PMTCT Integration Assessment Tanzania

|
ASSESSMENT OF THE
INTEGRATION OF PMTCT WITHIN
MNCH SERVICES AT HEALTH
FACILITIES IN TANZANIA

______________________________________________________________________________________
SEPTEMBER 2012
This publication was made possible through the support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
through the U.S. Agency for International Development under contract number GHH-I-00-07-00059-00, AIDS Support and
Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.

ASSESSMENT OF THE
INTEGRATION OF PMTCT
WITHIN MNCH SERVICES AT
HEALTH FACILITIES IN
TANZANIA

The authors' views expressed in this publication do not necessarily reflect the views of the U.S. Agency for
International Development or the United States Government.

AIDS Support and Technical Assistance Resources Project

AIDS Support and Technical Assistance Resources, Sector I, Task Order 1 (AIDSTAR-One) is funded by the
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International
Development (USAID) under contract no. GHH-I-00–07–00059–00, funded January 31, 2008. AIDSTAR-
One is implemented by John Snow, Inc., in collaboration with Broad Reach Healthcare, Encompass, LLC,
International Center for Research on Women, MAP International, Mothers 2 Mothers, Social and Scientific
Systems, Inc., University of Alabama at Birmingham, the White Ribbon Alliance for Safe Motherhood, and
World Education. The project provides technical assistance services to the Office of HIV/AIDS and USG
country teams in knowledge management, technical leadership, program sustainability, strategic planning, and
program implementation support.

Recommended Citation

Blazer, Cassandra, Bisola Ojikutu, Karen Schneider, and Molly Higgins-Biddle. 2012. Assessment of the
Integration of PMTCT within MNCH Services at Health Facilities in Tanzania. Arlington, VA: USAID’s AIDS
Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.

Acknowledgments

The AIDSTAR-One team wishes to thank the Tanzania Ministry of Health and Social Welfare for their
cooperation and facilitation during data collection for this study. Thanks to Dr. Elizabeth Stringer of the
University of North Carolina, Chapel Hill, for her contributions and review of the data collection tools. The
AIDSTAR-One team is also grateful for the support, facilitation, and review by Dr. Patrick Swai of the U.S.
Agency for International Development/Tanzania, Dr. Patrick Rwehumbiza of the U.S. Centers for Disease
Control and Prevention/Tanzania, Dr. Neema Rusibamayila, Dr. Debora Kajoka, Dr. Moke Magoma, and
Dr. Jema Bisimba. AIDSTAR-One would like to thank members of the Tanzania Prevention of Mother-to-
Child Transmission Interagency Technical Team for their input. The team is grateful to Leopold Wami and
the data collection team for logistics, operational management, and data collection. Finally, the team expresses
gratitude to the facility staff who provided the information that serves as the foundation of this report.

Abstract

Background: In Tanzania in 2009, 68 percent of HIV-positive pregnant women received prevention of
mother-to-child transmission of HIV (PMTCT) prophylaxis. Integrating PMTCT services with maternal,
newborn, and child health (MNCH) programs has been promoted by the World Health Organization to
increase access to services. The goal of this study is to determine the impact of integration on quality
indicators within the PMTCT cascade.
Methodology: In this study a level of integration (LOI) rating system was developed to measure the degree
of PMTCT and MNCH integration at the site level. The scale ranked sites from 0-20 with higher scores
indicating greater service integration. A cross sectional survey capturing service delivery factors associated
with integration was administered to personnel at PMTCT sites randomly sampled from 14 regions stratified
by volume and site type in October and November of 2011. Aggregate site level process and outcome data
was collected from implementing partners for the previous 12 months. Correlations between variables were
tested using nonparametric methods, including the Spearman rank correlation test (p < 0.05) and the
Wilcoxon-Mann-Whitney test (p < 0.05).
Results: From the site assessments of 70 facilities, median LOI score was 12 (range 0.5-20). Hospitals had
the highest median LOI scores (16.5) followed by health centers (14.75) and dispensaries (10). Higher LOI
scores were positively correlated with quality of care indicators: percent tested for HIV and received results in
antenatal care (ρ = 0.33, p = 0.02), percent who received more effective combination antiretroviral therapy
for PMTCT prophylaxis in antenatal care (ρ = 0.40, p = 0.002), percent initiating antiretroviral therapy for
their own health in antenatal care (ρ = 0.52, p < 0.0001), and percent who initiated exclusive breastfeeding (ρ
= 0.30, p = 0.02). Level of integration was not correlated with the percent of infants receiving antiretroviral
therapy prophylaxis.
Conclusions: Integration of PMTCT and MNCH may increase access to PMTCT services. Efforts should be
targeted toward improving integration at lower level, community facilities in Tanzania.

AIDSTAR-One
John Snow, Inc.
1616 Fort Myer Drive, 16th Floor
Arlington, VA 22209 USA
Phone: 703-528-7474
Fax: 703-528-7480
E-mail: info@aidstar-one.com
Internet: aidstar-one.com

CONTENTS
Acronyms............................................................................................................................................................................ ix
Introduction ........................................................................................................................................................................ 1
Background..................................................................................................................................................................... 1
Purpose ........................................................................................................................................................................... 2
Methods ............................................................................................................................................................................... 5
Data Collection Methods............................................................................................................................................ 5
Sampling Strategy .......................................................................................................................................................... 6
Team Training and Pilot Study................................................................................................................................... 7
Field Work Protocols and Survey Respondents ................................................................................................... 8
Assessment Limitations ............................................................................................................................................... 8
Findings ............................................................................................................................................................................... 11
General Site Characteristics .................................................................................................................................... 11
HIV Testing and Counseling ..................................................................................................................................... 12
PMTCT Guidelines and Protocols .......................................................................................................................... 13
Family Planning ............................................................................................................................................................ 15
CD4 Testing ................................................................................................................................................................. 16
Antiretroviral Therapy for Women’s Health....................................................................................................... 17
Labor and Delivery ..................................................................................................................................................... 19
Exposed Infant Follow-up ......................................................................................................................................... 19
Community Linkages.................................................................................................................................................. 21
Patient-Provider Ratio ............................................................................................................................................... 22
Training ......................................................................................................................................................................... 22
Supervision ................................................................................................................................................................... 22
Commodities ............................................................................................................................................................... 25
Monitoring and Evaluation ........................................................................................................................................ 27
Integration Analysis ......................................................................................................................................................... 29
Level of Integration Score Methodology ............................................................................................................... 29
Integration Analysis Findings .................................................................................................................................... 31
Conclusions and Recommendations ........................................................................................................................... 35
References ......................................................................................................................................................................... 37
Appendix A: Power Analysis ......................................................................................................................................... 39
Appendix B: Sample of 70 Selected Facilities ............................................................................................................ 41
Appendix C: Interviewees by Title, per Facility ....................................................................................................... 43

vii

Appendix D: World Health Organization PMTCT Treatment Guidelines and Protocols, 2010 ................. 45
Appendix E: Tanzania National Recommendations—Antiretroviral Prophylaxis Regimens for PMTCT,
2007 .................................................................................................................................................................................... 47
Appendix F: Descriptive Statistics on Reporting Sites ............................................................................................ 49

viii

ACRONYMS
ANC antenatal care
ART antiretroviral therapy
ARV antiretroviral
AZT azidothymidine
AZT+3TC azidothymidine + lamivudine
CRS Catholic Relief Services
DBS dried blood spots
DOD U.S. Department of Defense
EGPAF Elizabeth Glaser Pediatric AIDS Foundation
HAART highly active antiretroviral therapy
HTC HIV testing and counseling
ICAP International Center for AIDS Care and Treatment Programs
LOI level of integration
MDH Management and Development for Health
MNCH maternal, newborn, and child health
PCR polymerase chain reaction
PEPFAR U.S. President’s Emergency Plan for AIDS Relief
PMTCT prevention of mother-to-child transmission
sdNVP single-dose nevirapine
UNAIDS Joint United Nations Programme on HIV/AIDS
WHO World Health Organization
USAID U.S. Agency for International Development

ix

INTRODUCTION
Each year, approximately 430,000 babies are born to HIV-infected mothers (World Health
Organization [WHO] 2010a). Over 90 percent of HIV infections in young children and infants are a
result of mother-to-child transmission (WHO 2010a). Prevention of mother-to-child transmission
(PMTCT) interventions can reduce transmission from 25 to 35 percent to less than 5 percent (WHO
2010b).
The Joint United Nations Programme on HIV/AIDS’ (UNAIDS’) campaign to end mother-to-child
transmission by 2015, which calls for a reduction in HIV infections in children by 90 percent and a
reduction in maternal deaths related to HIV by 50 percent, will require increased resources devoted
to PMTCT, increased capacity of health care workers, new technologies, and improved access to
quality interventions for women, children, and families. Tanzania’s PMTCT program is a flagship
effort in the UNAIDS Countdown to Zero campaign (UNAIDS 2011). Program leaders and national
level stakeholders have shown their commitment to the campaign by promoting strategies that
enable increased access to and improved quality of maternal and child health care, particularly for
the HIV-exposed and infected. One of those strategies is integrating PMTCT interventions within
maternal, newborn, and child health (MNCH) services.
Prevention of mother-to-child transmission and MNCH services are traditionally implemented as
separate programs: they are supported by vertical funding streams, may be located in different areas
of a single facility, and are often staffed separately. In guidelines released in 2010, WHO
recommended that health facilities integrate PMTCT with MNCH services to improve patient
follow-up and adherence (WHO 2010c). Also, the U.S. Global Health Initiative prioritizes integrated
health service delivery with an emphasis on a women- and girl-centered approach. Integration of
PMTCT within MNCH offers the opportunity to target women for HIV prevention services, to
decrease attrition, to share resources and information, and to ultimately prevent mother-to-child
transmission of HIV.

