Age-Related Differences in Socio-demographic and Behavioral Determinants of HIV Testing and Counseling in HPTN 043/NIMH Project Accept.

Youth represent a large proportion of new HIV infections worldwide, yet their utilization of HIV testing and counseling (HTC) remains low. Using the post-intervention, cross-sectional, population-based household survey done in 2011 as part of HPTN 043/NIMH Project Accept, a cluster-randomized trial of community mobilization and mobile HTC in South Africa (Soweto and KwaZulu Natal), Zimbabwe, Tanzania and Thailand, we evaluated age-related differences among socio-demographic and behavioral determinants of HTC in study participants by study arm, site, and gender. A multivariate logistic regression model was developed using complete individual data from 13,755 participants with recent HIV testing (prior 12 months) as the outcome. Youth (18-24 years) was not predictive of recent HTC, except for high-risk youth with multiple concurrent partners, who were less likely (aOR 0.75; 95% CI 0.61-0.92) to have recently been tested than youth reporting a single partner. Importantly, the intervention was successful in reaching men with site specific success ranging from aOR 1.27 (95% CI 1.05-1.53) in South Africa to aOR 2.30 in Thailand (95% CI 1.85-2.84). Finally, across a diverse range of settings, higher education (aOR 1.67; 95% CI 1.42, 1.96), higher socio-economic status (aOR 1.21; 95% CI 1.08-1.36), and marriage (aOR 1.55; 95% CI 1.37-1.75) were all predictive of recent HTC, which did not significantly vary across study arm, site, gender or age category (18-24 vs. 25-32 years).

Intimate partner violence during pregnancy and associated mental health symptoms among pregnant women in Tanzania: a cross-sectional study.

OBJECTIVE: Violence against pregnant women is a prevalent issue with severe health implications, especially during pregnancy. This study seeks to determine the prevalence of intimate partner violence against women during pregnancy and its associated mental health symptoms. DESIGN: Cross-sectional survey conducted from December 2011 to April 2012. SETTING: Muhimbili National Hospital antenatal clinic in Dar es Salaam, Tanzania. SAMPLE: 1180 pregnant antenatal care patients. METHODS: Trained interviewers conducted face-to-face standardised interviews with the women in a private room prior to their antenatal care appointment. (PTSD), anxiety and depressive symptoms were assessed through the Conflict Tactics Scale, the John Hopkins Symptom Checklist (25) and the Posttraumatic Diagnostic Scale. MAIN OUTCOME MEASURES: The Conflict Tactics Scale, the John Hopkins Symptom Checklist (25) and the Posttraumatic Diagnostic Scale. RESULTS: Of the 1180 women who were interviewed, 27% reported experiencing both physical and sexual intimate partner violence in the index pregnancy, with 18% reporting physical violence and 20% reporting sexual violence. After adjusting for the sociodemographic characteristics of women, women who experienced physical and/or sexual intimate partner violence during pregnancy were significantly more likely to have moderate PTSD (AOR 2.94, 95% CI 1.71-5.06), anxiety (AOR 3.98, 95% CI 2.85-5.57) and depressive (AOR 3.31, 95% CI 2.39-4.593) symptoms than women who did not report physical and/or sexual intimate partner violence during pregnancy. CONCLUSIONS: About three out of ten women experienced physical or sexual intimate partner violence during pregnancy by an intimate partner, which was significantly associated with poor mental health symptoms. These rates are alarming, and justify training and education of antenatal care providers to raise awareness.

Iatrogenic ureteric and bladder injuries in obstetric and gynaecologic surgeries.

