Introducing the TAZAMA study: measuring trends in HIV spread, prevention, treatment and care in Kisesa

1. Introducing the TAZAMA study: measuring trends in HIV spread, prevention, treatment and care in Kisesa Mark Urassa, Raphael Isingo, Milalu Ndege, Milly Marston, Julius Mngara, Basia Zaba and John Changalucha TAZAMA / NACP seminar Dar-es-Salaam, September 19th 2008

2. Structure of presentation • Introduction to the TAZAMA study • How we measure HIV infection, risk behaviour and access to care • Our findings about HIV prevalence and incidence trends from 1994 to now • The main policy implications of these findings

3. City The location of the TAZAMA study site

4. Kisesa ward and its population Population • About 20,000 people in 1994, fourteen years later 28,000; growth 2.4% per year, faster in and near trading centre • Ethnicity: 95% are Sukuma • Religion: 74% Christian, 23% Traditional, 3% Islam • Education: 14 primary schools (11 public, 3 private) and 2 secondary schools (1 public, 1 private) • Health: 7 health facilities (4 public, 3 private) including VCT service and new ART clinic run by the research project Economy • Per capita income below $120 per year • Farming is main source of income, petty trading common, including selling agricultural produce in Mwanza city

5. Objectives of the TAZAMA study • To improve understanding of the dynamics of the HIV epidemic • To asses the demographic, social and economic impacts of the HIV/AIDS epidemic • To evaluate the effects of national prevention, treatment and care interventions as implemented in Kisesa Ward • To measure child and adult mortality and fertility in the general population and by HIV status • To asses the leading causes of death through verbal autopsy • To asses changes in the family structure due to HIV epidemic • To provide reliable data for district health planning

6. The different types of research • Demographic surveys • house to house, whole pop • keep track of births, deaths and movements • twice a year • simple, quick questions • Serological surveys • adults invited to village clinics • HIV & other lab tests • every 3 years • long questionnaire about behaviour & other risks • In depth enquiries • specially selected individuals • sensitive topics • timing as required • some open-ended questions &/or qualitative interviews • Operations research • community groups, village leaders, health services • help national surveillance • timing continuous / as required • IEC activities and feedback

7. Timing of our study components

8. Demographic surveillance • Visit every household and collect information from household head or other adult member • Ask about births, pregnancies, deaths, moves in or out, update information on school attendance • Link children to mothers and fathers, adults to their spouses • Follow-up death reports with verbal autopsy interview • Use demographic data to identify eligible persons for sero-survey and special topic surveys

9. Black lines show past members of the household who died, dark grey lines show past members who now live somewhere else. 6 columns of pre-printed identifying information Our very simple demographic data collection form pale grey shading shows which fields should not be filled

10. Sero-surveys • Resident adults 15+ invited to special village clinics • Clinics provide treatment for common illnesses, family members can also be treated • Long questionnaire on socio-demographic background, sexual behaviour, other risk factors, knowledge and attitudes • Finger prick blood samples are tested anonymously at NIMR laboratory (lab and field staff cannot link test results to personal identifiers) • VCT services offered during last 3 surveys, using separate samples of venous blood

11. Registration & consent Identification Socio-economics Residence & mobility Condom knowledge First sex Pregnancy history Marital history Sex within marriage Polygamy Non marital partners High risk sex Family planning STI symptoms & treatment HIV knowledge Injections & blood transfusion Stigma & HIV attitude Use of health services Experience of VCT Sero-survey questionnaire covers:

12. 3 sets of informed consents If we link our lab results to our VCT attendance data we can see what percent of HIV positive people had VCT – they are the ones who will be able to access ART The first page from our 19-page sero-survey questionnaire

13. Survey 5: provisional data includes ineligible temporary visitors Surveys 1-4: numbers exclude ineligible temporary visitors Sero-survey participation,1994-2007 1994-1995 15-44 years 5,672 attended (74%) 1996-1997 15-46 years 6,174 attended (75%) 69% follow-up 1999-2000 15+ years 5,650 attended (68%) 52% follow-up 2003-2004 15+ years 6,943 attended (66%) 50% follow-up 2006-2007 15+ years 9,334 attended (~73%) ~52% follow-up

14. HIV prevalence trends in Kisesa

15. largest changes are due to migration, not sero-conversion or death Is prevalence change a reliable guide to the course of the epidemic?

16. Trends in HIV incidence: Infection rates by calendar year

17. Incidence peaks later for men and then continues at a higher rate than for women There are secondary incidence peaks at older ages for both men and women Full details of HIV incidence age pattern emerge when all data analysed together poster 5

18. Provisional results from sero5 (unlinked data) • Participants as percent of invited: 62% (invitations issued to adults resident in DSS 19 or DSS 20; true participation rate calculated after DSS 21, expected to be ~ 73%) • Overall HIV prevalence = 7.3% (down from 8.2%) • Cannot calculate incidence prior to linking • Proportion accessing VCT = 17.3% (up from 9.2%)

19. How representative is Kisesa?

20. Overall conclusions • There are encouraging signs of decline in incidence which appears to have started in the late 1990s. • When we compare incidence in men and women we do not see the kind of female disadvantage that prevalence data suggest. Women become infected at earlier ages, but their overall life time risk is similar to that of men BUT • It is possible that the incidence decline was part of the natural epidemic dynamic, rather than a response to prevention campaigns • It is worrying that incidence and prevalence in remote rural areas are now catching up with the roadside settlements and trading centre • A crucial question for future research is the impact of ART roll-out on HIV incidence

21. Policy implications SURVEILLANCE • ANC surveillance needs to continue to try and cover rural areas, where the epidemic may still be growing • National surveys such as DHS / AIS should take in age groups 50-64, as prevalence and incidence may not be falling so fast in these age groups PREVENTION • Messages need to be tailored towards older people and rural inhabitants, not just high risk groups and youth TREATMENT AND CARE • There will be continued demand for services in rural areas, and access needs of older people need thought