BACKGROUND
Tanzania has a generalized HIV epidemic with a 6.2 percent prevalence (UNAIDS 2008) among all
adults and a 6.8 percent prevalence among women (TACAIDS, ZAC, NBS, OCGS, and Macro
International Inc. 2008). In 2008, an estimated 1.3 million adults and children were living with HIV
in Tanzania, with about 10 percent of those being children under age 18 (United Republic of
Tanzania 2010). Women and girls are more likely to be living with HIV than men and boys, and 8.2
percent of pregnant women are infected (National AIDS Control Programme 2007). Every year,
between 70,000 and 80,000 infants are at risk of acquiring HIV during pregnancy, labor and delivery,
or through breastfeeding (United Republic of Tanzania 2010).
The 2007 Tanzania National PMTCT Guidelines advance PMTCT/MNCH integration, providing
specific guidance and practical applications for integrating PMTCT services during antenatal care
(ANC), reproductive and child health, and postnatal care (United Republic of Tanzania Ministry of
Health and Social Welfare). The WHO HIV/MNCH Technical Working Group developed an
operational definition for integration that this report endorses. Integration is defined as “the

1

organization, coordination, and management of multiple activities and resources to ensure the
delivery of more efficient and coherent services in relation to cost, output, impact, and use
(acceptability)” (U.S. President’s Emergency Plan for AIDS Relief [PEPFAR] 2011, 5). Effective
integration requires coordination at multiple levels, within and among government and partner
agencies, including policies and guidelines, administration and governance, funding, human
resources, information systems, and commodity supply chains. Integration may also require service
delivery by a multidisciplinary team, which is often supported by several partners and provided in a
mutually reinforcing manner at the facility, community, and household levels. Integration may need
to be incremental. It can also be conceptualized in terms of patient experience at the service delivery
level (as illustrated in Figure 1) through a continuum of care: from a woman of childbearing age
through pregnancy, delivery, and beyond. The recommended package should be accessible,
affordable, and acceptable to women and children, and is most effective if provided early and if it is
accessible throughout the continuum of care.

Figure 1. The Lifecycle Continuum of Care

Source: PEPFAR 2011, 5

Funding for the national PMTCT program in Tanzania is predominantly provided by PEPFAR,
through its agencies that are responsible for implementing the plan. These agencies include the U.S.
Agency for International Development (USAID), the U.S. Centers for Disease Control and
Prevention (CDC), and the U.S. Department of Defense (DOD). Other sources of funding have
included the Global Fund to Fight AIDS, Tuberculosis and Malaria (for test kits, reagents, and
antiretroviral [ARV] drugs), UNITAID (for pediatric ARVs), and the government’s own internal
resources through the Ministry of Health and Social Welfare, the Prime Minister’s Office, and the
Regional Affairs and Local Government office. In 2007, in an effort to expand access to health
services to the most remote regions of the country, the National AIDS Control Program
implemented a regionalization strategy for PEPFAR implementing partners, wherein partners were
asked to coordinate and deliver PMTCT services in close partnership with regional and district
medical offices in up to five geographical regions (PEPFAR 2010). This resulted in expansion of the
PMTCT program in rural areas and in dispensaries and health centers, which are the facilities where
the most Tanzanian women receive primary care.
Despite notable expansion of the PMTCT program, the development of several guidelines and
protocols for improving access to PMTCT interventions across the continuum of MNCH services,
and a considerable number of women accepting HIV testing and counseling (HTC), in 2009, only
approximately 68 percent of women who tested positive for HIV received antiretroviral therapy
(ART) for PMTCT, and only about 15 to 20 percent of children who tested HIV-positive through
DNA polymerase chain reaction (PCR) received ART (PEPFAR 2010).

PURPOSE
The purpose of this report is to assess the U.S. Government-supported PMTCT program in
Tanzania, focusing on identifying programmatic achievements and challenges, defining and

2

measuring the level of integration at health facilities, and examining the association between the level
of integration and health outcomes.

3

METHODS
USAID/Tanzania contracted AIDSTAR-One for the purpose of documenting and assessing the
level of integration of the U.S. Government-supported PMTCT program. A cross-sectional survey
tool capturing service delivery factors associated with PMTCT/MNCH integration was administered
to key personnel at 70 randomly sampled PMTCT sites.

DATA COLLECTION METHODS
The Ministry of Health and Social Welfare, with support from PEPFAR through USAID, the U.S.
Centers for Disease Control and Prevention, the U.S. DOD, and other funding partners, operates
approximately 3,626 PMTCT facilities (United Republic of Tanzania 2010). A facility-based rapid
assessment of PMTCT facilities was conducted among 70 randomly sampled facilities in Tanzania.
At each site, the data collection team administered a site assessment tool 1 and conducted a facility
walk-through 2 to capture existing infrastructure information. One recorder from each team took
notes during the interview and the walk-through. Data were entered at the end of each day into an
Access database created for this project.
The site assessment tool was created by PMTCT experts at John Snow, Inc., in collaboration with
partner agencies. Some components of the tool were adapted from instruments developed by FHI
360, the Linkages Project (implemented by the Academy for Educational Development), and the
PMTCT Effectiveness in Africa: Research and Linkages to Care and Treatment (PEARL) study.
This tool examined the extent of PMTCT and MNCH integration via specific program dimensions
such as protocols and guidelines, staffing, training, service delivery, laboratory services, supply chain,
and monitoring and evaluation. The facility walk-through (adapted from an FHI 360 template) is a
standard facility checklist to capture the availability of specific infrastructure at each site. Both tools
yield an aggregate score that was used in statistical analysis.
In addition, the PMTCT implementing partners were asked to submit site level data on 33 indicators
related to ANC, labor and delivery, HIV testing, PMTCT and ART (mothers and infants), and
family planning for the 70 randomly selected facilities. All implementing partners submitted data,
with the exception of the U.S. DOD which was providing technical assistance at five of the facilities
in the sample. While site assessments were completed for 70 health facilities, indicator data were
only collected for 65 facilities. Using the data, AIDSTAR-One then calculated facility-level
percentages, for example, to determine the percent of pregnant women in ANC who tested positive
for HIV. AIDSTAR-One also reviewed the indicators for data quality issues (e.g., missing data,
numerator larger than the denominator, etc.) and requested clarifying information from the
implementing partners. Some implementing partners provided updated data; others did not.
Indicators with data quality issues were considered missing and excluded from the analyses.

1
Tool available at http://www.aidstar-one.com/sites/default/files/PMTCT_Site_Assessment_Tool_Sept2011.doc.
2
Tool available at http://www.aidstar-one.com/sites/default/files/Facility_WalkThrough_Questionnaire_Oct2011.doc.

5

SAMPLING STRATEGY
There are seven main U.S. Government-supported PMTCT implementing partners in Tanzania:
1. Catholic Relief Services (CRS; through AIDSRelief)
2. The International Center for AIDS Care and Treatment Programs (ICAP)
3. U.S. DOD
4. Deloitte (through TUNAJALI)
5. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)
6. EngenderHealth
7. Management and Development for Health (MDH).

