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Ginsburg C, Bocquier P, Béguy D, Afolabi S, Kahn K, Obor D, Tanser F, Tomita A, Wamukoya M, Collinson MA. Association between internal migration and epidemic dynamics: an analysis of cause-specific mortality in Kenya and South Africa using health and demographic surveillance data. BMC Public Health 2018; 18:918. [PMID: 30049267 PMCID: PMC6062880 DOI: 10.1186/s12889-018-5851-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 07/16/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Many low- and middle-income countries are facing a double burden of disease with persisting high levels of infectious disease, and an increasing prevalence of non-communicable disease (NCD). Within these settings, complex processes and transitions concerning health and population are underway, altering population dynamics and patterns of disease. Understanding the mechanisms through which changing socioeconomic and environmental contexts may influence health is central to developing appropriate public health policy. Migration, which involves a change in environment and health exposure, is one such mechanism. METHODS This study uses Competing Risk Models to examine the relationship between internal migration and premature mortality from AIDS/TB and NCDs. The analysis employs 9 to 14 years of longitudinal data from four Health and Demographic Surveillance Systems (HDSS) of the INDEPTH Network located in Kenya and South Africa (populations ranging from 71 to 223 thousand). The study tests whether the mortality of migrants converges to that of non-migrants over the period of observation, controlling for age, sex and education level. RESULTS In all four HDSS, AIDS/TB has a strong influence on overall deaths. However, in all sites the probability of premature death (45q15) due to AIDS/TB is declining in recent periods, having exceeded 0.39 in the South African sites and 0.18 in the Kenyan sites in earlier years. In general, the migration effect presents similar patterns in relation to both AIDS/TB and NCD mortality, and shows a migrant mortality disadvantage with no convergence between migrants and non-migrants over the period of observation. Return migrants to the Agincourt HDSS (South Africa) are on average four times more likely to die of AIDS/TB or NCDs than are non-migrants. In the Africa Health Research Institute (South Africa) female return migrants have approximately twice the risk of dying from AIDS/TB from the year 2004 onwards, while there is a divergence to higher AIDS/TB mortality risk amongst female migrants to the Nairobi HDSS from 2010. CONCLUSION Results suggest that structural socioeconomic issues, rather than epidemic dynamics are likely to be associated with differences in mortality risk by migrant status. Interventions aimed at improving recent migrant's access to treatment may mitigate risk.
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Affiliation(s)
- Carren Ginsburg
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown, Johannesburg, 2193 South Africa
- INDEPTH Network, Accra, Ghana
| | - Philippe Bocquier
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown, Johannesburg, 2193 South Africa
- Centre de Recherches en Démographie, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Donatien Béguy
- African Population and Health Research Centre, Nairobi, Kenya
| | - Sulaimon Afolabi
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown, Johannesburg, 2193 South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown, Johannesburg, 2193 South Africa
- INDEPTH Network, Accra, Ghana
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - David Obor
- KEMRI & CDC - Centre for Global Health Research, Kisumu, Kenya
| | - Frank Tanser
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Andrew Tomita
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Mark A. Collinson
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown, Johannesburg, 2193 South Africa
- INDEPTH Network, Accra, Ghana
- Department of Science and Technology/ Medical Research Council, South African Population Research Infrastructure Network, Johannesburg, South Africa
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Cuadros DF, Sartorius B, Hall C, Akullian A, Bärnighausen T, Tanser F. Capturing the spatial variability of HIV epidemics in South Africa and Tanzania using routine healthcare facility data. Int J Health Geogr 2018; 17:27. [PMID: 29996876 PMCID: PMC6042209 DOI: 10.1186/s12942-018-0146-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Large geographical variations in the intensity of the HIV epidemic in sub-Saharan Africa call for geographically targeted resource allocation where burdens are greatest. However, data available for mapping the geographic variability of HIV prevalence and detecting HIV 'hotspots' is scarce, and population-based surveillance data are not always available. Here, we evaluated the viability of using clinic-based HIV prevalence data to measure the spatial variability of HIV in South Africa and Tanzania. METHODS Population-based and clinic-based HIV data from a small HIV hyper-endemic rural community in South Africa as well as for the country of Tanzania were used to map smoothed HIV prevalence using kernel interpolation techniques. Spatial variables were included in clinic-based models using co-kriging methods to assess whether cofactors improve clinic-based spatial HIV prevalence predictions. Clinic- and population-based smoothed prevalence maps were compared using partial rank correlation coefficients and residual local indicators of spatial autocorrelation. RESULTS Routinely-collected clinic-based data captured most of the geographical heterogeneity described by population-based data but failed to detect some pockets of high prevalence. Analyses indicated that clinic-based data could accurately predict the spatial location of so-called HIV 'hotspots' in > 50% of the high HIV burden areas. CONCLUSION Clinic-based data can be used to accurately map the broad spatial structure of HIV prevalence and to identify most of the areas where the burden of the infection is concentrated (HIV 'hotspots'). Where population-based data are not available, HIV data collected from health facilities may provide a second-best option to generate valid spatial prevalence estimates for geographical targeting and resource allocation.
