TB/HIV KAP SURVEY REPORT

TB/HIV KAP SURVEY REPORT MALINDZA TB/HIV PROJECT September, 2014 DISCLAIMER: The author s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government - 1-2 9

CONTENT - 2-2 9 Table of Contents List of Abbreviations -------------------------------------------------------------------------------i Acknowledgements ---------------------------------------------------------------------------------ii 1.0 Executive Summary ------------------------------------------------------------------------ - 3-1.0 INTRODUCTION -------------------------------------------------------------------------- - 4-1.1 Organization --------------------------------------------------------------------------------------------------- - 4-1.1.1 Vision and Mission ----------------------------------------------------------------------------------------- - 4-1.2 The Project ----------------------------------------------------------------------------------------------------- - 5-1.3 Study Rationale /Purpose ------------------------------------------------------------------------------------ - 6-1.4 Research Objectives ------------------------------------------------------------------------------------------ - 7-2.0 Methodology and sampling --------------------------------------------------------------- - 7-2.1 Research approach or methodology ------------------------------------------------------------------------ - 7-2.2 Inclusion and Exclusion criteria: --------------------------------------------------------------------------- - 7-2.3 Data Collection: ----------------------------------------------------------------------------------------------- - 7-2.4 Data Analysis -------------------------------------------------------------------------------------------------- - 8-2.5 Ethical Consideration ---------------------------------------------------------------------------------------- - 8-2.6 Limitations of the study --------------------------------------------------------------------------------------- - 8-3.0 FINDINGS ----------------------------------------------------------------------------------- - 8-3.1 Demographics ------------------------------------------------------------------------------------------------- - 8-3.2 Access to Joyful Hearts Services -------------------------------------------------------------------------- - 10-3.3 KNOWLEDGE----------------------------------------------------------------------------------------------- - 10-3.3.1 Knowledge on HTC -------------------------------------------------------------------------------------- - 10-3.3.2 Knowledge on TB Transmission ----------------------------------------------------------------------- - 11-3.3.3 Knowledge on TB Treatment Adherence ------------------------------------------------------------- - 12-3.3.4 Knowledge on ART Adherence ------------------------------------------------------------------------ - 12-3.4 ATTITUDES ------------------------------------------------------------------------------------------------- - 13-3.4.1 Attitudes on HTC ----------------------------------------------------------------------------------------- - 13-3.4.2 Attitudes on knowing ones HIV Status ---------------------------------------------------------------- - 13-3.4.3 Attitudes on TB ------------------------------------------------------------------------------------------- - 14-3.4.4 Attitude on Disclosure ----------------------------------------------------------------------------------- - 14-3.5 PRACTICES ------------------------------------------------------------------------------------------------- - 15-4.0 CONCLUSIONS ---------------------------------------------------------------------------------------------- - 15-5.0 RECOMMENDATIONS ------------------------------------------------------------------------------------ - 16-6.0 LESSONS LEARNT ------------------------------------------------------------------------------------------ - 17 - APPENDICES -------------------------------------------------------------------------------------- - 18 - Appendis 1: Consent form -------------------------------------------------------------------------------------- - 18 - Appendis 2 : Questionnaire ------------------------------------------------------------------------------------ - 20 -

BASIC INFORMATION /INFORMATIONS PERSONNELLES/ TAARIFA ZA MSINGI ------------------------------------------------------------------------------------------ - 20-1.0 Executive Summary The Malindza Communities are susceptable to communicable diseases as they have over the years been exposed to migrant people. The study on Knowledge, Attitudes and Practices (KAP) on TB/HIV was appointed by Joyful Hearts Organization to examine the level of knowledge, attitudes and practices on TB/HIV in four distinct sites namely, Malindza Refugee Camp, Sikhuphe Village, Malindza Highway, and Mbadlane. The survey aimed to establish the Knowledge, Attitudes, and Practice of the people of Malindza in matters of HIV/AIDS& TB so that the right programs could be put in place to control the diseases. The survey therefore focused on the people that are on TB Treatment, Living with someone who has TB and people living with HIV/AIDS among others. A total of 190 people were interviewed from the four implementation sites, 50 were sampled from Sikhuphe Village, Malindza Highway and Mbadlane respectively while 40 were sampled from the Malindza Refugee Camp. A quantitative data collection methodology was used. A questionnaire, consisting of 4 sections, was developed in English and translated into SiSwati, Burundese, Congolese, Ethopian, Mozambican, Rwandese and Somalian to suit the target group. The findings indicate that the respondents have fairly high, level of knowledge on HIV/AIDS and TB. About 83.7% (n=159) of the respondents indicated that it is important for couples to test and know their HIV status. An overwhelming majority, 96.8% (n=184) indicated that one can get TB when a person with TB coughs or sneeze. The results on knowledge also reveal that, 97.4% (n=185) of the respondents believe that getting tested for HIV is important as it helps in accessing treatment. However,12% (n=23) of the respondents indicated that, HIV positive people have to continue testing for HIV which is an indication of a gap that may exist in terms of knowledge hence there might be a need to strengthen messages on HTC. In terms of attitudes, the results indicate that 50% (n=95) of the respondents would undergo HIV testing even when their partners have tested negative. About 49.5% (n=94) of the respondents agreed that one can still enjoy sex after testing positive for HIV while 48.9% (n=93) agreed that even when married and faithful to one partner there is still a need for HIV testing. With regard to practices; 34.7% (n=66) of males and 47.9% (n=124) of females indicated that, they already know their HIV status. The findings also show that those who are actively testing are aged between 21-30 years. - 3-2 9

