Changes in male sexual behaviour in response to the AIDS epidemic: evidence from a cohort study in urban Tanzania.

OBJECTIVE: To examine changes in sexual behaviour among men in urban Tanzania. DESIGN: An observational cohort study among factory workers during 1991-1994. METHODS: Data from five follow-up visits with structured questionnaire-guided interviews and biomedical data were analysed to examine trends in sexual behaviour and sexually transmitted disease/HIV among 752 men. In-depth interviews were conducted to evaluate the magnitude of reporting bias. RESULTS: During the 2 years of observation, the proportion of men with more than one sexual partner during the month preceding the interview declined from 22.3 to 12.2%. The proportion of men reporting casual sex partners during the last month was almost halved: from 9.8 to 5.2%. The decline in the reporting of extramarital partners was gradual and pronounced. There were only minor changes in reported condom use, notably an increase in use with casual partners, and no changes in coital frequency. Data from in-depth interviews confirmed that reduction in sexual partners was the predominant change. CONCLUSIONS: This study documents that, in response to the AIDS epidemic, changes in male sexual behaviour are taking place in urban areas in Africa. The predominant change among these men, who are predominantly married and aged over 25 years, is a reduction of the number of sexual partners, although condom use remains low.

PIP: During October 1991 to April 1994, health workers in Tanzania interviewed and conducted a physical examination of 752 men who had made at least 4 follow-up visits to the clinic at a large urban textile factory in Mwanza to examine trends in sexual behavior and sexually transmitted disease (STD)/HIV of factory workers and their spouses. Each man was followed for about 2 years. Researchers aimed to determine whether the intervention to reduce HIV transmission at the clinic had an impact on sex behavior. The intervention included free and effective treatment of STDs, a syphilis test at each visit, voluntary HIV counseling services, and health education activities (workshops, peer educators). The proportion of married men increased from 83.4% to 88.4% during the study period. Men were less likely to have more than 1 sexual partner in the previous month after 5 visits than before the first visit (12.2% vs. 22.3%; p 0.01 for trend). They were also less likely to have had casual partners during the previous month (5.2% vs. 9.8%; p 0.001 for trend). Married men were less likely to have extramarital relations (6.5% vs. 20.1% for regular non-cohabiting partner; p 0.01 and 2.7% vs. 8; p 0.001). Condom use in the previous month did not change significantly (2.5% vs. 3.1%; p = 0.377). It did increase significantly with a casual partner, however (7.6% vs. 27.3%; p = 0.002 for trend). Frequency of intercourse did not change. The HIV-incidence rate decreased considerably (1.77 vs. 0.66/100 person-years of observation for a rate ratio of 0.37). Multiple sex partners in the previous month was more common among men 20-29 years old or who consumed moderate or excessive amounts of alcohol than among those over age 40 or who consumed no alcohol. These findings suggest that even though sexual activity did not decline, it became more commonly with 1 partner and within marriage, especially among men 40 and older who did not drink alcohol. Condom use remained low, except with casual partners. ¿

HIV-1 incidence and HIV-1 associated mortality in a cohort of urban factory workers in Tanzania.

OBJECTIVE: To determine HIV-1 incidence and HIV-1 associated mortality in a prospective cohort study. To determine whether the cohort is suitable for studies aiming to determine the impact of interventions on HIV-1 incidence. METHODS: The study population was a cohort of 1772 urban factory workers (1478 men and 294 women) in northwest Tanzania. The study took place from October 1991 to September 1993. Outcome measures were HIV-1 seroconversion and death. RESULTS: HIV-1 incidence was 1.2 (95% CI 0.7-2.0) per 100 person-years (pyr). Crude annual mortality was 4.9 per 100 pyr in those with and 0.3 in those without HIV-1 infection, giving an age and sex adjusted mortality ratio of 12.9 (95% CI 5.4-30.7). Of all deaths, 62% were attributable to HIV-1 infection. CONCLUSION: HIV-1 infection was a major public health problem, being the major cause of death in this adult population. At an HIV-1 incidence of 1.2 per 100 pyr, a large cohort size would be required to evaluate the impact of interventions on HIV-1 incidence.

