Low mortality risk but high loss to follow-up among patients in the Tanzanian national HIV care and treatment programme.

UNLABELLED: OBJECTIVE To analyse survival and retention rates of the Tanzanian care and treatment programme. METHODS: Routine patient-level data were available from 101 of 909 clinics. Kaplan-Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow-up using Egger's nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals. RESULTS: In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow-up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months, and were higher among males, those under 45 kg and those with CD4 counts below 50 cells/µl at ART initiation. In the first year on ART, median CD4 count increased by 126 cells/µl, with similar changes in both sexes. CONCLUSION: Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition.

Three years of HIV/AIDS care and treatment services in Tanzania: achievements and challenges.

The Tanzania HIV Care and Treatment Plan was launched in October 2004 aiming at providing 440,000 AIDS patients with antiretroviral drugs (ARVs) and track disease progression in 1.2 million HIV+ persons by the end of the 2008. This paper is intended to provide information to stake holders of the achievements and challenges of the HIV Care and Treatment Plan since its inception in 2004. Facility patient reports are aggregated at district and then regional level before being sent to the national level where they are aggregated to form a national report. By December 2007, 210 health facilities were offering HIV care and treatment services in Tanzania. About 123,147 (5%) of the 2,636,785 estimated people living with HIV and AIDS were enrolled, and 71,439 (13.6%) of the estimated 527,357 AIDS cases commenced ART. More females than males started ART, F:M ratio being 3:2. Most (49%) patients were started ART due to low CD4 counts (< 200). About 6,618 patients had their initial ARV regimen changed due to starting anti-TB treatment 679 (10%), peripheral neuropathy 812 (12%), skin rash 378 (6%), and stock out 247 (4%) or other reasons (18%), while 2,653 (42%) had no reason recorded. The proportion of patients still alive and on ART at 6, 12 and 24 months after initiation of treatment was 60%, 60%, and 50%, respectively, while those collecting ARVs on schedule was 34%, 25% and 10% respectively. About 3,084 patients developed TB after starting ART, of whom 1,557 (approximately 50%) patients during the first three months of treatment. During the three years (2004-2007) of HIV care and treatment services in Tanzania, there has been an increase in the number of CTC facilities, geographical coverage of services, the number of enrolled patients and those on ART. However, the set target for ART services has not been achieved and there are significant geographical variations in these achievements, which do not correspond with either population density or disease burden. Efforts should be made to i) ensure equitable accessibility when scaling up ART services in Tanzania, ii) improve the recording and reporting system and iii) armonize the activities of various stakeholders.

Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990-1993.

HIV prevention through peer education and condom promotion among truck drivers and their sexual partners is described. Trends during an initial 18-month intensive phase, followed by a 24-month maintenance phase, were monitored with surveys. Trends for self-reported condom use were: increase among men (56 to 74%) during the first phase with a decrease (72%) during the maintenance phase. Respective figures for women were 51%, 91% and 70%. Multivariate analyses revealed that men most likely to report using condoms were unmarried, had children, were more educated, had previously reported a genital ulcer, and perceived themselves at risk for HIV infection (OR = 1.95-3.47). Women tending to use condoms were unmarried, aware of the limitations of condoms, not in denial as to the existence of HIV, harboured inaccurate information about HIV transmission and were afraid (OR = 1.35-2.52). Both sets of results suggest that the most sexually experienced men and women who did not have a permanent stable relationship and who perceived themselves at risk, were most likely to use a condom. Peer education was an effective tool for increasing knowledge and encouraging appropriate behaviour change. It was most effective as an intensive high-input intervention and sustainable with the relatively stable population of truck drivers.

Association between leprosy and HIV infection in Tanzania.

