Social, cultural and sexual behavioral determinants of observed decline in HIV infection trends: lessons from the Kagera Region, Tanzania

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Abstract

This paper is a follow-up of earlier findings by the Kagera AIDS Research Project (KARP), which documented declining trends in the prevalence and incidence of HIV infection in the Kagera region of Tanzania. The paper examines socio-cultural and sexual behavioral changes as possible determinants of the observed declining trends in Bukoba, the largest urban area of the region. The study used in-depth interviews, focus group discussions, field observations and ethnographic assessments to collect the required data. The findings suggest that since the initial years of the epidemic there have been significant changes in sexual behaviors, norms, values, and customs that are considered high-risk for HIV transmission. The findings show an increase in condom use, abstinence, zero grazing (sticking to one sexual partner) and uptake of voluntary HIV testing while traditional practices such as polygamy, widow inheritance, excessive alcohol consumption, and sexual networking are declining. We suggest that these changes are partly a result of the severity of the epidemic itself in the study area, and interventions that have been carried out in this area since 1987. The major interventions have included health education, the distribution of condoms, AIDS education in schools, voluntary HIV counseling and testing. These are encouraging findings that give hope and we believe that other places within Tanzania and other countries experiencing a severe AIDS crisis have much to learn from this experience. However, changes in norms and behavior are vulnerable; people in Kagera are still at risk and there is a need for continued intervention together with monitoring of the direction of the epidemic.

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)

  • M Alary

    Decline in the prevalence of HIV and sexually transmitted diseases among female sex workers in Contonou, Benin, 1993–1999

    Acquired Immune Deficiency Syndrome

    (2002)
  • G Asiimwe-Okiror

    Change in sexual behavior and decline in HIV infection among young pregnant women in urban Uganda

    Acquired Immune Deficiency Syndrome

    (1997)
  • J.M Baeten

    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)
  • K.D Benefo 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)
  • P Berger et al.

    The social construction of reality. A treatise in the sociology of knowledge

    (1967)
  • B.P Bowser

    The social dimension of the AIDS epidemic

    International Journal of Sociology and Social Policy

    (2002)
  • K Fylkesnes

    Declining HIV prevalence and risk behaviors in ZambiaEvidence from surveillance and population-based surveys

    Acquired Immune Deficiency Syndrome

    (2001)
  • P.D Ghys

    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)
  • E Goffman

    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,...
  • A Kamali

    Seven-year trends in HIV-1 infection rates and changes in sexual behavior among adults in rural Uganda

    Acquired Immune Deficiency Syndrome

    (2000)
  • S.H Kapiga et al.

    Sexual behavior patterns and condom use in TanzaniaResults from the 1996 demographic and health survey

    AIDS Care

    (2002)
  • Killewo, J. Z. J. (1994). Epidemiology towards the control of HIV infection in Tanzania with special reference to the...
  • J.Z.J Killewo et al.

    Prevalence of HIV-1 infection in the Kagera region of TanzaniaA population-based study

    Acquired Immune Deficiency Syndrome

    (1990)
  • J.Z.J Killewo et al.

    Incidence of HIV-1 infection among adults in the Kagera Region of Tanzania

    International Journal of Epidemiology

    (1993)
  • J Kitzinger

    Qualitative researchIntroducing focus groups

    British Medical Journal

    (1995)
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