Misperception of peer beliefs reinforces inequitable gender norms among Tanzanian men.

Gender role ideology, i.e. beliefs about how genders should behave, is shaped by social learning. Accordingly, if perceptions about the beliefs of others are inaccurate this may impact trajectories of cultural change. Consistent with this premise, recent studies report evidence of a tendency to overestimate peer support for inequitable gender norms, especially among men, and that correcting apparent 'norm misperception' promotes transitions to relatively egalitarian beliefs. However, supporting evidence largely relies on self-report measures vulnerable to social desirability bias. Consequently, observed patterns may reflect researcher measurement error rather than participant misperception. Addressing this shortcoming, we examine men's gender role ideology using both conventional self-reported and a novel wife-reported measure of men's beliefs in an urbanising community in Tanzania. We confirm that participants overestimate peer support for gender inequity. However, the latter measure, which we argue more accurately captures men's true beliefs, implies that this tendency is relatively modest in magnitude and scope. Overestimation was most pronounced among men holding relatively inequitable beliefs, consistent with misperception of peer beliefs reinforcing inequitable norms. Furthermore, older and poorly educated men overestimated peer support for gender inequity the most, suggesting that outdated and limited social information contribute to norm misperception in this context.

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries.

OBJECTIVE: To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between >42 days and within 1 year postpartum. DESIGN: Open population cohort (Health and Demographic Surveillance Systems). SETTING: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa. POPULATION: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019. METHODS: InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42 days versus 43-365 days postpartum adjusting for HDSS and time period (2000-2009 and 2010-2019). MAIN OUTCOME MEASURES: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs). RESULTS: Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 between 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000-2009 and 2010-2019. CONCLUSIONS: Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden settings.

Unmet need for modern contraception by HIV status: findings from community-based studies implemented before and after earlier ART initiation program in rural Tanzania.

BACKGROUND: Tanzania Health policy insists on the need to provide all women access to contraception despite HIV status. We used data from two HIV epidemiologic serological surveys carried out at different periods of ART provision in rural Tanzania to assess the level of unmet need for modern contraception by HIV status and associated factors. METHODS: We performed secondary data analysis of two surveys conducted at the Magu Health and Demographic Surveillance System site, in Mwanza, Tanzania. Information on unmet need for modern contraception was derived from fertility desire and contraception use. Unmet need, HIV status, and socioeconomic and demographic variables were analysed. The percentage of women with unmet needs for modern contraception by HIV status is presented for the 2012 and 2017 surveys. Bivariate and multivariate analyses using logistic regression were used to investigate associated factors showing adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). RESULTS: Data from 3352 and 3196 women aged 15-49 years collected in the 2012 and 2017 surveys, respectively, were analysed. The percentages of women with unmet needs for modern contraception in the 2012 and 2017 surveys were 30.9% (95% CI 29.4-32.6) and 31.6% (95% CI 30.0-33.3), respectively. The unmet need for modern contraception was 26% lower in HIV-uninfected women in 2012 (aOR = 0.74; 95% CI 0.569-0.973); p = 0.031). Risk factors for unmet need for modern contraception in 2012 were HIV uninfected (adjusted OR = 0.74; 95% CI 0.569-0.973); p = 0.031), married marital status (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), higher education (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), and taking alcohol (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001). Only two factors were associated with unmet need for modern contraception in 2017: married marital status (adjusted OR = 0.46; 95% CI 0.305-0.722); p = 0.001) and women who earned for their families (aOR = 0.66; 95% CI 0.494-0.887); p = 0.006). DISCUSSION: Nearly one-third of women had an unmet need for modern contraception, which was lower in HIV-uninfected women than in WLHIV-infected women. The study has identified women whose demand for contraception has not been met: WLHIV, post marital women, women with low education and women who were reported to earn money for their families. Family planning interventions should be tailored to these groups of women.

Comparison of survival analysis approaches to modelling age at first sex among youth in Kisesa Tanzania.

