Maternal systemic or cord blood inflammation is associated with birth anthropometry in a Tanzanian prospective cohort.

OBJECTIVES: HIV infection is associated with chronic systemic inflammation, with or without antiretroviral therapy. Consequences for foetal growth are not understood, particularly in settings where multiple maternal infections and malnutrition are common. The study was designed to examine maternal systemic circulating and umbilical cord blood cytokine concentrations in relation to birth anthropometry in a Tanzanian prospective cohort. METHODS: A 9-plex panel of maternal plasma cytokines in HIV-positive (n = 44) and HIV-negative (n = 70) mothers and the same cytokines in umbilical cord blood collected at delivery was assayed. Linear regression modelled associations between maternal or cord blood cytokines and birth anthropometry. RESULTS: Health indicators (haemoglobin, mid-upper-arm circumference, body mass index) in HIV-positive mothers without considerable immunosuppression did not differ from HIV-negative women. Despite this, HIV-exposed infants had lower birthweight and length. Subgroup analyses indicated that HIV management using HAART was associated with lower plasma TNF-α, as were longer durations of any antiretroviral therapy (≥2 months). Greater maternal plasma TNF-α was associated with earlier delivery (-1.7 weeks, P = 0.039) and lower birthweights (-287 g; P = 0.020), while greater umbilical cord TNF-α (-1.43 cm; P = 0.036) and IL-12p70 (-2.4 cm; P = 0.008) were associated with shorter birth length. Birthweight was inversely associated with cord IL-12p70 (-723 g; P = 0.001) and IFN-γ (-482 g, P = 0.007). Maternal cytokines during pregnancy did not correlate with umbilical cord cytokines at delivery. CONCLUSIONS: Systemic inflammation identified in maternal plasma or umbilical cord blood was associated with poorer birth anthropometrics in HIV-exposed and HIV-unexposed infants. Controlling maternal and/or foetal systemic inflammation may improve birth anthropometry.

Low mortality risk but high loss to follow-up among patients in the Tanzanian national HIV care and treatment programme.

UNLABELLED: OBJECTIVE To analyse survival and retention rates of the Tanzanian care and treatment programme. METHODS: Routine patient-level data were available from 101 of 909 clinics. Kaplan-Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow-up using Egger's nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals. RESULTS: In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow-up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months, and were higher among males, those under 45 kg and those with CD4 counts below 50 cells/µl at ART initiation. In the first year on ART, median CD4 count increased by 126 cells/µl, with similar changes in both sexes. CONCLUSION: Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition.

The impact of mobility on HIV control: a modelling study.

Mobility is associated with HIV due to more risky sexual behaviour of mobile groups such as travellers and migrants. Limited participation of such groups may reduce the effectiveness of HIV interventions disproportionally. The established STDSIM model, which simulates transmission and control of HIV and STD, was extended to simulate mobility patterns based on data from Tanzania. We explored the impact of non-participation of mobile groups (travellers and recent migrants) on the effectiveness of two interventions: condom promotion and health education aiming at partner reduction. If mobile groups do not participate, the effectiveness of both interventions could be reduced by 40%. The impact of targeting travellers with a combined HIV campaign is close to that of a general population intervention. In conclusion, it is important to account for possible non-participation of migrants and travellers. If non-participation is substantial, impact of interventions can be greatly improved by actively approaching these people.

The "seeded" focus group: a strategy to recruit HIV+ community members into treatment research.

OBJECTIVE(S): We piloted an innovative community-based recruitment approach to contact known HIV+ individuals for referral to treatment without endangering their confidentiality. METHODS: Nested within an HIV cohort study, operations research to monitor and improve rural uptake of antiretroviral therapy (ART) was conducted alongside the introduction of Tanzania's national treatment programme. We confronted the challenge of recruiting participants without inadvertently disclosing their HIV status to family or other community members. During post-test counselling, nurses compiled a list of HIV+ persons who expressed interest in being contacted when ART became available. Study numbers, but not names, of 12 "seeds" were added to a randomly generated list of residents, matched by age group and sex, and all were invited to participate in focus-group discussions on community perceptions of treatment. After the discussion, the original counsellors met each participant in private, inviting the "seed" for ART referral and offering VCT to others. RESULTS: Ten "seeds" were successfully located and attended the local focus-group discussion; all subsequently volunteered to undergo clinical tests in advance of receiving antiretroviral therapy. They also agreed to participate in a study of barriers to ART access. The other focus-group members contributed useful information on levels of understanding and support for treatment, and several came forward for HIV testing. CONCLUSIONS: The "seeded" focus group is a very straightforward and easily arranged method of recruiting HIV+ people for research or service delivery within a wider context of engaging with local community perceptions.

Scaling up stigma? The effects of antiretroviral roll-out on stigma and HIV testing. Early evidence from rural Tanzania.

