Ecological aspects shaping child labour in Tanzania's artisanal and small-scale gold mines: A qualitative inquiry.

Background: This study describes factors promoting child labour in small-scale gold mines in rural Tanzania, a pernicious problem despite the country's adoption of laws and regulations intended to curb it. Methods: Employing a phenomenological design, we collected qualitative data using focus group discussions and in-depth interviews to describe factors promoting children's engagement in small-scale gold mining activities in three districts in Tanzania. Data analysis applied constructs from the ecological system theory. Results: Child labour was reported to be common in the small-scale gold mines and abject household poverty was reported as the main factor pushing children to work in the mines because of their respective households' inability to provide for their basic needs. Other underlying factors stated included divorce and family disintegration and limited diversification of income-earning activities. The migratory nature of artisanal mining led some miner parents to not prioritize the education of their children. Furthermore, peer pressure and parental influence, especially of mothers, promoted entry into mining or reinforced its continuation. Early socialisation of children as future miners and lack of perspective and societal expectations of other life trajectories contributed to persistent child labour within mining communities. At the government level, the study participants mentioned poor reinforcement of mining regulations as another factor that legitimised child labour in the mines. Conclusion: Since factors promoting child labour in small-scale gold mines are multifaceted, efforts for its elimination require a multi-layered approach aimed at addressing the root-causes at the micro-, meso-, exo- and macro-level systems.

Balancing HIV testing efficiency with HIV case-identification among children and adolescents (2-19 years) using an HIV risk screening approach in Tanzania.

To optimize HIV testing resources, programs are moving away from universal testing strategies toward a risk-based screening approach to testing children/adolescents, but there is little consensus around what defines an optimal risk screening tool. This study aimed to validate a 12-item risk screening tool among children and adolescents and provide suggested fewer-item tool options for screening both facility out-patient and community populations by age strata (<10 and ≥10 years). Children/adolescents (2-19 years) with unknown HIV status were recruited from a community-based vulnerable children program and health facilities in 5 regions of Tanzania in 2019. Lay workers administered the screening questions to caregivers/adolescents; nurses enrolled those eligible for the study and tested all participants for HIV. For each screening item, we estimated sensitivity, specificity, positive predictive value and negative predictive value and associated 95% confidence intervals (CI). We generated a score based on the count of items with a positive risk response and fit a receiver operating characteristic curve to determine a cut-off score. Sensitivity, specificity, positive predictive value (PPV; yield) and number needed to test to detect an HIV-positive child (NNT) were estimated for various tool options by age group. We enrolled 21,008 children and adolescents. The proportion of undiagnosed HIV-positive children was low (n = 76; 0.36%; CI:0.29,0.45%). A screening algorithm based on reporting at least one or more items on the 10 to 12-item tool had sensitivity 89.2% (CI:79.1,95.6), specificity 37.5% (CI:36.8,38.2), positive predictive value 0.5% (CI:0.4,0.6) and NNT = 211. An algorithm based on at least two or more items resulted in lower sensitivity (64.6%), improved specificity (69.1%), PPV (0.7%) and NNT = 145. A shorter tool derived from the 10 to 12-item screening tool with a score of "1" or more on the following items: relative died, ever hospitalized, cough, family member with HIV, and sexually active if 10-19 years performed optimally with 85.3% (CI:74.6,92.7) sensitivity, 44.2% (CI:43.5,44.9) specificity, 0.5% (CI:0.4,0.7) PPV and NNT = 193. We propose that different short-tool options (3-5 items) can achieve an optimal balance between reduced HIV testing costs (lower NNT) with acceptable sensitivity. In low prevalence settings, changes in yield may be negligible and NNT may remain high even for an effective tool.

ART use and associated factors among HIV positive caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children. METHODS: Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use. RESULTS: In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61-0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15-1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45-0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11-1.83). Caregivers aged 40-49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13-1.41). CONCLUSIONS: Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania.

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.

Understanding the association between caregiver sex and HIV infection among orphans and vulnerable children in Tanzania: learning from the USAID Kizazi Kipya project.