The findings indicate a need to strengthen knowledge on HIV/AIDS and TB and to scale up HTC services as an entry point to care and treatment. Efforts have to be made to provide comprehensive information on the importance of HTC and treatment. There is also a need to develop intensive TB awareness programmes to ensure that people have the right knowledge, access treatment and adherence as there seems to be a gap between knowledge and practice. There is also a need for more information on issues on ART treatment so that people can understand the role played by ART or treatment among HIV positive individuals. Issues of disclosure also need to be included in programming to ensure that a comprehensive package on HIV/AIDS and TB is delivered to beneficiaries. 1.0 INTRODUCTION 1.1 Organization Joyful Hearts is a Non-Governmental Organization established in August 2011 to focus on rebuilding lives of Swazi people and refugees/asylum seekers affected by HIV/AIDS & TB, poverty and hunger through the provision of humanitarian aid, health care and social economic assistance to help them move towards a better future. The organization is registered under the Swaziland Government companies Act- No. 8 of 2009, Certificate No 1051 of 2011. The organization operates a centre that provides social and health related services, mainly TB/HIV services at the Malindza Refugee Reception Centre. 1.1.1 Vision and Mission The vision of Joyful Hearts is to see to it that the people of Africa are able to pursue a common goal of peace, justice, prosperity, and spiritual transformation despite their circumstances and differences. Motivated by the love of the Lord Jesus Christ, Joyful Hearts mission is to promote the message of peace, justice, prosperity, and spiritual transformation as manifested in the teachings of Jesus Christ in the New Testament. Therefore, Joyful Hearts shall always Endeavour to empower people to unite and strive towards a common goal of self-sustainability in socio-economic matters through establishing centers of hope in different communities, building imaginary bridges whereby believers and non-believers could coexist in tolerance to one another fostering personal growth in all spheres of personal life. Joyful Hearts beneficiaries shall be expected to respect human rights, fight for self-sustainability in socio-economic matters, and be tolerant to people of different beliefs and mores. Joyful hearts acknowledges that while their work is motivated by Christian beliefs, the services provided by the organization do not include proselytizing to individuals receiving the services. All beneficiaries receive equal access to the services regardless of their religious beliefs. - 4-2 9

The organization s services include: Enhancing access to TB/HIV services: Through partnership with Malindza Clinic and Good Shepherd Hospital, Joyful hearts brings health services for easy access to TB/HIV treatment, awareness messages, screening to people with symptoms, and HTC services. Income generating projects: The organization strengthens groups through skills provision, equipment and materials to start up income generating projects. Nutritional support: The organization provides food and clothing to vulnerable families at the refugee camp. Psychological support: PSS is provided through counseling and support groups for people on TB/HIV treatment. Community based care services: Joyful Hearts provides the community with HIV counseling and testing and home based care to Malindza and surrounding communities. 1.2 The Project Joyful Hearts Organization engages in this project as a collaborative partner with Malindza Refugee Clinic and Good Shepherd Hospital to improve access to HTC and TB services. Permission was granted by the Ministry of Home affairs for Joyful Hearts to conduct TB/HIV services in Malindza. The Malindza Refugee Clinic currently does not have the capacity to provide HTC, TB as well as Care and Support services. The clinic is staffed with only one nurse and one nursing assistant. Their time is primarily occupied with addressing the general health needs of the refugee population and the Malindza community. Moreover, the nurse and nursing assistant are not trained in TB or HIV management. However, Good Shepherd Hospital (GSH) in partnership with the Swaziland National AIDS Programme (SNAP) has identified the Malindza Refugee Clinic as a future ART re-fill and initiation site. Good Shepherd Hospital has committed itself to develop the capacity of the Malindza Refugee Clinic as they work towards becoming an ART initiation site. Through this project, Joyful Hearts will assist the Malindza Refugee Clinic in providing services to the Malindza Refugee Camp and community so that people will have access to HTC, TB, as well as Care and Support services. This project will also assist GSH in meeting its objective of developing the capacity of Malindza Refugee Clinic. Through this project, Joyful Hearts will be adding one additional nurse and one full time HTC/TB counselor to provide needed health care services. There are currently 522 refugees at Malindza Refugee Camp. In addition, Joyful Hearts aims to reach up to 2794 people from 3 neighboring communities, which brings the total of Joyful Hearts targets to 3316 people by September 2014.Joyful Hearts has an operating facility at Malindza Clinic that provides TB - 5-29

screening and referral services. The facility also provides HIV counseling and testing for the refugee population and people from the Malindza Communities. Those tested positive for HIV are referred to Malindza Clinic. Due to capacity issues, GSH provides HIV services to Malindza Clinic on a monthly basis. TB suspects are referred directly to Good Shepherd Hospital for follow up services. On TB access improvement, Joyful Hearts has already partnered with the Stop TB Program and Good Shepherd Hospital. The organizations are working on developing a Memorandum of Agreement to complement their joint efforts. Stop TB Program is providing Joyful Hearts with screening tools, literature, and sputum bottles. Good Shepherd Hospital is the referral centre. After Joyful Hearts has identified TB suspects, the sputum is sent to Good Shepherd for laboratory testing. Those that are confirmed positive with TB are then initiated on TB treatment by Good Shepherd Hospital. Joyful Hearts focuses mainly on TB treatment adherence support, psychological and spiritual support. 1.3 Study Rationale /Purpose This KAP Survey could be best understood as an Implementation Research. The assumption was that Joyful Hearts Organization was not the first organization to work with the people of Malindza on HIV/AIDS and TB programs and there was a need to understand why previous interventions did not yield the intended outcomes; if they did impact the area, and why was there a prevalence of defaulters on TB treatment. Could it be that people are not well informed on issues of TB, or there was a cultural barrier to treatment, furthermore, could it be that there was a programmatic problem on the part of serviceproviders? The survey was aimed at: Determining the best way to introduce practical solutions to eradicating defaulters on TB treatment in the Malindza area To sensitize the people on TB control, and create linkages on care and support for patients with TB and HIV; facilitating their full-scale implementation, evaluation and modification. To conduct a baseline effort in order to understand the situation on the ground in the targeted sites since Joyful Hearts Organization is currently engaged in a HIV/AIDS & TB Project in the Malindza Refugee Camp, Sikhuphe Village, Malindza Highway, and Mbadlane. The KAP survey would help Joyful Hearts Organization to be able to measure impact made by their intervention as well as have a continuous assessment of methods used to intervene, while modifying and adapting the existing health systems in place. While there are national and regional interventions like DOTS, HOME BASED CARE, and TB/HTC programs in place to try and make sure that TB was controlled and there were fewer defaulters, there - 6-29

