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Background Many programmes on young people and HIV/AIDS prevention have focused on the in-school and channeled sexual and reproductive health messages through schools with limited activities for the young people's families. The assumption has been that parents in African families do not talk about sexual and reproductive health (SRH) with their children. These approach has had limited success because of failure to factor in the young person's family context, and the influence of parents. This paper explores parent-child communication about SRH in families, content, timing and reasons for their communication with their children aged 14-24 years in rural Tanzania. Methods This study employed an ethnographic research design. Data collection involved eight weeks of participant observation, 17 focus group discussions and 46 in-depth interviews conducted with young people aged 14-24 years and parents of young people in this age group. Thematic analysis was conducted with the aid of NVIVO 7 software. Results Parent-child communication about SRH happened in most families. The communication was mainly on same sex basis (mother-daughter and rarely father-son or father-daughter) and took the form of warnings, threats and physical discipline. Communication was triggered by seeing or hearing something a parent perceived negative and would not like their child to experience (such as a death attributable to HIV and unmarried young person's pregnancy). Although most young people were relaxed with their mothers than fathers, there is lack of trust as to what they can tell their parents for fear of punishment. Parents were limited as to what they could communicate about SRH because of lack of appropriate knowledge and cultural norms that restricted interactions between opposite sex. Conclusions Due to the consequences of the HIV pandemic, parents are making attempts to communicate with their children about SRH. They are however, limited by cultural barriers, and lack of appropriate knowledge. With some skills training on communication and SRH, parents may be a natural avenue for channeling and reinforcing HIV/AIDS prevention messages to their children.

Projections of fertility of HIV positive women as ART scales up are needed to plan prevention of mother-to-child transmission (PMTCT) services. We describe differences in exposure to pregnancy between HIV positive and HIV negative women by age, region and national ART coverage to evaluate the extent to which behavioural differences explain lower fertility among HIV positive women and assess whether exposure to pregnancy has changed with antiretroviral treatment (ART) scale-up. We analysed 46 nationally representative household surveys in sub-Saharan Africa conducted between 2003 and 2015 to estimate risk of exposure to recent sex and pregnancy of HIV positive and HIV negative women by age using a log binomial model. We tested for regional and urban/rural differences and associations with national ART coverage. We estimated an adjusted fertility rate ratio of HIV positive to HIV negative women adjusting for differences in exposure to pregnancy. Exposure to pregnancy differs significantly between HIV positive and negative women by age, modified by region. Younger HIV positive women have a higher exposure to pregnancy than HIV negative women and the opposite is true at older ages. The switch occurs at 25-29 for rural women and 30-34 for urban women. There was no evidence that exposure to pregnancy of HIV positive women have changed as national ART coverage increased. The inferred rate of fecundity of HIV positive women when adjusted for differences in exposure to pregnancy were lower than unadjusted fertility rate ratios in women aged 20-29 and 20-24 in urban and rural areas respectively varying between 0.6 and 0.9 over regions. The direct effects of HIV on fertility are broadly similar across ages, while the dramatic age gradient that has frequently been observed is largely attributable to variation in relative sexual exposure by age.

Model-based estimates of the global proportions of maternal deaths that are in HIV-infected women range from 7% to 21%, and the effects of HIV on the risk of maternal death is highly uncertain. We used longitudinal data from the Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA) network to estimate the excess mortality associated with HIV during pregnancy and the post-partum period in sub-Saharan Africa. The ALPHA network pooled data gathered between June, 1989 and April, 2012 in six community-based studies in eastern and southern Africa with HIV serological surveillance and verbal-autopsy reporting. Deaths occurring during pregnancy and up to 42 days post partum were defined as pregnancy related. Pregnant or post-partum person-years were calculated for HIV-infected and HIV-uninfected women, and HIV-infected to HIV-uninfected mortality rate ratios and HIV-attributable rates were compared between pregnant or post-partum women and women who were not pregnant or post partum. 138 074 women aged 15–49 years contributed 636 213 person-years of observation. 49 568 women had 86 963 pregnancies. 6760 of these women died, 235 of them during pregnancy or the post-partum period. Mean prevalence of HIV infection across all person-years in the pooled data was 17·2% (95% CI 17·0–17·3), but 60 of 118 (50·8%) of the women of known HIV status who died during pregnancy or post partum were HIV infected. The mortality rate ratio of HIV-infected to HIV-uninfected women was 20·5 (18·9–22·4) in women who were not pregnant or post partum and 8·2 (5·7–11·8) in pregnant or post-partum women. Excess mortality attributable to HIV was 51·8 (47·8–53·8) per 1000 person-years in women who were not pregnant or post partum and 11·8 (8·4–15·3) per 1000 person-years in pregnant or post-partum women. HIV-infected pregnant or post-partum women had around eight times higher mortality than did their HIV-uninfected counterparts. On the basis of this estimate, we predict that roughly 24% of deaths in pregnant or post-partum women are attributable to HIV in sub-Saharan Africa, suggesting that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women. Wellcome Trust, Health Metrics Network (WHO).

