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A Compendium Report of Tanzania, Mozambique & Burkina Faso

A Publication by:Agency for Co-operation and Research in Development

ARV COMMUNITY KNOWLEDGE,AWARENESS, ACCESSIBILITY& THE POLICY ENVIRONMENT

Cover photo:Researcher, Mr. Narathius Asingwire with members of WONA-NDLELA, an Association of PLHAs in Inhambane, Mozambique

A Compendium Report of Tanzania, Mozambique & Burkina Faso 2007

Acronyms

ACORD AgencyforCo-operationandResearchinDevelopment

ART Anti-retroviralTherapy

ARVs Anti-retroviralDrugs

DDH DistrictDesignatedHospital

EAC EastAfricanCommunity

HASAP HIVandAIDSSupportandAdvocacyProgram

IEC Information,EducationandCommunication

IGA IncomeGeneratingActivity

MoH MinistryofHealth

NGOs NonGovernmentalOrganizations

PLHA PersonsLivingwithHIVandAIDS

PMTCT PreventionofMothertoChildTransmission

PEPFAR UnitedStatesPresidentialEmergencyPlanforAIDSRelief

SADC SouthernAfricanDevelopmentCommunity

TAWOLIHA TanzaniaWomenLivingwithHIVandAIDS

TRIPS TradeRelatedInternationalPropertyRights

TWG TechnicalWorkingGroup

UNAIDS TheJointUnitedNationsProgramofHIVandAIDS

UNGASS UnitedNationsGeneralAssemblySpecialSessiononAIDS

VCT VoluntaryCounsellingandTesting

WAMATA WalioKatikaMapambanodhidiyaUkimwiTanzania

WHO WorldHealthOrganization

WTO WorldTradeOrganization

i

ARV Community Knowledge, Awareness, Accessibility & The Policy Environmentii

�A Compendium Report of Tanzania, Mozambique & Burkina Faso 2007

Table of Contents

ACRONYMS........................................................................................................................................ i

TABLEOFCONTENTS...................................................................................................................... v

EXECUTIVESUMMARY................................................................................................................... vii

1.0 INTRODUCTION...................................................................................................... 1

1.1 Introduction................................................................................................................ 1

1.2 ContextoftheThreeARVStudies........................................................................... 1

1.3 TheStudyProblemandJustification........................................................................ 2

1.4 ObjectivesoftheThreeStudies.................................................................................. 2

1.5 ScopeoftheStudies.................................................................................................... 2

1.6 MethodologyandApproach ..................................................................................... 2

2.0 PROFILESOFARVRECIPIENTS............................................................................................. 5

2.1 Introduction................................................................................................................ 5

2.2 Socio-demographicProfilesofARVRecipients...................................................... 5

3.0 KNOWLEDGEANDAWARENESSOFARVTREATMENT................................................ 7

3.1 Introduction.................................................................................................................. 7

3.2 KnowledgeandUnderstandingofARVTreatment............................................... 7

3.3 KnowledgeonEligibilityofARVTreatment........................................................... 7

3.4 SourcesofInformationonARVTreatment.............................................................. 10

4.0 ARVAVAILABILITY,ACCESSIBILITYANDUSE.................................................................. 11

4.1 Introduction................................................................................................................. 11

4.2 AvailabilityofARVs................................................................................................... 11

4.3 AccesstoARVs............................................................................................................ 12

4.4 ARVUse/UtilizationofARVTreatmentServices.................................................. 13

�i ARV Community Knowledge, Awareness, Accessibility & The Policy Environment

5.0 IMPACTOFARVUSEANDBARRIERSTOACCESSIBILITY.............................................. 15

5.1 Introduction.................................................................................................................. 15

5.2 ImpactofARVUse...................................................................................................... 15

5.3 BarrierstoUseofARVs.............................................................................................. 17

6.0 NATIONALANDINTERNATIONALPOLICIES................................................................... 19

6.1 Introduction.................................................................................................................. 19

6.2 NationalPoliciesandFrameworks........................................................................... 19

6.3 InternationalPoliciesandFrameworks................................................................... 20

7.0 CONCLUSIONSANDRECOMMENDATIONS...................................................................... 21

7.1 Introduction.................................................................................................................. 21

7.2 Conclusions.................................................................................................................. 21

7.3 Recommendations....................................................................................................... 21

REFERENCES......................................................................................................................................... 25

List of TablesTable1:Socio-demographicprofilesofARVrecipients.................................................................. 5

Table2:KnowledgeonwhoiseligibletouseARVs................................................................................ 8

Table3:SourcesofInformationonARVTreatment.......................................................................... 9

Table4:GeographicalaccesstoARVs................................................................................................. 13

List of FiguresFigure1:DistributionofARVrecipientsin3countriesbyoccupation......................................... 6

Figure2:ARVRecipients’firsttimetohearARVtreatmentinMozambique.............................. 7

Figure3:ARVRecipients’firsttimetohearofARVtreamentinTanzania.................................. 7

�iiA Compendium Report of Tanzania, Mozambique & Burkina Faso 2007

IntroductionIn2006,theAgencyforCo-operationandResearchinDevelopment(ACORD)throughitsHIVandAIDSSupportandAdvocacyProgram(HASAP)undertookAnti-retroviraldrugs(ARVs)studiesin Burkina Faso, Tanzania and Mozambique.Theoverallobjectiveofthethreestudieswastogenerate information to be used for advocacybyACORD,aswellasotherrelevantactors,forincreased equitable accessibility to AIDS careand treatment services in African countries.The specific objectives of the studies included,amongothers,to:

• Find out peoples’ knowledge andunderstanding of ARV treatment aswell as sources of information forARVtreatment,

• AssessARVaccessibilityandusebythepopulationinthethreecountries,

• FindouttheimpactofARVuse,• Analyse the national and international

policies1and• Make recommendations aimed at

addressing identified gaps in theprovisioningofARVsrelatedservices.

All the threestudiesadoptedacombinationofqualitativeandquantitativemethodologies.ARVrecipientsweretheprimarystudyparticipants.A total of 103, 58 and 176 ARV recipientswere interviewed in Tanzania, Mozambiqueand Burkina Faso respectively. Other studyparticipantsincludednon-usersofARVs(eligiblePLHAsnotonARVsbyownchoice),membersofthegeneralcommunity,andhouseholdmembersofARVbeneficiaries,healthworkersanddistrictofficials.TechnocratsintheMinistriesofHealth,the National AIDS Control Program (NACP),WHO,UNAIDS,andassociationsofPLHAs.

Key Results

Profiles of ARV Recipients In all the three countries, the majority ofARVrecipientswere femaleandbasicallyresided inurbanareas.MostoftheARVusersinTanzania1 ThisaspectofthestudywasnotcoveredinBurkinaFaso

andMozambiquewereheadsofhouseholdsandhadattainedlowlevelsofformaleducationi.e.,primary education and were generally poor asreflected by their main occupation. Almost aquarter (18%)of theARVusers’households inTanzania had an estimated monthly income ofless than US $10 per month and slightly overa tenth (12%) earned between US $ 25-40 permonth.

Knowledge and Awareness of ARV TreatmentOverall, people’s knowledge about eligibilitytouseARVs including those currentlyonARTwas limited. More than two-thirds (67.9%)and almost all (89.5%) ARV recipients inboth Tanzania and Mozambique respectivelybelieved that all PLHAs should be on ARVs.A significant proportion of ARV users sharedthe view thatARVs can be used in preventionof infection with HIV andAIDS. Glaring gapsin knowledge about ARVs, especially on whoqualifiestotakethedrugsandthecircumstanceswarranting a complete discontinuation of useof the drugs, existed. Comparatively, ARVusersinMozambiquewerelessknowledgeablecomparedtothoseinTanzania.TheknowledgegapwasalsoevidentintheperceivedreasonsfortakingARVswherebyoverathirdofthesamplein Tanzania, and a quarter in Mozambique,believed that takingARVs would prevent HIVandAIDS.ARVknowledgegapswerenotonlyconfinedtoordinarycommunitymembers,buthealthworkersaswell.

Study findings revealed varying degrees ofpopularityofthedifferentsourcesofinformationonARVtreatmentandservices.Forinstance,inTanzaniaandBurkinaFaso,Healthproviders/counsellors at the ARV dispensing site werereported as the main source of information onARVs,whereasinMozambique,theywereamongtheleastcitedsourcesinsteadthecommonlycitedsourceofinformationaboutARVtreatmentwastheradio.Inallthestudyareas,thecommonlycited type of information received from thevariousmodesofcommunicationwason“accessto ARV treatment centres”. The major aspects

Executi�e Summary

�iii ARV Community Knowledge, Awareness, Accessibility & The Policy Environment

ofARVtreatmentwerenotbeingdisseminatedoutsidetheARVdispensingsitesinallthestudycountries.

ARV Availability, Accessibility and UseThough availability of ARVs showed signs ofincrease, itwasstill inadequate inall the threecountries especially for those residing in ruralareas. Accessibility to ARVs was therefore notuniversal to all in need in the three countries.Various barriers to use of and access to ARVsincluding facility based, policy, awareness,and transport related, as well as nutritional,were cited in almost all the three countries. InMozambique and Tanzania ARVs are freelyprovided and hence no direct cost is incurredby the beneficiaries, but in Burkina Fasogovernment does not provide universal accessto treatment,althoughsomepeopleareable toaccessthedrugsfreethroughorganizationssuchasSOS-SIDA,butothershavetopay.

At the health facility, the commonly citedbarrier to use and access to ARV treatmentservices was the inadequacy of personnel atthe ARV dispensing site. All countries visitedacknowledged having challenges with healthworkerstrainedtoprovidespecializedAIDScare.Theotherfacilityrelatedbarrierwasinadequacyofpremisesandotherfacilities.

Existing policies are also potential barriersto access ARV treatment. Apparently, someguidelines inadvertently constrain access toservices. Further, ARV users, non-users andpotential users alike wanted to be assuredthat ARVs would always be available and thefree ARV program sustainable. Lack of clearinformationon theabilityandreadinessof thegovernmentstosustainthesupplyoffreeARVswas reportedly causing worry and discomfort,leadingtonon-useofARVs.

Lowawarenessdue to lackofappropriateandadequateinformationonARVswascitedwidelyasakeybarriertouseofARVtreatmentservices.Cases of PLHAs refusing to enrol for ARVtreatmentservicesduetofearofsideeffectswereunderscoredinthesestudies.Overall,transportrelatedbarriersowingtothecostsinvolvedwerethemost frequently cited obstacles in BurkinaFaso.

Impact of ARV use and Barriers to AccessibilityOverall,thepositiveandnegativeimpactofARVuseontheindividualbeneficiarieswasyettobeexperiencedsinceARVusewasrelativelyrecentinthestudysites.Nonetheless,theindividuallyrealizedbenefitofimprovedhealthwascitedbyalmostalltheusersinthethreecountries,rangingfromenergizedhopetolive;beingabletoresumework and commercial activities, planning fortheir families,and tocontributing to thewiderstruggleofcombatingHIVandAIDS.

