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

Acceptability of Condom Promotion and Distribution Among 10-19 Year-Old Adolescents in Mpwapwa and Mbeya Rural Districts, Tanzania.

\ud The HIV/AIDS pandemic remains a leading challenge for global health. Although condoms are acknowledged for their key role on preventing HIV transmission, low and inappropriate use of condoms persists in Tanzania and elsewhere in Africa. This study assesses factors affecting acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural districts of Tanzania. Data were collected in 2011 as part of a larger cross-sectional survey on condom use among 10-19 year-olds in Mpwapwa and Mbeya rural districts of Tanzania using a structured questionnaire. Associations between acceptability of condom promotion and distribution and each of the explanatory variables were tested using Chi Square. Multivariate logistic regression model was used to examine independent predictors of the acceptability of condom promotion and distribution using STATA (11) statistical software at 5% significance level. Mean age of the 1,327 adolescent participants (50.5% being males) was 13.5 years (SD = 1.4). Acceptance of condom promotion and distribution was found among 37% (35% in Mpwapwa and 39% in Mbeya rural) of the adolescents. Being sexually active and aged 15-19 was the strongest predictor of the acceptability of condom promotion and distribution (OR = 7.78, 95% CI 4.65-12.99). Others were; not agreeing that a condom is effective in preventing transmissions of STIs including HIV (OR = 0.34, 95% CI 0.20-0.56), being a resident of Mbeya rural district (OR = 1.67, 95% CI 1.28-2.19), feeling comfortable being seen by parents/guardians holding/buying condoms (OR = 2.20, 95% CI 1.40-3.46) and living with a guardian (OR = 1.48, 95% CI 1.08-2.04). Acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural is low. Effect of sexual activity on the acceptability of condom promotion and distribution is age-dependent and was the strongest. Feeling comfortable being seen by parents/guardians buying or holding condoms, perceived ability of condoms to offer protection against HIV/AIDS infections, district of residence and living arrangements also offered significant predictive effect. Knowledge of these factors is vital in designing successful and sustainable condom promotion and distribution programs in Tanzania.\u

Preliminary outcomes of a paediatric highly active antiretroviral therapy cohort from KwaZulu-Natal, South Africa

BACKGROUND: Few studies address the use of paediatric highly active antiretroviral therapy (HAART) in Africa. METHODS: We performed a retrospective cohort study to investigate preliminary outcomes of all children eligible for HAART at Sinikithemba HIV/AIDS clinic in KwaZulu-Natal, South Africa. Immunologic, virologic, clinical, mortality, primary caregiver, and psychosocial variables were collected and analyzed. RESULTS: From August 31, 2003 until October 31, 2005, 151 children initiated HAART. The median age at HAART initiation was 5.7 years (range 0.3–15.4). Median follow-up time of the cohort after HAART initiation was 8 months (IQR 3.5–13.5). The median change in CD4% from baseline (p < 0.001) was 10.2 (IQR 5.0–13.8) at 6 months (n = 90), and 16.2 (IQR 9.6–20.3) at 12 months (n = 59). Viral loads (VLs) were available for 100 children at 6 months of which 84% had HIV-1 RNA levels ≤ 50 copies/mL. At 12 months, 80.3% (n = 61) had undetectable VLs. Sixty-five out of 88 children (73.8%) reported a significant increase (p < 0.001) in weight after the first month. Eighty-nine percent of the cohort (n = 132) reported ≤ 2 missed doses during any given treatment month (> 95%adherence). Seventeen patients (11.3%) had a regimen change; two (1.3%) were due to antiretroviral toxicity. The Kaplan-Meier one year survival estimate was 90.9% (95%confidence interval (CI) 84.8–94.6). Thirteen children died during follow-up (8.6%), one changed service provider, and no children were lost to follow-up. All 13 deaths occurred in children with advanced HIV disease within 5 months of treatment initiation. In multivariate analysis of baseline variables against mortality using Cox proportional-hazards model, chronic gastroenteritis was associated with death [hazard ratio (HR), 12.34; 95%CI, 1.27–119.71) and an HIV-positive primary caregiver was found to be protective against mortality [HR, 0.12; 95%CI, 0.02–0.88). Age, orphanhood, baseline CD4%, and hemoglobin were not predicators of mortality in our cohort. Fifty-two percent of the cohort had at least one HIV-positive primary caregiver, and 38.4% had at least one primary caregiver also on HAART at Sinikithemba clinic. CONCLUSION: This report suggests that paediatric HAART can be effective despite the challenges of a resource-limited setting

Sociodemographic context of the AIDS epidemic in a rural area in Tanzania with a focus on people's mobility and marriage

