By Gwamaka Mwakyusa – Art in Tanzania internship
2018, 1.6 million people were living with HIV in Tanzania. This equates to an estimated HIV prevalence among adults of 4.6%. In the same year, 72,000 people were newly infected with HIV, and 24,000 people died from an AIDS-related illness.
Despite the numbers, Tanzania has done well to control the HIV epidemic over the last decade. Scaling up access to antiretroviral treatment (ART) has meant that between 2010 and 2018, the number of new infections declined by 13% and the number of people dying from an AIDS-related illness has halved.
Key affected populations in Tanzania
Tanzania’s HIV epidemic is generalized, meaning it affects all sections of society, but there are also concentrated epidemics among certain population groups, such as people who inject drugs, men who have sex with men, mobile populations, and sex workers. Heterosexual sex accounts for the vast majority (80%) of HIV infections in the country and women are particularly affected.
The severity of the epidemic varies geographically. Some regions of Tanzania report no HIV prevalence (Kusini Unguja and Kaskazini Pemba) while other regions have prevalence as high as 11.4% (Njombe). Overall, the epidemic has remained steady due to ongoing new infections, population growth and increased access to treatment.
Women are disproportionately affected by HIV in Tanzania. In 2018, 880,000 women aged 15 and over were living with HIV, compared to 580,000 adult men. In the same year, more than 36,000 women acquired HIV, compared to around 27,000 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. HIV prevalence is highest among women aged 45-49, at 12% (compared with 8.4% among men of this age
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.9 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.
It is estimated that more than half the population in Tanzania are aged 19 and under.11
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 2018, just under 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).13 In 2016/17, 3.4% of women aged 20-24 were living with HIV, compared to 0.9% of their male counterparts.
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 demonstrated 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 together (48%) or by 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 demonstrated adequate knowledge on how to prevent HIV and could correctly reject common misconceptions about how the virus is transmitted.17 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.
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 Program (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 be higher
A 2015 study of 480 people who use drugs in the northwestern 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.
Migration is common in Tanzania. In particular, the expansion of the mining sector has led to greater urbanization 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 truck stops and miners: all of whom have high levels of HIV prevalence.
Long-distance truck drivers, agricultural plantation workers and fishermen working along coastal trading towns are also at an increased risk of HIV. For example, a 2015 study by the International Organization for Migration on truck drivers in Dar es Salaam found all those surveyed had established 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.
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.
Tanzania criminalizes sex work, and it is punishable by law. 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 previous 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
programs, 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 high levels of sexual violence, multiple partners and condom less sex.
Men who have sex with men (MSM)
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.36 However previous 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.
HIV testing and counselling (HTC) in Tanzania
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 high levels of sexual activity. THIS found that around 79% of adolescent men and 61% of adolescent women had never tested for HIV before.
Over the last decade, Tanzania has increased its efforts to get more people testing for HIV. The number of voluntary counselling and testing (VCT) sites in the country has rapidly expanded (around 2,100 as of 2013).
In the same year Tanzania introduced new HIV testing approaches such as home-based testing, community testing and provider-initiated testing.
Since 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 providing 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 programs 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 prevention programs in Tanzania
In 2018, 72,000 people became HIV-positive in Tanzania. Although new infections have declined by 13% since 2010, more needs to be done to reduce HIV transmission.
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 in order to reduce new HIV infections. The guidelines also commit to implementing comprehensive prevention services for a number of 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.
Significant 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 newborns. 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.
The Tanzanian government recognizes 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 additional 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 behavior 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.
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, a number of civil society organizations provide additional sexual and reproductive health and HIV education, in and out of school settings.
Voluntary medical male circumcision (VMMC)
Circumcision is an effective HIV prevention strategy, reducing a man’s risk of acquiring HIV by approximately 60%. When used in combination with other prevention measures, circumcision is an important addition to HIV-prevention options for men.
In 2010 the government prioritized 11 regions for scaling VMMC and set a target of 2.8 million circumcisions by 2016.60 Around 2.6 million men were circumcised between 2015 and 2018, equating to around 80% of 15 to 49-year-old men.
CASE STUDY: Creating demand for VMMC
When a VMMC project was first established in the Kaliua District, Tabora, many men were put off by rumors that the removed foreskins would be used for conducting rituals. To dispel these rumors and create demand for the service, peer educators from the project hold meeting with community leaders to answer specific questions and address any concerns about the safety of VMMC and the disposal of foreskins.