In most instances, the use of ARVs had notresultedintoadverseeffectsonfamilyrelations.Instancesoffamilymembersshowingapositiveand more caring attitude were reported in allthe threecountries,although isolated instancesamong spouses and members of extendedfamily who developed hostile attitudes werealsoreported.

WithregardtotheimpactofprovisionofARVson other health services, the major problem inboth public and private health facilities is theassociatedenormousrunningcostsessentialfora sustainable program. No doubt, successes intreatingPLHAsincreasesdemandonthehealthsystem.This isboth in termsofpersonnelandinfrastructure. What is very important to noteinthethreecountries,wasthereassuranceandexpressedcommitmentfromthegovernmentstoaddresstheconstraintsintheARVprogram.

National and International Policies TanzaniaandMozambiquehavecomprehensiveNational Strategic Frameworks for HIV andAIDS—i.e., Tanzania has a National HIVand AIDS Care and Treatment Plan whichspecifically guides the implementation andmanagementoftheARVprograminthecountry,and similarlyMozambiquea “NationalHealthSector Strategic Plan to Combat STIs and HIVandAIDS”.Bothcountrieshavedevelopedotherpolicy guidelines and frameworks to promoteprovisioningofARVs.What iscommon is thatthe policy guidelines on care and treatmentarenotexplained inampledetail.Other issuessuch as the mechanisms for monitoring andfollow-upofpeopleonARVs,plans for rollingout to address the equity problems, inbuiltsustainability mechanisms for availability ofARVs and accessibility, incentive plans formanufacturers of ARVs etc., are also not well

ixA Compendium Report of Tanzania, Mozambique & Burkina Faso 2007

articulated by the policy’s goal and objectivesin the countries studied. In both Tanzania andMozambique there was no evidence adducedby the studies that the policies in place aredisseminated to those mandated to implementthem.

Like all developing countries, changes in theglobalpoliciesregardingARVssuchaspolicieson patent rights have affected Tanzania,Mozambique and Burkina such as the WorldTrade Organization Agreement on Trade-RelatedAspects of Intellectual Property Rights(TRIPS)thatwasintroducedin1995.WithIndiacomplyingwiththeTRIPSAgreementeffectiveMarch2006,theARVexpansionprogramshavebeenunderthreatinleastresourcedcountries.

RecommendationsforNationalActionA number of recommendations for nationalaction have been made. These include thefollowing:• Poverty reduction efforts targeting PLHAs

onARVs• Addressingtheequityproblemsbetweenthe

urbanandtheruralareasregardingaccesstoARVsaswellasinformationaboutthesame

• Evolving a multi-faceted IEC strategy fordisseminating factual information on ARVtreatment

• Mounting campaigns targeting stigma anddiscrimination

• Scaling up of ethical and effective VCTServices

• Provisioningofnutritionalandfoodsupportto the most vulnerable PLHAs on ARVtreatment

• Targeting and increasing the proportion ofmalesusingARVs

• Improvement of the general health caresystemandhumanresources

Wider recommendations at Regional and Pan African levelThewiderrecommendationsatregionalandPanAfrican level entail the involvementofAfricangovernmentsinaconcertedefforttogetherwithcivil society organizations to engage in globalpolicies and debates. Part of which involvesintensive advocacy and lobbying around thefollowingareas:

• Fundingforhealthservicesandresourcemobilisation

• Operationalization and harmonizationofnationalandregionalpolicies

• Expediting the legislation of TRIPSflexibilitiesandenhancedengagementinglobalpolicies

x ARV Community Knowledge, Awareness, Accessibility & The Policy Environment


�.0 Introduction

1.1 IntroductionIn2006,theAgencyforCo-operationinResearchandDevelopment(ACORD)throughitsHIVandAIDSSupportandAdvocacyProgram(HASAP),undertookAnti-retroviraldrugs(ARVs)studiesin Burkina Faso, Tanzania and Mozambique.Thestudiesfocusedoncommunityaccessibilityto ARVs, knowledge and awareness of ARVs,and also examined the policy environmentwithin which the ARV Program was beingimplemented.Aspartofdisseminatingfindingsthat arose from the three studies, HASAPdecided to abridge the reports into this singlepopular version i.e., the Compendium Report(CR).TheimmediateobjectivesofthisCRwerelargelyfourfold,namely:

• To situate the CR in a clear ARVbackgroundandcontext

• Toprovideananalyticalsummaryofthethreereports

• To identify the various similarities andordifferencesinthefindingsofthethreecountries

• To compile the recommendations forpolicy makers and implementers atnationalandinternationallevels

1.2 Background of the StudiesItisovertwoandahalfdecadessinceHIVandAIDS emerged on the world scene as one ofthe most devastating human calamities of the20th century. With the onslaught of HIV andAIDSclaimingthousandsoflives,governmentsworld over devoted resources to combat itsspreadintheirgeneralpopulations—preventioninterventions. As prevention interventionstookroot in several countries, theneed tocareand treat people living with HIV and AIDS(PLHAs) emerged, posing a big challenge topoorly resourced countries such as Tanzania,MozambiqueandBurkinaFasowhereACORDhas programs. Thus, in the last couple ofyears, the issue of extending access to ARVshas increasingly dominated the policy agendaat the international and national levels with

civil societiesmore thaneverbefore increasingtheir advocacy efforts regarding increased anduniversalaccessibilitytoARVs.

Advocacy for increased access to ARVs inTanzania, Mozambique and Burkina Faso hastoa largeextentbeenprecipitatedbythe ‘3by5’ initiative of WHO that aimed at reaching 3million people in need of ARV treatment by2005,aswellasotherlarge-scaleinitiatives,suchastheUnitedStatesPresidentialEmergencyPlanforAIDSRelief(PEPFAR)Fund,variousWorldBankinitiatives,suchastheRegionalTreatmentAcceleration Programme and other UnitedNations supported initiatives. Resultant fromtheUNcommitments,mostcountriesinthesub-Saharan Africa region came under pressure tosetandmeettargetsinrelationtoARVaccessbytheyear2005,whichtargetsseemedtohavebeenhighly unrealistic. For example, the target forsome of the countries whereACORD operatessuch as Burkina Faso in WestAfrica is 20,000,but only 2,000 people are currently receivingtreatment.InthecaseofTanzaniainEastAfrica,the target is 200,000, but currently only 19,000have been reached. The situation is not anydifferentinMozambique, itwasestimatedthat210,000 HIV+ people in need of ART shouldhaveaccesstoARVsbyOctober,2005butonly25,465 were onART (IRIN, January 2006). It ispartly in view of this situation that actors intheareaofHIVandAIDSsuchasACORDareincreasinglybecominginterestedintheissueofARVprovisioningandaccessibility.

ACORD’sinterestintheissueofaccesstoARVsrelates directly to one of the three key aims ofitsHIV andAIDSmission,namely to“promote equal access to information, services and treatment by challenging all forms of discrimination and social exclusion”. Guided by this mission, ACORDcommissionedthestudies,whichcovered,amongothers,remoteandmarginalizedcommunitiesinthethreecountries.

� ARV Community Knowledge, Awareness, Accessibility & The Policy Environment

1. 3 The Study Problem and Justification

ARVprovisioningisarelativelyrecentinitiativein developing countries such as Tanzania,MozambiqueandBurkinaFaso.Duetolimitedresources,currenteffortstoprovideARVstothenationalshavebeencharacterisedwitha lotofinequities—largelyreachingtheelite,theaffluentcategories in thegeneralpopulationanda fewindividuals in theurbanareas.Thus,universalaccessibilitytoARVsinpoorcountriesisyettobe achieved.All this is happening amidst lackof empirically documented experiences withregardtoARVsaccessibilityandtheimplicationsit has on the individuals, households andcommunities.TherehasbeenlimitedresearchonconsequencesanddimensionsofARVprogramimplementation at community level and hencethe compelling reasons and justification forACORDtoundertakethesestudies.

1. 4 Objectives of the Three Studies

The overall objective of the three studieswas to serve as an advocacy tool for ACORDand other actors involved in advocating forincreased equitable accessibility to AIDS careandtreatmentinAfricancountries.Thespecificobjectivesincluded:1. To find out peoples’ knowledge and

understandingofARVtreatmentaswellassourcesofinformationforARVtreatment

2. ToassessARVaccessibilityandusebythepopulationinselectedcommunitiesinthethreecountries

3. To investigate barriers to ARVs accessand adherence such as stigma, distanceto services, attitude of service providers,inadequateinformationaboutcorrectuse,costofARVsand/orrelatedservices

4. To analyse potential threats to ARVstreatmentincludingthreatsposedbyfoodsecurityandnutrition

5. To analyse the impactofARVuseon thepopulation, including gender relationsand household income levels as well ason other health services, in particularprimaryhealthcareservicesasaresultofintroducingARVs

6. To analyse the extent relevant nationalandinternationalpoliciesandframeworksfacilitateand/or, constrainaccess toARVtreatment

7. To seek the views of service providerson the quality and coverage of theARVprogrammewithaviewtoidentifyingthestrengths and weakness and thus makerecommendationsaimedataddressingtheidentifiedgapsintheprovisioningofARVrelatedservices,includingaccessanduse

1.5 Scope of the StudiesUnlike Burkina Faso, the studies in Tanzaniaand Mozambique put particular emphasison “community knowledge and awarenessregardingARVsaswellasthepolicyenvironmentwithin whichARVs are dispensed. In Burkina,thefocuswasonaccesstoandbenefitsofARVtreatment.

1.6 Methodology and ApproachA combination of qualitative and quantitativemethodologies was employed in conductingthese studies. Quantitative methods helpedto investigate individuals’ knowledge andawareness, accessibility and use of services,barriersencounteredbytheARVrecipients,andimpactonhouseholdrelations.Ontheotherhand,qualitative data complemented quantitativedata,andlargelyhelpedinexploringthecontextwithin which ARV treatment is accessed ingreaterdetail.However, thescopeof study forBurkinaFasowasrestrictedtoassessingqualityandcoverageoftheARVprogramme.

