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Evaluation report

2007 Tanzania: Joint Review of the National HIV Response in Zanzibar 2004-2007



Executive summary

Background:
The first three HIV cases in Zanzibar were diagnosed in 1986 at Mnazi Mmoja hospital. RGoZ took early action; after the identification of the HIV index case, the Ministry of Health and Social Welfare (MoHSW) led a newlyestablished technical committee to address issues on HIV as a disease of public health importance. Furthermore, the RGoZ established a special task force under the Chief Minister’s Office (CMO) with Ministerial Principal Secretaries as its members (ZAC, 2003).
Under the leadership of the technical committee, successive Medium Term Plans [MTP I-III] were formulated and implemented with various levels of achievements and impact (ZAC, 2003). There was a marked difference between MTP I and MTP II on the one hand and MTP III on the other hand: MTP III was a multisectoral plan in which not only MoHSW was responsible for the HIV response, the others were not.
MoHSW established the Zanzibar AIDS Control Programme (ZACP) in 1987 to lead all efforts to respond to the epidemic. Technical AIDS Committees (TACs) were formed in all RGoZ ministries by 2004. The greater part of MTP III was implemented during the donor embargo3 from 1995 to 2000. The lack of funding severely hampered the implementation of MTP III activities. There was a second challenge for the implementation of MTP3: whilst the management structures (ZACP and TACs) were in place to execute the multisectoral MTP3, ZACP did not have the mandate to coordinate the activities of other sectors.
The first challenge was over after the election results in 2000 were accepted by development partners and funding for HIV was made available again; the second challenge was addressed in June 2002 when an Act by the House of Representatives led to the creation of ZAC, a national entity responsible for coordinating the HIV response within all sectors – including civil society and the private sector. Specifically, ZAC was tasked, first of all, with developing strategic guidance for all sectors to participate in the HIV response in Zanzibar.
Soon after the establishment of ZAC, a situation analysis was carried out with a four-fold purpose: (i) to analyse the status of the HIV epidemic, the determining factors and drivers of the epidemic; (ii) to assess the extent to which MTP III (1998-2002) was implemented as a multisectoral plan; (iii) to identify achievements and constraints encountered; and (iv) to propose recommendations and the way forward as input into the formulation of a multisectoral Zanzibar National HIV and AIDS Strategic Plan – the ZNSP.
The situation analysis revealed 18 key recommendations, which formed the basis of the objectives and strategies of the ZNSP. The ZNSP was launched in June 2005, and covers the time period June 2005 to June 2009 (up to the end of the 2008-09 RGoZ fiscal year). The ZNSP has been ZAC’s guiding document, and thus forms the core of what was planned in terms of the HIV response in Zanzibar.
After the launch of the ZNSP, the MoHSW prepared the Zanzibar Health Sector HIV Strategy (HSSP) for the period 2005-06 to 2010-11. The HSSP defines specific goals, objectives and strategies (in line with the broad ZNSP objectives) for the health sector’s HIV response. Other Ministries followed suit in developing HIV workplace programmes for their Ministries and mainstreaming HIV into their core functions.

Purpose/Objective:
The main purpose of the Joint Review was to determine to what extent Zanzibar has mounted a relevant and comprehensive HIV response of appropriate scale, and what should be done to improve the HIV response in future. To achieve this main purpose, a number of evaluation questions were developed – as detailed in Annex A.
Conceptual framework of the Joint Review: When the Joint Review of the HIV Response in Zanzibar was designed, a conceptual framework was agreed on. This conceptual framework would not only guide the review process, but also the evaluation questions and the division of labour between the members of the Joint Review team. In terms of the conceptual framework, it was agreed that first, the drivers of the epidemic needed to be understood, as these would influence how the country should respond to HIV. Then, the extent of the HIV response needed to be investigated – i.e. whether the HIV services (HIV prevention services, HIV care and treatment services and HIV impact mitigation services) that were implemented, were relevant, comprehensive and of appropriate scale – this was the second part of the Review. These HIV services can only be implemented if an enabling environment for HIV service delivery exists (legal framework; political will; effective planning, management and coordination; resource mobilisation and utilization; capacity; and advocacy) – therefore, the enabling environment was the third aspect that was investigated. Finally, the fourth aspect that was investigated was the extent to which the HIV response (i.e. the services delivered and enabling environment) are being monitored and evaluated. The conceptual framework described here is illustrated in Annex B.

