Infection prevention and control and related practices in African neonatal units: The Pan-African neonatal care assessment study (PANCAS).

BACKGROUND: The burden of neonatal mortality is primarily borne by low- and middle-income countries (LMICs), including deaths due to healthcare-associated infections (HAIs). Few studies have assessed infection prevention and control (IP&C) practices in African units caring for small and/or sick newborns aimed to reduce HAIs. METHODS: We performed a mixed-methods study composed of a survey and virtual tour to assess IP&C and related practices. We created a survey composed of multiple-choice and open-ended questions delivered to site respondents via Zoom or video equivalent. Respondents provided a virtual tour of their unit via video and the study team used a checklist to evaluate specific practices. RESULTS: We recruited 45 units caring for small and sick newborns in 20 African countries. Opportunities to optimize hand hygiene, Water, Sanitation and Hygiene (WASH) practices, Kangaroo Mother Care, and IP&C training were noted. The virtual tour offered further understanding of IP&C challenges unique to individual sites. All respondents expressed the need for additional space, equipment, supplies, education, and IP&C staff and emphasized that attention to maternal comfort was important to IP&C success. DISCUSSION: This study identified opportunities to improve IP&C practices using low-cost measures including further education and peer support through learning collaboratives. Virtual tours can be used to provide site-specific assessment and feedback from peers, IP&C specialists and environmental engineering experts.

SARS-CoV-2 co-detection with influenza and human respiratory syncytial virus in Ethiopia: Findings from the severe acute respiratory illness (SARI) and influenza-like illness (ILI) sentinel surveillance, January 01, 2021, to June 30, 2022.

SARS-CoV-2 co-infection with the influenza virus or human respiratory syncytial virus (RSV) may complicate its progress and clinical outcomes. However, data on the co-detection of SARS-CoV-2 with other respiratory viruses are limited in Ethiopia and other parts of Africa to inform evidence-based response and decision-making. We analyzed 4,989 patients' data captured from the national severe acute respiratory illness (SARI) and influenza-like illness (ILI) sentinel surveillance sites over 18 months period from January 01, 2021, to June 30, 2022. Laboratory specimens were collected from the patients and tested for viral respiratory pathogens by real-time, reverse transcription polymerase chain reaction (RT-PCR) at the national influenza center. The median age of the patients was 14 years (IQR: 1-35 years), with a slight preponderance of them being at the age of 15 to less than 50 years. SARS-CoV-2 was detected among 459 (9.2%, 95% CI: 8.4-10.0) patients, and 64 (1.3%, 95% CI: 1.0-1.6) of SARS-CoV-2 were co-detected either with Influenza virus (54.7%) or RSV (32.8%) and 12.5% were detected with both of the viruses. A substantial proportion (54.7%) of SARS-CoV-2 co-detection with other respiratory viruses was identified among patients in the age group from 15 to less than 50 years. The multivariable analysis found that the odds of SARS-CoV-2 co-detection was higher among individuals with the age category of 20 to 39 years as compared to those less than 20 years old (AOR: 1.98, 95%CI:1.15-3.42) while the odds of SARS-CoV-2 co-detection was lower among cases from other regions of the country as compared to those from Addis Ababa (AOR:0.16 95%CI:0.07-0.34). Although the SARS-CoV-2 co-detection with other respiratory viral pathogens was minimal, the findings of this study underscore that it is critical to continuously monitor the co-infections to reduce transmission and improve patient outcomes, particularly among the youth and patients with ILI.

Brief Report: Self-Reported HIV-Positive Status but Subsequent HIV-Negative Test Results in Population-Based HIV Impact Assessment Survey Participants-11 Sub-Saharan African Countries, 2015-2018.