1.6.1 Study areas StudyareasinthethreecountrieswerepurposivelyselectedbasedonthepresenceofoperationsandinterventionsbyACORD,existenceoforganizedassociationsofpeoplelivingwithHIVandAIDS(PLHAs)andpresenceof functionalARVsites.Selection of the study sites was also cognizantof the rural – urban divide. For instance inTanzania,thestudywascarriedoutinMwanzaarea with both urban and rural characteristicsandSengeremaDistrict,whichisbasicallyrural.InMozambique,MaputoprovinceandMaputoCityrepresentedthetypicalurbansettingwhilethedistrictsofPandaandMaxixeinInhambaneprovincerepresentedtheruralareas.InBurkinaFaso,PôandOuagadougourepresentedtheruralandurbanstudyareasrespectively.Coverageofthe rural and urban areas enabled the studiesto identifydifferences in the level, quality andaccessibility of ARV services in the differentgeo-economic areas. National capitals in the


threecountrieswere included in thestudies tocaptureviewsofthenationalpolicy-makersandplanners—technocratsandotherstakeholders.

1.6.2 Study participants/sampleIn all the three countries,ARV recipients werethe primary study participants. The procedureof selection varied. For instance, whereas inTanzaniaARVrecipientswerecapturedmainlyduring the clinic days where a total of 1032recipients were subjected to exit interviews, inMozambique snowball3 sampling techniqueswere used to trace 58 ARV recipients in theircommunities. In Burkina Faso, a total of 176PLHAs affiliated to prominent AIDS careorganizations in the twoareasof studyand66serviceproviderswererandomlyselected.Other study participants included non-usersofARVs (eligiblePLHAsnotonARVsbyownchoice), members of the general community,and householdmembers ofARV beneficiaries,healthworkersanddistrictofficials.Technocratsin the Ministries of Health, the NationalAIDSControlProgram(NACP),WHO,UNAIDS,andassociations4ofPLHAswerealsoreached.

1.6.3 Data collection methods Quantitativedatawascollectedthroughpersonalinterview using a structured questionnairewhich was administered to ARV recipientsand other community members5. The tool wasadministeredbytrainedsurveypersonnelfluentinthelocallanguagesofthethreecountries.

2 Out of the 103 beneficiaries ofARVs fromTanzania; 89.3%(n=92)werefromMwanza,whileslightlyoveratenth(10.7%;n=11)werefromSengeremaDistrict

3 BureaucratichurdlesrelatingtoclearingoftheresearchteambythedirectorsofhospitalsandabsenceofARVrecipientsatthesitesmadeitimpossibletoconductexitinterviews

4 PLHAAssociationsincludedSocialandHealthDevelopmentforPLHAs(SHDEPHA+)andTanzaniaWomenLivingwithHIVandAIDS(TAWOLIHA);UTOMI,WONA-NDLELAinInhambane Provincial capital, TINHENA and RENSIDA inMaputoCityaswellasAJUDECOinPandadistrict.

5 Only covered in theMozambique to bridge the gap in theTanzaniaandBurkinaFasostudies

Interviewers in Mozambique undergoing a training session

QualitativedatawascollectedthroughliteraturereviewofvariousdocumentsonHIVandAIDScareandtreatment;thekeypoliciesandplanningframeworks.KeydocumentsincludedHIVandAIDSNationalPolicyonHIVandAIDS,NationalHealth Strategic Framework for STI/HIV andAIDS(2004-2008)inthecaseofMozambiqueandtheNationalMulti-SectoralStrategicFrameworkonHIV/AIDS(2003-2007)forTanzania,MinistryofHealthCareandTreatmentGuidelines(2004),documentsbytheUNAIDSandWHO.

Other sources of qualitative data were keyinformantsatdistrictandnationallevels,healthworkersinARVsitesandleaders/representativesof associations of PLHAs and AIDS serviceorganizationsespeciallythosethatwereonARVtreatment,andlocalleaders),directobservationandinthecaseofBurkinaFaso,useofachecklistforassessingorganizationalcapacitiesofserviceproviders.

1.6.4 Data managementAll the dully filled questionnaireswere editedand entered into the computer using theEpidemiological Software package (EPI-INFO)and further analysis was conducted using theStatisticalPackagefortheSocialScientist(SPSS).Theanalysiswasmainlydescriptivewithsomecross-tabulations, to establish the causal-effectrelationships between significant variables.For the qualitative data, thematic and contentapproach was used for analysis. Dominantthemes were developed on the basis of studyobjectivesunderwhichdatawasanalysedandpresented.

� ARV Community Knowledge, Awareness, Accessibility & The Policy Environment


2.0 ProfilesofARVRecipients

2.1 IntroductionProfiles ofARVs recipients are very importantto appreciate in any policy debate regardingaccessibilityandutilizationofARVs.Thesocio-demographic characteristics are particularlyimportantduetotheirpotentialtoinfluencetheextent towhich beneficiaries accessARVs, usethemandadheretoARVuse.

2.2 Socio-demographic Profiles of ARV Recipients

Thefindings of the three studies revealed thatthemajorityoftheARVrecipientswerefemalesand basically residing in urban areas. Thus, inthethreecountries,thereweregreatdisparitiesinaccesstoARVsbylocalityofusualresidence.SeeTable1formoredetails.

Table 1: Socio-demographic profiles of ARV recipients

Characteristic Tanzania Mozambique Burkina Faso�

% (N=�0�) % (N=�8) % (N=�76)

LocalityRural

Urban8.8

91.29.0

91.022.777.3

Sex Male

Female31.168.9

28.072.0

3070

Marital status Single/Nevermarried

Married/cohabitingWidowed

Divorced/Separated

10.742.731.115.5

62.120.78.68.6

25382412

Education le�el Neverattendedschool

PrimarylevelSecondaryLevelPostSecondary

Others

6.873.817.52.00.0

10.045.035.03.07.0

2935283.40.0

RelationshipwiththeheadofhouseholdHimself/herselfhead

SonDaughter

UncleAunt

GrandparentOthers(Specify

66.02.91.05.81.02.9

20.4

56.910.324.10.01.70.06.9

-------

The gender disparity in access to treatmentwithARVsispartlyareflectionoftheopennessexhibitedbyfemaleswhoarelivingwithHIVandAIDScomparedtomen,andalsoademonstrationof better health seeking behaviour by femalesthanmales.Inseveralgroupdiscussions,femaleusers whose partners were also using ARVscommentedthattheystartedusingARVsbeforetheirpartnersdid.

Findings furthershowedthatmostof theARVusersinTanzaniaandMozambiquewereheadsof households. By implication in the Africancontext, household heads are breadwinners. Ahigh dependency ratio at the household level(i.e. severalhouseholdmembersdependingonthehouseholdhead),incaseswherethemajority

6 ARV Community Knowledge, Awareness, Accessibility & The Policy Environment

ofbreadwinnersarelivingwithHIVandAIDS,canrepresentanuncertainfuturefortheentirehousehold.

Mostof theARVusershadattained lowlevelsof formal education i.e., having attained onlyprimaryeducation.MorethanahalfoftheARVrecipients in the three countries had attainedprimaryleveleducation.

2.3 Economic Profiles of ARV Users

Most of the ARV beneficiaries in the threecountries were generally poor as reflected bytheirmainoccupation,whichat the same timewasthemainsourceofincomeformanyexceptfor students and housewives. For instance, inTanzania,majorityearnedalivingthroughpettytrading(47%)whileinBurkinaFaso,overathirdwere house keepers. In all the three countrieswith exception of Mozambique, chances offindingcivilservantsandwealthypeopleamongARVrecipientswereminimal.SeeFigure1.

Interviews with key informants revealed thatmost of the civil servants and wealthy peopleprefer to remain anonymous when it comes toaccessing and using ARVs. It was noted thattheserarelydisclosetheirHIVstatusforfearofbeing stigmatized and discriminated. Majorityof such people have not had the courage andwilltogoforVCT.

RelatedwiththeoccupationofARVuserswerethe levels of income and household headshipstatus; both of which can potentially affectARV accessibility, use and adherence. Forinstance, almost a quarter (18%) of the ARVusers’householdsinTanzaniahadanestimatedmonthlyincomeoflessthanUS$10permonthandslightlyoveratenth(12%)earnedbetweenUS$25-40permonth.

FurtheranalysisoftheeconomicprofilesofARVbeneficiariesrevealedthatmajorityofhouseholdswerelivingabovetheirincomebracket-estimatedmonthly household expenditure far exceededincomeearnedpermonth.Theoverandaboveexpenditure in such households was reportedtobemadepossiblebysomeincomehandoutsfromrelativesandorfriends,borrowing,sellingoff somehousehold items;allofwhicharenotsustainableandcaneasilyplungeahouseholdinto a vicious cycle of poverty especially in asituationwherethefamilymemberusingARVsis at the same time the head of the householdandabreadwinner.

In most cases (specifically for Tanzania andMozambique)theARVuserswereheadsoftheirhouseholds and breadwinners. This situationcouldbeexacerbatedbythefactthatthebiggestproportion ofARV users had children of theirown—hencetheburdenofcare.

The above findings in the three countriesthereforeunderscorethechallenginglivelihoodconditionsthatARVusershavetocopewith.Itispossibletodeducethatitwouldbeunlikelyforsuchpoorpeopletostartantiretroviraltherapy(ART)iftheyweretopayforthem.

05

1015

2025

3035

4045

50

Peas

antf

arm

er

Civ

ilse

rvan

t

Teac

her

Bus

ines

s

Petty

trad

ing

Cas

ualw

orke

r

Hou

sek

eepi

ng

Stu

dent

Oth

er

Non

e

Bur

kina

Fas

o

Moz

ambi

que

Tanz

ania

Figure 1: Distribution of ARV recipients in 3 countries by occupation

7A Compendium Report of Tanzania, Mozambique & Burkina Faso 2007

3.0 KnowledgeandAwarenessofARVTreatment

3.1 IntroductionThe level of awareness and knowledge anindividualhasonaparticularaspectdetermineshowhe/she relates to that aspect. In this case,knowledge of what constitutes ARVs, theirutility,andproblemsassociatedwithtakingthemwere issues deemed pertinent to using ARVs.This section, therefore, presents a synthesis ofthe study findings on the levels of awarenessand knowledge about ARVs including suchintricaciesasunderstandingofARV treatment,thesourcesandmeansofinformationonARVs.

3.2 Knowledge and Understanding of ARV Treatment

Figure 2: ARV Recipients’ first time to hear ARV treatment in Mozambique

10.5

54.4

22.8

12.3

0

10

20

30

40

50

60

Percentage

Lessthan1yearago

1-3yearsago 4-5yearsago 5andmoreyearsago

The study findings revealed that knowledgeaboutARVswasveryrecentlyacquiredinallthethree countries. Most of the study participantsin the different countries had heard, for thefirst time, aboutARV treatment in a period ofbetween less than one year and three yearspreceding the studies. Variations across thedifferentcountriesunderstudyexistedbutwerenotquitesignificant.Forinstance,inTanzaniathebiggerproportion(38.2%)comparedto10.5%inMozambiqueand34%inBurkinaFasoreportedthattheyfirstheardaboutARVtreatment less

than one year ago. Further, only about a tenth(11.8%and12.3%)inTanzaniaandMozambiquerespectively reported their first time to haveheardaboutARVtreatmentasbeingover5yearsago,while15%inBurkinaFasohadheardaboutARVtreatment4yearsback.SeeFigures2and3. Figure 3: ARV Recipients’ first time to hear of ARV treatment- Tanzania

38.2

28.4

21.6

11.8

0

5

10

15

20

25

30

35

40

Percentage

Lessthan1yearago

1-2yearsago 3-4yearsago 5andmoreyearsago

The findings further confirm that knowledgeof ARVs especially in developing countries;a category, in which the three countries ofTanzania,MozambiqueandBurkinaFasofall,isrelativelyrecent.

