Studies at Ilembula Lutheran Hospital, Tanzania: HIV Awareness ...

Studies at Ilembula Lutheran Hospital, Tanzania:
HIV Awareness among Students and Health Care
Workers in Rural Tanzania
Cecilia Anderson, e-mail: popstar_77@hotmail.com
Malin Kim, e-mail: kh00hama@medstud.gu.se
The Sahlgrenska Academy at Gothenburg University, Sweden. 2003
Supervisors:
Rune Anderson, MD, PhD, Research and Development Centre, Skaraborg Hospital, Skövde,
Sweden.
Willis L.Temihango, Doctor in Charge, Ilembula Lutheran Hospital, Ilembula, Tanzania

List of abbreviations and foreign expressions
AIDS Acquired Immune Deficiency Syndrome
Clinical Officer A person with medical training who assists the doctor
ELCT Evangelical Lutheran Church in Tanzania
HIV Human Immune Deficiency Virus
ILH Ilembula Lutheran Hospital
INWTS Ilembula Nurses and Midwives Training School
Mganga A traditional doctor, witch doctor
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
Veo A governmental secretary
Waganga Plural of mganga, traditional doctors
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Index
ABSTRACT........................................................................................................................................................... 5
BACKGROUND:.................................................................................................................................................... 5
A BRIEF INTRODUCTION TO TANZANIA................................................................................................... 5
FACTS ABOUT THE COUNTRY............................................................................................................................... 5
THE HIV PANDEMIC......................................................................................................................................... 6
PRESENT SITUATION............................................................................................................................................ 6
THE VIRUS .......................................................................................................................................................... 7
THERAPY............................................................................................................................................................. 7
HIV/AIDS AND POVERTY................................................................................................................................... 7
HIV IN THE REPUBLIC OF TANZANIA .................................................................................................................. 7
HIV/AIDS AT ILEMBULA VILLAGE/HOSPITAL..................................................................................................... 8
HOME BASED CARE ............................................................................................................................................ 9
THE VILLAGE OF ILEMBULA........................................................................................................................ 9
LIFESTYLE AND TRADITIONS ............................................................................................................................... 9
SICKNESS AND HEALTH AS SEEN BY THE PEOPLE OF ILEMBULA......................................................................... 11
ILEMBULA LUTHERAN HOSPITAL............................................................................................................ 11
GENERAL INFORMATION ................................................................................................................................... 11
SUMMARY OF HOSPITAL SERVICES 2002 ........................................................................................................... 12
ILEMBULA NURSES AND MIDWIVES TRAINING SCHOOL................................................................. 12
METHODS .......................................................................................................................................................... 13
RESULTS OF THE QUESTIONNAIRES ....................................................................................................... 14
SOCIO-ECONOMIC SITUATION............................................................................................................................ 14
Age: ............................................................................................................................................................. 14
Profession.................................................................................................................................................... 14
Gender......................................................................................................................................................... 14
Family.......................................................................................................................................................... 14
Religion ....................................................................................................................................................... 14
Economical situation ................................................................................................................................... 14
KNOWLEDGE OF HIV ........................................................................................................................................ 15
First source of information.......................................................................................................................... 15
Ways of transmission................................................................................................................................... 15
Difference between HIV and AIDS.............................................................................................................. 17
Ways to cure HIV......................................................................................................................................... 17
Risk groups.................................................................................................................................................. 18
Estimated prevalence of HIV in Ilembula.................................................................................................... 18
Spread of HIV.............................................................................................................................................. 18
PROFESSIONAL SITUATION ................................................................................................................................19
Information at work..................................................................................................................................... 19
Hospital routines and risk at work .............................................................................................................. 19
Information to the patients .......................................................................................................................... 21
PRIVATE LIFE .................................................................................................................................................... 21
HIV among friends and relatives................................................................................................................. 21
Informing friends and relatives ................................................................................................................... 21
Protecting oneself........................................................................................................................................ 23
Sexual partners............................................................................................................................................ 24
Children....................................................................................................................................................... 25
RESULTS INTERVIEWS ................................................................................................................................. 25
HIV IN GENERAL............................................................................................................................................... 25
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What do you think are the reasons why HIV is still spreading so rapidly?................................................. 25
Do people usually want to know if they are HIV positive or not? How about you?.................................... 26
What do you think can be done to prevent the spread of HIV? What about the future?.............................. 26
Why is HIV stigmatized? ............................................................................................................................. 27
FAMILY AND FRIENDS ....................................................................................................................................... 27
Is it difficult for a person to tell relatives and partners that s(he) is infected with HIV? ............................ 27
Do the families usually take care of relatives suffering from AIDS?........................................................... 27
HIV AT WORK................................................................................................................................................... 28
Do you sometimes feel at risk of getting HIV at work? How do you protect yourself? ............................... 28
When employees at the hospital accidentally prick themselves with a dirty needle, what do they usually do?
..................................................................................................................................................................... 28
Do HIV infected persons usually take precautions not to transmit the disease to others?.......................... 28
At what age do people usually start having sexual intercourse?................................................................. 29
Do people in general have sexual intercourse before marriage/ outside marriage? .................................. 29
What do people think about condoms? Do people know how to use them? ................................................ 29
CULTURE AND RELIGION ................................................................................................................................... 30
Do people believe in traditional healers? Do they think that the healers can cure HIV? ........................... 30
When it comes to HIV, are there any differences between: ......................................................................... 31
DISCUSSION ...................................................................................................................................................... 32
VALIDITY OF THE RESULTS................................................................................................................................32
KNOWLEDGE AND SPREAD OF HIV ................................................................................................................... 33
BEHAVIOUR, TRADITIONS AND BELIEFS. ........................................................................................................... 34
CONCLUSIONS ................................................................................................................................................. 36
ACKNOWLEDGEMENTS................................................................................................................................36
APPENDIX.......................................................................................................................................................... 37
QUESTIONS ASKED DURING THE INTERVIEWS.................................................................................................... 37
QUESTIONNAIRE................................................................................................................................................ 38
INTERWIEV WITH WILLIS TEMIHANGO, DOCTOR IN CHARGE AT ILEMBULA LUTHERAN HOSPITAL ................... 40
INTERVIEW WITH ALIFA LUPENDE, PRINCIPAL OF INMTS................................................................................ 41
INTERVIEW WITH ONE OF THE EVANGELISTS OF THE LUTHERAN CHURCH OF ILEMBULA .................................. 42
INTERVIEW WITH THE CHAIRMAN OF ILEMBULA ............................................................................................... 42
INTERVIEW WITH A TRADITIONAL DOCTOR (MGANGA)...................................................................................... 43
REFERENCES.................................................................................................................................................... 44
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Abstract
Background:
An increasing number of people throughout the world are affected by the HIV-pandemic. A
key group in controlling the spread of the virus is the healthcare-workers, since they have
both medical knowledge and insight to the general believes and behaviour of the patients.
Purpose:
The aim of study is to describe and analyse HIV awareness and risk behaviour among health
care workers and student nurses in the Tanzanian village of Ilembula. We also want to receive
information about their general picture of the HIV situation in the area. Our wish is that this
survey will provide information helping to design future intervention programs.
Methods:
A total number of 164 questionnaires were handed out to the health care workers at Ilembula
Lutheran Hospital and the students at Ilembula Nurses and Midwives Training School.
Interviews were conducted with 41 health care workers and students. The answers collected
from the questionnaires influenced our choice of topics discussed during these interviews. In
addition to this, we collected information from other individuals with influence in the
Ilembula community.
Results:
Both health care workers and students have good knowledge of HIV.
Concerning other issues, the results of the questionnaires and interviews often pointed in
different directions. The informants generally believed their own behaviour to be different
from others.
Conclusions:
There are numerous complicated factors contributing to the spread of the disease, of which the
most important is ignorance. Education alone is not enough to stop the epidemic or change
people’s behaviour.
A brief introduction to Tanzania
Facts about the country
Area: 945084 km2
Capital city: Dodoma
Population: 35.2 million
Head of state: President Benjamin Mkapa
GNP per capita: 264 USD
Currency: Tanzanian Shilling
[1]
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The republic of Tanzania is situated is East Africa. The name Tanzania is a symbolic
construction of Tanganyika (the mainland) and Zanzibar (an island outside the eastern coast).
The costal areas have tropical climate, while the inland is warm and dry. The bulk of the
country is a highland plateau, which is relatively uninhabited. [1]
The population of Tanzania was estimated to be 35.2 million in 2002 [1] and the annual
population growth rate is 2.3%. The average number of births per woman is 5.5 and infant
mortality rate is 105.9 per 1000 live births [2]. Life expectancy has been decreasing in the
past decade, and is now down to 43.1 years for women and 40.3 years for men. [3]
There are more than 120 ethnical groups in Tanzania, all differing in culture, customs and
language. The biggest groups are Sukuma and Nyamwezi. About a dozen tribes form half of
the countries population, but no ethnic group dominates. This has resulted in a balance of
power and much lower level of ethnic conflict than elsewhere in Africa. Religion has also
been a unifying factor, with 45% Christianity, 35% Islam and 20% traditional religions. [4]
Official languages are Swahili and English. Literacy rate is 57% for women and 79% for men
[5]. Seven years of primary school is mandatory and free of charge, although the parents have
to pay for school uniforms and books. Most secondary schools are boarding schools with high
tuition fees that are beyond the economical capacity of most Tanzanian families. Few people
continue to higher education. [1]
Tanzania gained independence in 1961, after being colonized first by the Germans and after
world war one by the British. The decades that followed, Tanzania tried to create a society
based on radical socialism and self-reliance, which ultimately failed. Recurrent periods of
draught, military interventions in neighbour countries and sinking world market prices of
coffee have contributed to the economical instability. Tanzania is now one of the world’s
poorest countries and heavily dependent on development aid. Most people are peasants and
farming is the core of the economy. Main export goods are minerals, cashew nuts, coffee, tea,
spices and cotton. Unemployment rate is 30-40%. [1] It has been estimated that about 60% of
the population in Tanzania lack access to modern healthcare, either because they live too far
from the nearest dispensary or because they can’t afford to pay for medical services. [6]
The HIV pandemic
Present situation
The HIV/AIDS pandemic poses one of the greatest challenges to global public health. With
over 40 million of infected people in the world [7] HIV/AIDS is the leading cause of death in
Africa and the fourth leading cause of death worldwide. Sub-Saharan Africa is the world’s
most severely affected region [8] with 25-28.2 million people infected [7].
The HIV/AIDS pandemic has interacted with other public health problems, most notably
tuberculosis (TB). It is reported that in countries of sub-Saharan Africa most admissions are
due to HIV related conditions including TB. [9]
There is a direct correlation between countries with high levels of other sexually transmitted
infections (STI) and HIV infection. The presence of an STI has been shown to increase the
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isk of HIV infection in any single contact 2-10 times depending on the nature and severity of
the STI. To some extent, this may explain the significant differences between HIV spread in
many wealthier countries, where STI rates tend to be much lower, compared to poorer
countries. [9]
The Virus
HIV belongs to the genus Lentivirus of the family Retroviridae and has been divided into two
groups:
• HIV Type 1, responsible for the global pandemic.
• HIV Type 2, less pathogenic than HIV-1 and largely restricted to West Africa, with
limited spread to other countries.
HIV-1 is further classified in three groups:
• M, major, is further divided into subtypes or clades. The subtypes are unevenly
distributed around the world with A, C and D being most common in Africa and B
occurring in Europe and America.
• Group O, outliner, is largely restricted to the central African region.
• Group N, non-M non-O, is rare and has been identified with only a few individuals in
Cameroon. [9]
Therapy
To treat AIDS, Highly Active Antiretroviral Therapies (HAART) are used. However, the high
cost of drugs and the infrastructure needed to administer and monitor their use have so far put
these medications beyond reach of most HIV-infected persons, especially in third world
countries. [10]
HIV/AIDS and poverty
The relationship between HIV/AIDS and economic development is complex. HIV/AIDS
negatively affects economic growth on the one hand. On the other hand, weak economy
makes it difficult for nations and individuals to mount adequate and comprehensive responses
to the epidemic. In many ways poverty creates vulnerability to HIV infection, causes rapid
progression of the infection due to malnutrition and limits access to social and healthcare
services.
Death of a young adult often means loss of a father/mother and family bread earner.
This means that HIV causes a growing breakdown of social networks.
Ultimately the high cost of care and burials is putting a severe strain on the already
overburdened households. [10]
HIV in the Republic of Tanzania
In Tanzania, the first AIDS cases were reported from the North-Western part of the country
(Kagera Region) in November 1983. [11]
About 98% of the adult population in Tanzania is now aware of HIV/AIDS [10]. In spite of
this, HIV/AIDS related stigma is one of the key challenges in the prevention and control of
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the epidemic. Yet, HIV continues to spread and approximately 15% of the sexually active
population is infected.
Over 70% of those infected are aged between 20-49 years. Since they are the very future of
the nation this leads to a major development crisis that affects all sectors. Absenteeism from
workplaces and deaths reflect the manifestation of the epidemic. Other problems are lowering
of life expectancy, increasing the dependency ratio, reducing growth in GDP, increasing
poverty, raising infant and child mortality as well as the growing numbers of orphans. It has
serious and direct implications on the social services and welfare [8]. Widows and orphans are
often deprived of their inheritance rights by relatives through the application of outdated
traditional and customary laws. [10]
HIV/AIDS at Ilembula village/hospital
According to doctor Temihango, 60 % of the beds of the hospital are occupied by HIV
patients. In 2002, AIDS was the most common cause of death in Ilembula [12]. Number 2 on
the list was malaria, which can be more severe if the patient has HIV. Number 3 was
pneumonia followed by tuberculosis [12]. These diseases can be secondary to AIDS.
The prevalence of HIV/AIDS at Ilembula is measured in three ways: Clinical AIDS,
voluntary screening and screening of blood donors. In 2002, 69% of those clinically suspected
were infected with HIV. 15% of the blood donors and 13 % of those who came for voluntary
testing were found to be HIV positive. [12]
The hospital is following the guidelines of the ELCT (Evangelical Lutheran Church of
Tanzania). The most important projects to prevent HIV/AIDS are according to doctor
Temihango:
• To educate all the nearby parish leaders through workshops. This was done in July
2002.
• To take care of the orphans whose parents died of AIDS or other causes. Although
most orphans are taken care of by relatives, the hospital orphanage has room for ten
children. At present there are 44 orphans in Ilembula village, 32 in Iglehetsa and 9 in
Igula. When they grow older, the hospital provides them with school uniforms, books
and some other necessities.
• To teach the students about HIV/AIDS.
40-45 minutes teaching is given to the students at primary school grade 5-7. They are
told to use condoms but do not get instructions on how to use them.
• To give pre- and post counselling.
The hospital as well as the church encourage people to test themselves for HIV. All
the test takers receive pre- and post counselling. The HIV negatives are given advice
on how to stay negative, while the positives are told how to take care of themselves
and protect others. The infected individuals have ongoing counselling throughout life.
Some of the nurses and clinical officers are trained to be counsellors, under the
direction of Mr Mbilinyi, the HIV coordinator of the hospital. Since the hospital is
Christian, the counsellors are not supposed to recommend people to use condoms but
to abstain from sex outside marriage.
• To have home based care for AIDS patients. [13]
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Home Based Care
Since the prevalence of HIV continues to increase, it has become obvious that the hospital
lacks the resources needed to care for all patients dying of AIDS. This means that there is less
time to focus on patients suffering from other medical conditions. To prevent this, a home
based program for HIV patients is being developed. When functioning, the home based care
will provide the following advantages:
• The overcrowding of the hospitals will be reduced.
• For a long time, the people of Ilembula has treated and cared for their sick relatives in
their family compounds. It is culturally preferred and accepted.
• When a person is admitted to hospital, all close family members will go there to stay
near their sick relative. If it’s possible for the infected person to receive treatment at
home, the relatives can continue to perform their regular work.
• Isolation of the infected person will be avoided. There will also be time and peace to
discuss future problems with the family.
• Because of the many drug resistant micro organisms that are present, hospital
environment can shorten the life of a person with AIDS.
• For the hospital as well as for the family, it’s less expensive to take care of the AIDS
patient at home.
Before the program can be fully implemented there are some issues that need to be dealt with:
• The family of the infected person must be willing to cooperate. Some people might
fear that caring for an AIDS patient will put them at risk of being infected.
• HIV is still carrying a stigma and to be visited by healthcare workers could be very
embarrassing.
• Some of the employees of the hospital must be willing to visit patients at their homes,
sometimes in remote villages.
According to the nurse in charge of the home based care, only about 30 patients are taking
part in the program, but that she is planning to expand it to more villages. When she comes to
a new village, she visits the chairman and asks him to recommend her suitable patients. She
tries to visit the affected families once a month, not only to check the health of the patients,
but also to give them advice on health care. She also hands out medicines and booklets with
information about HIV and other common medical problems. At this point, no patient that is
benefiting from this program has HIV as his /her working diagnosis. The nurse in charge
knows that at least 11 of the 30 patients are infected, but only the patients may bring up
HIV/AIDS for discussion. If the nurse takes the initiative to mention HIV, the patient will
probably refuse to se her again. The stigmatisation of the disease makes this way of helping
HIV-infected patients complicated. It’s not only important to reduce the risk of rumours about
the families that are visited; the patients themselves mostly don’t want to realize that they are
suffering from HIV.
The village of Ilembula
Lifestyle and traditions
Ilembula is located in the Iringa region, Njombe district, in the southern highlands of
9

