Risky sexual behaviour and other socio-economic and cultural contexts for HIV infection
In this study mobility and migration were found to be among the socio-economic and cultural contexts predisposing mobile population to HIV infection. Another study in Tanzania found the same factors which are associated with occupational group such as fishermen to be important risk factors for HIV transmission [
17]. Other studies conducted in Tanzania have shown that numerous aspects of migration-being separated from one's spouse (both the traveller and the one staying behind), the frequency of travel, and the duration of time away from home-impact on risky sexual behaviour [
18]. High levels of short and long term mobility and being close to the trading centre were significantly associated with increased HIV incidence [
19]. More importantly, a risky sexual behaviour occurred more often in mobile, co-resident men, and in women living apart from their husbands, who infrequently see them, than in men and women who are separated for long periods of time [
20].
A study on commercial motorbike-taxi riders, locally known as
bodabodamenan indigenous employment group that is highly mobile but have not been studied before, has gone beyond epidemiological parameters and tried to highlight the social conditions which act as opportunities for HIV infection [
21]. However, it should be noted that mobility is not always associated with risky sexual behaviour. One study in Tanzania, for example, found that the
Maasaimen do not have sex outside wedlock when they travel to towns on business [
22]. Furthermore, it was also revealed that extramarital sexual relationships were not exceptional even in non-fishing community where polygamy and Christianity are widely practiced. This finding is intriguing as polygamy and Christianity are highly incompatible.
Although the extent of transactional sex (exchange of sex for material support including money and gifts) is not known, it is known that there are various forms of transactional sex taking place in Tanzania,
chomolea sex, which was found to be common in study communities is one of them. However, the line between transactional sex and female sex work is blurred. Many of the women who have had sex in return for gifts, money and the like would not classify themselves as sex workers. One study in a mining town in northwest Tanzania for instance, found many types of women receive payments for sex, distinguished by permanency of residence, age, relationship status, accommodation and income-earning activity, and that such activities were most likely to take place in towns, as a result of economic opportunities available there (in contrast to the poverty surrounding areas), which were often accessed by offering sex in exchange for money or gifts [
23]. Despite the argument that motivations for transactional sex, the way it is negotiated, its scale and consequences are still little understood [
23,
24], transactional sex is likely to increase the risk of HIV and other STIs by encouraging partner change, making relatively affluent men (often higher risk) more desirable, and creating uneven power relationship which makes it difficult to negotiate for condom use [
24,
25].
The importance of addressing sexual culture in research pertaining to AIDS has been underscored elsewhere [
26]. More importantly, behavioural interventions should directly address how embedded transactional sex is in sexual culture [
25]. Furthermore, no AIDS prevention programme can afford to ignore the socio-economic aspects of sexual behaviour or operate in isolation from the need for action on poverty and gender inequality. It should be noted that the meaning of sexual behaviour is not as self-evident as it appears. Anthropological accounts start from the premises that sexual behaviour is socially constructed-that is, its content and meaning are determined within social relations. However, the meaning of sex is not necessarily the same across all relationships. For instance, procreative aims may be emphasised fairly exclusively in marital sex but not in non-marital or extra-marital relationships. Knowledge of the extent of the separation of sex from reproductive aims for both sexes will be important both in assessing 'risk' categories and in the formulation of campaigns to promote condom use and safer sex [
27].
Among study communities it has also been revealed that there still exist traditional practices such as female to female marriages, death cleansing through unprotected sexual intercourse, wife sharing and inheritance; and traditional male and female circumcision that health interventionists have got to contend with in promoting AIDS control measures. In most cases these traditional practices are sanctioned by clan leaders. A recent study has revealed that traditional circumcision practices for cultural reasons are still common in Tanzania [
28]. Furthermore, the practice of inheriting widows and wife sharing in the form of in-laws sexual relationships is also taking place in several districts of Kagera region in Tanzania [The Tanzania Red Cross Society & Danish Red Cross, unpublished report]. Regarding the issue of addressing the afore-mentioned cultural practices, there has been a long-running debate as to whether sexual cultures in sub-Saharan Africa are permissive or characterised by restrictive rules, rituals and self-restraint and the fight against AIDS in Africa is often presented as a fight against 'cultural barriers' [
29]. However, we do concur with writers who perceive them as not 'cultural barriers' in the war against AIDS, and therefore should not be seen as promoting the spread of HIV but we should rather try to make such behaviour and practices safer in a way that is culturally acceptable to the people [
11,
29].
Over-night social functions coupled with excessive alcohol consumption have been found to constitute social contexts for HIV infection in the study communities. Similarly, dusty discos have also been pointed out as social contexts for sexual and reproductive health risks and vulnerability for adolescents in rural Mwanza [
30]. In the same vein, alcohol use is a key social behaviour that has been consistently associated with increased risk of HIV acquisition in many settings. In a systematic review and meta-analyses of 20 studies conducted in Africa, alcohol drinkers had 57-70% greater risk of being HIV infected than non-drinkers [
31]. There are several factors which may account for the increased risk of HIV among alcohol drinkers. Alcohol has been associated with increased risk of other STIs which are known to facilitate HIV acquisition and transmission [
32]. In a review of empirical studies conducted in sub-Saharan Africa, alcohol consumption was consistently related to risky sexual behaviour, including multiple sexual partners and lack of condom use [
33]. Thus, alcohol may be associated with high risky sexual behaviour which facilitates HIV acquisition and transmission.
Preventive measures against HIV and AIDS
Human behaviour is complex; widespread behaviour changes are challenging to achieve; and there are important gaps in our knowledge about the effectiveness of HIV prevention. Yet the research to date clearly documents the impact of numerous behavioural interventions in reducing HIV infection. We also know that in all cases in which national HIV epidemics have reversed, broad-based behaviour changes were central to success [
5]. Nevertheless, sexual practices have proven difficult to change. Contemporarily, condom is promoted most often as a device to avoid STIs including HIV. However, condom use often represents a decision to have 'unnatural' or 'undesirable' sex, for example with prostitutes [
6]. The use of condoms during sexual intercourse may even become symbolic of suspicion and mistrust. This leads to problems of negotiating condom use among partners who are socially intimate. Therefore, understanding decision-making and power in sexual relationships is crucial to promoting and predicting condom use. However, a recent review of 18 meta-analyses found significant increase in condom use and reductions in unprotected sex [
5]. Furthermore, a recent study in Tanzania found that there were significant increases in condom use amongst young women and older men over 15 year period [
34]. Nevertheless, the limiting factors with regard to condom use from our study can be summarised as follows: lack of knowledge on how to use them, practical factors such as limited availability of condoms because of inadequate supply, or inaccessibility of stock and financial constraints.
Basing on both the experience from review of the previous interventions designed and implemented in the study communities, study findings and recommendations; and stakeholders views during dissemination workshops; the following is a brief outline of the interventions developed in a form of an intervention manual: Strategies for the provision of action-oriented and community-integrated health education/promotion at all levels; strategies for reaching adolescents; strategic income generating activities for empowerment; developing more gender-sensitive health-financing mechanisms; integration of HIV services with reproductive health services; strategies for reaching orphaned children; provision of medical support/counselling; strategies for addressing harmful cultural practices/behaviour; prevention of HIV infection through syndromic management of STIs; expanding the provision of antiretroviral treatment and condom promotion programme.