3.3 Knowledge on Eligibility of ARV Treatment

VariousproxyindicatorsonlevelsofknowledgeaboutARTandARVs,ingeneral,weretestedinthestudycountries.Overall,people’sknowledgeabout eligibility to use ARVs including thosecurrentlyonARTwaslimited.Thestudyresultsrevealedinsignificantvariationsacrossthethreecountries. For instance, more than two-thirds(67.9%) and almost all (89.5%)ARV recipientsinbothTanzaniaandMozambiquerespectivelybelievedthatallPLHAsshouldbeonARVs.ThisimpliesthatonlyathirdofARVusersinTanzania

8 ARV Community Knowledge, Awareness, Accessibility & The Policy Environment

andaboutatenthofusersinMozambiquehadcorrectknowledgeregardingwhoshouldbeonARVs, i.e. only PLHAs that are recommendedand advised by a doctor should start or takeARVsi.e.(aftertakingaCD4testcountaswellasundergoingprofessionalclinicaldiagnosis).

FindingsonknowledgeoneligibilitytoARVusefurtherrevealedthatasignificantproportionofARV users shared the view that ARVs can beused in prevention of infection with HIV andAIDS.SeeTable2.

The knowledge gap was also evident in theperceived reasons for taking ARVs wherebyover a third of the sample in Tanzania and aquarter in Mozambique believed that takingARVs would prevent HIV andAIDS. This canparticularlyunderminetheeffectivenessofHIVandAIDSpreventioncampaignsespecially the“Abstinence, Be Faithful and Use Condoms”

Table 2: Knowledge on who is eligible to use ARVs

KnowledgeAspect Tanzania Mozambique

% (N=�0�) % (N=�0�)

Category of persons perceived to (who should) be on ARVtreatment***

AllPLHAsOnlyPLHAswhohavebeenrecommendedbyamedicaldoctor

Othercategories

67.932.10.0

89.549.11.8

PerceivedreasonfortakingARVtreatment***TopreventHIVandAIDS

TotreatAIDSTotreatopportunisticinfectionsrelatedtoHIVandAIDS

TostrengthentheimmunesystemTotreatpain

35.31

31.437.319.6

22.864.922.624.612.3

PerceivedlengthoftimeforonetostayonARVtreatmentAllthetime

AlwaysexceptwhenthemedicaldoctorrecommendsotherwiseDon’tknow

97.112

60.735.73.6

WhentostopARVtreatmentNocircumstance

OntherecommendationofadoctorWhenhe/shegetsbetter

IftherearesideeffectsIfridiculedbyfamily/communitymembers

Don’tknow

70.6-1

14.71

5.9

50.952.6

01.83.55.3

Problemsassociatedwithnot takingARVmedicationasprescribedby the doctor***

NoneDevelopingresistance

ResurfacingofpainDevelopingofside-effect

DevelopingfullblownAIDSOthers

11.750.54.911.729.11.9

26.324.65.33.5

15.826.3

*** Multiple Responses were allowed

Itisalsoimportanttonote,thatfactualinformationabout ARVs and their utility constitute partof the content of counselling. Glaring gaps inknowledge about ARVs, especially on whoqualifiestotakethedrugsandthecircumstanceswarranting a complete discontinuation of useofthedrugs,existedinallcommunitiesvisited.Comparatively, ARV users in Mozambiquewere lessknowledgeablecompared to those inTanzania;highlevelsoftreatmentilliteracyweremoreevidentamongusersinMozambique.

(ABC)campaign.For,peoplecanstartindulgingin sexual behaviours and practices that canpotentially expose them to the risks of HIVinfection hoping that ARVs will be a solution.Alltheseknowledgegapsneedtobeaddressed.People need information on ARV servicesincludinginformationonHIVtesting.


“Dissemination of correct knowledge on ARVs both in urban and rural areas is very important in promotion of ARV use…the community has to be prepared and be informed that treatment is available. We need to begin with community mobilization and sensitization about ARVs before we think of rolling out”

-KeyInformant,MoH-Mozambique

ARV knowledge gaps are not only confinedto ordinary community members, but healthworkersaswell. AlthoughthestudiesdidnotcoverhealthworkersintermsofassessingtheirknowledgeofARVs,otherstudiesthatprecededthisonee.g.,inMozambiqueconcludedthatthelevel of knowledge on AIDS was very low inallranksofhealthworkersasevidencedbythe

Table 3: Sources of Information on ARV Treatment

SourceoflearningaboutARVs*** Tanzania Mozambique

% (N=�0�) % (N=�0�)

SourcesofinformationonARVtreatmentRadiomessages

TelevisionmessagesBillboardAdvertising

Posters/brochures/fliersNewspapersDramashow

Friends/RelativesCounsellor/healthprovider

Localleaders/villagemeetingNGOstaff

36.014.01.05.06.01.0

17.058.07.09.0

65.97.11.20.60.62.44.711.20.60.6

TypeofinformationonARVtreatmentcurrentlyreceivedAccesstoARVtreatmentcentres

ServicesofferedatARVtreatmentCentresCorrectuseofARVs/adherencetoARVs

SideeffectsofusingARVAdvantagesofusingARVs

None

46.56.9

33.74.0

35.66.9

61.231.944.015.538.80.9

ARVtreatmentsitehasinformationonARVtreatmentYesNo

Don’tknow

93.23.92.9

62.412.125.4

ARVinformationdeliverymeansLeaflets

BrochuresPosters

BookletsOralsessions

3.12.16.31

91.7

33.332.411.112.064.8

*** Multiple Responses were allowed

bignumberofhealthworkerswhowereneitherabletogivegoodinformationtopatientsandthepublicingeneral,norabletotreatopportunisticinfections(OIs)properly(Conjumba,2003).ThisthenmeansthatARVknowledgecampaignsneedtobeallembracingcoveringthehealthworkersaswellespeciallythoseinthelowcadre.

SegregationofdataonARVknowledgebysexoftherespondentgenerallyrevealedlittledifferencebetweenmenandwomenusersofARVs.Onlyin Mozambique were slight differences noted;male respondents were found to have a slightedgeoverthefemalecounter-parts.Manymorefemalerespondents(88.8%)wereoftheviewthateverypersonlivingwithHIVandAIDSshouldbe on ARV medication as compared to 78.1%malerespondents.Butoverall,femaleARVusersseemedtobemoreexposedtosensitizationandcounsellingregardingAIDScare.

�0 ARV Community Knowledge, Awareness, Accessibility & The Policy Environment

3.4 Sources of Information on ARV Treatment

Findingsrevealedvaryingdegreesofpopularityof thedifferent sourcesof informationonARVtreatmentandservices.Forinstance,whereasinTanzaniaandBurkinaFaso6,Healthproviders/counsellors at the ARV dispensing sites werereported as the main source of information onARVs, in Mozambique they were among theleast cited sources instead the commonly citedsourceofinformationaboutARVtreatmentwasradio.SeeTable3.

3.4.1 Most Popular/Common sources of information on ARVSIn Tanzania, findings revealed that the mostpopularmeansofdeliveryofinformationaboutARV treatment were the oral sessions held byhealthworkers/counsellorsonsite.ThesituationinMozambiquewasslightlydifferent,whereasoralsessionsfeaturedmostasthepopularmeansofdeliveryofARVinformation,therewereothermeansthatwerenotablesuchasbrochuresandleaflets.WhatallthisimpliesisthatinTanzania,outside the ARV dispensing sites, not muchinformation isdisseminated to the community.Further,itimpliesthatinformationaboutARVsis not disseminated for the sake of informingpeopleandraisingtheirawarenessaboutARVs,buttoprepareintendinguserstotakeandadheretoARVuse.InBurkinaFaso,somerespondentsnoted that theyhadheard ofARVswhen theytravelled to neighbouring countries, such asIvoryCoast.

3.4.2 Types of information received about ARVsWith regard to the type of information thatwasbeingreceivedbythepopulationfromthevarioussourcesofinformation,findingsshowednodifferencesacross thedifferentcountries. Inallthestudyareas,thecommonlycitedtypeofinformationreceivedfromthevariousmodesofcommunicationwason“accesstoARVtreatmentcentres”,i.e.wheretheARVsiteswerelocated.Information on correct use or adherence toARVs,althoughnotassignificant,wasnotablyreceived.As can be seen in Table 4 above, themajoraspectsofARVtreatmentwerenotbeing

6 Studyrespondents inBurkinaFasoreportedtohaveheardmostaboutARVtreatmentfromassociationslikeSOS-SIDA–anassociationwherePLWHAaccessARVtreatmentfrom.Butnoquantitativedatawascollected.

disseminated outside the ARV dispensingsites in all the study countries—Tanzania andMozambique.Ithastobenotedthatforpeopleto be motivated to seek ARV treatment, theyneedtobeprovidedwithinformationonseveralaspects including advantages of using ARVs,possible side-effects, types of services that areoffered at the ARV treatment centres and onthesignificanceofadherenceonceapersonhasstartedtakingARVsontherecommendationofaqualifiedmedicaldoctor.Alltheserepresenttheknowledgegapsthathavetobebridged.

3.4.3 Disparities in Information access Segregationofdatabygender,ageandlevelsofeducation revealed no variations in sources ofinformationandaccesstoinformationonARVs.However,significantdifferencesexistedbetweenARVusersinurbanareasandthoseintypicallyruralsettingsinallthreecountries.

3.4.4 RecommendationsFor the general community, much moreinformation is needed, especially on HIVtesting, before a person can start thinking ofARVs. Availability of ARVs potentially acts asa motivating factor for people to seek testingservices. This means that as ARV literacyis promoted, the governments and otherstakeholders in the three countries where thestudieswereconductedhavetoensureequitableprovisioning of HIV testing facilities. Oncethis is done, then the population needs to besensitized and provided with information onthe availability of HIV testing and counsellingservices.

Regardingthedisparitiesinaccesstoinformationabout ARVs, it can be noted that awarenessraising and sensitization on ARVs ought towiden to include all sections of the society;the richand the poor,usersofARVs andnon-users,PLHAsandthosethatareHIVnegative,i.e., reaching everyone. This strategy seeks toarouse social support for PLHAs to useARVs,but also goes hand in hand with strategies foreliminating stigma and discrimination, whichalsounderminetheuseofARVsandadherence.Methods which reinforce highly interpersonal,customised,individualisedmeansofdeliveryofinformationneedtobepromoted.