Methodology:
Who governed the Joint Review? The Joint Review was governed by a Joint Review Steering Committee that was chaired by ZAC. The members of the Steering Committee included representatives of, civil society, the private sector, faith-based sector, development partners, departments within ZAC, and different Ministries within RGoZ.
Who undertook the Joint Review? The Joint Review was undertaken by a review team comprising of a team leader and the consultants for each of six thematic areas that were defined – HIV prevention in the community; HIV prevention at health facilities; HIV treatment and care; HIV monitoring and evaluation (M&E); district and community response, and enabling environment.
What methodology was used for the Joint Review? The Joint Review methodology involved collecting and analyzing both secondary and primary data: secondary data were extracted from existing reports, reviews, and other documents relating to the HIV response in Zanzibar (see Section 7 for a full list of reference documents), whilst primary data were collected from key informants4 (judgment sampling was used to select them) through focus group discussions (FGDs), small group discussions or individual interviews. The review team followed these methodological steps in conducting the review:
• Developed individual evaluation questions for each of the thematic areas;
• Gathered and reviewed all relevant secondary data;
• Developed guides for discussions with stakeholders – focus group discussion guides for the FGDs and interview guides for the small group discussions and individual interviews;
• Arranged and conducted the FGDs and interviews;
• Analysed and synthesized secondary and primary data collected;
• Prepared thematic area Joint Review reports and presented these to the Steering Committee for peer review;
• Drafted an overall Joint Review Report to document the Joint Review results (this report);
• Presented the draft Joint Review Report to the Steering Committee and a Technical Review panel for peer review;
• Developed a set of milestones jointly at the Technical Review workshop;
• Finalised the Joint Review Report and milestones; and
• Published and disseminated the Joint Review results widely.

Methodological Limitations: As with any research there were some limitations, which are important when interpreting the Joint Review results, to the methodology used. These limitations are:
• First, the secondary data used were collected by other teams over which the review team had no control. Therefore, weaknesses or gaps in the secondary data could, potentially, be reflected as weaknesses or gaps in the Joint Review Report. Wherever possible, the review team pointed out these weaknesses or gaps.
• Second, there was a lack of data. Not all the surveys, surveillance and research that were identified as priorities in 2004 have been undertaken. There was also not extensive routine data about HIV service delivery in Zanzibar. The reason is that the system that was designed for capturing HIV service delivery data – the Zanzibar HIV and AIDS Programme Monitoring System (ZHAPMoS) – only became operational in October 2006; therefore, only one quarter of data were available (October to December 2006).
• Third, the primary data collected were subject to the review team’s interpretation, as in any qualitative data collection process.

