SITUATION ANALYSIS (DISTRICT LEVEL) TO IDENTIFY STAKEHOLDERS FOR TB-HIV COLLABORATION AND MAP

SERVICE PROVIDERS

(Year I)

Report of

Rupandehi District

Government of NepalMinistry of Health and Population National Tuberculosis Centre Nepal

2010

THE BRITAIN NEPAL MEDICAL TRUST

Serving the People of Nepal Since 1967

2

SITUATION ANALYSIS (DISTRICT LEVEL) TO IDENTIFY STAKEHOLDERS FOR TB/HIV COLLABORATION AND

MAP SERVICE PROVIDERS

Reportof

Rupandehi District

Government of Nepal THE BRITAIN NEPAL MEDICAL TRUST Ministry of Health and Population

National Tuberculosis Centre Serving the people of Nepal since 1967

Nepal

2010

3

FOREWORD

Since 1967 BNMT has been working with the government of Nepal to combat tuberculosis

(TB). Initially, BNMT worked in Eastern Nepal to improve the health and well-being of the

people living there and contributed in the development of National TB Programme (NTP).

Since the beginning of the NTP, BNMT has been a partner of development and has been

assisting the GoN within the framework of the National Tuberculosis Programme (NTP). The

goal of the NTP is to reduce morbidity, mortality and transmission of TB until it is no longer

a health problem. BNMT’s contribution to the National Tuberculosis Programme consists of

quality assurance of TB sputum microscopy, expansion of treatment services, advocacy,

communication and social mobilization, TB-HIV program and Public private mix within 27

districts of Nepal. NTP is receiving support from the Global Fund under Round 4 and Round

7 and BNMT is assisting NTC in the successful implementation of the activities proposed

under both Rounds.

Series of Operational Research (OR) activities to assist evidence based programme planning

and implementation on TB-HIV were proposed by the NTP under Round 7 of the Global

Fund support. One such intervention proposed is “Situation analysis to identify stakeholders

for TB-HIV collaboration and map service providers”. Situation analysis studies are planned

to assist in the programme planning and monitoring as it provides important baseline

indicators against which the activities could be implemented and programme performance

could be assessed.

In light of the above, BNMT carried out a study “Situation analysis to identify stakeholders

for TB-HIV collaboration and map service providers” in Rupandehi district in January 2010

at the time of implementing TB-HIV collaboration activities in the districts. The study aimed

to assess the current situation of TB-HIV collaboration and mapping of implementation level

partners in Rupandehi district. The ultimate objective of the study is to assist in better

targeting of the TB-HIV collaboration programme in the respective districts and establish

referral system between VCT and DOTS centers.

4

BNMT wishes to take this opportunity to thank Dr. Kashikant Jha, NTC Director and other

members of the PMU for their technical and financial support for the conduct of the study. I

would also like to thank the Regional Health Directorate, Western Development Region,

District Public Health Officer, HIV focal person, District Tuberculosis Leprosy Officer

(DTLO), DACC coordinator and Chairperson of DOTS committee of Rupandehi district and

all the other government line agencies and local NGOs for their support. My sincere thanks

goes to the health service providers, female community health workers and community

people at large without whose support and cooperation, this study would not have possible.

Dr. Ghanshyam Bhatta, Program Coordinator, TB-HIV, BNMT led the BNMT team. I thank

him for his leadership in the successful design and conduct of the study along with his team

members.

We at BNMT hope that the report will help to understand the current situation and strengthen

the targeted planning and monitoring of the activities regarding TB-HIV collaboration to

reduce the incidence of TB-HIV in the respective districts.

Dr. Bhanu B. Niraula and Ms. Sadhana Shrestha

Country Directors

BNMT

July 2010

5

ACKNOWLEDGEMENTS

I would like to express my sincere gratitude to all the participants who actively participated

in the study and shared their experiences and helped in making the study a success.

I would also like to thank Dr. Kashikant Jha, NTC Director, Regional Health Directorate,

Western Development Region, District Public Health Officer, HIV focal person and District

Tuberculosis Leprosy Officer of Rupandehi district for their technical and managerial

support.

The support from other local NGOs and the service providers working in all DOTS and VCT

centers throughout the entire study was really appreciable which makes it possible to bring

this study in this form.

I am deeply indebted to Dr. Bhanu Niraula and Ms. Sadhana Shrestha, Country Directors,

BNMT for their encouragement and support to carry out the study.

My sincere appreciation goes to all the study team members including Mr. Sunil Acharya

(Consultant), Ms. Manita Pandey and Mr. Suman Shrestha (Research Officers-field) and Ms.

Sabina Rijal (Data Management Officer) for their hard work.

Dr. Ghanshyam Bhatta

Program coordinator,

BNMT

July 2010

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TABLE OF CONTENTS

Page

FOREWORD………………………………………………………………………....... ii-iii

ACKNOWLEDGEMENTS……………………………………………………............. iv

TABLE OF CONTENTS………………………………………………………………. v

LIST OF TABLES AND FIGURES……………………………………………........... vi

ABBREVIATIONS...………………………………………………………………….. vii-viii

EXECUTIVE SUMMARY……………………………………………………………. ix-x

Chapter 1: INTRODUCTION

1.1 Background................................................................................................................ 1-3

1.2 Brief profile of Rupandehi district ............................................................................ 3

1.3 Study Objectives........................................................................................................ 4

Chapter 2: METHODOLOGY ........................................................................................ 5-6

Chapter 3: KEY FINDINGS

3.1 TB and HIV cases……………...……………………………………………........... 7

3.2 TB and HIV service provision and practices………………………………………. 8-10

3.3 TB-HIV collaborative services………………..…………………………………… 10-12

3.4 Referral services……...…………………………………………………………….. 12-13

3.5 Coordination and reporting………………………………………………………… 13

3.6 Human resource available in the health institutions….............................................. 13

3.7 Training received by service providers……………………………………….......... 14

3.8 Findings of qualitative survey……………………………………………………… 15-22

3.9 Organization and management issue………………………………………………. 22-26

Chapter 4: CONCLUSION and RECOMMENDATIONS……...................................... 27-29

References ....................................................................................................................... 30

Annexes............................................................................................................................ 31-48

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LIST OF TABLES AND FIGURES

Page

Table 1 Estimated population and health service outlets in Rupandehi district……..... 3

Table 2 Reported TB and HIV cases, Rupandehi, 2010..……………………………. 7

Table 3 TB and HIV service providers………………………………….…….............. 8

Table 4 Community participation in DOTS programme, Rupandehi....………………. 9

Table 5 Services provided from VCT centers …………………………....................... 10

Table 6 Collaborative services provided from DOTS centers………………...…..…… 11

Table 7 Collaborative services provided from VCT centers ….……………………… 12

Table 8 Referral practices of DOTS and VCT centers……...….............……………... 12

Table 9 Distribution of health institution by reporting place ………………………… 13

Figure 1 Number of staffs employed in the health institutions..………………………..

Figure 2 Training received by health institution staffs………………………………….

14

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ABBREVIATIONS

ART Antiretroviral Therapy

ARV Antiretroviral

CBO Community Based Organization

DACC District Aids Coordination Committee

DOTS Directly Observed Treatment Short-Course

DPHO District Public Health Office

EPI Expanded Programme on Immunization

FCHV Female Community Health Volunteer

FGD Focus Group Discussion

GF Global Fund

HFMC Health Facility Management Committee

HIV/AIDS Human Immune Deficiency Virus/Acquired Immunodeficiency Syndrome

HP Health Post

INGO International Non-Government Organization

MOHP Ministry of Health and Population

NAP National AIDS Program

NCASC National Centre for AIDS and STD Control

NTP National Tuberculosis Program

OPD Outpatient Department

PHCC Primary Health Care Centre

PLHIV People Living with HIV

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SAARC South Asian Association for Regional Cooperation

SEAR South East Asia Region

SHP Sub Health Post

STAC SAARC Tuberculosis and HIV/AIDS Centre

STI Sexually Transmitted Infections

TB Tuberculosis

VCT Voluntary Counseling and Testing

WHO World Health Organization

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EXECUTIVE SUMMARY

The objectives of the study were to: identify and map the existing service providers working

in areas of TB and/or HIV, explore and document the current practices of TB-HIV

collaborative activities, and explore the constraints and opportunities for developing TB-HIV

collaborative activities among the service providing agencies in Rupandehi district.

Methodology

The study utilized a mix of quantitative and qualitative information. Quantitative information

was obtained through secondary and primary sources. Secondary sources mainly included

reports and documents published by NTC, NCASC and DoHS. Primary information was

collected through the administration of semi-structure questionnaire among Key Informants.

Qualitative information was collected through Focus Group Discussions among TB patients,

HIV infected people and TB-HIV co-infected people in the community. Qualitative

information related to TB and HIV issues at the district was collected through the interview

of district level stakeholders and partners. A total of 15 DOTS centers and 4 VCT centers

were visited for the study.