AIDSTAR-One contacted the implementing partners located in Tanzania before drawing the sample
and asked for an enumerated list of their affiliated facilities and the average volume of ANC patients
at these facilities. This list included 1,245 facilities, which served as the sampling frame or universe
for the study. AIDSTAR-One used the United Republic of Tanzania Ministry of Health and Social
Welfare’s Online Health Facility Registry 3 to obtain information on the type of facility (dispensary,
health center, district hospital, other hospital, regional hospital, referral/consultation hospital, or
other), ownership (government, voluntary/religious, parastatal, private, or other), operational status
(operational, not operating, or under construction), and region/district 4 for the sample of facilities.
The determination of the number of facilities to be sampled was based on a power calculation that
indicated the minimal number of facilities necessary to conduct the statistical analyses used (linear
regression) to examine the results with 80 percent power and a medium effect size (see Appendix
A). The power calculation was conducted using G*-power 3.1.2, an online power calculator
(University of Kiel, Germany). All sampling analyses were performed in SAS version 9.2 (SAS
Institute, Inc., Cary, NC).

SAMPLING PROCEDURE
The goal of the sampling procedure was to include facilities with different ANC patient volume
levels from all of the major PMTCT implementing partners across Tanzania (see Figure 2 for a map
of survey site locations). Volume was categorized as low (50 to 99 patients), moderate (100 to 199
patients), and high (≥ 200 patients), and was based on information gathered from implementing
partners. Facilities with fewer than 50 patients seen in the past month were excluded because their
volume of ANC patients was too low to provide useful information for this assessment. Facilities
were subsequently sampled by implementing partner and volume to ensure that all partners were
represented and that the distribution of patient volume within each partner of the sample matched
that of the greater list of facilities. The sample was selected using a stratified cluster sampling
procedure.
The number of facilities selected from each implementing partner was proportional to the
implementing partner’s representation in the enumerated facility list. Appendix B shows the
stratification by implementing partner and volume. To ensure that there were an adequate number

3
www.moh.go.tz/health_facility_registry/
4
Information on facilities residing on Pemba and Unguja islands was not included in the Tanzanian health facility registry.

6

of facilities sampled from each partner, the sample size was rounded up from 68 facilities to 70
facilities. The total number of facilities randomly sampled was 70 with at least one facility sampled
from each volume level of each implementing partner, except for Deloitte because there were zero
high volume facilities for this partner.
In some instances, facilities selected by random sampling had to be removed from the cohort
selected and replaced by an alternate site for reasons such as no longer providing PMTCT services,
no longer operating, no staff at the facility upon arrival of the data collection team, not located in
stated location, or logistically impossible to reach during the assessment period. In these cases (n =
5), implementing partners and the district health management teams were contacted to suggest a
replacement facility with similar characteristics (e.g., size, type, PMTCT services provided, location,
and implementing partner).

Figure 2. Map of Tanzania by Region and PEPFAR PMTCT Implementing Partner: Survey
Site Selections Indicated

TEAM TRAINING AND PILOT STUDY
AIDSTAR-One contracted a Tanzania-based monitoring and evaluation organization, JL
Consulting, to coordinate logistics of the assessment and provide qualified individuals for data
collection. Eighteen monitoring and evaluation associates were contracted through JL Consulting to
comprise six teams of three individuals. Each team was comprised of one clinician and two

7

additional individuals who were trained in research methods and data collection. A senior
monitoring and evaluation associate acted as the team leader on each team.
Assessment training was conducted by a senior HIV/AIDS advisor at John Snow, Inc., on October
26 and 28. The training addressed: an introduction of PMTCT; PMTCT/MNCH integration
components; clinical review of terms, drug names, and HIV transmission; study goals and objectives;
study methods; the site assessment and walk-through tools; roles and responsibilities of team
members; database software, including data entry; and logistics.
On October 27, the six teams were deployed to six MDH sites in Dar es Salaam that were not
included in the sample to pilot the tools (Mwananyamala Hospital, Mbande Dispensary, Kimara
Dispensary, Buguruni Health Center, Chanika Dispensary, and Mbagala Rangi Tatu Dispensary).
Four of the six teams were accompanied by senior AIDSTAR-One or JL Consulting staff. Each
team debriefed at the end of the pilot, discussed what worked and challenges, and suggested
revisions to the tools. Some revisions were made to the site assessment and walk-through tools, and
the team reconvened on October 28 to discuss revisions, challenges, and receive training on data
entry. The teams were deployed to the sample sites on Saturday, October 29.

FIELD WORK PROTOCOLS AND SURVEY
RESPONDENTS
Upon arrival to a region, the team reported to the regional medical officer and the district medical
officer in the district where the facility is located as a courtesy call. In addition, teams liaised with
coordinators from the implementing partners who assisted with locating facilities.
At each facility, the teams introduced themselves and the project to the staff in-charge who was a
medical officer, clinical officer, or nurse. After describing the tool to the staff in-charge, the data
capturers asked to interview staff with expertise in each area of interest. Respondents were selected
by the staff in-charge and included clinical officers, nurses, or medical assistants (see Appendix C for
list of interviewees). For questions requiring additional specialized input, laboratory and pharmacy
leadership were queried.
The tool was administered in Swahili, with all data capturers fluent in Swahili. An average of 3.5
hours were spent at each site.

ASSESSMENT LIMITATIONS
There are several limitations to this analysis. The sample size was small due to funding limitations.
Although appropriate calculations were made to assure appropriate power, findings may not be
generalizable to all sites in Tanzania. In addition, aggregate data obtained from implementing
partners was utilized as opposed to collecting patient level data at each site, which may have
provided more reliable indicator estimates.
Much of this assessment was dependent on responses from survey respondents who were site staff.
Survey respondents were primarily selected by the leadership at each site. It is possible that there was
inherent selection bias in that process. Data from key informants who were not selected but who
may have been able to provide important information may not have been captured. Data capturers
were also limited to administering the survey to staff available on that day. Input from staff who may
have provided critical information but who were not present on the day of the assessment was not

8

obtained. In addition, staff turnover is known to be high, and responses were not stratified based on
the length of employment at the particular site. Lastly, staff responses may suffer from recall bias.
Though these limitations exist, they are inherent to assessments of this nature. Gaps in knowledge
have been identified and should be explored further. The results of this assessment can be used to
draw some general conclusions about PMTCT services and PMTCT/MNCH integration in
Tanzania.

9

FINDINGS
Findings from the site assessment and facility walk-through tools are detailed in the following
section.

GENERAL SITE CHARACTERISTICS
Seventy sites supported by seven implementing partners and programs across 48 districts and 14
regions of Tanzania were assessed (see Appendix B). Of the sites visited, 58.6 percent were
dispensaries, 28.6 percent were health centers, and 12.9 percent were district hospitals or other types
of hospitals, including one site which was a regional hospital. Most of the facilities in the sample are
located in rural areas (64.3 percent), whereas 22.9 percent are in urban locations, and 12.9 percent
are located in peri-urban or suburban areas. The estimated population covered by all facilities was
4,191,394. Tables 1 and 2 provide sample description by implementing partner, site type, and
volume.

Table 1. Sample by Implementing Partner and Site Type

Implementing Dispensary Health Center Hospital Overall
Partner (n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
CRS (AIDSRelief) 18 43.9% 4 20.0% 0 0% 22 31.4%
U.S. DOD 2 4.9% 2 10.0% 1 11.1% 5 7.1%
EGPAF 14 34.2% 7 35.0% 0 0% 21 30.0%
EngenderHealth 1 2.4% 2 10.0% 3 33.3% 6 8.6%
Deloitte (TUNAJALI) 1 2.4% 1 5.0% 2 22.2% 4 5.7%
ICAP 1 2.4% 4 20.0% 1 11.1% 6 8.6%
MDH 4 9.8% 0 0% 2 22.2% 6 8.6%

Table 2. Sample by Volume and Site Type

Volume Dispensary Health Center Hospital Overall
(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
50 to < 100 (low) 22 53.7% 8 40.0% 6 66.7% 36 51.4%
100 to < 200 (moderate) 14 34.1% 6 30.0% 2 22.2% 22 31.4%
> 200 (high) 5 12.2% 6 30.0% 1 11.1% 12 17.1%

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HIV TESTING AND COUNSELING
HIV testing and counseling is a basic service that should be integrated within ANC and labor and
delivery (see Table 3 for HTC services offered by site type). All sites (70) offer HTC at ANC, and
95.7 percent (67 sites) offer HTC as an integrated service within ANC during regular clinic hours,
testing every woman at her first prenatal care visit. Sixty-five percent (45 facilities) use an opt-in
approach to testing (defined as “the client is explicitly asked for consent to test and it must be
given”), whereas 34 percent (24 facilities) use an opt-out approach (defined as “all women accessing
ANC are tested unless they explicitly refuse”). Of note, opt-out and opt-in were specifically defined
by the data capturer who administered the survey. Facilities reported using both group and
individual pre-test counseling, but the majority of sites use group pre-test counseling (91 percent).
Pre-test counseling is offered across all sites at ANC, although some facilities also have voluntary
counseling and testing or a care and treatment clinic on-site where patients are referred for HTC.
Post-test counseling is offered for individuals or couples at all sites.
Every facility queried utilizes rapid test kits and provides results to women the same day as the test.
All sites (70) reported that if the first rapid test is positive, a second confirmatory test is conducted.
If the second test is negative, 48.6 percent (34 sites) conduct a third tie-breaker rapid test. Seventeen
percent (12 sites) stated that if the rapid test is positive, the confirmatory procedure is to refer
patients to another facility. This is likely due to stockout of HIV test kits. Ninety percent (63 sites)
routinely offer HTC to partners as part of the PMTCT program. Only one site reported not having
any type of disclosure support system in place for women who test positive.

