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Background: Same-sex attracted men in Tanzania and globally carry a disproportionate burden of HIV. Drawing on qualitative research, this article explores healthcare providers' ideas and recommendations regarding how to improve HIV prevention among same-sex attracted men. Methods: We carried out a qualitative study among healthcare workers in the cities of Dar es Salaam and Tanga in Tanzania between August 2018 and October 2019. Data were collected using qualitative methods of data collection, specifically in-depth interviews, focus group discussions, and participant observation. Study participants were recruited through a purposive sampling strategy that aimed to ensure variation in age, education, and work experience. Forty-eight interviews with 24 healthcare workers, six focus group discussions, and participant observation were conducted. A total of 64 persons participated in the study. Results: This paper describes five different "ways of reasoning" that were identified among healthcare workers regarding how to strengthen HIV prevention among same-sex attracted men. One held that punitive measures should be taken to prevent HIV transmission, another that health services needed to become more friendly towards men who have sex with men, a third that healthcare workers should reach out to provide more education to this population, a fourth called for strengthened collaboration between healthcare providers and same-sex attracted men in healthcare delivery, and the fifth proposed that activistic efforts be taken to remove structural barriers for same-sex attracted men to access healthcare. Conclusion: When reflecting on what is needed to strengthen HIV prevention among men who have sex with men, healthcare workers described six different ideas. One was that restrictive and punitive measures ought to be taken to prevent HIV transmission through same-sex sex. The remaining five promoted understanding of and support for same-sex attracted men. They prescribed more healthcare education, measures to improve attitudes among healthcare workers, healthcare delivery with user involvement, and political action to achieve law reform. Finally, some study participants raised concerns about the implementation of the national comprehensive package for key populations. [ABSTRACT FROM AUTHOR]

This paper deals with a theme that has been a topical issue since the beginning of 2020, the outbreak of coronavirus, by comparison with the philosophical and epistemological aspects of HIV/AIDS as they are reflected in different genres of Swahili literature. I will illustrate findings obtained through my analysis of William Mkufya's novels dealing with HIV/AIDS in a prospective way with the upcoming literature dealing with the Covid-19 pandemic. The conclusions I have drawn from the analysis of the philosophical novels, by the Tanzanian intellectual William Mkufya, will be the departure point for my follow-up research on the epistemological, ontological and phenomenological aspects of Covid-19 in Tanzania through different genres of Swahili literature. The potential objectives of this forthcoming research will be the following: firstly, to establish a fictional genre that articulates knowledge about Covid-19; secondly, to explore the evolution of Swahili language used to communicate messages on Covid-19; thirdly, to illustrate the changes undergone by literature after the impact of the Covid-19 outbreak; and finally, to investigate the philosophical perspectives characterising this literary stream: Humanist or post-humanist? [ABSTRACT FROM AUTHOR]

To diagnose ≥90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15–24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15–24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve ≥90% diagnostic coverage. [ABSTRACT FROM AUTHOR]

Introduction: In October 2013, Tanzania adopted Option B+ under which HIV-positive pregnant women are initiated on antiretroviral therapy in reproductive and child health clinics at diagnosis. Studies have shown that adherence and retention to antiretroviral treatment can be problematic. Methods: We implemented a group randomized controlled trial in 24 reproductive and child health clinics in eight districts in Mbeya region. The trial tested the impact of implementing paper-based appointment tracking and community outreach systems on the rate of missed appointments and number of days covered by dispensed antiretroviral medications among women previously established on antiretroviral therapy. We used interrupted time series analysis to assess study outcomes. Clinic staff and patients in intervention clinics were aware of the intervention because of change in clinic procedures; data collectors knew the study group assignment. Results: Three months pre-intervention, we identified 1924 and 1226 patients established on antiretroviral therapy for six months or more in intervention and control clinics, respectively, of whom 83.4% and 86.9% had one or more post-intervention visits. The unadjusted rate of missed visits declined from 36.5% to 34.4% in intervention clinics and increased from 38.9% to 45.5% in control clinics following the intervention. Interrupted time series analyses demonstrated a net decrease of 13.7% (95% CI [-15.4,-12.1]) for missed visits at six months post-intervention. Similar differential changes were observed for visits missed by 3, 7, 15, or 60 days. Conclusion: Appointment-tracking and community outreach significantly improved appointment-keeping for women on antiretroviral therapy. The facility staff controlled their workload better, identified missing patients rapidly, and worked with existing community organizations. There is now enough evidence to scale up this approach to all antiretroviral therapy and Option B+ reproductive and child health clinics in Tanzania as well as to evaluate the intervention in medical clinics that treat other chronic health conditions. Trial registration: Registry for International Development Impact Evaluations ID- [ABSTRACT FROM AUTHOR]

Background: HIV prevalence among people who use drugs (PWUD) in Tanzania is 4–7 times higher than in the general population, underscoring an urgent need to increase HIV testing and treatment among PWUD. Drug use stigma within HIV clinics is a barrier to HIV treatment for PWUD, yet few interventions to address HIV-clinic drug use stigma exist. Guided by the ADAPT-ITT model, we adapted the participatory training curriculum of the evidence-based Health Policy Plus Total Facility Approach to HIV stigma reduction, to address drug use stigma in HIV care and treatment clinics (CTCs). Methods: The first step in the training curriculum adaptation process was formative research. We conducted 32 in-depth interviews in Dar es Salaam, Tanzania: 18 (11 men and 7 women) with PWUD living with HIV, and 14 with a mix of clinical [7] and non-clinical [7] CTC staff (5 men and 9 women). Data were analyzed through rapid qualitative analysis to inform initial curriculum adaptation. This initial draft curriculum was then further adapted and refined through multiple iterative steps of review, feedback and revision including a 2-day stakeholder workshop and external expert review. Results: Four CTC drug use stigma drivers emerged as key to address in the curriculum adaptation: (1) Lack of awareness of the manifestations and consequences of drug use stigma in CTCs (e.g., name calling, ignoring PWUD and denial of care); (2) Negative stereotypes (e.g., all PWUD are thieves, dangerous); (3) Fear of providing services to PWUD, and; (4) Lack of knowledge about drug use as a medical condition and absence of skills to care for PWUD. Five, 2.5-hour participatory training sessions were developed with topics focused on creating awareness of stigma and its consequences, understanding and addressing stereotypes and fears of interacting with PWUD; understanding drug use, addiction, and co-occurring conditions; deepening understanding of drug use stigma and creating empathy, including a panel session with people who had used drugs; and working to create actionable change. Conclusion: Understanding context specific drivers and manifestations of drug use stigma from the perspective of PWUD and health workers allowed for ready adaptation of an existing evidence-based HIV-stigma reduction intervention to address drug use stigma in HIV care and treatment clinics. Future steps include a pilot test of the adapted intervention. [ABSTRACT FROM AUTHOR]

Background: Mobility is a key social determinant of health for female sex workers (FSWs). While extant research has focused on the adverse effects of mobility for FSWs, there are very few studies that have examined the multiple ways in which mobility may impact the lives of these mobile women from their perspective. This qualitative study aims to fill this gap by exploring how mobility impacts the lives, livelihoods, and HIV care and treatment from the perspectives of women living with HIV in two epidemic settings, the Dominican Republic and Tanzania. Methods: We conducted two rounds of in-depth interviews with 12 Dominican women and 12 Tanzanian women who were 18 years plus, had an HIV-positive diagnosis, and reported having exchanged sex for money in the last month. We utilized thematic analysis with a focus on intra- and intercomparisons to observe patterns within and across the two contexts. Results: We identified a salient pattern of three thematic "mobility paradoxes," which related to both disruptors and benefits of sex work mobility: (1) uncertainty versus autonomy: while sex work mobility often took place in contexts of vulnerability, which often led to women experiencing violence, it simultaneously benefitted women by allowing them to choose where they stayed and make plans on their terms; (2) financial insecurity versus profitability: although participants sometimes made less money than expected when they traveled for sex work, there was a powerful economic benefit for mobile women as it increased their likelihood of profitability; and (3) disorder and interruptions versus strategy and social support in HIV care and treatment: participants reported that they were sometimes inconsistent with their HIV appointments and medications when they traveled for sex work. On the other hand, mobility contributed to participants often becoming more strategic and creative in their HIV care and treatment and relying on one another for support. Conclusions: Findings indicate that sex work mobility is a nuanced, complex, and paradoxical phenomenon. Implications include the development of strengths-based and community empowerment mobile health initiatives tailored to mitigate disruptors of mobility while maximizing benefits for this population. [ABSTRACT FROM AUTHOR]

Background: HIV Early Infant Diagnosis (HEID) is critical for the timely initiation of HIV treatments and improved health outcomes among HIV-infected infants. However, the uptake of HEID remains largely low in Tanzania. This descriptive scoping review of evidence on HEID among HIV-exposed infants in Tanzania seeks to understand the dynamics of HEID, ART use and adherence to inform targeted interventions and promote its uptake. Methods: The Arksey and O'Malley's methodological framework guided this scoping review. We searched for peer-published articles on HEID in Tanzania through PubMed and Google Scholar with full-text retrieval from HINAR. We included only English language articles published between 2013 and 2022. Further searches for the materials on the reference lists of the publications yielded additional relevant articles. We carried out an inductive thematic analysis to analyze and synthesize the data. Results: In all, nine articles met the inclusion criteria and, hence, qualified for the review. The variations in the uptake of HEID in the empirical literature reviewed indicate an upward trend. HEID increased from 77.2% in 2009 to 97.8% in 2011 in Kilimanjaro, Mbeya and Tanga and from 53.2% in 2014 to 69.2% in 2016 in Dar es Salaam. The median age at the initial test ranged from 5.6 weeks in Kilimanjaro to 8.6 weeks in Mbeya. The uptake of HEID was necessitated by individual, household and health facility factors. Unknown HIV status at conception, low level of education of the household head, and large household size negatively affected uptake of HEID. The health facility factors such as unavailability of the test kits, long distances to the facility and transport costs negatively influenced HEID uptake. The percentage of HIV-positive infants on ART ranged from 52.7 to 61%, and loss to follow ranged from 31 to 61%. Conclusion: The uptake of HEID varied among regions depending on individual, household and health facility factors. Multifaced efforts are needed to address these factors for accelerated uptake of HEID and improved health outcomes and survival among this strategic population group. [ABSTRACT FROM AUTHOR]

