Social, cultural and sexual behavioral determinants of observed decline in HIV infection trends: lessons from the Kagera Region, Tanzania
Introduction
The HIV-1 epidemic in sub-Saharan Africa is currently approaching its third decade, and various approaches have been used in order to monitor HIV trends in different settings (Kamali, 2000). In monitoring HIV trends, several studies in Africa have used population-based cross-sectional and longitudinal studies to better understand HIV infection prevalence and incidence trends in the general population. Some of these studies have been supplemented by studies attempting to understand patterns of behaviors associated with HIV/AIDS in the same population. Such study designs have been indispensable in identifying the factors that have been shaping the dynamics of the epidemic. Unfortunately, because of the high cost involved, very few longitudinal studies have included qualitative components that focus on socio-cultural and sexual behavioral changes.
The Kagera AIDS Research Project (KARP) is a bilateral (Tanzania/Sweden) research project that is unique in that it is an interdisciplinary long-term research commitment that has been able to follow the progression of the HIV/AIDS epidemic in Kagera since 1987. Since Kagera was the first region in Tanzania to be severely affected by the epidemic, the government, local as well foreign NGOs have carried out many public health intervention programs in this area. However, little is known today about the impact of these efforts. Additionally, little is known about how the severity of HIV/AIDS itself has also been instrumental in transforming the ways of life of the people who live in this area.
A population-based survey conducted by KARP in the region in 1987 showed a high prevalence of HIV infection, ranging between 0.4% and 10% of the population in the rural areas and 24.2% in the urban area of Bukoba (Killewo et al., 1990). A follow-up study in 1989 showed corresponding incidence figures in which the highest HIV incidence was in the Bukoba urban area (Killewo et al., 1993). The age-specific annual incidence was highest in those between 25 and 34 years for men and 15 and 24 years for women (ibid.) The KARP has continued to monitor HIV-1 infection prevalence and incidence trends in both the rural and urban areas of Kagera using both sentinel surveillance and population-based studies. Findings from these studies indicate a downward trend in both prevalence and incidence. In the Bukoba urban area, the prevalence of age-adjusted HIV-1 decreased from 24.2% in 1987 to 18.2% in 1993 and later to 13.3% in 1996. The age-specific decline was steepest among females aged 15–24 years. No age group exhibited a significant upward prevalence trend (Kwesigabo, 2001). A follow-up study of the incidence also showed a significant decrease. Analysis of socio-demographic characteristics indicated a significant decline among Christians, among people with comparatively high education (at least 7 years of schooling), and among married couples. Questions about behavioral factors indicated a rise in condom use and a rise in the proportion of individuals getting married, accompanied by a decrease in age at first marriage. Age at first intercourse seemed to decrease over time, and a majority reported having only one sexual partner (Kwesigabo, 2001; Kwesigabo et al. (1998), Kwesigabo et al. (2000); Kwesigabo, Killewo, & Sandstrom, 1996).
Section snippets
Objectives of the study
We believe that the results from our quantitative studies described above, though of course encouraging, also raise new questions that cannot be answered using the quantitative toolbox alone. Thus, the overall objective of this study was to explore the underlying factors that might help to understand and explain the observed declining trends of HIV infection By carrying out a qualitative study, we wanted to understand how the HIV/AIDS situation was perceived at individual, group and community
Theoretical framework
It is evident that heterosexual transmission of HIV infection is the most important in the AIDS epidemic in sub-Saharan Africa. As such, in the absence of cure or effective vaccine for AIDS, most African countries have focused on arresting the spread of the HIV virus by encouraging and promoting sexual behavior change (Benefo & Takyi, 2002). Risk reduction through sexual behavioral change is an important means of cutting the chain of transmission of HIV infection in high HIV prevalence and
Methods of data collection and analysis
This study was carried out in Bukoba, the regional capital of the Kagera region, located in the northwestern part of Tanzania on the shores of Lake Victoria. According to the 2002 National Population Census, the town has an approximate total population of 81,221 inhabitants of whom 40,822 are males and 40,399 are females. Most belong to the Bahaya ethnic group. The majority of the people living in this town are Christians (predominantly Catholics and Protestants) followed by Moslems and few