Table 3. HIV Testing and Counseling Services Offered, by Site Type

Dispensary Health Center Hospital Overall
(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Test women at ANC 41 100% 20 100% 9 100% 70 100%

Offer HTC during regular clinic 39 95.1% 19 95.0% 9 100% 67 95.7%
hours
Use opt-out approach* 17 41.5% 5 25.0% 2 22.2% 24 34.3%

Offer pre-test counseling at ANC 41 100% 20 100% 9 100% 70 100%

Use rapid tests 41 100% 20 100% 9 100% 70 100%

Administer second confirmatory 41 100% 20 100% 9 100% 70 100%
test (when first test indicates
positive result)
Administer third tie-breaker test 14 34.1% 13 65.0% 7 77.8% 34 48.6%

Refer women for confirmatory 9 22.0% 2 10.0% 1 11.1% 12 17.1%
HIV test
Routinely offer HTC to partners 36 87.8% 19 95.0% 8 88.9% 63 90.0%

Offer disclosure support for 41 100% 19 95.0% 9 100% 69 98.6%
women who test positive
* Opt-out approach: all women accessing ANC are tested unless they explicitly refuse.

12

Several challenges to implementing quality HTC were captured through qualitative responses. Low
male partner involvement was identified as a common problem (70 percent of respondents). Other
challenges cited included: test kit and equipment shortages (54 percent of sites), patient denial of
HIV test results (30 percent), patient reluctance to disclose HIV status to partners (28 percent), lack
of trained staff or high workload (28 percent), discordant couples (24 percent), and stigma or patient
fear of isolation (14 percent).

PMTCT GUIDELINES AND PROTOCOLS
Respondents were asked to identify which PMTCT guideline was used to guide management of
patients; data collectors did not require verification such as by observing a paper copy. Most sites (75
percent) reported using the National Guidelines of Tanzania 2007; one reported using WHO 2006
guidelines; one site reported using WHO 2010 guidelines; one site did not know; and 13 reported
“other,” including seven sites that use the revised National Guidelines of Tanzania 2010. (See
Appendices D and E for WHO 2010 PMTCT guidelines for ARV prophylaxis and Tanzania’s 2007
national PMTCT guidelines for ARV prophylaxis, respectively.)
Survey results reveal that only two facilities of those sampled do not offer ARV prophylaxis. Table 4
shows regimens of ARV prophylaxis offered to ART-ineligible HIV-positive pregnant women. Most
facilities offer azidothymidine (AZT) from 14 weeks gestation (65.7 percent), single-dose nevirapine
(sdNVP; 84.4 percent), and azidothymidine + lamivudine (AZT+3TC; 71.4 percent) at labor and
delivery for ART-ineligible women. Less than half of the sites reported offering twice daily
AZT+3TC for seven days postpartum. Only 10 percent (seven sites) offer triple drug therapy
starting at 14 weeks gestation and continued until delivery or until one week after infant exposure to
breast milk. Eleven percent (eight facilities) noted that they offer daily AZT or triple drug therapy
from 28 weeks gestation.

Table 4. Regimens of ARV Prophylaxis Offered to ART-ineligible HIV-positive Pregnant
Women, by Site Type*

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
sdNVP 31 75.6% 19 95.0% 9 100% 59 84.4%
Daily AZT from 14 weeks 29 70.7% 14 70.0% 3 33.3% 46 65.7%
gestation
AZT+3TC during labor and 27 65.9% 17 85.0% 6 66.7% 50 71.4%
delivery
Twice daily AZT+3TC for seven 15 36.6% 9 45.0% 4 44.4% 28 40.0%
days postpartum
Triple ARV prophylaxis from 14 3 7.3% 2 10.0% 2 22.2% 7 10.0%
weeks gestation until one week
after all breastfeeding has ended
Other† 1 2.4% 4 20.0% 3 33.3% 8 11.4%
* Note: The reported numbers and percentages for each regimen are not mutually exclusive.
†
Of facilities who reported offering “other” regimens, seven offered daily AZT from 28 weeks gestation, and one offered triple-drug therapy
from 28 weeks gestation.

13

Table 5 shows regimens and integration with ANC. Single-dose nevirapine for prophylaxis is
dispensed or obtained within ANC or the labor ward at 80 percent of the sampled facilities (56 sites)
or elsewhere at the same facility at 2.9 percent of facilities (two sites). Antiretroviral prophylaxis with
more efficacious regimens is offered at ANC at 80 percent of facilities (56 sites), and offered
elsewhere at the same facility at 5.7 percent of facilities (four sites).

Table 5. Regimens of ARV Prophylaxis Offered to ART-ineligible HIV-positive Pregnant
Women Integrated with ANC Services, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
sdNVP for prophylaxis for women
Integrated with ANC 29 70.7% 18 90.0% 9 100% 56 80.0%
Offered at ANC at different 0 0% 1 5.0% 0 0% 1 1.4%
day/time
Offered elsewhere at the same 2 4.9% 0 0% 0 0% 2 2.9%
facility
Not offered 10 24.4% 1 5.0% 0 0% 11 15.7%
Among those that responded “not 3 30.0% 0 0% 0 0% 3 27.3%
offered,” referral provided
ARV prophylaxis with more efficacious regimens
Integrated with ANC 33 80.5% 15 75.0% 8 88.9% 56 80.0%
Offered at ANC at different 0 0% 1 5.0% 0 0% 1 1.4%
day/time
Offered elsewhere at the same 0 0% 3 15.0% 1 11.1% 4 5.7%
facility
Not offered 8 19.5% 1 5.0% 0 0% 9 12.9%
Among those that responded “not 5 62.5% 1 100% 0 0% 6 66.7%
offered,” referral provided

Qualitative data revealed several common challenges to providing PMTCT to HIV-positive women,
including: equipment and/or drug shortages (30 percent of sites); stigma or patient fear of isolation
(19 percent); patients lost to follow-up (19 percent); patient denial of HIV test results (17 percent);
patient reluctance to disclose HIV status to their partner (17 percent); patient refusal of medication
or do not follow medication instructions (13 percent); staff shortage (11 percent); and lack of
partner involvement (10 percent). Additionally, challenges to integrating PMTCT within ANC
service delivery can be found in Table 6.

14

Table 6. Challenges Integrating PMTCT within ANC Services

Challenge Number of Sites Percentage of Sites
Staff shortage 37 53%
High workload 25 36%
Building too small/too few rooms 17 24%
Equipment/supplies/drug shortages 17 24%
Staff training 8 11%

Ninety-three percent of facilities (65 sites) offer ARV prophylaxis for HIV-exposed infants (see
Table 7). Four facilities reported not providing delivery services and referring all HIV-positive cases
for delivery and HIV-exposed infant follow up. Two sites do not provide any prophylaxis, for
women or infants, and one site will begin providing services for children in 2012. All three of these
sites have been referring all positive clients elsewhere for care and treatment.

Table 7. Regimens of ARV Prophylaxis Offered for HIV-exposed Infants, by Site Type*

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
sdNVP at birth only 27 65.9% 14 70.0% 5 55.6% 46 65.7%
sdNVP at birth and daily until 28 68.3% 16 80.0% 5 55.6% 49 70.0%
one week after breastfeeding has
ended
ARV prophylaxis for infants 37 90.2% 19 95.0% 9 100% 65 92.8%
(sdNVP or AZT)
*The reported numbers and percentages for each regimen are not mutually exclusive.

