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The prevalence of adverse birth outcomes is highest in resource-limited settings such as sub-Saharan Africa. Maternal consumption of diets with adequate nutrients during pregnancy may protect against these adverse outcomes.To determine the association between maternal dietary animal source foods (ASF) consumption and the risk of adverse birth outcomes among HIV-negative pregnant women in Tanzania.Using dietary intake data from 7564 HIV-negative pregnant, we used Poisson regression with the empirical variance (GEE) to estimate the relative risk (RR) of adverse birth outcomes (preterm birth, very preterm birth, small for gestation age (SGA), low birth weight (LBW), stillbirth and neonatal death) for higher versus lower ASF frequency of intake.Median (interquartile range) daily dietary intake of animal protein was 17 (1-48) grams. Higher ASF protein intake frequency was associated with lower risk of neonatal death (Q4 vs Q1 RR: 0.59; 95% CI: 0.38, 0.90; P for trend = 0.01). Higher fish intake was associated with lower risk of very preterm birth (high vs low tertile RR: 0.76; 95% CI: 0.58, 0.99; P for trend = 0.02). Meat intake was protective of preterm birth (RR = 0.73; 95% CI: 0.65, 0.82; P0.001), very preterm birth (P0.001), LBW (P0.001), and neonatal death (P = 0.01) but associated with increased risk of SGA (RR = 1.19; 95% CI: 1.01, 1.39; P = 0.04). Any egg intake was protective of very preterm birth (RR = 0.52; 95% CI: 0.32, 0.86; P = 0.01) compared to no egg intake. Finally, dairy intake was associated with lower risk of preterm birth (RR = 0.82; 95% CI: 0.68, 0.98; P = 0.03) and very preterm birth (RR = 0.53, 95% CI: 0.34, 0.84; P = 0.01).Higher frequency of dietary intake of ASF is associated with lower risk of adverse birth outcomes in urban Tanzania. Promoting prenatal dietary intake of ASF may improve birth outcomes in this region and similar resource-limited settings.Clinical Trial Registry Number: NCT00197548.

Background Maternal micronutrient status is critical for child growth and nutrition. It is unclear whether maternal multiple micronutrient supplementation (MMS) during pregnancy and lactation improves child growth and prevents child morbidity. Methods This study aimed to determine the effects of prenatal and postnatal maternal MMS on child growth and morbidity. In this double-blind, randomized–controlled trial, 8428 HIV-negative pregnant women were enrolled from Dar es Salaam, Tanzania, between 2001 and 2004. From pregnancy (12–27 weeks of gestation) through to 6 weeks postpartum, participants were randomized to receive daily oral MMS or placebo. All women received daily iron and folic acid during pregnancy. From 6 weeks postpartum through to 18 months postpartum, 3100 women were re-randomized to MMS or placebo. Child-growth measures, haemoglobin concentrations and infectious morbidities were assessed longitudinally from birth to ≤18 months. Results Prenatal MMS led to modest increases in weight-for-age z-scores (mean difference: 0.050; 95% confidence interval: 0.002, 0.099; p = 0.04) and length-for-age z-score (mean difference: 0.062; 95% confidence interval: 0.013, 0.111; p = 0.01) during the first 6 months of life but not thereafter. Prenatal or postnatal MMS did not have benefits for other child outcomes. Conclusions Whereas maternal MMS is a proven strategy to prevent adverse birth outcomes, other approaches may also need to be considered to curb the high burdens of child morbidity and growth faltering.

ObjectivesTo explore the potential use of body mass index (BMI), proteinuria and total lymphocyte count changes in predicting immunological and virological response in individuals with HIV initiated on antiretroviral treatment (ART).DesignProspective cohort study.SettingThree urban HIV care and treatment centres in Dar es Salaam.ParticipantsIndividuals with HIV initiating ART.Outcome measuresHIV viral load ≥1000 copies/mL (viral non-suppression) at 6 months after ART initiation.ResultsOf 215 (out of 220 enrolled) participants who returned for evaluation at 6 months, 147 (66.8%) were women. At 6 months of follow-up, 89.4% (76/85) of participants with sustained weight gain were virally suppressed compared with 31.8% (7/22) with sustained loss, p5% from baseline to 6 months (adjusted RR 2.73, 95% CI (1.36 to 5.47)), lymphopaenia at 6 months (adjusted RR=4.54, 95% CI (2.19 to 9.39)) and proteinuria at 6 months (adjusted RR=2.63, 95% CI (1.25 to 5.54)).ConclusionsChange in BMI, total lymphocyte count and presence of proteinuria can monitor and predict ART response and may be particularly helpful in settings when CD4 counts and viral load monitoring are unavailable.

Background Zinc and vitamin A supplementation have both been shown to affect iron status, hemoglobin (Hb) concentration, and anemia in animal and human studies. However, evidence on their combined use in pregnancy, in the context of iron-folic acid (IFA) supplementation, remains limited. Objective This study determined the effects of prenatal zinc, vitamin A, and iron supplementation on maternal hematologic and micronutrient status at delivery in Tanzania. Methods We analyzed 2 large randomized controlled trials, using generalized estimating equations, and examined the effect of daily zinc (25 mg) and vitamin A (2500 IU) supplementation starting in the first trimester of pregnancy compared with placebo (n = 2500), and separately evaluated the safety and efficacy of daily iron (60 mg) supplementation among iron-replete pregnant women (n = 1500). Blood samples from baseline and delivery were tested for Hb, serum ferritin, soluble transferrin receptor, plasma zinc, and zinc protoporphyrin. Results Zinc and vitamin A supplementation were associated with lower Hb concentrations at delivery of -0.26 g/dL (95% CI: -0.50, -0.02 g/dL) and -0.25 g/dL (95% CI: -0.49, -0.01 g/dL), respectively. Vitamin A increased mean ferritin concentrations at delivery (14.3 μg/L, 95% CI: 1.84, 29.11 μg/L), but was associated with increased risk of severe anemia (RR: 1.41; 95% CI: 1.06, 1.88). Among women who were iron replete at baseline, iron supplementation reduced the risk of iron depletion at delivery by 47% (RR: 0.53; 95% CI: 0.43, 0.65). There was no effect of zinc or iron supplements on plasma zinc concentrations. Conclusions Our findings support existing WHO guidelines on prenatal iron, vitamin A, and zinc supplementation among pregnant women. In this setting, scaling uptake of prenatal iron supplements is warranted, but prenatal zinc and vitamin A supplementation did not benefit maternal hematologic status at delivery. In settings where vitamin A deficiency is endemic, the efficacy and safety of the WHO recommended prenatal vitamin A supplementation require further evaluation.

