08.X1302: - Qualitative behavioral study in adults PARTNER: UCSF

PHE: Qualitative behavioral study among adults to investigate the causes of decline of HIV prevalence

among youth in Botswana.

1.Title: Qualitative behavioral study among adults to investigate the causes of decline of HIV prevalence

among youth in Botswana

2.Summary: This is proposed as a 1-year formative research, with a total projected budget of $125,000.

3.Investigators: Stephane Bodika, MD, MPH (BOTUSA); Negussie Taffa MD, MPH , PhD(BOTUSA);

George W. Rutherford MD, MPH & Sandy Schwarcz MD (UCSF); others to be determined.

4.Project Description: for the past few years, a significant decline in HIV prevalence among youth has been

observed in Botswana. In an attempt to understand the causes of this prevalence decline, USG supported

MOH's DHAPC to conduct a qualitative behavioral study among youth initially. There are evidence that

intergenerational sex and multiple and concurrent sexual partnership in Botswana. This activity intends to

assess how adults' sexual behavior interferes in this declining HIV prevalence to allow holistic approach in

the designing or reinforcing effective prevention interventions in the communities. Between May 2008 and

August 2008, a to be determined partner (TBD) will assist BOTUSA and the MOH to implement this study

among a convenient sample of adult males and females in different districts with declining, stable and

increasing HIV prevalence. The study will consist of focus group discussions and in-depth interviews with a

sample of adults and will cover various topics including risk sexual behavior, multiple and concurrent sexual

partnership, condom use, transactional sex and intergeneration sex. It will cover also discussion with

discordant couples to unveil their sexual behavior and the potential risk this behavior represent to the youth.

Between December 2008 and March 2009, the TBD partner will assist with data analysis, report

preparation, and dissemination of results and recommendations.

5.Primary Research Question: What are the risk sexual behaviors adults indulge in which potentially affect

youth HIV infection? What is the dynamic of the intergenerational sex and its trends in districts with different

HIV prevalence? What is amplitude of transactional sex involving youth and its reasons? What are the

configuration of adults' sexual network and the importance of youth in this network?

6.Programmatic Importance: Understanding the adults' sexual behavior and the level of their involvement of

the youth in these behaviors is essential in order to develop and target effective prevention strategies.

Youth are a key group in which to assess basic knowledge of HIV transmission and related risk behaviors

because they are a vulnerable group, risk behaviors are often established during adolescence, and

prevention and educational efforts, if implemented prior to sexual debut can effectively prevent acquisition

of HIV. Studies have shown that girls enter into sexual relationships with older men (who are more likely

than younger men/boys to be HIV-infected) and the result is higher HIV prevalence in adolescent girls than

boys. Determining the prevalence of such behavior as well as the factors that contribute to this behavior

(such as the desire for having sex with virgins in exchange with items of monetary value from their older

sexual partners) can form the basis for intervention. Furthermore, prevention interventions targeting youth

will be enhanced by these targeting adults who have intergeneration sex with young people. By conducting

such study in different districts with different trends of HIV prevalence, the MOH will learn lessons about the

effectiveness of different interventions implemented in these districts targeting adults. This survey will inform

national quantitative surveys to really quantity the magnitude of the findings.

7.Methods: Focus group discussions will be organized with adults from different social strata (by

profession, education, gender…) in districts with declining, stable and increasing HIV prevalence among the

youth. The groups will be homogenous to facilitate full participation of all the members.

8.There will be an in-depth interview with a sample of community members selected by convenience. The

interview will help to closely follow up on the major themes with will emerge during the focus group

discussions.

9.Population of Interest: A convenient sample of adults from different social strata (by profession,

education, gender…) in districts with declining, stable and increasing HIV prevalence among the youth.

These districts will be the same like where the qualitative behavioral study among youth would have been

conducted through FY 07 funding.

10.Information Dissemination Plan: Between December 2008 and March 2009, the TBD partner will assist

with data analysis, report preparation, and dissemination of results and recommendations. The selected

partner will conduct a 1-day Data Use and Results Dissemination Workshop with key stakeholders in order

to disseminate result of this survey.