Key findings

A total of 2325 TB cases were reported in the hospitals and peripheral health service

facilities of Rupandehi district in the period 2008/09. Majority of the male and female TB

cases were between the age groups of 15-24 to 55-64 years. A total of 427 HIV cases were

reported till the period June 2009. The highest proportion of infected cases was concentrated

in age groups 25-44. The government had the largest TB and HIV service network in

Rupandehi district. Only a few I/NGOs and 1 Medical college were involved in TB and HIV

service provision in the district. Fifteen institutions were providing DOTS services and 4

institutions were providing VCT services. There was one ART center in the district being run

by the government hospital. Only 1 health institution was conducting intensified TB case

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finding activities. The study results revealed that 12 institutions in Rupandehi district had

community participation in their DOTS programme.

All the DOTS centers were conducting collaborative activity like condom promotion and

supply and about 90 percent were providing information on HIV to TB patients using IEC

materials. The collaborative activities being conducted by VCT centers mainly focused on

client education about TB and referral of HIV positive clients for clinical care. Very low

numbers of institutions were providing referral services. Most patients were referred to

I/NGO facilities or government hospitals. Overall, the practice of use of referral slips,

documentation of referral cases and feedback mechanism was poor.

The health institutions staffs were also lacking the skills in tackling the TB-HIV co-infection

cases. Only the staffs of 75 percent VCT centers had got training on TB while the staffs of

only 20 percent DOTS centers had got training on HIV. Almost all the health institutions also

addressed the need of deployment of adequate and qualified human resources for the

provision of services on TB-HIV co-infection.

The study results indicated that the M&E mechanism in the government sector needs a lot of

improvements. The study result indicated to numerous constraints and challenges being faced

by the health institutions. The health institutions especially in the government sector were

constantly facing interruptions in the supply of equipment and drugs and many of them were

also lacking laboratory facility. The study findings showed that the governmental health

intuitions i.e. PHC, HP and Hospitals did not have any services on TB and HIV co-infection.

Many institutions had not followed the TB-HIV collaborative effort as it was supposed to.

The coordination and collaboration mechanism among institutions was poor.

Recommendations

The findings of situation analysis therefore, points out to the need of strengthening of

different aspects of TB-HIV program including skill development, institutional capacity

building, referral mechanism, planning and M&E, and inter-agency collaboration in

Rupandehi district

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Chapter 1: INTRODUCTION

1.1 Background

Tuberculosis (TB) is considered as the leading infectious killer for people living with

HIV/AIDS (PLHIV) worldwide with at least one in three people with HIV developing an

active TB disease. HIV promotes the progression of latent or recent TB infection to active

TB disease. TB-HIV co-infection has affected the African countries the most where 80% of

global co-infected people reside. The rapidly growing epidemics of HIV seem to be a crucial

barrier for TB control in South East Asia Region (SEAR) including Nepal. SEAR bears

about 17% of Global TB and HIV co-infection cases. Thus, collaboration between TB and

HIV/AIDS program is essential to improve access to comprehensive TB and HIV prevention,

care and support services for affected populations and saving lives.

Tuberculosis is one of Nepal's major public health problems. About 45% of the population is

infected with TB, out of which 60% are in the productive age group. Every year, 44,000

people develop active TB, of whom 20,000 have infectious pulmonary disease. These 20,000

can spread the disease to others. Introduction of treatment by Directly Observed Treatment

Short course (DOTS) has already reduced the numbers of deaths; however, 8,000-11,000

people continue to die every year from this disease. Expansion of the cost-effective and

highly-successful DOTS treatment strategy has proven its efficacy in Nepal and has had a

profound impact on mortality and morbidity. By achieving the global target of diagnosing

70% of new infectious cases and curing 85% of these patients, 60,000 deaths will be

prevented over the next five years. High cure rates will reduce the transmission of TB, lead to

a decline in the incidence of this disease, and ultimately aid in achieving our objectives of TB

control.

DOTS was introduced in 1996 after a joint Government/WHO review of the National

Tuberculosis Programme (NTP) revealed that only 30% of TB cases were registered, and of

these only 40% were treated successfully. The cure rate in the first cohort of DOTS patients

was over 89%. By July 2000 the program had been expanded to 178 treatment centers in 66

districts and covered 75% of the population. The treatment success rate in DOTS centers is

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now approximately 89%; and, the national treatment success rate has reached nearly 85%. In

the period 2007/08, a total of 33,419 TB patients were registered and treated under the NTP.

One of the reasons for the persistent burden of TB is a failure to address the principal risk

factors. The risk associated with TB can be put in three groups: the process of infection,

progression to disease and outcome of a disease episode. Environmental factors that govern

exposure to infecting bacilli include crowding, hospitalization, migration, imprisonment,

ventilation and the ambient prevalence of infectious disease (mostly sputum smear positive).

Among factors that influence the progression to diseases following infection, HIV co-

infection is outstandingly important; others are age, sex, diabetes, tobacco, alcohol, TB strain

virulence and malnutrition. Factors that affect the outcome of a disease episode include

where treatment is given (eg. public or private sector), whether treatment is interrupted and

drug resistance. The adverse outcomes most commonly measured are treatment failure and

death. Some other risk factors for TB are commonly invoked but ill defined, ethnicity and

poverty among them.

In the context of Nepal, a situation analysis of TB-HIV co-infection was conducted in 2006.

The study revealed the fact that there is an absence of policy framework for collaborative

work as well as lack of resource allocation from government for collaborative activities. The

study also highlighted lack of formal referral mechanism between two programs though some

informal referral system exists in certain cases. However, both the program has major

individual strategies like DOTS for NTP and VCT for HIV/AIDS. In recent times, Nepal has

made some progress in TB-HIV collaborative program. The National Tuberculosis Program

(NTP) in its revised Long Term Plan (2010-2015) has envisaged collaboration with National

AIDS Program (NAP) to decrease the burden of TB-HIV in population affected by both

diseases.

In response to the dual burden of the diseases, a central level working groups (TB-HIV sub

technical group) has been formulated recently. Similarly, task forces on TB-HIV

coordination have been established and national policies and strategies are also formulated.

Though these policies and strategies have been formulated, till date strong evidences are

14

lacking as to the exact situation of the formulated collaborative activities at implementation

level.

In this context in January, 2010 BNMT carried out a situation analysis in Rupandehi district

of Nepal. The purpose of the analysis was to identify and document the existing collaboration

in formal and informal sectors and facilitate in identifying the gaps in TB/HIV collaboration

both in policy and practice level.

1.2 Brief profile of Rupandehi district

Rupandehi district, a part of Lumbini Zone, is one of the seventy-five districts of Nepal. The

district, with Siddharthanagar as its headquarters, covers an area of 1,360 km². The

population is currently estimated to be close to one million.

Both government and private sector institutions are currently providing health services in the

district. Government has the district wide health service network: 2 hospitals at the district

headquarters and 5 Primary Health Care Centre (PHCC), 6 Health Post (HP) and 58 Sub-

health Post (SHP) in the peripheral areas. It also has a district wide network of EPI and

Outreach clinics and Female Community Health Volunteers (FCHVs) (Table 1).

Table 1: Estimated population and health service outlets in Rupandehi district

S. No Description Total numberA Estimates of population sub-groups (for

the period 2008/09)1 District population 8532592 < 1 year population 216403 < 5 year population 1125424 Married women of reproductive age

(MWRA)163205

5 Expected pregnancy 31240B Government service outlets (for the period

2008/09) 1 Hospitals 22 PHCC 53 HP 64 SHP 58

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5 EPI clinic 2526 PHC/ORC clinic 2227 FCHV 1290

Source: Department of Health Services (DoHS), 2009

1.3 Study objectives

The overall objective of the study was to assess the current situation of TB-HIV collaboration

and mapping of implementation level partners in Rupandehi district. The specific objectives

were:

To identify and map the existing service providers working in areas of TB and/or

HIV in Rupandehi district,

To explore and document the current practices of TB-HIV collaborative activities

in Rupandehi district, and,

To explore the constraints and opportunities for developing TB-HIV collaborative

activities among the service providing agencies operating in Rupandehi district.

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Chapter 2: METHODOLOGY

The study utilized a mix of quantitative and qualitative information. Quantitative information

was collected through review of institutional records and administration of semi-structured

interview schedule (questionnaire) among health institution staffs working at district and

peripheral or community levels. Qualitative information was collected mainly through Focus

Group Discussions and in-depth interview.

2.1 Study population

Following three categories of respondents were included in the situation analysis:

The first category of respondents included the TB and HIV program focal persons,

program coordinators, DTLA/O, other technical staff and in-charge of health facilities

located at district and peripheral levels (e.g., government hospital and PHCC and HP, all

DOTS centers and all VCT centers).