SETTING: An epidemiological study of the interaction of leprosy and HIV infection in Tanzania. OBJECTIVE: To establish the prevalence of HIV infection among leprosy patients, and to measure the association of HIV and leprosy by comparing the HIV prevalence in leprosy patients and blood donors. DESIGN: Testing for HIV infection in consecutively diagnosed leprosy patients (new and relapsed after MDT) in all regions in Tanzania successively for a period of 3 to 6 months during 1991, 1992 and 1993. RESULTS: Out of the total estimated eligible leprosy patients, 697 patients (69%) entered the final analysis. The HIV prevalence among these leprosy patients was 12% (83/697) as compared to 6% (8960/ 158,971) in blood donors examined in Tanzania during the same period. There were no significant differences in HIV seroprevalence by age, sex, residence or type of disease. However, the adjusted odds ratio (OR) of the presence of a BCG scar was 1.9 [95% confidence interval (CI) 1.1-3.3] among HIV-positive leprosy cases compared to HIV-negative leprosy cases. Comparing leprosy cases with blood donors as controls, the logistic regression model, controlling for sex, age group and residence, showed the OR for HIV seropositivity among leprosy patients to be 2.5 (95% CI 2.0-3.2). This association existed in all strata, but was strongest in the 15-34-year age group. No difference of HIV status between multibacillary and paucibacillary leprosy could be shown to exist. The point estimate of the population attributable risk of HIV infection for leprosy was 7%. CONCLUSION: HIV infection is associated with leprosy and might reverse the epidemiological trend of the slow decline in case notification in Tanzania if HIV infection is increasing greatly. Previous BCG vaccination loses its protection against leprosy in the presence of HIV infection. A repeated study is recommended in order to validate these findings, whereby recording of the disability grading of the cases is necessary to adjust for delay in diagnosis.

PIP: The association between HIV infection and leprosy was investigated in 731 consecutive leprosy cases from all 20 regions of Tanzania. These cases represented 69% of total notified new and relapsed leprosy cases reported in the 1991-93 study period. HIV prevalence among the 679 patients for whom complete data were available was 12% (83 cases). Leprosy patients aged 35-54 years and those without a BCG scar were significantly less likely than their counterparts aged 15-34 years and those with a BCG scar to be HIV-infected. There were no significant differences in HIV prevalence in terms of sex, urban or rural residence, new or relapsed cases, and paucibacillary or multibacillary leprosy. Among controls--all 158,971 blood donors tested for HIV during 1991 to 1993--HIV prevalence was 6%. The overall odds ratio for HIV infection among leprosy patients compared with controls, after adjustments for sex, age, and residence, was 2.5 (95% confidence interval, 2.0-3.2). Point estimates of the attributable risk and the population attributable risk were 57% and 7%, respectively. These findings indicate that HIV infection significantly increases the risk of leprosy in Tanzania and compromises the protective effect of BCG vaccination. Although case notifications of leprosy in Tanzania have not changed appreciably in the past 13 years, expansion of the HIV epidemic could have a significant effect on the epidemiology of leprosy.

Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania.

BACKGROUND: A community-randomised trial was undertaken to assess the impact, cost, and cost-effectiveness of averting HIV-1 infection through improved management of sexually transmitted diseases (STDs) by primary-health-care workers in Mwanza Region, Tanzania. METHODS: The impact of improved treatment services for STDs on HIV-1 incidence was assessed by comparison of six intervention communities with six matched communities. We followed up a random cohort of 12,537 adults aged 15-54 years for 2 years to record incidence of HIV-1 infection. The total and incremental costs of the intervention were estimated (ingredients approach) and used to calculate the total cost per case treated, the incremental cost per HIV-1 infection averted, and the incremental cost per disability-adjusted life-year (DALY) saved. FINDINGS: During 2 years of follow-up, 11,632 cases of STDs were treated in the intervention health units. The baseline prevalence of HIV-1 infection was 4%. The incidence of HIV-1 infection during the 2 years was 1.16% in the intervention communities and 1.86% in the comparison communities. An estimated 252 HIV-1 infections were averted each year. The total annual cost of the intervention was US$59,060 (1993 prices), equivalent to $0.39 per head of population served. The cost for STD case treated was $10.15, of which the drug cost was $2.11. The incremental annual cost of the intervention was $54,839, equivalent to $217.62 per HIV-1 infection averted and $10.33 per DALY saved (based on Tanzanian life expectancy) or $9.45 per DALY saved (based on the assumptions of the World Development Report). In a sensitivity analysis of factors influencing cost-effectiveness, cost per DALY saved ranged from $2.51 to $47.86. INTERPRETATION: Improved management of STDs in rural health units reduced the incidence of HIV-1 infection in the general population by about 40%. The estimated cost-effectiveness of this intervention ($10 per DALY) compares favourably with that of, for example, childhood immunisation programmes ($12-17 per DALY). Cost-effectiveness should be further improved when the intervention is applied on a larger scale. Resources should be made available for this highly cost-effective HIV control strategy.