Findings and Conclusions:
Relevance, Comprehensiveness & Scale of Community-based HIV Prevention
Relevance of HIV prevention services in the community
There are more prevention efforts in the community in 2007 than in 2004, and the messages communicated are partially relevant because they focus primarily on creating awareness and on the sexual transmission of HIV. However, not all MARPs are reached – the focus seems to be on creating awareness that ‘there is HIV’ (which is already high at 99.8% (NBS and ORC Macro, 2005)). Also, HIV prevention efforts are not linked to substance use prevention (particularly for the youth) or to income-generating activities for the youth and are therefore not relevant to all the drivers of the epidemic.
Comprehensiveness of HIV prevention services in the community
HIV prevention is more extensive than in 2003, but still not fully comprehensive – for seven reasons. First, although the ZNSP stipulates clearly which populations should be targeted, not all MARPs defined in the ZNSP are targeted (prisoners, seasonal workers and persons involved in the transportation sector). There are also some new MARPs that still need to be targeted (e.g. tourism sector employees). Second, HIV prevention efforts in the community have primarily focused on creating awareness about HIV, and not on the HIV prevention services for MARPs and the general population defined in the ZNSP. For example, many of the women interviewed in an education sector impact assessment had never seen a male or female condom or had its use demonstrated (HR Consult, 2007). Third, all available communication media have not been used extensively – e.g. the radio (the most accessible form of mass communication) has not been used. Fourth, there
are no programmes to address gender imbalances and efforts to ensure the quality of HIV prevention efforts have only just commenced. Fifth, the issue of positive prevention – prevention of re-infection by HIV positive persons, was not addressed at all. Sixth, the data show clearly that knowledge levels in Pemba are significantly lower and access to services more restricted than in Unguja. This indicates that more effort is required in Pemba. Seventh, workplace programmes have not adequately covered trade unions, the informal sector or private sector.
Scale of HIV prevention services in the community
More persons than in 2003 have been reached with HIV prevention efforts in the community and more institutions from all sectors (civil society, the public sector, and higher learning institutions) are involved in HIV prevention efforts (see Table 32 in Annex F for a summary of HIV prevention efforts to different populations). There are 242 Civil Society Organisations (CSOs) based in Unguja and 137 based in Pemba
working in all aspects of development; many of these CSOs provide HIV prevention services to different segments of the population. Almost all CSOs, even those who implement programmes unrelated to HIV, incorporate HIV prevention education in their programmes, which has enabled more people to be reached with HIV information. There is therefore some level of scale-up, but more needs to be done. Only 38 out of 294 shehias reported HIV prevention activities, suggesting that there is a rural/urban divide in access to services.

Achievement of ZNSP Objectives in Terms of HIV Prevention in Communities
There is progress towards the ZNSP objectives for HIV prevention in MARPs and the general population. The only HIV response activity that was not listed as a ZNSP strategy was pre-marital HIV testing. There is, however, a need to focus on (a) the sensitive, practical education that is needed when doing HIV prevention and (b) on reaching the hard-to-reach geographic areas and hidden MARPs, as the ZNSP design originally intended.
Specific Challenges and Gaps in 2007
• Increased knowledge has led not to changes in behaviour: HIV prevention efforts have not resulted in measured behaviour change in the general population, and not enough is known about higher risk behaviour amongst MARPs.
• HIV prevention messages are targeted mainly at the general population in urban areas, do not provide practical information, and are delivered through too-narrow communication channels.
(a) HIV prevention target mainly the general population in urban areas. As Table 29 illustrates, most programmes focus on the general population, instead of on MARPs (not only the hidden MARPs, but also the non-hidden MARPs such as prisoners, fishermen, house girls, clove pickers, etc.). Furthermore, new vulnerable populations emerged even during this review have also not been targeted. Interventions are also urban-biased. Even within urban areas, HIV prevention messages are not always available at places of entertainment (from where high risk sexual behaviour originates).
(b) HIV prevention messages are too general, do not provide practical information and does not cover all information that needs to be conveyed. What HIV prevention programmes have achieved to date is to create universal awareness that 'there is HIV in Zanzibar'. However, knowledge levels amongst the general population are not comprehensive (only 45% women and 23% men had knew the three ways in which the sexual transmission of HIV could be stopped and reject two main misconceptions about HIV (NBS and ORC Macro, 2005), and little is known about levels of appropriate knowledge amongst MARPs. The messages themselves are also general, without providing practical education and knowhow and without addressing some of the sensitive messages or practical information (e.g. demonstrating how a condom works). Messages conveyed only focus on the sexual prevention of HIV and do not address other drivers, such as substance use among the youth. Also, the promotion of premarital testing for HIV has not been accompanied by messages emphasizing that it should be done ethically, confidentially, voluntarily, that the final choice rests with the couple and that couples should be referred if one or both test positive.
(c) The mechanisms/channels used for the communication are not comprehensive. Disabled persons not only need specific messages and focus due to their increased vulnerability, they also need special mechanisms – e.g. Braille machines – to be able to access the communications messages. Currently, there is only one teacher for blind people in Zanzibar. The radio is not used, and persons with special
needs (e.g. the deaf) have not been reached with education programmes.
• Lack of regular supply of male and female condoms. In particular, it is those persons who need condoms the most – CSWs, MSM, IDUs (the hidden populations) – who have the most problems accessing condoms.
• Mechanisms to reach youth are one-dimensional and not well coordinated. Anti-AIDS clubs for in-school youth and youth centres for out of school youth are the main mechanisms used to reach the youth. These efforts are not comprehensive, not well coordinated, and not linked with income generating activities for the youth.
• Workplace HIV programmes have not been implemented in all sectors, do not focus on the informal sector (although most people are employed informally) and only address internal mainstreaming (that is, the workforce, but not clients).
• IDUs cannot access the equipment that they need to prevent HIV infection. Integrated supply, demand and harm reduction efforts have not been implemented. Pharmacies refuse to sell syringes to drug users, which limits IDUs’ ability to acquire sterile injection paraphernalia. This makes it much harder for IDUs to protect themselves against HIV infection.
• Gender imbalances in society limit women’s access to HIV prevention services. Although women have more comprehensive knowledge than men, they cannot access the HIV prevention services that they need or negotiate safer sex practices.