PIP: The objectives were to determine HIV-1 incidence and HIV-1 associated mortality in a prospective cohort study and to determine whether the cohort is suitable for studies attempting to determine the impact of interventions on HIV-1 incidence. The study population was a cohort of 2038 urban factory workers in northwest Tanzania of whom 1772 workers (1478 men or 87% and 294 women or 89%) had enrolled in the study during October 1991 to September 1993. 471 (27%) of the total study population were lost to follow-up by the end of the study period. Outcome measures were HIV-1 seroconversion and death. At intake, 153 of 1478 (10.4%) men and 52 of 294 (17.7%) women were infected with HIV-1. In the study period, 17 seroconversions took place in 1365.9 person years of follow-up giving an HIV-1 incidence rate of 1.2/100 person-years of follow-up. No association was found between seroconversion and age or sex. The crude annual mortality rate was 4.9/100 person-years in those with and 0.3/100 person-years in those without HIV-1 infection, giving an age- and sex-adjusted mortality ratio of 12.9. The age- and sex-adjusted population attributable risk was 0.5/100 person-years, and of all deaths, 62% were attributable to HIV-1 infection. Of the 14 HIV-1 infected people who died, 9 met the criteria of the 1987 revised Centers for Disease Control/World Health Organization AIDS case definition: one had cryptococcal meningitis and eight HIV wasting syndrome. Two others had had weight loss and fever, but the evidence was inadequate to make or reject the diagnosis of AIDS. The remaining three without an AIDS diagnosis had pulmonary tuberculosis, diarrhea, and pyomyositis, respectively. HIV-1 infection was a major cause of death in this adult population. At an HIV-1 incidence of 1.2/100 person-years, a large cohort size would be required to evaluate the impact of interventions on HIV-1 incidence.

Sexual partner change and condom use among urban factory workers in northwest Tanzania.

OBJECTIVE: To describe sexual partner change and condom use at the intake of a cohort study of urban factory workers in Tanzania. METHODS: From October 1991 to March 1992, 926 male and 170 female factory workers were interviewed using a structured, pre-coded questionnaire. Questionnaire reliability was assessed by pre-testing and comparison with results of unstructured interviews and carrying out repeat questionnaires on a sub-sample. RESULTS: Almost half of both men and women had had sexual intercourse by their 17th birthday. The period of premarital sex had an interquartile range of 2 to 10 years in men and 0 to 2.5 years in women. Having had sexual intercourse in the past month with more than one partner was reported by 22% of the men and 5% of the women. Factors associated with multiple partners in men were being born in or near Mwanza Region, having low education and low income, and being married. Condoms had been used in the past month by 3% only, mainly with casual partners. Condom use in men was associated with being young, living in town, being born in Kagera Region, high education and high income, being circumcised, and having causal or steady (non- martial) partners. CONCLUSION: Information, education and communication (IEC) on sexual relationships and condom use should start at an early age, and include education at primary schools. Much sexual partner change appears to occur through steady (non-marital) partnerships, indicating the need for IEC to be expanded beyond groups such as commercial sex workers and their clients.

PIP: A cohort study of urban workers was initiated in a factory in Mwanza Municipality, Tanzania, October 1991 to March 1992, in order to identify risk factors for HIV-1 seroconversion and for contracting other STDs. All respondents were interviewed for 30-45 minutes in Kiswahili using a structured and pre-coded questionnaire that was slightly different for men and women. In the first 19 weeks 1096 workers (926 male, 170 female) were enrolled. Participants were more likely to be under 25 years old. By the 15th birthday 16% of male and 6% of female respondents reported having had sexual intercourse; by the 17th birthday these percentages were 44% and 33%, respectively. In those who had ever married, the median period of having had premarital sexual intercourse was 5 years (interquartile range 2-10 years) in men and 1 year (interquartile range 0-2.5 years) in women. Marriage survival was slightly longer for men than for women (0.05 p 0.1). 724/926 (78%) of male and 76/170 (45%) of the female factory workers were married and living together with their spouse. Of the 724 married men 45 (6%) had 2 wives, the others had 1 wife only. Among the married respondents 607/717 (85%) of the men and 71/76 (93%) of the women reported having had sex with their spouse in the past 4 weeks (men: median 4 times, women: median 5 times). Having had more than one sexual partner in the past month was reported by 205/926 (22%) of men and 8/170 (5%) of women. Factors associated with having had multiple sexual partners in the past month were: being born in Mwanza or the neighboring Mara or Shinyanga Regions, having had less education or having a low income, and being married. Having had more than one sexual partner in the past month was also associated with having ever had a genital discharge. Overall, 141/924 (15%) of men and 30/170 (18%) of women had ever used a condom. Only 28/924 (3%) of men and 5/170 (3%) of women had used a condom in the past month.

