Epidemiology of alcohol use and alcohol use disorders among people living with HIV on antiretroviral therapy in Northwest Tanzania: implications for ART adherence and case management.

Alcohol use disorders (AUD) among people living with HIV (PLHIV) are associated with poor health outcomes. This cross-sectional study examined current alcohol use and AUD among 300 PLHIV on ART at four HIV care centres in Northwest Tanzania. Participants' data were collected using questionnaires. Alcohol use was assessed using Alcohol Use Disorders Identification Test (AUDIT). Logistic regression was used to examine associations between each outcome (current drinking and AUD) and sociodemographic and clinical factors. Association between alcohol use and ART adherence was also studied. The median age of participants was 43 years (IQR 19-71) and 41.3% were male. Twenty-two (7.3%) participants failed to take ART at least once in the last seven days. The prevalence of current drinking was 29.3% (95% CI 24.2-34.8%) and that of AUD was 11.3% (8.2%-15.5%). Males had higher odds of alcohol use (OR 3.03, 95% CI 1.79-5.14) and AUD (3.89, 1.76-8.60). Alcohol use was associated with ART non-adherence (OR = 2.78, 1.10-7.04). There was a trend towards an association between AUD and non-adherence (OR = 2.91, 0.92-9.21). Alcohol use and AUD were common among PLHIV and showed evidence of associations with ART non-adherence. Screening patients for alcohol use and AUD in HIV clinics may increase ART adherence.

'Young men should work hard': adult men's views of young people in Mwanza, Tanzania.

In 2014, there were 1.8 billion young people aged 10-24 years globally, 16% of whom live in sub-Saharan Africa. Young people are met with significant technological advancement but also constraints in securing stable livelihoods and broader cultural and societal changes. While praised for their ingenuity and resourcefulness, young people also face high expectations and judgment, both in terms of their capacity to contribute to their communities and in maintaining the moral and societal fabric. We conducted a photovoice exercise with 16 adult men aged 22 to 42 in Mwanza, Tanzania. After two days of training, participants were given nine days to take pictures of their family lives, activities outside their home and what is important to them. Thereafter, they were asked to choose, rank and provide captions for 25 photos and interviewed about their choices. The interviews were recorded, summarised, and analysed thematically. Young people, capturing anyone from a teenager to a 25-year-old, emerged as a key theme in all interviews and photographs. Other key themes in relation to young people were livelihood opportunities, with a strong connotation on 'hard work'; education, with an emphasis on the importance of letting young people attend school; gender equality in respect to fair distribution of household chores and women working to supplement family income; recreational activities and challenging environments for young men, capturing bad nutrition, poor road conditions, harmful work and living conditions, as well as decaying morals. Overall, adult participants both admired young men and women for their energy and innovation while also expecting them to prescribe to existing moral and community standards. Understanding the high expectations and concerns of adults and how those shape the environment in which young people transition into adulthood is key to develop programmes for young people by considering their local context.

Women's understanding of economic abuse in North-Western Tanzania.

INTRODUCTION: Economic abuse is a form of intimate partner violence that still lacks a clear conceptualization and therefore is often overlooked next to physical, sexual and psychological abuse. While existing categorizations recognize economic intimate partner violence as economic control, economic exploitation and employment sabotage, current measurements of economic abuse rarely capture all its forms, and the issue has not been widely explored in low- and middle-income country settings. METHODS: We conducted in-depth interviews with 18 women in Mwanza, Tanzania to understand local perceptions and experiences of economic intimate partner violence. We used a thematic analysis approach. RESULTS: Our study illustrates the complexity of economic abuse as a unique form of intimate partner violence, with women experiencing economic exploitation, employment sabotage, economic control and male economic irresponsibility. Gender norms and expectations actively played a key role in furthering abusive economic behaviour as women attempted to generate their own income and participate in financial decisions. Women's constructs and reactions to economic abuse diverged sharply from the traditional marital expectations of dutifully accepting male control and the men being the main breadwinners in the family. Despite it being widespread, women did not find economic abuse acceptable. CONCLUSION: The results highlight that economic abuse is a complex issue and that more research on the pathways and manifestations of economic abuse globally would be beneficial. Existing measurement tools should be widened to address all dimensions of economic abuse. Addressing economic abuse will require multi-strategy interventions, working at the individual and community-level to address gender roles and masculinity norms, working with both men and women.

Couples data from north-western Tanzania: Insights from a survey of male partners of women enrolled in the MAISHA cluster randomized trial of an intimate partner violence prevention intervention.

