Burden of diseases in poor resource countries: meeting the challenges of combating HIV/AIDS, tuberculosis and malaria

Poverty, ill health and ignorance are closely interlinked and each is a determinant of the other. HIV/AIDS, malaria and tuberculosis are by far the commonest causes of ill-health and death in the poorest countries of the world which happen to be in the tropics and temperate countries in Africa, Asia and South America. Morbidity and mortality from these three diseases have a major socio-economic impact on individuals, communities and nations, due to the vicious cycle of poverty, ill health and ignorance. In Tanzania morbidity due to HIV/AIDS, tuberculosis and malaria leads to irrecoverable losses in productivity, inadequately trained workforce due to absence from training by the sick, heavy health care budgets to treat these otherwise preventable diseases, less competitive economy, higher labour force turnovers and unstable national budgets. If not controlled continuing rise in incidence of HIV/AIDS, malaria and TB may threaten the survival of small enterprises and ability to attract foreign investments leading to a rise in unemployment. Thus, investments in the improvement of health including HIV/AIDS, malaria and TB if done well will bring substantial benefits for the national economy including an increase in productivity. In this paper a review of the impact of HIV/AIDS, TB and malaria in Tanzania is done with an attempt to propose how research can contribute to improved efforts towards more effective prevention and control efforts. The need for multidisplinary research efforts in addressing the three disease conditions is proposed. Keywords: HIV/AIDS, malaria, tuberculosis, burden, poverty, researchTanzania Health Research Bulletin Vol. 7(3) 2005: 179-18

Community determinants of health care seeking for tuberculosis : the role of socio-cultural determinants and gender in Tanzania

The WHO End TB strategy targets to end the global tuberculosis epidemic by 2035 with a reduction of 90% new cases, a 95% reduction in deaths, and to ensure that no family is burdened by catastrophic costs as a result of tuberculosis. In order to reach this ambitious goal, not only strengthening of tuberculosis control programs, discovery, development and evaluation of novel and sensitive tuberculosis diagnostics tools will be required, but also actions with regard to social determinants of tuberculosis and health care seeking, particularly in low-income settings with high tuberculosis burden. Furthermore, novel and more sensitive TB diagnostics tools will only have an impact at the population-level if the millions of undiagnosed TB cases reach health care centres timely for diagnosis and treatment. The low tuberculosis case detection observed in Tanzania and elsewhere is not only due to limitations in tuberculosis diagnostics, but also in the socio-cultural and economic factors which are relevant for tuberculosis healthcare seeking, timely diagnosis and treatment. This doctoral thesis therefore aimed to assess the pathways and costs of care from the onset of tuberculosis symptoms, to explain patient and diagnostic delays and loss to diagnostic follow-up during health care seeking, and finally to explore the role of traditional healers in tuberculosis management and control in Tanzania, using quantitative and qualitative methods. It firstly makes use of data obtained from the on-going tuberculosis cohort study in Dar es Salaam Tanzania, interviewing 100 confirmed and 100 presumptive tuberculosis patients on pathways to care and on direct and indirect costs, with data recording on tablets using the OpenDataKit (ODK) application. Secondly, data were collected during an intervention study on intensified case findings at pharmacies in Tanzania, administering a semi-structured explanatory model interview based on the EMIC framework for cultural epidemiology to 136 presumptive and confirmed TB patients. It further used data from in-depth interviews and structured interviews with 90 traditional healers in urban, peri-urban and rural districts of Tanzania. Pathways to care in confirmed tuberculosis patients were complex compared to the presumptive patients. In confirmed patients, pathways involved several visits to health care facilities before diagnosis, while that of the presumptive patients were more direct with only one or few visits to healthcare facilities before diagnosis. Confirmed and presumptive TB patients spent a median of 31% of their monthly household income on health expenditure for all five visits to healthcare facilities. Indirect costs were considerably higher than direct costs both in confirmed and presumptive TB patients. A patient delay of ≥3 weeks was observed in almost two thirds of our participants from the intervention study. In addition, loss to diagnostic follow-up was observed in 44.1%. Prior consultations with traditional healers were associated with patient delay but not with loss to diagnostic follow-up. Gender differences were observed in patient delay and LDFU, whereby the odds of patient delay were higher in females than in males, and also loss to diagnostic follow-up was higher in females than in males. Knowledge on cough and tuberculosis related symptoms was limited among traditional healers and varied in urban, peri-urban and the rural settings. Costs spent for traditional healers for treatment of cough and tuberculosis symptoms were lower than costs incurred by patients from the formal healthcare providers. Traditional healers in all three study sites referred patients for further treatment. Collaboration among the traditional healers, the government (NTLP) and other stakeholders was limited. There was a significant association between collaboration with the government and referring patients to hospitals for further treatment. The results from this PhD project contribute to our understanding on the pathways and costs of care in confirmed and presumptive tuberculosis patients. This study is among a few to report costs associated with tuberculosis taking into account gender differences and poverty status. Furthermore, it contributes to open questions regarding patient delay and loss to diagnostic follow-up during healthcare seeking. Our study is also among the few to address the gap on the role of traditional healers in tuberculosis management particularly from sub-Sahara Africa. Given the importance of tuberculosis in terms of global disease burden, and the WHO’s ambitious goal to end tuberculosis by 2035, planning and specific interventions which integrate social and biomedical solutions are needed