Second category of respondents included TB patients, HIV infected people and TB-HIV

co-infected people.

Third category of respondents included officials of district level stakeholders and partner

institutions including DHO, DACC and DOTS committee.

A total of 15 DOTS centers and 4 VCT centers were visited for the study.

2.2 Data collection techniques and tools

As mentioned above, both quantitative and qualitative technique was adopted to obtain the

required information. Quantitative information was obtained through secondary and primary

sources. Secondary sources mainly included reports and documents published by NTC,

NCASC and DoHS. Primary information was collected through the administration of semi-

17

structured questionnaire among Key Informants. A total of 19 Key Informants were

interviewed in the district and peripheral areas. The interview schedule is presented in Annex

7 and list of institutions included in the study is presented in Annex 8 and 9.

The information collected in the in-depth interview includes:

- Estimated and reported cases of TB and HIV in the district,

- Types of preventive and curative TB and HIV services provided by the health

institutions including participation of the institutions in DOTS,

- Practices of the health institutions on maintaining confidentiality of client information

and referral of clients,

- Affiliation of health institutions with various committees operating in the district and

the institution’s participation in TB-HIV collaborative activities,

- Information on management issues that included program planning, monitoring,

reporting and supervision procedures, and,

- Problem and constraints being faced by the institutions in implementing TB-HIV

collaborative activities and suggestions on ways of strengthening the program.

Qualitative information was collected through Focus Group Discussions among TB patients,

HIV infected people and TB-HIV co-infected people in the community. Qualitative

information related to TB and HIV issues at the district was collected through the interviews

of district level stakeholders and partners. The in-depth interview guideline is presented in

Annex 5 and 6.

The information collected in the FGDs mainly focused on awareness of people on TB, HIV,

DOTS and ARV; TB and HIV practices prevailing in the community; and problems faced by

community people in seeking TB and HIV services. A total of 3 FGDs was organized in the

community to solicit qualitative information. The FGD guideline is presented in Annexes 2,

3 and 4.

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Chapter 3: FINDINGS

Information on various aspects of TB and HIV programs being conducted by various

institutions in the district was collected. The information included details of program such as

activities implemented, availability of DOTS, community participation in DOTS, provision

of VCT services, availability of HIV testing and counseling facilities, case finding activities,

and collaboration among institutions working in TB and HIV sector. This section presents

general findings of the survey on these issues.

3.1 TB and HIV cases

Table 2: Reported TB and HIV cases, Rupandehi, 2008/2009

Age group Male Female Total

TB cases

0-14 3.3 7.6 5.515-24 21.1 23.0 22.025-34 19.8 24.1 22.035-44 13.0 16.2 14.645-54 14.0 10.5 12.255-64 16.6 11.5 14.065+ 12.2 7.2 9.7

Total (%) 100.0 100.0 100.0N 1628 697 2325

HIV cases (cumulative figure)0-14 7.7 6.6 7.115-24 2.3 9.6 6.025-34 40.6 42.8 41.735-44 36.8 32.5 34.745-54 10.3 7.2 8.855-64 2.3 1.2 1.865+ 0 0 0.0

Total (%) 100.0 100.0 100.0N 261 166 427

A total of 2325 TB cases were reported in the hospitals and peripheral health institutions of

Rupandehi district in the period 2008/09. There is no specific pattern of infection in male and

19

female cases. By age, majority of the male and female TB cases were between the age groups

of 15-24 to 55-64 years (Table 2).

Similarly, a total of 427 HIV cases were reported in Rupandehi district till the period 2009.

By age, the highest proportion of infected cases was concentrated in the age groups 25-44.

The age pattern of HIV infection is similar to the infection pattern reported in NCASC data

in that the infection is highest in ages between 15 to 44 years (NCASC, MoHP, 2010).

3.2 TB and HIV service provision and practices

3.2.1 TB and HIV service providers

Various government, private

sectors and I/NGOs are

providing a variety of TB

and/or HIV services in

Rupandehi district. Among

these agencies, the

government had the largest

health service network: 70

percent of the services were

covered by government hospitals and peripheral health facilities like Primary Health Care

Centre (PHCC) and health Posts (HP). The share of I/NGOs and private sector in TB and

HIV service provision was 30 percent (Table 3). In case of government service outlets in

Rupandehi district, hospitals are located in urban while PHC and HP are located in semi-

urban or peripheral areas. The service outlets of I/NGOs and private sectors are mostly

located in urban or semi-urban areas. Of the total institutions, 15 were providing DOTS

services and 4 institutions were providing VCT services. The Lumbini hospital was

providing both DOTS and ART services.

Table 3: TB and HIV service providers, Rupandehi, 2010

Program area S.N Sector/type Number

TB(DOTS center)

1 Government hospital 22 Government peripheral

health institutions12

3 Medical college 1HIV

(VCT, ART center)

1 VCT centers 42 ART center 1

Lumbini hospital runs both DOTS and ART center Some of the sectors overlap with each other

20

On the question of maintaining confidentiality of patient information, all the health

institutions (N=19) in Rupandehi district reported that they maintain confidentiality.

3.2.2 Community participation in DOTS programme

At present, support groups of PLHIVs, CBOs and other community groups are encouraged to

participate in TB-HIV collaborative activities with health institutions. These community

groups could participate in identifying and referring suspected TB cases for TB services;

identify and refer HIV vulnerable and at-risk population to HIV services; and, support and

ensure DOTS for TB patients and ART-treatment adherence to AIDS cases.

Thus at the time of this analysis 12 health institutions (80%) in Rupandehi district were

reported to have community participation in their DOTS programme. All institutions were

participating in DOTS through active DOTS committee. Similarly, two-third (66.7%) were

also participating through community based or family based DOTS. Similarly about 40

percent were participating in DOTS through DOTS centers (Table 5).

Table 4: Community participation in DOTS

Community participation in DOTS Number PercentYes 12 80.0No 3 20.0Total (N) 15 100.0Methods of community participationThrough active DOTs committee 12 100.0Through community based DOTS or family based DOTS 8 66.7Through DOTS 5 41.7Total (N) 12 100Note: Percent totals may exceed 100.0 due to multiple responses.

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3.2.3 Services provided from VCT centers

During the study period, all 4

VCT centers in Rupandehi

district were providing a range

of services to HIV infected

patients. The services provided

through all these institutions

include: pre and post test

counseling, HIV and STI

prevention counseling, HIV

testing, condom promotion and

distribution, quality assurance system for HIV testing, quality assurance system for

counseling and referral services.

3.3 TB-HIV collaborative services

The burden on TB services goes up due to the increase in TB attributable to HIV, coupled

with the increase in HIV related morbidity and mortality in TB patients. Improved

collaboration between TB and HIV programs leads to more effective control of TB among

HIV infected. TB control can better contribute in HIV control which in turn leads to

significant health gains.

Thus the national TB-HIV collaborative policy focuses on the interface of TB and HIV/AIDS

epidemic and joint programs are intended to be carried out as part of the health sector

response to co-infection. In line with this policy TB-HIV coordination committees have been

established at national, regional and district levels.

At present, the district level Sub-committees are formed under the umbrella of District Aids

Coordination Committee (DACC). The sub-committee is chaired by District (Public) Health

Table 5: Services provided from VCT centersRupandehi, 2010

Description Number of institutions

Percentage

Pre and post test counseling 4 100HIV and STIs prevention counseling

4 100

HIV testing 4 100Condom promotion and supply 4 100Referral services 4 100Quality assurance system for HIV testing

2 50

Quality assurance system for counseling

2 50

Note: Percent totals may exceed 100 due to multiple responses

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Officer. They review performance and implement national policies and strategies of TB-HIV

collaborative activities in the respective districts.

The study results further revealed that most of the institutions with DOTS program were also

conducting a variety of collaborative activities. All the DOTS centers were conducting

condom promotion and supply activities. 26.6 percent DOTS centers were providing

Syndromic STI treatment for TB patients and HIV prevention counseling. Similarly, nearly

90 percent of these institutions (N=13) were providing information on HIV to TB patients

using IEC materials (Table 6).

Table 6: Collaborative services provided through DOTS centers, Rupandehi, 2010

DescriptionTotal institutions

Number Percent Condom promotion and supply 15 100.0HIV prevention counseling 4 26.6Provide syndromic STI treatment for TB patient 4 26.6Providing information on HIV to TB patients using IEC materials 13 86.7Total (N) (15) 100Note: Percent totals may exceed 100.0 due to multiple responses.

Regarding intensified TB case finding, only 1 out of the 15 institutions reported of

conducting intensified TB case finding. During the study period, this activity was being

conducted through home based care volunteers and through FCHV.

In Rupandehi district, all 4 VCT centers were conducting some of the collaborative activities

during the study period. The collaborative activities of all 4 institutions were mainly focused

on client education about TB and STIs, referral of HIV infected clients for clinical care,

screening of clients for STIs, and treatment for STIs. In addition, 3 institutions were also

involved in other services like managing TB testing and TB treatment (Table 7).

