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HIV & AIDS in Tanzania
The current situation
Around 1.6 million people are living with HIV in Tanzania - six percent of the population.1 Although this number has recently fallen slightly, the epidemic’s severity differs widely from region to region, with some regions reporting an HIV prevalence of less than 2 percent (Arusha) and others as high as 16 percent (Iringa).2 An estimated 150,000 Tanzanians were newly infected with HIV in 2011, which is over 400 new infections every day.3 In the same year, 83,528 Tanzanians died from AIDS.
The HIV epidemic on Tanzania mainland is described as generalised, meaning it affects all sectors of the population. Heterosexual sex accounts for the majority of infections (80 percent) on Tanzania mainland. On the semi autonomous island of Zanzibar the HIV prevalence is far lower among the general population (0.6 percent) and the epidemic is more concentrated, primarily affecting female sex workers, men who have sex with men and injecting drug users (IDUs).4
A study published in 2005, using evidence drawn from Kenya and Tanzania, exposed findings which challenged some widely held assumptions about the effects of HIV and AIDS. The study found that generally the highest prevalence of HIV was found amongst the wealthiest households, particularly affecting wealthy women, as opposed to poorer and rural households.5 Since the study, academics have suggested various reasons for this phenomenon: wealthier people tend to have the resources which lead to greater and more frequent mobility and expose them to wider sexual networks, encouraging multiple and concurrent relationships. They also tend to have greater access to HIV medications that prolong their lives and are more likely to live in urban areas, which have the highest prevalence.6
However, the HIV prevalence gap between wealthier urban groups and poorer rural communities is slowly closing.7 A 2008 study found that knowledge of sexually transmitted infections was ‘alarmingly low’ in rural Tanzania and associated with low condom use and HIV infection.8 Reduced prevalence has mainly been noted among the most educated (those who attended secondary school) while among those with no formal education, prevalence has not decreased and the number of new infections has risen.9 Because access to health care and knowledge of HIV and AIDS is typically lower in rural areas, prevention efforts must be increased if new infections are going to be reduced. However, the Tanzanian Parliamentary AIDS Coalition has been acknowledged as exemplary, as an example of the role that politicians can play in creating legislature to combat HIV and AIDS.10
Affected groups in Tanzania
Women in Tanzania are particularly affected by HIV and AIDS. In 2011, women comprised nearly 60 percent of people living with HIV. Among the 15-24 age group, prevalence is 2 percent among young women and 4 percent among young men.11 Women tend to become infected earlier, which is partly due to the tendency of women to have older partners or get married earlier.12 Another reason for the higher prevalence is the difficulty women experience negotiating safer sex because of gender inequality.13 One example of women’s dependency is the widespread culture of ‘sugar daddies’: women will often accept the sexual advances of older men, or ‘sugar daddies’ for a variety of reasons including money, affection and social advancement.
“I have a child and when I go with a man like him, he can give me something to buy milk for the child.”14 Aisha, a young woman at a party in the Mkinga district
The OneLove Campaign is a regional campaign aiming to target such practices in nine countries in Southern Africa including Tanzania, Lesotho, Malawi, Swaziland, and South Africa. From 2008 to 2011, the campaign aims to highlight the HIV risk associated with having multiple and concurrent partners, through mass media (television and radio announcements), a televised drama series, films, poster campaigns and community outreach.