Intake of a cohort study of urban factory workers in northwest Tanzania. Risk factors for HIV-1 infection.

A cohort study has been started of urban factory workers and their spouses in Tanzania, in order to 1) identify risk factors for HIV-1 seroconversion, and 2) document changes over time in risk behaviour, in particular condom use and partner change, and determine whether these are associated with a reduced incidence of HIV-1 and other sexually transmitted diseases. We report findings at intake from October 1991 to March 1992. Study participants were interviewed, examined, and screened for HIV-1 and syphilis. HIV-1 prevalence was 91/926 (10%) in males and 36/217 (17%) in females. Statistically significant risk factors for HIV-1 infection in males were age group, region of birth, not being married for more than 5 years, being uncircumcised, having had a genital ulcer in the past four months, and having received injections from medical staff in the past four months. HIV-1 incidence in this group is expected to be between 1% and 2% per year. It is concluded that a longitudinal study is needed to assess the importance of partner change. This cohort appears to be suitable for such a study as HIV-1 incidence is expected to be fairly high, HIV-1 prevalence and risk factors are comparable to those of the general population and cooperation of the factory workers is good.

A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 1. Prevalence and incidence.

OBJECTIVE: To determine the prevalence of syphilis and the prevalence and incidence of self-reported STD syndromes in the population of Mwanza Region, North-Western Tanzania. METHODS: A population-based random cluster sample survey, stratified by rural, roadside or urban residence, of 4173 individuals aged 15-54 years was performed in 1990-91. The seroprevalence of syphilis (using TPHA and RPR) and the prevalence and incidence of self-reported genital ulcer syndrome (GUS) and genital discharge syndrome (GDS) were determined. RESULTS: Active syphilis was detected in 9% of the adult population, while 15% had serological evidence of past or current infection. Seroprevalence was significantly lower in the rural than in the roadside and urban populations, but there was little difference between men and women. Amongst men, a history of GDS was reported by 28%, and a history of GUS by 14%, with point prevalences of 2.3% and 1.3% respectively. Annual incidence among men were 6.8% for GDS and 3.6% for GUS. Women reported these conditions less frequently. There was little difference between the strata in the prevalence or incidence of reported STD syndromes. CONCLUSION: Sexually transmitted diseases represent a major public health problem in both the rural and urban populations of Mwanza Region.

A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour.

OBJECTIVE: To determine risk factors for syphilis and sexually transmitted disease (STD) syndromes, and to study health seeking behaviour among those with STD syndromes, in the population of Mwanza Region, North-Western Tanzania. METHODS: A population-based random cluster sample survey, stratified by rural, roadside or urban residence, of 4173 individuals aged 15-54 years was performed in 1990-91. The seroprevalence of syphilis and the prevalence and incidence of self-reported genital ulcer syndrome (GUS) and genital discharge syndrome (GDS) are reported in the accompanying paper. This paper reports on risk factors for these conditions and on health seeking behaviour among those reporting them. RESULTS: In both sexes, the risk of STDs increased with the reported number of sexual partners in the previous five years. Men who were separated, divorced or widowed were at increased risk of STDs, but this was not the case among women. Higher educational status was associated with an increased risk of urethral discharge in males but with a decreased prevalence of syphilis in females. Male circumcision was associated with an increased risk of urethral discharge but a reduced prevalence of syphilis. Nearly all men, and 90% of women, reporting symptoms of genital discharge or ulceration had sought treatment. Of these, approximately 70% of males and 60% of females had sought treatment in the official health sector. CONCLUSIONS: Targetted health education concerning risk reduction for HIV infection and other STDs should be a high priority in this population. Improved case management of STDs in health centres and dispensaries may have a substantial impact on the incidence of these infections.

HIV-1 infection as a risk factor for leprosy; a case-control study in Tanzania.

