Accelerating HIV and AIDS services delivery in Kigoma region, Tanzania

Introduction Tanzania Commission for AIDS and UNAIDS reports 1.7 million Tanzanians are HIV-positive. The Joint United Nations Program on HIV/AIDS set 95%, 95% 95% targets to be achieved by 2025. An assessment was done to understand the region’s position, which found the underperformance of critical HIV and AIDS indicators. This prompted the region to accelerate HIV interventions by providing frontline healthcare providers with skills and knowledge, essential equipment, and other infrastructure, after which the assessment of the indicators was conducted to document the outcome of interventions. Methods we conducted a descriptive study in Kigoma region in June 2022 by comparing HIV and AIDS indicators performance in the pre-intervention and post interventions arms. High-volume CTCs were purposefully selected. We used a pre-tested checklist to assess new HIV-positive on antiretroviral (ARV), pregnant women living with HIV on ARV, and people living with HIV offered multi-month dispensing. We further assessed HIV viral load (HVL) specimen collection, HIV suppression status, and HVL test results turnaround time. We cleaned the information using an MS Excel sheet and tabulated results using STATA software version 13. Results we assessed 27 care and clinics. The proportion gain in the index client elicitation was 13%. Sexual partners mentioned during index client elicitation had an increase of 145 individuals. The yield among consented sexual partners gained by 14%. The ARV initiation among new HIV -positive and pregnant women living with HIV gained a proportion of 2%. Multi-month dispencing was found to have an 8% increase. The turnaround time for HVL test results decreased by 21 days, and the viral load suppression status increased by 4%. Conclusion the assessment demonstrated the accelerated HIV and AIDS service delivery due to implementing a comprehensive package of HIV and AIDS management. We recommend in-service capacity building regarding training, basic equipment, and infrastructure.


Introduction
The strategies and mitigation of the United Nations (UN) to end HIV and AIDS by 2030 have been set as part of the Sustainable Development Goals [1]. In December 2020, the Joint United Nations Program on HIV/ AIDS (UNAIDS) set new targets to be achieved by 2025. The target is to ensure 95% of people living with HIV and AIDS (PLHIV) know their status, 95% of all people who tested HIV positive are receiving antiretroviral treatment (ART), and 95% of all people who are receiving ART are virally suppressed [2].
Records from the Ministry of Health, Tanzania Commission for AIDS (TACIDS), and UNAIDS indicate that about 1.7 million, or 4.8% of Tanzanians aged 15-49, are HIV-positive with approximately 77,000 new HIV infections and 27,000 AIDS-related deaths annually [3]. According to Tanzania HIV Impact Survey, which was conducted in 2017, The HIV prevalence in Kigoma region was estimated to be 2.9%. During this survey study, Kigoma's prevalence rate was low compared to the other nearby regions of Tabora, Geita, and Katavi [3]. Literature shows that the new HIV infections and transmission of HIV in Kigoma are prevalent among refugee populations who are enclosed in the camps with no physical activities [4]. HIV is also prevalent among the migratory fishermen along Lake Tanganyika shore who work and stay away from their families for a long time [5]. The availability of a high number of roaming cattle-rearing communities who usually move from high-burden HIV regions to Kigoma region has increased the HIV burden in Kigoma Region [6,7].
Skilled and knowledgeable healthcare providers have been shown to accelerate the decline of HIV and AIDS morbidity, mortality, and its sequelae [8,9]. According to the assessment conducted at Kigoma HIV care and treatment clinics in January-February 2022, some indicators that could lead to the achievement of the 95 95 95 targets by 2025 were underperforming. The DHIS2 data show that testing coverage declined by 17% in 2021 compared to 2020. Moreover, health facilities were also notably struggling to provide services for ART initiation, multi months dispensing (MMD), and HIV viral load (HVL) coverage.
Kigoma region decided to comprehensively accelerate the HIV interventions, including providing frontline healthcare providers with skills and knowledge, provision of essential equipment, and other infrastructure per National AIDS control guidelines to institutional capacity to provide HIV and AIDS care to PLHIV [10]. Afterward, the region assessed the HIV and AIDS service delivery. The study aimed at describing the changes in HIV and AIDS service delivery indicators following the implementation of comprehensive HIV and AIDS management interventions.