BACKGROUND: Many studies analyze sexual and reproductive event data using descriptive life tables. Survival analysis has better power to estimate factors associated with age at first sex (AFS), but proportional hazards models may not be right model to use. This study used accelerated failure time (AFT) models, restricted Mean Survival time model (RMST) models, with semi and non-parametric methods to assess age at first sex (AFS), factors associated with AFS, and verify underlying assumptions for each analysis. METHODS: Self-reported sexual debut data was used from respondents 15-24 years in eight cross-sectional surveys between 1994-2016, and from adolescents' survey in an observational community study (2019-2020) in northwest Tanzania. Median AFS was estimated in each survey using non-parametric and parametric models. Cox regression, AFT parametric models (exponential, gamma, generalized gamma, Gompertz, Weibull, log-normal and log-logistic), and RMST were used to estimate and identify factors associated with AFS. The models were compared using Akaike information criterion (AIC) and Bayesian information criterion (BIC), where lower values represent a better model fit. RESULTS: The results showed that in every survey, the Cox regression model had higher AIC and BIC compared to the other models. Overall, AFT had the best fit in every survey round. The estimated median AFS using the parametric and non-parametric methods were close. In the adolescent survey, log-logistic AFT showed that females and those attending secondary and higher education level had a longer time to first sex (Time ratio (TR) = 1.03; 95% CI: 1.01-1.06, TR = 1.05; 95% CI: 1.02-1.08, respectively) compared to males and those who reported not being in school. Cell phone ownership (TR = 0.94, 95% CI: 0.91-0.96), alcohol consumption (TR = 0.88; 95% CI: 0.84-0.93), and employed adolescents (TR = 0.95, 95% CI: 0.92-0.98) shortened time to first sex. CONCLUSION: The AFT model is better than Cox PH model in estimating AFS among the young population.

The impacts of COVID-19 and its policy response on access and utilization of maternal and child health services in Tanzania: A mixed methods study.

The SARS-Cov-2 virus (COVID-19) has had a global social and economic impact. Despite the growing evidence, its effects on access and delivery of maternal and child health services in low-income countries are still unclear. This cross-sectional case study was conducted in Mjini Magharibi, Chake Chake, and Ilala districts in Tanzania to help fill this gap. The study combined qualitative and quantitative data collection methods, providing an account of the evolution of the pandemic and the associated control measures in Tanzania. We drew from 34 in-depth interviews, 60 semi-structured interviews, and 14 focus group discussions with key informants, patients, and health providers, and complemented the findings with a review of pandemic reports and health facility records. We followed the Standards for Reporting Qualitative Research (SRQR) to provide an account of the findings. Our account of the pandemic shows that there was at times an inconsistent policy response in Tanzania, with diverse control measures adopted at various stages of the epidemic. There was a perception that COVID-19 services were prioritized during the epidemic at the expense of regular ones. There were reports of reorganisation of health facilities, reallocation of staff, rescheduled antenatal and postnatal clinics, and reduced time for health education and child monitoring. Scarcity of essential commodities was reported, such as vaccines, equipment, and medical supplies. Such perceptions were in part supported by the routine utilization evidence in the three districts, showing a lower uptake of antenatal, postnatal, family planning, and immunization services, as well as fewer institutional deliveries. Our findings suggest that, although the policy response in Tanzania was erratic, it was rather fear of the pandemic itself and diversion of resources to control COVID-19, that may have contributed most to lower the utilization of mother and child services. For future emergencies, it will be crucial to ensure the policy response does not weaken the population's demand for services.

Fertility trends by HIV status in a health and demographic surveillance study in Magu District, Tanzania, 1994-2018.

BACKGROUND: Sub-Saharan Africa (SSA) has the highest fertility rates and highest HIV disease burden globally. However, it is not clear how the rapid expansion of anti-retroviral therapy (ART) for HIV has impacted the fertility gap between HIV-infected and uninfected women. We used data from a Health and Demographic Surveillance System (HDSS) in north-western Tanzania to explore trends in fertility rates and the relationship between HIV and fertility over the 25-year period. METHODS: From 1994 to 2018, births and population denominators from the HDSS population were used to obtain age-specific fertility rates (ASFRs) and total fertility rates (TFRs). HIV status was extracted from eight rounds of epidemiologic serological surveillances (1994-2017). Fertility rates by HIV status and in different levels of ART availability were compared over time. Independent risk factors for fertility changes were examined using Cox proportional hazard models. RESULTS: There were 24,662 births from 36,814 women (15-49) who contributed a total of 145,452.5 Person-Years of follow-ups. The TFR declined from 6.5 births per woman in 1994-1998 to 4.3 births per woman in 2014-2018. The number of births per woman was 40% lower in women living with HIV than in HIV-uninfected women (4.4 vs. 6.7), although this difference narrowed over time. The fertility rate in HIV-uninfected women was 36% lower in 2013-2018 than in 1994-1998(age-adjusted HR = 0.641; 95% CI 0.613-0.673). In contrast, the fertility rate in women living with HIV was relatively unchanged over the same follow up period (age-adjusted HR = 1.099; 95% CI 0.870-1.387). CONCLUSIONS: There was a notable fertility decline among women in the study area from 1994 to 2018. Fertility remained lower in women living with HIV than in HIV-uninfected women, but the difference continued to narrow over time. These results highlight the need for more research into fertility changes, fertility desire and family planning use in Tanzanian rural communities.

