Royal Mirage Hotel, Dar es Salaam

I am finding myself frustrated. In the States, I get frustrated working in HIV prevention because it seems inexcusable that transmission still occurs. I am also finding myself frustrated with the situation in Tanzania. HIV/AIDS is a topic that is openly discussed. Due to efforts of politicians and prevention campaigns, many people test for HIV. The government provides HIV education, condoms, and free anti-retroviral medications. Prevalence rates have decreased over the last few years (from 7 or 8% in 2003), the the incidence is still around 4.9% (that's the number that people kept quoting me, but research after my return home indicates rates closer to 6%). To put it in perspective, the overall prevalence rate for the U.S. is around 0.3%. However, depending on what studies you look at, in certain populations of MSM in the U.S., prevalence can be anywhere from 8-25%! I think that the incidence rate among the population that we tested at our agency was about 4% in 2007. So, although it is easy to assume that HIV is not an issue in the U.S. and is only a really catastrophic problem in Sub-Saharan Africa, in certain populations, rates are comparable to those in Africa. Yet we don't have PEPFAR to help prevent and treat HIV domestically. In addition to combating HIV in developing countries, we really need to be amping up prevention efforts domestically as well. It's too easy to believe that HIV can't touch us here, but it does... everyday, in great magnitude.

I keep asking people here why HIV is so difficult to prevent despite the availabiliy of education, condoms, testing, and ART, but I keep getting vague answers like "people are people". I understand that people aren't using condoms as consistently as they should and abstinence is not a realistic goal, but I want to understand more about specific obstacles people face, so that creative (and hopefully effective) prevention efforts can be implemented. I understand a bit about the population that I work with in Long Beach. I can see how certain factors are exacerbating the problem: drug use, fatalism, perceived invincibility, the idea that HIV can be managed by drugs, cultural influences in disproportionally affected minority communities that may limit open discussion about HIV and sex, prostitution, poverty, the role of women as caretakers (neglecting their own well-being), incarceration, popularity of high-risk behaviors like barebacking, the phenomenon of gift-givers and bug-catchers... the list goes on and on. I want a list like this to explain to me why HIV persists in Tanzania. I know that there might be some factors that differ from what I see in Long Beach, and I'm sure that there are many that intersect as well. The most I've been able to elucidate is that there is a struggle with monogamy (it is acceptable for men to have several wives/sex partners), women have difficulty negotiating condom use, and women have low social status that limits their freedom to test and they may also face domestic violence issues. I want more answers than this.

The water situation is really very dire. There is such a huge need for clean water and proper sewage and waste treatment. We really take water for granted in the U.S. We visited with a couple men from Engineers Without Borders to see what they are trying to do to help with the problem. We visited a village to see how they get their water from a well and even carried buckets of water on our heads as they do. The severity of the poverty in Tanzania is becoming more and more apparent to me. When I think of the excess we experience in the U.S., it makes me a little bit sick. For as much money as we spend of stuff we don't need, we could probably provide water and sewage infrastructure for a whole country.

I have remained in high spirits and have had no problems adjusting to our travel (even when things aren't going super), but I find myself secretly outraged at this crazy world we live in. This hotel has TVs and watching the news about Gaza has literally made my stomach turn.

I'm too tired to write any more tonight. More tomorrow, when we'll have visited the CDC programs for malaria and HIV. Yay!!