C Nyamukapa

HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe

Abstract AIDS has increased the number of orphans and vulnerable children (OVCs) in sub-Saharan Africa who could suffer detrimental life experiences. We investigated whether OVCs have heightened risks of adverse reproductive health outcomes including HIV infection. Data on HIV infection, sexually transmitted infection (STI) symptoms and pregnancy, and common risk factors were collected for OVCs and non-OVCs in a population survey of 1523 teenage children in eastern Zimbabwe between July 2001 and March 2003. Multivariate logistic regression was used to test for statistical association between OVC status, adverse reproductive health outcomes and suspected risk factors. Amongst women aged 15–18 years, OVCs had higher HIV prevalence than non-OVCs (3.2% versus 0.0%; p=0.002) and more common experience of STI symptoms (5.9% versus 3.3%; adjusted odds ratio = 1.75, 95% CI 0.80–3.80) and teenage pregnancy (8.3% versus 1.9%; 4.25, 1.58–11.42). OVCs (overall), maternal orphans and young women with an infected parent were more likely to have received no secondary school education and to have started sex and married, which, in turn, were associated with poor reproductive health. Amongst men aged 17–18 years, OVC status was not associated with HIV infection (0.5% versus 0.0%; p=1.000) or STI symptoms (2.7% versus 1.6%; p=0.529). No association was found between history of medical injections and HIV risk amongst teenage women and men. High proportions of HIV infections, STIs and pregnancies among teenage girls in eastern Zimbabwe can be attributed to maternal orphanhood and parental HIV. Many of these could be averted through further female secondary school education. Predicted substantial expanded increases in orphanhood could hamper efforts to slow the acquisition of HIV infection in successive generations of young adults, perpetuating the vicious cycle of poverty and disease.

Causes and consequences of psychological distress among orphans in eastern Zimbabwe

Abstract Substantial resources are invested in psychological support for children orphaned or otherwise made vulnerable in the context of HIV/AIDS (OVC). However, there is still only limited scientific evidence for greater psychological distress amongst orphans and even less evidence for the effectiveness of current support strategies. Furthermore, programmes that address established mechanisms through which orphanhood can lead to greater psychological distress should be more effective. We use quantitative and qualitative data from Eastern Zimbabwe to measure the effects of orphanhood on psychological distress and to test mechanisms for greater distress amongst orphans suggested in a recently published theoretical framework. Orphans were found to suffer greater psychological distress than non-orphans (sex- and age-adjusted co-efficient: 0.15; 95% CI 0.03–0.26; P=0.013). Effects of orphanhood contributing to their increased levels of distress included trauma, being out-of-school, being cared for by a non-parent, inadequate care, child labour, physical abuse, and stigma and discrimination. Increased mobility and separation from siblings did not contribute to greater psychological distress in this study. Over 40% of orphaned children in the sample lived in households receiving external assistance. However, receipt of assistance was not associated with reduced psychological distress. These findings and the ideas put forward by children and caregivers in the focus group discussions suggest that community-based programmes that aim to improve caregiver selection, increase support for caregivers, and provide training in parenting responsibilities and skills might help to reduce psychological distress. These programmes should be under-pinned by further efforts to reduce poverty, increase school attendance and support out-of-school youth.

Measuring trends in age at first sex and age at marriage in Manicaland, Zimbabwe

Objective: To identify reporting biases and to determine the influence of inconsistent reporting on observed trends in the timing of age at first sex and age at marriage. Methods: Longitudinal data from three rounds of a population-based cohort in eastern Zimbabwe were analysed. Reports of age at first sex and age at marriage from 6837 individuals attending multiple rounds were classified according to consistency. Survival analysis was used to identify trends in the timing of first sex and marriage. Results: In this population, women initiate sex and enter marriage at younger ages than men but spend much less time between first sex and marriage. Among those surveyed between 1998 and 2005, median ages at first sex and first marriage were 18.5 years and 21.4 years for men and 18.2 years and 18.5 years, respectively, for women aged 15–54 years. High levels of reports of both age at first sex and age at marriage among those attending multiple surveys were found to be unreliable. Excluding reports identified as unreliable from these analyses did not alter the observed trends in either age at first sex or age at marriage. Tracing birth cohorts as they aged revealed reporting biases, particularly among the youngest cohorts. Comparisons by birth cohorts, which span a period of >40 years, indicate that median age at first sex has remained constant over time for women but has declined gradually for men. Conclusions: Although many reports of age at first sex and age at marriage were found to be unreliable, inclusion of such reports did not result in artificial generation or suppression of trends.