Background: The rising prevalence of non-communicable diseases (NCDs) alongside the continuing high burden of HIV poses a serious challenge to middle- and low-income countries' healthcare systems. Pilot studies of integrated models of service delivery for HIV, hypertension and diabetes have demonstrated that they are feasible and acceptable among patients and care providers. This study assessed multi-stakeholders' perspectives of the delivery and receipt of integrated care in Tanzania. Methods: A qualitative process evaluation was conducted in Dar es Salaam region of Tanzania where the integrated service delivery model was implemented from July to November 2021. In-depth interviews were held with seven key informants at the national, regional and district levels, eight healthcare providers, two researchers working at the integrated clinic and forty patients benefiting from integrated services at a large hospital. Three focus group discussions were held with community leaders and residents of the hospital's catchment area, and clinic level observations were conducted. Thematic analysis was conducted followed by the use of Bronfenbrenner's ecological model to identify factors pertinent to sustaining and scaling up of the integrated model. Results: Participants of the study at all levels were aware of the increased prevalence of NCDs specifically for hypertension and diabetes and were concerned about the trend of increasing co-morbid conditions among people living with HIV (PLHIV). The integrated service delivery model was positively perceived by stakeholders because of its multiple benefits for both patients and the healthcare system. These include stigma and discrimination reduction, improved quality of care, efficient use of limited resources, cost and time saving, reduced duplication of services and fostering of early detection for undiagnosed conditions. The organisation of the clinic was critical in increased satisfaction. Several challenges were observed, which included costs for NCD services relative to free care for HIV and inconsistent availability of NCD medications. Conclusion: Stakeholders reported numerous benefits of the integrated service delivery model that are fundamental in improving the health of many Tanzanians living with NCDs and HIV. These benefits highlight the need for policy and decision-makers to sustain and expand the integrated service delivery model as a solution to many challenges facing the health system especially at the primary care level. [ABSTRACT FROM AUTHOR]

The perception of stigma can contribute to virological failure among people living with HIV (PLHIV). This study was conducted to find out how stigmatization and self-stigma affect the ability of people living with HIV (PLHIV) in Dar es Salaam, Tanzania, to keep their viral load down. This was a hospital-based cross-sectional study conducted in Temeke Regional Referral Hospital (RRH) and Amana RRH at the Care and Treatment Clinic (CTC) between July and August 2020 using a structured questionnaire with open- and close-ended questions. Multivariate logistic regression analysis was used to examine the factors of viral load suppression. The Chi-square test was used to compare the factors of stigmatization and viral load suppression. Altogether, 406 PLHIV participated, with the most being female respondents, 298 (73.2%). The majority (50%) were aged between 25 and 44 years, whereas 171 (42.5%) respondents were married. Most of the participants, 382 (94.6%), were on a dolutegravir-based regimen, with the majority, 215 (52.8%), having a refill interval of three months. Most respondents, 379 (93.1%), disclosed their status. Most participants, 355 (87.4%), preferred having a separate HIV clinic, while 130 (32.1%) participants were not ready to be attended by the health care workers (HCWs) familiar to them. Male patients were 60% less likely to suppress their viral load as compared to female patients (adjusted odds ratio [aOR]: 0.4, 95% confidence interval [95%]: 0.19–0.77, p-value = 0.007). The refill interval was significantly associated with viral load suppression. For example, patients with a one-month refill interval had odds of 0.01 (95% CI: 0.003–0.42, p-value = 0.0001) compared to six-month refill intervals. Stigmatization elements appeared to influence viral load suppression among PLHIV in the Dar es Salaam area, significantly predicting viral load outcomes when gender and time between refills were considered. [ABSTRACT FROM AUTHOR]

Background: In Africa, data on viral suppression among human immunodeficiency virus (HIV)-positive children and adolescents on antiretroviral (ART) are scarce. This study aimed to determine determinants of HIV viral load (VL) non-suppression among HIV-positive children and adolescents (< 20 years old) who attend care and treatment clinics (CTCs) in Tabora region from January 2018 to April 2022. Data were abstracted from CTCs' database and patient records including socio-demographic, ART drug regimen, clinical, virological and immunological features, for a maximum of 52 months. Viral non-suppression was defined as plasma VL ≥ 1000 copies/mil after 6 months on ART, during the follow-up period. Cox proportional hazards regression model and hazard ratios (HRs) were used in estimating the determinants of viral non-suppression. Results: A total of 378 HIV-positive children (0–9 years) and adolescents (10–19 years) were enrolled, of whom 124 (32.8%) had virological non-suppression. The overall rate of VL non-suppression was 1.38 (95% CI 1.15, 1.64) per 100 person-months of observation. After adjusting for other factors, determinants of viral non-suppression were poor ART adherence level at initiation of ART (HR = 3.3; 95% CI 2.16, 4.91), low CD4 count at ART initiation (HR = 1.66; 95% CI 1.20, 2.30), nevirapine (NVP)-based regimen (HR = 2.64; 95% CI 1.32, 5.26), efavirenz (EFV)-based regime (HR = 2.08; 95% CI 1.03, 4.18), lopinavir/ritonavir (LPV/r)-based regimen (HR = 2.21; 95% CI 1.13, 4.32) and being on second-line regimen (HR = 6.11; 95% CI 2.50, 14.96). Conclusions: HIV viral non-suppression among children and adolescents on ART in central Tanzania in the Tabora region is high (32.8%) and is associated with poor ART adherence level, low CD4 count, NVP-, EFV-, and LPV/r-based regimen. Early initiation of ART and intensified monitoring are required to improve viral suppression rates of HIV-infected children to attain the third goal of the UNAIDS 95-95-95. [ABSTRACT FROM AUTHOR]

Background: Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. Methods: An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). Results: More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). Conclusions: Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less "linkage-ready". Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed. [ABSTRACT FROM AUTHOR]

Background: HIV/AIDS remains the leading cause of death in sub-Saharan Africa. Due to multiple constraints experienced by households that seem to be disproportionally affected, families generally seek assistance from the community and external economic support. Previous researchers studied socioeconomic and gender inequality in HIV/AIDS prevalence in sub-Saharan African countries. However, very few researchers have paid attention to the external economic support for HIV/AIDS affected households in Tanzania. This study investigates the difference in economic support among households affected or not affected by the HIV/AIDS epidemic in Tanzania. Methods: Data used stemmed from the Tanzania HIV Impact Survey 2016–2017 (THIS) of the Population-based HIV Impact Assessment (PHIA) project, collected between 2016 and 2017 in Tanzania. The study population were the heads of households (adults) with age greater than 15. The dependent variable for the study was economic support. This consisted of both material and non-material assistance obtained from outside the household. Socio-demographic (economics) characteristics constituted the predictors of the study. Descriptive statistics and econometric modelling were used to analyse determinants associated with external economic support. Oaxaca-Blinder decomposition method was also performed to investigate the difference in economic support depending on households' serological status in Tanzania. Results: A total of 12,008 households were included. Almost 11% of the household heads indicated that their households received economic support. HIV/AIDS affected 7% of households. The mean age of the household heads was 45 years (SD ± 15) with a range of 16–80. The majority of household heads were men (72%). Being a household head affected by HIV/AIDS increases the probability to receive external economic support (p < 0.05). The difference in external economic support between the two groups (HIV/AIDS and no- HIV/AIDS households) was - 0.032 (p < 0.01). This gap was observed to favour households affected by HIV/AIDS. Almost 72% (− 0.023/− 0.032) of this difference was explained by characteristics such as the wealth index (p < 0.01), residence area (urban) (p < 0.01), marital status (widowed (p < 0.05) and divorced or separated) (p < 0.1) and age (p < 0.01). Conclusion: The difference in economic support across households affected or not affected by HIV/AIDS was explained by wealth index, residence area, marital status and age. These findings represent important implications for health policy regarding future economic support strategies for HIV/AIDS-affected households. [ABSTRACT FROM AUTHOR]

Evidence has demonstrated that immediate HIV treatment initiation upon a positive HIV test, referred to as Test and Treat, can help people living with HIV live longer, healthier lives and prevent HIV transmission. Although Tanzania adopted the evidence-based Test and Treat strategy since 2016, men were not being adequately reached for HIV services. A national campaign was launched to promote the new HIV services with a focus on men. To inform the development and implementation of the campaign, we conducted formative audience insights-gathering (AIG) sessions to assess facilitators and barriers to accessing HIV Test and Treat services and inform the concepts and materials for the campaign. Qualitative AIG interviews and focus group discussions were conducted with 54 people who were unaware or aware of their HIV status and currently or not currently on treatment, as well as health workers. Facilitators and barriers included a fear of testing positive, the desire to belong, control their narratives, and reinvent themselves to achieve their dreams and live a happy life. The campaign played off a My Happiness! creative concept to position antiretroviral therapy (ART) as a solution to fears around what life would be like after a positive HIV diagnosis. The development and implementation of the campaign were informed by the AIG sessions and national stakeholders, leading to strong partners' buy-in that supported the scale-up of the ongoing campaign from 12 to 26 regions via the collaborative efforts of government, donors, and implementing partners. [ABSTRACT FROM AUTHOR]

