Age-specific and sex-specific mortality in 187 countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010

https://www.who.int/reproductivehealth/publications/general/lancet_2.pdf

Sexual behaviour in context: a global perspective.

THE CULTURES OF South Asia are largely gender stratified, characterized by patrilineal descent, patrilocal residence, inheritance and succession practices that exclude women, and hierarchical relations in which the patriarch or his relatives have authority over family members. Levels and patterns of female autonomy vary considerably within the region, however, and the question is why. Two arguments have been advanced in the literature to support the hypothesis that women in Pakistan have less autonomy and control over their own lives than do women in India. The first argues that in Pakistan as in other Islamic settings, women occupy a separate and distinctive position that effectively denies them education and autonomy. Women’s lack of control over their own lives has been cited as the central factor underlying the poorer mortality outcomes experienced by Islamic societies (Caldwell 1986: 175). The second argument draws on research conducted in India that demonstrates the dominant influence of behavior and norms imprinted by regionally prescribed social systems, and points out that the social systems that characterize the southern region provide women more exposure to the outside world, more voice in family life, and more freedom of movement than do the social systems of the north (Dyson and Moore 1983; Basu 1992; Jejeebhoy 2000). In this view, to which we subscribe, region plays the major conditioning role, and once region is controlled, Muslim women exert about as much autonomy in their lives as do Hindu women, wherever they reside. The argument in favor of regional social systems as opposed to religion as the driving force is strengthened by evidence suggesting wide variations in the ways in which gender and behavioral norms are manifested across a range of Islamic countries (see for example, Obermeyer 1992).

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Women's Autonomy in India and Pakistan: The Influence of Religion and Region

OBJECTIVE: To examine the factors responsible for the disparity in HIV prevalence between young men and women in two urban populations in Africa with high HIV prevalence. DESIGN: Cross-sectional survey, aiming to include 1000 men and 1000 women aged 15-49 years in Kisumu, Kenya and Ndola, Zambia. METHODS: Participants were interviewed and tested for HIV and other sexually transmitted infections. Analyses compared the marital and non-marital partnership patterns in young men and women, and estimated the likelihood of having an HIV-infected partner. RESULTS: Overall, 26% of individuals in Kisumu and 28% in Ndola were HIV-positive. In both sites, HIV prevalence in women was six times that in men among sexually active 1 5-19 year olds, three times that in men among 20-24 year olds, and equal to that in men among 25-49 year olds. Age at sexual debut was similar in men and women, and men had more partners than women. Women married younger than men and marriage was a risk factor for HIV, but the disparity in HIV prevalence was present in both married and unmarried individuals. Women often had older partners, and men rarely had partners much older than themselves. Nevertheless, the estimated prevalence of HIV in the partners of unmarried men aged under 20 was as high as that for unmarried women. HIV prevalence was very high even among women reporting one lifetime partner and few episodes of sexual intercourse. CONCLUSIONS: Behavioural factors could not fully explain the discrepancy in HIV prevalence between men and women. Despite the tendency for women to have older partners, young men were at least as likely to encounter an HIV-infected partner as young women. It is likely that the greater susceptibility of women to HIV infection is an important factor both in explaining the male-female discrepancy in HIV prevalence and in driving the epidemic. Herpes simplex virus type 2 infection, which is more prevalent in young women than in young men, is probably one of the factors that increases women's susceptibility to HIV infection.

Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia.

was 36.7% (95% confidence interval [CI], 29.4%-44.0%) in the breastfeeding arm and 20.5% (95% CI, 14.0%-27.0%) in the formula arm (P = .001). The estimated rate of breast milk transmission was 16.2% (95% CI, 6.5%-25.9%). Forty-four percent of HIV-1 infection in the breastfeeding arm was attributable to breast milk. Most breast milk transmission occurred early, with 75% of the risk difference between the 2 arms occurring by 6 months, although transmission continued throughout the duration of exposure. The 2-year mortality rates in both arms were similar (breastfeeding arm, 24.4% [95% CI, 18.2%-30.7%] vs formula feeding arm, 20.0% [95% CI, 14.4%-25.6%]; P = .30). The rate of HIV-1‐free survival at 2 years was significantly lower in the breastfeeding arm than in the formula feeding arm (58.0% vs 70.0%, respectively; P = .02). Conclusions The frequency of breast milk transmission of HIV-1 was 16.2% in this randomized clinical trial, and the majority of infections occurred early during breastfeeding. The use of breast milk substitutes prevented 44% of infant infections and was associated with significantly improved HIV-1‐free survival.

