Verbal autopsy can consistently measure AIDS mortality: a validation study in Tanzania and Zimbabwe

BACKGROUND: Verbal autopsy is currently the only option for obtaining cause of death information in most populations with a widespread HIV/AIDS epidemic. METHODS: With the use of a data-driven algorithm, a set of criteria for classifying AIDS mortality was trained. Data from two longitudinal community studies in Tanzania and Zimbabwe were used, both of which have collected information on the HIV status of the population over a prolonged period and maintained a demographic surveillance system that collects information on cause of death through verbal autopsy. The algorithm was then tested in different times (two phases of the Zimbabwe study) and different places (Tanzania and Zimbabwe). RESULTS: The trained algorithm, including nine signs and symptoms, performed consistently based on sensitivity and specificity on verbal autopsy data for deaths in 15-44-year-olds from Zimbabwe phase I (sensitivity 79%; specificity 79%), phase II (sensitivity 83%; specificity 75%) and Tanzania (sensitivity 75%; specificity 74%) studies. The sensitivity dropped markedly for classifying deaths in 45-59-year-olds. CONCLUSIONS: Verbal autopsy can consistently measure AIDS mortality with a set of nine criteria. Surveillance should focus on deaths that occur in the 15-44-year age group for which the method performs reliably. Addition of a handful of questions related to opportunistic infections would enable other widely used verbal autopsy tools to apply this validated method in areas for which HIV testing and hospital records are unavailable or incomplete

High Burden of Prevalent and Recently Acquired HIV among Female Sex Workers and Female HIV Voluntary Testing Center Clients in Kigali, Rwanda

Objectives: To estimate HIV prevalence and risk factors in population-based samples of female sex workers (FSW) and female voluntary counseling and testing (VCT) clients in Rwanda. Methods: We conducted a cross-sectional survey of 800 FSW and 1,250 female VCT clients in Rwanda, which included interviewing and testing for HIV-1/2, HSV-2 and pregnancy, and BED-CEIA and Avidity Index (AI) to identify recent infections among HIV-infected women. Results: Prevalence of HIV-1, HSV-2, and pregnancy were 24% (95% CI: 21.0-27.0), 59.8% (56.4-63.2), and 7.6% (5.8-9.5) among FSW, and 12.8% (10.9-14.6), 43.2% (40.4-46.0), and 11.4% (9.7-13.3) among VCT clients, respectively. Thirty-five percent of FSW and 25% of VCT clients had never been HIV tested. Per national guidelines, 33% of newly HIV-diagnosed FSW and 36% of VCT clients were already eligible for ART based on CD4,350 cells/ml. Condom use at last sex was higher among FSW (74%) than VCT clients (12%). In age and district of residence-adjusted models, HIV-1 seropositivity was associated with HSV-2 co-infection; recent treatment for sexually transmitted infection (STI); genital symptoms; forced sex; imprisonment; widowhood; and alcohol consumption. Eleven percent of FSW and 12% of VCT clients had recently acquired HIV-1 per BED-CEIA and AI. HSV-2 infection and recent STI treatment were associated with recent HIV infection in both groups, and being married and vaginal cleansing were associated with recent infection before last sex among VCT clients. Conclusions: This population-based survey reveals a high HIV prevalence and incidence among FSW and female VCT clients in Kigali, the scale of which is masked by the low general-population HIV prevalence in Rwanda. HIV/STI and family planning services should be strengthene

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

HIV prevalence and sexual behaviour changes measured in an antenatal clinic setting in northern Tanzania

OBJECTIVES: To assess the feasibility of collecting sexual behaviour data during HIV surveillance in antenatal care (ANC) clinics, and to establish whether these data can provide information about the correlates of HIV infection in this population. METHODS: Sexual behaviour surveys were conducted in the context of two HIV sentinel surveillance rounds in 11 ANC clinics in north west Tanzania between 2000 and 2002. Responses of individual women were anonymously linked to their HIV status. Three clinic catchment areas overlapped with a community based longitudinal study, which provided independent estimates of HIV prevalence and sexual behaviour. Changes between rounds and differentials between clinics were assessed and a two level logistic regression model used to identify behavioural and contextual correlates of HIV in 3689 women under 25 years of age. RESULTS: Women attending clinics were willing to participate in the study. The sexual behaviour data obtained were internally consistent and tallied reasonably well with sexual behaviour data collected in the community overlapping the clinic catchment. Clear relations emerged between HIV infection and measures of sexual exposure: OR 1.20 (95% CL 1.12 to 1.28) for each year of premarital exposure and 1.09 (1.04 to 1.16) for each year after first marriage; background prevalence OR 1.15 (1.04 to 1.26) associated with each percentage point increase in background prevalence at the clinic; and certain partnership variables such as partner's age OR 0.58 (0.45 to 0.76) if partner less than 10 years older. CONCLUSION: Conducting sexual behaviour surveys in the context of ANC clinics surveillance is feasible and yields useful data