International Union Against Tuberculosis and Lung Disease Public Health Action Health solutions for the poor

VOL 11 no 2 PUBLISHED 21 JUNE 2021

Knowledge, awareness and use of HIV services among the youth from nomadic and agricultural communities in E. Ngadaya,1 G. Kimaro,1 A. Kahwa,1 N. P. Mnyambwa,1 E. Shemaghembe,2 T. Mwenyeheri,1,3 A. Wilfred,1 S. G. Mfinanga1 http://dx.doi.org/10.5588/pha.20.0081 Despite recent advancements in treatment strategies, AFFILIATIONS BACKGROUND: Nomadic life not only prevents the 1 Muhimbili Medical many people with HIV or at risk for HIV still do not Research Centre, National community from accessing and utilising HIV services but have access to HIV services. This is particularly true for Institute for Medical also deters them from obtaining reliable information on Research, Dar es Salaam, sub-Saharan Africa, where a considerable population in- Tanzania HIV. fected with HIV are unaware of their status and, once di- 2 Department of Sociology METHODS: We conducted a cross-sectional study of agnosed, experience high rates of loss to follow-up. In and Anthropology, youth aged 10–24 years from the Kilindi and Ngoron- University of Dar es Tanzania, 5.1% of its population is HIV-infected, while Salaam, Dar es Salaam, goro Districts in Tanzania to assess knowledge, accessibil- 2% of youth aged 15–24 years are HIV-positive.6 The sex- Tanzania ity and utilisation of HIV/AIDS services among nomadic 3 Centre for Disease Control ual debut of adolescents in Tanzania has been reported and Prevention, Dar es and agricultural youths. to be as low as 9 years; hence, the higher risk of acquir- Salaam, Tanzania RESULTS: Of 518 youths interviewed, 279 (53.9%) were ing HIV/AIDS and other sexually transmitted diseases.7 CORRESPONDENCE males, and 276 (53.3%) were from agricultural commu- Although there has been an increase in knowledge Correspondence to: Esther nities. A significant proportion of youths from agricultural Ngadaya, Muhimbili Medical among the youth (15–24 years), comprehensive and ac- Research Centre, National communities had correct knowledge of AIDS (n = 126, curate understanding of HIV remain below average.8 Institute for Medical 45.8%; P = 0.002), HIV transmission (n = 273, 98.9%; P = Research, Dar es Salaam, Nomadic communities constantly change loca- Tanzania. email: engadaya@ 0.001) and comprehensive knowledge of HIV/AIDS (n = tions; ensuring the accessibility of HIV services to yahoo.com 78, 28.5%; P = 0.009) compared to nomads. Youths these communities might thus prove challenging than ACKNOWLEDGMENTS from agricultural communities were two times (OR 1.8, when dealing with communities in permanent settle- This research was supported by the Global Fund Round 8 95% CI 1.2–2.6) more likely to be aware of the availabil- 9 ments. Inadequate access to comprehensive sex edu- through Health Users Trust ity of formal HIV services. Awareness of the availability of cation among youths who are sexually active under- Fund of Tanzanian National HIV services was higher among married individuals than Institute for Medical mine efforts aimed at protecting them from Research, Dar es Salaam, in unmarried ones (OR 3.8, 95% CI 2.0–7.4), and signifi- contracting HIV through access to high-quality HIV Tanzania. cantly higher among youths with secondary/college edu- 9,10 Data analysed in this study services. Utilisation of the HIV services can also be have been included in this cation than in those who did not have formal education hampered by limited financial resources, lack of article, except some datasets (OR 5.3, 95% CI 2.3–12.4). The uptake of HIV services health care facilities and poor means of transport.11 which may be obtained from was lower among nomadic youths. the corresponding author on The availability and accessibility of HIV/AIDS services, reasonable request. CONCLUSION: Knowledge, awareness and utilisation of coupled with raising awareness among children ap- Conflict of interests: none declared. HIV/AIDS transmission services were low in general, and proaching sexual maturity, offer the best hope in HIV even lower among nomadic youths, calling for more tar- prevention. This article highlights the difference in KEY WORDS geted interventions. youth; nomadic; terms of HIV knowledge, awareness, accessibility, and agriculturalist; HIV/AIDS utilisation of HIV services among youths from no- madic and agricultural communities as a means to un- dolescents and young people represent a signifi- derstanding barriers to