-2003/2004

BACKGROUND

This paper presents the prevalence of human immunodeficiency virus (HIV) and syphilis infections among women attending antenatal clinics (ANC) in Tanzania obtained during the 2003/2004 ANC surveillance.

METHODS

Ten geographical regions; six of them were involved in a previous survey, while the remaining four were freshly selected on the basis of having the largest population among the remaining 20 regions. For each region, six ANC were selected, two from each of three strata (urban, peri-urban and rural). Three of the sites did not participate, resulting into 57 surveyed clinics. 17,813 women who were attending the chosen clinics for the first time for any pregnancy between October 2003 and January 2004. Patient particulars were obtained by interview and blood specimens were drawn for HIV and syphilis testing. HIV testing was done anonymously and the results were unlinked.

RESULTS

Of the 17,813 women screened for HIV, 1,545 (8.7% (95% CI = 8.3-9.1)) tested positive with the highest prevalence in women aged 25-34 years (11%), being higher among single women (9.7%) than married women (8.6%) (p < 0.07), and increased with level of education from 5.2% among women with no education to 9.3% among those at least primary education (p < 0.001). Prevalence ranged from 4.8% (95% CI = 3.8%-9.8%) in Kagera to 15.3% (95% CI = 13.9%-16.8%) in Mbeya and was; 3.7%, 4.7%, 9.1%, 11.2% and 15.3% for rural, semi-urban, road side, urban and 15.3% border clinics, respectively (p < 0.001). Of the 17,323 women screened for syphilis, 1265 (7.3% (95%CI = 6.9-7.7)) were positive, with highest prevalence in the age group 35-49 yrs (10.4%) (p < 0.001), and being higher among women with no education than those with some education (9.8% versus 6.8%) (p < 0.0001), but marital status had no influence. Prevalence ranged from 2.1% (95% CI = 1.4%-3.0%) in Kigoma to 14.9% (95% CI = 13.3%-16.6%) in Kagera and was 16.0% (95% CI = 13.3-18.9), 10.5% (95% CI = 9.5-11.5) and 5.8% (95% CI = 5.4-6.3) for roadside, rural and urban clinics, respectively. Syphilis and HIV co-infection was seen in 130/17813 (0.7%).

CONCLUSION

The high HIV prevalence observed among the ANC clinic attendees in Tanzania call for expansion of current voluntary counselling and testing (VCT) services and access to antiretroviral drugs (ARV) in the clinics. There is also a need for modification of obstetric practices and infant feeding options in HIV infection in order to prevent mother to child transmission of HIV. To increase uptake to HIV testing the opt-out strategy in which all clients are offered HIV testing is recommended in order to meet the needs of as many pregnant women as possible.

Impact of long-term civil disorders and wars on the trajectory of HIV epidemics in sub-Saharan Africa

From the mid-1970s, seven countries in sub-Saharan Africa have experienced civil disorders and wars lasting for at least 10 years. In two-- Sierra Leone during 1991-2002, and Somalia from 1988 and continuing--adult HIV prevalence remained below 1%. In the Democratic Republic of the Congo, HIV prevalence appears to have stabilised during post-1991 civil disorder and war. Limited information from Angola (civil war 1975 -2002) and Liberia (civil disorder and war from 1989 and continuing) suggests low HIV prevalence. Mozambique's HIV prevalence was near 1% after its 1975 - 1992 civil war, but increased dramatically in the first post-war decade. Across African countries with long-term wars, HIV seems to have spread more slowly than in most neighbouring countries at peace. This evidence contributes to the ongoing debate about the factors that explain differential epidemic trajectories, a debate which is crucial to the design of HIV prevention programmes. One possible explanation for slow epidemic growth in wartime is that unsterile health care accounts for an important proportion of HIV transmission during peacetime, but much less when wars disrupt health services. However, other explanations are also possible. The roles of sex and blood exposures in HIV epidemics in war and peace await empirical determination.

HIV and Islam: is HIV prevalence lower among Muslims?

Religious constraints on sexuality may have consequences for the transmission of sexually transmitted diseases. Recognising that several Islamic tenets may have the effect, if followed, of reducing the sexual transmission of HIV, this paper tests the hypothesis that Muslims have lower HIV prevalence than non-Muslims. Among 38 sub-Saharan African countries, the percentage of Muslims within countries negatively predicted HIV prevalence. A survey of published journal articles containing data on HIV prevalence and religious affiliation showed that six of seven such studies indicated a negative relationship between HIV prevalence and being Muslim. Additional studies on the relationship of risk factors to HIV prevalence gave mixed evidence with respect to following Islamic sexual codes (e.g., vs. extramarital affairs) and other factors, but that benefits arising from circumcision may help account for lower HIV prevalence among Muslims.

The application of geographical information systems to important public health problems in Africa

Africa is generally held to be in crisis, and the quality of life for the majority of the continent's inhabitants has been declining in both relative and absolute terms. In addition, the majority of the world's disease burden is realised in Africa. Geographical information systems (GIS) technology, therefore, is a tool of great inherent potential for health research and management in Africa. The spatial modelling capacity offered by GIS is directly applicable to understanding the spatial variation of disease, and its relationship to environmental factors and the health care system. Whilst there have been numerous critiques of the application of GIS technology to developed world health problems it has been less clear whether the technology is both applicable and sustainable in an African setting. If the potential for GIS to contribute to health research and planning in Africa is to be properly evaluated then the technology must be applicable to the most pressing health problems in the continent. We briefly outline the work undertaken in HIV, malaria and tuberculosis (diseases of significant public health impact and contrasting modes of transmission), outline GIS trends relevant to Africa and describe some of the obstacles to the sustainable implementation of GIS. We discuss types of viable GIS applications and conclude with a discussion of the types of African health problems of particular relevance to the application of GIS.