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Affiliation(s)
- Diego F Cuadros
- Department of Geography and Geographic Information Science, University of Cincinnati, Cincinnati, OH, 45221, USA. .,Health Geography and Disease Modeling Laboratory, University of Cincinnati, Cincinnati, USA.
| | - Benn Sartorius
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Chris Hall
- Geographical Information Systems and Science Program, Kingston University, London, UK
| | - Adam Akullian
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, USA
| | - Till Bärnighausen
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Heidelberg Institute for Public Health, University of Heidelberg, Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Frank Tanser
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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53
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Larmarange J, Diallo MH, McGrath N, Iwuji C, Plazy M, Thiébaut R, Tanser F, Bärnighausen T, Pillay D, Dabis F, Orne‐Gliemann J. The impact of population dynamics on the population HIV care cascade: results from the ANRS 12249 Treatment as Prevention trial in rural KwaZulu-Natal (South Africa). J Int AIDS Soc 2018; 21 Suppl 4:e25128. [PMID: 30027600 PMCID: PMC6053480 DOI: 10.1002/jia2.25128] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/17/2018] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION The universal test and treat strategy (UTT) was developed to maximize the proportion of all HIV-positive individuals on antiretroviral treatment (ART) and virally suppressed, assuming that it will lead to a reduction in HIV incidence at the population level. The evolution over time of the cross-sectional HIV care cascade is determined by individual longitudinal trajectories through the HIV care continuum and underlying population dynamics. The purpose of this paper is to quantify the contribution of each component of population change (in- and out-migration, HIV seroconversion, ageing into the cohort and definitive exit such as death) on the HIV care cascade in the context of the ANRS 12249 Treatment as Prevention (TasP) cluster-randomized trial, investigating UTT in rural KwaZulu-Natal, South Africa, between 2012 and 2016. METHODS HIV test results and information on clinic visits, ART prescriptions, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the population of resident adults living with HIV with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each entry or exit on the average cascade score and their annualized total contribution, by component of change. RESULTS While the average cascade score increased over time in all clusters, that increase was constrained by population dynamics. Permanent exits and ageing into the people living with HIV cohort had a marginal effect. Both in-migrants and out-migrants were less likely to be retained at each step of the HIV care continuum. However, their overall impact on the cross-sectional cascade was limited as the effect of in- and out-migration balanced each other. The contribution of HIV seroconversions was negative in all clusters. CONCLUSIONS In a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression, ultimately attenuating any population-level impact on HIV incidence. CLINICAL TRIAL NUMBER NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).
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Affiliation(s)
- Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
| | - Mamadou Hassimiou Diallo
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
| | - Nuala McGrath
- School of Nursing and Public HealthAfrica Health Research InstituteUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Faculty of Medicine and Faculty of Social, Human and Mathematical SciencesUniversity of SouthamptonSouthamptonUK
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - Collins Iwuji
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolFalmerBrightonUK
| | - Mélanie Plazy
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Rodolphe Thiébaut
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Frank Tanser
- School of Nursing and Public HealthAfrica Health Research InstituteUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
| | - Till Bärnighausen
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Global Health & PopulationHarvard School of Public HealthHarvard UniversityBostonMAUSA
- Institute of Public HealthFaculty of MedicineHeidelberg UniversityHeidelbergGermany
| | - Deenan Pillay
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Division of Infection and ImmunityUniversity College LondonLondonUK
| | - François Dabis
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Joanna Orne‐Gliemann
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
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Rasmussen DA, Wilkinson E, Vandormael A, Tanser F, Pillay D, Stadler T, de Oliveira T. Tracking external introductions of HIV using phylodynamics reveals a major source of infections in rural KwaZulu-Natal, South Africa. Virus Evol 2018; 4:vey037. [PMID: 30555720 PMCID: PMC6290119 DOI: 10.1093/ve/vey037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite increasing access to antiretrovirals, HIV incidence in rural KwaZulu-Natal remains among the highest ever reported in Africa. While many epidemiological factors have been invoked to explain such high incidence, widespread human mobility and viral movement suggest that transmission between communities may be a major source of new infections. High cross-community transmission rates call into question how effective increasing the coverage of antiretroviral therapy locally will be at preventing new infections, especially if many new cases arise from external introductions. To help address this question, we use a phylodynamic model to reconstruct epidemic dynamics and estimate the relative contribution of local transmission versus external introductions to overall incidence in KwaZulu-Natal from HIV-1 phylogenies. By comparing our results with population-based surveillance data, we show that we can reliably estimate incidence from viral phylogenies once viral movement in and out of the local population is accounted for. Our analysis reveals that early epidemic dynamics were largely driven by external introductions. More recently, we estimate that 35 per cent (95% confidence interval: 20-60%) of new infections arise from external introductions. These results highlight the growing need to consider larger-scale regional transmission dynamics when designing and testing prevention strategies.
