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VU Research Portal

Health care for chronic diseases in rural Tanzania

Mwangome, M.N.

2016

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Mwangome, M. N. (2016). Health care for chronic diseases in rural Tanzania: Including non-communicable diseases in primary care towards health for all.

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Chapter 6

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Chapter 6

106

Abstract /ŶƚƌŽĚƵĐƟŽŶ

Current HIV policies in Tanzania have adopted the three long-term impact results of zero ŶĞǁ ŝŶĨĞĐƟŽŶƐ͕ ǌĞƌŽ ,/s ĚĞĂƚŚƐ ĂŶĚ ǌĞƌŽ ƐƟŐŵĂ ĂŶĚ ĚŝƐĐƌŝŵŝŶĂƟŽŶ͘ ^ƚƌĂƚĞŐŝĞƐ ƚŽ ƌĞĂĐŚ ƚŚĞƐĞƌĞƐƵůƚƐŝŶĐůƵĚĞƐĐĂůŝŶŐͲƵƉ,/sƚĞƐƟŶŐĂŶĚĐŽƵŶƐĞůŝŶŐ;,dͿ͖ƉƌĞǀĞŶƟŶŐŵŽƚŚĞƌͲƚŽͲ child transmission (PMTCT); and strengthening care and treatment clinic (CTC) services. WƌĞǀŝŽƵƐƐƚƵĚŝĞƐƐŚŽǁĞĚƚŚĂƚ,/sƉŽůŝĐǇĂŶĚŐƵŝĚĞůŝŶĞƌĞĐŽŵŵĞŶĚĂƟŽŶƐǁĞƌĞŶŽƚĂůǁĂǇƐ ŝŵƉůĞŵĞŶƚĞĚŝŶƌƵƌĂů^ŽƵƚŚdĂŶǌĂŶŝĂ͘dŚŝƐƐƚƵĚǇĂŝŵƐƚŽŝĚĞŶƟĨǇĨĂĐŝůŝƚĂƟŶŐĂŶĚŝŵƉĞĚŝŶŐ ĨĂĐƚŽƌƐƌĞŐĂƌĚŝŶŐ,/sŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶ͘ Methods ƋƵĂůŝƚĂƟǀĞ ƐƚƵĚǇ ŽĨ Ϯϯ ƐĞŵŝͲƐƚƌƵĐƚƵƌĞĚ ŝŶƚĞƌǀŝĞǁƐ ǁŝƚŚ ĨĂĐŝůŝƚǇ ŵĂŶĂŐĞƌƐ͖ ŚĞĂůƚŚĐĂƌĞ ǁŽƌŬĞƌƐ͖ ĚŝƐƚƌŝĐƚ͕ ƌĞŐŝŽŶĂů ĂŶĚ ŶĂƟŽŶĂů ,/s ĐŽŽƌĚŝŶĂƚŽƌƐ͘ &ŝǀĞ ŚĞĂůƚŚ ĨĂĐŝůŝƟĞƐ ǁĞƌĞ purposively selected by level, ownership and proximity to district headquarters. Interviews ǁĞƌĞ ĂŶĂůǇǌĞĚ ĂĐĐŽƌĚŝŶŐ ƚŽ &ůĞƵƌĞŶ͛Ɛ ĮǀĞ ĚĞƚĞƌŵŝŶĂŶƚƐ ŽĨ ŝŶŶŽǀĂƟŽŶ ƵƉƚĂŬĞ ƌĞůĂƚĞĚ ƚŽ͗ ƐƚƌĂƚĞŐŝĞƐƵƐĞĚŝŶŐƵŝĚĞůŝŶĞĚĞǀĞůŽƉŵĞŶƚĂŶĚĚŝƐƐĞŵŝŶĂƟŽŶ͖ŐƵŝĚĞůŝŶĞĐŚĂƌĂĐƚĞƌŝƐƟĐƐ͖ƚŚĞ ŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƟŶŐŽƌŐĂŶŝǌĂƟŽŶ͖ŐƵŝĚĞůŝŶĞƵƐĞƌƐ͖ĂŶĚƚŚĞƐŽĐŝŽͲĐƵůƚƵƌĂůĂŶĚƌĞŐƵůĂƚŽƌǇ context. Results ůůĨĂĐŝůŝƟĞƐƉƌŽǀŝĚĞĚ,d͕WDddĂŶĚdƐĞƌǀŝĐĞƐĞǆĐĞƉƚƚŚĞƉƌŝǀĂƚĞĚŝƐƉĞŶƐĂƌǇǁŚŝĐŚ ŽŶůǇŽīĞƌĞĚ,d͘ůůĨĂĐŝůŝƟĞƐŽīĞƌŝŶŐWDddĂŶĚdŚĂĚƚŚĞƌĞƐƉĞĐƟǀĞůĂƚĞƐƚŐƵŝĚĞůŝŶĞ ďƵƚŶŽĨĂĐŝůŝƚǇŚĂĚƚŚĞ,dŶĂƟŽŶĂůŐƵŝĚĞůŝŶĞĚŽĐƵŵĞŶƚ͘EŽŶͲŝŶǀŽůǀĞŵĞŶƚŽĨƉƌŽǀŝĚĞƌƐŝŶ ƌĞǀŝƐŝŽŶƐ ĂŶĚ ǁĞĂŬ ƉůĂŶŶŝŶŐ ĨŽƌ ŐƵŝĚĞůŝŶĞ ĚŝƐƐĞŵŝŶĂƟŽŶ ŝŵƉĞĚĞĚ ƚŚĞŝƌ ŝŵƉůĞŵĞŶƚĂƟŽŶ͘ >ĞŶŐƚŚǇŐƵŝĚĞůŝŶĞƐĂŶĚƚŚŽƐĞǁƌŝƩĞŶŝŶŶŐůŝƐŚǁĞƌĞƵŶĚĞƌͲƵƐĞĚ͕ĂŶĚĂĐƟǀŝƟĞƐƉĞƌĐĞŝǀĞĚ ƚŽďĞĐŽŵƉůŝĐĂƚĞĚ͕ůŝŬĞt,KͲƐƚĂŐŝŶŐ͕ǁĞƌĞĂǀŽŝĚĞĚ͘ǀĂŝůĂďŝůŝƚǇŽĨƐƚĂīĂŶĚůĂĐŬŽĨƐƵƉƉůŝĞƐ ůŝŬĞ ƚĞƐƚ ŬŝƚƐ ĂŶĚ ŵĞĚŝĐĂƟŽŶ ŝŵƉĞĚĞĚ ŝŵƉůĞŵĞŶƚĂƟŽŶ͘ ŽůůĂďŽƌĂƟŽŶ ďĞƚǁĞĞŶ ĨĂĐŝůŝƟĞƐ ĞŶŚĂŶĐĞĚŝŵƉůĞŵĞŶƚĂƟŽŶ͕ĂƐĚŝĚƉĞĞƌƐƵƉƉŽƌƚĂŵŽŶŐƉƌŽǀŝĚĞƌƐ͘WƌŽǀŝĚĞƌĐŚĂƌĂĐƚĞƌŝƐƟĐƐ ŝŶĐůƵĚŝŶŐ ĞĚƵĐĂƟŽŶ ůĞǀĞů͕ ŬŶŽǁůĞĚŐĞ ŽĨ͕ ĂŶĚ ĐŽŵŵŝƚŵĞŶƚ ƚŽ ƚŚĞ ŐƵŝĚĞůŝŶĞ ŝŶŇƵĞŶĐĞĚ ŝŵƉůĞŵĞŶƚĂƟŽŶ͘ ĐĐŽƌĚŝŶŐ ƚŽ ƉƌŽǀŝĚĞƌƐ͕ ĚĞƚĞƌŵŝŶĂŶƚƐ ŽĨ ĐůŝĞŶƚƐ͛ ƐĞƌǀŝĐĞ ƵƐĞ ŝŶĐůƵĚĞĚ ŐĞŶĚĞƌ ŶŽƌŵƐ͕ ƐƟŐŵĂ͕ ƚƌƵƐƚ ĂŶĚ ƉĞƌĐĞŝǀĞĚ ďĞŶĞĮƚƐ͘ dŚĞ ƌĞŐƵůĂƚŽƌǇ ĐŽŶƚĞǆƚ ƉƌŽŚŝďŝƚĞĚ private hospitals from buying HIV supplies.

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͙͘͞/ĐĂŶũƵƐƚƐĂǇŝƚŝƐůĂǆŝƚǇ͙͗͘͟ƋƵĂůŝƚĂƟǀĞƐƚƵĚǇŽĨĨĂĐŝůŝƚĂƟŶŐĂŶĚŝŵƉĞĚŝŶŐ ĨĂĐƚŽƌƐŽĨ,/sŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶŝŶƚǁŽ^ŽƵƚŚĞƌŶĚŝƐƚƌŝĐƚƐŽĨdĂŶǌĂŶŝĂ 107 /ŶƚƌŽĚƵĐƟŽŶ /ŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚƚŚĞϮϬϭϬ:ŽŝŶƚƵŶŝƚĞĚŶĂƟŽŶƐƉƌŽŐƌĂŵŵĞŽŶ,/sĂŶĚ/^;hE/^Ϳ ƐƚƌĂƚĞŐǇ ĨŽƌ ϮϬϭϭͲϮϬϭϱ ĞŶƟƚůĞĚ ͞ŐĞƫŶŐ ƚŽ ǌĞƌŽ͕͟ dĂŶǌĂŶŝĂ ŚĂƐ ĂĚŽƉƚĞĚ ƚŚĞ ƚŚƌĞĞ ŐůŽďĂů ůŽŶŐͲƚĞƌŵŝŵƉĂĐƚƌĞƐƵůƚƐŽĨǌĞƌŽŶĞǁ,/sŝŶĨĞĐƟŽŶƐ͕ǌĞƌŽ,/sͲƌĞůĂƚĞĚĚĞĂƚŚƐĂŶĚǌĞƌŽ,/sͲ ƌĞůĂƚĞĚ ƐƟŐŵĂ ĂŶĚ ĚŝƐĐƌŝŵŝŶĂƟŽŶ ;ŬŶŽǁŶ ĂƐ ͞ƚŚĞ ƚŚƌĞĞ ǌĞƌŽƐ͟Ϳ ŝŶƚŽ ŝƚƐ ĐƵƌƌĞŶƚ ŶĂƟŽŶĂů ŵƵůƟƐĞĐƚŽƌĂů ,/s ƐƚƌĂƚĞŐŝĐ ĨƌĂŵĞǁŽƌŬ /// ;ϮϬϭϯͬϭϰͲϮϬϭϳͬϭϴͿ ĂŶĚ ƚŚĞ ŚĞĂůƚŚ ƐĞĐƚŽƌ ,/s ƐƚƌĂƚĞŐŝĐ ƉůĂŶ /// ;ϮϬϭϯͲϮϬϭϳͿ ;ϭ͕ ϮͿ͘ dŚĞ ƐƚƌĂƚĞŐŝĞƐ ŝĚĞŶƟĮĞĚ ƚŽ ĂĐŚŝĞǀĞ ƚŚĞƐĞ ƚŚƌĞĞ ǌĞƌŽƐŝŶĐůƵĚĞƐƚƌĞŶŐƚŚĞŶŝŶŐĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚƐĞƌǀŝĐĞƐ;dͿ͕ƐĐĂůŝŶŐƵƉ,/sƚĞƐƟŶŐĂŶĚ ĐŽƵŶƐĞůůŝŶŐ;,dͿĂŶĚůŝŶŬŝŶŐĐůŝĞŶƚƐƚŽĨĂĐŝůŝƟĞƐĂŶĚĐŽŵŵƵŶŝƚǇͲďĂƐĞĚƐĞƌǀŝĐĞƐ͕ƉƌĞǀĞŶƟŽŶ of mother-to-child transmission of HIV (PMTCT), early infant diagnosis, and care and ŵĂŶĂŐĞŵĞŶƚŽĨĐŽͲŝŶĨĞĐƟŽŶƐ;ϭͿ͘

