Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa.

Adherence levels in Africa have been found to be better than those in the US. However around one out of four ART users fail to achieve optimal adherence, risking drug resistance and negative treatment outcomes. A high demand for 2nd line treatments (currently ten times more expensive than 1st line ART) undermines the sustainability of African ART programs. There is an urgent need to identify context-specific constraints to adherence and implement interventions to address them. We used rapid appraisals (involving mainly qualitative methods) to find out why and when people do not adhere to ART in Uganda, Tanzania and Botswana. Multidisciplinary teams of researchers and local health professionals conducted the studies, involving a total of 54 semi-structured interviews with health workers, 73 semi-structured interviews with ARTusers and other key informants, 34 focus group discussions, and 218 exit interviews with ART users. All the facilities studied in Botswana, Tanzania and Uganda provide ARVs free of charge, but ART users report other related costs (e.g. transport expenditures, registration and user fees at the private health facilities, and lost wages due to long waiting times) as main obstacles to optimal adherence. Side effects and hunger in the initial treatment phase are an added concern. We further found that ART users find it hard to take their drugs when they are among people to whom they have not disclosed their HIV status, such as co-workers and friends. The research teams recommend that (i) health care workers inform patients better about adverse effects; (ii) ART programmes provide transport and food support to patients who are too poor to pay; (iii) recurrent costs to users be reduced by providing three-months, rather than the one-month refills once optimal adherence levels have been achieved; and (iv) pharmacists play an important role in this follow-up care.

Local understanding, perceptions and reported practices of mothers/guardians and health workers on childhood malaria in a Tanzanian district--implications for malaria control.

Knowledge on local understanding, perceptions and practices of care providers regarding management of childhood malaria are needed for better malaria control in urban, peri-urban and rural communities. Mothers of under five children attending five purposively selected public health facilities in the Kibaha district, Tanzania, were invited to participate in 10 focus group discussions (FGDs). The health workers of these facilities were included in six other FGDs to elicit their professional views. Analysis was done using interpretative and qualitative approaches. Both health workers and all mothers were clear about the signs and symptoms of homa ya malaria, a description consistent with the biomedical definition of mild malaria. Although most of the mothers related this to mosquito bites, some did not. Mothers also described a severe childhood illness called degedege, consistent with convulsions. Most of the mothers failed to associate this condition with malaria, believing it is caused by evil spirits. Urinating on or fuming the child suffering from degedege with elephant dung were perceived to be effective remedies while injections were considered fatal for such condition. Traditional healers were seen as the primary source of treatment outside homes for this condition and grandmothers and mother in-laws are the key decision makers in the management. Our findings revealed major gaps in managing severe malaria in the study communities. Interventions addressing these gaps and targeting mothers/guardians, mother in-laws, grandmothers and traditional healers are needed.

Acceptability of voluntary HIV testing with counselling in a rural village in Kagera, Tanzania.

A pilot study on acceptability of voluntary HIV testing with counselling was performed in a rural village in Kagera, Tanzania as a potential intervention against HIV transmission. Village residents were prepared by their leaders and subsequently invited to health education group meetings to volunteer for the test. Consenting individuals were interviewed to determine awareness and acceptance of the offer followed by pre-test counselling and taking of a blood sample for subsequent HIV testing. Two months later, the results of the test were returned with post-test counselling coupled with a short interview of a random sample of adults in the village. Of the 245 adults responding to the call, 137 (55.9%) subsequently volunteered. The main reason for volunteering was to know the HIV status (96%). Among those who were aware of the offer, the main reason for not volunteering was that they felt unlikely to catch AIDS, implying that they had a false perception of being at low risk. In this study a significant proportion were willing to volunteer for the HIV test and to receive the results, indicating a moderate level of acceptability. The results also indicate the need for developing innovative ways of enhancing acceptability of voluntary HIV testing with counselling. However, the relationship between knowledge of HIV status and behavioural change is complex and therefore several potential mechanisms may exist by which HIV testing in combination with counselling can influence behaviour. For this reason, people should be given the choice of knowing their HIV status since it may constitute a potential mechanism for influencing behaviour towards reduction of HIV transmission.

PIP: The acceptability of voluntary HIV testing with counseling was investigated in a pilot study conducted in a rural village in Kagera, Tanzania, in 1993. Village residents were informed about the study by their leaders and invited to attend health education group meetings to learn more about the study. 245 (54%) of the 450 adults in the village attended the group meetings. 137 attendees (55.9%) volunteered to participate and received both pretest counseling and HIV testing at that time. 2 months later, researchers returned to the village to give test results and conduct post-test counseling. 13 volunteers (9.8%) were HIV-positive. After post-test counseling, half the infected volunteers and 37.5% of HIV-negatives indicated they would adapt safer sex practices, including reducing their number of sexual partners. Interviews conducted at the second visit with 195 village residents revealed half of the volunteers compared with only one-third of nonparticipants had a relative with AIDS. 96% of those who volunteered did so to learn their HIV status. Seven men and 22 women did not want their spouse to know their HIV test result. Among those who were aware of the study but did not volunteer, the main reasons for nonparticipation were the perception of low personal HIV risk and feeling healthy and strong. These findings indicate a moderate level of acceptability of voluntary HIV screening. The extent to which such testing can reduce HIV transmission remains to be addressed in well-controlled studies.