seemed to be a lot of patients in this target group who still defaulted on TB treatment leading to other strands of infections like MDR-TB or XDR-TB. The survey proposed to get information on what could be the possible causes of the obtaining scenario by gauging the information on the ground on TB, access to health services, and the quality of the services. JOYFUL HEARTS ORAGNIZATION hoped to get information on these programmatic gaps through the study and hopefully come up with strategies to intervene in a way that would eventually yield a sustainable impact in the Malindza area. 1.4 Research Objectives The objectives of the study were as follows: To assess knowledge levels and gaps around HIV/AIDS and TB To assess attitudes towards HIV/AIDS and TB; and To assess practices around HIV/AIDS and TB 2.0 Methodology and sampling 2.1 Research approach or methodology The study assessed knowledge, attitude and practices of the sampled individuals in the four sites (Malindza Refugee Camp, Malindza Highway, Sikhuphe Village, and Mbadlane). A total of 190 individuals (both males and females) aged between 15 to 50+ were targeted by the study. 2.2 Inclusion and Exclusion criteria: The study was aiming to get information from only the people who reside in Malindza, in specific areas; focus was on Malindza Refugee Reception Centre, Malindza Highway, Sikhuphe Village, and Mbadlane. The participants were interviewed in their homes. The data collectors would count three homesteads and the fourth one would be part of the sample. At the Malindza Refugee Reception Centre, 40 participants were interviewed sampled from 7 different nationalities. 150 participants came from the three mobile sites with each site having 50 individuals interviewed. A total of 190 participants were interviewed. 2.3 Data Collection: A structured questionnaire for conducting one-on-one interviews was used. The questionnaire comprised of the following sections; The first section collected demographics while the second section collected data on knowledge with each question seeking a response of either True, False or don t know. The third section collected data on attitudes with each question seeking a response of either Strongly Agree, Agree, Strongly Disagree or Disagree while the last section collected data on practices with questions seeking a response of either True, False or don t know and a range of multiple responses. This paper-based questionnaire was then converted or uploaded into the mobile data colletion technology called MAGPI which is downloaded into smart phones. - 7-2 9

The questionnaire were simplified and translated into various languages including Siswati to suit the target group. The questions were adapted from the advocacy, communication and social mobilization for tuberculosis control. 2.4 Data Analysis The data was collected using smart phones and uploaded into the online Magpi console from the smart phones. The data was then exported to Excel then analysed using SPSS software. Different variables were used in the data analysis such as age, sex and community. 2.5 Ethical Consideration This study methodology was designed to address the following ethical principles: Efforts were made to protect individual autonomy, and minimize harm and maximize benefits by using procedures which were consistent with sound research designs that took these issues into consideration. This exercise did not pose the physical risks associated with a physical procedure or intervention, such as obtaining tissue or blood samples. 2.6 Limitations of the study Respondents under 15 years of age were not included as they would not have been able to provide answers to all questions. Because of the sample size, the findings of the survey cannot be generalized into a bigger population outside of the sampled communities. The survey was conducted after the intervention of the project had started, therefore it cannot be interpreted as a baseline survey. 3.0 FINDINGS 3.1 Demographics A total number of 190 people were interviewed from the four implementing sites. The sites are Malindza Refugee Camp, Sikhuphe Village, Malindza Highway, and Mbadlane. The sample was structured to have 40 people from the different nationalities in the Malindza Refugee Reception Centre, and 50 individuals from each of the mobile outreach sites. The demographics are presented in Graph below: - 8-2 9

20 18 16 14 12 10 8 6 4 2 0 17,9 15,8 13,7 13,2 12,6 12,6 10,5 8,4 8,4 8,4 7,4 7,9 8,4 7,4 6,3 6,8 5,3 4,7 4,2 4,2 3,6 3,7 3,7 1,6 1,6 1,6 0,5 0,5 Highway Refugee Camp Mbadlane Sikhuphe Female Male 15-20 21-30 31-40 41-49 50+ Figure 1: Demographic Information The highest number of respondents across all four sites were females at 55.8% (N=106). The majority of female respondents were from Malindza Highway at 17.9% (N=34) followed by Sikhuphe Village at 15.8% (N=30). However, at the Malindza Refugee Camp the majority of respondents were males at 12.6% (N=24). In terms of age 34.8% (N=66) were 21-30 representing the most reached age bracket. 11% (N=21) of respondents were from the 50+ age bracket representing the least reached. Other demographic variables that were taken into consideration include Marital Status, Level of Education, Employment Status and Nationality. With regard to marital status, 46.8% (N=89) of the respondents were married while 34% (N=65) were single or never married. 51.6% (N=98) of the respondents attained high school education followed by 32.6% (N=62) with primary school level of education. The findings also revealed that 63.7% (N=121) of the respondents were unemployed while 5.8% (N=11) were working informal fulltime. The nationalities are presented in table below: Table 1: Nationalities Nationality Number Percentage Burundese 11 5,8 Congolese 13 6,8 Ethopian 1,5 Mozambican 2 1,1 Other 3 1,6 Rwandese 9 4,7 Somalian 5 2,6-9 - 2 9