��A Compendium Report of Tanzania, Mozambique & Burkina Faso 2007

4.0 ARVAvailability,AccessibilityandUse

4.1 IntroductionAvailability of ARVs denotes the situation ofusers’ ability to get the drugs (ARVs) anytimetheyneedthem.Ontheotherhand,accessibilityalso implies users being able to reach withrelativeeasetheARVdispensingsiteand,obtainARVtreatmentandservices.ThisSectionfocusesontheseaspectsofARVprovisioning.

2.2 Availability of ARVsAvailabilityofARVs,thoughimproving,isstillinadequateinallthethreecountriesofstudy.

4.2.1 Availability of ARVdispensing/ distribution sitesIn Mozambique, literature shows that only34 health facilities in the whole country wereprovidingHighlyActiveAntiretroviralTherapy(HAART)byendof2005.ThesituationismuchthesameinBurkinaFaso.Ofthethreecountries,itisonlyTanzaniawithasizablenumberofARTtreatment sites i.e. 204 sites. In Burkina Faso,quitedifferentfromMozambiqueandTanzania,serviceprovidershadaverylowopinionoftheavailability ofARVs nationally with almost all(98%) observing that ARVs were not widelyavailable,andhencenoteasytoaccess—acleardemonstrationofequityproblems.

4.2.2 Disparities in availability of ARVs dispensing/distribution sites The issue of equity in distribution of ARVprovisioning sites across communities in thedifferent countries featured prominently. Thatthere is more concentration of ARV treatmentsitesinurbanareasandlittleinruralareasisnotdebatable.Forinstance,inMozambique,Maputocityhad10ARVdispensingsitesbyendof2003comparedto3sites inInhambane–atypicallyruralprovince.DistributionofsitesinTanzaniawasnotanydifferenteither;MwanzaCityhad2sitesdispensingARVswhileSengeremadistrict;aruralareahadonlyonesite. InBurkinaFasothesituationwassimilartothatintheothertwocountriesasthefollowingquoteillustrates.

“One of the weaknesses of the current programme is that ARVs are not available in most of the health districts….I have to go to the capital Ouagadougou every month to get my ARVs”

- Male ARV beneficiary from Nahouri,

BurkinaFaso

4.2.3 Distribution of ARV dispensing sites As is mentioned in the above section, thisinequitable distribution of health facilities thatdispense ARVs implies that majority of thepersons onARVs are concentrated in typicallyurbansettingsasopposedtoruralareaswhereover 80% of the population resides in mostdevelopingcountries.

“There are about 40,000 people on ARVs in Mozambique, but most of these are in Maputo because that is where most of the health centres are concentrated and hence the services available…”

-KeyInformant,UNAIDS-Mozambique

4.2.4 Ongoing initiatives to increase availability of ARVs On a positive note though, Governments ofthe three countries with support from donorsand other stakeholders are taking initiativesto ensure that free ARVs are always availablein the few sites which have been accredited.For instance, the freeARV regime in Tanzaniastarted inMwanza inOctober2004andayearlater it spread out to cover Sengerema Districtand no cases of failure to get replenishmentswere reported. Virtually all respondents (98%)revealedthattheygotARVtreatmentwhenevertheyvisitedtheARVdispensingunits.Similarly,in Mozambique, almost all the respondentswhoweretakingARVs-50outof58notedthattheyalwaysgotARVsattheirrespectivehealthfacilities.However,casesoferraticdrugsuppliesweremorecommoninBurkinaFaso.

�� ARV Community Knowledge, Awareness, Accessibility & The Policy Environment

“The drugs are not always supplied on time and recipients have to wait whilst the drugs should be taken daily….for example, this month we only received enough for 80 people, which is below the amount required”

-CounsellorfromKadiogo,BurkinaFaso

4.2.5 Sustainable availability and provision of ARVsAlthough issues of availability are generallytakencareof,continuityinaccesshasnotbeenguaranteed. Reassurance that free ARVs arethere to stay is lacking hence the uncertainty–evengovernmentofficialswerenotcertainofthe future. For instance, a government officialin Sengerema District, Tanzania in response tothe issue of the future of theARV programmehadthistosay;“we assume the supply of free ARVs will continue”. Even UNAIDS (March 2006)acknowledges that the lack of secure fundingfor most national ART programmes beyond2008remainsaconcern.Thishighlightsaneedfor advocacy to urge African governments toconsiderbudgetingforARVprogrammesinsteadofheavilyrelyingondonorsupport.

“If the programme comes to an end, what will happen to me since I have no income? How can continuity be secured so as to sustain those currently on treatment “

-FemaleFGDparticipant,Kadiogo,AJPO,BurkinaFaso

The uncertainty of sustainable supply ofARVs was discouraging potential ARV usersparticularlyinTanzaniawherenon-usersnotedthat they were better off not to start on ARVsthan starting on them and then default, whichwouldbedisastrousfortheirlives.

4. 3 Access to ARVsFrom secondary sources, it emerged thataccessibilitytoARVswasnotuniversaltoallinneedinthethreecountries.Ofthethreecountries,Tanzaniahadachievednotableaccessibility-bymidJuly2006therewere83,000peopleenrolledwith42,000onARVs; thoughencouraging, thefigure was still far off the national target ofreaching 100,000 people with ARVs by end ofDecember 2006. The situation inMozambiquewas much worse; about 260,000 Mozambicanswere recorded as being in need of ARVs, butonlyabout37,000wereaccessingARVsbyendofOctober2006(MoH;NAC).Similarly,inBurkinaFasooutofanestimated45,000PLHAsinneedof ARV treatment, only 5,200 was accessingARVsasofendof2005.

4.3.1 Access to ARV dispensing /distribution sitesWithregardtogeographicalaccessibilitytoARVtreatment services, studyfindings showed lowlevelsofaccess,especiallyforpeopleresidingintypicalruralsettings. Inall thethreecountries,majorityof thepeopleaccessingARVswere inurbanareas.Forinstance,PandainMozambiquehad less than a tenth of the sample of ARVrecipients. Transport was reported as the mainfactor that affected accessibility to ARVs. Thedistances travelled were long; the averageestimated distance from the ARV recipient’shome to the site was 9.8km and 10.5km inTanzaniaandMozambiquerespectively.Incitingkeyproblemsrelatingtoaccessandavailabilityby service providers in Burkina Faso, distanceof support structures and lack of transportfacilities toaccessservicesfeatureprominently.SeeTable4forcomputeddataofTanzaniaandMozambique.


Table 4: Geographical access to ARVs

Access Count

Tanzania Mozambique

EstimateddistancefromARVbeneficiary’shometoARVsiteAverage(Mean)

NearestFarthest

9.8km0.5km70km

10.5km1km

28.3km

EstimatedtimetakentotravelfromhometosourceofARVsAverage/mean

Minimum/shortestMaximum/longest

54min3min

500min[8hrs]

56min6.7min

120min(2hrs)

MeansoftransporttoARVTreatmentCentreWalkingonfoot

bicycle/motorcyclevehicle

train

38.2%7.8%

59.8%1%

67.9%-

32.1%-

GiventhatbeforeonestartsusingARVs,s/hehastovisitthesiteforaminimumof3times,includingtesting for CD4 cell count and undergoingadherence counselling, such distances area hindrance to the poor but potential users.Importanttonote,allARVdispensingsiteswerelocatedinurbancentres,whichconstrainsaccesstoARVsbytheruralbasedusersandintendingusers,duelargelytotransportproblems.EveninruraldistrictssuchasSengeremaandInhambanein Tanzania andMozambique respectively, thedispensingsiteswerelocatedinthemainurbancentresof thedistricts.Oneof the fewcasesofnon-adherents, was reported to have failed toraisethetransportfareanddecidedtoquittheARVprogramaltogether.

Overall,however,accessibilitytoARVtreatmentservices has tremendously improved overthe years, but the numbers are still far belowachieving UNAIDS desired universal access.Apparently, there is limited access comparedtotheneedinallthecommunitiesstudiedandit is reportedly more skewed against the ruralbasedARVusers.Planstoroll-outtolowerlevelhealth facilities including rural based facilitiesareunderwayinallthethreecountries.Butforsuch localization of ARV dispensing servicesto be relevant, it ought to go hand in handwith promotion of VCT and activities aimedat eliminating stigma and discrimination. Thelittle, but significant incident thathappened inSengerema illuminates this point. The hospitalnursewhohelpedthestudyteamtotraceusersin their residences, had to first remove heridentifyinggownbeforeapproachingthehomeof the user for fear of arousing unnecessary

suspicion from neighbours who would startspeculating that the household had a PLHAthat would culminate into stigmatization anddiscriminationoftheoccupantsforthwith.

4.4 ARV Use/Utilization of ARV Treatment Services

Among users of ARVs, high adherence levelswere reported in all the study communities.PLHAswhohadtakenthedecisiontostartusingARVswerestilldeterminedtoensuremaximumadherence.However,itshouldbenotedthatARVuseisarelativelynewpracticeinthesecountries,although Burkina Faso and Mozambique hadaslightly longerhistoryofARVusecomparedto Tanzania. Slightly over a quarter (26.9%) ofARV recipients in Mozambique and 8.3% inBurkina had started taking ARVs before 2003.InTanzania,provisioningofARVsbecamemoreprominent in 2005. The difference was that inTanzaniaARVprovisioningtothenationalswasmuchmoreaninitialgovernmentinitiativeanddonorsjustboughtincomparedtoMozambiqueand Burkina Faso, where the initial initiativeoriginatedfromoutside—donors.Segmentation of data on ARV users accordingtogender,atteststothefactthatARVusehasagenderdimension.Findingsrevealedthatfemalepersons account for the biggest proportion ofARVusers.Forinstance,inMozambique,almostthree-quarters of the ARV beneficiaries werefemales compared to slightly over a quarterwhoweremen—72.4%and27.6%respectively.Almost equal proportions of female andmaleARV beneficiaries were reported in Burkina


Faso–73.6%and26.4%respectively.InTanzaniathere were also more female than male users.For instance,over70%of the registeredPLHAbenefiting from the services ofAIDSOutreachNyakatowerefemales.

ACORD Staff with research team and participants during the project participatory action research study in Mwanza, North Western Tanzania, May 2006

In Inhambaneprovincial capital-Mozambique,membersofWONA-NDLELA;anassociationofPLHAs,itwasnotedthatoutofthe60members,43wereonARVsandmajoritywerewomen.Inanother association of PLHAs in Maputo city,TINHENA with a total of 285 members, over90%werewomen.