the optimal utilisation of HIV/ Acant proportion of people living with HIV world- AIDs services among such communities. wide.2 Adolescence is a dynamic developmental phase that is associated with significant physiological and psychosocial changes that may, to some extent, con- METHODS tribute to increased HIV/AIDS risk, especially when This was a cross-sectional study conducted in 2010 in- there is poor and limited availability of healthcare ser- volving youths from nomadic and agricultural commu- vices.1 In 2019 alone, 460,000 young people aged 10– nities living in the districts of Kilindi () 24 years were newly infected with HIV, of whom and Ngorongoro (Arusha Region) in Tanzania. We used 170,000 were adolescents aged 10–19 years.2 This wor- both qualitative and quantitative data collection ap- rying global trend is even worse in sub-Saharan Africa, proaches. The study was conducted at three different where young and adolescents, especially women con- levels: health care facilities, schools (secondary and pri- tinue to be disproportionately affected by HIV.3 Ado- mary) and at the community level. Data were collected lescents, especially those living in poverty, are at using semi-structured interviews of youths aged 10–24 heightened risk for HIV/AIDS, and the majority drop 4 years and in-depth interviews with key informants (KIs). Received 9 December 2020 out of school to help their families survive. Many Accepted 2 March 2021 women get pregnant or give birth before the age of 18; Study areas three times more cases are therefore reported from ru- The study was conducted in Ngorongoro and Kilindi PHA 2021; 11(2): 69–74 ral areas and poor communities.5 Districts in Arusha and Tanga Regions, respectively. e-ISSN 2220-8372 Public Health Action HIV services among nomadic youth in Tanzania 70

Kilindi (area: 6444 km2; population: 236,833)12 is one of the eight ordinators, council multi-sectorial HIV/AIDS coordinators and vil- districts of Tanga Region, located in the north-east of Tanzania lage leaders. We collected information on the availability, and bordered to the east by the District and Handeni accessibility, and utilisation of HIV/AIDS services among youth Town Council, to the north and west by the and any perceived hindering factors. and the south by the . Sample size Ngorongoro District (area: 14,036 km2; population: 174,278)12 A minimum sample size of 572 respondents from both Kilindi is one of the five districts of the Arusha Region, located in north- and Ngorongoro Districts was calculated using a proportion of ern Tanzania and bordered to the north by Kenya, to the east by 45% of youths with comprehensive knowledge about HIV/AIDS6 Monduli District, to the south by the Karatu District and the west at 80% power of a test, marginal of error 5% and 1.5 design effect by the Mara Region. The district is mainly inhabited by Maasai to clear variations between clusters. The sample size was then ad- people whose major socio-economic activity is pastoralism. justed by adding a non-response rate of 10% making a total of 628 respondents. Sampling procedure and data collection Selection of adolescents Data collection The two districts of Ngorongoro and Kilindi were purposefully se- Semi-structured questionnaires were used to collect information lected due to the presence of both cultivators and pastoralists. Vil- on HIV/AIDS awareness and service availability, accessibility and lages in the districts were listed based on predominant economic utilisation among youths. In-depth interview guides were used to activities (cultivators vs. pastoralists) to ensure mutual exclusivity gather the desired HIV services-related information from the KIs of the population study. Four villages were randomly selected in and health service providers. Before the actual data collection, Ngorongoro: two villages with the majority of cultivators and the pre-testing was performed to validate the questionnaire tool. remaining two villages where the majority were pastoralists. Nine Data management and analysis villages were selected in Kilindi District, of which five villages had Quantitative data analysis a large proportion of cultivators, whereas the remaining four vil- Data were double-entered and cleaned using EpiData v3.1 (Epi- lages had a large proportion of pastoralists. In the selected vil- Data Association, Odense, Denmark). For open-ended responses, lages, we conducted interviews with both in-school and out-of- the study team coded the responses before the