dŚĞƚŚƌĞĞǌĞƌŽƐŚĂǀĞďĞĞŶĂĚŽƉƚĞĚĂƚĂƟŵĞǁŚĞŶ,/sƉƌĞǀĂůĞŶĐĞŝŶƚŚĞĂĚƵůƚƉŽƉƵůĂƟŽŶ ŚĂƐĚĞĐůŝŶĞĚĨƌŽŵϳйŝŶϮϬϬϰƚŽϱ͘ϯйŝŶϮϬϭϮ;ϯͿ͕ǁŝƚŚϭ͘ϱŵŝůůŝŽŶƉĞŽƉůĞĞƐƟŵĂƚĞĚƚŽďĞ living with HIV by the end 2014 (4). Important successes in the response towards HIV in dĂŶǌĂŶŝĂŝŶĐůƵĚĞĂŶŽǀĞƌϱϬϬйŝŶĐƌĞĂƐĞŝŶŶƵŵďĞƌŽĨŚĞĂůƚŚĨĂĐŝůŝƟĞƐƉƌŽǀŝĚŝŶŐdƐĞƌǀŝĐĞƐ ĨƌŽŵϮϬϬŝŶϮϬϬϲ͕ƚŽϭϮϬϵĨĂĐŝůŝƟĞƐŝŶϮϬϭϯǁŚŝĐŚƌĞƉƌĞƐĞŶƚƐϮϰйŽĨĂƚŽƚĂůŽĨϱϬϱϮŚĞĂůƚŚ ĨĂĐŝůŝƟĞƐ;ϱͲϳͿ͖ĂŶŝŶĐƌĞĂƐĞŝŶŶƵŵďĞƌŽĨƉĂƟĞŶƚƐĞŶƌŽůůĞĚŝŶƚŚĞŶĂƟŽŶĂůĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚ ƉƌŽŐƌĂŵŵĞďǇŽǀĞƌϱϬϬйďĞƚǁĞĞŶϮϬϬϲĂŶĚϮϬϭϮĨƌŽŵϭϭϱ͕ϱϵϳƚŽϳϰϵ͕ϯϬϮƉĂƟĞŶƚƐ;ϳ͕ ϴͿ͖ĂŶĚŚŝŐŚĐŽǀĞƌĂŐĞŽĨWDddƐĞƌǀŝĐĞƐ͕ǁŝƚŚϵϳйŽĨƌĞƉƌŽĚƵĐƟǀĞĂŶĚĐŚŝůĚŚĞĂůƚŚĐůŝŶŝĐƐ ŽīĞƌŝŶŐWDddƐĞƌǀŝĐĞƐďǇĞŶĚŽĨϮϬϭϯ;ϱͿ͘ĐĐŽƌĚŝŶŐƚŽĮŶĚŝŶŐƐŽĨĂϮϬϭϮdĂŶǌĂŶŝĂŶƐƵƌǀĞǇ͕ ZsƚƌĞĂƚŵĞŶƚǁĂƐŽīĞƌĞĚďǇϮϭйŽĨŐŽǀĞƌŶŵĞŶƚŚĞĂůƚŚĨĂĐŝůŝƟĞƐĂŶĚϭϴйŽĨƉƌŝǀĂƚĞŚĞĂůƚŚ ĨĂĐŝůŝƟĞƐŝŶĐůƵĚŝŶŐĨĂŝƚŚͲďĂƐĞĚ͕ŶŽŶͲŐŽǀĞƌŶŵĞŶƚĂůŽƌŐĂŶŝǌĂƟŽŶ;E'KͿĂŶĚƉƌŝǀĂƚĞͲĨŽƌͲƉƌŽĮƚ ŚĞĂůƚŚĨĂĐŝůŝƟĞƐ;ϵͿ͘dŚĞƐĞĂƉƉĂƌĞŶƚƐƵĐĐĞƐƐĞƐĂƌĞŚŽǁĞǀĞƌĐŽŶƚƌĂƐƚĞĚǁŝƚŚƚŚĞƐƟůůůĂƌŐĞ ŶƵŵďĞƌŽĨ,/sͲƌĞůĂƚĞĚĚĞĂƚŚƐĞƐƟŵĂƚĞĚĂƚϰϲ͕ϬϬϬŝŶϮϬϭϰ;ϭϬͿ͘&ƵƌƚŚĞƌŵŽƌĞ͕ŝŶϮϬϭϮ͕ĂďŽƵƚ 30% of HIV-infected persons aged 15-49 years had not been diagnosed (11) and several ƐƚƵĚŝĞƐŚĂǀĞĚĞŵŽŶƐƚƌĂƚĞĚƚŚĂƚƵƐĞŽĨ,/sƐĞƌǀŝĐĞƐĂŶĚƌĞƚĞŶƟŽŶŝŶdŝƐƐƟůůĂŵĂũŽƌ challenge in Tanzania (12, 13).

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Chapter 6 108 dĂďůĞϭĚŝƟŽŶƐŽĨ,d͕WDdd͕dŶĂƟŽŶĂůŐƵŝĚĞůŝŶĞĚŽĐƵŵĞŶƚƐĂŶĚƚŚĞŝƌĂƉƉƌŽǀĂůǇĞĂƌ ϭϯϳ dŚĞƋƵĂůŝƚǇŽĨ,/sƐĞƌǀŝĐĞƉƌŽǀŝƐŝŽŶǁŝůůŚĂǀĞĂĚŝƌĞĐƚŝŵƉĂĐƚŽŶƚŚĞŽƵƚĐŽŵĞƐŽĨƚŚĞƉƌŽƉŽƐĞĚ ƐƚƌĂƚĞŐŝĞƐ;ϭϰͿ͘/ŶdĂŶǌĂŶŝĂ͕ƚŚĞŝŵƉůĞŵĞŶƚĂƚŝŽŶŽĨƚŚĞŶĂƚŝŽŶĂů,/sͬ/^ĐŽŶƚƌŽůƉƌŽŐƌĂŵŵĞ ;EWͿŚĂƐďĞĞŶƐƵƉƉŽƌƚĞĚďǇĐůŝŶŝĐĂůƉƌĂĐƚŝĐĞŐƵŝĚĞůŝŶĞĨŽƌ,d;ϭϱ͕ϭϲͿ͕WDdd;ϭϳ͕ϭϴͿĂŶĚ d;ϴͿ͕ǁŚŝĐŚĂƌĞƌĞǀŝƐĞĚƚŽŝŶĐŽƌƉŽƌĂƚĞŶĞǁĞǀŝĚĞŶĐĞĂŶĚĂƌĞŝŶƚĞŶĚĞĚĂƐƚŽŽůƐĨŽƌĐůŽƐŝŶŐƚŚĞ ŐĂƉďĞƚǁĞĞŶĞǀŝĚĞŶĐĞĂŶĚĂĐƚƵĂůƉƌĂĐƚŝĐĞ;ϭϵͿ͘dĂďůĞϭƐŚŽǁƐƚŚĞĚŝĨĨĞƌĞŶƚĞĚŝƚŝŽŶƐŽĨ ŐƵŝĚĞůŝŶĞƐĂŶĚƚŚĂƚŐƵŝĚĞůŝŶĞƐĨŽƌ,d͕WDddĂŶĚdǁĞƌĞŝƐƐƵĞĚĂƚĂŵĞĚŝĂŶŝŶƚĞƌǀĂůŽĨϰ͕ϰ ĂŶĚϱǇĞĂƌƐƌĞƐƉĞĐƚŝǀĞůǇ͘ dĂďůĞϭĚŝƚŝŽŶƐŽĨ,d͕WDdd͕dŶĂƚŝŽŶĂůŐƵŝĚĞůŝŶĞĚŽĐƵŵĞŶƚƐĂŶĚƚŚĞŝƌĂƉƉƌŽǀĂůǇĞĂƌ ,/sƉƌĂĐƚŝĐĞŐƵŝĚĞůŝŶĞƐ zĞĂƌ ,/sdĞƐƚŝŶŐĂŶĚĐŽƵŶƐĞůŝŶŐ ϭ͘ EĂƚŝŽŶĂů'ƵŝĚĞůŝŶĞƐĨŽƌsŽůƵŶƚĂƌǇŽƵŶƐĞůŝŶŐĂŶĚdĞƐƚŝŶŐ;sdͿ͘ ϮϬϬϱ Ϯ͘ 'ƵŝĚĞůŝŶĞƐĨŽƌ,/sdĞƐƚŝŶŐĂŶĚŽƵŶƐĞůŝŶŐŝŶůŝŶŝĐĂů^ĞƚƚŝŶŐƐ;W/dͿΎ ϮϬϬϳ ϯ͘ EĂƚŝŽŶĂůŐƵŝĚĞůŝŶĞƐĨŽƌĐŽŵƉƌĞŚĞŶƐŝǀĞ,/sdĞƐƚŝŶŐĂŶĚŽƵŶƐĞůŝŶŐη _ϮϬϭϯ ,/sĐĂƌĞĂŶĚƚƌĞĂƚŵĞŶƚ ϰ͘ EĂƚŝŽŶĂůŐƵŝĚĞůŝŶĞĨŽƌƚŚĞĐůŝŶŝĐĂůŵĂŶĂŐĞŵĞŶƚŽĨ,/sĂŶĚ/^͕ϭƐƚ_{ĞĚŝƚŝŽŶ} _ϮϬϬϮ ϱ͘ EĂƚŝŽŶĂůŐƵŝĚĞůŝŶĞƐĨŽƌƚŚĞĐůŝŶŝĐĂůŵĂŶĂŐĞŵĞŶƚŽĨ,/sĂŶĚ/^͕ϮŶĚ_{ĞĚŝƚŝŽŶ} _ϮϬϬϱ ϲ͘ EĂƚŝŽŶĂůŐƵŝĚĞůŝŶĞƐĨŽƌƚŚĞĐůŝŶŝĐĂůŵĂŶĂŐĞŵĞŶƚŽĨ,/sĂŶĚ/^͕ϯƌĚ_{ĞĚŝƚŝŽŶ} _ϮϬϬϵ ϳ͘ EĂƚŝŽŶĂů'ƵŝĚĞůŝŶĞƐĨŽƌƚŚĞůŝŶŝĐĂůDĂŶĂŐĞŵĞŶƚŽĨ,/sĂŶĚ/^͕ϰƚŚ_{ĞĚŝƚŝŽŶ͘} _ϮϬϭϮ WƌĞǀĞŶƚŝŽŶŽĨŵŽƚŚĞƌƚŽĐŚŝůĚƚƌĂŶƐŵŝƐƐŝŽŶ ϴ͘ EĂƚŝŽŶĂůƉƌĞǀĞŶƚŝŽŶŽĨŵŽƚŚĞƌƚŽĐŚŝůĚƚƌĂŶƐŵŝƐƐŝŽŶŐƵŝĚĞůŝŶĞƐ͕ϭƐƚ_{ĞĚŝƚŝŽŶ} _ϮϬϬϰ ϵ͘ EĂƚŝŽŶĂůŐƵŝĚĞůŝŶĞƐĨŽƌƉƌĞǀĞŶƚŝŽŶŽĨŵŽƚŚĞƌƚŽĐŚŝůĚƚƌĂŶƐŵŝƐƐŝŽŶ͕ϮŶĚ_{ĞĚŝƚŝŽŶ} _ϮϬϬϳ ϭϬ͘ EĂƚŝŽŶĂů'ƵŝĚĞůŝŶĞƐĨŽƌŽŵƉƌĞŚĞŶƐŝǀĞĂƌĞŽĨWƌĞǀĞŶƚŝŽŶŽĨDŽƚŚĞƌͲƚŽͲŚŝůĚ dƌĂŶƐŵŝƐƐŝŽŶŽĨ,/s͕ϯƌĚĚŝƚŝŽŶ͘ ϮϬϭϮ ϭϭ͘ EĂƚŝŽŶĂů'ƵŝĚĞůŝŶĞƐĨŽƌĐŽŵƉƌĞŚĞŶƐŝǀĞĐĂƌĞƐĞƌǀŝĐĞƐĨŽƌƉƌĞǀĞŶƚŝŽŶŽĨŵŽƚŚĞƌƚŽ ĐŚŝůĚƚƌĂŶƐŵŝƐƐŝŽŶŽĨ,/sĂŶĚŬĞĞƉŝŶŐŵŽƚŚĞƌƐĂůŝǀĞ͘ ϮϬϭϯ ΎWƌŽǀŝĚĞƌͲŝŶŝƚŝĂƚĞĚƚĞƐƚŝŶŐĂŶĚĐŽƵŶƐĞůŝŶŐ /ŶϮϬϭϮͲϭϯ͕ƚŚĞŶĞƚǁŽƌŬĨŽƌŶĂůǇǌŝŶŐ>ŽŶŐŝƚƵĚŝŶĂůWŽƉƵůĂƟŽŶͲďĂƐĞĚ,/sͬ/^ĚĂƚĂŽŶĨƌŝĐĂ ;>W,ͿƵŶĚĞƌƚŽŽŬĂŶĂůǇƐĞƐƚŽƵŶĚĞƌƐƚĂŶĚƚƌĞŶĚƐŝŶŵŽƌƚĂůŝƚǇĂƩƌŝďƵƚĂďůĞƚŽ,/sͬ/^ŝŶ its 10 member Health and Demographic surveillance (HDSS) in six African countries (20). Subsequent studies were undertaken to understand the contextual factors at the policy, ŚĞĂůƚŚ ƐǇƐƚĞŵƐ ĂŶĚ ĐŽŵŵƵŶŝƚǇ ůĞǀĞů ƚŚĂƚ ŵĂǇ ŝŶŇƵĞŶĐĞ ƚŚĞƐĞ ŵŽƌƚĂůŝƚǇ ƚƌĞŶĚƐ ŝŶ ĞĂĐŚ ƐĞƫŶŐ͘dŚĞĮƌƐƚŽĨƚŚĞƐĞ͞ĐŽŶƚĞǆƚ͟ƐƚƵĚŝĞƐǁĂƐĂƌĞǀŝĞǁŽĨŶĂƟŽŶĂůƉŽůŝĐŝĞƐĂŶĚŐƵŝĚĞůŝŶĞƐ regarding HTC, PMTCT and CTC services in the six countries, including Tanzania (21). This ǁĂƐĨŽůůŽǁĞĚďǇĂƐƵƌǀĞǇŽĨƚŚĞŚĞĂůƚŚĨĂĐŝůŝƟĞƐƐĞƌǀŝŶŐƚŚĞƉŽƉƵůĂƟŽŶƐŽĨƚŚĞϭϬ,^^Ɛ͘ dŚĞ/ĨĂŬĂƌĂ,^^ũŽŝŶĞĚƚŚĞ>W,ŶĞƚǁŽƌŬŝŶϮϬϭϬĂŶĚŚĂƐďĞĞŶĐŽŶĚƵĐƟŶŐĚĞŵŽŐƌĂƉŚŝĐ surveillance of about 125,000 people since 1996 (22). The site includes 12 public health ĨĂĐŝůŝƟĞƐǁŚŝĐŚǁĞƌĞƐƵƌǀĞǇĞĚĂƐƉĂƌƚŽĨƚŚĞ>W,ƐƵƌǀĞǇ;ϮϯͿ͘ŽŵƉĂƌŝŶŐŶĂƟŽŶĂů,/s ƉŽůŝĐŝĞƐĂŶĚŐƵŝĚĞůŝŶĞƐǁŝƚŚƌĞƉŽƌƚĞĚƉƌĂĐƟĐĞƐǁŝƚŚŝŶƚŚĞƐĞŚĞĂůƚŚĨĂĐŝůŝƟĞƐƐŚŽǁĞĚƚŚĂƚ ƚŚĞƌĞǁĞƌĞŝŵƉůĞŵĞŶƚĂƟŽŶŐĂƉƐŽĨƐŽŵĞŐƵŝĚĞůŝŶĞƌĞĐŽŵŵĞŶĚĂƟŽŶƐĨŽƌ,d͕WDddĂŶĚ CTC. Table 2 presents some examples of the gaps found.