There are 230,000 children living with HIV and 1.3 million children orphaned by AIDS in Tanzania.15 Grandmothers and other relatives often provide invaluable support to orphans, but they are still more vulnerable to poverty, sexual abuse and poor nutrition than children who live with both their parents.16 They also receive little support from the Tanzanian government: less than 1 in ten receive some type of support (usually school related assistance) while less than 5 percent receive medical or social support.17
Mobile and displaced populations
Population movement is common in Tanzania, especially among young men. In particular, the expansion of the mining sector has led to greater urbanisation and mobility between rural and urban areas. This means that young and sexually active men come into close contact with ‘high risk sexual networks’ made up of sex workers, women at truckstops and miners: all of whom have high levels of HIV prevalence.18 However, it is not only mobile men who are at increased risk of HIV infection. Women who travel away from home five or more times in a year have been found to be twice more likely to be infected by HIV than women who do not travel.19
Tanzania’s coastal trade as well as its border with eight countries exposes a host of vulnerable populations to HIV. A field assessment conducted by the International Organisation of Migration in 201020 concluded that transport workers, border personnel, fishermen and seafarers were more likely to have multiple sexual partners and less likely to use condoms than the general population.21 Access to treatment and prevention initiatives in these areas was also minimal, underlining the regional variation in access to HIV services.22 In Tanzania’s border and lake areas, 1 in 5 people are HIV positive.23
Injecting drug users
It is thought that there are around 25,000 injecting drug users (IDUs) in Tanzania, half of whom may be infected with HIV.24 Female drug users in particular are at great risk of becoming infected with HIV (the HIV prevalence among women IDUs is thought to be twice that of men), although the reasons for this are not fully known.25 26 27 One particularly dangerous practice which has become a concern is that of ‘flash-blood’ where a user injects heroin or another drug and then draws a syringe full of blood that is passed to a second user to inject.28 HIV prevention and treatment for injecting drug users in Tanzania has not traditionally been a focus of government or donor attention. However, in 2011, with assistance from PEPFAR, Tanzania became the first country in sub-Saharan Africa to implement a harm reduction programme for IDUs.29
“"Flashblood is a syringe-full of blood drawn back immediately after initial injection that is passed to a companion to inject" ”
Zanzibar’s AIDS Commission identifies injecting drug users as a high-risk group, and has made efforts to identify and address the prevalence of HIV among the population.30 31 As an island and gateway to and from the African mainland, Zanzibar is situated along a major corridor for drug trafficking. Around one in six IDUs in Zanzibar is infected with HIV according to official estimates,32 but some believe the HIV prevalence is even higher.33 In Zanzibar, HIV transmission occurs mainly among IDUs, female sex workers and men who have sex with men; groups which often come into contact with one another. For example, 1 in 4 men who have sex with men in Zanzibar is also an injecting drug user.34 The tendency to have multiple partners, share needles, engage in 'flash-blood' practices, and have unprotected sex place drug users in Zanzibar at high risk of HIV infection.
HIV prevention in Tanzania
Voluntary counselling and testing services (VCT) were first initiated in 1989 in Tanzania but coverage was very low and by 2001 there were still only 92 public VCT services (reportedly reaching 4 percent of the population) covering the entire country.35
Since 2003, the number of VCT sites in the country has rapidly increased. VCT services are now available at 2134 sites across the country and according to the 2007-2009 Malaria and AIDS Indicator Survey, more than 80 percent of people know where to get an HIV test.36 37
A high profile campaign was launched by the Tanzanian government in 2007 with the aim of testing 4 million Tanzanians within six months.38 This $56 million national testing drive was publicly endorsed by the president Kikwete and many other members of Parliament, who were the first to take the test.39 By the end of the six months, more than 3 million Tanzanians were tested through the campaign.40
The number of people who have been tested in the last twelve months and know their results rose from an average of 1 in 20 in 2003/2004 to around 1 in 3 in 2011.41 42 The number of facilities that provide HIV testing and counselling increased slightly between 2009 and 2010 to around 2,193 facilities, which equates to nearly 11 facilities per 100,000 of the adult population.43
Community based VCT (CBVCT) involves mobile VCT services and community-based support services.44 CBVCT delivers HIV testing to individuals that are unable or unwilling to access standard clinic based VCT (SVCT), which is often some distance from communities. According to a recent study, access to CBVCT can lead to an increase in the uptake of testing among individuals that have never tested before, suggesting CBVCT should be used in areas where HIV uptake is low.45 The study found that in communities with both CBVCT and SVCT, 39 percent of those who tested were first time testers, compared with 9 percent in communities that could only access SVCT.
In 1999, less than a quarter of women and just a third of men used condoms outside marriage.46 This had risen to around 42 percent for both sexes in 2008.47 However, contraception is still a very controversial topic in this religious country, populated mainly by Christians and Muslims.
Such tension is evident from the long drawn-out disturbance experienced by the Anglican Church in the large region of Arusha where a bishop, Simon Makundi, advocated condom use to prevent HIV and AIDS while his church goers vehemently protested against such a stance. The church endured closures and patrol by armed guards during the six years of upheaval caused by the row. In the end, the case was brought to the high court by the bishop against the churchgoers before the bishop decided to withdraw the case.48
Despite these tensions, the Tanzanian government officially recognises the role of condom use in the prevention of HIV/AIDS and has made it an integral part of its fight against the epidemic. In 2007, more than 120 million condoms were distributed in Tanzania, which was double the number distributed in 2005.49 In 2009, around 140 million condoms were made available.50 In the same year, the government, in partnership with Population Services International, unveiled a six-year pilot programme to install a hundred condom vending machines in Tanzania, in particular in bars and nightclubs.51 Condoms are reportedly stocked in 94 percent of bars and 80 percent of retail outlets.52 Nevertheless, condom use during higher risk sex is still very low – in 2011, only 35 percent of men and women who had more than one sexual partner in the past year reported using a condom the last time they had sex.53
Prevention of mother-to-child transmission of HIV (PMTCT)
Nearly a fifth of all HIV new infections in Tanzania are due to mother-to-child transmission, meaning that thousands of babies are infected through their mothers every year. To avoid mother-to-child transmission, antiretroviral treatment for both mother and baby as well as safer feeding practices must be integrated into routine reproductive health services.
