Control of HIV and other sexually transmitted infections : Studies in Tanzania and Zambia

Abstract: Background: Efforts to control STI/HIV in sub-Saharan Africa has met with difficulties. Although the epidemic seems to be levelling off, prevalence and incidence are still high in many parts. In spite of 20 years of HIV control activities little or no behavioural change has been reported in Tanzania. Reasons for this could be that determinants of transmission have not been properly addressed or that changing sexual behavioural patterns is difficult and demands long-term interventions to succeed. It could also be that the balance between prevention and care is not optimal or that implementation has not been efficient. In my studies I have focused on the health system and how interventions are planned and implemented. Objective : The overall objective is to identify and characterise major obstacles to the control of sexually transmitted infections and HIV in Zambia and Tanzania, respectively. Methods : In papers I and II we determined treatment efficacy and the quality of STI care through participant observation and patient interviews. The main method in papers III and IV-VI was participant observation including interviews and the study of grey and published literature. In paper VII the capacity for antiretroviral treatment (ART) was estimated through a scenario analysis. Main findings : Paper I showed that the Zambian STI treatment algorithms for genital ulcers were not efficacious as the treatment for chancroid lacked efficacy; paper II demonstrated that the health education part of syndromic management including condom promotion was poor and that vaginal examinations were rarely carried out. Paper III has two components. One is on health sector reform including effects of integration of HIV control activities into horizontal functions and the other on management aspects of STI/HIV control in Tanzania - also the subject of papers IV-VI. There are large differences in prevalence within Tanzania. The limited analysis of disease determinants and the little efforts at explaining these have resulted in plans that do not forcefully tackle the core problems surrounding sexual behaviour and the probability for transmission. Furthermore, since policies in many HIV related areas, such as ART, are linked to international politics, there is a large gap between policies and national and local resources. This has often led to the formulation of unrealistic plans, which are poorly adapted to the resource limitations and therefore rarely fully implemented. Instead they are outlined to attract funding. This has increased drastically during the last few years, but the human resources have remained limited. Although better funding opens up for improvements, over-financing will not increase service output much. The ongoing health sector reform has had to consider a situation of limited resources and how these should be allocated. The short-term interest of effective HIV control has stood against the long-term needs to strengthen the whole system - a dilemma not yet resolved, and now further complicated by over-funding for ART. Paper VII shows that international plans for an ART scale up are unrealistic and that only part of the treatment targets set in the national plan are likely to be met mainly due to the lack of qualified staff. Conclusions : Disease determinants need to be further researched and analysed. Country specific plans are needed. Current plans for HIV control are neither realistic nor adapted to actual resources causing distortion to how these are used. Plans have to aim at an optimal balance between prevention and care, and focus on the core of the problem: determinants of new infections. Operational issues have to be tackled. Neither STI case management nor ARV treatment currently contribute much directly to a reduction of HIV incidence, but may, if reinforced, add to the effect of prevention efforts. A multi-component prevention programme, if prioritised and scaled up, might - through synergistic interaction have a major effect of the epidemic and significantly reduce HIV incidence.