OBJECTIVE: To investigate the interplay between antiretroviral therapy (ART) scale-up, different types of stigma and Voluntary Counselling and Testing (VCT) uptake 2 years after the introduction of free ART in a rural ward of Tanzania. METHODS: Qualitative study using in-depth interviews and group activities with a purposive sample of 91 community leaders, 77 ART clients and 16 health providers. Data were analysed for recurrent themes using NVIVO-7 software. RESULTS: The complex interplay between ART, stigma and VCT in this setting is characterised by two powerful but opposing dynamics. The availability of effective treatment has transformed HIV into a manageable condition which is contributing to a reduction in self-stigma and is stimulating VCT uptake. However, this is counterbalanced by the persistence of blaming attitudes and emergence of new sources of stigma associated with ART provision. The general perception among community leaders was that as ART users regained health, they increasingly engaged in sexual relations and "spread the disease." Fears were exacerbated because they were perceived to be very mobile and difficult to identify physically. Some leaders suggested giving ART recipients drugs "for impotence," marking them "with a sign" and putting them "in isolation camps." In this context, traditional beliefs about disease aetiology provided a less stigmatised explanation for HIV symptoms contributing to a situation of collective denial. CONCLUSION: Where anticipated stigma prevails, provision of antiretroviral drugs alone is unlikely to have sufficient impact on VCT uptake. Achieving widespread public health benefits of ART roll-out requires community-level interventions to ensure local acceptability of antiretroviral drugs.

Influence of timing of sexual debut and first marriage on sexual behaviour in later life: findings from four survey rounds in the Kisesa cohort in northern Tanzania.

OBJECTIVES: To evaluate quality of sexual debut and first marriage data, measure trends and study the association of risky sexual behaviour in youth with adult risk behaviour. METHODS: Reports on age at first sex (AFS) and age at first marriage (AFM) from the Kisesa cohort study, 1994-2004, were evaluated for consistency and used to describe trends in median age-at-event and time spent single but sexually active in different birth cohorts. The association of these variables with marital stability and numbers of partners at later ages was explored using statistical regression techniques. RESULTS: AFS and AFM were inconsistently reported by 32% and 33% of respondents, respectively, but there was no general tendency to report lower or higher ages at a later report date. In 10-year birth cohorts born between 1950-9 and 1980-9, male median AFS declined from 18.1 to 17.0 years and female median AFM rose from 16.2 to 16.6 years. Young people of both sexes currently spend longer sexually active but unmarried than previously. Early marriage is statistically associated with remarriage and polygamy; longer time between sexual debut and marriage is associated with higher numbers of partners at later stages of life. CONCLUSION: Inconsistent reporting of age-at-event introduces noise but does not bias estimates of population level indicators. Lengthening time spent single and sexually active suggests that men and women entering first marriage will have been exposed to increased numbers of non-marital partners. Successful youth interventions may also influence adult behaviour.

Male circumcision and susceptibility to HIV infection among men in Tanzania.

BACKGROUND: Evidence from ecological studies and from studies of and sexually transmitted disease (STD) patients in sub-Saharan Africa suggests that there is a protective effect of male circumcision against HIV infection. There are, however, few population-based studies that have controlled adequately for potential confounding factors. METHODS: Data from five population-based studies in north-western Tanzania were used to investigate the association between male circumcision and the risk of HIV infection and STD. The effects of circumcision on HIV prevalence, syphilis (positive Treponema pallidum haemagglutination; TPHA) and self-reported STD were analysed, controlling for a range of demographic and sociocultural variables, and indicators of sexual behaviour. RESULTS: In north-western Tanzania, circumcision was previously restricted to Muslims and specific ethnic groups, but is now more widespread, particularly in urban areas and among more educated men. Assessment of the reliability and validity of self-reported circumcision status showed that these data could be considered fairly accurate, although there was some tendency for circumcision to be over-reported. On univariate analysis, circumcision status was unrelated to HIV prevalence in most studies. After controlling for confounding variables, however, there was a modest but significant reduction of the HIV prevalence among circumcised men [odds ratio (OR), 0.62; 95% confidence interval (CI), 0.48-0.81]. This effect appeared stronger in urban areas (OR, 0.46; 95% CI, 0.32-0.68) and roadside villages (OR, 0.65; 95% CI, 0.42-1.01) than in rural areas and islands (OR, 1.00 and 1.01 respectively). There was no association between circumcision status and syphilis serology (TPHA), but there was a positive association between circumcision and self-reported STD, although this was not significant after adjustment for confounding variables. CONCLUSION: Male circumcision has a protective effect against HIV infection in this population, which may be stronger in urban areas and roadside settlements than in the rural areas. Ethnic group and religious denomination are no longer the sole determinants of male circumcision.

