STRATEGIC AssEssMENT TO DEFINE A COMPREHENSIVE RESPONSE TO HIV IN IRINGA, TANZANIA RESEARCH BRIEF ISOLATING HIV RISK FACTORS FROM THE TANZANIA HIV/AIDS AND MALARIA INDICATOR SURVEY STRATEGIC ASSESSMENT TO DEFINE A COMPREHENSIVE RESPONSE TO HIV IN IRINGA, TANZANIA RESEARCH BRIEF ISOLATING HIV RISK FACTORS FROM THE TANZANIA HIV/AIDS AND MALARIA INDICATOR SURVEY September 2013 The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP). Iringa Strategic Assessment Brief: HIV risk factors from the DHS TABLE OF CONTENTS TABLE OF CONTENTS .............................................................................................................. 2 INTRODUCTION ..................................................................................................................... 3 Rationale ............................................................................................................................................. 3 Aim ...................................................................................................................................................... 3 HIV in Tanzania and Iringa ................................................................................................................ 3 METHODS ............................................................................................................................ 5 RESULTS .............................................................................................................................. 6 DISCUSSION......................................................................................................................... 11 Limitations ......................................................................................................................................... 12 Conclusions ........................................................................................................................................ 12 REFERENCES ....................................................................................................................... 13 Page 2 Iringa Strategic Assessment Brief: HIV risk factors from the DHS INTRODUCTION Rationale The Iringa region of Tanzania has among the highest rates of HIV in the country (Tanzania Commission for AIDS [TACAIDS], 2008). The reasons behind this elevated HIV prevalence are not fully understood, and the response to HIV in Iringa has thus far been insufficient to match the need. The Iringa strategic assessment was designed to inform the development of comprehensive HIV prevention interventions that respond to key factors linked to HIV-related risk in Iringa, Tanzania. The strategic assessment synthesized existing data; conducted additional analyses of representative population-based data from the Tanzania HIV/AIDS and Malaria Indicator Survey; and conducted a large number of qualitative interviews and focus groups with key informants, service delivery providers and clients, and people at heightened risk of HIV in Iringa. Together, these findings provide a better understanding of the reasons behind the high HIV prevalence in the region and help to identify and tailor an appropriate set of interventions to address it. In this brief, we present findings of risk factors for HIV in the Iringa region with an in-depth analysis of data from the 2007/2008 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS). Aim Descriptive statistics from the 2007/8 THMIS and other sources provide a preliminary starting point for understanding HIV risk in Iringa; however, to date, there has not been a comprehensive analysis of these data beyond descriptive statistics that examine risk factors for HIV in Iringa and the rest of Tanzania. This study performs robust statistical analyses using the 2007/8 THMIS data, including multivariate logistic regression, to examine the drivers of HIV in Iringa, Tanzania. Together with the other strategic assessment studies, these data can be used to inform the development of more effective HIV prevention programs in this region. HIV in Tanzania and Iringa In 2009, an estimated 1.4 million persons were living with HIV in Tanzania (UNAIDS, 2009). The nation’s 2007/8 THMIS estimated an HIV prevalence of 5.6% among the general population. Women are disproportionately affected, with an HIV prevalence of 7% compared to the 5% prevalence reported among men (TACAIDS, 2008). Iringa is one of 26 administrative regions in Tanzania. In the 2007/8 THMIS, Iringa’s estimated HIV prevalence of 16% was the highest among all administrative regions in the country. The figure was nearly 2.5 times the national average and considerably higher than the two regions with next highest prevalence, Dar es Salaam (9%) and Mbeya (9%). Though the recent estimates represent an overall national decrease in HIV prevalence since the 2004/05 THMIS, prevalence in the Iringa region has remained unchanged (TACAIDS, 2008). Further, in the Iringa region, HIV prevalence is almost twice as high in urban areas (30%) relative to rural areas (16%) and is also higher among women (18%) relative to men (12%) (TACAIDS, 2008). Estimates from the 2007/8 THMIS showed that HIV prevalence in the region among youth ages 15-24 years was twice as high in young women compared to young men (8.2% vs. 4.8%) (TACAIDS, 2008). When examining modes of transmission in the Iringa region, 85% of HIV Page 3 Iringa Strategic Assessment Brief: HIV risk factors from the DHS transmission occurs through heterosexual contact and only 6% is attributed to mother-to-child transmission of HIV (PEPFAR, 2006). HIV incidence data are not available for Iringa, but data from the neighboring region of Mbeya indicate an approximate HIV incidence of 1.35 per 100 person-years (PY) during the years 2002-2006, with rates as high as 2.75 per 100 PY (Geis et al., 2011). The reasons behind the high HIV prevalence in Iringa are not fully understood; however, some evidence suggests that higher levels of risk factors and lower levels of protective factors exist in this region relative to other regions. For example, the prevalence of HIV knowledge as measured by the THMIS is lower in Iringa for women (18.7%) and men (32.4%) compared to the national prevalence of 39.6% and 44.3%, respectively (TACAIDS, 2008). Migration and mobility are also common in the region, and recent data triangulation efforts indicate that mobility may play an important role in the region’s high prevalence. The majority (61.4%) of men and women in Iringa reported travelling in the past year; among those who had travelled, slightly over one-third (37%) spent more than a month away from home (TACAIDS, 2008). Migration and mobility may be a particularly concerning risk factor for HIV among female sex workers (FSW). While studies have not been conducted in the Iringa region specifically, the estimated HIV prevalence among FSW in towns and truck stops throughout Tanzania is as high as 60%, and between 32% and 50% among bar-based FSW (MHSW, 2004). Other factors such as low prevalence of male circumcision, late initiation of HIV-infected individuals into clinical care and antiretroviral therapy (ART), and structural vulnerabilities for young women and girls also appear to contribute to ongoing HIV transmission. Only 30% of men in Iringa report being circumcised, compared to 67% of men nationally (TACAIDS, 2008). The percentages of adults ever tested for HIV in Iringa are 51.8% of women and 34.1% of men, compared to 40.9% of women and 29.2% of men nationally (TACAIDS, 2008). Although HIV care and treatment data are not available for Iringa specifically, in Tanzania, an estimated 22% of those eligible for ART are receiving it (UNAIDS, 2010). Page 4 Iringa Strategic Assessment Brief: HIV risk factors from the DHS METHODS This study used data from the 2007/2008 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) to assess risk factors for HIV infection in the Iringa region relative to the rest of Tanzania. The THMIS survey utilizes a conventional two-stage cluster sample representative of both urban and rural areas at the national level. In the first stage, 120 clusters of households were identified. An average of 25 households were then randomly sampled from each cluster, resulting in an overall sample of approximately 3,000 households. In all households, women and men of reproductive age (15-49 years) were eligible to participate. A total of 15,044 individuals were included in the 2007/8 survey in Tanzania, of which 445 were from Iringa. However, there has recently been a change in region boundaries, with Njombe becoming its own region. Therefore, these results must be interpreted in the context of the geographical boundaries which were represented during this data collection. Survey sample weights were used to adjust for population density and oversampling of some sub- populations. We first performed descriptive analyses to assess differences in risk factors among those living with HIV and those not infected to confirm original descriptive results from the THMIS. We then used chi-squared tests to compare risk factors and demographic factors between HIV-infected and uninfected individuals. This analysis was stratified by