Tanzania. The population in central Ilembula is estimated to be over 5000 [13] and the near
proximity there are about 30,000 people, the females slightly outnumbering the males. [11]
The majority of the people belong to the Bena tribe, although Hehe, Nyakusa, Samgu and
Kinga are also represented. [13]
Ilembula is a rural village that lacks many modern facilities. Electricity is only available to a
few and in the dry season, water supplies may be scarce. The majority of the people have no
regular income. Most of them are subsistence farmers although some sustain themselves by
small scale business. The basic diet of the people in the village consists of "Ugali" (maize
porridge) and beans, usually eaten with greens and tomatoes. On special occasions, hens,
goats or cows are slaughtered and served with rice or potatoes. [13]
A typical household consists of a husband, a wife and five to six children. Polygamy still
occurs. Marriage is an agreement between two families and the main topic in the negotiations
is the amount of dowry the fiancée and his family has to pay. Customarily, widows are
inherited as wives by the brothers of their deceased husbands, but this tradition seems to be
fading. At present, it is common for unmarried girls to become mothers at an early age. This
is considered a shame in the community. [13]
Bena belong to a patrilineal society, which means their descent is followed through males. In
general, all property of the family is considered to belong to the male family members. The
wife is seen primarily as the mother of one’s children. A marriage is not completed until the
first child is born. The man is the head of the household and his duties are to build houses,
plough, take care of cattle and bring cash to the family. The woman takes care of the home
and assists her husband. She also works in the fields, were he responsibilities include planting,
weeding and harvesting. [13]
In the past few years the spread of HIV has had vast effects on the family structure. Due to the
increasing numbers of infected, the number of orphans is growing rapidly. The older
generation often gets the burden of providing food and raising children when the younger part
of the population has fallen ill or died. [14]
Like other villages in the area, Ilembula has a chairman. Decisions concerning financial
issues, security, social development, health, education and buildings are made at village
meetings. The smallest administrative body is a "10-cell" leader, nominated by the inhabitants
of 10-20 houses. The 10-cell leaders work in close cooperation with the village leaders. Their
duty is to supervise people, to attend village activities and to make sure people follow the
local rules issued by the village government. They also serve as a communication link
between their cells and village leaders, primary school teachers and health care workers. [13]
The Bena people emphasise the importance of each individual’s good behaviour within the
family and other social relationships. Good behaviour involves fulfilling of the moral
expectations based on cultural values and knowledge of the culturally defined sex- and aged
based rules. This ensures harmonious co-existence, but breaking the behavioural rules and
taboos is punished by Good or ancestral spirits through illness and failures in life. [13]
To explain some of the attitudes and thoughts of the Tanzanian people, their concept of time
might be a help. The linear concept of indefinite past, present and an infinite future is foreign
to the African way of thinking. Instead the time is two-dimensional with a long past and a
present. The future as an actual time is absent apart from up to a few years hence. [13]
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In Ilembula, religion is an important issue. In the year of 1906, the first missionaries appeared
at Ilembula. By now, most of the inhabitants in Ilembula are Lutheran or Roman Catholics.
The Christian values and rules do not always agree with the traditions that the tribes have
practiced for hundreds of years. [13]
Sickness and health as seen by the people of Ilembula
A central value in Bantu cultures, including Bena, is life or "vital force". Vital force exists in
everything and in every being in the universe. The source of vital force is God or the creator.
The most important chains linking living human beings to God are the ancestors. The goal is
to acquire as much vital force as possible and to assure that it will remain perpetually in ones
descendants. Illness and suffering are considered to arise when ones vital force is decreased.
[6]
The causes of illness are usually attributed to the violation of a taboo or an insult of ancestral
spirits. People with special skills can also use magic to curse others. The illness has to be
cured by acts of reconciliation or the use of medicines. Sometimes people ask the "mganga"
(medicine man, plural waganga) for help. The mganga can help them finding out who caused
the problem and what measures need to be taken against it. Some of them also use medical
plants and tattoos based on traditional knowledge. [14]
In present day Tanzania, traditional healers operate alongside the modern health care system.
Traditional medicine is considered to be the only efficient cure for some illnesses, while
modern health care facilities are used for others. In general it is up to the man to decide where
the sick family members should receive treatment. [13]
Please. See appendix for a summary of an interview with one of the waganga in Ilembula.
Ilembula Lutheran Hospital
General information
The need for health care facilities in the Ilembula area was recognized when people from the
surroundings turned to a German missionary station for help with medical issues. In 1942 a
dispensary was founded and in 1950 it became a hospital.
Today it provides healthcare services within the fields of internal medicine, paediatrics,
surgery, gynaecology, obstetrics, dentistry, ophthalmology and nutrition. It is also a teaching
hospital for nurse and midwife students at Ilembula School of nursing. In addition, there is an
orphanage with admission capacity of 10 children [12]
The catchment area of the hospital is inhabited by more than 350,000 people. There are 317
beds, but the bed occupancy rate is over 100% in most of the hospital wards. The hospital
employs 7 doctors, 75 nurses and 15 clinical officers. The hospital is grant aided by the
Ministry of Health for 44 employees and 147 beds. [12]
Ilembula Lutheran Hospital is owned and run by the Evangelical Lutheran church in Tanzania
(ELCT) [12]. ELCT covers a large area in the Southern part of the country where it has a
number of Health institutions [15]. The church decides the guidelines and the rules of the
11

