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

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

3

Data Sources

• 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

4

• Projected national prevalence has stabilised at a high level – just over 6 %

• Other prevalence data confirm this observation (see next slides)

0

1

2

3

4

5

6

7

8

9

1980

1983

1986

1989

1992

1995

1998

2001

2004

2007

2010

HIV

pre

vale

nce

rat

e (%

)

Projected HIV prev alence - National

National HIV prevalence trends

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

7

8.2

6.4 6.4

7.1

9.99.6

7.78.7

6.6

7.9

5.7

0

2

4

6

8

10

12

HIV prev:ANC clients

HIV prev:blood donors

HIV prev:population-based

survey

Projected HIVprevalence

HIV

or s

yphi

lis p

reva

lenc

e (%

)

2001/02 (25 ANC sites, 152 000 blood donors) 2003/04 (57 ANC sites, 154 000 blood donors)2005/06 (92 ANC sites, 129 000 blood donors) 2007

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 : 1Female: male ratio in 2007 1.4 : 1

7.7

6.86.3

4.7

7

5.8

0

1

2

3

4

5

6

7

8

9

2003 2007

HIV

pre

vale

nce

(%

)

Women Men Total

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

0

2

4

6

8

10

12

14

15-19 20-24 25-29 30-34 35-39 40-44 45-49

HIV

pre

vale

nce

(%)

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

Fem

ale:

Mal

e H

IV p

reva

lenc

e ra

tio

Women Men F:M ratio

2003

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

0

2

4

6

8

10

12

15-19 20-24 25-29 30-34 35-39 40-44 45-49

HIV

pre

vale

nce

(%)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Fem

ale:

Mal

e H

IV p

reva

lenc

e ra

tio

Women Men F:M ratio

2007

11

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

0

5

10

15

20

25

30

35

40

45

50

Lesotho 2004 (Pop Prev 24%)

Kenya 2003 (Pop Prev 7%)

Malawi 04 (Pop Prev 12%)

Tanzania 03/04(Pop Prev 7%)

Uganda 05 (Pop Prev 6%)

Swaziland 07 (Pop Prev 26%)

Typ

es o

f di

scor

dan

t co

uple

s (%

)

0

5

10

15

20

25

30

35

40

45

50

Pop

ulat

ion

HIV

pre

vale

nce

(%)

Concordant (both positive) Male positive

Female positive Population-based prevalence

12

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

0

1

2

3

4

5

6

7

8

9

10

Women Men Women Men

2003 2007

HIV

pre

vale

nce

(%)

No education Primary incomplete Primary complete Secondary +

13

More wealthy persons are more likely to be HIV positive

0

2

4

6

8

10

12

Women 2003 Men 2003 Total 2003

HIV

pre

vale

nce

(%)

Lowest wealth quintile Second wealth quintileMiddle wealth quintile Fourth wealth quintileHighest wealth quintile

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

Women, 2003

0%

20%

40%

60%

80%

100%

Never union (Ever

had sex)

Never in union

(Never had sex)

Currently married Formerly married

% women with this marital status Women - HIV prevalence

15

Men, 2003

0%

20%

40%

60%

80%

100%

Never union (Ever

had sex)

Never in union

(Never had sex)

Currently married Formerly married

Men with this marital status Men - HIV prevalence

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

% 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

HIV prevalence is almost double in urban than in rural areas

0

2

4

6

8

10

12

1419

80

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Prev

alen

ce ra

te (%

)(t

otal

pop

ulat

ion)

Projected HIV prevalence - NationalProjected HIV prevalence - UrbanProjected HIV prevalence - Rural

18

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

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

200000019

80

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

To

tal n

um

ber

of

per

son

s liv

ing

wit

h H

IV

Number HIV+ (national)

Number HIV+ (urban)

Number HIV+ (rural)

19

HIV prevalence in areas of mobility is higher than in rural areas, and prevalence in urban areas may be reducing

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Border Roadside Rural Semi-urban Urban

HIV

pre

va

len

ce

2001 2003 2005NOTE ‘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%)

0

2

4

6

8

10

12

14

16

Kigo

ma

Arus

ha

Man

yara

Kilim

anja

ro

Sing

ida

Mtw

ara

Dod

oma

Kage

ra

Tang

a

Lind

i

Mor

ogor

o

Ruk

wa

Mw

anza

Mar

a

Pwan

i

Ruv

uma

Tabo

ra

Shin

yang

a

Mbe

ya

Dar

es

Sala

am

Iring

a

HIV

pre

vale

nce

(%

)

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

F:M

HIV

pre

vale

nce

rat

io

HIV prevalence 2007

F:M HIV prevalence ratio 2007

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)

R2 = 0.18290.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

0 5 10 15

Region's HIV prevalence (%)

Rat

io o

f U

rban

: R

ura

l P

op

ula

tio

n i

n

the

Reg

ion

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

p = 0.0001 in 2003p = 0.07 in 2007

R2 = 0.0044

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

0 5 10 15 20

Region's HIV prevalence in 2007 (%)

Ru

ral

to U

rban

Po

pu

lati

on

Rat

io i

n

Reg

ion

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

R2 = 0.33

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

-4 -2 0 2 4 6

Change in regions' HIV prevalence (%) from 2003 to 2007

Ru

ral

to u

rba

n p

op

ula

tio

n r

ati

o

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

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

Relationship between circumcision status and HIV prevalence in regions is and remains strong (strongest

predictor of HIV prevalence levels in regions)