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Affiliation(s)
- David A Rasmussen
- Department of Entomology and Plant Pathology, North Carolina State University, Raleigh, NC, USA
- Bioinformatics Research Center, North Carolina State University, Raleigh, NC, USA
| | - Eduan Wilkinson
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Alain Vandormael
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
- Research Department of Infection & Population Health, University College London, UK
| | - Deenan Pillay
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, UK
| | - Tanja Stadler
- Department of Biosystems Science and Engineering, ETH Zürich, Basel, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Department of Global Health, University of Washington, Seattle, USA
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56
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Nöstlinger C, Loos J. Migration patterns and HIV prevention in Uganda. Lancet HIV 2018; 5:e158-e160. [PMID: 29490876 DOI: 10.1016/s2352-3018(18)30023-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 06/08/2023]
Affiliation(s)
| | - Jasna Loos
- Department of Public Health, Institute of Tropical Medicine, Antwerp 2000, Belgium
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57
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Olawore O, Tobian AAR, Kagaayi J, Bazaale JM, Nantume B, Kigozi G, Nankinga J, Nalugoda F, Nakigozi G, Kigozi G, Gray RH, Wawer MJ, Ssekubugu R, Santelli JS, Reynolds SJ, Chang LW, Serwadda D, Grabowski MK. Migration and risk of HIV acquisition in Rakai, Uganda: a population-based cohort study. Lancet HIV 2018; 5:e181-e189. [PMID: 29490875 PMCID: PMC6195205 DOI: 10.1016/s2352-3018(18)30009-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 06/03/2023]
Abstract
BACKGROUND In sub-Saharan Africa, migrants typically have higher HIV prevalence than non-migrants; however, whether HIV acquisition typically precedes or follows migration is unknown. We aimed to investigate the risk of HIV after migration in Rakai District, Uganda. METHODS In a prospective population-based cohort of HIV-negative participants aged 15-49 years in Rakai, Uganda, between April 6, 1999, and Jan 30, 2015, we assessed the association between migration and HIV acquisition. Individuals were classified as recent in-migrants (≤2 years in community), non-recent in-migrants (>2 years in community), or permanent residents with no migration history. The primary outcome was incident HIV infection. We used Poisson regression to estimate incidence rate ratios (IRRs) of HIV associated with residence status with adjustment for demographics, sexual behaviours, and time. Data were also stratified and analysed within three periods (1999-2004, 2005-11, and 2011-15) in relation to the introduction of combination HIV prevention (CHP; pre-CHP, early CHP, and late CHP). FINDINGS Among 26 995 HIV-negative people who participated in the Rakai Community Cohort Study survey, 15 187 (56%) contributed one or more follow-up visits (89 292 person-years of follow-up) and were included in our final analysis. 4451 (29%) were ever in-migrants and 10 736 (71%) were permanent residents. 841 incident HIV events occurred, including 243 (29%) among in-migrants. HIV incidence per 100 person-years was significantly increased among recent in-migrants compared with permanent residents, for both women (1·92, 95% CI 1·52-2·43 vs 0·93, 0·84-1·04; IRR adjusted for demographics 1·75, 95% CI 1·33-2·33) and men (1·52, 0·99-2·33 vs 0·84, 0·74-0·94; 1·74, 1·12-2·71), but not among non-recent in-migrants (IRR adjusted for demographics 0·94, 95% CI 0·74-1·19 for women and 1·28, 0·94-1·74 for men). Between the pre-CHP and late-CHP periods, HIV incidence declined among permanent resident men (p<0·0001) and women (p=0·002) and non-recent in-migrant men (p=0·031), but was unchanged among non-recent in-migrant women (p=0·13) and recent in-migrants (men p=0·76; women p=0·84) INTERPRETATION: The first 2 years after migration are associated with increased risk of HIV acquisition. Prevention programmes focused on migrants are needed to reduce HIV incidence in sub-Saharan Africa. FUNDING National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, National Institutes of Health; the Centers for Disease Control and Prevention; the Bill & Melinda Gates Foundation; and the Johns Hopkins University Center for AIDS Research.
