Food insecurity is associated with food consumption patterns and anthropometric measures but not serum micronutrient levels in adults in rural Tanzania.

OBJECTIVE: The purpose of the present paper is to assess the relationship between food insecurity and food consumption patterns, anthropometric measures and serum micronutrient levels in rural Kilimanjaro, Tanzania. DESIGN: A population-based cross-sectional study was carried out between March and May of 2005. SETTING: Rural Kilimanjaro, Tanzania. SUBJECTS: Analysis was restricted to 1014 adults aged 15-44 years with children and complete data. RESULTS: A large majority of the participants (91 %) reported some kind of food insecurity. Food insecurity was significantly associated with age, marital status and occupation. Participants reporting food insecurity were significantly less likely to frequently consume animal products, fruits and vegetables compared with participants categorized as food secure. Women categorized as experiencing individual food insecurity had a larger waist circumference than food-secure women (P = 0.026) while the mean BMI of women appeared to decline if they had a child who was food insecure (P = 0.038). There were no observed differences in serum micronutrient levels by food insecurity status. CONCLUSIONS: Food insecurity is highly prevalent and associated with food consumption patterns, waist circumference and BMI of women in rural Tanzania. Further studies should apply self-report measures in assessing food insecurity to larger and more diversified populations.

Prevalence and predictors of failure to return for HIV-1 post-test counseling in the era of antiretroviral therapy in rural Kilimanjaro, Tanzania: challenges and opportunities.

In this era of antiretroviral therapy (ART) a limited number of population-based studies have investigated the extent of voluntary counseling and testing acceptance and completion in Africa. The aim of this study was to assess the prevalence and predictors of failure to return for HIV post-test counseling (PTC) among adults in rural Kilimanjaro, Tanzania. Following a cross-sectional survey, people aged 15-44 years living in Oria village were interviewed and offered individual HIV-1 pre-test counseling. They were asked to return for PTC two weeks after blood sample collection. HIV-1 testing was accepted by 1491 (97.6%) of participants with 98.9% expressing desire to know their results. The proportion of individuals who did not return for PTC was 50.9%. These proportions did not differ by sex. Seropositive HIV result (AOR: 2.2; 95%CI: 1.3-4.3 for women and AOR: 2.1, 95%CI: 1.2-5.7 for men), low HIV/AIDS-transmission and ART availability knowledge, perceived low risk of HIV infection, not accepting to share results (men only) and inability to self-prevent HIV infection (women only) predicted failure to return for PTC. Additionally, participants were more likely not to return for PTC if they had no-formal education or reported recent sexual-risk behaviors, for both sexes. Age, prior HIV testing or AIDS-related clinical symptoms were not associated with return for PTC in this population. These findings suggest that low returns for PTC, especially for HIV-seropositive individuals, result in a substantial missed opportunity for prevention and care. Knowledge of ART accessibility is necessary but not sufficient to promote adequate return for PTC. The high attendance for pre-test counseling should be utilized to identify potential individuals who may not return for PTC and to promote risk reduction and care.

The role of in-migrants in the increasing rural HIV-1 epidemic: results from a village population survey in the Kilimanjaro region of Tanzania.

OBJECTIVE: To investigate the magnitude of rural in-migration and the role of in-migrants in the observed increase in HIV-1 prevalence in rural Kilimanjaro, Tanzania. METHODS: A cross-sectional study involving the adult population aged 15-44 years residing in a rural village was conducted from March to May of 2005. Participants were interviewed regarding their risk behaviors and gave blood for HIV-1 and syphilis testing. RESULTS: Overall, the response rate was 73.0% (1528/2093). A total of 699 (48.1%) participants reported having in-migrated to the village at some point during their life. The prevalences of HIV-1 infection were 1.8%, 2.3%, and 3.7% among non-in-migrant, long-term in-migrant, and recent in-migrant men, respectively (p(trend)<0.001). The corresponding prevalences among women were 9.2%, 11.5%, and 14.5%, respectively (p(trend)=0.048). The odds of HIV-1 infection were higher among recent in-migrants as compared to non-in-migrants (men: adjusted odds ratio (AOR) 2.4, 95% CI 1.8-6.6; women: AOR 2.3, 95% CI 1.1-5.0). Risk behaviors were inversely related to years since in-migration for both sexes. CONCLUSIONS: The results suggest that rural in-migration is common for both men and women. In-migrants were at higher risk for HIV-1 infection and contributed significantly to increased rural HIV-1 prevalence. More studies to examine the rate and broader causes of rural in-migration in similar communities are called for. These may help in the design of intervention strategies for curbing the rising rural HIV epidemic.

