By Goodness Njakoi – Art in Tanzania internship
Human immunodeficiency virus (HIV) is a Lentivirus, family Retroviridae, that causes acquired immunodeficiency syndrome (AIDS). There are two types, HIV-1 and HIV-2, of which HIV-1 is the more widely distributed and more pathogenic. AIDS is not a single disease but a syndrome, that is, a group of signs, symptoms, and diseases associated with a common pathology. Currently, epidemiologists define AIDS as the presence of several opportunistic or rare infections along with infection by human immunodeficiency virus (HIV) or as a severe decrease in the number of CD4+ cells (6200/ml of blood) and a positive test showing the presence of antibodies against HIV. The infections include diseases of the skin, such as shingles and disseminated (widespread) herpes; diseases of the nervous system, including meningitis, toxoplasmosis, and Cytomegalovirus disease; diseases of the respiratory system, such as tuberculosis, Pneumocystis pneumonia, histoplasmosis, and coccidioidomycosis; and diseases of the digestive system, including chronic diarrhea, thrush, and oral hairy leukoplakia. A rare cancer of blood vessels called Kaposi’s sarcoma is also commonly seen in AIDS patients. AIDS often results in dementia during the final stages.
HIV stays a public health concern in many sub-Saharan African countries including Tanzania. The national prevalence among adolescents and adults aged 15-49 years is estimated to be 4.8%. Prevalence among women is higher compared to men (6.2% versus 3.7%). The number of people living with HIV increased from 1.3 million in 2010 to 1.7 million in 2019, while deaths associated with AIDS decreased from 52,000 in 2010 to 27,000 in 2019 In Tanzania HIV is a generalized epidemic affecting both urban and rural populations, but there are also concentrated epidemics among certain population groups such as people who inject drugs, gay people, mobile populations and sex workers. Heterosexual sex accounts for the vast majority (80%) of HIV infections in the country and women are particularly affected.
Over the last two decades, despite wide geographical diversity in absolute levels of incidence, adolescent girls and young women have been disproportionately affected by new HIV infections compared to male counterparts. To end new infections among the growing population of adolescents in the country, HIV prevention programmes must address the gender inequalities driving excessive risk among adolescent girls more effectively. The country also suffers from a severe shortage health workers—there are only three trained health professionals for every 10,000 people. This means that many who are HIV-positive go undiagnosed and untreated.
The severity of the epidemic varies geographically. In mainland Tanzania, HIV prevalence varies across regions, with the southern highland regions of Njombe (11.4), Iringa and Mbeya as well as Mwanza region having much higher HIV prevalence compared to other regions. Meanwhile, HIV prevalence in Zanzibar is low with about 6,990 people living with HIV while Kusini Unguja and Kaskazini Pemba report no HIV prevalence. The number of new HIV infections decreased from 82,000 in 2018 to 77,000 in 2019.
The percentage of pregnant women enrolled in prevention of mother-to-child transmission (PMTCT) services reached 92% in 2019. However, poor retention rates among pregnant and lactating mothers (67% and 83% respectively) remain a challenge, contributing towards the mother-to-child HIV infection rate of 11% in 2019 against the global target of 5%. Early infant diagnosis uptake is also low, and the paediatric antiretroviral therapy (ART) coverage of 66% in 2019 lags the national target of achieving 90% coverage by 2022.
Key Affected Populations in Tanzania
Women are disproportionately affected by HIV in Tanzania. In 2019, 980,000 women aged 15 and over were living with HIV, compared to 630,000 adult men. In the same year, 40,000 women acquired HIV, compared to around 29,000 men. The nationally representative 2016-2017 Tanzania Impact Survey (THIS) found that women aged 15-39 are more than twice as likely to be living with HIV as their male counterparts. Gender inequality is widespread among women of all ages in Tanzania. In 2016, around 30% of women aged 15-49 who had ever been married or in a long-term relationship were estimated to have experienced physical or sexual violence from a male intimate partner in the past 12 months. This increases many women’s vulnerability to HIV, either directly, through sexual violence, or indirectly, through an inability to negotiate condoms or prevent their partner from having other sexual relationships. In addition, women tend to become infected earlier because they have older partners and get married earlier.