actual analysis. school youths (i.e., have either never been to school or have Cleaned data were exported to Stata v3.1 (Stata Corp, College Sta- completed their primary or secondary schools, or were school tion, TX, USA) for analysis. Cross-tabulation using the χ2 test was dropouts). To gain access to both in-school and out-of-school performed to assess the relationship between dependent variables youths, interviews were conducted at schools and in the commu- and explanatory variables. For all variables with a P value of  nity. Primary students aged 10–14 years were conveniently se- 0.05, univariate analysis was performed to examine the odds of lected to participate in the study, while all secondary school one outcome for an explanatory variable which includes the classes were eligible for sampling and participation in the study. background characteristics of the nomadic and agriculturalist Systematic random sampling was used to select 10% of students youths. from each class (primary or secondary schools). The sampling in- A youth was regarded as having correct knowledge about HIV/ terval of 10 was used to select participants after random (simple AIDS when they responded correctly that a HIV-infected person is random) selection from the list. Out-of-school youths were se- a person living with HIV, while AIDS is a state of being ill due to lected from households under the custody of the 10 cell leaders. opportunistic infections among HIV-infected persons. When a With assistance from the 10 cell leaders, households with boys student who correctly answered questions on HIV and AIDS was and girls aged 10–24 years were listed and selected using a simple deemed to have comprehensive knowledge of HIV/AIDS. Knowl- random method, and consented respondents were interviewed. edge of prevention was categorised as correct if a youth responded We collected data to ascertain awareness and knowledge on HIV/ correctly on important aspects of behaviour: always using con- AIDS and HIV/AIDS services offered, as well as the perception of doms, staying faithful to one partner and abstinence. A youth the accessibility and utilisation of the services. In addition, we who mentioned all three was considered to have comprehensive gathered information on knowledge on possible informal sectors knowledge of HIV prevention. Knowledge of HIV transmission that offered HIV services and factors that might hinder proper was considered correct if a youth was able to mention any of the HIV/AIDS service utilisation among the youth. four transmission routes: sexual intercourse, sharing of sharp in- Selection of healthcare workers struments with an infected person, HIV-infected blood transfu- A district hospital from each district was purposefully included in sions, HIV transmission from mother-to-child. If they mentioned the study. In collaboration with the respective district medical of- all four, they were considered to have comprehensive knowledge fice, we made two separate lists – one for all health centres and of HIV transmission. another one for all dispensaries available in each district and se- Qualitative data analysis lected 10% of the health centres and 5% of the dispensaries (one Voice-recorded interviews were transcribed for content-coding health centre and one dispensary per district). We gathered infor- and a senior social scientist went through all the transcripts and mation on possible factors considered to contribute to the low audios to confirm their correctness and completeness. A few se- utilisation of HIV/AIDS-related services, as well as the perceived lected interviews were individually examined by the research appropriateness of HIV/AIDS services delivered from healthcare team to ensure quality of the transcription. The transcripts were workers. then subjected to thematic analysis according to Braun and Selection of the key informants Clarke’s method.12 A stepwise approach was used for the thematic KIs were purposefully selected to cover a wide range of sources of analysis of the qualitative data. At first, several themes were gen- HIV/AIDS service delivery information among youth. Key infor- erated from the research questions on a consensual basis (deduc- mant interviews (KIIs) were conducted with the district AIDS co- tive logic). These were then coded, and matrices were developed Public Health Action HIV services among nomadic youth in Tanzania 71

