Place matters: multilevel investigation of HIV distribution in Tanzania

Msisha, Wezi Ma; Kapiga, Saidi Hb; Earls, Felton Jc; Subramanian, SVc

doi: 10.1097/QAD.0b013e3282f3947f
Epidemiology and Social

Objective: To examine the extent to which the regional and neighborhood distribution of HIV in Tanzania is caused by the differential distribution of individual correlates and risk factors.

Methods: Nationally representative, cross-sectional data on 12 522 women and men aged 15–49 years from the 2003–2004 Tanzanian AIDS Indicator Survey. Three-level multilevel binary logistic regression models were specified to estimate the relative contribution of regions and neighborhoods to the variation in HIV seroprevalence.

Results: Spatial distribution of individual correlates (and risk factors) of HIV do not explain the neighborhood and regional variation in HIV seroprevalence. Neighborhoods and regions accounted for approximately 14 and 6% of the total variation in HIV. HIV prevalence ranged from 1.8% (Kigoma) to 6.7% (Iringa) even after adjusting for the compositional make-up of these regions. An inverse association was observed between log odds of being HIV positive and neighborhood poverty [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.09–0.61] and regional poverty (OR 0.97, 95% CI 0.95–0.99).

Conclusion: Our study provides evidence for independent contextual variations in HIV, above and beyond that which can be ascribed to geographical variations in individual-level correlates and risk factors. We emphasize the need to adopt both a group-based and a place-based approach, as opposed to the dominant high-risk group approach, for understanding the epidemiology of HIV as well as for developing HIV intervention activities.

From the aEurope and Central Asia Human Development Sector, The World Bank, Washington, DC, USA

bDepartment of Population and International Health, Harvard School of Public Health, Boston, Massachusetts, USA

cDepartment of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts, USA.

Received 16 May, 2007

Revised 12 October, 2007

Accepted 19 October, 2007

Correspondence to S.V. Subramanian, Department of Society, Human Development and Health, Harvard School of Public Health, 677 Huntington Avenue, 7th Floor, Boston, MA 02115-6096, USA. Tel: +1 617 432 6299; fax: +1 617 432 1135; e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.