The problem definition & the substance of interventions

Policies and the problem definition

The problem definition that is used internationally to direct control activities appears to be the result of an analysis, which to a large extent is derived from the context of HIV in Western high-income countries. Prevention is based on individual behavioural change and individual human rights, whereas social norms give priority to the community over the individual in many communities in sub-Saharan Africa. (Hyden and Lanegran, 1991). The importance of the local, cultural, social and economic context for sexual behaviour as pointed out in paper VI, has not been fully recognised in Tanzania. This is in accordance with what has also been pointed out for Zimbabwe (Decosas and Padian, 2002). Prevention will in the most affected population require both a reduction in the size of the sexual networks and a reduction in the likelihood of HIV transmission at each intercourse (fig. 13). To communicate this implies a need to address local socio-cultural and socio-economic determinants with the aim of achieving changes to social norms. Such an approach has not yet been explicitly discussed in Tanzania. With the introduction of ART the focus of interventions has instead shifted from prevention and a problem definition based on local contexts to the care of the sick. Yet, it seems obvious that a highly affected low-income country with a weak health system cannot use the treatment of those already infected as a main strategy to reduce the impact of HIV. There is no evidence base for a strongly treatment-based approach to HIV control in such settings. The balance between the two main aims of HIV/AIDS control, prevention of infection and prolongation of life became distorted when most resources are allocated to care. It seems clear that more life-years are likely to be saved through the prevention of new infections, rather than through the treatment of people who are about to develop AIDS. This is also reflected in cost-effectiveness estimates (Creese et al., 2002;

Marseille et al., 2002, Stover et al. 2006). Encouragingly, however, moves to address prevention issues more forcefully have been initiated of late (UNAIDS, 2006; African Union, 2006).

Prevention efforts directed at heterosexual transmission are further hampered by the fact that matters related to sexual activity are not publicly debated in Tanzania. A wealth of knowledge

with regard to the norms of how sexual activity is regulated within different ethnic groups and settings in Tanzania was noted to exist within the leadership of HIV control activities and their consultants. Still, these issues have not been brought to the public level maybe both because the issue at stake concerns sexuality and because they are therefore politically sensitive. Still, some of the issues, such as a levelling out of gender imbalances, are already part of government policies. But also certain biological factors are evidently difficult to tackle. Thus, a number of key determinants for HIV transmission have not as yet been sufficiently addressed in efforts to control the HIV epidemic in Tanzania and most of the rest of sub-Saharan Africa. These include both biomedical and social determinants (fig 13):

• Male circumcision

• Genital ulcer disease, in particular HSV-2

• Social norms out of tune in an era of a major deadly sexually transmitted infection;

including norms that maintain gender imbalances:

o Concurrent partnerships

o The freedom of male sexual activity

o Protection and control of the sexual activity of adolescent girls o Risky traditional practices

Addressing the social norms demands the involvement of the community in control efforts. This has also not been sufficiently achieved yet.

The substance of interventions

The template plans have not been good at taking locally generated evidence into consideration and where sexual behaviour is concerned they have to a large extent built on internationally formulated stereotypes. Therefore, many driving factors behind the epidemic have not been addressed. HIV/AIDS control activities in Tanzania started in 1985 and were up until 2002 determined by plans formulated with strong support and directives initially from WHO and since 1996 from UNAIDS, but implemented by the Ministry of Health.

Interventions were divided into those aimed at preventing transmission through sexual routes, from mother to child, through blood and skin-piercing instruments and those employed to monitor the epidemic and finally those that aimed at mitigating the effects of the epidemic (see above under 1.3 Interventions and implementers, page 51). It was realised early on that single men in the military, mines and along the trucking routes were particularly exposed and that sex workers as well as other young women were important for the propagation of the epidemic. It also became clear that age asymmetry, widow inheritance and some other traditional practices

were important in most areas. The importance of other STIs for HIV transmission was demonstrated initially through observational studies and later confirmed through a randomized control trial conducted in Mwanza, Tanzania (Grosskurth et al. 1995).

The interventions have partly shifted as there has been an increase in knowledge as regards the different determinants. As new interventions have been introduced internationally, such as STI control, counselling, home-based care and ARV treatment, they have also gradually been introduced in HIV control in Tanzania. Interventions have thus mainly been determined by the general policies of international agencies. Local research findings, even from Tanzania, have with few exceptions, such as the findings of the Mwanza trial on the effect of STI control on HIV transmission, had little influence on the substance of interventions.

