Joint efforts from public, private sectors, civil society and communities are needed in order to accomplish the NACP set goals. Prioritisation is essential to ensure that limited resources are utilized to produce the desired goals. The Health Sector Strategy for HIV and AIDS -II, (HSHSP - II) - 2008-2012 has identified a limited number of national HIV priority areas, rather than attempt to include “every thing that needs to be done” in the plan.
The three goals of the health Sector response will be attained through objectives, strategies, interventions and activities in four main Thematic Areas:
Thematic area 1: Prevention
The HIV epidemic in Tanzania is the result of a complex interplay between biological, socio-cultural and socio-economic factors. The strategies outlined here aim to decrease the risk of infection among the general population, with special attention to young people, both through enhancing knowledge and skills and through making relevant health services more accessible and youth friendly. The health sector at the community level will contribute towards a dialogue about sexuality, gender roles and cultural practices in order to initiate critical reflection and action to reduce local factors that increase vulnerability to HIV.
Availability of relevant health services, such as management of Sexually Transmitted Infections, HIV Testing and Counseling (HTC), Prevention of Mother to Child Transmission (PMTCT) and Safe Blood will be further expanded while safeguarding the quality and ensuring gender sensitivity. Condoms, both male and female, will be made available in all health facilities. Further more, additional innovative outlets and channels will be established to increase availability and accessibility of condoms to the general population.
The available evidence shows that financial resources allocated to broad prevention programs have a range of positive effects on public health in general. A comprehensive review of literature concludes that “broad primary prevention programs are at least 28 times more cost-effective than HAART, and that broad primary prevention has a range of positive spin-off effects on public health and disease control in general and no known side-effects.” Therefore an intensified and comprehensive prevention program is very critical.
Intervention Area 1: Prevention of Mother to Child Transmission of HIV
Prevention of Mother to Child Transmission of HIV (PMTCT) has become a crucial intervention in the global fight against the epidemic. In Tanzania about 1.4 million women become pregnant each year. Data from ANC HIV sentinel surveillance sites in Tanzania (2005) indicate that the overall HIV prevalence among pregnant women attending antenatal clinics is 8.2%. When effectively and appropriately implemented, PMTCT services have the potential to prevent infection in babies who would otherwise be born HIV-positive or contract the infection during delivery and breast feeding.
Prevention of mother-to-child transmission of HIV core interventions include:
In order to provide the above PMTCT intervention will be:
Increase the percentage of HIV positive pregnant women who receive ARVs from 34% in 2007 to 80% by 2012 to reduce the transmission of HIV from mothers to their children, during pregnancy, birth and/or breast-feeding and ensure access to care and treatment for mothers and babies.
Intervention Area 2a: Prevention of Sexual Transmission of HIV: STI Prevention and Management
Adequate treatment of patients with sexually Transmitted Infections (STIs) and their partners can reduce the rate of transmission of HIV in the population, as has been demonstrated in a community based STI intervention study done in Mwanza, Tanzania in 1995. Furthermore, it reduces the reproductive – tract and obstetric complications associated with STIs. Interventions for STIs have therefore been considered essential in HIV prevention programmes. However, the public in general, particularly young people, tend to be ill-informed about STIs. According to Demographic and Health Survey (DHS) 2004-2005, about 11% of the sexual population contract STIs annually while it is assumed that, only 60% utilizes the existing STIs services.
The Surveillance of HIV and Syphilis Infection among Antenatal Mothers in the reproductive and child health (RCH), 2005/2006 indicates the overall syphilis sero-prevalence of 6.9% (Surveillance of HIV and Syphilis Infections among antenatal clinic attendees 2005/2006).
To expand quality comprehensive STI services and enhance appropriate utilization of services.