Recommendations:
Recommendations on HIV Prevention in the Community and at Health Facilities
(1) Develop a culturally-appropriate condom promotion, procurement, storage, distribution, use, disposal and quality control strategy, and include funding for its implementation in the MTEF. The condom strategy should be culturally appropriate, educate young people on condom use, instructions on how to use it in Swahili. After the strategy has been approved, MoHSW and the private sector should implement
the provisions of the condom strategy with immediate effect.

(2) Diversify HIV prevention messages, target the implementation of HIV prevention programmes, and develop a mechanism to accredit peer educators. The main challenge identified in this Joint Review in terms of HIV prevention is that HIV prevention messages are too general and not focused on specific education messages, messages are not communicated using all possible communication channels, and messages do not reach all persons who need it. It is therefore recommended that a national HIV prevention conference should take place which would lead to HIV prevention efforts being more focused, and implementing partners committing to reach specific target groups with specific messages. The conference should include sessions focusing on:
A: Determining the proportion of infection
• Modelling of the HIV response in Zanzibar in 10 and 20 years, depending on different prevention strategies chosen
• Presentation of size estimation and behavioural surveillance research
• Estimating the proportion of infection
B: Sharing experiences in terms of implementing HIV prevention programmes
• Experiences with programmes for in-school youth (such as AIDS awareness clubs), out-of-school youth, and people with disabilities
• Experiences with programmes to empower women through religious institutions
• Experiences with pre-marital HIV testing and with peer education programme for health care workers in the health care system
• Efforts to reach the hard-to-reach islets and MARPs (hidden and non-hidden MARPs – prisoners, traders, passengers of transportation services, students at study camps, massage parlor girls, persons who tend to funerals, etc)
• Experiences with tested/ proven behaviour change interventions from other, similar countries
• How the Great Lakes Initiative on AIDS (GLIA) – a regional institution of which Tanzania is a member state - can assist to support Zanzibar’s mobile populations
• Mechanisms and channels of communication in Zanzibar, with a specific focus on those with special communication needs (e.g. for people with disabilities) in terms of all aspects of the HIV response
• Discussion on communicating about male circumcision and how to communicate about it in Zanzibar
• Experiences from the media in terms of IEC messages
C: Updating HIV prevention strategies
• Update the HIV communication and advocacy strategy
• Develop IEC materials focusing on HIV prevention and substance use prevention for specific target audiences

This conference should take place AFTER the results of the current round of biological and behavioural studies of MARPs have been released. It should use QSCR data from ZHAPMoS. The outcomes of the conference should be that (a) the proportion of infection in Zanzibar would have been estimated; (b) the National HIV communications and advocacy strategy would have been updated; and (c) ZAC and ZACP
would have a set of standard IEC materials with targeted, appropriate education messages – specific for each target population.