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Chapter 6

110

Tanzania. One was conducted in the referral hospital serving our study site and it found that ůĂĐŬŽĨŬŶŽǁůĞĚŐĞĂŵŽŶŐƉƌŽǀŝĚĞƌƐ͕ƐƟŐŵĂĂŵŽŶŐĐŽŵŵƵŶŝƚǇŵĞŵďĞƌƐ͕ĂŶĚƵŶĂǀĂŝůĂďŝůŝƚǇ ŽĨZsƐĂƚƌĞůĞǀĂŶƚǁŽƌŬƐƚĂƟŽŶƐĐĂƵƐĞĚƉŽŽƌŝŵƉůĞŵĞŶƚĂƟŽŶŽĨWDddŐƵŝĚĞůŝŶĞ;ϯϮͿ͘ dŚĞƐĞĐŽŶĚdĂŶǌĂŶŝĂŶƐƚƵĚǇƌĞŐĂƌĚŝŶŐďƌĞĂƐƞĞĞĚŝŶŐŐƵŝĚĞůŝŶĞƐĨŽƌ,/sͲŝŶĨĞĐƚĞĚŵŽƚŚĞƌƐ ƐŚŽǁĞĚ ƚŚĂƚ ƐůŽǁŶĞƐƐ ŽĨ ŐƵŝĚĞůŝŶĞ ĚŝƐƐĞŵŝŶĂƟŽŶ͕ ƵƐĞ ŽĨ ŶŐůŝƐŚ ůĂŶŐƵĂŐĞ ŝŶ ŵĂŶƵĂůƐ͕ ůĂĐŬŽĨƐƵŵŵĂƌŝĞƐ͕ůĂĐŬŽĨƐƵƉƉŽƌƟǀĞƐƵƉĞƌǀŝƐŝŽŶ͕ĂŶĚĂďƐĞŶĐĞŽĨĂƌĞĂĚŝŶŐĐƵůƚƵƌĞǁĞƌĞ ĐŚĂůůĞŶŐĞƐƚŽƚŚĞĚŝƐƐĞŵŝŶĂƟŽŶĂŶĚŚĞŶĐĞŝŵƉůĞŵĞŶƚĂƟŽŶŽĨƚŚĞŐƵŝĚĞůŝŶĞ;ϯϯͿ͘ ,ŽǁĞǀĞƌ͕ŶŽƐƚƵĚŝĞƐƐƉĞĐŝĮĐĂůůǇĞǆƉůŽƌĞĚĨĂĐƚŽƌƐ͕ĂĐƌŽƐƐƚŚĞĚĞǀĞůŽƉŵĞŶƚ͕ĚŝƐƐĞŵŝŶĂƟŽŶ ƚŽŝŵƉůĞŵĞŶƚĂƟŽŶƉƌŽĐĞƐƐĞƐ͕ƚŚĂƚŝŶŇƵĞŶĐĞƚŚĞŝŵƉůĞŵĞŶƚĂƟŽŶŽĨŶĂƟŽŶĂůŐƵŝĚĞůŝŶĞƐĨŽƌ the delivery of key HIV services including HTC, PMTCT and CTC. We therefore conducted a ƋƵĂůŝƚĂƟǀĞƐƚƵĚǇƚŽĮŶĚŽƵƚǁŚĂƚŵĂĚĞƉƌŽǀŝĚĞƌƐŽĨ,d͕WDddĂŶĚdƐĞƌǀŝĐĞƐĂĚŚĞƌĞ ƚŽŽƌĚĞǀŝĂƚĞĨƌŽŵƚŚĞŐƵŝĚĞůŝŶĞƐŝŶƐĞůĞĐƚĞĚĨĂĐŝůŝƟĞƐǁŝƚŚŝŶƚǁŽĚŝƐƚƌŝĐƚƐŝŶ/ĨĂŬĂƌĂǁŚĞƌĞ the facility surveys were conducted.

Methods

^ƚƵĚǇĚĞƐŝŐŶĂŶĚƐĞƫŶŐ

dŚŝƐǁĂƐĂƋƵĂůŝƚĂƟǀĞƐƚƵĚǇǁŚĞƌĞďǇǁĞĐŽŶĚƵĐƚĞĚŝŶͲĚĞƉƚŚŝŶƚĞƌǀŝĞǁƐ͘tĞƐĞůĞĐƚĞĚƚŚĞ ŝŶƚĞƌǀŝĞǁĞĞƐĨƌŽŵĮǀĞŚĞĂůƚŚĨĂĐŝůŝƟĞƐŽīĞƌŝŶŐ,/sƐĞƌǀŝĐĞƐƚŽ/ĨĂŬĂƌĂ,^^ƌĞƐŝĚĞŶƚƐ͘dŚŝƐ ƐŝƚĞŝƐůŽĐĂƚĞĚŽŶĂƌŝǀĞƌǀĂůůĞǇĂŶĚƐƉĂŶƐƚǁŽĚŝƐƚƌŝĐƚƐǁŝƚŚĂƚŽƚĂůƉŽƉƵůĂƟŽŶŽĨϲϳϯ͕ϬϴϯŝŶ 2012 (34). Over 70 ethnic groups live here, 60% of who are immigrants including nomadic ĞƚŚŶŝĐŝƟĞƐĨƌŽŵEŽƌƚŚĞƌŶdĂŶǌĂŶŝĂ͕ĂƩƌĂĐƚĞĚďǇƚŚĞĨŽĚĚĞƌ;ϮϮͿ͘tĞƐĞůĞĐƚĞĚƚŚĞĨĂĐŝůŝƟĞƐ ƉƵƌƉŽƐŝǀĞůǇƚŽŝŶĐůƵĚĞĚŝīĞƌĞŶƚŽǁŶĞƌƐŚŝƉ͕ĚŝīĞƌĞŶƚůĞǀĞůƐĂŶĚǀĂƌǇŝŶŐĚŝƐƚĂŶĐĞƐĨƌŽŵƚŚĞ ĚŝƐƚƌŝĐƚŽƌƌĞŐŝŽŶĂůŵĞĚŝĐĂůŽĸĐĞƌ͛ƐŽĸĐĞ͘dŚĞƌĞĨŽƌĞǁĞŝŶĐůƵĚĞĚŽŶĞƉƌŝǀĂƚĞ;ĐŽŵƉĂŶǇͿ ŚŽƐƉŝƚĂů͕ƚǁŽƉƵďůŝĐŚĞĂůƚŚͲĐĞŶƚƌĞƐ͕ŽĨǁŚŝĐŚŽŶĞǁĂƐŝŶƚƌĂŶƐŝƟŽŶƚŽďĞĐŽŵĞĂƐƵďͲĚŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂů ;ŚĞƌĞĂŌĞƌ ƌĞĨĞƌƌĞĚ ƚŽ ĂƐ ƐƵďͲĚŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂůͿ͕ ŽŶĞ ƉƌŝǀĂƚĞ ;ĂƚŚŽůŝĐ ŚƵƌĐŚͿ dispensary and one public dispensary. Only the sub-district hospital was located within ǁĂůŬŝŶŐĚŝƐƚĂŶĐĞŽĨƚŚĞĚŝƐƚƌŝĐƚŵĞĚŝĐĂůŽĸĐĞƐ͘ůůĨĂĐŝůŝƟĞƐĞǆĐĞƉƚƚŚĞƉƌŝǀĂƚĞĚŝƐƉĞŶƐĂƌǇ ŽīĞƌĞĚĂůůƚŚƌĞĞ,/sƐĞƌǀŝĐĞƐ͗,dŝŶǀŽůǀŝŶŐW/dĂŶĚǀŽůƵŶƚĂƌǇĐŽƵŶƐĞůŝŶŐĂŶĚƚĞƐƟŶŐ;sdͿ͖ WDddŝŶǀŽůǀŝŶŐƚĞƐƟŶŐŽĨĞǆƉĞĐƚĂŶƚŵŽƚŚĞƌƐ͕ƚŚĞŝƌƉĂƌƚŶĞƌƐĂŶĚŝŶĨĂŶƚƐǁŚĞŶďŽƌŶĂƐǁĞůů ĂƐƚƌĞĂƟŶŐŵŽƚŚĞƌƐĂŶĚŝŶĨĂŶƚƐǁŚŽƚĞƐƚƉŽƐŝƟǀĞĂŶĚƌĞĨĞƌƌŝŶŐƉĂƌƚŶĞƌƐǁŚŽƚĞƐƚƉŽƐŝƟǀĞƚŽ d͖ĂŶĚdƐĞƌǀŝĐĞƐǁŚŝĐŚŝŶĐůƵĚĞŵŽŶŝƚŽƌŝŶŐĂŶĚƚƌĞĂƟŶŐ,/sŝŶĨĞĐƟŽŶĂŶĚŽƉƉŽƌƚƵŶŝƐƟĐ ŝŶĨĞĐƟŽŶƐ͘ dŚĞ ƉƌŝǀĂƚĞ ĚŝƐƉĞŶƐĂƌǇ ƉƌŽǀŝĚĞĚ ŽŶůǇ ,/s ƚĞƐƟŶŐ ƐĞƌǀŝĐĞƐ͕ ĂůƐŽ ƚŽ ĞǆƉĞĐƚĂŶƚ ŵŽƚŚĞƌƐ͕ĂŶĚƌĞĨĞƌƌĞĚƚŚŽƐĞǁŚŽƚĞƐƚƉŽƐŝƟǀĞƚŽĂŚĞĂůƚŚͲĐĞŶƚƌĞ͘ ^ƚƵĚǇƉĂƌƟĐŝƉĂŶƚ͕ƐĂŵƉůŝŶŐĂŶĚƌĞĐƌƵŝƚŵĞŶƚ

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͙͘͞/ĐĂŶũƵƐƚƐĂǇŝƚŝƐůĂǆŝƚǇ͙͗͘͟ƋƵĂůŝƚĂƟǀĞƐƚƵĚǇŽĨĨĂĐŝůŝƚĂƟŶŐĂŶĚŝŵƉĞĚŝŶŐ ĨĂĐƚŽƌƐŽĨ,/sŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶŝŶƚǁŽ^ŽƵƚŚĞƌŶĚŝƐƚƌŝĐƚƐŽĨdĂŶǌĂŶŝĂ