Methods
Study setting: Kigoma region is in the northwestern corner of Tanzania, on the eastern shore of Lake Tanganyika. It borders the Democratic Republic of Congo to the west through Lake Tanganyika, the Republic of Burundi to the North-West, Kagera region to the North, the region Borders Tabora and Geita region to the East, and Katavi region to the South. According to the Tanzania National Census conducted in 2022, the region has a population of 2.5 million (1.2 million males and 1.3 million females). The region has 286 health facilities, including nine hospitals, 37 health centers, and 240 dispensaries. Of the 286 health facilities, 83 provide care and treatment services to people living with HIV, and 183 are standalone facilities that provide Prevention of MotherTo Child Transmission (PMTCT) services. The region has several health implementing partners, including Tanzania Health Promotion Support (THPS) which provides HIV and AIDS support to 62 (22%) of health facilities in the region, and Management and Development for Health (MDH), which focus on voluntary medical male circumcision (VMMC). In the region, there are other vertical programs from the Ministry of Health, operating under the National AIDS Control Program (NACP) and Tanzania Commission for AIDS (TACAIDS). The vertical programs cover the provision of condoms, antiretroviral drugs, HIV rapid testing kits, polymerase chain reaction (PCR) machines, and service provision registers.
Intervention implemented: we designed and implemented a comprehensive campaign to ensure all care and treatment clinics (CTCs) and standalone Prevention of Mother to Child Transmission (PMTCT) clinics have all the necessary equipment and skills. We assessed the availability of rapid diagnostic kits for HIV, antiretroviral (ARV) drugs (adult and pediatric formulations), HIV viral load and dried blood spot (DBS) collection kits, working PCR machines, and paper or computerized data recording systems. In the CTCs and PMTCT standalone facilities, which had deficits, we refilled the missing items to meet the NACP prerequisites. Then, from each CTCs and PMTCT standalone health facility, we comprehensively trained healthcare providers and peer educators on providing HIV and AIDS services, including health facilities and community-based HIV testing strategies, ARV dispensing, client enrollment, client tracking and tracing back, and index client testing. We further trained healthcare providers on HIV viral load and DBS specimen collection, testing, and results tracking.
Study design: this descriptive study was conducted in Kigoma region in June 2022, covering January to June 2022. We compared 3 months before the intervention (pre-intervention arm) to 3 months after the interventions (post-intervention arm).
Study participants: the participants were any healthcare providers who received the comprehensive package for HIV and AIDS management. These included those who were working among the selected CTCs in Kigoma region in areas of HIV testing in the community, providers-initiated testing and counseling (PITC), antiretroviral dispensing, reproductive and child health (RCH) clinics, and laboratories.
Sampling strategy: we did a purposeful sampling technique focusing on those high-volume CTCs in the region. CTCs were enlisted with the current number of people living with HIV, and from the list, the top 27 CTCs were included in the assessment to have a representative sample.
Data collection tool: under close guidance from the NACP of the Ministry of Health Tanzania, we selected indicators from the DHIS2 database focusing on the underperforming indicators before implementing the comprehensive interventions. Then, we reviewed and contextualized the NACP-approved assessment questionnaires by rephrasing and omitting the questions which were found irrelevant to Kigoma region context, including HIV and AIDS service in the refugee population. The questionnaire was piloted at Kigoma Region Referral Hospital for validity and consistency.
Variables definition: assessment variables were the number of new people living with HIV (PLHIV) who tested positive for HIV in a respective month. Sexual partners who were mentioned to have a sexual relationship with PLHIV consented to test for their HIV status. Other variables were PLHIV eligible for HVL specimen collection, HVL specimen results returned, and PLHIV who were eligible for ARV Multi-Month Dispensing (MMD). New people living with HIV who were asked to mention their sexual partners (index client elicitation), the number of HIV-positive index clients (yield), HIV viral load (HVL) specimen, the number of HVL results suppressed, and PLHIV given ARV for more than one month (Multi-month dispensing) ( Table 1).
Data collection: the assessing team comprised five technical officers, including Regional AIDS Control Coordinator, Regional Data Manager, Regional CTC Coordinator, Regional Quality Improvement focal person, and Public Health Officer from the WHO Kigoma field office. The team reviewed National AIDS Control Program assessment checklist and contextualized it to fit in Kigoma context. The assessment checklist was pre-tested to familiarize with the checklist and validation of the data to be collected. Upon reaching respective CTCs, we reviewed both community-based HIV and AIDS services registers, including HIV testing services registers and index client elicitation registers. We further reviewed ARV registers, isoniazid preventive therapy (IPT) registers, Outpatient department attendance registers), Provider Initiated Testing and Counselling (PITC) registers, PMTCT registers, ART dispensing, and HIV Viral Load registers. For the computerized CTCs, we reviewed the care and treatment system used to record PLHIV information at a health facility level (CTC2 database).