2. Young People
It is estimated that more than half the population in Tanzania are aged 19 and under. THIS reported HIV prevalence among young people (ages 15-24) at 1%, with young women around four times more likely than young men to be living with HIV (2% prevalence among young women, compared to 0.6% prevalence among young men). Prevalence among children (ages 0-14) is 0.3%. In 2019, 24,000 young people in Tanzania became HIV-positive; roughly two-thirds of whom were young women (16,000 new infections among young women, compared to 7,600 among young men. The disparity between the sexes is linked to age-related vulnerabilities experienced by young women that intersect with widespread gender inequality. For instance, Tanzania’s ‘sugar daddy’ culture, in which young women embark on sexual relationships with older men in exchange for material goods or social advancement, is a key driver of HIV among young women. Even though their partners come from age groups with higher HIV prevalence than younger men, and may also engage in other sexual relationships, young women are often unable to negotiate condom use due to the unequal power balance in these relationships. This is proven by a study involving 18- to 24-year-old women in Dar es Salaam, which found that in couples of the same age decisions about condom use were made together (48%) or by the young women alone (34%). Decision-making during sex with older men was predominantly made by the male partner (79%).
Many young people are also unaware about how to prevent transmission. In 2016/17, just 37% of young people showed adequate knowledge on how to prevent HIV and could correctly reject common misconceptions about how the virus is transmitted. Young people, particularly young men, are also less likely than older age groups to test for HIV. As a result, in 2016/17 it was estimated that only half of young people living with HIV were aware of their status.
3. People Who Inject Drugs (PWID)
Tanzania is home to a significant population of people who inject drugs (sometimes referred to as PWID). In 2014, Tanzania National AIDS Control Programme (NACP) estimated there were 30,000 people who inject drugs in the country, 35% of whom were living with HIV. HIV prevalence among women who inject drugs is thought to be twice that of their male peers. The reasons for this are not fully known although possible factors include women who inject drugs being involved in sex work or being last in line when syringes are shared. Data on people who inject drugs varies widely between studies, due to the hidden nature of this population. Existing evidence suggests heroin use is on the rise and this population group is growing.
Most studies involving people who inject drugs in Tanzania have been conducted in Dar es Salaam and Zanzibar. Zanzibar is a gateway to the African continent and is also situated along a major corridor for drug trafficking. Around one in six people who live in Zanzibar and inject drugs is living with HIV, according to 2010 estimates, although some believe this figure may be higher. A 2015 study of 480 people who use drugs in the north-western city of Mwanza found that 13.5% of respondents injected drugs, 67% of whom shared needles. This study suggests that injecting drug use, particularly heroin, is now a significant issue in a major city outside Dar es Salaam and Zanzibar.
4. Mobile Populations
Migration is common in Tanzania. 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 ‘considerable risk sexual networks’ made up of sex workers, women at truck stops and miners: all of whom have prominent levels of HIV prevalence. Long-distance truck drivers, agricultural plantation workers and fisher men working along coastal trading towns are also at an increased risk of HIV. For example, a 2015 study by the International Organisation for Migration on truck drivers in Dar es Salaam found all those surveyed had proven sexual relationships with partners at truck stops whom they considered permanent or second wives (described as ‘Mapoza’). A 2018 study involving around 400 people from fishing communities in Tanzania found an overall HIV prevalence of 14%, although this varied widely depending on location, from 7.2% to 23.8%. Around 38% of study participants living with HIV who had been diagnosed had not started treatment.28 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 as likely to be infected with HIV than women who do not travel.
5. Sex Workers
Sex work is considered criminal, and it is punishable by law in Tanzania. Despite this, it is estimated that around 150,000 people, mainly women, sell sex, especially in Dar-es-Salaam. In 2018, HIV prevalence among female sex workers was estimated at 15.4%. However, as with many other key population groups, data is limited and earlier estimates suggest HIV prevalence among this group is much higher, at around 31%. Around 70% of sex workers are estimated to use condoms. This is despite sex workers having poor access to HIV prevention programmes, which are thought to reach around one in five. The gender inequalities that result in women being disproportionately affected by HIV in Tanzania are acutely felt by female sex workers. The fact that sex work is also illegal means sex workers are subject to abuse and human rights violations from clients and from those in authority, including police officers and healthcare workers. This means many sex workers are reluctant to access HIV prevention, testing and treatment services while also being exposed to prominent levels of sexual violence, multiple partners and condom less sex.