BACKGROUND: HIV testing is a critical step to accessing antiretroviral therapy (ART) because early diagnosis can facilitate earlier initiation of ART. This study presents aggregated data of individuals who self-reported being HIV-positive but subsequently tested HIV-negative during nationally representative Population-Based HIV Impact Assessment surveys conducted in 11 countries from 2015 to 2018. METHOD: Survey participants aged 15 years or older were interviewed by trained personnel using a standard questionnaire to determine HIV testing history and self-reported HIV status. Home-based HIV testing and counseling using rapid diagnostic tests with return of results were performed by survey staff according to the respective national HIV testing services algorithms on venous blood samples. Laboratory-based confirmatory HIV testing for all participants identified as HIV-positives and self-reported positives, irrespective of HIV testing results, was conducted and included Geenius HIV-1/2 and DNA polymerase chain reaction if Geenius was negative or indeterminate. RESULTS: Of the 16,630 participants who self-reported as HIV-positive, 16,432 (98.6%) were confirmed as HIV-positive and 198 (1.4%) were HIV-negative by subsequent laboratory-based testing. Participants who self-reported as HIV-positive but tested HIV-negative were significantly younger than 30 years, less likely to have received ART, and less likely to have received a CD4 test compared with participants who self-reported as HIV-positive with laboratory-confirmed infection. CONCLUSIONS: A small proportion of self-reported HIV-positive individuals could not be confirmed as positive, which could be due to initial misdiagnosis, deliberate wrong self-report, or misunderstanding of the questionnaire. As universal ART access is expanding, it is increasingly important to ensure quality of HIV testing and confirmation of HIV diagnosis before ART initiation.

Use of Electronic Quality Monitoring Tool and Central Dashboard to Improve Clinical and Programmatic Decisions.

The HIV service quality improvement tool is deployed in 123 health facilities in Ethiopia. The tool uses a central dashboard for visualization and decision making at the health facility and higher levels of the health systems. The dashboard is developed on excel with analytics about HIV testing, case finding, treatment linkage and quality indicators. The dashboard was developed based on the requirements requested during discussions with HIV clinicians and the program team.

Data-Exchange Between Electronic Medical Record and Viral-Load Laboratory Database Towards Improving HIV Care in Ethiopia.

Electronic viral load (VL) Test Ordering and Result Reporting System (ETORRS) was introduced to create data exchange between the existing VL database and the electronic medical record (EMR) system, with the aim of reducing laboratory test results turnaround time (TAT), improving data quality, and supporting timely clinical response for patients with high VL. This use case is an illustrative example of initiating and adopting the principles of health information exchange for a priority health program.

Prevalence and factors associated with inconsistent condom use among female sex workers in Ethiopia: findings from the national biobehavioral survey, 2020.

BACKGROUND: The HIV prevalence among Ethiopian female sex workers (FSWs) is estimated to be around 18.5%, which implies that FSWs' sexual partners are significantly exposed to HIV infection and that may be a major factor in HIV transmission in the community. However, it has long been known that using condoms correctly and consistently is an extremely cost-effective global method for preventing HIV infection, but inconsistent condom use (ICU) would pose the greatest proximal risk of HIV acquisition and transmission. Understanding the prevalence and associated risk factors of inconsistence condom use among FSWs would inform policymakers to design programmatic interventions in the context of Ethiopia. METHODS: This analysis used data from the 'National HIV and STIs Bio-behavioral Survey (NHSBS)', which was conducted between December 2019 up to May 2020 by using a respondent-driven sampling (RDS) technique among FSWs aged 15 years and older who were selling sex in selected major cities and towns in Ethiopia. A multi-level logistic regression model was fitted to assess town and individual-level variations simultaneously to adjust hierarchical variations. Statistical significance was determined by using a P-value less than 0.05 with a 95% confidence interval (CI) not including one. RESULTS: Overall, 6,085 FSWs from 16 cities and towns participated in the study. The prevalence of inconsistent condom use across the 16 cities and towns was 17.1% [95% CI (16.5, 17.8)]. Inconsistent condom use was significantly higher among FSWs who had depression compared to those without depression [AOR = 1.43; 95% CI (1.13,1.82)], used any drug [AOR = 1.43; 95% CI (1.14-1.79)], had history of sexual violence [AOR = 1.75; 95% CI (1.43, 2.16)], changed sex selling location [AOR = 1.27; 95% CI (1.06, 1.51)], longer period of sex selling experience [AOR = 3.01; 95% CI (2.27, 3.99)], ever had anal sex [AOR = 2.74; 95% CI (2.15, 3.5)], had ≥ 2 non-paying sexual partner [AOR = 2.99; 95% CI(2.26, 3.95)], selling sex `in more than two cities [AOR = 3.01;95% CI (2.27, 3.99)], who lacked access to condom [AOR = 2.1; 95% CI (1.69, 2.67)], and did not have HIV knowledge [AOR = 1.39; 95% CI (1.15, 1.68)]. CONCLUSION: Inconsistent condom use among FSWs is prevalent in Ethiopia and is associated with marital status, education status, depression, alcohol drinking, drug use, sexual violence, being raped, lack of knowledge about HIV, practising anal sex, selling sex in different locations, having more than two non-paying sexual partners, working in more than two cities, and lack of access to condom at the workplace. Programme interventions to enhance consistent condoms use among FSWs need to take these factors into consideration.