111

sampling at the facility level, we approached the facility manager who helped in the ŝĚĞŶƟĮĐĂƟŽŶŽĨƚŚĞƉƌŽǀŝĚĞƌƐŽĨ,d͕WDddĂŶĚdƐĞƌǀŝĐĞƐ͘tŚĞƌĞƚŚĞƌĞǁĞƌĞŵƵůƟƉůĞ providers, we requested to speak with the most senior or longest-serving provider as they ǁĞƌĞůŝŬĞůǇƚŽŚĂǀĞŵŽƌĞĞǆƉĞƌŝĞŶĐĞǁŝƚŚŝŵƉůĞŵĞŶƚĂƟŽŶŽĨƚŚĞŐƵŝĚĞůŝŶĞ͘ ŌĞƌ ŽďƚĂŝŶŝŶŐ ĂƉƉƌŽǀĂů ŽĨ ĨĂĐŝůŝƚǇ ŵĂŶĂŐĞƌƐ͕ ĚŝƐƚƌŝĐƚ ĂŶĚ ƌĞŐŝŽŶĂů ŵĞĚŝĐĂů ŽĸĐĞƌƐ ĂŶĚ ŶĂƟŽŶĂů /^ ĐŽŶƚƌŽů ƉƌŽŐƌĂŵŵĞ ĚŝƌĞĐƚŽƌ ƌĞƐƉĞĐƟǀĞůǇ͕ ĞĂĐŚ ƌĞƐƉŽŶĚĞŶƚ ǁĂƐ ĂƐŬĞĚ ƚŽ ƉƌŽǀŝĚĞǁƌŝƩĞŶŝŶĨŽƌŵĞĚĐŽŶƐĞŶƚƚŽƉĂƌƟĐŝƉĂƚĞ͘dŚĞĚŝƐƚƌŝĐƚŽĸĐĞƌŽĨŽŶĞĚŝƐƚƌŝĐƚĚŝĚŶŽƚ ƚƵƌŶƵƉĨŽƌƚŚƌĞĞŝŶƚĞƌǀŝĞǁĂƉƉŽŝŶƚŵĞŶƚƐĂŶĚǁĂƐĐŽŶƐŝĚĞƌĞĚƚŽŚĂǀĞĚĞĐůŝŶĞĚƚŽƉĂƌƟĐŝƉĂƚĞ͘ /ŶƚĞƌǀŝĞǁƐŽĨƉƌŽǀŝĚĞƌƐǁĞƌĞĐŽŶĚƵĐƚĞĚŝŶƚŚĞǀŝĐŝŶŝƚǇŽĨƚŚĞŚĞĂůƚŚĨĂĐŝůŝƚǇĂŌĞƌǁŽƌŬ͘dŚŽƐĞ ŽĨŬĞǇŝŶĨŽƌŵĂŶƚƐǁĞƌĞĐŽŶĚƵĐƚĞĚŝŶƚŚĞŝƌŽĸĐĞƐ͘ůƚŚŽƵŐŚǁĞŚĂĚƉůĂŶŶĞĚƚŽŝŶƚĞƌǀŝĞǁϮϲ ƌĞƐƉŽŶĚĞŶƚƐ͕ƐĂƚƵƌĂƟŽŶŽŶĂůůŝƐƐƵĞƐŽĨŝŶƚĞƌĞƐƚǁĂƐĂƩĂŝŶĞĚĂŌĞƌϭϰƉƌŽǀŝĚĞƌƐ͕ĮǀĞĨĂĐŝůŝƚǇ managers and four key informants were interviewed hence recruitment was stopped.

^ƚƵĚǇƚŽŽůƐĂŶĚĚĂƚĂĐŽůůĞĐƟŽŶ

We used three semi-structured interview guides, for providers, facility managers and key informants, which were translated into Kiswahili. We piloted and then adapted the ŐƵŝĚĞƐĂĐĐŽƌĚŝŶŐƚŽƚŚĞĮŶĚŝŶŐƐĨƌŽŵƚŚĞƉŝůŽƚŝŶƚĞƌǀŝĞǁƐ͘dŚĞŐƵŝĚĞƐŝŶĐůƵĚĞĚƋƵĞƐƟŽŶƐ about their knowledge and experiences regarding HIV guideline development or revision, ŐƵŝĚĞůŝŶĞĚŝƐƐĞŵŝŶĂƟŽŶĂŶĚŝŵƉůĞŵĞŶƚĂƟŽŶ͘WƌŽǀŝĚĞƌƐǁĞƌĞĂĚĚŝƟŽŶĂůůǇĂƐŬĞĚĂďŽƵƚƚŚĞŝƌ ƚŚŽƵŐŚƚƐŽƌĞǆƉĞƌŝĞŶĐĞƐŽŶǁŚǇŐƵŝĚĞůŝŶĞƌĞĐŽŵŵĞŶĚĂƟŽŶƐǁĞƌĞŶŽƚĂůǁĂǇƐŝŵƉůĞŵĞŶƚĞĚ͕ ǁŝƚŚƉƌŽďĞƐĨŽƌƚŚĞĚŝīĞƌĞŶƚĚĞƚĞƌŵŝŶĂŶƚƐŽĨŝŶŶŽǀĂƟŽŶƵƉƚĂŬĞĂĐĐŽƌĚŝŶŐƚŽ&ůĞƵƌĞŶ͘dŚĞƐĞ ƋƵĞƐƟŽŶƐǁĞƌĞƐƉĞĐŝĮĐƚŽŽƵƌĮŶĚŝŶŐƐƌĞŐĂƌĚŝŶŐƚŚĞŝŵƉůĞŵĞŶƚĂƟŽŶŐĂƉƐĨƌŽŵƚŚĞĐŽŶƚĞǆƚ studies. For instance, we found that providers in the context study did not always provide post-test counseling and so we asked why this would happen. Facility managers were in ĂĚĚŝƟŽŶĂƐŬĞĚĂďŽƵƚƚŚĞŝƌƌŽůĞƐŝŶŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶ͘<ĞǇŝŶĨŽƌŵĂŶƚƐǁĞƌĞĂƐŬĞĚ ĂďŽƵƚƚŚĞŝƌƌŽůĞŝŶŐƵŝĚĞůŝŶĞĚĞǀĞůŽƉŵĞŶƚ͕ƌĞǀŝƐŝŽŶĂŶĚŝŵƉůĞŵĞŶƚĂƟŽŶ͕ĂŶĚĨŽƌƚŚĞŝƌǀŝĞǁƐ ŽƌĞǆƉĞƌŝĞŶĐĞƐŽŶǁŚĂƚŝŶŇƵĞŶĐĞƐŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶ͘

Interviews were conducted in July 2015 in Swahili by author MM and 2 experienced assistants with masters and bachelors training in social science. Interviews were recorded and took on average about 1 hour for providers and half an hour for facility managers and key informants.

ĂƚĂĂŶĂůǇƐŝƐ

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Chapter 6 112 ŝǀĞƚĞƌŵŝŶĂŶƚƐƌĞůĂƚĞĚƚŽƚŚĞŽƌŐĂŶŝǌĂƟŽŶ͕ĂŶĚǀ͘ĞƚĞƌŵŝŶĂŶƚƐƌĞůĂƚĞĚƚŽƚŚĞƐŽĐŝĂů͕ĐƵůƚƵƌĂů ĂŶĚƌĞŐƵůĂƚŽƌǇĐŽŶƚĞǆƚŽĨŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶ͘tĞĐŽŶƐŝĚĞƌĞĚƚŚĞŐƵŝĚĞůŝŶĞƐƚƌĂƚĞŐǇƚŽ ŵĞĂŶƚŚĞĂƉƉƌŽĂĐŚƚŚĂƚǁĂƐƵƐĞĚŝŶŐƵŝĚĞůŝŶĞĚĞǀĞůŽƉŵĞŶƚĂŶĚĚŝƐƐĞŵŝŶĂƟŽŶ͘ƵƌŝŶŐĂŶĂůǇƐŝƐ͕ ƚŚĞĐŽĚĞƐǁĞƌĞŽƌŐĂŶŝǌĞĚĂĐĐŽƌĚŝŶŐƚŽƚŚĞƌĞƐƉŽŶĚĞŶƚŐƌŽƵƉƚŽůŽŽŬĨŽƌƉĂƩĞƌŶƐ͘tĞůŽŽŬĞĚ ĨŽƌƐŝŵŝůĂƌŝƟĞƐĂŶĚĚŝīĞƌĞŶĐĞƐŝŶƌĞƐƉŽŶƐĞƐďĞƚǁĞĞŶƉƌŽǀŝĚĞƌƐŝŶĚŝīĞƌĞŶƚůĞǀĞůƐŽĨĨĂĐŝůŝƟĞƐ͕ŝŶ ƉƵďůŝĐĂŶĚƉƌŝǀĂƚĞĨĂĐŝůŝƟĞƐĂŶĚďĞƚǁĞĞŶƉƌŽǀŝĚĞƌƐ͕ĨĂĐŝůŝƚǇŵĂŶĂŐĞƌƐĂŶĚŬĞǇŝŶĨŽƌŵĂŶƚƐ͘ ƚŚŝĐĂůĐŽŶƐŝĚĞƌĂƟŽŶƐ ƚŚŝĐĂů ĂƉƉƌŽǀĂů ǁĂƐ ŽďƚĂŝŶĞĚ ĨƌŽŵ ƚŚĞ ŝŶƐƟƚƵƟŽŶĂů ƌĞǀŝĞǁ ďŽĂƌĚ ŽĨ ƚŚĞ /ĨĂŬĂƌĂ ,ĞĂůƚŚ /ŶƐƟƚƵƚĞ;/,/ͿŝŶdĂŶǌĂŶŝĂĂŶĚƚŚĞEĂƟŽŶĂů/ŶƐƟƚƵƚĞĨŽƌDĞĚŝĐĂůZĞƐĞĂƌĐŚ͛ƐĞƚŚŝĐĂůĐŽŵŵŝƩĞĞ ;E/DZͬ,YͬZϴ͘ĞͬǀŽů/ͬϯϱϭ;ϭϮͬϲͬϮϬϭϱͿ͘ůůƐƚƵĚǇƉĂƌƟĐŝƉĂŶƚƐƉƌŽǀŝĚĞĚŝŶĨŽƌŵĞĚĐŽŶƐĞŶƚ͘ Results ŚĂƌĂĐƚĞƌŝƐƟĐƐŽĨƉĂƌƟĐŝƉĂŶƚƐ dĂďůĞϯƐŚŽǁƐƐŽŵĞĐŚĂƌĂĐƚĞƌŝƐƟĐƐŽĨƚŚĞƌĞƐƉŽŶĚĞŶƚƐ͘ůůĨĂĐŝůŝƚǇŚĞĂĚƐǁĞƌĞĐůŝŶŝĐŝĂŶƐ͕ with two of them being medical doctors.

dĂďůĞϯ͗ŚĂƌĂĐƚĞƌŝƐƟĐƐŽĨƉĂƌƟĐŝƉĂŶƚƐ ϭϰϰ ĨŽƌƐŝŵŝůĂƌŝƚŝĞƐĂŶĚĚŝĨĨĞƌĞŶĐĞƐŝŶƌĞƐƉŽŶƐĞƐďĞƚǁĞĞŶƉƌŽǀŝĚĞƌƐŝŶĚŝĨĨĞƌĞŶƚůĞǀĞůƐŽĨĨĂĐŝůŝƚŝĞƐ͕ŝŶ ƉƵďůŝĐĂŶĚƉƌŝǀĂƚĞĨĂĐŝůŝƚŝĞƐĂŶĚďĞƚǁĞĞŶƉƌŽǀŝĚĞƌƐ͕ĨĂĐŝůŝƚǇŵĂŶĂŐĞƌƐĂŶĚŬĞǇŝŶĨŽƌŵĂŶƚƐ͘ ƚŚŝĐĂůĐŽŶƐŝĚĞƌĂƚŝŽŶƐ ƚŚŝĐĂůĂƉƉƌŽǀĂůǁĂƐŽďƚĂŝŶĞĚĨƌŽŵƚŚĞŝŶƐƚŝƚƵƚŝŽŶĂůƌĞǀŝĞǁďŽĂƌĚŽĨƚŚĞ/ĨĂŬĂƌĂ,ĞĂůƚŚ/ŶƐƚŝƚƵƚĞ ;/,/ͿŝŶdĂŶǌĂŶŝĂĂŶĚƚŚĞEĂƚŝŽŶĂů/ŶƐƚŝƚƵƚĞĨŽƌDĞĚŝĐĂůZĞƐĞĂƌĐŚ͛ƐĞƚŚŝĐĂůĐŽŵŵŝƚƚĞĞ ;E/DZͬ,YͬZϴ͘ĞͬǀŽů/ͬϯϱϭ;ϭϮͬϲͬϮϬϭϱͿ͘ůůƐƚƵĚǇƉĂƌƚŝĐŝƉĂŶƚƐƉƌŽǀŝĚĞĚŝŶĨŽƌŵĞĚĐŽŶƐĞŶƚ͘ ZĞƐƵůƚƐ ŚĂƌĂĐƚĞƌŝƐƚŝĐƐŽĨƉĂƌƚŝĐŝƉĂŶƚƐ dĂďůĞϯƐŚŽǁƐƐŽŵĞĐŚĂƌĂĐƚĞƌŝƐƚŝĐƐŽĨƚŚĞƌĞƐƉŽŶĚĞŶƚƐ͘ůůĨĂĐŝůŝƚǇŚĞĂĚƐǁĞƌĞĐůŝŶŝĐŝĂŶƐ͕ǁŝƚŚ ƚǁŽŽĨƚŚĞŵďĞŝŶŐŵĞĚŝĐĂůĚŽĐƚŽƌƐ͘ dĂďůĞϯ͗ŚĂƌĂĐƚĞƌŝƐƚŝĐƐŽĨƉĂƌƚŝĐŝƉĂŶƚƐ <ĞǇ ŝŶĨŽƌŵĂŶƚƐ WƌŝǀĂƚĞŚŽƐƉŝƚĂů WƵďůŝĐƐƵďͲĚŝƐƚƌŝĐƚ WƵďůŝĐŚĞĂůƚŚĐĞŶƚƌĞ WƌŝǀĂƚĞĚŝƐƉĞŶƐĂƌǇ WƵďůŝĐĚŝƐƉĞŶƐĂƌǇ

dŽƚĂů Eсϰ Eсϰ Eсϰ Eсϰ Eсϯ Eсϰ

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113

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Chapter 6

114

ĂŶĚŚĂƉŚĂǌĂƌĚĚŝƐƚƌŝďƵƟŽŶŽĨƚŚĞĚŽĐƵŵĞŶƚƐ͘&ŽƌŝŶƐƚĂŶĐĞ͕ǁĞĨŽƵŶĚƚŚĂƚƚŚĞ,dϮϬϭϯ ŐƵŝĚĞůŝŶĞĚŽĐƵŵĞŶƚŚĂĚŶŽƚƌĞĂĐŚĞĚĂŶǇŽĨƚŚĞĮǀĞĨĂĐŝůŝƟĞƐĂƚƚŚĞƟŵĞŽĨƚŚĞƐƚƵĚǇŝŶ :ƵůǇϮϬϭϱ͘dŽĐŽƉĞǁŝƚŚƚŚĞŝŶĂĚĞƋƵĂĐǇŽĨĐŽƉŝĞƐ͕ďŽƚŚƚŚĞĚŝƐƚƌŝĐƚŽĸĐĞƌĂŶĚƚŚĞŚĞĂůƚŚͲ centre manager explained how they made photocopies of only important pages and sent ƚŽƚŚĞĨĂĐŝůŝƟĞƐƚŚĂƚŚĂĚŶŽƚǇĞƚƌĞĐĞŝǀĞĚĐŽƉŝĞƐ͘<ĞǇŝŶĨŽƌŵĂŶƚƐĂůƐŽĞǆƉůĂŝŶĞĚŚŽǁƚŚĞǇ coach and mentor these providers on the guideline that they have not yet received. (Table 4, quote 1)

