The association between HIV and fertility in a cohort study in rural Tanzania.

Recent studies in sub-Saharan Africa have shown that fertility is reduced among HIV-infected women compared with uninfected women. The size and pattern of this fertility reduction has important implications for antenatal clinic-based surveillance of the epidemic and also for estimates and projections of the demographic impact of the epidemic. This paper examines the association between HIV and fertility in Kisesa, a rural area in Tanzania, where HIV prevalence among adults is about 6% and gradually increasing. The analysis is based on data obtained through a demographic surveillance system in Kisesa during 1994-98 and two large sero-surveys of all residents in 1994-95 and 1996-97. The HIV-associated fertility reduction among women was investigated by estimating fertility rates by HIV status and prevalence rates by fertility status. A substantial reduction (29%) was observed in fertility among HIV-infected women compared with HIV-uninfected women. The fertility reduction was most pronounced during the terminal stages of infection, but no clear association with duration of infection was observed. Use of modern contraception was higher among HIV-infected women. However, both among contracepting and non-contracepting women, a substantial reduction in fertility was seen among HIV-infected women

Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural Tanzania.

In population-based surveys on sexual behaviour, men consistently report higher numbers of sexual partners than women, which may be associated with male exaggeration or female under-reporting or with issues related to sampling, such as exclusion of female sex workers. This paper presents an analysis of data collected in the context of a longitudinal study in rural Tanzania, where a sexual partnership module was applied to all participating men and women in the study population. Since the study design included all men and women of reproductive ages and did not involve sampling, these data provide a unique opportunity to compare the consistency of aggregate measures of sexual behaviour between men and women living in the same villages. The analysis shows that non-marital partnerships were common amongst single people of both sexes--around 70% of unmarried men and women report at least one sexual partner in the last year. However, 40% of married men also report having non-marital partners, but only 3% of married women did so. Single women reported about half as many multiple partnerships in the last year as men. Under-reporting of non-marital partnerships was much more common among single women than among married women and men. Furthermore, women were more likely to report longer duration partnerships and partnership with urban men or more educated men than with others. If a woman reports multiple partners, biological data indicate that she is at high risk of contracting HIV. For men, however, there is only a weak association between number of partnerships and the risk of HIV, and it cannot be excluded that men, especially single men, exaggerate the number of sexual partners

Trends in HIV and sexual behaviour in a longitudinal study in a rural population in Tanzania, 1994-2000.

OBJECTIVE: To describe the trends in HIV transmission and sexual behaviour in a rural population in Africa. DESIGN: An open community cohort study with demographic surveillance and surveys of all consenting adults. METHODS: All residing adults aged 15-44 years who participated in surveys in 1994-1995, 1996-1997 and 1999-2000 were tested for HIV infection and provided information on sexual behaviour. The district AIDS control programme was the only intervention. RESULT: The prevalence of HIV among adults aged 15-44 years increased gradually from 5.9% in 1994-1995 to 6.6% in 1996-1997 and 8.1% in 1999-2000. The incidence of HIV increased from 0.8 to 1.3 per 100 person-years during 1994-1997 and 1997-2000, respectively. In spite of a modest increase in knowledge during the study period, most individuals continued to feel that they were not at risk of HIV, and sexual risk behaviour remained largely unchanged, except for a small increase in condom use. HIV transmission levels continued to be higher in the trading centre than in the nearby rural villages within this small geographical area, although differences became smaller over time. CONCLUSION: The gradual and continuing spread of HIV and the striking lack of change in sexual behaviour in this rural population suggest that the low-cost district intervention package does not appear to be adequate to stem the growth of the epidemic, and more intensive AIDS control efforts are needed

Use of data from HIV counselling and testing services for HIV surveillance in Africa.

The implementation of HIV counseling and testing services for HIV surveillance in Africa is discussed. The antiretroviral treatment for HIV-infected adults has expanded with the help of WHO's '3 by 5' strategy. In Tanzania, the expansion aimed to have more than 600 voluntary HIV counseling and testing sites by the year 2006. Data-collection activities in voluntary HIV counseling and testing clinics have been expected to fulfil donor-driven reporting requirements that include program monitoring and assessment. Aggregation of data from various counseling and testing services to obtain national estimates presents analytical problems as patients referred from medical wards to a testing center within a hospital are different from those using a walk-in center located in the community. Routine data-collection activities in voluntary HIV counseling and testing centers serve various purposes to ensure proper test results

HIV and mortality of mothers and children: evidence from cohort studies in Uganda, Tanzania, and Malawi.