Most facilities determine patient adherence with the use of ARV prophylaxis for the mother and
infant by patient self-report at ANC or at postpartum visits (88.6 percent of facilities). Twenty
facilities determine adherence by checking pharmacy records or the ANC card, 17 sites are linked
with outreach where patients are asked about adherence outside of ANC or the postpartum visit, 2
sites request that patients bring their drugs to postpartum visits, and 2 sites that offer ARV
prophylaxis do not follow up on adherence. Of the 70 sites assessed, 44 percent (31 sites) offer
highly active antiretroviral therapy (HAART) to eligible HIV-positive pregnant women who need
treatment for their own health.

FAMILY PLANNING
Although almost all of the facilities (98.6 percent or 68) reported offering family planning counseling
to every woman who tests positive for HIV, 18.6 percent (13 sites) reported zero HIV-positive
women using family planning methods, and 25.7 percent (18 sites) reported zero women living with
HIV using long-lasting family planning methods (see Table 8).

15

Table 8. Family Planning

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Offer family planning counseling to 39 95.1% 20 100% 9 100% 68 97.1%
every HIV-positive woman
Offer family planning counseling to 40 97.6% 19 95.0% 8 88.9% 67 95.7%
every woman who comes for ANC
Zero HIV-positive women using 8 19.5% 3 15.0% 2 22.2% 13 18.6%
family planning methods
“Do not know” number/percent of 10 24.4% 9 45.0% 4 44.4% 23 32.9%
HIV-positive women using family
planning methods
Zero use of long-lasting family 13 31.7% 4 20.0% 1 11.1% 18 25.7%
planning methods by HIV-positive
women
“Do not know” number/percent of 1 2.4% 1 5.0% 0 0% 2 2.8%
HIV-positive women using long-
lasting family planning methods

These findings represent the extent of what was obtained from facilities regarding family planning
during the assessment. It is suggested that a more comprehensive assessment of family planning
offerings and uptake across Tanzanian health facilities is undertaken. Funders, the Ministry of
Health, and implementing partners might also prioritize collection of family planning indicators,
including uptake, during monitoring and evaluation supportive supervision visits and in monthly
reports.

CD4 TESTING
Of the 70 health facilities providing PMTCT services, 15.7 percent (11 sites) have the ability to run
CD4 tests on-site, 27.1 percent (19 sites) draw blood for CD4 testing on-site and send the specimen
to a lab offsite for analysis, then provide results to the woman back at the initial ANC facility, and
57.1 percent (40 facilities) refer for all aspects of CD4 testing. Eighty-one percent of the facilities
that draw blood for CD4 testing on-site deliver results within one week of testing, whereas 13
percent take up to two weeks. Three percent take up to one month to deliver results.
Forty-three percent of facilities (30 sites) draw blood somewhere at the facility to conduct CD4
testing, whether it is conducted on-site or the specimen is sent to a lab for testing. Of those 30
facilities, 13 draw blood for CD4 testing during normal ANC clinic visits, 12 offer CD4 blood draw
at ANC but at a different time, and 5 refer women elsewhere on-site for CD4 blood draw (see Table
9). Forty-four percent of facilities (31 sites) provide the results of CD4 testing on-site; 14 deliver
results during normal ANC clinic visits, 14 deliver results at ANC at a different time, and at 3
facilities women go somewhere aside from ANC at the same facility to receive their results.

16

Table 9. CD4 Testing Integration with ANC Services, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Blood drawn for CD4 count
Offered at ANC at different 3 7.3% 4 20.0% 5 55.6% 12 17.1%
day/time
Offered elsewhere at the same 2 4.9% 3 15.0% 0 0% 5 7.1%
facility
Not offered 31 75.6% 7 35.0% 2 22.2% 40 57.1%
If not offered, referral provided 28 90.3% 7 100% 1 50.0% 36 90.0%
Results of CD4 delivered
Offered at ANC at different 4 9.8% 5 25.0% 5 55.6% 14 20.0%
day/time
Offered elsewhere at the same 1 2.4% 1 5.0% 1 11.1% 3 4.3%
facility
Not offered 30 73.2% 7 35.0% 2 22.2% 39 55.7%
If not offered, referral provided 24 80.0% 7 100% 0 0% 31 79.5%

ANTIRETROVIRAL THERAPY FOR WOMEN’S
HEALTH
Forty-four percent of facilities (31 sites) offer HAART to eligible HIV-positive pregnant women
who need treatment for their own health, although eligibility criteria varies across sites. Twenty-
seven facilities provide HAART for women with a CD4 count less than 350, and four offer HAART
for those with a CD4 count less than 200 (see Table 10). Of the 39 facilities that do not provide
HAART for women’s health, 36 report referring patients to a separate facility for treatment. Of the
31 facilities that provide HAART for women’s health, 19 offer treatment within the ANC clinic at
the same time as ANC services, 5 offer at the ANC clinic but at a different time (not integrated in
the normal ANC visit), and 7 facilities provide treatment elsewhere at the same facility (see Table
11).
Sixty-eight percent of the 31 facilities offering HAART for women’s health initiate treatment within
one week of determining eligibility. Twenty-six percent initiate HAART between two weeks and one
month. At one site (three percent of those offering HAART for women’s health), women must wait
more than one month for treatment, and at another site, providers initiate treatment once the
woman understands the importance of adherence to treatment. Interviewees reported several
reasons for not offering HAART for women’s health, including a lack of trained staff (reported by
94.6 percent of sites), no care and treatment clinic (86.5 percent), and inadequate infrastructure (8.1
percent).

17

Adherence support for mother-infant pairs is offered at 93 percent of facilities (65 of 70). Sixty
provide treatment adherence support at regular ANC visits, four offer it at a different time within
the ANC clinic, and at one facility, women can receive adherence support elsewhere at the facility.
Forty-four percent of facilities (31 of 70 sites) discuss treatment and support options with HIV-
positive pregnant women within ANC during normal hours, five sites provide this at a different
time, three provide counseling elsewhere at the facility, and 31 facilities do not provide any sort of
treatment and support counseling on-site. Of the 31 who do not provide counseling, 30 offer a
referral to a different facility to discuss treatment options.

Table 10. HAART Initiation for Women’s Health, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Facilities that provide HAART for 8 19.5% 16 80.0% 7 77.8% 31 44.3%
women's own health
HAART initiation criteria among sites offering ART for women’s health
WHO staging* 6 75.0% 11 68.8% 4 57.1% 21 67.7%
CD4 count < 350* 8 100% 13 81.3% 6 85.7% 27 87.1%
CD4 count < 200* 2 25.0% 2 12.5% 0 0% 4 12.9%
Other (facility refers women to 1 2.4% 0 0% 0 0% 1 1.4%
nearby care and treatment clinic for
ART initiation, except on some days
when staff from care and treatment
clinic offer ART in the facility
outpatient department)
* Responses are not mutually exclusive.

Table 11. Integration of HAART for Women’s Health with ANC Services, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Facilities that provide HAART for 8 19.5% 16 80.0% 7 77.8% 31 44.3%
woman's own health
HAART offered for women's health
Offered at ANC at different day/time 0 0% 5 25.0% 0 0% 5 7.1%
Offered elsewhere at the same 1 2.4% 5 25.0% 1 11.1% 7 10.0%
facility
Not offered 33 80.5% 4 20.0% 2 22.2% 39 55.7%
If not offered, referral provided 31 93.9% 4 100% 1 50.0% 36 92.3%

18

LABOR AND DELIVERY
Sixty-four facilities have labor and delivery wards. Sixteen facilities reported zero deliveries for HIV-
positive women on average per month, and five did not know (mean deliveries for HIV-positive
women per month: 4.7; minimum: 0; maximum: 55). All of the facilities with labor and delivery
wards reported testing women of unknown status at labor and delivery (see Table 12). Ten facilities
offer caesarean sections for HIV-positive women at delivery. Sites not offering caesarean sections
provide referrals for women who want to explore that option.