Correction: Prevalence and factors associated with hepatitis B and C virus infections among female Sex workers in Ethiopia: Results of the national biobehavioral Survey, 2020.

[This corrects the article DOI: 10.1371/journal.pone.0269510.].

Determinants of sexually transmitted infections among female sex workers in Ethiopia: a count regression model approach.

Background: Sexually transmitted infections (STIs) remain a major public health problem worldwide, with the burden of these infections being high among female sex workers (FSWs), who are often not aware of their infection status. This study aimed to determine the factors that are associated with the number of STIs among FSWs in Ethiopia. Methods: A cross-sectional bio-behavioral study involving respondent-driven sampling (RDS) was conducted among 6,085 FSWs in 16 towns in Ethiopia. The hurdle Poisson regression model was fitted using STATA Version 16.2. The incident rate ratio and adjusted odds ratio with a 95% confidence interval were employed to show the strength and direction of the association. A p-value of ≤0.05 was used as a threshold for statistical significance. Results: At least one STI was identified in 1,444 (23.64%) of the FSWs. Age group 35-49 years [IRR = 2.32; 95% CI (1.43, 3.74)], forced first sex [IRR = 1.32; 95% CI (1.01, 1.74)], condom breakage [IRR = 1.32; 95% CI (1.01, 1.74)], and a history of depression [IRR = 1.55; 95% CI (1.12, 2.18)] increase the number of STIs. FSWs aged 25-34 years [AOR = 2.99; % CI (2.54, 3.52)] and 35 = 59 years [AOR = 8.05; % CI (6.54, 9.91)], who were selling sex for 5-10 years [AOR = 1.30; 95% CI (1.1, 1.55)], and above 11 years [AOR = 1.21; 95% CI (1.03, 1.43)] were more likely to get STIs. Conclusion: STIs are common in Ethiopia. The covariates age, educational status, monthly income, condom failure, age at the first sexual encounter, and long duration of sexual practice are significant predictors of STIs. Health interventions among FSWs need to include awareness generation about the prevention and control of STIs and address the determinants identified in this analysis.

Contraception and intersection with HIV services in 11 high HIV burden sub-Saharan African countries: Results from the population-based HIV Impact Assessment cross-sectional studies conducted from 2015 to 2018.