ZĞŐĂƌĚŝŶŐ ƚƌĂŝŶŝŶŐ͕ ƌĞƐƉŽŶĚĞŶƚƐ ǁŚŽ ǁĞƌĞ ůŽǁĞƌ ĐĂĚƌĞ ƚŚĂŶ ĐůŝŶŝĐŝĂŶƐ ĨƌŽŵ Ăůů ĨĂĐŝůŝƟĞƐ except the sub-district hospital, complained about what they perceived as unfairness in ƚŚĞ ƐĞůĞĐƟŽŶ ŽĨ ƚƌĂŝŶĞĞƐ ŝŶ ƚŚĂƚ ƚŚĞ ƐĂŵĞ ƉĞŽƉůĞ ĂƩĞŶĚĞĚ ƚƌĂŝŶŝŶŐƐ ŽǀĞƌ ĂŶĚ ŽǀĞƌ͕ ĂŶĚ ƚŚĂƚ ƐŽŵĞ ƉƌŽǀŝĚĞƌƐ ǁŚŽ ĚŽŶ͛ƚ ƉĂƌƟĐŝƉĂƚĞ ŝŶ ,/s ƐĞƌǀŝĐĞƐ ǁĞƌĞ ƐŽŵĞƟŵĞƐ ƐĞůĞĐƚĞĚ ĨŽƌ ƵƉĚĂƚĞƚƌĂŝŶŝŶŐƐ͘dŚĞƌĞŐŝŽŶĂůŽĸĐĞƌĐŽŶĐƵƌƌĞĚǁŝƚŚƚŚĞƐĞƐĞŶƟŵĞŶƚƐ͘ĞƐŝĚĞƐƐĞůĞĐƟŽŶŽĨ trainees, some PMTCT providers indicated that they failed to learn some aspects when the ƐĞƐƐŝŽŶƐǁĞƌĞĚĞůŝǀĞƌĞĚŝŶŶŐůŝƐŚŽƌǁŚĞŶŽŶůǇĂĨĞǁƚƌĂŝŶĞĞƐŐŽƚƚŽƉƌĂĐƟĐĂůůǇƉĞƌĨŽƌŵĂ skill during training. (Table 4, quote 2)

ƚĂůůĨĂĐŝůŝƟĞƐ͕ĂĐƵůƚƵƌĞŽĨŝŶƚĞƌŶĂůĚŝƐƐĞŵŝŶĂƟŽŶŽĨŶĞǁŐƵŝĚĞůŝŶĞƐǁĂƐƌĞƉŽƌƚĞĚ͘/ŶƚŚŝƐ͕ ƐƚĂīǁŚŽŚĂĚƌĞƚƵƌŶĞĚĨƌŽŵƚƌĂŝŶŝŶŐƌĞƉŽƌƚĞĚƚŽƚŚĞƌĞƐƚŽĨƐƚĂīŽŶǁŚĂƚƚŚĞǇůĞĂƌŶƚĂŶĚ shared any material they came with. Respondents explained that this was done during ƌŽƵƟŶĞŵĞĞƟŶŐƐůŝŬĞƚŚĞĚĂŝůǇĐůŝŶŝĐĂůŚĂŶĚŽǀĞƌŵĞĞƟŶŐƐĂƚƚŚĞƐƵďͲĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂůĂŶĚ ƚŚĞǁĞĞŬůǇ,/sƐĞƌǀŝĐĞƐƉƌŽǀŝĚĞƌƐŵĞĞƟŶŐƐĂƚƚŚĞƉƌŝǀĂƚĞŚŽƐƉŝƚĂůĂŶĚƐŽŽŶůǇƚŚŽƐĞǁŚŽ ĂƩĞŶĚĞĚƚŚĞƉĂƌƟĐƵůĂƌŵĞĞƟŶŐŐŽƚƚŽůĞĂƌŶŽĨƚŚĞŐƵŝĚĞůŝŶĞƵƉĚĂƚĞƐ͘ ĞƚĞƌŵŝŶĂŶƚƐƌĞůĂƚĞĚƚŽƚŚĞŐƵŝĚĞůŝŶĞ KŶĐĞ ƚŚĞ ŐƵŝĚĞůŝŶĞ ƌĞĂĐŚĞĚ ƚŚĞ ĨĂĐŝůŝƟĞƐ͕ ƚŚĞǇ ǁĞƌĞ ŶŽƚ ĂůǁĂǇƐ ƌĞĂĚ ďĞĐĂƵƐĞ ĂĐĐŽƌĚŝŶŐ ƚŽ Ăůů ƌĞƐƉŽŶĚĞŶƚƐ͕ ŐƵŝĚĞůŝŶĞƐ ǁƌŝƩĞŶ ŝŶ ŶŐůŝƐŚ ǁĞƌĞ ĚŝĸĐƵůƚ ƚŽ ĐŽŵƉƌĞŚĞŶĚ ĨŽƌ ŶŽŶͲ ĐůŝŶŝĐŝĂŶĐĂĚƌĞƐŽĨƉƌŽǀŝĚĞƌƐ͘dŚĞŶĂƟŽŶĂůŽĸĐĞƌƐĞǆƉůĂŝŶĞĚƚŚĂƚƚŚĞƌĞǁĂƐůĂĐŬŽĨĮŶĂŶĐĞƐ ƚŽƚƌĂŶƐůĂƚĞĂŶĚƌĞͲƉƌŽĚƵĐĞƚƌĂŶƐůĂƚĞĚĐŽƉŝĞƐ͘/ŶĂĚĚŝƟŽŶ͕ŐƵŝĚĞůŝŶĞĚŽĐƵŵĞŶƚƐƚŚĂƚǁĞƌĞ ƉĞƌĐĞŝǀĞĚƚŽďĞůĂƌŐĞĂŶĚŚĂǀŝŶŐĂůŽƚŽĨƚĞǆƚǁĞƌĞĐŽŶƐŝĚĞƌĞĚƵŶĂƩƌĂĐƟǀĞƚŽƌĞĂĚ͘/ŶƐƚĞĂĚ͕ ƉƌŽǀŝĚĞƌƐĂƉƉƌĞĐŝĂƚĞĚƐƵŵŵĂƌŝǌĞĚĨŽƌŵƐŽĨŐƵŝĚĞůŝŶĞůŝŬĞƐƚĂŶĚĂƌĚŽƉĞƌĂƟŶŐŐƉƌŽĐĞĚƵƌĞƐ ;^KWƐͿ͕ŇŽǁĐŚĂƌƚƐŽƌĚƌĂǁŝŶŐƐ͘,ŽǁĞǀĞƌ͕ŶĂƟŽŶĂůĂŶĚƌĞŐŝŽŶĂůŽĸĐĞƌƐƐƚĂƚĞĚƚŚĂƚĨƵŶĚƐ ůĂĐŬĞĚ ĨŽƌ ƚŚĞ ƉƌŽĚƵĐƟŽŶ ĂŶĚ ĚŝƐƚƌŝďƵƟŽŶ ŽĨ ƚŚĞƐĞ ƐƵŵŵĂƌŝǌĞĚ ŐƵŝĚĞůŝŶĞƐ͘ ZĞŐĂƌĚŝŶŐ ƚŚĞ ŐƵŝĚĞůŝŶĞ ƌĞĐŽŵŵĞŶĚĂƟŽŶƐ͕ ƚŚĞŝƌ ƉĞƌĐĞŝǀĞĚ ĐŽŵƉůĞǆŝƚǇ Žƌ ĞĂƐĞ ŽĨ ŝŵƉůĞŵĞŶƚĂƟŽŶ ǁĂƐƌĞƉŽƌƚĞĚƚŽďĞŝŵƉĞĚŝŶŐĂŶĚĨĂĐŝůŝƚĂƟŶŐŝŵƉůĞŵĞŶƚĂƟŽŶƌĞƐƉĞĐƟǀĞůǇ͘dŚĞƉĞƌĐĞŝǀĞĚ complexity of WHO staging in CTC guideline or use of capillary tubes to sample blood in HTC ĂŶĚWDddŐƵŝĚĞůŝŶĞŵĂĚĞƉƌŽǀŝĚĞƌƐĂǀŽŝĚƚŚĞƐĞĂĐƟǀŝƟĞƐ͘;dĂďůĞϰ͕ƋƵŽƚĞϯͿ