11.Budget Justification: Funds are required to support staff effort and travel to review and revise protocol

and data collection tools, obtain necessary ethical approvals from HRDC, and CDC, and to assist with

implementation of this PHE as follows:

Salaries/fringe benefits: $40.000

Equipment: $20,000

Supplies: $10,000

Travel: $20,000

Other: $35,000

Year 01 Total: $125,000 USD

08.X1304: PHE - HIV-related Mortality Validation

The team has changed the funding mechanism for this activity to be UTAP from New CoAg, and the prime

partner from TBD to UCSF. (April 08 Reprogramming)

1.Title: Updating of HIV-Related Mortality Statistics & Validation of Cause of Death Data.

2.Summary: In order to clarify the accuracy of reported AIDS related mortality data in Botswana we propose

to conduct an assessment and validation of causes of child and adult mortality in Botswana in which we will

estimate the extent of over-or under-reporting or misclassification of mortality due to HIV/AIDS by

comparing death certificate coded cause of death with medical chart diagnoses. Through this work, we will

advise on improving the accuracy of mortality reporting and utilization of mortality statistics to improve public

health surveillance and policy decision making in Botswana. This project is expected to end in FY08 and

the two year cost is estimated at $150,000.

3.Investigators: UCSF Investigators: George W. Rutherford MD MPH, Rand Stoneburner MD, Sandy

Schwarcz MD, Gail Kennedy MPH; Tracy Creek MD (CDC/GAP-Atlanta). Local co-Investigators: Negussie

Taffa MD, PhD; Stephane Bodika MD, MPH (BOTUSA); Anna Majalantle & Diemo Motlapele (CSO),

Florindo Gomez MD (Botswana Ministry of Health).

4.Status of study/progress to date: In 2007, UCSF assisted team Botswana with the development of a

research protocol to update and collect all available HIV-related institutional mortality statistics, as well as

ART and PMTCT programmatic data from 1993 through 2006, in order to assess changes in HIV-related

mortality following scale up of ART and PMTCT programs, and estimate the degree of potential under-

reporting of HIV-related mortality in Botswana. A protocol to update, collect, and analyze mortality and

program through 2006 was approved by ethical review committees at UCSF, CDC, and HRDC in Botswana.

Further technical assistance to assist the MOH Central Statistics Office in coding, entering, and publishing

this data occurred. An amended research protocol for conducting de-identified patient chart review to

validate mortality data and describe the extent of potential misclassification of AIDS-related mortality was

drafted, reviewed by key stakeholders in Botswana and submitted for review and approval by respective

ethical review committees at UCSF, CDC, and HRDC in Botswana.

5.Lessons Learned: It's difficult to give full picture of lessons learned on this project as the progress so was

is limited to protocol development and preparing the background work of coding cause of death using ICD-

10. The later took quite some time in order to clear backlog of patient chart coding dating back from 2004 to

2006.

6.Information Dissemination Plan: Early in FY08, findings from the updated mortality and programmatic

datasets including overall trends, and correlations between infant mortality and PMTCT program uptake,

and adult mortality and ART program uptake will be shared with key stakeholders in a Dissemination

Meeting. This information is expected to update our understanding on the impact of HIV/AIDS on adult

mortality and the extent to which large scale ART can help curb this. Likewise the impact of high PMTCT

program uptake on infant and child mortality over time will be assessed.

7.Planned FY08 activities: Detailed analyses of updated mortality datasets on trends, and correlations

between infant mortality and PMTCT program uptake, and adult mortality and ART program uptake;

8.Findings from these analyses will be shared with key stakeholders during a Dissemination Workshop

9.Following the Dissemination Workshop, abstracts will be developed for presentation at local and

international meetings;

10.Data collection for the Cause of Death Validation Study will be completed, and preliminary results will be

reviewed with all Investigative staff.

.

11.Budget Justification: In the second year of this 2-year effort, funds will be required to support staff effort

and travel to conduct final analyses on updated mortality data as described, attend a Dissemination Meeting

in-country to present findings, and plan for the development of abstracts and manuscripts; to assist with

data collection and analysis of the Mortality Validation Study as outlined for this PHE as follows:

Salaries/fringe benefits:$26,000

Equipment: $14,000

Supplies: $20,000

Tavel: $25,000

Contractual Costs: $15,000

Other:$50,000

Year 01 Total: $150,000 USD

08.X1303: Behavioral Surveillance Survey among High-School Students

We have changed the funding mechanism for this activity to be UTAP from New CoAg, and the prime

partner from TBD to UCSF. (April 08 Reprogramming)

1.Title: Baseline behavioral surveillance survey among high-school students in Botswana.

