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

The impact of antenatal HIV diagnosis on postpartum childbearing desires in northern Tanzania: a mixed methods study.

With the expansion of routine antenatal HIV testing, women are increasingly discovering they are HIV-positive during pregnancy. While several studies have examined the impact of HIV on childbearing in Africa, few have focused on the antenatal/postpartum period. Addressing this research gap will help tailor contraceptive counseling to HIV-positive women's needs. Our study measures how antenatal HIV diagnosis affects postpartum childbearing desires, adjusting for effects of HIV before diagnosis. A baseline survey on reproductive behavior was administered to 5,284 antenatal clients before they underwent routine HIV testing. Fifteen months later, a follow-up survey collected information on postpartum reproductive behavior from 2,162 women, and in-depth interviews with 25 women investigated attitudes toward HIV and childbearing. HIV diagnosis was associated with a long-term downward adjustment in childbearing desires, but not with changes in short-term postpartum desires. The qualitative interviews identified health concerns and nurses' dissuasion as major factors discouraging childbearing post-diagnosis. At the same time, pronatalist social norms appeared to pressure women to continue childbearing. Given the potential for fertility desires to change following antenatal HIV diagnosis, contraceptive counseling should be provided on a continuum from antenatal through postpartum care, taking into account the conflicting pressures faced by HIV-positive women in relation to childbearing

Reproductive behaviour and HIV status of antenatal clients in northern Tanzania: opportunities for family planning and preventing mother-to-child transmission integration.

OBJECTIVES: To examine reproductive and contraceptive history and intentions by HIV status among women at antenatal clinics to help inform initiatives to integrate family planning into antenatal/preventing mother-to-child transmission services in Mwanza region, Tanzania. DESIGN: A questionnaire survey was carried out in antenatal clinics in Mwanza region, Tanzania in 2007-2008. METHODS: : We interviewed 5284 pregnant women attending 15 antenatal clinics offering HIV testing in Mwanza City and Magu district, northern Tanzania. The questionnaires asked about reproductive and contraceptive history and intentions, and sexual behaviour. Subject to participants' consent, we collected blood to determine HIV status and linked these results to the questionnaire data through individual numbers. RESULTS: HIV prevalence was 8.9% overall, and family planning ever use was 26%. HIV-positive and HIV-negative women differed with respect to age, parity, length of last birth interval, child survival, childbearing intentions and intention to breastfeed. HIV-positive women were more likely to have used family planning, particularly hormonal methods. Patterns of family planning use and unmet need for contraception yielded useful information for the design of family planning counselling services at antenatal clinics. CONCLUSION: Our survey findings point to numerous potential benefits of offering family planning counselling as a part of antenatal services, particularly in clinics offering HIV testing. The differences in reproductive history and intentions between HIV-positive and HIV-negative women highlight the necessity of tailoring family planning counselling to their specific needs

He for she? Variation and exaggeration in mens support for womens empowerment in northern Tanzania.

Achieving gender equality fundamentally requires a transfer of power from men to women. Yet data on mens support for womens empowerment (WE) remains scant and limited by reliance on self-report methodologies. Here, we examine mens support for WE as a sexual conflict trait, both via direct surveys (n = 590) and indirectly by asking mens wives (n = 317) to speculate on their husbands views. Data come from a semi-urban community in Mwanza, Tanzania. Consistent with reduced resource competition and increased exposure to relatively egalitarian gender norms, higher socioeconomic status predicted greater support for WE. However, potential demographic indicators of sexual conflict (high fertility, polygyny, large spousal age gap) were largely unrelated to mens support for WE. Contrasting self- and wife-reported measures suggests that men frequently exaggerate their support for women in self-reported attitudes. Discrepancies were especially pronounced among men claiming the highest support for WE, but smallest among men who held a professional occupation and whose wife participated in wage labour, indicating that these factors predict genuine support for WE. We discuss the implications of these results for our understanding of both individual variation and patriarchal gender norms, emphasising the benefits of greater exchange between the evolutionary human sciences and global health research on these themes

Postpartum Contraception in Northern Tanzania: Patterns of Use, Relationship to Antenatal Intentions, and Impact of Antenatal Counseling.

In Tanzania, unmet need for contraception is high, particularly in the postpartum period. Contraceptive counseling during routine antenatal HIV testing could reach 97 percent of pregnant women with much-needed information, but requires an understanding of postpartum contraceptive use and its relationship to antenatal intentions. We conducted a baseline survey of reproductive behavior among 5,284 antenatal clients in Northern Tanzania, followed by an intervention offering contraceptive counseling to half the respondents. A follow-up survey at 6-15 months postpartum examined patterns and determinants of postpartum contraceptive use, assessed their correspondence with antenatal intentions, and evaluated the impact of the intervention. Despite high loss to follow-up, our findings indicate that condoms and hormonal methods had particular and distinct roles in the postpartum period, based on understandings of postpartum fertility. Antenatal intentions were poor predictors of postpartum reproductive behavior. Antenatal counseling had an effect on postpartum contraceptive intentions, but not on use. Different antenatal/contraceptive service integration models should be tested to determine how and when antenatal counseling can be most effective

Misperception of peer beliefs reinforces inequitable gender norms among Tanzanian men.