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͙͘͞/ĐĂŶũƵƐƚƐĂǇŝƚŝƐůĂǆŝƚǇ͙͗͘͟ƋƵĂůŝƚĂƟǀĞƐƚƵĚǇŽĨĨĂĐŝůŝƚĂƟŶŐĂŶĚŝŵƉĞĚŝŶŐ ĨĂĐƚŽƌƐŽĨ,/sŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶŝŶƚǁŽ^ŽƵƚŚĞƌŶĚŝƐƚƌŝĐƚƐŽĨdĂŶǌĂŶŝĂ 115 ĞƚĞƌŵŝŶĂŶƚƐƌĞůĂƚĞĚƚŽƚŚĞŚĞĂůƚŚƉƌŽǀŝĚĞƌ;ƵƐĞƌŽĨŐƵŝĚĞůŝŶĞͿ /ŶĚŝǀŝĚƵĂů ĐŚĂƌĂĐƚĞƌŝƐƟĐƐ ŽĨ ƉƌŽǀŝĚĞƌƐ ŝŶŇƵĞŶĐĞĚ ŚŽǁ ŐƵŝĚĞůŝŶĞ ǁŽƵůĚ ďĞ ŝŵƉůĞŵĞŶƚĞĚ͘ dŚĞĐŽŵŵŝƚŵĞŶƚŽĨĨĂĐŝůŝƚǇŵĂŶĂŐĞƌƐĂŶĚĚŝƐƚƌŝĐƚĐŽͲŽƌĚŝŶĂƚŽƌƐǁĂƐŝŵƉŽƌƚĂŶƚŝŶĨĂĐŝůŝƚĂƟŶŐ ŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶĂĐĐŽƌĚŝŶŐƚŽƚŚĞƌĞŐŝŽŶĂůŽĸĐĞƌ͘WƌŽǀŝĚĞƌƐŝŶĚŝĐĂƚĞĚƚŚĂƚŚĂǀŝŶŐĂ ƉŽƐŝƟǀĞĂƫƚƵĚĞƚŽǁĂƌĚƐƚŚĞŐƵŝĚĞůŝŶĞ͕ďĞůŝĞǀŝŶŐƚŚĂƚƚŚĞƐĞƌǀŝĐĞƐĂƌĞďĞŶĞĮĐŝĂůƚŽĐůŝĞŶƚƐĂŶĚ ŚĂǀŝŶŐĐŽŶĮĚĞŶĐĞŝŶƚŚĞŝƌŽǁŶĂďŝůŝƟĞƐĐĂƵƐĞĚƚŚĞŵƚŽĨŽůůŽǁƚŚĞŐƵŝĚĞůŝŶĞ͘;dĂďůĞϰ͕ƋƵŽƚĞϰͿ ĐĐŽƌĚŝŶŐƚŽŬĞǇŝŶĨŽƌŵĂŶƚƐĂŶĚƚŚĞƉƵďůŝĐĚŝƐƉĞŶƐĂƌǇdƉƌŽǀŝĚĞƌ͕ůŽǁůĞǀĞůŽĨĞĚƵĐĂƟŽŶ ŵĂĚĞ ŝƚ ĐŚĂůůĞŶŐŝŶŐ ĨŽƌ ůŽǁĞƌ ĐĂĚƌĞ ƐƚĂī ƚŽ ĐŽŵƉƌĞŚĞŶĚ ŐƵŝĚĞůŝŶĞƐ͘ <ĞǇ ŝŶĨŽƌŵĂŶƚƐ also thought that lack of a reading culture among providers impeded proper guideline ŝŵƉůĞŵĞŶƚĂƟŽŶ͘ ĐĐŽƌĚŝŶŐ ƚŽ ƐŽŵĞ WDdd ĂŶĚ d ƉƌŽǀŝĚĞƌƐ͕ ůĂǆŝƚǇ Žƌ ĚŝƐƌĞŐĂƌĚ ďǇ ƉƌŽǀŝĚĞƌƐŽĨƐŽŵĞŐƵŝĚĞůŝŶĞƌĞĐŽŵŵĞŶĚĂƟŽŶƐĐĂƵƐĞĚƚŚĞŵŶŽƚƚŽƌĞͲƚĞƐƚŵŽƚŚĞƌƐǁŚŽ ŝŶŝƟĂůůǇƚĞƐƚĞĚ,/sŶĞŐĂƟǀĞĨŽƌWDddĂƚƚŚĞƐƵďͲĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂů͘;dĂďůĞϰ͕ƋƵŽƚĞϱͿ /ƚĞŵĞƌŐĞĚƚŚĂƚƉƌŽǀŝĚĞƌƐƐŽŵĞƟŵĞƐŐŽƚĐƌĞĂƟǀĞƚŽĞŶƐƵƌĞŐƵŝĚĞůŝŶĞĂĐƟǀŝƚǇŽƌƐƚĞƉƐǁĞƌĞ implemented. For instance, HTC provider in the private hospital explained how running out ŽĨďƵīĞƌďĞĨŽƌĞƚĞƐƚƐƚƌŝƉƐŝŶƚŚĞŬŝƚĂƌĞĮŶŝƐŚĞĚŵĂĚĞŚĞƌĐŚĂŶŐĞĨƌŽŵƵƐŝŶŐǁŚŽůĞďůŽŽĚ ĂƐƌĞƋƵŝƌĞĚĨŽƌ,/sƚĞƐƟŶŐĂƚƚŚĞƉŽŝŶƚŽĨĐĂƌĞ͕ƚŽƵƐŝŶŐƐĞƌƵŵĂƐŝƐĚŽŶĞĨŽƌďůŽŽĚĨŽƌ ƚƌĂŶƐĨƵƐŝŽŶǁŚĞƌĞďǇďƵīĞƌŝƐŶŽƚƌĞƋƵŝƌĞĚ͘ƚƚŚĞƉƵďůŝĐĚŝƐƉĞŶƐĂƌǇƚŚĞǇƐĞŶƚƚŚĞŵŽƚŚĞƌƐ ƚŽĚĞůŝǀĞƌůĞƩĞƌƐƚŽƚŚĞŝƌŵĂůĞƉĂƌƚŶĞƌƐ͕ŝŶǀŝƟŶŐƚŚĞŵƚŽĐŽŵĞĨŽƌƚĞƐƟŶŐ͘;dĂďůĞϰ͕ƋƵŽƚĞϲͿ dŚŝƐĐƌĞĂƟǀŝƚǇǁĂƐŚŽǁĞǀĞƌƐŽŵĞƟŵĞƐŚĂƌŵĨƵůĂƐǁĂƐĞǆƉůĂŝŶĞĚďǇƚŚĞƌĞŐŝŽŶĂůŽĸĐĞƌŝŶ Table 4, quote 7. ƚĂůůĨĂĐŝůŝƟĞƐĂŶĚĨŽƌĂůů,/sƐĞƌǀŝĐĞƐ͕ƉƌŽǀŝĚĞƌƐĚĞƐĐƌŝďĞĚŚŽǁƚŚĞǇƐƵƉƉŽƌƚĞĚĞĂĐŚŽƚŚĞƌ ǁŝƚŚƚŚĞƵŶĚĞƌƐƚĂŶĚŝŶŐŽĨŐƵŝĚĞůŝŶĞƐďǇƐĞĞŬŝŶŐĐůĂƌŝĮĐĂƟŽŶƐĨƌŽŵĞĂĐŚŽƚŚĞƌĂŶĚƌĞŵŝŶĚŝŶŐ each other of guideline requirements. They reported how facility managers helped out ŝŶ ĂĐƚƵĂů ŝŵƉůĞŵĞŶƚĂƟŽŶ͕ ŝŶ ŝŶƚĞƌƉƌĞƟŶŐ ŶŐůŝƐŚ ŐƵŝĚĞůŝŶĞƐ͕ ĂŶĚ ŝŶ ŽďƚĂŝŶŝŶŐ ƐƵƉƉůŝĞƐ ǁŚĞŶƚŚĞǇƌƵŶŽƵƚ͘ŝƐƚƌŝĐƚĂŶĚƌĞŐŝŽŶĂůŽĸĐĞƌƐŝŶĚŝĐĂƚĞĚƚŚĂƚƚŚĞǇƐƵƉƉŽƌƚĞĚŐƵŝĚĞůŝŶĞ ŝŵƉůĞŵĞŶƚĂƟŽŶ ƚŚƌŽƵŐŚ ƐƵƉĞƌǀŝƐŝŽŶ ĂŶĚ ĐŽĂĐŚŝŶŐ ŽĨ ƉƌŽǀŝĚĞƌƐ͘ dŚŝƐ ǁĂƐ ĐŽƌƌŽďŽƌĂƚĞĚ ďǇƉƌŽǀŝĚĞƌƐĂƚĂůůĨĂĐŝůŝƟĞƐĂůƚŚŽƵŐŚƐĞŶƟŵĞŶƚƐǁĞƌĞĞǆƉƌĞƐƐĞĚďǇƐŽŵĞƉƌŽǀŝĚĞƌƐƚŚĂƚ supervisors were more interested in the number of persons served than in circumstances under which services are provided. (Table 4, quote 8)

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Chapter 6

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ĐĐŽƌĚŝŶŐ ƚŽ ŶĂƟŽŶĂů ĂŶĚ ƌĞŐŝŽŶĂů ŽĸĐĞƌƐ͕ ŝŶĐƌĞĂƐĞĚ ƉĂƟĞŶƚ ůŽĂĚ ŵĂŬĞƐ ƉƌŽǀŝĚĞƌƐ ŝŵƉůĞŵĞŶƚŐƵŝĚĞůŝŶĞƐƉŽŽƌůǇĂŶĚĐŽŶǀĞƌƐĞůǇůĞƐƐƉĂƟĞŶƚůŽĂĚĂůůŽǁĞĚĨŽƌďĞƩĞƌŐƵŝĚĞůŝŶĞ ŝŵƉůĞŵĞŶƚĂƟŽŶ͘&ŽƌĞǆĂŵƉůĞ͕ĐŽŵƉůĞƟŽŶŽĨƌĞŐŝƐƚĞƌƐďǇƚŚĞŚĞĂůƚŚĐĞŶƚĞƌ͛ƐdƉƌŽǀŝĚĞƌ͕ provision of comprehensive counseling by the PMTCT provider at the sub-district hospital ĂŶĚ,/sƚĞƐƟŶŐŽĨĂůůĞůŝŐŝďůĞƉĂƟĞŶƚƐĂƩĞŶĚŝŶŐŽƵƚƉĂƟĞŶƚƐĞƌǀŝĐĞƐĂƚƚŚĞƉƵďůŝĐĚŝƐƉĞŶƐĂƌǇ ǁĞƌĞŶŽƚĚŽŶĞĚƵƌŝŶŐďƵƐǇƟŵĞƐ͘;dĂďůĞϰ͕ƋƵŽƚĞϭϬͿ /ŶĂĚĞƋƵĂĐǇŽĨƐƉĂĐĞƚŽƉƌŽǀŝĚĞ,/sƐĞƌǀŝĐĞƐĐĂƵƐĞĚůĂĐŬŽĨƉƌŝǀĂĐǇĂŶĚĐŽŶĮĚĞŶƟĂůŝƚǇĨŽƌ ĐůŝĞŶƚƐĂŶĚƉĂƟĞŶƚƐĂƚĂůůĨĂĐŝůŝƟĞƐ͘ƚƚŚĞƉƵďůŝĐĚŝƐƉĞŶƐĂƌǇ͕ŽƵƚƉĂƟĞŶƚĂŶĚdƐĞƌǀŝĐĞƐ ǁĞƌĞŽīĞƌĞĚŝŶƚŚĞƐĂŵĞƌŽŽŵďǇĚŝīĞƌĞŶƚƉƌŽǀŝĚĞƌƐĂůƚĞƌŶĂƚĞůǇ͘;dĂďůĞϰ͕ƋƵŽƚĞϭϭͿ ^ƚŽĐŬͲŽƵƚƐ ŽĨ ^ ŬŝƚƐ͕ ,/s ƚĞƐƚ ŬŝƚƐ ĂŶĚ ŵĞĚŝĐĂƟŽŶ ĐŽŵƉůĞƚĞůǇ ŚĂůƚĞĚ ƚŚĞ ƉƌŽǀŝƐŝŽŶ ŽĨ ƐĞƌǀŝĐĞƐůŝŬĞ,/sƚĞƐƟŶŐ͕ĞĂƌůǇŝŶĨĂŶƚĚŝĂŐŶŽƐŝƐĂŶĚŵĂŶĂŐĞŵĞŶƚŽĨŽƉƉŽƌƚƵŶŝƐƟĐŝŶĨĞĐƟŽŶƐ͘ dŚĞ ƌĞĂƐŽŶƐ ŐŝǀĞŶ ĨŽƌ ŵŝƐƐŝŶŐ ƐƵƉƉůŝĞƐ ǁĞƌĞ ďŽƚŚ ŝŶƚĞƌŶĂů ĂŶĚ ĞǆƚĞƌŶĂů ƚŽ ƚŚĞ ĨĂĐŝůŝƟĞƐ͘ tŝƚŚŝŶĨĂĐŝůŝƟĞƐ͕,dƐĞƌǀŝĐĞƐǁĞƌĞŵŽƐƚůǇĂīĞĐƚĞĚ͕ǁŝƚŚŬĞǇƌĞĂƐŽŶƐŝŶĐůƵĚŝŶŐ͕ƌƵŶŶŝŶŐŽƵƚ ŽĨďƵīĞƌďĞĨŽƌĞƚŚĞĂĐĐŽŵƉĂŶǇŝŶŐƚĞƐƚƐƚƌŝƉƐǁĞƌĞĮŶŝƐŚĞĚǇĞƚƚĞƐƚƐĐĂŶŶŽƚďĞƵƐĞĚǁŝƚŚ ďƵīĞƌĨƌŽŵĂŶŽƚŚĞƌŬŝƚ͖ŵŝƐƵƐĞŽĨƚĞƐƚƐďǇƉƌŽǀŝĚĞƌƐŝŶĐůƵĚŝŶŐƐƚĞĂůŝŶŐƚŚĞŵĨŽƌƉƌŝǀĂƚĞƵƐĞ͖ ĂŶĚƉŽŽƌƌĞĐŽƌĚŝŶŐůĞĂĚŝŶŐƚŽƵŶĚĞƌͲƌĞƉŽƌƟŶŐŽĨƚĞƐƚƐĚŽŶĞĐĂƵƐŝŶŐƵŶĚĞƌͲĨŽƌĞĐĂƐƟŶŐŽĨ ƐƵƉƉůǇŶĞĞĚƐ͘dŚĞĞǆƚĞƌŶĂůƌĞĂƐŽŶƐƌĞůĂƚĞĚƚŽŝŶĞĸĐŝĞŶĐŝĞƐŽĨƚŚĞŵĞĚŝĐĂůƐƚŽƌĞƐĚĞƉĂƌƚŵĞŶƚ ;D^ͿƌĞƐƵůƟŶŐŝŶƐƚŽĐŬŽƵƚƐŽĨŵĞĚŝĐĂƟŽŶƐŽƌ^ŬŝƚƐ͕ĚĞůĂǇƐŝŶĚĞůŝǀĞƌŝŶŐĂǀĂŝůĂďůĞƐƚŽĐŬ͕ ŽƌĚĞůŝǀĞƌǇŽĨŽŶůǇĂƉŽƌƟŽŶŽĨƚŚĞƌĞƋƵŝƌĞŵĞŶƚƐĨŽƌƚŚĞ,/sƚĞƐƟŶŐĂůŐŽƌŝƚŚŵĞ͘Ő͘ƚŚĞ,/s ƐĐƌĞĞŶŝŶŐƚĞƐƚŬŝƚǁŝƚŚŽƵƚƚŚĞ,/sĐŽŶĮƌŵĂƟŽŶƚĞƐƚŬŝƚ͘;dĂďůĞϰ͕ƋƵŽƚĞϭϮͿ dŽĐŽƉĞǁŝƚŚƐŚŽƌƚĂŐĞƐŽĨƐƵƉƉůŝĞƐ͕ƉƌŽǀŝĚĞƌƐĞǆƉůĂŝŶĞĚƚŚĂƚĂƚĨĂĐŝůŝƚǇůĞǀĞů͕ƚŚĞǇƉƌŝŽƌŝƟǌĞĚ which groups of clients to test according to facility plans e.g. blood donors in the private ŚŽƐƉŝƚĂů͕WDddŵŽƚŚĞƌƐĂƚƚŚĞƐƵďͲĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂůĂŶĚƐǇŵƉƚŽŵĂƟĐƉĂƟĞŶƚƐĂƚƚŚĞƉƵďůŝĐ health-centre and dispensary. They also borrowed supplies like ARVs and test kits from ŶĞŝŐŚďŽƵƌŝŶŐĨĂĐŝůŝƟĞƐƚŽĞŶƐƵƌĞƚŚĂƚƐĞƌǀŝĐĞƐĐŽŶƟŶƵĞĚ͘;dĂďůĞϰ͕ƋƵŽƚĞϭϯͿ

