A qualitative study of discourses on heterosexual anal sexual practice among key, and general populations in Tanzania: implications for HIV prevention.

BACKGROUND: The risk of contracting HIV through heterosexual anal sex (HAS) is significantly higher than from vaginal intercourse. Little has been done to understand the discourses around HAS and terms people use to describe the practice in Tanzania. A better understanding of discourses on HAS would offer useful insights for measurement of the practice as well as designing appropriate interventions to minimise the risks inherent in the practice. METHODS: This study employed qualitative approaches involving 24 focus group discussions and 81 in-depth interviews. The study was conducted in 4 regions of Tanzania, and included samples from the general population and among key population groups (fishermen, truck drivers, sex workers, food and recreational facilities workers). Discourse analysis was conducted with the aid of NVIVO versions 8 and 10 software. RESULTS: Six discourses were delineated in relation to how people talked about HAS. Secrecy versus openness discourse describes the terms used when talking about HAS. "Other" discourse involved participants' perception of HAS as something practiced by others unrelated to them and outside their communities. Acceptability/trendiness discourse: young women described HAS as something trendy and increasingly gaining acceptability in their communities. Materiality discourse: describes HAS as a practice that was more profitable than vaginal sex. Masculinity discourse involved discussions on men proving their manhood by engaging in HAS especially when women initiated the practice. Masculine attitudes were also reflected in how men described the practice using a language that would be considered crude. Public health discourse: describes HAS as riskier for HIV infection than vaginal sex. The reported use of condoms was low due to the perceptions that condoms were unsuitable for anal sex, but also perceptions among some participants that anal sex was safer than vaginal sex. CONCLUSION: Discourses among young women and adult men across the study populations were supportive of HAS. These findings provide useful insights in understanding how different population groups talked about HAS and offer a range of terms that interventions and further research on magnitude of HAS could draw on when addressing health risks of HAS among different study populations

A review of interventions addressing structural drivers of adolescents' sexual and reproductive health vulnerability in sub-Saharan Africa: implications for sexual health programming.

BACKGROUND: Young people particularly women are at increased risk of undesirable sexual and reproductive health (SRH) outcomes. Structural factors have been reported as driving some of these risks. Although several interventions have targeted some of the structural drivers for adolescent's SRH risk, little has been done to consolidate such work. This would provide a platform for coordinated efforts towards adolescent's SRH. We provide a narrative summary of interventions in sub-Saharan Africa (sSA) addressing the structural drivers of adolescents' SRH risk, explore pathways of influence, and highlight areas for further work. METHODS: 33 abstracts and summary reports were retrieved and perused for suitability. Fifteen documents met the inclusion criteria and were read in full. Papers and reports were manually reviewed and 15 interventions that met the criteria for inclusion were summarised in a table format. RESULTS: Most of the interventions addressed multiple structural factors, such as social norms, gender inequality, and poverty. Some interventions focused on reducing economic drivers that increased sexual risk behaviours. Others focused on changing social norms and thus sexual risk behaviours through communication. Social norms addressed included gender inequality, gender violence, and child socialisation. The interventions included components on comprehensive sexuality and behaviour change and communication and parenting, using different designs and evaluation methods. Important lessons from the narrative summary included the need for a flexible intervention design when addressing adolescents, the need for coordinated effort among different stakeholders. CONCLUSION: There are encouraging efforts towards addressing structural drivers among adolescents in (sSA). There is, however, a need for interventions to have a clear focus, indicate the pathways of influence, and have a rigorous evaluation strategy assessing how they work to reduce vulnerability to HIV. There is also a need for coordinated effort among stakeholders working on adolescent vulnerability in sSA

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

Deciphering the Complex Distribution of Human Immunodeficiency Virus Type 1 Subtypes among Different Cohorts in Northern Tanzania.