Tanzania’s PMTCT programme was first piloted in 2000 with the aim of rolling out PMTCT to all reproductive and child health services. Overall, 74 percent of all HIV positive pregnant women in need of ARV therapy to reduce the risk of HIV transmission to their child received it in 2011.54 According to Tanzania’s National Paediatric HIV scale up plan (2009-2013), the aim was for the country to reach 80 percent by 2012.55 56
Like most other sub-Saharan African countries, Tanzania has a very young population. A third of the country’s population are aged 10 to 24,57 when most become sexually active.58 An estimated seven percent of 15-24 year olds are infected with HIV but risky sexual behaviour among 15-19 year olds has been decreasing in recent years. This is most evident when one considers the proportion of this population reporting multiple partners –the number of 15-19 year olds reporting two or more partners decreased by half from 2004-2008.59 Yet, condom use is still far too low among this age group. Less than a third of young people report using a condom when they first had sex, confirming the need for comprehensive sex education within this age group.60
Sex education is a vital part of reaching young people and ensuring that HIV incidence does not increase in the coming years. However, sex education is not widespread in Tanzanian schools and pregnancy is the lead cause of girls dropping out of school; 25 percent of women under 18 in Tanzania are already mothers.61
Without consistent and clear messages on HIV prevention at primary school, students often miss out on the vital information that can stop them from transmitting or becoming infected with HIV. In Tanzania enrolment into school can begin late (at age 9) and is often extended due to other pressures on student’s life, such as agricultural work or inability to pay for school or school items, which extends a pupil’s time at primary school. Therefore, some primary school students can be as old as 17.
A 2008 report noted the lack of integration of information about HIV and AIDS into the Tanzanian national curriculum, despite claims by the Ministry of Education that teachers are well informed and equipped to provide HIV and AIDS education.62 63 Some major challenges identified by the report included problematic teacher-pupil relationships, lack of resources, stigma and cultural taboos, and a lack of culturally sensitive information. The Tanzanian government admits their HIV prevention initiatives among youth are ‘poorly coordinated’.64 Without an effective, widespread government led prevention programme in schools, civil society organisations often have to step in to fill the gap.
One particular initiative, which aims to improve sexual and reproductive health among youth, is the local Femina HIP (Health Information Project.) Started in 1999, this multimedia civil society initiative distributes two glossy magazines and runs an interactive website and TV talkshow, all of which target youth with information about healthy lifestyles, sexuality and the risk of STDs including HIV/AIDS.65 One magazine, entitled ‘Fema’ is distributed to young men and women aged 15-25 in 2500 schools and workplaces in Tanzania. The other magazine entitled ‘Si Mchezo!’ (No Joke!) is aimed at out of school youth, mainly in rural areas and is estimated to reach 2 million people with every issue.66 The magazine is specially written for semi-literate audiences and has a local focus. Femina HIP’s interactive website67 and weekly talk show provide other popular platforms for young people to engage politicians, local celebrities and each other on issues which are otherwise little discussed either in the school room or at home.
HIV and AIDS treatment in Tanzania
In 2001 the newly launched National Policy on HIV/AIDS recognised antiretroviral treatment as a right for all people living with HIV, at a time when no Tanzanians were receiving antiretroviral treatment.68
It was not until the Ministry of Health developed a Health sector strategy (2003-2008) though that any plans to scale up HIV treatment were outlined by the government. In 2003, the William J Clinton Foundation and a group of Tanzanian experts created a step-by-step Care and Treatment Plan (2003-2008), which was then adopted by the Tanzanian cabinet. The five-year plan proposed the roll out of antiretroviral therapy to 19 health facilities in 3 months and a total of 96 health facilities within one year. In 2003, the Tanzanian government adopted the scheme and the following year pledged to provide antiretroviral drugs free of charge to all people living with HIV by 2008. In 2004, only about 0.5 percent of those with advanced HIV were receiving treatment.