Background: Despite several interventions, the prevalence of anemia and related complications remains high among infants in Tanzania. Objective: We sought to determine the predictors of iron-deficiency anemia (IDA) among infants of HIV-negative women in Dar es Salaam, Tanzania. Methods: Cross-sectional analysis of 2826 mother–infant pairs who participated in a trial of vitamins and perinatal outcomes in Dar es Salaam, Tanzania. Hemoglobin and mean corpuscular volume were used to determine the prevalence of anemia among infants at 6 and 12 months. Multiple logistic regression was used to determine the maternal and infant risk factors for anemia during infancy. Results: We found high prevalence of anemia (90%) and IDA (44.2%) among infants. Higher maternal education (odds ratio [OR] = 0.52), maternal normal hemoglobin at enrollment (OR = 0.68) and during the early postpartum period reduced the odds of IDA at 6 months (OR = 0.56). The odds of IDA at 6 months were higher among males (OR = 1.65), wealth score below median (OR = 1.35), low birth weight (LBW; OR = 1.75), and small for gestational age (SGA) infants below the third centile (OR = 1.95) or third to less than fifth centile (OR = 2.29). Higher maternal education lowered the odds of IDA at 12 months (OR = 0.25). Wealth score below median (OR = 1.44), preterm delivery (OR = 1.94), SGA (less than third centile; OR = 2.40), and LBW (OR = 2.89) increased the odds of IDA during infancy in the study population. Dietary diversity was low for infants and women in the study sample. Conclusion: Interventions to reduce the risk of infant IDA should address women’s education, improvement of wealth status, and optimal care for premature, SGA, and LBW infants.

Context The association between weight change and mortality among participants with incident type 2 diabetes (T2D) was unclear. Objective To examine above association and evaluate the impact of lifestyle on it. Methods This prospective analysis included 11 262 incident T2D patients from Nurses’ Health Study and Health Professionals Follow-up Study. We assessed weight change bracketing T2D diagnosis in relation to mortality. We also examined potential effect modification by a healthy lifestyle consisting of high-quality diet, regular physical activity, nonsmoking status, and moderate alcohol consumption. Results On average, T2D patients lost 2.3 kg during a 2-year time window spanning the T2D diagnosis, and body weight increased afterwards following a trajectory similar to that of nondiabetics. Compared with patients with a stable weight, T2D patients who lost ≥10% body weight had a 21% (95% CI, 9%-35%) increased all-cause mortality. Lifestyle significantly modified these associations: the hazard ratios (95% CIs) of all-cause mortality comparing ≥10% weight loss with stable weight were 1.63 (1.26-2.09) among participants with a deteriorated lifestyle, 1.27 (1.11-1.46) for a stable lifestyle, and 1.02 (0.81-1.27) for an improved lifestyle (Pinteraction < 0.001). Major weight loss was associated with increased cause-specific mortality and similar effect modifications by lifestyle were also observed. Conclusion Significant weight loss upon T2D incidence was associated with increased mortality, although improved lifestyle quality abolished these associations. These results highlight the role of adopting a healthy lifestyle for newly diagnosed T2D patients, especially among those who might lose weight unintentionally, and improving long-term survival.

Background Screening and diagnosis of iron deficiency anemia (IDA) is cumbersome as it may require testing for hemoglobin, ferritin, and an inflammatory biomarker. Objective The aim of this study was to compare the diagnostic capacity of hematologic biomarkers to detect IDA among pregnant women in Tanzania. Methods We pooled data from an iron supplementation trial of 1500 iron replete pregnant woman and a prospective cohort of 600 iron deficient pregnant women. Receiver operating characteristic curves (ROC) for hematologic biomarkers were used to assess the sensitivity, specificity, and area under the curve (AUC) for iron deficiency (ID) and iron deficiency anemia (IDA), crude, or corrected for inflammation. Regression models assessed the relationship of baseline biomarker categories (gestational age 110g/L with IDA at delivery (RR = 0.73; 95% CI: 0.47, 1.13) was attenuated. Baseline hepcidin>1.6μg/L was associated with reduced risk of anemia at delivery by 49% (95% CI: 27%, 45%). Conclusion Ascertaining hemoglobin and hepcidin levels may improve the targeting of iron supplementation programs in resource-limited countries, though hepcidin’s high costs may limit its use.

Anemia in HIV-infected patients improves with highly active antiretroviral therapy (HAART); however, it may still be associated with mortality among patients receiving treatment. We examined the associations of anemia severity and iron deficiency anemia (IDA) at HAART initiation and during monthly prospective follow-up with mortality among 40,657 adult HIV-infected patients receiving HAART in Dar es Salaam, Tanzania. Proportional hazards models were used to examine the associations of anemia severity and IDA at HAART initiation and during follow-up with mortality. A total of 6,261 deaths were reported. Anemia severity at HAART initiation and during follow-up was associated with an increasing risk of mortality (trend tests P < 0.001). There was significantly higher mortality risk associated with IDA at HAART initiation and during follow-up versus no anemia or iron deficiency (both P < 0.001). These associations differed significantly by gender, body mass index, and iron supplement use (all interaction test P < 0.001). The magnitude of association was stronger among men. Mortality risk with severe anemia was 13 times greater versus no anemia among obese patients, whereas it was only two times greater among underweight patients. Higher mortality risk was observed among iron supplement users, irrespective of anemia severity. Anemia and IDA were significantly associated with a higher mortality risk in patients receiving HAART. Iron supplementation indicated an increased mortality risk, and its role in HIV infections should be examined in future studies. Given the low cost of assessing anemia, it can be used frequently to identify high-risk patients in resource-limited settings.

