Cost and Cost-Effectiveness of a Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision in Tanzania: Spending More to Spend Less.

BACKGROUND: Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20-34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20-34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness. SETTING: Tanzania (Njombe and Tabora regions). METHODS: Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios. RESULTS: Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and$130 in Njombe, and in the control arms $70 and$191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed. CONCLUSIONS: Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving

Factors associated with problem drinking among women employed in food and recreational facilities in northern Tanzania.

BACKGROUND: There is growing evidence that alcohol consumption is associated with increased risk of HIV infection. To determine factors associated with problem drinking, we analyzed data collected in two prospective cohorts of at-risk female food and recreational facility workers in northern Tanzania. METHODS: We enrolled HIV seronegative women aged 18-44 years and employed in the towns of Geita, Kahama, Moshi, and Shinyanga. At enrolment, women were interviewed to obtain information about alcohol use, using CAGE and AUDIT screening scales, and risk factors for HIV infection. Blood and genital samples were collected for detection of HIV and sexually transmitted infections (STIs). We characterized alcohol use, concordance, and agreement of the scales, and examined the associations between characteristics of participants and problem drinking as defined by both scales using logistic regression. Lastly, we assessed problem drinking as a risk factor for recent sexual behavior and prevalent STIs. RESULTS: Among enrollees, 68% women reported ever drinking alcohol; of these 76% reported drinking alcohol in the past 12 months. The prevalence of problem drinking was 20% using CAGE and 13% using AUDIT. Overall concordance between the scales was 75.0% with a Kappa statistic of 0.58. After adjusting for age, independent factors associated with problem drinking, on both scales, were marital status, occupation, facility type, increasing number of lifetime sexual partners, and transactional sex in the past 12 months. In addition, women who were problem drinkers on either scale were more likely to report having ≥ 1 sexual partner (CAGE: aOR = 1.56, 95% confidence interval, CI: 1.10-2.23; AUDIT: aOR = 2.00, 95% CI: 1.34-3.00) and transactional sex (CAGE: aOR = 1.79, 95% CI: 1.26-2.56; AUDIT: aOR = 1.51, 95% CI: 1.04-2.18), in the past 3 months. CONCLUSION: These findings suggest that interventions to reduce problem drinking in this population may reduce high-risk sexual behaviors and contribute in lowering the risk of HIV infection

The private practice within public hospitals in Tanzania : an exploratory study at Muhimbili national hospital and Bugando medical centre

Bibliography: leaves 50-51.In the late 1980s, many governments in the low-income countries could not fund their health care budgets adequately due to poor availability of fmancial resources. This resulted into deterioration of the public health sectors in general. Inadequacy of consumables and other supplies, and low payment for health workers were among the problems faced. Governments in some of these countries introduced public private mix (PPM) to address these problems. In 1996, the government of Tanzania allowed private practice in public hospitals called 'the fast track' service. This study investigated the organizational and management system of this type of PPM, its impacts and the factors determining people's demand for the fast track service. Data was collected through interviews with health care providers and patients, and document reviews. Systematic and random sampling methods were used to select participants. Data was analysed using STAT A package. The study found that the executive directors of the hospitals headed the fast track management teams, with the executive committees coordinated by the executive secretaries. The committees included specialist doctors involved in the PPM. The study findings also show that about 85% of health care providers reported that the practice played an important role in supplementing the hospitals' budgets as well as health workers' incomes. In one of the study hospitals, the "fast track" services contributed more than 26% of the total income during a 5-year period. Likewise, it has significantly improved the access to health care services. This was achieved through retaining health workers, improving the infrastructure, adequate supply of consumables and drugs, and raising funds to subsidise treatments for poor patients. However, the fast track services resulted in specialists spending less time with public patients. In addition, the standards of private care were still lower in the "fast track" when compared to what is expected in a private health care setting, and private patients were offered very poor diagnostic tests and investigation services. Concerns were also raised about the poor management of the funds generated from private services

The epidemiology of HIV and HSV-2 infections among women participating in microbicide and vaccine feasibility studies in Northern Tanzania.

