Equity and HIV/AIDS

Determinants of facility readiness for integration of family planning with HIV testing and counseling services: evidence from the Tanzania service provision assessment survey, 2014–2015
Bintabara D; Nakamura K; Seino K: BMC Health Services Research 17(844), doi: https://doi.org/10.1186/s12913-017-2809-8, 2017

This study examined determinants of facility readiness for integration of family planning with HIV testing and counseling services in Tanzania using data from the 2014–2015 Tanzania Service Provision Assessment Survey. A total of 1188 facilities were assessed and considered ready for integration of family planning with HIV testing and counseling services if they scored ≥ 50% on both family planning and HIV testing and counseling service readiness indices as identified by the World Health Organization. Of all the health facilities, 915 reported offering both family planning and HIV testing and counseling services, while only 536 were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned, having routine management meetings, availability of guidelines, in-service training of staff, and availability of laboratories for HIV testing. The authors judge the proportion of facility readiness for the integration of family planning with HIV testing and counseling in Tanzania to be unsatisfactory and suggest that the Ministry of Health distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and refresher training to health providers, as determinants of facility readiness.

Determinants of facility readiness for integration of family planning with HIV testing and counselling services: evidence from the Tanzania service provision assessment survey, 2014–2015
Bintabara D; Nakamura K; Seino K: BMC Health Services Research 17 (1) doi: 10.1186/s12913-017-2809-8 , 2017

This paper examines determinants of facility readiness for integration of family planning with HIV testing and counselling services in Tanzania using data from the 2014–2015 Tanzania Service Provision Assessment Survey. Facilities were considered ready for integration of family planning with HIV testing and counselling services if they scored ≥ 50% on both family planning and HIV testing and counselling service readiness indices as identified by the World Health Organization. A total of 1188 health facilities were included in the study. Of all of the health facilities, 915 reported offering both family planning and HIV testing and counselling services, while only 536 were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned; having routine management meetings, availability of guidelines, in-service training of staff, and availability of laboratories for HIV testing. The proportion of facility readiness for the integration of family planning with HIV testing and counselling in Tanzania was noted to be unsatisfactory. The authors argue that Ministry of Health should distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and the provision of refresher training to health providers, as these were among the determinants of facility readiness.

Prevention of mother to child transmission of HIV in Tanzania: assessing gender mainstreaming on paper and in practice
Nyamhanga T; Frumence G; Simba D: Health Policy and Planning 32 (Suppl 5)ppv22-v30, 2017

Despite recognition of gender in Tanzania’s political arena and prioritization of prevention of mother to child transmission (PMTCT) by the health sector, there is very little information on how well gender has been mainstreamed into National PMTCT guidelines and organizational practices at service delivery level. Using a case study methodology, the authors combined document review with key informant interviews to assess gender mainstreaming in PMTCT on paper and in practice in Tanzania. The authors reviewed PMTCT policy/strategy documents using the World Health Organisation’s Gender Responsive Assessment Scale. The scale differentiates between level 1 to 5. Key informant interviews were conducted with 26 leaders purposively sampled from three government health facilities in Mwanza city to understand their practices. The gender responsiveness of PMTCT policy/strategy documents varies. Those which are gender sensitive indicate gender awareness, but with no remedial action developed; while those which are gender specific go beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. The interviews suggested that there has been little attention to the holistic integration of gender in the delivery of PMTCT services.

Factors influencing risky sexual behaviour among Mozambican miners: a socio-epidemiological contribution for HIV prevention framework in Mozambique
Martins-Fonteyn E; Loquiha O; Baltazar C; et al: International Journal of Equity in Health 16(179), doi: https://doi.org/10.1186/s12939-017-0674-z, 2017