IMPORTANCE: In the past 4 years, the American Cancer Society and the US Preventive Services Task Force updated recommendations to initiate colorectal cancer (CRC) screening at 45 years of age to address the increasing incidence of CRC among adults younger than 50 years. However, empirical evidence evaluating the potential benefits of screening in younger populations is scant. OBJECTIVE: To examine the association between endoscopy initiation at different ages and risk of CRC among US women. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study used data from the Nurses’ Health Study II, which included US female health professionals followed up from 1991 through 2017. Data analysis was performed from August 2020 to June 2021. EXPOSURE: Age at initiation of sigmoidoscopy or colonoscopy for screening (routine screening or because of family history) or symptoms. MAIN OUTCOMES AND MEASURES: Incident CRC, confirmed by medical records, pathology reports, and the National Death Index. Cumulative incidence of CRC in each group was estimated with age as the time scale, and the absolute risk reduction associated with endoscopy initiation at different ages through 60 years was calculated. Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% CIs, stratified by age and calendar year of questionnaire cycle and adjusted for CRC risk factors in the multivariable models. RESULTS: Among 111 801 women aged 26 to 46 years (median, 36 years) at enrollment, 519 incident CRC cases were documented over 26 years, encompassing 2 509 358 person-years of follow-up. In the multivariable analysis, compared with no endoscopy, undergoing endoscopy was associated with a significantly lower risk of incident CRC for age at initiation before 45 years (HR, 0.37; 95% CI, 0.26-0.53), 45 to 49 years (HR, 0.43; 95% CI, 0.29-0.62), 50 to 54 years (HR, 0.47; 95% CI, 0.35-0.62), and 55 years or older (HR, 0.46; 95% CI, 0.30-0.69). The absolute reduction in the estimated cumulative incidence of CRC through 60 years of age was 72 per 100 000 persons for initiation of endoscopy at 45 to 49 years of age vs 50 to 54 years of age. Compared with no endoscopy, initiation of endoscopy before 50 years of age was also associated with a reduced risk of CRC diagnosed before 55 years of age (

Growth faltering in early childhood is prevalent in many low resource countries. Poor maternal dietary diversity during pregnancy has been linked with increased risk of fetal growth failure and adverse birth outcomes but may also influence subsequent infant growth. Our aim is to assess the role of prenatal maternal dietary diversity in infant growth in rural Uganda. Data from 3291 women and infant pairs enrolled in a birth cohort from 2014 to 2016 were analysed (NCT04233944). Maternal diets were assessed using dietary recall in the second or third trimesters of pregnancy. Maternal dietary diversity scores (DDS) were calculated using the FAO Minimum Dietary Diversity for Women (MDD‐W). Cox regression models were used to evaluate associations of the DDS with the incidence of underweight, stunting and wasting in infants from 3 to 12 months, adjusting for confounding factors. The median DDS for women was low, at 3.0 (interquartile range 3.0–4.0), relative to the threshold of consuming five or more food groups daily. Infants of women in highest quartile of DDS (diverse diets) were less likely to be underweight (adjusted hazard ratio: 0.70, 95% confidence interval: 0.61, 0.80) compared with infants of women in Quartile 1 (p for trend

Background Malaria infection during pregnancy has negative health consequences for both mothers and offspring. Sub-microscopic malaria infection during pregnancy is common in most African countries. We sought to identify factors associated with sub-microscopic placental malaria, and its association with adverse pregnancy outcomes among HIV-negative pregnant women in Dar es Salaam, Tanzania. Methods We recruited a cohort of pregnant women during their first trimester and assessed for the occurrence of placental malaria and pregnancy outcomes. The follow-up was done monthly from recruitment until delivery. Histopathology placental malaria positive results were defined as the presence of malaria pigment or parasitized erythrocytes on the slide (histology-positive (HP)), and the sub-microscopic placental infection was defined as positive Plasmodium falciparum DNA by polymerase chain reaction (DNA PCR) amplification in a negative histopathology test. Adverse pregnancy outcomes investigated included low birth weight (birth weight below 2.5 kg), prematurity (live birth below 37 weeks), and small-for-gestational-age (SGA) (live born with a birth weight below 10th percentile for gestational age and sex). Weighted baseline category logit, log-binomial, and log-Poisson models were used to assess factors associated with placental malaria, and its association with adverse pregnancy outcomes. Results Among 1115 women who had histopathology and DNA PCR performed, 93 (8%) had HP placental infection, and 136 (12%) had the sub-microscopic placental infection. The risk of sub-microscopic placental malaria was greater in women who did not use mosquito prevention methods such as bed nets, fumigation, or mosquito coils (odds ratio (OR) = 1.75; 95% confidence interval (CI): 1.05–2.92; P = 0.03) and in women who were anemic (OR = 1.59; 95% CI: 1.20–2.11; P = 0.001). Women who were underweight had reduced odds of sub-microscopic placental malaria infection (OR = 0.33; 95% CI: 0.17–0.62; P = 0.001). Women who were overweight/obese had 1.48 times higher the odds of HP placental malaria compared to normal weight (OR = 1.48; 95% CI: 1.03–2.11; P = 0.03). HP placental malaria infection was associated with an increased risk of SGA births (RR = 1.30, 95% CI: 0.98–1.72, P = 0.07). In contrast, the sub-microscopic infection was associated with a reduced risk of SGA births (RR = 0.61, 95% CI: 0.43–0.88, P = 0.01). Placental malaria was not associated with low birth weight or prematurity. Conclusion Malaria prevention methods and maternal nutrition status during early pregnancy were important predictors of sub-microscopic placental malaria. More research is needed to understand sub-microscopic placental malaria and the possible mechanisms mediating the association between placental malaria and SGA.

BackgroundIn 2015, a China-UK-Tanzania tripartite pilot project was implemented in southeastern Tanzania to explore a new model for reducing malaria burden and possibly scaling-out the approach into other malaria-endemic countries. The 1,7-malaria Reactive Community-based Testing and Response (1,7-mRCTR) which is a locally-tailored approach for reporting febrile malaria cases in endemic villages was developed to stop transmission andPlasmodiumlife-cycle. The (1,7-mRCTR) utilizes existing health facility data and locally trained community health workers to conduct community-level testing and treatment.MethodsThe pilot project was implemented from September 2015 to June 2018 in Rufiji District, southern Tanzania. The study took place in four wards, two with low incidence and two with a higher incidence. One ward of each type was selected for each of the control and intervention arms. The control wards implemented the existing Ministry of Health programmes. The 1,7-mRCTR activities implemented in the intervention arm included community testing and treatment of malaria infection. Malaria case-to-suspect ratios at health facilities (HF) were aggregated by villages, weekly to identify the village with the highest ratio. Community-based mobile test stations (cMTS) were used for conducting mass testing and treatment. Baseline (pre) and endline (post) household surveys were done in the control and intervention wards to assess the change in malaria prevalence measured by the interaction term of ‘time’ (post vs pre) and arm in a logistic model. A secondary analysis also studied the malaria incidence reported at the HFs during the intervention.ResultsOverall the 85 rounds of 1,7-mRCTR conducted in the intervention wards significantly reduced the odds of malaria infection by 66% (adjusted OR 0.34, 95% CI 0.26,0.44, p ConclusionThe 1,7-mRCTR approach significantly reduced the malaria burden in the areas of high transmission in rural southern Tanzania. This locally tailored approach could accelerate malaria control and elimination efforts. The results provide the impetus for further evaluation of the effectiveness and scaling up of this approach in other high malaria burden countries in Africa, including Tanzania.