A case-control study was carried out in Tanzania to determine the relative risk of those with HIV-1 infection for getting leprosy. Cases were 93 consecutively diagnosed patients with leprosy aged 15-54 years from the Mwanza Region. Controls were a representative population sample of 4161 people drawn from a stratified cluster sample from urban areas, roadside settlements, and rural villages. HIV-1 infection was determined by enzyme-linked immunosorbent assay (ELISA); Western blot was used when the ELISA result was indeterminate. The HIV-1 prevalence in leprosy cases was 10% in rural (7 of 72) and in roadside and urban areas (2 of 21); in controls these prevalences were 3.4% and 9.9%, respectively. The relative risk of HIV-1 infection for the development of leprosy was estimated to be 2.2 [95% confidence interval (CI) = 1.0-4.7; p = 0.07]. HIV-1 infection was significantly associated with multibacillary (MB) leprosy (odds ratio 4.6; CI = 1.3-13.2) but not with paucibacillary leprosy (odds ratio 1.4; 95% CI = 0.4-3.8). The population etiological fraction for the development of MB leprosy attributable to HIV-1 infection in this population is estimated to be 13% (95% CI = 4%-23%). We conclude that HIV-1 is a risk factor for the development of MB leprosy. The impact of the HIV-1 epidemic on the incidence of leprosy so far has been limited since HIV-1 occurs mainly in urban areas and leprosy in rural areas.

Sentinel surveillance for HIV-1 among pregnant women in a developing country: 3 years' experience and comparison with a population serosurvey.

OBJECTIVES: To establish unlinked, anonymous sentinel surveillance for HIV-1 among pregnant women attending an antenatal clinic, to determine age-specific seroprevalences, to monitor trends and to compare seroprevalence with that detected by a population serosurvey. To establish the sustainability and costs of surveillance. DESIGN: Sentinel surveillance for HIV through serial collection of unlinked, anonymous seroprevalence data from antenatal care; comparison of sentinel data with those from a population serosurvey; financial and general audit of the sentinel surveillance. SETTING: A community antenatal clinic in a large urban centre, Mwanza Municipality, Tanzania, eastern Africa, between October 1988 and September 1991. PATIENTS: Pregnant women attending for antenatal care. MAIN OUTCOME MEASURE: Age-specific HIV-1 seroprevalences, trends over time, difference from age-specific population seroprevalences, sustainability and costs. RESULTS: Overall HIV-1 seroprevalence was 11.5% (95% confidence interval, 10.5-12.4); differences in age-specific prevalences were not significant. There was no clear evidence of change in seroprevalence over the study period in any age group, although there was some indication of a rise in some age groups in 1988-1989. Sentinel surveillance among pregnant women may have significantly underestimated population HIV-1 seroprevalence for women under the age of 35 years. HIV-1 surveillance proved feasible and sustainable. Additional recurrent costs were US$1.7 per specimen for unlinked anonymous testing and US$0.57 per woman for syphilis screening. CONCLUSIONS: HIV-1 seroprevalence did not change significantly over 3 years, probably implying a substantial incidence of HIV-1 infection. In this setting seroprevalence in pregnant women may have underestimated population seroprevalence in women aged under 35 years. With modest inputs and good organization unlinked anonymous HIV-1 sentinel surveillance of pregnant women can be introduced and sustained in an African setting. This may usefully be carried out in conjunction with syphilis screening.

PIP: Between October 1989 and September 1991, health workers took blood samples from pregnant women attending Makongoro Clinic in Mwanza, Tanzania, to determine age-specific HIV-1 seroprevalence in pregnant women, trends over 3 years, and the feasibility, sustainability, and costs of HIV monitoring and to compare age-specific seroprevalences in pregnant women with those of all women. Overall, HIV prevalence among pregnant women stood at 11.5%. Even though the younger and older age groups had lower seroprevalence than the other age groups (10% for those under 20 years old, 11% for 30-34 year olds, and 8.3% for = or 35 year olds vs. 12.8% for 25-29 year olds and 12.3% for 20-24 year olds), the differences were not significant. HIV seroprevalence appeared to increase in 1988-89 in most age groups, but no significant evidence of a linear trend occurred during the study period for any age group. This absence of significant change in HIV seroprevalence over 3 years likely indicated a considerable HIV incidence. The population serosurvey revealed an HIV seroprevalence of 15.1% among the general adult female population, suggesting that the sentinel surveillance among pregnant women could have greatly underestimated population HIV seroprevalence for women under 35 years old (p = .02). Sentinel surveillance improved the clinic's ability to detect anemia and reintroduced syphilis screening. Unlinked anonymous testing resulted in additional recurrent costs of S$1.7/specimen. Syphilis screening added recurrent costs of US$0.57/woman. These findings indicated that health workers in Africa can successfully introduce and maintain anonymous HIV-1 sentinel surveillance of pregnant women and this can be accomplished with concurrent syphilis screening.