1. Expand coverage of quality comprehensive STI services to all public, FBO and private health facilities and make the services user friendly particularly for youth and other vulnerable population
2. Assure quality for STI services (clinical aspects).
Improve STI programme management and coordination at all Intervention areas
2b: Prevention of Sexual Transmission of HIV: Male Circumcision
The association of male circumcision (MC) and reduced HIV prevalence has been reported in a number of observational studies. Three randomized controlled trials conducted in South Africa and the neighboring countries of Kenya and Uganda on male circumcision and HIV transmission have demonstrated a 50-60% decrease in the risk of acquiring HIV infection among men who underwent circumcision during the trial compared to those who were not circumcised. Therefore, there is compelling global evidence that safe male circumcision should be one of the public health interventions to reduce the transmission of HIV especially in countries with high HIV and AIDS burden and low male circumcision prevalence. Furthermore, other studies have demonstrated a number of other health benefits of male circumcision including reduction of: RTIs in children, Genital Ulcer Disease, cervical and penile carcinoma. Reported social benefits include increased sexual pleasure in both partners and personal hygiene.
The practice of male circumcision in Tanzania is often for religious and cultural reasons rather than for the purpose of HIV prevention. Modernization and peer pressure have been documented as other reasons for male circumcision. Medical indications for male circumcision include phimosis and paraphimosis. In most regions and districts this is done in health facilities but in some districts traditional male circumcision is still being practiced. In Tanzania, male circumcision is commonly practiced in many communities and the overall prevalence is about 70% (THIS 2003/04).
Though THIS findings indicated that the difference between HIV prevalence among circumcised and uncircumcised men was not significant (7% versus 6%), ecological comparison from the same study show a pattern of lower HIV prevalence in circumcising than in non-circumcising belts. For example, the high HIV-prevalence regions of Mbeya and Iringa have relatively low male circumcision rates (34.4% and 37.7% respectively) compared to Manyara with male circumcision rate of above 80% and HIV prevalence of 2%.
To promote medically safe male circumcision for health benefits and as a preventive measure against HIV transmission
Intervention Area 3a: Prevention of Transmission in Health-Care Settings: Safe Blood
HIV transmission through blood-transfusion, contaminated blood-products, occupational exposure in health care settings as well as through traditional practices (skin piercing, female genital mutilation, unsafe male circumcision) account only for a relatively low percentage of the overall transmission. However, reduction of transmission risks in these settings is of importance to safeguard the health of the population in general and of the health service providers.
The MOHSW has continued to ensure that blood transfusion is safe in all levels of health services by screening blood for Transfusion Transmissible Infections (TTIs) which include HIV, HBV, HCV and syphilis. Health care workers have also been trained on injection safety and proper hospital waste management.
Increase supply of safe blood from 15% to 50% of the blood transfusing hospitals by 2012.
Intervention Area 3b: Prevention of Transmission in Health-Care Settings: Workplace Interventions for Health Care Workers (HCW)
Health Care Workers (HCWs) may acquire infection at places of work as an occupational risk or through sexual networking. In health care settings, universal bio-safety precautions and safe waste management is essential for prevention of nosocomial transmission of infectious agents.
To implement comprehensive workplace interventions in the health sector focused on the prevention, care, treatment and support of employees, employers and their families.
Intervention area 4a: Vulnerable Population Groups: Targeted Youth Programmes
Young people aged 10 to 24 constitute a third of the Tanzanian population. About 4% of women aged 15-24 and 3% of men 15-24 are HIV positive. (TDHS 2004-2005). Prevention of HIV in young people is an investment that will ensure future HIV-free generations. In Tanzania22% of 15-19 year-old girls are married. Further research shows that more than 30% of sexually active girls had a coerced sexual debut. Once they become sexually active, young people tend to have multiple partners. About 52% of female19 years old, had been pregnant or had had a child, and almost half of these had no formal education. Nearly a third of the victims of unsafe abortion were teenagers, of whom almost half were 17 years of age or younger. Females and males aged 15-24 had had sex before 15 and 18 years respectively. Twelve percent of young women and 9% of young men had had sex by age 15. (TDHS 2004-2005). Young people must be proactive to protect themselves from unwanted pregnancies as well as HIV AND AIDS and other Sexually Transmitted Infections
Increase adolescents access, participation and utilization of innovative integrated and quality health services.