based on key themes. Patterns, including similarities and differ- cally analysed for their content, taking note of confounding is- ences, were documented, and important quotes in the partici- sues or inconsistencies, as well as contradictory responses in the pants’ own words were included in the data analysis. Thematic themes. analysis was conducted to generate information on sources of Ethics approval and consent to participate HIV/AIDS service delivery among youths. The KIs were systemati- The study protocol received ethical clearance from the Medical Research Co-ordinating Committee of the National Institute for TABLE 1 Social demographic characteristics of study participants Medical Research, Dar es Salaam, Tanzania, before it was imple- mented. All study participants aged 18 years provided written Agriculturalist Nomadic youth youth informed consent; written informed consent was obtained from Variable n (%) n (%) parents or guardians those who aged 18 years. Assent for mi- nors, risks, benefits and comfort of the respondents were followed District as required as per the research ethical guidelines. Kilindi 137 (49.6) 99 (40.9) Ngorongoro 139 (50.4) 143 (59.1) Age, years RESULTS Mean ± SD 17.9 ± 3.4 17.2 ± 3.6 18 142 (51.4) 136 (56.4) Sociodemographic characteristic Table 1 gives the sociodemographic characteristics of the partici- 18 134 (48.6) 105 (43.6) pants. A total of 518 respondents were interviewed; males com- Sex prised the majority (53.9%) of the study population. The age Male 144 (52.2) 135 (55.8) range of the study participants was 10–24 years; mean age of Female 132 (47.8) 107 (44.2) youths from agricultural and nomadic communities was respec- Occupation tively 17.9 years (standard deviation [SD] 3.4) and 17.2 years (SD Petty trader 23 (8.4) 5 (2.1) 3.6). The majority (n = 146, 53.9%) from farming communities Unemployed 16 (5.8) 4 (1.7) had completed their secondary school education, compared to 98 Agriculture and animal husbandry 137 (49.8) 106 (43.8) (41.0%) youth from the nomadic communities. Student 99 (36.0) 127 (52.5) Marital status Knowledge of HIV transmission and prevention Married 54 (20.1) 48 (19.9) Table 2 gives information on the knowledge of HIV transmission Single 214 (79.9) 193 (80.1) and its prevention among youths. A higher proportion of youth Education level from agricultural communities had correct knowledge of what No formal education 15 (5.5) 24 (10.0) constitutes AIDS than youths from the nomadic communities Primary education 110 (40.6) 117 (49.0) (45.8% vs. 32.2%; P = 0.002). Correct knowledge on whether HIV Secondary school education 146 (53.9) 98 (41.0) can be transmitted from one person to another was significant SD = standard deviation. higher among youths from the agricultural than those from no-

TABLE 2: Knowledge of HIV transmission, prevention and comprehensive knowledge of HIV/AIDS among youth from agriculturalist and nomadic communities

Agriculturalist Nomad Variable n (%) n (%) P value Knowledge of HIV transmission Correct knowledge of HIV 84 (30.7) 82 (33.9) 0.434 Correct knowledge of AIDS 126 (45.8) 78 (32.2) 0.002 Correct knowledge of whether HIV can be transmitted from one person to another 273 (98.9) 223 (92.2) 0.001 Correct knowledge of whether HIV can be transmitted through sexual intercourse 247(89.5) 204 (84.7) 0.10 Correct knowledge whether HIV can be transmitted through sharing of sharp instruments with an infected person 222 (80.4) 134 (55.4) 0.001 Correct knowledge of whether HIV can be transmitted through infected blood transfusions 77 (27.9) 62 (25.6) 0.559 Correct knowledge of whether HIV can be transmitted from mother to child 30 (10.9) 24 (9.9) 0.723 Knowledge of HIV prevention Correct knowledge of whether HIV is preventable 225 (83.6) 184 (76.0) 0.032 Correct knowledge of whether HIV can be prevented through the use of a condom during sexual intercourse 160 (58.0) 96 (39.7) 0.001 Correct knowledge of whether HIV can be prevented through avoidance of sharing of sharp instruments 138 (50.0) 94 (39.0) 0.012 Correct knowledge of whether HIV can be prevented through sexual abstinence 95(34.4) 99 (40.9) 0.128 Correct knowledge HIV can be prevented through sexual intercourse with one non-infected partner 35 (12.7) 43(17.8) 0.106 Comprehensive knowledge of HIV/AIDS Comprehensive knowledge of HIV/AIDS 78 (28.5) 45 (18.6) 0.009 Comprehensive knowledge of HIV transmission routes 18 (6.5) 17 (7.1) Comprehensive knowledge of HIV preventive routes 8 (2.9) 3 (1.2) Public Health Action HIV services among nomadic youth in Tanzania 72