Effect of Breastfeeding and Formula Feeding on Transmission of HIV-1: A Randomized Clinical Trial

Objectives: To describe recent trends in age at first sex in African countries, identifying and making due allowances for a variety of common reporting errors. Methods: Demographic and Health Surveys (DHS) data from six African countries conducting three or more surveys since 1985 were analysed using survival analysis techniques, combining information on virginity status and retrospective reporting of age at first sex. Hazard analysis was used to separate the effects of reporting error and compositional change and to estimate true changes in sexual debut over time. A multistate life table analysis incorporating transition to first marriage allowed cohorts to be classified according to person years spent as virgins, as sexually active unmarried, and married. Results: Intersurvey comparisons generally suggested a slow secular rise in age at first sex. However, tracing birth cohorts between surveys revealed inconsistencies-median ages reported by female members of a birth cohort in their teens were generally higher than those reported when they reached their twenties, even when allowing for residence and education changes-probably a result of young, sexually active women denying they had ever had sex. Male birth cohorts tend to display the opposite kind of bias. Conclusions: Uganda, Kenya, and Ghana have experienced a more pronounced and unambiguous decline in premarital sexual activity than Tanzania, Zambia, and Zimbabwe, with statistically significant increases in age at first sex. In addition, Uganda has maintained a very short interval between onset of sexual activity and marriage for both sexes.

https://sti.bmj.com/content/sextrans/80/suppl_2/ii28.full.pdf

Age at first sex: understanding recent trends in African demographic surveys.

OBJECTIVE: To describe the trends in HIV transmission and sexual behaviour in a rural population in Africa. DESIGN: An open community cohort study with demographic surveillance and surveys of all consenting adults. METHODS: All residing adults aged 15-44 years who participated in surveys in 1994-1995, 1996-1997 and 1999-2000 were tested for HIV infection and provided information on sexual behaviour. The district AIDS control programme was the only intervention. RESULT: The prevalence of HIV among adults aged 15-44 years increased gradually from 5.9% in 1994-1995 to 6.6% in 1996-1997 and 8.1% in 1999-2000. The incidence of HIV increased from 0.8 to 1.3 per 100 person-years during 1994-1997 and 1997-2000, respectively. In spite of a modest increase in knowledge during the study period, most individuals continued to feel that they were not at risk of HIV, and sexual risk behaviour remained largely unchanged, except for a small increase in condom use. HIV transmission levels continued to be higher in the trading centre than in the nearby rural villages within this small geographical area, although differences became smaller over time. CONCLUSION: The gradual and continuing spread of HIV and the striking lack of change in sexual behaviour in this rural population suggest that the low-cost district intervention package does not appear to be adequate to stem the growth of the epidemic, and more intensive AIDS control efforts are needed.

Trends in HIV and sexual behaviour in a longitudinal study in a rural population in Tanzania, 1994-2000.