Recently, the food and malnutrition issues have taken centre stage within the arena of HIV/AIDS epidemic, with several calls being made for context-specific health and nutrition interventions to deal with the emerging food insecurity and malnutrition issues in settings with high burdens of HIV/AIDS. The use of probiotics as nutritional supplements in HIV/AIDS-affected and resource-poor settings has also been advocated. This paper presents the results of a qualitative study on community knowledge and perceptions about probiotics and their potential impact on people's everyday life in the context of the HIV/AIDS epidemic. In-depth interviews (n=26) were conducted with residents in Mwanza, Tanzania. The results showed that people living with HIV/AIDS, who were using probiotic yogurt produced through a joint partnership of Western Heads East, Tanzania Medical Research Institute and the Tukwamune Women's Group, reported perceived beneficial effects, such as gain in weight and improved health and well-being. Yet, these beneficial effects might be resulting in growing misconceptions about probiotic yogurt being 'medicine' for the treatment of HIV/AIDS; this is leading some people living with HIV/AIDS to abandon taking their antiretroviral medications based on the view that the probiotic yogurt is making them feel much better. The findings illustrate the potential challenges with regard to the introduction of nutritional food supplements into new contexts plagued by malnutrition and infectious diseases. Public-health education and awareness programmes are needed when introducing novel foods into such contexts. [ABSTRACT FROM AUTHOR]

Introduction: People who inject drugs (PWID) in Dar es Salaam, Tanzania, have a high prevalence of HIV and hepatitis C virus (HCV). While needle and syringe programmes (NSP), opioid agonist therapy (OAT) and anti‐retroviral therapy (ART) are available in Tanzania, their coverage is sub‐optimal. We assess the impact of existing and scaled up harm reduction (HR) interventions on HIV and HCV transmission among PWID in Dar es Salaam. Methods: An HIV and HCV transmission model among PWID in Tanzania was calibrated to data over 2006–2018 on HIV (∼30% and ∼67% prevalence in males and females in 2011) and HCV prevalence (∼16% in 2017), numbers on HR interventions (5254 ever on OAT in 2018, 766–1479 accessing NSP in 2017) and ART coverage (63.1% in 2015). We evaluated the impact of existing interventions in 2019 and impact by 2030 of scaling‐up the coverage of OAT (to 50% of PWID), NSP (75%, both combined termed "full HR") and ART (81% with 90% virally suppressed) from 2019, reducing sexual HIV transmission by 50%, and/or HCV‐treating 10% of PWID infected with HCV annually. Results: The model projects HIV and HCV prevalence of 19.0% (95% credibility interval: 16.4–21.2%) and 41.0% (24.4–49.0%) in 2019, respectively. For HIV, 24.6% (13.6–32.6%) and 70.3% (59.3–77.1%) of incident infections among male and female PWID are sexually transmitted, respectively. Due to their low coverage (22.8% for OAT, 16.3% for NSP in 2019), OAT and NSP averted 20.4% (12.9–24.7%) of HIV infections and 21.7% (17.0–25.2%) of HCV infections in 2019. Existing ART (68.5% coverage by 2019) averted 48.1% (29.7–64.3%) of HIV infections in 2019. Scaling up to full HR will reduce HIV and HCV incidence by 62.6% (52.5–74.0%) and 81.4% (56.7–81.4%), respectively, over 2019–2030; scaled up ART alongside full HR will decrease HIV incidence by 66.8% (55.6–77.5%), increasing to 81.5% (73.7–87.5%) when sexual risk is also reduced. HCV‐treatment alongside full HR will decrease HCV incidence by 92.4% (80.7–95.8%) by 2030. Conclusions: Combination interventions, including sexual risk reduction and HCV treatment, are needed to eliminate HCV and HIV among PWID in Tanzania. [ABSTRACT FROM AUTHOR]

Background: A variety of strategies have been used to reach men with HIV self-testing services, including social network-based HIV self-test kits distribution. However, few studies have assessed men's comfort to distribute to or receive HIV self-test kits from close male friends within the same social network. In this study, we assessed men's comfort to distribute to and/or receive HIV self-test kits from close male friends and associated factors among men who socialize in networks locally referred to as "camps" in Tanzania.Methods: Data are from the baseline survey of a cluster-randomized controlled trial conducted in June 2019 with 18 social networks or "camps" in Dar es Salaam, Tanzania. Participants were 18-year-old or older male camp members who were HIV-negative at the time of enrolment. We used the Generalized Estimating Equations (GEE) to assess factors associated with being comfortable to distribute to and/or receive HIV self-test kits from close male members within one's social network.Results: Of 505 participants, 67.9% (n = 342) reported being comfortable to distribute to while 68.2% (n = 344) were comfortable to receive HIV self-test kits from their close male friends. Ever having heard about HIV self-testing (Adjusted Prevalence Ratio (Adj. PR): 1.6; 95% Confidence Interval [CI]: 1.3, 1.9), willingness to self-test for HIV in front of a sexual partner (Adj. PR: 3.0; 95%CI: 1.5, 6.1) and exposure to peer-led HIV self-testing education and promotion (Adj. PR: 1.4; 95%CI: 1.2, 1.7) were significantly associated with being comfortable to distribute HIV self-test kits to close male members within one's social network. Similar results were observed for being comfortable to receive HIV self-test kits from a close male friend within one's social network.Conclusions: Overall, these findings suggest that distribution of HIV self-test kits through close male friends could improve the proportion of men reached with HIV self-testing services and improve HIV testing rates in this population where uptake remains low. However, additional promotional strategies such as peer-led HIV self-testing education are needed to raise awareness and increase the proportion of men who are comfortable to receive and/or distribute HIV self-testing kits. [ABSTRACT FROM AUTHOR]

Mortality assessment in cohorts with high numbers of persons lost to follow-up (LTFU) is challenging in settings with limited civil registration systems. We aimed to assess mortality in a clinical cohort (the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO)) of human immunodeficiency virus (HIV)-infected persons in rural Tanzania, accounting for unseen deaths among participants LTFU. We included adults enrolled in 2005–2015 and traced a nonrandom sample of those LTFU. We estimated mortality using Kaplan-Meier methods 1) with routinely captured data (method A), 2) crudely incorporating tracing data (method B), 3) weighting using tracing data to crudely correct for unobserved deaths among participants LTFU (method C), and 4) weighting using tracing data accounting for participant characteristics (method D). We investigated associated factors using proportional hazards models. Among 7,460 adults, 646 (9%) died, 883 (12%) transferred to other clinics, and 2,911 (39%) were LTFU. Of 2,010 (69%) traced participants, 325 (16%) were found: 131 (40%) had died and 130 (40%) had transferred. Five-year mortality estimates derived using the 4 methods were 13.1% (A), 16.2% (B), 36.8% (C), and 35.1% (D), respectively. Higher mortality was associated with male sex, referral as a hospital inpatient, living close to the index clinic, lower body mass index, more advanced World Health Organization HIV clinical stage, lower CD4 cell count, and less time since initiation of antiretroviral therapy. Adjusting for unseen deaths among participants LTFU approximately doubled the 5-year mortality estimates. Our approach is applicable to other cohort studies adopting targeted tracing. [ABSTRACT FROM AUTHOR]

Background: HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania. Methods: Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January–March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers' HIV status disclosure being the outcome variable was conducted. Results: The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16–1.28); unmarried (OR = 1.12, 95% CI 1.03–1.23); widowed (OR = 1.12, 95% CI 1.07–1.18); those without health insurance (OR = 1.36, 95% CI 1.28–1.45); age 61 + years (OR = 1.72, 95% CI 1.59–1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04–1.25); and rural residents (OR = 1.58, 95% CI 1.34–1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001). Conclusion: While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population. [ABSTRACT FROM AUTHOR]

Background: Prevalence of HIV infection among people who inject drugs (PWID) has been reported to be higher than that of the general population. The present study aimed to estimate the prevalence of HIV infection and associated risk factors among PWID in Dar es Salaam, Tanzania, following the introduction of a comprehensive HIV intervention package (CHIP) for PWID in the country in 2014. Methods: We conducted an integrated bio-behavioral survey (IBBS) among PWID using respondent-driven sampling (RDS) in Dar es Salaam, Tanzania, between October and December 2017. Data on socio-demographic characteristics and risky behaviors were collected through face-to-face interviews. Blood samples were collected and tested for HIV infection. We accounted for weighting in the analyses, and logistic regression was performed to assess risk factors for HIV infection. Results: A total of 611 PWID (94.4% males and 5.6% females) with a median age of 34 years (IQR 29–38) were recruited. The overall prevalence of HIV infection was 8.7% (95% CI 6.5–10.9). The prevalence of HIV infections for males and females were 6.8% (95% CI 4.7–8.9%) and 41.2% (95% CI 23.7–58.6%) respectively. Adjusted weighted logistic regression analysis (WLRA) showed that being a female (aOR 19.1; 95% CI 5.9–61.8), injecting drugs for more than 10 years (aOR = 7.32; 95% CI 2.1–25.5) compared to 1 year or less and being 45 years or older (aOR = 34.22; 95% CI 2.4–489.5) compared to being 25 years or younger were associated with increased odds of HIV infection. Use of a sterile needle at last injection decreased odds of HIV infection (aOR = 0.3; 95% CI 0.1–0.8). Conclusions: The present study observed a decline in prevalence of HIV infections among PWID in Dar es Salaam (8.7%) compared to a previous estimate of 15.5% from an IBBS conducted in 2013. Despite the decrease, HIV prevalence remains high among PWID compared to the general population, and women are disproportionally affected. The decline may be possibly attributed to the on-going implementation of CHIP for PWID, highlighting the need for strengthening the existing harm reduction interventions by incorporating access to sterile needle/syringe and addressing the layered risks for women. [ABSTRACT FROM AUTHOR]