madic communities (98.9% vs. 92.2%; P = 0.001). Similarly, cor- Ten KIs had secondary school education with additional profes- rect knowledge on whether HIV can be transmitted through shar- sional training, 3/14 had secondary school education and 1/14 ing of sharp instruments was higher among youth from had received primary school education. Nine were married, four agricultural communities than in youths from nomadic commu- were single and one was widowed. nities (80.4% vs. 55.4%; P = 0.001). The majority of youth from Of the 54 healthcare facilities with any of the HIV services, 25 cultivator communities were more likely to be aware that HIV is (46.3%) were located in nomadic communities compared to 29 preventable (83.6% vs. 76%; P = 0.032). (53.7%) in agricultural communities. Only six facilities in each community provided care and treatment services. Informal ser- Awareness on the availability and utilization of HIV/AIDS vice providers that extend HIV services to clients were also avail- preventive and care services able in both communities. Six out of seven KIs from nomadic Table 3 shows that youths from agricultural communities were communities and 2/7 from agricultural communities reported more likely to be aware (OR 2.4, 95% CI 1.6–3.6) of the availabil- having traditional healers, religious leaders and non-governmen- ity of formal health care facilities with HIV counselling services tal organisations that provide HIV services. Traditional healers than youths from nomadic communities. Youths from farming were reported to provide traditional remedies that cure HIV and communities were more likely to be aware of the available formal other opportunistic infections. Religious leaders were reported to healthcare facilities with HIV testing and care and treatment ser- provide spiritual services that can cure HIV. HIV services provided vices in their communities than youths from nomadic communi- in nomadic communities were reported by 6/7 KIs to be poor, ties. It was unlikely for youths from nomadic to be aware of the with insufficient supply of HIV test kits, antiretrovirals (ARVs) presence of traditional healers, religious leaders and community and lack of qualified staff. Five of the seven KIs from agricultural leaders who deliver HIV services in their communities (OR 0.3, communities reported that services to be very good because of the 95% CI 0.1–0.7; OR 0.6, 95% CI 0.4–0.9; and OR 0.5, 95%CI 0.3– availability of well-trained staff, equipment, reagents and HIV test 0.9, respectively). The use of informal health care facilities for kits and ARVs. More than 50% of employees who provided HIV HIV services was lower among youths from nomadic communi- services in both communities had received on-the-job training in ties than their agricultural counterparts (OR 0.6, 95% CI 0.4–0.9). HIV services. During the quantitative interviews, it was noted Youths from nomadic communities were more likely (OR 4.0, that 63 (34.2%) youths from nomadic communities could not get 95% CI 2.7–6.0) to spend more than 30 minutes to get to the all HIV services they needed during their last visit to a health fa- nearest healthcare facility with HIV services than youths from ag- cility for HIV services; 62 (40.0%) youths from agricultural com- ricultural communities. munities reported similar observations. Missing services included Perception of the key informants on the quality, voluntary counselling and testing, as well as HIV education, sup- accessibility and utilisation of HIV services ply of condoms, ARVs, sexually transmitted infection services and A total of 14 key informants (6 men, 8 women) with over 10 sexual reproductive health education. Some of the youths re- years’ working experience were interviewed; of these, half were ported returning home without HIV service due to long queues. from Ngorongoro. Two were district HIV/AIDS coordinators, two KIs also reported lack of youth-friendly services, nomadic life, council HIV/AIDS coordinators, two community leaders and eight low education among communities, misleading beliefs (for e.g., healthcare workers working at either of the following depart- nomadic communities, especially the Maasai cannot be affected ments: care and treatment centres, prevention of maternal to by HIV), poor infrastructures, distant healthcare facilities and child transmission of HIV, and voluntary counselling and testing. widely dispersed communities as contributing factors for the un- We also interviewed nurses in charge of the healthcare facilities. derutilisation of HIV services.