Swazi 145 76,3 Tanzanian 1,5 Total 190 100,0 3.2 Access to Joyful Hearts Services A majority, 63.3 % (n=31) of our respondents had accessed HTC services from our sites. HTC was used as an entry point for treatment, care and support which would explain why people accessed it more than the other services provided by Joyful Hearts. Table 2: Access to Joyful Hearts Services Services Access HTC 16.3 ART Adherence 0.5 Pre-ART Adherence 1.1 TB Adherence 1.1 HIV/TB Awareness 1.6 Home Visits 2.6 Food Donation 0 Other 0.5 3.3 KNOWLEDGE 3.3.1 Knowledge on HTC The section was assessing the knowledge on HIV/AIDS and TB prevention, transmission from one person to another, adherence to treatment and the knowledge on the importance of HTC. The research findings show that a majority of the respondents had sufficient knowledge on the importance of HTC. The participants showed that they understand how important it is to test for HIV. About 83.7% (N=159) of the people interviewed felt couple counseling and testing was important and 97.4% (N=185) of the participants believe that testing for HIV helps in accessing treatment. It further came out that the participants believe in the importance of both partners testing for HIV as 96. 3% (N=183) affirmed it as important. 93. 7% (N=178) of the participants felt that everyone should test for HIV and 91. 6% (N=174) felt not only pregnant women should test for HIV. - 10-2 9

Findings on the knowledge of the frequency of testing were consistent with the findings on the Couple counseling and testing for 83,7 15,3 Testing_for_HIV_helps_in_accessi It is important for both partners 97,4 96,3 1,1 3,2 TRUE FALSE Everyone should test for HIV 93,7 5,3 No Response Not only pregnant women should 91,6 7,4 0% 20% 40% 60% 80% 100% Figure 2: Importance of HTC importance of HTC. About 82.1% (N=156) of the participants are aware that HIV positive people do not necessarily have to continue testing for HIV. However, there were 12.1% (N=23) who felt HIV positive people have to continue testing for HIV manifesting lack of knowledge on the frequency of testing. 93.7% (N=178) of the participants felt that early detection of HIV is important. 95.3% (N=181) of the people interviewed felt that a person should always test for HIV. HIV positive people do n't have to continue testing for HIV Early detection of HIV is important 12,1 93,7 82,1 5,8 TRUE FALSE A person should always test for HIV 95,3 3,7 No Response 0% 20% 40% 60% 80% 100% Figure 3: Frequency of HTC 3.3.2 Knowledge on TB Transmission Findings on knowledge on TB transmission revealed that 66. 8% (N=127) of the participants knew that TB cannot be transmitted through sexual intercourse while 26. 3% (N=50) felt it can and 6. 8% (N=13) chose not to respond. 96. 8% (N=184) felt that one can get TB when a person with TB coughs or sneezes, 75. 3% (N=143) felt that one cannot get TB through a handshake, while 20. 0% (N=38) felt it is possible to get TB through a handshake. 87. 4% (N=166) of the participants felt that being HIV positive increases the chances of being infected with TB and 95. 8% (N=182) showed that anyone can contract TB. - 11-29

You cannot get TB through sexual 66,8 26,3 6,8 You can get TB when a person with TB You cannot get TB through handshake 96,8 75,3 20 2,1 1,1 4,7 TRUE FALSE Being HIV positive increases the chances 87,4 5,37,4 No Response Anyone can contact TB 95,8 3,7 0,5 Figure 4: Knowledge on Transmission of TB 0% 20% 40% 60% 80% 100% 3.3.3 Knowledge on TB Treatment Adherence About 96.3% (N=183) of the participants believe that adhering and completion of TB treatment would cure TB, 85. 5% (N=163) felt one cannot stop taking TB treatment just because it has many side effects, 92. 1% (N=175) felt that one cannot stop TB treatment even when they feel better, and 93. 2% (N=177) felt that failure to adhere to treatment can lead to a more complicated type of TB known as MDR. The chart below show the presentation of the results: 96,3 1,62,1 One cannot stop taking the TB treatment One cannot stop the TB treatment even Failure to adhere to treatment can lead to 85,5 92,1 93,2 7,9 6,3 7,4 0,5 2,1 4,7 TRUE FALSE No Response 75% 80% 85% 90% 95% 100% Figure 5: Knowledge on TB Treatment Adherence 3.3.4 Knowledge on ART Adherence About 94.7% (N=180) of the participants felt that there is no need to increase the effectiveness of medication. 57.9% (N=110) felt that adhering and completion of ART will not cure HIV while 37.4% (N=71) felt it would cure HIV and 4.7% (N=9) decided not to respond. 63.2% (N=120) felt that ART/TB treatment should be taken at the same time every day while 36.8% (N=70) felt it does not have to be taken at the same time every day. 91.6% (N=174) felt that one cannot stop taking the ART treatment anytime they feel better while 5.3% (N=10) felt it can be done and 3.2% (N=6) decided not to respond. Chart 5 below shows the presentation of results: - 12-2 9

There is no need to increase the Adhering and completion of ART will not ART/TB treatment shoulsd be taken at One cannot stop taking the ART 57,9 63,2 94,7 91,6 37,4 36,8 2,6 4,7 0 5,3,2 TRUE FALSE No Response 0% 20% 40% 60% 80% 100% Figure 6: Knowledge on ART Adherence 3.4 ATTITUDES 3.4.1 Attitudes on HTC About 93% (N=176) said that they could still test even when their partners tested negative for HIV, whilst only 53.2% believe that one can still enjoy sex after testing positive for HIV. If my partner test negative I still need for me to test for HIV 50 42,6 5,3 0,5 Agree If I test positive for HIV I could enjoy having sex 49,5 3,7 35,3 7,9 Strongly Agree Disagree Strongly Disagree If I test positive for HIV I must enroll for pre-art 40,5 16,3 27,9 11,6 No Response 0% 20% 40% 60% 80% 100% Figure 7: Attitudes on HTC 3.4.2 Attitudes on knowing ones HIV Status About 95.7% (N=182) believe that if married and faithful to one s partner there is still a need to test for HIV and 31. 1% (N=59) agreed that it is good to test for HIV before one gets sick and 46, 2% (N=122) strongly agreed. Those who felt that it is possible to live a normal life even after testing positive for HIV were 39. 5% (N=75) for those who agreed and 38.4% (N=73) for those who strongly agreed. Chart 7 below has the presentation of results: - 13-2 9