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Affiliation(s)
- Oluwasolape Olawore
- Department of Epidemiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Aaron A R Tobian
- Department of Epidemiology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | | | | | | | | | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda
| | | | - John S Santelli
- Heilbrunn Department of Population and Family Health, Columbia University, New York, NY, USA
| | - Steven J Reynolds
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda; Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Larry W Chang
- Department of Epidemiology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda; Makerere University School of Public Health, Kampala, Uganda
| | - Mary K Grabowski
- Department of Epidemiology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda.
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58
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Dzomba A, Govender K, Mashamba-Thompson TP, Tanser F. Mobility and increased risk of HIV acquisition in South Africa: a mixed-method systematic review protocol. Syst Rev 2018; 7:37. [PMID: 29486798 PMCID: PMC6389209 DOI: 10.1186/s13643-018-0703-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 02/19/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In South Africa (home of the largest HIV epidemic globally), there are high levels of mobility. While studies produced in the recent past provide useful perspectives to the mobility-HIV risk linkage, systematic analyses are needed for in-depth understanding of the complex dynamics between mobility and HIV risk. We plan to undertake an evidence-based review of existing literature connecting mobility and increased risky sexual behavior as well as risk of HIV acquisition in South Africa. METHODS/DESIGN We will conduct a mixed-method systematic review of peer-reviewed studies published between 2000 and 2015. In particular, we will search for relevant South African studies from the following databases: MEDLINE, EMBASE, Web of Science, and J-STOR databases. Studies explicitly examining HIV and labor migration will be eligible for inclusion, while non-empirical work and other studies on key vulnerable populations such as commercial sex workers (CSW) and men who have sex with men (MSM) will be excluded. DISCUSSION The proposed mixed-method systematic review will employ a three-phase sequential approach [i.e., (i) identifying relevant studies through data extraction (validated by use of Distiller-SR data management software), (ii) qualitative synthesis, and (iii) quantitative synthesis including meta-analysis data]. Recurrent ideas and conclusions from syntheses will be compiled into key themes and further processed into categories and sub-themes constituting the primary and secondary outcomes of this study. Synthesis of main findings from different studies examining the subject issue here may uncover important research gaps in this literature, laying a strong foundation for research and development of sustainable localized migrant-specific HIV prevention strategies in South Africa. SYSTEMATIC REVIEW REGISTRATION Our protocol was registered with PROSPERO under registration number: CRD 42017055580. ( https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017055580 ).
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Affiliation(s)
- Armstrong Dzomba
- Africa Health Research Institute (AHRI), K-RITH Tower Building, 719 Umbilo Road, Durban Private Bag X7, Congella, Durban, South Africa
- Discipline of Public Health Medicine, Africa Health Research Institute (AHRI) and University of KwaZulu-Natal, K-RITH Tower Building, 719 Umbilo Road, Durban Private Bag X7, Congella, Durban, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV/AIDS Research Division, Durban, South Africa
- Howard College, University of KwaZulu-Natal, King George V Avenue, Durban, 4001 South Africa
| | - Tivani P. Mashamba-Thompson
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- Africa Health Research Institute, (AHRI), School of Nursing and Public Health, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa—CAPRISA, Congella, Durban, South Africa
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59
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Tanser F, Azongo DK, Vandormael A, Bärnighausen T, Appleton C. Impact of the scale-up of piped water on urogenital schistosomiasis infection in rural South Africa. eLife 2018; 7:33065. [PMID: 29460779 PMCID: PMC5819946 DOI: 10.7554/elife.33065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/31/2018] [Indexed: 12/31/2022] Open
Abstract
Recent work has estimated that sub-Saharan Africa could lose US$3.5 billion of economic productivity every year as a result of schistosomiasis and soil-transmitted helminthiasis. One of the main interventions to control schistosomiasis is the provision of safe water to limit the contact with infected water bodies and break the cycle of transmission. To date, a rigorous quantification of the impact of safe water supplies on schistosomiasis is lacking. Using data from one of Africa's largest population-based cohorts, we establish the impact of the scale-up of piped water in a typical rural South African population over a seven-year time horizon. High coverage of piped water in the community decreased a child's risk of urogenital schistosomiasis infection eight-fold (adjusted odds ratio = 0.12, 95% CI 0.06-0.26, p<0.001). The provision of safe water could drive levels of urogenital schistosomiasis infection to low levels of endemicity in rural African settings.