  According to World Health Organization (WHO) data, vital registration coverage has risen in recent years to around 40% of global deaths, but with a very unequal global distribution, as shown by GBD-2010 region in Figure 1. [...]more than 30% of the world's population live in regions where less than 5% of all deaths are registered--a critical ongoing concern for understanding global health [5]. Since GBD-2010 included all possible data, it is difficult to determine the external validity of the findings beyond the available data, or to establish the overall validity of the estimates.

Introduction Existing estimates of contraceptive use in Tanzania rely on cross-sectional or retrospective study designs. This study used a 2-year, retrospective, month-by-month calendar of contraceptive utilization among women aged 15–49 years. Methods We estimated the median duration of contraceptive use, factors associated with use, and contraceptive discontinuation rates in sexually active women, using life tables and Cox proportional hazard model. Results A total of 5416 women contributed to the analysis in the study. Of the 5416 women, 942 (17%) had never had sex, 410 (7.6%) had no sexual partner in the last year. Among the 5416 women, 4064 were sexually active during the period, 814 (21.1%) were pregnant or amenorrheic, 610 (15.0%) were using contraception, and 1203 (29.6%) did not want to get pregnant but were not using contraception. In the 1813 women who wanted to avoid pregnancy, contraceptive use was lower among women over 35 years compared to younger ones (OR = 0.28, 95%CI: 0.19, 0.41), and in HIV positive women (OR = 0.89, 95%CI: 0.60–1.32). On the other hand, use was higher among women who were married/living together compared to unmarried ones (OR = 2.23, 95% CI: 1.54, 3.23). Using a 2-year retrospective contraceptive calendar, 1054 women reported contraceptive use, 15.8% discontinued within 6 months and 30.5% discontinued within 12 months. Higher rates of contraceptive discontinuation were observed among women who used pills (OR = 1.86, 95%CI: 1.25, 2.77) or injections (OR = 2.04, 95%CI: 1.59, 2.61) compared to those who used implants. Conclusion Contraceptive use was significantly associated with age, education and parity, but not with HIV status. HIV status, number of living children and education are not statistically associated with discontinuation of contraceptive use Pills and injections had the highest rates of discontinuation. Wider choice and greater accessibility of long-acting contraceptive methods with better effectiveness and convenience may serve women better. Furthermore, special efforts may be needed to remove barriers to contraceptive use amongst younger women.

Malawi, which has about 80 000 deaths from AIDS every year, made free antiretroviral therapy available to more than 80 000 patients between 2004 and 2006. We aimed to investigate mortality in a population before and after the introduction of free antiretroviral therapy, and therefore to assess the effects of such programmes on survival at the population level. We used a demographic surveillance system to measure mortality in a population of 32 000 in northern Malawi, from August, 2002, when free antiretroviral therapy was not available in the study district, until February, 2006, 8 months after a clinic opened. Causes of death were established through verbal autopsies (retrospective interviews). Patients who registered for antiretroviral therapy at the clinic were identified and linked to the population under surveillance. Trends in mortality were analysed by age, sex, cause of death, and zone of residence. Before antiretroviral therapy became available in June, 2005, mortality in adults (aged 15–59 years) was 9·8 deaths for 1000 person-years of observation (95% CI 8·9–10·9). The probability of dying between the ages of 15 and 60 years was 43% (39–49) for men and 43% (38–47) for women; 229 of 352 deaths (65·1%) were attributed to AIDS. 8 months after the clinic that provided antiretroviral therapy opened, 107 adults from the study population had accessed treatment, out of an estimated 334 in need of treatment. Overall mortality in adults had decreased by 10% from 10·2 to 8·7 deaths for 1000 person-years of observation (adjusted rate ratio 0·90, 95% CI 0·70–1·14). Mortality was reduced by 35% (adjusted rate ratio 0·65, 0·46–0·92) in adults near the main road, where mortality before antiretroviral therapy was highest (from 13·2 to 8·5 deaths per 1000 person-years of observation before and after antiretroviral therapy). Mortality in adults aged 60 years or older did not change. Our findings of a reduction in mortality in adults aged between 15 and 59 years, with no change in those older than 60 years, suggests that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy in rural Malawi, which led to a decline in adult mortality that was detectable at the population level. Wellcome Trust and British Leprosy Relief Association.

