WHO and Global Health Monitoring: The Way Forward

Ties Boerma and colleagues from WHO describe the agency's work and future in health indicator monitoring, as part of a cluster of PLoS Medicine articles on global health estimates

The price of promiscuity: why urban males in Tanzania are changing their sexual behaviour

This article presents evidence of a substantial change in sexual behaviour among urban factory workers during the last four years; it discusses the nature of this change and the reasons for it. Fear of AIDS was the main motivating factor, followed by economic hardship: because AIDS is incurable and because sexual relationships have a substantial transactional component, workers see themselves as paying the price of promiscuity with their lives as well as their dwindling financial resources. Respondents preferred partner reduction, and in particular sticking to one partner, to condom use. Condoms were not popular, mainly because of fears that they were impregnated with HIV and because of their association with promiscuous behaviour

New strategies for HIV surveillance in resource-constrained settings: an overview.

Additional funding recently became available to help resource-constrained countries scale up their HIV treatment and prevention activities. This increased funding is accompanied by an increased demand for accountability from stakeholders. Many countries will need to make substantial improvements in their current HIV surveillance methods to monitor the collective national impact of these treatment and prevention initiatives. However, whereas most resource-constrained countries have monitored the prevalence of HIV, they have collected little information on other events in the HIV disease process, such as HIV incidence, rate of HIV drug resistance, number of deaths due to AIDS and only modest emphasis has been placed on AIDS reporting in generalized epidemics, resulting in severe underreporting. In addition, data on mortality trends are often not gathered. Furthermore, less than half of the countries with low-level/concentrated epidemics have tailored their surveillance systems to the local epidemic, behavioral surveillance is often not present, an integrated analysis of data is not widespread, and data are rarely used to inform policy. In January 2004, a conference was convened in Addis Ababa, Ethiopia, to examine new strategies for surveillance in resource-constrained countries, and their use in monitoring and evaluating HIV activities. This supplement summarizes the newest approaches and lessons learned for HIV/AIDS surveillance, based on presentations and discussions from that conference. This article provides an overview of HIV/AIDS surveillance in resource-constrained settings and discusses the history, current approaches, and future directions for HIV/AIDS surveillance in generalized and low-level/concentrated epidemics

Orphanhood, child fostering and the AIDS epidemic in rural Tanzania

The AIDS epidemic has caused an increase in adult mortality and consequently an increase in the numbers of orphaned children. Data were used from the Kisesa Community Study in northwest Tanzania, to assess the prevalence and consequences of orphanhood in the context of existing child care practices in a rural area with moderately high HIV-prevalence. This study was carried out in a ward with about 20,000 people with HIV prevalence of 6.2 per cent among adults 15-44 years and slightly over one-third of adult deaths associated with HIV/AIDS. Seven point six per cent of children under 15 and 8.9 per cent of children under 18 had lost one or both parents. Child fostering was very common. Virtually all orphans and foster-children were cared for by members of the extended family, often the maternal grandparents: 14 per cent of households had at least one orphan. Such households did not have a lower economic status, but had a less favourable dependency ratio. Households with orphans were also more likely to be female-headed. Follow-up mortality rates were similar among orphans, foster-children and other children, for both sexes. Mobility was much higher among orphans and foster-children, and orphans and foster-children had somewhat lower school attendance rates: lower enrolment and higher dropout rates. The problem of rapidly increasing numbers of orphans needs to be considered in the context of previously high levels of adult mortality, child-fostering practices and general poverty. The extended family seems to be able to absorb the increase in orphans, because caring for children of other members of the family is widespread, whether the parents are alive or dead. This study yields no evidence that orphans as a group are disadvantaged, although certain subgroups of orphans or orphan households may be more vulnerable and in need of support

Levels and causes of adult mortality in rural Tanzania with special reference to HIV/AIDS

Data from a longitudinal study in northwest Tanzania were used to assess the levels of adult mortality and the leading causes of death. Adult mortality in this rural area was high and 42 per cent of persons aged 15 will die before their sixtieth birthday at current mortality rates. Mortality in this population with an HIV prevalence of about six per cent in 1994-95, has increased by about one-third because of HIV/AIDS, and further increase is likely. Other infectious diseases cause nearly a quarter of deaths and non-communicable diseases are still a relatively minor cause. The occurrence of the AIDS epidemic may have further delayed the onset of the epidemiological transition in many parts of Africa

Regional Differences in Intervention Coverage and Health System Strength in Tanzania.

Assessments of subnational progress and performance coverage within countries should be an integral part of health sector reviews, using recent data from multiple sources on health system strength and coverage. As part of the midterm review of the national health sector strategic plan of Tanzania mainland, summary measures of health system strength and coverage of interventions were developed for all 21 regions, focusing on the priority indicators of the national plan. Household surveys, health facility data and administrative databases were used to compute the regional scores. Regional Millennium Development Goal (MDG) intervention coverage, based on 19 indicators, ranged from 47% in Shinyanga in the northwest to 71% in Dar es Salaam region. Regions in the eastern half of the country have higher coverage than in the western half of mainland. The MDG coverage score is strongly positively correlated with health systems strength (r = 0.84). Controlling for socioeconomic status in a multivariate analysis has no impact on the association between the MDG coverage score and health system strength. During 1991-2010 intervention coverage improved considerably in all regions, but the absolute gap between the regions did not change during the past two decades, with a gap of 22% between the top and bottom three regions. The assessment of regional progress and performance in 21 regions of mainland Tanzania showed considerable inequalities in coverage and health system strength and allowed the identification of high and low-performing regions. Using summary measures derived from administrative, health facility and survey data, a subnational picture of progress and performance can be obtained for use in regular health sector reviews

State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys

Background Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries. Methods We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as diff erence and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries—ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Signifi cance was determined using 95% CIs. Findings National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a diff erence of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the diff erence between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in fi ve high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda. Interpretation Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations

Using health surveillance systems data to assess the impact of AIDS and antiretroviral treatment on adult morbidity and mortality in Botswana

Introduction: Botswana's AIDS response included free antiretroviral treatment (ART) since 2002, achieving 80% coverage of persons with CD450% and >30% through 2011, while continuing to increase in older women. Conclusions: Adult mortality in Botswana fell markedly as ART coverage increased. HIV prevalence declines may reflect ART-associated reductions in sexual transmission. Triangulation of surveillance system data offers a reasonable approach to evaluate impact of HIV/AIDS interventions, complementing cohort approaches that monitor individual-level health outcomes

Estimating Incidence from Prevalence in Generalised HIV Epidemics: Methods and Validation

Timothy Hallett and colleagues develop and test two user-friendly methods to estimate HIV incidence based on changes in cross-sectional prevalence, using either mortality rates or survival after infection