If I am married and faithful to my partner I still do have to test for HIV It is good to know my HIV status before I get sick If I know my status I would still live a normal life 31,1 48,9 39,5 64,2 38,4 46,8 17,9 0% 20% 40% 60% 80% 100% 3,7 Agree 3,2 Strongly Agree Disagree Strongly Disagree No Response Figure 8: Attitudes on knowing ones HIV Status 3.4.3 Attitudes on TB When asked on the need for TB screening especially when living with a person on TB treatment, 19. 5% (N=37) from Malindza Refugee Clinic agreed. 20. 0% (38) from Highway strongly agreed, while in Mbadlane and Sikhuphe Village 14.7% (N=28) per area strongly agreed. The chart below has the presentation of the results: Mbadlane 10,5 14,7 0,5 Agree Sikhuphe Village Highway Malindza Refugee Clinic 3,7 11,1 19,5 20 14,7 0,5 1,1 0,50 Strongly Agree Disagree Strongly Agree No Response 0% 20% 40% 60% 80% 100% Figure 9: Attitudes on TB 3.4.4 Attitude on Disclosure About 20.5% (N=39) males and 20. 5% (N=39) agreed that they would disclose their status. 11. 6% (N=22) males and 18.4% (35) strongly agreed that they would disclose their status respectively. The age group that appeared to be ready to disclose their status is the one between the ages of 21-30 as 14. 7% (N=28) agreed and 10. 0% (N=19) strongly agreed that they would disclose their status. Chart 9 below presents the findings: - 14-2 9

100% 80% 60% 40% 20% 2,6 4,2 0,5 2,6 1,,6 8,9 4,2 12,1 4,7 7,4 4,2 11,6 10 18,4 1,6 6,3 5,3 20,5 20,5 4,2 14,7 9,5 8,9 0,5 0 6,8 3,7 No Response Strongly Disagree Disagree Strongly Agree Agree 0% Male Female 15-20 21-30 31-40 41-49 50+ Figure 10: Attitudes on Disclosure 3.5 PRACTICES About 34.7% (N=66) males and 47.9% (N=91) females reported that they already know their HIV status. The age groups that had the highest number of people who know their status were between the ages of 21-30 at 26. 3% (N=50) and the lowest age bracket was the one between the ages of 15-20 at 7. 4% (N=14). 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 9,5 7,9 5,3 2,6 3,7 1,6 4,2 34,7 47,9 26,3 22,1 17,4 9,5 7,4 Male Female 15-20 21-30 31-40 41-49 50+ No Yes Figure 11: Knowledge of HIV Status 4.0 CONCLUSIONS 1. Importance of HTC a majority of the participants showed knowledge on the importance of HTC 2. Frequency of HTC there are significant gaps on the knowledge of the frequency of testing - 15-29

3. Access to JHO services people are not able to distinguish between a service provided by Malindza Refugee Clinic and Joyful Hearts. They view the two organizations as one entity in terms of delivery 4. Transmission of TB there gaps on knowledge on transmission of TB. As much as people are aware how TB can be transmitted, they seem to lack knowledge in modes of transmission 5. Adherence to treatment knowledge on the importance of adherence to treatment needs to be translated to practice. The people seem to know it is important to adhere but when it comes to actually doing it they lack 6. ART treatment there are misconceptions on ART that needs to be corrected. A targeted education on ART treatment needs to be conducted as part of adherence counseling. 7. Attitudes on HTC the people s attitudes towards HTC are positive and this needs to be taken advantage of in using HTC as an entry point to care, treatment and support 8. Knowledge of HIV status there are gaps in people knowing their status and this needs a scale up in HTC services 9. Knowledge on TB there are gaps in knowledge on TB 10. Attitudes on disclosure there is a willingness to disclose but it is not enough 11. Practices there is a need to scale up the services both programmatically and geographically 5.0 RECOMMENDATIONS 1.1 Importance of HTC: Since many people see the importance of testing for HIV, there is a need to scale up HTC services as an entry point to care and treatment. Efforts have to be made to provide information that would make the few that responded negatively on the importance of HTC. 1.2 Frequency of HTC: People need to be informed that soon after testing positive for HIV the next step is treatment. This information needs to be shared by HTC counsellors when providing the services. 1.3 Access to JHO services: There is a need to scale up the support care services, care and treatment in order to provide a comprehensive service. All those who test positive for HIV must immediately be linked to treatment. 1.4 Transmission of TB: It is recommended that intensive TB awareness programmes be developed and implemented as there are participants who showed lack of knowledge when it came to the transmission of TB. 1.5 Adherence to treatment: The majority of participants valued adherence to treatment, however, there is a need to inform the people on the ground about the benefits of adherence to treatment. There seems to be a gap between practice and knowledge so it is recommended that more people are exposed to the benefits of adherence to treatment through literature, community mobilizations, and one on one counselling sessions. - 16-29