INTRODUCTION: Globally, around 30% of ever-partnered women have experienced physical and/or sexual intimate partner violence (IPV) during their lifetime. To date, most research into causes and prevention of IPV involves surveys of women, with little research into risk-factors for male perpetration. This paper describes a survey of male partners of women participating in the MAISHA cluster randomised trial (CRT) of an IPV prevention intervention, in Mwanza City, Tanzania. Using linked couples' data, we explore man-, woman-, and relationship-/household-level factors associated with physical and sexual IPV. METHODS: Women were interviewed at baseline and 29-months follow-up. At follow-up, women were asked for consent to invite their partner to participate in the male survey. We describe response rates for the women's follow-up and male partners' surveys, and identify factors associated with women's consent to approach partners. Multivariate logistic regression was used to explore factors associated with women's past-year experiences of physical and sexual IPV. RESULTS: 512 (65%) partnered women consented for the partner to be approached, higher among intervention than control women. 425 (83%) male partners were interviewed. Women consenting were disproportionately likely to be in longer-term relationships. Past-year IPV was associated with lower consent among control women, but greater consent in the intervention arm. Factors associated with increased odds of physical IPV were women's childhood experiences of abuse, young age, women's lower income and women's attitudes justifying IPV. Sexual IPV was associated with women's childhood experiences of abuse, young age, educational disparity within couple, men's alcohol use and women's poor mental health. CONCLUSIONS: We successfully conducted a survey of male partners with the full consent of women trial participants. The breadth of factors associated with IPV demonstrates the need for IPV prevention interventions to work with women and men, and specifically couples. Interventions should address risk-factors for both physical and sexual IPV.

Factors associated with modern contraceptives use among postpartum women in Bukombe district, Geita region, Tanzania.

INTRODUCTION: Modern contraceptive use during the first year postpartum potentially prevents unplanned pregnancies and help to improve maternal and child health. Therefore, identifying factors associated with contraceptive utilization among women of reproductive age during extended postpartum period is essential. OBJECTIVE: This study aimed to assess factors associated with modern contraceptives use among postpartum women in Bukombe District, Geita region. METHOD: A community-based cross-sectional study was conducted among women who were in their first year after child birth in Bukombe district. A total of 511 women were included using multistage sampling techniques. Data were collected using a structured questionnaire. Data analysis was performed using Stata 15 (College Station, Texas, USA). RESULTS: The prevalence of postpartum modern contraceptive was 11.9%. The most frequently used method was implant (6.5%). Most women started to use the contraceptive during the first three months after delivery. Living in urban (AOR = 1.85, 95% CI: 1.20-3.79), having business (AOR = 2.35, 95% CI: 1.31-2.28), last born aged 3-4 months (AOR = 3.31, 95% CI: 1.11-9.85) and menses resumption (AOR = 9.24, 95% CI: 3.60-23.72) were predictors for postpartum contraceptive use. However, fear of side effects, poor knowledge about contraceptives, husband restrictions, distance to health facility and contraceptive availability were reported as barriers for postpartum modern contraceptive use. CONCLUSION: Prevalence of postpartum modern contraceptive use in the study area is still low. Numerous factors were reported as barriers for postpartum contraceptive use. A strategy such as health education on befits of post-partum modern contraceptive use and counseling women about side effects may help to improve its uptake.

A cluster randomized controlled trial to assess the impact on intimate partner violence of a 10-session participatory gender training curriculum delivered to women taking part in a group-based microfinance loan scheme in Tanzania (MAISHA CRT01): study protocol.

