Effects of schistosomes on host anti-viral immune response and the acquisition, virulence, and prevention of viral infections: A systematic review.

Although a growing number of studies suggest interactions between Schistosoma parasites and viral infections, the effects of schistosome infections on the host response to viruses have not been evaluated comprehensively. In this systematic review, we investigated how schistosomes impact incidence, virulence, and prevention of viral infections in humans and animals. We also evaluated immune effects of schistosomes in those coinfected with viruses. We screened 4,730 studies and included 103. Schistosomes may increase susceptibility to some viruses, including HIV and Kaposi's sarcoma-associated herpesvirus, and virulence of hepatitis B and C viruses. In contrast, schistosome infection may be protective in chronic HIV, Human T-cell Lymphotropic Virus-Type 1, and respiratory viruses, though further research is needed. Schistosome infections were consistently reported to impair immune responses to hepatitis B and possibly measles vaccines. Understanding the interplay between schistosomes and viruses has ramifications for anti-viral vaccination strategies and global control of viral infections.

Stigma of infidelity associated with condom use explains low rates of condom uptake: qualitative data from Uganda and Tanzania.

Despite widespread messaging supporting male (external) condom use to prevent HIV in endemic settings, utilization of condoms is low across sub-Saharan Africa. A thorough understanding of barriers to condom use as a form of HIV prevention is necessary to reduce HIV transmission. Here, we present qualitative data from rural eastern Africa to explain low utilization of condoms among heterosexual adults. Focus groups and interviews were conducted in Tanzania and Uganda between 2016 and 2019. A content analysis approach was used to identify attitudes about condoms and factors related to use/non-use. We found that strategies such as abstinence and being faithful to one's partner are perceived as ideal but rarely achievable methods of HIV prevention. Condoms are used in the setting of "failure" to abstain or be faithful and are therefore stigmatized as markers of infidelity. As such, use within cohabiting and long-term relationships is low. Our data suggest that negative perceptions of condoms may stem from persistent effects of the formerly applied "ABC" HIV prevention approach, a public health messaging strategy that described A-abstinence, B-be faithful, and C-use a condom as tiered prevention tools. Condom uptake could increase if HIV prevention messaging acknowledges existing stigma and reframes condom use for proactive health prevention. These studies were approved by Weill Cornell Medicine (Protocols 1803019105 and 1604017171), Mbarara University of Science and Technology (Protocol 16/0117), Uganda National Council of Science and Technology (Protocol SS-4338), and the Tanzania National Institute for Medical Research (Protocol NIMR/HQ/R.8c/Vol.I/1330).

Condoms are used to prevent HIV infection. Even though public health organizations have encouraged people to use condoms, many people in sub-Saharan Africa do not, especially in sexual encounters with someone that they are living with or married to. In this study, we wanted to understand the reasons that people were not using condoms. Between 2016 and 2019, we spoke with individuals in Uganda in one-on-one interviews about HIV prevention and testing and with focus groups in Tanzania about family planning. We analyzed transcripts of these conversations to find common themes about people's impressions of condom use. We learned that many of our participants believed that abstaining from sex and being faithful were the best ways to prevent HIV infection, but that they were not realistic strategies in the long term. Condoms were thought of as a useful tool for prevention when you "fail" at abstinence and monogamy. They were linked with being unfaithful, so people did not feel comfortable suggesting their use in committed relationships. These findings show that the "ABC" strategy for HIV prevention education may be continuing to make people think negatively about condom use. This strategy presented a tiered approach to HIV prevention, telling people it was best to (A) abstain, (B) be faithful to one's partners, and (C) use a condom. In order to increase engagement with HIV prevention, public health messages need to acknowledge the negative associations between condoms and infidelity.

The burden of HIV, syphilis and schistosome infection and associated factors among adults in the fishing communities in northwestern Tanzania.

