Situation Assessment HIV Counseling and Testing in Iringa Region. March 2009

Transcription

1 Situation Assessment HIV Counseling and Testing in Iringa Region March 2009

2 Acronyms AIDS Acquired Immune Deficiency Syndrome AMREF African Medical Research Foundation CDO Community Development Officer CHAC Council HIV/AIDS Coordinator CSO Civil society organization CT counseling and testing CTC Care and Treatment Centre DACC District AIDS Control Coordinator DMO District Medical Officer GoT Government of Tanzania HBC Home based care HIV Human Immunodeficiency Virus HMIS Health Management Information System IDU Intravenous drug user ILS Integrated Logistics System IP Infection Prevention LMIS Logistics Management Information System NACP National AIDS Control Programme MARP Most at Risk Person MOHSW Ministry of Health and Social Welfare PEPFAR President s Emergency Plan for AIDS Relief PITC Provider initiated testing and counseling PLHA People living with HIV/AIDS PMTCT Prevention of mother to child transmission RHMT Regional Health Management Team RMO Regional Medical Officer STI Sexually transmitted infection SCMS Supply chain management system THMIS Tanzania HIV/AIDS and Malaria Indicator Survey T-MARC Tanzania Marketing and Communications Company UHAI-CT Universal HIV/AIDS Intervention for Counseling and Testing USAID United States Agency for International Development USG United States Government VCT Voluntary counseling and testing Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 v

3 Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 vi

4 Table of Contents Acronyms... viii Table of Contents... iii Executive Summary... viii Background... x Overview of Iringa Region... x Situation Assessment Objectives and Methods...xi Key Findings...xiii District by District Findings Makete District Ludewa District Njombe District Iringa Municipal Council Appendix 1: References for High Risk in Iringa Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 vii

5 Executive Summary The Universal HIV/AIDS Intervention for Counseling and Testing (UHAI-CT), Angaza Zaidi and Tunajali are three initiatives funded though the United States Agency for International Development by the President s Emergency Plan for AIDS Relief (PEPFAR). UHAI-CT, implemented by Jhpiego an affiliate of Johns Hopkins University - with partners Africare and the Tanzania Marketing and Communications Company, focuses on expanding access to counseling and testing services through outreach counseling to high-risk groups and provider initiated testing and counseling (PITC). 1 Angaza Zaidi, implemented by the African Medical Research Foundation (AMREF) in collaboration with Management Sciences for Health, focuses on providing high quality voluntary counseling and testing (VCT) through centralized sites, as well as outreach counseling and testing. Tunajali, implemented by partners Deloitte Touche and Tomatsu East Africa and Family Health International provides high quality care and treatment services through health facilities and communitybased partners. All three programs work in conjunction with Tanzania s Ministry of Health and Social Welfare (MOHSW) and the National AIDS Control Programme (NACP) to achieve Government of Tanzania (GoT) national goals for reaching people with HIV/AIDS testing and care and treatment services. All are implementing activities in Iringa region Tanzania s highest HIV prevalence region. In Iringa, women had a prevalence of 18. 6% and men 12.1%, with an overall adult prevalence of 15.7% (THMIS 2007/08). In December 2008 UHAI-CT, Angaza Zaidi and Tunajali came together to conduct a joint needs assessment in four districts (Iringa Urban, Makete, Ludewa, and Njombe) in Iringa region. The scope of work was: to review counseling and testing (CT) services, examine GoT facilities readiness to roll-out PITC, and to appraise linkages between CT and care and treatment services. Some of the key findings from the Situation Assessment include the following: Although voluntary counseling and testing (VCT) has been offered in Iringa for many years, PITC has not been rolled out in Iringa. In 2008, five health care providers were trained as trainers (TOTs) by the National AIDS Control Programme (NACP) in PITC, and the Regional Health Management Team (RHMT) has been oriented to PITC. However, on an operational level, PITC has not been rolled out in any districts in Iringa region. The two key barriers to PITC rollout appear to be human resources and supply chain management. These two issues appear to be more or less pressing depending on the level of health service. For example, the staffing situation at rural health centers is insufficient for the easy provision of PITC, while the lack of adequate testing supplies was more urgent in hospital settings. Thus the rollout of PITC will need to take into account the particular constraints of districts and different levels of health facility. Weakness in supply chain management was evident in the health facilities in the form of poor ordering, recording and forecasting. District officials seemed largely unaware of ordering procedures and thus were unable to provide supportive supervision to the health facilities (since health facilities generally order directly from MSD zonal stores). There was a quantity of Capilus test still present in Iringa (left over from the President s testing campaign), which meant that facilities were using Capilus rather than Bioline (indicated in the national testing algorithm). 1 PITC is a nationally-endorsed strategy of offering HIV testing through care providers to person attending health care facilities as a standard component of medical care. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 viii

6 The team noted that there was an unequal presence of civil society organizations (CSOs) in Iringa region. There was a strong presence of civil society organizations (CSOs) working in Makete and Iringa Urban districts, while Njombe has only few (but well experienced) CSOs, and Ludewa had very scarce CSO resources. Communities in the districts the team visited identified social issues such alcohol use, transactional sex, and traditional practices such as polygamy and wife inheritance as causes of HIV transmission. Livelihood-related risks were largely around migration and having a large cash income. People who were identified as high risk included: Migrant workers (tea estates, wattle factories, potato cultivation and softwood) Communities which host migrant workers Miners Fishing communities Secondary school students University students Sex workers Truck drivers Intravenous drug users (IDUs) The quality of data on counseling and testing was reported to be of variable quality. Some districts (Iringa Urban, Njombe) had quite good submission rates, meaning that facilities were submitting their monthly reports regularly, but the accuracy / completeness of the data was still reported to be average to poor. There was no standard way of processing counseling and testing data at district level. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 ix

7 Background The Iringa Situation Assessment on HIV Testing and Counseling was a joint effort between three initiatives funded though the United States Agency for International Development by the President s Emergency Plan for AIDS Relief (PEPFAR) UHAI-CT, Angaza Zaidi, and Tunajali. All three partners are working in the Iringa region to improve quality and availability of HIV counseling and testing and links to care and treatment services for HIV/AIDS. A collaborative process was conducted to design the assessment, conduct the fieldwork, and write up a final report. The Iringa Regional Medical Officer s (RMO s) office collaborated by providing the assessment team with the support of regional medical staff who had been trained as TOTs in PITC by the NACP. In addition, district councils participated by providing the assessment team with Community Development Officers (CDOs). Great cooperation was received from the District Medical Officer s (DMO s) office in every district visited. This assessment covers four of the seven districts of Iringa Region. The decision to cover these four was based on time constraints. The four districts were selected to represent a selection of the north / south geography of the region, as well as a balance of urban and rural districts. The four districts covered in the Situation Assessment included: Iringa Urban, Ludewa, Makete and Njombe. Further baseline investigation is expected to occur in the remaining districts as the programs roll out or expand in those areas. Overview of Iringa Region Iringa region is the region that currently has the highest HIV prevalence in Tanzania, with an overall prevalence of 14.7% (THMIS 2007/08 preliminary report). Throughout the region, many organizations work together with the regional and district authorities to address HIV/AIDS. According to THMIS findings (2007 / 08), testing in Iringa is slightly higher than the national average: whereas nationally, 41.3% of women have ever been tested for HIV, in Iringa, 51.8% of women have been tested. For men, nationally, 29.2% have ever been tested, whereas in Iringa 34% of men have ever been tested for HIV. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 x