The effect of maternal multivitamin supplementation on breast milk vitamin B12 concentrations has not been examined in Tanzania, where the prevalence of maternal plasma B12 insufficiency is 25.6%. Multivitamins (containing 50 &micro, g vitamin B12) or placebo were provided during pregnancy and in the postpartum period. Breast milk samples were collected at or around six weeks postpartum from 491 participants in a trial of multivitamins (NCT00197548). Linear and logistic regression models were used to examine the effect of supplements on vitamin B12 concentration in milk and its associations with other variables including potential confounders. Median vitamin B12 concentration in breast milk was 206 pmol/L and 70% of women had levels indicating inadequacy (&lt, 310 pmol/L). Multivitamin supplements did not significantly reduce the odds of inadequate vitamin B12 in breast milk, suggesting suboptimal absorption. A single unit increase in maternal hemoglobin at six weeks was associated with 18% lower odds of inadequate vitamin B12 in breast milk. Participants with higher BMI at baseline had double the odds of having inadequate vitamin B12 than the reference group (&lt, 22 kg/m2). Trials to determine the optimal dose, route, and duration of supplementation to improve maternal B12 status in Sub-Saharan Africa are of utmost importance.

Background: In 2015, a China-UK-Tanzania tripartite pilot project was implemented in south-eastern Tanzania to explore a new model to reduce the malaria burden with the aim of eventually scaling-up the approach in Africa. Chinese and Tanzanian teams have developed a locally-tailored malaria control approach screening for febrile cases in endemic villages on Day 1 followed by focal treatment of holoendemic villages within 7 days to stop transmission at the same phase of the plasmodium life-cycle. This 1,7-Reactive Community-based Testing and Response (1,7-mRCT) model can utilize existing health facility data and locally trained community-based health workers to conduct community-level testing and treatment. Methods: Matched malaria incidence pairs of control and intervention wards were chosen. The latter arm was selected for the 1,7-mRCT approach, while the control wards relied on long-lasting insecticide-treated bednets only. The 1,7-mRCT activities included community testing and treatment of malaria infection. Case-to-suspect ratios of malaria cases were aggregated at the village level weekly to identify the village with the highest ratio. Community-based mobile test stations (cMTS) were used for mass testing and treatment. The pilot project was implemented from September 2015 to June 2018 with 85 rounds of 1,7-mRCT implemented in the intervention wards. Comparing the two arms of approach we look for any change in malaria prevalence from the baseline to the endline survey. Besides we also studied the malaria incidence reported at the health facilities after interventions in the treated villages. Findings: Compared to the control wards, the 1,7-mRCT model significantly reduced the malaria infections by 66% (adjusted OR 0.34, 95%CI 0.26-0.44, p

BACKGROUND: Hematological status may predict HIV disease progression and mortality among adults initiating highly active antiretroviral therapy (HAART). OBJECTIVES: We aimed to examine the relation of anemia and iron status at HAART initiation with survival and morbidity outcomes. METHODS: We conducted a case-cohort study of 570 HIV-infected adults initiating HAART who were enrolled in a trial of multivitamins in Tanzania. Hemoglobin, serum ferritin, and hepcidin concentrations were assessed at HAART initiation and participants were followed up monthly. We adjusted serum ferritin for inflammation using a regression correction method to characterize hematological status. Cox proportional hazards models were used to estimate HRs for mortality and incident clinical outcomes. RESULTS: We found an 83% prevalence of anemia, 15% prevalence of iron deficiency anemia, and 66% prevalence of anemia of chronic diseases (ACD). The prevalence of elevated iron was 33% and 19% had iron deficiency (ID). After multivariate adjustment, severe anemia (HR: 2.57; 95% CI: 1.49, 4.45) and ACD (HR: 4.71; 95% CI: 2.91, 7.62) were associated with increased risk of mortality as compared with nonanemic participants. In addition, both ID (HR: 2.65; 95% CI: 1.08, 7.78) and elevated iron (HR: 2.83; 95% CI: 2.10, 3.82) were associated with increased risk of mortality as compared with normal iron concentrations. Severe anemia and elevated iron concentrations were associated with incident wasting and >10% weight loss (P values

We examined the associations of plasma vitamin D concentration and adverse pregnancy outcomes among HIV-negative women in Dar-es-Salaam, Tanzania. We used an unmatched case-control study design, with 25-hydroxyvitamin D [25(OH)D] concentration assessed in the first trimester. Cases were individuals with adverse pregnancy outcomes, including stillbirth, premature birth, or small for gestational age births (SGA). Unconditional logistic regression and weighted logistic regression models were used to describe the associations of 25(OH)D concentration with the composite of adverse pregnancy outcome and individual adverse pregnancy outcomes, respectively. We included 310 cases and 321 controls. In controls, 5(2%) were vitamin D deficient (25(OH)D &lt, 20 ng/mL), and 17(5%) had insufficient 25(OH)D concentration (20.0&ndash, 29.9 ng/mL). Women with 25(OH)D &lt, 20 ng/mL had 1.82 times the odds of occurrence of the composite adverse pregnancy outcome (OR = 1.82, 95% CI: 0.56&ndash, 5.93, p = 0.32), however we noted a non-linear association between 25(OH)D concentration and adverse pregnancy outcome (p = 0.02). We found a 3-fold increased odds of stillbirth in women with low 25(OH)D concentration (OR = 3.11, 95% CI: 1.18&ndash, 8.23, p = 0.02). Vitamin D concentration in early pregnancy may be an important factor in determining the course of pregnancy. Further research is needed to investigate whether the association of maternal 25(OH)D concentration in early pregnancy and stillbirth is causal.

