Monitoring trends in HIV prevalence among young people, aged 15 to 24 years, in Manicaland, Zimbabwe

BACKGROUND: In June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. We assessed progress toward this target in Manicaland, Zimbabwe, using repeated household-based population serosurvey data. We also validated the representativeness of surveillance data from young pregnant women, aged 15 to 24 years, attending antenatal care (ANC) clinics, which UNAIDS recommends for monitoring population HIV prevalence trends in this age group. Changes in socio-demographic characteristics and reported sexual behaviour are investigated. METHODS: Progress towards the UNGASS target was measured by calculating the proportional change in HIV prevalence among youth and young ANC attendees over three survey periods (round 1: 1998-2000; round 2: 2001-2003; and round 3: 2003-2005). The Z-score test was used to compare differences in trends between the two data sources. Characteristics of participants and trends in sexual risk behaviour were analyzed using Student's and two-tailed Z-score tests. RESULTS: HIV prevalence among youth in the general population declined by 50.7% (from 12.2% to 6.0%) from round 1 to 3. Intermediary trends showed a large decline from round 1 to 2 of 60.9% (from 12.2% to 4.8%), offset by an increase from round 2 to 3 of 26.0% (from 4.8% to 6.0%). Among young ANC attendees, the proportional decline in prevalence of 43.5% (from 17.9% to 10.1%) was similar to that in the population (test for differences in trend: p value = 0.488) although ANC data significantly underestimated the population prevalence decline from round 1 to 2 (test for difference in trend: p value = 0.003) and underestimated the increase from round 2 to 3 (test for difference in trend: p value = 0.012). Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines. CONCLUSIONS: In Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends

Effects of cash transfers on Children's health and social protection in Sub-Saharan Africa: differences in outcomes based on orphan status and household assets

BACKGROUND: Unconditional and conditional cash transfer programmes (UCT and CCT) show potential to improve the well-being of orphans and other children made vulnerable by HIV/AIDS (OVC). We address the gap in current understanding about the extent to which household-based cash transfers differentially impact individual children’s outcomes, according to risk or protective factors such as orphan status and household assets. METHODS: Data were obtained from a cluster-randomised controlled trial in eastern Zimbabwe, with random assignment to three study arms – UCT, CCT or control. The sample included 5,331 children ages 6-17 from 1,697 households. Generalized linear mixed models were specified to predict OVC health vulnerability (child chronic illness and disability) and social protection (birth registration and 90% school attendance). Models included child-level risk factors (age, orphan status); household risk factors (adults with chronic illnesses and disabilities, greater household size); and household protective factors (including asset-holding). Interactions were systematically tested. RESULTS: Orphan status was associated with decreased likelihood for birth registration, and paternal orphans and children for whom both parents’ survival status was unknown were less likely to attend school. In the UCT arm, paternal orphans fared better in likelihood of birth registration compared with non-paternal orphans. Effects of study arms on outcomes were not moderated by any other risk or protective factors. High household asset-holding was associated with decreased likelihood of child’s chronic illness and increased birth registration and school attendance, but household assets did not moderate the effects of cash transfers on risk or protective factors. CONCLUSION: Orphaned children are at higher risk for poor social protection outcomes even when cared for in family-based settings. UCT and CCT each produced direct effects on children’s social protection which are not moderated by other child- and household-level risk factors, but orphans are less likely to attend school or obtain birth registration. The effects of UCT and CCT are not moderated by asset-holding, but greater household assets predict greater social protection outcomes. Intervention efforts need to focus on ameliorating the additional risk burden carried by orphaned children. These efforts might include caregiver education, and additional incentives based on efforts made specifically for orphaned children

Medical Pluralism Predicts Non-ART Use among Parents in Need of ART: A Community Survey in KwaZulu-Natal, South Africa

Despite documented common use of traditional healers and efforts to scale up antiretroviral treatment (ART) in sub-Saharan Africa, evidence on whether medical pluralism predicts ART use is inconclusive and restricted to clinic settings. This study quantitatively assesses whether medical pluralism predicts ART use among parents in need of ART in South Africa. 2,477 parents or primary caregivers of children were interviewed in HIV-endemic communities of KwaZulu-Natal. Analysis used multiple logistic regression on a subsample of 435 respondents in need of ART, who reported either medical pluralism (24.6 %) or exclusive public healthcare use (75.4 %). Of 435 parents needing ART, 60.7 % reported ART use. Medical pluralism emerged as a persistent negative predictor of ART utilization among those needing it (AOR [95 % CI] = .556 [.344 - .899], p = .017). Use of traditional healthcare services by those who need ART may act as a barrier to treatment access. Effective intersectoral collaboration at community level is urgently needed

Reproductive health and lifestyle factors associated with health-related quality of life among perinatally HIV-infected adolescents in Uganda

