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

2. 2 Methodology 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 2 nd NMSF – made observations and recommendations for the Joint Review

3. 3 Data Sources Tanzania HIV and syphilis sentinel surveillance reports from the National AIDS Control Programme’s website (www.nacp.go.tz)www.nacp.go.tz Other reports relating to HIV prevalence and incidence from the National AIDS Control Programme’s website (www.nacp.go.tz)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 Programmewww.tazamaproject 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

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

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

6. 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. 7 Despite the national stabilization, there is significant heterogeneity in HIV prevalence

8. 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. 9 Before 2003, women of young ages and men of older ages are more likely to be HIV positive, but this is changing Sources : Graph 1.2 from NACP (2007) Source: THIS, 2003-04

10. 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. 11 Amongst discordant couples, males are more likely to be HIV positive

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

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

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

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

16. 16 HIV prevalence is almost double in urban than in rural areas % population who live in this location % HIV+ (2003- 04 THIS) % HIV+ (2007-08 THMIS) Urban 23% 10.9%8.7% Rural 77% 5.3%4.7%

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

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

19. 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. 20 HIV prevalence varies greatly in different regions (1% to 15%)

21. 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. 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 p = 0.0001 in 2003 p = 0.07 in 2007 2007

23. 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. 24 HIV prevalence and male circumcision status 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))

25. 25 HIV prevalence and male circumcision status 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

26. 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. 27 HIV prevalence and migration 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)

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

29. 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. 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. 31 Have risk factors for HIV transmission changed over time?

32. 32 Age of sexual debut has increased

33. 33 More men are having multiple partners, and rates of multiple partners amongst women have remained constant FEMALEMALE 19921996199920041992199619992004 Total 4 612 49 2735 30 Age groups: 15-1969155 373626 Age groups: 20-244715513414237 Age groups: 15-24571551439 33 Age groups: 25-49 - 6104 - 263429 Age groups: 15-49 - 6124 - 303630 Residence: Urban 481657303123 Residence: Rural 46104 263633 Education: No Education 451149193430 Education: Primary 4712510283631 Education: Secondary and Higher 2411233225

34. 34 More men are having casual partners, and rates of casual partners amongst women have remained constant FEMALEMALE 199619992004199619992004 Total 18 27 19 38 51 46 Age groups: 15-19435342789798 Age groups: 20-24213222687974 Age groups: 15-24294029728783 Age groups: 25-49132014303930 Age groups: 15-49182719425546

35. 35 Rates of condom use during casual sex has rapidly increased – almost doubled over time FEMALEMALE 199619992004199619992004 Total 16 22 33 32 34 51 Age groups: 15-19171940232639 Age groups: 20-24202437 3651 Age groups: 15-2418213931 46 Age groups: 25-49132427334056 Age groups: 15-49162233323551 Urban 273248415267 Rural 101522282744 No Education 4101871433 Primary 172433323449 Secondary and Higher 354456476578

36. 36 Transactional sex 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).

37. 37 High percentage of men and women who accepted gifts or favours in return for sex (1994) % of individuals that accepted gifts or favours the last time they had sex with someone other than their regular spouse in Tanzania (1994) % men age 15-49 reporting payment for sexual intercourse in the past 12 months (2007) Age groupWomenMen 15 – 192016 5 20 – 241416 13 25 – 291815 11 30 – 39721 9 40 - 49411 6

38. 38 Risk of HIV transmission through IDU needle sharing is increasing 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

39. 39 SUMMARY – Epi Trends 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

40. 40 SUMMARY – Epi Trends 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

41. 41

42. 42 SUMMARY – Behavioural Trends

43. 43 ABCs of Safe Sex in Tanzania

44. 44 Compare this with …..

