Women are heavily burdened by HIV in Tanzania, 690,000 women aged 15 and over living with HIV.6 According to the 2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey, HIV prevalence for women was 6.2%, compared to 3.8% for men.7 Women aged 23-24 were also twice as likely to be living with HIV, than men of the same age. HIV prevalence among women ranged from 1% among those aged 15-19 to 10% among women aged 45-49.8
Women tend to become infected earlier, because they have older partners and get married earlier.9 They also experience great difficulty in negotiating safer sex because of gender inequality. The ‘sugar daddy’ culture is widespread in Tanzania. Women will often accept the sexual advances of older men, or ‘sugar daddies’ for a variety of reasons including money, affection and social advancement. Intimate partner violence is also an issue, 35% of women are said to have experienced this.10
"I have a child and when I go with a man like him, he can give me something to buy milk for the child." - Aisha, a young women at a party in the Mkinga district 11
People who inject drugs (PWID) and HIV in Tanzania
The official proportion of PWID who are living with HIV stands at 16% in 2013, down markedly from previous estimates of around 51%. However, the figure may not be completely representative of the true impact of HIV on PWID, with other studies indicating an HIV prevalence of anywhere between 35% to 42% among this group.12
Female drug users in particular are at great risk of becoming infected with HIV (the HIV prevalence among women PWID is thought to be twice that of men), although the reasons for this are not fully known.13
Zanzibar is a gateway to the African continent and is also situated along a major corridor for drug trafficking. Around one in six PWID in Zanzibar is infected with HIV according to 2010 estimates, but some believe this figure may be higher.14 15 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.
Mobile populations and HIV in Tanzania
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 ‘high risk sexual networks’ made up of sex workers, women at truck stops and miners: all of whom have high levels of HIV prevalence.16Long-distance truck drivers, agricultural plantation workers and fisherman working along coastal trading towns are also at an increased risk of HIV.
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.17
Young people and HIV in Tanzania
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, the age most become sexually active.18 An estimated 2% of 15-24 year olds are living with HIV, accounting for 11% of all people living with HIV in Tanzania.
Young people engaging in risky sexual behaviour (such as not using condoms), having multiple sexual partners, and first having sex before the age of 15 remain significant challenges in the country response. Comprehensive knowledge about HIV is also low – less than half of young people have adequate knowledge. However improvements have been made in recent years. The percentage of young girls having sex before 15 decreased from 11% to 9%.19 Condom use has also increased, but is still inadequate, with only 34.1% of young men, and 41.5% of young women using a condom in the last year.
Men who have sex with men (MSM) and HIV in Tanzania
The proportion of HIV infections that arise from sex between men in Tanzania is very low, however MSM are still disproportionately affected by the epidemic, with 22.2% of MSM living with HIV.20
This figure has declined significantly from previous estimates of 42%, however still more has to be done. Less than half (42%) of all MSM reported using a condom during their last sexual contact, and only quarter of MSM were reached with some sort of HIV prevention programme.
HIV testing and counselling (HTC) in Tanzania
Over the last decade, Tanzania has increased their efforts to get more people testing for HIV. The number of voluntary counselling and testing (VCT) sites in the country has rapidly expanded, there are now 2,137 sites across the country. According to the 2010-2011 Malaria and AIDS Indicator Survey, more than 90% of people knew where to get an HIV test.21
In order to facilitate this boost, a high profile campaign was launched by the Tanzanian government in 2007 with the aim of testing 4 million Tanzanians within six months.22 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.23
By the end of the six months, more than 3 million Tanzanians were tested through the campaign.24
Data from the 2010-2011 Malaria and AIDS Indicator Survey indicate that 67% of women and 50% of men had ever been tested for HIV. Data from the same survey indicated that more and more Tanzanians knew where to test, and were taking the opportunity to test.
Antiretroviral treatment (ART) in Tanzania
The percentage of people receiving antiretroviral treatment in Tanzania stands at 37.5%. Tanzania have made significant gains in the scale-up of their antiretroviral treatment programmes, with the number of people on ART steadily increasing since 2010. By December 2013, 1.3 million people were enrolled at care and treatment centres, and 500,000 PLHIV were receiving ARVs. In 2013, 43 ART facilities were added, making a total of 1209 health facilities that provided HIV treatment – equating to three facilities per 100,000 of the population.25
The Tanzanian government has begun to simplify drug regimens and move to fixed-dose combinations (FDC) and phase out toxic drugs such as Stavudine. In addition, new guidelines are being issued to increase eligibility and access to ART to sero-discordant couples, all pregnant women living with HIV and key affected populations.
