Applying the equity lens to HIV service coverage: insights from Magu HDSS, North-West Tanzania Doris Mbata, Alison Wringe, Mark Urassa, Ray Nsigaye, Raphael Isingo, Milalu Ndege, Maria Roura, Benjamin Clark, Jim Todd, Basia Zaba NIMR-Tanzania & LSHTM-UK 9 th INDEPTH AGM, Pune INDIA 26 th October, 2009

Magu HDSS : 5 villages + trading centre City

Study population Population – 30,000; growth 2.4% per year – Ethnicity: 95% are from the Sukuma tribe – Religion: 74% Christian, 23% Traditional, 3% Islam – Education: 14 primary schools, 2 secondary schools – Health: 7 health facilities Economy – Per capita income below $120 per year – Farming is main source of income, petty trading common HIV – Incidence 1.1% – Prevalence: women 8.2% and men 7.5%. Higher in roadside villages, but increasing in remote rural areas

Sero surveys (~ every 2-3 years) At temporary village clinics, invite adults 15+ Questions on HIV, health services, sexual behaviour, marriage history, family circumstances Research HIV tests (informed consent without disclosure) Opportunity for VCT (separate, MoH protocol - rapid tests) Health care (clinical diagnosis, lab tests and free drugs) for family Demographic surveillance (~ every 6 months) Household interviews, proxy reports allowed Births, deaths, in and out movements Enables spouse, parent-child links to be ascertained Cohort study activities

HIV services VCT: free at mobile clinics during serosurveys and permanently at Kisesa health centre (MoH protocol) Tanzanian government started ART programme end 2004, initially in “Care and Treatment Centres” (CTC) in 4 zonal referral hospitals, then decentralised to district hospitals and health centres Referrals to the CTC in Mwanza City ~ 20km away CTC recently opened in Kisesa health centre Sep 2008 All HIV services are free: VCT, lab tests, drugs, consultations Local NGO provides home-based care, referral escort and supports PLHA club

Objectives of the research VCT services: To describe the uptake of VCT among HIV+ Referral from VCT to CTC: To describe the delays in referral from VCT to CTC. ART initiation: To describe the proportion of HIV+ receiving ART, and to estimate the unmet need for ART. Qualitative research: To explain the findings from the analysis of the services, we show qualitative results.

Methods: quantitative Denominator: HIV+ at any serosurvey and eligible (alive, resident) for sero-survey round 5 in Uptake of VCT, referral appointments and ART initiation were described by year, age, sex and residence. Delays (in days) were measured referral from VCT, to registration at the CTC ART needs were described by year, age, sex and residence. Estimates were obtained from survival time post-HIV infection among sero-converters and age-specific mortality rates among prevalent cases. Sex- age- and residence-specific estimates of ART coverage obtained by comparing ART uptake and estimated ART need

Methods: qualitative 4 sex- and residence-specific focus group discussions with patients 52 in-depth interviews with patients and health workers Aim: To explore factors influencing use of HIV services.

Coverage with HIV services: by the end of 2007 * as a % of total HIV+; † as a % of previous row total HIV-infected; N=1364 n % * % † Diagnosed at VCT34025 Referred to CTC clinic Registered at CTC clinic73543 Screened for ART eligibility67592 Ever eligible for ART42363 Ever initiated ART37388

Unmet need for HIV services No VCT VCT, no referral No CTC registration Registered, not screened On ARTScreened, not eligibleEligible, no ART

Percentage MaleFemale Days delay between referral and ART clinic registration by sex Not registered 1-9 months 8 to 30 days 1 to 7 days Same day

Percentage Rural RoadsideTrading Centre Days delay between referral and registration by residence at diagnosis Not registered 1-9 months 8 to 30 days 1 to 7 days Same day

ART coverage

Qualitative findings 4 major themes emerged to explain relatively slow uptake of HIV services, despite their availability: Health systems barriers: long journey, transport costs, waiting times Psychosocial issues: Family & community stigma => lack of care & support, feelings of hopelessness & denial of disease progression Beliefs about ART: misconceptions regarding efficacy and duration of treatment. Rumours that ART accelerated death, HIV curable Alternative health providers: HIV attributable to witchcraft => seeking care from traditional healers, resulting in delays in HIV service use

Qualitative findings These findings help to explain socio-demographic differences in accessing HIV services Gender Married women: expectations of negative responses from spouses Men: concerns about poverty, lack of time, unfamiliarity with health services; relatively more urgent need for treatment Area of residence Remote rural residents: less exposure to HBC, PLHIV groups, less access to VCT and ART information => leading to more misconceptions, stigma Higher transport costs, longer times away from home associated with using HIV services – some use of accessible traditional healers

Discussion Referral systems: Facilitates link between HIV testing and treatment; enable access/delays to be monitored by sex etc. Gender equity: Similar access to HIV services, but ART coverage lower among men… due to their relatively more urgent need for ART. Evolving patterns as HIV testing expands (PMTCT etc)? Residence: strongly influences access to ART. Coverage 2 x higher among trading centre residents compared to those in rural areas. Will decentralisation reduce geographic inequities? Attrition levels through the process of accessing HIV treatment following a diagnosis are high among all groups, but the biggest challenge remains increasing VCT uptake among ALL HIV-positive Monitoring: There is a need to continue monitoring access to ART in health centres, hospitals and through population based cohorts.

Acknowledgements National Institute of Medical Research London School of Hygiene & Tropical Medicine Magu District Bugando Medical Centre Study participants Funding: The Global Fund, through Tanzania Government INDEPTH Network