Background Intermittent preventive treatment during pregnancy (IPTp) is a highly-recommended intervention to prevent maternal and neonatal complications associated with malaria infection. Despite fairly high antenatal care (ANC) coverage in Tanzania, low IPTp uptake rates represent a gap in efforts to decrease complications attributed to malaria in pregnancy. The objective of this study was to examine if availability, readiness and managing authority are associated with uptake of IPTp during ANC. Methods Data for this analysis come from a cross-sectional survey, the Tanzania Service Provision Assessment conducted between 2014 and 2015. Principal component analysis was used to create scores for availability of malaria services and readiness for the provision of services. Generalized estimating equation models with logit link and the binomial distribution assessed factors that impact the uptake of IPTp by pregnant women attending ANC. Results Higher fraction of women in their third trimester than second (68% versus 49%, OR = 2.6; 95% CI (2.1–3.3)), had received at least one dose of IPTp. There was a wide variation in the availability and readiness of malaria services provision and diagnostic tools by managing authorities. Public facilities were more likely than private to offer malaria rapid diagnostic test, and more providers at public facilities than private diagnosed and/or treated malaria. Women who attended facilities where direct observation therapy was practiced were more likely to have received at least one dose of IPTp (64% versus 46% who received none; p

OBJECTIVE The objective of this study was to assess the effectiveness of a routine multivitamin supplementation program for adults living with HIV in Tanzania. DESIGN We conducted a retrospective cohort study of 67 707 adults enrolled in the Dar es Salaam HIV care and treatment program during 2004-2012. METHODS The Dar es Salaam HIV care and treatment program intended to provide all adult patients with multivitamin supplements (vitamins B-complex, C, and E) free of charge; however, intermittent stockouts and other implementation issues did not afford universal coverage. We use Cox proportional hazard models to assess the time-varying association of multivitamin supplementation with mortality and clinical outcomes. RESULTS The study cohort contributed 41 540 and 129 315 person-years of follow-up time to the antiretroviral therapy (ART)-naive and ART-experienced analyses, respectively. Among 48 207 ART-naive adults, provision of multivitamins reduced the risk of mortality [adjusted hazard ratio (aHR): 0.69; 95% confidence interval (CI): 0.59-0.81], incident tuberculosis (TB) (aHR: 0.83; 0.76-0.91), and meeting ART eligibility criteria (aHR: 0.78; 95% CI: 0.73-0.83) after adjustment for time-varying confounding. Among 46 977 ART-experienced patients, multivitamins reduced mortality (hazard ratio: 0.86; 95% CI: 0.80-0.92), incident TB (aHR: 0.78; 95% CI: 0.73-0.84), and immunologic failure (aHR: 0.70; 95% CI: 0.67-0.73). The survival benefits associated with provision multivitamins appeared to be greatest during the first year of ART and declined over time (P value

Background: Overweight and obesity are increasingly prevalent among HIV-infected populations. We describe their prevalence and associated risk factors among HIV-infected adults in Dar es Salaam, Tanzania. Methods: A cross-sectional study was conducted to determine the proportion of patients who were overweight or obese at enrollment to care and treatment centres from 2004 to 2011. Multivariate relative risk regression models were fit to identify risk factors. Results: A total of 53 825 patients were included in the analysis. In all, 16% of women and 8% of men were overweight, while 7% and 2% were obese, respectively. In multivariate analyses, older age, higher CD4 count, higher hemoglobin levels, female sex, and being married were associated with obesity and overweight. World Health Organization HIV disease stage, tuberculosis history, and previous antiretroviral therapy were inversely associated with obesity and overweight. Conclusion: Overweight and obesity were highly prevalent among HIV-infected patients. Screening for overweight and obesity and focused interventions should be integrated into HIV care.

OBJECTIVES: Preterm birth, small for gestational age (SGA) and low birth weight (LBW) are risk factors for morbidity and mortality among infants. High-quality maternal diets during pregnancy may protect against these adverse birth outcomes. The objective of this research is to prospectively examine the association of maternal dietary diversity and quality during pregnancy with birth outcomes among women in Dar es Salaam, Tanzania. METHODS: We analyzed data from 7553 HIV-negative pregnant women enrolled in a multivitamin trial at 12–27 weeks gestation. Dietary intake was assessed using 24-hour dietary recalls. Log binomial regression methods were used to assess associations of Minimum Dietary Diversity for Women (MDD-W) and Prime Diet Quality Score (PDQS) with preterm, SGA, LBW, fetal loss, very preterm, severe SGA and very low birth weight (VLBW). RESULTS: In the previous 24 hours, 99.9% of women reported consuming grains, roots and tubers, 57.9% meats, 4.7% eggs and 0.5% nuts and seeds. Median MDD-W score was 3.0 ± 1.0. For the PDQS, women consumed at least 4 servings/week of green leafy vegetables (100%) and other vegetables (64.7%) and consumption of refined grains was high (99.6%). Higher MDD-W scores were associated with lower risk of SGA (RR highest vs. lowest quintile 0.74, 95% CI: 0.62, 0.89). Higher PDQS scores were associated with lower risk of preterm birth (RR: 0.55, 95% CI: 0.46, 0.67); LBW (RR: 0.53, 95% CI: 0.40, 0.71); fetal loss (RR: 0.53, 95% CI: 0.34,0.82), very preterm (RR: 0.33, 95% CI: 0.17, 0.64) and VLBW (RR: 0.49, 95% CI: 0.26, 0.92) comparing women in highest vs. lowest quintiles. CONCLUSIONS: PDQS was inversely associated with preterm, very preterm, LBW, VLBW and fetal loss, and MDD-W was inversely associated with SGA. These findings suggest that in addition to diet diversity, diet quality should be considered as important in understanding dietary risk factors for poor birth outcomes. FUNDING SOURCES: This work has been supported by the National Institutes of Child Health and Human Development. Co-authors were supported by a grant from the National Institute of Child Health and Human Development and the National Institutes of Health.

Objective To examine how a healthy lifestyle is related to life expectancy that is free from major chronic diseases. Design Prospective cohort study. Setting and participants The Nurses’ Health Study (1980-2014; n=73 196) and the Health Professionals Follow-Up Study (1986-2014; n=38 366). Main exposures Five low risk lifestyle factors: never smoking, body mass index 18.5-24.9, moderate to vigorous physical activity (≥30 minutes/day), moderate alcohol intake (women: 5-15 g/day; men 5-30 g/day), and a higher diet quality score (upper 40%). Main outcome Life expectancy free of diabetes, cardiovascular diseases, and cancer. Results The life expectancy free of diabetes, cardiovascular diseases, and cancer at age 50 was 23.7 years (95% confidence interval 22.6 to 24.7) for women who adopted no low risk lifestyle factors, in contrast to 34.4 years (33.1 to 35.5) for women who adopted four or five low risk factors. At age 50, the life expectancy free of any of these chronic diseases was 23.5 (22.3 to 24.7) years among men who adopted no low risk lifestyle factors and 31.1 (29.5 to 32.5) years in men who adopted four or five low risk lifestyle factors. For current male smokers who smoked heavily (≥15 cigarettes/day) or obese men and women (body mass index ≥30), their disease-free life expectancies accounted for the lowest proportion (≤75%) of total life expectancy at age 50. Conclusion Adherence to a healthy lifestyle at mid-life is associated with a longer life expectancy free of major chronic diseases.