2.Summary: This is proposed as a 2-year PHE effort, with a total projected budget of $350,000 and a year 1

budget of $200,000.

3.Investigators: Stephane Bodika, MD, MPH (BOTUSA); Negussie Taffa MD, MPH , PhD(BOTUSA);

others to be determined.

4.Project Description: In 2007, the MOE in Botswana conducted a consensus building workshop to plan for

a national surveillance study of HIV-related knowledge and behaviors among high school students.

Consensus meetings were convened in-country, and draft protocols, procedures, and survey instruments

were prepared. Between April 2008 and March 2009, a yet to be dermined partner will assist BOTUSA and

the MOE to implement a baseline cross-sectional survey of HIV-related behaviors among a sample of male

and female high-school students enrolled in 9-12th grades in Botswana. Between April 2009 and March

2010, the partner will assist with data analysis, report preparation, and dissemination of baseline results and

recommendations for continued annual administration of this surveillance exercise so that national

behavioral trends among youth in Botswana can be observed prospectively.

5.Primary Research Question: What are the baseline levels of knowledge of HIV transmission and the

baseline sexual and other risk behavioral patterns among currently enrolled high school students in

Botswana?

6.Programmatic Importance: Understanding the prevalence of HIV risk behaviors in populations at risk for

HIV is essential in order to develop and target effective prevention strategies. Youth are a key group in

which to assess basic knowledge of HIV transmission and related risk behaviors because they are a

vulnerable group, risk behaviors are often established during adolescence, and prevention and educational

efforts, if implemented prior to sexual debut can effectively prevent acquisition of HIV. Studies have shown

that girls enter into sexual relationships with older men (who are more likely than younger men/boys to be

HIV-infected) and the result is higher HIV prevalence in adolescent girls than boys. Determining the

prevalence of such behavior as well as the factors that contribute to this behavior (such as the desire for

obtaining items of monetary value from their older sexual partners) can form the basis for intervention.

Furthermore, risk behaviors serve as an early marker of HIV incidence, that is, the risk behaviors precede

HIV acquisition. In addition, this activity will assist the MOE to follow trends in risk behaviors, which is a

method of predicting HIV incidence and to assess the impact of different HIV prevention programs targeting

youth implemented in school in Botswana. Thus, providing information on the required modifications in the

design of current prevention programs or mandating the design of new ones.

7.Methods: A three stage multi-cluster sampling strategy will be used to obtain a representative sample of

high school students. The first stage will be identifying primary sampling units which will consist of provinces

(cities, or other reasonable unit) that will be categorized into X strata based on degree of urbanicity (and any

other meaningful measures so that all areas are represented in the sample). A sample of X schools within

each strata will be sampled using probability proportionate to size. Within each school, X classrooms will be

randomly selected and all students within these classrooms will be asked to complete a written anonymous

survey. The classrooms should be selected to ensure that they are required courses. The analysis will be

weighted based upon demographics (e.g. sex) and applied to each record. The weights will be scaled so

the weighted count of students will equal the proportions of students in each grade to match national

population proportions.

8.Population of Interest: A representative sample of X high school students selected from X districts in

Botswana.

9.Information Dissemination Plan: Between April 2009 and June 2009 (year 2 of this PHE) a 10-day Data

Use and Results Dissemination Workshop will be conducted with key stakeholders in order to disseminate

baseline results, and to review recommendations for continued annual administration of this surveillance

exercise to support future surveillance activities among High School student on an annual basis.

10.Budget Justification: In Year 1 of this 2 year effort, funds will be required to support staff effort and travel

to review and revise protocol and data collection tools, obtain necessary ethical approvals from HRDC, and

CDC, and to assist with implementation of this PHE as follows:

Salaries/fringe benefits: $80,000

Equipment: $15,000

Supplies: $10,000

Travel: $30,000

Other: $65,000

Year 01 Total: $200,000 USD