The reliability and validity of self-report measures used to evaluate adolescent HIV/AIDS prevention programs in sub-Saharan Africa.

The use of reliable and valid tools to evaluate theory-based health interventions is widely accepted as critical to the behavioral sciences. However, quite often the psychometric properties of survey instruments used to evaluate behavioral interventions are not published, limiting our understanding of how the theory works. The purpose of this study was to present the results of psychometric analyses on measures used to evaluate an HIV/AIDS prevention program for youth in Tanzania. We first began by pilot-testing a self-administered questionnaire with sixth and seventh-grade students in nine schools in 11 villages throughout the Kahe ward of Tanzania (n = 524). Theory-based scales tapped into intrapersonal, social and attitudinal factors. Reliability was evaluated by examining internal consistency, while validity was determined by examining content, construct and discriminant validities. The results indicate that the scales constructed are reasonably reliable and valid measures. Use of these measures should be considered when designing, implementing, and analyzing interventions targeting youth in sub-Saharan Africa.

Trends in HIV-1 prevalence and risk behaviours over 15 years in a rural population in Kilimanjaro region of Tanzania.

BACKGROUND: Monitoring dynamics in HIV-1 infection and risk behaviours is important in evaluating, adjusting and scaling up prevention programmes. The objective of this study was to estimate trends in the prevalence of HIV-1 infection and risk behaviours over 15 years in a rural village population in Kilimanjaro region of Tanzania using repeated population-based cross-sectional surveys. METHODS: Four rounds of HIV-1 sero-epidemiological and behavioural surveys were completed during 1991 to 2005 in the study village. House-to-house registrations of people aged 15-44 years with an address in the village were conducted before each survey. All consenting individuals were then interviewed for pertinent risk behaviours and tested for HIV-1 seropositivity. RESULTS: Participation proportions ranged from 73.0% to 79.1%. Overall, age and sex-adjusted HIV-1 prevalence increased from 3.2% in 1991 to 5.6 % in 2005 (relative increase 75.0%; ptrend < 0.001). The increase was significant for both men and women (ptrends < 0.001) and more evident among women aged 35-44 years (2.0% to 13.0%, ptrend < 0.001). Among participants aged 15-24 years a decrease in number of sexual partners was observed with a corresponding stable HIV-1 prevalence. Participants aged 25-44 years continued to report multiple sexual partners, and this was corroborated with increased HIV-1 prevalence trend (4.0% to 9.0%, ptrends < 0.001). Among men aged 25-44 years and women aged 15-24 years significant increases in condom use were observed (ptrend < 0.01). CONCLUSION: The HIV-1 prevalence seems to have increased among older participants but remained stable among younger participants. Encouraging trends toward safer sex practices were observed among young participants, while only modest behavioural changes were seen among the older participants. Prevention efforts in rural areas need to be intensified and to address people of all ages.

Prevalence and risk factors for HIV-1 infection in rural Kilimanjaro region of Tanzania: implications for prevention and treatment.