Tanzania Commission for AIDS (TACAIDS) have identified a number of challenges relating to the scale up of ART – including limited financial resource base for ART and for testing; weak supply chain management systems; and poor drug management and drug stock-outs.26
HIV prevention programmes in Tanzania
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 (MTCT).27 Tanzania aims to virtually eliminate MTCT and reach 90% of all pregnant women with treatment, reduce the MTCT rate to less than 5%, and maternal and child mortality by 90% by 2017. In 2013 77% of all pregnant women are on antiretroviral treatment for PMTCT.28
To reach as many women as possible, 93% of PMTCT services are now integrated with reproductive and child health services. 85% of all women are now tested for HIV during antenatal care visits. This has contributed to a 48% reduction in MTCT from 2009 to 2012. 53% of women are also receiving ART for their own health.29
However MTCT rates remain high. This can be attributed to a lack of access to PMTCT services during pregnancy, inefficient antiretroviral drug regimens, drug stock-outs and poor adherence to treatment. Plans are now currently under way to address these issues and to roll out option B+.30
Condom promotion
The Tanzanian government recognises condom promotion as an integral part of its fight against the epidemic. In 2013, over 109 million condoms and 1.7 million female condoms were distributed.31
In partnership with Population Services International, the government installed a hundred condom vending machines in Tanzania in 2009, targeting bars and nightclubs.32 Condoms are reportedly stocked in 94% of bars and 80% of retail outlets.33
Condom use during last sexual intercourse has increased significantly from 46.3% to 58% for women, and from 49% to 59% for men between 2008 and 2012.34 In comparison, less than a quarter of women and a third of men used condoms outside of marriage in 1999. However this still leaves many people at risk, with more to be done by the government.
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 diseases (STIs).
In one Tanzanian pilot, cash incentives of US$10 or US$20 were given to young adults aged 18-30, as long as they were free from STIs. One year into the study, there was a 25% risk reduction STIs. These programmes show that economic benefit can positively influence people to use condoms more frequently.35
Harm reduction
In 2011, with assistance from PEPFAR, Tanzania became the first country in sub-Saharan Africa to implement a harm reduction programme for PWIDs.36 Methadone substitution treatment andneedle exchange programmes are implemented at the small scale, and will be expanding. The number of syringes distributed per person is the highest in sub-Saharan Africa and among the highest in the world.37
HIV and TB co-infection in Tanzania
The World Health Organisation classifies Tanzania as a high burden country for Tuberculosis (TB), and one of the highest TB/HIV burden countries.38 In 2013, 64,000 cases of TB were presented and 83% were counselled and tested for HIV. Of this group, 39% were found to be co-infected with HIV.39
The government have prioritised the integration of TB services with HIV services to minimise 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.40
The number of people living with HIV who presented with Tuberculosis and received treatment for HIV and TB increased from 25.9% in 2012 to 54% in 2013. However, this still leaves a large portion of people with HIV/TB co-infected without comprehensive treatment.41
Barriers to HIV prevention programmes in Tanzania
Structural barriers
According to WHO, Tanzania has one of the worst physician-to-patient ratios in the world, with just 0.031 physicians per 1,000 people in 2012.42 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 also showed that 40% of all doctors in Tanzania work in the private sector.43
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.
Legal Barriers
In 2008, the Tanzanian parliament passed the HIV and AIDS Act, protecting the rights of People Living with HIV and AIDS. The Act makes it illegal to discriminate against someone because of their HIV status.
However, harmonisation with other legislation is needed to ensure that different laws do not contradict 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.
Social barriers
Gender inequalities and gender based violence continue to hamper the HIV response in Tanzania.44 This challenge has been recognised by TACO, and there are plans to implement a Gender Operational Plan for HIV to address these issues, with the hope of getting equal access to HIV prevention, treatment care and support mitigation activities within communities and workplaces.
Stigma and discrimination is also a major challenge. The Tanzania Stigma Index Report by the NACOPHA show clear infringements on the rights of people living with HIV in health, work and school settings. This type of stigma means that many people living with HIV practice self-censorship and have feelings of guilt that affect the quality of life.
"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." - A young girl from Tanzania 45
Economic barriers
More financial resources are needed in order to scale-up the response, especially in line with new WHO treatment guidelines and with the adoption of option B+. More resource is also needed to ensure that proper monitoring and reporting systems are in place for transparency of funding.46
The Tanzanian HIV response is heavily reliant on foreign funding, with 95% coming from foreign donors. Greater investment on the part of Tanzania can ensure that funding interests are diversified so that they can fulfil objectives of own national plans.
The way forward
Although HIV prevalence has fallen in Tanzania over the past decade, tens of thousands of people become infected with HIV every year.47 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.
There is also a greater need for targeted HIV programming for key affected populations. As well as programmes that reach hard-hit pockets of communities along high traffic areas
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.48 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 epidemic continues to have on its economy and society.
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