The epidemic, it seems, is a result of a complex interplay between biological, socio-cultural, socio-economic and political factors. No single factor has been identified that can fully explain the different epidemiological patterns either across the African continent or in Tanzania. There is, however, increasing evidence that a combination of a few factors, both biomedical and social, might explain most of the variation in HIV occurrence. The main biomedical factors include increased transmission due to genital ulcer disease, in particular herpes simplex-2 infection and the lack of male circumcision. The main underlying socio-cultural factors, it seems, includes pro-natal values, the gender imbalance, concurrent partnerships and the sexual freedom of males. Socio-economic factors include urbanisation, sex work and men and women living separately due to economic activities such as mining, the military and seasonal jobs. There are several feasible interventions to tackle these determinants, but many of them have not yet been addressed.
Efforts to control HIV in sub-Saharan Africa have met with considerable difficulties. Although indications are that the epidemic is leveling off in most parts of the continent, including Tanzania, the prevalence and incidence levels are still high in many places. Little or no behavioural change has been reported in most parts of Tanzania in spite of 20 years of HIV control activities. Condom use remains low. Reasons for this could be that the disease determinants are poorly defined and therefore not properly addressed or that the task of changing old life patterns is difficult and demands long-term interventions to succeed. It is certainly also linked to the large gap in the understanding of reality, between the population groups who are most affected by the epidemic, and these staff in international agencies who to a large extent direct control efforts.
Another reason could be that control activities have not been efficiently implemented. A health sector reform to reinforce the system has been ongoing since the mid 1990s. This reform has not directly addressed the main problem of the sector – the shortage of resources. Both the reform and HIV control have to a large extent been governed from the outside on the basis of general ideas, which do not consider the specific situation in Tanzania. Many of the specific Tanzanian problems have therefore not yet been addressed. This has reduced effectiveness.
The HIV problem – the disease determinants
Little or no effort has been made to explain the differences in prevalence between the different regions and ethnic groups in Tanzania. Since sexuality is not openly discussed in public the determinants of the variation has not been brought up. The importance of concurrent partnerships in large sexual networks as an explanation for the uneven distribution of the disease has not yet been researched in Tanzania, but there is solid knowledge about the existence of this pattern of sexual contacts both at the community level and among programme managers at the national level. There are strong reasons to identify the determinants of HIV transmission in Tanzania more explicitly. The focus of interventions must be on prevention. It is crucial that an open discussion is initiated at the local and national level about how to change the perceptions that govern sexual behaviour.
Policies
There is a huge gap between national policies and the local realities. Policies are often strongly influenced by international politics. Both government and donor policies have to be better adapted to the realities and the resources available at national and local levels. These must guide policies and implementation, and therefore be subject to a more thorough analysis. The health sector reform has to address the resource problem more forcefully. The government must be assured of long-term financing to become more independent. It must subsequently take more responsibility for control efforts while donors should have more of a monitoring and evaluating role.
Plans and the substance of interventions
The current large gap between policies and reality leads to the formulation of unrealistic plans.
These are still comprehensive in nature since the main purpose is to attract funding. Feasibility is not seriously considered. The lack of a clear and specific definition of transmission factors of HIV has made it impossible to outline effective plans. These have mainly been templates of internationally outlined plans and therefore not considered the specificities of the Tanzanian situation. It is necessary to move away from these to country specific plans. These have to be based on existing local evidence. The main objective of planning must shift from assuring financial resources to maximising the use of scarce resources.
It seems that interventions directed at the community and that are aimed at behavioural change have had a strong impact on the epidemic in Uganda. There are good reasons to intensify current efforts encouraging the involvement of the community, both qualitatively and quantitatively, also in Tanzania. These should aim at social norm change, at feasible limitations to male sexual freedom and be culturally adapted to the different ethnic groups and social contexts. It is known from the struggle against female genital mutilation that achieving these changes will be difficult and will demand long-term sustained efforts. These have to be led by people with a deep understanding of and influence of the local context.
Operationalisation
Since plans are not adapted to the local resource level, they cannot in practice function as an instrument that directs implementation. Many of the previous ambitious plans have never been implemented. Realistic plans must be outlined. The human resource problem must be addressed.
The first measure might be to attempt to use existing staff more effectively through a further reform of the remuneration system.
There is a risk that the multi-sectoral approach could lead to resources being spread too thinly.
An initial focus on key sectors, such as health, local government, education and defence, is likely to be a more effective option. The use of experienced NGOs to strengthen the regional level and support implementation at district level and below, which is now actually practised through the Tanzania Multi-sectoral AIDS Control Project (T-MAP), is commendable and should be expanded to also include the health sector. There is a need to subject the health sector and STD/AIDS control to a joint analysis, which focuses on the human resource issue. The short-term need to address the AIDS problem through effective systems, implying strong vertical components in a resource poor setting, stand against the long-term interest of the gradual reinforcement of the entire health system through integration and the establishment of functional horizontal operational systems. The solution might be to do both at the same time – both to strengthen the system and support important interventions through projects.
Prioritised interventions
There is a need to prioritise instead of spreading resources too thin. Addressing determinants that fuel the epidemic and maintain sexual networks as well as factors that increase the probability of transmission must be short-term priorities. These should also include major programmes for male circumcision and a study on the feasibility of control of HSV-2 in the Tanzanian context.
Synergistic effects through a combination of interventions
Major interventions like STI control and ART are in themselves not likely to have any major direct impact on the epidemic in Tanzania. The scaling up of interventions is likely to lead to problems of the maintenance of quality and considerable loss of effectiveness because of the weakness of the system. Community effectiveness of STI control is likely to be low. ART is likely to have little impact on the incidence of HIV. However, both these interventions, if reinforced, can still contribute to HIV control mainly through making prevention more effective.
There is a need to review the current focus on care in control efforts and there are strong reasons to shift focus to prevention. The focus of interventions has to be on sexual behavioural patterns including concurrent partnerships and the main determinants of transmission, including circumcision status and genital ulcer disease. Bearing the low infectivity of the virus in mind, a combination of prevention interventions, including prioritised and context specific interventions aimed at changing behaviour and social norms as well as STI control and ART, if scaled up, is likely to have a decisive effect on the epidemic. However, social norm change is also likely to meet with great resistance and will demand an effort that is maintained over a very long time.
In order to ensure that there is no doubt where the focus of HIV control must be, maybe it is time to shift from the current two-objective approach: the prevention of new infections and prolongation of life of those infected and who are about to develop AIDS, to a strategy with one single main objective and also see the current life prolongation objective as an indirect contribution to this:
PREVENTION OF NEW HIV INFECTIONS