Introduction

A New Model for Prevention and Care

The East African nation of Tanzania would appear to have many strikes against it in the battle against HIV/AIDS. With its western provinces located within the historical African epicenter of the epidemic, Tanzania has struggled since the mid-1980s with some of the highest HIV infection rates in the world, and AIDS is now the leading cause of death among Tanzanian adults. Data on HIV seroprevalence among pregnant women attending antenatal clinics — a globally accepted measure of how far HIV infection has spread through the general population — show national averages of more than 13 percent, with rates higher than 30 percent in one district. At clinics in high-risk areas such as towns on transportation routes, that figure can rise to 50 percent or more. The country's National AIDS Control Program predicts that up to 2.4 million Tanzanians will be infected by the year 2000.

Other HIV/AIDS-related health projections for Tanzania are equally discouraging. By the year 2010, given current national trends in HIV infection rates, life expectancy for Tanzanians will drop from 65.2 years to 36.5 years. Child mortality rates for 2010 — primarily due to mother-child transmission — will rise from 95.8 to 166.1 per thousand. The number of children orphaned by AIDS could exceed 850,000 by 2000, an enormous economic burden on the country's health and welfare systems and a terrible psychosocial blow to the generation upon whom the country's future rests.

Greatly exacerbating the crisis is the fact that Tanzania is also one of the most poverty-stricken countries in the world. With a per capita income of only $90 per year — and many other health and development demands on its national budget — Tanzania has few resources to devote to curbing the epidemic. Able to spend only about $4 per capita annually on public health expenditures, the government health system lacks the funds to cover the most basic of health care needs for its population, much less treat most cases of opportunistic infections caused by HIV. The expensive new protease inhibitors and other antiretroviral medications that have had such an impact on the course of the disease in wealthier countries are unaffordable for a country such as Tanzania, where the costs of offering them to all those suffering from AIDS would exceed 50 percent of the entire gross national product.

The point is often made that HIV/AIDS is as much a development crisis for impoverished countries as it is a health problem. The gradual and modest gains that Tanzania has achieved over the last few decades in economic and social development are indeed threatened by the demands the epidemic makes on the country's limited resources. The high costs of treatment, the diversion of funds from other pressing health and social needs, and the strain of providing care for hundreds of thousands of orphans and support to bereaved, impoverished families are only part of the picture. Perhaps the biggest sacrifice the country makes to the epidemic is the loss of its farmers, factory workers, teachers, parents, small businesspeople, community leaders — citizens from all walks of life in their most productive years, who drive the economy, grow the nation's food and raise the next generation. The toll is high, and the effects are immediate. The death of some 8,000 farm workers per year due to AIDS, for example, has had a serious impact on a nation that is deeply dependent on internal agricultural production.

Yet it is also this threatened human capital from which HIV/AIDS prevention and care efforts draw strength. For decades, Tanzanians have lived within a political culture that stresses cooperative action in solving their nation's problems. One result has been the growth of strong, committed nongovernmental service and advocacy organizations that seek to improve their communities and further public interests in health, social welfare, and policy reform.

Within this setting has flourished an innovative approach to HIV/AIDS prevention and care called the "cluster" strategy. Developed by the Tanzania AIDS Project (TAP), which is funded by the U.S. Agency for International Development and was managed by the AIDS Control and Prevention (AIDSCAP) Project from 1993 to 1997, the cluster concept maximizes the effectiveness of indigenous service organizations that once worked separately to curb the epidemic — NGOs, PVOs, medical and public health institutions, government agencies, religious and political organizations — by bringing them together to work in regional "clusters." (TAP continues through 1998 under a cooperative agreement between USAID/Tanzania and Family Health International.)

This collaborative approach guarantees sharing of scarce regional resources, eliminates competition for funds and duplication of efforts, and encourages a rich cross-fertilization of ideas. Such strengthening of regional prevention and care NGOs has led to the effective decentralization of HIV/AIDS programming, as TAP put planning and decision making into local hands, creating solutions that are deeply rooted in each community and much more responsive to local and regional needs.

TAP's nine regional clusters — made up of more than 180 community-based organizations — have since the project's beginning in 1993 maintained a comprehensive program of integrated prevention strategies, including behavior change communication, condom social marketing, prevention of sexually transmitted infections, policy advocacy, and workplace programs, with special efforts to reach youth and other population sectors at risk. Each of the clusters is also involved in providing basic care, counseling and support for those already infected, for local families impoverished by the death of a breadwinner to AIDS and for some of the many thousands of Tanzanian children orphaned by the epidemic.

The Tanzanian cluster system — the only such national endeavor of its kind in the world — has the potential to serve as a global model for bringing about significant behavior change and for building capacity and sustainability in resource-poor settings. This report takes a look at this national success story in prevention, an encouraging and refreshing challenge to traditional perspectives on HIV/AIDS prevention programming.