45. 45 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 ABCs of Safe Sex in Cote d’Ivoire (1998 to 2005)

46. 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. 47 There is, however, also great variation in behaviours

48. 48 % of never-married young men and women who have never had sex % sexually-active men and women who have had multiple partners % sexually-active men and women who have had non regular partners % sexually-active men and women who have used condoms during sex with non regular partners “A” - Abstinence“B” – Be faithful “C” – use condom MenWomenMenWomenMenWomenMenWomen National 15% increase 3% increase 7% decrease 50% decrease 8% increase 17% increase 69% increase 169% increase Rural 3% increase 4% increase No change 5% increase 13% increase 68% increase 280% increase Urban 24% increase 4% increase 33% decrease 25% decrease 9% increase 15% increase 71% increase 93% increase No education No change 25% decrease 32% increase 25% decrease 50% increase 17% increase 457% increase 650% increase Sec educ + 152% increase 1% decrease 34% decrease No change 4% increase 17% increase 60% increase 74% increase Younger 61% increase 3% increase 57% increase 20% decrease 11% increase 10% increase 58% increase 156% increase Older 160% increase 9% decrease No change 50% decrease 7% decrease 15% increase 88% increase 208% increase

49. 49 In conclusion: How has sexual behaviour changed? 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

50. 50 Recommendations for the Joint Review

51. 51 SO1: Promote abstinence, delayed sexual debut, partner reduction and consistent condom use among young people in and out of school Need to expand focus from the focus on young people and urban areas BCC and SCC efforts need to reach rural areas, and older adults too (especially older females)

52. 52 SO2: Reduce risk of HIV infection among the most vulnerable populations MARPs are in existence, but little is known about them Size estimation studies are needed, behavioural interactions with other MARPs and gen pop, and HIV prevalence testing Specific programmes for other populations with disproportionately high HIV burdens such as fishing populations, females affected by sexual and domestic violence, and the military, and short-term migrant populations

53. 53 SO3: Expand workplace interventions, with special attention to mobile and migrant workers Mobile work force goes beyond truck drivers Short term migrant workers, e.g. all of us here at workshop today, is vulnerable Target and focus HIV prevention programmes Need to analyse HIV testing in DHS by ‘time spent away from home’

54. 54 SO4: Prevent, treat and control other sexually transmitted infections (STI) Plausible biological evidence that STIs increase HIV transmission However, despite their common behavioral pathways, STIs and HIV are not necessarily highly correlated at the population level (Gray and Wawer, 2008). Hypothesis that reducing STI infection reduces HIV transmission has been extensively tested and at least 8-9 trials have found no effect. There is thus insufficient evidence to support STI treatment for HIV prevention.

55. 55 SO4: Prevent, treat and control other sexually transmitted infections (STI) However, offering STI treatment to vulnerable groups, including sex workers and men-having-sex-with-men, who may have a high STI burden, may help to build rapport and trust and solidarity and as such may be a component of a comprehensive intervention. STIs are an important health problem in their own right - greater than HIV in many countries - and as such STI control for the general population should be a priority, but in keeping with the recommendations of the Commission on AIDS in Asia, financed by non-HIV health resources.

56. 56 SO5: Promote and expand HIV testing and counseling services VCT is cornerstone of many prevention programmes Provides entry point for care and support Effectiveness of programme for HIV prevention is mixed – meta review shows it resulted in increased condom use, but no decreases in multiple or concurrent partners Focus in rural areas – this is where most HIV positive persons are

57. 57 SO6: PMTCT Need to focus on preventing HIV transmission during pregnancy – increased risk for transmission (Shisana et al., 2005) No epi-based recommendations, except to scale up the service and ensure 100% compliance

58. 58 SO7: Promote and distribute condoms Demand is clearly there. In 2007, condoms distributed : –150 million male condoms (less than 10 condoms/man aged 15 to 49 /year) –709 000 female condoms Need to scale up supply Make available in rural areas

59. 59 SO8: Prevent HIV transmission through blood transfusions, exposure to contaminated body fluids and contaminated instruments Strengthen the volunteer blood donor programme Male school-level donors with secondary education is a good option: low prevalence and signs of reducing higher risk behaviour

60. 60 SO9: Introduce new prevention interventions Male circumcision – implement as soon as programmatic ‘how-to’ evaluation has been completed and operational guidelines have been prepared HSV-2 treatment – not effective in reducing viral shedding (Cowan et al., 2008)