(3) Catalyse all sectors to commit to delivering specific messages to specific target audiences using all possible communication channels. Once the HIV prevention conference has taken place, implementers should commit to reaching specific target audiences with specific messages and using the channels of communication defined at the HIV prevention conference. The umbrella organisations (ABCZ, ZANGOC,
TACs, the media and others) should play a coordinating role in mobilizing all organisations to become involved in HIV prevention and commit to fulfilling a specific role.
(4) After the HIV prevention conference, develop guidelines relating to the new areas of HIV prevention: (a) guidelines for pre-marital testing for the faith-based society29; (b) guidelines for accrediting peer educators and ensuring the quality of peer education programmes; (c) guidelines for an alternative livelihood programme (economic empowerment programme) for the youth; and (d) guidelines for VCT post test clubs.
(5) Implement an alternative livelihood programmes (economic empowerment programmes) for unemployed youth, and link the implementation of these to HIV prevention and substance use prevention programmes. These programmes should aim to provide the unemployed youth with skills on how to become involved in income-generating activities and opportunities to access wage employment.
(6) Establish VCT post test clubs in the community for all persons who undergo HIV testing to reinforce behaviour change amongst those persons who have HIV negative test results.
(7) Fast track the implementation of the HIV and substance use prevention programmes defined in the SUHISP according to WHO protocols and accompanied by an education package for the community.
(8) Decentralise the national blood transfusion service for Unguja and Pemba. Strengthening it would include (a) establishing blood banks at district hospitals, (b) developing a reliable distribution system; (c) developing a test kit reagent procurement system; and (d) developing a national non-financial reward scheme to a targeted group of low risk blood donors.
(9) Strengthen the PMTCT programme by (a) developing a comprehensive PMTCT communications strategy30; (b) link it to the provision of paediatric ARV treatment; and (c) evaluate the PMTCT programme to assess why the male partners uptake has been so low.
(10) Promote HBV vaccination for all health workers, all persons who provide services to MARPs, and all MARPs.
(11) Roll-out PEP services and universal precautions to all health facilities in Zanzibar.

Recommendations on HIV Care and Treatment
(12) Strengthen the health care system for the provision of HIV prevention, care and treatment services to ensure reliable, predicable and sustainable supply of drugs and supplies. Strengthening the system includes the drug procurement system, infrastructure, and human resources for health - to ensure reliable and predictable supply of STI drugs, OI drugs, condoms and ARVs.
(13) Promote private-public partnerships in terms of HIV care and treatment provision.
(14) Strengthen the laboratory system in terms of quality assurance, specimen transport, infant diagnosis and drug resistance surveillance.

Recommendations on HIV Impact Mitigation
(15) Implement a minimum package of HIV impact mitigation services that would be appropriate within the Zanzibari context. Such a minimum package would include (i) the strengthening of services provided to MVCs and improved coordination of MVC activities; and (ii) strengthening PLHIV associations by providing opportunities for them to be involved in HIV prevention and impact mitigation activities, and by providing access to income-generating activities.