Objective:To describe the incidence of and risk factors for overweight and obesity following antiretroviral therapy (ART) initiation.Methods:We used Cox proportional hazards models to investigate risk factors for incident overweight and obesity in 79 074 individuals aged 15 years or older who initiated ART in Dar es Salaam, Tanzania.Results:Twenty-five percent of the patients became overweight and 10% became obese. The incidence rate of obesity was 3.2 per 100 person-years (95% confidence interval [CI]: 3.1-3.3) in patients who were of normal weight before starting ART and 22.6 per 100 person-years (95% CI: 21.9-23.3) in those who were overweight. Lower CD4 count was associated with a higher risk of overweight and obesity ( P value for trend < .0001).Conclusion:There is a high burden of overweight and obesity after starting ART, leading to proportions of these 2 conditions that are similar to those in the general population.

We examined the incidence of herpes zoster (HZ) before and after the initiation of antiretroviral therapy (ART), and risk factors for HZ among human immunodeficiency virus (HIV)-infected individuals in Tanzania. A cohort study was conducted among HIV-positive individuals enrolled in HIV care and treatment clinics in Dar es Salaam, Tanzania. A Cox proportional hazard model was used to examine the effect of ART on the risk of HZ after adjusting for sociodemographics and time-varying clinical and nutritional factors. Among 72,670 HIV-positive individuals, 2,312 incident cases of HZ (3.2%) occurred during the median follow-up of 15 months (interquartile range: 3–35). The incidence rate of HZ significantly declined from 48.9 (95% confidence interval [CI] = 46.7–51.0) per 1,000 person-years before ART to 3.7 (95% CI = 3.3–4.1) per 1,000 person-years after the initiation of ART (P < 0.001). The risk of HZ declined with longer duration on ART. Low CD4 cell count, older age, female sex, district of Dar es Salaam, and year of enrollment were independently associated with the risk of HZ in the multivariate analysis. Low body mass index and anemia were not associated with the risk of HZ. The risk of HZ substantially declined after ART initiation in this large cohort of HIV-infected individuals. Earlier initiation of ART could reduce the risk of HZ and other opportunistic infections among HIV-infected individuals in sub-Saharan Africa.

Although the beneficial effects of antiretroviral (ARV) therapy for preventing mother-to-child transmission are indisputable, studies in developed and developing countries have reported conflicting findings on the association between ARV exposure and adverse birth outcomes. We conducted a prospective observational study at 10 human immunodeficiency virus (HIV) care and treatment centers in Dar es Salaam, Tanzania. Multivariate log-binomial regression was used to investigate the associations between ARV use and adverse birth outcomes among HIV-negative HIV-exposed infants. Our findings demonstrate an increased risk of adverse birth outcomes associated with the use of highly active antiretroviral therapy during pregnancy. Further studies are needed to investigate the underlying mechanisms and identify the safest ARV regimens for use during pregnancy.

Objective The objective of this study is to determine the incidence rate and risk factors of tuberculosis (TB) among HIV-infected adults accessing antiretroviral therapy (ART) in Tanzania. Design A prospective observational study among HIV-infected adults attending HIV clinics in Dar es Salaam. Methods We estimated TB incidence rates among HIV-infected patients prior to and after ART initiation. We used Cox proportional hazard regressions to determine the predictors of incident TB among HIV-infected adults enrolled in the HIV care and treatment programme. Results We assessed 67 686 patients for a median follow-up period of 24 (interquartile range: 8-49) months; 7602 patients were diagnosed with active TB. The TB incidence rate was 7.9 [95% confidence interval (95% CI), 7.6-8.2] per 100 person-years prior to ART initiation, and 4.4 (95% CI, 4.2-4.4) per 100 person-years for patients receiving ART. In multivariate analyses, patients on ART in the first 3 months had a 57% higher risk of TB (hazard ratio: 1.57, 95% CI, 1.47-1.68) than those not on ART, but the risk significantly decreased with increasing duration of ART. Risk factors for incident TB included being male, having low BMI or middle upper arm circumference, lower CD4 cell count and advanced WHO disease stage. There was seasonal variation for incident TB, with higher risk observed following the rainy seasons (May, June and November). Conclusion In TB endemic regions, HIV-infected patients initiating ART, particularly men and those with poor nutritional status, should be closely monitored for active TB at ART initiation. In addition to increasing the access to ART, interventions should be considered to improve nutritional status among HIV-infected patients.

BACKGROUND/OBJECTIVES To identify factors associated with plasma polyunsaturated fatty acid (PUFA) levels among 3-month-old Tanzanian infants. SUBJECTS/METHODS Infants (n = 238) and mothers (n = 193) randomly selected from participants in the neonatal vitamin A supplementation randomized controlled trial. A cross-sectional study of maternal-infant pairs at 3 months postpartum. RESULTS All infant total, n-3, n-6, and individual PUFA levels were correlated with maternal levels. Infant plasma n-3 PUFA levels were higher when maternal n-3 PUFA levels were higher (mean difference in infant % fatty acid per unit increase in maternal levels ± standard error: 0.79 ± 0.08; P

Objective To examine the association between complementary feeding and risks of diarrhea and acute respiratory infection (ARI) among HIV-exposed infants aged 6-24 months. Design We prospectively used an Infant and Child Feeding Index (ICFI) to measure complementary feeding practices (breastfeeding status, food consistency, dietary diversity, food group frequency, and meal frequency). We determined the association of ICFI and each of its components with the risk of diarrhea and ARI. Generalized estimating equations were used to estimate the relative risks for morbidity episodes. Setting Dar es Salaam, Tanzania. Subjects A total of 2092 HIV-exposed infants followed from 6 months of age to 24 months of age. Results The ICFI score ranged from 0 to 9; the median score was 6 (interquartile range = 4-7). Low ICFI scores were likely associated with increased risk of dysentery [low vs. high tertile risk ratio (RR): 1.40; 95% confidence interval (CI): 0.93 to 2.10; P for trend = 0.02] and respiratory infection (low vs. high tertile RR: 1.16; 95% CI: 0.96 to 1.41; P for trend = 0.01). Low dietary diversity scores were likely associated with higher risk of dysentery (low vs. high tertile RR: 1.47; 95% CI: 0.92 to 2.35; P for trend = 0.03) and respiratory infection (low vs. high tertile RR: 1.41; 95% CI: 1.13 to 1.76; P for trend = 0.01). Low food consistency scores were associated with higher risk of respiratory infection (RR: 1.77; 95% CI: 1.40 to 2.26; P Conclusions In this setting, low ICFI, dietary diversity, and food consistency scores were likely associated with increased risk of diarrhea and ARI among HIV-exposed infants.