This gender dimension does not in any wayconnote that it is mainly women who are inneedofARVs.Mostwomentendtovisithealthcentresthanmenwheretheyaccessinformationon ARVs, and for expecting mothers, they areoften counselled to take an HIV test, and iffound positive are encouraged to enrol on the“prevention of mother to child transmission(PMTCT)program.DiscussionswithmembersofvariousassociationsofPLHAsrevealedthatoftenmendonotdisclosetheirstatustotheextentthatevenwhentheyareonARVtreatment,itismoreofaprivatematter—theykeepittothemselvescomparedtowomenwhofinditeasytodiscloseandjoinassociationsofPLHAsforpsychosocialandmaterialsupport.


5.0ImpactofARVUseandBarrierstoAccessibility

5.1 IntroductionThis Section presents synthesized findings ontheimpactofARVsontheindividualrecipient,theirhouseholds,thecommunityandimpactonotherhealthservices. ItalsohighlightsbarrierstoARVsaccessibility.

5.2 Impact of ARV Use

5.2.1 Impact on the individual and household levelsOverall, the positive and negative impact ofARV use on the individual beneficiary is yettobe felt sinceas indicatedearlier,ARVuse isrelativelyrecentinthestudysites.Nonetheless,the individually realized benefit of improvedhealth was cited by almost all the users in thethree countries ranging from energized hopeto live;abilitytoresumeworkandcommercialactivities, planning for their families, and tocontributingtothewiderstruggleofcombatingHIV andAIDS.A real life case of Sophia7 is a7 Sophiaconsentedtohaveherrealnameandpictureusedin

thisreport.ShewasalsoamemberoftheresearchteamthatconductedthestudyinMozambique.

“I came to learn about my HIV sero-status in 2005, after several episodes of sicknesses. Given the shock of the HIV results and the battle with TB, I was hospitalized for 6 months. At the time of hospitalization, my CD4 count was 30 and I was weighing 28-30 kilograms. I started on ARVs, which I attribute my life and current good health to.

I was very sick, I could not talk, but ARVs made me regain my life and health.”

Sophia,whoseCD4countatthetimeofthisstudywasaround220,wasweighing58KgshadbecomeanHIVActivistrunningHIVandAIDS related programs on Television (TV)tosensitizethepopulationontheepidemicandtopromotetheuseofARVs.Sophiawhohad started being discriminated in society especiallyafterleavinghospitalduetoher

physicallooks,hasnowbecomeaTVstar,andisnowlookingafterheryoungsiblings,which could not have been possible hadshenotstartedonARVs.

clearexampleofwhatARVscandotoone’slifeiftakenconsistently.

This case of Sophia, a Mozambican, brings thepointhomethatuseofARVscanleadtoimprovedeconomicproductivityandhencefamilywelfareasaresultofreducedepisodesof illnessesand

reduction in family costs on frequent medicalcareforaPLHA.

5.2.3 Impact of ARV use on family and community behaviourInmostinstances,useofARVshadnotresultedintoadverseeffectsonfamilyrelations.Instancesof family members showing a positive andmore caring attitude were reported in all thethree countries, although isolated instanceswere reported among spouses and membersof extended family who developed hostileattitudes. In Burkina Faso it was found outthat 45% of the ARV beneficiaries reportedsignificantimprovementinrelationswithfamilymemberssincetakingARVs,onlyin10%ofthe


cases reported no change in relationship whilea fifth of the beneficiaries reported improvedrelationswithneighboursandothercommunitymembers.

However,outsidethesocialcircleofusers,andtheir immediate family, there were indicationsthat use of ARVs had not been given a goodreception by some community members. Insome of the communities visited, an air ofresentmenttowardsARVtreatmentwasevident[withapossibilityofincreasingunlesscheckedby sensitization campaigns]. Their disapprovalwasmoreinclinedonthelikelycompromiseonriskavertingapproaches;theyarguedthatuserslose all the symptoms associated with AIDSandsomeevenengageinunprotectedsexwithunsuspecting people. This finding highlightstheneedtomovebeyondfocusingontherightsof PLHAs to include their responsibilities inprotectingtherightsofothers(inpreventionofHIVspread).

5.2.4 Impact of ARVs on other health servicesThe major problem with ARV provisioning inboth public and private health facilities is theassociatedenormousrunningcostsessentialfora sustainable program. No doubt, successes intreatingPLHAsincreasesdemandonthehealthsystem.This isboth in termsofpersonnelandinfrastructure; most of the ARV dispensingsites did not have all the required facilitiessuch as CD4 count machines hence hospitalfunds were expended to get the tests done. Ineffect, the private facilities had to subsidizetherunningcostsforARVsandyetmajorityofARVrecipientsdidnotpayforservices.Thein-chargeofSengeremahospital,amissionfacilityinTanzania,lamentedthatprovidingARVswastoobigaburdenonthehospital.

“The laboratory technicians at Sengerema are too few to handle all the cases…the programme is taking our best personnel; highly qualified and experienced. We don’t have enough people…we have only three counsellors who can competently provide counselling services in addition to other designated duties, yet counselling for ARV beneficiaries and those coming to test is becoming a daily service

-Medicalin-charge,SengeremaHospital,Tanzania

ChallengesofpersonnelwerealsorifeinBurkinaFasoandMozambique.AcaseofPandaHealthfacility inMozambique succinctly summarizestheprevailingsituation.

PANDA HEALTH FACILITY - MOZAMBIQUEWhereas Panda Health facility nowprovidesARVs,nomorestaffhavebeenrecruited. What one notes is that the most qualified health worker, i.e. the healthcentre director, is the one in-charge oftheARVprogramassistedbyotherstaffthatunderwentthetraining.Although,notmentioned,theARVprogramistakingthebestofthebestatthecentre.Inaddition,peoplewhocomeforHIVtesting,lineupwithpatientsofroutinemedication,whichoftenslowsdown theprocess.The timeofwaiting is therefore prolonged,whichimpactsonqualityofservicesprovided.

What is very important to note in the threecountries, is the reassurance and expressedcommitment from the governments to addresstheconstraintsintheARVprogram.Forinstance,inTanzania,itwasrevealedthatgovernmentwasintheprocessofworkingoutaMemorandumofUnderstandingtobesignedbetweengovernmentand private providers clearly spelling out thecommitment of either party once they (privatefacility) have been designated to run an ARVprogram.

�7A Compendium Report of Tanzania, Mozambique & Burkina Faso 2007

5.3 Barriers to ARV UseVarious barriers to use and access ARVsincludingfacilitybased,policy,awareness,andtransport related, as well as nutritional, werecited in almost all selected communities in thethreecountries.

5.3.1 Direct costs for ARVs InMozambique and TanzaniaARVs are freelyprovided and hence no direct cost is incurredby the beneficiary to access ARVs. However,in Burkina Faso government does not provideuniversal access to treatment, although somepeopleareabletoaccessthedrugsfreethroughorganizations such as SOS-SIDA, but othershavetopay.

TheonlycategoryofpeopleinBurkinaFasothathavefreeaccesstoARVsarethoseonlowincomeand/ornoincomelinkedtoassociations,nationaland regional hospitalswho are identified by adoctor,pharmacistandsocial servicesagentorassociationofficer.ThisselectioncriterioncouldbesostigmatizinganddemeaningtotheextentofputtingoffpotentialARVusers.

5.3.2 Facility related barriers Atthehealthfacility,thecommonlycitedbarrierforusingandaccessingARVtreatmentserviceswas the inadequacy of personnel at the ARVdispensingsite. IncreasedaccessibilitytoARVsisnotonlyafunctionoftheavailabilityofdrugsand health facilities, but also availability ofqualifiedhealthpersonnel.Allcountriesvisitedacknowledged having challenges with healthworkers trained to provide specialized AIDScare.ForinstanceinMozambique,thesituationwas more pathetic compared to the rest of theSouthern Africa Development Community(SADC)regionasrevealedbythefollowing:

• Therewere17,000healthworkersofwhich11,000 were trained and that quality ofcare was being hampered by the minimalqualificationofhealthpersonnel.

• Only6%weremedicaldoctorsofthe11,000healthworkers,andconsequently less than50%ofthedistricthospitalshadadoctor

• The number of nurses per patient was1:5,000—thelowestintheSADCregioni.e.,comparedtoSouthAfrica(1:125);Botswana(1:457);Zambia(1:610);Malawi(1:1298)andZimbabwe(1:704).

• There was a limited number of counsellorsandpharmacists

• High turnover of trained health workerswithanannuallossof7%duetotransfersordeathofthedistricthealthstaff.

• ByMarch2004,thecountryhadanestimated240doctorsthathadbeentrainedtodeliverART.

Key informants in all the countries visitedconcurred that their national health systemswere constrained by lack of human resources.UNAIDS (March 2006) in particular notedthat scaling up treatment highlighted criticalweaknessesinhealthsystemsthatneededtobeaddressed, notably infrastructure and humanresources.Although trainingofhealthworkerstoprovidespecialisedAIDScarehadbeendone,ithadnotsolvedthehumanresourceproblem.

Theotherfacilityrelatedbarrierwasinadequacyofpremises.Inallhealthfacilitiesvisited,itwasreportedthatthenumberofARVrecipientshadbeenontheincreasewhichhadinadvertentlyledto congestion. For instance, in Tanzania whenthestudyteamvisitedSekouToure,PLHAshadjammedthecorridorswherecounselling,testingand dispensing of ARVs was being done. Thestudyteamhadtosqueezethroughthecrammedcorridor. It was revealed at Sengerema that onARVclinicdays,therewasalwaysascrambleforfacilitiessuchasseats/benchesbetweenroutinepatients andbeneficiaries ofARVs. Laboratorycapacitywasamajorweakness inall the threecountriesandadditionalresourcesandexpertisewould also be needed to assure the quality oflaboratoryinfrastructureoverthelongterm.

Tanzania at the time of this study was tryingto recruit more people to handle ARVs. Therecruited and trained persons were to be senttoallARVdispensingfacilitiesbothprivateandpublic.Likewise,Mozambiqueplannedtotrain2000intermediate-levelhealthcareprofessionals.Burkina was also seeking to broaden its list ofpeoplequalifiedtoprescribeARVs.

5.3.3 Policy related barriers ExistingpoliciesarepotentialbarrierstoaccessARV treatment. Apparently, some guidelinesinadvertently constrain access to services. InTanzania for example, the restriction on whereanARVrecipientgets8drugs,wascitedamong

8 ARV beneficiaries are not allowed to be served in any other site


constraintstoaccessorbarringanyotherpersonfromcollectingARVsonbehalfoftherecipientfromthedispensingsite,whichcouldcontributetonon-adherence.Thiscertainlyposesparticularchallenges to users who are bed ridden andthose with transport problems. This calls forinnovations andflexibility inpolicyguidelinesso as to help increase adherence as well asconvincingnon-userstoenrol.InBurkinaFaso,the plan was to decentralize drug dispensingsites to ensure easier access for users in ruralareas.

