Tuesday, December 30, 2008

Kenya's Neighbours, Uganda and Tanzania

How does Kenya’s HIV epidemic compare to those of neighbouring Uganda and Tanzania?

Well, HIV probably arrived first in Uganda, next in Tanzania and then in Kenya. After that, it took very different courses in each country. It spread quickly and rose to a peak prevalence of 14% in Uganda. It spread less quickly in Tanzania and peaked at below 8%. And, having started later in Kenya, it spread quickly and prevalence peaked at just over 10%.

As the graph below shows, there has been a gradual decline in prevalence in Uganda and in Tanzania. However, the decline in prevalence in Kenya reversed around 2004 and now stands at 7.8%, higher than it was back in 2002.

The next graph shows that death rates also have very different patterns in each country. Aids deaths started later in Kenya, as you would expect if HIV arrived later. But the number of deaths rose very rapidly and peaked at perhaps over 140000. This is far higher than Uganda and Tanzania, whose rates peaked at 120000.

Death rates in all three countries are now declining. One would expect this trend to be enhanced as anti-retroviral therapy (ART) is rolled out because this keeps more people living with HIV alive for longer.

The graph below plots the estimated numbers of people living with HIV and Aids. The rising number in Kenya is probably due to a combination of new infections and people living longer because of ART. The fact that the number in Tanzania is stable could be for similar reasons, except that there, the death rate is still pretty high. This is, of course, just one analysis and a quick and dirty analysis, for that matter. It’s possible that Uganda has a low rate of new infections at present; I don’t have access to recent figures.

Personally, I think the above figures alone can tell us very little about how the HIV epidemics stand in these three countries at the moment. I think the way HIV affects a country, how the epidemic spreads, waxes and wanes, depends on many things. Of particular importance are health and health services, education and literacy, various economic factors, social services, infrastructure and much else.

The annual Human Development Report collects national figures and uses them to calculate indices of various aspects of development. Thus, the gender development index shows inequalities between men and women in health, education and economic welfare; the life expectancy index shows the relative achievement of a country in life expectancy at birth; the education index brings together adult literacy and school enrolment; and the human development index (HDI) brings together health, education and economic welfare, being a composite of the education index, the life expectancy index and the GDP index. The GDP Index shows the gross domestic product per capita for a country.

There is a large amount of overlap among these figures, but they are all reproduced here to show how the three countries stand in relation to each other. From this chart, they would all seem pretty close together. In most cases, Kenya is a little better off than Uganda and Uganda is a little better off than Tanzania. If these factors also have an influence on the course a HIV epidemic takes in a country, each country’s epidemic may become more and more alike, despite their initial differences.

However, if you look at trends in the HDI (the only one for which historical trends are supplied), Kenya is not only out of step with Uganda and Tanzania, after being ahead of them for many years; Kenya’s HDI has also been declining for a long time. Over the same period, Uganda and Tanzania’s HDI has been improving.

Well, putting all these figures together doesn’t really put one in a position to analyse each country in sufficient detail to make predictions about what will happen next. Out of the three countries, only Kenya is seeing prevalence increase, after an initial improvement. It’s possible that Uganda and Tanzania’s prevalence are levelling off and will rise, but it’s hard to say.

However, a recent paper shows that prevalence is still increasing in Tanzania in more rural areas, though it is declining in less rural areas. Bear in mind, over 80% of people in Tanzania live in rural areas. Another paper suggests that the behaviour change that was said to have reduced HIV prevalence in Uganda substantially in the nineties and early 2000s is now reversing, that condom use is declining and unsafe sex is increasing.

Rural areas in Tanzania are less likely to benefit from HIV education, perhaps any education, from health services and other social services. And those in Uganda who are deciding to ignore the safe sex message, if the message is still being broadcasted, may need to be approached in a different way. What worked during a time of high prevalence followed by a time of high death rates, may not work now that the word ‘Uganda’ is usually accompanied by mentions of the country’s success in reducing HIV prevalence.

Among all the indicators relating to sexual behaviour that are collected by Demographic and Health Surveys, none show that one of the three countries is significantly ‘better’ or ‘worse’ than the other. These figures, even taken all together, don’t suggest why Tanzania’s prevalence never reached as high as Kenya’s or why Kenya’s never reached as high as Uganda’s.