OBJECTIVE: To review iatrogenic ureteric and urinary bladder injuries from obstetric and gynaecological surgeries treated in the urology department analysing; ureteric anatomy, aetiologic factors, diagnosis, treatment and outcomes. DESIGN: A retrospective study. SETTING: Institute of Urology, Kilimanjaro Christian Medical Center (KCMC), Moshi, Tanzania. SUBJECTS: Twenty three women were treated for iatrogenic ureteric and bladder injuries secondary to obstetric and gynaecological procedures in the department of urology between June 1994 and July 2004. RESULTS: Hysterectomy was the leading cause of ureteric injuries contributing to nine (47.4%) of the 19 ureteric injuries. Caesarian sections were the second leading cause and contributed 6(31.6%) of 19 ureteric injuries. Vesical vaginal fistula (VVF) repairs lead to two (10.5%) ureteric injuries one of which was bilateral. There was a case each (5.3%) from ovarian cystectomy and forceps delivery. There were only three cases of intra-operative diagnosis of ureteric injuries. There were four bladder injuries half of which came from hysterectomy. The leading definitive urological treatment for ureteric injury was ureteric re implantation and all kidneys were saved. CONCLUSION: Iatrogenic ureteric and bladder injuries from gynaecologic surgeries are globally rare but are liable to occur due to the inherent ureteric anatomic factors in the pelvis. Intra-operative diagnosis of injury is a rare feature. The practical principles to prevent and repair ureteric injuries have been presented and discussed. The true risk to the patient lies in delayed, missed diagnosis and inadequate treatment. Endourologic techniques offer an alternative diagnostic and treatment method for women previously injured in open pelvic surgeries.

Predictors of HIV-1 serostatus disclosure: a prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania.

OBJECTIVES: To examine the socio-demographic and behavioral factors predictive of women's disclosure of an HIV-positive test result in Dar es Salaam, Tanzania. DESIGN: From April 1995 to May 2000, 1078 HIV-positive pregnant women participated in an ongoing randomized trial on micronutrients and HIV-1 vertical transmission and progression. Disclosure to a partner or to a female relative was assessed 2 months after post-test counseling and at 6 monthly follow-up visits. Socio-demographic, health, behavioral and psychological factors were measured at baseline and during follow-up. METHODS: Predictors of time to disclosure of HIV serostatus were determined using Cox proportional hazards regression models. RESULTS: Prevalence of disclosure to a partner ranged from 22% within 2 months to 40% after nearly 4 years. Women were less likely to disclose to their partners if they were cohabiting, had low wage employment, had previously disclosed to a female relative, or reported ever-use of a modern contraceptive method. Women reporting fewer than six lifetime sexual partners or knowing someone with HIV/AIDS were more likely to disclose to their partners. Disclosure to a female relative was predicted by knowing more than two individuals with HIV/AIDS, full economic dependency on their partner, high levels of social support, and prior attendance at a support group meeting. CONCLUSIONS: A substantial proportion of HIV-infected pregnant women never disclosed their result to a partner or a close female relative. Lack of disclosure may have limited their ability to engage in preventive behaviors or to obtain the necessary emotional support for coping with their serostatus or illness.

Urinary diversion in children with mainly exstrophy and epispadias: alternative to primary bladder closure.

OBJECTIVE: To review the long term outcome of children who underwent urinary diversion for various non-malignant conditions and to assess the suitability of urinary diversion as an alternative treatment to primary bladder closure in cases of bladder exstrophy epispadias complex. DESIGN: A retrospective study. SETTING: Institute of Urology, Moshi, Tanzania. SUBJECTS: Fifteen children who underwent urinary diversion for various non-malignant conditions between 1985 and 1997. RESULTS: Fifteen children underwent urinary diversion for: exstrophy epispadias complex (n = 12) neurogenic bladder (n = 2) and trauma (n = 1). Seven children underwent Mainz pouch II diversion, six had classical ureterosigmoidostomy and two had appendicovesicostomy. One patient with a solitary kidney developed ureteral stenosis at the implantation site and was undiverted. Metabolic acidosis was well compensated with none of the patients requiring sodium bicarbonate supplements. All the patients except one were continent. CONCLUSION: We conclude that continent urinary diversion in children offers a viable alternative method for children with bladder exstrophy epispadias complex.

Active case finding for tuberculosis among people who inject drugs on methadone treatment in Dar es Salaam, Tanzania.