The prevalence and incidence of HIV in the ART era (2006-2016) in North West Tanzania.

BACKGROUND: Sub-Saharan countries bear a disproportionate percentage of HIV infections and HIV-related deaths despite the efforts to strengthen HIV prevention and treatments services, including ART. It is important to demonstrate how these services have contributed to reducing the epidemic using available population data. METHODS: We estimated the prevalence and incidence rates from a cohort running over 23 years in Magu District, Mwanza Region-North West Tanzania. Adults 15 years and over who were residents of the Kisesa observational HIV cohort study between 2006 and 2016 were eligible for inclusion. Survival analysis was used to calculate person-time at risk, incidence rates and 95% confidence intervals (CIs). Cox regression models were used for the risk factor analyses disaggregated by sex and age group. RESULTS: The HIV prevalence in the sero-surveys decreased from 7.2% in 2006/07 to 6.6% in 2016, with a notable decrease of over 50% for both men and women aged 15-24 years. The incidence rate for HIV was estimated to be 5.5 (95% CI 4.6-6.6) per 1,000 person-years in women compared to 4.6 (95% CI 3.5-5.8) in men, with a decrease over time. Despite the availability of ART services, the uptake is still small. CONCLUSIONS: New infections are still occurring, with high HIV incidence in individuals aged below 45 years. With new guidelines and the 95-95-95 UNAIDS target, prevalence and incidence must be adequately assessed. In addition, there is a need for additional efforts to assess the impact of HIV/AIDS prevention programmes and intervention services, especially in these areas where resources are limited.

Why marry early? Parental influence, agency and gendered conflict in Tanzanian marriages.

Global health interventions increasingly target the abolishment of 'child marriage' (marriage under 18 years, hereafter referred to as 'early marriage'). Guided by human behavioural ecology theory, and drawing on focus groups and in-depth interviews in an urbanising Tanzanian community where female early marriage is normative, we examine the common assumption that it is driven by the interests and coercive actions of parents and/or men. We find limited support for parent-offspring conflict. Parents often encouraged early marriages, but were motivated by the promise of social and economic security for daughters, rather than bridewealth transfers alone. Moreover, forced marriage appears rare, and adolescent girls and young women (AGYW) were active agents in the transition to marriage, sometimes marrying against parental wishes. Support for gendered conflict was stronger. AGYW were described as being lured into unstable relationships by men misrepresenting their long-term intentions. Community members voiced concerns over these marriages. Overall, early marriage appears rooted in limited options, encouraging strategic, but risky choices on the marriage market. Our results highlight plurality and context dependency in drivers of early marriage, even within a single community. We conclude that engaging with the importance of context is fundamental in forging culturally sensitive policies and programs on early marriage.

No association between fertility desire and HIV infections among men and women: Findings from community-based studies before and after implementation of an early antiretroviral therapy (ART) initiation program in the rural district of North-western Tanzania.

Background: Fertility is associated with the desire to have children. The impacts of HIV and antiretroviral therapy (ART) on fertility are well known, but their impacts on the desire for children are less well known in Tanzania. We used data from two studies carried out at different periods of ART coverage in rural Tanzania to explore the relationship between HIV infection and fertility desires in men and women. Methods: We conducted secondary data analysis of the two community-based studies conducted in 2012 and 2017 in the Magu Health and Demographic system site, in Tanzania. Information on fertility desires, HIV status, and social-economic and demographic variables were analyzed. Fertility desire was defined as whether or not the participant wanted to bear a child in the next two years. The main analysis used log-binomial regression to assess the association between fertility desire and HIV infection. Results: In the 2012 study, 43% (95% CI 40.7-45.3) of men and 33.3% (95% CI 31.8 - 35.0) women wanted another child in the next two years. In 2017 the percentage rose to 55.7% (95% CI 53.6 - 57.8) in men and 41.5% (95% CI 39.8 - 43.1) in women. Although fertility desire in men and women were higher in HIV uninfected compared to HIV infected, age-adjusted analysis did not show a statistical significance difference in both studies (2012: PR=1.02, 95%CI 0.835 - 1.174, p<0.915 and 2017: PR = 0.90 95%CI 0.743 - 1.084 p= 0.262). Discussion: One-third of women and forty percent of men desired for fertility in 2012, while forty percent of women and nearly half of men desired for fertility in 2017. The data showed fertility desire, in 2012 and 2017 were not related to HIV infection in both periods of ART coverage.