Table 12. PMTCT Integration at Labor and Delivery, by Site Type, among Sites that Offer
Labor and Delivery

(n = 37) (n = 19) (n = 8) (n = 64)
n % n % n % n %
Test women of unknown status at labor 37 100% 19 100% 8 100% 64 100%
and delivery
Dispense ARVs for HIV-positive women 31 83.8% 19 100% 8 100% 58 90.6%
at labor and delivery
Dispense ARVs for HIV-exposed infants 29 78.4% 18 94.7% 7 87.5% 54 84.4%
at labor and delivery
Offer caesarean section for HIV- 1 2.7% 2 10.5% 7 87.5% 10 15.6%
positive women
Elective caesarean section for HIV- 1 2.7% 2 10.5% 1 12.5% 4 6.3%
positive women where possible

EXPOSED INFANT FOLLOW-UP
Eighty-seven percent of facilities (61 sites) identify exposed infants at their first postnatal visit at
reproductive and child health services. Infants of infected mothers also have their exposure status
recorded on child health cards, and 80 percent of facilities identify children this way. In addition,
18.5 percent of facilities (13 sites) noted that community health workers also identify children who
are symptomatic. Facilities reported monitoring and following up with mother-infant pairs at
postpartum clinics (97 percent), pediatric clinics (33 percent), pediatric HIV clinics (11 percent),
ART clinics (27 percent), infant feeding counseling sessions (59 percent), and growth monitoring
sessions in communities (30 percent).
Forty-one facilities obtain dried blood spots (DBS) for PCR testing of infants between 4 and 6
weeks of age (see Table 13). All of the sites in the sample send specimens to a central lab for testing
and provide results back at the initiating facility. Of the 41 sites that obtain DBS for PCR, 36 offer
that service at the same time as the normal ANC, four offer it at a different time within ANC, and at
one facility, DBS collection occurs elsewhere on-site (see Table 14).

19

Table 13. HIV Testing for Exposed Infants, by Site Type*

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Facilities offering DBS collection for 16 39.0% 16 80.0% 9 100% 41 58.6%
PCR testing
DBS for PCR at four to six weeks† 14 34.1% 14 70.0% 9 100% 37 52.9%
DBS for PCR at less than 18 months if 6 14.6% 10 50.0% 2 22.2% 18 25.7%
baby is symptomatic†
DBS for PCR at 18 months† 5 12.2% 8 40.0% 3 33.3% 16 22.9%
Serologic testing at 18 months 7 17.1% 4 20.0% 3 33.3% 14 20.0%
Serologic testing at < 18 months if 1 2.4% 1 5.0% 0 0% 2 2.9%
mother’s status is unknown
No tests available for exposed infants 22 53.7% 4 20.0% 0 0% 26 37.1%
* All sites that offer PCR testing collect the DBS on-site and send the sample to an offsite lab for testing.
†
Response choices are not mutually exclusive.

Table 14. Integration of DBS for PCR within ANC, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Facilities offering DBS collection for 16 39.0% 16 80.0% 9 100% 41 58.6%
PCR testing
DBS sample taken for PCR
Integrated with ANC 15 36.6% 12 60.0% 9 100% 36 51.4%
Offered at ANC at different day/time 1 2.4% 3 15.0% 0 0% 4 5.7%
Offered elsewhere at the same facility 0 0% 1 5.0% 0 0% 1 1.4%
Not offered 25 61.0% 4 20.0% 0 0% 29 41.4%
If not offered, referral provided 23 92.0% 4 100% 0 0% 27 93.1%

Postnatal services offered to exposed infants at facilities in the sample include: early ART (47
percent); treatment adherence support (54 percent); nutrition counseling (91 percent); cotrimoxazole
preventive treatment (93 percent); tuberculosis screening and diagnosis (43 percent); tuberculosis
prevention including isoniazid prophylaxis (13 percent); tuberculosis management and treatment (24
percent); and psychosocial support (94 percent; see Table 15). All facilities promote exclusive
breastfeeding for HIV-positive women, HIV-negative women, and women of unknown status. Most
facilities provide follow-up support and lactation management: 22 sites use home visits and 62 sites
follow up at postnatal care. Six sites report not providing any lactation management or follow up to
women who are HIV-positive. Three facilities supply infant formula to women who are HIV-
positive, if requested. The majority of sites provide follow up to mother-infant pairs at a postpartum
clinic (see Table 16).

20

Table 15. Postnatal Services for Children Born to HIV-positive Mothers, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Early ART 17 41.5% 10 50.0% 6 66.7% 33 47.1%
Treatment adherence support 18 43.9% 14 70.0% 6 66.7% 38 54.3%
Nutrition counseling/support and 37 90.2% 18 90.0% 9 100% 64 91.4%
infant feeding
Cotrimoxazole preventive treatment 37 90.2% 19 95.0% 9 100% 65 92.9%
Tuberculosis screening and diagnosis 9 22.0% 14 70.0% 7 77.8% 30 42.9%
Tuberculosis prevention, including 4 9.8% 3 15.0% 2 22.2% 9 12.9%
isoniazid prophylaxis
Tuberculosis management and 8 19.5% 7 35.0% 2 22.2% 17 24.3%
treatment
Psychosocial support 40 97.6% 17 85.0% 9 100% 66 94.3%
None of the above 1 2.4% 0 0% 0 0% 1 1.4%

Table 16. Follow up of HIV-positive Mother-Infant Pairs, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Postpartum clinic 40 97.6% 19 95.0% 9 100% 68 97.1%
Pediatric clinic (general) 14 34.1% 8 40.0% 1 11.1% 23 32.9%
Pediatric HIV clinic 2 4.9% 4 20.0% 2 22.2% 8 11.4%
ART clinic 5 12.2% 10 50.0% 4 44.4% 19 27.1%
Nutrition/infant feeding counseling 31 75.6% 6 30.0% 4 44.4% 41 58.6%
sessions
Growth monitoring sites in the 15 36.6% 5 25.0% 1 11.1% 21 30.0%
community
Other (“when come to other 1 2.4% 0 0% 0 0% 1 1.4%
services”)

COMMUNITY LINKAGES
Facilities were asked about their knowledge of a range of services provided at the community level,
and linkages between the facility and community. Forty-four percent of facilities (31 sites) reported
that community-based organizations or community health workers provide information to women
in the community about PMTCT, and 33 percent of facilities reported that local community-based
organizations or individuals provide referrals for PMTCT from the community to the facility. Other
services that facilities reported were available to its communities include: psychosocial support (57

21

percent), breastfeeding support (34 percent), home-based clinical services for people living with HIV
(44 percent), socioeconomic support (35 percent), growth monitoring for infants (27 percent),
immunization follow-up (27 percent), and family planning (38.5 percent). Sixteen percent of facilities
(11 sites) reported linkages to community organizations that follow up with women who do not
return for HIV test results, and 20 percent (14 facilities) reported a community linkage with an
organization that follows up with women who do not return for sdNVP.

PATIENT-PROVIDER RATIO
A patient-to-provider ratio was generated using the number of ANC patients seen at each site on the
day of the assessment (data collected in the site assessment tool) and the number of providers
(medical officers, clinical officers, PMTCT nurses, maternal and child health care/ANC nurses, and
midwives) observed by the data collector during the site walk-through on the day of the assessment
(data collected in the facility walk-through tool). The median ratio of patients seen in ANC to ANC
providers seen during the walk-through was four ANC patients to one ANC provider (mean: 6.6;
standard deviation: 7.9). The patient-provider ratio was not correlated with the PMTCT-ANC
integration score (the integration score is described in detail later; Spearman correlation coefficient:
0.19, p = 0.11).
Fifty-three percent of facilities (37 sites) reported that staff shortages were a primary challenge to
integrating PMTCT services with ANC or other programs, and 35.7 percent (25 sites) noted that a
high workload was also a challenge. Sixty percent of facilities (42 sites) reported that increasing the
number of staff would be a welcome assistance needed to improve integration. Twenty-eight percent
of facilities (14 sites) reported that a lack of trained staff or high staff workload was a challenge for
providing HTC, and 11 percent (8 sites) reported that staff shortage was a challenge for providing
PMTCT to HIV-positive women. Staffing is an issue for logistics management at four percent of
facilities (three sites).

TRAINING
Eleven percent of facilities (eight sites) noted that a lack of staff training or capacity building was a
challenge to integrating PMTCT with ANC or other programs, and 34.3 percent of facilities (24
sites) noted that the provision of staff training would improve integration at the site. Six percent of
facilities (four sites) reported lack of staff training as a challenge to providing PMTCT to HIV-
positive women. Table 17 shows types of training received by health care workers in the past year.

SUPERVISION
Eighty-nine percent of facilities (62 sites) reported that supervision for the PMTCT clinical nursing
staff is provided on a regular basis, and 74 percent of facilities (52 sites) noted that supervision was
provided in the last three months. Of those who reported regular supervision, 40 sites reported that
a supervisor observed staff at work, 51 sites reported that a supervisor provided feedback on staff
performance, 59 noted that the supervisor discussed problems staff encountered, and 60 reported
that the supervisor checked staff members’ reports.

