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Reflections on the HIV Epidemic in northern Tanzania

In 3 filmed interviews spanning over 30 years, Neurologist and Researcher, William Howlett reflects on the on-going HIV epidemic, from the first documented case to the situation today.

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ABC of HIV/AIDS
Photo:
William Howlett

As a medically trained humanitarian, Howlett first travelled to Africa in 1980. From 1984, he began as a Ministry-appointed specialist physician at Kilimanjaro Christian Medical Center (KCMC), in Moshi, in northern Tanzania. He has remained closely associated with KCMC ever since. Learn more about Howlett’s experiences.

In the first video, from 1987, he describes the beginning of the epidemic with the first officially documented case of HIV-AIDS that was diagnosed at KCMC in March 1984. In the third video from 2018, he cites UNAIDS statistics from 2016, to underline the scope of the epidemic. In Tanzania, a country of 55 million people, 1.4 million are HIV-infected. The UNAIDS statistics further indicate that in 2016, it is estimated that there are 55 000 new HIV-infections and 33 000 AIDs-related deaths annually.

 

1987 – is it an epidemic?

At the time of the video, 60 cases of AIDs had been documented at KCMC, arriving at an ever increasing rate since the first case in 1984. While the issue is tragic, the video provides a fascinating insight into the situation “at the front-lines.” The idea of an epidemic is just beginning to be considered. Understanding of the situation is in its early phases: how long is the incubation? How exactly is it spread? How can we treat it? Will there be a vaccine? Who is at risk?

Unlike in Europe and the West, AIDs in Africa is a heterosexual illness. Victims are adults of both sexes in their sexual prime. Howlett says that most of the cases he has seen have come from urban centres. People are beginning to understand that the full impact of the disease is invisible, because of the long incubation time from infection to full-blown disease. The tragedy of transmission to new-borns is just beginning to be observed.

The only defence against dying of AIDS, is to use condoms. Blood screening is starting to be implemented in major centres.

This video’s intended audience was humanitarian volunteers in Europe, intending to come to Africa. Howlett tells them that they need to be clear about their responsibilities to themselves and their families. That they need to understand potential, long-term impacts of any decisions they make. It is not the same situation, he says, as it was for volunteers 5-10 years ago.

 

Link to video

 

1989 – all are equal before AIDs

Just 2 years later, Howlett is interviewed again. It is interesting to note how much understanding of the epidemic has grown in the 2 years since his first interview. Research and reporting is increasing. Howlett says that Tanzania has reported 2 500 cases thus far to WHO.

Focus is being placed on Public Education measures. It is beginning to be understood, to use metaphors, that AIDs cases represent just the tip of the iceberg for a disease that has an incubation time as long as 7-8 years, or longer. The epidemic is spreading from the main concentration of cases in urban centres, where there are high levels of promiscuity. Such areas with prostitution, travellers, mobile populations create “whirlpools” of infection and may have rates of infection in these high risk population groups more than 70%. The infection spreads from these urban nodes to rural areas, spreading in “ripples”, as travellers return home to their families.

A highly specific blood test has been developed to ensure safer blood supplies, although, Howlett explains, this is not a major transmission route in Africa.

Howlett says that the difference between the AIDs epidemic in Europe and Africa is largely cultural. In the West, he says, there is less promiscuity. In Africa, promiscuity is more tolerated, especially in “travelling” communities of truck-drivers and businessmen. Specific communities of sexual workers have become established in all urban centres. In a cycle of poverty, it may be the only choice available to many women. These women, Howlett explains, act as repositories, and the visiting men are the vectors spreading the disease along transportation routes and to their homes, in rural settings.

Howlett and his wife, Juliet, have become increasingly engaged in Public Education – holding talks in Public Meetings, developing education materials, reaching out to social leaders … However, he says that providing information is not enough to change behaviour – people have to understand the information and its implications for their lives and the lives of their family members.. Be responsible. Tests are available – get tested. Be celibate if you are HIV positive, or, at least, use a condom. All are equal before AIDs, he says. Nearly 100% of patients with AIDs die.

 

Link to video

 

2018 – the epidemic continues

Today, HIV-AIDs is a major global health burden – and particularly so in sub-Saharan Africa, and in Tanzania especially, where over 30 million people have died of the disease. Progress has been made. While there is no vaccine, the development and availability of anti-retroviral treatments (ARTs) is ensuring that the infection is no longer automatically a death sentence. Perhaps nowhere is this a greater triumph than when ART is combined with pre-exposure prophylaxis (PrEP) in the prevention of mother to child transmission for HIV+ pregnant women and their babies.

However, the epidemic continues, and in some areas in Africa, such as southern Tanzania, it is actually increasing. Why?
 

Concurrency

Howlett says that some of the reasons behind differences in the progress of the epidemic in “the West” and Africa are grounded in the cultural differences. Primary among these are the accepted patterns of sexual activity. Howlett refers to the concept of “concurrency”, which was developed by medical doctor, researcher, and journalist, Helen Epstein. Concurrency refers to having long-term concurrent relationships with several partners. This practice is widespread in Africa and contrasts with the more serially monogamous relational behaviour in the West. Howlett also underlines the impact of the rampant poverty in Africa, which can turn sex into a form of currency, in particular for the children orphaned by AIDS, who grow up in a chaos that may render them particularly vulnerable to becoming infected as adults.
 

Most infectious stage

Another tragic risk factor that we now know, says Howlett, that the disease is at its most infectious state in the first 3 weeks after infection, “Stage One”, when the infected person shows no symptoms, but carries a very high viral load.

Four factors: promiscuity and concurrency, in addition to HIV stage, combined with geographic clustering (urban centres with high sexual activity), and the presence of other sexually transmitted diseases, provide us today with a kind of model for the epidemic. But, what is the way forward?
 

90-90-90

Globally, there is a great deal of data today about HIV-AIDs, says Howlett. Plans are being made, such as UNAIDS 90-90-90, which states:

  • By 2020, 90% of all people living with HIV will know their HIV status.
  • By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

 

Way forward

Howlett believes the way forward to combat this epidemic involves several parallel, complementary approaches.

  • Education: a rigorous and targeted approach that moves beyond informing to understanding
  • Barrier protection: the condom is to HIV as the mosquito net is to malaria
  • Providing drugs to high risk groups: test and treat whole at risk populations

Access the PowerPoint that accompanies this video.

Link to video