Previous research suggests that Tanzanian MSM might prefer consulting pharmacies and drugstores, rather than public healthcare services, when in need of STI medicines and treatment. Yet, few studies have explored the experiences of providing services to MSM clients among those working at pharmacies and drugstores and examined what challenges they encounter in providing these services. To gain increased knowledge and understanding of the perceived challenges encountered by pharmacists and drugstore workers when providing STI services to MSM clients in Dar es Salaam, Tanzania. In early 2016, 16 semi-structured interviews were conducted with persons working at private pharmacies and drugstores in Dar es Salaam. Data were interpreted through qualitative content analysis. The overarching theme that emerged was labelled 'Fighting an uphill battle', which reflected the challenges pharmacy workers experienced during interactions with MSM clients, and in particular service provision. Pharmacy workers tried to act upon the best of their knowledge to meet the needs of clients, given their understanding of risks and obstacles that MSM faced. Yet, the lack of educational and professional preparedness and insufficient financial and human resources, regarded as necessary to meet the needs of a stigmatised client group, formed barriers for effective service delivery. In order to support pharmacists and drug-store workers in Tanzania to address perceived challenges for service delivery to MSM clients, systematic and continuous training on MSM's sexual health is required. Furthermore, inter-professional cooperation that harnesses provider involvement from all tiers in the healthcare system is essential to offer complementary services to ensure proper STI care and treatment. Thus, interventions that focus on inter-professional communication and interaction between pharmacists and physicians could have a positive impact on timely referrals of suspected STI cases among marginalised populations. [ABSTRACT FROM AUTHOR]

Background: HIV-related stigma significantly impacts HIV care engagement, including in prevention of mother-to-child transmission of HIV (PMTCT) programs. Maisha is a stigma-based counseling intervention delivered during the first antenatal care (ANC) visit, complementing routine HIV counseling and testing. The goal of Maisha is to promote readiness to initiate and sustain treatment among those who are HIV-positive, and to reduce HIV stigmatizing attitudes among those who test negative.Methods: A pilot randomized control trial will assess the feasibility and acceptability of delivering Maisha in a clinical setting, and the potential efficacy of the intervention on HIV care engagement outcomes (for HIV-positive participants) and HIV stigma constructs (for all participants). A total of 1000 women and approximately 700 male partners will be recruited from two study clinics in the Moshi municipality of Tanzania. Participants will be enrolled at their first ANC visit, prior to HIV testing. It is estimated that 50 women (5%) will be identified as HIV-positive. Following consent and a baseline survey, participants will be randomly assigned to either the control (standard of care) or the Maisha intervention. The Maisha intervention includes a video and counseling session prior to HIV testing, and two additional counseling sessions if the participant tests positive for HIV or has an established HIV diagnosis. A subset of approximately 500 enrolled participants (all HIV-positive participants, and a random selection of HIV-negative participants who have elevated stigma attitude scores) will complete a follow-up assessment at 3 months. Measures will include health outcomes (care engagement, antiretroviral adherence, depression) and HIV stigma outcomes. Quality assurance data will be collected and the feasibility and acceptability of the intervention will be described. Statistical analysis will examine potential differences between conditions in health outcomes and stigma measures, stratified by HIV status.Discussion: ANC provides a unique and important entry point to address HIV stigma. Interventions are needed to improve retention in PMTCT care and to improve community attitudes toward people living with HIV. Results of the Maisha pilot trial will be used to generate parameter estimates and potential ranges of values to estimate power for a full cluster-randomized trial in PMTCT settings, with extended follow-up and enhanced adherence measurement using a biomarker.Trial Registration: ClinicalTrials.gov, NCT03600142. Registered on 25 July 2018. [ABSTRACT FROM AUTHOR]

Background: Little has been documented about partner violence among adolescent girls and young women (AGYW) who are out of school, a factor associated with HIV acquisition. To understand areas for prioritising HIV prevention intervention efforts, we explored the prevalence and correlates of partner violence among out of school AGYW in Shinyanga, Tanzania. Methods: A cross-sectional analysis of data from AGYW aged 15–23 years recruited in a cluster randomised trial conducted between October and December 2017 was used to examine correlates of partner violence. Data were collected through an Audio Computer-Assisted Self-interview. Multivariate logistic regression analysis was used to evaluate the association. Results: 2276 (75.5%) AGYW were sexually active. Of these, 816 (35.9%) reported having experienced violence from partners in the last six months. After adjusting for other covariates, being formerly married (AOR = 1.55, 95% CI:1.02, 2.37), having children (AOR = 1.79, 95% CI:1.47, 2.16), anxiety and depression symptoms (AOR = 3.27, 95%CI: 2.15, 4.96), having engaged in sex work in the past six months (AOR = 1.92, 95% CI: 1.45, 2.53) and economic deprivation (AOR = 1.61, 95% CI: 1.34,1.92) were significantly associated with partner violence. Conclusions: Almost one in three sexually active AGYW had experienced partner violence in the 6 months preceding the survey. The findings underscore the need for future research to focus on understanding the reasons and dynamics underlying high level of partner violence among AGYW. Furthermore, there is a need for implementing intervention programs that aim to reduce economic deprivation among AGYWs and address social norms and structures perpetuating violence against AGYW. Trial registration: ClinicalTrials.gov—ID . [ABSTRACT FROM AUTHOR]

The modelling of HIV trends in Tanzania uses surveillance data from antenatal clinics after adjusting for the reduction in fertility of women living with HIV (WLWH). The rollout of HIV care and treatment services has enabled many WLWH to start on antiretroviral treatment (ART) earlier and are counselled on the options to prevent HIV transmission to their children. The assumption that being HIV positive leads to lower fertility needs to be revisited. This study aims to quantify the effect of ART program expansion on the fertility rate of WLWH in Tanzania. We used Cox regression model to estimate fertility rate and associated factors among WLWH of reproductive age (15–49 years) who enrolled in HIV care and treatment at 57 centers in Tabora from 2008 to 2014. A decomposition of Poisson regression was used to explore the reasons for fertility rate differences observed among WLWH. A total of 6,397 WLWH aged 15–49 years were followed for a median time of 2.0 years. The total fertility rate of 48.8/1,000 person years (95%CI: 44.6 to 52.9/1,000) was inversely proportional to age and WHO clinical staging. WLWH on ART had higher fertility compared to those not started on ART (aHR = 1.5, 95%CI: 1.2–1.9). Being married or cohabiting, having higher CD4 cell count and not using contraceptives were associated with higher fertility rate. The fertility rate after post-ART initiation was 54.95/1,000 and among pre-ART users was 40.52/1,000, a difference of 14.43/1,000 in fertility rate between the groups. In the decomposition analysis, proximate determinants of fertility rate among WLWH on ART accounted for a 93.8% smaller increase than expected. In an era of ART expansion in Tabora region, fertility rates of WLWH increased. Higher fertility rates in women on ART may alter the estimation of HIV prevalence and incidence. [ABSTRACT FROM AUTHOR]

Background: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model. Methods: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n = 67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings. Results: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability. Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers. [ABSTRACT FROM AUTHOR]

Background: According to the 2016-2017 Tanzania HIV Impact Survey, 55% of men diagnosed with HIV during the survey self-reported that they were unaware of their HIV status. As a response, the Government of Tanzania launched a Test and Treat campaign in June 2018 with a focus on reaching men and developed the 2018-2020 Male Catch-Up plan. This article reports (1) the enablers and barriers of HIV testing services (HTS) uptake among men (2) and describes the strategies that were proposed as part of the Male Catch-Up Plan to address some of these barriers.Method: Qualitative in-depth interviews were conducted with 23 men in Dar es Salaam to explore HTS enablers and barriers. To develop the Male Catch-Up Plan strategies, a desk review of published studies, and analyses of national implementers of HIV/AIDS interventions were conducted. An additional 123 interviews were also carried out with key implementers of HIV/AIDS interventions, healthcare workers, secondary school boys and members of the community in Iringa and Tanga.Results: Enablers of HTS included the desire to check one's health, high HIV risk perception, wanting to protect oneself if tested negative, and being encouraged by their sexual partners. Barriers of HTS were fear of a positive test result, and low HIV risk perception. Proposed strategies from the Male Catch-Up Plan to address these barriers included non-biomedical and biomedical approaches. Non-biomedical strategies are social and cultural approaches to promote an enabling environment to encourage health seeking behavior, safe behavior, and providing peer education programs and social marketing to promote condoms. Biomedical approaches consisted of expanding targeted HIV testing, HIV self-testing, and integrating HIV services with other health services.Conclusion: A number of barriers contribute to the low uptake of HTS among men in Tanzania. National strategies have been developed to address these HTS barriers and guide the national Test and Treat campaign focusing on increasing HTS uptake among men. [ABSTRACT FROM AUTHOR]

