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Situation Response Analysis final report- Summary


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Situation Response Analysis final report- Summary

  2. 2. ii On 19th November 2009, the consultants presented the results of the Situation Response Analysis to a 40-member Technical Working Group (TWG) for discussion and validation. All the comments received from the TWG have since been integrated into this final report. The recommendations therein were agreed upon by the TWG. Submitted to Zanzibar AIDS Control Programme by: Dr. Wairimu Muita, Lead Consultant: ___________________________________ Date: _______________________________
  3. 3. iii TABLE OF CONTENTS ACKNOWLEDGEMENTS v LIST OF ACRONYMS vi EXECUTIVE SUMMARY vii 1. BACKGROUND PROGRAMME INFORMATION 1 1.1 Vision of the National HIV and AIDS Programme 1 1.2 Programme Mission 1 2. INTRODUCTION TO THE SITUATION RESPONSE ANALYSIS 2 2.1 Purpose of the Situation Response Analysis 2 2.2 Objectives of the Situation Response Analysis 2 3. SITUATION RESPONSE ANALYSIS METHODOLOGY 3 3.1 Sampling Procedures 3 3.2 Data collection 5 3.3 Pre-testing of tools 5 3.4 Populations targeted at the health facilities 5 3.5 Ethical considerations 6 3.6 Limitations 6 4. HIV AND AIDS PROGRAMMATIC ISSUES 7 4.1 Coordination of HIV and AIDS services 7 4.2 The Ministry of Health and Social Welfare 8 4.3 Funding Mechanisms 10 4.4 Contributions of the UN and Development Partners in Preventive Services 10 4.5 Contributions of private agencies, NGOs and FBOs in HIV preventive services 11 5. HUMAN RESOURCE AT VARIOUS VCT, PMTCT AND CCT SITES 12 5.1 Staffing at the various sites 12 5.2 A Demographic Profile of the Service Providers Interviewed 12 5.3 HIV and AIDS training 14 6. THE TARGET POPULATIONS OF THE PREVENTIVE SERVICES 19 6.1 Respondents among clients of VCT, PMTCT and CCT services 19 6.2 Most at risk populations (MARPs) defined 20 7. COVERAGE OF HEALTH EDUCATION 21 7.1 Target population for health education 21 7.2 Health education topics 22 7.3 Outreach Services 23
  4. 4. iv 7.4 IEC materials for Health education 23 8. STI DIAGNOSIS AND TREATMENT 26 8.1 Syphilis test and treatment in PMTCT sites 26 8.2 Service providers’ awareness of STI syndromic management 27 8.3 Infections other than HIV health workers fear contracting at work place 27 8.4 Partner involvement 28 8.5 STIs Prevention: Missed Opportunities 29 9. COUNSELLING AND TESTING 30 9.1 Counselling in VCT and PITC 30 9.2 Counselling and testing in PMTCT 31 9.3 HIV in infants 36 9.4 Enrolment of HIV positive children in care and treatment clinics 39 9.5 Components of CCT for adults in Zanzibar 43 9.6 Integration of TB and CCT services 46 10. LINKAGES BETWEEN HIV SERVICES AND OTHER SERVICES 48 10.1 Home-based care 48 10.2 Referrals 49 10.3 Receiving Referrals 49 10.4 Sending referrals 51 10.5 Successes and problems associated with referrals 51 10.6 Monitoring and Evaluation 52 11. NGOS: GEOGRAPHICAL DISTRIBUTION AND CAPACITY 53 1.1 Geographical Distribution of NGOs providing HIV Preventive Services 53 11.2 The Capacity of NGOs providing HIV preventive services 53 12. ACCESSIBILITY OF VCT, PMTCT AND CCT SERVICES 56 12.1 Distance to health facility 56 12.2 Cost of services 57 12.3 Waiting times 57 12.4 Clients’ perceptions of the HIV-related services received 58 12.5 Health care provider gender preferences of the clients 58 12.6 The presence of stigma and discrimination against PLHIV and MARPs 59 13. RECOMMENDATIONS 61 14. REFERENCES 66 15. APPENDICES 67
  5. 5. v LIST OF TABLES AND CHARTS Table 3.1: Details of health facilities sampled 4 Table 3.2: List of organizations for key informants 4 Table 3:3 Health Facility Personnel Interviewed by Site 5 Table 5.1: Training received by VCT Health Care Providers interviewed 15 Table 5.2: Training received by PMTCT Health Care Providers interviewed 16 Table 5.3: Training received by CCT health care providers interviewed 17 Table 5.4: Human Resource-related Strengths and Weaknesses 18 Table 8.1: Reported types of infections likely to be contracted at the workplace 28 Table 9.1: Information provided to clients during pre-test counseling 30 Table 9.2: The importance of Post-test Counselling as reported by the health care providers 32 Table 9.3: Use of Contrimoxazole prophylaxis in children 39 Table 9.4: Types of ARV drug formulations available at sites 40 Table 9.5: Reported importance of adherence counseling 43 Table 9.6: Type of adherence counseling information CCT personnel give clients 43 Table 9.7: Components of CCT services provided at clinics 44 Table 9.8: Problems experienced during service provision and suggested solutions 46 Table 10.1: Sites from which HIV clinics draws their referrals 50 Table 10.2: Number of VCT, PMTCT and CCT sites to which HIV clinics send their referrals 50 Table 10.3: Site–related successes, problems and adequacy of referrals 51 Table 12.1: Average waiting times: Health care providers’ and clients’ reports 57 CHARTS Chart 5.1: Age groups of respondents in health facilities 12 Chart 5.2: Service duration in specific site 14 Chart 6.1: Reported IEC Materials Availability 24 Chart 8.1: Respondents’ suggestions regarding how to improve male partner involvement 29 Chart 9.1: Respondents’ views on breach of confidentiality 34 Chart 10.1: Proportion of Service Sites Offering Home-based Care 48 BOXES Box 6.1: VCT, PMTCT and CCT Clients Interviewed 19 Box 6.2: Special Population Groups 21 Box 12.1: The Opening Hours of the Health Facilities Visited 58
