HIV infection is unevenly distributed across geographic area, gender, age, groups and social economic classes in the country. The percentage of the population infected by HIV ranges from less than three percent across most of the country to more than 44.4 percent in certain sub populations. The epidemic has struck more the most economically active group of adults, those aged 15-45.
Distribution of AIDS cases:
Between 1st January and 31st December, 1999, a total of 8,850 AIDS cases were reported to the NACP from the 20 regions of mainland Tanzania bringing the number of AIDS cases from 1983 to 118,713. Simulation model estimates that only 1 out of 5 AIDS cases are reported. NACP, therefore, estimates that 44,250 cases occurred in 1999 and 600,000 cumulative AIDS cases have occurred from 1983 to 1999 (www.ppu.go.tz).
The distribution of AIDS cases by age and sex during the period January through December 1999 (is summarized in www.ppu.go.tz) for both sexes most cases falling within the age group 20-49 years; peak age for females being 25-29 years while that for males is 30-34 years. Generally females acquire HIV infection at an earlier age compared to males, assuming a similar incubation period for both sexes. Specific case rates in 1999 indicate that males have a higher case rate (28.2 per 100,000 population) compared to females (26.5 per 100,000 population).
The total population for 1999 has been projected from the 1988 population census using exponential growth model with an annual population growth rate of 2.8%, the NACP estimates that only 1 out of 5 AIDS cases are reported due to under utilisation of health services, under diagnosis, under reporting and delays in reporting. However, the data is believed to reflect the trend of AIDS cases in the country.
The country’s response
During the last eighteen years, Tanzania has undertaken many different approaches in attempting to slow the spread of HIV infection and minimize its impact on individuals, families and the society in general. Since 1983, when the first 3 AIDS cases in Tanzania were reported, the HIV epidemic has progressed differently in various population groups while national response has developed itself into phases of programme activities led by the National AIDS Control Programme since 1985. The programme phases started with a two-year phase called Short Term Plan (1985-1986). Subsequent phases were termed Medium Term Plans lasting for five-year periods beginning with MTP-I (1987-1991), followed by MTP-II (1992-1996) and now the MTP-III, which was beginning in 1998. Through these programme phase successful national responses have been identified, the most effective ones being those touching on the major determinants of the epidemic and addressing priority areas that make people vulnerable to HIV infection.
Situation analysis
A situation analysis of HIV/AIDS in Tanzania was performed in 1997 and has shown a worsening epidemiological situation whereby the epidemic has rapidly spread into rural areas thereby increasing the previously low rural prevalence to more than 10% in some areas. Mother-to-child transmission appears to be on the increase, as more and more women continue to become infected and pregnant.
The youth and the women have been the most affected groups because of economic, social-cultural, biological and anatomical reasons. Hence, poverty, which reflects the country’s economy, is an important determinant. Mobile population groups have also been categorised as vulnerable to HIV infection as their occupation forces them into high-risk sexual behaviour. The mobile population groups include commercial sex workers, petty traders, migrant workers, military personnel and long distance truck drivers.
Determinants of the epidemic have been identified and grouped into societal, behavioural and biological ones. The HIV/AIDS epidemic has had a serious impact on the country’s economy. It has affected agricultural and industrial production as well as affected socio-demographic parameters such as life expectancy. AIDS orphans have been increasing in number while families, communities and the Government cannot cope with the needed resources to cater for their needs.
As regards the country’s response to the epidemic there have been various national efforts to control the spread of HIV. While the initial efforts were mainly implemented by the MOH, overtime, there has been gradual involvement of other public sectors, NGOs and community-based organizations. This multi-sectoral response to the HIV/AIDS/STDs problem has involved, among others, IEC activities for the prevention of HIV transmission, care for AIDS patients in hospitals and at home, family life education, Government budgetary allocation for AIDS activities, condom procurement and distribution and STD management activities. Encompassing all the above responses is the development of a National Policy on HIV/AIDS/STDs to widen and strengthen the national response against the epidemic.
Epidemiological Situation of HIV/AIDS/STDs in Tanzania
In Tanzania, transmission of HIV occurs mainly through heterosexual contact beginning in the early teen years and peaking before the age of 30. Since 1983, when the first three AIDS cases in Tanzania were reported, the HIV epidemic has progressed differently in various population groups. Early in the epidemic, urban populations and communities located along highways were most affected. According to the NACP HIV/AIDS/STD Surveillance Report No.11, 1996, the epidemic has rapidly spread to rural communities and in 1997, more than 10% of women attending antenatal clinics situated in some rural areas have been found to be HIV infected.
