Methodology

1. HIV epidemiological and Sexual Behavioural Trends in Tanzania Mainland:Implications for the HIV Response Joint Review 2008Marelize Gorgens-Albino (GAMET)Dr R Kalinga (TACAIDS)

2. Secondary analysis of available epidemiological data Areas investigated: National HIV prevalence trends Heterogeneity in national prevalence trends Incidence trends Supplemented with data from community-level studies in TZ Risk factors that have influenced trends At individual level (sexual behaviour) At community level and society level Reviewed nine strategic objectives for HIV prevention in the 2nd NMSF – made observations and recommendations for the Joint Review Methodology

3. Tanzania HIV and syphilis sentinel surveillance reports from the National AIDS Control Programme’s website (www.nacp.go.tz) Other reports relating to HIV prevalence and incidence from the National AIDS Control Programme’s website (www.nacp.go.tz) Purposive search of all known documents relating to HIV in Tanzania: UNGASS report, latest Tanzania HIV and Malaria Indicator Survey Report, Global Fund Five-Year Evaluation Report Search for research articles from Google Scholar (http://scholar.google.com) and PubMed, using the search words “HIV incidence Tanzania”, and “HIV prevalence Tanzania”: resulted in 563 search results, of which 91 were relevant for the analysis Purposive search of documents from the TAZAMA project (www.tazamaproject), upon recommendation of Dr G Somi, Head of Epidemiology at MoHSW’s National AIDS Control Programme All national survey reports from Tanzania that were available on the MEASUREDHS website (www.measuredhs.com) Hard copies of reports provided by the UNAIDS country office Data Sources

4. National HIV prevalence trends • Projected national prevalence has stabilised at a high level – just over 6 % • Other prevalence data confirm this observation (see next slides) Source: Tanzania NACP, 2005: project HIV prevalence using EPP

5. National HIV prevalence trends NACP, 2005: AIDS case reporting (around 7% of total new infections)

6. National HIV prevalence trends Caution – see variance in # of ANC sites, and blood donors are 98% replacement family donors and 83% male donors

7. Despite the national stabilization, there is significant heterogeneity in HIV prevalence

8. Women of are more likely to be HIV positive, with some exceptions Female: male ratio in 2003: 1.2 : 1 Female: male ratio in 2007 1.4 : 1

9. Before 2003, women of young ages and men of older ages are more likely to be HIV positive, but this is changing Source: THIS, 2003-04 Sources: Graph 1.2 from NACP (2007)

10. Before 2003, women of young ages and men of older ages are more likely to be HIV positive, but this is changing Source: THMIS 2007-08

11. Amongst discordant couples, males are more likely to be HIV positive

12. Persons with higher education levels used to have higher prevalence, but this is changing

13. More wealthy persons are more likely to be HIV positive Keep in mind: wealth and education levels strongly correlated

14. Married or formerly married men and women are most likely to have higher risk behaviour

15. Married or formerly married men and women are most likely to have higher risk behaviour

16. HIV prevalence is almost double in urban than in rural areas

17. HIV prevalence is almost double in urban than in rural areas

18. Demographics has resulted in more HIV+ persons in rural than in urban areas

19. HIV prevalence in areas of mobility is higher than in rural areas, and prevalence in urban areas may be reducing NOTE ‘Roadside’ refers to those ANC sites that are in clinics that are close to major trading towns or transport routes in Tanzania. ‘Border’ refers to the ANC site located in Kyela, on the border with Zambia

20. HIV prevalence varies greatly in different regions (1% to 15%)

21. Regional differences strongly associated with (a) percentage rural population; and (b) education (which are strongly correlated with wealth, education levels and living in urban areas) 2003

22. However, the association between HIV prevalence and % rural population has weakened over time, implying that HIV infection patterns in rural areas could be changing faster than in urban areas 2007 p = 0.0001 in 2003 p = 0.07 in 2007

23. This hypothesis confirmed by the fact that regions with larger proportions of urban populations are more likely to have had bigger positive changes in HIV prevalence

24. 70% of Tanzanians are circumcised Five regions with low circumcision rates (<50%) Iringa (43%) Kagera (27%) Rukwa (31%) Shinyanga (38%) Tabora (26%) Circumcision cuts across religious lines (72% of Muslims and 68% of Protestants circumcised (THIS 2003-04)) HIV prevalence and male circumcision status