Other policies which were nutritional relatedwerecitedinsomecommunitiesasabarrier,butonlyspecifictoTanzaniawhereintendingARVuserswere required tosignacompliance formdeclaringthattheywouldadheretocorrectuseofARVs.Amongtheconditionswastheabilitytoaffordspecialdiet,asteadysourceofincome,clean water etc. Consequently, importanceof food becomes an essential element of thecontinuumofcareforPLHA.

“I attended several seminars on ARVs and they emphasize that one must take six meals a day, but I can hardly afford a single meal, so I could not start taking ARVs”

-MaleARVnon-user,Mwanza,Tanzania

Lastly,ARVusers,non-usersandpotentialusersalikewantedtobeassuredthatfreeARVsweretheretostayandtheprogramwassustainable.Lack of clear information on the ability andreadiness of the governments to sustain thesupply of free ARVs was reportedly causingworry and discomfort, leading to non-use ofARVs.

5.3.4 Awareness related barriers Lowawarenessdue to lackofappropriateandadequateinformationonARVswascitedwidelyasakeybarriertouseofARVtreatmentservices.As earlier indicated, the major aspects ofARVtreatmentwerenotbeingdisseminatedoutsidetheARVdispensingsites.Thecommonlyheardmessages in the media were on places whereARVs could be accessed. Apparently, this leftmanywithlittleornoknowledgeofARVs.Therewere even claims that ARVs were introducedwithoutpriorpreparationsofPLHAs todispel

thefeardrivenbymythsandmisinformation.InTanzaniaforinstance,itwasnotedthatthefocusof thegovernmentwasreportedlyonensuringenough supplies of ARVs on the assumptionthatfreesuppliesofARVswouldbeenoughtoattractPLHAtousethedrugs.CasesofPLHAsrefusingtoenrolforARVtreatmentservicesduetofearofsideeffectswereunderscoredinthesestudies.

“Some people out rightly decline the idea of starting on ARVs that their condition might worsen…they fear the possible side-effects”

-DistrictHome-BasedCareCoordinator,Sengerema,Tanzania

“A donor gave us free ARVs for 3 years; we were 5 people but only 2 agreed to take the ARVs. Although the donor said the drugs were brought because of me, I refused because I was not ready. Unfortunately, the 2 who took the drugs died because of drug reactions. I nursed one of them before she died; I still remember the side effects, even up today I cannot take ARVs; I have told the doctors”

-ARVnon-user,MwanzaCity,Tanzania

5.3.5 Transport related barriers Transport related barriers to access and use ofARVswere themost frequently citedobstaclesinBurkinaFaso.Transportasabarrier toARVuseisdoubleedged.Itconstrainstheusersandpotential users and also makes it difficult forhealthserviceproviderstomakefollow-upvisits.As earlier indicated, access toARV dispensingsiteswaspoor–theaverageestimateddistancefrom the ARV recipient’s home to the ARVdispensing sites is long, which translates intohigh travel fares that discourages users andleadstonon-adherence.Onesuchcasewascitedin the islands of Lake Victoria which is about70kms from the ARV site in Sengerema – theuserdefaultedduetohightravelfares.


6.0 National and International Policies

6.1 IntroductionIssues relating to the policy environment inwhichARVprogrammesarebeingimplementedwere not covered in Burkina Faso as theywere inMozambique and Tanzania. None theless, it should be noted that both national andinternational policies can either promote orconstrain accessibility to and use of ARVs aswellasprogramrollingout.

6.2 National Policies and Frameworks

The policy environment in the two countriesprovided a favourable environment forimplementation of ARV programmes. BothTanzaniaandMozambiquehavecomprehensiveNational Strategic Frameworks for HIV andAIDS—i.e., Tanzania has a National HIV andAIDSCareandTreatmentPlanwhichspecificallyguidestheimplementationandmanagementoftheARVprograminthecountry,andsimilarlyMozambiquea“NationalHealthSectorStrategicPlan to Combat STIs and HIV andAIDS”. Forthelater,thepolicydirectionfortheprovisioningof ARVs and rolling out is embedded in thatPlan. It is the national overall reference pointand framework upon which HIV and AIDSinterventionsandguidelinesarebasedincludingthoseforARVsascomparedtoTanzaniawherethe “National HIV andAIDS Policy (2001)”, isthe supreme and reference document to guidetheHIVandAIDSresponse.

It is important to note that both countrieshave developed other policy guidelines andframeworks to promote provisioning ofARVs such as the “Policy on HIV Testing andTreatment”,TheARTGuidelines(2004)andthe“TheNutritional Guidelines” forMozambiqueand the “National Guidelines for the ClinicalManagement of HIV and AIDS (April 2005)”in the case of Tanzania. Tanzania also has TheNational Multi-Sectoral Strategic Frameworkon HIV and AIDS (NMSSF) 2003-2007 whichoperationalizesitsNationalHIVandAIDSPolicy.Thisframework,amongothers,providesforthetreatment of common opportunistic infections,

including ARVs, and recognises that theprovisionofappropriatecareincludingaccesstohighly effective anti-retroviral treatment is oneofthecornerstonesofeverynationalstrategy.

Whatiscommontobothcountries isthattheirpolicyguidelinesoncareandtreatmentarenotexplainedinampledetail.Forinstance,whereasTanzania’s policy goal and objectives are veryclear on HIV prevention, it provides a generalandcursoryattention to the issueof treatmentunder its third specific objective-“Care forPLHAs”. Advocacy for increased access ofPLHAstomedicalcaremainlyARVsisnotwellarticulated.Otherissuessuchasthemechanismsfor monitoring and follow-up of people onARVs,plansforrollingouttoaddresstheequityproblems,inbuiltsustainabilitymechanismsforavailabilityofARVsandaccessibility, incentiveplans for manufacturers of ARVs etc. are alsonot well articulated by the policy’s goal andobjectives.Alltheseneedtoclearlycomeoutinthecountry’sNationalpolicyonHIVandAIDS.

In the case of Mozambique, the challengeis mostly on the content in the Nationalstrategic plan document. This overarchingnational framework is divided into parts; the“Strategic Component—Situational Analysisand the “Operationalization”. The StrategicComponent itself is a detailed document thatpresentsasituationalanalysis,amongothers,onindicatorsfordiseaseassessment,driversoftheepidemic, IEC activities, prevention activities,treatment, mitigation of the impact etc. Butbeingasituationalanalysis,itdoesnotprovideacomprehensiveanalysistotheaspectofARVs.It largely provides background informationwhichhassincebeenovertakenbyevents.Mostof it is centred on prevention of the infectionandhenceneedstobereviewedtocaterforARVprovisioningandaccessibility.


6.3 International Policies and Frameworks

Like all developing countries, changes in theglobalpoliciesregardingARVssuchaspolicieson patent rights have affected Tanzania,Mozambique and Burkina. According toUNAIDS report (March 2006) patents havebecome one of the most hotly debated issuesin essential medicines since the World TradeOrganization Agreement on Trade-RelatedAspectsof IntellectualPropertyRights (TRIPS)was introduced in 1995. This was followed bythe Doha Ministerial Declaration on the TRIPSAgreement and Public Health of 2001, whichclarifiedthattheAgreementcontainsflexibilitiesthatallowcountriestoimportandproducegenericversionsofantiretroviraldrugsunderpatenttoprotectpublichealth.This, in turn,providedamechanism for increasing competition amongpharmaceutical manufacturers, reducing drugprices and expanding access to antiretroviraltherapy.UNAIDShas,however,warnedthatthepublic health impact of the TRIPS flexibilitieswill depend on how effectively countriesimplement and use them within their nationalsystems. In the same report it is observed thatlow and middle-income countries often lackthe capacity to effectively administer policiesgoverning intellectual property rights and alsolackinformationaboutthestatusofpatentsonessential medicines, which is needed to makeuseoftheTRIPSflexibility.Giventhissituation,countries such as Tanzania, Mozambique andBurkina could be better off dealing with theseaspectsintheirregionalgroupings.

Allthethreecountriesi.e.Tanzania,Mozambiqueand Burkina are members of a number ofregionalbodiessuchasSADC,theEastAfricanCommunity (EAC) and ECOWAS. These aimatharmonizingmemberStates’HIVandAIDSPolicies, Strategies and Treatment Protocols.Member states in EAC have even been urgedto consider joint procurement of ARVs basedontheharmonizedEACARTProtocolsinordertofurtherreducecostofthedrugsandincreaseaccess.

IntheparticularcaseofTanzania,allthepartnerstatesintheEAChaveestablishedprogramsforscaleupanddistributionofARVstopatientsintheirjurisdiction.Thishashappenedinthelasttwo-three years using cheap generic productsmainly from India. However, with India

complyingwiththeTRIPSAgreementeffectiveMarch2006,theseexpansionprogramsareunderthreat.Indiashallnotbeabletoproducecheapgeneric ARVs through reverse engineering.The option EAC member countries have is tomanufacturethedrugsthemselves.

As of now developing countries includingTanzania, Mozambique and Burkina Faso andotherpartnerstatesintheregionalbodiesneedtopasslegislationthatcanenablethemtoexploitpositively the flexibilities provided in TRIPS,and also vigorously produce generic drugs fortheir nationals. But overall, the three countrieswhere these studies were conducted are allrecognizedashavingenablingnationalpoliciesthat can potentially accelerate availability andaccessibilityofARVs.


7.0 ConclusionsandRecommendations

7.1 IntroductionThis final Section of the Report draws theconclusions and suggestions arising out of thestudyfindings.Thesuggestionsaresynthesisedfrom the views of study participants on whatthey considered to be the role of civil society,ACORDinclusiveinthiseraofARVs—HIVandAIDScareandtreatment.

7.2 ConclusionsOverall,provisioningofARVtreatmentservicesis a recent initiative in all the three countriesof Tanzania, Mozambique and Burkina Faso.TherearestilldauntingchallengeswithregardtoARVavailability,accessibilityandutilization.Universal accessibility of ARVs especially offree ARVs will take a while to be realised inall the countries. Inequity in distribution ofARV dispensing sites is more skewed for thetypicallyruralsettings–eveninruralareas,ARVdispensingsitesarelocatedintheurbanpartsofthecommunity.Asofnow,mostARVsitesinthethreecountriesarelocatedinurbancentres.ThisisanequityproblemthatcharacterisestheARVprogrammesandrequiresattention.ItisevenabiggerprobleminBurkinaFasowhereARVsarenotprovidedfreely.

Availability of ARVs does not easily translateinto accessibility and use, unless the generalpoverty situation is addressed.As is typical ofallpoverty-strickenhouseholds,theexpenditureofhouseholds captured in this studyexceededthe estimated monthly income. This kind ofsituation threatens ARV accessibility, use andadherence; implying that programs aimed atexpandingARVaccessibilityshouldgohandinhandwithpovertyeradicationprograms.