TABLE 3 Awareness of youth on the availability and utilisation of formal and informal healthcare services in their communities*

Agriculturalist Nomadic youth youth Variable Total n (%) n (%) OR (95% CI) Awareness of the availability of the following formal health care facilities: HIV counselling 285 174 (61.1) 111 (39.0) 2.4 (1.6–3.6) HIV testing 303 186 (61.4) 117 (38.6) 2.6 (1.7–3.8) Care and treatment 222 131 (59.0) 91 (41.0) 1.8 (1.2–2.7) Awareness of the availability of informal healthcare facilities with HIV services Traditional healers 48 14 (29.2) 34 (70.8) 0.3 (0.1–0.7) Religious leaders 104 44 (42.3) 60 (67.7) 0.6 (0.4–0.9) Community leaders 85 34 (40.0) 51 (60.0) 0.5 (0.3–0.9) Ever attended health care facility for HIV services HIV counselling 173 94 (54.30 79 (45.7) 1.1 (0.8–1.6) HIV testing 180 102 (56.7) 78 (43.3) 1.3 (0.9–1.8) Care and treatment 40 21 (52.5) 19 (47.5) 1 (0.5–1.9) Informal health care facility for any HIV services 72 30 (41.7) 42 (58.3) 0.6 (0.4–0.9) Average time to the nearest formal health care facility with HIV services, min 30 179 133 (74.3) 46 (25.7) 4.0 (2.7–6.0) 30 324 136 (42.0) 188 (58.0)

* Nomadic community is the reference group. OR = odds ratio; CI = confidence interval. Public Health Action HIV services among nomadic youth in Tanzania 73

…stigmatisation among groups of young people and wrong per- in the young and never-married adults. The level of HIV knowl- ception about HIV contribute to the failure of many young people to access and utilise HIV services. (KI from a nomadic community) edge among youths was higher in agricultural than in nomadic families; however, less than 50% of the youths in both communi- Challenges highlighted by the majority of the KIs in nomadic ties could only mention at least one correct method of HIV pre- communities included the inferior position of women, especially vention. Less than 5% of the youth in both study communities in the Maasai communities, where the majority of women do not had a correct comprehensive knowledge of HIV prevention. Previ- participate in HIV education. Traditional beliefs, cultural values ous studies have shown that a low level of knowledge of HIV/ and customs that govern the Maasai community with regard to AIDS and HIV prevention routes have been negatively associated matters of sexuality and sex education affecting their children with a variety of sexual health-related attitudes and beliefs.15,16 continued to be a barrier to providing HIV-related education in Contrary to the data from the Tanzania Demographic and Health these communities. Some patients mentioned that food scarcity Survey 2010 that show more than 70% of individuals aged 15–24 prevented them from taking ARVs. Factors contributed to poor ac- had a correct comprehensive knowledge of HIV transmission,6 cessibility and utilisation of HIV services among youths from agri- our study demonstrates that this is not the case among the no- cultural communities included distance of facilities from the madic and agricultural communities living in Kilindi and Ngoron- community, food scarcity that made some patients discontinue goro Districts, where a high number of youths lacked comprehen- ARV intake, and lack of confidentiality and lack of financial re- sive knowledge on how HIV/AIDS is transmitted. Although HIV sources to execute planned HIV activities. prevalence in the study communities is still very low,17 the high rate of urbanisation and movement of people between urban and Youth feels embarrassed to take HIV test and pick-up condoms from the open areas free of charges; instead, they find some other rural areas may subject the youth to the increased risk of HIV 18 [more discrete] ways of getting condoms or having unprotected transmission, especially if infected youth enter the circle. sex. (KI from an agricultural community) Formal healthcare facilities with quality HIV services were more available in agricultural than in nomadic communities. DISCUSSION Awareness about the availability of formal HIV services was two times higher among youths living in agricultural communities. The results from this study highlight several differences in aware- Other studies have shown that the availability and awareness of ness, knowledge, perception and utilisation of HIV among youths the services are mandatory in any service utilisation; the opposite from nomad and agricultural communities. Youths from agricul- may deter somebody from seeking and utilising such services.18,19 tural communities were more knowledgeable, with correct per- Married youths had increased odds of awareness than those who ceptions about prevention and control of HIV, including the were not married from both communities, while utilisation of for- availability of formal HIV services than their counterparts