Intervention area 4b: Most At Risk Populations (MARPs): Commercial Sex Workers (CSW), Men with have sex with men (MSM, mobile workers, and Injecting Drug Users (IDUs).
Vulnerability to HIV infection is substantially higher in specific population groups than in the general sexually active population. This is either related directly to their occupational activities (sex workers), their social and cultural marginalization (MSM), or their professions which bring them in frequent contacts with places of sexual mixing (bar maids). Such occupations necessitate longer periods of separation from families or stable relationships (migrant workers including miners, military) or complete breakdown of stable social environment (refugees, injecting drug users). These groups need special attention because of their importance in the dynamics of the epidemic when they act as a bridge for transmission from their sub group to the general population.
Men who have sex with men (MSM)
Despite the fact that, it is widely spoken, there is no hard data regarding MSM although MSM practices have been reported in institutional settings. However, MSM have not been considered to any great extent in national HIV and AIDS interventions. MSM behaviors and sexualities may include bisexuality, and HIV epidemic amongst MSM and the heterosexual HIV epidemic are thus interconnected.
Sex workers are predominantly female and are at very high risk of HIV infection and are vulnerable due to multiple sexual networks and limited capacity to ensure safe sex during each and every sexual encounter.
Injecting drug use (IDU)
Injecting drug use has long been recognized as a high risk practice for HIV transmission as needles and syringes may be shared between users without sterilization. The extent of IDU in Tanzania is under-researched.
Drug use enhances the risk of HIV infections either directly or indirectly by lowering inhibitions, which lead to risky behaviours. The results of THIS (2003-2004) showed that there were higher prevalence of HIV, especially when the alcohol use is by the female partner –overall was 8% (13.7% women and 6.9% men). The spread of HIV is associated with all forms of drug use including smoking, alcohol use, inhalation and drug injecting. In particular, drug in-take through shared syringes poses a higher risk of HIV infection.
A study carried out in 2001 in Dar-es-salaam, in densely populated area, indicated that 18% of drug users are IDUs. More recent studies revealed that between 31% and 42% of IDUs are HIV positive and the situation is more serious among females.
Prevent transmission of HIV among MARPs.
Intervention area 5: Prevention Services for People Living with HIV and AIDS (Positive Prevention)
Positive prevention aims at assisting people living with HIV and AIDS to take measures that avoid exposing others to infection as well as avoiding re-infection. Re-infection has a negative impact on disease pathogenesis. If preventive measures are not undertaken by PLHIV, infection may be transmitted to others including discordant couples. Also, if PLHIV get re infected with new types of viruses, this can aggravate the progression of the infection. Data from Tanzania (THIS 2003/2004) revealed that up to 8% of couples in the country have discordant HIV sero-status. This calls for the need to promote positive prevention. Stigma is still a bottleneck in making PLHIV access care and treatment services. Major stigma incidences are observed in health care settings and in communities.
Reduce the risk of PLHIV getting new infections or infecting others with HIV.
Thematic Area 2: Care and Treatment for People living with HIV and AIDS
The objective of this priority area is to improve the wellbeing ofPeople living with HIV (PLHIV) by providing treatment, care, and other clinical services for the management of opportunistic infections
Care and treatment services for people living with HIV and AIDS include provision of ARVs, and other clinical services for the management of opportunistic infections. Wide access to ARVs was initiated in the country in October 2004 as part of the National care and treatment plan (2003-2008). The National care and treatment plan targeted to enroll 440,000 patients on ART by end five years of implementation. During the first year for implementation the target was to provide ARV to 44,000 patients. The targets were further increased to provide ART services to 100,000 by end of 2006. In terms of facility coverage the number increased from 96 to 200 by December 2007. These facilities included all referral regional and district hospitals as well as some private and Faith Based hospitals. All the same home based care is a imperative service in mitigating the physical, mental, spiritual, and socio-economic difficulties experienced by PLHIV and their families, completing the bridge in the continuum of care for the health services to the community. HSS target for 2003 – 2006 was to provide services to 5,000 PLHIV by 2005, conversely by the end of 2006 PLHIV reached with HBC services were 50,000 and the services had been established in 70 districts (53%) in Tanzania mainland.
