Multiple sexual relationships and the stigma associated with anti-retroviral therapy in rural Tanzania : implications for HIV prevention and treatment interventions

Background: Risky sexual behavior, HIV-related stigma, and poor access to HIV care and treatment are three interrelated factors in the prevention and treatment of HIV. For every person starting on HIV treatment, there are three who become newly infected, and social stigma hinders enrollment and access to HIV treatment. The scale-up of antiretroviral therapy (ART) in resource-limited settings has been one of the largest public health operations of our time. The current decrease of AIDS funding in Tanzania spawned the investigations in this thesis that simultaneously takes these three interrelated dynamics into account.

The primary aim of this thesis is to provide insights that will assist in the development of a nationwide and scientifically sound HIV/AIDS prevention and treatment strategy.

Methods: Qualitative and quantitative research approaches were used to collect and analyze the data. Paper I examines the attitudes, perceptions, and practices among healthcare workers, ART patients, and community members in regards to ART care and the perceived social consequences of the ART rollout. Paper II investigates female-driven multiple sexual partnership systems among both men and women in the community. In Paper III, a population-based survey was conducted as a follow-up to the findings in Paper I. This survey assessed the knowledge and attitudes about ART and ART patients among men and women aged 15 to 49 years old that had heard of ART. In paper IV we estimated the rates of pre-ART care and ART coverage. These values were calculated as the percentage of HIV-positive people receiving care or ART compared to those in need of treatment or care in the Rufiji district ART program from 2005 to 2010.

Results: The primary perception among participants in the studies was that ART was a means to extend life only for a brief period of time. They often employed the expression ‘‘marehemu mtarajiwa’’ or ‘‘dead to be’’ to describe patients on ART. Participants also assumed that ART patients pose a threat to society because they look healthier after starting on ART and intentionally transmit HIV to others (Paper I). Among those who had heard of ART, 24% were poorly informed about ART, 8% were moderately informed, and 68% were highly informed. In regards to ART-related stigma, 28% were the least stigmatizing, 41% were moderately stigmatizing, and 31% were highly stigmatizing toward persons taking ART. Participants who were well informed about ART held less negative beliefs about ART patients (Paper II).

ART coverage increased during each year of the program for women over the age of 25, but decreased for men and those younger than 25 years, the two groups who are not accessing the district ART program (Paper III). Socialization processes undertaken during adolescence have a profound impact on the likelihood of engaging in female-driven multiple sexual partnership systems (Paper IV).

Conclusion: The findings in this thesis capture the variable characteristics of sexual partnerships, ART-related stigma, and access to ART program intervention. They provide the detailed understanding of the sexual behavior, stigma, and ART coverage pattern in Rufiji district that is necessary for the optimal design of both HIV prevention and treatment interventions.

List of scientific papers

I. Agnarson AM, Masanja H, Ekström AM, Eriksen J, Tomson G, Thorson A. Challenges to ART scale-up in a rural district in Tanzania: stigma and distrust among Tanzanian health care workers, people living with HIV and community members. Trop Med Int Health. 2010 Sep; 15(9):1000-7.
https://doi.org/10.1111/j.1365-3156.2010.02587.x

II. Agnarson AM, Levira F, Masanja H, Ekström AM, Thorson A. Antiretroviral treatment knowledge and stigma-implications for programs and hiv treatment interventions in rural tanzanian populations. PLoS One. 2013; 8(1):e53993.
https://doi.org/10.1371/journal.pone.0053993

III. Levira F, Agnarson AM, Masanja H, Basia Z, Ekström AM, Thorson A. Antiretroviral treatment coverage in a rural district in Tanzania: a modeling study using empirical data. [Manuscript]

IV. Agnarson AM, Strömdahl S, Levira F, Masanja H, Thorson A. Female-driven multiple sexual partnership systems in rural part of Tanzanian province. [Manuscript]