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Table 7: Collaborative services provided through VCT centers, Rupandehi, 2010

DescriptionTotal institutions

Number PercentClient education about TB 4 100.0Client education about STIs 4 100.0Referral of HIV infected clients for clinical care 4 100.0Screening clients for STIs 4 100.0Treatment for STIs 4 100.0Manage TB testing 3 75.0Manage TB treatment 3 75.0Total (N) (4) 100Note: Percent totals may exceed 100.0 due to multiple responses.

However due to low awareness of government policy and guideline on coordination and

collaboration, collaborative effort among these agencies had not been effective. In some

cases especially in the government sector, the current collaboration is the result of personal

effort of the institution staffs. This issue was pointed out by several stakeholders during the

in-depth interviews. The interview results also indicated that most of the health institution

staffs strongly felt the need for inter agency collaboration to tackle the issue of TB-HIV co-

infection. They further pointed out the need for DACC and DOTS committee to be proactive

in this regard.

3.4 Referral services

A total of 13 out of 15 or

about 87% DOTS centers in

Rupandehi district were

providing referral services to

TB patients for HIV

services. Similarly, all 4

VCT centers also were also

found providing referral

services to HIV infected for

TB screening and treatment. The study results further showed that most of the patients were

Table 8: Distribution of health institutions by referral practices, Rupandehi, 2010

Refer TB patient for HIV servicesTotal institutions

Number PercentYes 13 86.7No 2 13.3Total (N) 15 100.0Refer HIV patient for TB service Yes 4 100.0No 0 0.0Total (N) 4 100.0Use of referral slipsYes 13 76.5No 4 23.5Total (N) 17 100.0

24

referred to government hospitals (Lumbini Zonal Hospital and Bhim Hospital). The patients

were also referred to I/NGO institutions including Red cross, Navakiran, Astha and Namuna

Bikash Parishad. Most of these centers practicing referrals (N=13) claimed that they always

use referral slips while referring their clients to other institutions (Table 8).

The study result also showed that relatively higher numbers of institutions that refer patients

never or only sometimes communicate to the institutions where they referred patients to. In

course of the study, only 4 institutions reported of always communicating about the referral

patients. Likewise, all DOTS and VCT centers included in this study reported that other

health institutions also send referral cases to them. Similarly, these centers claimed that they

maintain records of incoming and outgoing referral cases.

3.5 Coordination and reporting

The study finding indicated that

majorities of DOTS and VCT

centers send their program

activities report to D/PHO and a

few other centers also send

report to the

agencies/committees with whom

they are affiliated to such as

NCASC (Table 9).

3.6 Human resource available in the health institutions

The study findings showed that the number of staffs working in the health institutions ranged

from less than 5 staffs (in 3 institutions) to more than 15 staffs (in 3 institutions). Slightly

more than half (52.6%) institutions (N= 10) were employing 5 to 10 staffs. Similarly, another

3 of the institutions were employing 11 to 15 staffs (Figure 1).

Table 9: Distribution of health institutions by reporting place, Rupandehi, 2010

DescriptionTotal institutions

Number PercentDOTS CenterDHO/DPHO 15 100.0Regional Health Directorate (RHD) 1 6.7Total (15) 100VCT CenterDHO/DPHO 2 50.0NCASC 4 100.0Total (4) 100Note: Percent totals may exceed 100.0 due to multiple responses.

25

3.7 Training received by service providers

Regarding training on TB and HIV, the overall result showed that the staffs of all DOTS

centers (N=15) had received training on TB while the staffs of only 20 percent DOTS centers

(N=5) had received training on HIV. Similarly the staffs of all VCT centers (N=4) had

received training on HIV while the staffs of three-quarter of VCT centers (75%; N=3) had

received training on TB (Figure 2).

26

3.8 Findings of Qualitative Survey

In the situation analysis, FGD was conducted among PLHIV, TB patient and TB-HIV

infected persons in Rupandehi district. These discussions mainly focused on participants

understanding of TB, HIV, and TB-HIV co-infection issues, health services seeking

behavior, behavior of health service providers and type of services/support they receive from

the service providing institutions. Similarly, in-depth interviews of health service providers

including officials of district level committees and D/PHO were also conducted in the survey.

The interview was broadly focused on the population sub groups that are at risk of TB and

HIV in Rupandehi district, types of services available in health institutions, problems and

challenges faced by the institutions in providing services and ways of resolving the problems

and challenges. This section therefore presents general findings of the survey regarding these

issues.

3.8.1 FGDs among PLHIV, TB patient, and TB-HIV co-infected

Knowledge and understanding of TB, HIV, and TB-HIV co-infection

All the PLHIV participants had knowledge about HIV. Majorities of PLHIV perceived HIV

as a life threatening condition. Most had acquired detailed knowledge about HIV through

different institutions they had visited after being infected by the virus. They had acquired the

knowledge about HIV during the counseling sessions at the VCT centers. Only a few PLHIV

possessed knowledge about TB. Majorities had no knowledge that HIV infected person is at

high risk of getting TB. The FGD result indicated that very little or no information was given

to them by the health service providers when they were diagnosed HIV positive. Only 3 out

of 6 FGD participants were asked to get TB test by the service providers who diagnosed them

being HIV positive.

The TB-HIV co-infected participants had knowledge about HIV. They also had knowledge

that once infected it cannot be cured. They however lacked other aspects of HIV infection

such as modes of HIV transmission and ways of prevention. Like PLHIV, the co-infected

27

participants had also heard about HIV from health service providers. A few of the

participants had also heard about it from the radio. The co-infected participants had basic

knowledge on TB. They had the knowledge that TB is a curable disease and knew about the

symptoms such as cough and fever. The participants however were not aware about the

proper dose or duration of drug intake for curing TB. The main source of their knowledge on

TB was friends/neighbors in the community and the health service providers, both at VCT

and DOTS center.

The discussion with TB patient revealed that all the participants had good knowledge of TB

including its symptoms, modes of transmission and ways of prevention. A few participants

had heard about TB from the community people and on radio while most had heard about it

from the health service providers. Regarding HIV, all had heard about the virus from

different sources but did not know important information like modes of transmission and

ways of prevention. The participants were not told about HIV by the health service providers.

Overall, the discussion result with PLHIV, and TB patients indicated that PLHIV and TB-

HIV co-infected participants had knowledge on TB and TB-HIV co-infection while most TB

patients did not have much information on HIV and AIDS. The FGD result further indicated

that TB patients were also not much keen on acquiring knowledge on HIV and/or TB-HIV

co-infection.

Health services seeking behavior

The FGD results indicated that privacy in the health institutions is the main factor for

determining the health services seeking behavior of PLHIV and TB-HIV co-infected people

in Rupandehi district. The other factors that motivate people for seeking services are the

behavior of health service providers and care takers, and extent of support they receive from

the people who work in I/NGOs and within the HIV support network.

Cost of services was also mentioned by the participants especially those with TB-HIV co-

infected as the important factor in determining whether to seek services or not. In course of

28

discussion, many of the participants mentioned that they could not go to private sector

institutions due to the high cost of services even though the quality of care and support was

good in those facilities. It was thus due to the cost factor that all co-infected participants had

sought services from government institutions.

In case of TB services, cost and service user’s trust in the quality of services and prospects of

cure of the disease was found to be the reason for using the services. Accessibility of the

services was also found to be one of the important reasons for them in using services.

Overall, the participants were satisfied with the DOTS services provided from the hospital

and other health institutions.

The discussion results also revealed that all participants were given basic information about

TB in the DOTS center that they had visited. The information they received was about the

duration of drug use, need of sputum check up, preventive measures for TB infection such as

harms of smoking and taking alcohol. All participants were also advised on the importance of

regular intake of TB treatment medicine. These participants however were not informed

about HIV or TB-HIV co-infection. Overall, all the TB patient had experienced good

behavior from the service providers.

Confidentiality of client information

Of the 3 groups of participants (PLHIV, TB-HIV co-infected, and TB patient), PLHIV and

the co-infected participants were more concerned about the practice of maintaining privacy

about their visits at the health institutions that they had visited. According to them, privacy

was one of the main factors that discourage them in seeking services in the health

institutions. All the participants however expressed their satisfaction over the services of

health service providers. They were also sure that information about their HIV positive status

and other details were kept confidential at the health institutions where they had visited.

29

Comparatively, the TB patient participants were more relaxed about the confidentiality issue.

Nearly all the TB patient said they have not felt the need of maintaining privacy in the health

institutions about their TB infection condition.