8 Table 1. Summary of HIV statistics for Iringa region s districts* District Total Population 2008 Estimated PLHAs (source: RMO s office) HIV prevalence rate # people on ARVs # of people tested for HIV (Jan Dec 08) Iringa Urban 117, % 3,330 15,905 Iringa Rural 268, % Figure not available 9,550 Kilolo 224, % 1,395 8,709 Mufindi 309, % 5,779 12,881 Njombe 476, % 4,012 14,156 Makete 116, % 3,057 4,481 Ludewa 139, % 1,021 9,332 Total 1,651,827* 230, %* 18,594 75,041 * the population estimates are a mix of projected census data and actual reports from districts, and thus may differ from other estimates of population ** because it is from a different source (district reports up to regional level) this figure is different from the population-based estimate from THMIS In order to roll out PITC, providers from hospitals and health centers in every district in the region will be trained. Table 2 below gives an estimation of the number of VCT sites, the number of Care and Treatment Centers (CTCs) and the total number of hospitals and health centers (the levels of health facility currently appropriate for PITC rollout) in the districts of region. In addition, the number of CTCs which will be handling an increased volume of referrals due to PITC, is shown. Table 2. Health facilities in Iringa region District Number of VCT sites Number of CTCs Total Number of Health Centres and Hospitals Number of VCT Trained providers (2008) Iringa Urban Iringa Rural Figure not available Kilolo Mufindi Njombe Makete Ludewa Total Situation Assessment Objectives and Methods The Situation Assessment was designed to provide important information relevant to regional, district and national level stakeholders, as well as to provide baseline information for the roll-out of new CT-related initiatives for the UHAI-CT and Angaza Zaidi programs. Tunajali, the CTC partner in the region, acted as a host to the Situation Assessment since their work in the region is extensive and CT programs are designed to link to their services. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 xi

9 The objectives of the Situation Assessment were: 1. To map existing HIV counseling and testing and care and treatment services available in the districts visited; 2. To identify high risk activities, livelihoods or communities in Iringa region and identify strategies for future outreach activities; 3. To assess the readiness of health facilities for PITC rollout; and 4. To determine baseline levels of PITC and outreach counseling occurring in the districts visited. After a joint planning period which lasted several weeks, and an orientation to data collection tools, joint teams from UHAI and Angaza Zaidi, joined by a PITC-trained provider from Iringa region, began data collection. Teams went to Ludewa, Makete, Njombe, and Iringa Urban. Data collection in the districts, which was done in conjunction with the DACC and the CHAC, occurred from December 8-18, Each team stayed three days per district. Before leaving the district, each team gave a brief feedback session to the DMO s office. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 xii

10 The following tools were used to answer the Assessment objectives: OBJECTIVE TOOLS METHODOLOGY Objective 1: To map existing HIV counseling and testing and care and treatment services available in the region Objective 2: To identify high risk activities, livelihoods or communities in Iringa region and identify strategies for future outreach Objective 3: To assess the readiness of health facilities for PITC rollout. Objective 4: To determine baseline levels of PITC and outreach counseling occurring in the region, by district District Interview Guide CSO Interview Guide Participatory research module Health Facility Assessment Guide District Interview Guide District level CT Service Record Health Facility CT Service Record Structured interviews with district officials and CSO staff Participatory research techniques (matrix and mapping) conducted with identified community members Structured observation / interview with facility in-charge Structured interview Monthly service delivery site reporting form Key Findings In 2008, five regional medical staff were trained as trainers in PITC by the NACP, although they have yet to begin rolling out training in the region. The RHMT was also oriented to PITC. The key barriers to introduction of PITC will be human resource shortages and supply chain management issues. These vary with the level of and location of health facility, with rural and lower level health facilities struggling more with human resource shortages, while hospitals and urban sites being challenged by commodity supply issues. Across all health facilities, consistently, challenges were noted in terms of ordering, receiving commodities, recording correctly, and forecasting supplies. In addition, district authorities who should be able to supervise the procurement processes were not aware of proper supply chain management systems. Additional training will need to be done with both districts (to be able to provide supportive supervision and follow up with MSD) and health facilities (on assigning a person to manage stock, order, record inputs, and follow up in case of stock-outs). Guidance will be sought from the PEPFAR-funded program Supply Chain Management Systems (SCMS), which has recently introduced a Logistics Management Information System (LMIS) intended to improve ordering and forecasting procedures on test kits. Many health facilities in Iringa are still using the Capilus HIV test rather than Bio-line (as the national HIV testing algorithm indicates). Training in PITC, as well as work with regional and district officials, should include components of support on the testing algorithm, ordering of test kits and supplies, and data management at both health facility and district level. In addition, guidance must be sought from NACP on what to do in regards to the national algorithm in the circumstance that Capilus are available rather than Bio-line. The strength of the presence of working CSOs in the districts varied. In Iringa Urban and Makete, many CSOs were present, some of which had experience with counseling and testing services. In Makete in particular, CSOs tended to be very active membership organizations of people living with HIV/AIDS (PLHAs). In Ludewa the team found very little CSO activity. In terms of reaching hard-to-reach populations with outreach services (in areas of extremely high prevalence) Makete and Njombe are areas with strong potential partners. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 xiii

11 A number of government, faith-based or non-governmental organizations are currently offering either mobile or static testing services in Iringa region. These include AMREF, Marie Stopes, UMATI, and the the Evangelical Lutheran Church of Tanzania (ELCT). Quality of data on counseling and testing was reported in all districts to be average to poor. Some districts (Iringa Urban, Njombe) had quite good submission rates, meaning that facilities were submitting their monthly reports regularly, but the quality was still reported to be average to poor. In Ludewa and Makete, the quality was reported to be poor and the submission rates of monthly reports were 63% and 72%, respectively. Inputs on data quality and data systems for counseling and testing data should be addressed in program rollout. Communities identified social issues such alcohol use, transactional sex, and traditional practices such as polygamy and wife inheritance as causes of HIV transmission. Livelihood-related risks were largely around migration and having a large cash income. People identified as high risk by community members are listed in Table 3, below. 2 Table 3. At-risk groups according to communities GROUP WHY AT RISK MENTIONED BY COMMUNITIES IN WHICH DISTRICT Migrant workers (tea estates, wattle factories, potato cultivation and softwood) Communities which host migrant workers Extended stay away from families, find partners in surrounding communities Engage in transactional sex or become second household to migrant workers Makete, Ludewa, Njombe Makete, Ludewa, Njombe Miners Have large disposable income at times Ludewa, Njombe Fishing communities Secondary school students boarding away from home University students Have disposable income at times, migratory nature of work Lack of boarding facilities for students means that girl students are sometimes placed with local families, sometimes in rooms together, and lack supervision. Tendency of older men to seek out these students because they are cheaper Tendencies to engage in transactional sex with those outside the university, plus having boyfriends in the university Ludewa Makete, Ludewa, Njombe, Iringa Urban Iringa Urban 2 The high risk groups and activities reported in this section were those reported by the participants in this Situation Assessment and thus represents their views. However, in Iringa, other groups at high risk have been documented in various studies and literature, including: out of school youth; teachers; barmaids; women traders. Appendix 1 contains a list of references for further information on high risk groups / livelihoods / activities in Iringa Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 xiv