OBJECTIVE: The United Nations' Sustainable Development Goal 3.7.1 addresses the importance of family planning. The objective of this paper is to provide information on family planning to policymakers to help increase access to contraceptive methods to women in sub-Saharan Africa. METHODS: We analyzed data from the Population-based HIV Impact Assessment studies conducted in 11 sub-Saharan African countries from 2015 to 2018 to assess the relationship between HIV services and family planning. Analyses were restricted to women aged 15-49 years who reported being sexually active within the past 12 months and had data on contraceptive use. RESULTS: Approximately 46.4% of participants reported using any form of contraception; 93.6% of whom used modern contraceptives. Women with a positive HIV status were more likely to use contraceptives (P < 0.0001) than HIV-negative women. Unmet need was higher among women who were confirmed to be HIV-negative in Namibia, Uganda, and Zambia than confirmed to be positive. Women aged 15-19 years used contraception less than 40% of the time. CONCLUSION: This analysis highlights crucial gaps in progress among HIV-negative and young women (aged 15-19 years). To provide access to modern contraception for all women, programs and governments need to focus on women who desire but do not have access to these family planning resources.

Predictors of HIV testing among youth 15-24 years in urban Ethiopia, 2017-2018 Ethiopia population-based HIV impact assessment.

INTRODUCTION: Youth (adolescents and young adults) aged 15-24 years comprise approximately 22% of Ethiopia's total population and make up 0.73% of HIV cases in urban Ethiopia. However, only 63% of HIV-positive youth are aware of their HIV status. We describe the HIV testing behaviors of youth 15-24 years and determined the characteristics of those who were most likely to be tested for HIV within the past year. METHODS: Using data from the 2017-2018 Ethiopia Population-based HIV Impact Assessment, we provide survey-weighted estimates and prevalence risk ratios for engagement in HIV testing in the 12 months preceding the survey. We model the likelihood of HIV testing one year or more before the survey compared to never testing, using a multinomial logistic regression model. RESULTS: Among HIV-negative and unaware HIV-positive youth 15-24 years old (N = 7,508), 21.8% [95% Confidence Interval (CI): 20.4-23.3%] reported testing for HIV in the last 12 months. Female youth [Prevalence Ratio (PR) = 1.6, 95% CI: 1.4-1.8], those aged 20-24 years (PR = 2.6, 95% CI:2.3-2.9), and those ever married (PR = 2.8, 95% CI: 2.5-3.1) were more likely to have tested for HIV within the last year. Adjusting for select demographic characteristics, sex with a non-spousal or non-live-in partner [Relative Risk (RR) = 0.3, 95% CI:0.1-0.8] among males did not increase their likelihood to test for HIV in the prior 12 months. Female youth engaged in antenatal care (RR = 3.0, 95% CI: 1.7-5.3) were more likely to test for HIV in the past year. CONCLUSION: The Ethiopian HIV case finding strategy may consider approaches for reaching untested youth, with a specific focus on adolescent males,15-19 years of age. This is critical towards achieving the UNAIDS HIV testing goal of 95% of all individuals living with HIV aware of their status by 2030.

Prevalence of syphilis and associated factors among female sex workers in Ethiopia: findings from a multilevel analysis of a national bio-behavioral survey.