OBJECTIVES: To quantify the burden of HIV, syphilis and schistosome infection and associated risk factors among adults living in seven fishing communities of Lake Victoria in northwest Tanzania. METHODS: Cross-sectional study conducted between 2015 and 2016 in the selected communities. In each community, we randomly selected a sample of adults from the general population and from three putative risk groups including the following: (i) fishermen, (ii) fish processors and traders, and (iii) women working in the recreational facilities. Participants were interviewed to obtain information about potential risk factors, and venous blood was collected for detection of HIV, syphilis and schistosome infections. We used logistic regression models to quantify the associations between potential risk factors and HIV, and also between schistosome infection and HIV. RESULTS: We enrolled 1128 people from selected fishing communities. The overall prevalence of HIV, syphilis and schistosome infection was 14.2%, 15.6% and 83.1%, respectively. Female recreational facility workers had the highest prevalence of HIV (30.4%) and syphilis (24%). The odds of being HIV infected were generally higher in all age categories. Transactional sex was commonly reported and especially receiving gifts for sex was found to be strongly associated with HIV (adjusted OR = 2.50; 95% CI: 1.44-4.34, P = 0.008). Confirmed serological syphilis was associated with increased odds of having HIV infection. HIV was not associated with schistosome infection in a combined dataset and when we examined this separately for men and women alone. CONCLUSIONS: We observed a high burden of HIV, syphilis and schistosome infections in the fishing communities. Targeted efforts to treat and control infections have the potential to improve health among their residents.

OBJECTIFS: Quantifier la charge du VIH, de la syphilis et de l'infection à schistosomes et les facteurs de risque associés chez les adultes vivant dans sept communautés de pêcheurs du lac Victoria dans le nord-ouest de la Tanzanie. MÉTHODES: Etude transversale menée entre 2015-2016 dans les communautés sélectionnées. Dans chaque communauté, nous avons sélectionné aléatoirement un échantillon d'adultes de la population générale et de trois groupes à risque présumés, notamment: 1) les pêcheurs, 2) les transformateurs et commerçants de poisson et 3) les femmes travaillant dans les établissements de loisirs. Les participants ont été interrogés pour obtenir des informations sur les facteurs de risque potentiels, et du sang veineux a été collecté pour la détection du VIH, de la syphilis et des infections à schistosome. Nous avons utilisé des modèles de régression logistique pour quantifier les associations entre les facteurs de risque potentiels et le VIH, ainsi qu'entre l'infection à schistosome et le VIH. RÉSULTATS: Nous avons recruté 1.128 personnes dans une sélection de communautés de pêcheurs. La prévalence globale de l'infection par le VIH, la syphilis et les schistosomes était de 14,2%, 15,6% et 83,1% respectivement. Les travailleuses des établissements de loisirs avaient la prévalence la plus élevée du VIH (30,4%) et de la syphilis (24%). Les chances d'être infecté par le VIH étaient généralement plus élevées dans toutes les catégories d'âge. Les rapports sexuels transactionnels étaient fréquemment rapportés et surtout le fait de recevoir des cadeaux pour le sexe était fortement associé au VIH (OR ajusté = 2,50; IC95%: 1,44-4,34 ; P = 0,008). La syphilis sérologique confirmée était associée à une probabilité accrue d'être infecté par le VIH. Le VIH n'était pas associé à une infection à schistosome dans un ensemble de données combinées et lorsque nous avons examiné cela séparément pour les hommes et les femmes. CONCLUSIONS: Nous avons observé une charge élevée d'infections par le VIH, la syphilis et les schistosomes dans les communautés de pêcheurs. Des efforts ciblés pour traiter et contrôler les infections ont le potentiel d'améliorer la santé des résidents.

Cascade of care for HIV-seroconverters in rural Tanzania: a longitudinal study.

We examined the HIV care cascade in a community-based cohort study in Kisesa, Magu, Tanzania. We analyzed the proportion achieving each stage of the cascade - Seroconversion, Awareness of HIV status, Enrollment in Care and Antiretroviral therapy (ART) initiation - and estimated the median and interquartile range for the time for progression to the next stage. Modified Poisson regression was used to estimate prevalence risk ratios for enrollment in care and initiation of ART. From 2006 to 2017, 175 HIV-seroconverters were identified. 140 (80%) knew their HIV status, of whom 97 (69.3%) were enrolled in HIV care, and 87 (49.7%) had initiated ART. Time from seroconversion to awareness of HIV status was 731.3 [475.5-1345.8] days. Time from awareness to enrollment was 7 [0-64] days, and from enrollment to ART initiation was 19 [3-248] days. There were no demographic differences in enrollment in care or ART initiation. Efforts have been focusing on shortening time from seroconversion to diagnosis, mostly by increasing the number of testing clinics available. We recommend increased systematic testing to reduce time from seroconversion to awareness of status, and by doing so speed up enrollment into care. Interventions that increase enrollment are likely to have the most impact in achieving UNAIDS targets.