Introduction: Studies have shown high prevalence of human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) among men who have sex with men (MSM) globally. Other studies have shown that barriers to accessing the HIV/STI services from the health facilities are among the factors that contribute to the increased prevalence among MSM. This study was aimed at determining the proportion of MSM who accessed health care and disclosed their sexual orientations to health workers (HWs) and anticipated barriers if they disclosed their sexual orientation. Material and methods: A cross sectional study with both quantitative and qualitative methods was conducted from April to June 2015 in four districts of Tanga, Tanzania. Two hundred and sixty-six MSM were enrolled in the study using the respondent-driven sampling method. Quantitative data were collected using a structured administered interview and entered in SPSS 23.0 for analysis while qualitative data were collected using in-depth interview and focus group discussion, analyzed and interpreted. Results: The mean age of the participants was 27.2 (SD ± 6.7) years, 48% were married or cohabiting. 68.8% of MSM had not accessed HIV/STI services until they were sick. 13.4% never attended the health facilities for treatments even if they were sick due to fear of stigma and discrimination. 67.8% had ever disclosed their sexual orientation to HWs. Conclusions: MSM need to be empowered to overcome their perceived fears towards health care workers. Efforts should be put into breaking the cycle of negative information and perceptions of MSM from HWs and the community. [ABSTRACT FROM AUTHOR]

Background: Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home.Methods and Findings: As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified.Conclusions: A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC.Trial Registration: ClinicalTrials.gov NCT01932138. [ABSTRACT FROM AUTHOR]

Community health workers (CHWs) play a critical role in health promotion, but their workload is often oriented around a single disease. Renewed interest in expansion of multipurpose CHWs to cover an integrated package of services must contend with the debate over how effectively CHWs can perform an increased range of tasks. In this study, we examine whether an existing cadre of HIV-focused paid volunteer CHWs in Iringa, Tanzania, can take on new maternal, newborn and child health (MNCH) promotion tasks without adversely affecting their HIV role. HIV household visits conducted per month were extracted from CHW summary forms covering up to 14 months pre-intervention and 12 months of intervention data. A comparative interrupted time series using a generalized estimating equation assessed population-averaged longitudinal trends in monthly HIV visit count in the intervention ('dual-role' CHWs) vs comparison group ('single-role' CHWs). Analyses were stratified by district, accounting for secular trends, seasonality and covariates. The time series consisted of 4022 observations for HIV visit count from 187 CHWs (41% dual role). Prior to MNCH training, dual-role CHWs averaged 25-30% more HIV visits per month compared with single-role CHWs, with no other significant pre-intervention differences between groups. CHWs began conducting MNCH visits shortly after receiving training, but in the initial month of intervention, there was a 6-9% drop in the mean number of HIV visits per month among dual-role CHWs. Otherwise, there was no significant difference between single- and dual-role CHWs in the trajectories of monthly HIV visits before and after adding MNCH tasks. Dual-role CHWs appeared able to maintain their HIV client workload after adding MNCH tasks to their routines, albeit with an initial slight decline in HIV workload. This dual-role CHW model suggests potential spare capacity in vertically oriented programmes, with productivity gains possible through integration. [ABSTRACT FROM AUTHOR]

Background: Infection with Human Immunodeficiency Virus is a serious public health problem that threatens the lives of many people including health care workers. Health care workers are frequently exposed to occupational hazards throughout their careers. Health care workers are at risk of being infected by the virus when caring for patients in health care facilities. Utilization of HIV Post-exposure Prophylaxis (HIV PEP) is very vital once an individual is exposed. Aim: The aim of this study is to determine the prevalence of occupational exposure, knowledge of, availability and utilization of post exposure prophylaxis among health care workers in Singida District Council, Tanzania. Methods: A descriptive cross sectional study was conducted from April to May 2013. Health care workers actively treating patients were enrolled from 18 heath facilities in Singida District Council. Data were collected using a self-administered questionnaire, and analysed using Stata version 12. Results: Out of 239 participants, slightly more than half, 124 (52%) had inadequate overall knowledge of HIV PEP. Of the 239, 121(50.6%) participants experienced occupational exposure. Two leading types of exposure were blood splash 57(47.1%) and needle stick injuries 45 (37.2%),respectively. Among the 121 exposed participants, 83(68.6%) reported the exposure incident, 91(75.2%) had an HIV test, 32 (26.4%), started HIV PEP after testing, 28 (23.1%), completed HIV PEP, and 65 (53.7%) had a follow-up HIV test. About two thirds (159/239), of participants reported that HIV PEP services were available at the time the study was conducted, and 49 (20.5%), reported daily access to HIV PEP service. Conclusion: The prevalence of occupational exposure among health care workers is high with low utilization of HIV PEP. The majority of healthcare workers had inadequate knowledge of HIV PEP. The findings highlight the need to improve the level of knowledge of HIV PEP and utilization of PEP among this at-high-risk-group in Singida. [ABSTRACT FROM AUTHOR]

Objective: To determine if a protein-calorie supplement (PCS) plus a micronutrient supplement (MNS) improves outcomes for HIV-infected lactating women and their infants. Design: Randomized, controlled trial. Setting: Dar es Salaam, Tanzania Subjects, participants: Pregnant HIV-infected women enrolled in PMTCT programs who intended to breastfeed for 6 months. Intervention: Randomization 1:1 to administration of a PCS plus MNS versus MNS alone among 96 eligible women beginning in the third trimester and continuing for 6 months of breast-feeding. Main outcome measure(s): Primary: infant weight at 3 months. Secondary: maternal BMI at 6 months. Results: PCS resulted in significant increases in daily energy intake compared to MNS at all time points (range of differences: +388–719 Kcal); and increases in daily protein intake (range of differences: +22–33 gm). Infant birth weight (excluding twins) was higher in the PCS than MNS groups: 3.30 kg vs 3.04 kg (p = 0.04). Infant weight at 3 months did not differ between PCS and MNS groups: 5.63 kg vs 5.99 kg (p = 0.07). Maternal BMI at 6 months did not differ between PCS and MNS groups: 24.3 vs 23.8 kg/m2 (p = 0.68). HIV transmission occurred in 0 infants in the PCS group vs 4 in the MNS group (p = 0.03). Conclusions: In comparison to MNS the PCS + MNS intervention was well tolerated, increased maternal energy and protein intake, and increased infant birth weight, but not weight at 3 months or maternal BMI at 6 months. Reduced infant HIV transmission in the PCS + MNS group was observed. Trial registration: Clinical Trials.Gov . [ABSTRACT FROM AUTHOR]

Objectives: Our objectives were to describe trends in enrolment and clinical outcomes in the open, prospective Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) in the Morogoro region of southern Tanzania, and identify strengths and areas for improvement in the care of HIV-positive individuals in rural Tanzania. Methods: We included adults (≥15 years) and children (<15 years) enrolled in the cohort in 2005–2014. The cohort underwent significant changes from autumn 2012 to optimise care. We evaluated mortality and loss to follow-up (LTFU) using competing risks methods, ART usage, opportunistic infections (OI), co-infections and laboratory abnormalities. Results: Overall, 7010 adults and 680 children were enrolled; enrolment peaked in 2008 but has increased steadily since 2011. Among adults (65% female; median age 37 [interquartile range 31–45] years), the proportion referred from hospital wards quadrupled in 2013–14 versus earlier years. 653 (9%) adults died and 2648 (38%) were LTFU; the five-year cumulative probabilities of death and LTFU were 10.3% and 44.0%, respectively. Among children, 69 (10%) died and 225 (33%) were LTFU. The corresponding five-year probabilities were 12.1% and 39.6%. Adult ART use (regardless of eligibility) increased from 5% in 2005 to 89% in 2014 (similarly among children), with 9% on second-line therapy in 2014 (17% of children). OI diagnoses increased over time; tuberculosis prevalence at enrolment quadrupled from 6% in 2011 to 26% in 2014. The proportion of newly-enrolled participants assessed for laboratory abnormalities peaked at nearly 100% in 2014 (from a minimum of 24%), yet abnormality prevalences remained fairly constant. Conclusions: In this cohort, ART usage improved dramatically and is approaching targets of 90%. Improved screening led to increases in detection of OIs and laboratory abnormalities, suggesting that a large number of these co-morbidities previously went undetected and untreated. Further work will address the high LTFU rates and implications for mortality estimates, and the management and outcomes of co-morbidities. [ABSTRACT FROM AUTHOR]

Background: Interventions incorporating constructs from behavioral economics and psychology have the potential to enhance HIV ‘treatment as prevention’ (TasP) strategies. To test this hypothesis, we evaluated an intervention to improve antiretroviral therapy (ART) adherence based on the concepts of social norms and priming. Methods: We used tools from marketing research and patient-centered design to develop a combination intervention that included visual feedback about clinic-level retention in care, a self-relevant prime, and useful take-home items with the priming image. The intervention was implemented at two HIV primary clinics in Shinyanga, Tanzania in 2-week intervals for six months. We conducted a quasi-experimental pilot study with a random sample of exposed and unexposed adult patients living with HIV infection (PLHIV) to compare retention and the proportion of patients with medication possession ratio (MPR) ≥95% after six months. Intervention acceptability was determined with a convenience sample of 405 PLHIV at baseline (n = 189) and endline (n = 216). Results: Medical records were reviewed for 438 PLHIV (320 intervention, 118 standard of care). In adjusted analyses, PLHIV exposed to the intervention were significantly more likely to be in care after 6 months (87% vs. 79%, adjusted odds ratio (ORa) = 1.73, 95% CI: 1.08, 2.78, p<0.05) and were more likely to achieve MPR≥95% (70% vs. 59%, OR = 1.51, 95% CI: 0.96, 2.37, p = 0.07). The intervention was associated with increases in staff support of treatment goals (100% vs. 95%, p = 0.01) and life goals (66% vs. 50%, p<0.01), the perceived likelihood of other patients’ adherence (54% vs. 32%, p<0.01), support from other patients (71% vs. 60%, p = 0.03), and being very satisfied with care (53% vs. 35%, p<0.01). Conclusions: This novel intervention has the potential to improve the clinic experience, short-term retention in care, and ART adherence. Future studies are needed to expand the generalizability of the approach and evaluate effectiveness on clinical outcomes. Trial registration: Clinicaltrials.gov [ABSTRACT FROM AUTHOR]