6. Men Who Have Sex With Men
Same-sex sexual relations are illegal in Tanzania. As a result, data on this population group is extremely limited, a situation made worse by a government-sanctioned crackdown on LGBT people that began in 2015. In 2018, 8.4% of men who have sex with men (sometimes referred to as MSM) in Tanzania were estimated to be living with HIV. However earlier estimates released in 2014 put prevalence much higher, at 25%. This data suggested there were 49,700 men who have sex with men in the country. In 2014, only around 14% of men who have sex with men reported using condoms consistently. However, data from 2013 put condom use levels at 63%, highlighting how patchy the evidence currently is.
Tanzanian Government Attitude Towards Tackling HIV/AIDS
The Government considers the HIV/AIDS epidemic is a national public health threat affecting Tanzanian society economically, politically, socially, and culturally. The Government states it is committed to the national vision of freeing the country from the epidemic and having a generation live without fear of HIV and the acquired immunodeficiency syndrome (AIDS). A vision will be reached in line with the UNAIDS vision of three zeros: zero new HIV infections, zero discrimination, and zero AIDS-related deaths.
The government of Tanzania adopted the National HIV/AIDS policy in 2001 and acknowledged that stigma was a key issue fueling HIV infection. In 2008, the government passed the HIV and AIDS Prevention and Control Act aimed at protecting the human rights of those living with HIV, including the prohibition of discrimination.
The Government of Tanzania has made substantial progress in HIV/AIDS prevention, care, treatment, and impact mitigation. Progress has been made in resource mobilization, communication, advocacy, and community participation. The government continues to increase the level of funding for the national response to HIV/AIDS in its annual budget and through collaboration with national and international communities.
The government has faced social, economic, and development challenges resulting from the HIV/AIDS epidemic and has made various efforts to address these challenges. This work requires a concerted, multidisciplinary effort from all HIV/AIDS stakeholders at all levels, including government and nongovernment, civil society organizations (CSOs), communities, and individuals. Under the Prime Minister’s Office, TACAIDS is mandated to provide strategic leadership and coordination of the HIV/AIDS national response through development of a strategic framework and national guidelines for HIV. The development of the National Guidelines on HIV Prevention Strategy and the National Stigma and Discrimination Reduction Strategy are the government’s road maps to curbing the epidemic. The revised National HIV Policy 2011, the National Multisectoral Strategic Framework (2013-2017), and the fourth National Multisectoral Strategic Framework (2018-2023) are the guiding tools for the implementation of HIV activities. These documents are developed in line with international guidelines on HIV and human rights to ensure the accountability of the government and other stakeholders (the private sector, development partners, CSOs, and the community) in their actions within the national HIV/AIDS response
The Tanzania HIV Impact Survey (THIS), a household-based national survey, was conducted between October 2016 and August 2017 to measure the status of Tanzania’s national HIV response. It surveyed over 14,000 households and interviewed more than 33,000 adults (15 and older) and 10,000 children (14 and younger). THIS offered HIV counselling and testing with return of results, and collected information about household and individual characteristics, and uptake of HIV care and treatment services. The THIS is the first national HIV survey that covered populations of all ages and other indicators that were not part of the three surveys conducted previously in the country. These added indicators included: HIV incidence, CD4 T-cell count, viral load (VL) suppression (VLS), antiretroviral (ARV) drug resistance and presence of ARV drugs in the blood; HIV prevalence among children aged 0-9 years, early adolescent children aged 10-14 years, and elders aged 50 years and older; and the prevalence of syphilis, acute or chronic hepatitis B, and past or current hepatitis C.
The survey, which is part of the multi-country Population-based HIV Impact Assessment (PHIA), was conducted by ICAP at Columbia University in partnership with the Government of Tanzania through the Tanzania Commission for AIDS (TACAIDS) and Zanzibar AIDS Commission (ZAC), funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR) and technical help from the U.S. Centers for Disease Control (CDC). THIS provides an important new reference point in Tanzania’s march toward epidemic control within its borders and the global response to HIV at large.