Discussion
We observed a significant gain in the HIV and AIDS service monitoring indicators as we compared the pre and post interventions arms of the study periods. There was a notable gain in the identification of new HIVinfected individuals, sustainably enrollment into care and treatment with a significant proportion gain in the HIV viral suppression among people who live with HIV infection. The identification of new HIV-infected individuals was compared before implementation and after the implementation of the comprehensive capacity-building package for HIV and AIDS services.
We found a proportion gain of 13% in accelerating the Region's effort of achieving the first 95% of the global target on HIV and AIDS services. A similar finding was found in the study by Phaswana-Mafuya N et al. in a rural area of the Eastern Cape, South Africa [11].
During the assessment, we found an exponential increase in newly diagnosed people living with HIV being asked to mention their sexual partners (elicitation) [12]. We further found an increase of 14% in the proportion of new HIV infections among sexual partners who were mentioned during the elicitation of index clients. This finding simulates the finding in the study conducted by Boeke et al. 2018 Uganda, which showed an HIV positivity increase in a special group of HIV exposure [13]. However, it contradicts the finding in the study done by Moucheraud C et al. conducted in 2022 Malawi, which shows a decrease in new HIV infections among adults at outpatient clinics [14].
Ethical consideration and confidentiality: the assessment was a routine after-health intervention assessment organized by Kigoma Health Management Team and approved by Assistant Region Administrative Secretary for Health. Before the field visit to CTCs, a courtesy visit was conducted to the respective Head of Health Department in the Districts and, subsequently, the health facility in-charges of the CTCs included in the study. The populated questionnaires from respective CTCs were labeled with letters to maintain confidentiality.

Results
The trend of the proportion of new HIV-diagnosed clients who were asked to mention their sexual partners (i.e. index clients elicitation) changed from 70% in January, 87% in February, and 88% in March. For the pre-intervention period (January-March), the average proportion was 84%, and for the post-intervention period was 97% ( Among new HIV-positive pregnant women, the ART initiation for the respective month was 75%-January, 81%-February, 83%-March, 83%-April, and 80%-May. There was no available information month of June (Table 3  On enrollment in CTCs of newly diagnosed people living with HIV, we did not find a notable change in the number of enrolled people living with HIV. However, we noted a significant number of newly diagnosed people living with HIV who presented signs and symptoms suggestive of tuberculosis co-infections implying late presentation to health facilities. A review conducted by Girardi E et al. 2017 to sub-saharan Africa papers has found similar findings indicating PLHIV late presentation to CTC and co-infected with other opportunistic infections such as tuberculosis [15]. We also found many pregnant women who were positive for HIV infection at first attendance at RCH clinics, similar to the study by Kharsany et al. in 2015 in rural South Africa [16]. In addition, we found many pregnant women living with HIV who were not offered antiretroviral therapy, predisposing their unborn child to the risks of in-utero HIV infections. The UNAIDS gap report 2014 documented similar findings of many pregnant women living with HIV not being offered ARV during pregnancy [17]. The finding contradicts the U.S. Department of Health and Human Services recommendation for sub-African countries [18].
During the assessment, we looked at the trend of antiretroviral drugs' multi-month dispensing among eligible people living with HIV. We found a change in proportions from 90% to 98% for pre-and postintervention, respectively. Ruhago G et al. 2022 Tanzania found similar findings, indicating a high percentage of MMD distribution to stable PLHIV [19]. To ascertain the HIV viral load suppression status as one of the global targets to be achieved by 2025, we assessed the HIV viral load suppression status among people living with HIV. We found a positive shift in proportions before and post-interventions, which is recommended in the WHO consolidated HIV Strategic information guide 2020 [20]. During the assessment, we found a decrease in turnaround time for HVL test results from an average of 35 days before and 14 days after the interventions. Matovu JK 2021 in Uganda reported on the significance of shorter turnaround time concerning HVL and PLHIV monitoring [21].
Our study had the following limitations: Our study had a short time post interventions period which may have negatively affected the cumulative impact of the interventions. There was a mix of database sources; for facilities with no computerized database posing a question of data accuracy, the data were extracted from service registers, while for facilities with a computerized database, we extracted from a computer database. We further focused on the high-volume care and treatment that may have increased the change proportions.

Conclusion
The study demonstrated the accelerated achievement in HIV and AIDS service delivery, which was driven by the dissemination of a comprehensive package of HIV and AIDS management. We recommend promoting inservice capacity building in terms of comprehensive training, equipment supply, and infrastructure availability.