The UNAIDS 90-90-90 Target has set the goal that, by 2020, 90% of the HIV infected should know their status, 90% of those diagnosed should be in treatment, and 90% of those in treatment should achieve viral suppression. The UNAIDS GAP Report (2014) presses the need for countries to achieve a major redeployment of effort and resources towards tackling HIV among at-risk populations with a view to achieving that target (UNAIDS (STI/blog)).
Redeployment, a report by Congressional staff delegates on a visit to Tanzania hosted by the Infectious Diseases Society of America’s (IDSA) Global Education and Research Foundation gives a detailed account of the practical problems facing the attempt to make such ambitions a reality on the ground – even where UNAIDS recommendations are embedded in official government planning policy. Evidence from visits of the staff delegates to Dar-es-Salaam, Zanzibar and Mbeya in the rural highlands is illustrated with well-chosen photographs. These problems fall into three general categories.
First, there is a human resource problem. At present, there is a 65% vacancy rate for health-care positions in the public sector. According to the government figures, health workforce capacities have steadily declined from 67,000 in 1994/5 to 54,245 in 2002 to 48,000 in 2015. The PEPFAR (President’s Emergency Plan For AIDS Relief) operational plan attributes this in some measure to gaps in Tanzania’s education capacities with large classes and poorly trained teachers, leading to pupils leaving school without adequate study, problem solving and analytic skills.
As regards redeployment of these limited resources in line with UNAIDS recommendations, this is hindered by the fact that at risk groups may be criminalized (e.g. drug-users, sex workers, MSM) and are certainly stigmatized. Much of the outreach to them is through civil society organizations. While the government has policies to support and defend their efforts, there is little in the way of financial investment. Civil society organizations are hampered by the largely voluntary nature of their workforce, and the absence of adequate data concerning the size and whereabouts of at-risk populations (though it is estimated that between 2010 and 2015 the number of IDU rose from 25,000 to 50,000). The prison population seems to be altogether inaccessible.
Thirdly, HIV transmitted to children born to infected mothers is often ignored, and the number of adolescents dying of AIDS has risen by a third since 2005. This is partly because stigma surrounding a disease associated with IDUs, sex-workers MSM prevents parents from seeking diagnoses for their children. The situation is not helped be the frequently poor state of record-keeping with no digitalization and folders “jammed into, stacked on top of, and spilling out of record cabinets”.
Though no doubt inadequate, data on “at risk” populations is not altogether absent. Studies published in STI journal relevant to populations in specific places visited by delegates include an evaluation of surveys of MSM in Zanzibar, Haji & Kibona (STIs), and a discussion of the socio-demographic context of the epidemic in Mbeya, Riedner & Groskurth (STIs), focussing on female bar-workers. As a poor but high-mobility rural population, Mbeya appears to share some socio-demographic characteristics with Mzanza province in the NW (bordering Lake Victoria) which has figured in a number of studies at the beginning of the last decade. A number of these focus on barmaids as a particularly high-risk population (Hoffmann & Hoelscher(STIs); Boerma & Mwaluko (STIs); Bloom & Boerma (STIs)).