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Affiliation(s)
- Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Daniel K Azongo
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Upper East Region, Ghana
| | - Alain Vandormael
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute of Epidemiology and Health Care, University College London, London, United Kingdom.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States.,Institute for Public Health, University of Heidelberg, Heidelberg, Germany
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Palk L, Blower S. Geographic variation in sexual behavior can explain geospatial heterogeneity in the severity of the HIV epidemic in Malawi. BMC Med 2018; 16:22. [PMID: 29422096 PMCID: PMC5806472 DOI: 10.1186/s12916-018-1006-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/11/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, where ~ 25 million individuals are infected with HIV and transmission is predominantly heterosexual, there is substantial geographic variation in the severity of epidemics. This variation has yet to be explained. Here, we propose that it is due to geographic variation in the size of the high-risk group (HRG): the group with a high number of sex partners. We test our hypothesis by conducting a geospatial analysis of data from Malawi, where ~ 13% of women and ~ 8% of men are infected with HIV. METHODS We used georeferenced HIV testing and behavioral data from ~ 14,000 participants of a nationally representative population-level survey: the 2010 Malawi Demographic and Health Survey (MDHS). We constructed gender-stratified epidemic surface prevalence (ESP) maps by spatially smoothing and interpolating the HIV testing data. We used the behavioral data to construct gender-stratified risk maps that reveal geographic variation in the size of the HRG. We tested our hypothesis by fitting gender-stratified spatial error regression (SER) models to the MDHS data. RESULTS The ESP maps show considerable geographic variation in prevalence: 1-29% (women), 1-20% (men). Risk maps reveal substantial geographic variation in the size of the HRG: 0-40% (women), 16-58% (men). Prevalence and the size of the HRG are highest in urban centers. However, the majority of HIV-infected individuals (~75% of women, ~ 80% of men) live in rural areas, as does most of the HRG (~ 80% of women, ~ 85% of men). We identify a significant (P < 0.001) geospatial relationship linking the size of the HRG with prevalence: the greater the size, the higher the prevalence. SER models show HIV prevalence in women is expected to exceed the national average in districts where > 20% of women are in the HRG. Most importantly, the SER models show that geographic variation in the size of the HRG can explain a substantial proportion (73% for women, 67% for men) of the geographic variation in epidemic severity. CONCLUSIONS Taken together, our results provide substantial support for our hypothesis. They provide a potential mechanistic explanation for the geographic variation in the severity of the HIV epidemic in Malawi and, potentially, in other countries in sub-Saharan Africa.
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Affiliation(s)
- Laurence Palk
- Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, 760 Westwood Plaza, Office 27-423, Los Angeles, California, 90095, USA
| | - Sally Blower
- Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, 760 Westwood Plaza, Office 27-423, Los Angeles, California, 90095, USA.
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Vandormael A, Dobra A, Bärnighausen T, de Oliveira T, Tanser F. Incidence rate estimation, periodic testing and the limitations of the mid-point imputation approach. Int J Epidemiol 2018; 47:236-245. [PMID: 29024978 PMCID: PMC5837439 DOI: 10.1093/ije/dyx134] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/18/2017] [Accepted: 06/29/2017] [Indexed: 11/12/2022] Open
Abstract
Background It is common to use the mid-point between the latest-negative and earliest-positive test dates as the date of the infection event. However, the accuracy of the mid-point method has yet to be systematically quantified for incidence studies once participants start to miss their scheduled test dates. Methods We used a simulation-based approach to generate an infectious disease epidemic for an incidence cohort with a high (80-100%), moderate (60-79.9%), low (40-59.9%) and poor (30-39.9%) testing rate. Next, we imputed a mid-point and random-point value between the participant's latest-negative and earliest-positive test dates. We then compared the incidence rate derived from these imputed values with the true incidence rate generated from the simulation model. Results The mid-point incidence rate estimates erroneously declined towards the end of the observation period once the testing rate dropped below 80%. This decline was in error of approximately 9%, 27% and 41% for a moderate, low and poor testing rate, respectively. The random-point method did not introduce any systematic bias in the incidence rate estimate, even for testing rates as low as 30%. Conclusions The mid-point assumption of the infection date is unjustified and should not be used to calculate the incidence rate once participants start to miss the scheduled test dates. Under these conditions, we show an artefactual decline in the incidence rate towards the end of the observation period. Alternatively, the single random-point method is straightforward to implement and produces estimates very close to the true incidence rate.
