HIV/AIDS in the Shadows of Reproductive Health Interventions

Abstract

In December 1999, the Tanzanian president declared HIV/AIDS a national disaster. By the time the National Policy on HIV/AIDS was released in 2001, an estimated 750,000 women of reproductive age were infected. Yet in spite of the impact of HIV on reproductive health, AIDS and reproductive health programmes are still thought of and implemented through separate channels, to the detriment of both. However, although AIDS remains in the shadows of reproductive health interventions, the lack of AIDS talk does not lessen the impact of the disease on people's lives. During the course of my participant observations in maternal and child health/family planning (MCH/FP) clinics collected during 25 months of fieldwork in 10 clinics in Morogoro, Ruvuma and Kilimanjaro Regions, I rarely heard about AIDS. This article attempts to analyse why. Historically competing bureaucracies in MCH/FP and gender and development are not easily unified with a vertical HIV/AIDS control programme under the umbrella of “reproductive health”. HIV/AIDS cannot merely be inserted into existing family planning programmes, re-named “reproductive health” programmes. As the AIDS epidemic is transformed through new technologies, reproductive health policy and priorities will be called into question and force us to look at the state of the African health care system, networks of care-giving, and how individuals and communities fail when there is no socio-economic safety net.

Résumé

En décembre 1999, le Président tanzanien a qualifié le VIH/SIDA de catastrophe nationale. Quand la politique nationale sur le VIH/SIDA a été publiée en 2001, quelque 750 000 femmes en âge de procréer étaient infectées. Malgré l'impact du VIH, les programmes de santé génésique et de lutte contre le SIDA sont encore pensés et appliqués dans des réseaux séparés, au détriment des deux. Néanmoins, si le SIDA demuere dans l'ombre des interventions de santé génésique, le manque de débat n'atténue pas l'impact de la maladie sur la vie des gens. Pendant mes 25 mois de travail dans 10 dispensaires de santé maternelle et infantile et de planification familiale (SMI/PF) des régions de Morogoro, Ruvuma et Kilimanjaro, j'ai rarement entendu parler du SIDA. Cet article tente de savoir pourquoi. Des services de SMI/PF et de développement des femmes traditionnellement concurrents ne fusionnent pas facilement avec un programme vertical de lutte contre le VIH/SIDA sous le chapeau de la « santé génésique ». Le VIH/SIDA ne peut être simplement intégré dans les programmes de planification familiale, rebaptisés « programmes de santé génésique ». A mesure que l'épidémie de SIDA est transformée par les nouvelles technologies, les politiques et les priorités de santé génésique sont remises en question et nous forcent à examiner l'état du système de santé africain et des réseaux de soins, et la manière dont les individus et les communautés échouent quand un filet de sécurité socio-économique fait défaut.

Resumen

En diciembre 1999, el Presidente de Tanzania declaró el VIH/SIDA un desastre nacional. Al momento de publicar la Polı́tica Nacional de VIH/SIDA en 2001, aproximadamante 750,000 mujeres en edad reproductiva estaban infectadas. Sin embargo, a pesar del impacto de VIH sobre la salud reproductiva, todavı́a se consideran y se implementan los programas de SIDA y de salud reproductiva por separado, para el perjuicio de ambos. Sin embargo, aunque el SIDA permanece a la sombra de las intervenciones en salud reproductiva, el silencio respecto al SIDA no amortigua el impacto de la enfermedad sobre las vidas de las personas. Durante observaciones participativas realizadas durante un total de 25 meses de trabajado de campo en 10 clı́nicas de salud materno-infantil/planificación familiar en las regiones de Morogoro, Fuvuma y Kilimanjaro, rara vez escuché hablar de SIDA. Este artı́culo intenta explicar el por qué. Las burocracias de salud materno-infantil/planificación familiar y de género y desarrollo-que históricamente compiten entre si-no se unifican fácilmente con un programa vertical de VIH/SIDA bajo el paraguas de la “salud reproductiva”. Tampoco se puede simplemente insertar la prevención, tratamiento y cuidado de VIH/SIDA en los programas existentes de planificación familiar re-titulados como programas de “salud reproductiva”. Mientras la epidemia de VIH esté transformada por las nuevas tecnologı́as, se verán cuestionadas las polı́ticas y prioridades de la salud reproductiva y nos veremos obligados a mirar el estado del sistema de salud africano, las redes de cuidado, y la manera en que fallan los individuos y comunidades cuando no existen mecanismos de seguridad socio-económica.