“According to WHO, Tanzania has one of the worst physician-to-patient ratios in the world”
A total of $539 million over the five-year period was committed to rolling out treatment, with the majority of funds coming from USAID and the Global Fund. In line with the rapid scale up, Government spending on antiretroviral drugs increased from $2 million in 2003 to $17 million in 2005.69
Working closely with its international partners, the Ministry of Health and Social services has now established care and treatment services across the country. As of December 2009, about 200,000 people in need of treatment had been enrolled; that is under half of the 440,000 by 2008 envisaged in the care and treatment plan.70 According to the latest WHO guidelines, in 2011, 40 percent of Tanzanians in need of treatment were receiving it.71 Continuing treatment, or patient retention, is essential for the success of a treatment regime: yet in Tanzania only 65 percent of HIV positive adults and children are known to be on ARV drugs a year after beginning therapy.72 Whilst overall access to treatment improved somewhat between 2009 and 2010, a significant difference remains between the proportion of children and adults that have access to treatment. In 2010 access to antiretroviral treatment was extremely low for children in Tanzania with treatment coverage reaching only 14 percent.73
Tanzania has implemented WHO recommendations that the antiretroviral drug stavudine should be phased-out and replaced by less toxic and more effective antiretroviral drugs. Whilst Tanzania only began implementing the phase-out in 2011, efforts must be maintained if the current numbers of people taking stavudine (63 percent) are to be placed on more effective regimens before the date for completion (2015 for Tanzania).74
Health sector shortages
According to WHO, Tanzania has one of the worst physician-to-patient ratios in the world, with just 0.02 doctors and 0.37 nurses and midwives per 1,000 people.75 The lack of doctors is a particular problem in rural areas, where there are often only nurses available to treat patients. Qualified doctors and nurses emigrating abroad because of better pay, conditions and training opportunities means that health sector shortages remain a critical problem to the scale up of HIV treatment, counselling and prevention in Tanzania.
Stigma and discrimination
“At home my mother and myself have tested and been found positive. She has told me not even to tell my relatives; not even my own sister because she is afraid I will be stigmatised”76 A young girl from Tanzania
In 2008, the Tanzanian parliament passed the HIV and AIDS Act, protecting the rights of People Living with HIV and AIDS.77 The Act provides a legal framework for the national response and was created through a process that involved community groups, a network of journalists who recorded experiences of people living with HIV, as well as lawyers and members of the government.
The 2008 law makes it illegal to discriminate against someone because of their HIV status or the HIV status of a family member and obliges the government and employers to advocate against stigma and discrimination.78 However, sufficient training on the reforms for those who implement the law and public awareness of the rights included is needed for the law to be effective. The law must also be harmonised with other legislation in order to ensure that different laws do not contradict and work against each other. For example, the criminalisation of high-risk groups in Tanzania such as sex workers and men who have sex with men is at odds with the 2008 law as it makes it almost impossible for these groups, already marginalised and stigmatised, to access care and treatment.
Discrimination leads to an unwillingness to take an HIV test and to disclose results to family, friends or sexual partners. A 2005 USAID study conducted in Dar Es Salaam found that only half of HIV positive respondents had disclosed their status to intimate partners.79 The average time from receiving results to disclosing them was 2.5 years for men and 4 years for women. Stigma, specifically fear of abandonment, job or property loss and violence were reasons for this delay. Such fear increases the chance that HIV will be transmitted to a partner, that preventative behaviour will be avoided and that uptake of treatment will be delayed.80
Lack of knowledge about AIDS is one driver of stigma and discrimination. Four out of ten women and a third of men surveyed in the 2007-2009 HIV and Malaria Indicator Survey reported that they would not buy fresh vegetables from a shopkeeper who has HIV, and half of all women and 40 per cent of men said they would feel it necessary to keep it a secret if a family member was infected with HIV.81
Stigma and the beliefs that it can perpetuate (such as an HIV positive person has been cursed by witchcraft) can lead to reduced motivation to seek treatment. One study in rural Kisesa, which observed the uptake of the national antiretroviral treatment programme in Tanzania, found that ‘fear of stigma’ was a concern for all those interviewed. In particular, the participants did not want their status disclosed or expressed reluctance to identify a ‘treatment buddy’ as required by the programme. According to the study, “pervasive stigma remains the most formidable barrier” to taking up free antiretroviral treatment in rural areas.82
It is often assumed that the roll out of antiretroviral treatment will lead to a decrease in AIDS-related stigma and discrimination as treatment allows people with HIV to live longer and productive lives, thereby 'normalising' HIV and AIDS. However, according to some studies which have looked at the impact of increased access to HIV treatment in Tanzania, HIV/AIDS-related stigma is "still a major problem" in the country.83 One reason is that HIV and AIDS continues to be associated with immoral behaviour, and is therefore seen as a 'punishment'. The need to increase the visibility of people living with HIV, for example through the media, government-led public awareness campaigns and the involvement of faith organisations is necessary, as is training for local HIV organisations on addressing the causes and consequences of HIV/AIDS-related stigma in their communities.