The major challenge has been the capacity to reach the primary health facilities so as to increase access of services to rural communities. Other challenges include widespread stigma and discrimination and ability to sustain quality services.
This section addresses provision of care, treatment and support services across a continuum of care at health facility and community levels.
Intervention Area 1: Facility Based Services
The plan focuses on scaling up activities, strengthening adherence to ART, integrating various HIV and AIDS programs with other health programs, and linking facility based interventions to community and home based care services. The strategy has taken into consideration the fact that there is low enrolment of children and males, and has designed activities aiming at increasing enrolment of these populations, including early infants’ diagnosis and follow up of children exposed to HIV.
Strategic Objective - 1
To strengthen and scale up implementation of comprehensive care and treatment services in public and private facilities so as to provide ART services to 90% of all PLHIV in need of ART of which 18% will be children by 2012
Strategic Objective - 2
To improve the quality of care for both PLHIV as well as TB patients by strengthening the collaboration between TB and HIV programs at all levels.
Strategic Objective - 3
To provide quality HIV/AIDS care and treatment to PLHIV and improve the quality of life by 2012.
Intervention Area 2: Community Based Care Services
The number of patients with HIV and AIDS related diseases continues to increase steadily. Between 50% - 60% of adult patients admitted in medical wards are believed to be due to HIV related causes. This places a significant burden on health professionals caring for the terminally ill. It is becoming difficult to give quality care in many of the already overburdened public health care facilities. In addition, results from studies done among patients with advanced HIV disease showed that many preferred to be nursed at home.
The introduction of ART services in Tanzania has been challenged to establish effective linkages with successful home based care programs in order to increase patient identification, support adherence to treatment and follow-up.
Strategic Objective - 1
To strengthen and scale up the implementation of standard package of home based care services for HIV and AIDS in all districts.
To strengthen effective linkages and referrals between community based and clinical service to ensure the provision of comprehensive services across a continuum of care for PLHIV
Thematic Area 3: Cross cutting issues
The objective of this priority area is to adapt existing programs and develop innovative responses to reduce the impact of the epidemic on communities, social services and economic productivity.
The National Multi-Sectoral Strategic Framework on HIV AND AIDS 2008-2012, lists cross cutting issues including the enabling environment and gives a set of strategic objectives and core strategies for each objective. The areas are mentioned as follows:
These areas are cross-cutting and have a bearing on each of the activities in prevention, treatment, care and support thematic areas.
Laboratory is one of the important components in HIV and AIDS interventions. It supports prevention, care and treatment services as well as monitoring the epidemic and drug susceptibility activities. In order to support the comprehensive HIV and AIDS interventions, it is important to have good quality and equitable laboratory services.
Intervention Area 2: HIV Testing and Counseling (HTC) Services
The National Guidelines for Voluntary Counseling and Testing (2005) clearly state that HTC provides an opportunity to access accurate and comprehensive information on HIV, AIDS and STIs. It serves as an entry point to prevention, care, treatment and support, programmes and enables people to understand their HIV status and learn about supportive behaviors for protecting and preventing further spread of HIV.
It has been noted that the demand for counseling and testing is high creating the need to introduce new approaches for HIV Testing and Counseling (HTC) to complement the client initiated Voluntary Counseling and Testing (VCT). These new approaches include Provider Initiated Testing and Counseling (PITC) and Home Based Counseling and Testing a (HBCT). Further more; the existing public, private and voluntary agencies services are available in only a small proportion of health facilities and cannot handle the high demand for this service. The establishment of stand alone VCT sites has been slow and unsatisfactory. Therefore, there is need to expand the existing systems.
To improve access and enhance use of quality HIV Testing and Counseling (HTC).
Intervention Area 3a: IEC, BCC Programming and Stigma Reduction Interventions: Behavioral Change Communication (BCC)
Behavior change communication (BCC) is a process by which information and skills are shared and disseminated to people in the specific target audience with the intention of influencing them to adopt sustained changes in behavior or attitude. Behavior change as a process, involves knowledge and attitudes, a favorable social, cultural and physical environment for the expected change to take place.