UNAIDS official estimates of national HIV prevalence are based on trends observed in antenatal clinic surveillance, after adjustment for the reduced fertility of HIV positive women. Uptake of ART may impact on the fertility of HIV positive women, implying a need to re-estimate the adjustment factors used in these calculations. We analyse the effect of antiretroviral therapy (ART) provision on population-level fertility in Southern and East Africa, comparing trends in HIV infected women against the secular trends observed in uninfected women. We used fertility data from four community-based demographic and HIV surveillance sites: Kisesa (Tanzania), Masaka and Rakai (Uganda) and uMkhanyakude (South Africa). All births to women aged 15-44 years old were included in the analysis, classified by mother's age and HIV status at time of birth, and ART availability in the community. Calendar time period of data availability relative to ART Introduction varied across the sites, from 5 years prior to ART roll-out, to 9 years after. Calendar time was classified according to ART availability, grouped into pre ART, ART introduction (available in at least one health facility serving study site) and ART available (available in all designated health facilities serving study site). We used Poisson regression to calculate age adjusted fertility rate ratios over time by HIV status, and investigated the interaction between ART period and HIV status to ascertain whether trends over time were different for HIV positive and negative women. Age-adjusted fertility rates declined significantly over time for HIV negative women in all four studies. However HIV positives either had no change in fertility (Masaka, Rakai) or experienced a significant increase over the same period (Kisesa, uMkhanyakude). HIV positive fertility was significantly lower than negative in both the pre ART period (age adjusted fertility rate ratio (FRR) range 0.51 95%CI 0.42-0.61 to 0.73 95%CI 0.64-0.83) and when ART was widely available (FRR range 0.57 95%CI 0.52-0.62 to 0.83 95%CI 0.78-0.87), but the difference has narrowed. The interaction terms describing the difference in trends between HIV positives and negatives are generally significant. Differences in fertility between HIV positive and HIV negative women are narrowing over time as ART becomes more widely available in these communities. Routine adjustment of ANC data for estimating national HIV prevalence will need to allow for the impact of treatment.

Background Studies based on high-quality linked data in developed countries show that even minor linkage errors, which occur when records of two different individuals are erroneously linked or when records belonging to the same individual are not linked, can impact bias and precision of subsequent analyses. We evaluated the impact of linkage quality on inferences drawn from analyses using data with substantial linkage errors in rural Tanzania. Methods Semi-automatic point-of-contact interactive record linkage was used to establish gold standard links between community-based HIV surveillance data and medical records at clinics serving the surveillance population. Automated probabilistic record linkage was used to create analytic datasets at minimum, low, medium, and high match score thresholds. Cox proportional hazards regression models were used to compare HIV care registration rates by testing modality (sero-survey vs. clinic) in each analytic dataset. We assessed linkage quality using three approaches: quantifying linkage errors, comparing characteristics between linked and unlinked data, and evaluating bias and precision of regression estimates. Results Between 2014 and 2017, 405 individuals with gold standard links were newly diagnosed with HIV in sero-surveys ( n  = 263) and clinics ( n  = 142). Automated probabilistic linkage correctly identified 233 individuals (positive predictive value [PPV] = 65%) at the low threshold and 95 individuals (PPV = 90%) at the high threshold. Significant differences were found between linked and unlinked records in primary exposure and outcome variables and for adjusting covariates at every threshold. As expected, differences attenuated with increasing threshold. Testing modality was significantly associated with time to registration in the gold standard data (adjusted hazard ratio [HR] 4.98 for clinic-based testing, 95% confidence interval [CI] 3.34, 7.42). Increasing false matches weakened the association (HR 2.76 at minimum match score threshold, 95% CI 1.73, 4.41). Increasing missed matches (i.e., increasing match score threshold and positive predictive value of the linkage algorithm) was strongly correlated with a reduction in the precision of coefficient estimate (R 2  = 0.97; p  = 0.03). Conclusions Similar to studies with more negligible levels of linkage errors, false matches in this setting reduced the magnitude of the association; missed matches reduced precision. Adjusting for these biases could provide more robust results using data with considerable linkage errors.

Assumptions about survival of HIV-infected children in Africa without antiretroviral therapy need to be updated to inform ongoing UNAIDS modelling of paediatric HIV epidemics among children. Improved estimates of infant survival by timing of HIV-infection (perinatally or postnatally) are thus needed. A pooled analysis was conducted of individual data of all available intervention cohorts and randomized trials on prevention of HIV mother-to-child transmission in Africa. Studies were right-censored at the time of infant antiretroviral initiation. Overall mortality rate per 1000 child-years of follow-up was calculated by selected maternal and infant characteristics. The Kaplan-Meier method was used to estimate survival curves by child's HIV infection status and timing of HIV infection. Individual data from 12 studies were pooled, with 12,112 children of HIV-infected women. Mortality rates per 1,000 child-years follow-up were 39.3 and 381.6 for HIV-uninfected and infected children respectively. One year after acquisition of HIV infection, an estimated 26% postnatally and 52% perinatally infected children would have died; and 4% uninfected children by age 1 year. Mortality was independently associated with maternal death (adjusted hazard ratio 2.2, 95%CI 1.6-3.0), maternal CD4<350 cells/ml (1.4, 1.1-1.7), postnatal (3.1, 2.1-4.1) or peri-partum HIV-infection (12.4, 10.1-15.3). These results update previous work and inform future UNAIDS modelling by providing survival estimates for HIV-infected untreated African children by timing of infection. We highlight the urgent need for the prevention of peri-partum and postnatal transmission and timely assessment of HIV infection in infants to initiate antiretroviral care and support for HIV-infected children.

To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries. We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance. There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy. Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.