  6. 6. vi ACKNOWLEDGEMENTS This report was written by Drs. Wairimu Muita (lead consultant) and Maryam S. Hemed and Bartholomew Katole (national consultants). Many people and organizations have contributed to the successful completion of the Situation Response Analysis. The analysis would not have been possible without the exceptional input of the members of the technical working group (TWG) that provided advice and guidance. The recommendations in Section 13 of this report are those of this working group. The contributions of this dynamic TWG are acknowledged and deeply appreciated. We are grateful to the management of ZACP for the support accorded to us throughout the six week period. We were well taken care of and are most grateful to the staff of ZACE. Each ZACP driver assigned to us at any given time had to wait for us as we worked until late in the night and they never complained. To them we say thank you. The support from the UNJOINT, UNICEF and PEPFAR/CDC has made this Situation Response Analysis possible and our gratitude is deeply appreciated. Additional to the above, many others have contributed to this work. In particular the contributions of the following are most appreciated: the key informants, officers in charge of the various service sites, lab technicians, health care providers and clients from public and private health institutions and NGOs and FBOs. Support from all the partners working on the ground and providing support to the MOHSW response to HIV is acknowledged and appreciated.
  7. 7. vii ACRONYMS ABC Abstain, be faithful or use a condom AIDS Acquired Immune Deficiency Syndrome ANC Ante –natal clinic ART Anti-retroviral therapy ARV Anti-retroviral CHN Community Health Nurses BCC Behaviour Change Communication CCT Comprehensive care and treatment CDC Centre for Disease Control and Prevention CTC Care and treatment CHAI Clinton …… DACCOM District AIDS Coordinating Committee DHMT District Health Management Team FP Family planning FBO Faith-based organization HAART Highly Active Anti Retroviral Therapy HBC Home-based care HEU Health education unit HBC Home Based Care HIV Human Immune deficiency Virus HR Human relations HSSP Health Sector Strategic Plan HSRS IEC Information, Education, Communication IDUs Intravenous drug users IMAI Integrated management of adult illnesses IMCI Integrated management of children’s illnesses MARPs Most at risk populations MDM Medicos Del Mundo MoHSW Ministry of Health and Social Welfare M&E Monitoring and evaluation MTCT Mother to child transmission MSM Men who have sex with men NGOs Non-governmental organizations OIs Opportunistic Infections PEP Post Exposure Prophylaxis PEPFAR Presidential …. PHCC Primary Health Care Centre PHCU Primary health care units PHN Public Health Nurse PITC Provider Initiated Counseling and Testing
  8. 8. viii PLHIV People living with HIV PMTCT Prevention of Mother to Child Transmission RCH Reproductive and Child Health Programme RGZ Revolutionary Government of Zanzibar SHACCOM Shehia AIDS Coordinating Committee STIs Sexually Transmitted Infections SW Sex worker TB Tuberculosis TBA Traditional birth attendants UN United Nations UNDP United Nations Development Programme UNFPA United Nations Fund for Population Activities UNICEF United Nation’s Children Fund UN JOINT Joint United Nations Programme URT United Republic of Tanzania VCT Voluntary HIV Counselling and Testing WB The World Bank WHO World Health Organisation ZACP Zanzibar AIDS Control Programme ZANGOC Zanzibar Non Governmental Organisation Coalition ZAPHA+ Zanzibar Association of People living with HIV ZNSP Zanzibar National HIV and AIDS Strategic Plan ZYF Zanzibar Youth Forum
  9. 9. ix EXECUTIVE SUMMARY Zanzibar’s response to HIV and AIDS goes back to late 1986 when the first three HIV cases were identified (ZAC, 2008). After its establishment in 1987, Zanzibar AIDS Control Programme (ZACP) formulated the Medium Term Plans to inform the initial national response to HIV. A population-based HIV survey in Unguja and Pemba reported a prevalence rate for the general population of 0.6% (HIV sentinel surveillance 2008). Zanzibar has a concentrated epidemic, that is highest among most at risk populations (MARPs) including intravenous drug users (IDUs), sex workers (SWs) and men who have sex with men (MSM), among others. The risk of HIV is reported to be four to six times higher among females than males (RGZ, 2007). The Vision of HIV and AIDS Programme is to contribute to the attainment of the Zanzibar National Strategic Plan’s vision “to have a Zanzibar population which is free from the HIV and AIDS threat and which has a sense of caring and supporting all