PIP: Improved management of sexually transmitted diseases (STDs) is consistently advocated as an effective strategy for HIV prevention. The impact, cost, and cost-effectiveness of this approach were evaluated in a prospective, comparative study of six communities in Tanzania's Mwanza Region in which primary health care center workers were trained to provide improved STD treatment and six matched non-intervention communities. The baseline prevalence of HIV was 4% in both groups. During the 2-year study period, 11,632 cases of STDs were treated in the intervention health units. The HIV seroconversion rate was 1.16% in the intervention communities and 1.86% in the comparison communities--a difference in HIV incidence of 0.70 (95% confidence interval, 0.37-1.09) and a reduction of about 40%. The total annual cost of the intervention was US$59,060 ($0.39 per person served). The cost of STD treatment was $10.15 per case. An estimated 252 HIV-1 infections were averted each year. The incremental annual cost of the program was $54,839, equivalent to $217.62 per HIV infection averted and $10.33 per disability-adjusted-life-year (DALY) saved. The estimated cost-effectiveness compares favorably with that of childhood immunization programs ($12-17 per DALY saved) and could be further enhanced through implementation of the intervention on a wider scale. The intervention subsequently has been expanded to encompass 65 health units in Mwanza Region, with no increase in investment costs.

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).

Epidemiology of HIV-1 infection in Tanzania: an update

Information gathered todate from various sources indicate that the HIV/AIDS epidemic is increasing at alarming rates throughout Tanzania. Two populations are of particular importance; namely antenatal clinic attenders and adolescents. Among pregnant women attending antenatal clinics in Mbeya; Mwanza and Kagera regions the prevalence of HIV antibody has increased from 10 percent to 16 percent (Mbeya) and from 8 percent to 14 percent (Mwanza) in a little over a period of one year. Among the 15-19 year old; the prevalence of HIV infection was 0. percent in 1897 and by 1990 levels of 7.0 percent had been documented. Among the 20-24 years age group; the HIV prevalence increased five fold from 1.6 percent in 1987 to 8.2 percent in 1990. It is very unlikely that HIV and AIDS prevalences will stabilize in the very near future

Epidemiology of HIV-1 infection in Tanzania: an update

Information gathered to date from various sources indicate that the HIV/AIDS epidemic is increasing at alarming rates throughout Tanzania. Two populations are of particular importance; namely antenatal clinic attenders and adolescents. Among pregnant women attending antenatal clinics in Mbeya; Mwanza and Kagera regions the prevalence of HIV antibody has increased from 10 percent to 16 percent (Mbeya) and from 8 percent to 14 percent (Mwanza) in a little over a period of one year. Among the 15-19 year old; the prevalence of HIV infection was 0. percent in 1987 and by 1990 levels of 7.0 percent had been documented. Among the 20-24 years age group; the HIV prevalence increased five fold from 1.6 percent in 1987 to 8.2 percent in 1990. It is very unlikely that HIV and AIDS prevalences will stabilize in the very near future