This analysis focuses on how sociocultural and economic characteristics of a poor semi-urban and rural population (Kisesa ward) in north west Tanzania may directly and indirectly affect the epidemiology of HIV and other sexually transmitted infections (STI). Poverty and sociocultural changes may contribute to the observed high levels of marital instability and high levels of short and long term migration in Kisesa, especially among younger adults. Marriage and migration patterns are important underlying factors affecting the spread of HIV. The most cost-effective intervention strategy may be to focus on the trading centre in which mobility is higher, bars were more common, and HIV prevalence and incidence were considerably higher than in the nearby rural villages. If resources suffice, additional work can be undertaken in the rural villages, although it is not clear to what extent the rural epidemic would be self sustaining if the interventions in the trading centre were effective

Changes in male sexual behaviour in response to the AIDS epidemic: evidence from a cohort study in urban Tanzania

To examine changes in sexual behaviour among men in urban Tanzania. An observational cohort study among factory workers during 1991-1994. Data from five follow-up visits with structured questionnaire-guided interviews and biomedical data were analysed to examine trends in sexual behaviour and sexually transmitted disease/HIV among 752 men. In-depth interviews were conducted to evaluate the magnitude of reporting bias. During the 2 years of observation, the proportion of men with more than one sexual partner during the month preceding the interview declined from 22.3 to 12.2%. The proportion of men reporting casual sex partners during the last month was almost halved: from 9.8 to 5.2%. The decline in the reporting of extramarital partners was gradual and pronounced. There were only minor changes in reported condom use, notably an increase in use with casual partners, and no changes in coital frequency. Data from in-depth interviews confirmed that reduction in sexual partners was the predominant change. This study documents that, in response to the AIDS epidemic, changes in male sexual behaviour are taking place in urban areas in Africa. The predominant change among these men, who are predominantly married and aged over 25 years, is a reduction of the number of sexual partners, although condom use remains low. During October 1991 to April 1994, health workers in Tanzania interviewed and conducted a physical examination of 752 men who had made at least 4 follow-up visits to the clinic at a large urban textile factory in Mwanza to examine trends in sexual behavior and sexually transmitted disease (STD)/HIV of factory workers and their spouses. Each man was followed for about 2 years. Researchers aimed to determine whether the intervention to reduce HIV transmission at the clinic had an impact on sex behavior. The intervention included free and effective treatment of STDs, a syphilis test at each visit, voluntary HIV counseling services, and health education activities (workshops, peer educators). The proportion of married men increased from 83.4% to 88.4% during the study period. Men were less likely to have more than 1 sexual partner in the previous month after 5 visits than before the first visit (12.2% vs. 22.3%; p 0.01 for trend). They were also less likely to have had casual partners during the previous month (5.2% vs. 9.8%; p 0.001 for trend). Married men were less likely to have extramarital relations (6.5% vs. 20.1% for regular non-cohabiting partner; p 0.01 and 2.7% vs. 8; p 0.001). Condom use in the previous month did not change significantly (2.5% vs. 3.1%; p = 0.377). It did increase significantly with a casual partner, however (7.6% vs. 27.3%; p = 0.002 for trend). Frequency of intercourse did not change. The HIV-incidence rate decreased considerably (1.77 vs. 0.66/100 person-years of observation for a rate ratio of 0.37). Multiple sex partners in the previous month was more common among men 20-29 years old or who consumed moderate or excessive amounts of alcohol than among those over age 40 or who consumed no alcohol. These findings suggest that even though sexual activity did not decline, it became more commonly with 1 partner and within marriage, especially among men 40 and older who did not drink alcohol. Condom use remained low, except with casual partners.

Targeting antiretroviral therapy:Lessons from a longitudinal study of morbidity and treatment in relation to CD4 count in Thailand

The aim of the study was to quantify the incidence of illness and treatment behaviour in relation to CD4 count, age, and gender among a cohort of persons living with HIV/AIDS in Thailand. 464 participants with a CD4 count between 50 and 550 cells/mm3 were followed up for 12 months. Multiple Poisson regression was used to model the adjusted incidence rate ratio of illness and care seeking at different levels. The incidence of morbidity and treatment pattern were significantly different among participants with different CD4 count, age and gender. For example, morbidity incidence was significantly higher among participants with CD4 count of less than 200 cells/mm, among female participants, and participants aged 35 years or over. Females made significantly higher use of hospital ambulatory care and private clinics than males and males made significantly more use of private pharmacies. The potential opportunity cost of not providing ART to these different groups can be estimated and used to inform further economic evaluation and policy decisions on whether to provide ART at all and which patient groups to prioritise