Prevalence and Factors Associated with Depression and Anxiety among HIV-infected Pregnant Women in Kilimanjaro Region, Tanzania

Introduction: Antenatal depression and anxiety in women living with HIV are associated with a number of poor maternal and child outcomes, and undermine the world target of eliminating mother-to-child transmission (MTCT) of HIV. Despite the importance of antenatal mental health, the data on the factors associated with common mental illnesses in HIV-infected women are limited. Thus, the aim of the present study was to determine the prevalence and factors associated with depression and anxiety among pregnant women living with HIV and attending antenatal clinics in Kilimanjaro region, Tanzania. Methods: We analysed the baseline data from an ongoing cohort study of 200 pregnant women living with HIV and attending antenatal care in two districts of the Kilimanjaro region. Women were eligible for inclusion in the parent cohort study if they were HIV-infected and in their second or third trimester of pregnancy. Antenatal depression and anxiety were assessed using the Edinburgh Postnatal Depression Scale and the Brief Symptom Scale, respectively. A multivariate logistic regression model was used to assess the factors that were independently associated with anxiety, depression and comorbidity of anxiety and depression. Variables with a p-value less than 0.15 in univariate analysis were included in the final multivariate model. Results: Participants had a median (IQR) age of 30 years (26-35). About half were married (n=98, 49.0%) and knew their HIV status prior to the index pregnancy (n=105, 52.5%). When asked whether they had disclosed their status to anyone, 159 (79.5%) had disclosed to at least one person and more than half (n=119/170, 70.0%) had disclosed to their sexual partner. Fifty (25.0%) screened positive for possible depression and this was associated with being single (aOR=4.0, 95% CI=1.2–13.7), food insecurity (aOR=2.6, 95% CI=1.0–6.6), and HIV shame (aOR=1.2, 95% CI=1.1–1.3). Of the 197 women who completed the anxiety questionnaire, 47 (23.5%) screened positive for anxiety which was associated with being ashamed of having HIV (aOR=1.1, 95% CI=1.1 – 1.2). The prevalence of comorbid symptoms of depression and anxiety was 17.8% (n=35). HIV shame and lifetime experience of violence (aOR=3.4, 95% CI=1.2 – 9.6) were found to be independently associated with comorbid depression and anxiety. Conclusion: One in every four pregnant women living with HIV screened positive for anxiety and/or depression. The majority of women with depressive symptoms also had anxiety symptoms. In this population, a number of factors were associated with depression and anxiety. These factors ranged from marital status and lifetime experience of violence, food insecurity to HIV-related shame. In order to successfully engage women in HIV care and support their well- being, prevention of MTCT (PMTCT) programmesshould have strategiesto screen and support women with mental illnesses

Determinants of isoniazid preventive therapy completion among people living with HIV attending care and treatment clinics from 2013 to 2017 in Dar es Salaam Region, Tanzania. A cross-sectional analytical study.

BACKGROUND: Tuberculosis (TB) disease is a common opportunistic infection among people living with HIV (PLHIV). WHO recommends at least 6 months of isoniazid Preventive Therapy (IPT) to reduce the risk of active TB. It is important to monitor the six-month IPT completion since a suboptimal dose may not protect PLHIV from TB infection. This study determined the six-month IPT completion and factors associated with six-month IPT completion among PLHIV aged 15 years or more in Dar es Salaam region, Tanzania. METHODS: Secondary analysis of routine data from PLHIV attending 58 care and treatment clinics in Dar es Salaam region was used. PLHIV, aged 15 years and above, who screened negative for TB symptoms and initiated IPT from January, 2013 to June, 2017 were recruited. Modified Poisson regression with robust standard errors was used to estimate prevalence ratios (PR) and 95% confidence interval (CI) for factors associated with IPT completion. Multilevel analysis was used to account for health facility random effects in order to estimate adjusted PR (APR) for factors associated with IPT six-month completion. RESULTS: A total of 29,382 PLHIV were initiated IPT, with 21,808 (74%) female. Overall 17,092 (58%) six-month IPT completion, increasing from 42% (773/1857) in year 2013 to 76% (2929/3856) in 2017. Multilevel multivariable model accounting for health facilities as clusters, showed PLHIV who were not on ART had 46% lower IPT completion compared to those were on ART (APR: 0.54: 95%CI: 0.45-0.64). There was 37% lower IPT completion among PLHIV who transferred from another clinic (APR: 0.63: 95% CI (0.54-0.74) compared to those who did not transfer. PLHIV aged 25-34 years had a 6% lower prevalence of IPT completion as compared to those aged 15 to 24 years (APR:0.94 95%CI:0.89-0.98). CONCLUSION: The IPT completion rate in PLHIV increased over time, but there was lower IPT completion in PLHIV who transferred from other clinics, who were aged 25 to 34 years and those not on ART. Interventions to support IPT in these groups are urgently needed

