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Tanzania is the largest country in eastern Africa. It lies between Mozambique and Kenya and has a coastline on the Indian Ocean. It also borders Malawi, Zambia, Democratic Republic of the Congo, Uganda, Rwanda and Burundi. The country is divided into 26 regions, 21 of which are on the mainland (formerly Tanganyika) and five on the island of Zanzibar.

Tanganyika was a German colony — part of German East Africa — from the late 19th century until the end of World War I, when a League of Nations mandate ceded control of most of the territory to the United Kingdom. The island of Zanzibar was an early Arab and Persian trading port that was made a British protectorate in 1890 as part of an Anglo-German agreement. In the early 1960s, both the mainland and island gained independence from Britain, soon merging to form the United Republic of Tanzania. The country remains comprised of those two semiautonomous states, and political tensions persist between the island and the mainland.

Tanzania has been ruled by the same party, Chama Cha Mapinduzi (CCM), since its independence. In 1995, the first multiparty elections were held, but CCM, led by Benjamin Mkapa, retained control. In December 2005, Jakaya Mrisho Kikwete, previously the foreign minister, was elected to a five-year term as president, the fourth since the country’s independence from the U.K. in 1961.

The face of HIV

The first case of AIDS in Tanzania was diagnosed in 1983. Four years later, there were cases in every Tanzanian district. AIDS is the leading cause of death in Tanzania, responsible for about 30 percent of all fatalities.

According to the U.S. Centers for Disease Control and Prevention, 70.5 percent of the people living with HIV/AIDS are ages 25 to 49; 15 percent are 15 to 24 years old, with 60 percent of all new infections falling in this age group. With 45 percent of the Tanzanian population under 15, the high rate of infection among young people is a growing concern.

Women between 25 and 34 have the highest rate of infection, and single women are more likely to be infected than married women. According to Tanzania’s Global Fund Coordinating Mechanism, 82 percent of all HIV transmissions is through heterosexual sex and 6 percent is through mother-to-child transmission. The remaining 12 percent comprises intravenous drug use, men having sex with men and blood transfusions.

The first case of AIDS in Zanzibar was diagnosed in 1986. Its current infection rate in Zanzibar—about 0.6 percent compared with almost 9 percent overall in Tanzania—is a fraction of the mainland’s for several reasons. The regional and societal differences in infection rates, knowledge of the disease, prevention measures and access to health care are significant. For example, according to a study by the University of California, San Francisco, when asked about measures that can be taken to prevent infection, 73 percent of urban women mentioned condoms, compared with 49 percent of rural women. For men, condoms were mentioned by 82 percent in urban settings and by 67 percent in rural settings. In Zanzibar, only 32 percent of women and 44 percent of men mentioned condoms.

The HIV infection rate in Zanzibar is a fraction of the mainland’s for several reasons. For one, Zanzibar has a more controlled population. The movement of people to and from the island is much lower than on the mainland. In addition, Zanzibar has a “fairly well developed civil society response to AIDS,” said Michael Gehron, the outreach coordinator in Tanzania for PEPFAR, the President’s Emergency Plan for AIDS Relief, a five-year, $15 billion U.S. initiative to fight AIDS abroad.

Throughout the whole country, however, the devastating affects of HIV are highly visible.

“People are constantly ill, going to the hospital, dying,” Gehron said. “At first I thought they had a culture oriented towards funerals, but it turns out there are just a lot of people dying.”

Challenges to fighting the HIV epidemic

Although it is one of the most politically stable countries in Africa, Tanzania is one of the poorest countries in the world. It ranks 162 out of 177 on the United Nations’ Development Program’s Human Development Index, a comparative measure of factors affecting the quality of life in a given country. More than one-third of Tanzania’s population lives below the poverty level.

Poor transportation infrastructure and limited access to vehicles also pose significant challenges to delivering health care services. “Lots of people point to the difficulty of reaching the remote populations,” Gehron said. “Tanzania is the largest country in East Africa and has a population of 40 million and very, very few roads. Eighty percent of the population is rural.”

Another challenge is polygyny, which increases the infection risk because of multiple sex partners. According to a report by the University of California, San Francisco, 29 percent of all Tanzanian women and 15 percent of men are involved in polygynous marriages.

Unequal access to resources has led to a higher infection rate among women in the country. For example, as of 1999, 40 percent of Tanzanian women had never attended school, compared with 31 percent of men. The illiteracy rate among women is 29 percent; among men, 14 percent. In prevention programs aimed at schoolchildren, the relatively low rate of schooling is a hindrance.

With new political leadership in place — the current president was elected at the end of 2005 — PEPFAR’s Gehron says although combating HIV is a priority of the Tanzanian president, how that will play out in the new government remains to be seen.

Tanzanian government response

In 1987, the government created the National AIDS Control Program, which placed AIDS coordinators in all of the country’s 26 districts. In 1999, then-President Mkapa declared HIV a national disaster and called for scaled-up efforts to combat the disease.

In 2001, the government established the Tanzania Commission for AIDS, which was charged with providing “strategic leadership” for a national response to the epidemic.

In January 2003, the government published the National Multisectoral Strategic Framework on HIV/AIDS 2003-2007, which was designed to launch a national policy on fighting the disease and give guidance to partners in the fight.

But many factors, including insufficient resources, corruption and inadequate leadership have prevented the country’s response from being as effective as it could be.

U.S. government response

The U.S. government is the largest HIV/AIDS donor in Tanzania. In fiscal 2005, the country received $28.1 million for prevention activities, or 30.6 percent of the country’s total PEFPAR funding for prevention, care and treatment. Another $19.2 million — or 21 percent — went to care, while treatment activities were allocated $44.5 million — or 48.4 percent.

The U.S. government works closely with the Ministry of Health and the Commission on AIDS, both of which are prime partners that receive funding directly from PEPFAR. The U.S. is also forming a partnership with the Ministry of Education and, through the U.S. Department of Defense, is establishing a humanitarian program with the defense department in Tanzania to address the epidemic.

Additionally, PEPFAR is working with 80 local nongovernmental organizations, which receive grants.

“What we’re trying to do is try to build indigenous capacity” to promote sustainability, said Tracy Carson, Tanzania’s PEPFAR coordinator. “We should be putting ourselves out of business.”

Tanzanians tend to be socially conservative, and in many cases, according to Gehron, faith-based organizations are the only groups that can reach certain parts of the population. Although in 2005 only two faith-based organizations in Tanzania — Catholic Relief Services and World Vision International — were prime partners, PEPFAR works through many local faith-based organizations. Those sub-partners receive money through prime partners rather than directly from the U.S. government.

One particularly successful part of PEPFAR’s work in Tanzania is spreading the AIDS message, Gehron said. “Tanzania has a high percentage of people who are aware of what HIV is and how not to get it,” he said. “What we’re trying to do is work on behavior change.” The message is spread on radio programs and in schools.

One area in which PEPFAR has made a significant difference is in supplying antiretroviral treatment, or ART, to the people of Tanzania. In October 2004, only about 1,500 people were receiving ART, a drug regimen that has largely transformed HIV/AIDS from a fatal condition to a manageable illness. Ten months later, that number had increased nearly tenfold to more than 14,000.

According to the Country Operational Plan for fiscal 2006, PEPFAR’s goal is to provide ART to 45,000 people by the end of the fiscal year. Gehron said the program is on track to do that.

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