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Affiliation(s)
- Alain Vandormael
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
| | - Adrian Dobra
- Department of Statistics, Department of Biobehavioral Nursing and Health Informatics, Center for Statistics and the Social Sciences, and Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, USA
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute for Public Health, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
- Research Department of Infection and Population Health, University College London, London, UK
| | - Tulio de Oliveira
- Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Research Department of Infection and Population Health, University College London, London, UK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
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62
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Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial. Lancet HIV 2017; 5:e116-e125. [PMID: 29199100 DOI: 10.1016/s2352-3018(17)30205-9] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/13/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Universal antiretroviral therapy (ART), as per the 2015 WHO recommendations, might reduce population HIV incidence. We investigated the effect of universal test and treat on HIV acquisition at population level in a high prevalence rural region of South Africa. METHODS We did a phase 4, open-label, cluster randomised trial of 22 communities in rural KwaZulu-Natal, South Africa. We included individuals residing in the communities who were aged 16 years or older. The clusters were composed of aggregated local areas (neighbourhoods) that had been identified in a previous study in the Hlabisa subdistrict. The study statisticians randomly assigned clusters (1:1) with MapInfo Pro (version 11.0) to either the control or intervention communities, stratified on the basis of antenatal HIV prevalence. We offered residents repeated rapid HIV testing during home-based visits every 6 months for about 4 years in four clusters, 3 years in six clusters, and 2 years in 12 clusters (58 cluster-years) and referred HIV-positive participants to trial clinics for ART (fixed-dose combination of tenofovir, emtricitabine, and efavirenz) regardless of CD4 cell count (intervention) or according to national guidelines (initially ≤350 cells per μL and <500 cells per μL from January, 2015; control). Participants and investigators were not masked to treatment allocation. We used dried blood spots once every 6 months provided by participants who were HIV negative at baseline to estimate the primary outcome of HIV incidence with cluster-adjusted Poisson generalised estimated equations in the intention-to-treat population after 58 cluster-years of follow-up. This study is registered with ClinicalTrials.gov, number NCT01509508, and the South African National Clinical Trials Register, number DOH-27-0512-3974. FINDINGS Between March 9, 2012, and June 30, 2016, we contacted 26 518 (93%) of 28 419 eligible individuals. Of 17 808 (67%) individuals with a first negative dried blood spot test, 14 223 (80%) had subsequent dried blood spot tests, of whom 503 seroconverted after follow-up of 22 891 person-years. Estimated HIV incidence was 2·11 per 100 person-years (95% CI 1·84-2·39) in the intervention group and 2·27 per 100 person-years (2·00-2·54) in the control group (adjusted hazard ratio 1·01, 95% CI 0·87-1·17; p=0·89). We documented one case of suicidal attempt in a woman following HIV seroconversion. 128 patients on ART had 189 life-threatening or grade 4 clinical events: 69 (4%) of 1652 in the control group and 59 (4%) of 1367 in the intervention group (p=0·83). INTERPRETATION The absence of a lowering of HIV incidence in universal test and treat clusters most likely resulted from poor linkage to care. Policy change to HIV universal test and treat without innovation to improve health access is unlikely to reduce HIV incidence. FUNDING ANRS, GiZ, and 3ie.
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Vandormael A, de Oliveira T, Tanser F, Bärnighausen T, Herbeck JT. High percentage of undiagnosed HIV cases within a hyperendemic South African community: a population-based study. J Epidemiol Community Health 2017; 72:168-172. [PMID: 29175867 DOI: 10.1136/jech-2017-209713] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/18/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Undiagnosed HIV infections could undermine efforts to reverse the global AIDS epidemic by 2030. In this study, we estimated the percentage of HIV-positive persons who remain undiagnosed within a hyperendemic South African community. METHODS The data come from a population-based surveillance system located in the Umkhanyakude district of the northern KwaZulu-Natal province, South Africa. We annually tested 38 661 adults for HIV between 2005 and 2016. Using the HIV-positive test results of 12 039 (31%) participants, we then back-calculated the incidence of infection and derived the number of undiagnosed cases from this result. RESULTS The percentage of undiagnosed HIV cases decreased from 29.3% in 2005 to 15.8% in 2011. During this period, however, approximately 50% of the participants refused to test for HIV, which lengthened the average time from infection to diagnosis. Consequently, the percentage of undiagnosed HIV cases reversed direction and steadily increased from 16.1% to 18.9% over the 2012-2016 period. CONCLUSIONS Results from this hyperendemic South African setting show that the HIV testing rate is low, with long infection times, and an unsatisfactorily high percentage of undiagnosed cases. A high level of repeat HIV testing is needed to minimise the time from infection to diagnosis if the global AIDS epidemic is to be reversed within the next two decades.