Altered Cervical Mucosal Gene Expression and Lower Interleukin 15 Levels in Women With Schistosoma haematobium Infection but Not in Women With Schistosoma mansoni Infection.

BACKGROUND: Schistosomiasis increases the risk of human immunodeficiency virus (HIV) acquisition in women by mechanisms that are incompletely defined. Our objective was to determine how the cervical environment is impacted by Schistosoma haematobium or Schistosoma mansoni infection by quantifying gene expression in the cervical mucosa and cytokine levels in cervicovaginal lavage fluid. METHODS: We recruited women with and those without S. haematobium infection and women with and those without S. mansoni infection from separate villages in rural Tanzania with high prevalences of S. haematobium and S. mansoni, respectively. Infection status was determined by urine and stool microscopy and testing for serum circulating anodic antigen. RNA was extracted from cervical cytobrush samples for transcriptome analysis. Cytokine levels were measured by magnetic bead immunoassay. RESULTS: In the village where S. haematobium was prevalent, 110 genes were differentially expressed in the cervical mucosa of 18 women with versus 39 without S. haematobium infection. Among the 27 cytokines analyzed in cervicovaginal lavage fluid from women in this village, the level of interleukin 15 was lower in the S. haematobium-infected group (62.8 vs 102.9 pg/mL; adjusted P = .0013). Differences were not observed in the S. mansoni-prevalent villages between 11 women with and 29 without S. mansoni infection. CONCLUSIONS: We demonstrate altered cervical mucosal gene expression and lower interleukin 15 levels in women with S. haematobium infection as compared to those with S. mansoni infection, which may influence HIV acquisition and cancer risks. Studies to determine the effects of antischistosome treatment on these mucosal alterations are needed.

Gene Expression Differences in Host Response to Schistosoma haematobium Infection.

Schistosome worms infect over 200 million people worldwide. They live in the host's bloodstream and alter host immunity. Epidemiological data suggest that males and females have different responses to schistosome infection, but the effect of sex on systemic response is undetermined. Our objective was to characterize differences in peripheral blood transcriptional profiles in people with or without active Schistosoma haematobium infection and to determine whether this signature differs between males and females. mRNA was isolated using poly(A) selection and sequenced on an Illumina Hi-Seq4000 platform. Transcripts were aligned to the human hg19 reference genome and counted with the HTSeq package. Genes were compared for differential expression using DESeq2. Ingenuity Pathway Analysis (IPA) was used to identify gene networks altered in the presence of S. haematobium We enrolled 33 participants from villages in rural Tanzania where S. haematobium is endemic. After correction for multiple comparisons, we observed 383 differentially expressed genes between those with or without S. haematobium infection when sex was included as a covariate. Heat-mapping of the genes with >1.5-fold differences in gene expression revealed clustering by S. haematobium infection status. The top networks included development, cell death and survival, cell signaling, and immunologic disease pathways. We observed a distinct whole blood transcriptional profile, as well as differences in men and women, with S. haematobium infection. Additional studies are needed to determine the clinical effects of these divergent responses. Attention to sex-based differences should be included in studies of human schistosome infection.

Schistosomiasis and HIV-1 viral load in HIV-infected outpatients with immunological failure in Tanzania: a case-control study.

BACKGROUND: Schistosoma sp. infection has been shown to interact with HIV-1 by modifying susceptibility to the virus and impacting AIDS outcome, but very little is known about the potential impact of Schistosoma sp. infection on the efficiency of antiretroviral treatment (ART) in HIV-1 infected individuals. One study suggested increased immunological failure in patients infected with schistosomes compared to those uninfected. To our knowledge, no report exists on the virological response to ART in schistosome-infected individuals. In addition, viral load in HIV-1 infected individuals changes over the course of the HIV infection. This study assessed the impact of HIV-1/Schistosoma sp. co-infections on viral load in people with immunological failure on ART, taking into account the duration of HIV-1 infection. METHODS: We enrolled HIV-1 infected Tanzanian adults over 18 years of age who had used first line ART for more than 6 months and were identified to have immunological failure by the WHO criteria (50% drop from peak CD4 count, or CD4 count equal to or below baseline after 6 months of ART, or CD4 count below 100cells/mm3 after 1 year of ART). Patients were also tested for schistosome infection by microscopy for ova in urine and stool and by circulating anodic antigen (CAA) levels in serum. The duration of HIV-1 infection was calculated using baseline CD4+ T-cell (CD4) counts determined at enrollment. Univariable and multivariable analyses were conducted to compare viral loads in schistosome infected and uninfected patients. RESULTS: A total of 188 patients were enrolled. After univariable analysis, female sex, lower peak CD4 counts, lower current CD4 counts, anemia, and shorter time infected with HIV-1 were all significantly associated with higher viral load. Schistosome infection was not associated with viral load even after adjusting for sex, current CD4 counts and duration of HIV-1 infection. CONCLUSIONS: The current study of HIV-infected patients with immunological failure on ART suggests that once ART is introduced, ART is the dominant driver of viral load and schistosome infection may no longer have an impact.