The cumulative AIDS cases as reported from surveillance reports collected by the National AIDS Control Programme (NACP) in Tanzania mainland, rose from 25,503 at the end of 1990 to 88,667 in 1996. Over 80% of the reported AIDS cases were in the age group 20 - 44 years.
Prevalence of HIV Infection:
HIV prevalence in male blood donors was 8.7% and in female blood donors the prevalence was 12.6. This difference is statistically significant. Extrapolating these rates to the Tanzania mainland adult population, 1,259,539 persons aged 15-49 years (1,745,320 adults aged 15 and above) were infected with the AIDS virus as at December 1999. In general the prevalence of HIV infection of both men and women has been continuously increasing for the past eight years. Prevalence, among female blood donors in Dar es Salaam has been remarkably high from 1997-1999, largely
Prevalence of HIV infection among blood donors shows some specific difference with regard to age and sex. In 1999, as in previous years, higher prevalence of HIV infection was seen among females than in males of the same age group. The prevalence across the age groups for male ranges between 7.9% and 14.9% for the age groups 50-54 and 35-39 years respectively
Since AIDS is a late consequence of HIV infection, the long incubation period of between 5 and 10 years and the absence of significant symptoms at the early stages of infection, make it impossible to know the exact number of HIV infections in the country. The only reliable data available is that from blood donors and the few sero-prevalence studies in selected regions. In 1986, 6.8% of adult male donors and 8.2% females were HIV positive (average from population studies 7%). Extrapolation from these figures in an estimated population of 15,500,000 adults in mainland Tanzania results in at least 1,350,000 HIV positives which is 8.7% of the adult population. At least 5% of the infected population could develop to full-blown AIDS, giving approximately 68,00 AIDS cases per year.
According to the blood donor data of 1996, HIV prevalence was high among young adults in the age groups 20 - 24, 25 - 29 and 30 - 34. Infection rates in these groups ranged from 5.9% to 7.9% among males, and from 9.3% to 10.1% among females, the latter being affected at earlier ages than the former.
Although it is estimated that the prevalence of HIV infection among adult’s blood donors is 8.7%, the range varies from 5% to 20%. Regions mostly affected are Kagera, Iringa and Mbeya with a prevalence range of 15% to 20%, Dar es Salaam, Rukwa, Shinyanga and Mwanza with a prevalence range of 10% to 15% while Ruvuma, Kilimanjaro and Mtwara are in the prevalence range of 5% to 10%.
Vertical transmission of HIV from mother to child is also considerable in Tanzania. In 1996 this accounted for about 4% of all reported AIDS cases. The problem seems to be on the rise as more women continue to become infected and pregnant. Data from sentinel surveys in antenatal clinics show sero-prevalence rates of 5.5% to 23%, and assuming a 30% prenatal transmission rate, the proportion of new-borns expected to be infected could reach 7 per cent.
HIV/AIDS is increasingly becoming the major underlying factor for hospital admissions and deaths. Many diseases, which seemed to have been controlled ten years ago, have returned to previous levels due to HIV/AIDS. For example the prevalence of HIV infection among 128 newly detected tuberculosis patients in Mbeya in 1995 was 52%, whereas that proportion in Bukoba hospital in 1992 was 57.4%. Studies conducted in Dar es Salaam, Hai and Morogoro showed that HIV/AIDS is the leading cause of adult mortality especially among women.
Population groups mostly affected
From the above observations it can be seen that two groups emerge as the most affected. These are the youth and the women. Several reasons can be advanced to explain this observation. Early marriage and early initiation of sex among women, young girls having sex with older men, peer pressure for high-risk behaviour, biological and anatomical predisposition are some of the most important reasons. In addition, failure of women to protect themselves from HIV infections due to economic hardships, repressive customary laws, beliefs and polygamy could all contribute to this state of affairs.
A third group mostly affected is the poor. This group is most likely illiterate and unemployed, as a result; it might use sex as a means of earning a living. Again, women are more likely to get involved than men, for lack of alternative means of survival.
A fourth group of those mostly affected is the so-called “mobile populations” which consists of those who work and stay away from home for varied lengths of time during a year. These include commercial sex workers (CSW), petty traders, migrant workers, military personnel and long distance truck drivers. Their inability to negotiate for safer sex with their clients puts them at a high risk. Another group of workers in risky occupations is that of health workers who may inadvertently handle infected material in the course of their work. These often lack the necessary protective gear and education to prevent them from coming into contact with infected materials.
Determinants of the Epidemic
The main determinants are societal, behavioural and biological. These singly or in combination provide opportunities for HIV infection to occur to an individual.