Childhood undernutrition is a major public health problem in sub-Saharan Africa. Undernutrition, including stunting, wasting and underweight, has been identified as underlying cause of 35% of all deaths among young children (Black et al., 2008). Children suffering from undernutrition also experience the worst neurodevelopmental outcomes (Gutbrod et al., 2000). Tanzania is among the top ten countries with highest burden of childhood malnutrition, with a prevalence of 42% stunting, 17% underweight and 4% wasting among the under-five children (Unicef, 2009). Many studies have pointed out that malnutrition during childhood is actually a continuation of the malnutrition present at birth (Christian, 2009, Mukhopadhyay et al., 2012, Arifeen et al., 2000). Studies showed that, despite catch up growth, a large proportion of low birth weight (LBW) infants fail to attain the expected weight and height during infancy (Christian, 2009, Casey et al., 1990, Binkin et al., 1988). Compared to infants born with normal weight, LBW infants are also more prone to postnatal growth faltering (weight or height

OBJECTIVES: We prospectively investigated fever symptoms and maternal diagnosis of malaria in pregnancy (MIP) in relation to child HIV infection among 2368 pregnant HIV-positive women and their infants followed up from pregnancy until 6 weeks post-delivery in Tanzania. METHODS: Doctors clinically diagnosed and treated MIP and fever symptoms during prenatal health care. Child HIV status was determined via DNA polymerase chain reaction (PCR). Multivariable logistic regression models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for HIV mother-to-child transmission (MTCT) by the 6th week of life. RESULTS: Mean gestational age at enrolment was 22.2 weeks. During follow-up 16.6% of mothers had at least one MIP diagnosis 15.9% reported fever symptoms and 8.7% had both fever and MIP diagnosis. Eleven per cent of HIV-exposed infants were HIV-positive by 6 weeks. The RR of HIV MTCT was statistically similar for infants whose mothers were ever vs. never clinically diagnosed with MIP (RR 1.24; 95% CI 0.94-1.64) were diagnosed with one vs. no clinical MIP episodes (RR 1.07; 95% CI 0.77-1.48) and had ever vs. never reported fever symptoms (RR 1.04; 95% CI 0.78-1.38) in pregnancy. However the HIV MTCT risk increased by 29% (95% CI 4-58%) per MIP episode. Infants of women with at least two vs. no MIP diagnoses were 2.1 times more likely to be HIV infected by 6 weeks old (95% CI 1.31-3.45). CONCLUSIONS: Clinical MIP diagnosis but not fevers in HIV-positive pregnant women was associated with an elevated risk of early HIV MTCT suggesting that malaria prevention and treatment in pregnant HIV-positive women may enhance the effectiveness of HIV prevention in MTCT programmes in this setting. Future studies using a laboratory-confirmed diagnosis of malaria are needed to confirm this association. (c) 2013 British HIV Association.

We prospectively determined the association between undernutrition and incidence of acute respiratory infections (ARIs) among 711 children born to HIV-infected women. Overall, underweight was associated with a 58% increased risk of ARI. Similarly, wasting (54%), very low birth weight (88%) and child HIV infection (62%) were significantly associated with increased risk of ARI during the first 2 years. Breastfeeding was associated with 52% reduction in risk of ARI only during the first 12 months of life. Among HIV-exposed, but uninfected, children, underweight, wasting and stunting were associated with 73%, 61% and 33% increased risk of ARI, respectively. Very low birthweight and advanced maternal disease stage were also associated with increased risk of ARI. Similar results were observed among HIV-infected children, except for stunting and very low birth weight. Prevention of child undernutrition could have major impact in reducing child ARI morbidity in settings of high HIV prevalence.

Routinely collected dietary intakes were available for 925 HIV-infected pregnant women participating in a longitudinal clinical trial of vitamin supplementation in Dar es Salaam, Tanzania. Information on sociodemographic and economic characteristics was recorded. Dietary macronutrient intakes were computed and analyzed using the Tanzania Food Composition Tables. Women's age, parity, education level, and economic independence were positively related to diet intake. Women younger than 25 years were at highest risk of inadequate food and nutrient intake. By World Health Organization recommendations, almost two-thirds of the participants were energy deficient, and nearly half were protein deficient.

ObjectivePrematurity, stillbirth and other adverse birth outcomes remain major concerns in resource-limited settings. Poor dietary intake of micronutrients during pregnancy has been associated with increased risk of adverse outcomes. We determined the relationships between dietary Fe and Ca intakes during pregnancy and risks of adverse birth outcomes among HIV-negative women.DesignWomen’s diet was assessed through repeated 24 h diet recalls in pregnancy. Mean intakes of total Fe, Fe from animal sources and Ca during pregnancy were examined in relation to adverse birth outcomes and neonatal mortality. Women were prescribed daily Fe supplements as per standard perinatal care.SettingDar es Salaam, Tanzania.SubjectsA cohort of 7634 pregnant women.ResultsMedian (interquartile range) daily dietary intake of total Fe, animal Fe and Ca was 11·9 (9·3–14·7), 0·5 (0–1·1) and 383·9 (187·4–741·2) mg, respectively. Total Fe intake was significantly associated with reduced risk of stillbirth (trend over quartiles, P=0·010). Animal Fe intake was significantly associated with reduced risk of preterm birth and extreme preterm birth. Animal Fe intake was inversely related to neonatal mortality risk; compared with women in the lowest intake quartile, those in the top quartile were 0·51 times as likely to have neonatal death (95 % CI 0·33, 0·77). Higher Ca intake was associated with reduced risk of preterm birth (relative risk; 95 % CI: 0·76; 0·65, 0·88) and extreme preterm birth (0·63; 0·47, 0·86). Women in the highest Ca intake quartile had reduced risk of neonatal mortality (0·59; 0·37, 0·92).ConclusionsDaily dietary Fe and Ca intakes among pregnant women are very low. Improvement of women’s diet quality during gestation is likely to improve the risks of adverse birth outcomes.