those citizens infected and affected by HIV and AIDS”. The Programme’s Mission is to consolidate and build on the achievements of the health sector response to HIV and AIDS by improving access to a comprehensive HIV and AIDS care, treatment and prevention in an efficient, coordinate, equitable and dignified manner Since its inception, ZACP has periodically carried out monitoring and evaluation (M&E) activities at all levels, but despite many issues having emerged, these have so far not been systematic. The Situation Response Analysis of voluntary testing and counseling (VCT), prevention of mother to child HIV transmission (PMTCT) and comprehensive care and treatment (CCT) services throughout Zanzibar, is expected to fill this gap, by providing insights into what is really happening on the ground, identifying strengths, weaknesses and gaps and recommending opportunities for improvement. The Purpose of the Situation Response Analysis is to review the existing HIV-related health services in Zanzibar in terms of scope, quality, linkages and coordination. It has two broad objectives: a. Review the current implementation status of PMTCT, VCT and CCT services in terms of scope, quality, coverage and linkages in Zanzibar b. Assess the capacity of collaborating NGOs/FBOs and private organizations in the provision of HIV-related services with special emphasis (MARPs). The Methodology of the Situation Response Analysis A combination of systematic random and purposive sampling techniques were employed to sample eight primary health care units (PHCU), three private, faith- and non-governmental organizations (FBOs/NGOs), two cottage hospitals, two district and two tertiary hospitals from which data was later collected from 65 service providers in four (50%) CCT, 10 of 29 PMTCT and 13 of 44 VCT sites in Zanzibar. Snowball sampling was used to draw the agencies from which key informants were later drawn. Different structured schedules for different populations were used to collect quantitative data from health facility personnel – officers in charge of VCT, PMTCT and CCT sites, laboratory technicians and health care providers in these three sites. In addition, different question guides were also used to gather qualitative data from key informants. Research ethics were
  10. 10. x strictly observed. EPI INFO and SPSS were used to analyze the quantitative data, while the qualitative was analyzed thematically. Results of the Situation Response Analysis Generally, Zanzibar’s response to HIV at programme and health facility level is promising and has good donor support. Programmatic issues: Zanzibar AIDS Commission is the overall coordinator of the national HIV response and that of the non-health sector, while the medical/health national response is coordinated by ZACP. The former is responsible for facilitating the formulation of HIV policies and strategic plans, multisectoral approaches and monitoring and evaluation among others. The national response to HIV is guided by the HIV and AIDS Policy and Strategic Plan. Although PMTCT, VCT and other guidelines exist, there is little if any evidence that they are being used at health facility level. Human resource: There is an apparent gender imbalance among the service providers in VCT, PMTCT and CCT sites. The MOHSW is evidently working towards increasing male (partner) involvement particularly in the PMTCT and RCH services, and the service provider gender imbalance could affect these efforts. Forty-eight percent of the service providers in the three sites are aged at least 45 years old and will retire from formal service in the next 15 years. The personnel serving at the VCT, PMTCT and CCT are relatively knowledgeable and possess positive attitudes towards service to people living with HIV (PLHIV). They are also relatively well trained and have had a good mix of training in their core (VCT, PMTCT and CCT) service areas. There are however training gaps in areas such as integrated management of adult illnesses (IMAI), provider initiated treatment and care (PITC), tuberculosis/HIV and in monitoring and evaluation (M&E). The existing personnel at site level is over-stretched and this is likely to get worse with time if no measures are put in place to mitigate the situation. Infrastructure and service delivery: The existing infrastructure allows for the delivery of HIV- related services within the existing health care facilities and for integration of such services as PMTCT and RCH without the demand for immediate construction of new buildings. Some health facilities however do not have adequate seating space for clients and their partners and some facilities use counseling rooms that do not allow sufficient client privacy. Supplies & Equipment: There is one CD4 machine in Unguja and another in Pemba, but no PCR machine is either and related services have to be sought from the Mainland. There are reports of delays sometimes as long as two months before some health facilities receive the results of the samples sent for analysis. Zanzibar has an adequate supply of HIV diagnostic kits, ARV drugs, STIs and opportunistic infection drugs. Linkages Integration of Services: The private sector, non-governmental and faith based organizations (NGOs/FBOs) complement the MOHSW response to HIV. Continuum of health care is ongoing through appropriate integration of HIV, PMTCT and RCH, as well as family planning (FP) and comprehensive care and treatment services. The Ministry is offering free