BACKGROUND: Worldwide, almost one third (30%) of women who have been in a relationship have experienced physical and/or sexual violence from an intimate partner. Given the considerable negative impacts of intimate partner violence (IPV) on women's physical health and well-being, there is an urgent need for rigorous evidence on violence prevention interventions. METHODS: The study, comprising a cluster randomized controlled trial (RCT) and in-depth qualitative study, will assess the impact on women's past year experience of physical and/or sexual IPV of a participatory gender training curriculum (MAISHA curriculum) delivered to women participating in group-based microfinance in Tanzania. More broadly, the study aims to learn more about the factors that contribute to women's vulnerability to violence and understand how the intervention impacts on the lives of women and their families. Sixty-six eligible microfinance loan groups are enrolled and randomly allocated to: the 10-session MAISHA curriculum, delivered over 20 weeks (n = 33); or, to no intervention (n = 33). Study participants are interviewed at baseline and at 24 months post-intervention about their: household; partner; income; health; attitudes and social norms; relationship (including experiences of different forms of violence); childhood; and community. For the qualitative study and process evaluation, focus group discussions are being conducted with study participants and MAISHA curriculum facilitators. In-depth interviews are being conducted with a purposive sample of 18 participants. The primary outcome, assessed at 24 months post-intervention, is a composite of women's reported experience of physical and/or sexual IPV during the past 12 months. Secondary outcomes include: reported experience of physical, sexual and emotional/psychological IPV during the past 12 months, attitudes towards IPV and reported disclosure of IPV to others. DISCUSSION: The study forms part of a wider programme of research (MAISHA) that includes: a complementary cluster RCT evaluating the impact of delivering the MAISHA curriculum to women not receiving formal group-based microfinance; an economic evaluation; and a cross-sectional survey of men to explore male risk factors associated with IPV. MAISHA will generate rigorous evidence on violence prevention interventions, as well as further insights into the different forms and consequences of violence and drivers of violence perpetration. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02592252 , registered retrospectively on 13 August 2015.

Cost and Cost-Effectiveness of a Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision in Tanzania: Spending More to Spend Less.

BACKGROUND: Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20-34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20-34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness. SETTING: Tanzania (Njombe and Tabora regions). METHODS: Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios. RESULTS: Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and $130 in Njombe, and in the control arms $70 and $191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed. CONCLUSIONS: Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving.

"If You Are Not Circumcised, I Cannot Say Yes": The Role of Women in Promoting the Uptake of Voluntary Medical Male Circumcision in Tanzania.

Voluntary Medical Male Circumcision (VMMC) for HIV prevention in Tanzania was introduced by the Ministry of Health and Social Welfare in 2010 as part of the national HIV prevention strategy. A qualitative study was conducted prior to a cluster randomized trial which tested effective strategies to increase VMMC up take among men aged ≥20 years. During the formative qualitative study, we conducted in-depth interviews with circumcised males (n = 14), uncircumcised males (n = 16), and participatory group discussions (n = 20) with men and women aged 20-49 years in Njombe and Tabora regions of Tanzania. Participants reported that mothers and female partners have an important influence on men's decisions to seek VMMC both directly by denying sex, and indirectly through discussion, advice and providing information on VMMC to uncircumcised partners and sons. Our findings suggest that in Tanzania and potentially other settings, an expanded role for women in VMMC communication strategies could increase adult male uptake of VMMC services.

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.

Assessment of speech in neurological disorders: development of a Swahili screening test.

Assessments for acquired motor-speech disorders that look at movements of the articulators would appear at first glance to be universal. This may be true for the most basic non-speech aspects of movement. We argue that assessments for speech motor control must be attuned to language-specific variables to be fully valid. We describe the rationale for, and development of a motor-speech-disorder screening test for Swahili speakers which includes impairment measures as well as measures of intelligibility and speech-voice naturalness. We further describe its initial validation in terms of content validity, feasibility of administration and scoring without requirements for lengthy training and technical expertise and application to groups of people with and without Parkinson's disease in Tanzania. Results indicate that the protocol is ready to use in so far as it is acceptable to users (clinicians, patients), is feasible to use, shows good interrater reliability, and is capable of differentiating performance in healthy speakers and those whose speech is disordered. We highlight needs for further development, including issues around training, development of local norms for healthy speakers and for speakers with a variety of neurological disturbances, and extension of the tool to cover culturally valid assessment of impact of communication disorders.

Farming with your hoe in a sack: condom attitudes, access, and use in rural Tanzania.

This study examines condom knowledge, attitudes, access, and practices in rural Mwanza, Tanzania. From 1999-2002, six researchers carried out participant observation in nine villagesfor a total of 158 person-weeks. Many villagers perceived condoms negatively for multiple reasons, for example, the method's association with infection or promiscuity, reduced male sexual pleasure, and cultural understandings of meaningful sex. Men controlled the terms of sexual encounters and reported that they would use condoms only with risky partners, but few perceived their partners as such. Use of condoms appeared to be very low, primarily as a result of limited demand, although barriers to access also existed. These qualitative findings contrast with inconsistent survey reports of relatively high condom use in the same population. Intervention efforts should address the tradeoff between possible short- and long-term consequences of condom use, particularly for men, for example, reduced pleasure versus reduced HIV risk. If possible, surveys should assess the validity of reported condom use through comparison with other data, including qualitative findings and distribution/sales records.