Key Words:

• HIV/AIDs
• reproductive health services
• integration of services
• Tanzania

In 1983, Kagera Region reported Tanzania's first cases of AIDS. In December 1999, President Mkapa declared the epidemic a national disaster. By the time the National Policy on HIV/AIDS was released at the end of 2001, 7.8% of adults in Tanzania had HIV infection,¹ including an estimated 750,000 women of reproductive age, and AIDS was the leading cause of death among women of reproductive age. Already between 1992 and 1995 AIDS accounted for over 36% of all deaths in three regions of Tanzania.² Yet in spite of the impact of HIV on reproductive health, AIDS and reproductive health programmes are still thought of and implemented through separate channels, to the detriment of both important agendas in Tanzania. Similarly, in some areas of research, the emphasis on AIDS eclipses all other development issues, while in other areas, AIDS has had a negligible effect.³⁴ However, although AIDS remains hidden in the shadows of reproductive health interventions, the lack of AIDS talk does not lessen the impact of the disease on people's lives.

Tanzania's AIDS control efforts began in 1986 with the establishment of the National AIDS Control Programme, yet HIV prevalence rates continue to rise in most parts of the country.⁵ This Programme has been criticised for being thinly spread, lacking effective leadership, viewing AIDS primarily as a health issue⁶ and ignoring its behavioural and socio-economic aspects. However, the Programme provided the foundation for the development of a National Policy on HIV/AIDS (November 2001) and for the creation of the Tanzania Commission for AIDS to lead a multi-sectoral national response under the Prime Minister's Office.

Reproductive health needs in Tanzania are meant to be fulfilled through an integrated clinic structure designed to combine family planning and maternal and child health services. These integrated services may be situated within different types of health care structures: (1) a dispensary, the smallest type of health facility designed to serve a ward with a population of about 6,000; (2) a health centre, with 20–30 beds, that is supposed to function as a small hospital; or (3) a hospital, which may be classified as a district, regional or consulting hospital.⁷ Private services are also available for a fee from some church-based or NGO providers (such as the Marie Stopes Clinic or UMATI, the Tanzanian Family Planning Association). Still, 75% of all women using modern contraception obtain their contraceptives from government sources,⁷ and more than 60% of all health services are provided by the government,⁸ underscoring the importance of public service provision for reproductive health access in Tanzania.

Tanzania has been successful in implementing the family planning component of its reproductive health strategy. According to three Demographic and Health Surveys (DHS), family planning use in Tanzania more than doubled in the 1990s, rising from 10.4% of married women who were using a method in 1992 to 18.4% in 1996 and 25.4% by the 1999 survey.⁸¹⁰¹¹ There was also a consistent downward trend in the total fertility rate from 6.5 in the 1988 Census¹² to 5.6 in the 1999 Reproductive and Child Health Survey.⁸ However, the country has seen less success in improving other aspects of reproductive health. For example, the proportion of births assisted by trained medical personnel has declined steadily, and women are less likely to receive professional assistance at delivery than in the 1970s.⁹ Clinics are often lacking in essential supplies, including basic drugs. Furthermore, a recent nationally representative facility survey found that less than 1% of government dispensaries had a working light source, laboratory or refrigerator,⁸ and shortages of basic equipment and supplies found in Tanzanian clinics are an ongoing problem.⁸¹³¹⁴ The impact of HIV/AIDS and related illnesses on the already-declining public health sector can only be hypothesised. Yet, as Tibaijuka¹⁵ reminds us, “The deplorable state of public health facilities in the country will continue to contribute to the spread of disease, including HIV.”

Observation of family planning clinic visits: HIV/AIDS barely mentioned

In two field trips to Tanzania, in 1995–96 and 2000, I conducted interviews with providers and women attending for care, and observed clinic visits in maternal and child health/family planning (MCH/FP) clinics. On the first visit, over a period of 18 months, I visited ten clinic sites (equally distributed between urban and rural areas) in the Morogoro, Ruvuma and Kilimanjaro Regions and interviewed 200 women. The bulk of my participant observation was done in clinics where I also sampled women for my client interviews; however, I conducted similar research visits less frequently to other clinics for exploratory and comparative purposes. I spent no less than three weeks of observation at each site, and in some urban sites and one village I was able to visit regularly over a period of seven months. The main sites consisted of five urban clinics and five villages within the three regions. On the second visit, I spent six months in Kilimanjaro Region. I then made a brief trip back to Dar es Salaam and Kilimanjaro in 2002 for research dissemination. These regions and sites were chosen to represent areas of high, medium and low rates of contraceptive use, and clinic sites were chosen in consultation with district and regional MCH coordinators to reflect a variety of service provision scenarios. Details of the study methodology and findings are published elsewhere.⁸¹³