SETTING: Active case finding is a World Health Organization (WHO) endorsed strategy for improving tuberculosis (TB) case detection. Despite WHO recommendations for active case finding among people who inject drugs (PWID), few studies have been published. The historical focus of case finding has been in populations that are human immunodeficiency virus-positive, incarcerated or at higher occupational risk. OBJECTIVE: We sought to examine the yield of active case finding among PWID newly started on methadone in Tanzania. DESIGN: Of 222 methadone clients, 156 (70%) met with study administrators; 150 consented to participate, 139 (93%) of whom were male. The median age was 34 years. A symptom-based questionnaire was developed by the investigators and administered to every consenting patient by a native Swahili speaker. RESULTS: Of the 150 patients surveyed, 16 (11%) had one or more TB symptoms and were referred for laboratory testing. Six new TB cases were identified in this active case finding program, with a prevalence of 4%. CONCLUSION: This study presents the first data on TB prevalence in a population of PWID in Tanzania. This prevalence is 23 times that of the general Tanzanian TB prevalence of 0.2%. These results have significant implications for TB control.

Understanding women's experiences of distress during pregnancy in Dar es Salaam, Tanzania.

Several studies show depression is common during pregnancy. However, there is limited information in Tanzania on the magnitude of perceived distress during pregnancy and meanings ascribed to such distress. A descriptive survey collected data using unstructured interviews from 12 traditional practitioners and 10 peri-urban women with previous pregnancy related mental health concerns identified using a depression vignette. The objectives were to describe the sources and characteristics of distress during pregnancy, and idioms of distress that could inform cultural adaptation of depression screening tools. Narrative analysis showed an emergent category of "problematic pregnancies" framed women's recollections of prolonged periods of sadness. This experience was qualified using various idioms of distress that were differentially emphasized depending on informant's perceived causes of health concern. The idiom kusononeka was consistently used to describe extreme sadness across causal categories and clustered with at least two typical features of major depression. This suggested existence of a construct with similarities to biomedical criteria for depression. "Thinking too much" emerged as a distinctive expression associated with prolonged sadness. Distinctive expressions of social functioning impairments were identified that can inform depression severity assessments. In conclusion, contextual inquiry into experiences of psychological distress showed distinct local idioms that clustered in patterns similar to symptoms of biomedical depressive episodes. Further studies to assess the utility of local idioms of distress and distress related functional impairment in depression assessment tools are warranted.

Socio-economic and partner relationship factors associated with antenatal depressive morbidity among pregnant women in Dar es Salaam, Tanzania.

Depression during pregnancy may negatively influence social functioning, birth outcomes and postnatal mental health. A cross-sectional analysis of the baseline survey of a prospective study was undertaken with an objective of determining the prevalence and socio-demographic factors associated with depressive morbidity during pregnancy in a Tanzanian peri-urban setting. Seven hundred and eighty seven second to third trimester pregnant women were recruited at booking for antenatal care at two primary health care clinics. Prenatal structured interviews assessed socio-economic, quality of partner relationships and selected physical health measures. Depressive symptoms were measured at recruitment and three and eight months postpartum using the Kiswahili version of the Hopkins Symptom Checklist. Completed antenatal measures available for 76.2% participants, showed a 39.5% prevalence of depression. Having a previous depressive episode (OR 4.35, P<0.01), low (OR 2.18, P<0.01) or moderate (OR 1.86, P=0.04) satisfaction with ability to access basic needs, conflicts with the current partner (OR 1.89, P<0.01), or booking earlier for antenatal care (OR 1.87, P=0.02) were independent predictors of antenatal depression in the logistic regression model; together explaining 21% of variance in depression scores. Attenuation of strength of multivariate associations suggests confounding between the independent risk factors and socio-demographic and economic measures. In conclusion, clinically significant depressive symptoms are common in mid and late trimester antenatal clinic attendees. Interventions for early recognition of depression should target women with a history of previous depressive episodes or low satisfaction with ability to access basic needs, conflict in partner relationships and relatively earlier booking for antenatal care. Findings support a recommendation that antenatal services consider integrating screening for depression in routine antenatal care.