BACKGROUND: Syphilis is a highly contagious sexually transmitted infection posing a significant public health challenge, especially in developing countries, including sub-Saharan Africa. Female sex workers are exposed to sexually transmitted infections, including syphilis, because of their sexual behavior and limited access to health services. However, data on national syphilis prevalence estimates and the associated factors are scarce in Ethiopia. This, as well as our limited knowledge about the extent of clustering among female sex workers in the country, is a critical gap in information we aimed to fill through this analysis. METHODS: The study was a cross-sectional, bio-behavioral survey conducted among female sex workers in six cities and ten major towns in Ethiopia. Participants were selected using a respondent-driven sampling method. Survey participants provided blood samples for syphilis, HIV, and hepatitis serological testing. Survey data were collected via an interviewer-administered questionnaire. In this analysis, we employed descriptive statistics to summarize data on the study variables. In addition, we used multilevel bivariable and multivariable logistic regression models to examine the association between independent variables and the dependent variable (syphilis prevalence) while accounting for the clustering effect. RESULT: A total of 6085 female sex workers participated in the survey. Their median age [Interquartile Range (IQR) was 25 (8)] years, and a majority (96.1%) were in the 20-24-year-old age group. The prevalence of syphilis among female sex workers in Ethiopia's six cities and ten major towns was 6.2%. Being in the age group of 30-34 (AOR = 2.64; 95% CI = 1.40, 4.98) and 35-59 (AOR = 4.7; 95% CI = 2.5, 8.86), being divorced/widowed (AOR = 1.37; 95% CI = 1.03, 1.82), having no formal education (AOR = 3.38; 95% CI = 2.34, 5.11), primary 1st cycle (grades 1-4) education (AOR = 2.77; 95% CI = 1.79, 4.30), and having primary 2nd cycle (grades 5-8) education (AOR = 1.80; 95% CI = 1.21, 2.69) were significantly associated with syphilis among female sex workers. CONCLUSION: The prevalence of syphilis among female sex workers was high. Being divorced/widowed or in the older age group and having a low level of education were significantly associated with an increased risk of syphilis. The high prevalence and associated factors identified need to be considered in planning comprehensive interventions to control syphilis among female sex workers in Ethiopia.

Prevalence and factors associated with hepatitis B and C virus infections among female Sex workers in Ethiopia: Results of the national biobehavioral Survey, 2020.

BACKGROUND: Hepatitis B and C virus infections are endemic diseases in sub-Saharan Africa, the region with the highest prevalence of these infections in the world. Female sex workers are exposed to sexually transmitted infections, including hepatitis B and C, because of their high-risk sexual behavior and limited access to health services. There are no large-scale data on the prevalence of hepatitis B and C virus infections among female sex workers in Ethiopia, a critical gap in information this study aimed to fill. METHODS: This was a cross-sectional, biobehavioral survey conducted from December 2019-April 2020 among 6085 female sex workers aged ≥15 years and residing in sixteen (16) regional capital cities and selected major towns of Ethiopia. Blood samples were collected from the participants for hepatitis B and C virus serological testing. The data were collected using an open data kits (ODK) software and imported into STATA version16 for analysis. Descriptive statistics (frequencies and proportions) were used to summarize data on the study variables. Bivariable and multivariable logistic regression analyses were conducted to determine the strength of association between independent variables (risk factors) and the outcome (hepatitis B and C virus infection). Adjusted Odd ratio (AOR) was used to determine independent associations, 95% confidence interval to assess precision of the estimates, and a P value ≤ 0.05 to determine statistically significant. RESULTS: The prevalence of hepatitis B and C infections among the 6085 female sex workers was 2.6% [(95% CI (2.2,2.8)] and 0.5% [(95% CI (0.4,0.7)], respectively. Female sex workers who had 61-90 and ≥91 paying clients in the past six months [(AOR = 1.66; 95% CI, (0.99, 2.79); P = 0.054] and [(AOR = 1.66 95% CI, (1.11, 2.49); P = 0.013], respectively, age at first sex selling of 20-24 and >25 years [(AOR = 1.67; 95% CI, (1.14, 2.44); P = 0.009)] and [(AOR = 1.56; 95% CI (1.004, 2.43); P = 0.048)], respectively, known HIV positive status [(AOR = 1.64; 95% CI (1.03, 2.62); P = 0.036] were significantly associated with the prevalence of hepatitis B virus infection. Similarly, hepatitis C was significantly associated with, age at first sex ≤15 years and age 16-20 years [(AOR = 0.21; 95%CI (0.07,0.61); P = 0.005)] and [(AOR = 0.18; 95% CI (0.061, 0.53); P = 0.002)], respectively, known HIV positive status [(AOR = 2.85; 95%CI (1.10,7.37); P = 0.031)] and testing positive for syphilis [(AOR = 4.38; 95% CI (1.73,11.11); P = 0.002)], respectively. CONCLUSION: This analysis reveals an intermediate prevalence of hepatitis B and a low prevalence of hepatitis C infection among female sex workers in Ethiopia. It also suggests that population groups like female sex workers are highly vulnerable to hepatitis B, hepatitis C, and other sexually transmitted infections. There is a need for strengthening treatment and prevention interventions, including immunization services for hepatitis B vaccination, increasing HCV testing, and provision of treatment services.

