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

Magu HDSS : 5 villages + trading centre

City

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

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

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

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.

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

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.

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

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

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

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

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

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

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

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

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.

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