BACKGROUND: Variability in stages of the HIV-1 epidemic and hence HIV-1 prevalence exists in different areas in sub-Saharan Africa. The purpose of this study was to investigate the magnitude of HIV-1 infection and identify HIV-1 risk factors that may help to develop preventive strategies in rural Kilimanjaro, Tanzania. METHODS: A cross-sectional study was conducted between March and May of 2005 involving all individuals aged between 15-44 years having an address in Oria Village. All eligible individuals were registered and invited to participate. Participants were interviewed regarding their demographic characteristics, sexual behaviors, and medical history. Following a pre-test counseling, participants were offered an HIV test. RESULTS: Of the 2 093 eligible individuals, 1 528 (73.0%) participated. The overall age and sex adjusted HIV-1 prevalence was 5.6%. Women had 2.5 times higher prevalence (8.0% vs. 3.2%) as compared to men. The age group 25-44 years, marriage, separation and low education were associated with higher risk of HIV-1 infection for both sexes. HIV-1 infection was significantly associated with >2 sexual partners in the past 12 months (women: Adjusted odds ratio [AOR], 2.5 (95%CI: 1.3-4.7), and past 5 years, [(men: AOR, 2.2 (95%CI:1.2-5.6); women: AOR, 2.5 (95%CI: 1.4-4.0)], unprotected casual sex (men: AOR,1.8 95%CI: 1.2-5.8), bottled alcohol (Men: AOR, 5.9 (95%CI:1.7-20.1) and local brew (men: AOR, 3.7 (95%CI: 1.5-9.2). Other factors included treatment for genital ulcers and genital discharge in the past 1 month. Health-related complaints were more common among HIV-1 seropositive as compared to seronegative participants and predicted the presence of HIV-1 infection. CONCLUSION: HIV-1 infection was highly prevalent in this population. As compared to our previous findings, a shift of the epidemic from a younger to an older age group and from educated to uneducated individuals was observed. Women and married or separated individuals remained at higher risk of infection. To prevent further escalation of the HIV epidemic, efforts to scale up HIV prevention programmes addressing females, people with low education, lower age at marriage, alcohol consumption, condom use and multiple sexual partners for all age groups remains a top priority. Care and treatment are urgently needed for those infected in rural areas.

Perceptions of AIDS risk and condom use among out-of-school adolescents in Moshi rural district, northern Tanzania.

OBJECTIVE: To determine the magnitude of perceived AIDS risk among out-of-school adolescents in Moshi rural district of Kilimanjaro region, northern Tanzania. METHODS: A cross-sectional study involving face-to-face interviews with out-of-school adolescents in eleven rural villages in Moshi district, northern Tanzania. RESULTS: We found that of the 668 adolescents (10-19 years of age) surveyed, 45.4% were sexually active and significantly more men than women reported being sexually active (55.85 versus 23.0%, OR = 0.24, 95% CI = 0.16 to 0.34). Adolescents who had travelled to Moshi town or out of Tanzania were significantly more likely to be sexually active compared with those who have never travelled. Despite perception of AIDS risk, a large majority (70.5%) of sexually active adolescents reported having multiple sexual partners. Adolescents who perceived being at AIDS risk were less likely to report having multiple sexual partners and were more likely to report having used a condom at the last sexual intercourse. CONCLUSION: These findings indicate that adolescents in this rural population are still practising high risk sexual behaviours suggesting the need for youth-targeted intervention programmes in rural Tanzania.

Prevalence of HIV-1 infection in Zanzibar: results from a national HIV-1 serosurvey 2002.