R2 = 0.2171

0

10

20

30

40

50

60

70

80

90

100

0 2 4 6 8 10 12 14 16

HIV prevalence (%)

Me

n c

irc

um

cis

ed

(%

) p = 0.0002 in 2003p = 0.009 in 2007

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

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

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%19

80

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Inci

den

ce r

ate

(%)

(to

tal p

op

ula

tio

n)

Incidence rate - National

Incidence rate - Urban

Incidence rate - Rural

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)

0

50000

100000

150000

200000

250000

300000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

New

HIV

infe

ctio

ns

Total new HIV infections - National

Total new HIV infections - Urban

Total new HIV infections - Rural

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

15

24

6966

11 13

61

55

11 11

58

46

0

10

20

30

40

50

60

70

80

Women 15 to 19 who hadsex before age 15

Men 15 to 19 who hadsex before age 15

Women 18 to 19 who hadsex before age 18

Men 18 to 19 who hadsex before age 18

Perc

enta

ge o

f res

pond

ents

TRCHS 1999

TDHS 2004-05

THMIS 2007-08

33

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

FEMALE MALE

1992 1996 1999 2004 1992 1996 1999 2004

Total 4 6 12 4 9 27 35 30

Age groups: 15-19 6 9 15 5 15 37 36 26

Age groups: 20-24 4 7 15 5 13 41 42 37

Age groups: 15-24 5 7 15 5 14 39 39 33

Age groups: 25-49 - 6 10 4 - 26 34 29

Age groups: 15-49 - 6 12 4 - 30 36 30

Residence: Urban 4 8 16 5 7 30 31 23

Residence: Rural 4 6 10 4 10 26 36 33

Education: No Education 4 5 11 4 9 19 34 30

Education: Primary 4 7 12 5 10 28 36 31

Education: Secondary and Higher 2 4 11 2 3 32 25 25

34

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

FEMALE MALE

1996 1999 2004 1996 1999 2004

Total 18 27 19 38 51 46

Age groups: 15-19 43 53 42 78 97 98

Age groups: 20-24 21 32 22 68 79 74

Age groups: 15-24 29 40 29 72 87 83

Age groups: 25-49 13 20 14 30 39 30

Age groups: 15-49 18 27 19 42 55 46

35

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

FEMALE MALE

1996 1999 2004 1996 1999 2004

Total 16 22 33 32 34 51

Age groups: 15-19 17 19 40 23 26 39

Age groups: 20-24 20 24 37 37 36 51

Age groups: 15-24 18 21 39 31 31 46

Age groups: 25-49 13 24 27 33 40 56

Age groups: 15-49 16 22 33 32 35 51

Urban 27 32 48 41 52 67

Rural 10 15 22 28 27 44

No Education 4 10 18 7 14 33

Primary 17 24 33 32 34 49

Secondary and Higher 35 44 56 47 65 78

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

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 group Women Men Men

15 – 19 20 16 5

20 – 24 14 16 13

25 – 29 18 15 11

30 – 39 7 21 9

40 - 49 4 11 6

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

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

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

-80%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

10%

20%

30%

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Per

cen

tag

e ch

ang

e (

- ch

ang

e =

dec

reas

e in

pre

v;

+ c

han

ge

= i

ncr

ease

in

pre

v)

% change: women % change: men

42

SUMMARY – Behavioural Trends

43

ABCs of Safe Sex in Tanzania1996

1996

1996

1996

1996

1996

1996

1996

1999

1999

1999

1999

1999

1999

1999

1999

2004

2004

2004

2004

2004

2004

2004

2004

2007

2007

2007

2007

2007

2007

2007

2007

0

10

20

30

40

50

60

70

80

90

100

Young men Young women Males Females Males Females Males Females

Per

cen

tag

e (%

) in

th

is c

ateg

ory

"A"(abstinence)

% of never-married young men and women who have never had sex

"B"(be faithful)

% of sexually-active persons who have had multiple parters

"B"(be faithful)

% of sexually-active persons who have had sex with non regular non co-habitating

partners

"C"(be faithful)

% of sexually-active persons who used a condom during last

higher risk sex

44

Compare this with …..

45

32.6%

6.2%

30.5%

4.5%

51.6%

33.6%

21%

49%

10%

42%

6%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Young men Young Women Males Females Males Females

pe

rce

nt

1998 2005

B-youthMultiple partners in the past

year, ages 15-24

B-adultsMultiple partners in the past

year, ages 15-49

CCondom 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

7%

2%4%

0%

51%

23%

14%16%

2%

11%

2%

31%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Young men Young Women Males Females Males Females

pe

rce

nt

2000 2005

ANever married ages 15-24 who

had sex in the past year

BMultiple partners in the past

year, ages 15-49

CCondom 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

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 “B” – Be faithful “C” – use condom

Men Women Men Women Men Women Men Women

National 15% increase

3% increase

7% decrease

50% decrease

8% increase

17% increase

69% increase

169% increase

Rural 3% increase

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

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

Recommendations for the Joint Review

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

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

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

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

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

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

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

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

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

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)