Full Report on VCT Outreach Project

Here is the full report on the HIV testing Outreach that I have been doing.. it's a bit long, but it's a good read!!

Report on a HIV Voluntary Testing and Counselling (VCT) Outreach program in Lindi Region of Tanzania, funded by the Tanzanian Development Trust

By James Davies.  VSO Volunteer.  Laboratory Scientist, St Walburg’s Hospital, Nyangao, Lindi Rural Region, Tanzania.

Background to HIV and AIDS Prevalence in Tanzania.

The problems associated with HIV infection and AIDS in Tanzania are well known and documented.  Recent figures from the 2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)¹ show the average HIV prevalence rate in Mainland Tanzania (excluding Zanzibar where the prevalence rate is low 1.2%) to be 5.3% in men and women aged 15-49.  This represents a decrease from 5.8% in 2007-08 and from 7% in 2003-04. (See Figure 1)

Figure 1.  Trends in HIV Prevalence in Mainland Tanzania.  Source:  2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)¹

 There are however variations between sexes, with women having higher prevalence rates than men (6.3% vs. 3.9%) and Tanzanians living in urban areas are more likely to be HIV positive than those living in rural areas (7.2% vs. 4.3%).  There are large variations in prevalence rates depending on geographic location ranging from less than 1% in Pemba to a high of 14.8% in Njombe region.  In general the south westerly regions of Tanzania tend to have the higher infection rates (See figure 2)

Figure 2.  HIV Prevalence by region.  Source:  2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)¹

There are many efforts being made to reduce the HIV prevalence rate through education and through offering free counselling and testing for HIV at healthcare providing institutes (Provider Initiated Testing and Counselling - PITC) or at voluntary “drop in” centres (Voluntary Testing and Counselling - VCT).  The success of these initiatives is shown by the increase in the number of women and men who have ever been tested for HIV and received their results.  In 2011-12, 62% of women and 47% of men said they had been tested and received their results compared with just 37% of women and 27% of men in 2007-08. (See figure 3)

Figure 3.  Percentage of women and men who have ever been tested for HIV and received their results.  Source:  2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)¹

  Whilst improvements have been made to the number of people tested, there is still a large percentage of Tanzanians who have not been tested.  Also it is important that people are tested repeatedly,  as a negative result from a single HIV test does not guarantee the client is free of the virus (due to the sensitivity of the test method) thus clients must repeat testing after 3 months. 

Background to Lindi Region and St Walburg’s Hospital

Lindi region is one of Tanzania’s 26 administrative regions and is located in the South East of Tanzania bordering the Indian Ocean.   It has an area of approx. 67000 km² and one quarter of this in the northwest is part of the Selous Game reserve² (See Figure 2)     

It is one of the poorest regions in Tanzania, with almost 60% of the population falling into the lowest two wealth quintile brackets³. The majority of the population of almost 800,000 live in rural areas and survive by subsistence farming. The main cash crop in the region is Cashew nut, which are mainly exported to India.

The latest THMIS report shows the HIV prevalence in Lindi region to be lower than the national average, at 2.9%¹.  This may be due to the mainly rural population, in whom HIV prevalence rates are lower, and due to the work of the Ministry of Health and Social Welfare (MoHSW) and NGOs in the region to increase awareness of HIV/AIDS.

 

The Lindi region is subdivided into 6 districts (see Figure 4), the Lindi Rural district covers an area of over 7500 km² and includes the village of Nyangao where the District hospital of St Walburg’s is situated.  The district has a population of over 200 000 and most of these people live in small villages or townships⁴.   

 

Figure 4.  Map of Lindi Districts.  Source: Lindi.go.tz ².

The ability of village residents to access healthcare facilities is very limited, since there is only one tarmac road in the region (From Lindi town to Masasi town in the west) most villages are accessed by sand/dirt tracks which can be impassable in the rainy season.  Thus attending a hospital or dispensary that offers VCT will involve a walk of many kilometres.    