  11. 11. xi HIV&AIDS services e.g. testing, counseling and TB services in all public health facilities, which fosters equity in HIV-related services Monitoring and Evaluation: Since its establishment, ZACP has carried out M&E activities at programme and health facility levels. There is a uniform data collection and reporting system for all health facilities irrespective of ownership, although the extent to which these data are being analyzed and results applied and shared with the programme implementers is unclear. Research studies are periodically being carried out to keep track of HIV trends. There exists an effective operational referral system in Zanzibar that is extended to United Republic of Tanzania. There are reports however from the small clinics of delayed and/or lack of feedback of the results from both the Mainland and Mnazi Mmoja – Zanzibar’s referral hospital. Health education on HIV/AIDS issues: HIV and AIDS-related health education is provided five days a week in almost all public and most NGO health facilities provide health education on HIV/AIDS. Although various types of IEC materials were available at ZACP, few health facilities were found to have any IEC materials. STIs Prevention and Control: This is a priority area of the Zanzibar’s Health Sector HIV and AIDS Strategic Plan. Over two-fifths (43%) of the health providers interviewed have received training on STIs. Syphilis screening is being carried out in a third of ANC clinics, while others report an inadequate supply of the syphilis test kits. MARPs-targeted HIV-related services: Generally, services for MARPs are missing in most public health facilities. Some health providers report that they do not have the necessary skills and require further training before they can target these populations. Special clinical arrangements may be required in order for service providers to gain the trust of MARPs. VCT Services: 30 public and a few NGO health facilities are providing free VCT services, but the service is often interrupted in the latter when they run out of the test kits. PMTCT Services: 29 health facilities in Zanzibar providing PMTCT-related services and these are provided concurrently with RCH services by the same service providers and in the same premises, but supervised by different (ZACP and RCH) coordinators. All PMTCT personnel interviewed have been trained on PMTCT issues and (with the exception of one) infant feeding counselling. The Review Team noted an excellent coverage of Nevirapine prophylaxis among positive mothers and exposed infants (100%), as well as good adherence to the feeding options chosen and linkage to CCT, RCH and STIs services. Comprehensive Care and Treatment (CCT) Services: 1,794 PLHIV are on ART, which is about 97% of the 2009 target of 1800. There is reliable availability of first line ARV drugs in different formulations and CCT links to STIs, FP, TB and community services. Only eight health facilities in the whole of Zanzibar provide CCT-related services. There is an apparent dearth of service integration guidelines, which could lead to ad hoc integration.
  12. 12. xii Challenges: Several service-provision challenges have been noted and among the most prominent ones are:  the critical understaffing in the PMTCT, VCT and CCT sites, and  the equally critical rural/urban disparities in HIV-related health services, which favours the urban;  problems in the identification of exposed infants nationally  increasing numbers of home deliveries and accompanying risks maternal and child health-related risks, and  the limited success in increasing male involvement in HIV-related services, particularly in PMTCT. Capacity of NGOs/FBOs/private Sector: These organizations have limited, albeit expandable capacity to deliver HIV/AIDS services. They have the capacity to reach and serve MARPs and other vulnerable populations, which could be enhanced by the MOHSW and development partners. Recommendations A 40-member technical working group discussed in-depth the recommendations suggested by the Review Team, revised and added to them. Represented in the TWG were funding agencies, technical experts, programme coordinators and managers and service providers from the Mainland, Unguja and Pemba. The recommendations outlined under different themes in the Section 13 of this report are those agreed upon and therefore owned by this dynamic TWG, which also assessed and affirmed their relevance, practicability and viability. It is expected that ZAC and ZACP, the national programme coordinators of HIV-related health services and other activities and their key stakeholders will further deliberate upon these recommendations, and explore ways to implement each of them.