12 GROUP WHY AT RISK MENTIONED BY COMMUNITIES IN WHICH DISTRICT Sex workers Truck drivers Older orphans Widows / widowers High level of unprotected sexual interactions High level of commercial sex at truck stands, extended stays away from families Older orphans (particularly girls) are at risk of being seduced or used by men for sex New sexual partners. In some communities, wife inheritance in which the widow is taken on by an immediate male relative (though reportedly, the occurrence of this is going down) Njombe, Iringa Urban Njombe, Iringa Urban Makete Makete, Ludewa Intravenous drug users (IDUs) Bad judgment, needle use Iringa Urban There were perceived differences in different groups ability to access HIV testing services. For example, it was noted that when testing services are far away, women and especially widows, are less able to access services because they have family responsibilities. One community in Makete noted that the distance to testing services was preventing them from bringing in HIV-exposed children for testing. In discussions of what type of services would be best for reaching at-risk community members, many participants felt that mobile services which came to the community were the preferred method to get testing services, especially in cases where a permanent VCT center could not be built for the community. Mobile services were said to have the advantage of being close, being more anonymous, and having flexibility in where and to whom services were offered. At least one community in Makete indicated that people are not afraid of disclosure, since so many people are HIV positive in that community and since now, there is access to drugs to keep people alive. In general, discussions with community members pointed out that many people are willing to test if services were to be made available to them. Within health facilities, the linkages from testing to care and treatment varied. In many cases, the number of people registering with the CTC was the same number as those testing positive. However, mechanisms for referral were different in different health facilities. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January 2009 xv

13 District by District Findings Makete District Makete district is in the south western part of Iringa region, bordering Mbeya region. Based upon projections from the last census, the current population is approximately 116, 454 people. Many of the people living in Makete district earn their livelihoods through softwood timber raising and harvesting, potato farming, and migratory labor for tea plantations. Makete has been particularly hard-hit with the HIV virus. The President s national VCT campaign in 2007 revealed a HIV prevalence of 16.9%, but with some communities in the district reaching as high as 38% of the adult population which voluntarily tested. District Interview The interview was conducted with the Acting DMO (Dr. Lucy Milanzi), the District AIDS Control Coordinator (DACC) (Dr. Jonathan Kitundu), and the Counsel HIV/AIDS Coodinator (CHAC) (Ms. Anangile Mpalala). Makete District has not been officially oriented to PITC and is not practicing PITC at present. However, a number of government and FBO health facilities (estimated 13) are offering VCT services. A few NGOs either have their own VCT or participated in the President s campaign with outreach testing services. An estimated seven health facilities in the district are CTC s. Some mobile testing services implemented in the district are part of PMTCT programs. Ikonda Hospital conducts PMTCT mobile services which reach 32 villages. Supervisory visits are made from the Makete District Hospital to the four peripheral CTCs every month. A list of organizations / facilities providing HIV services is maintained by the CHAC, but the facilities do not commonly have access to this information. While those interviewed had heard of national guidelines on PITC, a copy was not available in the DMO s office. Copies of many of the other key HIV guidelines, however, (from PMTCT to VCT to HBC) were available. Ordering of test kits and condoms: In line with national policy, health facilities reported that they are not ordering condoms or test kits through the ILS system, but rather use the Report and Request (R&R) system. Participants reported that test kit supply was not currently a problem, with most facilities always having a good supply of kits. In terms of condoms, the district officials mentioned that there had previously been a problem with supply when MSD experienced a shortage of condoms. Since that time, however, they feel that they are receiving adequate supplies. The DACC pointed out that currently, in the whole district, Bio-line is not being used for testing. They are using up the existing stocks of Capilus test kits and will start using Bio-line and the new testing Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January District officials in Makete district come together to discuss HIV counseling and testing with the situation assessment team

14 algorithm, estimated to be in January. It is estimated that from January 2009, health care providers will need training in the new testing algorithm in Makete. Communications: According to the district officials, communications in Makete district centered largely around CSOs which have done outreach/awareness campaigns. A fair amount of work with PLHAs has been done by CSOs. Some dissemination of brochures has taken place. Radio and television were not seen to be a major part of communications around HIV in the district. Some of the communications materials which they were able to share with us were Si Mchezo magazine, and NACP leaflets such as Magonjwa ya Ngono, Lishe, Ulishaji wa mtoto, Misingi na sababu za kupima. Most-at-Risk People (MARP)/Communities: Makete District is the district with some of the highest HIV prevalence in all of Tanzania. During the national President s campaign for testing, some communities had a prevalence of close to 40% of the adult population that tested. Table 4 below shows prevalence in different communities of Makete District, based on data from the President s testing campaign in Table 4. High Prevalence Communities in Makete District VILLAGE LOCATION HIV PREVALENCE* Ujuvi Kitulo Ward 38% Misiwa Ipelele Ward 32.6% Mago Lupalilo Ward 28.2% Ilanga Ukwama Ward 26.8% Mang oto Mang oto Ward 24.8% Ibaga Mang oto 24.2% Usagatikwa Lupalilo Ward 23.5% Luwumbu Bulongwa Ward 22.6% * National Presidential VCT Campaign, 2007, information provided by DACC This extraordinarily high HIV prevalence rate means that community members are at high risk simply because of their geographical location. However, the district officials interviewed felt that factors which explained the high prevalence include: Migration for work (tea plantations, people coming in for softwood harvesting, potato business in Kitulo Ward) Social customs such as polygamy and inheritance of women Alcohol use An emphasis was put on the importance of working with Kitulo Ward to address prevention, testing, and access to services for those who are HIV positive. In addition, it was noted that counseling and testing services are simply not available in Kigulu Village in Kitulu Ward. This area is hard to reach, since one has to cross Mbeya Region before reaching the ward (which is technically still in Makete District). CSOs working in the district: District officials were able to name several CSOs which provide HIV/AIDS-related services to the communities in Makete District (these are described in more detail in the section below). The organization which the district team felt had the strongest capability in counseling and testing is the ELCT (currently offering VCT services through the Angaza VCT Centre). The other organizations (PIUMA, MASUPHA, SUMASESU, LCCB) were thought to be able to provide counseling and testing services if given some capacity building. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