Evidence for a contribution of the community response to HIV decline in eastern Zimbabwe

Membership of indigenous local community groups was protective against HIV for women, but not for men, in eastern Zimbabwe during the period of greatest risk reduction (1999–2004). We use four rounds of data from a population cohort to investigate: (1) the effects of membership of multiple community groups during this period; (2) the effects of group membership in the following five years; and (3) the effects of characteristics of groups hypothesised to determine their effect on HIV risk. HIV incidence from 1998 to 2003 was 1.18% (95% CI: 0.78–1.79%), 0.48% (0.20–1.16%) and 1.13% (0.57–2.27%), in women participating in one, two and three or more community groups at baseline versus 2.19% (1.75–2.75%) in other women. In 2003–2005, 36.5% (versus 43% in 1998–2000) of women were members of community groups, 50% and 56% of which discussed HIV prevention and met with other groups, respectively; the corresponding figures for men were 24% (versus 28% in 1998–2000), 51% and 58%. From 2003 to 2008, prior membership of community groups was no longer protective against HIV for women (1.13% versus 1.29%, aIRR = 1.25; p = 0.23). However, membership of groups that provided social spaces for dialogue about HIV prevention (0.62% versus 1.01%, aIRR = 0.54; p = 0.28) and groups that interacted with other groups (0.65% versus 1.01%, aIRR = 0.51; p = 0.19) showed non-significant protective effects. For women, membership of a group with external sponsorship showed a non-significant increase in HIV risk compared to membership of unsponsored groups (adjusted odds ratio = 1.63, p = 0.48). Between 2003 and 2008, membership of community groups showed a non-significant tendency towards higher HIV risk for men (1.47% versus 0.94%, p = 0.23). Community responses contributed to HIV decline in eastern Zimbabwe. Sensitive engagement and support for local groups (including non-AIDS groups) to encourage dialogue on positive local responses to HIV and to challenge harmful social norms and incorrect information could enhance HIV prevention.

Factors shaping the HIV-competence of two primary schools in rural Zimbabwe.

We present multi-method case studies of two Zimbabwean primary schools – one rural and one small-town. The rural school scored higher than the small-town school on measures of child well-being and school attendance by HIV-affected children. The small-town school had superior facilities, more teachers with higher morale, more specialist HIV/AIDS activities, and an explicit religious ethos. The relatively impoverished rural school was located in a more cohesive community with a more critically conscious, dynamic and networking headmaster. The current emphasis on HIV/AIDS-related teacher training and specialist school-based activities should be supplemented with greater attention to impacts of school leadership and the nature of the school-community interface on the HIV-competence of schools.

Patterns of uptake of treatment for self reported sexually transmitted infection symptoms in rural Zimbabwe

Objectives: To determine the extent of self reported symptoms perceived to be related to sexually transmitted infections and the patterns of subsequent treatment seeking behaviour in a predominantly rural population of Zimbabwe. Methods: A population based survey of 4331 men and 5149 women was conducted in rural Zimbabwe during 1998–2000. Structured confidential interviews collected data on self reported sexually transmitted infection symptoms, treatment seeking behaviour, sociodemographic characteristics, and sexual behaviour. Results: 25% of men aged 17–54 years report experiencing genital sores and 25% of men report experiencing urethral discharge; 30% of women aged 15–44 years report experiencing vaginal discharge. The lifetime number of sexual partners, age, and years of sexual activity were all significant predictors of symptoms for both men and women (all p values <0.001). 92% of men and 62% of women had sought treatment for their symptoms in the past year (p value <0.001). Men and women were equally likely to have sought treatment at a local hospital or clinic, but women were much less likely than men to have sought treatment at a different hospital or clinic. Among those who had sought treatment, men sought treatment faster than women and were more likely to report being “very satisfied” with their treatment than women. Conclusions: The gender differences in treatment seeking are of major concern for control efforts and further work on determining the reasons for these should be a priority. This would inform the likely impact of both increasing availability of local services and further reducing the stigma faced by those wishing to access such services.