hospital, which in the long run means that the hospital employees are expected to follow
Christianity. For example, if an unmarried female employee gets pregnant she is advised to
get married or look for another place to work.
Summary of hospital services 2002
Number of admissions...................10,689
Deaths ……………………………....782
Deliveries ………………………….2409
Caesarean Sections…………….. …..547
Major Operations ………………....1176
Laboratory Examinations……. ….47,976
Top ten diseases diagnosed
1. Malaria
2. Eye infections
3. Pneumonia
4. Diarrhoeal diseases
5. AIDS
6. Anaemia
7. Fractures
8. Tuberculosis
9. Cardiovascular diseases
10. Malnutrition
Top ten causes of death
1. AIDS
2. Malaria
3. Pneumonia
4. Tuberculosis
5. Diarrhoeal diseases
6. Malnutrition
7. Anaemia
8. Cardiovascular disease
9. Burns
10. Hypertension
Ilembula Nurses and Midwives Training School
INMTS was founded 1963 in order to enable ambitious girls to obtain higher education. Like
many other colleges in Tanzania it is a boarding school. At present, there are approximately
100 students and four teachers. The owner of the school is ELCT, but the school doesn’t
require the students to be Christians. However the majority is Christian and attending church
is mandatory in weekdays.
The school fee is 300,000Tsh /year, which includes tuition, meals, lodging, examinations,
books and medical expenses. The students also have to perform certain duties around the
school, such as taking care of the garden, growing vegetables and cleaning.
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While studying at the school, the students have to follow some specific rules. Some of them
are set by the Ministry of Health while others are decided by ELCT.
The governmental rules, which are quite elaborate include:
• Staying in the school area after 7 pm.
• Lights should be put out by midnight.
• Smoking, alcohol and other drugs are not permitted.
• The students must not use abusive or obscene language.
• Pregnant students have to postpone their education. They can apply to the school again
when the child is one year old.
• Students should not commit adultery.
In addition to this, the church requires the students to be polite, honest and live like
Christians.
The students are not allowed to visit relatives except during some holidays. The families are
allowed to visit them once a month. These rules also apply to the married students.
If there is an announcement at the hospital or the school that something has been stolen, the
students’ belongings will be searched through.
If a student breaks the rules the punishment will be a written warning, suspension or dismissal
depending on the severity of the violation.
Since the school has such a good reputation, the students face no difficulties to find a job after
graduating.
This information was received from Alifa Lupende, the principal of the school. For a
summary of the interview, please turn to the appendix section.
Methods
In total 83 questionnaires were distributed to second, third and fourth year students at INMTS.
All the questionnaires were returned. In addition to this, 81 questionnaires were handed out to
nurses, midwives, clinical officers and doctors at Ilembula Lutheran hospital. 33 of the
questionnaires were returned.
With the help of the matron or by ourselves, we met employees of the hospital in different
wards. Those willing to take part in an interview made an appointment and at the agreed time
we met either at an office at the hospital or at our guesthouse.
Since our survey is explorative, the questions were very open. They have been asked in a way
that shouldn’t give a hint about what answer is appropriate or preferred. The standardisation
rate is very low, since the person could steer to the subject that (s)he considered the most
important. The interviews had no time limit. Some of them lasted for half an hour and others
continued for up to two hours. Only the verbal measures were evaluated since it can be hard
to read other cultures’ body language and intonation.
The questionnaires as well as the interviews were strictly confidential. We did not ask the
participants to state their names. In the following text the participants will be referred to as
informants.
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As question number 10 ( Do you see yourself as a member of a special ethnical group?) was
generally misunderstood, we chose not to analyse the answers. The answers to question
number 18 (If you were found to have HIV in your blood, how many years do you think you
would live?) were to complex to account for. Question number 38 (Have you had sexual
contacts with prostitutes?) had to be excluded since we realized that the word prostitution has
another connotation in Tanzania.
To see a copy of the questionnaire and a list of the questions asked during the interviews,
please turn to the appendix.
Results of the questionnaires
Socio-economic situation
Age:
Students: The mean age of the participants was 23.6 years and the median age was 23 years.
The age span ranged from 20 to 30 years.
Health care workers: The age span ranged from 25 to 52 years, the mean being 31.4 and the
median 27 years. Three persons did not report their age.
Profession
Students: 24 students were in their second year, 17 were in their third year and 29 were fourth
year midwife students. 13 participants did not specify their present level of education.
Health care workers: 23 of the participants were nurses or midwives, 8 were clinical officers
and two were doctors. The doctors were considered to be too few for the aims of this survey
and were subsequently excluded.
Gender
Students: All the students were female.
Health care workers: 25 were female and 6 were male.
Family
Students: 7/83 (8%) of the students were married, 67/83 (81%) were single, 7/83 (8%) had
boyfriends and 2/83 (3%) had girlfriends. 9/83 (11%) had children. The number of people in
their households ranged from 3 to 12, the mean being 6.2 people.
Health care workers: 18/31 (58%) were married, 9/31 (29%) were single and 3/31 (9%) had
boyfriends. There were between one and nine people in their households, the mean being 4.5
and the median 4 people. 16/31 (52%) had children.
Religion
Students: 80/83 (96%) were Catholics or Christians of any denomination, while 3/83 (4%)
were Moslems. 65/83 (78%) attended religious services several times a week.
Health care workers: 31/31 (100%) were Catholics or Christians. 22/31 (71%) attended
religious services several times a week.
Economical situation
Students: 10/83 (12%) considered themselves to be poor or very poor, 41/83 (49%) were
average and 25/83 (30%) graded their economy as good or very good. The most common
14

professions of their fathers were farmer (31%), teacher (13%) and businessman (11%). The
mothers were farmers (27%), housewives (22%) and teachers (16%). 3/83 (4%) claimed that
their father was dead, while the same numbers for the mother were 2/83 (3%).
Health care workers: 8/31 (26%) were poor or very poor. 21/31 (71%) graded their economy
as average. One person said his/her economy was good. Their fathers were usually farmers
(32%) or peasants (13%). 7/31 (23%) claimed their father was dead. Common professions
among the mothers were farmer (36%), housewife (16%) and peasant (13%). 6/31(19%) of
the mothers were dead. 4/31 (13%) had lost both their parents.
Knowledge of HIV
First source of information
Most of the participants first heard of HIV at school. Other common sources of information
were parents and media.
19%
First Source of Information on
HIV /AIDS Among Students
0%
11% 2%
16%
52%
Friend
School
Church
Parents
Media
No answ er
Figure 1 Figure 2
15
First Source of Information on HIV
/AIDS Among Health Care
Workers
23%
6%
3%
3%
65%
Friend
School
Church
Parents
Media
No answ er
Ways of transmission
Nearly all participants claimed that HIV can be transmitted by sexual intercourse or from
mother to child during pregnancy and delivery. A clear majority also pointed out breast
feeding. Approximately half of them believed that the virus can be spread by kisses. Almost
nobody thought HIV can be transmitted by shaking hands or mosquito bites.