Services/support provided by health institutions and I/NGOs

About half of the PLHIV had undergone sputum test, and had received VCT and DOTS

services. The PLHIVs were also getting some financial support for children education from

various organizations. The PLHIV were also given drugs for HIV and TB. The participants

also had received counseling in the health institutions that they had visited. The discussion

result however showed that the information they received during counseling was limited. The

participants were also referred for TB test and/or HIV test and were also given referral slips.

3.8.2 In-depth interviews with DOTS Focal Person, DPHO, VCT, ART and PMTCT

focal persons

Risk group for TB and HIV infection

The in-depth interview results indicated that in Rupandehi district people mainly from

marginalized communities, slum dwellers and poor and illiterate people are more at risk of

TB infection. The interview results further indicated that the estimated cases of TB is around

1300 persons and incidence of TB especially in these communities is on the rise in recent

years.

In case of HIV, slum dwellers, factory workers, migrant workers and wives of migrant

workers are believed to be more at risk of getting HIV. Apart from them sex workers, IDUs,

MSM and people from poor and marginalized communities are also believed to be at risk of

HIV. According to the respondents, HIV cases in Rupandehi district is increasing and

currently estimated to be around 1000 persons. Majority of respondents also believed that the

cases might be higher than what is estimated.

30

Services at DOTS centers

The main services available in DOTS centers in Rupandehi district are as follows:

Diagnosis and treatment of TB cases

Supply of drugs

Counseling on TB and,

Referral of complicated cases to other health institutions

The interview results further indicated that out of 15 DOTS centers, 6 were also providing

services to HIV infected. Most of the DOTS centers had focused their activities in awareness

creation program as well. The responses of the DOTS focal persons further indicated that

collaborative programs on TB and HIV have so far not been conducted through the centers

and they are also not aware of any future plans of conducting such collaborative activities in

the district. The interview results further indicated that there were no specific programs

conducted from the centers to prevent TB patients from the risk of HIV infection. Likewise,

no TB case finding among HIV patients was being conducted in the district.

Services at VCT centers and other institutions for PLHIV and TB-HIV co-infected

At the time of study, 4 VCT centers were providing services in Rupandehi district. Apart

from the above, the other services available in selected government institution and I/NGOs in

Rupandehi district for PLHIV and TB-HIV co-infected people are as follows:

Pre and post test counseling of clients

HIV testing

HIV and STIs prevention counseling

Quality assurance system for HIV testing

Quality assurance system for counseling

Condom promotion and distribution

Referral of complicated cases

31

The interview results further indicated that so far no specific interventions were conducted

from those centers to prevent HIV patients from the risk of contracting TB. It was however

pointed out by the respondents that, information about the possibility of contracting TB was

provided to the PLHIV during counseling and suspected cases were referred to DOTS centers

for TB testing.

In Rupandehi district one ART center was providing services. Apart from treatment this

center provides counseling to patient about HIV related OI’s, recording and reporting and

referral of HIV infected people to other health institutions as needed.

Maintaining confidentiality of patient information

The interview results indicated that the DOTS focal persons see no need of maintaining

confidentiality of TB patients because according to them the community people including

those who are infected have now accepted TB infection as curable disease condition.

On the question of the system of maintaining confidentiality on information of HIV infected

people, the respondents claimed that the information is kept confidential in the centre. In the

interview it was also reported that the information is not disclosed to a third person or

outsiders unless the clients want to disclose their information. All the respondents claimed

that in order to keep the information confidential, first the client is assigned a unique code

number and that number is given to the patient for cross reference. Then onwards the same

code number is used in all prescription and other documents. Except counselor others do not

know about the records of HIV infected persons. It was further mentioned that counseling

session is conducted in a separate room.

3.8.3 In-depth interview with DPHO official

The main role played by DPHO in the district is planning, organizing, implementing and

monitoring/supervision of health programs. The DPHO also supports in activities such as TB

32

and HIV case findings, provide counseling and treatment, organize training of health

personnel and support IEC programs through its district wide network of health institutions.

A number of institutions directly or indirectly are currently involved in TB and HIV

programs. They provide a range of services including awareness creation, treatment, care and

support for the infected persons.

Inter-agency collaboration

According to D/PHO there was no committee in Rupandehi district to oversee and coordinate

TB-HIV collaborative programs. Likewise, there was also no in-built communication

mechanism between the institutions to organize collaborative activities. It was however

mentioned by the respondents that collaboration plan has already been initiated and they

hoped that some mechanism for interagency collaboration will be in place in near future. The

system of referring TB patient to VCT centre and vice versa was also being developed.

According to the respondents so far advocacy on TB-HIV infection has been done and

collaboration training for DOTS and VCT service provider was being provided.

According to the DACC chair, recently HERD had formed public private mixed executive

committee for planning and implementation of TB-HIV joint program. The committee had

13 members executive body chaired by executive director of Butwal Municipality, DPHO as

secretary and DTLO, DACC coordinator. Representatives of various agencies such as

Navakiran plus, and NATA, and volunteers, social workers and political parties were also the

members of this committee. The committee had drafted general outline of work plan with

major focus on strengthening existing VCT and DOTS center.

Interventions to minimize the risk of TB-HIV co-infection

ART and VCT services are the only intervention programs being implemented in the district

in the HIV sector. In course of the interviews it was reported that there was no specific

program or intervention aimed at preventing TB-HIV co-infection in the district. It was

33

however mentioned that information about the possibility of TB infection is provided to the

HIV infected people. The respondents in general perceive awareness creation on TB and HIV

as one of the interventional programs for preventing TB-HIV co-infection in the district.

National level support for TB-HIV activities

In course of interview it was mentioned that national level support was being provided for

selected types of TB-HIV collaborative activities. Those supports mainly focused on

advocacy on TB-HIV co-infection and training to service providers.

Community participation in TB and HIV programs

In case of TB, community people were participating in TB programs through the DOTS

committee in the institutions where those committees were functional. Community people

co-operated in the committee’s activities and their involvement in TB program was good.

Involvement of community people in HIV program however was virtually nonexistent in

Rupandehi district.

3.9 Organization and management issues

In course of situation analysis several issues related to organization and management of TB

and HIV services was also raised among the stakeholders and health institution staffs through

interviews and discussion meetings. The discussion mainly focused on four issues: planning,

decision making, monitoring and supervision procedure and practices and constraints and

challenges.

3.9.1 Planning procedures

In case of government institutions the planning procedure for general health services shows

an encouraging scenario. In course of the interviews nearly all PHCCs and HPs reported that

after the identification of the health services need of the community, the annual and quarterly

34

activity planning was done jointly by the health facility staff and the health facility

management committees. Then the annual plan was presented in the district level meeting

coordinated by the DPHO for approval. In case of government hospitals, the activity

planning was done jointly by the hospital staff, DTLO and D/PHO.

In I/NGOs and private sector institutions, it was reported that the planning was usually done

at the central level. In most of these institutions, the district and peripheral staff propose the

annual activities and the plan is finalized at the district and/or central level offices. Usually,

no outside agencies were involved in the planning process. It was however pointed out by

some respondents that occasionally, the activities were also planned by arranging meetings

participated by stakeholder, partner agencies and coordination committees. In those meetings

usually the health services needs of the district and communities were identified and

prioritized.

The government has implemented the Implementation Guidelines for TB and HIV/AIDS

Collaboration for Planning of TB and HIV Programs in 2009. As directed in the guideline,

NTP and NCASC have now initiated joint planning in order to ensure the implementation of

collaborative TB-HIV activities within the district through DACC and DOTS committees.

3.9.2 Decision making procedures

The interview result indicated that in case of peripheral government health facilities, most of

the decision was made at the joint meeting of health institution staff and the management

committees. In those facilities in case of major issues, the opinion of DPHO was also sought

before making the decision. In case of VCT centers, DACC was also involved in the decision

making process. Similarly in government hospital, the decision was usually made by the

senior level staff or the institution head-Medical Superintendent. The interview result

indicated that similar procedure was followed in I/NGOs private sector institutions in

decision making.

35

3.9.3 Monitoring and supervision procedures

Recently a core set of indicators and data collection tools have been developed within the

national monitoring and evaluation (M&E) framework. Based on this, development of a joint

supervision and monitoring system is now in progress. Once the system is finalized,

monitoring and supervision will be done as stated by the guideline. At present, a review

meeting is conducted every four months to monitor the program activities for TB programs.

The study results indicated that the monitoring and supervision mechanism needs a lot of

improvements for the monitoring and supervision of general health services. In the

government sector, the peripheral health institutions such as HP and SHP are supposed to be

regularly supervised and monitored by the D/PHO and/or Supervisor. It was also reported by

some institutions that NTC was also involved in monitoring and supervision of TB programs.

In practice, however, not much was being done to monitor and supervise the activities of

these institutions.

In course of situation analysis, very few institutions reported of regular monitoring of

activities by their supervisors, DTLO or DPHO. In the absence of regular monitoring these

institutions also do not get much input or feedback to sort out the problems or programmatic

issues they encounter. The analysis findings showed that usually the institutions get only oral

feedbacks. Similar situation was observed in case of I/NGOs and private sector institutions.