22

Table 17. Number of Facilities Reporting Health Care Workers Receiving Training in the
Last Year by Cadre and Training, and by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Training on PMTCT
Medical officer/clinical officer 15 36.6% 8 40.0% 5 55.6% 28 40.0%
Registered nurse 9 22.0% 9 45.0% 5 55.6% 23 32.9%
Enrolled nurse/midwife 22 53.7% 15 75.0% 9 100% 46 65.7%
Counselor 0 0% 4 20.0% 2 22.2% 6 8.6%
Lab technician 0 0% 7 35.0% 3 33.3% 10 14.3%
Medical assistant 18 43.9% 9 45.0% 1 11.1% 28 40.0%
Training on HTC
Counselor 1 2.4% 4 20.0% 2 22.2% 7 10.0%
Lab technician 2 4.9% 8 40.0% 4 44.4% 14 20.0%
Training on ART
Enrolled nurse/midwife 15 36.6% 14 70.0% 6 66.7% 35 50.0%
Counselor 0 0.0% 6 30.0% 1 11.1% 7 10.0%
Lab technician 1 2.4% 3 15.0% 1 11.1% 5 7.1%
Training on ART during pregnancy
Counselor 1 2.4% 2 10.0% 1 11.1% 4 5.7%
Lab technician 0 0% 3 15.0% 2 22.2% 5 7.1%

23

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Training on care of HIV-exposed infants
Counselor 1 2.4% 2 10.0% 1 11.1% 4 5.7%
Lab technician 0 0% 0 0% 1 11.1% 1 1.4%
Training on breastfeeding for HIV-positive women
Counselor 1 2.4% 2 10.0% 1 11.1% 4 5.7%
Lab technician 0 0% 1 5.0% 1 11.1% 2 2.9%
Medical assistant 12 29.3% 2 10.0% 0 0% 14 20.0%
Training on nutrition counseling for HIV-positive women and children
Counselor 1 2.4% 2 10.0% 0 0% 3 4.3%
Lab technician 0 0% 0 0% 0 0% 0 0%
Training on early infant diagnosis/DBS
Counselor 1 2.4% 3 15.0% 0 0% 4 5.7%
Lab technician 0 0% 4 20.0% 3 33.3% 7 10.0%

24

COMMODITIES
Availability of drugs and commodities was low at many facilities (see Table 18). Twenty-four percent
of facilities (17 sites) listed supplies and drug shortages as a major challenge to integrating PMTCT
services with ANC or other programs. Thirty-one percent of facilities (22 sites) reported that
improving the availability of supplies and drugs would improve their efforts at integration, and 54
percent (27 sites) reported test kit and equipment shortages were a challenge for providing HTC.

Table 18. Drug/Supply Availability, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
Rapid test (e.g., Bioline)
Currently available 29 70.7% 17 85.0% 9 100% 55 78.6%
Stockout in last three months 34 82.9% 14 70.0% 6 66.7% 54 77.1%
Site does not carry 0 0% 0 0% 0 0% 0 0%
Confirmatory test 2 (e.g., Determine)
Site does not carry 0 0% 0 0% 0 0% 0 0%
Confirmatory test 3 (e.g., Unigold)
Currently available 6 14.6% 7 35.0% 5 55.6% 18 25.7%
Site does not carry 29 70.7% 5 25.0% 3 33.3% 37 52.9%
Nevirapine
Site does not carry 4 9.8% 3 15.0% 0 0% 7 10.0%
Viral reagents for other HIV assays
AZT
AZT+3TC
Site does not carry 16 39.0% 0 0% 1 11.1% 17 24.3%

25

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
3TC
Efavirenz (EFV)
Stockout in last three months 8 19.5% 6 30.0% 0 0% 14 20.0%
Stavudine (d4T)
Stockout in last three months 9 22.0% 5 25.0% 0 0% 14 20.0%
Cotrimoxazole/Septrin
DBS supplies
Phlebotomy supplies
Site does not carry 4 9.8% 0 0% 0 0% 4 5.7%
ARV syrup for infants
Condoms
Needles/syringes
Currently available 38 92.7% 20 100% 7 77.8% 65 92.9%
Site does not carry 1 2.4% 0 0% 1 11.1% 2 2.9%

26

Challenges with logistics and supply chain management systems included: shortages of medical
supplies, drugs, and/or equipment (41 percent of sites); delay of supply orders (21 percent); lack of
transportation or road infrastructure challenges (16 percent); supply replenishment not containing
what was ordered (10 percent); and lack of communication (10 percent).

MONITORING AND EVALUATION
Ninety-three percent of facilities (65 sites) report reviewing data collected on PMTCT and ANC
with staff, and 53 sites note that this is done monthly. Table 19 outlines some of the uses of data at
the facility level as described by key staff.

Table 19. Uses of Data Collected on PMTCT, by Site Type

(n = 41) (n = 20) (n = 9) (n = 70)
n % n % n % n %
To evaluate/assess quality of 6 14.6% 8 40.0% 4 44.4% 18 25.7%
services delivered
To identify trends/status of HIV 12 29.3% 2 10.0% 1 11.1% 15 21.4%
in the community
To identify the quantity of 7 17.1% 3 15.0% 4 44.4% 14 20.0%
medication/equipment needed
To identify needs/challenges for 10 24.4% 4 20.0% 0 0% 14 20.0%
the clinic
To plan/budget for service 9 22.0% 3 15.0% 0 0% 12 17.1%
delivery
To improve patient/community 7 17.1% 0 0% 2 22.2% 9 12.9%
education
To identify patient attendance 1 2.4% 0 0% 1 11.1% 2 2.9%
To identify trends/status of HIV 4 9.8% 3 15.0% 3 33.3% 10 14.3%
within facility
To help follow up with 3 7.3% 2 10.0% 0 0% 5 7.1%
patients/identify the rate of loss
to follow-up
No use 0 0% 1 5.0% 0 0% 1 1.4%
To identify number of HIV- 1 2.4% 2 10.0% 0 0% 3 4.3%
positive patients
To know the number of patients 5 12.2% 0 0% 0 0% 5 7.1%

27

INTEGRATION ANALYSIS

LEVEL OF INTEGRATION SCORE METHODOLOGY
A level of integration (LOI) rating system was developed to quantify the degree to which PMTCT
services are integrated into MNCH services at the site level. A total integration score (0 to 20) was
assigned for each facility based on the availability of selected PMTCT services within the context of
ANC/labor wards. Sites with higher scores were determined to have a higher LOI. The availability
of the service was determined through interpreting responses on the site assessment tool. Aggregate
site level data for the fiscal year October 1, 2010, to September 30, 2011, were provided by
implementing partners. AIDSTAR-One requested 33 indicators from implementing partners. Of the
33 requested, 15 were used in the analysis (two were determined by the analysis team to be
unnecessary, four were used as denominators for other indicators, and 12 had less than 45 sites
reporting valid data, which was the cut off for the sample size for each indicator [70 percent of the
65 sites reporting data]). Correlations between variables were tested using nonparametric methods,
including the Spearman rank correlation test and the Wilcoxon-Mann-Whitney test (significant if p
< 0.05). All statistical analyses were completed in SAS version 9.2.
The LOI score was calculated using questions from the “Integration of PMTCT within
ANC/MNCH” section of the site assessment tool. The question number from the site assessment
tool, as well as the point allocation, are provided (Table 20).
Points from each question were summed to produce the total integration score, which potentially
could range from 0 to 20. The integration score was used in analyses as a continuous variable, and
had a Cronbach’s alpha of 0.76, which determines reliability or internal consistency (i.e., average
correlation) of items included in the score (≥ 0.7 is acceptable).
An infrastructure score was determined using the facility walk-through tool, as follows:
• The first section of the facility walk-through questionnaire includes questions about the services
offered at a facility. For each service that was provided, a facility received one point for the
infrastructure score. In addition, a facility received one point for the number of days it was open
for outpatient adult and/or child health services (Q9). The number of beds for inpatient
overnight care (Q10) was not included in the infrastructure score.
• The second section of the questionnaire includes questions about basic infrastructure. A facility
received one point for each “yes” response in this section and one point for each examining
room available for ANC/PMTCT services.
• The third section of the questionnaire includes questions about personnel. A facility received
one point if any of each type of personnel were observed. In other words, if any medical officers
were observed, the facility received one point, and if any clinical officers were observed, the
facility received one additional point, etc. Also, facilities received one point if the maternal and
child health/ANC nurse(s) was also the PMTCT nurse(s).