25. Men usually get circumcised in their early 20s (Nnko et al. 2001) More educated men are more likely to get circumcised (THIS 2003-04) Highly acceptable amongst Tanzanian men for personal hygiene purposes “Male circumcision is becoming more popular among a traditionally non-circumcising ethnic group in Tanzania, especially in urban areas and among boys who have attended secondary schools” (Nnko et al., 2001) Circumcision status and HIV prevalence significantly associated at individual level or at regional level HIV prevalence and male circumcision status

26. Relationship between circumcision status and HIV prevalence in regions is and remains strong (strongest predictor of HIV prevalence levels in regions) p = 0.0002 in 2003 p = 0.009 in 2007

27. Population-level data about HIV prevalence and migration not known (collected in DHS but not analysed) 3 community-level studies shows that: HIV prevalence and incidence higher amongst short-term migrant men and women who stay home (and alone, away from husbands) for long periods of time “Remarkably, risk behavior of men increased more when their wives moved than when they were mobile themselves” (Kishamawa et al, 2004) HIV prevalence and migration

28. Projected HIV incidence rate – change over time (national and urban stabilising, rural increasing)

29. Projected number of new infections every year – changes over time (increase at national level, slow increase in urban areas, rapid increase in rural areas)

30. HIV incidence – trends in younger ANC clients HIV prevalence rate amongst different age groups of ANC clients , Tanzania, 2001 to 2006 (change in 15 – 24 year old falls within confidence interval and not statistically significant) Source: NACP, 2007

31. Have risk factors for HIV transmission changed over time?

32. Age of sexual debut has increased

33. More men are having multiple partners, and rates of multiple partners amongst women have remained constant

34. More men are having casual partners, and rates of casual partners amongst women have remained constant

35. Rates of condom use during casual sex has rapidly increased – almost doubled over time

36. Ethnographic study found that: “The sex worker’s first motivation is economic. The numbers of commercial partners are decreasing. Condom use has been accepted in short-term relationships. Condom use is rarely accepted in long term relationships” (NACP, 2001, citing Outwater et al., 2000). Transactional sex

37. High percentage of men and women who accepted gifts or favours in return for sex (1994)

38. IDUs are present in Dar Injecting paraphenalia found with HIV antibodies in 30% of used needles in Dar Population-level importance not known: size of IDU population not known Risk of HIV transmission through IDU needle sharing is increasing

39. National adult HIV prevalence peaked in 1995 HIV prevalence is expected to increase in the future with scaled-up ARV treatment At the onset, the epidemic was growing fastest in areas with: larger or border towns, high population mobility (temporary migration due to labour factors), more employment and wealth, with more educated persons. Over time, the relationship between education and HIV risk changed with less educated persons becoming more likely to be HIV positive than more educated individuals SUMMARY – Epi Trends

40. Tanzania has a mature epidemic with annual HIV incidence stabilizing just below 1% 1.8 million persons with HIV – mostly in rural areas Absolute number of new infections has grown steeply over time, particularly in rural areas, due to population demographics Overall, females are at significantly higher risk of being HIV infected than males (2007 national survey: females 15-49 40% more likely to be HIV+) Bigger changes in prevalence amongst men, those educated, and those in urban areas SUMMARY – Epi Trends

42. SUMMARY – Behavioural Trends

43. ABCs of Safe Sex in Tanzania

44. Compare this with …..

45. ABCs of Safe Sex in Cote d’Ivoire (1998 to 2005) B-youth Multiple partners in the past year, ages 15-24 B-adults Multiple partners in the past year, ages 15-49 C Condom use last higher-risk sex, ages 15-49 Sources: Cote d’Ivoire 1998/99 DHS, Cote d’Ivoire 2005 AIS No significant change in A behaviors among youth

46. A Never married ages 15-24 who had sex in the past year B Multiple partners in the past year, ages 15-49 C Condom use last higher-risk sex, ages 15-49 Sources: Ethiopia 2000 & 2005 DHS, UNAIDS Epidemic Report 2007 ABCs of Safe Sex in Ethiopia 2000 to 2005

47. There is, however, also great variation in behaviours

49. Older men (20 to 24) and men with higher education were most likely to postpone sexual debut Older women (20 to 24) and women with no education were most likely to initiate sex earlier Older men (25 to 49) and men in urban areas were most likely to reduce their number of sexual partners Older women (25 to 49), educated women and women in urban areas were most likely to increase their sexual partners Older men (25 to 49) were most likely to stop having non regular partners More men with no education were likely to have non regular partners Women were most likely to increase their numbers of sexual partners Condom use across genders, age groups, residence and education levels has dramatically increased In conclusion: How has sexual behaviour changed?

50. Recommendations for the Joint Review