OBJECTIVE: To determine the prevalence of HIV-1 infection in Pemba and Zanzibar islands METHODS: We used an interviewer-administered questionnaire that consisted of pre-coded and open-ended questions consisting of 29 items. The questionnaire was developed in English and translated into Swahili language before use. The questionnaire was pilot tested and modified before use. A total of 30 Shehias were randomly selected for the survey out of a total of 248 Shehias. A Shehia is the smallest government administrative unit in Pemba and Zanzibar that consists of two to three villages. The study sample was obtained through cluster random sampling of 76 households from each Shehia. Informed consent was sought from the Head of household and from each potential eligible participant. Eligibililty criteria included all persons aged 12 years and above who slept overnight in the selected household at the time of the study. Exclusion criteria included non-residents of Zanzibar and Pemba such as tourists, Informed consent from persons below the age of 18 years were witnessed and ratified by their parents, guardians, caretakers or neighbours. All consenting participants were included in the study sample. Blood sports were collected using filters and tested for HIV-1 using ELISA test at the Zanzibar Reference Laboratory. Samples found positive for ELISA were subjected to a 2nd ELISA test. RESULTS: The total number of persons who participated in the survey was 5852 out of 5868 eligible persons giving the overall response rate of 99.7%. Of the 5852 persons who participated in the survey, 41% (N = 2414) were males and 59% N = 3455) were females. The overall mean age of the study population was 30.4 years with age ranging from 12-65 years. The overall prevalence of HIV-1 infection was 0.6% with more women being significantly affected than men (0.9% versus 0.2%; adjusted OR = 2.88, 95% CI = 1.16-7.12). Of the 5852 persons who participated in the survey, 5.7% admitted having had casual partner in the past 6 months and of these 19.6% reported having used a condom during the most recent casual sex. CONCLUSION: We conclude that HIV-1 infection in Zanzibar is still low and women are more affected than men.

Prevalence of and predictors of substance use among adolescents in rural villages of Moshi district, Tanzania.

PURPOSE: To determine the prevalence of substance use among primary school pupils and out-of-school adolescents in Moshi rural district, northern Tanzania. METHODS: A school-based cross-sectional study focusing on primary school adolescents in standards 6 and 7 in Kahe rural community. We also conducted a population-based cross-sectional study among out-of-school adolescents in the same rural villages. A self-administered questionnaire was used to collect data from the school-based survey while for the out-of-school survey the questionnaire was administered in the households using trained interviewers. RESULTS: A total of 545 in-school and 668 out-of-school adolescents participated in the study. Of the 545 school adolescents, 45.4% were males and 56.6% females while for the out-of-school adolescents, 68.1% were males and 31.9% females. Of the school adolescents, more males than females reported being alcohol drinkers (16.7% versus 9.2%; odds ratio (OR) = 1.9, 95% CI, 1.17 - 3.29). The prevalence proportions of cigarette smoking were 26.2% for men and 15.5% for women while prevalence proportions of marijuana smoking were 4.1% for men and 3.0% for women. As for the out-of-school adolescents, the prevalence proportions of alcohol use were 26.2% for men and 15.5% for women. The prevalence proportions of cigarette smoking were 14.3% for men and 1.9% for women while the prevalence proportions of marijuana smoking were 1.5% for men and 1.4% for women. CONCLUSIONS: Substance use among adolescents is very high suggesting the need for interventions in this rural population of Tanzania.

Validation of the Radimer/Cornell food insecurity measure in rural Kilimanjaro, Tanzania.

OBJECTIVE: The objective of the present study was to assess the construct validity, criterion-related validity and internal consistency of the Radimer/Cornell food insecurity measure for use in rural Tanzania. DESIGN: A cross-sectional community-based survey was conducted from March to May 2005. Key adaptations to the nine-item Radimer/Cornell items included translation to Swahili, replacing the term 'balanced diet' with 'full meal' and constructing the items as questions rather than statements. Factor analysis and Cronbach's alpha were used to assess validity and reliability, respectively. SETTING: Rural Kilimanjaro, Tanzania. SUBJECTS: Analysis was restricted to data from 530 women aged 15-44 years who had children under 5 years old. RESULTS: Principal component factor analysis revealed a two-factor solution: (1) altered eating pattern at household level and (2) altered eating pattern at child level. The two factors accounted for 66.2% of the total variance. The subscales developed had good reliability. Internal consistency of the scales was 0.853 and 0.784 for food insecurity at household level and food insecurity at child level, respectively. Only 14.0% of the women reported to be food-secure and 86.0% reported some kind of food insecurity. The Radimer/Cornell food insecurity measure showed significant associations with selected sociodemographic factors in the expected directions. There was also an association with the NHANES III (Third National Health and Nutrition Examination Survey) and CCHIP (Community Childhood Hunger Identification Project) indicators. CONCLUSION: Our findings suggest that the adapted Radimer/Cornell measure may have some utility in assessing food insecurity in settings like rural Tanzania.