1.6 ART treatment: It is recommended that more information is shared around the issue of HIV/AIDS and ART. A considerable number of participants responded that adherence to ART might lead to a cure of HIV. Basic information on HIV/AIDS needs to be disseminated so that people are aware of that currently there is no cure for HIV and what is the role of ART. 1.7 Attitudes on HTC: It is recommended that couple counselling be deliberately targeted coupled with index clients tracking. The people seem to appreciate the importance of counselling, but there are those who are using their spouses as a yard stick. 1.8 Knowledge on HIV status: Generally, the participants reflected the importance of knowing one s HIV status. However, there are some myths that still need to be addressed on HIV/AIDS. It is recommended that during outreaches and door to door campaigns, information be shared by HTC counsellors with the people on the ground. 1.9 Knowledge on TB: It is recommended that TB screening be conducted for everyone that has had contact with a person that has been on TB treatment. It is also recommended that TB screening be conduct at the Malindza Refugee Camp for everyone who lives there, staff, volunteers and the refugees. 1.10 Attitudes on disclosure: Status disclosure needs to be encouraged for those in the age brackets of 31-40 and 41-49 as they scored lower than the 21-30 age bracket, whereas, they are supposedly the age brackets that are at family level. It is recommended that disclosure counselling be provided by HTC counsellors whenever a person tests positive for HIV. 1.11 Knowledge of HIV status: There is still a big gap for HTC services so it is recommended that a more targeted strategy of door to door HTC coupled with index clients tracking be utilized to close the gaps. People are testing but there are those who are not accessing HTC services. 6.0 LESSONS LEARNT People generally know about HIV issues There are gaps on knowledge on TB There is still a need for education and information on HIV/AIDS There are evident myths on ART treatment People know but are not practicing what they know - 17-2 9

APPENDICES Appendix 1: Consent form JOYFUL HEARTS ORGANIZATION, TB KAP SURVEY Survey objective: To assess TB-related knowledge, attitudes, stigma and health-seeking practices amongst the age groups of 15 years of age and above 49 years in the communities of Malindza namely Malindza Refugee Camp, Malindza Highway, Sikhuphe Village and Mbadlane under Dvokodvweni Inkhundla. Who are we? INFORMED CONSENT Good morning/afternoon. My name is I am working with the Joyful Hearts Organization on a Knowledge Attitudes and Practices (KAP) Survey. Joyful Hearts Organization is an NGO working in the Malindza area on a TB/HTC Project in partnership with PEPFAR and USAID. If you agree, we would like to include you in this exercise. What are we doing? (Purpose) We are conducting a KAP survey to have a better understanding of at what level are the people of Malindza are when it comes to matters of TB and how they can better be served to improve the health services in the area. The information gathered will be used to analyze the Knowledge, Attitudes, and Practice of the people of Malindza. You have been selected to participate in this exercise because you live in this area. If you decide to participate, you will be one of the residents of Malindza selected to participate in the survey. Who will be in the study? This study targets people who reside in Malindza mainly from the communities of Malindza Refugee Camp, Malindza Highway, Sikhuphe Village, and Mbadlane. The participant should be 16 years of age or above. Procedure If you agree to participate in the exercise, you shall be required to respond to oral questions that require choosing the best option that best describe your opinion from a range of answers. The interview will not take more than 30 minutes. - 18-29

Benefits & Risks The information you give me will assist in making this study a success thus creating a potential effective health services for your community. A risk to participating in this study is that the questions may become too personal and relevant to your situation thus becoming embarrassing and uncomfortable. On the other hand, the benefit of your participation is that you will contribute useful information to program managers and potential health service providers so they may better provide programs for the people in Malindza. Possibility of withdrawal or declining specific questions: Your participation is very important to us. We want you to be honest and truthful in answering our questions. Your participation is completely voluntary. If any of the questions make you uncomfortable or you don t want to answer them, you do not have to. Not participating in the study will not affect your future access to services. Confidentiality: The responses you will give will be treated as a group response. Your name will not appear on the report and your responses will be treated with great confidentiality. Contact Information If you have any questions or feel you have been harmed in any way by participating in this study, please feel free to contact Janvier Batungwanayo: Program Director at Joyful Hearts Organization 76709115. Offer to answer questions: I can answer any questions you may have. If I don t have the information you require, I will tell you so and, if you wish, I will try to get an answer for you. Do you have any questions? (If yes, note the questions) Yes No Are you willing to participate in the study? Yes No Authorization You are making a decision whether or not to participate in this study. Your signed consent indicates that you understand the information provided and have had all your questions answered and have decided to participate. Participant s Signature Date Data collector obtained consent from the subject: Researcher s initials - 19-2 9 Thank you. Date

Appendis 2 : Questionnaire BASIC INFORMATION /INFORMATIONS PERSONNELLES/ TAARIFA ZA MSINGI ID QUESTION OPTIONS INSTRUCTION BI 1 Sex/ Sexe / Ginsia Male/ Masculin/ Kiume... 01 Female / Féminin / Kike....02 BI 2 Age / Age / Miaka 15-20... 01 21-30..02 BI 3 Marital Status Situation Matrimonial Hali ya ndoa 31-40... 03 41-49..04 Over 50..05 Married Monogamous Marié Monogame Ndoa ya mke mmoja Married Polygamous Marié polygame / Ndoa ya mitala Cohabiting Cohabitation/ Kinyumba na Single/Never Married Célibataire/Moja (Kamwe kuolewa) Widowed Veuf(ve) / Mjane Divorced Divorcé / Talaka S Tick one Pick one BI 4 BI 5 Level of Education Niveau d Education Kiwango cha Elimu Employment Status Emploi Hali ya Kazi No School Jamais été a l école/ Sikuenda shuleni Primary School Ecole Primaire / Shule ya Msingi High School Ecole secondaire/ Shule ya Sekondari Tertiary Tertiaire / Elimu ya Juu Literacy Classes Only Alphabétisation / Literacy madarasa Formal Fulltime Formel plein temps / Mda kamili Formal Part-time Formel temps partiel / Sehemu wakati Informal Fulltime Informel temps partiel / Rasmi sehemu wakati ajira Informal Part-time Informel plein temps/wakati rasmi Self-employed Autoemploi / Kujiajiri Unemployed Sans employ / Sina kazi Tick applicable - 20-2 9