Introduction: Decentralization of Directly Observed Treatment (DOT) for tuberculosis (TB) to the community (home-based DOT) has improved the coverage of TB treatment and reduced the burden to the health care facilities (facility-based DOT). We aimed to compare TB treatment outcomes in home-based and facility-based DOT under programmatic conditions in an urban setting with a high TB burden. Methodology: A retrospective analysis of a cohort of adult TB patients (≥15 years) routinely notified between 2010 and 2013 in two representative TB sub-districts in the Temeke district, Dar es Salaam, Tanzania. We assessed differences in treatment outcomes by calculating Risk Ratios (RRs). We used logistic regression to assess the association between DOT and treatment outcomes. Results: Data of 4,835 adult TB patients were analyzed, with a median age of 35 years, 2,943 (60.9%) were men and TB/HIV co-infection prevalence of 39.9%. A total of 3,593 (74.3%) patients were treated under home-based DOT. Patients on home-based DOT were more likely to die compared to patients on facility-based DOT (RR 2.04, 95% Confidence Interval [95% CI]: 1.52–2.73), and more likely to complete TB treatment (RR 1.14, 95% CI: 1.06–1.23), but less likely to have a successful treatment outcome (RR 0.94, 95% CI: 0.92–0.97). Home-based DOT was preferred by women (adjusted Odds Ratio [aOR] 1.55, 95% CI: 1.34–1.80, p<0.001), older people (aOR 1.01 for each year increase, 95% CI: 1.00–1.02, p = 0.001) and patients with extra-pulmonary TB (aOR 1.45, 95% CI: 1.16–1.81, p = 0.001), but less frequently by patients on a retreatment regimen (aOR 0.12, 95% CI: 0.08–0.19, p<0.001). Conclusions/significance: TB patients under home-based DOT had more frequently risk factors of death such as older age, HIV infection and sputum smear-negative TB, and had higher mortality compared to patients under facility-based DOT. Further operational research is needed to monitor the implementation of DOT under programmatic conditions. [ABSTRACT FROM AUTHOR]

Background: Since its launch in 2010, the Tanzania National Voluntary Medical Male Circumcision (VMMC) Program has focused efforts on males ages 10–34 in 11 priority regions. Implementers have noted that over 70% of VMMC clients are between the ages of 10 and 19, raising questions about whether additional efforts would be required to recruit men age 20 and above. This analysis uses mathematical modeling to examine the economic and epidemiological consequences of scaling up VMMC among specific age groups and priority regions in Tanzania. Methods and Findings: Analyses were conducted using the Decision Makers’ Program Planning Tool Version 2.0 (DMPPT 2.0), a compartmental model implemented in Microsoft Excel 2010. The model was populated with population, mortality, and HIV incidence and prevalence projections from external sources, including outputs from Spectrum/AIDS Impact Module (AIM). A separate DMPPT 2.0 model was created for each of the 11 priority regions. Tanzania can achieve the most immediate impact on HIV incidence by circumcising males ages 20–34. This strategy would also require the fewest VMMCs for each HIV infection averted. Circumcising men ages 10–24 will have the greatest impact on HIV incidence over a 15-year period. The most cost-effective approach (lowest cost per HIV infection averted) targets men ages 15–34. The model shows the VMMC program is cost saving in all 11 priority regions. VMMC program cost-effectiveness varies across regions due to differences in projected HIV incidence, with the most cost-effective programs in Njombe and Iringa. Conclusions: The DMPPT 2.0 results reinforce Tanzania’s current VMMC strategy, providing newfound confidence in investing in circumcising adolescents. Tanzanian policy makers and program implementers will continue to focus scale-up of VMMC on men ages 10–34 years, seeking to maximize program impact and cost-effectiveness while acknowledging trends in demand among the younger and older age groups. [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases (NCDs) are a leading cause of death among adults in sub-Saharan Africa, and chronic kidney disease (CKD) is a growing public health threat. Understanding knowledge, attitudes, and practices associated with NCDs is vital to informing optimal policy and public health responses in the region, but few community-based assessments have been performed for CKD. To address this gap, we conducted a cross-sectional survey of adults in northern Tanzania using a validated instrument. Methods: Between January and June 2014, we administered a structured survey to a random sample of adults from urban and rural communities. The validated instrument consisted of 25 items designed to measure knowledge, attitudes, and practices associated with kidney disease. Participants were also screened for CKD, diabetes, hypertension, and human immunodeficiency virus. Results: We enrolled 606 participants from 431 urban and rural households. Knowledge of the etiologies, symptoms, and treatments for kidney disease was low (mean score 3.28 out of 10; 95% CI 2.94, 3.63). There were no significant differences by CKD status. Living in an urban setting and level of education had the strongest independent associations with knowledge score. Attitudes were characterized by frequent concern about the health (27.3%; 20.2, 36.0%), economic (73.1%; 68.2, 77.5%), and social impact (25.4%; 18.6, 33.6%) of kidney disease. Practices included the use of traditional healers (15.2%; 9.1, 24.5%) and traditional medicines (33.8%; 25.0, 43.9%) for treatment of kidney disease as well as a willingness to engage with mobile-phone technology in CKD care (94.3%; 90.1, 96.8%). Conclusions: Community-based adults in northern Tanzania have limited knowledge of kidney disease. However, there is a modest knowledge base upon which to build public health programs to expand awareness and understanding of CKD, but these programs must also consider the variety of means by which adults in this population meet their healthcare needs. Finally, our assessment of local attitudes suggested that such public health efforts would be well-received. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess and characterize Mycobacterium tuberculosis complex (MTBC) genotypic diversity in Tanzania, as well as in neighbouring East and other several African countries. We used spoligotyping to identify a total of 293 M. tuberculosis clinical isolates (one isolate per patient) collected in the Bunda, Dar es Salaam, Ngorongoro and Serengeti areas in Tanzania. The results were compared with results in the SITVIT2 international database of the Pasteur Institute of Guadeloupe. Genotyping and phylogeographical analyses highlighted the predominance of the CAS, T, EAI, and LAM MTBC lineages in Tanzania. The three most frequent Spoligotype International Types (SITs) were: SIT21/CAS1-Kili (n = 76; 25.94%), SIT59/LAM11-ZWE (n = 22; 7.51%), and SIT126/EAI5 tentatively reclassified as EAI3-TZA (n = 18; 6.14%). Furthermore, three SITs were newly created in this study (SIT4056/EAI5 n = 2, SIT4057/T1 n = 1, and SIT4058/EAI5 n = 1). We noted that the East-African-Indian (EAI) lineage was more predominant in Bunda, the Manu lineage was more common among strains isolated in Ngorongoro, and the Central-Asian (CAS) lineage was more predominant in Dar es Salaam (p-value<0.0001). No statistically significant differences were noted when comparing HIV status of patients vs. major lineages (p-value = 0.103). However, when grouping lineages as Principal Genetic Groups (PGG), we noticed that PGG2/3 group (Haarlem, LAM, S, T, and X) was more associated with HIV-positive patients as compared to PGG1 group (Beijing, CAS, EAI, and Manu) (p-value = 0.03). This study provided mapping of MTBC genetic diversity in Tanzania (containing information on isolates from different cities) and neighbouring East African and other several African countries highlighting differences as regards to MTBC genotypic distribution between Tanzania and other African countries. This work also allowed underlining of spoligotyping patterns tentatively grouped within the newly designated EAI3-TZA lineage (remarkable by absence of spacers 2 and 3, and represented by SIT126) which seems to be specific to Tanzania. However, further genotyping information would be needed to confirm this specificity. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) and sexually transmitted infections (STIs), including HIV, remain important public health problems with devastating health effects for men and women in sub-Saharan Africa. There have been calls to engage men in prevention efforts, however, we lack effective approaches to reach and engage them. Social network approaches have demonstrated effective and sustained outcomes on changing risk behaviors in the U.S. Our team has identified and engaged naturally occurring social networks comprised mostly of young men in Dar es Salaam in an intervention designed to jointly reduce STI incidence and the perpetration of IPV. These stable networks are locally referred to as "camps." In a pilot study we demonstrated the feasibility and acceptability of a combined microfinance and peer health leadership intervention within these camp-based peer networks.Methods Design: We are implementing a cluster-randomized trial to evaluate the efficacy of an intervention combining microfinance with health leadership training in 60 camps in Dar es Salaam, Tanzania. Half of the camps have been randomized to the intervention arm, and half to a control arm. The camps in the intervention arm will receive a combined microfinance and health leadership intervention for a period of two years. The camps in the control arm will receive a delayed intervention. We have enrolled 1,258 men across the 60 study camps. Behavioral surveys will be conducted at baseline, 12-months post intervention launch and 30-month post intervention launch and biological samples will be drawn to test for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) at baseline and 30-months. The primary endpoints for assessing intervention impact are IPV perpetration and STI incidence.Discussion: This is the first cluster-randomized trial targeting social networks of men in sub-Saharan Africa that jointly addresses HIV and IPV perpetration and has both biological and behavioral endpoints. Effective approaches to engage men in HIV and IPV prevention are needed in low resource, high prevalence settings like Tanzania. If we determine that this approach is effective, we will examine how to adapt and scale up this approach to other urban, sub-Saharan African settings.Trial Registration: Clinical Trials.gov: NCT01865383 . Registration date: May 24, 2013. [ABSTRACT FROM AUTHOR]