Risky Behaviours Among Young People Living with HIV Attending Care and Treatment Clinics in Dar Es Salaam, Tanzania: Implications for Prevention with a Positive Approach.

Introduction: Prevention with a positive approach has been advocated as one of the main strategies to reduce new instances of HIV infection. Risky sexual behaviours among people living with HIV/AIDS are the cornerstone for this approach. Understanding the extent to which infected individuals practice risky behaviours is fundamental in designing appropriate population-specific interventions. With the HIV infection transmission rates remaining high among young people in sub-Saharan Africa, continued prevention among them remains a priority. This study therefore seeks to describe the magnitude and determinants of risky sexual behaviours among young people living with HIV. Methods: A cross-sectional study was conducted between June and July 2010 in selected Care and Treatment Clinics (CTCs) in Dar Es Salaam, Tanzania. A total of 282 HIV-positive patients aged 15-24 were interviewed about their sexual behaviours using a questionnaire. Results: Prevalence of unprotected sex was 40.0% among young males and 37.5% among young females (p<0.001). Multiple sexual partnerships were reported by 10.6% of males and 15.9% of females (p<0.005). More than 50% of the participants did not know about the HIV status of their sexual partners. A large proportion of participants had minimal knowledge of transmission (46.7% males vs. 60.4% females) and prevention (65.3% males vs. 73.4% females) of sexually transmitted infections (STIs). Independent predictors of condom use included non-use of alcohol [adjusted odds ratio (AOR), 0.40 95% confidence interval (CI); 0.17-0.84] and younger age (15-19 years) (AOR, 2.76, 95% CI: 1.05-7.27). Being on antiretroviral therapy (AOR, 0.38, 95% CI: 0.17-0.85) and not knowing partners' HIV sero-status (AOR, 2.62, 95% CI: 1.14-5.10) predicted the practice of multiple sexual partnership. Conclusions: Unprotected sex and multiple sexual partnerships were prevalent among young people living with HIV. Less knowledge on STI and lack of HIV disclosure increased the vulnerability and risk for HIV transmission among young people. Specific intervention measures addressing alcohol consumption, risky sexual behaviours, and STI transmission and prevention knowledge should be integrated in the routine HIV/AIDS care and treatment offered to this age group

Prevalence and clinical presentation of HIV infection among newly hospitalised surgical patients at Muhimbili National Hospital, Dar Es Salaam, Tanzania