Marriage customs and family related practices
We asked our informants about the contemporary family institutions of marriage and also practices in relation to death and mourning. We also inquired about other customs and practices that have been associated with HIV/AIDS in the past. Our questions centered on abstinence, multi-partnered sexual relations, polygamy, widow inheritance, romantic sex, marriage rituals, and death and mourning customs. In their responses, we insisted that the informants compare the present with what has happened in
Discussion
In general, the findings of this study indicate that the Bukoba urban area is no longer the same. The presence of a severe AIDS epidemic in the town is forcing people to change not only their sexual behavior but also some traditions and customs that they consider as high-risk for HIV infection. The findings indicate that condoms are more accepted today than before by both women and men and that the stigma against those who use them is fading. Most youths who are sexually active understand the
Conclusion
The nature of the AIDS epidemic in Kagera in general and Bukoba in particular is changing. The indication that the prevalence and incidence of HIV is decreasing in the general population is encouraging and gives hope. However, further studies are needed to find out if the epidemic is being pushed towards marginalized social groups. The first lesson learned from the Kagera experience is that the situation of HIV/AIDS in sub-Saharan Africa is not completely hopeless. The declining trends of HIV
Acknowledgements
We wish to convey our sincere acknowledgements and thanks to the Swedish International Development Agency, Department of Research Cooperation (SAREC) for funding the research activities of the Kagera AIDS Research Project (KARP) that included the fieldwork for this study. We would also like to acknowledge the support of the KARP team members based in Kagera for assisting us in collecting these data. A variety of government officials at the regional and district levels assisted us a great deal
References (33)
Decline in the prevalence of HIV and sexually transmitted diseases among female sex workers in Contonou, Benin, 1993–1999
Acquired Immune Deficiency Syndrome
(2002)Change in sexual behavior and decline in HIV infection among young pregnant women in urban Uganda
Acquired Immune Deficiency Syndrome
(1997)Trends in HIV-1 incidence in a cohort or prostitutes in KenyaImplications for HIV-1 vaccine efficacy trials
Journal of Acquired Immune Deficiency Syndrome
(2000)- et al.
Mass media effects on AIDS knowledge and sexual behavior in Africa with special reference to Ghana
International Journal of Sociology and Social Policy
(2002) - et al.
The social construction of reality. A treatise in the sociology of knowledge
(1967) The social dimension of the AIDS epidemic
International Journal of Sociology and Social Policy
(2002)Declining HIV prevalence and risk behaviors in ZambiaEvidence from surveillance and population-based surveys
Acquired Immune Deficiency Syndrome
(2001)Increase in condom use and decline in HIV and sexually transmitted diseases among female sex workers in Abidjan, Cote d’Ivoire, 1991–1998
Acquired Immune Deficiency Syndrome
(2002)Stigma. Notes on the management of spoiled identity
(1963)- Heguye, E. (1995). Young People's Perception of Sexuality and Condom Use in Kahe. In: Knut-Klepp, Knut-Inge, Biswalo,...
Seven-year trends in HIV-1 infection rates and changes in sexual behavior among adults in rural Uganda
Acquired Immune Deficiency Syndrome
Sexual behavior patterns and condom use in TanzaniaResults from the 1996 demographic and health survey
AIDS Care
Prevalence of HIV-1 infection in the Kagera region of TanzaniaA population-based study
Acquired Immune Deficiency Syndrome
Incidence of HIV-1 infection among adults in the Kagera Region of Tanzania
International Journal of Epidemiology
Qualitative researchIntroducing focus groups
British Medical Journal
Cited by (53)
A multilevel analysis of the determinants and cross-national variations of HIV seropositivity in sub-Saharan Africa: Evidence from the DHS
2011, Health and PlaceCitation Excerpt :For both males and females, the risk was higher among the previously married (widowed, divorced or separated), those who initiated sexual activity at a younger age, had multiple sexual partners or had premarital sex. Thus, there is need for intensified efforts towards appropriate behaviour change, already observed to be effective in combating the spread of HIV transmission in selected settings in Africa (Lugalla et al., 2004). One of the specific objectives of this paper was to identify potential pathways through which various background factors are associated with the risk of HIV infection.
Factors Affecting Utilization of Voluntary HIV Counseling and Testing Services among Teachers in Awi Zone, Northwest Ethiopia
2017, AIDS Research and Treatment