Social determinants
Commercial sex workers form a group that potentially increases the sexual transmission rate of HIV infection. Studies by AMREF along the major truck stops and towns have shown this group to have a high HIV prevalence of up to 60%. A study conducted by MUTAN in the Moshi municipality showed that bar workers had HIV infection prevalence rate of 32%, while a study in Dar es Salaam showed that 50% of the bar workers were HIV positive.
Stigma and discrimination against people living with HIV/AIDS are quite common in Tanzania. Studies done in communities in Magu, Mwanza by TANESA showed the level of stigma and denial for AIDS and HIV to be very high. Many people would not admit that their sick relative could be suffering from HIV/AIDS but believe instead in witchcraft as the cause of their sickness. This situation makes it difficult to convince people with wife-inheritance traditions not to marry women whose husbands may have died from AIDS.
A large proportion of the population with very low and/or irregular income is an important social determinant. Over 50% of Tanzanians live below the poverty line and females are worse than males. In addition, low and or irregular income creates an environment that encourages labour migration. Women in such situations may be easily tempted to exchange sex for money and this puts them and their spouses at risk for HIV. People with low income have less access to medical care including that for STDs and HIV/AIDS.
Social isolation for long periods and peer pressures for high-risk behaviour among the military form other social determinants. In Tanzania when one is enrolled in the army, one is confined in a camp and barred from getting married for six years. This makes one vulnerable to high-risk behaviour and hence to HIV infection especially when the army has no proper programs for HIV/AIDS prevention like the promotion of condom use and provision of IEC for HIV prevention.
Cultural norms, beliefs and practices that subjugate/subordinate women are important determinants these include cultural practices like wife inheritance, polygamy and female circumcision, which are common among many tribes in Tanzania. Obligatory sex in marital situations is condoned even by religion, and women cannot divorce in some faiths. Furthermore, in some cultures multiple sex partners for men is tolerated and may even be encouraged.
Young people leave home and school environments to become independent without a source of income. In Tanzania every year about 300,000 pupils leave primary education quite early (age 13 - 17yrs) and a significant proportion migrates to large towns like Dar es Salaam in search of employment. These youth and especially the female, become very vulnerable because they end up getting employment, which is poorly paid and in turn have to supplement their meagre income through unsafe sexual practices. Although there have been attempts to introduce sex education in schools, these have not adequately prepared those leaving school to confront sexual issues.
Illiteracy and lack of formal education is on the rise in Tanzania. In the eighties the level of literacy in the country was around 80%. At that time many people could read and understand messages meant for their well being. Today, the literacy rate has gone down to less than 60%; this means less people can understand written messages. This has been contributed by the fact that many young people are not being enrolled into schools and these are unfortunate because it has been shown that the prevalence of HIV infection in educated women is lower than in those who were not educated. The other contributing factor to the declining literacy rate is that the post-independence adult education campaigns are currently so poorly managed for lack of resources that there is little or no output.
Behavioural determinants:
Unprotected sexual behaviour among mobile population groups with multiple partners makes them vulnerable to HIV infection. The groups include long distance truck drivers who have been found to unprotect sexual intercourse with HIV sero-positivity of up to 50%. This is because they have multiple sexual partners available in all major truck stops. Migrant or seasonal workers are also vulnerable. It has been found that farm and plantation workers in Iringa and Morogoro for example, have HIV prevalence of about 30%, which is very high compared to the general population.
Reduced Social discipline for making good decisions about social and sexual behaviour. Long before the eighties when the AIDS epidemic became apparent Tanzanians were a disciplined society where traditional values and norms were cherished. But recently, social discipline has been eroded. This is so because of several factors such as failure of parents to institute traditional values and discipline to their children for lack of time. Sudden mushrooming of television programmes and other mass media have also contributed negatively to social discipline.
Biological determinants
STDs Infections (especially gonorrhoea and other genital discharges) are among the top-ten causes of disease in mainland Tanzania. Studies have found that patients with STDs are 2 to 9 times more likely to be infected with HIV. However because HIV and other STDs are both highly associated with high-risk sexual behaviour it is difficult to show the extent to which STD alone enhance infection of HIV. Nevertheless, studies in Mwanza have shown that STD management within the existing PHC system can reduce the incidence of HIV infection by about 40%.
Unsafe blood transfusion is a major determinant of HIV transmission. The HIV transmission rate through transfusion of contaminated blood is almost 100%. For this reason, in Tanzania all centres rendering this service are equipped with facilities to ensure safe blood transfusion. However, due to lack of regular supplies of reagents and equipment as well as lack of reliable power supply in some centres there is some risk of transfusing contaminated blood. This situation therefore calls for improved blood transfusion services in the whole country.
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