Background With increased survival of perinatally HIV - infected adolescents due to antiretroviral therapy (ART), the focus of HIV care has shifted to health-related quality of life (HRQoL) as a measure of disease progression, effects of ART co-morbidity and prognosis. We assessed factors associated with better HRQoL in perinatally HIV -infected adolescents in Uganda by determining the associations between sexual and reproductive health (SRH) or lifestyle experiences on HRQoL. Methods In a cross-sectional study, data on SRH, lifestyle experiences, socio demographic factors, communication with parents on sexuality and satisfaction of SRH services in ART clinics were collected from 614 HIV perinatally infected adolescents aged 10–19 using an interviewer-administered survey questionnaire. HRQoL data were collected using the Medical Outcomes Study HIV Health Survey instrument (MOS-HIV). Factors associated with better HRQoL were analysed using multiple logistic regression. Results The mean age was 16.2 ± 2.1 years, 362 (58.8 %) were females and 210 (34.2 %) were sexually active. Adolescents on ART were twice likely to present with better physical health (AOR = 2.07, 95 % CI: 1.24–3.46) and four times more likely to present with better mental health (AOR = 3.9, 95 % CI: 2.22–6.92) than those who were not on ART. There were no statistically significant associations between SRH (ever had sex, ever been pregnant, condom use, contraceptive use) or life style factors and physical health or mental health. Those with secondary or tertiary education were more likely to present with a better mental health (AOR = 5.3, 95 % CI: 1.86–15.41) compared those who had attained primary or no education. Participants who desired to have a child in future more likely (AOR 1.7, 95 % CI: 1.05–3.00) to present with a better mental health. Lack of communication with guardians on sexuality (AOR = 0.6, 95 % CI: 0.40–0.89), or dissatisfaction with SRH services (AOR 0.34, 95 % CI: 0.18–0.62) were associated with poorer mental health. Conclusion Among perinatally HIV-infected adolescents in Uganda, being on ART was associated with better physical and mental health while lack of communication with guardians on sexuality or dissatisfaction with SRH services was associated with poor mental health. Adolescents with pregnancy intentions were more likely to have a better mental health

Do HIV prevalence trends in antenatal clinic surveillance represent trends in the general population in the antiretroviral therapy era? The case of Manicaland, East Zimbabwe

Objective: National estimates of HIV trends in generalized epidemics rely on HIV prevalence data from antenatal clinic (ANC) surveillance. We investigate whether HIV prevalence trends in ANC data reflect trends in men and women in the general population during the scale-up of antiretroviral therapy (ART) in Manicaland, Zimbabwe. Methods: Trends in HIV prevalence in local ANC attendees and adults aged 15–49 years in towns, agricultural estates, and villages were compared using five rounds of parallel ANC (N = 1200) and general-population surveys (N = 10 000) and multivariable log-linear regression. Changes in the age pattern of HIV prevalence and the age distribution of ANC attendees were compared with those in the general population. Age-specific pregnancy prevalence rates were compared by HIV infection and ART status. Results: Cumulatively, from 1998–2000 to 2009–2011, HIV prevalence fell by 60.0% (95% confidence interval, 51.1–67.3%) in ANC surveillance data and by 34.3% (30.8–37.7%) in the general population. Most of the difference arose following the introduction of ART (2006–2011). The estates and villages reflected this overall pattern but HIV prevalence in the towns was lower at local ANCs than in the general population, largely because of attendance by pregnant women from outlying (lower prevalence) areas. The ageing of people living with HIV in the general population (52.4% aged >35 years, 2009–2011) was under-represented in the ANC data (12.6%) because of lower fertility in older and HIV-infected women. Conclusion: After the introduction of ART in Manicaland, HIV prevalence declined more steeply in ANC surveillance data than in the general population. Models used for HIV estimates must reflect this change in bias

Increasing Adolescent HIV Prevalence in Eastern Zimbabwe - Evidence of Long-Term Survivors of Mother-to-Child Transmission?

Recent data from the Manicaland HIV/STD Prevention Project, a general-population open HIV cohort study, suggested that between 2004 and 2007 HIV prevalence amongst males aged 15–17 years in eastern Zimbabwe increased from 1.20% to 2.23%, and in females remained unchanged at 2.23% to 2.39%, while prevalence continued to decline in the rest of the adult population. We assess whether the more likely source of the increase in adolescent HIV prevalence is recent sexual HIV acquisition, or the aging of long-term survivors of perinatal HIV acquisition that occurred during the early growth of the epidemic. Using data collected between August 2006 and November 2008, we investigated associations between adolescent HIV and (1) maternal orphanhood and maternal HIV status, (2) reported sexual behaviour, and (3) reporting recurring sickness or chronic illness, suggesting infected adolescents might be in a late stage of HIV infection. HIV-infected adolescent males were more likely to be maternal orphans (RR = 2.97, p,0.001) and both HIV-infected adolescent males and females were more likely to be maternal orphans or have an HIV-infected mother (male RR = 1.83, p,0.001; female RR = 16.6, p,0.001). None of 22 HIV-infected adolescent males and only three of 23 HIV-infected females reported ever having had sex. HIV-infected adolescents were 60% more likely to report illness than HIV-infected young adults. Taken together, all three hypotheses suggest that recent increases in adolescent HIV prevalence in eastern Zimbabwe are more likely attributable to long-term survival of mother-to-child transmission rather than increases in risky sexual behaviour. HIV prevalence in adolescents and young adults cannot be used as a surrogate for recent HIV incidence, and health systems should prepare for increasing numbers of long-term infected adolescents

HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe.