Recommendations on an Enabling Environment for HIV Service Delivery
A: Political Will and Commitment
(16) Strengthen government commitment to coordinate and lead the national response to HIV and AIDS, by implementing the UWAKUZA HIV strategy, by implementing workplace programmes for political party administrative staff; and by including HIV into the General Orders of Government to ensure that HIV be a central part of measuring Principal Secretary and District Commissioners’ performance.
B: Policy, strategies and legal frameworks
(17) Update the ZAC Act and revise / enact all laws and policies defined in the national HIV advocacy and communications strategy what would support the provisions of the national HIV policy.
C: Resource mobilisation
(18) Hold a resource mobilisation conference, subsequent to the HIV prevention conference, to focus and target available HIV resources.
(19) Develop a comprehensive resource mobilisation strategy, that may include: (i) signing a Memorandum of Understanding with development partners to ensure longer term commitment and some predictability of funding and technical support; (ii) alternatives to ZAC managing grants for HIV service delivery; (iii) simplifying funding applications for HIV funding; and (iv) ring-fencing HIV funding within the MTEF, and assign a minimum percentage of funding for HIV.
D: Coordination
(20) Strengthen the districts and shehias to coordinate HIV activities by (i) developing a registration system for CSOs; (ii) developing a system for annual planning of HIV interventions by all sectors and submission of plans to districts; and (iii) formalising the SHACCOMs and DACCOMs within government structures.
(21) Implement the principles of the Joint Assistance Strategy for Tanzania in terms of coordination between and with development partners.
E: Institutional Capacity Development
At Coordination Level
(22) Develop technical assistance plans and operational manuals for ZAC, ZACP, ZAPHA+, ABCZ, ZANGOC, DACCOMs, ZAC Board of Commissioners, the GF-CCM and IFF that will clearly define their operational roles and mandates as institutions responsible for aspects of coordination.
(23) Implement the updated ZAC Scheme of Service as per the approval granted by the ZAC Board of Commissioners.
At Implementation Level
(24) Develop and implement a structured national HIV capacity building plan and technical assistance plan with innovative, on the job learning opportunities and a recognition of prior learning system for civil society (e.g. CSOs and umbrella organisations), private sector (e.g. ABCZ), public sector (e.g. TACs,), and higher learning institutions to ensure their full participation in the HIV response and mainstreaming within their sectors.
(25) Formalise HIV capacity building within the academic institutions and government training institutions, and in conjunction with ZAMEA, so that M&E will be more attractive as a profession and a career path.
F: Advocacy
(26) Review the Communications and Advocacy Strategy to reflect the lessons from this Joint Review.
(27) Disseminate all HIV strategies, guidelines and policies to stakeholders involved in coordinating, monitoring, evaluating, planning, and implementing the HIV response.
(28) Implement a comprehensive, national community mobilisation campaign.
6.5 Recommendations on HIV Monitoring and Evaluation
(29) Strengthen routine monitoring at MoHSW by (i) developing an M&E strategy for MoHSW’s HIV M&E efforts, and (ii) harmonising MoHSW systems to provide routine data for Quarterly HIV Service Coverage Report every quarter in electronic format.
(30) Strengthen demand monitoring (monitoring of persons who need HIV impact mitigation services by reviving the CBMIS system (i.e. shehia-level registers of vulnerable persons).
(31) Ensure continued funding for the M&E of the national HIV response by (i) annually updating the national and district HIV M&E Road Maps and assigning resources to implement them, and (ii) developing HIV M&E budget guidelines for all sectors to enable them to budget for HIV M&E and include it as a separate line item in their budgets.
(32) Promote data use by (i) establishing an information and documentation centre to provide easy access to information; and (ii) developing and disseminating information products as mandated by the national HIV M&E system and distribute them.
(33) Develop and put in place a quality management system for CSOs through regular supervision, structured feedback and other quality control mechanisms.
(34) Develop a national HIV research strategy and agenda, and establish the institutional structures to coordinate research in Zanzibar. This research agenda should include (but not be limited to) this research / syntheses:
i) Complete size estimation studies and other planned research such as HIV prevalence and behaviour of other MARPs (not already covered).
ii) Conduct a national HIV ‘proportion of infection’ workshop with technical experts to estimate “Where has the last 100 infections come from?” The next review of the HIV response should not take place before this work has been completed.
iii) Conduct a randomised control trial of a comprehensive harm reduction programme
iv) Conduct research into the effectiveness of the current VCT sites and perceptions regarding issuing self test kits for HIV – the effectiveness of current VCT sites in terms of location, cost, the type and level of service provided, and the possibility of issuing self test kits to MARPs and other stakeholders who would like to access them.
Kindly refer to Annex K, where milestones for these objectives have been developed at the Technical Review of the Zanzibar Joint Review.



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