15 HMIS data submission to district level: The district authorities were asked about the timeliness and accuracy of the submission of counseling and testing data. Reports are supposed to be received by the 7 th day of the following month. As can be seen in Table 5 below, monthly site summary forms were received by the district with variable reliability. The overall average submission rate was 72% (in the months before the assessments, from 50% to 86% of the health facilities submitted their monthly summary forms). Table 5. Submission of Monthly Site Summary Forms, Makete District FACILITY J F M A M J J A S O AVERAGE SUBMISSION RATE District Hospital Makete 100% Ikonda Hospital 100% Bulongwa Lutheran Hospital % Matamba HC % Ipelele HC % Lupila HC 100% Ikuwo Dispensary % Mfumbi Dispensary % Ujuni Dispensary n/a n/a n/a n/a n/a n/a % Maliwa Dispensary % Mang oto Dispensary % Mbalatse Dispensary n/a n/a n/a n/a n/a n/a % Kitula PIUMA % Angaza -- 90% Overall average submission rate 72% The district officials rated the quality (accuracy, completeness) of the HIV counseling and testing data as only somewhat accurate and complete. Overall, there is room to improve in the data systems for counseling and testing information. Information systems for district health information: Data management within the district is not systematic. For example, there is a TB database and malaria database installed at district council offices, while the HIV and reproductive health information is managed through the DMO s office. While the Hospital Secretary is responsible for health information management, generally, the DACC is responsible for STI and counseling and testing information data management. This is only one part of his responsibilities. To be able to accommodate this work, he often works longer hours or uses his own private time to complete the work. The monthly report can take up to 3 days to prepare. The DMO s office has two computers. At one point, there was Internet connection through a network, but this has not been working for the past three months. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

16 The DACC has created his own Excel spreadsheet to manage counseling and testing data. There is no security password on the file. He has experienced data loss in the past, with accidental deletion of data. Since then, he makes back-ups on his flash-disk. Viruses are a major problem. For maintenance of the computers, a consultant from Iringa town is brought in (an arrangement made by the Makete District Council). However, no antivirus software is installed on the PCs and viruses occur frequently. Maintenance of computers happens infrequently because the money which would pay for this is a small fund which frequently has other priorities. CSOs interviewed A number of CSOs are active in Makete district. The CSOs who were interviewed are presented in this section. MASUPHA Based in Makete? Yes Registered? Yes, in 2005 Membership organization? Yes, PLHA, both male and female. Current membership is 560. Location of program activities/ beneficiaries Primary beneficiaries Current annual budget Full time, paid staff? Main activities District of Makete PLHA and orphans 24 million Tsh No 3 volunteer staff Community-based PMTCT awareness-raising program; capacity-building for members MASUPHA is a membership organization of PLHA. They have received funding from Firelight Foundation in UK, as well as from TANOPHA. They started in 2005 and grew from just 22 members to 560. They have relied a lot on peer education as a means of getting their messages out. They have cooperated with the CHMT to provide awareness-raising about counseling and testing by providing testimonies at health facilities and special events. However, they have never engaged health care providers to conduct testing and counseling. They have some experience with using local radio station (Kitulo FM) for communication. PIUMA Based in Makete? Yes, Bulongwa Registered? Yes, in 2007 Membership organization? Location of program activities / beneficiaries Primary beneficiaries Current annual budget Full time, paid staff? Yes, PLHA, both male and female. Current membership is 260. Bulongwa and Magoma Divisions, Makete District PLHA 40 million Tsh for activities, over 100 million donations of equipment 3 a clinical officer, a nurse and a secretary. Also 2 international volunteers who spend part of the year with the organization. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

17 Main activities Promote HIV testing for community; HIV counseling and testing; protects rights of members / PLHA; work for stigma reduction; income-generating activities for members; PIUMA is a membership organization of PLHA, started in 2007, which has received funding from an Austrian church foundation called Evangelical Association for World Mission (EAWM). They were the 2008 winners of the Foundation for Civil Society s Best NGOs of the Year award for the Southern Highlands Zone. PIUMA engages in service provision by providing counseling and testing services in their stand-alone site in Bulongwa town. They would like to start providing the service of counting CD4 for their members, and have the CD4 counter, but have not gotten it registered. They reported having conducted outreach activities, including projecting films, and going location to location encouraging people to test. They would like to increase the use of the local radio station. In the past, they have both engaged nurses from government hospitals to help with outreach activities, but now they are fortunate to have health care providers on staff. SUMASESU Based in Makete? Yes Registered? Yes, in 2004 Membership organization? Location of program activities/ beneficiaries Primary beneficiaries Current annual budget Full time, paid staff? Main activities no 20 villages throughout the district of Makete Youth, general population 80 million Tsh 10, and 90 volunteers Awareness-raising for HIV prevention through theatre, peer education, teachers, and religious leaders SUMASESU is an organization which focuses on HIV prevention among youth through outreach, education, and working through schools and religious leaders. Funded by FHI, they have a very communications-oriented approach which focuses on participatory theatre and peer education. The curriculum which they employ is called Christian Family Life Education. They are not currently engaged in provision of counseling and testing services. TAHEA Based in Makete? No, national organization. This office is under TAHEA Iringa, which has a presence in all 7 districts of Iringa Registered? Yes, in 1980 Membership organization? Location of program activities / beneficiaries Primary beneficiaries Current annual budget Full time, paid staff? Main activities Yes 70 villages in 3 divisions of Makete district OVCs, general population 401 million Tsh 5 and between 5 10 volunteers Nutrition education, legal support, material support, linkages to health care services for orphans and vulnerable children, Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

18 home based care TAHEA is a well-known national membership organization for professionals of all types in Tanzania. TAHEA Makete is under the umbrella of TAHEA Iringa. Funded by multiple sources (including Pact and Tunajali program), the focus of their work in on improving the lives of orphans and vulnerable children. They have utilized local radio station as well as brochures for outreach. They have a good relationship with the District Council, attending CMAC meetings and engaging them for technical assistance. They are not currently engaged in provision of counseling and testing services. They mentioned an interest in applying for a grant to reach out to young women attending secondary school, who are high risk because there are no accommodations for them. They therefore often live with families or rent rooms where many stay, and are at high risk for sexual abuse or may make poor choices and engage in transactional sex. Participatory Research Exercise The assessment team was welcomed to the village of Ivalalila, approximately 10 km from Makete town. Participatory exercises of mapping and a matrix were done to find out about MARPs within that community and effective outreach strategies to reach them. All participants were HIV positive and were open about their status. Key findings on HIV transmission included: From the participants perspective, the major contributing causes for HIV infection in this community were alcohol use and poverty (poverty causes spread of infection because of reliance on transactional sex). Transactional sex was very high. Participants reported that practically every sex act among unmarried people, the woman expects to get some compensation. Condoms are available for sale in the village as well as being distributed to HIV positive people who attend CTC, but are not widely used. Condoms or ulanzi One of the first factors mentioned in HIV transmission was alcohol use. Many small shops out of peoples homes sell the homemade brew, called ulanzi. One of the participants pointed out that the price of condoms is the same as the amount needed to get drunk on ulanzi: For 200 shillings, you can get a packet of condoms or you can get a litre of ulanzi. You can guess what people choose! Some of the traditions which contributed to the spread of HIV, such as widow inheritance and polygamy, have dramatically reduced in the last five years or so with the new awareness of HIV. As one participant noted: Tumeacha kurithi wanawake kwa sababu tunakwisha kwa vifo. (We stopped widow inheritance because it was wiping us out.) According to the participants, the most at risk people in this community were unmarried youth, widows and widowers. The reason given was the high rate of transactional sex for these groups. Testing children for HIV Key findings on outreach of HIV testing services included: One of the HIV positive mothers in the group felt that the Current situation of testing services makes it difficult for children of Ivalalila are not people to access testing. Makete town is a two hour walk being tested as they should be. there are no buses or other transport which goes HIV positive mothers are told to regularly to Makete. bring their children in to test for Women/widows are especially disadvantaged in seeking HIV. However, she said many testing services, since they have the responsibility to take people do not take the children care of the children. They cannot leave the kids for a full in because of the distance. Imagine, you are alone as a day (four hours walking plus the time to get the service). parent and you have two children who are supposed to Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa come Region, to Makete January for 2009 testing. 21 Four hours of walking, how will you carry them both?