HIV-seroconversion among HIV-1 serodiscordant married couples in Tanzania: a cohort study.

BACKGROUND: Heterosexual transmission is the main driver of the HIV epidemic in Tanzania. Only one estimate of the incidence rate of intra-marital HIV seroconversion in Tanzania has been reported and was derived from data collected between 1991 and 1995. Moreover, little is known about the specific risk factors for intra-marital seroconversion in Tanzania. Improved evidence around factors that increase the risk of HIV transmission to a serodiscordant spouse is needed to develop and improve evidence-based interventions. We sought to investigate the rate of intra-marital HIV seroconversion among HIV sero-discordant couples in Tanzania as well as its associated risk factors. METHODS: We identified all HIV positive individuals in the TAZAMA HIV-serosurvey cohort and followed up their serodiscordant spouse from 2006 to 2016. The rate of seroconversion was analyzed by survival analysis using non-parametric regressions with exponential distribution. RESULTS: We found 105 serodiscordant couples, 14 of which had a seroconverting spouse. The overall HIV-1 incidence rate among spouses of people with HIV-1 infection was 38.0 per 1000 person/years [22.5-64.1]. Notably, the HIV-1 incidence rate among HIV-1 seronegative male spouses was 6.7[0.9-47.5] per 1000 person/years, compared to 59.3 [34.4-102.1] per 1000 person/years among female spouses. Sex of the serodiscordant spouse was the only significant variable, even after adjusting for other variables (Hazard rate = 8.86[1.16-67.70], p = 0.036). CONCLUSIONS: Our study suggests that rates of HIV-1 seroconversion of sero-discordant partners are much higher within marriage than in the general population in Tanzania. The major risk factor for HIV-1 seroconversion is sex of the serodiscordant spouse, with female spouses being at very high risk of acquiring HIV infection. This suggests that future programs that target serodiscordant couples could be a novel and effective means of preventing HIV-1 transmission in Tanzania.

How gender and religion impact uptake of family planning: results from a qualitative study in Northwestern Tanzania.

BACKGROUND: Women in Tanzania report a high unmet need for both information about and access to family planning. Prior studies have demonstrated the complex and variable relationship between religious faith and beliefs about family planning in sub-Saharan Africa. We hypothesized that a major reason for the poor uptake of family planning in Tanzania is that women and their partners are uncertain about whether pregnancy prevention is compatible with their religious beliefs. METHODS: Twenty-four focus group discussions with 206 participants were conducted in Mwanza, Tanzania between 2016 and 2017: six groups were conducted among Christian men, six among Christian women, six among Muslim men, and six among Muslim women. Among Christians, 98% were Protestants. Focus groups were also divided by gender and religion to facilitate discussion about gender-specific and religion-specific factors influencing family planning utilization. Qualitative data were analyzed using a thematic, phenomenological approach. RESULTS: We identify two important themes regarding the intersections of religion and family planning practices. First, we report that dynamics of family planning are experienced differently based on gender, and that male authority conflicts with female embodied knowledge, leading to negotiation or covert contraceptive use. Second, religious acceptability of family planning methods is of central importance, though participants differed in their interpretations of their religion's stance on this question. Most who found family planning incompatible with their faith affirmed their responsibility to give birth to as many children as God would give them. Others found family planning to be acceptable given their moral responsibility to care for and protect their children by limiting the family size. CONCLUSIONS: Both religious tradition and gender dynamics strongly influence the uptake of family planning, with a wide range of interpretations of religious traditions affecting the perceived acceptability of family planning. Regardless of gender or religious affiliation, participants were unified by a desire to live according to religious tradition. Future efforts to improve uptake of family planning are likely to have maximal impact if they are tailored to inform, involve, and empower male heads of households, and to address questions of religious acceptability.