from mal HIV services was higher among youths from agricultural nomadic communities. Although causality cannot be determined communities than those from nomadic communities. Informal from cross-sectional data, it is reasonable to assume that youth health care facility utilisation for the same services was lower in with correct knowledge about HIV transmission and prevention nomadic communities. Although in the recent past, the focus has have a better understanding of HIV risk factors, and possibly may shifted from a health care perspective to multi-sectoral ap- feel more capable of reducing their risk of contracting HIV as re- proaches for the delivery of HIV services, the services offered by ported previously.13,14 The nomadic way of life may deprive no- some informal sectors (traditional healers and religious leaders) in mad communities of being reached by health and development the two districts are far beyond the scope of their capacities. Such programmes.9 services included claiming to treat HIV/AIDS, offering HIV coun- Although knowledge of HIV/AIDS was found to be higher selling and testing. among youths from agricultural families, only one third of youth HIV services in nomadic communities were located far from in both communities had correct knowledge of AIDS. More than their homes, and youths had to spend more than half an hour to three quarters of youth living in both communities failed to dif- get to the nearest health care facility with HIV services. However, ferentiate between HIV and AIDS. These results contradict those factors such as lack of youth-friendly services and privacy in of the general population reported by the Tanzania Demographic healthcare facilities may prevent some from seeking the services. and Health Survey 2010,6 which reported that the majority of Hunger was highlighted in this study as one of the barriers to ac- Tanzanian adults were aware that people infected with HIV do cessing and utilising HIV services; in some cases, patients discon- not necessarily show signs of infection. In this survey, 85% of tinued ARV use due to lack of food. Similar findings have been re- women and 87% of men were reported to know that a ported previously.14 The remoteness of the nomadic communities, healthy-looking person could have the virus that causes AIDS.6 poor infrastructures such as roads, and poor distribution of The difference between the two studies can be attributed to the healthcare facilities may explain the problems besetting these communities involved in the studies. In our study, we involved communities. two very rural communities, whereas the 2010 demographic sur- vey involved both urban and rural communities; data from urban Limitation communities may conceal the knowledge gap that exists in re- Possible limitations of this study include possible biases such as mote areas of the country. Moreover, nomadic communities tend recall bias. In addition, we did not assess the impacts of other bar- to be reserved and non-inclusive that are fiercely attached to their riers (e.g., sociocultural and financials barriers) to accessibility norms and cultural values. The huge difference in the knowledge and utilisation of HIV services. between the two communities from that of the general popula- tion calls for more efforts targeted to these communities. CONCLUSION In Tanzania, HIV/AIDS prevention programmes focuse on three important aspects of behaviour: the use of condoms, stay- Knowledge and utilisation of HIV/AIDS transmission and preven- ing faithful to one partner and delaying sexual debut (abstinence) tion services were low among youths in both communities. How- Public Health Action HIV services among nomadic youth in Tanzania 74

ever, youths from nomadic communities had significantly lower 9 Habib AG, Jumare J. Migration, pastoralists, HIV infection and access to knowledge and less awareness of HIV and AIDS than youths from care: the nomadic Fulani of northern Nigeria. African J AIDS Res 2008; 7: 179–86. agricultural communities. Provision of continued education about 10 UNAIDS. UNAIDS report on the global AIDS epidemic, 2013. Geneva, Swit- HIV/AIDS transmission and prevention is therefore imperative. zerland: UNAIDS, 2013. 11 Pellowski JA. Barriers to care for rural people living with HIV: a review of do- References mestic research and health care models. J Assoc Nurses AIDS Care 2013; 24: 422–437. 1 Sawyer SM, et al. Adolescence: a foundation for future health. Lancet 2012; 12 National Bureau of Statistics. Population and housing census: population 379: 1630–1640. distribution by administrative areas, 2012. Dar es Salaam, Tanzania: NBS, 2 United Nations International Children’s Emergency Fund. Adolescent HIV 2013. prevention. UNICEF Data 2020. New York, NY, USA: UNICEF, 2020. https:// 13 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol data.unicef.org/topic/hivaids/adolescents-young-people/ Accessed December 2006; 3(2): 77–101. 