Positive Correlation Between Women's Status and Intimate Partner Violence Suggests Violence Backlash in Mwanza, Tanzania.

Urbanization in low and middle-income nations is characterized by economic and demographic shifts largely understood to be beneficial to women's empowerment. These changes include increased education and wage-labor opportunities, a disruption of traditional patrilocal residence systems, and reductions in spousal age gap and fertility. However, such changes may drive a "violence backlash," with men increasing intimate partner violence (IPV) in efforts to challenge women's shifting status. To date, tests of this idea primarily relate to women's changing economic status, with less known about the demographic correlates of IPV in urbanizing settings. Addressing this, we conducted a cross-sectional study of IPV behavior and attitudes in an urbanizing community in Mwanza, northern Tanzania (n = 317). Consistent with a violence backlash, IPV was reported more often among women educated at higher levels than their husband, and women earning similar, rather than lower, wages to their husband were more likely to report that he condones IPV. These findings were independent of women's absolute education and income. Furthermore, less frequent paternal kin contact, and relatively small spousal age gaps, generally understood to boost women's empowerment, were associated with an increased risk of experiencing IPV. Less frequent paternal kin contact was also associated with an increased likelihood that a husband condones IPV. Contrary to our predictions, relatively lower fertility, generally linked to higher women's empowerment, did not predict IPV behavior and women with high, rather than low, fertility were more likely to report that their husband condones IPV. Overall, our results support the notion of a violence backlash corresponding to economic changes for women that accompany urbanization. In contrast, demographic changes associated with urbanization have more variable relationships. Drawing on these results, we suggest future research avenues for better understanding the vulnerability of women to IPV in urbanizing settings.

Viral Load Status Before Switching to Dolutegravir-Containing Antiretroviral Therapy and Associations With Human Immunodeficiency Virus Treatment Outcomes in Sub-Saharan Africa.

BACKGROUND: Dolutegravir is being rolled out globally as part of preferred antiretroviral therapy (ART) regimens, including among treatment-experienced patients. The role of viral load (VL) testing before switching patients already on ART to a dolutegravir-containing regimen is less clear in real-world settings. METHODS: We included patients from the International epidemiology Databases to Evaluate AIDS consortium who switched from a nevirapine- or efavirenz-containing regimen to one with dolutegravir. We used multivariable cause-specific hazards regression to estimate the association of the most recent VL test in the 12 months before switching with subsequent outcomes. RESULTS: We included 36 393 patients at 37 sites in 5 countries (Democratic Republic of the Congo, Kenya, Rwanda, Tanzania, Uganda) who switched to dolutegravir from July 2017 through February 2020, with a median follow-up of approximately 11 months. Compared with those who switched with a VL <200 copies/mL, patients without a recent VL test or with a preswitch VL ≥1000 copies/mL had significantly increased hazards of an incident VL ≥1000 copies/mL (adjusted hazard ratio [aHR], 2.89; 95% confidence interval [CI], 1.99-4.19 and aHR, 6.60; 95% CI, 4.36-9.99, respectively) and pulmonary tuberculosis or a World Health Organization clinical stage 4 event (aHR, 4.78; 95% CI, 2.77-8.24 and aHR, 13.97; 95% CI, 6.62-29.50, respectively). CONCLUSIONS: A VL test before switching to dolutegravir may help identify patients who need additional clinical monitoring and/or adherence support. Further surveillance of patients who switched to dolutegravir with an unknown or unsuppressed VL is needed.

Age patterns of HIV incidence in eastern and southern Africa: a modelling analysis of observational population-based cohort studies.