Gender role ideology, i.e. beliefs about how genders should behave, is shaped by social learning. Accordingly, if perceptions about the beliefs of others are inaccurate this may impact trajectories of cultural change. Consistent with this premise, recent studies report evidence of a tendency to overestimate peer support for inequitable gender norms, especially among men, and that correcting apparent norm misperception promotes transitions to relatively egalitarian beliefs. However, supporting evidence largely relies on self-report measures vulnerable to social desirability bias. Consequently, observed patterns may reflect researcher measurement error rather than participant misperception. Addressing this shortcoming, we examine mens gender role ideology using both conventional self-reported and a novel wife-reported measure of mens beliefs in an urbanising community in Tanzania. We confirm that participants overestimate peer support for gender inequity. However, the latter measure, which we argue more accurately captures mens true beliefs, implies that this tendency is relatively modest in magnitude and scope. Overestimation was most pronounced among men holding relatively inequitable beliefs, consistent with misperception of peer beliefs reinforcing inequitable norms. Furthermore, older and poorly educated men overestimated peer support for gender inequity the most, suggesting that outdated and limited social information contribute to norm misperception in this context

Do accurate HIV and antiretroviral therapy knowledge, and previous testing experiences increase the uptake of HIV voluntary counselling and testing? Results from a cohort study in rural Tanzania.

BACKGROUND: Despite the introduction of free antiretroviral therapy (ART), the use of voluntary counselling and testing (VCT) services remains persistently low in many African countries. This study investigates how prior experience of HIV and VCT, and knowledge about HIV and ART influence VCT use in rural Tanzania. METHODS: In 2006-7, VCT was offered to study participants during the fifth survey round of an HIV community cohort study that includes HIV testing for research purposes without results disclosure, and a questionnaire covering knowledge, attitudes and practices around HIV infection and HIV services. Categorical variables were created for HIV knowledge and ART knowledge, with "good" HIV and ART knowledge defined as correctly answering at least 4/6 and 5/7 questions about HIV and ART respectively. Experience of HIV was defined as knowing people living with HIV, or having died from AIDS. Logistic regression methods were used to assess how HIV and ART knowledge, and prior experiences of HIV and VCT were associated with VCT uptake, with adjustment for HIV status and socio-demographic confounders. RESULTS: 2,695/3,886 (69%) men and 2,708/5,575 women (49%) had "good" HIV knowledge, while 613/3,886 (16%) men and 585/5575 (10%) women had "good" ART knowledge. Misconceptions about HIV transmission were common, including through kissing (55% of women, 43% of men), or mosquito bites (42% of women, 34% of men).19% of men and 16% of women used VCT during the survey. After controlling for HIV status and socio-demographic factors, the odds of VCT use were lower among those with poor HIV knowledge (aOR = 0.5; p = 0.01 for men and aOR = 0.6; p < 0.01 for women) and poor ART knowledge (aOR = 0.8; p = 0.06 for men, aOR = 0.8; p < 0.01 for women), and higher among those with HIV experience (aOR = 1.3 for men and aOR = 1.6 for women, p < 0.01) and positive prior VCT experience (aOR = 2.0 for all men and aOR = 2.0 for HIV-negative women only, p < 0.001). CONCLUSIONS: Two years after the introduction of free ART in this setting, misconceptions regarding HIV transmission remain rife and knowledge regarding treatment is worryingly poor, especially among women and HIV-positive people. Further HIV-related information, education and communication activities are urgently needed to improve VCT uptake in rural Tanzania

Trends in HIV & syphilis prevalence and correlates of HIV infection: results from cross-sectional surveys among women attending ante-natal clinics in Northern Tanzania.

BACKGROUND: Sentinel surveillance for HIV in ante-natal clinics (ANC) remains the primary method for collecting timely trend data on HIV prevalence in most of sub-Saharan Africa. We describe prevalence of HIV and syphilis infection and trends over time in HIV prevalence among women attending ante-natal clinics (ANC) in Magu district and Mwanza city, part of Mwanza region in Northern Tanzania. HIV prevalence from ANC surveys in 2000 and 2002 was 10.5% and 10.8% respectively. In previous rounds urban residence, residential mobility, the length of time sexually active before marriage, time since marriage and age of the partner were associated with HIV infection. METHODS: A third round of HIV sentinel surveillance was conducted at ante-natal clinics in Mwanza region, Tanzania during 2006. We interviewed women attending 27 ante-natal clinics. In 15 clinics we also anonymously tested women for syphilis and HIV infection and linked these results to the questionnaire data. RESULTS: HIV prevalence was 7.6% overall in 2006 and 7.4% at the 11 clinics used in previous rounds. Geographical variations in HIV prevalence, apparent in previous rounds, have largely disappeared but syphilis prevalence is still higher in rural clinics. HIV prevalence has declined in urban clinics and is stable in rural clinics. The correlates of HIV infection have changed over time. In this round older age, lower gravidity, remarriage, duration of marriage, sexual activity before marriage, long interval between last birth and pregnancy and child death were all associated with infection. CONCLUSIONS: HIV prevalence trends concur with results from a community-based cohort in the region. Correlates of HIV infection have also changed and more proximate, individual level factors are now more important, in line with the changing epidemiology of infection in this population

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