Educating religious leaders to promote uptake of male circumcision in Tanzania: a cluster randomised trial.

BACKGROUND: Male circumcision is being widely deployed as an HIV prevention strategy in countries with high HIV incidence, but its uptake in sub-Saharan Africa has been below targets. We did a study to establish whether educating religious leaders about male circumcision would increase uptake in their village. METHODS: In this cluster randomised trial in northwest Tanzania, eligible villages were paired by proximity (<60 km) and the time that a free male circumcision outreach campaign from the Tanzanian Ministry of Health became available in their village. All villages received the standard male circumcision outreach activities provided by the Ministry of Health. Within the village pairs, villages were randomly assigned by coin toss to receive either additional education for Christian church leaders on scientific, religious, and cultural aspects of male circumcision (intervention group), or standard outreach only (control group). Church leaders or their congregations were not masked to random assignment. The educational intervention consisted of a 1-day seminar co-taught by a Tanzanian pastor and a Tanzanian clinician who worked with the Ministry of Health, and meetings with the study team every 2 weeks thereafter, for the duration of the circumcision campaign. The primary outcome was the proportion of male individuals in a village who were circumcised during the campaign, using an intention-to-treat analysis that included all men in the village. This trial is registered with ClinicalTrials.gov, number NCT 02167776. FINDINGS: Between June 15, 2014, and Dec 10, 2015, we provided education for church leaders in eight intervention villages and compared the outcomes with those in eight control villages. In the intervention villages, 52·8% (30 889 of 58 536) of men were circumcised compared with 29·5% (25 484 of 86 492) of men in the eight control villages (odds ratio 3·2 [95% CI, 1·4-7·3]; p=0·006). INTERPRETATION: Education of religious leaders had a substantial effect on uptake of male circumcision, and should be considered as part of male circumcision programmes in other sub-Saharan African countries. This study was conducted in one region in Tanzania; however, we believe that our intervention is generalisable. We equipped church leaders with knowledge and tools, and ultimately each leader established the most culturally-appropriate way to promote male circumcision. Therefore, we think that the process of working through religious leaders can serve as an innovative model to promote healthy behaviour, leading to HIV prevention and other clinically relevant outcomes, in a variety of settings. FUNDING: Bill & Melinda Gates Foundation, National Institutes of Health, and the Mulago Foundation.

Schistosomiasis and hydration status: Schistosoma haematobium, but not Schistosoma mansoni increases urine specific gravity among rural Tanzanian women.

OBJECTIVES: Schistosome infections can damage organs important for water homeostasis, especially the kidneys. Urogenital schistosomiasis (caused by Schistosoma haematobium) increases protein and blood in urine and intestinal schistosomiasis (caused by S. mansoni) affects total body water. However, no data exist on how different schistosome species affect urine specific gravity (USG), a hydration biomarker. Therefore, we assessed the relationship between S. haematobium- and S. mansoni-infected and uninfected women and USG in rural Tanzania. MATERIALS AND METHODS: Surveys were conducted and stool and urine samples were collected among 211 nonpregnant women aged 18-50. S. haematobium eggs were detected using the urine filtration method. S. mansoni eggs were detected using the Kato Katz method. USG was measured using a refractometer and analyzed as both a continuous and dichotomous variable. Regression (linear/logistic) models were estimated to test the relationship between infection and hydration status. RESULTS: The prevalence of S. haematobium was 5.9% and S. mansoni was 5.4% with no coinfections. In regression models, S. haematobium-infected women had significantly higher USG (Beta = 0.007 g mL-1 ; standard error = 0.002; p = 0.001) and odds (Odds ratio: 7.76, 95% CI: 1.21-49.5) of elevated USG (>1.020 g mL-1 ) than uninfected women, whereas S. mansoni-infected women did not. DISCUSSION: Schistosoma haematobium, but not S. mansoni, infection is associated with higher USG and risk of inadequate hydration. Future work should determine whether findings are attributable to parasite-induced debris in urine or urinary tract pathologies and signs of renal damage. Human and non-human primate studies using USG in schistosome-endemic areas should account for schistosomiasis.

Tetanus in adult males, Bugando Medical Centre, United Republic of Tanzania.