These institutions also lack an established monitoring and supervision system.

3.9.4 Constraints and challenges

The study result indicated that the health institutions were facing numerous constraints and

challenges. Low awareness of community people about TB and HIV and TB-HIV co-infection

issue was agreed as one of the main challenges faced by the health service providers both at

district and peripheral levels. People with problems, especially those with HIV were

stigmatized and discriminated in the community.

36

The study findings showed that the governmental health intuitions i.e. PHC, HP and

Hospitals did not have any or very limited services on TB and HIV co-infection. Since TB is

one of the prioritized programs so far the focus of governmental sector is on TB alone. The

health institutions including the hospitals do not have a holistic approach to address the issue

of co-infection. Though the government has recently (2009) adopted a policy and guideline

to address TB-HIV co-infection issue, the district level stakeholder/partner agencies and

health institution staffs were not fully aware about this policy and guidelines. Thus the

concerned institutions had not been able to set the future direction of TB and HIV program in

the district.

The other constraints and challenges indicated by most of the stakeholder/partner institutions

and health facility staffs are summarized below:

At the district level

Lack of adequate equipments and other resources - especially budget at D/PHO to

work for TB-HIV co-infection

Lack of data base for the formulation and implementation of TB, HIV and TB-HIV

co-infection activities in the district.

Lack of awareness among community people about TB and HIV or TB-HIV co-

infection

Presence of stigma especially related to HIV.

Lack of training to health personnel on TB, HIV and TB-HIV co-infection

Lack of case finding activities on TB, HIV and TB-HIV co-infection.

Lack of community participation in TB and HIV programs.

Absence of local level plan and policy for the TB-HIV collaborative programs and

monitoring of these programs

Several government agencies, I/NGOs and private sector institutions are working in

TB and HIV sector in the district but the coordination and collaboration among these

institutions is lacking

The TB and HIV programs are treated as separate issue and thus are currently

implemented separately by different institutions.

37

For many institutions, maintaining privacy of clients has become a major challenge.

This is especially true for some peripheral health institutions where there is no

provision of a separate room or space for patient consultation/examination.

At the institutional level

Due to the social stigma and attitude of community people towards HIV, PLHIV

hesitate to visit VCT center for lab test and other services. Thus increasing the flow of

VCT service seekers is one of the main challenges faced by VCT centers.

Lack of budget, test kits, training to service providers.

Changing the perspectives of community people towards HIV has become one of the

challenges faced by the health institutions.

Health institution staff lack adequate skill in tackling TB-HIV co-infection cases

Most health institutions lack proper referral system that documents each of the

incoming and outgoing referral cases.

38

Chapter 4: CONCLUSION AND RECOMMENDATIONS

Conclusion

A total of 2325 TB cases were reported in the hospitals and peripheral health service

facilities of Rupandehi district in the period 2008/09. Majority of the male and female TB

cases were between the age groups of 15-24 to 55-64 years. A total of 427 HIV cases were

reported till the period June 2009. The highest proportion of infected cases was concentrated

in age groups 25-44. The government had the largest TB and HIV service network in

Rupandehi district. Only a few I/NGOs and 1 Medical college were involved in TB and HIV

service provision in the district. Fifteen institutions were providing DOTS services and 4

institutions were providing VCT services. ART service was also being provided by the

government hospital. Only 1 health institution was conducting intensified TB case finding

activities. The study results revealed that 12 institutions in Rupandehi district had community

participation in their DOTS programme.

Similarly, the VCT centers were conducting some of the TB-HIV collaborative activities at

the time of the study. The collaborative activities mainly focused on client education about

TB, referral of HIV infected clients for clinical care, managing TB testing and treatment. The

major collaborative activities being conducted by the DOTS centers include condom

promotion and supply and providing information on HIV to TB patients using IEC materials.

Very low numbers of institutions were providing referral services. Most patients were

referred to I/NGO facilities or government hospitals. Overall, the practice of use of referral

slips, documentation of referral cases and feedback mechanism was poor.

The health institutions staffs were also lacking the skills in tackling the TB-HIV co-infection

cases. Only the staffs of 75 percent VCT centers had got training on TB while the staffs of

only 20 percent DOTS centers had got training on HIV. Almost all the health institutions also

addressed the need of deployment of adequate and qualified human resources for the

provision of services on TB-HIV co-infection.

39

The study results indicated that the M&E mechanism in the government sector needs a lot of

improvements. In course of the study, very few institutions reported of regular monitoring of

their activities by the supervisors or D/PHO. The study result indicated to numerous

constraints and challenges. Low awareness of community people about TB and HIV and TB-

HIV co-infection issue was agreed as one of the main challenges faced by the health service

providers. The study findings showed that the governmental health intuitions i.e. PHC, HP

and Hospitals currently did not have any services on TB and HIV co-infection. Many

institutions had not followed the TB-HIV collaborative effort as it was supposed to. The

coordination and collaboration mechanism among institutions was poor.

The health institutions especially in the government sector were constantly facing

interruptions in the supply of equipment and drugs and many of them also were lacking

laboratory facility. For many institutions, maintaining privacy of clients had become a major

issue. This is especially true for government peripheral health institutions where there was no

provision for a separate room or space for patient consultation/examination.

Recommendations

Based on the findings of situation analysis following actions are recommended for effective

implementation of TB-HIV collaboration activities in Rupandehi district:

1. The situation analysis showed that the health institution staff in Rupandehi district

lack adequate skills in tackling TB-HIV co-infection. In course of the study, it was

found that most of the providers were not clear on terminologies such as

‘Prophylaxis’ or ‘intensified TB case finding’. So there is a need for conducting

orientation training to the health institution staff on these terminologies and standard

procedures.

2. The health institution staffs, especially those working at DOTS and VCT centers were

not clear on national TB-HIV policy and implementation guideline. These staffs need

to have up to date information on these policies and guidelines.

40

3. The findings of in-depth interviews with health institution staff and the FGDs with

PLHIV showed that the referral mechanism in the district health institutions was very

poor. This finding calls for the need of a strong referral system in place with clearly

spelled out referral procedures (use of referral slips, documentation etc) in the district

for effective TB-HIV collaborative services.

4. Many stakeholders and health service providers felt that TB and HIV infected people

were facing problems because of the long distance they need to travel from and to

VCT/DOTS center. It is therefore recommended that the agencies should try to locate

these centers in closer vicinity so that concerned people have easy access to both type

of services.

5. Several government, private sector institutions and I/NGOs were working in TB and

HIV sector in Rupandehi district but the coordination and collaboration among those

institutions was lacking. Many stakeholders pointed out the need for establishment of

a committee to conduct and monitor TB-HIV activities. Such committee should be

able to establish good network between all I/NGOs and government offices involved

in TB-HIV activities.

6. The discussion with PLHIV and health institution staff revealed that HIV infected

people are highly stigmatized and discriminated in the community. This finding

showed the need for conducting awareness creation activities in the community.

7. Many government institutions were lacking a separate counseling room for HIV

infected people. This not only discourages people to visit these facilities but also has

proved difficult for the service providers in maintaining privacy of the patient who

visit them. Thus it is recommended that establishment of a counseling room be

regarded as a priority issue in these institutions.

8. Adequate data base on TB and HIV needs to be created for the formulation and

implementation of TB, HIV and TB-HIV co-infection activities in the district.

The findings of situation analysis therefore, points out to the need of strengthening of

different aspects of TB-HIV program including skill development, institutional capacity

building, referral mechanism, planning and M&E, and inter-agency collaboration in

Rupandehi district.

41

REFERENCES

WHO, Manual for Participants Management of TB/HIV Collaborative Activities, 2005

TB-HIV Co-infection; action, Advocacy to control TB Internationally [Online]. 2008 [Cited

February 9, 2009]; Available from: URL:http://www.action.org/site/geteducated/134

SAARC Tuberculosis Centre ‘Situation Analysis of TB, HIV/AIDS and TB/HIV co-infection

in the SAARC region’- SAARC/ Canada Regional tuberculosis and HIV/AIDS project ;

December 2003

Communicable Diseases: Tuberculosis; Fact sheets on TB [Online]. 2006 April [Cited 2009];

Available from: URL:

http://www.searo.who.int/EN/Section10/Section2097/Section2106_10679.htm

Health Research and Social Development Forum (HERD), Situation Analysis of TB and HIV

Programme Collaboration in Nepal; November 2006, Final draft submitted to World Health

Organization (WHO), Nepal.

Ministry of Health and Population, National Centre for AIDS and STD Control (NCASC)

and National Tuberculosis Centre (NTC) ' Policy and Strategy Guideline on Collaborative

TB/HIV Control Activities in Nepal' [Draft copy].

