Adolescents' Communication with Parents, Other Adult Family Members and Teachers on Sexuality: Effects of School-Based Interventions in South Africa and Tanzania.

Cluster-randomized controlled trials were carried out to examine effects on sexual practices of school-based interventions among adolescents in three sites in sub-Saharan Africa. In this publication, effects on communication about sexuality with significant adults (including parents) and such communication as a mediator of other outcomes were examined. Belonging to the intervention group was significantly associated with fewer reported sexual debuts in Dar es Salaam only (OR 0.648). Effects on communication with adults about sexuality issues were stronger for Dar es Salaam than for the other sites. In Dar, increase in communication with adults proved to partially mediate associations between intervention and a number of social cognition outcomes. The hypothesized mediational effect of communication on sexual debut was not confirmed. Promoting intergenerational communication on sexuality issues is associated with several positive outcomes and therefore important. Future research should search for mediating factors influencing behavior beyond those examined in the present study.

Lessons from Tanzania on the integration of HIV and tuberculosis treatments into methadone assisted treatment.

To successfully address HIV and TB in the world, we must address the healthcare needs of key populations, such as drug users, and we must do this urgently. Currently in Tanzania, as in many countries, the care for these medical disorders is separated into disease specific clinical environments. Our consortium began working to integrate HIV and TB clinical services into the methadone program in Dar es Salaam, Tanzania. We present the key lessons learned in this process of integration and the importance of integrating HIV/TB into the methadone program, which serves as a critical anchor for adherence to clinical services. Integrated healthcare for people who use drugs is clearly a long-term goal and different health systems will progress upon this continuum at different rates. What is clear is that every health system that interacts with drug users must aspire to achieve some level of integrated healthcare if the incidence rates of HIV and TB are to decline.

An Overview of HIV Prevention Interventions for People Who Inject Drugs in Tanzania.

In the past decade, Tanzania has seen a rapid rise in the number of people who inject drugs (PWID), specifically heroin. While the overall HIV prevalence in Tanzania has declined recently to 5.6%, in 2009, the HIV prevalence among PWID remains alarmingly high at 35%. In this paper, we describe how the Tanzania AIDS Prevention Program (TAPP), Médecins du Monde France (MdM-F), and other organisations have been at the forefront of addressing this public health issue in Africa, implementing a wide array of harm reduction interventions including medication-assisted treatment (MAT), needle and syringe programs (NSP), and "sober houses" for residential treatment in the capital, Dar es Salaam, and in Zanzibar. Looking toward the future, we discuss the need to (1) extend existing services and programs to reach more PWID and others at risk for HIV, (2) develop additional programs to strengthen existing programs, and (3) expand activities to include structural interventions to address vulnerabilities that increase HIV risk for all Tanzanians.

Drug trafficking, use, and HIV risk: the need for comprehensive interventions.

The rapid increase in communication and transportation between Africa and other continents as well as the erosion of social fabric attended by poverty, ethnic conflicts, and civil wars has led to increased trafficking and consumption of illicit drugs. Cannabis dominates illicit trade and accounts for as much as 40% of global interdiction. Due to escalating seizures in recent years, the illicit trade in heroin and cocaine has become a concern that has quickly spread from West Africa to include Eastern and Southern Africa in the past 10 years. All regions of Africa are characterized by the use of cannabis, reflecting its entrenched status all over Africa. Most alarming though is the use of heroin, which is now being injected frequently and threatens to reverse the gain made in the prevention of HIV/AIDS. The prevalence of HIV infection and other blood-borne diseases among injection drug users is five to six times that among the general population, calling for urgent intervention among this group. Programs that aim to reduce the drug trafficking in Africa and needle syringe programs as well as medication-assisted treatment (MAT) of heroin dependence while still in their infancy in Africa show promise and need to be scaled up.

HIV risk behaviors, perceived severity of drug use problems, and prior treatment experience in a sample of young heroin injectors in Dar es Salaam, Tanzania.

Interviews were conducted with 203 male and 95 female heroin injectors aged 17 to 25 in Dar es Salaam, Tanzania. Nearly one-quarter of participants reported injecting with needles used by someone else. Few reported cleaning needles with bleach. Multiple sexual partnerships, unprotected sex, and trading sex for money were especially present among women, the majority (55%) of whom was HIV seropositive. Self reports suggest the presence of heroin dependence among users. While most participants expressed a desire to quit their use, only 14 (5%) had been in treatment. There appears to be a large unmet need for heroin use treatment. These findings need to be considered in light of a potential forthcoming wave of heroin injection in sub-Saharan Africa.

Flashblood: blood sharing among female injecting drug users in Tanzania.