Sentinel surveillance for HIV-1 infection: how representative are blood donors, outpatients with fever, anaemia, or sexually transmitted diseases, and antenatal clinic attenders in Mwanza Region, Tanzania?

OBJECTIVE: To assess the validity of extrapolation from sentinel data by comparing the HIV-1 prevalence of various sentinel groups with that of the general population in Mwanza Region, Tanzania. METHODS: In a population survey, 4161 individuals were selected in a stratified random cluster sample. Sentinel groups (all in the age group 15-54 years) included blood donors (n = 1090); patients examined at district hospitals for the presence of malaria parasites (n = 1488), anaemia (n = 1339), or syphilis (n = 33); and antenatal clinic attenders (n = 1193). The HIV-1 serostatus of individuals selected from the population survey was tested using enzyme-linked immunosorbent assay (ELISA) and Western blot; 51% of the blood donors were tested using HIVCHEK, and all others using ELISA. HIV-1 prevalence was standardized for age, sex, and urban/non-urban location. RESULTS: HIV-1 prevalence (standardized by age, sex, and residence) in Mwanza Region was 4.0% (3.0% in non-urban areas and 11.3% in town). The standardized HIV-1 prevalences in the sentinel groups were: blood donors, 4.5%; patients with fever, 11.6%; patients with anaemia, 8.9%; urban sexually transmitted disease patients, 27.1%; urban antenatal clinic attenders, 11.8%. The crude prevalence in blood donors was 6.0%. CONCLUSION: Blood donors who are related to blood recipients appear to be a representative sentinel group in this region, provided that data are standardized for age, sex, and urban/non-urban location. Patients with fever and antenatal clinic attenders may reflect trends, but data from patients with fever markedly overestimate, and data from antenatal clinic attenders underestimate, population HIV-1 prevalence. Because self-selection of blood donors may become more pronounced, this comparison should be repeated later or elsewhere, should the opportunity arise.

PIP: When full-scale surveys of HIV-1 prevalence are not possible, sentinel surveillance is conducted at specific sites with specific population groups. In this study, 2 sentinel groups have been monitored since 1989 in the Mwanza region on the shores of Lake Victoria in Tanzania. The groups included blood donors in all hospitals of the region an prenatal clinic attenders in Mwanza Municipality. Also considered specifically for this study were outpatients from all 6 district hospitals (including 2 roadside hospitals) who had given blood samples. Population survey data on HIV prevalence between August 1990 and February 1991 were available for reference use. The sample included 1090 blood donors aged 15-54 years, 800 outpatients from district hospitals, and 1193 pregnant women attending a prenatal clinic. Blood donors (49%) were tested with enzyme immunosorbent assay (ELISA). Outpatients provided capillary blood samples collected on filter paper, of which 4605 samples were further tested with ELISA. 1866 were excluded because of age, inadequate samples, or missing data. The results of the comparison of HIV prevalence in the sentinel group and in the population survey showed that in both groups HIV-1 infection was more common in women, particularly those 15-34 years old, than in men, who were particularly affected in the 25-44 year old group. Blood donors, who were mostly male and related to the recipient, showed a crude HIV-1 prevalence of 6% (65 out of 1090). Rates were standardized, and standardized prevalence ratios were calculated. In the general population in both surveys, prevalence was 4.5%. Men had a higher prevalence in non-urban areas. Among outpatients with fever who gave blood for anemia, the crude prevalence was 9% (115 out of 1339). Prevalence was higher in the sentinel group. Of the 33 sexually transmitted diseases outpatients screened for syphilis, 33% (11) were seropositive. Prenatal clinic attenders had a HIV-prevalence of 12% (138 out of 1193).

The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural villages in Mwanza Region, Tanzania.