During observation of family planning clinic visits, I rarely heard about AIDS. There were AIDS-related NGO projects, usually operating in the towns, in some cases, separate sexually transmitted infection (STI) clinics within hospitals and the government AIDS Control Programme in Tanzania. But in the course of the “normal” visit for family planning, AIDS was confined to a brief mention during counselling for informed choice, in which women were told that condoms prevent STIs such as HIV, and other methods do not. Although the service providers I observed were never shy about giving their clients health care advice, both solicited and unsolicited, HIV/AIDS was not a topic in these conversations. Why was it that AIDS was so conspicuously absent from interactions in MCH/FP clinics?

Petchesky¹⁶ argues that the indivisibility of rights is critical to thinking about women's health and empowerment. Yet, the historically-competing bureaucracies in family planning, maternal and child health, gender and development, and HIV/AIDS are not easily unified under the umbrella of “reproductive health”. A population discourse dominated by concern for controlling fertility, whether by women, couples or governments, precludes adequate incorporation of the challenges that AIDS brings to health care policy. Today, reproductive health programmes in many developing countries are still being implemented through the same structures as the old population policies. When HIV/AIDS is at the centre of women's lives— even though it is unspoken—and reproductive health services do not involve meaningful interventions for prevention and treatment, AIDS threatens to render meaningless the other important accomplishments of the reproductive health agenda. In the midst of the AIDS pandemic in many African communities, “reproductive health” might be best understood as being able to remain healthy long enough to reproduce and raise children. In this context, Bangser argues: “A renewed commitment to primary health care is perhaps the most critical need in Tanzania to establish a foundation for reproductive health”.¹⁷

One of the best MCH/FP clinics I visited in Tanzania, Karanga Clinic (not its real name), gave women a health education lecture and counselling for informed choice in small groups; then each woman selected a method alone with the service provider. As part of the lecture, women were told about the advantages and disadvantages of the methods in the standard “cafeteria” menu of contraceptives provided. In most urban MCH/FP clinics, this consisted of contraceptive pills, IUDs, injectables, contraceptive foam and condoms. Women could also be referred for contraceptive implants or surgical sterilisation. Diaphragms were supposed to be part of the method mix, but in practice were not available. As regards the risk of HIV infection, one typical lecture I attended included the message that condoms were the only contraceptive that protects against sexually transmitted infections, such as HIV, but nothing more. Or, in the words of another Tanzanian service provider I observed:

“You should use one if you are concerned about that sort of thing.”

Although condoms are distributed at MCH/FP clinics, men in Tanzania, as elsewhere, often make the final decision on condom usage, and men are almost universally absent from MCH/FP clinics.

HIV the worst problem but it's “just too much”

One of Morogoro's most respected obstetrician–gynaecologists surprised me during an interview when I asked her: “What is the biggest gynaecological problem here in Morogoro?” and she responded, “People are lacking in education about family planning. They have seven or even eight children each.” According to the 1999 Reproductive and Child Health Survey, in 93.5% of all couples both partners knew a modern method of contraception.⁸ Given the nearly universal knowledge of family planning in the country, I was surprised that this was the biggest problem she saw in her practice. Wanting to understand more about her work in other areas of reproductive health, I asked: “Which STIs do you treat most often?” Immediately she answered: “Syphilis” but then she stopped and added: “HIV, of course is the highest, but it is just too much”. Thus, syphilis and some gonorrhoea could be treated, and condoms and other contraceptives could be distributed to her patients, but HIV was just too much.