A counseling intervention to address HIV stigma at entry into antenatal care in Tanzania (Maisha): study protocol for a pilot randomized controlled trial.

BACKGROUND: HIV-related stigma significantly impacts HIV care engagement, including in prevention of mother-to-child transmission of HIV (PMTCT) programs. Maisha is a stigma-based counseling intervention delivered during the first antenatal care (ANC) visit, complementing routine HIV counseling and testing. The goal of Maisha is to promote readiness to initiate and sustain treatment among those who are HIV-positive, and to reduce HIV stigmatizing attitudes among those who test negative. METHODS: A pilot randomized control trial will assess the feasibility and acceptability of delivering Maisha in a clinical setting, and the potential efficacy of the intervention on HIV care engagement outcomes (for HIV-positive participants) and HIV stigma constructs (for all participants). A total of 1000 women and approximately 700 male partners will be recruited from two study clinics in the Moshi municipality of Tanzania. Participants will be enrolled at their first ANC visit, prior to HIV testing. It is estimated that 50 women (5%) will be identified as HIV-positive. Following consent and a baseline survey, participants will be randomly assigned to either the control (standard of care) or the Maisha intervention. The Maisha intervention includes a video and counseling session prior to HIV testing, and two additional counseling sessions if the participant tests positive for HIV or has an established HIV diagnosis. A subset of approximately 500 enrolled participants (all HIV-positive participants, and a random selection of HIV-negative participants who have elevated stigma attitude scores) will complete a follow-up assessment at 3 months. Measures will include health outcomes (care engagement, antiretroviral adherence, depression) and HIV stigma outcomes. Quality assurance data will be collected and the feasibility and acceptability of the intervention will be described. Statistical analysis will examine potential differences between conditions in health outcomes and stigma measures, stratified by HIV status. DISCUSSION: ANC provides a unique and important entry point to address HIV stigma. Interventions are needed to improve retention in PMTCT care and to improve community attitudes toward people living with HIV. Results of the Maisha pilot trial will be used to generate parameter estimates and potential ranges of values to estimate power for a full cluster-randomized trial in PMTCT settings, with extended follow-up and enhanced adherence measurement using a biomarker.

Prevalence, predictors and reasons for home delivery amongst women of childbearing age in Dodoma Municipality in central Tanzania

Introduction: The objective was to determine the prevalence, predictors and reasons for home delivery amongst women of childbearing age in Dodoma, Tanzania. Methods: A cross-sectional study was conducted amongst women living in Dodoma Municipality. Data were collected using adapted questionnaires and analysed using SPPS version 23. A multivariable logistic regression model was used to assess the independent predictors of home delivery. Results: A total of 425 women of childbearing age were enrolled in this study. The mean (\ub1 SD) age of the participants was 28.7 (\ub17.1) years. The prevalence of home delivery was 35.5% (n=150, 95% CI 30.9 \u2013 40.2). Women with secondary school and above had 93% less odds of home delivery than women who had no education (AOR=0.0795% CI: 0.03-0.18). Women who lived in rural areas (AOR=3.49, 95% CI: 2.12-5.75), and women living more than 5km from health facilities (AOR=2.67, 95% CI: 1.65-4.37) had higher odds of home delivery. The main reasons for home delivery were transportation cost, and long distance to the nearest health facilities. Conclusion: In this population, the prevalence of home delivery remained to be high. To address this more collaborative multisectoral effort like strengthening health education and strengthening maternity waiting homes are needed