Department of Health Services (DoHS), MoHP, Annual Report 2064/65 (2007/2008), Nepal

Government, 2009

42

ANNEXESAnnex 1

The Britain Nepal Medical Trust (BNMT)

Situation Analysis (District Level) to Identify Stakeholders for TB/HIV

Collaboration and Map Service Providers

Consent form

Namaste! My name is………………………. I have come from an organization named ' The

Britain Nepal Medical Trust'. Currently this organization is conducting one research called

situational analysis of TB/HIV collaboration at implementation level. The general objective

of this study is to assess the existing situation and recommend possible interventions for

implementing TB/HIV collaborative activities in Morang/ Banke / Kanchanpur district of

Nepal. I request you to participate in this study. You will not be directly benefited by

participating in this study but we hope that the information given by you will be very useful

in future while implementing TB/HIV collaboration activities. Your participation in this

interview will be completely voluntary and you could halt this interview at any time if you

wish. However, I want you to participate as your views will be important for us.

I would like to assure you that the information provided by you will be totally kept

confidential. The total time for this interview will be about 45 minutes to 1 hour.

If you are interested to participate in this interview, I would like to request you for the

agreement to participate here.

If participant disagrees ………… 1. Stop here

If participant aggress …………… 2. Start the interview

Name of participant: ………………… Date: ………………

Signature……………….

I would like to thank you very much for your participation and would like to welcome in this

interview.

43

ANNEX 2

Focus Group Discussion (FGD) guideline for TB patients

1. Health Seeking Behavior:

- Types of service providers consulted till now from the beginning (which service

provide collaborate and which don’t)

- Reason behind selecting that type of health care provider (Probe for: accessibility,

affordability, confident in getting cured)

- Responses from each service provider (Probe for: Service provider’s behavior)

- Information kept confidential or not?

-Consequences from particular service provider (Probe for: Diagnosis, counseling,

referral etc.)

2. Knowledge and perception of the disease: (from where did you get this information?)

3. Information provided on HIV/AIDS from service providers:

- Mode of transmission

- Symptoms and causes

-Displayed relevant materials (IEC materials)

- Treatment (ARV services)

4. Referral to VCT from any of the service providers consulted?

- Used referral slip

- Well documented about referral in the organization

5. Services used - HIV testing

-Used VCT services

- HIV prevention counseling, Condom promotion and supply

- Syndromic STIs treatment

- Trainings provided on HIV

- Other types of service provided

44

ANNEX 3

Focus Group Discussion (FGD) guideline for PLHIV(People living with HIV)

1. Health Seeking Behavior:

- Types of service providers consulted till now from the beginning (which service

provide collaborate and which don’t)

- Reason behind selecting that type of health care provider (Probe for: accessibility,

affordability, confident in getting cured)

- Responses from each service provider (Probe for: Service provider’s behavior)

- Information kept confidential or not?

- Consequences from particular service provider (Probe for: Diagnosis, counseling,

referral etc.)

2. Knowledge and perception of the disease: (from where did you get this information?)

3. Information provided on TB from service providers:

- Mode of transmission

- Symptoms, cause and diagnosis methods

- Treatment duration and facilities (DOTS center)

- Types

-Displayed relevant materials (NTP/ IEC materials)

4. Referral for TB investigation from any of the service providers consulted?

- Used referral slip

- Well documented about referral in the organization

5. Services used?

- Have ever been tested sputum?

- Trainings provided on TB

- Other types of facilities received (i.e. Nutritional services)

45

ANNEX 4

Focus Group Discussion (FGD) guideline for TB/HIV co-infected people

1. Health seeking behavior

- Types of service providers consulted till now from the beginning (which service

provide collaborate and which don’t)

- Reason behind selecting that type of health care provider (Probe for: accessibility,

affordability, confident in getting cured)

- Responses from each service provider (Probe for: Service provider’s behavior)

- Information kept confidential or not?

- Consequences from particular service provider (Probe for: Diagnosis, counseling,

referral etc.)

2. Knowledge and perception of the disease (from where did you get this information?)

3. Information provided on TB/HIV

- Mode of transmission

- Symptoms, cause and diagnosis

- Treatment method (treatment duration and facilities)

- Displayed relevant materials (IEC materials)

4. Referral for TB/HIV investigation from any of the service providers consulted?

- Used referral slip

- Well documented about referral in the organization

5. Services used?

- HIV testing/sputum testing

- Use of VCT/DOTS services

- HIV prevention, counseling, condom promotion and supply

- Training provided on TB

- Other types of facilities received (i.e. Nutritional services)

46

ANNEX 5

In-depth Interview guideline for services provider at VCT and DOTS centre

Information on interviewee

Date of interview:

Name of interviewee Age (years)

Post: Sex:

Name of health institution:

Working experience in current institution:

Working experiences in related field (years)

1. General Information:

1.1 How are you being involved in TB and/or HIV program? (Roles and responsibilities)

1.2 Can you tell in brief about the situation of TB and HIV/AIDS of the region? (Probe: for

high risk groups, estimated number of cases, marginalized group)

2. Service related questions:

2.1 Are you providing services in TB or/and HIV or/and TB-HIV co infection from your

organization?

2.2 If yes, what sort of services are you providing? (probe: Types of services, training,

counseling, treatment and care etc)

2.3 If no, is there any plan in future to provide such services? (probe: related to TB-HIV co-

infection)

2.4 What are the major interventional aspects conducted at your organization to decrease the

burden of TB in PLHA? (Probe: prevention of TB, case finding, linkage with DOTS, TB

control)

2.5 What are the major interventional aspects conducted at your organization to decrease the

burden of HIV in TB patients? (probe: Provision of HIV testing and counseling,

47

introduction of HIV prevention and treatment method, HIV/AIDS care and support, ART

treatment)

2.6 What is the prophylaxis for TB at your Institute?

2.7 What sort of OI prophylaxis is done for HIV patients in your institute?

2.8 How do you assure the confidentiality of clients is maintained?

2.9 What are the existing resources that you utilize for TB or/and HIV or/and TB-HIV co-

infection in the organization?

3. Problems and challenges

3.1 What are the major problems and challenges that you face while providing the services

on TB or/and HIV or/ and TB-HIV co-infection? How these problems can be overcome?

(Probe: problems from patients, resource distribution, social stigma, role of health

worker, superstition)

Thank You

48

ANNEX 6

In-depth interview guideline for stakeholders (DTLA, DAAC

Chairperson, HIV focal person, DOTS committee)

Name of interviewee Age (years)

Post: Sex:

Name of health institution:

Working experience in current institution:

Working experiences in related field (years)

1. General information

1.1 How are you being involved in the TB and/or HIV program? (Roles and responsibilities)

1.2 Can you tell in brief about the situation of TB and HIV/AIDS of the district? (Probe for

high risk groups, estimated number of cases, marginalized group)

1.3 Who are the major stake holders in providing services on TB and HIV/AIDS in this

district? And, what services are they providing? (Probe for following services : TB care,

VCT, PLHA support, clinical HIV/AIDS care, STI treatment, Family planning, Condom

promotion, Nutritional support, Orphan care/ social support, Psychological support)

2. Mechanism for collaboration

2.1 Is there any existing coordination committee for TB/ HIV joint activities in this district?

2.2 If yes, who are the members and how is it functioning?

2.3 If no, is there any plan to form one in the future?

2.4 Has any surveillance of HIV prevalence among TB patient been conducted in this

district?

2.5 If yes, when and by who? What was the major finding? (Get a copy of report if available)

2.6 Has any collaborative plan for TB/HIV joint activities been done in this district?

2.7 If yes, can you describe it in brief (Probe for: when was planning done, who participate,

what (were the major activities, what was the source of resources) (Get a copy if available)

2.8 If no, is there any plan in the future to do make such collaborative planning?

2.9 What sort of researches has been conducted in this district in the field of TB and/or

HIV/AIDS? (Probe for: any periodic survey, periodic surveillance, time of the research,

49

researching organization/ individual, study site, major objective of the research, method,

major findings)

3. Intervention to decrease burden of TB in PLHA and burden of HIV in TB patients

3.1 What are the major interventional programs conducted in the district to decrease the

burden of TB in people living with HIV/AIDS (Prevention of TB, TB case finding, linkages

with DOTS, Tuberculosis control in health care settings)

3.2 What are the major interventional programs conducted in the district to decrease the

burden of HIV in Tuberculosis patients (Probe: Provision of HIV testing and counseling,

introduction of HIV prevention and treatment methods, HIV/AIDS care and support,

3.3 Are there any focused program for marginalized groups and high risk group? If yes, can

you tell it in brief.

How do you ensure the confidentiality of the clients is maintained?