Importance of HTC STATEMENT FALS TRUE E K 1 Only pregnant women should test for HIV Seules les femmes enceintes devraient faire le test du VIH/ Wanawake wajawazito tu lazima kupima ukimwi K2 Only the very sick should test for HIV Seules les personnes très malades devraient faire le test du VIH/ Tu wagonjwa sana lazima kupima ukimwi K3 Once my partner has tested it is not important for me to test Une fois que mon/ma partenaire a fait le test du VIH, ce n est pas important pour moi de le faire Kama mpenzi wangu anajipima ukimwi mimi siwezi kujipima ukimwi K4 A person should only test for HIV once in their lives Une personne doit faire le test du VIH une fois dans sa vie Mtu lazima tu kupima ukimwi mara moja katika maisha yake K5 Early detection of HIV is important Il est important de faire le dépistage du VIH Kupima mapema ya ukimwi ni muhimu Knowledge on TB/ Connaissance sur la Tuberculose/ Maarifa juu ya Kifua kikuu NATIONALITY K6 N1 N2 N3 N4 N5 N6 N7 N8 Swazi Congolese Burundese Somalian Mozambican Rwandese Tanzanian Ethopian N9 Other HIV positive people should test continually for HIV Les personnes séropositives devraient continuellemt faire le test du VIH Watu wenye ukimwi wanapaswa mtihani daima kupima ukimwi K7 K8-21 - 2 9 Testing for HIV helps in accessing treatment Le test du VIH permet d avoir accès au traitement Kupima ukimwi kunamsaidia mtu katika kupata madawa. Couple counseling and testing for HIV is not important Le dépistage et le conseil au couple n est pas important Ushauri wanandoa na kupima ukimwi ni si muhimu

K9 K10 K11 K12 K13 K14 K15 K16 HTC is only done in government hospitals and clinics Le dépistage du VIH et le conseil sonts fait dans les hopitaux et cliniques publics seulement Ushauri ka kupima ukimwi ni kufanyika tu katika hospitali na kliniki za serikali There are HIV/TB services around my community On trouve des servives du VIH et de la Tuberculose autour de ma communauté Kuna huduma za ukimwi na kifua kikuu karibu jamii yangu Knowledge on TB/ Connaissance sur la Tuberculose/ Maarifa juu ya Kifua kikuu Anyone can contract TB N importer qui peut contracter la tuberculose Mtu yeyote anaweza kupata kifua kikuu Being HIV positive increases the chances of one getting infected with TB Etre séropositif peut augmenter le risque de contracter la tuberculose Kuwa na ukimwi kunawongeza riski za kupata kifua kikuu You can get TB through handshake Vous pouvez avoir la tuberculose en serant la main de quelqu un Unaweza kupata Kifua kikuu kupitia kupiga mikono You can TB when a person with TB coughs or sneezes Vous pouvez contracter la tuberculose quand une personne avec la tuberculose touse ou éternue Unaweza kupata kifua kikuu wakati mtu aliye na kifua kikuu anapokohoa au anapiga chafya You can get TB through sexual intercourse Vous pouvez avoir la tuberculose à travers les relations sexuelles Unaweza kupata kifua kikuu kwa njia ya kufanya tendo la mapenzi TB can be prevented from spreading by covering your mouth with a cloth when coughing or sneezing On peut eviter la propagation de la tuberculose en se couvrant la bouche avec un habit/ tissus quand on éternue ou tousse. Kifua kikuu kinaweza kuzuiwa kueneza na kufunika mdomo wako na nguo wakati wa kupiga chafya au kukohoa K17 K18 AD1 A room with a TB patient must be kept clean and well ventilated Une chambre/ maison avec une personne sous traitement anti tuberculeux doit être propre et bien aérée Chumba kwa mtu juu ya madawa ya kifua kikuu lazima iwekwe safi na vizuri hewa kuingia TB can be cured especially when dictated early La tuberculose peut guerir surtout quand elle est détectée très tôt. Kifua kikuu kinaweza kutibiwa hasa wakati kupimiwa mapema Adherence to Treatment/ L observance au traitement / Kupata madawa Failure to adhere to treatment can lead to a more complicated type of TB known as MDR Le défaut de prendre correctement le traitement contre la tuberculose peut conduire à une forme plus compliquée de la maladie appelée MDR Kushindwa kuzingatia madawa ya kifua kikuu inaweza kusababisha aina ngumu zaidi inajuikana kama MDR - 22-2 9

AD2 AD3 AD4 AD5 AD6 AD7 AD8 One can stop taking the ART treatment anytime they feel better On peut arrêter de prendre les antirétroviraux (ARV) aussi tôt qu on se sent mieux Mtu anaweza kuacha kunywa madawa ya ukimwi kwa haraka kama anajisikia vizuri One can stop taking the TB treatment because it has many side effects On peut arrêter de prendre le traitement contre la tuberculose parcequ il a plusieurs effects secondaires Mtu anaweza kuacha kunywa madawa ya kifua kikuu kwa sababu ina madhara mengi One can stop taking the TB treatment anytime they feel better On peut arrêter de prendre le traitement de la tuberculose quand on se sent mieux Mtu anaweza kuacha kunywa madawa ya kifua kikuu wakati wowote anajisikia vizuri ART/TB treatment should be taken at the same time everyday Les antiretroviraux (ARV) et le traitement contre la tuberculose peuvent être pris en même temps chaque jour Mtu anaweza kunywa madawa ya ukimwi au kifua kikuu wakati huo kila siku Adhering and completion of TB treatment will cure TB Accepter et terminer le traitement de la tuberculose peuvent conduire à la guérison de la tuberculose Kunywa na kukamilisha madawa ya kifua kikuu kunaweza kupona kifua kikuu Adhering and completion of ART will cure HIV Accepter et prendre un traitement complet des antirétroviraux (ARV) peut guérir le VIH Kunywa na kukamilisha madawa ya ukimwi kunaweza kupona ukimwi To increase the effectiveness of the medication is advisable to combine it with traditional medicine Pour accroître l efficacité des médicaments, il est conseillé de les associer avec la médicine traditionnelle. Kuongeza ufanisi wa dawa ni vyema kuchanganya na madawa ya kienyeji. AT1 Statement/ Taarifa/ ATTITUDES / ATTITUDE/ MTAZAMO If I test positive for HIV I could still enjoy having sex Si je suis testé séropositif je peux continuer d avoir les relations sexuelles Kama mimi mtihani maambukizi ya ukimwi, mimi bado ninaweza kuendelea kufurahia kufanya tendo la ndoa (kufanya mapenzi) Stron gly disagr ee Disagr ee Agre e Strong ly Agree 3 4 AT2 AT3 If I test positive for HIV I must enroll for pre-art Si je suis testé séropositf je dois immédiatement m enregistrer pour le pre-arv Kama mimi mtihani maambukizi ya ukimwi, mimi lazima kujiandikisha kwa kabla ya ART mara moja If my partner test negative for HIV then there is no need for me to test for HIV 3 4 3 4-23 - 2 9