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Affiliation(s)
- Alain Vandormael
- Africa Health Research Institute (AHRI), Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Frank Tanser
- Africa Health Research Institute (AHRI), Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Till Bärnighausen
- Africa Health Research Institute (AHRI), Durban, South Africa.,Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Massachusetts, USA.,Heidelberg Institute for Public Health, University of Heidelberg, Heidelberg, Germany
| | - Joshua T Herbeck
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, Washington, USA
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Akullian A, Bershteyn A, Klein D, Vandormael A, Bärnighausen T, Tanser F. Sexual partnership age pairings and risk of HIV acquisition in rural South Africa. AIDS 2017; 31:1755-1764. [PMID: 28590328 PMCID: PMC5508850 DOI: 10.1097/qad.0000000000001553] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/16/2017] [Accepted: 05/23/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To quantify the contribution of specific sexual partner age groups to the risk of HIV acquisition in men and women in a hyperendemic region of South Africa. DESIGN We conducted a population-based cohort study among women (15-49 years of age) and men (15-55 years of age) between 2004 and 2015 in KwaZulu-Natal, South Africa. METHODS Generalized additive models were used to estimate smoothed HIV incidence rates across partnership age pairings in men and women. Cox proportional hazards regression was used to estimate the relative risk of HIV acquisition by partner age group. RESULTS A total of 882 HIV seroconversions were observed in 15 935 person-years for women, incidence rate = 5.5 per 100 person-years [95% confidence interval (CI), 5.2-5.9] and 270 HIV seroconversions were observed in 9372 person-years for men, incidence rate = 2.9 per 100 person-years (95% CI, 2.6-3.2). HIV incidence was highest among 15-24-year-old women reporting partnerships with 30-34-year-old men, incidence rate = 9.7 per 100 person-years (95% CI, 7.2-13.1). Risk of HIV acquisition in women was associated with male partners aged 25-29 years (adjusted hazard ratio; aHR = 1.44, 95% CI, 1.02-2.04) and 30-34 years (aHR = 1.50, 95% CI, 1.08-2.09) relative to male partners aged 35 and above. Risk of HIV acquisition in men was associated with 25-29-year-old (aHR = 1.72, 95% CI, 1.02-2.90) and 30-34-year-old women (aHR = 2.12, 95% CI, 1.03-4.39) compared to partnerships with women aged 15-19 years. CONCLUSION Age of sexual partner is a major risk factor for HIV acquisition in both men and women, independent of one's own age. Partner age pairings play a critical role in driving the cycle of HIV transmission.
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Affiliation(s)
- Adam Akullian
- Institute for Disease Modeling, Global Good Fund, Bellevue, Washington, USA
| | - Anna Bershteyn
- Institute for Disease Modeling, Global Good Fund, Bellevue, Washington, USA
| | - Daniel Klein
- Institute for Disease Modeling, Global Good Fund, Bellevue, Washington, USA
| | - Alain Vandormael
- Africa Health Research Institute, University of KwaZulu-Natal, Mtubatuba, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, University of KwaZulu-Natal, Mtubatuba, South Africa
- Institute for Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Frank Tanser
- Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
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65
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Tomita A, Vandormael AM, Bärnighausen T, de Oliveira T, Tanser F. Social Disequilibrium and the Risk of HIV Acquisition: A Multilevel Study in Rural KwaZulu-Natal Province, South Africa. J Acquir Immune Defic Syndr 2017; 75:164-174. [PMID: 28291049 PMCID: PMC5429974 DOI: 10.1097/qai.0000000000001349] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Few population-based multilevel studies have quantified the risks that social context poses in rural communities with high HIV incidence across South Africa. We investigated the individual, social, and community challenges to HIV acquisition risk in areas with high and low incidence of HIV infection (hotspots/coldspots). METHODS The cohort (N = 17,376) included all HIV-negative adults enrolled in a population-based HIV surveillance study from 2004 to 2015 in a rural South African community with large labor migrancy. Multilevel survival models were fitted to examine the social determinants (ie, neighborhood migration intensity), community traits (ie, HIV prevalence), and individual determinants of HIV acquisition risk in identified hotspots/coldspots. RESULTS The HIV acquisition risk (adjusted hazard ratio [aHR] = 1.05, 95% confidence interval [CI]: 1.01 to 1.09) was greater in hotspots with higher neighborhood migration intensity among men. In women, higher neighborhood migration intensity (aHR = 1.02, 95% CI: 1.01 to 1.02) was associated with a greater HIV acquisition risk, irrespective of whether they lived in hotspot/coldspot communities. HIV acquisition risk was greater in communities with a higher prevalence of HIV in both men (aHR = 1.07, 95% CI: 1.03 to 1.12) and women (aHR = 1.03, 95% CI: 1.01 to 1.05), irrespective of hotspot/coldspot locations. CONCLUSION HIV acquisition risk was strongly influenced by gender (ie, young women), behavior (ie, sexual debut, contraception, circumcision), and social determinants. Certain challenges (ie, community disease prevalence) for HIV acquisition risk impacted both sexes, regardless of residence in hotspot/coldspot communities, whereas social determinants (ie, neighborhood migration intensity) were pronounced in hotspots among men. Future intervention scale-up requires addressing the social context that contributes to HIV acquisition risk in rural areas with high migration.
