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Anna Zhang

August 16th, 2022

Fighting HIV in Tanzania: it is not just about sex

0 comments | 4 shares

Estimated reading time: 10 minutes

Anna Zhang

August 16th, 2022

Fighting HIV in Tanzania: it is not just about sex

0 comments | 4 shares

Estimated reading time: 10 minutes

Tanzania has been fighting a war against HIV for decades, but infection rates remain high despite policymakers spending billions of dollars on prevention every year. 4.8% Tanzanian adults still live with HIV, compared to 0.16% in the UK. In 2019 alone, 27,000 Tanzanians died from AIDS. This is because policymakers paid insufficient attention to evidence highlighting the importance of the structural factors including social stigma, criminalization of key populations, and gender inequality. Instead, they spent most HIV prevention funds on altering individual behaviours, such as sex education and condom promotion.

Policymakers in Tanzania continue to focus on HIV prevention measures that target individual choice and behaviour, particularly sexual transmission. In Tanzania’s 2017-2022 HIV prevention strategy, the government aims to increase condom use amongst people with multiple sex partners to 85% and sex education coverage in schools. These policies are based on a reductionist understanding of HIV transmission assuming that sexual transmission (through unprotected sex) is the single most important cause of HIV infection.

However, overwhelming evidence highlights structural causes of HIV transmission. Social stigma and criminalisation of key populations are the main social and legal factors that need to be addressed before behavioural policies can be effective. Key populations are groups at higher risk of HIV infection. The biggest three are female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM). Global research shows that FSW are on average 14 times more likely to catch HIV, PWID 22 times, and MSM 13 times compared to the general population. However, all three groups are illegal under Tanzanian law, which means they have to conceal their identities from the government, limiting their ability to access state-funded HIV prevention services. Without legal protection, female sex workers are vulnerable to sexual violence, human rights violations, and unprotected sex. With MSM being an already highly stigmatised group, the Tanzanian government suspended the registration of any non-profit organisations that supports homosexuality in 2016. Social stigma towards FSW, PWID, and MSM further increases their vulnerability towards HIV because these groups are seen as shameful and undeserving of help. Consequently, although policymakers introduced the HIV service package for key populations in 2019, access is still limited due to persistent social stigma and discrimination.

Gender inequality is another important structural reason behind HIV transmission. Firstly, due to male superiority in a patriarchal society, women face an increased risk of violence during sex and have little power to negotiate condom use. There is currently no legislation protecting women from domestic violence. Secondly, unequal economic status and property ownership result in women being economically dependent on men. Fear of abandonment. limits their ability to pressure men to use condoms.

The implication is that  individual behaviours are shaped by the broader legal, political, and socio-economic contexts. Education and promotion of condom use cannot be effective without addressing these structural factors . Therefore, most studies suggest that a combination of behavioural and structural approaches would maximise the effectiveness of HIV prevention. But policymakers in Tanzania focus mostly on the former. Whilst the most recent progress report in 2020 highlights efforts to address some of the structural factors, most remain at early developmental stage. In contrast, most behavioural prevention policies have been developed for decades and progress is rapid. This is evidence of a  technical bias because policymakers pay overwhelming attention to one type of evidence but ignore another types of evidence that is also relevant to the issue.

This bias has two underlying causes: path-dependent allocative decisions and preferences for short-term political returns. In Tanzania, funding for HIV prevention is allocated through priority-setting discussions. Due to fear of losing funds and hence their sources of income, agencies amplify the importance of their own department. For example, condom promotion agencies will not advocate for a shift in funding to tackle structural causes. Additionally, policymakers are pressured to make great impacts in a short time, so they always prioritise rapid-output’ interventions over ‘deep-impact’ interventions. It takes a long time to change social norms, including social stigma towards sex workers and acceptance of homosexuality. The self-interest of policymakers discourages them from shifting to structural prevention measures as impacts are usually indirect and difficult to measure.

HIV transmission is a multifaceted issue – the wider social, political, and legal structures behind it are difficult to address. However, I am not being pessimistic about the future of HIV prevention. Recognising the political nature of policymaking, creating incentives for policymakers to be more evidence-based is the way forward. Tanzania has been fighting a war against HIV for almost 40 years – it is time for a real change. The sooner policymakers shift to a structural approach, the more lives saved from the HIV epidemic.

About the author

Anna Zhang

Anna is a first-year student studying International Social and Public Policy at the London School of Economics. She is particularly interested in investigating education inequalities and social classes.

Posted In: International Social and Public Policy

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