OBJECTIVE: To determine the prevalence of HIV-1 infection and to identify the most important risk factors for infection. DESIGN: A cross-sectional population survey carried out in 1990 and 1991 in Mwanza Region, Tanzania. METHODS: Adults aged 15-54 years were selected from the region (population, 2 million) by stratified random cluster sampling: 2434 from 20 rural villages, 1157 from 20 roadside settlements and 1554 from 20 urban wards. Risk factor information was obtained from interviews. All sera were tested for HIV-1 antibodies using enzyme-linked immunosorbent assay (ELISA); sera non-negative on ELISA were also tested by Western blot. RESULTS: The response rate was 81%. HIV-1 infection was 1.5 times more common in women than in men; 2.5% of the adult population in rural villages, 7.3% in roadside settlements and 11.8% in town were infected. HIV-1 infection occurred mostly in women aged 15-34 years and men aged 25-44 years. It was associated with being separated or widowed, multiple sex partners, presence of syphilis antibodies, history of genital discharge or genital ulcer, travel to Mwanza town, and receiving injections during the previous 12 months, but not with male circumcision. CONCLUSION: This study confirms that HIV-1 infection in this region in East Africa is more common in women than in men. The results are consistent with the spread of HIV-1 infection along the main roads. There is no evidence that lack of circumcision is a risk factor in this population.

PIP: Between August 1990 and February 1991, health workers took blood samples from, and trained interviewers spoke to, 5145 15-to-54-year-old adults living in either an urban area (1554), in a rural village (2434), or in a roadside settlement (1157) in the Mwanza Region of Tanzania to determine the prevalence of HIV-1 infection and its most significant risk factors. The prevalence rate of HIV-1 infection was highest in urban areas, lower in roadside settlements, and lowest in rural areas (11.8%, 7.3%, and 2.5%, respectively), suggesting that HIV-1 had spread along main roads. Yet, there were as many people infected with HIV-1 in rural areas of the Mwanza Region as there were in Mwanza town. Women were 1.2 (rural) to 1.7 (urban) times more likely to be infected with HIV-1 than were men, indicating greater efficiency of HIV-1 transmission from men to women than from women to men. HIV-1 infection peaked in the 15-to-34-year-old group in women and in the 25-to-44-year-old group in men. Separated, divorced, or widowed men and women were at increased risk of being HIV-1 infected, even when controlled for numerous factors (odds ratio (OR) = 3.4 and 1.6, respectively). This may have been an indication of multiple partners, since the question concerning multiple partners was vague. Other important risk factors for women and men were syphilis antibodies (OR = 1.7 and 1.85), history of genital discharge or chancroid (OR = 2, 1.6 and 2.7, 1.6), travel to Mwanza town (OR = 2.1 and 1.7), and receiving injections during the previous 12 months (OR = 1.5 and 1.9). There was no link between male circumcision and HIV-1 infection. In fact, there seemed to be a moderate protective effect (OR = 0.8). This effect may be even more likely since urban men, who were at greatest risk of HIV-1 infection (8.7% vs. 5.4% [roadside] and 2.4% [rural]), had the highest rate of circumcision (61% vs. 29% and 17%, respectively).

Kagera 1989 health survey: 1. Human immunodeficiency virus seroprevalence in adolescents.

One thousand four hundred and fifty five adolescents were surveyed for Human Immunodeficiency Virus (HIV) infection in an area experiencing AIDS epidemic. The study was done in order to estimate control measures. Among the 1455 adolescents serosurveyed, 47 (3.2%) were HIV infected, of whom 30 (63.8%) were all aged 10-15 years old. The male/female ratio was 1:1. Of all the adolescents examined 830 (57.1%) were attending school. Among the selected potential risk factors namely non-school enrollment, illicit injections, blood transfusion and sexually transmitted diseases none of these was significantly associated with HIV seropositivity. Special care should be taken when interviewing adolescents on sensitive issues like the ones associated with HIV infection. In this study potential risk factors for getting HIV infection were rarely reported, thus making it difficult to get significant association with the HIV infection.

PIP: 738 male and 717 female adolescents and young adults aged 10-19 years in Ishozi ward of Kagera rural community were surveyed for HIV infection. Only 36 males and 70 females admitted to having experienced sexual intercourse, with 29 of these experienced females being married. 3.2% of the sample was seropositive. 30 of these 47 with HIV, or 63.8%, were aged 10-15. In fact, subjects in the 10-12, 13-15,, and 16-19 year age groups were infected in almost equal proportions, as were males and females. Since customary laws prohibit sexual intercourse before marriage for both sexes, fear may have driven respondents to underreport the extent of their sexual activity. Some correlation may also exist between school enrollment and HIV infection, with teachers or other school workers being vectors of infection. No significant association with HIV seropositivity was, however, found with potential factors for infection such as non-school enrollment, illicit injections, blood transfusion, and sexually transmitted diseases. Special care should be taken when interviewing adolescents on sensitive issues such as those associated with HIV infection to elicit as much information as possible on potential risk factors which may be present for becoming infected with HIV.