AIDS has increased the number of orphans and vulnerable children (OVCs) in sub-Saharan Africa who could suffer detrimental life experiences. We investigated whether OVCs have heightened risks of adverse reproductive health outcomes including HIV infection. Data on HIV infection, sexually transmitted infection (STI) symptoms and pregnancy, and common risk factors were collected for OVCs and non-OVCs in a population survey of 1523 teenage children in eastern Zimbabwe between July 2001 and March 2003. Multivariate logistic regression was used to test for statistical association between OVC status, adverse reproductive health outcomes and suspected risk factors. Amongst women aged 15-18 years, OVCs had higher HIV prevalence than non-OVCs (3.2% versus 0.0%; p = 0.002) and more common experience of STI symptoms (5.9% versus 3.3%; adjusted odds ratio = 1.75, 95% CI 0.80-3.80) and teenage pregnancy (8.3% versus 1.9%; 4.25, 1.58-11.42). OVCs (overall), maternal orphans and young women with an infected parent were more likely to have received no secondary school education and to have started sex and married, which, in turn, were associated with poor reproductive health. Amongst men aged 17-18 years, OVC status was not associated with HIV infection (0.5% versus 0.0%; p = 1.000) or STI symptoms (2.7% versus 1.6%; p = 0.529). No association was found between history of medical injections and HIV risk amongst teenage women and men. High proportions of HIV infections, STIs and pregnancies among teenage girls in eastern Zimbabwe can be attributed to maternal orphanhood and parental HIV. Many of these could be averted through further female secondary school education. Predicted substantial expanded increases in orphanhood could hamper efforts to slow the acquisition of HIV infection in successive generations of young adults, perpetuating the vicious cycle of poverty and disease

High prevalence of affective disorders among adolescents living in Rural Zimbabwe.

Poor mental health accounts for considerable disease burden among young people globally. We investigated the prevalence and determinants of affective disorders among rural Zimbabwean youth in 2006. We undertook a cross-sectional survey among 1495 Zimbabwean youth aged 15-23 (median 18) from 12 rural communities in three provinces in south-eastern Zimbabwe. Mental health was assessed using the Shona Symptom Questionnaire (SSQ), a locally validated 14-item indigenous screening tool for affective disorders, notably depression and anxiety disorders. Participants scoring >or=8/14 were considered at risk of being affected and >or=11 as at risk of being severely affected. Most participants (93.1%) completed the SSQ. Of these, 51.7% (95%CI:49.0-54.3%) scored >or=8/14 and 23.8% (95%CI:21.5-26.0%) scored >or=11. Affective disorders were independently associated with household poverty (adjusted odds ratio (AOR) 1.9, 95%CI:1.4-2.7), living in a female-headed household (AOR 1.3, 95%CI:1.0-1.7), having moved home within last 5 years (AOR 1.4, 95%CI:1.0-1.9) and feeling stigmatized (AOR being shunned by others 3.7, 95%CI:2.5-5.7). There was a strong linear association between risk of affective disorders and sexual risk taking (ever sex AOR 1.5, 95%CI:1.0-2.4, and 2.8, 95%CI:1.9-4.2 for affected and severely affected, respectively, test for trend P or=2 lifetime partners AOR 2.3, 95%CI:1.1-4.8 and 5.4, 95%CI:2.7-10.7, test for trend P < 0.001). This study indicates high levels of psychological morbidity among rural Zimbabwean youth which was associated with sexual risk taking. Interventions to prevent, identify and treat mental health disorders in this vulnerable population are urgently required. In HIV-endemic countries, such interventions may also help reduce HIV transmission

Asset ownership among households caring for orphans and vulnerable children in rural Zimbabwe: The influence of ownership on children's health and social vulnerabilities

The high prevalence of human immunodeficiency virus/acquired immune deficiency syndrome in sub-Saharan Africa has resulted in a dramatic increase in orphans and vulnerable children (OVC) over the past decade. These children typically rely on extended family networks for support, but the magnitude of the crisis has resulted in traditional familial networks becoming overwhelmed and more economically and socially vulnerable. Previous research consistently demonstrates the positive influence of household asset ownership on children's well-being. Using data from impoverished households caring for OVC in rural Manicaland Province, Zimbabwe, this study explores the influence of household asset ownership on OVC health vulnerability (HV) and social vulnerability (SV). Findings indicate that asset ownership is associated with significantly lower SV, in terms of school attendance and birth registration. Yet, assets do not emerge as a direct influence of OVC HV as measured by disease and chronic illness, although having a chronically ill adult in the household increases HV. These findings suggest that asset ownership, specifically a combination of fixed and movable assets, may offset the influence of other risk factors for children's SV