I was surprised to find a lack of attention to HIV/AIDS among service providers like her, who might be expected to deal with it most directly. One doctor working at an NGO clinic said that this was because there was no functional STI clinic in his locale, which presumably he thought should have carried out this task if it existed. In 1996, the STI specialist at Karanga Clinic said that most people in Morogoro bought medications and treated themselves for STIs because “they are ashamed and don't come [to the clinic]”. If she suspected that a patient had HIV, she would refer them to the Regional Hospital. The Hospital, she reported, would tell the person they were testing for typhoid, but would actually do an HIV test. If the test gave a positive result, they would not tell the patient for fear that he or she would commit suicide. The gap between protocols for HIV testing and the actual responses of local institutions was immense in the mid-1990s. Yet I found from the interviews I conducted even in 1995–96 that knowledge about AIDS—e.g. that it was sexually transmitted and had no cure—was nearly universal. So where did this unwillingness of reproductive health workers to discuss AIDS come from?*

Health system structural constraints on integrated care

Why was the need to combat HIV/AIDS not having a synergistic effect on improving the health care system and boosting economic development in countries like Tanzania? There are both local and global constraints on providing reproductive health services to HIV-positive women. AIDS problems are most often being dealt with through policies and projects which are seen as competitors for reproductive health funding, not as contributors to rethinking reproductive health policies and priorities. Financial uncertainty, uncoordinated donor efforts, and tensions in the decentralisation of service provision have led to stalled integration efforts throughout the Tanzanian health care system.¹⁸ Similarly, the insights of the reproductive health agenda, wedding reproductive health, empowerment and the right to health care, are not easily incorporated into the behavioural models of HIV/AIDS interventions.

By the year 2000, awareness of the importance of improving women's reproductive health had been effectively disseminated in Tanzania. The National Family Planning Programme was renamed the National Reproductive and Child Health Sector (NRCHS), consisting of six units: Family Planning, School Health, Community-Based Health Care, Integrated Management of Childhood Illnesses, and the Safe Motherhood Initiative.¹⁸ At the end of the decade, however, the 1998 Annual Report still described a national situation as one where clinics were well supplied with contraceptives, but highly inadequate in providing other reproductive health services.¹⁹ As for the critical reproductive health challenge that HIV/AIDS presents to the implementation of programmes designed to prevent births, not disease, the last “main general finding” of the Tanzanian report states: “Integration of STI/HIV/AIDS in most of MCH/FP clinics has not been started.”¹⁹ [my emphasis]

Entrenched, separate HIV/STI and MCH/FP vertical programmes, common throughout Africa,²⁰ cannot meet the needs of women in countries like Tanzania. On the other hand, HIV/AIDS cannot merely be inserted into existing family planning programmes, renamed reproductive health programmes. The reproductive health agenda can benefit from the lessons learned from years of trying to insert “women” into “development” through Women in Development programmes. Ultimately, the conceptualisation of the problems and solutions had to be changed, and the focus on gender has encouraged a rethinking of the meaning of development and the power relations that constitute who does development and for whom. HIV/AIDS must bring about an analogous paradigm shift within the reproductive health agenda—AIDS challenges us not just to expand the scope of the old population policies with interventions for tackling the disease, but to rethink the justifications for these policies, their primary actors and their goals.

Hopefully, the reinvigorated effort on the part of the Tanzanian government and its donors, as evidenced by the 2001 formulation of goals of the Tanzania AIDS Commission, will lead to a genuinely multi-sectoral approach that will balance service provision, funding and coordination efforts throughout the country.

While the discourse shift from population control to women's reproductive health was long overdue, AIDS challenges us to think creatively about the multiple aspects of this agenda. The cost of treating an adult with AIDS in Tanzania has been estimated at US $295—without life-saving antiretroviral drugs—in a country that spends only US $10 per capita on health care.²¹ As the AIDS epidemic is transformed through new technologies such as antiretrovirals it will call into question priorities of reproductive health policies. AIDS forces us to look at the state of the African health care system, networks of care-giving, and how individuals and communities fail when there is no socio-economic safety net.

As more work is written linking the medical epidemic of AIDS with the social dislocation and economic abjection of Africa,²²²³ the breadth of the umbrella of reproductive health will prove increasingly useful. As with global concern about overpopulation before it, AIDS can be the crisis that mobilises policymakers, donors and community-level activists, but the scope of action must range beyond family planning and further than the health sector. If the goals of the ICPD in Cairo in 1994 for promoting women's empowerment and fighting the many forms of inequality have not inspired sufficient commitment on their own, even though they should have done so, perhaps the immensity of the AIDS epidemic will finally push us beyond “politics-as-usual”.

Notes

1 Perhaps this unwillingness has lessened since then as confidentiality, HIV counselling and notification are dealt with explicitly in the 2001 National Policy on HIV/AIDS.