This study seeks to understand the various factors influencing HIV-related risk behaviours and the resulting HIV positive status of Mozambican miners employed by South African mines to inform a broader and more effective HIV preventive framework in Mozambique. It used data sourced from the first integrated biological and behavioural survey among Mozambican miners earning their living in South African mines. The odds of reporting one sexual partner were roughly three times higher for miners working as perforators as opposed to other types of occupation. The odds of condom use – always or sometimes – for miners in the 31-40 age group were three times higher than the odds of condom use in the 51+ age group. Miners with lower education levels were less likely to use condoms. The odds of being HIV positive when the miner reports use of alcohol or drugs is 0.32 times lower than the odds for those reporting never use of alcohol or drugs. And finally, the odds of HIV positive status for those using condoms were 2.16 times that of miners who never used condoms, controlling for biological and other proximate determinants. In Mozambique, behavioural theory emphasising personal behavioural changes is the main strategy to combat HIV among miners. The findings suggested that there is a need to change thinking processes about how to influence safer sexual behaviour. This only stresses the need for HIV prevention strategies to exclusively transcend individual factors while considering the broader social and contextual phenomena influencing HIV risk among Mozambican miners.

Community burden of undiagnosed HIV infection among adolescents in Zimbabwe following primary healthcare-based provider-initiated HIV testing and counselling: A cross-sectional survey
Simms V; Dauya E; Dakshina S, et al.: Public Library of Science Medicine (PLOSMed) 14(7) doi: https://doi.org/10.1371/journal.pmed.1002360, 2017

The authors investigated the change in the community burden of undiagnosed HIV infection among older children and adolescents following implementation of provider-initiated testing and counselling (PITC) in Harare, Zimbabwe. Over the course of 2 years (2013–2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6–15 years. In 2015, the authors conducted a representative cross-sectional survey of 8–17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out. Of 7,146 children in 4,251 eligible households, 76.8% agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% and over a third of participants with HIV were undiagnosed. Based on extrapolation from the survey sample to the community, the authors estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures none of which are perfect. Facility-based approaches are argued to be inadequate in achieving universal coverage of HIV testing among older children and adolescents, and community-based approaches are identified as necessary in this age group.

Voluntary Medical Male Circumcision for HIV Prevention in 14 Priority Countries in Eastern and Southern Africa
World Health Organisation: WHO, Geneva, 2017

This progress brief outlines key highlights of the VMMC (Voluntary Medical Male Circumcision) intervention in Eastern and Southern Africa. Nearly 15 million VMMCs have been performed for HIV prevention in 14 countries of eastern and southern Africa. These circumcisions are reported to potentially avert over half a million new HIV infections through to 2030. In 2016, 2.8 million VMMCs were performed and all countries in the region, except Uganda and Rwanda, increased the number of VMMCs performed in the year. The majority of clients were aged 15 years or older.

Socioeconomic differences in mortality in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: a population surveillance analysis
Kabudula C; Houle B; Collinson M; et al.: The Lancet Global Health 5(9) doi: https://doi.org/10.1016/S2214-109X(17)30297-8, 2017

The authors assessed socioeconomic disparities in mortality indicators in a rural South African population over the period 2001–13 using data from 21 villages of the Agincourt Health and socio-Demographic Surveillance System (HDSS). They calculated the probabilities of death from birth to age 5 years and from age 15 to 60 years, life expectancy at birth, and cause-specific and age-specific mortality by sex (not in children <5 years), time period, and socioeconomic status (household wealth) quintile for HIV/AIDS and tuberculosis, other communicable diseases (excluding HIV/AIDS and tuberculosis) and maternal, perinatal, and nutritional causes, non-communicable diseases, and injury. They quantified differences with relative risk ratios and relative and slope indices of inequality. The authors found significant socioeconomic status gradients for mortality and life expectancy at birth, with outcomes improving with increasing socioeconomic status. An inverse relation was seen for HIV/AIDS and tuberculosis mortality and socioeconomic status that persisted from 2001 to 2013. Deaths from non-communicable diseases increased over time in both sexes, and injury was an important cause of death in men and boys. Neither of these causes of death, however, showed consistent significant associations with household socioeconomic status. The poorest people in the population continue to bear a high burden of HIV/AIDS and tuberculosis mortality, despite free antiretroviral therapy being made available from public health facilities. They argue that integrated strategies are needed to improve access to and uptake of HIV testing, care, and treatment, and management of non-communicable diseases in the poorest populations.