St Walburg’s hospital is the only hospital in the district, and has an active Care and Treatment Centre (CTC), where patients can come for VCT, and to receive treatment for diseases such as HIV and TB.   The Hospital has for a number of years received funding from various donors in order to provide an outreach program to visit villages in the region and provide free testing and counselling for HIV.  These programs have been very successful in reaching many hundreds of villagers who may not otherwise have been tested for HIV. 

In 2013 however, no funding was available from usual sources, and so VSO volunteer James Davies applied to the TDT for a grant to continue the VCT Outreach Program.

 

2013 VCT Outreach Project

Implementation

In order to continue the work of the VCT outreach program, the TDT was approached in April 2013 for a grant of TSH 1,250,000 (approx. £500 GBP) and the grant was approved.  The grant proposal was to visit 6 or 7 villages, with the money used to pay for the cost of hiring the Hospital vehicle and driver, re-imbursement for the staff who would give up their weekend days to perform the HIV testing and Counselling and for some of the associated consumable items.  Also there were small monetary payments to people in the villages that will help to organise visits.  The HIV tests themselves are free as they are supplied by the Government.  (See Appendix 1)

The project was led by James Davies, VSO volunteer, together with Salvina Mpunga, Site Manager for VCT at Nyangao Hospital who has organised previous Outreach programs.

Letters were sent to village leaders about a week in advance to prepare them for our arrival and to ask them to organise a suitable building to accommodate our visit, along with 2 village helpers, an announcer and a drum.  The visits were arranged for either a Saturday or Sunday so that the Hospital staff that performed the testing and counselling would be available and not at work.  Two staff from the laboratory and two from the CTC came to each village visit.

The village visits usually followed a similar format.  We travelled to the village using the hospital 4x4 vehicle and upon our arrival we were greeted by the village leader or secretary, and shown to the building that was to be our clinic for the day.  The arranged helpers and the announcer and drum would ensure that all the villagers knew of our presence and encourage people to come for testing.   

 

The Hospital 4x4 vehicle – Essential to access the remote villages

  

The building used for our clinic in Ndawa

The building used for our clinic in Mahiwa

The building used for our clinic in Mtama A

 When clients came for testing, they were tested using a simple rapid HIV test.  These tests use a small amount of blood obtained from a finger-prick sample, and results are ready within about 5 minutes. The test is reliable and easy to perform making it ideal for such settings where full laboratory facilities are not available. 

 

VSO Volunteer James Davies and a member of Laboratory staff ready to receive clients for testing

Laboratory staff taking a Finger-Prick sample of blood

 

HIV Rapid test strip.  Blood is applied to the bottom of the test strip with a drop of buffer liquid.  The blood migrates up the test strip and develops indicator lines.  One line in the “control” region indicates a negative test; An additional line in the “patient” region indicates a positive test

Laboratory staff taking a Finger-Prick sample of blood

Once the results of the test were ready, the client was given the results during a confidential counselling session performed by a trained HIV counsellor from the Hospital’s CTC.  During the counselling session the client was given advice on how to reduce the risk of HIV transmission and when to come back for another test and given the opportunity to ask questions

Two sisters being counselled by a trained counsellor. (Although usually counselling is on a one-to-one basis).

 Outcome of the VCT Outreach Project

The TDT grant enabled visits to 8 villages in the Lindi Rural district over a period of 8 weeks.  This was more than the predicted 7 villages due to budget under spend on some of the visits.  The distance from the hospital to the village (round trip) ranged from 10km to 64km (See Table 1).

The turnout for each village visit was good and in total 724 people were tested for HIV.  There was a roughly even distribution of sex; 389 (53.7%) were male and 335 (46.3%) were female (See Table 2)    Stratification by age (age ranges are those used by the MoHSW) also showed a roughly even distribution between ages (See Table 3). 

Of the 724 people tested two new cases (0.3%) of HIV infection were detected -one male (41 years) and one female (28 years).

Impact and Discussion

The two HIV positive cases identified have been referred to the Hospital CTC clinic to start treatment on anti-retroviral drugs.   The treatment is provided free through the MoHSW, and if compliance with treatment is good then these clients can expect a prolonged and higher quality of life than if they were left untreated. 