19 The current situation of testing services makes it very difficult for children of HIV positive mothers to get tested: Kwa kuwa huduma iko mbali, wengi wetu hawajapeleka watoto kupima. (Because the service is far, many of us have not taken our children to be tested.) Definite preference of the participants was for testing services (along with services for care and treatment) to be available in the community. The feeling among participants was that people would come out to test in high numbers if the service was available locally. A monthly visit for outreach services was seen as the second-best option. Disclosure of HIV status was not seen as a major barrier in accessing HIV testing. Participants did not think that people would prefer to go elsewhere to test because of the fear of disclosure. As one participant described: Mwanzoni tulikuwa na uoga, lakini sasa, sio. (At first we were scared to disclose our status, but now, no longer.) It was noted that the availability of medicine through the CTCs had caused a major difference in disclosure. Now, instead of guarding their status, people s priorities have shifted to getting on treatment and staying alive. Participants in the participatory research exercise, Ivalalila Village, Makete Facility Assessments As part of the Situation Assessment, two health facilities (Bulongwa Hospital and Ipelele Health Centre) were visited. Both facilities were CTCs. The main purposes of the assessment were to understand current status of counseling and testing and care and support services available through the facility; to assess readiness for the introduction of PITC; understand their system for ordering key supplies for counseling and testing; and to understand the situation of reporting health information up to district level. Ipelele Health Centre Ipelele Health Centre is located approximately 30 km southwest of Iwawa (the capital of Makete district). They started offering CTC services in January of 2008, but did not start reporting to the district until October Currently, they have over 115 clients enrolled in their CTC services. Ipelele Health Centre Staffing VCT trained staff? Guidelines on PITC present? Adequacy of wards for PITC? Ordering through ILS (is facility A,B, or C) 5 : 1 Clinical Officer, 2 nurses, 1 nursing assistant, and one lab attendant None (2 were previously trained, but one retired and one is studying) Yes, 2 copies For the wards, space is inadequate and privacy is a problem since wards are open. In OPD, FP / RH privacy would be adequate. At CTC, the VCT center is already established. A Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

20 Total number of VCT clients reported in 2008 Percent testing positive for HIV Total number of clients enrolled in CTC % 168 Total number on ART 85 The health centre is dramatically understaffed, with only five staff running a facility which is supposed to be run by 20 staff. While guidelines on PITC (National Guidelines for Clinical Management of HIV/AIDS -2005) were present in the health centre, similar to all of Iringa Region, they have not formally started PITC. Also, the facility was missing all of the other relevant HIV guidelines (PMTCT, VCT, etc) Data is meticulously entered into registers, however, providers had difficulty with the CTC register and had made errors. The facility in-charge reported that they struggle with filling in the registers correctly but try to correct errors internally before reports are sent up. The providers found the VCT register to be simpler to fill and were consistently filling it out. With the monthly summary forms, they said they had only recently started filling them and sending to the district level. Plots of the number of VCT clients had been created and posted, indicating that not only are they filling in the registers, they are using the data. The CTC appeared to be providing high quality services, with a welcoming and clean infrastructure. The providers present were able to present the services well and it appears to be well utilized by community members. Conclusion on introduction of PITC: While this facility may have the physical infrastructure to support PITC (with the exception of privacy), the understaffing of the facility would have a dramatic effect on ability of providers to provide additional services. Providers already report having to stay beyond normal working hours to handle high caseloads. Supplies for testing and condoms, at this time, do not represent a challenge to the health centre. Supplies are adequate for demand and stock-outs are not occurring. However, possibly due to understaffing, the ledgers and ordering forms are not being maintained properly, with many errors. Bulongwa Hospital Bulongwa Hospital is located approximately 20 km southwest of Iwawa in the town of Bulongwa. It is a Lutheran Hospital. They have been offering CT services since Bulongwa Hospital Staffing VCT trained staff? Guidelines on PITC present? Adequacy of wards for PITC? Ordering through ILS (is facility A,B, or C) 39 nurses; 4 clinical officers; 2 AMOs 5 trained in VCT; 11 trained in PMTCT Yes, 2 copies Space in wards is adequate, but privacy is lacking since wards are all open. Hand washing facilities and sharps disposals are available. n/a (not using ILS, using Report and Requisition form) Total number of VCT 572 Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

21 clients reported in 2008 Percent testing positive for HIV Total number of clients enrolled in CTC 22% 213 Total number on ART 110 The hospital is not using the ILS system to order supplies. They receive test kits quarterly from DMO by the 3 rd month of the quarter (March, June, Sept, Dec), and they keep a three-month buffer stock. The orders which go to the DMO include the test kit needs for all subdivisions of the hospital, and are coordinated through the laboratory. Generally, these are delivered by the DMO only a few times has the hospital had to send a car to pick them up. While the hospital did not experience stock-outs of test kits, they did have a batch that were set to expire within a month which they were then not able to use. The in-charge, did, however, report that they have big problem keeping gloves, anticoagulant and vacutainer tubes in stock (vacutainer tubes will be needed in less quantity when Bio-line is introduced instead of the Capilus they are currently using). When they are stocked out of gloves, they generally go buy directly from MSD in Mbeya. For condom supplies, condoms are ordered directly through the DMOs office. Ordering condoms from the district is not coordinated within the hospital thus RH orders directly from DMO on a monthly basis using forms designed for that purpose, while VCT orders condoms from the DACC. They have not experienced stock-outs of condoms. They indicated that filling of the register is difficult, especially PMTCT. The CTC register was clearly problematic for them. For the monthly site summaries, when looking through the register, one would find two to three entries for each month, since they had made errors the fits time they filled in the form, left it and gone to the next page. Conclusion on Introduction of PITC: This hospital has resources which will make the introduction of PITC possible, including some staff trained in VCT, working CTC, and adequate infrastructure. Some infrastructure additions may be needed to create areas with visual and auditory privacy in wards to facilitate PITC. Supplies are likely to be problematic. Supplies of gloves and some of the necessary equipment for testing were already mentioned as a problem for the facility. Some inputs will be needed to build capacity on data recording. Although the area of VCT was not observed to be problematic, the recording and aggregation of the CTC data was full of errors and problems. Ludewa District Ludewa district is in the south of Iringa region, approximately 150 km south of Njombe. The district contains portions of the Livingstone Mountains, and borders Malawi on Lake Nyasa. Based on 2007 projections, the population is 139,932 people in the district (65,768 males and 74,164 females). Many of Ludewa district s population earn their livelihoods engaging in small scale agriculture on the mountainsides, fishing on Lake Nyasa, working on tea plantations, and in mines for coal, gold and iron ore. According to the regional records (RACC s office) Ludewa has the highest prevalence of HIV in the region, with 16.9% of adults tested being HIV positive. District Interview Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