AIMS: This study examined the association between the blood-sharing practice of 'flashblood' use and demographic factors, human immunodeficiency virus (HIV) status and variables associated with risky sex and drug behaviors among female injecting drug users. Flashblood is a syringe-full of blood passed from someone who has just injected heroin to someone else who injects it in lieu of heroin. DESIGN: A cross-sectional study. SETTING: Dar es Salaam, Tanzania. PARTICIPANTS: One hundred and sixty-nine female injecting drug users (IDUs) were recruited using purposive sampling for hard-to-reach populations. MEASUREMENTS: The association between flashblood use, demographic and personal characteristics and risky sex and drug use variables was analyzed by t-test and chi(2) test. The association between flashblood use and residential neighborhood was mapped. FINDINGS: Flashblood users were more likely to: be married (P = 0.05), have lived in the current housing situation for a shorter time (P < 0.000), have been forced as a child to have sex by a family member (P = 0.007), inject heroin more in the last 30 days (P = 0.005), smoke marijuana at an earlier age (P = 0.04), use contaminated rinse-water (P < 0.03), pool money for drugs (P < 0.03) and share drugs (P = 0.000). Non-flashblood users were more likely to live with their parents (P = 0.003). Neighborhood flashblood use was highest near downtown and in the next two adjoining suburbs and lowest in the most distant suburbs. CONCLUSIONS: These data indicate that more vulnerable women who are heavy users and living in shorter-term housing are injecting flashblood. The practice of flashblood appears to be spreading from the inner city to the suburbs.

HIV seroprevalence in a sample of Tanzanian intravenous drug users.

Injection drug use has recently emerged in sub-Saharan Africa. The purpose of this study was to assess the factors associated with increased risk of testing HIV-positive in a sample of injection drug users (IDUs) in Dar es Salaam, Tanzania. Participants were recruited by a trained outreach worker or were referred by IDUs who had completed the study. Blood specimens and self-reported socioeconomic and behavioral data were collected from 315 male and 219 female IDUs. Data were analyzed using univariate odds ratios and multivariate logistic regression modeling. Forty-two percent of the sample tested HIV-positive. Several socioeconomic, injection, and sexual factors were found to be associated with increased odds of testing HIV-positive. Multivariate analysis showed that having had sex more than 81 times in past 30 days, earning less than 100,000 shillings (US$76) in the past month, residency in Dar es Salaam for less than 5 years, and injecting for 3 years were independently associated with the greatest risk of infection. The rate of HIV infection in this sample of IDUs was found to be very high, suggesting that injection drug use may be a factor in the continuing epidemic in sub-Saharan Africa. The factors associated with increased risk of HIV infection suggest further research is needed on the needle use and sexual networks of IDUs.

The application of Intervention Mapping in developing and implementing school-based sexuality and HIV/AIDS education in a developing country context: the case of Tanzania.

AIMS: Effective sexuality and HIV/AIDS education programmes are needed to protect young people against HIV/AIDS and teenage pregnancy in Tanzania and other Sub-Saharan African countries. Using a theory- and evidence-based approach and adapting the programmes to local contexts, increases the effectiveness of these programmes. This paper describes and discusses the challenges and opportunities concerning the application of Intervention Mapping (IM) in the development and implementation of a sexuality and HIV/AIDS education programme targeting young people aged 12-14 in Tanzania. METHODS: The sexuality and HIV/AIDS programme was designed in a participatory manner, involving researchers, curriculum developers and teachers' and students' panels. The programme comprised five lessons, organized around 23 sessions with the aim of delaying the onset of sexual intercourse and increase correct and consistent condom use among young people. The programme was delivered by trained teachers as an extracurricular lesson. CONCLUSIONS: The IM protocol facilitated the development of a comprehensive sexuality and HIV/AIDS education programme relevant and appropriate to the social cultural context and the needs of learners in Tanzania. The paper has demonstrated that, although the IM was developed in the Western context, it can be used in a flexible manner to adapt to local contexts such as those in Sub-Saharan Africa.

Parents' and teachers' communication about HIV and sex in relation to the timing of sexual initiation among young adolescents in Tanzania.

AIMS: Early sexual debut is associated with increased HIV risk among young adolescents in sub-Saharan Africa. Our study examines parents' and teachers' communication about sexual matters in relation to the timing of sexual initiation among students aged 12-14 years old in Dar es Salaam, Tanzania. METHODS: Virgin primary school students were followed prospectively for 6 months to assess sexual initiation. Socio-demographic, psychosocial, and behavioural factors were assessed with a structured questionnaire. Univariate and multivariate logistic regression analyses were performed. RESULTS: Of 2477 adolescents, 26.9% of students reported communicating about HIV and sex with parents and 35.6% communicated with teachers. Communication with teachers about HIV and sex was associated with delayed sexual initiation among adolescents after adjusting for potential confounding factors (OR=0.59, 95%CI=0.40-0.89, p=0.01). However, parental communication was not associated with the timing of sexual initiation. The perception that most peers are sexually active was a significant predictor of early sexual debut (test for linear trend, p=0.002). Students who do not live with a biological mother were marginally more likely to initiate sex compared to those who live with a biological mother (OR=1.39, 95%CI=0.97-1.99, p=0.08). CONCLUSIONS: Teachers can play an effective role in discussing HIV and sex with young adolescents. Our study highlights the necessity of responsible adults discussing sexual matters with young adolescents in sub-Saharan Africa. More research is required to better understand the role of parental communication about sexual matters and strategies for improving the quality of parental communication.