Spatial distribution and determinants of HIV prevalence among adults in urban Ethiopia: Findings from the Ethiopia Population-based HIV Impact Assessment Survey (2017-2018).

The design and evaluation of national HIV programs often rely on aggregated national data, which may obscure localized HIV epidemics. In Ethiopia, even though the national adult HIV prevalence has decreased, little information is available about local areas and subpopulations. To inform HIV prevention efforts for specific populations, we identified geographic locations and drivers of HIV transmission. We used data from adults aged 15-64 years who participated in the Ethiopian Population-based HIV Impact Assessment survey (October 2017-April 2018). Location-related information for the survey clusters was obtained from the 2007 Ethiopia population census. Spatial autocorrelation of HIV prevalence data were analyzed via a Global Moran's I test. Geographically weighted regression analysis was used to show the relationship of covariates. The finding indicated that uncircumcised men in certain hotspot towns and divorced or widowed individuals in hotspot woredas/towns might have contributed to the average increase in HIV prevalence in the hotspot areas. Hotspot analysis findings indicated that, localized, context-specific intervention efforts tailored to at-risk populations, such as divorced or widowed women or uncircumcised men, could decrease HIV transmission and prevalence in urban Ethiopia.

Progress towards controlling the HIV epidemic in urban Ethiopia: Findings from the 2017-2018 Ethiopia population-based HIV impact assessment survey.

INTRODUCTION: In 2014, the Joint United Nations Programme on HIV/AIDS set an 'ambitious' 90-90-90 target for 2020. By 2016, there were disparities observed among countries in their progress towards the targets and some believed the targets were not achievable. In this report, we present the results of data from the Ethiopia Population-based HIV Impact Assessment survey analyzed to assess progress with the targets and associated factors. METHODS: We conducted a nationally representative survey in urban areas of Ethiopia. Socio-demographic and behavioural data were collected from consenting participants using a structured interview. HIV testing was done following the national HIV rapid testing algorithm and seropositivity confirmed using a supplemental laboratory assay. HIV viral suppression was considered if the viral load was <1,000 RNA copies/ml. Screening antiretroviral drugs was done for efavirenz, lopinavir, and tenofovir, which were in use during the survey period. In this analysis, we generated weighted descriptive statistics and used bivariate and logistic regression analysis to examine for associations. The 95% confidence interval was used to measure the precision of estimates and the significance level set at p<0.05. RESULTS: Of 19,136 eligible participants aged 15-64 years, 614 (3% [95% CI: 0.8-3.3]) were HIV-positive, of which 79.0% (95% CI: 4.7-82.7) were aware of their HIV status, and 97.1% (95% CI: 95.0-98.3 were on antiretroviral therapy, of which 87.6% (95% CI: 83.9-90.5) achieved viral load suppression. Awareness about HIV-positive status was significantly higher among females (aOR = 2.8 [95% CI: 1.38-5.51]), significantly increased with age, the odds being highest for those aged 55-64 years (aOR = 11.4 [95% CI: 2.52-51.79]) compared to those 15-24 years, and was significantly higher among those who used condom at last sex in the past 12 months (aOR = 5.1 [95% CI: 1.68-15.25]). Individuals with secondary education and above were more likely to have achieved viral suppression (aOR = 8.2 [95% CI: 1.82-37.07]) compared with those with no education. CONCLUSION: Ethiopia made encouraging progress towards the UNAIDS 90-90-90 targets. The country needs to intensify its efforts to achieve the targets. A particular focus is required to fill the gaps in knowledge of HIV-positive status to increase case identification among population groups such as males, the youth, and those with low education.