Monitoring of HIV-1 infection prevalence and trends in the general population using pregnant women as a sentinel population: 9 years experience from the Kagera region of Tanzania

In the Kagera region of Tanzania, a population-based study was initiated in 1987 followed by the establishment of antenatal-clinic-based sentinel surveillance system in the town of Bukoba in 1990. Repeat studies in both populations in Bukoba in 1993 and 1996 made it possible to study the dynamics of HIV infection prevalence and incidence in the area. This study aims at comparing the findings from this sentinel surveillance system with those of cross-sectional studies in the general population to assess its validity in estimating HIV prevalence and their trends in the general population. A multistage cluster sampling technique was used in the population-based studies whereas the antenatal-clinic-based population was obtained by consecutively recruiting antenatal care attenders coming for the first time during a given pregnancy. Antibodies against HIV infection were tested using two independent enzyme-linked immunosorbent assay (ELISA) antibody detection tests. Unlinked anonymous testing strategy was adopted for the sentinel population. Age-adjusted prevalence among antenatal care attenders decreased from 22.4% (95% confidence interval [CI], 20.6-25.2) in 1990 to 16.1% (95% CI, 15.9-18.8) in 1993 and further to 13.7% (95% CI, 11.8-14.3) in 1996. These results closely resemble those of the general population of adult women in the clinic's catchment area (the town of Bukoba) where the age-adjusted prevalence of 29.1% (95% CI, 24.4-34.6) in 1987 showed a decrease in the studies in 1993 18.7% (95% CI, 15.1-23.0) and in 1996 14.9% (95% CI, 12.0-17.1). The study indicates that general population trend estimates can be generated using sentinel surveillance data based on pregnant women visiting an antenatal clinic for the first time during a given pregnancy. The benefits of using this group outweigh its limitations that are brought about by possible selection bias. Continued surveillance of the epidemic based on antenatal care patients as a sentinel population is therefore recommended.

HIV heterogeneity and proximity of homestead to roads in rural South Africa: an exploration using a geographical information system

objective To describe heterogeneity of HIV prevalence among pregnant women in Hlabisa health district, South Africa and to correlate this with proximity of homestead to roads. methods HIV prevalence measured through anonymous surveillance among pregnant women and stratified by local village clinic. Polygons were created around each clinic, assuming women attend the clinic nearest their home. A geographical information system (GIS) calculated the mean distance from homesteads in each clinic catchment to nearest primary (1 degrees ) and to nearest primary or secondary (2 degrees ) road. results We found marked HIV heterogeneity by clinic catchment (range 19-31% (P < 0.001). A polygon plot demonstrated lower HIV prevalence in catchments remote from 1 degrees roads. Mean distance from homesteads to nearest 1 degrees or 2 degrees road varied by clinic catchment from 1623 to 7569 m. The mean distance from homesteads to a 1 degrees or 2 degrees road for each clinic catchment was strongly correlated with HIV prevalence (r = 0.66; P = 0.002). conclusions The substantial HIV heterogeneity in this district is closely correlated with proximity to a 1 degrees or 2 degrees road. GIS is a powerful tool to demonstrate and to start to analyse this observation. Further research is needed to better understand this relationship both at ecological and individual levels, and to develop interventions to reduce the spread of HIV infection.

Planning reproductive health in conflict: a conceptual framework

A conceptual framework for planning reproductive health services for refugees is presented for use by those involved in planning field activities. Secondary sources of data are recommended to describe pre-existing patterns and trends in reproductive health status and likely determinants of any change in status, for populations which have been subsequently affected by conflict. The interaction between these patterns and the conflict itself is then analyzed, taking into account the shift in health status and service availability as the conflict progresses through various recognized phases. The potential impact of conflict is thus hypothesized in order to make initial plans for incorporating reproductive health services into standard relief packages. Two case studies are presented: Rwanda demonstrates the use of the framework in a relatively short but dramatic conflict, for which there was also substantial prior evidence on reproductive health status; Cambodia is used, in contrast, to demonstrate the use of the framework in a much more complex conflict which has been occurring over the last 20 years.

AIDS epidemic in Kagera region, Tanzania--the experiences of local people

This study is part of a collaborative study of HIV infection and AIDS which was launched in 1987 in the Kagera region, Tanzania. This region is characterized as one of the areas most affected by the AIDS epidemic. In order to describe and analyse the epidemiology of HIV infection in the area and also to contribute to the intervention process, a long-term population-based project was initiated. The study was launched in January 1989 as an in-depth behavioural study to describe the experiences of the local people of the AIDS epidemic in the region. The specific objectives were to determine the people's attitudes, perceptions, responses and norms relevant to AIDS-related problems. The data were collected through tape recorded interviews, focus group discussions and direct observations of risk behaviour. The interviews were conducted in 10 villages, in urban and rural Bukoba as well as in Muleba districts. In each village five households were selected and visited once a week for about 6 months. The focus group discussions were held mainly with young males, females, married women and married men, elders and religious leaders, government and party leaders, and other key informants. Perceptions, attitudes and patterns of behaviour among the local people are described in the context of the HIV transmission in the area. The descriptions give answers to questions like: How do people perceive and interpret AIDS? How do they react to AIDS? How do they judge causes and risks? What are the attitudes to people with AIDS and those suspected to have AIDS? What are the implications of these values in affected communities?