Background: The AIDS epidemic is now more than a decade old and direct evidence of mortality impact has become measurable, as indicated by an increasing number of publications presenting empirical data from less developed countries.Methods: This review focuses on the evidence of mortality impact among adults and children in community studies. The majority of these studies are located in Africa, particularly eastern Africa, where the AIDS epidemic is conjectured to be older than in other less developed countries.Results: Community studies show a two- to threefold increase in total adult mortality with an even larger increase in mortality among young adults in communities with adult HIV prevalence levels below 10%. Mortality amongst HIV-infected adults ranges from 5 to 11% per year, and more than half of all adult deaths can be attributed to HIV. HIV-infected women die at an earlier age than men and thereby lose significantly more productive years of life. Follow-up studies of incident cases are few but population-based data indicate that the median survival time is substantially longer than originally thought on the basis of mortality amongst HIV-infected commercial sex workers. Tuberculosis incidence is on the increase, but evidence of additional impact on mortality is hitherto limited. Infant and early child mortality among children of HIV-infected mothers is two to five times higher than among children of HIV-negative mothers in follow-up studies of maternity-based and community samples.Conclusion: There is now empirical evidence of the mortality impact of HIV. AIDS from several community studies. The large increase in adult mortality and moderate increase in child mortality lead to dramatic falls in life expectancy. For instance, in a rural area of Uganda, which has an HIV prevalence of 8%, life expectancy has dropped from just under 60 years to 42.5 years. (C) 1998 Lippincott-Raven Publishers.

Mortality impact of the AIDS epidemic: evidence from community studies in less developed countries

Objective: To assess the spread of HIV into rural areas. Methods: Since 1994 a demographic surveillance system (with 5-monthly rounds) and open adult cohort study have been established in a rural ward in Tanzania. Two sero-surveys of all resident adults aged 15-44 and 15-46 years were conducted in 1994-1995 and 1996-1997 respectively. Qualitative data were collected on mobility, bars and commercial sex. Results: Attendance of the two rounds of survey was 5820 (78%) and 6413 (80%) in 1994/1995 and 1996/1997 respectively. HIV prevalence increased from 5.8% to 6.6%. HIV incidence was 0.73 and 0.84 per 100 person years among men and women respectively. HIV incidence under the age of 20 years was low among both sexes. Striking differences in HIV prevalence and incidence were observed within the small geographic area studied: HIV prevalence in the trading center was twice that in the area surrounding the trading center (within 2km) and three to four times that in the rural villages (within 8km of the trading center). Aggregate level data showed significant differences between the trading center and nearby rural villages in terms of sexual behavior, commercial sex workers, mobility of the population, and alcohol use. Conclusion: This study documents the existence of very substantial HIV prevalence and incidence differences within a small geographic rural area. The rapid decrease in HIV prevalence within a small rural area emphasizes the importance of concentrating HIV prevention efforts on high transmission areas, such as trading centers, especially in resource-poor settings. Furthermore, this has considerable implications for monitoring the spread of HIV through sentinel sites, as such sites are typically located in high transmission areas.

Spread of HIV infection in a rural area of Tanzania.

Male circumcision status is considered an important cofactor in the spread of HIV and sexually transmitted disease. There is limited evidence that male circumcision practices in Africa may be changing. The aim was to assess the determinants of male circumcision status in a traditionally noncircumcising ethnic group and to investigate the reasons for increasing acceptance of circumcision. Data from a factory workers study and a rural cohort study in northwest Tanzania were used to analyze the levels and determinants of male circumcision status and assess the reliability of self-reported data. Qualitative data from focus group discussions and in-depth interviews were obtained to ascertain norms and values in relation to male circumcision. Male circumcision has become more popular in recent years and 21% of 3491 men reported themselves as circumcised. An increase in circumcision rates was observed in the rural cohort study during 1994-97 though reporting inconsistencies are common. Circumcision rates were higher among men with higher levels of education and in Muslim men. Men are often circumcised in their late teens or 20s. The reasons for the increasing popularity of circumcision were investigated in group discussions and in-depth interviews. The most frequently mentioned reason was health-related; circumcision was thought to enhance penile hygiene reduce sexually transmitted disease incidence and improve sexually transmitted disease cure rates. Male circumcision is becoming more popular among a traditionally noncircumcising ethnic group in Tanzania especially in urban areas and among boys who have attended secondary schools. (authors)

Boerma Jt

Papers

Age at first sex: understanding recent trends in African demographic surveys.

Trends in HIV and sexual behaviour in a longitudinal study in a rural population in Tanzania, 1994-2000.

Mortality impact of the AIDS epidemic: evidence from community studies in less developed countries

Spread of HIV infection in a rural area of Tanzania.

Dynamics of male circumcision practices in northwest Tanzania.