Objectives In a large cohort of HIV-infected Tanzanians, we assessed: (i) rates of first-line treatment failure and switches to second-line ART; (ii) the effect of switching to second-line ART on death and loss to follow-up; and (iii) treatment outcomes on second-line ART by regimen. Methods HIV-1-infected adults (≥15 years) initiated on first-line ART between November 2004 and September 2012, and who remained on initial therapy for at least 24 weeks before switching, were studied. Survival analyses were conducted to examine the effect of second-line ART on mortality and loss to follow-up in: (i) the whole cohort; (ii) all patients eligible for second-line ART by immunological failure (IF) and/or virological failure (VF) criteria; and (iii) patients eligible by VF criteria. Results In total, 47 296 HIV-infected patients [mean age 37.5 (SD 9.5) years, CD4 175 (SD 158) cells/mm 3 , 71% female] were included in the analyses. Of these, 1760 (3.7%) patients switched to second-line ART (incidence rate = 1.7/100 person-years). Higher rates of mortality were observed in switchers versus non-switchers in all patients and patients with ART failure using IF/VF criteria. Switching only protected against mortality in patients with ART failure defined virologically and with the highest level of adherence [switching versus non-switching; >95% adherence; adjusted HR = 0.50 (95% CI = 0.26-0.93); P = 0.03]. Conclusions Switching patients to second-line ART may only be beneficial in a select group of patients who are virologically monitored and demonstrate good adherence. Our data emphasize the need for routine viral load monitoring and aggressive adherence interventions in HIV programmes in sub-Saharan Africa.

Objective. To determine whether human immunodeficiency virus (HIV) infection is associated with increased risk of malaria incidence and recurrence in children. Methods. Newborn infants of HIV-infected mothers were enrolled at 6 weeks and followed for 2 years. HIV status was assessed by enzyme-linked immunosorbant assay and confirmed by HIV DNA polymerase chain reaction. Malaria was defined as (1) physician-diagnosed clinical malaria; (2) probable malaria, in which laboratory testing is requested for parasitemia; and (3) blood smear–confirmed malaria. Cox proportional hazards models estimated hazard ratios (HRs) for development of first and second malaria episodes, and generalized estimating equation models estimated malaria rate differences per 100-child-years in relation to time-updated HIV status. Results. Child HIV infection was associated with clinical (HR, 1.34; 95% confidence interval [CI], 1.12–1.61), probable (HR, 1.47; 95% CI, 1.19–1.81), and confirmed (HR, 1.67; 95% CI, 1.18–2.36) malaria episodes. Per 100 child-years, HIV-infected children experienced 88 (95% CI, 65–113), 36 (95% CI, 19–53), and 20 (95% CI, 9–31) more episodes of clinical, probable, and confirmed malaria episodes, respectively, than HIV-uninfected children. Among children with ≥1 malaria episodes, those with HIV infection developed second clinical (HR, 1.28; 95% CI, 1.04–1.57), probable (HR, 1.60; 95% CI, 1.26–2.14), and confirmed (HR, 2.27; 95% CI, 1.06–3.89) malaria sooner than HIV-uninfected children. Conclusions. HIV infection is a risk factor for the development of malaria. Proactive malaria disease prevention and treatment is warranted for all children, particularly those with HIV infection in settings of coendemicity.

Objective: To determine the relationship between sex and antiretroviral therapy (ART) outcomes in an urban Tanzanian setting. Design: Longitudinal analysis of a cohort of HIV-infected adult men and women on ART enrolled at the Management and Development for Health (MDH)-President's Emergency Plan For AIDS Relief (PEPFAR) HIV care and treatment program in Dar es Salaam, Tanzania. Methods: Clinical and immunologic responses to ART were compared between HIV-infected men and women enrolled from November 2004 to June 2008. Cox regression analyses were used to study sex differences with regard to mortality, immunologic failure (WHO, 2006) and loss to follow-up, after adjusting for other risk factors for the outcomes. Results: Four thousand, three hundred and eighty-three (34%) men and 8459 (66%) women were analyzed. Men were significantly more immunocompromised than women at enrollment in terms of stage IV disease (27 vs. 23%, P < 0.001) and mean CD4 + cell count (123 vs. 136 cells/μl, P< 0.001). In multivariate analyses, men had a significantly higher risk of overall mortality [hazard ratio 1.19, 95% confidence interval (CI) 1.05-1.30, P < 0.001], immunologic nonresponse defined as CD4 cell count less than 100 cells/μl after at least 6 months of initiating ART (hazard ratio 1.74, 95% CI 1.44-2.11, P

There is limited published research examining lipid-soluble vitamins in human immunodeficiency virus (HIV)-infected pregnant women, particularly in resource-limited settings. This is an observational analysis of 1078 HIV-infected pregnant women enrolled in a trial of vitamin supplementation in Tanzania. Baseline data on sociodemographic and anthropometric characteristics, clinical signs and symptoms, and laboratory parameters were used to identify correlates of low plasma vitamin A (81 mm/h; P

Purpose Animal and in vitro studies suggest that aspirin may inhibit breast cancer metastasis. We studied whether aspirin use among women with breast cancer decreased their risk of death from breast cancer. Methods This was a prospective observational study based on responses from 4,164 female registered nurses in the Nurses' Health Study who were diagnosed with stages I, II, or III breast cancer between 1976 and 2002 and were observed until death or June 2006, whichever came first. The main outcome was breast cancer mortality risk according to number of days per week of aspirin use (0, 1, 2 to 5, or 6 to 7 days) first assessed at least 12 months after diagnosis and updated. Results There were 341 breast cancer deaths. Aspirin use was associated with a decreased risk of breast cancer death. The adjusted relative risks (RRs) for 1, 2 to 5, and 6 to 7 days of aspirin use per week compared with no use were 1.07 (95% CI, 0.70 to 1.63), 0.29 (95% CI, 0.16 to 0.52), and 0.36 (95% CI, 0.24 to 0.54), respectively (test for linear trend, P < .001). This association did not differ appreciably by stage, menopausal status, body mass index, or estrogen receptor status. Results were similar for distant recurrence. The adjusted RRs were 0.91 (95% CI, 0.62 to 1.33), 0.40 (95% CI, 0.24 to 0.65), and 0.57 (95% CI, 0.39 to 0.82; test for trend, P = .03) for 1, 2 to 5, and 6 to 7 days of aspirin use, respectively. Conclusion Among women living at least 1 year after a breast cancer diagnosis, aspirin use was associated with a decreased risk of distant recurrence and breast cancer death.