Monitoring prevention or emergence of HIV drug resistance: results of a population-based foundational survey of early warning indicators in mainland Tanzania.

BACKGROUND: In Tanzania, routine individual-level testing for HIV drug resistance (HIVDR) using laboratory genotyping and phenotyping is not feasible due to resource constraints. To monitor the prevention or emergence of HIVDR at a population level, WHO developed generic strategies to be adapted by countries, which include a set of early warning indicators (EWIs). METHODS: To establish a baseline of EWIs, we conducted a retrospective longitudinal survey of 35 purposively sampled care and treatment clinics in 17 regions of mainland Tanzania. We extracted data relevant for four EWIs (ART prescribing practices, patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months) from the patient monitoring system on patients who initiated ART at each respective facility in 2010. We uploaded patient information into WHO HIVResNet excel-based tool to compute national and facility averages of the EWIs and tested for associations between various programmatic factors and EWI performance using Fisher's Exact Test. RESULTS: All sampled facilities met the WHO EWI target (100%) for ART prescribing practices. However, the national averages for patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months fell short, at 26%, 54% and 38%, respectively, compared to the WHO targets ≤ 20%, ≥ 70%, and ≥ 80%. Clinics with fewer patients lost to follow-up 12 months after ART initiation and more patients retained on first-line-ART at 12 months were more likely to have their patients spend the longest time in the facility (including wait-time and time with providers), (p = 0.011 and 0.007, respectively). CONCLUSION: Tanzania performed very well in EWI 1a, ART prescribing practices. However, its performance in other three EWIs was far below the WHO targets. This study provides a baseline for future monitoring of EWIs in Tanzania and highlights areas for improvement in the management of ART patients in order not only to prevent emergence of HIVDR due to programmatic factors, but also to improve the quality of life for ART patients.

"When in the body, it makes you look fat and HIV negative": the constitution of antiretroviral therapy in local discourse among youth in Kahe, Tanzania.

Antiretroviral therapy (ART) is becoming increasingly more accessible within the health care system in Tanzania. However, the impact of the increased availability of ART on local conceptions about medicines, health and physical wellbeing has not been fully explored. In this article we examine how ART is constituted within local discourses about treatment and healing. Based on 21 focus group discussions with young people aged 14-24 years in a rural area (Kahe), we examine how local terms and descriptions of antiretroviral therapy relate to wider definitions about the body, health, illness and drug efficacy. Findings illustrate how local understandings of ART draw on a wider discourse about the therapeutic functions of medicines and clinical dimensions of HIV/AIDS. Therapeutic efficacy of antiretroviral medication appeared to overlap and sometimes contradict locally shared understandings of the clinical functions of medicines in the body. Implications of ART on bodily appearance and HIV signs may influence conceptions about sick role, perpetuate stigma and affect local strategies for HIV prevention. Structural inequities in access, limited information on therapeutic efficacy of ART and perceived difficulties with status disclosure appear to inform local conceptions and possible implications of ART. Policy and programme interventions to foster public understanding and acceptability of ART should emphasize treatment education about the benefits and limitations of therapy and increased access to ART in rural areas, and should integrate voluntary status disclosure and HIV prevention.