KƌŐĂŶŝǌĂƟŽŶĂů ĨĂĐƚŽƌƐ ƚŚĂƚ ĨĂĐŝůŝƚĂƚĞĚ ŝŵƉůĞŵĞŶƚĂƟŽŶ ŽĨ ŐƵŝĚĞůŝŶĞ ŝŶĐůƵĚĞĚ ĨŽƌŵĂů ƌĞŝŶĨŽƌĐĞŵĞŶƚ ŽĨ ƚŚĞ ŐƵŝĚĞůŝŶĞ ďǇ ŝŶƚĞŐƌĂƟŶŐ ƚŚĞŝƌ ĂŝŵƐ ŝŶƚŽ ĨĂĐŝůŝƚǇ ƉƌŝŽƌŝƟĞƐ͕ ĂƐ ǁĂƐ reported for the sub-district hospital. According to the facility manager, it was a facility ƉƌŝŽƌŝƚǇƚŽŵĂǆŝŵŝǌĞŵĂƚĞƌŶĂůĂŶĚĐŚŝůĚŚĞĂůƚŚĂŶĚƚŚĞƌĞĨŽƌĞŵŽƌĞƐƚĂīǁĂƐĂůůŽĐĂƚĞĚƚŽ WDdd͕ĂŶĚƚĞƐƟŶŐĨŽƌWDddǁĂƐƉƌŝŽƌŝƟǌĞĚǁŚĞŶƚĞƐƚŬŝƚƐǁĞƌĞŝŶƐŚŽƌƚĂŐĞ͘dŚĞƌĞŐŝŽŶĂů ŽĸĐĞƌ ĂŶĚ ƐƵďͲĚŝƐƚƌŝĐƚ ŚŽƐƉŝƚĂů ŵĂŶĂŐĞƌ ƐƚĂƚĞĚ ƚŚĂƚ ďĞŝŶŐ ŶĞĂƌ ƚŚĞ ƌĞŐŝŽŶĂů Žƌ ĚŝƐƚƌŝĐƚ ŵĞĚŝĐĂůŽĸĐĞƐŵĂĚĞŝƚĞĂƐŝĞƌƚŽŐĞƚƐƵƉƉŽƌƚŝŶŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶĂŶĚƚŽƌĞĐĞŝǀĞ guideline copies and supplies as soon as they were available.

ĞƚĞƌŵŝŶĂŶƚƐƌĞůĂƚĞĚƚŽƚŚĞƐŽĐŝĂů͕ĐƵůƚƵƌĂůĂŶĚƌĞŐƵůĂƚŽƌǇĐŽŶƚĞǆƚ

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117

ĞǆĂŵƉůĞ͕ ŚĂǀŝŶŐ ĂůƚĞƌŶĂƟǀĞ ĞǆƉůĂŶĂƟŽŶƐ ĨŽƌ ďĞŝŶŐ ƐŝĐŬ ďĞƐŝĚĞƐ ,/s ŝŶĨĞĐƟŽŶ͕ ůŝŬĞ ďĞŝŶŐ ďĞǁŝƚĐŚĞĚ͕ĐĂƵƐĞĚƐŽŵĞƉĂƟĞŶƚƐƚŽƌĞĨƵƐĞĞŶƌŽůŵĞŶƚƚŽd͕ĚĞƐƉŝƚĞĂƉŽƐŝƟǀĞ,/sƚĞƐƚ͘ The pastoralist community was reported to be highly mobile and patriarchal. Their nomadic ĞǆŝƐƚĞŶĐĞĐĂƵƐĞĚƚŚĞŵƚŽŵŝƐƐƐĐŚĞĚƵůĞĚdǀŝƐŝƚƐŽŌĞŶĂŶĚƐŝŶĐĞƚŚĞŝƌŵĞŶŚĂĚƚŚĞůĂƐƚ ǁŽƌĚ͕ƚŚĞǇĐŽƵůĚƌĞĨƵƐĞƚŚĞŝƌǁŝǀĞƐƚŽƉĂƌƟĐŝƉĂƚĞŝŶƚĞƐƟŶŐŽƌƚƌĞĂƚŵĞŶƚĨŽƌ,/s͘'ĞŶĞƌĂůůǇ ƚŚŝƐ ĐŽŵŵƵŶŝƚǇ ǁĂƐ ƉĞƌĐĞŝǀĞĚ ƚŽ ŚĂǀĞ ůŽǁ ůĞǀĞůƐ ŽĨ ĞĚƵĐĂƟŽŶĂů ĂƩĂŝŶŵĞŶƚ ĂŶĚ ƉŽŽƌ awareness about HIV which hindered their use of HIV services. (Table 4, quote 14)

Refusals to cooperate with HIV services also happened for non-cultural reason. Providers ĚĞƐĐƌŝďĞĚƚŚĂƚƐŽŵĞƉĂƟĞŶƚƐĞƐƉĞĐŝĂůůǇŵĞŶ͕ƌĞĨƵƐĞĚƚŽƚĞƐƚĨŽƌ,/sŝŶW/dŽƌWDdd͘dŚĞ reasons they gave for refusal included that they were not ready, they were busy or they had ƚƌĂǀĞůůĞĚ͘ZĞŐĂƌĚŝŶŐ,dŝŵƉůĞŵĞŶƚĂƟŽŶ͕ƚŚĞĨĞĂƌŽĨƐƟŐŵĂǁĂƐƚŚŽƵŐŚƚďǇƉƌŽǀŝĚĞƌƐƚŽ be the real reason of men refusing to test for HIV in HTC or PMTCT and not being busy or travelling.

At the private hospital and the sub-district hospital, tested clients refused post-test ĐŽƵŶƐĞůůŝŶŐĐůĂŝŵŝŶŐŝƚƚŽŽŬƵƉŵƵĐŚƟŵĞĂŶĚĂůůƚŚĞǇǁĂŶƚĞĚǁĞƌĞƚŚĞŝƌƌĞƐƵůƚƐ͘;dĂďůĞϰ͕ quote 15) ĐĐŽƌĚŝŶŐƚŽƉƌŽǀŝĚĞƌƐ͕ƐƟŐŵĂŽƌĨĞĂƌŽĨŝƚƉƌĞǀĞŶƚĞĚƉĂƟĞŶƚƐĨƌŽŵĐŽŽƉĞƌĂƟŶŐǁŝƚŚƐŽŵĞ dŐƵŝĚĞůŝŶĞƌĞƋƵŝƌĞŵĞŶƚƐůŝŬĞďƌŝŶŐŝŶŐŵĞĚŝĐĂƟŽŶďŽƩůĞƐĨŽƌƉŝůůĐŽƵŶƚƐ͕ĂůůŽǁŝŶŐ, ǁŽƌŬĞƌƐƚŽǀŝƐŝƚƚŚĞŵŽƌũŽŝŶŝŶŐƉĂƟĞŶƚƐƵƉƉŽƌƚŐƌŽƵƉƐ͕ĂĐĐŽƌĚŝŶŐƚŽĂůůdƉƌŽǀŝĚĞƌƐ͘/ƚĂůƐŽ ŵĂĚĞƐŽŵĞƉĂƟĞŶƚƐƚŽŶŽƚĚŝƐĐůŽƐĞƚŚĞŝƌƐƚĂƚƵƐ͕ĞǀĞŶƚŽĐĂƌĞƌƐ͕ǁŚŝĐŚƉƌŽǀŝĚĞƌƐĨĞůƚƉƵƚƐ carers at risk of being infected. (Table 4, quote 16)

tĞĨŽƵŶĚƚŚĂƚƉĂƟĞŶƚƐ͛ůĂĐŬŽĨŵŽŶĞǇƚŽďƵǇŵĞĚŝĐĂƟŽŶŽƌƚŽĞŶƌŽůŝŶƚŚĞĐŽŵŵƵŶŝƚǇ ŚĞĂůƚŚ ĨƵŶĚ ;Ă ŐŽǀĞƌŶŵĞŶƚ ƉƌŽŵŽƚĞĚ ŝŶƐƵƌĂŶĐĞ ƐĐŚĞŵĞͿ ĐĂƵƐĞĚ ƐŽŵĞ ƉĂƟĞŶƚƐ ƚŽ ŵŝƐƐ ƚĂŬŝŶŐƚŚĞŝƌĚĂŝůǇƉƌŽƉŚǇůĂǆŝƐŵĞĚŝĐĂƟŽŶǁŚŝĐŚƉĂƟĞŶƚƐŚĂĚƚŽďƵǇƐŝŶĐĞƚŚĞĨƌĞĞƉƌŽƉŚǇůĂǆŝƐ ŵĞĚŝĐĂƟŽŶǁĂƐŶŽůŽŶŐĞƌĂǀĂŝůĂďůĞĂƚƚŚĞƉƵďůŝĐŚĞĂůƚŚͲĐĞŶƚƌĞĂŶĚƚŚĞƐƵďͲĚŝƐƚƌŝĐƚŚŽƐƉŝƚĂů͘ /ƚ ĂůƐŽ ĞŵĞƌŐĞĚ ƚŚĂƚ ƐŽŵĞ ƉĂƟĞŶƚƐ ƌĞƉŽƌƚĞĚ ĚŽƵďƚƐ ĂďŽƵƚ ƚŚĞ ,/s ƚĞƐƟŶŐ ĞǆƉĞƌƟƐĞ ŽĨƉƌŽǀŝĚĞƌƐŝŶůŽǁĞƌůĞǀĞůĨĂĐŝůŝƟĞƐ͕ĂŶĚƌĞĨƵƐĞĚƚŽĂĐĐĞƉƚƚŚĞŝƌƌĞƐƵůƚƐŽƌĞŶƌŽůĨŽƌd͘ However, this was reportedly less common among pregnant women accessing PMTCT ƐĞƌǀŝĐĞƐǁŚŽƉĞƌĐĞŝǀĞĚƚŚĞƉŽƚĞŶƟĂůƚŽƉƌŽƚĞĐƚƚŚĞŝƌƵŶďŽƌŶďĂďŝĞƐĂƐĂŶŝŵƉŽƌƚĂŶƚĨĂĐƚŽƌ ĞǆƉůĂŝŶŝŶŐƚŚĞŝƌĂŐƌĞĞŵĞŶƚƚŽƉĂƌƟĐŝƉĂƚĞŵŽƌĞƌĞĂĚŝůǇ͘;dĂďůĞϰ͕ƋƵŽƚĞϭϳͿ