22 The interview was conducted with the DMO (Dr. Thobias Mkina), the DACC (Mr. Donald Mwahongo) and the CHAC (Mr. Thomas Kiowi). Ludewa District has not been officially oriented to PITC and is not practicing PITC at present. However, at least 13 health facilities are offering VCT services. Some of these facilities only added VCT as a service in There are seven health facilities in the district which are care and treatment centers (CTC s). This service started in 2001 in the district hospitals, and in the health centres. While the government health facilities offer no outreach services for HIV, the Mission hospital (Lugarawa) has limited outreach services for VCT and care and treatment. There is no centralized list of referral agencies (organizations/facilities providing HIV services) maintained at district level. However, all facilities have referral protocols (eg. Nindi Health Center has a VCT but no CTC, and thus refers clients to Ludewa District Hospital, while Mavanga, Amani and Madilu Health centers refer to Lugarawa Hospital, and Kiyombo refers to Mlangali). Ordering of Test Kits and Condoms: Condoms were reported to be available most of the time in health facilities offering counseling and testing. One of the Mission hospitals (Lugarawa) does not offer condoms to clients due to religious prohibition. District officials also reported (incorrectly) that test kits are ordered through the ILS system, indicating that the district authorities are not aware of the logistics around test kit supply. Supply of test kits was reported to be a problem in some health facilities. There was a delay in receiving test kits which occurred in September 2008, but supplies are generally arriving on time at present. Challenges in keeping facilities stocked with test kits have much to do with geographical barriers to reaching health facilities. Communications: Communication in terms of media coverage is very poor. The only radio station reception is from Malawi. For any communication needs, the district uses a public address system mounted on a car or truck. In terms of communication materials, only a few issues of Femina magazines (Cheza Salama) were found at the district hospital. MARPs /Communities: Ludewa District has a very high HIV prevalence. This HIV prevalence rate means that communities are at high risk simply because of their geographical location. However, the district officials interviewed felt that certain groups were at substantially elevated risk: Fishermen and staff of fisheries camps (along Lake Malawi) Miners (gold) in Mundindi Ward Workers on tea plantations (Madope Ward) Secondary school students (esp. girls) Secondary school girls were said to be at high risk because many of the secondary schools don t provide boarding facilities, while many of the students come from far away and must live in the town. It is a common practice for these students to rent rooms either in households or a group of girls to rent rooms together. In either case, they become vulnerable to offers of transactional sex or rape. The following were traditions or conditions which were thought to lead to the elevated rate of HIV in the district: Social customs such as traditional celebrations (ngoma) and inheritance of women Alcohol use (local brew is found throughout the district and many rely on it for income) It was stressed that the best way to reach these at-risk groups would be through mobile campaigns, including drama, and behavior change communications (BCC) materials such as leaflets, etc. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

23 The primary barrier to testing was thought to be the long distance to services. It was also proposed that stigma and fear of breaching confidentiality might prevent people from accessing testing services. There are some religious beliefs in the population in the district as well that prevent people from using ARVs as therapy for HIV infection. From the health infrastructure side, health facilities are facing severe shortages of personnel. CSOs Working in the District: While only one CSO working in the district was visited, other CSOs were also described. These included: Milo Sailun Orphanage Centre (MISO), Self Help Assistance Mission (SHAM), SHIDEFA, Tumaini and Mapambazuko, Umoja wa Vijana wa Kikristo Anglican, Bakwata AIDS Project (BAPRO), Luilo, Okoa Akina Mama na Watoto (LOKINAWA), Mlangali Development Association (MLADEA), Mawengi Development Association (MADA) and Madio Development Association (MDA). IDYDC has funding from Tunajali program to provide HBC services in the district (described in more detail in the section below). HMIS Data Submission to District Level: The district authorities were asked about the timeliness and accuracy of the submission of counseling and testing data. As can be seen in Table 6 below, monthly site summary forms were received by the district with variable reliability. The overall average submission rate was 63%. Table 6. Submission of Monthly Site Summary Forms, Ludewa District Facility J F M A M J J A S O N Average submission rate District Hospital Ludewa 100% Lugarawa Hospital % Milo Hospital % Manda HC 100% Makonde HC % Mlangali HC -- 90% Nindi HC % Mawengi HC n/a n/a n/a n/a % Madunda HC % Lupanga Dispensary % Luvuyo Dispensary n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a -- Madili Dispensary % Amani Dispensary n/a n/a n/a n/a n/a n/a -- 80% Mavanga Dispensary % Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

24 Kiyombo Dispensary % Luilo Dispensary % Overall average submission rate 63% The district officials rated the quality (accuracy, completeness) of the HIV counseling and testing data as only somewhat accurate and complete. One of the identified areas of need is for orientation to service providers to improve the quality of data coming up from health facilities. However, data and administrative issues at district level appear to need assistance as well. An example of poor systems at the district level was seen during the team s visit, since there was letter from the Regional Hospital requesting attendance at the Regional Office, which was addressed to the DMO, who forwarded it to the DED for action. The letter was lost at that point, although the regional representative who was accompanying the team confirmed that the letter was faxed and received two weeks prior. Overall, there is room to improve in the data systems for counseling and testing information, from both health facilities and from district level. Information Systems for District Health Information: The DACC is responsible for counseling and testing information data management, although this is only one of his responsibilities. The DACC was working on reports in Word since he is not very strong in Excel. He indicated that the monthly report can take up to a week and a half to prepare. Data on STI is managed by the STI coordinator. The DMOs office has three computers at its disposal, but only two are functioning. Data loss has occurred in for these files in the past, due to viruses attacking files. No antivirus software is installed on the PCs and viruses occur frequently. For maintenance of the computers, University Computing Center comes in on a very occasional basis, although there are no funds which are set aside for this purpose. CSO interviewed One CSO working in Ludewa district was interviewed. IDYDC Based in Ludewa? No, based in Iringa town Registered? Yes, 1994 Membership organization? Location of program activities / beneficiaries Primary beneficiaries Current annual budget no 15 wards, 53 villages in Ludewa district PLWHA and OVCs 201 million Tsh Full time, paid staff? 7 Main activities Home based care, advocacy for counseling and testing, orientation to family members of PLHA on home care for HIV positive persons Home based care, awareness-raising for counseling and testing; and orientation to family members of PLHA on home care for HIV positive persons. In near future they will be doing counseling and Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