PROBLEM: In the United Republic of Tanzania, the incidence of non-neonatal circumcision-related tetanus is probably underreported. APPROACH: We analysed charts and extracted information on outcome and wound location for non-neonatal cases of tetanus admitted to the intensive care unit of Bugando Medical Centre between 2001 and 2016. LOCAL SETTING: Bugando Medical Centre, which is one of four teaching referral hospitals in the United Republic of Tanzania, has a 13-bed intensive care unit that manages all admitted patients with tetanus. Within the United Republic of Tanzania, formal programmes of tetanus immunization are targeted at infants or women. RELEVANT CHANGES: From our inpatient logs, we identified six patients with non-neonatal tetanus among male patients with a recent history of circumcision. Only one of these patients had been circumcised within a subnational programme of voluntary medical male circumcision. The other five had been circumcised outside of the programme - e.g. at small rural dispensaries or by a traditional provider with no formal medical training. The six patients were aged 11-55 years and five (83%) of them died in hospital - all of overwhelming sepsis. LESSONS LEARNT: Within the Tanzanian programme of voluntary medical male circumcision, education on wound hygiene probably helps to reduce the incidence of non-neonatal circumcision-related tetanus. The corresponding incidence among the boys and men who are circumcised beyond this subnational programme is probably higher. The training of all circumcision providers in wound care and a vaccination programme to ensure that male Tanzanians receive tetanus immunization post-infancy are recommended.

High prevalence of sexually transmitted infections in pregnant adolescent girls in Tanzania: a multi-community cross-sectional study.

BACKGROUND: Limited data document sexually transmitted infections (STIs) among pregnant adolescents in sub-Saharan Africa, where prenatal screening typically includes only HIV and syphilis. Given that HIV incidence in this population is among the world's highest, we sought to assess the prevalence and factors associated with STIs in a population of rural pregnant adolescents in Tanzania. METHODS: We enrolled 403 pregnant adolescent girls from 10 antenatal clinics near Mwanza, Tanzania. Girls answered structured interviews about sexual health and risk factors and were tested for six common STIs. RESULTS: 199 girls (49.4%) had at least one STI. Herpes Simplex Virus- Type 2 was most prevalent (139 girls, 34.5%), followed by trichomoniasis (54 girls, 13.4%), chlamydia (46 girls, 11.4%), gonorrhoea (27 girls, 6.7%), syphilis (21 girls, 5.2%) and HIV (30 girls, 4.7%). Of note, 53/199 (26.6%) of girls with laboratory-proven STIs were asymptomatic. On multivariable analysis, the presence of any STI was associated with being in a long-term (as opposed to short-term) relationship (OR=2.6 (1.4 to 4.9) p=0.004), younger age at first sexual debut (OR=0.9 per year (0.8 to 0.99), p=0.034), increasing age difference between the girl and her partner (OR=1.1 (1.0 to 1.1) per year, p=0.03) and history of prior pregnancy (OR=1.6 (1.0 to 2.6), p=0.04). CONCLUSIONS: STIs affected half of rural pregnant adolescents in Tanzania. Our work demonstrates the urgent need to incorporate routine STI testing into antenatal care in Tanzania to prevent morbidity and mortality in young girls and their babies. We also identify behavioural and demographic risk factors that can be used to target interventions to those at highest risk.

Barriers to access reproductive health care for pregnant adolescent girls: a qualitative study in Tanzania.

AIMS: In Tanzania, approximately 25% of adolescents give birth and 50% more become sexually active during adolescence. We hypothesised that reproductive health education and services for adolescent girls are inaccessible and conducted this study to gain insights into their perceptions of sexually transmitted infections (STIs) and barriers to reproductive health service utilisation in rural Mwanza, Tanzania. METHODS: We conducted nine focus groups among pregnant adolescents aged 15-20 years. Data were transcribed, translated and coded for relevant themes using NVivo10 software for qualitative data analysis. RESULTS: Most participants were aware of the dangers of STIs to themselves and their unborn babies, but did not perceive themselves as at risk of acquiring STIs. They viewed condoms as ineffective for preventing STIs and pregnancies and unnecessary for those in committed relationships. Stigma, long waiting times, and lack of privacy in the clinics discouraged adolescent girls from seeking reproductive health care. CONCLUSION: Reproductive health care for adolescent girls who are not pregnant is practically nonexistent in Tanzania. Healthcare access for pregnant young women is also limited. Targeted changes to increase clinic accessibility and to provide reproductive health education to all rather than only pregnant women have the potential to address these gaps.