Hudson, already in 1996 discussed the importance of concurrent partnerships (Hudson, 1996) on the basis of findings from Uganda (Hudson, 1993) and proposed what could be done to prevent HIV infection. He even called this a “paradigm shift” and suggested already then that efforts should be made to break the sexual networks as even small changes in these might have substantial effects on transmission (Woodhouse et al., 1994). Even though many of these proposals might have been unrealistic in the Tanzanian context, they were based on findings that merited an assessment regarding their importance in each setting.

Similarly, the successful approaches to HIV control in Uganda, characterised by openness, the involvement of religious organisations, community-based and culturally appropriate behavioural change strategies, have only been repeated to some extent in Tanzania. These approaches, it seems, led to the formation of more open social communication networks, which has yielded behavioural change (Stoneburner and Low-Beer, 2004) and might pave the way for future changes.

Incidence has to be reduced in order to control the HIV epidemic. The main aim of control activities has to be the prevention of new infections and a focus on determinants that drive the epidemic in each context as pointed out in paper VI. The review of the literature and the analysis of determinants show that certain determinants are likely to be more important for the propagation of the epidemic than others (fig.13). It is the main determinants outlined in figure 13 that need to be addressed if an evidence-based approach is to be used. Such urgent and feasible

interventions include the reduction of concurrent sexual relations, avoidance of separation of men and women due to socio-economic factors, such as giving the right of military conscripts to marry, and efforts to reduce risky sex with young girls (Laga, 2001), such as the abolishment of early initiation, increase of condom use among young people as well as offering circumcision through the regular health services.

Following such scaled up short-term interventions, long-term goals aiming at social norm change or even “social revolution” (Mandela, Guardian Nov 2001) might have to be defined.

Such an analysis of determinants has to be carried out on the basis of the understanding of the local context and a detailed knowledge of the specific interplay between a number of determinants that carry site specific weights as pointed out by Buve et al. (1995). To my knowledge this has not been done much either in Tanzania or elsewhere in Africa, nor has it been part of the international planning formats.

Thus, as far as I know, there have not been any interventions aimed at a break up of large sexual networks nor to discourage contacts between older men and young women. Still, research also from Tanzania has shown that this is likely to be an important factor for disease transmission (Boerma et al., 2003). Similarly, apart from activities in some privately run larger mines very little action has been taken to address the situation of single men in small mines. In Tanzania new conscripts are not allowed to marry during the first six years of service, which leads to a large number of single men in demand of sexual services. This issue has as far as I have been informed also not been addressed. In addition, the issue of the early initiation of girls in the south of the country has not been tackled. The issue of involving community members by informing them in a detailed way about epidemiological data as suggested in paper III has also not been brought up.

It therefore seems that neither evidence nor local disease determinants are able to influence the choice of interventions in Tanzania in the current aid architecture. It also seems to have been a tendency to passively wait for the international agencies to initiate control activities rather than using the improving national capacities. Sometimes, as has been the case with male circumcision, the people themselves have taken action and preceded the international research community, the donors and the Government. Thus, male circumcision increased already in the

early 1990s in Tanzania (Caldwell and Caldwell, 1996) and has probably increased substantially since then in urban settings, while the international research community has been very careful not to make any hasty conclusions on findings, which to many have seemed clear for a long time (Bongaarts et al. 1989). Furthermore, locally generated epidemiological reports have not been used much either to focus preventive efforts or as a basis for discussion on the importance of ethnically specific rules for sexual behaviour. Such a discussion might have to be initiated if social norms are to be changed.

Such changes we know from the long struggle against female genital mutilation are extremely difficult to introduce and continue to be met with strong resistance. Similarly, a struggle against widow inheritance, the early initiation of girls, child marriages and eventually even polygamy will be very long and difficult. Still it has to be initiated. If, as former President Mandela expressed it, there is a need for a social revolution, it has to be started. Although ARV treatment in itself is important and may indirectly contribute to the struggle it risks becoming a side track, which deviates resources from prevention efforts if given too much prominence. It does not constitute a starting point of the “revolution”. Perhaps the most feasible way to initiate this would be by attempting to change risky traditional practices. Although these may not be very important epidemiologically, altering or abandoning them will show that change is possible.

A biomedical approach would be to try to address biologically important determinants such as the lack of male circumcision and HSV-2 infection. The control of these determinants might be easier to achieve and might have to involve reinforced efforts towards producing an HSV-2 vaccine.

Certainly these two approaches have to be implemented in parallel. They should constitute the central part of HIV control as they both aim at reducing new HIV infection without which the epidemic cannot be controlled.