Mother to child during pregnancy/delivery
Figure 3
Students: Believed ways of transmission
Eating from the same plate
Shaking hands
Caring for an HIV infected
Kissing
Sexual intercourse
Intra venous drug abuse
Breast feeding
By mosquitos
0% 20% 40% 60% 80% 100%
Health Care Workers: Believed ways of transmission
Mother to child during pregnancy/delivery
Figure 4
Eating from the same plate
Shaking hands
Caring for an HIV infected
Kissing
Sexual intercourse
Intra venous drug abuse
Breast feeding
By mosquitos
0% 20% 40% 60% 80% 100%
16
yes
no
don't know
no answer
yes
no
don't know
no answer

Difference between HIV and AIDS
A majority of the students and the healthcare workers knows that there is a difference between
HIV and AIDS. Most of them are able to explain that AIDS is a manifest disease and HIV is
the virus that causes the disease.
68
66
64
62
60
58
56
54
Students: Differences between HIV and AIDS
yes (80%) correct explaination (71%)
Figure 5. Number of students who claimed that there is a difference between HIV and AIDS and how many of
them who could explain the differences.
27
26
25
24
23
22
21
20
Health Care Workers: Difference between HIV and
AIDS
yes (84%) correct explanaition (71%)
Figure 6. Number of health care workers who claimed that there is a difference between HIV and AIDS and how
many of them who could explain the differences.
Ways to cure HIV
Students: 77/83 (93%) said that there is no medicine to cure HIV, while 6/83 (7%) claimed
they did not know.
Health care workers: 30/31 (97%) claimed that curing HIV is impossible and one person said
she did not know.
17

Risk groups
Students: 66/83 (68%) thought that some groups of people were more likely to be infected
than others. Groups often mentioned were young people, drivers, bar maids, teachers and
healthcare workers.
Health care workers: 17/31 (55%) believed that some groups were particularly likely to be
infected and 15/31 (49%) pointed out the young generation as a risk group. Other groups were
students, soldiers, prostitutes, barmaids, drivers, medical workers and married people.
Estimated prevalence of HIV in Ilembula.
Both students and health care workers estimated the rate of infection to be approximately 25%
18
16
14
12
10
8
6
4
2
0
Figure 7
9
8
7
6
5
4
3
2
1
0
Figure 8
Students: What is the rate of HIV infection in Ilembula?
1/100 5/100 10/100 15/100 20/100 25/100 30/100 >35/100 no answer
Health Care Workers: What is the rate of HIV infection in Ilembula?
1/100 5/100 10/100 15/100 20/100 25/100 30/100 >35/100 no answer
Spread of HIV
The factors contributing to the spread of HIV were believed to be:
Students:
1. Sexual activity (25%)
2. Poverty (22%)
3. Lack of education (12%)
4. Unwillingness to use condoms / Ignorance(11%)
5. Prostitution/ alcohol/ infidelity/
lack of medicines/ desire/
sexual intercourse before marriage/
blood transfusions (1-8%)
18

Health care workers:
1. Sexual activity, unsafe sex and infidelity (48%).
2. Poverty (22%)
3. Ignorance (20%)
4. Prostitution, drinking /difficulties in changing one’s habits/ tradition of marrying widows
(3-14%)
Professional situation
Information at work
Students: 79/83 (95%) thought they had received sufficient information about HIV at school
and at work.
Health care workers: 25/31 (81%) claimed that they were well informed about HIV.
Hospital routines and risk at work
Students: 67/80(82%) believed that the hospital routines were good enough to prevent the
spread of HIV. 9/83 (11%) were not satisfied with the routines at the hospital and pointed out
problems such as lack of gloves, old equipment and lack of time to inform the patients.
45/83 (54%) were worried that they might get infected with HIV at work. Situations that were
considered particularly risky included blood sampling, injections, dressing open wounds,
washing bloodstained laundry, working at the operation theatre and attending deliveries.
Some said that sometimes the hospital runs out of gloves, which forces the staff to work with
bare hands. Others expressed concern about the fact that the gloves are washed and used over
and over again. One of the participants said she felt at risk of getting infected at work because
male co-workers sometimes want to have sex with female employees.
Picture 1 Washed gloves
63/83 (76%) tried to protect themselves by using gloves. Other ways of avoiding HIV
infection were covering open wounds, washing hands and using disinfectant.
19

Health care workers: 19/31 (61%) believed the hospital routines were good enough to prevent
the spread of the virus. 8/31 (26%) were unsatisfied with the routines, the reasons for this
being lack of gloves, lack of other protective articles, lack of strong disinfectant and shortage
of staff. 18/31 (58%) were afraid of getting infected at work and 20/31 (65%) said that there
are specific situations where they feel at risk of being infected. These situations included
operations, dressing of wounds, deliveries and blood sampling. One person said she felt at
risk whenever she was exposed to an infected person. 22/31 (71%) said they tried to protect
themselves by wearing gloves. Other ways of avoiding infection were washing hands with
disinfectant, covering wounds and using sterile equipment.
Are the routines for preventing the
spread of HIV/AIDS at your hospital
sufficient?
Figure 9
Have you recieved sufficient
information about how to protect
yourself at work?
Are you worried that you will get
infected at work?
Are the routines for preventing the
spread of HIV/AIDS at your
hospital sufficient?
Figure 10
Have you recieved sufficient
information about how to protect
youirself at work?
Are you worried that you will get
infected at work?
Students
0 20 40 60 80 100
0% 20% 40% 60% 80% 100%
Health Care Workers
0% 20% 40% 60% 80% 100
%
20
no
don't know
no answer
yes
yes
no
don't know
no answer

Information to the patients
Students: 71/83 (81%) of the students tried to inform patients about HIV and 51/83 (61%)
believed that the information could have an impact on the patient’s way of living. 9/83 (11%)
thought it was not always possible for the patients to follow their advice, the reasons for this
being financial problems, negligence and the tradition of having several wives or partners.
Health care workers: 25/31 (81%) of the participants informed their patients about HIV and
22/31 (71%) believed that information could affect people’s behaviour. 3/31 (10%) thought
that following their advice was sometimes difficult for the patients, since they had no money
to buy condoms or simply because they didn’t want to protect themselves. One participant
said it was impossible for her patients to follow her advice, because their husbands were
negligent about the issue.
Private life
HIV among friends and relatives
Most of the participants had relatives or friends who they knew to be infected with HIV.
100%
80%
60%
40%
20%
0%
Relatives and /or friends with HIV
65%
21
68%
yes yes
Students Health Care Workers
Figure 11 Numbers of students and health care workers who have HIV positive relatives and friends.
Informing friends and relatives
A majority of the informants claimed that they could discuss HIV with relatives and friends as
well as co-workers and patients. If they were found to be HIV positive, they would usually
inform close family members.

Other relatives
Figure 12
Mother
Father
Partner
Friends
Coworkers
Other relatives
Figure 13
Mother
Father
Partner
Friends
Coworkers
Other relatives
Figure 14
Partner
Parents
Friends
Coworkers
Patients
Others
Students: With whom can you talk about HIV?
0% 20% 40% 60% 80% 100%
Health Care Workers: With whom can you talk about HIV?
0% 20% 40% 60% 80% 100%
Students: If you were found to have HIV, who would you inform?
0% 20% 40% 60% 80% 100%
22
yes
no
don´t know
no answer
yes
no
don't know
no answer
yes
no
don't know
no answer

Other relatives
Figure 15
Health Care Workers: If you were found to have HIV, who would you
inform?
Partner
Parents
Friends
Coworkerrs
Patients
Others
0% 20% 40% 60% 80% 100%
23
yes
no
don't know
no answer
Protecting oneself
Students: Common ways of protecting oneself from HIV were:
1. Not having sexual intercourse (35%)
2. Abstain from sex until marriage/ be faithful (28%)
3. Avoid wet kissing/ not sharing toothbrushes/ taking blood tests before starting a sexual
relationship/ praying to God (1-8%)
76/83 (92%) claimed that they would ask their partner to take a blood test before starting a
sexual relationship. If a partner wanted to have unprotected sex, 36/83 (43%) would refuse to
have sex with him or her, while 33/83 (40%) would try to convince their partner to use a
condom anyway. Only one person said it did not matter to her.
Health care workers: Common ways of protecting oneself from HIV were:
1. Having just one partner (16%)
2. Avoiding sex before marriage/ using condoms (10%)
3. Abstaining from sexual intercourse/ avoiding blood transfusions and practicing careful
personal hygiene (3-6%)
22/31 (71%) said they usually ask a partner to take a blood test before starting a sexual
relationship. One person said she asks her partner to use condom instead. 10/31 (32%) would
refuse if a partner wanted to have unprotected sex and another 10/31 (32%) would try to
convince their partner to use a condom anyway. 4/31 (13%),of whom two were married,
claimed it didn’t matter to them.
The question concerning who usually decides if to use a condom or not, was often
misunderstood. Instead of choosing a, b or c (the man, the woman or both) most participants
ticked a box under each option. This makes it impossible to draw any specific conclusions.
Some of the written comments we received in response to the question were:

• The man is the decision maker. The woman is always commanded by the man.
• The man does not care about or fear HIV.
• The man, because he does not feel happy during sexual intercourse.
• The man, because the man is able to choose whether he wants a child or not
• The man, because the man can tear it.
• The man, because the woman has no power during sexual intercourse.
• The man, because if the woman decides to use a condom and the man does not agree,
he can force her.
• The man can not decide, because a woman can feel bad if she will be forced.
• The woman, because the man doesn’t care.
• The woman, because she has fear to get HIV.
• The woman, because she is afraid of pregnancy and venereal diseases. .
• Because the woman may fear to get an infection from the man she decides to use a
condom or not.
• Both, because they are able to choose whether to get a child or not or to avoid cross
infection from one person to another.
• We must all agree to use condoms in order to prevent the friction to avoid HIV.
• For myself I don’t like condoms because they are not good for protection.
• Not the woman because she is afraid when say to use condom the man will refuse to
do sexual intercourse.
Sexual partners
Students: Most of the students claimed they had no sexual experience. A smaller number had
had one or two sexual partners. 29/83 (35%) stated that their partners are usually men, (2/82
(2%) preferred women and 10/82 (12%) had sexual relationships with both men and women.
42/83 (51%) left the question unanswered. 9/83 (11%) said that it is sometimes difficult to
say no when someone asks for sex.
Health care workers: 7/31 (23%) said that they had never had a sexual relationship with
anybody, while 48% claimed that they had had one sexual partner. One person said that she
did not remember how many sexual partners she had had and another person claimed that she
had had 350 sexual partners. 7/31 (23%) did not answer the question. Three participants
claimed that they had never had a sexual relationship with anyone, even though they had
children. 2/31 (6%) said that it is sometimes difficult to say no when someone asks for sex.
Only one person gave a reason for this: It is shameful for a man to reject a woman’s wish.
24

50
40
30
20
10
0
Figure 16
16
14
12
10
8
6
4
2
0
Figure 17
Students: Number of sexual partners
none (54%) one (29%) two (7%) no answer (10%)
Health Care Workers: Number of sexual partners
none (23%) one (48%) 350 (3%) Don´t remember (3%) No answer (23%)
Children
Students: 78/83 (95%) would not want to have children if they were found to be HIV positive.
Health care workers: None of the participants would want to have children if they were HIV
positive, but four persons left the question unanswered.
Results interviews
HIV in general
What do you think are the reasons why HIV is still spreading so rapidly?
The factors considered to contribute to the spread of the virus were (in order of priority):
1. Ignorance
2. Alcohol
3. Poverty
4. Prostitution
5. Negligence/unwillingness to change one’s habits
6. Lack of education
7. Infidelity/ the tradition of having many partners
8. Dislike of condoms
25