Background: In Tanzania information is lacking on the prevalence of HIV infection in surgical patients in tertiary care facilities, in whom there are many points of special interest. Objective: To determine the prevalence of HIV infection and associated clinical and demographic features among hospitalised surgical patients at Muhimbili National Hospital (MNH). Setting: Muhimbili National Hospital. Materials and Methods: Consecutive newly admitted patients were tested for HIV antibodies after pre-test counselling. Sera were tested using a dual ELISA algorithm. The data were analysed to determine the prevalence of HIV infection and relationships of serostatus with clinical and socio-demographic characteristics. Results: Of 1,534 patients admitted during the study, 1,031(67.2%) consented to HIV testing following pre-test counselling. The prevalence of AlDS-related clinical features in patients who declined to be HIV tested was similar to that of seronegative patients, but significantly lower than that of seropositive patients. The overall age-adjusted HIV prevalence was 10.5% (95% Cl=9.9-14.0). The highest age-specific HIV prevalence was in the age group 35-44 years at 27.9%. No one was infected in the age group 0-4 years (n=111). Differences in prevalence between age groups were statistically significant (

A Vision Based Lane Marking Detection, Tracking and Vehicle Detection on Highways

Changing street conditions is an important issue in the applications in mechanized route of vehicles essentially because of vast change in appearance in lane markings on by variables such substantial movement and changing daylight conditions of the specific time of day. A path identification framework is an imperative segment of numerous computerized vehicle frameworks. In this paper, we address these issues through lane identification and vehicle recognition calculation to manage testing situations, for example, a lane end and flow, old lane markings, and path changes. Left and right lane limits will be distinguished independently to adequately handle blending and part paths utilizing a strong calculation. Vehicle discovery is another issue in computerized route of vehicles. Different vehicle discovery approaches have been actualized yet it is hard to locate a quick and trusty calculation for applications, for example, for vehicle crashing (hitting) cautioning or path evolving system .Vision-based vehicle recognition can likewise enhance the crash cautioning execution when it is consolidated with a lane marking identification calculation. In crash cautioning applications, it is vital to know whether the obstruction is in the same path with the sense of self vehicle or not

Antimicrobial susceptibility pattern of Vibrio cholerae 01 strains during two cholera outbreaks in Dar Es Salaam, Tanzania

Objective: To determine and compare the antimicrobial susceptibility patterns of Vibrio cholerae 01 strains, which were isolated in two cholera epidemics in 1997 and 1999 in Dar es Salaam.Methods: V. cholerae 01 strains isolated from patients with cholera in Dar es Salaam city during 1997 (94 isolates) and 1999 (87 isolates) were stored on nutrient agar slants at room temperature and antimicrobial susceptibility pattern was determined, using Kirby Bauermethod.Setting: Department of Microbiology and Immunology, Muhimbili Medical Centre, Dar es Salaam, Tanzania.Results: A total of 181 V. cholerae 01 strains were studied during two epidemic periods when tetracycline or erythromycin was used for treatment of patients with severe disease. Among the 94 V. cholerae Ol strains isolated in 1997; 98.6%, 93.6%, 83%, 81.9%, 36.2%, 35.5%, 3.2% were sensitive to ciprofloxacin, tetracycline, ampicillin, erythromycin, nalidixic acid, chloramphenicol and trimethoprim/ sulphamethoxazole, respectively. Among the 87 V. cholerae 01 isolates collected in 1999, 100%, 58.6%, 46.0%, 46%, 47.1%, 19.5%, 3.4% were sensitive to ciprofloxacin, tetracycline, ampicillin, erythromycin, chloramphenicol, nalidixic acid and trimethoprim/sulphamethoxazole, respectively. Between 1997 and 1999, there was a significant increase in the proportion of V. cholerae 01 isolates resistant to tetracycline, ampicillin, nalidixic acid and to erythromycin but there was no change for susceptibility tociprofloxacin and trimethoprim/ sulphamethoxazole.Conclusion: Significant proportion of V. cholerae 0l strains in Dar es Salaam were resistant to commonly used antimicrobial agents during the two years of the study. Therefore, there is a great need to control the utilisation of antimicrobial agents in cholera control, in additionto continuing carrying out surveillance of antimicrobial resistance as a guide to choice of antimicrobial treatment. Rotational use of the available drugs with regular monitoring of susceptibility may contribute to continuing usefulness of such drugs

Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing policies to expand health insurance coverage and achieve better access to quality healthcare for all. Recent reforms have included improved community health funds (iCHFs), and others are underway to implement a mandatory national health insurance scheme in order to expand access to services and improve financial risk protection. Governance is a crucial structural determinant for the successful implementation of health financing reforms, however there is little understanding of the governance elements that hinder the implementation of health financing reforms such as the iCHF in Tanzania. Therefore, this study used the perspectives of health sector stakeholders to explore governance factors that influence the implementation of health financing reforms in Tanzania. We interviewed 36 stakeholders including implementers of health financing reforms, policymakers and health insurance beneficiaries in the regions of Dodoma, Dar es Salaam and Kilimanjaro. Normalisation process theory and governance elements guided the structure of the in-depth interviews and analysis. Governance factors that emerged from participants as facilitators included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of iCHF enrolment due to digitisation of registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from community level and limited resources due to iCHF design. If stakeholders do not address the governance factors that hinder the implementation of health financing reforms, then current efforts to expand health insurance coverage are unlikely to succeed on their own

vpu and env sequence variability of HIV-1 isolates from Tanzania

No abstract availabl

Diagnostic Delay and Associated Factors among Patients with Pulmonary Tuberculosis in Dar es Salaam, Tanzania.

Tanzania is among the 30 countries with the highest tuberculosis (TB) burdens. Because TB has a long infectious period, early diagnosis is not only important for reducing transmission, but also for improving treatment outcomes. We assessed diagnostic delay and associated factors among infectious TB patients. We interviewed new smear-positive adult pulmonary TB patients enrolled in an ongoing TB cohort study in Dar es Salaam, Tanzania, between November 2013 and June 2015. TB patients were interviewed to collect information on socio-demographics, socio-economic status, health-seeking behaviour, and residential geocodes. We categorized diagnostic delay into ≤ 3 or > 3 weeks. We used logistic regression models to identify risk factors for diagnostic delay, presented as crude (OR) and adjusted Odds Ratios (aOR). We also assessed association between geographical distance (incremental increase of 500 meters between household and the nearest pharmacy) with binary outcomes. We analysed 513 patients with a median age of 34 years (interquartile range 27-41); 353 (69%) were men. Overall, 444 (87%) reported seeking care from health care providers prior to TB diagnosis, of whom 211 (48%) sought care > 2 times. Only six (1%) visited traditional healers before TB diagnosis. Diagnostic delay was positively associated with absence of chest pain (aOR = 7.97, 95% confidence intervals [CI]: 3.15-20.19; P < 0.001), and presence of hemoptysis (aOR = 25.37, 95% CI: 11.15-57.74; P < 0.001) and negatively associated with use of medication prior to TB diagnosis (aOR = 0.31, 95% CI: 0.14-0.71; P = 0.01). Age, sex, HIV status, education level, household income, and visiting health care facilities (HCFs) were not associated with diagnostic delay. Patients living far from pharmacies were less likely to visit a HCF (incremental increase of distance versus visit to any facility: OR = 0.51, 95% CI: 0.28-0.96; P = 0.037). TB diagnostic delay was common in Dar es Salaam, and was more likely among patients without prior use of medication and presenting with hemoptysis. Geographical distance to HCFs may have an impact on health-seeking behaviour. Increasing community awareness of TB signs and symptoms could further reduce diagnostic delays and interrupt TB transmission