Comparison of artesunate–mefloquine and artemether–lumefantrine fixed-dose combinations for treatment of uncomplicated Plasmodium falciparum malaria in children younger than 5 years in sub-Saharan Africa: a randomised, multicentre, phase 4 trial

SummaryBackgroundWHO recommends combinations of an artemisinin derivative plus an antimalarial drug of longer half-life as treatment options for uncomplicated Plasmodium falciparum infection. In Africa, artemether–lumefantrine is the most widely used artemisinin-based combination therapy, whereas artesunate–mefloquine is used infrequently because of a perceived poor tolerance to mefloquine. WHO recommends reconsideration of the use of artesunate–mefloquine in Africa. We compared the efficacy and safety of fixed-dose artesunate–mefloquine with that of artemether–lumefantrine for treatment of children younger than 5 years with uncomplicated P falciparum malaria.MethodsWe did this multicentre, phase 4, open-label, non-inferiority trial in Burkina Faso, Kenya, and Tanzania. Children aged 6–59 months with uncomplicated malaria were randomly assigned (1:1), via a computer-generated randomisation list, to receive 3 days' treatment with either one or two artesunate–mefloquine tablets (25 mg artesunate and 55 mg mefloquine) once a day or one or two artemether–lumefantrine tablets (20 mg artemether and 120 mg lumefantrine) twice a day. Parasitological assessments were done independently by two microscopists who were blinded to treatment allocation. The primary outcome was the PCR-corrected rate of adequate clinical and parasitological response (ACPR) at day 63 in the per-protocol population. Non-inferiority was shown if the lower limit of the 95% CI for the difference between groups was greater than −5%. Early vomiting was monitored and neuropsychiatric status assessed regularly during follow-up. This study is registered with ISRCTN, number ISRCTN17472707, and the Pan African Clinical Trials Registry, number PACTR201202000278282.Findings945 children were enrolled and randomised, 473 to artesunate–mefloquine and 472 to artemether–lumefantrine. The per-protocol population consisted of 407 children in each group. The PCR-corrected ACPR rate at day 63 was 90·9% (370 patients) in the artesunate–mefloquine group and 89·7% (365 patients) in the artemether–lumefantrine group (treatment difference 1·23%, 95% CI −2·84% to 5·29%). At 72 h after the start of treatment, no child had detectable parasitaemia and less than 6% had fever, with a similar number in each group (21 in the artesunate–mefloquine group vs 24 in the artemether–lumefantrine group). The safety profiles of artesunate–mefloquine and artemether–lumefantrine were similar, with low rates of early vomiting (71 [15·3%] of 463 patients in the artesunate–mefloquine group vs 79 [16·8%] of 471 patients in the artemether–lumefantrine group in any of the three dosing days), few neurological adverse events (ten [2·1%] of 468 vs five [1·1%] of 465), and no detectable psychiatric adverse events.InterpretationArtesunate–mefloquine is effective and safe, and an important treatment option, for children younger than 5 years with uncomplicated P falciparum malaria in Africa.FundingAgence Française de Développement, France; Department for International Development, UK; Dutch Ministry of Foreign Affairs, Netherlands; European and Developing Countries Clinical Trials Partnership; Fondation Arpe, Switzerland; Médecins Sans Frontières; Swiss Agency for Development and Cooperation, Switzerland

Implementation of evidence-based multiple focus integrated intensified TB screening to end TB (EXIT-TB) package in East Africa : a qualitative study