Understanding the relationship between couple dynamics and engagement with HIV care services: insights from a qualitative study in Eastern and Southern Africa
Wamoyi J; Renju J; Moshabela M, et al.: Sexually Transmitted Infections, 93(Issue Supplement 3), doi: http://dx.doi.org/10.1136/sextrans-2016-052976, 2017

This paper explores the interplay between couple dynamics and the engagement of people living with HIV (PLHIV) with HIV care and treatment services in three health and demographic surveillance sites in Tanzania, Malawi and South Africa. A qualitative study was conducted involving 107 in-depth interviews with PLHIV with a range of HIV care and treatment histories, including current users of HIV clinics, and people not enrolled in HIV care. Interviews explored experiences of living with HIV and how and why they chose to engage or not with HIV services. The authors found an interplay between couple dynamics and HIV care and treatment-seeking behaviour in the three countries. Being in a relationship impacted on the level and type of engagement with HIV services in multiple ways. In some instances, couples living with HIV supported each other which improved their engagement with care and strengthened their relationships. The desire to fulfil societal expectations and attract a new partner, or have a baby with a new partner, or to receive emotional or financial support, strengthened on-going engagement with HIV care and treatment. However, fear of blame, abandonment or abuse resulted in unwillingness to disclose and often led to disputes or discord between couples. There was little evidence of intra-couple understanding of each other’s lived experiences with HIV, and the authors found that couples rarely interacted with the formal health system together. Couple dynamics influenced engagement with HIV testing, care and treatment for both partners through a myriad of pathways. The authors propose that couple-friendly approaches to HIV care and treatment move beyond individualised care and which recognise partner roles in HIV care engagement.

Adolescent HIV Programming: Ready here we come!
International HIV/AIDS Alliance: International HIV/AIDS Alliance. UK 2017

This guide is one of a series of good practice guides, and contains information, strategies and resources to help HIV programmers implement HIV programming for adolescents. Adolescents are now included as a separate target group in global and national strategies. Increased access to HIV testing and treatment means that, more than ever, adolescents living with HIV know their status and are living longer on antiretroviral therapy (ART). Much more work is needed, however, to meet adolescents’ needs for prevention, care, treatment and support services. Barriers to access, poor uptake of both prevention and treatment services, stigma and discrimination, as well as challenges with adherence to treatment contribute significantly to HIV-related morbidity and mortality among adolescents. This Good Practice Guide contains information, strategies and resources to help programmers meet the standards for Alliance HIV programming for adolescents. Implementing these standards is one of the ways that the Alliance, our partners and other organisations define and promote a unified and quality-driven approach to HIV programming.

Effect of non-monetary incentives on uptake of couples’ counselling and testing among clients attending mobile HIV services in rural Zimbabwe: a cluster-randomised trial
Sibanda E; Tumushime M; Mufuka J; et al.: The Lancet Global Health 5(9), doi: https://doi.org/10.1016/S2214-109X(17)30296-6, 2017

Couples’ HIV testing and counselling (CHTC) is associated with greater engagement with HIV prevention and care than individual testing and is cost-effective, but uptake remains suboptimal. The authors aimed in this work to determine the impact of incentives for CHTC on uptake of couples testing and HIV case diagnosis in rural Zimbabwe. 68 rural communities (the clusters) in four districts receiving mobile HIV testing services were randomly assigned to incentives for CHTC or not. Allocation was not masked to participants and researchers. Randomisation was stratified by district and proximity to a health facility. Within each stratum random permutation was done to allocate clusters to the study groups. In intervention communities, residents were informed that couples who tested together could select one of three grocery items worth US$1·50. Standard mobilisation for testing was done in comparison communities. The primary outcome was the proportion of individuals testing with a partner. Analysis was by intention to treat. 3 months after CHTC, couple-testers from four communities per group individually completed a telephone survey to evaluate any social harms resulting from incentives or CHTC. The study indicated that small non-monetary incentives, which are potentially scalable, were associated with significantly increased CHTC and HIV case diagnosis. Incentives did not increase social harms beyond the few typically encountered with CHTC without incentives. The authors suggest that the intervention could help achieve UNAIDS 90-90-90 targets.

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