9. Local traditions, such as polygamy or the custom of inheriting the wife of a deceased
brother.
Almost everybody pointed out ignorance, alcohol and prostitution as parts of the problem.
Excessive drinking is common in the area, particularly among the men. Local brew, such as
alcohol made of bamboo, is cheap and available everywhere. Since the most common way of
supporting oneself is farming and the work load varies with the season, sometimes the men
gather at the bars to get some diversion. Women working at the bars are poor and often open
to suggestions about having sex for money. Young women, particularly those without
education, turn to prostitution because they see no other way to support themselves. Others
sell sexual services in order to be able to afford some luxury, such as nice clothes or
expensive hairdos.
Some men work far away from their families, which gives them opportunities to socialize
with women without anyone knowing. If the man spends much time away from home, women
are sometimes willing to pay for sexual favours.
We were told that a lot of people just do not care about themselves and their health. They
think they have enough worries already and that AIDS does not deserve more attention than
for example malaria and tuberculosis. The risk of getting infected with HIV is a part of life
and it is not worth the trouble trying to avoid it. This attitude decreases the use of condoms.
Some informants claimed that lack of education leads to misconceptions about HIV. For
example, it can be difficult to understand that a person who looks healthy can be carrying the
virus.
Do people usually want to know if they are HIV positive or not? How about you?
Opinions differ on this matter. Some of the informants said they wanted to know their HIV
status, while others preferred not knowing. Of those asked, about 50% had tested themselves
for HIV.
The informants said that the main reason for not wanting to test oneself is that people want to
live in peace, without worrying about a future they cannot change. Since there is very little
help to get, they see no point in knowing if they are carrying the virus or not. The risk of
transmitting the disease to others is of less importance. There is a widespread belief that if you
find out that you are HIV positive, you will die earlier because of mental distress. People also
fear that rumours will arise if they have to visit the hospital frequently. In spite of this, more
and more people come to the hospital for voluntary testing. The reasons could be that the
hospital is now providing the tests for free and that some of the churches in the area refuse to
marry couples unless they show a certificate saying that they are HIV negative. There is an
ongoing political discussion in Tanzania about weather testing before marriage should be
made mandatory by law.
Most of the informants believed that more people would come for testing if antiviral therapy
was available.
What do you think can be done to prevent the spread of HIV? What about the future?
Preventive measures suggested by the informants included (in order of priority):
1. Pre-and post counselling
26

2. Repeated education
3. Making people afraid of getting the disease
4. Convincing people to change their behaviour
5. Encouraging infected individuals be open about their medical condition
6. Taking measures to increase the standard of living
Counselling is believed to generate several positive effects. It will make people more likely to
take an HIV test, tell others if they are infected and be willing to protect others.
Many believed that HIV could be stopped by further education on the issue. Some said that to
stop the disease, people must be persuaded to use condoms or abstain from sex before
marriage. Few had any ideas about how this could be done, but some believed fear is the best
prevention. Others said that Tanzania has a lot to learn from Uganda, where the fight against
HIV has been more successful. For example, when a person has died of AIDS, this should be
announced at the funeral and HIV positive individuals should be encouraged to step forward
and tell others about their disease. There was also a small group of informants who thought
that the legal system has to strike down harder on those who are spreading the disease. One
informant said that people should be recommended to masturbate instead of having multiple
partners.
Questions about the future generated gloomy and pessimistic answers. Few thought it would
be possible to control the spread of the disease. Some even said that AIDS will continue to
kill, eventually leading to the end of mankind.
Why is HIV stigmatized?
HIV is often associated with irresponsibility and promiscuity. The main reason for this is not
the disease itself, but the way it is transmitted. If the infected lives in an area where
Christianity or Islam is dominating, it also indicates that the person is a sinner, since none of
the religions approve of adultery and sex before marriage. There is also a belief that HIV is a
punishment from God.
There are still some people who lack proper knowledge about HIV, which means that they
don’t know how to deal with the problem. This can create unnecessary fears of HIV and the
infected persons.
Family and friends
Is it difficult for a person to tell relatives and partners that (s)he is infected with HIV?
A majority claimed that it’s difficult to disclose one’s HIV status for family and friends. The
stigma is one of the main reasons for this. People also fear being accused of transmitting the
disease to their partner. Some of the informants told us that those who inform their partners
are putting themselves at risk of being beaten or even killed. The fear of retaliations make
many individuals keep their disease as a secret.
There is also a fear that family and friends will turn their backs at the infected.
Do the families usually take care of relatives suffering from AIDS?
Most of the informants claimed that the families usually take good care of a sick relative. The
hospital provides education on how to care for infected individuals. The recommendations
include serving nutritious food, using gloves when necessary and giving psychological
support to the affected. Having received this information the relatives are usually less
27

eluctant to help the sick person. Even so, some family members are afraid and refuse to have
close contact with the infected when the symptoms of AIDS become evident.
A small group of the informants said that HIV patients often are abandoned by their families.
Some of the nurses had noticed that when relatives find out that the patient is suffering from
HIV, they sometimes stop visiting him or her. Others deny the sick person further health care,
saying it is unnecessary to spend money on someone who is going to die anyway.
HIV at work
Do you sometimes feel at risk of getting HIV at work? How do you protect yourself?
A majority of the informants were afraid of getting infected at work. Some wards were
considered to be more dangerous than others. When the hospital runs out of gloves the few
that are left are distributed to the more risky ones. One of the nurses said that when there are
no gloves available she refuses to work. Another informant claimed that he is “scared to
death” and asks God for protection every day. Others felt that as long as their skin is intact,
there is no reason to worry.
Only one person brought up the problem that even patients at the hospital may get infected
with the virus if the health care workers are not careful.
When employees at the hospital accidentally prick themselves with a dirty needle, what
do they usually do?
Almost all of the informants would squeeze out some blood and wash the wound with
antiseptic. Some would test themselves for HIV, others would not. Most of them preferred to
test the patient instead. The reasons for not wanting to test oneself were that the risk of getting
infected is so small and the fear of being HIV positive. Since there is no insurance to cover
this kind of accidents, nothing good will come out of a positive test.
One of the informants said that testing herself would be useless, since she would still not
know if she got the virus from the patient or her husband.
One of the students explained that for a student, taking an HIV test at the hospital is difficult,
since this will raise doubts about her morals.
Do HIV infected persons usually take precautions not to transmit the disease to others?
A clear majority of the informants stated that HIV positive individuals usually try to infect as
many others as possible. When people find out that they are infected, the reaction is often a
feeling of injustice and hunger for revenge. Many of them fear to die alone and want to share
their destiny with others. There is a certain expression for this: Tufe wengi, meaning
approximately “let us die together in a large number”. One of the students stressed that this
behaviour is particularly common among uneducated people. Those who are educated know
that there are many other sexually transmitted diseases and are therefore less inclined to
practice unsafe sex. One of the doctors and a couple of the health care employees told us that
28

the best way of stopping people from spreading the disease is to instruct them to avoid other
venereal diseases. Telling people to practice safe sex in order to protect others is useless.
Generally spoken, those who were working with counselling of HIV patients had a more
positive attitude towards them. They did not think it was common to deliberately spread the
virus. Even among others, counselling was seen as a way of preventing this behaviour. If the
patients know that they will have regular check-ups at the hospital, they are more likely to
follow the recommendations.
Sexual behaviour
At what age do people usually start having sexual intercourse?
The answers to this question ranged from 12 to 20 years. Some believed that it is getting
more and more common to start having sex at an early age. One reason for this could be that
the HIV pandemic has forced teachers to put sexual education on the schedule already in
primary school, which makes children curious about sex. It happens that girls as young as 10
or 12 years turn up at the hospital because of pregnancy. One of the nurses explained that
instead of protecting themselves by using condoms, some men prefer looking for sexual
partners among very young girls without sexual experience.
The informants said that the youngsters are aware of HIV when they start their first sexual
relationship, but doubt that they take the disease seriously.
Do people in general have sexual intercourse before marriage/ outside marriage?
All informants except one said that people do not abstain from sex until marriage. On the
contrary, young people usually want to try out several sexual partners before they choose a
future spouse. Most informants also stated that extramarital affairs are common. Some said
that the low status of women is making this problem worse.
There are some local customs that enhance and justify infidelity. For example, it is a tradition
among women in the area to abstain from sexual intercourse while breast feeding. There is a
belief that the semen from the man can contaminate the breast milk, giving the child
diarrhoea. Usually women continue to breast feed until it is time to have a second child.
During this period it is more or less accepted for a man to have a mistress. The hospital
recommends abstinence for forty days after delivery, but even that period can be too long for
some men. However, the female informants emphasized that for a woman with higher
education, it is easier to demand fidelity from her husband.
Infidelity occurs among women as well, even though it is less accepted. Sometimes, the man
is working far away from the family, which paves the way for extramarital relationships for
both spouses.
What do people think about condoms? Do people know how to use them?
Generally spoken, condoms do not seem to be very popular. The reasons for this include:
• Condoms diminish the sensations.
• There is always a risk that they will break.
29