Onapositivenotethough,itisworthynotingthatevenwithinsuchashorttimeofintroductionoftheARVprogrammes, themasseshaveamorethan average knowledge and understandingofARVtreatment.The informationonARVs isbasicallyprovidedatARVsites/healthfacilitiesby health workers and counsellors, whichimplies that other members in the communitywhodonotorrarelyvisittheARVsitesorhealth

facilitieshardlygetinformationonARVs.

Everyhealthprogramhasitsimpact—negativeorpositive,soistheARVprogram.AlthoughitisstilltooearlytotakestockofthelongtermimpactoftheARVprogramduetotheshorttimeithasbeen implemented, the study has neverthelessrevealed a few aspects of impact. The positiveimpact on the individual beneficiary has beenimproved health and increased productivity,but the negative impact is increasingly beingreflected in the costs associatedwith accessingARVssuchastransportcostsandforfeitingsomehouseholdneedsamongothers.

7.3 RecommendationsThe recommendations are categorized intotwo; those which are for national action, andthose which require regional and PanAfricanconcertedapproach.Infact, theremaybeneedfor more in-depth research at the regional andPanAfricanlevel.

1.1.1 Recommendations for national action

Poverty reduction efforts: - The socio-demographic and economic profiles of all theARVusersrevealedthatmajorityarepoor.TheseconditionsofpovertydoubleasbarrierstoARVaccessibilityanduse,whichrequireaction.Twoscenariosaresuggested(i)thatPLHAonARVsand whose health is deteriorating should betargetedwithsafety-nets—e.g.,directnutritionalsupport, and any other support as deemedcritical,and(ii)forPLHAwhosehealthhasnotbeen greatly compromised, their householdsshouldbetargetedwithmicro-creditsupport.

Addressing the equity problems:- The studyfindings showed that ARV sites were almosta preserve of urban areas, which createdimbalancesinaccesstoinformationandserviceprovisionbetweentheurbanandtheruralareas,andyetmajorityofthepeoplestayinruralareas.It is therefore recommended that alongsidestimulating demand for ARVs, government


should decentralize dispensing of ARVs tolower health units to ease accessibility, andpromoteuse.ThisimpliesrollingouttheARVprogramin“hardtoreach”ruralcommunitiesorthoseatthemarginsofsociety.TreatmentandrelatedservicesneedtobeavailedfreelytoallthosewhoneedthemespeciallyinBurkinaFasowheretheARVprogramisnotentirelyfree.

Regardingthedisparitiesinaccesstoinformationabout ARVs, it can be noted that awarenessraising and sensitization on ARVs ought towiden to include all sections of the society;the richand the poor,usersofARVsandnon-users,PLHAsandthosethatareHIVnegative,i.e., reaching everyone. This strategy seeks toarouse social support for PLHAs to useARVs,but also goes hand in hand with strategies foreliminating stigma and discrimination, whichalsounderminetheuseofARVsandadherence.Methods which reinforce highly interpersonal,customised,individualisedmeansofdeliveryofinformationneedtobepromoted.

Multi-faceted IEC strategy for factual information: -ThestudyfindingsrevealedlowlevelsofARVknowledgeandawarenessinthegeneral population—both in urban and ruralareas. Secondary data also pointed to lack ofadequate ARV knowledge among the healthproviderstodisseminatefactualandappropriateARV information. The study findings alsorevealed that health providers/counsellors attheARVdispensingsiteswerethemainsourceofinformationonARVs.Itisrecommendedthatamulti-facetedstrategyoftheradio,printmedia,community-based health educators, healthworkersandcivilsocietyorganizationsbeusedto disseminate knowledge and information onARVs—i.e.,toincreaseARVliteracyanddispelmythsandfearsthatarebarrierstoARVuse.

Campaigns targeting stigma and discrimination: - Although stigma and discrimination werereportedlyonthedecrease, therewasevidencethat they still existed in some sections of thecommunities, which underminedARV uptake.It is thereforerecommendedthatGovernmentswithsupportofotherstakeholderssuchas thecivilsocietyshouldsustainthecampaignagainststigma and discrimination, which underminessocialsupportfortakingARVs.

VCT Services: - Study findings indicated thatfor localization of ARV dispensing services to

be relevant, it ought to go hand in hand withpromotion of ethical, effective and sustainableVCTservices.EthicallyandeffectivelydeliveredVCT services can contribute greatly towardseliminatingstigmaanddiscrimination.

Nutritional and Food support: - There is nodoubtthatappropriatenutritionconstitutesthefirst line in treatmentofAIDSrelated illnesses.ThereforenutritionalprogramsandavailabilityofadequatefoodtopeopleonARVsneedtobefinancedbygovernmentandotherplayersinthefieldaspartoftheARVprogram.Thiswill,amongothers, contribute to adherence, and attractpotentialuserstoembracetheprogram.Indeed,theissueofnutritionalandfoodsupportisatthecentreofARVutilizationinMozambique.

Increasing the proportion of men using ARVsThe findings revealed that more females thanmales were using ARVs, which highlights theneedtoreachouttothemales.Oneofthemainintervention points to encourage the men touse ARVs is through reduction and eventualelimination of stigma and discrimination.Sustained awareness raising, sensitization andcounselling of the community al large wouldrealize impressive changes in the number ofmenusingARVs.

Improvement of the general health care system and human resources: - BeforerollingoutARVprovisioninginallthethreecountries,deliberateefforts must be made to improve the generalhealthcaresystem.Thereisanurgentneedformoretrainingofhealthpersonnelinbothpublicand health facilities, and also to advocate forimproved terms and conditions of service forenhancedrecruitmentandretention.

Support for structures of and for PLHAs:-PLHAassociationsplayavitalroleinidentifyingpeopleinneedoftreatmentandsupportingthemwithessential information and counselling. Theseassociationsmustbesupportedandstrengthenedthroughincreasedfinancialsupportandcapacitybuilding.

7.3.2 Wider recommendations at Regional and PAN African level

Funding for health services and resource mobilisation:- The issue of limited resourceshasbeendocumented as a barrier to equitableaccessibilitytoARVs.Thisconstraintaffectsall


the three countries. This study recommendsincreased advocacy for enhanced fundingfor health services and other components formanagingHIVandAIDStomeetcurrentneeds.Itisthereforeimportantthatresourcemobilizationand advocacy efforts are supported. Similarly,focus should be placed on efficient allocationof resources along the different interventionsto thepublicandprivateproviders, improvingcollaboration and partnerships, strengtheningcentralgovernmentanddistrictstoensurethatthe resources are used in efficient delivery ofservicestothetargetgroups.

Operationalization of national policies and frameworks:- Although the ARV program isstillrelativelynew,thestudyrevealedarichandconducive national HIV and AIDS policy andframework. The limitation is the translation ofthispolicyenvironmentorpoliciesintoconcreteprograms on the ground. There is thereforeneedforincreasedlobbyingandadvocacy,andtomobilizeresourcesso that thesepoliciescanbetranslatedintosustainablefundedprogramsaimedatenhancingARVaccessibilityanduseintheregionandsub-SaharanAfricancountries.

Expediting the legislation of TRIPS flexibilities and enhanced engagement in global policies:-The study revealed a possible difficultly insustainingthesupplyofARVstonationalsintheregionasIndia,whichusedtobethemainsourceofARVsfortheregion,hascompliedwithTRIPS.Countriesinsub-SaharanAfricaneedtosustaintheirengagementwithinternationalbodiesandpowerful governments in the world that aresettingtheagendaforARVmanufacturingandsupply.


References

ACORD (December 2005), “Strengthening theLivelihood of Marginalized Communities andtheirCapacitytoAdvocatefortheirRightsandAchieve/Contribute to Food Sovereignty”.ACORDMozambiqueAreaProgram2006-2010.

ACORD (2006), “ARVs Accessibility andImplications in Selected Sites: A Studyof Communities’ Perspective and PolicyEnvironment in Tanzania”. ACORD TanzaniaCountryProgram

ECA(Undated),“Mozambique:TheChallengesof HIV/AIDS Treatment and Care”. AddisAbaba,Ethiopia.

GoM(November2004),“TheNationalStrategicPlan for theCombatAgainstHIV/AIDS”.PartI—Strategic Component-Situational Analysis.Maputo

GoM(November2004),“TheNationalStrategicPlan for theCombatAgainstHIV/AIDS”.PartII—Operationalization.Maputo

GoM—“UNGASS Declaration of CommitmentonHIV/AIDS”,ProgressReport2003-2005

GoM(2004),“TheARTGuidelines”,MinistryofHealth,Maputo

StopAIDSCampaign,“Policybriefing:AccesstoEssentialMedicinesforHIV”May2006“Tanzania:freefoodprogrammetocomplimentfree ARVs” article published online by PlusNews,on:www.PlusNews.org

The United Republic of Tanzania, “Guidelinesfor the Clinical Management of HIV/AIDS”secondedition,April2005

TheUnitedRepublicofTanzania,“TheNationalHIV/AIDSCareandTreatmentPlan2003-2008”,NationalAIDSControlProgramme,MinistryofHealth

TheUnitedRepublicofTanzania(January2003),“National Multi-Sectoral Strategic FrameworkonHIV/AIDS2003-2007”,ThePrimeMinister’sOffice

The United Republic of Tanzania (November,2001), “National Policy on HIV/AIDS (2001)”,ThePrimeMinister’sOffice

UNAIDS(March2006)ProgressonGlobalAccesstoHIVAntiretroviralTherapyAReporton3by5andBeyond

UNAIDS—http://www.unaids.org/en/Regions_Countries/Countries/Mozambique.asp

USAID (March 2006), USAID Health: HIV/AIDS,Countries,MozambiqueUNESCO (June 2002), “HIV/AIDS Preventionand Care in Mozambique: A Socio-culturalApproach”.Maputo.

WHO (2005), “Summary Country Profile forHIV/AIDSTreatmentScale-up”,Geneva

(Footnotes)1 ThesampleincludesbothPLHAsandserviceprovidersbut

thefiguresinthetableareforonlyPLHAs

Contact ACORD:

KAMPALAOFFICE:PlotNo.1272GgabaRoad,Block15Nsambya,P.O.Box280KampalaUgandaTel:(+256)414267668/266596E-mail:[email protected]

LONDONOFFICE:DevelopmentHouseBlock15,56-64LondonStreetLondonEC2A4JXUnitedKingdomTel:+44(0)70650850E-mail:[email protected]

NAIROBIOFFICE:ACKGardenHouse,1stNgongAvenueP.O.Box61216-00200Nairobi,KenyaTel:+254(020)2721185/1172E-mail:[email protected]

Website:www.acordinternational.org

ISSN No.: 1812-1276

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