3.2 How do you ensure the confidentiality of the clients is maintained?

3.3 What are the existing resources for TB and HIV joint activities in the district. (Human

resources, drugs, equipment, donors and others)

4. Support from National level

4.1 What sort of support are you getting from national level for TB/HIV joint activities.

(Probe: from national TB/HIV coordination committee, Types of training provided,

motivations and others)

4.2 Does any monitoring and evaluation activities being done by national level?

4.3 Is there any communication system prevalent (Probe: within service providers of TB and

HIV, within clients of TB and HIV services) If yes, can you tell it in brief. (Get any

document if available)

5. Community participation

5.1 In your opinion, how are community people involved in the TB and HIV programs

(Probe for TB, HIV and TB/HIV joint collaboration)

6. Problems/Challenges and Action to be taken

6.1 What do you think are the major problems and challenges in the implementation joint

TB/HIV collaboration activities in this district? How these problems can be overcome?

(Probe: Problems in mechanism of coordination, resource distribution, from community,

social stigma, role of health workers)

50

ANNEX 7

The Britain Nepal Medical Trust (BNMT)

Situation Analysis (District Level) to Identify Stakeholders for TB/HIV Collaboration

and Map Service Providers

Questionnaire for Health Institution

Name of Interviewer: Time of start:

Date of interview: …./…./…….. Time of end:

Section I General Information

1 Health institution no : …………2 Name of health institution: ………………………………….3 Address: District: ……………….. Ward no……….. Tole Name…………………………………4 Name of interviewee: ……………………………………………………………………5 Position: …………………………………6 Duration of work in the organization : ………………. Years

SN Questions Answers Code Go to7 What type of organization is this?

I/NGO � 1

Peripheral government HI (PHC, HP, SHP) � 2

Government Hospital � 3

Private organization � 4

Urban DOTS center � 5

Medical College � 68 What is the catchment area of this Health

Institution (Define in terms of geographical location. (Get a map if available)

9 What is the distance from catchments area to this health institution?

51

10 Which ethnic groups live in the catchments area?

11 What is the number of Total target population ? Total population

12.What is the number of estimated TB cases in this area?

Estimated TB cases

13What is the number of estimated HIV cases in this area?

Estimated HIV cases

14 Is the information on client kept confidential in the institution?

Yes � 1

No � 0

15 If not, why?

16 Please provide us the following information on the clients (Registered in the Health institution)Age group TB PLHA

Male Female Other sex Female Male FemaleOther sex

0-1415-2425-3435-4445-5455-6465+

Section II : Type of service provided and status of collaboration in TB/HIV program

SNQuestions Answers Code Go to

17 Does this institution provides service on Tuberculosis (DOTS)? Yes �

1 13

No �0 17

18 Does this centre provide any of the following collaborative activity? (Multiple answer possible ) Discuss HIV with TB patients as part of routine patient IEC �

Yes. 1

Provide VCT to TB patients �No. 0

HIV prevention counseling �

Condom promotion and supply �

52

Provide clinical care for PLHA with TB �

Provice syndromic STI treatment for TB patients �

Referral of non TB patients with HIV �

19 Is this institution is conducting intensified TB case finding? (Multiple answer possible)

No � Yes. 1

Yes, through private practitioner �

No. 0

Yes, through VCT centres � Y es, through PLHA groups �

Yes, in prisions � Yes, through Home based care volunteers �

Yes, traditional healer �20 How is community participated in DOTS? (Multiple answer

possible) No � Yes. 1

Yes, an active DOTS committee is there � No. 0

Yes, through Community based DOTS or Family based DOTS �

Yes, through Home based care volunteers � Others( Specify) �

21 Does it provide any of the following services? (Multiple answer possible) Contrimoxazole preventive therapy for TB patients � Yes. 1

Clinical care for patients with HIV and TB � No. 0

ART for eligible patients for HIV and TB �22 Does this institution provides service on VCT? Yes � 1 18

No � 0 2023 What types of services are provided through this center?

(Multiple answer possible)Pre and post test counseling � Yes. 1

HIV and STIs prevention counseling � No. 0

HIV testing �Condom promotion and distribution �Post test club or referral for ongoing support �Quality Assurance system for HIV testing �

53

Quality Assurance system for counseling �24 Does this institution provides any of the following collaborative

activities?(Multiple answer possible) Client education about TB � Yes. 1 �

Client education about STIs � No. 0 �

Referral of HIV (+) clients for clinical care �Screening clients for TB �Treatment for TB �Screening clients for STIs �Treatment for STIs �

25 Does this institution provides services on Treatment of HIV?Yes � 1 21

No � 0 2326 What types of services are provided through this centre?

(Multiple answer possible) Nursing care � Yes. 1

HIV prevention counseling � No. 0

Condom promotion and distribution �Treatment of HIV-related clinical problems �ARV referral/ treatment �Syndromic STIs treatment �Universal HIV prevention precautions �Referral to appropraite supportive services �

27 Does this institution provides any of the following collaborative activities? (Multiple answer possible)

Cotrimoxazole preventive treatment � Yes. 1

Isoniazid preventive treatment � No. 0

Antiretroviral treatment (ART) �28

Do you refer TB patients for HIV services? Yes � 1

No � 0

29 Do you refer HIV infected people for TB services? Yes � 1

No � 030 Where do you refer normally?31 Do you use referral slip while referring patients?

Yes � 1

No � 132 How often do you communicate with the center?

Never �

54

Sometimes when we refer patients �

Always when we refer patients �

Conduct regular meetings �33 Do any referral patients come to your organization from other

organization? Yes � 1 28

No � 0 3134 Do you provide feedback of the referral patients to the

organization from where they had been referred? Yes � 1

No � 035 How do you provide these feedbacks?

In written document � 0

During meetings held with other organizations � 1

From supervisors � 2

From the patients who had been referred� 3

36 Do you maintain the documentation of referral patients coming from other organization at your organization and vice versa?

Yes � 1

No � 037 Is this organization affiliated with any coordination committee? Yes � 1

No � 038 If yes, which coordination committee is this organization

affiliated with?

39 In which aspects you are getting support from the committee? Planning of joint TB /HIV activities � 0

Mobilization of resources for program� 1

Capacity building including training � 2

Section III : Management of the cases

40 How planning of the activities is done at your organization(Probe: Types of planning activities, involved organization, personals, planning process)

41Details of service providers in the organization

Position Filled Training (TB)- Specify Training (VCT)- specify

Doctor

Nurse

HA

55

ANM

AHW

Others (Specify)

Others (Specify)

42 How decision making is done in this organization (Probe: Involved personal, decision making method, example of decision making )

43 Where do you report the activities of your organization? Only within this organization � 0

DHO/DPHO � 1

Regional health office � 2

NTC � 3

NCASC � 4

NTC and NCASC � 5

Others (Specify) � 6

44 How supervision and monitoring is done in this organization ?(Probe: Who supervises, when subject, feedback, oral or written)

45 Specific Budget

Type Budget Equipment Period of Support

Remarks

GoN

NGO

INGO

Others (Specify)………

46 In your view what might be the challenges in this organization for TB/HIV collaboration ?(Probe: Care and treatment, budget management, equipment, transmission management )

47 Any other things that you like to suggest for the proper collaboration of TB/HIV

56

ANNEX 8

Health institutions working in the area of TB in Banke district

S.N. Organization Address

1. Lumbini PHCC Lankapur, 2

2. Lumbini Zonal Hospital Butwal, 7

3. Anandaban Health Post Anandaban, 9, Salghari

4. Chhapiya Health Post Dayanagar, 3, Chhapiya

5. Semara Bazaar Health Post Makrahat, 8

6. Parauha Health Post Parauha, 1

7. Devdaha Sub-Health Post Devdaha, 1, Khaireni

8. Dhakdhai PHCC Dhakdhai, 4

9. Bhim hospital Siddhartha, 13

10. Universal college of medical science Siddhartha, 1, Ranigaun

11. Basantapur PHCC Basantapur, 9

12. Raypur PHCC Raypur, Aamua

13. Motipur PHCC Sau, Pharsatikar, 1

14. Majhgauwa Health Post Beninagar, 9

15. Karmachhawa Health Post Bishnupur, 4

57

ANNEX 9

Health institutions working in the area of HIV and AIDS in Banke district

S.N. Organization Address

1. Namuna Integrated Development Council-VCT

Butwal, 10, Milan path

2. Mono Supporting Mapple Group (BDS)-VCT

Siddhartha, 8, Bank Kaloni

3. Nagarjun Development Community (NDC)-VCT

Butwal, 11, Milanchowk

4. FPAN-VCT Butwal, 7, Hatbazar

5. Lumbini Zonal Hospital, ART Butwal, 7, Hospital line

58

ANNEX 10

59

Study Team Members

Dr. Ghanshyam Bhatta Programme Coordinator

Mr. Sunil Acharya Report Writing (Consultant)

Ms. Manita Pandey Research officer

Mr. Suman Shrestha Research officer

Ms. Sabina Rijal Data Management Officer

Ms Rinju K.C. Consultant

60