Improving access to HIV services among rural communities

Results from the TAZAMA study in Tanzania

Alison Wringe

London School of Hygiene and Tropical Medecine17th July, 2011: IAS, Rome

Overview

• TAZAMA & the Kisesa HIV cohort study• Key research results on access to HIV services

– Unmet need for HIV services including PMTCT– The relationship between stigma and VCT use – Community responses: Village AIDS Committees

and home-based care• Implications of findings for PMTCT

Kisesa cohort : 5 villages + trading centre in Magu

City

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 clinic registration Registered, not screened

On ART Screened, not eligible Eligible, no ART

Key results (2)

0%

20%

40%

60%

80%

100%

Urban Roadside settlement

Remote village

Cum

ulat

ed %

tre

ated

Residence area of mother

Percent HIV positive mothers accessing PMTCT treatment by residence

only child treated

only mother treated

mother and baby treated

n=84 n=31 n=53

Urassa et al. IAS Vienna 2010

Unmet need for HIV services

Impact of stigma on VCT use

Ref: Roura,2008

01

23

45

67

89

10

11

12

13

14

15

HIV

Kno

wle

dg

e le

vels

male female

pre post pre post

HIV knowledge levels in the pre-training and post-training survey, by sex

Village AIDS Committees: HIV knowledge

Challenges in delivering HBC

Staffin g

Co mmu nityfacto rs

F in an cin g

He alth syste m

L a rg e r wo rk fo rce to p ro vid era n g e o f HIV ca re se rvi ce s

F acto rs in flue ncin g e ffe ctiv e scale u p o f HBC prog ramme s

Rat

iona

le f

or

scal

ing

up h

ome-

bas

ed c

are

L i n ks a n d re l a ti o n sh ip swi th h e a l th fa ci l i t i e s a n d

HCW p ro b le m a ti c

No t su sta in a b le , a ffe cte db y ch a n g e s i n d o n o r

p o l i c i e s

Less

ons

lea

rned

fro

m C

HW

pro

gram

mes

Re d u ce s b u rd e n o n h e a l thfa ci l i t i e s a n d stre n g th e n s

h e a l th syste m s

S u sta i n a b le ? S im i l a r o rl o we r co st vs h e a l th fa ci l i ty

ca re

M a y a d d re ss sti g m a a n dp ro m o te fa m i l y a n dco m m u n i ty su p p o rt

T ra i n in g , su p e rvi si o n a n dre m u n e ra ti o n p o l i c i e s

n e e d e d

Co m m u n i ty re cru i tm e n tn o t a lwa ys tra n sp a re n t;

a m b i g u o u s ro le s

Implications for PMTCT research• Poor access to HIV services including PMTCT explained by

interplay between individual, social and programmatic factors: responses only targeting the individual unlikely to be succesful

• Increasing the number of services alone doesn’t necessarily translate into improved access or reduced HIV-related stigma

• Community-based initiatives have enormous potential to improve access - but need to be properly resourced in order to be effective

• Many lessons regarding the scale-up of community-level initiatives can be learned from past programmes

Acknowledgements

• Study participants in Kisesa

• Staff at the Kisesa health centre and Mwanza hospitals

• National Institute of Medical Research

• TAZAMA team in NIMR & LSHTM