The primary aims of THIS were to estimate the national-level annual HIV incidence among adults aged 15 years and older, and the subnational prevalence of viral load (VL) suppression (VLS), defined as HIV ribonucleic acid (RNA) less than 1,000 copies/millilitre (mL), among HIV-positive adults. Secondary aims of THIS were to measure national and regional adult HIV prevalence; national and regional distribution of CD4 counts; detection of ARVs in blood; national prevalence of transmitted HIV drug resistance; national paediatric HIV prevalence; progress toward the 90-90-90 targets defined by UNAIDS; and national prevalence of syphilis, hepatitis B (HBV) infection and hepatitis C virus (HCV) infection. The survey also collected information on behaviours associated with HIV acquisition and transmission, common HIV comorbidities, and other health conditions. The “90-90-90” refer to targets set by UNAIDS to achieve control of the HIV epidemic by 2020 and are defined as 90% of all people living with HIV (PLHIV) will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained ART; and 90% of all people receiving ART will have VLS.
Key findings from the report revealed that 5.0% of adults (15-64 years) in Tanzania were currently living with HIV. A substantial percentage of these adults – nearly 40% – are unaware of their positive status, well-below the UNAIDS target of 90% of all people living with HIV knowing their status in 2020. Conversely, there has been progress in adults living with HIV who are aware of their status, with 93.6% receiving anti-retroviral therapy (ART) and 87.0% of those on ART having viral load suppression. After the report’s release, the National Council of People living with HIV and AIDS (NACOPHA) announced that the results will be used to design awareness campaigns on prevention, medication and stigma for people living with HIV in Tanzania.
HIV/AIDS Testing and Counselling
Results from THIS suggests around 65% of adults in Tanzania have taken an HIV test at least once (59% of men and 71% of women) but only a third regularly test for HIV (every 12 months). Around 16% of adults who tested positive during THIS had never been tested for HIV before (20% of men and 14% of women). Adolescents (ages 15-19) have particularly low testing levels, despite prominent levels of sexual activity. THIS found that around 79% of adolescent men and 61% of adolescent women had never tested for HIV before.
In 2013, Tanzania introduced new HIV testing approaches such as home-based testing, community testing and provider-initiated testing. Since then, other testing approaches, such as index testing, have also been introduced. As a result of these accelerated efforts, in 2018 the number of people living with HIV who were aware of their status was 78%, compared with 64% in 2015.
In 2018 the Tanzanian government began to fully scale-up self-testing for HIV and is focusing on supplying self-testing kits for hard-to-reach groups. For example, using antennal clinics to provide pregnant women with self-testing kits to pass onto their husbands or boyfriends. Pilot programmes are also being carried out to learn how best to provide self-testing kits to the partners of sex workers and other key and vulnerable populations.
The Tanzanian government has also begun a campaign called Furaha Yangu! (My Happiness!) to increase the number of young men and adolescent boys testing for HIV.
HIV/AIDS Prevention Programs
Tanzania is currently implementing its fourth Health Sector HIV and AIDS Strategic Plan (HSHSP IV), which runs between 2017 and 2022. The strategy aims to increase access to combination prevention services for the general population to reduce new HIV infections. The guidelines also commit to implementing comprehensive prevention services for several key populations, including adolescent girls and young women, female sex workers, men who have sex with men, people who inject drugs, prisoners and migrant populations.
- Prevention of mother-to-child transmission (PMTCT)
Noteworthy progress that has been made in the prevention of mother-to-child transmission (PMTCT) in the past few years in Tanzania. In 2018, 93% of pregnant women living with HIV were receiving effective ART, compared to 75% in 2010. It is estimated that ART coverage among pregnant women living with HIV has averted around 14,000 new infections among new-borns. However, 8,600 children still acquired HIV in 2018. One of the reasons for HIV transmission still occurring vertically (from parent to child) is that not all pregnant women are tested for HIV. In 2018, 91% of pregnant women attending antenatal services received HIV testing. In addition, only half (47%) of infants exposed to HIV during pregnancy were tested for HIV within eight weeks of birth (known as ‘early infant diagnosis’). To reach as many women as possible, the vast majority of PMTCT services are now integrated with reproductive and child health services. Inefficient antiretroviral drug regimens for pregnant women and new mothers, drug stock-outs and poor adherence to treatment also contribute to the continuing transmission of HIV via this route.