AT4 AT5 AT6 AT7 AT8 AT9 Si mon/ ma partenaire est testé séronégatif (ve) je n ai pas besoin de faire le test du VIH. Kama mpenzi wangu vipimo hasi kwa HIV hakuna haja kwa ajili yangu na kupima ukimwi If I know my HIV status I would be stressed and die 3 4 earlier Si je connais ma séropositivité je serais stressé et mourais très tot Kama mimi kujua hali yangu ya ukimwi, nitakuwa alisisitiza na kufa mapema It is good to know my HIV status before I get sick 3 4 C est bon de connaître mon statut sérologique avant de tomber malade Ni vizuri kujua hali yangu ya ukimwi kabla ya kupata ugonjwa I have confidence in the HTC/TB services provided in 3 4 my community J ai confiance aux services de Conseil et dépistage du VIH et de la tuberculose offert dans ma communauté Nina imani katika huduma za ukimwi na kifua kikuu zinazotolewa katika jamii yangu If I am married and faithful to my partner I do not have 3 4 to test for HIV Si je suis marié et fidèle à mon/ ma partenaire, je n'ai pas besoin de faire le dépistage du VIH Kama mimi kuolewa na mwaminifu kwa mpenzi wangu mimi sina haja ya kupima ukimwi If I live with a person on TB treatment I should be 3 4 screened for TB continuously Si je vis avec une personne sous traitement de la tuberculose, je dois faire le dépistage de la tuberculose continuellement. Kama mimi kuishi na mtu ambaye anapata madawa ya kifua kikuu mimi lazima kuendelea kupimwa kifua kikuu Attitudes towards HIV/TB Treatment Attitudes à l'égard du traitement du VIH et de la tuberculose. Mitazamo kuhusu madawa ya ukimwi / kifua kikuu I cannot take my medication if I do not have anything to eat Je ne dois pas prendre mes médicaments si je n ai rien à manger Siwezi kunywa madawa yangu kama sina kitu chochote cha kula 3 4 AT1 0 If on ART/TB treatment I would not like people to know Si j etais sous le traitement du VIH/ de la tuberculose, je n aimerais pas que les gens sachent Kama mimi kunywa madawa ya ukimwi/ kifua 3 4-24 - 2 9

AT1 1 AT1 2 AT1 3 AT1 4 AT1 5 AT1 6 P1 P2 kikuu napenda si kama watu kujua. If I test positive I would disclose my status to my partner Si je suis testé séropsitif (ve) je devrais divulguer ma séropositivité à mon/ma partenaire Kama mimi virusi napenda kuelezea hali yangu mpenzi wangu My family would support me if I was to be on ART/TB treatment Ma famille me soutiendrait si je suis sous le traitement antirétroviral Familia yangu itanisaidia kama mimi kunywa madawa ya ukimwi I have access to ART/TB services within my community J'ai accès au traitement antirétroviral / antituberculeux dans ma communauté Mimi ninaweza kupata madawa ya ukimwi/ kifua kikuu na ndana ya jamii yangu I can access ART services without fear of being discriminated Je peux avoir accés au traitement antirétroviral sans crainte d'être discriminés. Mimi wanaweza kupata huduma za kifua kikuu bila oga ya kubaguliwa If my medication gives me side effects I should stop taking immediately Si mes médicaments ont beaucoup d'effets secondaires je peux arrêter de les prendre immédiatement Kama dawa yangu ina mengi ya madhara naweza kuacha kuzipata mara moja It is a good idea to take a break from treatment once in a while C'est une bonne idée de prendre une pause de traitement de temps en temps Ni wazo nzuri kuchukua mapumziko na matibabu mara moja kwa wakati Practices / Pratiques / Mazoezi Do you know your HIV status? Connaissez-vous votre statut sérologique (du VIH)? Je, unajua hali yako ya ukimwi? When was the last time you tested for HIV? Quand était la dernière fois que vous avez testé 3 4 3 4 3 4 3 4 3 4 3 4 Yes No 0-3 3-6 6-9 9-12 - 25-2 9

P3 P4 P5 pour le VIH? Wakati mara ya mwisho kupima ukimwi? What would be your reason for or against testing? Quelles seraient vos raisons pour ou contre les test? Nini itakuwa sababu zako kwa au dhidi ya kupima? If you will notice TB symptoms what would you do? Que feriez-vous si vous remarquez les symptomes de la tuberculose? Kama wewe utakuwa taarifa ya kifua kikuu ungefanya nini? Where do you usually go when you are sick? Où avez-vousbl habitude d aller lorsque vous êtes malade? Wapi kawaida wewe kwenda wakati wewe ni mgonjwa? - 26-2 9