Funding: This study was part of the EXIT-TB project funded by the European & Developing Countries Clinical Trials Partnership 2 (EDCTP2) program supported by the European Union (Grant number CSA2016S-1608).Introduction Tuberculosis (TB) remains a major cause of morbidity and mortality, especially in sub-Saharan Africa. We qualitatively evaluated the implementation of an Evidence-Based Multiple Focus Integrated Intensified TB Screening package (EXIT-TB) in the East African region, aimed at increasing TB case detection and number of patients receiving care. Objective We present the accounts of participants from Tanzania, Kenya, Uganda, and Ethiopia regarding the implementation of EXIT-TB, and suggestions for scaling up. Methods A qualitative descriptive design was used to gather insights from purposefully selected healthcare workers, community health workers, and other stakeholders. A total of 27, 13, 14, and 19 in-depth interviews were conducted in Tanzania, Kenya, Uganda, and Ethiopia respectively. Data were transcribed and translated simultaneously and then thematically analysed. Results The EXIT-TB project was described to contribute to increased TB case detection, improved detection of Multidrug-resistant TB patients, reduced delays and waiting time for diagnosis, raised the index of TB suspicion, and improved decision-making among HCWs. The attributes of TB case detection were: (i) free X-ray screening services; (ii) integrating TB case-finding activities in other clinics such as Reproductive and Child Health clinics (RCH), and diabetic clinics; (iii), engagement of CHWs, policymakers, and ministry level program managers; (iv) enhanced community awareness and linkage of clients; (v) cooperation between HCWs and CHWs, (vi) improved screening infrastructure, (vii) the adoption of the new simplified screening criteria and (viii) training of implementers. The supply-side challenges encountered ranged from disorganized care, limited space, the COVID-19 pandemic, inadequate human resources, inadequate knowledge and expertise, stock out of supplies, delayed maintenance of equipment, to absence of X-ray and GeneXpert machines in some facilities. The demand side challenges ranged from delayed care seeking, inadequate awareness, negative beliefs, fears towards screening, to financial challenges. Suggestions for scaling up ranged from improving service delivery, access to diagnostic equipment and supplies, and infrastructure, to addressing client fears and stigma. Conclusion The EXIT-TB package appears to have contributed towards increasing TB case detection and reducing delays in TB treatment in the study settings. Addressing the challenges identified is needed to maximize the impact of the EXIT-TB intervention.Publisher PDFPeer reviewe

Individual and composite adverse pregnancy outcomes in a randomized trial on isoniazid preventative therapy among women living with human immunodeficiency virus

CITATION: Theron, G. et al. 2021. Individual and Composite Adverse Pregnancy Outcomes in a Randomized Trial on Isoniazid Preventative Therapy Among Women Living With Human Immunodeficiency Virus. Clinical infectious diseases, 72(11):e784–e790. doi:10.1093/cid/ciaa1482The original publication is available at https://academic.oup.com/cid/Background: International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1078, a randomized noninferiority study designed to compare the safety of starting isoniazid preventive therapy (IPT) in women living with human immunodeficiency virus (HIV) either during pregnancy or after delivery, showed that IPT during pregnancy increased the risk of composite adverse pregnancy outcomes, but not individual outcomes. Many known factors are associated with adverse pregnancy outcomes: these factors' associations and effect modifications with IPT and pregnancy outcomes were examined. Methods: Pregnant women living with HIV from 8 countries with tuberculosis incidences >60/100 000 were randomly assigned to initiate 28 weeks of IPT either during pregnancy or at 12 weeks after delivery. Using univariable and multivariable logistic regression and adjusting for factors associated with pregnancy outcomes, composite and individual adverse pregnancy outcome measures were analyzed. Results: This secondary analysis included 925 mother-infant pairs. All mothers were receiving antiretrovirals. The adjusted odds of fetal demise, preterm delivery (PTD), low birth weight (LBW), or a congenital anomaly (composite outcome 1) were 1.63 times higher among women on immediate compared to deferred IPT (95% confidence interval [CI], 1.15-2.31). The odds of fetal demise, PTD, LBW, or neonatal death within 28 days (composite outcome 2) were 1.62 times higher among women on immediate IPT (95% CI, 1.14-2.30). The odds of early neonatal death within 7 days, fetal demise, PTD, or LBW (composite outcome 3) were 1.74 times higher among women on immediate IPT (95% CI, 1.22-2.49). Conclusions: We confirmed higher risks of adverse pregnancy outcomes associated with the initiation of IPT during pregnancy, after adjusting for known risk factors for adverse pregnancy outcomes.https://academic.oup.com/cid/article/72/11/e784/5913421?login=truePublishers versio