Male circumcision and susceptibility to HIV infection among men in Tanzania.

BACKGROUND: Evidence from ecological studies and from studies of and sexually transmitted disease (STD) patients in sub-Saharan Africa suggests that there is a protective effect of male circumcision against HIV infection. There are, however, few population-based studies that have controlled adequately for potential confounding factors. METHODS: Data from the five population-based studies in north-western Tanzania were used to investigate the association between male circumcision and the risk of HIV infection and STD. The effects of circumcision on HIV prevalence, syphilis (positive Treponema pallidum haemagglutination; TPHA) and self-reported STD were analysed, controlling for a range of demographic and sociocultural variables, and indicators of sexual behaviour. RESULTS: In north-western Tanzania, circumcision was previously restricted to Muslims and specific ethnic groups, but is now more widespread, particularly in urban ares and among more educated men. Assessment of the reliability and validity of self-reported circumcision status showed that these data could be considered fairly accurate, although there was some tendency for circumcision to be over-reported. On univariate analysis, circumcision status was unrelated to HIV prevalence in most studies. After controlling for confounding variables, however, there was a modest but significant reduction of the HIV prevalence among circumcised men [odds ratio (OR), 0.62; 95% confidence interval (CI), 0.48-.81]. This effect appeared stronger in urban areas (OR, 0.46; 95% CI, 0.32-0.68) and roadside villages (OR, 0.65; 95% CI, 0.42-1.01) than in rural areas and islands (OR, 1.00 and 1.01 respectively). There was no association between circumcision status and syphilis serology (TPHA), but there was a positive association between circumcision and self-reported STD, although this was not significant after adjustment for confounding variables. CONCLUSION: Male circumcision has a protective effect against HIV infection in this population, which may be stronger in urban areas and roadside settlements than in the rural areas. Ethnic group and religious denomination are no longer the sole determinants of male circumcision.

Adjusting ante-natal clinic data for improved estimates of HIV prevalence among women in sub-Saharan Africa.

OBJECTIVES: To find a simple and robust method for adjusting ante-natal clinic data on HIV prevalence to represent prevalence in the general female population in the same age range, allowing for fertility differences by HIV status. BACKGROUND: HIV prevalence comparisons for pregnant women and women in the general community show that prevalence in the latter is significantly higher than in the former. An adjustment procedure is needed that is specific for the demographic and epidemiological circumstances of a particular population, making maximum use of data that can easily be collected in ante-natal clinics or are widely available from secondary sources. METHODS: Birth interval length data are used to allow for subfertility among HIV-positive women. To allow for infertility, relative HIV prevalence ratios for fertile and infertile women obtained in community surveys in populations with similar levels of contraception use are applied to demographic survey data that describe the structure of the population not at risk of child-bearing. RESULTS: For populations with low contraception use, the procedure yields estimates of general female HIV prevalence of 35-65% higher than the observed ante-natal prevalence, depending on population structure. Results were verified using general population prevalence data collected in Kisesa (Tanzania) and Masaka (Uganda). For high contraception use populations, adjusted values range from 15% higher to 5% lower, but only limited verification has been possible so far. CONCLUSIONS: The procedure is suitable for estimating general female HIV prevalence in low contraception use populations, but the high contraception variant needs further testing before it can be applied widely.

Spread of HIV infection in a rural area of Tanzania.

OBJECTIVE: To assess the spread of HIV into rural areas. METHODS: Since 1994 a demographic surveillance system (with 5-monthly rounds) and open adult cohort study have been established in a rural ward in Tanzania. Two sero-surveys of all resident adults aged 15-44 and 15-46 years were conducted in 1994 1995 and 1996-1997 respectively. Qualitative data were collected on mobility, bars and commercial sex. RESULTS: Attendance of the two rounds of survey was 5820 (78%) and 6413 (80%) in 1994/1995 and 1996/1997 respectively. HIV prevalence increased from 5.8% to 6.6%. HIV incidence was 0.73 and 0.84 per 100 person years among men and women respectively. HIV incidence under the age of 20 years was low among both sexes. Striking differences in HIV prevalence and incidence were observed within the small geographic area studied: HIV prevalence in the trading center was twice that in the area surrounding the trading center (within 2 km) and three to four times that in the rural villages (within 8 km of the trading center). Aggregate level data showed significant differences between the trading center and nearby rural villages in terms of sexual behavior, commercial sex workers, mobility of the population, and alcohol use. CONCLUSION: This study documents the existence of very substantial HIV prevalence and incidence differences within a small geographic rural area. The rapid decrease in HIV prevalence within a small rural area emphasizes the importance of concentrating HIV prevention efforts on high transmission areas, such as trading centers, especially in resource-poor settings. Furthermore, this has considerable implications for monitoring the spread of HIV through sentinel sites, as such sites are typically located in high transmission areas.