Factors associated with unawareness of HIV-positive status in urban Ethiopia: Evidence from the Ethiopia population-based HIV impact assessment 2017-2018.

BACKGROUND: The HIV epidemic in Ethiopia is concentrated in urban areas. Ethiopia conducted a Population-based HIV Impact Assessment (EPHIA) in urban areas between October 2017 and April 2018 to measure the status of the country's response to the epidemic. METHODS: We conducted field data collection and HIV testing in randomly selected households using the national, rapid testing algorithm with laboratory confirmation of seropositive samples using a supplemental assay. In addition to self-report on HIV diagnosis and treatment, all HIV-positive participants were screened for a set of HIV antiretroviral (ARV) drugs indicative of the first- and second-line regimens. We calculated weighted frequencies and 95% confidence intervals to assess regional variation in participants' level of unawareness of their HIV-positive status (adjusted for ARV status). RESULTS: We interviewed 20,170 survey participants 15-64 years of age, of which 19,136 (95%) were tested for HIV, 614 (3.2%) tested positive, and 119 (21%) of HIV-positive persons were unaware of their HIV status. Progress towards the UNAIDS first 90 target (90% of people living with HIV would be aware of their HIV status by 2020) substantially differed by administrative region of the country. In the bivariate analysis using log binomial regression, three regions (Oromia, Addis Ababa, and Harari), male gender, and young age (15-24 years) were significantly associated with awareness of HIV positive status. In multivariate analysis, the same variables were associated with awareness of HIV-positive status. CONCLUSION: One-fifth of the HIV-positive urban population were unaware of their HIV-positive status. The number of unaware HIV-positive individuals has a different distribution than the HIV prevalence. National and regional planning and monitoring activities could address this potentially substantial source of undetected HIV infection by increasing HIV testing among young people, men and individuals who do not use condoms.

Unawareness of HIV Infection Among Men Aged 15-59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015-2019.

BACKGROUND: Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries. METHODS: Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV. RESULTS: A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity. CONCLUSION: Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services.

EMJ series on statistics and methods: variables, populations and samples

This the first article in the EMJ Series on Statistics and Methods describes "variables" which represent different demographic and clinical characteristics of several individuals in a data set. Various attributes of quantitative and qualitative variables, including type, scale of measurement and values they may take are presented. Some descriptive statistics and graphic summaries are introduced. Pertinent examples drawn from journal articles are provided. The article also defines "population" as used in statistics and epidemiology and highlights population in size and scope in the context of the research question to be answered. It emphasizes the need for explicitly defining sampling based on the research question in a particular study. In addition, the articles introduces concepts and notations related to parameter and statistic. It highlights the need for using appropriate sampling method in selecting a representative sample of the study population and to be able to make valid inferences and generalizations. It is indicated in this articles that specific issues requiring further details will be addressed in the Series articles in subsequent Issues of EMJ

EMJ series on statistics and methods: normal distribution and the central limit theorem

This second article in the EMJ Series on Statistics and Methods dwells on the basics of sampling distribution of' variables', which are presented in detail in the preceding article in this Issue of the Ethiopian Medical Journal (EMJ). The present article highlights recommended routines that need to be undertaken in order to understand information collected in a particular study before embarking on doing complex statistical analyses. It underscores the importance of descriptive statistics as a means to getting insights into data quality and learn about the scale and distribution of different variables in a data set. The article emphasizes the need for assessing the sampling distributions of variables as a prerequisite to making decide on selection of appropriate statistical techniques for in a data set. It describes salient features of a normally distributed random variable and touches on some other probability distributions commonly used in epidemiological studies. The article also describes the central limit theorem highlighting salient points on its conceptual basis in understanding sampling distributions of sample means and the implications of using normal distribution to make inference about the population based on summary measures from a sufficiently large sample