The effects of Hiv on fertility by infection duration: evidence from African population cohorts before antiretroviral treatment availability

Objectives: To estimate the relationship between HIV natural history and fertility by duration of infection in east and southern Africa before the availability of antiretroviral therapy and assess potential biases in estimates of age-specific subfertility when using retrospective birth histories in cross-sectional studies. Design: Pooled analysis of prospective population-based HIV cohort studies in Masaka (Uganda), Kisesa (Tanzania) and Manicaland (Zimbabwe). Methods: Women aged 15–49 years who had ever tested for HIV were included. Analyses were censored at antiretroviral treatment roll-out. Fertility rate ratios were calculated to see the relationship of duration of HIV infection on fertility, adjusting for background characteristics. Survivorship and misclassification biases on age-specific subfertility estimates from cross-sectional surveys were estimated by reclassifying person-time from the cohort data to simulate cross-sectional surveys and comparing fertility rate ratios with true cohort results. Results: HIV-negative and HIV-positive women contributed 15 440 births and 86 320 person-years; and 1236 births and 11 240 000 person-years, respectively, to the final dataset. Adjusting for age, study site and calendar year, each additional year since HIV seroconversion was associated with a 0.02 (95% confidence interval 0.01–0.03) relative decrease in fertility for HIV-positive women. Survivorship and misclassification biases in simulated retrospective birth histories resulted in modest underestimates of subfertility by 2–5% for age groups 20–39 years. Conclusion: Longer duration of infection is associated with greater relative fertility reduction for HIV-positive women. This should be considered when creating estimates for HIV prevalence among pregnant women and prevention of mother-to-child transmission need over the course of the HIV epidemic and antiretroviral treatment scale up.OBJECTIVES To estimate the relationship between HIV natural history and fertility by duration of infection in East and Southern Africa before the availability of antiretroviral therapy, and assess potential biases in estimates of age-specific sub-fertility when using retrospective birth histories in cross-sectional studies. DESIGN Pooled analysis of prospective population-based HIV cohort studies in Masaka (Uganda) Kisesa (Tanzania), and Manicaland (Zimbabwe). METHODS Women aged 15-49 who had ever tested for HIV were included. Analyses were censored at antiretroviral treatment roll out. Fertility rate ratios were calculated to see the relationship of duration of HIV infection on fertility, adjusting for background characteristics. Survivorship and misclassification biases on age-specific subfertility estimates from cross-sectional surveys were estimated by reclassifying person time from the cohort data to simulate cross-sectional surveys and comparing fertility rate ratios to true cohort results. RESULTS HIV negative and positive women contributed 15,440 births and 86320 person years; and 1,236 births and 11240 thousand person years respectively to the final dataset. Adjusting for age, study site and calendar year, each additional year since HIV sero conversion was associated with a 0.02 (95%CI 0.01-0.03) relative decrease infertility for HIV-positive women. Survivorship and misclassification biases in simulated retrospective birth histories resulted in modest underestimates of sub-fertility by 2-5% for age groups 20-39y. CONCLUSION Longer duration of infection is associated with greater relative fertility reduction for HIV-positive women. This should be considered when creating estimates for HIV prevalence among pregnant women and PMTCT need over the course of the HIV epidemic and ART scale-up.