Smokeless tobacco use among adolescents in Ilala Municipality, Tanzania.

Smokeless tobacco use is a significant part of the overall world tobacco problem. When the habit is introduced early in life, it increases the chance for permanent addiction and primes adolescents for use of harder drugs, exposing them to higher risk of oral cancer and other adverse effects of tobacco. This baseline study aimed at providing descriptive information on smokeless tobacco knowledge and use among adolescents at a time just before the ban on such products was enforced nationally on 1st December 2006. Six out of 101 primary and four out of 11 secondary schools were randomly selected in Ilala Municipality, Tanzania. A total of 1011 students were randomly selected and interviewed; boys (mean age = 14.5 years) accounted for 50.7% and girls (mean age = 13.6 years) 49.3%. The prevalence of tobacco use was 5.9% (boys = 9%; girls = 2.4%). Prevalence of smokeless tobacco use was 3.6%, about half of all who have ever smoked. Most popular brand of smokeless tobacco reported was Kuberi (44.8%) followed by Gutka (6.9%). Twelve (41%) of the smokeless tobacco users were using the products almost everyday. Among the reasons reported for smokeless tobacco use were pleasure (27.6%), smell (17.2%) and taste (6.9%). However, 48.3% of the users did not know why they used the product for the first time. Smokeless tobacco products were branded as nutritional supplements with different tastes and strengths, ideal for enticing the curiosity of adolescents. Given the crafty practice of the tobacco industry and salesmen, there is need for monitoring of availability of these products in circulation and enforcement of the ban nationally and globally to institute measures for effective elimination of this harmful practice.

Skinning the goat and pulling the load: transactional sex among youth in Dar es Salaam, Tanzania.

Transactional sex has been associated with risk of HIV infection in a number of studies throughout sub-Saharan Africa. Urban young women are economically vulnerable and at heightened risk of HIV infection in Tanzania; yet there are few studies that have explored relationship dynamics, including transactional sex, in this setting. This paper sheds light on the broader context of sexual relationships among youth at risk for HIV, how transactional sex plays out in these relationships, and how the transactional nature of relationships affects women's risk for HIV. We conducted 60 in depth interviews and 14 focus group discussions with young men and women, 16-24 years old, in Dar es Salaam, Tanzania. These data guided the development of a community based HIV and violence prevention intervention for young men. Youth described the exchange of sex for money or other material goods in all types of sexual relationships. While the exchange was explicit in casual relationships, young women voiced material and monetary expectations from their committed partners as well. Young men described their pursuit of multiple partners as sexually motivated, while women sought multiple partners for economic reasons. Young men were aware of the expectations of material support from partners, and acknowledged that their ability to provide for a partner affected both the longevity and exclusivity of their relationships. Youth described a deep mistrust of the motivations and commitment of their sexual partners. Furthermore, young women's financial dependence on men impacted their ability to negotiate safe sexual behaviors in both casual and committed relationships. Programs designed to reduce HIV risk among Tanzanian youth need to take into account the transactional component of sexual relationships and how such exchanges differ according to partner type.

Multivitamin supplementation in HIV-positive pregnant women: impact on depression and quality of life in a resource-poor setting.

OBJECTIVES: The primary objective of this study was to examine the effect of vitamin supplementation on health-related quality of life and the risk of elevated depressive symptoms comparable to major depressive disorder (MDD) in HIV-positive pregnant women in Dar es Salaam, Tanzania. METHODS: From April 1995 to July 1997, 1078 HIV-positive pregnant women were enrolled in a randomized controlled trial. We examined the effects of vitamin supplementation on quality of life and the risk of elevated depressive symptoms, assessed longitudinally every 6-12 months. RESULTS: A substantial prevalence of elevated depressive symptoms (42%) was observed in HIV-positive pregnant women. Multivitamin supplementation (B-complex, C and E) demonstrated a protective effect on depression [relative risk (RR)=0.78; P=0.005] and quality of life [RR=0.72 for social functioning (P=0.001) and vitality (P=0.0001); RR=0.70 for role-physical (P=0.002)]; however, vitamin A showed no effect on these outcomes. CONCLUSIONS: Multivitamin supplementation (B-complex, C and E) resulted in a reduction in risk of elevated depressive symptoms comparable to MDD and improvement in quality of life in HIV-positive pregnant women in Tanzania.