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Table 20. Site Assessment Tool Point Allocation

Offered during Offered within Offered
routine hours the ANC unit elsewhere
within the ANC at a different on-site or
unit at the time as other not offered
same time as services on-site
other services
Q50d: Psychosocial counseling is offered 1 0.5 0
(partner disclosure, stigmatization)
Q50fp: Family planning counseling 1 0.5 0
Q50e: ARV prophylaxis for PMTCT with 1 0.5 0
sdNVP for mothers
Q50f: ARV prophylaxis for PMTCT with 1 0.5 0
more efficacious combinations including dual
and triple ART
Q50g: ARV prophylaxis for infants (sdNVP or 1 0.5 0
AZT)
Q50h: Infant feeding counseling and 1 0.5 0
exclusive breastfeeding support for positives
Q50i: Infant formula available for those who 1 0.5 0
do not breastfeed
Q50j: Blood for CD4 count drawn for 2 1 0
positives
Q50k: Results of CD4 returned to patients 2 1 0
on-site
Q50l: Treatment and support options 1 0.5 0
discussed with women eligible for treatment
on-site
Q50n: ART offered to eligible women for 2 1 0
their own health (not PMTCT)
Q50o: Exposed infant evaluation conducted 2 1 0
in ANC/MNCH on a regular schedule
Q50p: DBS for HIV detection in infants done 2 1 0
between 4 and 6 weeks of age
Q50r: Adherence support is available to 1 0.5 0
mother-infant pairs
Q50s: Cotrimoxazole offered to exposed 1 0.5 0
infants

30

• The fourth section of the questionnaire includes questions about counseling and examination
areas. Facilities received one point for having an examination bed or table in the exam room and
one point for having a toilet or latrine for both patients and staff.
• The fifth section includes questions about equipment and drug storage. A facility received one
point for each piece of equipment observed. One point was also awarded for each “yes”
response to the drug storage questions.
• The last section includes questions about lab facilities. A facility received two points if there was
a diagnostic laboratory in the facility. Two points were awarded if a facility conducted HIV rapid
tests. For HIV viral load, CD4 count, and PCR, four points were awarded if a facility conducted
the test and three points were awarded if a facility collected and sent specimens to another
facility.
• No points were awarded to a facility in the infrastructure score for a response of “no,”
“undetermined,” or “don’t know” to any question in the facility walk-through.

INTEGRATION ANALYSIS FINDINGS
Key questions driving the analysis included:
• What is the relationship between facility type, LOI, and infrastructure score?
• What is the correlation between the LOI score and various quality indicators reported for each
site?

RELATIONSHIP AMONG FACILITY TYPE, LEVEL OF
INTEGRATION, AND INFRASTRUCTURE SCORE
The median integration score was 12 (range 0.5 [low LOI] to 20 [high LOI]). As shown in Table 21,
hospitals were found to have the highest median LOI score at 16.5 (range 11 to 19) followed by
health centers at 14.75 (range 7.5 to 19) and dispensaries at 10 (range 0.5 to 20). The difference
between dispensaries and hospitals and dispensaries and health centers was statistically significant (p
< 0.05). Health centers have a significantly higher median LOI score than dispensaries, and hospitals
have a significantly higher median LOI score than both dispensaries and health centers.

Table 21. Median Integration and Infrastructure Scores by Type of Facility

Indicators Dispensary Health Hospital Dispensary Health Health Hospital
(n = 41) Center (n = 9) vs. Other Center vs. Center vs.
Median (n) (n = 20) Median (n) (p value) Dispensary vs. Other
Median (n) (p value) Hospital (p value)
(p value)
Number of new 410.0 (39) 686.5 (18) 884.5 (8) 0.003 0.03 0.1 0.008
patients in ANC
Integration score 10.0 (39) 14.75 (18) 16.5 (8) 0.0003 0.003 0.41 0.02
Infrastructure score 47.0 (39) 58.0 (18) 58.0 (8) <0.0001 0.0001 0.62 0.09
Wilcoxon-Mann-Whitney test (nonparametric version of t-test) reporting p values; red text indicates significant at p < 0.05.

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QUALITY INDICATORS BY SITE TYPE
As reflected in Table 22, dispensaries had the lowest proportion of HIV-positive mothers who
initiated exclusive breastfeeding (6.3 percent), followed by health centers (33.3 percent), and
hospitals (48.5 percent). Dispensaries also had a significantly lower percentage of HIV-positive
pregnant women who received more efficacious regimens for PMTCT in ANC and HIV-positive
pregnant women who initiated ARV treatment in ANC than health centers or hospitals, whereas
hospitals had the highest proportions of both.

Table 22. Median Indicator Values by Facility Type

(n = 41) Center (n = 9) vs. Other Center vs. Center vs. Other
Median (n) (n = 20) Median (p value) Dispensary vs. (p value)
Median (n) (p value) Hospital
(n) (p value)
Number of new patients in 410.0 (39) 686.5 884.5 0.003 0.03 0.1 0.008
ANC (18) (8)
Pregnant women newly 0.2% (39) 0.7% 1.3% (8) 0.0005 0.01 0.31 0.007
enrolled in ANC with (18)
known HIV-positive status
Pregnant women who 58.5% (36) 74.2% 94.4% 0.03 0.1 0.7 0.2
received HIV test results in (12) (5)
ANC
Pregnant women who were 2.1% (32) 4.7% 4.2% (4) 0.16 0.17 0.74 0.82
tested and received results (16)
in labor and delivery
Pregnant women who 64.5% (32) 90.8% 94.4% 0.03 0.1 0.6 0.1
received HIV counseling (12) (5)
and education in ANC
Pregnant women who 2.1% (32) 7.4% 7.3% (4) 0.08 0.12 0.74 0.36
received HIV counseling (16)
and education in labor and
delivery
Pregnant women who 1.3% (39) 2.7% 5.7% (8) 0.005 0.1 0.04 0.003
tested HIV-positive in ANC (18)
Pregnant women who 0% (32) 0.3% 0.4% (4) 0.008 0.03 0.67 0.1
tested positive in labor and (16)
delivery
Pregnant women arriving 0.8% (32) 3.3% 12.9% 0.0003 0.002 0.22 0.02
in labor and delivery with (16) (4)
known positive status
HIV-positive mothers who 6.3% (35) 33.3% 48.5% 0.001 0.01 0.1 0.008
initiated exclusive (18) (7)
breastfeeding
Infected pregnant women 4.5% (35) 4.1% 15.7% 0.7 0.8 0.8 0.8
who received sdNVP in ANC (18) (8)

32

(n = 41) Center (n = 9) vs. Other Center vs. Center vs. Other
Median (n) (n = 20) Median (p value) Dispensary vs. (p value)
Median (n) (p value) Hospital
(n) (p value)
HIV-positive pregnant 8.3% (35) 34.9% 44.4% 0.01 0.06 0.1 0.03
women who received other (18) (6)
ARV regimens for PMTCT in
ANC
HIV-positive pregnant 0% (34) 6.6% 28.2% 0.003 0.04 0.1 0.007
women initiating ARV (14) (6)
treatment in ANC
Infants who received only 0% (23) 25.0% 19.4% 0.23 0.3 0.97 0.54
sdNVP in labor and delivery (16) (7)
Infants who received other 45.8% (22) 89.2% 83.6% 0.26 0.34 0.95 0.55
ARV regimens for PMTCT in (16) (7)
labor and delivery
Infants born to HIV-positive 0% (35) 12.5% 31.7% 0.02 0.1 0.2 0.02
women enrolled in ANC (17) (7)
Wilcoxon-Mann-Whitney test (nonparametric version of t-test) reporting p values; red text indicates significant at p < 0.05.

IMPACT OF INTEGRATION SCORE ON QUALITY OF CARE
INDICATORS
According to the aggregated monitoring data reported for 65 sites during fiscal year 2011, 48,938
pregnant women newly enrolled in ANC in 2011. Of these women enrolled, 2,535 were living with
HIV. On average, sites provided 59.9 percent of HIV-positive women with PMTCT prophylaxis in
2011 (descriptive statistics from monitoring data are included in Appendix F). Level of integration
was positively correlated with quality of care indicators, which include: percent tested for HIV and
received results in ANC (ρ = 0.33, p = 0.02), percent who initiated exclusive breastfeeding (ρ =
0.30, p = 0.02), percent who received more effective combination ART for PMTCT prophylaxis (ρ
= 0.40, p = 0.002), and percent initiating ART for their own health (ρ = 0.52, p < 0.0001).
Integration did not appear to correlate with the percent of women who received sdNVP, the percent
of infants who received only sdNVP in labor and delivery, or the percent of infants who received
other ARV regimens for PMTCT in labor and delivery (Table 23).

33

PMTCT Integration Assessment Tanzania

PMTCT Integration Assessment Tanzania

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