Hypertension, kidney disease, HIV and antiretroviral therapy among Tanzanian adults: a cross-sectional study.

BACKGROUND: The epidemics of HIV and hypertension are converging in sub-Saharan Africa. Due to antiretroviral therapy (ART), more HIV-infected adults are living longer and gaining weight, putting them at greater risk for hypertension and kidney disease. The relationship between hypertension, kidney disease and long-term ART among African adults, though, remains poorly defined. Therefore, we determined the prevalences of hypertension and kidney disease in HIV-infected adults (ART-naive and on ART >2 years) compared to HIV-negative adults. We hypothesized that there would be a higher hypertension prevalence among HIV-infected adults on ART, even after adjusting for age and adiposity. METHODS: In this cross-sectional study conducted between October 2012 and April 2013, consecutive adults (>18 years old) attending an HIV clinic in Tanzania were enrolled in three groups: 1) HIV-negative controls, 2) HIV-infected, ART-naive, and 3) HIV-infected on ART for >2 years. The main study outcomes were hypertension and kidney disease (both defined by international guidelines). We compared hypertension prevalence between each HIV group versus the control group by Fisher's exact test. Logistic regression was used to determine if differences in hypertension prevalence were fully explained by confounding. RESULTS: Among HIV-negative adults, 25/153 (16.3%) had hypertension (similar to recent community survey data). HIV-infected adults on ART had a higher prevalence of hypertension (43/150 (28.7%), P = 0.01) and a higher odds of hypertension even after adjustment (odds ratio (OR) = 2.19 (1.18 to 4.05), P = 0.01 in the best model). HIV-infected, ART-naive adults had a lower prevalence of hypertension (8/151 (5.3%), P = 0.003) and a lower odds of hypertension after adjustment (OR= 0.35 (0.15 to 0.84), P = 0.02 in the best model). Awareness of hypertension was ≤ 25% among hypertensive adults in all three groups. Kidney disease was common in all three groups (25.6% to 41.3%) and strongly associated with hypertension (P <0.001 for trend); among hypertensive participants, 50/76 (65.8%) had microalbuminuria and 20/76 (26.3%) had an estimated glomerular filtration rate (eGFR) <60 versus 33/184 (17.9%) and 16/184 (8.7%) participants with normal blood pressure. CONCLUSIONS: HIV-infected adults on ART >2 years had two-fold greater odds of hypertension than HIV-negative controls. HIV-infected adults with hypertension were rarely aware of their diagnosis but often have evidence of kidney disease. Intensive hypertension screening and education are needed in HIV-clinics in sub-Saharan Africa. Further studies should determine if chronic, dysregulated inflammation may accelerate hypertension in this population.

Oesophageal varices, schistosomiasis, and mortality among patients admitted with haematemesis in Mwanza, Tanzania: a prospective cohort study.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common cause of hospital admissions worldwide. Aetiologies vary by sociodemographics and geography. Retrospective studies of endoscopies in much of Africa have documented oesophageal varices as a leading cause of UGIB. Prospective studies describing outcomes and associations with clinical factors are lacking. METHODS: We conducted a prospective cohort study at a referral hospital in Mwanza, Tanzania where schistosomiasis is endemic. Adults admitted with haematemesis underwent laboratory workup, schistosomiasis antigen testing and elective endoscopy, and were followed for two months for death or re-bleeding. We assessed predictors of endoscopic findings using logistic regression models, and determined prediction rules that maximised sensitivity and positive predictive value (PPV). RESULTS: Of 124 enrolled patients, 13 died within two months (10%); active schistosomiasis prevalence was 48%. 64/91(70%) patients had oesophageal varices. We found strong associations between varices and numerous demographic or clinical findings, permitting construction of simple, high-fidelity prediction rules for oesophageal varices applicable even in rural settings. Portal vein diameter ≥ 13 mm or water sourced from the lake yielded sensitivity, specificity, PPV and NPV >90% for oesophageal varices; presence of splenomegaly or water sourced from the lake maintained sensitivity and PPV >90%. CONCLUSIONS: Our results guide identification of patients, via ultrasound and clinical examination, likely to have varices for whom referral for endoscopy may be life-saving. Furthermore, they support empiric anti-schistosome treatment for patients with UGIB in schistosome-endemic regions. These interventions have potential to reduce UGIB-related morbidity and mortality in Africa.