Risk behaviors and vulnerability to HIV infection among Tanzanian youth.

PIP: Focusing on increased vulnerability to HIV infection, this article examines some of the contexts within which these risk-taking behaviors occur and illustrates that the risk of contracting the disease is just one of the many risks with which Tanzanian youths are confronted. The sexual and substance use behaviors, and the relationship between such behaviors and economic factors, are discussed. Where evidences exist, attempts are made to compare the prevalence of these behaviors among male and female youths, as well as urban and rural youths. The extent to which males and females engage in risk-taking behaviors is unknown; however, studies show that, depending on age and gender, between 17% and 61% of youths are sexually active. Rates in HIV transmission vary by gender and by whether the youths are rural or urban inhabitants. Factors like adverse socioeconomic conditions, unemployment, lack of parental guidance and supervision, and culture all influence sexual risk-taking behaviors among youths. Meanwhile, increasing use of drugs and alcohol among the young population has been closely linked to increased vulnerability to unprotected sexual intercourse. Again, survival needs play a major role in sustaining risk behaviors. The paper concludes by outlining policy implications of youth risk behaviors, taking into account a multisectoral approach in dealing with the problem.^ieng

Women's barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counselling and testing.

In view of the ever-increasing HIV/AIDS epidemic in sub-Saharan Africa, the expansion of HIV-1 voluntary counselling and testing (VCT) as an integral part of prevention strategies and medical research is both a reality and an urgent need. As the availability of HIV-1 VCT grows two limitations need to be addressed, namely: low rates of HIV-1 serostatus disclosure to sexual partners and negative outcomes of serostatus disclosure. Results from a study among men, women and couples at an HIV-1 VCT clinic in Dar es Salaam, Tanzania are presented. The individual, relational and environmental factors that influence the decision to test for HIV-1 and to share test results with partners are described. The most salient barriers to HIV-1 testing and serostatus disclosure described by women include fear of partners' reaction, decision-making and communication patterns between partners, and partners' attitudes towards HIV-1 testing. Perception of personal risk for HIV-1 is the major factor driving women to overcome barriers to HIV-1 testing. The implications of findings for the promotion of HIV-1 VCT programmes, the implementation of partner notification policies and the development of post-test support services are discussed.

Validity of the Hopkins Symptom Checklist-25 amongst HIV-positive pregnant women in Tanzania.

OBJECTIVE: To validate the Hopkins Symptom Checklist-25 (HSCL-25) for use as a depression screen amongst human immuno-deficiency virus (HIV) positive pregnant women. METHOD: Amongst 903 (mean age 24.8 years) HIV-positive pregnant women, a two-phased design included measures for health-related quality of life, perceived social support, and the HSCL-25 screen for depressive (HSCL-15 subscale) and anxiety symptoms. The Structured Clinical Interview for DSM-IV (SCID) was independently administered on a stratified random subsample. RESULTS: Internal consistency of the HSCL-25 (alpha 0.93) and HSCL-15 (alpha 0.9) was adequate, with expected findings demonstrated in discriminant validity analysis. A depression-anxiety construct explained nearly 40% of the variance. Eight individual HSCL-25 items demonstrated an area under the curve (AUC) greater than 0.6 for DSM-IV major depression and the HSCL-25 and HSCL-revised had an optimal depression cut-off score of 1.06 and 1.03 for the HSCL-15. CONCLUSION: The HSCL-25 demonstrated utility as a screen for depression; its inability to gauge severity of symptoms in this cultural context is discussed.