Funding for HIV and AIDS in Tanzania
The Tanzanian HIV and AIDS response is heavily reliant on foreign funding. Almost all (95 percent) of the funding for HIV and AIDS programmes comes from foreign donors of which more than two thirds is from the Global Fund and PEPFAR.84 HIV and AIDS funding makes up one third of all aid coming to Tanzania.85 In total, more than $400 million was committed to HIV and AIDS in 2007/2008.86
Eighty percent of donor funding does not appear in Tanzania’s own government budget and is instead managed by the donor governments or partners. This means that it is not always necessarily aligned with the goals set out in Tanzania’s National Policy on AIDS. For example, less than a quarter of PEPFAR and Global Fund money in Tanzania is spent on prevention despite the government inclusion of prevention as the key focus of the National Multisectoral Framework.87 Tanzania’s public expenditure review has expressed concern that the government cannot take the lead role in policy and planning it needs to implement its National Multisectoral Strategic Framework when so much of its HIV and AIDS funding comes from external aid.88
Although donor spending on HIV and AIDS in 2009 was not affected by the financial crisis, this is mainly because previous funding commitments are still being honoured.89 Adverse effects of economic hardship in Tanzania such as job losses and budget cuts could affect the provision of antiretrovirals and other medical supplies in the future and worsen health worker shortages. Moreover, capping of PEPFAR funding in 2010 and reduced funds available to the Global Fund will likely make it difficult for Tanzania to expand treatment and care services unless the domestic budget for HIV and AIDS is increased.
Although HIV prevalence has fallen in Tanzania over the past decade, tens of thousands of people become infected with HIV every year.90 Stigma against HIV positive people and human resource shortages are among the obstacles to ensuring a sustained reduction of new HIV infections and to providing care and treatment to those already infected. Although Tanzania has long been a popular country with foreign donors, in a strained financial climate, the current levels of funding are by no means guaranteed. Signs have already appeared that the capping of PEPFAR funds is affecting the provision of drugs for HIV positive people in Tanzania.91 Increased funding for HIV and AIDS from the Tanzanian government and commitment to prevention efforts will be necessary if Tanzania is to overcome the debilitating effects the HIV and AIDS epidemic continues to have on its economy and society.
The history of HIV and AIDS in Tanzania
The first cases of AIDS were reported in the Kagera region in 1983 and by 1987 every region in the country had reported AIDS cases. In 1985, the government set up the NACP (National AIDS Control Programme) to coordinate the response and established AIDS coordinators in each district in the country.92
In order to confront the growing epidemic, the NACP developed a medium term plan for the period 1987-1991 which was then followed by two more medium term plans covering 1992-1996 and 1998-2002. These plans had three main aims: the decentralisation of the health sector response, reducing HIV transmission and relieving the social consequences of HIV/AIDS through care and assistance.93 However, according to Tanzania’s first National Multisectoral Framework (2003-2007) the three medium term plans did not halt the spread of HIV. By the time the third medium term plan came into being HIV prevalence had reached 8 percent.94 It is important to bear in mind however that, at this time, Tanzania had no coordinated monitoring and evaluation system, and systems for collecting data on HIV prevalence varied widely from region to region. Therefore, frequent delays in reporting as well as general underreporting suggest that the HIV prevalence could have been much higher.
Following the declaration of 'war' on HIV/AIDS by former president Mkapa, a national policy (which had been under development since 1991) was finalised in 2001.95 In the same year, the Tanzanian Parliamentary AIDS Coalition was established, a group of concerned political leaders who have since mobilised MPs and officials to create policies and laws that would help to combat the epidemic.96
The Tanzania Commission for AIDS (TACAIDS) was then established in 2002 to coordinate the multisectoral response, bringing together all stakeholders including government, business and civil society to provide strategic guidance to HIV/AIDS programmes, projects and interventions.97 In 2003, TACAIDS launched the first National Multisectoral Framework (NMSF) 2003-2007, which outlined all areas of focus for stakeholders including cross cutting themes like stigma and discrimination, as well as prevention, care and support and dealing with the socio-economic consequences of HIV and AIDS. Under each broad theme, certain strategic areas were identified (such as school based prevention or blood safety) and goals, challenges, targets and indicators of success were specified.98
Tanzania’s second National Strategic Framework (2008-2012) analyses the achievements and challenges faced in the implementation of the first NMSF, as well as identifying new targets and indicators of success.99
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