Irrational use of antibiotics in the Moshi Municipality Northern Tanzania: a cross sectional study

Introduction: irrational use of antibiotics includes prescription of incorrect doses, self-medication and treatment of non-bacterial illness. As a direct consequence of irrational antibiotic use, resistance to the commonly available antibiotics has been increasing rapidly. This phenomenon is associated with poorer health outcomes, longer hospitalization, increased cost to both the patient and government, and increased mortality. The aim of this study was to determine the prevalence of, and examine factors associated with, irrational use of antibiotics in the Moshi municipality, Northern Tanzania. Methods: we conducted a cross-sectional descriptive study between April and May 2017 in the Moshi municipality. Twelve drug outlets, of which five were pharmacies and seven accredited drug dispensing outlets (ADDOs), were selected at random. On exiting these outlets, all adults who had purchased antibiotics were interviewed using structured questionnaires. Results: a total of 152 adults were enrolled in this study. The median (QR) age was 31 years (25-42). The majority, 94 (61.8%), of the participants were female. ADDOs contributed 81 (53.3%) and pharmacies contributed 71 (46.7%) of all participants. Overall, 135 (88.8%) of antibiotic purchases were irrational. The most prevalent form of irrational antibiotic use was non-prescription usage; 116 of the 152 (76.3%) purchases fell in this category. Purchases of the incomplete dosage and purchases for non-bacterial illness were also widespread. Poor knowledge about the use of antibiotics had a significant association with irrational use of antibiotics (aOR=5.1, 95% CI: 1.80-15.15). Conclusion: irrational use of antibiotics is highly prevalent in this population. Non-prescription use of antibiotics is the most prevalent form. Poor knowledge about antibiotic use plays a significant role in irrational antibiotic use. There is a need to review the accessibility of antibiotics in drug outlets

Suicidal Attempts among Secondary School-Going Adolescents in Kilimanjaro Region, Northern Tanzania

Suicide attempts among adolescents are common and can lead to death. The study aimed to determine the prevalence and factors associated with suicide attempts among secondary school-going adolescents in the Kilimanjaro region, northern Tanzania. The study used data from two repeated regional school-based student health surveys (RSHS), conducted in 2019 (Survey 1) and 2022 (Survey 2). Data were analyzed for secondary school students aged 13 to 17 years from four districts of the Kilimanjaro region. The study included 4188 secondary school-going adolescents: 3182 in Survey 1 and 1006 in Survey 2. The mean age in Survey 1 was 14 years and the median age in Survey 2 was 17 years ( p < 0.001). The overall prevalence of suicide attempts was 3.3% (3.0% in Survey 1 and 4.2% in Survey 2). Female adolescents had higher odds of suicide attempts (aOR = 3.0, 95% CI 1.2-5.5), as did those who felt lonely (aOR = 2.0, 95% CI 1.0-3.6), had ever been worried (aOR = 1.9, 95% CI 1.0-3.5), or had ever been bullied (aOR = 2.2, 95% CI 1.2-4.1). Suicidal attempts are prevalent among secondary school-going adolescents in the Kilimanjaro region, northern Tanzania. In-school programs should be established to prevent such attempts