Female Empowerment as Part of the Solution to

Although the rates are likely underestimated due to lack of infrastructure for national reporting systems, the HIV rate was reported as 4.7% in 2015, which translated to 1.4 million people living with HIV [2]. The HIV rate in Tanzania is disproportionately higher for women than for men. According to the 2011-2012 Tanzania HIV/AIDS and Malaria Indicator Study (THMIS), the prevalence rate among women was 6.2% whereas the prevalence rate for men was 3.8% [3]. For women, the HIV prevalence was 1% at ages 15-19 and 10% at ages 45-49.4


Perspective
In less economically developed countries (LEDCs), such as Tanzania, HIV/AIDS is a disease of poverty where prevalence rates are higher for women than for men. The World Health Organization (WHO) stated in 2012 that HIV/AIDS was the second leading cause of death in less economically developed countries (LEDCs) [1].
Although the rates are likely underestimated due to lack of infrastructure for national reporting systems, the HIV rate was reported as 4.7% in 2015, which translated to 1.4 million people living with HIV [2]. The HIV rate in Tanzania is disproportionately higher for women than for men. According to the 2011-2012 Tanzania HIV/AIDS and Malaria Indicator Study (THMIS), the prevalence rate among women was 6.2% whereas the prevalence rate for men was 3.8% [3]. For women, the HIV prevalence was 1% at ages 15-19 and 10% at ages 45-49.4 Because HIV prevalence is higher in women and because the modes of transmission make women vulnerable to infection, empowering women should help to combat HIV and to decrease prevalence rates. In Tanzania, for instance, 80% of HIV infection is transmitted through sexual activity with a heterosexual partner [4]. Thus, if women had more support through education, gender equality initiatives, and control over safe sexual practices, then the rate should decrease in the female population.
Education about HIV is insufficient in schools and communities, with less than 50% of adolescents having adequate knowledge [5,6]. It was estimated that in 2014, 6% of adolescents ages 10-19 were HIV positive [7]. Even if sexual education is available in schools, children often do not complete their education. For example, in 2012 only 45% of secondary students ages 14-17 were enrolled in school [8]. Enrollment rates in schools are even lower for girls. Reasons for this include early pregnancies, lack of access to bathrooms during menstruation, sexual harassment by male teachers and early forced marriages [9]. Gender inequality is another major contributor to high rates of HIV in Tanzanian women. Although gender inequality is illegal, as stated by the Tanzanian Constitution, women often feel powerless to refrain from having sexual intercourse or safer sex with an HIV-infected partner [10]. By refusing to have sexual relations, women are often forced from their homes and consequently lose their financial security [11]. In addition, they are more at risk of sexual assault, with 48% of married women reporting sexual violence in 2010 [3,12]. Women also tend to contract HIV at an earlier age than men, both because they often marry older men and marry earlier in life [13]. For example, a study of Tanzanians aged 15-24 reported that in 2012 there were about 26,000 new infections in women and about 14,000 in men [14].
Several other activities including condom use, polygamy, and prostitution also influence HIV prevalence. Condom use decreases the likelihood of transmitting HIV by 88% [15]. Consequently, the Tanzanian government has implemented a program to supply free condoms. However, distribution to rural areas can be problematic. Also of concern is the Demographic and Healthy Survey and Malaria Indicator Survey 2015-16, which revealed that only 15% of sexually active unmarried women used condoms [16]. Due to inequality in many sexual relationships, women often do not have the power to insist that their partner use a condom.
The practice of polygamy, which is legal under the constitution of Tanzania, is another risk factor that increases the risk of HIV transmission [17]. Contributing to this practice are mobile populations including miners, long distance truck drivers, fishermen, and plantation workers. These men often have sexual activity with sex workers, putting themselves at increased risk of contracting HIV, and then, in turn, infecting their other female partners [18]. This is demonstrated by the International Organization for Migration in 2015, whereby 100% of truck drivers in Dar es Salaam interviewed reported sexual relationships with women at truck stops whom they described as their second wives [19].
Prostitution adds to the high rate of sexual transmission of HIV, especially for women living in poverty, as it provides them with a source of income needed to survive [20]. In addition, if women are IV drug users, their rate of HIV prevalence is double that of their male counterparts. The reason for this is unclear, but it is postulated that if female sex workers are also sharing needles with their customers, then they will be the last to receive the shared needle, thus increasing their potential exposure to an HIV-contaminated needle [21]. Unsafe sexual practices including lack of condom use, polygamy, and prostitution each increase the risk of contracting HIV and if these risk-taking behaviours occur simultaneously, this leaves women even more vulnerable.
Just as women do not have the power to prevent themselves from acquiring HIV, they are similarly limited in their ability to prevent transmission of HIV to their newborn infants. Mother-tochild transmission (MTCT) accounts for almost 20% of new HIV infections in Tanzania [22,23]. 4 Antiretroviral therapy (ART) is provided free through government programs during pregnancy and childbirth and use of ART significantly decreases the risk of transmission to the newborn. Educating and empowering pregnant women to access ART will continue to decrease the rate of MTCT. As of 2015, 14% of pregnant women were not receiving effective ART. However, this is an improvement from 2013, at which time 23% did not receive ART [4]. Other factors responsible for the high rate of MTCT are ineffective ART drug regimens, drug stock-outs, and lack of compliance to treatment [4]. Some ART should be taken with food to avoid gastrointestinal side effects, but impoverished pregnant women cannot always rely on the availability of food, and thus may have poor adherence to treatment. Additionally, if the HIV viral load is high or unknown or if the woman is not taking ART, cesarean section would ideally be performed to decrease the rate of MTCT. However, with an extremely low healthcare worker to patient ratio (3.1:10,000 in 2012), most medical facilities in Tanzania cannot offer cesarean section due to lack of equipment and trained healthcare workers. Following birth, most Tanzanian women breastfeed, regardless of their HIV status, to decrease the risk of infant death from malnutrition. ART is recommended during breastfeeding to decrease MTCT; however, lack of access to ART, drug stock-outs, and intolerable side effects to ART compromise use of ART while breastfeeding as well.
There are several factors that contribute to the high rate of HIV in Tanzanian women, in particular, lack of HIV-related education, gender inequality, and lack of access to resources. If women were given more opportunity to develop strategies to access education and become more financially independent, they could become empowered to minimize the risks of contracting or transmitting HIV in the future.