25 testing, since three retired nurses were just sent to Morogoro for training. IDYDC is a development agency which has its headquarters in Iringa town, which has been active in Ludewa for the last 3 years. They have a good relationship with the district, having the DACC and CHAC on a taskforce to improve OVC care in Ludewa. In Ludewa, they provide material support to orphans (have supported over 2000 orphans), peer education for village government, etc. They have hired retired health personnel (currently three) to assist with counseling and testing activities. For communications, they have used a PAS, as well as circulating leaflets. Participatory Research Exercise A participatory research exercise was conducted in Ludewa village, a village just outside of Ludewa town. Participatory exercises of mapping and a matrix were done to find out about most at-risk people within that community and effective outreach strategies to reach them. Key findings on HIV transmission included: From the participants perspective, a major contributing causes for HIV infection in this community was alcohol use (ulanzi is said to increase sexual desire in addition to its intoxicating effects) Transactional sex was reported to be very common as participants reported that particularly widows and other women had sex for money Some traditions such as widow inheritance and wedding celebrations contribute to the spread of HIV in this community video shows, TV shows and discos were said to have high attendance by young people and to contribute to high risk According to the participants, the most at-risk people in this community were widows, (male) youth, and secondary school girls. In a number of cases, widows have sexual relations with either the late husband s family members or other community members, regardless of whether the husband died of AIDS or some other cause. The young boys in the village seem to be greater in number than the girls, and there is much unemployment resulting in drug and alcohol abuse. Secondary school girls were reported to be involved in transactional sex, for the purpose of hiring a room, to live on or simply to get nice new things. Community mobilization was started by elders and the village government after the village s high prevalence became known during the President s testing campaign. Some of the steps taken included: Village executive officers discuss issues with community members who seem to have extreme or unsafe sexual behavior; The village government has a by-law which does not allow clubs to operate after pm; The village chairman discusses HIV/AIDS or counseling and testing in every meeting which is held Some couples have adopted the habit of going together to alcohol clubs so as to minimize the risk of finding a new partner PLHA have formed post-test groups, are involved in income-generating projects (groundnuts) and are encouraging others to join and have started a groundnuts project Key findings on outreach of HIV testing services included: the district hospital testing services are well known and convenient for those who live close Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

26 preference of the participants was for testing services to be available locally via mobile outreach (mobile was preferred for confidentiality reasons) Perceived barriers to accessing HIV testing include low education levels, cultural norms and beliefs Participants in the participatory research exercise, Ludewa Facility Assessment As part of the situation assessment, Ludewa District Hospital, which is a CTC, was visited. The main purpose of this visit was to understand the current status of counseling and testing and care and support services available through the facility; to assess readiness for the introduction of PITC; understand their system for ordering key supplies for counseling and testing; and to understand the situation of reporting health information up to the district level. This is described in the section below. Ludewa District Hospital Ludewa District Hospital is located approximately 140 km southwest of Njombe District headquarters. Staffing 28 VCT trained staff? 4 Ludewa District Hospital Guidelines on PITC present? Adequacy of wards for PITC? Ordering through ILS (is facility A,B, or C) Total number of VCT clients reported in 2008 Yes (not seen but reported) Space is ample but auditory and visual privacy is not currently adequate n/a 1,427 Percent testing positive for HIV 22.7% Total number of clients enrolled in CTC 307 Total number on ART 57 Ordering of test kits is done on an as-needed basis rather than using a regular ILS system. The laboratory in-charge prepares the needs from all of the different section of the hospital and the pharmacist orders the kits directly from MSD Zonal office. The kits are then delivered to the hospital by MSD. They reported that they have not experienced a stock-out of kits in the past one year, but that they had some delays in the receipt of kits due to a longer time than expected in receiving the supplies after the order had gone in. They could anticipate some problems/concerns in increasing the volume of test kits in stock in case PITC is introduced. The supply of condoms was described as more problematic. There was a stock-out of condoms in September This was thought to be due to under-ordering. To compensate, the hospital took some stock from neighboring health centres and dispensaries. Coordination of ordering condoms is centralized, as sub-divisions of the hospital order through the pharmacist, who places the order with MSD Zonal Office. Lancets, capillary tubes and gloves were all reported to be in adequate supply (this facility was still using Capilus tests). Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

27 Unfortunately, ledgers and receipt books were not kept in a manner which facilitated follow up. In addition, the data management appeared to need improvement, and neither internal and external referrals are recorded. Conclusion on Introduction of PITC: Improvements would be necessary on physical infrastructure to provide for privacy for PITC. Supply systems for test kits and condoms (in particular) would need to be strengthened, including the recording and monitoring of supplies internally. Refresher training/orientation is needed for data management, and the establishment of a referral system is recommended. Supplies for testing and condoms, at this time, do not represent a challenge to the health centre, since supplies are adequate for demand and stock-outs are not occurring. However, possibly due to understaffing, the ledgers and ordering forms are not being maintained properly, with many errors. Njombe District Njombe district is in the south central part of Iringa region. Many of the people in Njombe district s population earn their livelihoods by tea raising, softwood timber raising and harvesting, potato farming, and wattle plantations. Makambako is at the junction to the main roads to Mbeya and Songea which runs through Njombe, and big centers like Makambako and Njombe town are both business centers and major truck stops. In this assessment Njombe district was treated as one district. However, recently Njombe was divided into two district councils: Njombe town council and Njombe district council. Njombe district is the most populated distict in Iringa region, with an estimated population of 476,094 (224,773 males and 251,321 females). Njombe has an HIV prevalence of 13 according to the regional records%. However the DACC s records show that, in the last year, HIV prevalence was as high as 45.6% among those coming for voluntary testing and counseling. District Interview The interview was conducted with the DMO (Dr. Charles Ng ingo), the DACC (Dr. Monica Kaduma) and the CHAC (Mr. Michael Haule). Njombe District has not been officially oriented to PITC and is not practicing PITC at present. However, a number of government and FBO health facilities (estimated 14) are offering VCT services. Apart from Angaza, two other NGOs have their own VCT. Both participated in the President s campaign with outreach testing services. Seven health facilities in the district are CTC s. Mobile testing services are done by the district health department through hospital staff, and Angaza. Marie Stopes offers mobile services as well. SHIPO in collaboration with Tunajali offers door-to-door and family counseling and testing (on a small scale). A comprehensive list of organizations/facilities providing HIV services for referral is available at district level, but the facilities do not have access to this information. While those interviewed were not familiar with the national guidelines on PITC, a copy was available, as were HBC guidelines. Copies of the other key HIV guidelines, including PMTCT, VCT, HBC were available: only Infection Prevention (IP) was not available. Ordering of test kits and condoms The participants reported that test kit supply was not currently a problem, with most facilities always having good supply of the kits. They have had the experience of MSD being out-of-stock of certain kits, or the kits were there but had been designated for another purpose (like the Uhuru Torch). In terms of condoms, the district officials mentioned that there had previously been a problem with supply when MSD experienced a shortage of condoms. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