OBJECTIVES: To prepare for future HIV prevention trials, we conducted prospective cohort studies among women working in food and recreational facilities in northern Tanzania. We examined the prevalence and incidence of HIV and HSV-2, and associated risk factors. METHODS: Women aged 18-44 years working in food and recreational facilities were screened to determine their eligibility for the studies. Between 2008-2010, HIV-negative women were enrolled and followed for 12 months. At enrolment and 3-monthly, we collected socio-demographic and behavioural data, and performed clinical examinations for collection of biological specimens that were tested for reproductive tract infections. Risk factors for HIV and HSV-2 incidence were investigated using Poisson regression models. RESULTS: We screened 2,229 and enrolled 1,378 women. The median age was 27 years (interquartile range, IQR 22, 33), and median duration working at current facility was 2 years. The prevalences of HIV at screening and HSV-2 at enrolment were 16% and 67%, respectively. Attendance at the 12-month visit was 86%. HIV and HSV-2 incidence rates were 3.7 (95% confidence interval, CI: 2.8,5.1) and 28.6 (95% CI: 23.5,35.0)/100 person-years, respectively. Women who were separated, divorced, or widowed were at increased risk of HIV (adjusted incidence rate ratio, aRR = 6.63; 95% CI: 1.97,22.2) and HSV-2 (aRR = 2.00; 95% CI: 1.15,3.47) compared with married women. Women reporting ≥3 partners in the past 3 months were at higher HIV risk compared with women with 0-1 partner (aRR = 4.75; 95% CI: 2.10,10.8), while those who had reached secondary education or above were at lower risk of HSV-2 compared with women with incomplete primary education (aRR = 0.42; 95% CI: 0.22,0.82). CONCLUSIONS: HIV and HSV-2 rates remain substantially higher in this cohort than in the general population, indicating urgent need for effective interventions. These studies demonstrate the feasibility of conducting trials to test new interventions in this highly-mobile population

Entwicklung von Membranen fuer Direktmethanol-Brennstoffzellen Abschlussbericht

Membrane characteristics are to be modified for higher power densities and higher fuel gas concentrations. In particular, the permeability to methanol is to be reduced significantly. The membranes and electrodes will be combined into a 500 W demonstration system for a gaseous DMFC.Ziel des Projektes ist es, die Membraneigenschaften so einzustellen, dass hoehere Leistungsdichten erzielt werden koennen und mit hoeheren Brenngaskonzentrationen gearbeitet werden kann. Es soll vor allem die Permeabilitaet der Membranen gegenueber Methanol entscheidend verringert werden. Durch Kombination der so erhaltenen Membranen und Elektroden soll dann ein Demonstrationssystem fuer eine gasfoermige DMFC mit 500 Watt aufgebaut werden, in dem alle notwendigen Komponenten enthalten sind. (orig.)SIGLEAvailable from TIB Hannover: F02B199 / FIZ - Fachinformationszzentrum Karlsruhe / TIB - Technische InformationsbibliothekBundesministerium fuer Bildung und Forschung, Berlin (Germany)DEGerman

CAGE and AUDIT alcohol screening questions.

<p>¹ A possible score of 4 on the CAGE scale.</p><p>² A possible score of 40 on the AUDIT scale.</p><p>³ Computed using these open-ended questions: (i) On average, how many days do you drink an alcohol-containing beverage in a week? (ii) On average, how many drinks containing alcohol do you have on a typical day when you are drinking?</p

Associations between problem drinking (based on CAGE and AUDIT) and long-term sexual behavior, socio-demographic and economic factors at the time of enrollment in a cohort of women working in food and recreational facilities in northern Tanzania.

<p>¹ A score of ≥2 out of a possible 4 on the CAGE scale.</p><p>² A score of ≥8 out of a possible 40 on the AUDIT scale.</p><p>³ Adjusted for independent predictors of problem drinking: age group (a priori confounder), marital status, enrolment site, facility type, lifetime sexual partners, transactional sex in past 12 months, and forced sex ever (variables shown in bold).</p><p>⁴ Adjusted for independent predictors of problem drinking: age group (a priori confounder), marital status, occupation, lifetime sexual partners, transactional sex in past 12 months, and forced sex ever (variables shown in bold).</p><p>⁵ Asset index based on household characteristics and assets using principal component analysis.</p><p>⁶ Adjusted for all factors listed in footnote 4, except occupation.</p><p>⁷ Informal food sellers at makeshift facilities.</p><p>⁸ Traditionally brewed alcohol vendors.</p><p>⁹ Adjusted for all factors listed in footnote 3, except facility type.</p

Associations of problem drinking with reported sexual behaviors in the past 3 months and sexually transmitted infections at the time of enrollment in a cohort of women working in food and recreational facilities in northern Tanzania.