BACKGROUND: The steady decline in child mortality observed in most African countries through the 1960s, 1970s, and 1980s has stalled in many countries in the 1990s because of the AIDS epidemic. However, the census and household survey data that generally are used to produce estimates of child mortality do not permit precise measures of the adverse effect of HIV on child mortality. METHODS: To calculate excess risks of child mortality as the result of maternal HIV status, we used pooled data from 3 longitudinal community-based studies that classified births by the mother's HIV status. We also estimated excess risks of child death caused by increased mortality among mothers. The joint effects of maternal HIV status and maternal survival were quantified using multivariate techniques in a survival analysis. RESULTS: Our analysis shows that the excess risk of death associated with having an HIV-positive mother is 2.9 (95% confidence interval = 2.3-3.6), and this effect lasts throughout childhood. The excess risk associated with a maternal death is 3.9 (2.8-5.5) in the 2-year period centered on the mother's death, with children of both infected and uninfected mothers experiencing higher mortality risks at this time. CONCLUSION: HIV impacts on child mortality directly through transmission of the virus to newborns by infected mothers and indirectly through higher child mortality rates associated with a maternal death

Mobility and HIV in Tanzanian couples: both mobile persons and their partners show increased risk.

OBJECTIVE: To investigate how mobility is related to sexual risk behavior and HIV infection, with special reference to the partners who stay behind in mobile couples. METHODS: HIV status, sexual behavior and demographic data of 2800 couples were collected in a longitudinal study in Kisesa, rural Tanzania. People were considered short-term mobile if they had slept outside the household at least once on the night before one of the five demographic interviews, and long-term mobile if they were living elsewhere at least once at the time of a demographic round. RESULTS: Overall, whereas long-term mobile men did not report more risk behavior than resident men, short-term mobile men reported having multiple sex partners in the last year significantly more often. In contrast, long-term mobile women reported having multiple sex partners more often than resident women (6.8 versus 2.4%; P = 0.001), and also had a higher HIV prevalence (7.7 versus 2.7%; P = 0.02). In couples, men and women who were resident and had a long-term mobile partner both reported more sexual risk behavior and also showed higher HIV prevalence than people with resident/short-term mobile partners. Remarkably, risk behavior of men increased more when their wives moved than when they were mobile themselves. CONCLUSIONS: More sexual risk behavior and an increased risk of HIV infection were seen not only in mobile persons, but also in partners staying behind. Interventions aiming at reducing risk behavior due to mobility should therefore include partners staying behind

Separation of spouses due to travel and living apart raises HIV risk in Tanzanian couples.

BACKGROUND: Persons with absent partners may be more vulnerable to risky sexual behavior and therefore HIV. Partner absence can be due to traveling (e.g., family visits or funerals) or to living apart (e.g., work-related or in polygamous marriages). We investigated to what extent partner absence leads to more risky sexual behavior in Tanzanian couples. METHODS: We compared 95 men and 85 women living apart with 283 men and 331 women living together. Only persons who were still married were included, either living apart or cohabiting at the time of the interview. Subjects were classified into 4 groups: coresidents being either nonmobile or mobile, and people living apart either frequently or infrequently seeing each other. RESULTS: Most people living apart were polygamously married. Men living apart did not report more extramarital sex than coresident men. However, among coresident men, extramarital sex was reported by 35% of those being mobile compared with 15% of those nonmobile. Among women, those living apart reported extramarital sex more often than coresidents (14% vs. 7%), and this was mainly due to women living apart who infrequently saw their husbands. CONCLUSIONS: Risky sexual behavior occurs more often in mobile coresident men, and in women living apart infrequently seeing their spouses. These groups are relatively easy to identify and need extra attention in HIV prevention campaigns

The impact of HIV/AIDS on mortality and household mobility in rural Tanzania.

OBJECTIVE: To assess the impact of the AIDS epidemic on mortality and household mobility before and after death. DESIGN: Open community cohort study with a demographic surveillance system and two sero-epidemiological surveys. METHODS: Ten rounds of demographic surveillance were completed during 1994-1998 in the study area, which has a population of about 20 000 people in a rural ward in north-west Tanzania. Households with deaths were visited for a detailed interview, including a verbal autopsy. Data on HIV status were collected in two surveys of all residents aged 15-44 years. RESULTS: Mortality rates among HIV-infected adults were 15 times higher than those among HIV-negative adults and HIV/AIDS was associated with nearly half of deaths at ages 15-44 years. Verbal autopsies without HIV test results considerably underestimated the proportion of deaths associated with HIV/AIDS. The mortality probability between 15 and 60 years was 49% for men and 46% for women and life expectancy was 43 years for men and 44 years for women. By their second birthday nearly one-quarter of the newborns of HIV-infected mothers had died, which was 2.5 times higher than among children of HIV-negative mothers. Mobility of household members before and after death was high. In 44% of households in which the head died all members moved out of the household. CONCLUSIONS: In this rural population with HIV prevalence close to 7% among adults aged 15-44 years during the mid-1990s, HIV/AIDS is having substantial impact on adult mortality. A common response to death of a head of household in this community is household dissolution, which has implications for measurement of the demographic and socio-economic impact of AIDS