Improve the provision of HIV and AIDS information through innovative approaches based on available evidence.
Intervention Area 3c: IEC, BCC programming and Stigma Reduction Interventions: Stigma and Discrimination
Stigma is a mark of shame or discredit on a person or a group of people. Stigma can manifest itself in a variety of ways, from ignoring the needs of a person or group to psychologically or physically harming those who are stigmatized.
Stigma causes discrimination which in turn leads to human rights violations for PLHIV and their families. Stigma and discrimination fuel HIV and AIDS epidemic because they hamper prevention and care efforts by sustaining silence and denial about HIV and AIDS. Also they contribute in the marginalization of PLHIV and those who are particularly vulnerable to HIV infection like men who have sex with men (MSM), sex workers (SWs), survivors of rape, Injecting Drug Users (IDUs), migrant populations and others.
The importance of addressing stigma in the context of BCC campaigns has programmatic implications that go beyond compassion and humane treatment. Failure to address stigma jeopardizes BCC programs in prevention, quality of care and policy.
Ensure stigma reduction interventions at all levels of health system..
Promotion of female and male condoms and their proper use are recognized to be an important aspect for prevention of sexual transmission of HIV and STIs/RTIs. Despite the concerted efforts towards condom promotion, their wider acceptance and use is still a challenge. Myths and misconceptions surrounding condom use still exists. There is a strong need to continue with rigorous efforts and/or campaigns including social marketing in order to minimize barriers towards condom use.
Strengthen promotion, availability, accessibility and use of condoms
Thematic area 4: HEALTH SYSTEM STRENGTHENING
Successful scale-up and utilization of a broad range of HIV and AIDS services and products requires a well functioning health system. The system should be able to respond, not only to current, but also to future emerging and re-emerging HIV and AIDS issues
In order for the system to produce the expected outcomes, it is necessary to have a mechanism that will ensure that appropriate inputs and processes are in place and are based on a strong foundation. Conceptually, as can be seen from Table 8, the system is expected to have a strong leadership base, strong programme management system, adequate human resource mix, efficient procurement and supply system. In addition, it requires strategic information and a good financial base to sustain it.
It is recognised that health systems constraints are the root cause of the poor outcomes of health interventions. It is therefore, necessary to examine the health system and find out whether it is able to provide answers to the following questions:
The major health system constraints in general can be grouped into 2 parts:
However, the constraints of the two parts are not mutually exclusive.
Strengthening health systems as part of HIV and AIDS scale up plan should ensure that
The entry points for the integration of STI, HIV and AIDS interventions can be at the point of service delivery, in the management of programs at district or local level, in the financing, procurement of resources and in the monitoring of programs at national level.
Therefore the two aspects of health system strengthening in terms of ensuring wider benefits while scaling up STI, HIV and AIDS programs will be addressed in this thematic section.
Intervention Area 1: National Strategic Planning and Program Management
As indicated in the introduction, HIV and AIDS epidemics have increased the burden in the already overstretched health care delivery system. This calls for innovative and renewed thinking on health systems and service delivery as well as infrastructure, human resources development and planning.
This section explores how strengthening health service delivery at all levels would be done through:
Strengthen managerial capacity for planning, resource allocation, utilization, implementation and monitoring of all, HIV and AIDS interventions at all levels.
Intervention area 2: Procurement and supply management Systems for STI, HIV and AIDS medicines, health commodities, laboratory reagents and supplies
Procurement, supply and management of medicines, health commodities and reagents are an important element for the HIV and AIDS responses. The Medical Stores Department was established to offer a centralized procurement, storage and distribution system for all health commodities. The MSD is the main stockiest and distributor of all medicines and laboratory supplies. Due to emerging demands of major public health diseases including HIV and AIDS, the ability of MSD coping with the demands is constrained.
Most HIV and AIDS medicines have been developed in the recent years and hence their long term safety in large populations have not been well established. For that reason, Tanzania Food and Drug Authority (TFDA) has in place a pharmacovigilance system for all medicines whereby health workers report adverse drug reactions occurring in their places of work.