The Magu Health and Demographic Surveillance System (Magu HDSS) is part of Kisesa OpenCohort HIV Study located in a rural area of North-Western Tanzania. Since its establishment in 1994, information on pregnancies, births, marriages, migrations and deaths have been monitored and updated between one and three times a year by trained fieldworkers. Other research activities implemented in the cohort include: sero surveys which have been conducted every 2-3 years to collect socioeconomic data, HIV sero status and health knowledge attitude and behaviour in adults aged 15 years or more living in the area; verbal autopsy (VA) interviews conducted to establish cause of death in all deaths encountered in the area; Llnking data collected at health facilities to community-based data; monitoring voluntary counselling and testing (VCT); and assessing uptake of antiretroviral treatment (ART). In addition, within the community, qualitative studies have been conducted to address issues linked to HIV stigma, the perception of ART access and adherence.In 2014, the population was over 35 000 individuals. Magu HDSS has contributed to Tanzanian estimates of fertility and mortality, and is a member of the INDEPTH network. Demographic data for Magu HDSS are available via the INDEPTH Network's Sharing and Accessing Repository (iSHARE) and applications to access HDSS data for collaborative analysis are encouraged. [ABSTRACT FROM AUTHOR]

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Background: The occurrence of HIV-1 and syphilis infections during pregnancy poses major health risks to the foetus due to mother-to-child transmission. We conducted surveillance of HIV and syphilis infections among pregnant women attending antenatal clinics (ANCs) in Mainland Tanzania in 2011. Methods: This surveillance was carried out in 133 ANCs selected from 21 regions in Tanzania. In each region, six ANC sites were selected, with urban, semi-urban, and rural areas contributing two each. All pregnant women who were attending selected sentinel ANC sites for the first time at any pregnancy between September and December 2011 were enrolled. Serial ELISA assays were performed to detect HIV infection in an unlinked anonymous manner using dried blood spot (DBS) after routine syphilis testing. Data analysis was conducted using Stata v.12 software. Results: A total of 39,698 pregnant women representing 2.4 % of all pregnant women (1.68 million) attending ANCs in the Mainland Tanzania were enrolled. The overall HIV prevalence was found to be 5.6 % (95 % CI: 5.4-5.8 %). The risk for HIV infection was significantly higher among women aged 25-34 (cOR = 1.97, 95 % CI: 1.79-2.16; p < 0.05), older than 35 years (cOR = 1.88, 95 % CI: 1.62-2.17; p < 0.05) and those having 1-2 and 3-4 previous pregnancies. HIV infection was less prevalent among women attending rural ANC clinics (cOR = 0.46, 95 % CI 0.4-0.52; p < 0.05). The overall syphilis prevalence was 2.5 % (95 % CI: 2.3, 3.6). The risk for syphilis infection was significantly higher among women attending semi-urban and rural clinics and those having 3-4, and 5 previous pregnancies (p < 0.05). Marital status and level of education were not statistically significant with either of the two infections. HIV and syphilis co-infections occurred in 109 of 38,928 (0.3 %). Conclusion: The overall prevalence of HIV infection (5.6 %) and syphilis (2.5 %) found among pregnant women attending ANC clinics in Tanzania calls for further strengthening of current intervention measures, which include scaling up the integration of prevention of mother to child transmission (PMTCT) services in Reproductive and Child Health (RCH) clinics. [ABSTRACT FROM AUTHOR]

Background: The risk of contracting HIV through heterosexual anal sex (HAS) is significantly higher than from vaginal intercourse. Little has been done to understand the discourses around HAS and terms people use to describe the practice in Tanzania. A better understanding of discourses on HAS would offer useful insights for measurement of the practice as well as designing appropriate interventions to minimise the risks inherent in the practice. Methods: This study employed qualitative approaches involving 24 focus group discussions and 81 in-depth interviews. The study was conducted in 4 regions of Tanzania, and included samples from the general population and among key population groups (fishermen, truck drivers, sex workers, food and recreational facilities workers). Discourse analysis was conducted with the aid of NVIVO versions 8 and 10 software. Results: Six discourses were delineated in relation to how people talked about HAS. Secrecy versus openness discourse describes the terms used when talking about HAS. "Other" discourse involved participants' perception of HAS as something practiced by others unrelated to them and outside their communities. Acceptability/trendiness discourse: young women described HAS as something trendy and increasingly gaining acceptability in their communities. Materiality discourse: describes HAS as a practice that was more profitable than vaginal sex. Masculinity discourse involved discussions on men proving their manhood by engaging in HAS especially when women initiated the practice. Masculine attitudes were also reflected in how men described the practice using a language that would be considered crude. Public health discourse: describes HAS as riskier for HIV infection than vaginal sex. The reported use of condoms was low due to the perceptions that condoms were unsuitable for anal sex, but also perceptions among some participants that anal sex was safer than vaginal sex. Conclusion: Discourses among young women and adult men across the study populations were supportive of HAS. These findings provide useful insights in understanding how different population groups talked about HAS and offer a range of terms that interventions and further research on magnitude of HAS could draw on when addressing health risks of HAS among different study populations. [ABSTRACT FROM AUTHOR]

Background: The Tanzanian Government started scaling up its antiretroviral treatment (ART) program from referral, regional and district hospitals to primary health care facilities in October 2004. In 2010, most ART clinics were decentralized to primary health facilities. ART coverage, i.e. people living with HIV (PLHIV) on combination treatment as a proportion of those in need of treatment, provides the basis for evaluating the efficiency of ART programs at national and district level. We aimed to evaluate adult ART and pre-ART care coverage by age and sex at CD4 < 200, < 350 and all PLHIV in the Rufiji district of Tanzania from 2006 to 2010. Methods: The numbers of people on ART and pre-ART care were obtained from routinely aggregated, patient-level, cohort data from care and treatment centers in the district. We used ALPHA model to predict the number in need of pre-ART care and ART by age and sex at CD4 < 200 and < 350. Results: Adult ART coverage among PLHIV increased from 2.9% in 2006 to 17.6% in 2010. In 2010, coverage was 20% for women and 14.8% for men. ART coverage was 30.2% and 38.7% in 2010 with reference to CD4 criteria of 350 and 200 respectively. In 2010, ART coverage was 0 and 3.4% among young people aged 15-19 and 20-24 respectively. ART coverage among females aged 35-39 and 40-44 was 30.6 and 35% respectively in 2010. Adult pre-ART care coverage for PLHIV of CD4 < 350 increased from 5% in 2006 to 37.7% in 2010. The age-sex coverage patterns for pre-ART care were similar to ART coverage for both CD4 of 200 and 350 over the study period. Conclusions: ART coverage in the Rufiji district is unevenly distributed and far from the universal coverage target of 80%, in particular among young men. The findings in 2010 are close to the most recent estimates of ART coverage in 2013. To strive for universal coverage, both the recruitment of new eligible individuals to pre-ART and ART and the successful retention of those already on ART in the program need to be prioritized. [ABSTRACT FROM AUTHOR]

Background Many clients of HIV care and treatment services have unmet contraceptive needs. Integrating family planning (FP) services into HIV services is an increasingly utilized strategy for meeting those unmet needs. However, numerous models for services integration are potentially applicable for clients with diverse health needs. This study developed and tested a ‘facilitated referral’ model for integrating FP into HIV care and treatment in Tanzania with the primary outcome being a reduction in unmet need for contraception among female clients.Methods The facilitated referral model included seven distinct steps for service providers. A quasi-experimental, pre- and post-test, repeated cross-sectional study was conducted to evaluate the impact of the model. Female clients at 12 HIV care and treatment clinics (CTCs) were interviewed pre- and post-intervention and CTC providers were interviewed post-intervention.Results A total of 323 CTC clients were interviewed pre-intervention and 299 were interviewed post-intervention. Among all clients, the adjusted decrease in proportion with unmet need (3%) was not significant (P = 0.103) but among only sexually active clients, the adjusted decrease (8%) approached significance (P = 0.052). Furthermore, the proportion of sexually active clients using a contraceptive method post-intervention increased by an estimated 12% (P = 0.013). Dual method use increased by 16% (P = 0.004). Increases were observed for all seven steps of the model from pre- to post-intervention. All providers (n = 45) stated that FP integration was a good addition although there were implementation challenges.Conclusion This study demonstrated that the facilitated referral model is a feasible strategy for integrating FP into HIV care and treatment services. The findings show that this model resulted in increased contraceptive use among HIV-positive female clients. By highlighting the distinct steps necessary for facilitated referrals, this study can help inform both programmes and future research efforts in services integration. [ABSTRACT FROM AUTHOR]