• There are rumours saying that condoms manufactured in Europe have holes in them,
because the Europeans want HIV to spread in Africa.
• Other rumours claim that the manufacturers deliberately add HIV to the material the
condoms are made of.
• Some people believe that condoms have pores. In Africa, where the climate is warm
and humid, these pores will grow big enough to allow passage of a virus.
• Some women fear that condoms will destroy the cervix or cause genital cancer.
Even some of the hospital employees believed these rumours to be true, pointing at the fact
that AIDS was non-existent before people started using condoms.
Most of the informants agreed that condoms are readily available, even in small villages.
They are handed out for free at the hospital and sold at small shops and kiosks in the
surroundings. Unfortunately, some people think it is embarrassing to ask for condoms. A
woman buying condoms can be reputed to be a prostitute and a man might be suspected of
adultery. One of the informants said that because they are too embarrassed to buy them, some
men borrow condoms from each other and use them several times. A large number of people
do not know how to use condoms properly or use them only in order to prevent pregnancy.
When a couple has been dating for a while they think they know each other well enough to
use other contraceptives instead.
Two of the informants told us that condoms are useless, because they had met patients who
claimed they got pregnant even though they used condoms.
Some of the students at the nursing school said that even though the hospital provides
condoms to the villagers, students are not allowed to fetch or possess any. The staff of the
school has a right to search through the personal belongings of the students and if they find a
condom, the student will be banned from classes or even sent home for a month. This is done
in order to help the students focusing on their studies.
Of those taking part in the interviews, some said it is difficult to recommend the patients to
use condoms without support from the church authorities. The representatives of the Catholic
Church do not approve of condoms, since they believe this would encourage people to engage
in sexual activities outside marriage. Condoms are also said to be sinful, because they prevent
conception. Some felt that by taking this standpoint, the church contributes to the problem.
Culture and religion
Do people believe in traditional healers? Do they think that the healers can cure HIV?
This question resulted in a diverse variety of answers. While some thought that these days
only a few believe in witch doctors, others claimed that they are still respected and powerful.
It happens that HIV patients are diagnosed in very late stages, because they receive treatment
from a traditional doctor before they turn to the hospital. It is also common that HIV patients
visit traditional doctors after realizing that there is very little the hospital can do for them.
Doctors at the hospital truthfully explain that there is no cure, while witch doctors sometimes
claim they have treatments that will wipe the virus out of the body. Sometimes the HIV
patients prefer traditional doctors because they discredit the hospital and give their clients a
less embarrassing diagnosis. For example, the healer can say that they have fallen ill because
somebody cursed them. Devastating family feuds can arise when a relative is accused of
putting a spell on a family member.
30

Some informants said that the witch doctors are thieves that are making a living out of other
people’s misery. Their services and advice can be expensive and it happens that families ruin
their economy, paying for useless drugs. Nevertheless, it happens that people with high
education turn to a witch doctor for help. One of the informants said that her sister had been
diagnosed with HIV several years ago, but was still healthy because of a brew she was taught
too cook by a traditional doctor. The informant did not know the recipe of this medicine, but
recalled that one of the ingredients was boiled meat. Two other informants confirmed that
there are rumours that pork can prolong life of HIV infected individuals.
Some informants expressed concern about the fact that the healers are making medical tattoos
with dirty instruments. However, some people are aware of this and bring their own
razorblades and knives.
When it comes to HIV, are there any differences between:
• educated and uneducated?
Few informants thought that there were any differences. The incubation time is long
and many educated people got the disease before the information was spread.
Educated people usually know more about the disease, but they still do not protect
themselves. Uneducated people are sometimes extra careful because they believe that
the HIV virus is transmitted very easily.
Some informants pointed out that many teachers have died of AIDS in spite of their
education.
• Rich and poor?
In the past, the majority of the HIV infected was rich, but the numbers have equalled
out. Wealthy people can afford to spend money on sexual favours while poverty
sometimes forces people into prostitution.
• Christian and non-Christians?
Almost everybody thought there were no differences between these groups. People
simply do not follow the rules of their religion.
• Men and women?
In Tanzania, the social status of women is inferior to men. The wellbeing of the males
is emphasized. When resources are limited, the nutrition and education of the
daughters are neglected. Finding a job without education is almost impossible, which
makes women economically dependent on their husbands. All the family assets belong
to the man, making it possible for him to spend money on prostitutes and mistresses.
Even if a woman knows that her husband is unfaithful, it is extremely difficult for her
to divorce him because her parents might have to pay back the dowry to the family of
the husband. The husbands are well aware of this and many of them take the
opportunity to abuse their power. Sometimes a woman can ask relatives or church
leaders to help her convincing the husband to be faithful and take care of his family. If
he refuses to listen to them, there is very little she can do to change the situation. One
of the informants said that finding a good husband in Tanzania is like winning in a
31

lottery and she thanks God every day for giving her a faithful man. When a couple
gets married they usually do not know each other very well and after a few months the
problems may start. While dating, the woman has a right to turn down her boyfriends
requests for sex, but after marriage she has no right to say no to her husband. Nor does
she have the right to criticize or question him in any way. Because of this, some
women chose not to get married at all.
Polygamy occurs, but only the man is allowed to have several spouses. It still happens
that a man inherits the wife of a deceased brother. If a woman fails to give her
husband children he is allowed to take a second wife. This custom is more common
among uneducated. Even so, one of the informants told us that her father, who is a
doctor, is a polygamist.
The local council in Ilembula recently dealt with the following case:
A man who had been working in another part of the country for two years returned to
his wife. She asked him to take an HIV test before they started any kind of intimate
life again, but he refused. In response to this, the woman kept a knife in her bed,
threatening to injure her husband if he touched her. Finally, the man agreed to be
tested. He was found to be HIV positive and the woman said she would never have
sexual intercourse with him again, unless he used a condom. The issue was brought up
for discussion at the local council, which concluded that the woman was right. The
man refused to accept this, insisting that his wife should obey him and fulfil all his
wishes. Eventually the wife divorced him.
The informant who discussed this case with us said that it clearly illustrates how little
respect some men have for women, thinking that they have a right to infect their wives
with a deadly disease.
Discussion
Validity of the results
This study was carried out by means of both questionnaires and interviews. These methods
sometimes provided us with contradicting information.
The credibility of this project depends to some extent on the number of questionnaires and
interviews. In spite of reminders, most of the health care workers didn’t turn their
questionnaires in. It was also very difficult to find participants to the interviews and of those
who made appointments, only a small share turned up. In conflict with the results of the
questionnaires, this could indicate that HIV is still a subject that people would rather not talk
about. Common explanations for failing to come were difficulties with English and
forgetfulness. Another reason was that we conducted some interviews in our guest house and
the students were not allowed to go outside school without a teacher’s permission.
Unfortunately, we didn’t receive that information until the end of our stay. One reason why
the questionnaires came out misleading could be that the hospital rules are very restrictive
when it comes to the sexual behaviour of staff and students. Some might have been anxious
about this, doubting the anonymity of the survey. Another source of error is the fact that few
health care workers returned the questionnaires. There is a risk that those who know they have
risky habits were particularly reluctant to participate.
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Those who came for interviews were very open and willing to discuss the matter, but we
noticed that in order to gain information, we had to bring up the topics in a general way,
avoiding questions that would point out the informant in person. We got the feeling that some
of the informants thought that the aim of the project was to lecture people and tell them how
they should live. The participant often claimed that his/her behaviour was very moral but that
other peoples’ wasn’t. Of course, it is very difficult for us to determine whether the behaviour
of the participants differs from that of people in general, but most of the health care workers
and students believed that there were few differences.
Most of the participants were well-educated women with Christian believes. Even though they
had a great experience in taking care of the people in the village, their background and
different set of values may have made them misinterpret the behaviour and attitudes of the
average Ilembulan person. We also believe that some important details may have been lost,
not only because the interviews were conducted in English but also because of our different
values and beliefs.
We also lack information about the males’ situation from their own perspectives.
Knowledge and spread of HIV
When comparing the results of our questionnaires to those of a survey conducted on pregnant
women at ILH in 2002, the differences are surprisingly small. From a general point of view,
the people of Ilembula have good knowledge of HIV/AIDS. [16] In spite of this, many of the
informants believe that HIV is spreading by kisses. A few of them had commented on the
questionnaires that kisses may give you HIV if both partners have a wound in their mouth.
We don’t know the number of informants who thought that kissing “without complications”
could transmit the virus.
When it comes to the spread of HIV, ignorance and lack of education were believed to add to
the problem. Still, few informants thought there were any differences between educated and
uneducated people. This means that there is a link missing between knowledge and behaviour.
One of the clinical officers described this phenomenon in a very illustrative way: People
know, but they don’t have the will to know. As long as the leading classes of the society are
reluctant to alter their lifestyle, it will be very difficult to change the behaviour of the lot. It is
a discomforting fact that many teachers have died of AIDS, since they serve as role models
for large numbers of children.
Next to all of the informants mentioned alcohol at some point during the interviews. Drinking
is believed to be highly associated with indulgent sexual behaviour. The informants claimed
that intoxication makes people forget all restrictions. We do not know if any survey has
shown a relation between abuse of alcohol and HIV infection, but we believe that this could
be the case.
Another probable reason is poverty. The so called Mandela Study has found a correlation
between HIV and socio-economic status in South Africa [17]. One reason could be that
poverty may lead to prostitution. Far from all of the women that are selling sexual favours are
seen as prostitutes by others, and don’t get paid for sexual intercourse regularly. Sometimes
trading sex for money also occurs within the relationship. This quotation is taken from “Sex
and HIV in the city economy of desire in urban Tanzania: “ For most Tanzanian men the aim
33

of having a girlfriend is to satisfy their sexual desires and for most Tanzanian girls having a
boyfriend is to get help for their basic needs. That’s why most girls prefer men who have
enough money.” [18]
It seems like people choose to apply only certain recommendations, rejecting others. For most
persons with medical education, some of the rumours about condoms should seem highly
unreasonable. Still, some people choose to believe in them. This is disquieting in many
aspects. The best way of stopping the spread of HIV among sexually active individuals is to
recommend the use of condoms. If the hospital employees do not trust condoms, it might be
difficult for them to convey this message to the patients. We are also concerned that older
nurses and midwives might transfer their negative attitude towards condoms to students, who
look up to experienced personnel.
People also seem to listen to the church authorities when they say that condoms are sinful, but
they are still reluctant to abstain from sex until marriage. Students learn at school that
condoms are far from always safe but even if they chose to believe that a condom would
protect them from HIV, they are not allowed to buy or keep them. When young individuals
decide to have sexual intercourse it may be best if they don’t do this in secret. If people are
more open about sex, the adults will have a chance to guide the youngsters in how to protect
themselves. Many Christian ideals, such as honesty, generosity and self-sacrifice are
consistent with the traditional culture and therefore easily incorporated in the modern
lifestyle. When traditions and Christian values collide, people randomly choose what suits
them best.
Common words and expressions used when the informants talked about sexual behaviour
were “desire” and “human needs”. Still people are forced to pretend that unmarried hospital
employees and adult students can be made celibates. The informants told that a person usually
starts sexual activities between 12-20 years of age. We think this gives a reason to assume that
some of the students and health care workers are breaking the rules.
A clear majority of the participants felt that they had received enough information on how to
protect themselves against HIV, but they still felt uneasy because the resources and routines
of the hospital are inadequate. Circumstances sometimes force them into situations where they
are at risk of being infected.
Behaviour, traditions and beliefs.
Our impression of the Ilembula community is that people usually help each other and share
the burdens. For this reason, it is hard to understand why many individuals don’t feel any
moral responsibility for the health and wellbeing of others. The informants agreed that
deliberately infecting another person is not acceptable. Nevertheless, most of them believed it
is common. Some people seem to have a fatalistic view of life, believing that the future is
predestined and impossible to change. Others simply believe that accidents could occur at
anytime anyway. Hence there is no way of escaping one’s destiny or protecting others from
theirs. This philosophy can also be traced in people’s lack of hope for the future. AIDS is a
disease that can be prevented, but people do not think it is possible to do this. This pessimism
is seen in the overestimation of the number of infected people in the area. More than fifty
percent believed the rate of infection to be 25% or higher. Statistics made at the hospital has
shown that the accurate number is about 15-20%.
34