<p>¹ A score of ≥2 out of a possible 4 on the CAGE scale.</p><p>² A score of ≥8 out of a possible 40 on the AUDIT scale.</p><p>³ The following potential confounders were considered: age, education, marital status, enrolment site, SES, age at first sex, facility type, occupation, age at first sex, lifetime partners, transactional sex in past 12, and forced sex ever. Age was retained in all models. Variables which changed the age-adjusted OR for the association of problem drinking with each outcome by >10% were retained.</p

Associations of <i>C. trachomatis</i>, <i>N. gonorrhoeae</i>, <i>T. vaginalis</i> and active syphilis (high-titre) with sociodemographic, behavioural and biological factors in a cohort of women at increased risk for HIV acquisition in northwestern Tanzania.

<p>Note: <i>C. trachomatis</i>, <i>N. gonorrhoeae</i> and <i>T. vaginalis</i> data from all visits were used in the analysis. For active syphilis (high-titre), data only from the enrolment visit were used since there were very few incident infections. “1” denotes the reference category throughout.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Celum1" target="_blank">[1]</a> ORs for sociodemographic variables adjusted for visit month, town, age and duration working in facility type; ORs for behavioural variables adjusted for these sociodemographic variables, number of lifetime partners and contraception; ORs for biological variables adjusted for these sociodemographic and behavioural variables, ever pregnant and gonorrhoea status (the results for these variables are shown in bold). Full results from each level shown in Table S1 in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221.s001" target="_blank">File S1</a>.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Schmid1" target="_blank">[2]</a> ORs for sociodemographic variables adjusted for visit month, town and age; ORs for behavioural variables adjusted for these sociodemographic variables and AUDIT; ORs for biological variables adjusted for these sociodemographic and behavioural variables, ever pregnant and chlamydia status (the results for these variables are shown in bold). Full results from each level shown in Table S2 in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221.s001" target="_blank">File S1</a>.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Tobian1" target="_blank">[3]</a> ORs for sociodemographic variables adjusted for visit month, town, age, education and marital status; ORs for behavioural variables adjusted for these sociodemographic variables (no behavioural variables included); ORs for biological variables adjusted for these sociodemographic and behavioural variables and current vaginal microbiota assessed by Nugent score (the results for these variables are shown in bold). Full results from each level shown in Table S3 in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221.s001" target="_blank">File S1</a>.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Moodley1" target="_blank">[4]</a> ORs for sociodemographic variables adjusted for visit month, town, age and education; ORs for behavioural variables adjusted for these sociodemographic variables and whether had concurrent partners in the last 3 months; ORs for biological variables adjusted for these sociodemographic and behavioural variables and <i>T. vaginalis</i> status (the results for these variables are shown in bold). Full results from each level shown in Table S4 in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221.s001" target="_blank">File S1</a>.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Fleming1" target="_blank">[5]</a> Combined complete primary and secondary since only two women who attended secondary school had active syphilis (high-titre) at enrolment.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Rours1" target="_blank">[6]</a> Based on responses to ten AUDIT questions. Scores based on responses to each question: 0–7 = non-drinker or low-risk; ≥8 harmful or hazardous drinking.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-WatsonJones1" target="_blank">[7]</a> Combined positive (from baseline) and positive (seroconverted during follow-up).</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Johnson1" target="_blank">[8]</a> Current syphilis status is defined as follows: RPR negative/RPR positive and TPPA negative = never infected (includes biological false positives); RPR negative and TPPA positive = previous infection; RPR positive and TPPA positive = active infection.</p><p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101221#pone.0101221-Kapiga1" target="_blank">[9]</a> All women HIV-negative at enrolment as per eligibility criteria.</p

Trend in prevalence of laboratory-diagnosed curable sexually transmitted infections and syndromes diagnosed over the 12 month follow-up period in a cohort of women at increased risk for HIV acquisition in northwestern Tanzania.

<p>CI = confidence interval; OR = odds ratio.</p