2020. 14 Hicks G, et al. Health literacy is a predictor of HIV/AIDS knowledge. Fam 3 UNAIDS. Miles to go—closing gaps, breaking barriers, righting injustices. Med 2006; 38(10): 717–723 Geneva, Switzerland: UNAIDS, 2018. https://www.unaids.org/en/resources/ 15 Pandarath A, et al. Community participation in HIV and ARV services: core documents/2018/global-aids-update Accessed December 2020. health issues. S Afr Health Rev 2006; 2006: 95–104. 4 UNAIDS. Young people and HIV/AIDS: opportunity in crisis. Intern Audit 16 Peltzer K, et al. Determinants of knowledge of HIV status in South Africa: re- 2009; 65: 1–28. sults from a population-based HIV survey. BMC Public Health 2009; 9: 174. 5 United Nations Population Fund. State of world population, 2013. New 17 Obermeyer CM, Osborn M. The utilization of testing and counseling for York, NY, USA: UNFPA, 2013. http://www.unfpa.org/publications/ HIV: A review of the social and behavioral evidence. Am J Public Health state-world-population-2013 Accessed March 2017. 2007; 97: 1762–1774. 6 National Bureau of Statistics. Tanzania Demographic and Health Survey, 18 Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission 2011. Dar-es-Salaam, Tanzania: NBS, 2011. https://dhsprogram.com/pubs/ (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government pdf/FR243/FR243%5B24June2011%5D.pdf Accessed March 2017. Statistician (OCGS), and ICF International. Tanzania HIV/AIDS and Malaria 7 Mbeba RM, et al. Barriers to sexual reproductive health services and rights Indicator Survey 2011–12. Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, among young people in Mtwara district, Tanzania: a qualitative study. Pan OCGS, and ICF International, 2013. Afr Med J 2012; 13 (Suppl 1): 13. 19 Meremo A, et al. Barriers to accessibility and utilization of HIV testing and 8 National Bureau of Statistics. The Tanzania HIV Impact Survey 2016–2017 counseling services in Tanzania: experience from Angaza Zaidi programme. (THIS): Final Report. Dar-es-Salaam, Tanzania: NBS, 2018. https://www.nbs. Pan Afr Med J 2016; 23: 1–12. go.tz/index.php/en/census-surveys/health-statistics/hiv-and-malaria- 20 Paulin HN, et al. HIV testing service awareness and service uptake among fe- survey/382-the-tanzania-hiv-impact-survey-2016-2017-this-final-report Ac- male heads of household in rural Mozambique: results from a province-wide cessed December 2020. survey. BMC Public Health 2015; 15: 1–11.

CONTEXTE : La vie nomade n’entrave pas seulement l’accès et comparées à celles des nomades. Les jeunes des communautés l’utilisation des services VIH par une communauté mais empêche agricoles étaient deux fois plus au courant (OR 1,8 ; IC 95% 1,2–2,6) également l’accès à une information VIH fiable de la disponibilité de services VIH formels. La connaissance de la MÉTHODES : Nous avons réalisé une étude transversale auprès de disponibilité de services VIH était plus élevée chez les jeunes mariés jeunes de 10–24 ans des districts de Kilindi et de Ngorongoro en (OR 3,8 ; IC 95% 2,0–7,4) comparés aux célibataires, et Tanzanie pour évaluer les connaissances, l’accessibilité et l’utilisation significativement plus élevée parmi les jeunes ayant eu une instruction des services VIH/SIDA parmi les jeunes nomades et agriculteurs. secondaire/supérieure comparés à ceux qui n’avaient eu aucune RÉSULTATS : Sur 518 jeunes, 279 (53,9%) étaient des garçons, 276 éducation formelle (OR 5,3 ; IC 95% 2,3–12,4). L’utilisation des (53,3%) venaient de communautés agricoles. Une proportion services VIH était plus faible parmi les nomades. significative des jeunes de communautés agricoles avaient des CONCLUSION : Les connaissances, la sensibilisation et l’utilisation connaissances correctes en matière de SIDA (n = 126 ; 45,8% ; P = des services de transmission du VIH/SIDA étaient bas et encore plus 0,002), de transmission du VIH (n = 273 ; 98,9% ; P = 0,001) de bas chez les jeunes nomades, appelant des interventions plus connaissances complètes du VIH/SIDA (n = 78 ; 28,5% ; P = 0,009) ciblées.

Public Health Action (PHA) welcomes the submission of articles on all This is an Open Access article distributed under the terms of the aspects of operational research, including quality improvements, cost- Creative Commons Attribution License CC-BY 4.0 published by benefit analysis, ethics, equity, access to services and capacity building, with The Union (www.theunion.org). a focus on relevant areas of public health (e.g. infection control, nutrition, Contact: [email protected] TB, HIV, vaccines, smoking, COVID-19, microbial resistance, outbreaks etc). Information on PHA: http://www.theunion.org/what-we-do/journals/pha