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Chapter 6 120 ŝƐĐƵƐƐŝŽŶ dŚŝƐ ƐƚƵĚǇ ŚĂƐ ƐŚŽǁŶ ƚŚĂƚ ĨĂĐƚŽƌƐ ƚŚĂƚ ŝŶŇƵĞŶĐĞ ŝŵƉůĞŵĞŶƚĂƟŽŶ ŽĨ ,/s ŐƵŝĚĞůŝŶĞ ĂƌĞ ŵƵůƟĨĂĐĞƚĞĚ͕ƐƉĂŶŶŝŶŐƚŚĞŐƵŝĚĞůŝŶĞƉƌŽĐĞƐƐĨƌŽŵĚĞǀĞůŽƉŵĞŶƚŽƌƌĞǀŝƐŝŽŶƚŽĚŝƐƐĞŵŝŶĂƟŽŶ ĂŶĚ ŝŵƉůĞŵĞŶƚĂƟŽŶ͘ dŚĞƐĞ ĨĂĐƚŽƌƐ ĂůƐŽ ŝŶǀŽůǀĞ ĚŝīĞƌĞŶƚ ƉůĂǇĞƌƐ ŝŶĐůƵĚŝŶŐ ƐĞƌǀŝĐĞ ƵƐĞƌƐ͕ ŚĞĂůƚŚ ƉƌŽǀŝĚĞƌƐ ĂŶĚ ŐƵŝĚĞůŝŶĞ ŵĂŬĞƌƐ ĂŶĚ ƌĞǀŝĞǁĞƌƐ ǁŚŽ ƚƌĂŶƐůĂƚĞ ĂƉƉƌŽǀĞĚ ŶĂƟŽŶĂů ƉŽůŝĐŝĞƐĂŶĚƐƚƌĂƚĞŐŝĞƐŝŶƚŽƉƌĂĐƟĐĞŐƵŝĚĞůŝŶĞ͘dŽĐŽŶƚƌŝďƵƚĞƚŽƚŚĞŐůŽďĂůĐĂůůƚŽĞůŝŵŝŶĂƚĞ ,/s͕ĂƉƉƌŽĂĐŚĞƐƚŽŝŵƉƌŽǀĞŝŵƉůĞŵĞŶƚĂƟŽŶŽĨ,d͕WDddĂŶĚdŐƵŝĚĞůŝŶĞƐŝŶdĂŶǌĂŶŝĂ ŵƵƐƚĂůƐŽďĞŵƵůƟĨĂĐĞƚĞĚ͕ĐŽŶƐŝƐƚĞŶƚǁŝƚŚƐƵŐŐĞƐƟŽŶƐŽĨ'ƌŽůĂŶĚ'ƌŝŵƐŚĂǁ;ϮϬϬϯͿ;ϯϱͿ͘ KƵƌĮŶĚŝŶŐƚŚĂƚƉůĂŶŶŝŶŐĨŽƌĚŝƐƐĞŵŝŶĂƟŽŶŽĨŐƵŝĚĞůŝŶĞǁĂƐǁĞĂŬŝƐŝŶůŝŶĞǁŝƚŚĮŶĚŝŶŐƐĨƌŽŵ ƚŚĞƐŽƵƚŚĞƌŶdĂŶǌĂŶŝĂƐƚƵĚǇǁŚŝĐŚĨŽƵŶĚƚŚĞĂďƐĞŶĐĞŽĨƐƚƌƵĐƚƵƌĞƐƚŽĨĂĐŝůŝƚĂƚĞĚŝƐƐĞŵŝŶĂƟŽŶ ŽĨ ďƌĞĂƐƚ ĨĞĞĚŝŶŐ ŐƵŝĚĞůŝŶĞ ƚŽ ďĞ Ă ŵĂũŽƌ ďĂƌƌŝĞƌ ƚŽ ŝŵƉůĞŵĞŶƚĂƟŽŶ ŽĨ ƚŚĞƐĞ ŐƵŝĚĞůŝŶĞ ;ϯϯͿ͘ ůƚŚŽƵŐŚ ŝŶ ƚŚĞ ĐƵƌƌĞŶƚ ƐƚƵĚǇ͕ Ă ĐŽŵďŝŶĂƟŽŶ ŽĨ ĂƉƉƌŽĂĐŚĞƐ ǁĂƐ ƵƐĞĚ ĨŽƌ ŐƵŝĚĞůŝŶĞ ĚŝƐƐĞŵŝŶĂƟŽŶĂƐĂĚǀŽĐĂƚĞĚďǇZŽďďŝĞĞƚĂů;ϮϬϬϮͿ;ϯϲͿ͕ƚŚĞŝƌƐƵĐĐĞƐƐǁĂƐƐƟŇĞĚďǇĂďƐĞŶĐĞ ŽĨĂĐůĞĂƌƐƚƌĂƚĞŐǇĂŶĚďƵĚŐĞƚĨŽƌŐƵŝĚĞůŝŶĞĚŝƐƐĞŵŝŶĂƟŽŶ͘dŚŝƐƐĞĞŵƐƚŽŚĂǀĞďĞĞŶǁŽƌƐĞ for HTC guideline as we found that no facility had the guideline documents, yet HTC is a core ƐĞƌǀŝĐĞŝŶƉƌĞǀĞŶƟŽŶĂŶĚĐŽŶƚƌŽůŽĨ,/s͘dŚŝƐŝƐďĞĐĂƵƐĞƚŚƌŽƵŐŚ,d͕ĚŝĂŐŶŽƐĞĚƉĂƟĞŶƚƐĐĂŶ be linked to both CTC and PMTCT services as required. A Mongolian study concluded that ĐŽŵƉƌĞŚĞŶƐŝǀĞĂŶĚƌŝŐŽƌŽƵƐƉůĂŶŶŝŶŐĨŽƌĚŝƐƐĞŵŝŶĂƟŽŶĂŶĚŝŵƉůĞŵĞŶƚĂƟŽŶŽĨŐƵŝĚĞůŝŶĞŝƐ ĐƌƵĐŝĂůĨŽƌŝŶĐƌĞĂƐĞĚůŝŬĞůŝŚŽŽĚŽĨŝŵƉůĞŵĞŶƚĂƟŽŶŽĨĚŝĂďĞƚĞƐĂŶĚŚǇƉĞƌƚĞŶƐŝŽŶŐƵŝĚĞůŝŶĞ;ϯϳͿ͘ dŚŝƐĐŽƵůĚĂůƐŽĂƉƉůǇĨŽƌŝŵƉƌŽǀĞŵĞŶƚŽĨ,/sŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶŝŶŽƵƌƐƚƵĚǇƐĞƫŶŐ͘ Once the guidelines reached the intended users, we found that use of English language, guideline in large text documents, and perceived complexity of the guideline impeded ŝŵƉůĞŵĞŶƚĂƟŽŶũƵƐƚůŝŬĞǁĂƐĨŽƵŶĚŝŶƚŚĞďƌĞĂƐƚĨĞĞĚŝŶŐƐƚƵĚǇĨƌŽŵ^ŽƵƚŚĞƌŶdĂŶǌĂŶŝĂ͘ DŽƌĞŽǀĞƌ͕ĂƐǇƐƚĞŵĂƟĐƌĞǀŝĞǁĨŽƵŶĚƚŚĂƚůĞƐƐĐŽŵƉůĞǆŝƚǇŽĨĚĞĐŝƐŝŽŶŵĂŬŝŶŐǁĂƐĂƐƐŽĐŝĂƚĞĚ with compliance with guideline (35). Although lack of funds to produce translated or summarized forms of the guidelines was reported, it was not clear why the limited funds available could not be used to produce Kiswahili guideline.

(18)

͙͘͞/ĐĂŶũƵƐƚƐĂǇŝƚŝƐůĂǆŝƚǇ͙͗͘͟ƋƵĂůŝƚĂƟǀĞƐƚƵĚǇŽĨĨĂĐŝůŝƚĂƟŶŐĂŶĚŝŵƉĞĚŝŶŐ ĨĂĐƚŽƌƐŽĨ,/sŐƵŝĚĞůŝŶĞŝŵƉůĞŵĞŶƚĂƟŽŶŝŶƚǁŽ^ŽƵƚŚĞƌŶĚŝƐƚƌŝĐƚƐŽĨdĂŶǌĂŶŝĂ 121 &ĞĂƚƵƌĞƐŽĨƚŚĞŝŵƉůĞŵĞŶƟŶŐŽƌŐĂŶŝǌĂƟŽŶƐƚŚĂƚŝŶŇƵĞŶĐĞĚŝŵƉůĞŵĞŶƚĂƟŽŶŽĨŐƵŝĚĞůŝŶĞ ŝŶ ƚŚŝƐ ƐĞƫŶŐ ƌĞŇĞĐƚ ƚŚĞ ŐĞŶĞƌĂů ǁĞĂŬŶĞƐƐĞƐ ŽĨ ƚŚĞ ŚĞĂůƚŚ ƐǇƐƚĞŵ ǁŚŝĐŚ ĂīĞĐƚƐ ŝŵƉůĞŵĞŶƚĂƟŽŶŽĨŶŽƚŽŶůǇ,/sŐƵŝĚĞůŝŶĞ͘&ŽƌŝŶƐƚĂŶĐĞ͕ŵĂŶĂŐĞŵĞŶƚŽĨƉƌŽǀŝĚĞƌƐ͕ƐƚŽĐŬ ŽƵƚŽĨƐƵƉƉůŝĞƐŶĞĞĚĞĚĨŽƌŝŵƉůĞŵĞŶƚĂƟŽŶůŝŬĞ,/sƚĞƐƚƐƚƌŝƉƐĂŶĚZsƐĂŶĚŝŶĂĚĞƋƵĂĐǇŽĨ ǁŽƌŬŝŶŐƐƉĂĐĞƚŚĂƚĐŽŵƉƌŽŵŝƐĞĚƉƌŝǀĂĐǇĂŶĚĐŽŶĮĚĞŶƟĂůŝƚǇŽĨƉĂƟĞŶƚƐ͘KŶŐŽŝŶŐŚĞĂůƚŚ ƐǇƐƚĞŵƐƚƌĞŶŐƚŚĞŶŝŶŐĞīŽƌƚƐĐĂŶĐŽŶƚƌŝďƵƚĞƚŽƐŽůǀŝŶŐƚŚĞƐĞĐŽŵŵŽŶƉƌŽďůĞŵƐĨŽƌĞǆĂŵƉůĞ͕ ŝŵƉƌŽǀĞŵĞŶƚŽĨƚŚĞŝŶĨŽƌŵĂƟŽŶƐǇƐƚĞŵƐĂƚDĞĚŝĐĂů^ƵƉƉůŝĞƐĞƉĂƌƚŵĞŶƚƚŽŝŵƉƌŽǀĞZs ĚĞůŝǀĞƌǇ;ϯϵͿĂŶĚŝŵƉƌŽǀĞŵĞŶƚŽĨŝŶĨƌĂƐƚƌƵĐƚƵƌĞĂŶĚƉĂƟĞŶƚƐŇŽǁĂƚĨĂĐŝůŝƟĞƐƚŽƌĞƐƉĞĐƟǀĞůǇ improve privacy and to contribute to reduced workloads (40-43).

īŽƌƚƐƚŽĐƌĞĂƚĞĚĞŵĂŶĚĨŽƌ,/sƐĞƌǀŝĐĞƐŵƵƐƚĂĚĚƌĞƐƐƚŚĞƐƉĞĐŝĮĐƐŽĐŝŽͲĐƵůƚƵƌĂůďĂƌƌŝĞƌƐ to using HIV services among the target community. In a 2012 HIV survey, 75% and 60% ŽĨdĂŶǌĂŶŝĂŶǁŽŵĞŶĂŶĚŵĞŶƌĞƐƉĞĐƟǀĞůǇĞǆƉƌĞƐƐĞĚĂƐƟŐŵĂƟǌŝŶŐĂƫƚƵĚĞƚŽǁĂƌĚƐ,/s ƉĂƟĞŶƚƐ ;ϯͿ͘ ZĞƐĞĂƌĐŚ ŝŶĚŝĐĂƚĞƐ ƚŚĂƚ ĂƉƉƌŽĂĐŚĞƐ ƚŽ ƚĂĐŬůĞ ƐƟŐŵĂ ƌĞƋƵŝƌĞ ŝŶƚĞƌǀĞŶƟŽŶƐ on policy, societal, health system, and individual levels (44). Current approaches to tackle ƐƟŐŵĂ ŚĂǀĞ ůĂƌŐĞůǇ ĨŽĐƵƐĞĚ ŽŶ ŬŶŽǁůĞĚŐĞ͕ ĂƫƚƵĚĞƐ ĂŶĚ ƌĞƐƉŽŶƐĞƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ;ϰϱͿ͘ According to Lorenz et al (2003), there is need to re-orient these approaches towards more ĞŵƉŚĂƐŝƐŽŶƚŚĞďƌŽĂĚĞƌƉŽůŝƟĐĂů͕ƐŽĐŝĂů͕ĐƵůƚƵƌĂů͕ĂŶĚĞĐŽŶŽŵŝĐĨŽƌĐĞƐƚŚĂƚĞŶĐŽƵƌĂŐĞƚŚĞ ƉƌŽĚƵĐƟŽŶĂŶĚŵĂŝŶƚĞŶĂŶĐĞŽĨƐƟŐŵĂ͘dŚŝƐŝŵƉůŝĞƐĚĞĂůŝŶŐǁŝƚŚƚŚĞƐŽĐŝĂůƐƚƌƵĐƚƵƌĞƐĂŶĚ ƉŽǁĞƌƌĞůĂƟŽŶƐƚŚĂƚĂůůŽǁƐƟŐŵĂƚŽƉƌŽƐƉĞƌǁŚŝĐŚĐĂŶŚĂƉƉĞŶŽŶůǇŝĨƐƟŐŵĂŝƐǀŝĞǁĞĚĂƐĂ ƉŚĞŶŽŵĞŶŽŶƚŚĂƚŝƐůŝŶŬĞĚƚŽŐƌŽƵƉƉƌŽĐĞƐƐĞƐĂŶĚĨƵŶĐƟŽŶŝŶŐ͕ƌĂƚŚĞƌƚŚĂŶǀŝĞǁŝŶŐŝƚĂƐĂŶ individual phenomenon (46). This is a view which Tanzania policy makers could adapt when ƐƚƌĂƚĞŐŝǌŝŶŐĂŐĂŝŶƐƚƐƟŐŵĂ͘

(19)

Chapter 6

122

(20)

123

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ƉƌĞǀĞŶƟŽŶ ŽĨ ŵŽƚŚĞƌ ƚŽ ĐŚŝůĚ ƚƌĂŶƐŵŝƐƐŝŽŶ ŽĨ ,/s ĂŶĚ ŬĞĞƉŝŶŐ ŵŽƚŚĞƌƐ ĂůŝǀĞ. 4th_{ed. 2013.}

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Chapter 6

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