Challenges of continuum of HIV/AIDS care and treatment in Tanzania : the effects of parasites co-infections, HIV clinical manifestations, and adherence to antiretroviral therapy

In Tanzania, the National AIDS Control Program with the support
of Non-Government Organizations is scaling-up Antiretroviral
Therapy (ART) services to peripheral (rural) health facilities. The
aim of scaling-up is to improve availability, access and adherence
to ART by all HIV-infected population.
HIV-infected persons in peripheral (rural) areas are at increased
risk for several medical co-morbidities including tuberculosis,
bacterial and parasitic infections. As ART is successfully made
universally available, non-AIDS co-morbidities caused by
helminths and malaria will emerge as leading problems that will
complicate care, adherence to ART and retention. These
challenges can be improved by comprehensive and
multidisciplinary management strategies. In addition a range of
interventions such as counselling, use of treatment assistants
and integrated health services delivery need to be enhanced to
improve adherence and treatment of co-morbidities.
However, concerns are raised regarding proper HIV/AIDS
management in the peripheral (rural) settings which focuses on
clinical monitoring and treatment of opportunistic infections.
Clinical monitoring is based on WHO clinical stages and CD4+
T-lymphocyte counts. Clinicians in the peripheral (rural) settings
faces challenges in accessing CD4+ T-lymphocyte counts, HIV
and AIDS clinical features not corresponding with WHO clinical
stages, co-infections and co-morbidity.
The aim of the work reported in this thesis was to conduct
research to investigate effects of concurrent parasites infections
and challenges of HIV/AIDS case management on peripheral
(rural) patients in order to contribute information towards better
care for HIV/AIDS patients in Tanzania.
The studies were conducted at Tumbi Hospital and Chalinze
Health Centre in Tanzania between April 2008 and June 2009.
The research consisted of three sub-studies carried out
consecutively utilizing different study designs and populations.
The first study examined the effects of parasite co-infection on
CD4+ T-lymphocyte counts, WHO clinical staging and
haemoglobin. In addition, the study attempted to develop a
simplified clinical staging by utilizing local experiences HIV/AIDS
clinical manifestation. Adult patients registering for the first time
at HIV-clinic were clinically examined for malaria parasites and
helminths. CD4 counts and haemoglobin were also analyzed.
Patients were initiated on treatments according to their respective
diagnosis and followed up for six months. At 6 months, clinical
procedures were performed similar to first contact assessment.
The second study utilized a case-control design to elucidate
factors associated with non-adherence to ART. Adult patients
attending care and treatment at the study clinics and being on
ART for at least three months were studied. Patients with ART
adherence of less than 95%; and those with more than 95%
were defined as cases and controls respectively.
The third study was an observation study which documented
experiences and lessons generated in the process of
implementing ART services at Chalinze health centre. Clinical
procedures were evaluated and document review was carried
out to solicit patients’ characteristics and enrolment rates.