BACKGROUND: Tanzania has met only 50.1% of the 90% target for diagnosing HIV in children. The country's pediatric case finding strategy uses global best practices of index testing, provider-initiated counselling and testing, and targeted community testing of at-risk populations to find about 50,000 children living with HIV (CLHIV) who are undiagnosed. However, context-specific strategies are necessary to find the hidden children to meet the full 90% target. This study assesses whether sex of the caregiver is associated with HIV status of orphans and vulnerable children (OVC) as a valuable strategy for enhanced pediatric case findings. METHODS: Data originate from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya Project, which works towards increasing OVC's and their caregivers' uptake of HIV/AIDS and other health and social services in Tanzania. Included in this study are 39,578 OVC ages 0-19 years who the project enrolled during January through March 2017 in 18 regions of Tanzania and who voluntarily reported their HIV status. Data analysis involved multi-level logistic regression, with OVC HIV status as the outcome of interest and caregiver's sex as the main independent variable. RESULTS: Three-quarters (74.3%) of the OVC included in the study had female caregivers, and their overall HIV prevalence was 7.1%. The prevalence was significantly higher (p < 0.001) among OVC with male caregivers (7.8%) than among OVC with female caregivers (6.8%), and indeed, multivariate analysis showed that OVC with male caregivers were significantly 40% more likely to be HIV-positive than those with female caregivers (OR = 1.40, 95% CI 1.08-1.83). This effect was the strongest among 0-4 year-olds (OR = 4.02, 95% CI 1.61-10.03), declined to 1.72 among 5-9 year-olds (OR = 1.72, 95% CI 1.02-2.93), and lost significance for children over age 9 years. Other significant factors included OVC age and nutritional status; caregiver HIV status and marital status; household health insurance status, and family size; and rural versus urban residence. CONCLUSIONS: OVC in Tanzania with male caregivers have a 40% higher likelihood of being HIV-positive than those with female caregivers. HIV risk assessment activities should target OVC with male caregivers, as well as OVC who have malnutrition, HIV-positive caregivers, or caregivers who do not disclose their HIV status to community volunteers. Further, younger HIV-positive OVC are more likely to live in rural areas, while older HIV-positive OVC are more likely to live in urban areas. These factors should be integrated in HIV risk assessment algorithms to enhance HIV testing yields and pediatric case-finding in the OVC population in Tanzania.

Swaziland HIV Incidence Measurement Survey (SHIMS): a prospective national cohort study.

BACKGROUND: Swaziland has the highest national HIV prevalence worldwide. The Swaziland HIV Incidence Measurement Survey (SHIMS) provides the first national HIV incidence estimate based on prospectively observed HIV seroconversions. METHODS: A two-stage survey sampling design was used to select a nationally representative sample of men and women aged 18-49 years from 14 891 households in 575 enumeration areas in Swaziland, who underwent household-based counselling and rapid HIV testing during 2011. All individuals aged 18-49 years who resided or had slept in the household the night before and were willing to undergo home-based HIV testing, answer demographic and behavioural questions in English or siSwati, and provide written informed consent were eligible for the study. We performed rapid HIV testing and assessed sociodemographic and behavioural characteristics with use of a questionnaire at baseline and, for HIV-seronegative individuals, 6 months later. We calculated HIV incidence with Poisson regression modelling as events per person-years × 100, and we assessed covariables as predictors with Cox proportional hazards modelling. Survey weighting was applied and all models used survey sampling methods. FINDINGS: Between Dec 10, 2010, and June 25, 2011, 11 897 HIV-seronegative adults were enrolled in SHIMS and 11 232 (94%) were re-tested. Of these, 145 HIV seroconversions were observed, resulting in a weighted HIV incidence of 2·4% (95% CI 2·1-2·8). Incidence was nearly twice as high in women (3·1%; 95% CI 2·6-3·7) as in men (1·7%; 1·3-2·1, p<0·0001). Among men, partner's HIV-positive status (adjusted hazard ratio [aHR] 2·67, 1·06-6·82, p=0·040) or unknown serostatus (aHR 4·64, 2·32-9·27, p<0·0001) in the past 6 months predicted HIV seroconversion. Among women, significant predictors included not being married (aHR 2·90, 1·44-5·84, p=0·0030), having a spouse who lives elsewhere (aHR 2·66, 1·29-5·45, p=0·0078), and having a partner in the past 6 months with unknown HIV status (aHR 2·87, 1·44-5·84, p=0·0030). INTERPRETATION: Swaziland has the highest national HIV incidence in the world. In high-prevalence countries, population-based incidence measures and programmes that further expand HIV testing and support disclosure of HIV status are needed. FUNDING: President's Emergency Plan for AIDS Relief (PEPFAR) by the Centers for Disease Control and Prevention.

Strengthening Health Systems for Chronic Care: Leveraging HIV Programs to Support Diabetes Services in Ethiopia and Swaziland.

The scale-up of HIV services in sub-Saharan Africa has catalyzed the development of highly effective chronic care systems. The strategies, systems, and tools developed to support life-long HIV care and treatment are locally owned contextually appropriate resources, many of which could be adapted to support continuity care for noncommunicable chronic diseases (NCD), such as diabetes mellitus (DM). We conducted two proof-of-concept studies to further the understanding of the status of NCD programs and the feasibility and effectiveness of adapting HIV program-related tools and systems for patients with DM. In Swaziland, a rapid assessment illustrated gaps in the approaches used to support DM services at 15 health facilities, despite the existence of chronic care systems at HIV clinics in the same hospitals, health centers, and clinics. In Ethiopia, a pilot study found similar gaps in DM services at baseline and illustrated the potential to rapidly improve the quality of care and treatment for DM by adapting HIV-specific policies, systems, and tools.