Targeting influential people within the community paid off. The number of people presenting for voluntary circumcision, which had previously been visited predominantly by boys from a nearby primary school, subsequently increased to an average of between 20-28 adult men each day.
The local outreach site and dispensary conducted more than 1,000 VMMCs in 2015.
Cash transfer programs
Cash transfer programs form part of a new arm of HIV prevention that focuses on integrated programs for social protection schemes and sexual health. Across sub-Saharan Africa these types of programs 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, as long as they were free from STIs. One year into the study, there was a 25% risk reduction in STIs. These programs show that economic benefit can positively influence people to use condoms more frequently.
In 2017 the Tanzanian government, in collaboration with UNICEF, began a cash transfer scheme called Cash Plus as part of a program 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.
In 2011, with assistance from PEPFAR, Tanzania became the first country in sub-Saharan Africa to implement a harm reduction program for people who inject drugs. A methadone treatment clinic opened up 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 remains limited, with just 20% of people who inject drugs able to access OST in 2018.
This is also the case with needle and syringe exchanges. In 2017, just 15 needles and syringes were distributed per person per year. As a result, it is estimated that around 14% of Tanzanian-based people who inject drugs are sharing needles when injecting.
Harm Reduction International also reports that the Tanzanian government has taken “regressive steps” in its harm reduction-related policy in recent years, with policy-makers continuing to favor abstinence-based approaches above harm reduction.
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 (ART) in Tanzania
Tanzania has significantly scaled up its antiretroviral (ART) programs in recent years, and the number of people on ART has been steadily increasing since 2010.
In 2017, Tanzania introduced the World Health Organization (WHO) recommended ‘test and treat’ guidelines, which makes anyone testing positive for HIV eligible for immediate treatment regardless of the level of HIV in their body. This has seen ART coverage expand significantly: 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.
HIV-positive women are far more likely to be on treatment than HIV-positive men. In 2018, 82% of women and 57% of men living with HIV were receiving ART.
Children (ages 0-14) are less able to access treatment than adults, with 65% of HIV-positive children on ART in 2018. However, this is an improvement on 2015 levels when just 53% of HIV- positive children were on treatment.
More than 95% of people on treatment are still in care after 12 months, according to 2018 data. This is closely linked to good levels of viral suppression. In 2018, 87% 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, overall, only 62% 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 high 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.
Civil society’s role
Poverty, poor institutional and infrastructural support, and social and cultural neglect are impeding an effective and progressive HIV response in Tanzania. In 2017, Civicus, the global alliance of civil society organizations and activists dedicated to strengthening citizen action and civil society, placed the country on a watch list due to growing threats to civic space. In February of the same year, the government closed 40 healthcare facilities providing HIV services under the premise that they were promoting homosexuality. In June 2017, President Magufuli severely criticized NGOs working for the rights of LGBTI people.
In 2018, Tanzania’s sustained anti-gay crackdown was part of a broader trend of suppression and a disappearing civil society voice. The repercussions have been felt through all key population groups, affecting access to HIV and sexual health services, and increasing stigma and discrimination.86 It has also resulted in hundreds of LGBT activists going into hiding in order to avoid punishment.
They are raiding houses. It is a horrible thing. It is just going to get worse. So many people are leaving the city, running away. They are targeting the activists, saying we are promoting homosexuality.
The WHO classifies Tanzania within the top 20 high burden countries for tuberculosis (TB) and for TB/HIV.
In 2017, just under 70,000 cases of TB were presented and 98% had a known HIV status. Of this group, 31% were co-infected with HIV, of whom 95% were on antiretroviral treatment. In the same year, 22,000 people living with HIV died due to TB. The death rate has halved since 2010 when there were 44,000 TB-related deaths among HIV-positive people in Tanzania.
The government has prioritized the integration of TB services with HIV services to minimize the burden of these two co-morbidities. Ensuring that people living with HIV are on antiretroviral treatment means that they are in a better place to fight off TB infection. Integrating these two services will also ensure greater access to TB treatment.
The Tanzanian government has done well to keep the country on track to reaching all of the TB targets set within the Millennium Development Goal (MDG) frameworks.
The number of people living with HIV who presented with TB and received treatment for HIV and TB increased from 16% in 2012 to 42% in 2017.92 However, this still leaves a large portion of people with HIV/TB co-infected without comprehensive treatment.