The HIV positive rate of 0.3% may suggest that the prevalence of HIV is low, however it must be remembered that this project was not measuring overall prevalence rate since people who already know their positive HIV status will not come for repeat testing.  Furthermore, there is still stigma attached to HIV infection so people who think they may be HIV positive may not want to know their status.

Besides the two new infections detected, this project had a number of less tangible but still important impacts.  It has increased awareness about HIV infection in the 724 people who were tested and counselled.  The counselling sessions provide valuable information about HIV infection and ways to reduce the risk of transmission of HIV.  This education is especially important in the younger generation who are more sexually active, and thus at higher risk of transmission of HIV.  The THMIS study revealed that 60% of young women and 53% of young men less than 24 years old in the Lindi region do not have a "comprehensive knowledge" about HIV/AIDS⁵.  This Outreach program provided counselling and information for 296 people below 24 years of age.

The project has also helped increase the profile of the Hospital amongst the residents of these villages.  Many healthcare facilities in Tanzania are understaffed and underfunded and the quality of care provided can be poor.  Local people can be afraid of visiting healthcare facilities if they are not confident about the quality of care and so will often visit traditional healers or present at Hospital in an advance stage of disease when it can be too late to provide treatment.  St Walburg’s hospital is recognised as being one of the best in the Lindi and Mtwara regions, and it is important that people are aware of and have trust in the services offered by local healthcare facilities as this means they are more likely to seek professional medical help when they need it. 

Although this Outreach program was modest in size, it was successful and the hospital hopes to continue this year’s Outreach program when more funds become available in order to reach villages that are even further from the hospital and thus have less access to VCT and other healthcare facilities.

 Feedback from Hospital Staff

The following quotations are feedback from staff at St Walburg’s hospital regarding the TDT funded Outreach program:

From Salvina Mpunga, Site manager, VCT Nyangao:

“Ungozi wa Hospitali ya nyangao wanatoa shukrani kwa msaada wa fedha ambao wamepata kutoka kwa TDT ambazo zimetumika kwa shughuli za outreach kwa vijiji ambavyo vimeizunguka hospitali yetu.

Nitumaini letu kwamba bado mtaendelea kutufadhili ili tuweze kupunguza kasi ya kuenea kwa maambukizi ya VVU.

Pia tunamshukuru ndugu jemsi ambae amefanya kazi kubwa ya kuomba fedha kwenu

Asante”

“The hospital leaders of Nyangao Hospital give thanks for the financial assistance that was received from TDT which has been used for outreach activities in villages around our hospital.  Our hope is that you will still continue for funding to reduce the spread of HIV infection.  We also thank James who did a lot of work in asking for the money from you.

Thankyou.

(Translation by James Davies)

From Monica Chalawe,  Head of Laboratory, St Walburg’s hospital:

“I have to thank the donors who donated some funds to enable us to conduct Outreach.  It has helped in different ways, for instance to give education to the people to live safely from getting HIV and for those affected to show the way of getting ARV <Anti retroviral drugs> by referring to CTC centres.  Also the outreach exercise helped to build a good relationship with the surrounding villagers.  Thank you a lot to TDT donors.

From Innocent Chingwile, Laboratory Scientist, St Walburg’s Hospital:

“Nyangao laboratory is very grateful for you volunteer services especially financial support.  We have visited many villages providing counselling services and testing so now many villagers have got knowledge on how HIV is transmitted, best ways of living with HIV and how to prevent themselves from acquiring.  Not only that but also now villagers are more eager to know their HIV status than before.  More Outreach are needed to cover other remaining villages so that everyone can be aware of HIV, also to have actual data pertaining to prevalence of HIV in our community.  We together appreciate your contribution to promote the health of our people”.

References

1.       2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)- HIV prevalence by region factsheet. Tanzania Commission for AIDS (TACAIDS).  March 2013.

2.       www.Lindi.go.tz.  Accessed 20/7/2013.

3. 2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)-final report. Tanzania Commission for AIDS (TACAIDS).March 2013.  pp 19-20.

4. Tanzania Population and Housing Census 2002.  Available from http://www.nbs.go.tz/tnada/index.php/catalog/7

5. 2011-12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS)-final report. Tanzania Commission for AIDS (TACAIDS). March 2013. Page 95.