2. Condom promotion
The Tanzanian government recognises condom promotion as an integral part of its fight against the epidemic. The goal of its 2017-2022 HIV prevention strategy is to ensure 85% of people engaged in multiple sexual partnerships use condoms correctly and consistently. To achieve this, around 260 million free condoms must be made available annually. However, weak supply lines and a lack of funding means this may not be achievable. In 2018, it was reported that the Global Fund to Fight AIDS, Tuberculosis and Malaria would finance 120 million public sector condoms, PSI would contribute around 18 million and an added 20 million would be provided by other sources. This leaves an impending shortfall of around 100 million condoms. In addition, more effective promotion is needed to encourage people to use condoms. In 2017, it was reported that just 30% of women and 46% of men used a condom the last time they had a sex with a non-marital, non-cohabiting partner. These levels are lower than previously reported, suggesting more people are engaging in risky sexual behaviour that leaves them vulnerable to HIV infection. Low condom use is also occurring among high-risk groups. For instance, a study involving 18- to 24-year-old women in Dar-es-salaam found that only 32% used a condom during sex with regular boyfriends. Condom use declined even further if the women were involved in transactional sexual relationships with older men, with only 2% saying they always used a condom during these types of sexual encounters.
3. HIV awareness and sex education
While Tanzania has a broad sex education curriculum, only a third of schoolteachers have been trained on how to deliver these lessons, meaning access is patchy. In addition, certain subjects, such as the examination of minority sexualities, are not covered. Condom demonstration and condom distribution is also not allowed during sex education lessons. On top of this, the number of people attending school beyond primary level is low, with only around 19% of people having some form of secondary education. This limits the opportunities to reach older adolescents with sexual health education. To fill these gaps, several civil society organisations provide added sexual and reproductive health and HIV education, in and out of school settings.
4. Cash transfer programmes
Cash transfer programmes form part of a new arm of HIV prevention that focuses on integrated programmes for social protection schemes and sexual health. Across sub-Saharan Africa these types of programmes have been shown to have a positive effect on preventing HIV and other sexually transmitted infections (STIs). In one Tanzanian pilot, cash incentives of US$10 or US$20 were given to young adults aged between 18 and 30, if they were free from STIs. One year into the study, there was a 25% risk reduction in STIs. These programmes show that economic benefit can positively influence people to use condoms more often.63 In 2017 the Tanzanian government, in collaboration with UNICEF, began a cash transfer scheme called Cash Plus as part of a programme to empower and strengthen the resilience and wellbeing of adolescents from the country’s poorest households. Cash Plus participants receive tailored, life skills training on various subjects, including sexual and reproductive health, as well as being linked to sexual and reproductive health and HIV services. They also receive financial support to either stay in school or start a small business and are supported by mentors and peer educators throughout.
5. Harm reduction
In 2011, with aid from PEPFAR, Tanzania became the first country in sub-Saharan Africa to implement a harm reduction programme for people who inject drugs. A methadone treatment clinic opened in Tanzania’s largest health facility, based in Dar es Salaam, then extended to a second hospital in the city. Although there has since been an increase in opioid substitution therapy (OST) interventions outside Dar es Salaam, access still is limited, with just 20% of people who inject drugs able to access OST in 2018. It is estimated that around 14% of Tanzanian-based people who inject drugs are sharing needles when injecting.
6. Pre exposure prophylaxis (PrEP)
In 2018 Tanzania began to scale up pre-exposure prophylaxis (PrEP), a daily course of antiretroviral drugs taken by HIV-negative people to protect themselves from infection, for key populations. The following year, the government announced plans to extend this nationwide, including expanding eligibility criteria to include adolescent girls and young women. As of 2019, it was estimated that between 3,200 and 3,700 people were using PrEP in Tanzania. Most of these people are adolescent girls and young women, although female sex workers and their partners and the HIV-negative partners of people living with HIV are also being targeted by implementation or demonstration projects.