Pharmacovigilance is a terminology used to indicate the process of detection, assessment, understanding and prevention of adverse effects, particularly long term and short term side effect of medicines. The long term and short term side effects are termed Adverse Drug Reactions (ADR) on patients that are using a pharmaceutical product.
To strengthen procurement, supply management and pharmacovigilance systems for STI, HIV and AIDS medicines, diagnostics and other commodities
Intervention area 3: Human Resource
Implementation of the HS HIV and AIDS Strategy II (2008-2012) to a large extent will depend on the number and quality of health workers at all levels in the health system. Tanzania has serious human resource for health shortage reaching a crisis situation. The establishment requires 55,404 HCWs of different cadre while only 21, 248 HCW (15,403 public and 5,845 private) are in place. Therefore, the implementation of the country’s health policy relies on the available 38% of the required human resource.
Establish a system to build and sustain human resource.
Intervention area 4a: Strategic information: Monitoring and Evaluation System
Tanzania AIDS commission (TACAIDS) is responsible for organisation and coordination of the national HIV and AIDS monitoring and evaluation (M&E) plan. Drawing from the national multisectoral M&E, the Ministry of Health and Social Welfare, through its NACP, organises the health sector M&E plan M&E unit of NACP is responsible for second generation surveillance and M&E of health sector interventions according to the health sector strategy for HIV/AIDS.
In collaboration with partners and academic institutions the M&E unit is responsible for standardization of M&E of HIV and AIDS intervention through development of protocols, training materials, and supervision guides. It also develops, prints and distributes data collection tools to all facilities, train regional and district trainers. It also coordinates implementation, analysis of data to produce reports and disseminate to all levels.
In addition to the second generation surveillance. The unit is currently implementing M&E activities for HIV and AIDS chronic care, HTC, PMTCT and STI, and M&E system for HBC is being established.
Service data is collected and summarised at service provision points using standardised forms and it flows to the district, regional and national levels.At each level a summary is generated and disseminated.
Strengthen monitoring and evaluation system to provide relevant comprehensive information in a timely manner for program management and planning.
Intervention area 4b: Strategic information: Behavioral and Biological Surveillance on STI, HIV and AIDS
In the transmission of HIV infection, both biological and behavioural factors play a significant role. Thus surveillance of HIV and AIDS needs to include both biological and behavioural aspects.
Strengthen surveillance activities to monitor the dynamics of the epidemic and the impact of STI, HIV and AIDS interventions.
Intervention area 4c: Strategic information: Surveillance of HIV, STIs and TB Drugs Resistance as well as Drug Adverse Effects
While the HIV and AIDS interventions are scaled up, there is a risk of emergence of HIV drug resistance. This risk needs to be identified early so that appropriate measures are instituted.
It must be borne in mind that before the start of the national HIV care and treatment program already there were PLHIV on ARVs. These individuals had used ARVs without existence of national HIV and AIDS treatment guidelines. Therefore, there is a fear of having a pool of people with resistant organisms.
There is also need to monitor STI and TB drug susceptibility patterns to inform policies on management of STIs and possible emergence of multi-drug resistant TB.
Strengthen surveillance of ARVs and STI drug resistance as well as pharmacovigilance of ARVs, STI drugs and OI medication
Intervention Area 5: Priority HIV and AIDS and STI Research
Research is essential in providing evidence- based information needed to support the national response against HIV and AIDS epidemic. Research facilitates the identification and understanding the drivers of HIV spreadand maintains quality of response (interventions)
To strengthen the health sector capacity to contribute to national HIV and AIDS and STI related research and development
Intervention Area 6: Documentation of Best Practices on HIV and AIDS in Tanzania
A Best Practice on HIV and AIDS is a body of knowledge about an aspect of HIV prevention, treatment or care that is based on practical experiences and lessons learned in a maturing field. A best practice should be replicable to improve the quality of an intervention that has as its objective the mitigation of one aspect of the HIV epidemic.
The primary purpose of a Best Practice is to :
Ensure establishment of mechanisms to document best practices on HIV and AIDS
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