Background It is widely assumed that voluntary counselling and testing (VCT) services contribute to HIV prevention by motivating clients to reduce sexual risk-taking. However, findings from sub- Saharan Africa have been mixed, particularly among HIV-negative persons. We explored associations between VCT use and changes in sexual risk behaviours and HIV incidence using data from a community HIV cohort study in northwest Tanzania. Methods Data on VCT use, sexual behaviour and HIV status were available from three HIV serological surveillance rounds undertaken in 2003-4 (Sero4), 2006-7 (Sero5) and 2010 (Sero6). We used multinomial logistic regression to assess changes in sexual risk behaviours between rounds, and Poisson regression to estimate HIV incidence. Results The analyses included 3,613 participants attending Sero4 and Sero5 (3,474 HIV-negative and 139 HIV-positive at earlier round) and 2,998 attending Sero5 and Sero6 (2,858 HIV-negative and 140 HIV-positive at earlier round). Among HIV-negative individuals VCT use was associated with reductions in the number of sexual partners in the last year (aRR Seros 4-5: 1.42, 95% CI 1.07-1.88; aRR Seros 5-6: 1.68, 95% CI 1.25-2.26) and in the likelihood of having a non-cohabiting partner in the last year (aRR Seros 4-5: 1.57, 95% CI 1.10-2.25; aRR Seros 5-6: 1.48, 95% CI 1.07-2.04) or a high-risk partner in the last year (aRR Seros 5- 6 1.57, 95% CI 1.06-2.31). However, VCT was also associated with stopping using condoms with non-cohabiting partners between Seros 4-5 (aRR 4.88, 95% CI 1.39-17.16). There were no statistically significant associations between VCT use and changes in HIV incidence, nor changes in sexual behaviour among HIV-positive individuals, possibly due to small sample sizes. Conclusions We found moderate associations between VCT use and reductions in some sexual risk behaviours among HIV-negative participants, but no impacts among HIV-positive individuals in the context of low overall VCT uptake. Furthermore, there were no significant changes in HIV incidence associated with VCT use, although declining background incidence and small sample sizes may have prevented us from detecting this. The impact of VCT services will ultimately depend upon rates of uptake, with further research required to better understand processes of behaviour change following VCT use. [ABSTRACT FROM AUTHOR]

Background In Tanzania, routine individual-level testing for HIV drug resistance (HIVDR) using laboratory genotyping and phenotyping is not feasible due to resource constraints. To monitor the prevention or emergence of HIVDR at a population level, WHO developed generic strategies to be adapted by countries, which include a set of early warning indicators (EWIs). Methods To establish a baseline of EWIs, we conducted a retrospective longitudinal survey of 35 purposively sampled care and treatment clinics in 17 regions of mainland Tanzania. We extracted data relevant for four EWIs (ART prescribing practices, patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months) from the patient monitoring system on patients who initiated ART at each respective facility in 2010. We uploaded patient information into WHO HIVResNet excel-based tool to compute national and facility averages of the EWIs and tested for associations between various programmatic factors and EWI performance using Fisher's Exact Test. Results All sampled facilities met the WHO EWI target (100%) for ART prescribing practices. However, the national averages for patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months fell short, at 26%, 54% and 38%, respectively, compared to the WHO targets ⩽20%, ⩾70%, and ⩾80%. Clinics with fewer patients lost to follow-up 12 months after ART initiation and more patients retained on first-line-ART at 12 months were more likely to have their patients spend the longest time in the facility (including wait-time and time with providers), (p = 0.011 and 0.007, respectively). Conclusion Tanzania performed very well in EWI 1a, ART prescribing practices. However, its performance in other three EWIs was far below the WHO targets. This study provides a baseline for future monitoring of EWIs in Tanzania and highlights areas for improvement in the management of ART patients in order not only to prevent emergence of HIVDR due to programmatic factors, but also to improve the quality of life for ART patients. [ABSTRACT FROM AUTHOR]

Background: Prior to the scale-up of antiretroviral therapy (ART), demographic surveillance cohort studies showed higher mortality among migrants than residents in many rural areas. Objectives: This study quantifies the overall and AIDS-specific mortality between migrants and residents prior to ART, during ART scale-up, and after widespread availability of ART in Rufiji district in Tanzania. Design: In Health and Demographic Surveillance System (HDSS), the follow-up of individuals aged 15-59 years was categorized into three periods: before ART (1998-2003), during ART scale-up (2004-2007), and after widespread availability of ART (2008-2011). Residents were those who never migrated within and beyond HDSS, internal migrants were those who moved within the HDSS, and external migrants were those who moved into the HDSS from outside. Mortality rates were estimated from deaths and person-years of observations calculated in each time period. Hazard ratios were estimated to compare mortality between migrants and residents. AIDS deaths were identified from verbal autopsy, and the odds ratio of dying from AIDS between migrants and residents was estimated using the multivariate logistic regression model. Results: Internal and external migrants experienced higher overall mortality than residents before the introduction of ART. After widespread availability of ART overall mortality were similar for internal and external migrants. These overall mortality experiences observed were similar for males and females. In the multivariate logistic regression model, adjusting for age, sex, education, and social economic status, internal migrants had similar likelihood of dying from AIDS as residents (adjusted odds ratio [AOR]-1.14, 95% confidence interval [CI]: 0.70-1.87)while external migrants were 70% more likely to die fromAIDS compared to residents prior to the introduction of ART (AOR-1.70, 95% CI: 1.06-2.73). After widespread availability of ARTwith the same adjustment factors, the odds of dying from AIDS were similar for internal migrants and residents (AOR-1.56, 95% CI: 0.80-3.04) and external migrants and residents (AOR-1.42, 95% CI: 0.76-2.66). Conclusions: Availability of ART has reduced the number of HIV-infected migrants who would otherwise return home to die. This has reduced the burden on rural communitieswho had cared for the return externalmigrants. [ABSTRACT FROM AUTHOR]

Background Accurately characterizing a drug's safety profile is essential. Trial harm and tolerability assessments rely, in part, on participants' reports of medical histories, adverse events (AEs), and concomitant medications. Optimal methods for questioning participants are unclear, but different methods giving different results can undermine meta-analyses. This study compared methods for eliciting such data and explored reasons for dissimilar participant responses. Methods Participants from open-label antimalarial and antiretroviral interaction trials in two distinct sites (South Africa, n = 18 [all HIV positive]; Tanzania, n = 80 [86% HIV positive]) were asked about ill health and treatment use by sequential use of (1) general enquiries without reference to particular conditions, body systems or treatments, (2) checklists of potential health issues and treatments, (3) in-depth interviews. Participants' experiences of illness and treatment and their reporting behaviour were explored qualitatively, as were trial clinicians' experiences with obtaining participant reports. Outcomes were the number and nature of data by questioning method, themes from qualitative analyses and a theoretical interpretation of participants' experiences. Results There was an overall cumulative increase in the number of reports from general enquiry through checklists to in-depth interview; in South Africa, an additional 12 medical histories, 21 AEs and 27 medications; in Tanzania an additional 260 medical histories, 1 AE and 11 medications. Checklists and interviews facilitated recognition of health issues and treatments, and consideration of what to report. Information was sometimes not reported because participants forgot, it was considered irrelevant or insignificant, or they feared reporting. Some medicine names were not known and answers to questions were considered inferior to blood tests for detecting ill health. South African inpatient volunteers exhibited a "trial citizenship", working to achieve researchers' goals, while Tanzanian outpatients sometimes deferred responsibility for identifying items to report to trial clinicians. Conclusions Questioning methods and trial contexts influence the detection of adverse events, medical histories and concomitant medications. There should be further methodological work to investigate these influences and find appropriate questioning methods. [ABSTRACT FROM AUTHOR]

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Objective: To determine maternal risk factors for stillbirth among pregnant HIV-infected women in sub-Saharan Africa.Design: Prospective cohort study nested within a micronutrient trial. At enrollment, maternal sociodemographic, obstetric, immunologic, clinical, and nutritional variables were measured. Women were followed through monthly clinic visits until delivery. Multivariate predictors of stillbirth were identified in Poisson regression models.Setting: Antenatal clinic in a tertiary care hospital in urban Dar es Salaam, Tanzania.Population: N=1,078 women enrolled between 12 and 27 weeks of gestation.Main Outcome Measures: Stillbirth (delivery of dead baby > or = 28 weeks' gestation), fresh stillbirth, and macerated stillbirth.Results: Among 1,017 singleton pregnancies, there were 49 stillbirths, yielding a stillbirth risk of 50.0 per 1,000 deliveries (95% Confidence Interval(CI) = 37.2, 65.6). Of stillbirths with known type, 53.7% were fresh and 46.3% macerated. In multivariate analyses, baseline measures of late (> or = 21 weeks' gestation) study entry (Relative Risk (RR) = 2.13, 95% CI = 1.17, 3.87), CD3 count > or = 1,179 cells/ml (RR = 2.15, 95% CI = 1.16, 4.01), stillbirth history (RR = 3.53, 95% CI = 1.30, 9.59), primiparity (RR = 3.65, 95% CI = 1.83, 7.29), and syphilis infection (RR = 2.06, 95% CI = 1.09, 3.88) predicted increased stillbirth risk. Late study entry, illiteracy, stillbirth history, primiparity, CD3 count > or = 1,179 cells/ml, gonorrhea infection, and previous hospitalization predicted increased risk of fresh stillbirth, while living alone and syphilis infection predicted increased risk of macerated stillbirth.Conclusions: Applying antenatal screening and preventive tools for the socioeconomic, obstetric, immunologic, and clinical risk factors identified may assist in reducing the high incidence of stillbirth among HIV-infected women in urban sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Copyright of Tropical Medicine & International Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)