BACKGROUND: As the HIV epidemic in sub-Saharan Africa matures, evidence about the age distribution of new HIV infections and how this distribution has changed over the epidemic is needed to guide HIV prevention. We aimed to assess trends in age-specific HIV incidence in six population-based cohort studies in eastern and southern Africa, reporting changes in mean age at infection, age distribution of new infections, and birth cohort cumulative incidence. METHODS: We used a Bayesian model to reconstruct age-specific HIV incidence from repeated observations of individuals' HIV serostatus and survival collected among population HIV cohorts in rural Malawi, South Africa, Tanzania, Uganda, and Zimbabwe, in a collaborative analysis of the ALPHA network. We modelled HIV incidence rates by age, time, and sex using smoothing splines functions. We estimated incidence trends separately by sex and study. We used estimated incidence and prevalence results for 2000-17, standardised to study population distribution, to estimate mean age at infection and proportion of new infections by age. We also estimated cumulative incidence (lifetime risk of infection) by birth cohort. FINDINGS: Age-specific incidence declined at all ages, although the timing and pattern of decline varied by study. The mean age at infection was higher in men (cohort mean 27·8-34·6 years) than in women (24·8-29·6 years). Between 2000 and 2017, the mean age at infection per cohort increased slightly: 0·5 to 2·8 years among men and -0·2 to 2·5 years among women. Across studies, between 38% and 63% (cohort medians) of the infections in women were among those aged 15-24 years and between 30% and 63% of infections in men were in those aged 20-29 years. Lifetime risk of HIV declined for successive birth cohorts. INTERPRETATION: HIV incidence declined in all age groups and shifted slightly to older ages. Disproportionate new HIV infections occur among women aged 15-24 years and men aged 20-29 years, supporting focused prevention in these groups. However, 40-60% of infections were outside these ages, emphasising the importance of providing appropriate HIV prevention to adults of all ages. FUNDING: Bill & Melinda Gates Foundation.

"I have never seen something like that": Discrepancies between lived experiences and the global health concept of child marriage in northern Tanzania.

BACKGROUND: The concept of 'child marriage' in global health distinguishes ostensibly harmful from healthy ages to marry at a universally-applied threshold of 18-years. With intensifying efforts to end child marriage, targeted communities are increasingly asked to change their perception of such marriages from relatively benign to profoundly problematic. The objective of this study is to understand how this shift in perception is navigated by adolescent girls and young women (AGYW). METHODS: Using qualitative data collected in 2019 from a semi-urban community in Tanzania where marriage under 18-years is common and campaigns to end child marriage ongoing, we contrast reports of lived experiences of marriage under 18-years among AGYW to views of child marriage as an abstract concept. Thirteen in-depth interviews with AGYW, as part of a wider qualitative study, were recorded, transcribed, and analyzed using a framework analysis approach. RESULTS: While many AGYW had heard of child marriage, the concept was routinely conflated with forced marriage, which is rare in the community, and non-marital teenage sex and pregnancy, which are common. As a likely consequence, participants disagreed on whether or not child marriage occurs locally. Furthermore, accounts of real-life marriages under 18 sometimes aligned with, but often departed from, common narratives about the purported causes and harmful consequences inherent to the global health concept of child marriage. CONCLUSIONS: We argue that engaging with diverse local views and experiences of marrying young is essential to producing culturally-sensitive, effective initiatives addressing the vulnerabilities of female adolescence.

He for she? Variation and exaggeration in men's support for women's empowerment in northern Tanzania.

Achieving gender equality fundamentally requires a transfer of power from men to women. Yet data on men's support for women's empowerment (WE) remains scant and limited by reliance on self-report methodologies. Here, we examine men's support for WE as a sexual conflict trait, both via direct surveys (n = 590) and indirectly by asking men's wives (n = 317) to speculate on their husband's views. Data come from a semi-urban community in Mwanza, Tanzania. Consistent with reduced resource competition and increased exposure to relatively egalitarian gender norms, higher socioeconomic status predicted greater support for WE. However, potential demographic indicators of sexual conflict (high fertility, polygyny, large spousal age gap) were largely unrelated to men's support for WE. Contrasting self- and wife-reported measures suggests that men frequently exaggerate their support for women in self-reported attitudes. Discrepancies were especially pronounced among men claiming the highest support for WE, but smallest among men who held a professional occupation and whose wife participated in wage labour, indicating that these factors predict genuine support for WE. We discuss the implications of these results for our understanding of both individual variation and patriarchal gender norms, emphasising the benefits of greater exchange between the evolutionary human sciences and global health research on these themes.