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Affiliation(s)
- Andrew Tomita
- Nelson R Mandela School of Medicine, University of
KwaZulu-Natal
- Africa Health Research Institute, University of KwaZulu-Natal
| | - Alain M. Vandormael
- Nelson R Mandela School of Medicine, University of
KwaZulu-Natal
- Africa Health Research Institute, University of KwaZulu-Natal
| | - Till Bärnighausen
- Africa Health Research Institute, University of KwaZulu-Natal
- Department of Global Health and Population, Harvard T.H. Chan School
of Public Health
- Institute for Public Health, University of Heidelberg
| | - Tulio de Oliveira
- Nelson R Mandela School of Medicine, University of
KwaZulu-Natal
- Africa Health Research Institute, University of KwaZulu-Natal
- Centre for the AIDS Programme of Research in South Africa
(CAPRISA)
| | - Frank Tanser
- Africa Health Research Institute, University of KwaZulu-Natal
- Centre for the AIDS Programme of Research in South Africa
(CAPRISA)
- School of Nursing and Public Health, University of
KwaZulu-Natal
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Abstract
In this article, I investigate how particular discourses surrounding class specific understandings of sexual behavior and female morality shape awareness and views of the disease and personal vulnerability. Although both groups belong to the working class, those employed by the transportation board consider themselves government servants and, therefore, "respectable gentlemen." Construction workers identify easily with their class position, recognizing and sometimes trying to live up to the stereotypes of free sexuality. These different perceptions directly affect their concern and awareness of risk factors for sexually transmissible infections and safe-sex practices. While the "respectable gentlemen" consider themselves invulnerable, the "street-savvy men" learned about risks and took precautions to prevent STIs.
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Affiliation(s)
- Sandya Hewamanne
- a Department of Sociology , The University of Essex , Colchester , Essex , United Kingdom
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Kohli A, Kerrigan D, Brahmbhatt H, Likindikoki S, Beckham J, Mwampashi A, Mbwambo J, Kennedy CE. Social and structural factors related to HIV risk among truck drivers passing through the Iringa region of Tanzania. AIDS Care 2017; 29:957-960. [PMID: 28107796 DOI: 10.1080/09540121.2017.1280127] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Truck drivers and their assistants have been identified as groups at higher risk for HIV infection. We sought to identify and describe the social and structural factors that may contribute to HIV risk among truck drivers who visit rest stops in Iringa, Tanzania, a region characterized by high levels of migration and mobility. This analysis was part of a comprehensive strategic assessment to examine HIV risk factors in Iringa. This analysis focuses on 11 in-depth interviews with truck drivers and a transport owner. A semi-structured interview guide was developed to elicit open-ended responses and enable probing. Interviews were conducted in Swahili, transcribed, and translated into English. Data analysis followed thematic analysis procedures that included initial reading of transcripts, development of a codebook and identification of themes through in-depth reading of transcripts. Drivers described structural risk factors for HIV including work conditions, the power imbalance between male drivers and their sexual partners and minimal perceived HIV risk with certain partners (e.g., regular partners and women selling sex). Multiple and inter-related social norms associated with truck stop environments influenced HIV risk, including peer influence and expectations, presence of sex workers, ability to purchase sex throughout their travel and alcohol consumption. These distinct social norms in truck stops and other rest points facilitated behavior that many participants said they would not engage in elsewhere. HIV prevention strategies with truck drivers should address individual, social and structural barriers to HIV prevention through partnerships with the health and transportation sectors, local government and local communities. HIV prevention services should be adapted to drivers' times and places of availability, for example, condom provision where/when drivers make decisions about or have sex. A focus on positive messaging and addressing specific challenges including the continual challenge of re-choosing and reinforcing decisions to engage in safer sexual behaviors is important.
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Affiliation(s)
- Anjalee Kohli
- a Johns Hopkins University School of Nursing , Baltimore , MD , USA
| | - Deanna Kerrigan
- b Department of Health, Behavior and Society , Johns Hopkins University , Baltimore , MD , USA
| | - Heena Brahmbhatt
- b Department of Health, Behavior and Society , Johns Hopkins University , Baltimore , MD , USA
| | - Samuel Likindikoki
- c Muhimbili University of Health and Allied Sciences , Dar es Salaam , Tanzania
| | - Justin Beckham
- d CIEE and Ruaha Catholic University , Iringa , Tanzania
| | - Ard Mwampashi
- c Muhimbili University of Health and Allied Sciences , Dar es Salaam , Tanzania
| | - Jessie Mbwambo
- c Muhimbili University of Health and Allied Sciences , Dar es Salaam , Tanzania
| | - Caitlin E Kennedy
- b Department of Health, Behavior and Society , Johns Hopkins University , Baltimore , MD , USA
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