Antiretroviral Treatment In Tanzania
Tanzania has scaled up its antiretroviral (ART) programmes in recent years, and the number of people on ART has been on the rise since 2010. In 2017, the World Health Organization (WHO) recommended ‘test and treat’ guidelines was introduced, which makes anyone testing positive for HIV eligible for immediate treatment regardless of the level of HIV in their body.
In 2018, 71% of people living with HIV in Tanzania were receiving ART, equivalent to 1.1 million people. This is around a 20% increase from 2015, when 52% of HIV-positive people were on ART. As of 2018, around 90% of people diagnosed with HIV began ART in less than seven days.
More than 95% of people on treatment are still in care after 12 months, according to 2018 data. This is intricately linked to good levels of viral suppression. In 2019, 83% of people diagnosed and on treatment were virally suppressed, with men and women enjoying similar levels of viral suppression (86% and 89% respectively). However, due to gaps in testing and linkage to care, only 69% of people living with HIV are virally suppressed.
Studies conducted in various regions of Tanzania have reported low linkage to care for people who test HIV-positive. For example, a study following around 1,000 people newly diagnosed with HIV in Mbeya, a rural area, found just 28% were successfully linked to care. Under-resourced, poorly coordinated health services, as well as prominent levels of HIV-related stigma were the main reasons these people did not begin treatment.
The Tanzanian government has begun to simplify drug regimens and move to fixed-dose combinations while phasing out toxic drugs such as Stavudine. Evidence is currently mixed as to whether levels of pre-treatment and acquired drug-resistant HIV are high enough to be considered a public health issue in Tanzania.
Major Challenges To HIV/AIDS Response
Stigma is a major challenge for HIV prevention and thus a priority area for intervention. HIV stigma manifests at both individual and community levels and affects negatively on mental health-invoking feelings of shame, guilt, fear, and depression. Many people prefer to attribute a relative’s sickness to witchcraft than to admit it is AIDS. People who are HIV positive in Tanzania are referred to as ”maiti inayotembea”. Stigma negatively affects delivery of key services, through discriminatory attitudes among service providers and through lack of uptake among those needing the service. Stigma can be a barrier to important HIV prevention actions, such as condom use, HIV testing, disclosure of HIV status and access to antiretroviral treatment.
According to the WHO, Tanzania has one of the worst physician-to-patient ratios in the world, with just 0.031 physicians per 1,000 people in 2012. The lack of doctors is a particular problem in rural areas, where there are often only nurses available to treat patients. Additionally, a recent study showed that 40% of all doctors in Tanzania work in the private sector. Qualified doctors and nurses are also emigrating abroad because of better pay, conditions and training opportunities. This means health sector shortages are still a critical problem to the scale up of HIV treatment, counselling and prevention in Tanzania.
Gender inequalities and gender-based violence experienced by women continue to hamper the HIV response in Tanzania. Men who have sex with men are also at an increased risk of sexual violence. Although data is limited, a study involving around 350 Tanzanian-based men who have sex with men found 94% had experienced some form of violence, including 73% who had experienced sexual violence.
Though HIV prevalence has fallen in over the past decade, tens of thousands of people still become infected with HIV every year. Stigma against HIV-positive people, the criminalisation of key population groups, and human resource shortages are preventing a sustained reduction in new HIV infections.
Specific HIV programming for people from hard-hit communities in certain areas is necessary to get Tanzania’s HIV epidemic under control. Focusing on national-level indicators means severely affected districts have previously been overlooked.
A 2015 analysis by PEPFAR cites health financing, supply chain, and performance and financial data collection as areas where Tanzania’s national HIV response needs improvement. In response to this, the government presented a comprehensive healthcare financing strategy to the Cabinet, with a focus on scaling up health insurance coverage, strengthening value for money, and engaging the private sector.
These efforts will be necessary if Tanzania is to overcome the debilitating effects the HIV epidemic continues to have on its economy and society. There is also an urgent need to address the lack of domestic funding for the HIV response so that Tanzania is not so reliant on international support to end its HIV epidemic.
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