Education attainment and the risk of HIV-1 infections in rural Kilimanjaro Region of Tanzania, 1991-2005: a reversed association.

OBJECTIVE: Previous studies found educated individuals to have higher risk of human immunodeficiency virus (HIV)-1 infection in Africa. A reverse in this association was predicted. We investigated the change in this association from 1991 to 2005 in a rural population in Tanzania. STUDY DESIGN: Two cross-sectional surveys were conducted in 1991(N = 1,152, response rate 76.4%) and 2005 (N = 1,528, 73.0%). Consenting individuals aged 15 to 44 years living in Oria village were interviewed and gave blood for HIV-1 testing. RESULTS: Primary [adjusted odds ratio (AOR), 2.7; 95% confidence interval (CI): 1.3-20.0] and secondary/higher education (AOR, 4.5; 95% CI: 1.4-24.9) were associated with increased risk of HIV-1 infection in 1991. A reversed association was observed in 2005 where reduced odds of infection were associated with primary (AOR, 0.5; 95% CI: 0.2-0.8) and secondary/higher education (AOR, 0.4; 95% CI: 0.3-0.9). This was most pronounced among educated men. Corresponding reduction in risk behaviors were observed. Increased odds of reporting ever use of condom (AOR, 2.8; 95% CI: 1.1-7.3) and 70% reduction in reporting >or=2 sexual partners in the past year was observed among educated women. Educated men reported 60% reduction in the odds of reporting >or=2 sexual partners in the past month preceding the last survey. CONCLUSIONS: A reversed association between education attainment and HIV-1 infection was observed in this population between 1991 and 2005. Education seems to have an empowering role in women. Decreased risk among educated men may have an impact on HIV-1 transmission. Improving education sector in rural areas might be instrumental in the fight against the HIV epidemic.

Incidence of HIV-1 infection and changes in prevalence of reproductive tract infections and sexual risk behaviours: a population-based longitudinal study in rural Tanzania.

This study aimed at describing the prevalence and incidence of HIV-1 and change in the prevalence of reproductive tract infections (RTIs) and sexual risk behaviours in the rural Kilimanjaro region of Tanzania. Two cross-sectional surveys among the total village population of Oria were conducted in 1991 and 1993. All individuals with a permanent address in the village were registered and invited to participate. After informed consent, participants gave blood for HIV-1 testing. Participants aged 15-44 years were interviewed regarding their socio-demographic characteristics and sexual risk behaviours and underwent genital examination and testing for RTIs. In 1991 and 1993, respectively, 3 239 (83.6%) and 2 191 (76.9%) individuals in the village participated. Prevalence of HIV-1 increased from 1.3% to 1.8%, but the difference was not significant (p = 0.17). HIV-1 incidence was 13.0/1000 person-years-at-risk (PYAR) for women and 4.3/1000 PYAR for men (relative risk was 3.0; 95% CI: 1.12-8.16). There was a significant increase in the prevalence of gonorrhoea, bacterial vaginosis and vaginal candidiasis (p < 0.001). The percentage of individuals who reported having multiple sexual partners during the 12 months preceding the survey increased from 12.9% to 24.1% (p < 0.001). The results suggest that RTIs and HIV-1 infections increased in this population in the early 1990s. Women were at higher risk of HIV-1 infection as compared to men. Sexual risk behaviours and RTIs may have contributed to HIV-1 transmission in this community. The data collected may help to inform the future design and evaluation of various intervention measures.