28 Training Needs: The district officials estimated that in the entire district, 21 providers have been trained in VCT, and an additional 36 could use training in VCT. An estimated 73 people would need to be trained in or oriented to PITC. Communications: District officials mentioned several sources of BCC messages in the district, including radio, TV, outreach, and billboards, posters and leaflets. Many of the messages they noted centered around HIV prevention, VCT and PMTCT. MARPs /Communities: Njombe hosts major trucking routes as well as migratory labor industries such as softwood raising and tea raising. Commercial sex is present and to a great extent it is associated particularly with the trucking routes. Table 7 below details some of the locations with the livelihoods that lead to increased risk of HIV. Table 7. Risks and Locations in Njombe district Risk Factor Tea plantations Timber plantations Potato plantations Migrants Commercial sex workers Local bars and clubs Truck stops Location(s) Lupembe, Kibena, Igima, Luponde, Kilocha Lupembe, most areas in the district Imalinyi, Njombe Town, Igominyi Ilembula, Makambako, Njombe Town Njombe Town, Makambako Most parts of the district Makambako Wattle plantations * information provided by DACC Kibena Given the risk factors in the district, the district officials counseled that mobile services would be the best way to reach at-risk populations. Some of the barriers which district officials felt that people face when it comes to testing were: stigma and fear that confidentiality would be breached, inadequate services to support them if diagnosed positive (far distance for many people to reach CTCs). It was noted that in the district, Ikondo and Imalilo were very remote, far off the main road, and thus completely lacked access to counseling and testing services. District officials were able to name several CSOs who provide HIV/AIDS-related services to the communities in Njombe District. These are not a comprehensive list, but the ones that they were aware of are described in the table below. CSOs working in Njombe district CSO Type of Work Serve which geographical areas Marie Stopes (INGO) VCT Makambako SHIPO Mobile VCT, HBC Lupembe, Wanging ombe Makambako, Njombe Town, Igominyi, Imalinyi HMIS Data Submission to District Level: Submission of data on counseling and testing to the district from the health facilities was said to be excellent in terms of regular reporting. In fact, all of the facilities responsible for reporting CT figures were reporting regularly in 2008, as can be seen in Table 8 below. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

29 Table 8. Submission of Monthly Site Summary Forms, Njombe District Facility J F M A M J J A S O Average submission rate Makambako HC 100% Lupembe HC 100% Uwemba HC 100% Njombe HC 100% Luponde Dispensary 100% Kipengele Dispensary 100% St David VCT 100% Marie Stopes 100% Angaza Njombe 100% Angaza Makambako 100% Overall average submission rate 100% The district officials rated the quality (accuracy, completeness) of the HIV counseling and testing data as only somewhat accurate and complete. Information systems for district health information: The DMOs office has three computers at its disposal. These are shared by the DACC, the VCT in-charge, the CTC in-charge and the STI in-charge to compile data and reports. The DACC prepares the monthly report which summarizes the facility-based information. There are up to five people involved in the production of the report, which generally takes up to three days to prepare. Viruses are a major problem. The DMO is responsible for maintaining the computers/installing anti-virus software. They indicated that there is up-to-date antivirus software on the computer (which had been downloaded from the internet). However, there is no particular budget set aside for maintenance of computers. There is an internet connection available through the DMO s office. CSOs interviewed The CSOs who were interviewed are presented in this section. Based in Njombe? NJODINGO Yes Registered? Yes, 2005 Membership organization? Yes, the members are CSOs working on HIV/AIDS in the district Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

30 Location of program activities / beneficiaries Primary beneficiaries Current annual budget Full time, paid staff? Main activities District of Njombe Local organizations (CBO, NGO and FBO) working on HIV/AIDS 60 million Tsh 4 and 2 volunteer staff Capacity building for local NGOs working on HIV/AIDS NJODINGO is an umbrella organization which brings together NGOs, CBOs and FBOs which work on HIV/AIDS in Njombe to improve their capacity, communication and coordination. They have over 280 members, but of these, 147 are active. An example of one of their recent capacity-building exercises was a training in financial management of HIV/AIDS for their members. NJODINGO is not a direct implementing agency. SHIPO Based in Njombe? Spread equally through Ludewa, Njombe and Mufindi districts Registered? Yes, in 2001 Membership organization? Location of program activities / beneficiaries Primary beneficiaries Current annual budget Full time, paid staff? Main activities No The whole of Njombe district General public (VCT activities); schoolchildren; women 1.3 billion for the whole organization 282 million for Home based care and VCT (for three districts including Ludewa, Njombe and Mufindi) 31 plus 2 international volunteers Building schools and donation of school equipment; supports Tunajali with home based care and counseling and testing services (including door to door) SHIPO is a large NGO which provides services in Njombe, Ludewa and Mufindi districts. Primarily, their work has been in infrastructure improvements such as building wells and schools. However, in the last three years, they have been receiving funding for home-based care and counseling and testing services. They have hired a nurse midwife who works with district authorities, nurses in the health facilities and volunteers to conduct HBC and VCT services in the villages. The nurse midwife who is a SHIPO staff member is also responsible for household and family counseling. In terms of communications, they have had some success in using a local radio station (Upland FM Radio) to reach the community with messages. Participatory Research Exercise Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January

31 For the participatory research exercise, a group of participants from Njombe town were assembled which included taxi drivers, bar workers, a DJ and plantation workers. Participatory exercises of mapping and a matrix were done to find out about most at risk people within that community and effective outreach strategies to reach them. Key findings on HIV transmission included: the trucking business has contributed to high risk in the area. There are areas where drivers park their lorries and the commercial sex work there is extremely high Tea plantations are areas of high risk since most of the workers are men, and most come without partners and look for partners while they are there Income=Risk Industries which generate high income (such as the wattle processing) cause high risk, according to participants. The men who come to cut logs get a lot of money. They use the money to seduce women, even peoples wives. Many marriages have been broken up because of these industries Alcohol use contributes to the spread of HIV and is virtually everywhere (either local brew or modern clubs Sexual abuse is common in workplaces like banks, hospitals, police stations as men in positions of power force sex on subordinates or on women seeking employment Commercial sex work is very active in Njombe, from guest houses to bars to music places to alcohol shops Secondary school students may be at very high risk as well (see text box) Key findings on outreach of HIV testing services included: There was a general agreement that people are ready to test if the services were available to them: tukijengewa vituo vya kupima tutapima, (If we are built the facilities to test, we will test.) Mobile services were seen to be good, but not just once in awhile. Mobile services should be offered regularly. There are populations in Njombe who move around a lot, like those harvesting softwood and those working on wattle production. For these people, mobile services are particularly important. For people like truck drivers, the service should be offered at the places they park their lorries. It was felt that it will be difficult to convince the workers in formal workplace settings to test and they will need to have special outreach sisi ni rahisi sana kukubali kupima kuliko maajiri na watu wa ofisini. (We ordinary people are much more likely to test than rich people and those high up in position.) Mobile outreach to bars and discos at night moonlight VCT is a good idea, especially for sex workers, taxi drivers, bar patrons, etc. One problem will be that people may be drunk. Facility Assessments As part of the situation assessment, two health facilities (Njombe District HIV risk for secondary school students Many of the big men from town like to take schoolgirls because they are cheap. These are the same men who go around with commercial sex workers. The schoolgirls also have relationships with schoolboys so this can lead to a big cycle of transmission. Report: Situation Assessment, Counseling, Testing and Care and Treatment Iringa Region, January