Innovative community based HIV counseling and testing models for identifying new HIV positive adults and children: a case of a countrywide program in Tanzania Presented by: Beati Mboya Amref Health Africa International Conference 26 November 2014

Contents Background Aim and Objectives The Intervention Results Lessons learned Challenges

Tanzania has a population of about 44.9 million (Census 2012) Tanzania HIV and Malaria Indicator Survey of 2007/08 and 2011/2012 HIV prevalence decreased from 9.4% in 2000 to 5.7% in 2007/8 to 5.1% in 2011/12 Percent of individuals ever tested has increased from about 30% in 2007/8 to 50% in 2011/12 The U.S. President's Emergency Plan for AIDS Relief through USAID Tanzania funded AMREF to implement a country wide HIV Testing and Counseling program, Angaza Zaidi Angaza Zaidi program addresses the need for increased HIV counseling and testing in Tanzania and identification & linkage of HIV positive individuals to continuum of care Background

Aim: Mobilize innovative strategies to rapidly scale-up counselling and testing (HTC) approaches in the Tanzania mainland Objectives: 1.Increase the number of Tanzanians who know their sero- status, receive counselling, and are linked to treatment, care, and prevention services 2.Compare the efficiency and effectiveness of different HTC approaches in identifying new HIV positive individuals Aim and Objectives

Programming BENEFICIRIES & COMMUNITIES Decentralization & Community Engagement Advocacy & System Strengthening Empowering Enabling Environment Mechanism Brandi ng Targeting Branding Partnership & Sub granting The Intervention (strategies, the model)

42 HTC Outlets established to provide onsite and outreach HTC services 31 PLHIV groups established and engaged in HIV prevention 957 health providers trained on HTC, grant-management, referral and M&E Conduct quarterly supportive supervision to all sites Engaged in development and dissemination of guidelines, SOPs and data collection tools The Intervention cont…

Angaza Zaidi HTC Modalities Standalone HTC (sHTC): independent static HTC outlet, not directly linked to a health facility, that is strategically located in high risk areas to attract a high volume of clients Integrated HTC (iHTC): a static HTC outlet, located near or within a facility and has directly linkage to a health facility- is regarded as part/section of a health facility Outreach Community Based HTC (cHTC): a mobile HTC outlet changes location from time to time and targets high population areas, hard to reach areas and high risk populations Angaza Zaidi offered HTC services through three key client- initiated modalities

Intervention – data collected before and after intervention Routine quantitative data collected using national tools Routine data quality control measures implemented at each level Data analyzed using Microsoft excel Effectiveness of different HTC modalities compared Expenditure per HIV positive client identified estimated for each modality Methods

RESULTS

Age Sex Distribution of Clients reached Sex<14 years>=14YrsTotal Male 25,217 (2.1%) 1,194,925 (97.9%) 1,220,142 (100%) Female 26,782 (2.4%) 1,094,375 (97.6%) 1,121,157 (100%) Total 51,999 (2.2%) 2,289,300 (97.8%) 2,341,299 (100%)

Percent of Individuals Testing HIV Positive by age group (n= 2,341,299 ) Percent of individuals testing positive was higher 14yrs

Comparison of proportion of individuals tested positive by sex Across the age categories, females had higher proportion of individuals testing HIV positive Difference between male & female among 14 yrs

Comparison of trends of proportion of individuals tested positive over years by age category Over the five years percent of individuals testing positive has decreased more among >14 years than <14years

HTC Modality Number TestedHIV+Ve% +ve Integrated HTC566,88351,1919.0% Standalone HTC451,44332,4077.2% Community Based HTC1,429,90341,8572.9% Number of Individuals reached through various HTC modalities cHTC reached many more individuals than the other two modalities iHTC was more efficient in identifying HIV+ve individuals than the other two modalities

Individuals tested by HTC approach by age category Majority were reached through outreach HTC approach (Over 55 percent of clients tested)

Distribution of percent Positive by HTC approach by Age Category Integrated & Stand alone HTC modalities were more effective in reaching more positive individuals compared to outreach

Comparison of proportion positives among Repeat testers Sex<14 years>14 years Males 3.3%1.3% Females 3.1%2.5% About 1 percent (4,236) of all repeat testers (385,256) were <14 years Among repeat testers, percent positive was higher among <14 years

Expenditure per individual reached by HTC Modality Stand alone sites seems more efficient than other modalities

 Outreach is effective in reaching many individuals within short time, both adults and children  Integrated & standalone approach are more effective in identifying HIV +ve individuals than outreach  Although standalone approach is the cheapest model, long term sustainability is a challenge  Percent positive among <14years is higher than adults, need further research to explain and understand the situation more  Improve cost-effectiveness of outreach HTC approach by targeting key and high-risk populations  More rigorous cost effective study to compare HTC modalities Lessons Learned

Major Challenges of the HTC programs Inadequate HIV test kits most of the time Staff turnover – issues in technical & financial reporting Effective referrals & linkages still a challenge