Inpatient mortality of HIV-infected adults in sub-Saharan Africa and possible interventions: a mixed methods review.

BACKGROUND: Despite the increased availability of anti-retroviral therapy, in-hospital HIV mortality remains high in sub-Saharan Africa. Reports from Senegal, Malawi, and Tanzania show rates of in-hospital, HIV-related mortality ranging from 24.2% to 44%. This mixed methods review explored the potential causes of preventable in-hospital mortality associated with HIV infections in sub-Saharan Africa in the anti-retroviral era. RESULTS: Based on our experience as healthcare providers in Africa and a review of the literature we identified 5 health systems failures which may cause preventable in-hospital mortality, including: 1) late presentation of HIV cases, 2) low rates of in-hospital HIV testing, 3) poor laboratory capacity which limits CD4 T-cell testing and the diagnosis of opportunistic infections, 4) delay in initiation of anti-retroviral therapy in-hospital, and 5) problems associated with loss to follow-up upon discharge from hospital. CONCLUSION: Our findings, together with the current available literature, should be used to develop practical interventions that can be implemented to reduce in-hospital mortality.

Female genital schistosomiasis is a neglected public health problem in Tanzania: Evidence from a scoping review.

Schistosoma haematobium, the parasite that causes urogenital schistosomiasis, is widely prevalent in Tanzania. In addition to well-known effects on the urinary tract, S. haematobium also causes clinically- evident damage to the reproductive tract in approximately half of infected women, which is known as female genital schistosomiasis (FGS). FGS has major gynecologic and social consequences on women's reproductive health, yet little information is available regarding FGS in Tanzania. To cover that gap, we conducted the present scoping review to examine the epidemiology of FGS in Tanzania (both in the mainland and Zanzibar island) and to make recommendations for future work in this area. The available evidence from community-based and hospital-based retrospective studies indicates that FGS is a significant health problem in the country. Very few community-based studies have been reported from mainland Tanzania, and Zanzibar. Our review highlights the scarcity of efforts to address FGS in Tanzania and the need for additional community-based studies. The studies will help us understand the true burden of the disease nationwide, to assess the impact of praziquantel on FGS lesions, and to address social and mental health in relation to FGS. This review emphasizes integration of delivery of FGS related services in primary health care systems through the reproductive health clinics which covers sexually transmitted infections, HIV and cervical cancer screening. These actions are essential if this neglected gynecological disease is to be addressed in Tanzania.

"If I chose to listen to people, I possibly wouldn't be using family planning": Impact of external influences on women's contraceptive autonomy in rural Northwest Tanzania.

BACKGROUND: There is an increasing emphasis on promoting women's autonomy in reproductive decision-making, particularly given global efforts to increase contraceptive access and uptake. Scales to quantify autonomy have inconsistently included the effect of external influences and focused primarily on influences of partners. OBJECTIVES: This study aimed to gain greater depth in understanding how influences including and beyond a woman's partner affect her contraceptive decision-making, as well as how external influences can overlap and further complicate contraceptive decision-making. DESIGN: A phenomenological, qualitative study in which in-depth interviews were conducted in three phases from May 2021 to February 2022 with women living in northwest Tanzania who had varying histories of contraceptive use or non-use. METHODS: One-on-one, in-depth interviews were conducted in Swahili, the national language of Tanzania, by trained female interviewers. Interviews were digitally recorded, transcribed, translated into English, and independently coded by three investigators. Analysis was conducted using NVivo. The codes developed from the transcripts were grouped into overarching themes with supporting illustrative quotes. RESULTS: A total of 72 women were interviewed. Partners were the most influential in women's family planning decision-making, followed by friends, relatives, community religious leaders, and healthcare providers. Out of the 52 women with a partner who had ever used family planning, 76.9% had discussed their desire to use family planning with their partner and nearly all reported strong pressures to use or not to use family planning from partners, family, and friends. Rarely, participants stated that they were devoid of any influence. CONCLUSION: In rural Tanzania, women's decision-making about family planning was highly impacted by external influences, including not only partners but also family, friends, and community. Indicators of women's reproductive autonomy and measurements of interventions to promote contraceptive use should incorporate measures of these external influences.