When marriage is the best available option: Perceptions of opportunity and risk in female adolescence in Tanzania.

Global health studies typically characterise adolescent marriage as a fundamental risk to female wellbeing. In contrast, ethnographic research among communities 'at risk' identifies that early marriage is often viewed as an opportunity weighed against locally feasible alternatives. Addressing this contradiction, we document perceived risks and opportunities of marriage, positioning them among wider concerns facing female adolescents in north-western Tanzania. On the basis of these data, we then provide recommendations for global efforts to end the marriage of minors. Thirteen focus groups and 26 in-depth interviews were conducted in 2019 with female adolescents, young women and men, and parents of female adolescents from a semi-urban community where adolescent marriage is normative. Data were compiled to synthesise narratives of adolescent risk and opportunity. Marriage was viewed as an opportunity for adolescent girls, bringing benefits such as increased social status. Risks sometimes outweighed benefits of marriage, but marriage remained desirable when structural constraints, like poverty, limited feasible alternatives and when adolescents faced similar risks, like pregnancy, outside of marriage. We conclude that remaining unmarried does not shield adolescents from adversity, and campaigns targeting adolescent marriage via criminalisation, without diminishing other risks of adolescence, may further limit rather than expand options for adolescent girls.

Lockdown measures in response to COVID-19 in nine sub-Saharan African countries.

Lockdown measures have been introduced worldwide to contain the transmission of COVID-19. However, the term 'lockdown' is not well-defined. Indeed, WHO's reference to 'so-called lockdown measures' indicates the absence of a clear and universally accepted definition of the term 'lockdown'. We propose a definition of 'lockdown' based on a two-by-two matrix that categorises different communicable disease measures based on whether they are compulsory or voluntary; and whether they are targeted at identifiable individuals or facilities, or whether they are applied indiscriminately to a general population or area. Using this definition, we describe the design, timing and implementation of lockdown measures in nine countries in sub-Saharan Africa: Ghana, Nigeria, South Africa, Sierra Leone, Sudan, Tanzania, Uganda, Zambia and Zimbabwe. While there were some commonalities in the implementation of lockdown across these countries, a more notable finding was the variation in the design, timing and implementation of lockdown measures. We also found that the number of reported cases is heavily dependent on the number of tests carried out, and that testing rates ranged from 2031 to 63 928 per million population up until 7 September 2020. The reported number of COVID-19 deaths per million population also varies (0.4 to 250 up until 7 September 2020), but is generally low when compared with countries in Europe and North America. While lockdown measures may have helped inhibit community transmission, the pattern and nature of the epidemic remains unclear. However, there are signs of lockdown harming health by affecting the functioning of the health system and causing social and economic disruption.

Direct maternal deaths attributable to HIV in the era of antiretroviral therapy: evidence from three population-based HIV cohorts with verbal autopsy.

OBJECTIVE: To assess whether HIV is associated with an increased risk of mortality from direct maternal complications. DESIGN: Population-based cohort study using data from three demographic surveillance sites in Eastern and Southern Africa. METHODS: We use verbal autopsy data, with cause of death assigned using the InSilicoVA algorithm, to describe the association between HIV and direct maternal deaths amongst women aged 20-49 years. We report direct maternal mortality rates by HIV status, and crude and adjusted rate ratios comparing HIV-infected and uninfected women, by study site and by ART availability. We pool the study-specific rate ratios using random-effects meta-analysis. RESULTS: There was strong evidence that HIV increased the rate of direct maternal mortality across all the study sites in the period ART was widely available, with the rate ratios varying from 4.5 in Karonga, Malawi [95% confidence interval (CI) 1.6-12.6] to 5.2 in Kisesa, Tanzania (95% CI 1.7-16.1) and 5.9 in uMkhanyakude, South Africa (95% CI 2.3-15.2) after adjusting for sociodemographic confounders. Combining these adjusted results across the study sites, we estimated that HIV-infected women have 5.2 times the rate of direct maternal mortality compared with HIV-uninfected women (95% CI 2.9-9.5). CONCLUSION: HIV-infected women face higher rates of mortality from direct maternal causes, which suggests that we need to improve access to quality maternity care for these women. These findings also have implications for the surveillance of HIV/AIDS-related mortality, as not all excess mortality attributable to HIV will be explicitly attributed to HIV/AIDS on the basis of a verbal autopsy interview.