Some health indicators show Tanzania to be in a far better position than the other two countries, despite public expenditure on health being lower. However, some of Tanzania’s health indicators are far poorer than the others. Other figures are very similar to those found in Uganda and Kenya. Education indicators are similarly mixed, though Kenya again has the highest level of public expenditure in education.

Some gender related figures do differ greatly. Kenya has very few female MPs, just over 7% them being women. For Uganda and Tanzania, the figures are 29.8% and 30.4%, respectively. More births are attended by skilled health personnel in Tanzania. And the rates of female genital mutilation are much higher in Kenya (32.2%) than in Uganda (0.6%) or Tanzania (14.6%).

Figures for communications, access to communications and media, water and sanitation vary somewhat here and there but there is still a surprising amount of similarity in these areas. All three countries have seen high population growth in the last thirty years and are predicted to continue growing. Demographic figures are also reasonably similar.

A notable exception is the urban population as a % of the total population, which stood at 20.7% in Kenya in 2005, 24.2% in Tanzania but only 12.6% in Uganda. Uganda also had a low urban population in 1975 and this is expected to continue. Urban population is thought to be a highly significant factor in the spread of HIV by some analysts. However, it is also argued that the HIV epidemic was unusual in Uganda, having started in rural areas and spread from there. In Kenya and Tanzania it was said to have started in urban areas.

In a nutshell, I think HIV spread readily in these countries because of poor health, education, social services, water and sanitation, governance, social cohesion and many other things. Many measures have been taken to reduce the spread of HIV, in the fields of health, education and other areas. However, unless the original development conditions that allowed HIV to spread are improved vastly, HIV will continue to spread.

The people of Kenya, Uganda and Tanzania may well need HIV education, but they are in far greater need of teachers and affordable, accessible schools. HIV health programmes are great, but only where there is an affordable, accessible health service. There is little point in educating people about sexual health and behaviour while ignoring reproductive health, sanitation, nutrition and other aspects of health.

As long as HIV is seen as a short term (or even medium term) crisis that will be resolved by crisis measures, it will continue to spread. Small gains may be made here and there, but without ensuring a healthy, well educated, secure population, HIV will never be conquered.

The conditions that allowed HIV to take hold and reach high levels in so many countries have been around for a long time and the HIV community seems to have allowed itself to be distracted by crises and crisis measures. It is the long term issues that need to be resolved, the same problems of poverty, exploitation and underdevelopment that have been around for as long as anyone can remember.



Chris said...

I'm very interested in this article. I am doing a presentation right now in my African Studies class about the HIV/AIDS problems in Kenya, and I was wondering where you got the infromation to make those two graphs.

It would be a great help.

Simon said...

Hi Chris
I can look up all the details tomorrow (Tuesday). When is your presentation? Most of the data comes from standard sources such as the UNAIDS site and the Human Development Report site.

Chris said...

My presentation is tomorrow, actually (Wednesday). But thank you for those referances, I'm sure they'll be a great help.

Simon said...

Ok, I can't really add much that isn't already in the article. The graphs were done on Excel using data from the sites mentioned. They are the best places to go for such data and you could also try http://www.measuredhs.com/ for other demographic and detailed data. Also, I did a short history of HIV in Kenya that may be useful, the link is below.


Good luck with the presentation.

Lisa said...

I am working on an essay on hiv/aids in uganda. I was wondering if it would be possible for you to send me the table you used to plot the first graph of hiv prevalence, if you have it.

Simon said...
This comment has been removed by the author.
Simon said...

Hi Lisa
I've pasted the figures below, let me know if you want them in a different format.

Good luck with the essay.

Kenya Uganda Tanzania
1990 3.2 13.7 4.8
1991 4.7 13.8 5.5
1992 6.4 13.5 6.2
1993 8.0 13.1 6.7
1994 9.4 12.5 7.1
1995 10.2 11.8 7.4
1996 10.6 11.1 7.5
1997 10.7 10.5 7.5
1998 10.4 9.8 7.4
1999 9.9 9.1 7.3
2000 9.2 8.5 7.1
2001 8.4 7.9 7.0
2002 7.5 7.4 6.8
2003 6.7 6.9 6.7
2004 6.6 6.5 6.5
2005 6.9 6.1 6.4
2006 7.3 5.7 6.3
2007 7.8 5.4 6.2

Anonymous said...

The format's fine.....thanks alot

Clay said...

Hopefully, people who are suffering from HIV will reduce year to year. It is not only for those three countries above but also for all countries in the world. It is very dangerous so it is needed by people in order to avoid something that can cause HIV.