applying the equity lens to hiv service coverage: insights from magu hdss, north-west tanzania doris...
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Applying the equity lens to HIV service coverage: insights from Magu HDSS,
North-West Tanzania
Doris Mbata, Alison Wringe, Mark Urassa, Ray Nsigaye, Raphael Isingo, Milalu Ndege, Maria Roura, Benjamin Clark, Jim Todd, Basia Zaba
NIMR-Tanzania & LSHTM-UK9th INDEPTH AGM, Pune INDIA
26th October, 2009
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Magu HDSS : 5 villages + trading centre
City
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Study populationPopulation
– 30,000; growth 2.4% per year – Ethnicity: 95% are from the Sukuma tribe– Religion: 74% Christian, 23% Traditional, 3% Islam– Education: 14 primary schools, 2 secondary schools – Health: 7 health facilities
Economy– Per capita income below $120 per year– Farming is main source of income, petty trading common
HIV– Incidence 1.1%– Prevalence: women 8.2% and men 7.5%. Higher in roadside villages, but
increasing in remote rural areas
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Sero surveys (~ every 2-3 years)• At temporary village clinics, invite adults 15+• Questions on HIV, health services, sexual behaviour, marriage history,
family circumstances• Research HIV tests (informed consent without disclosure)• Opportunity for VCT (separate, MoH protocol - rapid tests)• Health care (clinical diagnosis, lab tests and free drugs) for family
Demographic surveillance (~ every 6 months)• Household interviews, proxy reports allowed• Births, deaths, in and out movements• Enables spouse, parent-child links to be ascertained
Cohort study activities
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HIV services• VCT: free at mobile clinics during serosurveys and permanently at
Kisesa health centre (MoH protocol)
• Tanzanian government started ART programme end 2004, initially in “Care and Treatment Centres” (CTC) in 4 zonal referral hospitals, then decentralised to district hospitals and health centres
• Referrals to the CTC in Mwanza City ~ 20km away
• CTC recently opened in Kisesa health centre Sep 2008
• All HIV services are free: VCT, lab tests, drugs, consultations
• Local NGO provides home-based care, referral escort and supports PLHA club
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Objectives of the research
• VCT services: To describe the uptake of VCT among HIV+
• Referral from VCT to CTC: To describe the delays in referral from VCT to CTC.
• ART initiation: To describe the proportion of HIV+ receiving ART, and to estimate the unmet need for ART.
• Qualitative research: To explain the findings from the analysis of the services, we show qualitative results.
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Methods: quantitative• Denominator: HIV+ at any serosurvey and eligible (alive,
resident) for sero-survey round 5 in 2006-7.• Uptake of VCT, referral appointments and ART initiation were
described by year, age, sex and residence. • Delays (in days) were measured referral from VCT, to
registration at the CTC• ART needs were described by year, age, sex and residence.
Estimates were obtained from survival time post-HIV infection among sero-converters and age-specific mortality rates among prevalent cases.
• Sex- age- and residence-specific estimates of ART coverage obtained by comparing ART uptake and estimated ART need
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Methods: qualitative
• 4 sex- and residence-specific focus group discussions with patients
• 52 in-depth interviews with patients and health workers
Aim: To explore factors influencing use of HIV services.
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Coverage with HIV services: by the end of 2007
* as a % of total HIV+; † as a % of previous row total
HIV-infected; N= 1364
n %* %†
Diagnosed at VCT 340 25 25Referred to CTC clinic 169 12 50Registered at CTC clinic 73 5 43Screened for ART eligibility 67 5 92Ever eligible for ART 42 3 63Ever initiated ART 37 3 88
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Unmet need for HIV services
0%
20%
40%
60%
80%
100%
Mal
e
Fem
ale
Rem
ote
Roa
dsid
e
Tra
ding
cent
re
15-2
4
25-3
4
35-4
4
45+
SEX RESIDENCE AGE
Per
cen
tag
e o
f H
IV+
sero
par
tici
pan
ts
815549 266352 292597 467 321 310
No VCT VCT, no referral No CTC registration Registered, not screened
On ARTScreened, not eligible Eligible, no ART
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020
4060
8010
0P
erce
ntag
e
Male Female
Days delay between referral and ART clinic registrationby sex
Not registered
1-9 months8 to 30 days
1 to 7 daysSame day
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020
4060
8010
0P
erce
ntag
e
Rural Roadside Trading Centre
Days delay between referral and registrationby residence at diagnosis
Not registered
1-9 months
8 to 30 days
1 to 7 days
Same day
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0102030405060No. of Patients
6/20085/2008
4/20083/2008
2/20081/200812/2007
11/200710/2007
9/20078/2007
7/20076/2007
5/20074/2007
3/20072/2007
1/200712/2006
11/200610/2006
9/20068/2006
7/20066/2006
5/20064/2006
3/20062/2006
1/200612/2005
11/200510/2005
9/20058/2005
7/20056/2005
5/20054/2005
3/20052/2005
1/2005
Male
Male currently on ART
Male ever on ART
Male currently enrolled
Male ever enrolled
0 10 20 30 40 50 60No. of Patients
Female
Female currently on ART
Female ever on ART
Female currently enrolled
Female ever enrolled
Mon
thTreatment pyramid
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ART coverage
Variable CategoryHIV+ve and
eligible for SERO5Estimated ART need in 2005
Started ART by end 2007
Estimated ART coverage (%)
Total 1354 208 37 18
Men 547 90 12 13Women 807 118 25 21
15-24 266 22 1 525-34 461 68 13 1935-44 318 60 14 2345+ 309 58 9 16
Rural 679 103 14 14Roadside 304 51 8 16
Trading centre 371 54 15 28
SEX
AGE
AREA
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Qualitative findings4 major themes emerged to explain relatively slow uptake of HIV services, despite their availability:• Health systems barriers: long journey, transport costs, waiting times• Psychosocial issues: Family & community stigma => lack of care & support, feelings of hopelessness & denial of disease progression • Beliefs about ART: misconceptions regarding efficacy and duration of treatment. Rumours that ART accelerated death, HIV curable• Alternative health providers: HIV attributable to witchcraft => seeking care from traditional healers, resulting in delays in HIV service use
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Qualitative findingsThese findings help to explain socio-demographic differences in accessing HIV services
GenderMarried women: expectations of negative responses from spouses Men: concerns about poverty, lack of time, unfamiliarity with health services; relatively more urgent need for treatment
Area of residenceRemote rural residents: less exposure to HBC, PLHIV groups, less access to VCT and ART information => leading to more misconceptions, stigmaHigher transport costs, longer times away from home associated with using HIV services – some use of accessible traditional healers
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Discussion• Referral systems: Facilitates link between HIV testing and
treatment; enable access/delays to be monitored by sex etc.• Gender equity: Similar access to HIV services, but ART coverage
lower among men… due to their relatively more urgent need for ART. Evolving patterns as HIV testing expands (PMTCT etc)?
• Residence: strongly influences access to ART. Coverage 2 x higher among trading centre residents compared to those in rural areas. Will decentralisation reduce geographic inequities?
• Attrition levels through the process of accessing HIV treatment following a diagnosis are high among all groups, but the biggest challenge remains increasing VCT uptake among ALL HIV-positive
• Monitoring: There is a need to continue monitoring access to ART in health centres, hospitals and through population based cohorts.
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Acknowledgements•National Institute of Medical Research •London School of Hygiene & Tropical Medicine •Magu District •Bugando Medical Centre•Study participants
Funding: •The Global Fund, through Tanzania Government•INDEPTH Network