The stigma associated with HIV makes it impossible to create an open atmosphere were
infected individuals are fully accepted. A survey on this topic performed in South Africa has
shown that AIDS related stigmas are socially and culturally pervasive. According to this
survey, 26% of the respondents would not be willing to share a meal with a person living with
AIDS and 18% were unwilling to sleep in the same room as someone who has AIDS [19].
Another survey carried out in Dar es Salaam has shown that women often choose not to
disclose their HIV statues because of fear of a violent reaction by male partners [20].
Globally, it is easy to find a connection between high prevalence of HIV and low status of
women. The informants were well aware of this and listed a number of problems related to the
subordinating of women. We saw a tendency to rebel these traditions among both older and
younger women. For example, some of them said that they refuse to get married because they
don’t want a man in their lives. Others simply submit to the traditions. It is reassuring that
even the men identified the inferiority of women as an undesirable part of the culture, since
acknowledging a problem is the first step towards a change. There are numerous customs and
beliefs that need to be evaluated and abolished and most of them relate to women directly or
indirectly. The present situation, where men can afford to pay for sexual favours and women
cannot afford to say no, should never be accepted. In Mwalimwa in northern Tanzania, efforts
to change unproductive traditions have shown encouraging results. The village council have
cracked down on a variety of traditional, social and sexual practices that have made the area a
breeding ground for HIV. A survey indicates that 38% of the residents see safer behaviour in
their villages and teachers report a decline in pregnancies among schoolgirls. [21]
There is a general resistance to testing oneself for HIV. Our impression is that the main reason
for this is the fear that worry and depression will cause an early death. In present day
Tanzania, a positive blood test is the same as a death sentence. Therefore, most people who
know they are living a risky life prefer not knowing. This is extremely unfortunate, because it
means that a large number of individuals are unknowing of the fact that they are spreading the
virus. Antiviral therapy could increase the interest for voluntary testing. If combined with
proper and efficient counselling, this could be a way of limiting the spread. It is believed that
counselling would make people responsible and willing to protect others from the disease.
This opinion is supported by a survey conducted in Kenya, Tanzania and Trinidad. [22]
The problem is that only the people that are thinking about taking an HIV test are counselled.
These individuals have in one way already made a decision. We believe it’s necessary to
make efforts to reach out to the people that are far from convinced.
When compiling the results of the questionnaires, we noticed that economy and profession of
the parents did not influence the answers. The difference between second and fourth year
students was also small, which could indicate that the students already have good knowledge
of HIV when they start studying at the nursing school. This hints that the primary and
secondary schools have been successful in conveying the information. A majority of the
informants received their first information about HIV from school. Since the school seems to
reach out to a lot of people, perhaps it could be a tool in changing the attitudes towards HIV
and protection from HIV.
The traditional healers are sometimes worsening the situation. One of the main problems is
that some of them make people believe that HIV can be cured. If people believe them, they
are probably less interested in protecting themselves.
35

Uganda was often described as a possible role model for Tanzania. According to a survey
performed by the US Agency for International Development, the reasons for the successive
reduction of HIV in Uganda include making it a patriotic duty to inform others about one’s
HIV status, using well known faces and celebrities to reduce the stigma empowering of
women by giving them more political voice, and making religious leaders active in the
response to the epidemic. [23] We see no reason why this should not be implemented in
Tanzania.
Many of the reasons numbered up are connected with each other. Lack of education leads to
difficulties in getting a job, leading to poverty, leading to prostitution… Addressing one of
the problems could have many possible side effects.
Conclusions
• The healthcare workers at ILH and the students of INMTS have good knowledge of
HIV/AIDS.
• There are misconceptions about condoms, even among people with medical education.
• Education and knowledge of the disease do not guarantee abolition of risk behaviour.
• People are still reluctant to test themselves for HIV.
• Local customs, abuse of alcohol and the inferiority of women facilitate the spread of
the virus.
• Poverty is making the fight against HIV more complicated. Jobs to uneducated people
or scholarships would probably make a difference.
• The hospital needs more resources to protect the staff from infection. Greater access to
gloves would make the situation considerably better.
• Church traditions and hospital rules are sometimes counterproductive.
• Measures needed to improve the situation include strengthening of the laws
concerning HIV, empowering of women, reduction of the stigma, actions against
poverty and changing negative aspects of the culture.
Acknowledgements
We wish to thank Professor Rune Andersson for making this study possible and for his
invaluable assistance with the revision of the material. We also thank his secretaries
Lisbeth Jinnestål-Fernow and Anna-Lena Loft-Eriksson for helping us with the layout of
the questionnaire.
We also express our sincere gratitude to Dr Willis Temihango and Principal Alifa
Lupende, who were willing to share their experience and knowledge with us.
We would also like to thank the matron, who helped us carrying out the collection of
information and the treasurer, who very kindly lent us his personal computer. Special
thanks go to Aida, the nurse in charge of the home based care, who introduced us to her
work.
We also want to thank Dr Leena Pasanen for her pleasant aerobics classes and Ulla Kagali
for the lovely tea breaks at her veranda. We gratefully acknowledge Rehema Mgimba for
her helpful guidance, translations and general assistance.
36

In addition to this, we thank all the hospital employees, students, the village chairman, the
evangelist and the traditional healer, who participated in the study.
Appendix
Questions asked during the interviews
HIV in general
• What do you think are the reasons why HIV is still spreading so rapidly?
• Do people usually want to know if they are HIV positive or not? How about you?
• What do you think can be done to prevent the spread of HIV? What about the future?
• Why is HIV stigmatized?
Family and friends
• Is it difficult for a person to tell relatives and partners that (s)he is infected with HIV?
• Do the families usually take care of relatives suffering from AIDS?
HIV at work
• Do you sometimes feel at risk of getting HIV at work? How do you protect yourself?
• When employees at the hospital accidentally prick themselves with a dirty needle,
what do they usually do?
• Do HIV infected persons usually take precautions not to transmit the disease to others?
Sexual behaviour
• At what age do people usually start having sexual intercourse?
• Do people in general have sexual intercourse before marriage/ outside marriage?
• What do people think about condoms? Do people know how to use them?
Culture and religion
• Do people believe in traditional healers? Do they think that the healers can cure HIV?
• When it comes to HIV, are there any differences between:
Educated and uneducated?
Rich and poor?
Christian and non-Christians?
Men and women?
37

Questionnaire
Thank You for taking part in this study about HIV/AIDS. All information will be treated as
strictly confidential. Some of the questions are of a rather personal character. We hope that
this won’t make it difficult for you to answer the questions.
General questions:
1. Age
2. Sex
3. Profession (if student, please specify what you are studying)
4. Profession of your parents?
5. Marital status (married, single, boyfriend/girlfriend)
6. Do you have children? If yes, how many?
7. How many people are there in your household?
8. What is your religion?
9. How often do you attend religious services? Please mark the best option:
Several times a week
Once a week
Once or a couple of times a month
Once or a few times a year
Never
10. Do you see yourself as a member of a special ethnical group? If yes, please specify:
11. If you were to grade your economical situation, how would you classify it? Please
mark the best option:
Very poor
Poor
Average
Good
Very good
Questions about HIV/AIDS:
12. How did you first hear about HIV/AIDS? (e.g. from a friend, in school etc.)
13. In what ways do you think HIV/AIDS is spread from one person to another? Please
mark all the options you think are correct:
Eating or drinking from the same plates and cups?
Shaking hands/hugging/living in the same house?
Caring for/washing/changing clothes for someone who has AIDS?
Kissing
Having sexual contact
Injecting narcotic drugs
Breast feeding
From mother to child during pregnancy or delivery
By mosquitoes
Other way
14. Is there a medicine that can cure HIV/AIDS? If yes, please describe in short terms
what you know about that:
15. Is there any way to cure HIV/AIDS?
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16. Do you know if any special groups are more often infected with HIV/AIDS than
others? If yes, please specify:
17. What do you think is the rate of HIV/AIDS infection among adults in the area where
you live? (For example 1/10, 1/1000)
18. If you were found to have HIV in your blood, how many years do you think you
would live without medicine? With medicine?
19. What do you think are the reasons why HIV/AIDS has spread so rapidly?
20. Are there any differences between HIV and AIDS? If yes, please specify:
Professional situation:
21. Do you think that you have received sufficient information about how to protect
yourself and others from HIV/AIDS at work? If no, why not?
22. Do you think that the routines for preventing the spread of HIV/AIDS at your hospital
are sufficient? If no, why not?
23. At work, are there any specific situations in which you feel that you are at risk of
getting infected with HIV/AIDS? If yes, please specify:
24. At work, what do you do to protect yourself from getting infected with HIV/AIDS?
25. Are you worried that you will get infected with HIV/AIDS at work? If yes, why?
26. Do you inform your patients about HIV/AIDS? If yes, in what way?
27. Do you think the information you give your patients has an impact on their way of
living? If yes, in what way? If no, why not?
28. Is it possible for your patients to follow the advice you give them? Why, why not?
Private life:
29. Do you have any friends or relatives that are infected with HIV/AIDS? If yes, how
many?
30. What do you do to protect yourself against HIV/AIDS?
31. With whom can you talk about HIV/AIDS?
Mother
Father
Other relative/s/
Partner/
Friend/s/
Co-worker/s/
32. If a person wants to have sex with you, is it sometimes difficult to say no? If yes,
when and why?
33. When you meet a new partner, do you usually ask him/her to test for HIV/AIDS
before you start a sexual relationship? Why/ Why not?
34. How many sexual partners have you had?
35. Are your sexual partners men, women, both?
36. If your partner does not want to use a condom, what is your response? Please mark the
best option:
It doesn’t matter to me
I refuse to have sex with him/her
I try to convince him/her that we should use a condom
I break up with him/her
Other alternative
37. In general, who decides whether if to use a condom or not?
39