HIV risk behaviors in sub-Saharan Africa and Northern Thailand: baseline behavioral data from Project Accept.

BACKGROUND: Of 2.5 million new HIV infections worldwide in 2007, most occurred in sub-Saharan Africa and southeast Asia. We present the baseline data on HIV risk behaviors and HIV testing in sub-Saharan Africa and northern Thailand from Project Accept, a community-randomized controlled trial of community mobilization, mobile voluntary counseling and testing (VCT), and posttest support services. METHODS: A random household probability sample of individuals aged 18-32 years yielded a sample of 14,657, with response rates ranging from 84%-94% across the 5 sites (Thailand, Zimbabwe, Tanzania, and 2 in South Africa). Individuals completed an interviewer-administered survey on demographic characteristics, HIV risk behaviors, and history of VCT. RESULTS: In multivariate analysis, females, married individuals, less educated with 1 sexual partner in the past 6 months were more likely to have had unprotected intercourse in the previous 6 months. Rates of lifetime HIV testing ranged from 5.4% among males in Zimbabwe to 52.6% among females in Soweto. CONCLUSIONS: Significant risk of HIV acquisition in Project Accept communities exists despite 2 decades of prevention efforts. Low levels of recent HIV testing suggest that increasing awareness of HIV status through accessible VCT services may reduce HIV transmission.

Differences in HIV risk behaviors by gender in a sample of Tanzanian injection drug users.

This study investigated differences in drug use and sexual behaviors among from 237 male and 123 female heroin users in Dar es Salaam, Tanzania. Multivariate models of risk of needle sharing were estimated using multivariate logistic regression. Men were significantly older, more likely to inject only white heroin, share needles, and give or lend used needles to other injectors. Women were more likely to be living on the streets, have injected brown heroin, have had sex, have had a higher number of sex partners, and have used a condom with the most recent sex partner. Being male and earning less than US $46 in the past month were significant predictors of increased risk of needle sharing. Despite differences in sociodemographic, drug use, and sexual behaviors by gender, both male and female injectors in Dar es Salaam exhibit elevated risk of HIV infection associated with drug use.

HIV/AIDS and injection drug use in the neighborhoods of Dar es Salaam, Tanzania.

This study examines the intersection between needle-sharing practices and HIV recovered from used syringes collected from 73 heroin injection drug users (IDUs) in Dar es Salaam, Tanzania, between October 2003 and January 2004. To extract blood residue, syringes were flushed and 10 microliters of solution mixed with 120 microliters of a latex solution was placed on a Capillus HIV-1/2 slide. Thirty-five (57%) of the useable syringes tested positive for HIV antibodies. Results varied significantly: 90% of syringes tested HIV positive in a mixed-income neighborhood 2 kilometers from the city center: 0% of syringes tested HIV positive in the outlying areas. In addition, semistructured interviews were conducted with 51 IDUs. The interviews were content coded, and codes were collapsed into emergent themes regarding syringe-use practices. Injecting is a recent practice, particularly among heroin users in neighborhoods far from the city center. Sharing syringes has resulted in a high proportion of used syringes containing HIV-positive blood residue. Geographic distance is an indicator of recent adoption of IDU in neighborhoods and correlates strongly with the distribution of syringes containing HIV-positive blood residue.

High rates and positive outcomes of HIV-serostatus disclosure to sexual partners: reasons for cautious optimism from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania.

The rates, barriers, and outcomes of HIV serostatus disclosure to sexual partners are described for 245 female voluntary counseling and testing (VCT) clients in Dar es Salaam, Tanzania. VCT clients were surveyed 3 months after HIV testing to describe their HIV-serostatus disclosure experiences. Sixty-four percent of HIV-positive women and 79.5% of HIV-negative women (p = 0.028) reported that they had shared HIV test results with their partners. Among women who did not disclose, 52% reported the reason as fear of their partner's reaction. Both 81.9% of HIV-negative women and 48.9% of HIV-positive women reported that their partner reacted supportively to disclosure (p < 0.001). Less than 5% of women reported any negative reactions following disclosure. VCT should continue to be widely promoted. However, intervention approaches such as development of screening tools and new counseling approaches are important to ensure the safety of women who want to safely disclose HIV serostatus to their sexual partners.

HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania.

OBJECTIVES: Experiences of partner violence were compared between HIV-positive and HIV-negative women. METHODS: Of 340 women enrolled, 245 (72%) were followed and interviewed 3 months after HIV testing to estimate the prevalence and identify the correlates of violence. RESULTS: The odds of reporting at least 1 violent event was significantly higher among HIV-positive women than among HIV-negative women (physical violence odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.23, 5.63; sexual violence OR = 2.39; 95% CI = 1.21, 4.73). Odds of reporting partner violence was 10 times higher among younger (< 30 years) HIV-positive women than among younger HIV-negative women (OR = 9.99; 95% CI = 2.67, 37.37). CONCLUSIONS: Violence is a risk factor for HIV infection that must be addressed through multilevel prevention approaches.