In what ways do communities support optimal antiretroviral treatment in Zimbabwe

Little research has been conducted on how pre-existing indigenous community resources, especially social networks, affect the success of externally imposed HIV interventions. Antiretroviral treatment (ART), an externally initiated biomedical intervention, is being rolled out across sub-Saharan Africa. Understanding the ways in which community networks are working to facilitate optimal ART access and adherence will enable policymakers to better engage with and bolster these pre-existing resources. We conducted 67 interviews and eight focus group discussions with 127 people from three key population groups in Manicaland, eastern Zimbabwe: healthcare workers, adults on ART and carers of children on ART. We also observed over 100 h of HIV treatment sites at local clinics and hospitals. Our research sought to determine how indigenous resources were enabling people to achieve optimal ART access and adherence. We analysed data transcripts using thematic network technique, coding references to supportive community networks that enable local people to achieve ART access and adherence. People on ART or carers of children on ART in Zimbabwe report drawing support from a variety of social networks that enable them to overcome many obstacles to adherence. Key support networks include: HIV groups; food and income support networks; home-based care, church and womens groups; family networks; and relationships with healthcare providers. More attention to the community context in which HIV initiatives occur will help ensure that interventions work with and benefit from pre-existing social capital.

P1-S6.04 Education and lifetime risk of HIV infection in Manicaland, Zimbabwe

Background There is evidence that attendance at school is protective against HIV among young people in South Africa. Further work is required to investigate the effect of education on the life-time risk of HIV in sub-Saharan Africa. In this paper, we have examined the association between education and HIV infection/sexual risk behaviour among men and women of different ages in Zimbabwe. Methods The effects of education level (none or primary only; secondary or higher) on prevalent HIV infection and sexual risk behaviours among young people of school age (15–21 years) and older adults (22–54 years) were investigated using data from four rounds of an open cohort study collected between 1999 and 2008 in Manicaland, Eastern Zimbabwe. Multivariate regression models were used to investigate the independent effects of education, marriage and wealth. Results School-aged men, interviewed in 1999/2000, with secondary or higher education had significantly reduced risk of HIV infection compared to those with none or primary education only (adjusted OR=0.35; p=0.011). For older men, the effect of education level was not significantly associated with HIV risk (adjusted OR=1.17; p=0.125). For those interviewed in 2006/2008, education level was not found to be independently associated with HIV infection among school-aged or older men. At both time points, marital status and living in a town were independent risk factors for HIV among older men. Among women interviewed in 1999/2000, adjusted models indicate that a higher level of education had a significant protective effect for school-aged (adjusted OR=0.64; p=0.023) and older (adjusted OR=0.80; p=0.017) women. For those interviewed in 2006/2008, a higher level of education level was protective among school-aged (adjusted OR=0.56; p=0.040) but not older (adjusted OR=0.99; p=0.940) women. Marital status was an independent risk factors for HIV infection fort women of all ages. Conclusions There is evidence that secondary or higher education is protective against HIV infection among school-aged people in Zimbabwe, particularly women. Among older men, education does not appear to be protective against HIV. In 1999/2000, secondary or higher education was protective against HIV among older women. However, in 2006/2008, this protective effect was reduced. Further work to calculate the lifetime cumulative risk of HIV infection by education level, in this population, will be conducted.

Education, substance use, and HIV risk among orphaned adolescents in Eastern Zimbabwe

ABSTRACT There is a growing interest in education as a means to reduce HIV infection in vulnerable children in sub-Saharan Africa; however, the mechanisms by which education reduces HIV infection remain uncertain. Substance use has been associated with high-risk sexual behaviour and could lie on the causal pathway between education and HIV risk. Therefore, we used multivariable regression to measure associations between: (i) orphanhood and substance use (alcohol, recreational drugs, and smoking), (ii) substance use and sexual risk behaviours, and (iii) school enrolment and substance use, in adolescents aged 15–19 years, in Eastern Zimbabwe. We found substance use to be low overall (6.4%, 3.2%, and 0.9% of males reported alcohol, drug, and cigarette use; <1% of females reported any substance use), but was more common in male maternal and double orphans than non-orphans. Substance use was positively associated with early sexual debut, number of sexual partners, and engaging in transactional sex, while school enrolment was associated with lower substance use in males. We conclude that education may reduce sexual risk behaviours and HIV infection rates among male adolescents in sub-Saharan Africa, in part, by reducing substance abuse.