Increased understanding of the genetic diversity of HIV-1 is challenging but important in the development of an effective vaccine. We aimed to describe the distribution of HIV-1 subtypes in northern Tanzania among women enrolled in studies preparing for HIV-1 prevention trials (hospitality facility-worker cohorts), and among men and women in an open cohort demographic surveillance system (Kisesa cohort). The polymerase encompassing partial reverse transcriptase was sequenced and phylogenetic analysis performed and subtype determined. Questionnaires documented demographic data. We examined factors associated with subtype using multinomial logistic regression, adjusted for study, age, and sex. Among 140 individuals (125 women and 15 men), subtype A1 predominated (54, 39%), followed by C (46, 33%), D (25, 18%) and unique recombinant forms (URFs) (15, 11%). There was weak evidence to suggest different subtype frequencies by study (for example, 18% URFs in the Kisesa cohort versus 5-9% in the hospitality facility-worker cohorts; adjusted relative-risk ratio (aRR) = 2.35 [95% CI 0.59,9.32]; global p = 0.09). Compared to men, women were less likely to have subtype D versus A (aRR = 0.12 [95% CI 0.02,0.76]; global p = 0.05). There was a trend to suggest lower relative risk of subtype D compared to A with older age (aRR = 0.44 [95% CI 0.23,0.85] per 10 years; global p = 0.05). We observed multiple subtypes, confirming the complex genetic diversity of HIV-1 strains circulating in northern Tanzania, and found some differences between cohorts and by age and sex. This has important implications for vaccine design and development, providing opportunity to determine vaccine efficacy in diverse HIV-1 strains

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

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

Deciphering the Complex Distribution of Human Immunodeficiency Virus Type 1 Subtypes among Different Cohorts in Northern Tanzania

Background: Increased understanding of the genetic diversity of HIV-1 is challenging but important in the development of an effective vaccine. We aimed to describe the distribution of HIV-1 subtypes in northern Tanzania among women enrolled in studies preparing for HIV-1 prevention trials (hospitality facility-worker cohorts), and among men and women in an open cohort demographic surveillance system (Kisesa cohort). Methods: The polymerase encompassing partial reverse transcriptase was sequenced and phylogenetic analysis performed and subtype determined. Questionnaires documented demographic data. We examined factors associated with subtype using multinomial logistic regression, adjusted for study, age, and sex. Results: Among 140 individuals (125 women and 15 men), subtype A1 predominated (54, 39%), followed by C (46, 33%), D (25, 18%) and unique recombinant forms (URFs) (15, 11%). There was weak evidence to suggest different subtype frequencies by study (for example, 18 % URFs in the Kisesa cohort versus 5–9 % in the hospitality facility-worker cohorts; adjusted relative-risk ratio (aRR) = 2.35 [95 % CI 0.59,9.32]; global p = 0.09). Compared to men, women were less likely to have subtype D versus A (aRR = 0.12 [95 % CI 0.02,0.76]; global p = 0.05). There was a trend to suggest lower relative risk of subtype D compared to A with older age (aRR = 0.44 [95 % CI 0.23,0.85] per 10 years; global p = 0.05). Conclusions: We observed multiple subtypes, confirming the complex genetic diversity of HIV-1 strains circulating i

HIV and HSV-2 incidence and associations with socio-demographic, behavioural and biological factors, among women working in food and recreational facilities in northern Tanzania.

<p>RR = incidence rate ratio, CI = confidence interval. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068825#pone.0068825-WHO1" target="_blank">[1]</a> Numbers may not add up to total due to missing data. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068825#pone.0068825-National1" target="_blank">[2]</a> P-values from likelihood ratio test. The ORs for town are adjusted for age, and the ORs for age are adjusted for town. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068825#pone.0068825-Tanzania1" target="_blank">[3]</a> Estimated RRs adjusted for town, age, marital status and time-updated number of partners in last 3 months (the adjusted results for these variables are shown in bold). <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068825#pone.0068825-WatsonJones1" target="_blank">[4]</a> Estimated RRs adjusted for town, age, education and marital status (the adjusted results for these variables are shown in bold). <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068825#pone.0068825-Vallely1" target="_blank">[5]</a> Other hormonal contraceptives grouped with pill, due to low numbers. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068825#pone.0068825-Kapiga1" target="_blank">[6]</a> Results for syphilis, <i>T. vaginalis</i> (diagnosed by 72-hour culture) and bacterial vaginosis (diagnosed by Nugent criteria) not available for vaccines-preparedness cohort.</p