The man………………Why?
The woman……………Why?
Both…………………...Why?
38. Have you had sexual contact with prostitutes?
39. If you were found to have HIV in your blood, who would you inform?
Partner
Parent/s.
Other relative/s/
Friend/s/
Co-worker/s/
Patient/s/
Other
40. If you were found to have HIV in your blood, would you still want to have
children/more children?
Interwiev with Willis Temihango, doctor in charge at Ilembula Lutheran
Hospital
Willlis Temihango has been the doctor in charge at Ilembula Hostipal for 3 years. Since he
started working, he has seen the number of HIV infections increase. He believes that the three
most important factors that contribute to the spread are negligence, poverty and local culture.
In particular there are some traditions that are making the combat against HIV/AIDS more
difficult. For example all the family assets belong to the husband or the male family members.
The husband is also the head of the family and makes all the decisions. Daughters are set
behind sons and if there is not enough money to educate all the children, the girls are kept at
home. Malnutrition is also more common among girls. This makes poverty a huge problem
among women, sometimes forcing them into prostitution.
Polygamy still occurs, but the spouses don’t always stay within the boundaries of the
marriage. There is also a tradition of marrying the husband or wife of a deceased sibling. As
long as the partner of the deceased person looks healthy and fat (s)he is generally not believed
to be infected with HIV.
Another tradition that makes the situation complicated is the belief in traditional healers.
People often trust them even when they claim that they can cure HIV. There is also a
tendency to believe in destiny or the will of God. Since most of the people think that they
cannot influence the future, they just live for today without making plans for tomorrow.
According to the Tanzanian culture, love and sex do not always belong together. Sex is just a
release of urge and you don’t have to have warm feelings for your sexual partners. People
often get married for other reasons than love. Popular attributes are beauty and wealth. If the
circumstances change, they feel free to look for partners elsewhere. It is not uncommon to
visit prostitutes, particularly at bars. Since men usually prefer unprotected sexual intercourse,
a prostitute who wants to use a condom may earn only a fifth of the price she would get
without one. The majority of their customers are drivers, military people and policemen who
all feel that they are at risk of dying soon. For them, a disease that will kill you in
approximately 10 years does not seem very threatening.
Sometimes those who are infected with HIV try to infect as many others as possible to avoid
40

dying alone. When counselling patients Dr Temihango has a trick to prevent them from
spreading the disease. He tells them that in order to stay healthy they have to practise safe sex
or abstinence; otherwise they will catch other sexually transmitted diseases, which will
weaken their immunity. Simply telling people that they should avoid infecting others is
useless. If the antiviral drugs become available the entire African continent will get
uncontrollable, because people will stop taking any preventive measures at all.
Dr Temihango is somewhat disappointed that HIV has spread so rapidly in spite of all the
efforts that have been made to inform people. Sometimes he feels that it would be better if the
incubation period of the disease was much shorter, so that people could see a connection
between behaviour and death in AIDS. But he also emphasises that nobody knows what the
situation would be like if there were no intervention programs at all.
To illustrate how hard it could be for certain individuals to protect themselves from HIV, Dr
Temihango told the following story:
Once when he held a seminar in a village one of the women in the audience asked him:
-Can you tell me, for how long can a person live with HIV?
He answered:
-If you take good care of yourself you can live for up to ten years.
-And for how long can you live without any food?
-You can’t live without food for a very long time.
Then the woman said:
-I have four children and I pay their food, clothes and school fees by myself. The only way I
can do this is by selling local alcohol and my body. So what should I choose; that we all die
next month or that I die in ten years when my children are grown and can support themselves?
Interview with Alifa Lupende, principal of INMTS
Alifa Lupende has a degree in nursing, but is now in charge of the INMTS. At present, there
are 104 students and four teachers at the school. Even the principal herself is teaching.
While studying at the school, the students have to follow some specific rules. Some of them
are very strict and Mrs Lupende is well aware that the rules are not always followed. For
example some students make up stories to be able to leave the school area. The students are
allowed to have boyfriends, but they cannot show any signs of affection in public. The
principal is certain that most of them have boyfriends; otherwise they would be very different
from other women in their age. She tries to give them advice in order to help them staying out
of trouble. The students are encouraged to test themselves for HIV. Mrs Lupende also tells
them that a good boyfriend will wait for them and that HIV is not spread by kissing.
She does not advice the students to use condoms since they are not safe and tells them that
some men will purposely make small holes in the condom to infect their partners with HIV.
She has noticed that since the use of condoms has increased the number of HIV infections has
also been growing. However the students are supposed to teach the patients that come for
family planning about condoms.
Mrs Lupende claims that HIV is an important part of the education and she tries to mention it
as often as possible while teaching. There is also a recommendation from the ministry of
41

education that the school should show a film on HIV at least once every three month or
whenever necessary.
Since the school has such a good reputation, the students will face no difficulties to find a job
after graduating.
Interview with one of the evangelists of the Lutheran Church of Ilembula
According to the evangelist, the church is aware of the problems related to HIV and tries to
take an active part in the fight against the virus. For example the church has held two
seminars on HIV last year. More than 40 people attended the seminars. The key message from
the church authorities is to abstain from sexual intercourse before marriage, to test for HIV
before marriage and to stay faithful.
Extramarital sex and infidelity are forbidden in the Bible, but the evangelist is aware that this
occurs even among Christians. In spite of this, he cannot as a church authority advice people
to use condoms, since this would encourage them to break the rules of the religion.
The evangelist doesn’t see HIV as a punishment from God and infected people are welcome
to take part in the church activities. The church also tries to support them, morally and
spiritually. For example the church gives counselling to infected people and school uniforms
to orphans whose parents died from AIDS.
Interview with the chairman of Ilembula
The present chairman of Ilembula village has been at his position since 1995, but was selected
by the people in the year of 2000. In his area there are approximately 2500 inhabitants. He
knows most of them personally since its common that the inhabitants of Ilembula stay in the
village where they have grown up.
His foremost work is to do justice between the villagers and to make sure that the daily living
is working out as it should. He claims that the most common reasons of fighting are alcohol
and disagreements about the boundaries or the farms. He is co-operating with the veo, a
government employee, who functions as a policeman.
When discussing the HIV/AIDS issue, the chairman says that he doesn’t know the extent of
the problem is in the village. The villagers themselves would not take the initiative to discuss
this subject. According to the chairman, the people in the village are aware of HIV and its
risks, but he thinks that more needs to be done. He is trying to give information and advice
when attending funerals and other ceremonies. He advises the villagers to be faithful and
abstain from sexual intercourse before marriage or use condoms. He has seen that the shops
are making big business by selling condoms but he asks himself if they are really getting used.
When it comes to HIV/AIDS, the Chairman does not feel that he gets any support from the
government. Instead the village gets aid and assistance from others, for example the American
organization IDYDC. In July this year, they educated the leaders of the village and other
people with influence with the aim that they could spread the information about HIV and
family planning among the villagers of Ilembula.
He does not think that the stigmatisation of HIV/AIDS is the biggest problem. The key
problem is that people do not believe in the disease. Most of the people who are found to be
HIV positive ask a witchdoctor to help them finding out why they got the disease. Sometimes
42

the witchdoctor accuses a person of cursing the HIV infected or concludes that the infected
person has attracted the disease by breaking a taboo. In some way these beliefs can help the
infected. If the family thinks that (s)he got the disease because of a curse, it’s not as shameful
and they do not see any risk to get the disease themselves. This means that the infected will
not become isolated from family and friends. However the chairman himself believes that
HIV is transmitted to people without any witchcraft involved.
The chairman thinks it would be easier to deal with the problem if the authorities dared to
discuss the issue openly. If a person has died of AIDS it should be possible to announce that
at the funeral. This would make people less inclined to approach and start sexual relationships
with widows and widowers whose spouses died of AIDS. Unfortunately some of them
purposely transmit the disease to others.
There are some traditions that make the fight against HIV more difficult. Polygamy is still
common, but to inherit the wife of a dead brother is no longer an established tradition.
He claims that there is no prostitution in the village, but perhaps the girls that are selling
alcohol are selling their body as well.
Interview with a traditional doctor (mganga)
There are approximately 10 waganga working in Ilembula village. In the text below, the
mganga will be referred to as Mr M.
Mr M was a businessman until 1974, when he started working as a traditional doctor. He
decided to change his career when his dead grandparents started appearing in his dreams,
telling him recepies of medicines and concoctions to cure all kinds of illnesses. He is now
running a small consulting business in his private home in central Ilembula. The room where
he sees his patients is small and dark and the floor is covered with plastic containers and
boxes, where he keeps his medical herbs. In the middle on the room, there is a dried pumpkin
hanging from the ceiling. He uses the pumpkin to gain information about his clients. By
watching how it moves in the presence of the patient, he can tell what kind of disease the
patient is suffering from and sometimes which medicine he should choose. The medicines he
uses are made from plants and trees. If necessary, he can also perform venesection or make
medical scars and tattoos.
Every day, about 10-15 patients come to benefit from his expertise. The most common
problems are infertility, venereal diseases and inability to find a partner. He can even cure
homosexuality, which he considers to be an illness. He also removes curses and spells. If an
evil spirit has entered a patient’s body, he has the power to drive it away. Wealthy people pay
for his services, while those without money are treated for free.
Mr M claims he can cure all diseases except cancer, anaemia and conditions that require
surgery. He can take away HIV, if the patient seeks his attention before the disease has gone
too far. Those who are suffering from fully developed AIDS are beyond his ability to cure. He
has treated so many HIV patients that he does not even know the number. Sometimes it
happens that one of his clients falls ill and dies of AIDS, but this is not because his medicines
are ineffective, but because the patients has been reinfected after finishing the treatment. Mr
M stresses that his patients are allowed to go to the hospital to take HIV tests in order to make
sure that his medicines are working.
43

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