College of Medicine

FACTORS ASSOCIATED WITH RETENTION IN CARE

AMONG PEOPLE LIVING WITH HIV/AIDS IN UBUNGO

MUNICIPALITY, TANZANIA

BY

SYLVIA DENIS MOSHI

(MEDICAL DOCTOR- MD)

A thesis submitted to the Department of Public Health and Herbal Medicine, in partial

fulfillment for the degree of Master of Science in Public Health

December, 2021

ii

Certificate of Approval

The Dissertation of Sylvia Denis Moshi is approved by the Dissertation Examination

Committee:

_______________________________________

Prof. Fanuel Lampiao

(Chairman, Post Graduate Committee)

_______________________________________

Alinane Linda Nyondo-Mipando, RNM, Ph.D.

(Supervisor)

_______________________________________

Joan Rugemalila MD, MMED

(Supervisor)

_______________________________________

Adamson S. Muula, MBBS, MPH, Ph.D.

(Head of Public Health Department)

iii

Declaration

This thesis is my original work and has not been presented for a degree award in any other

university.

Name of the Candidate: Sylvia Denis Moshi

Signature:

Date: 30th December, 2021

iv

Dedication

I dedicate this thesis to my late parents, Denis Petro Moshi and Marcellina Melkiori. My guardian

parents, Mr. & Mrs. Stewart Petro Mlang’a for their wonderful support, who made me the woman

I am today. My lovely husband for his moral support and persistent prayers.

v

Acknowledgements

I would like to firstly give thanks to the Almighty God for his wonderful mercies and blessings

upon my life throughout my studies. Indeed, the Lord God is my strength.

My sincere gratitude goes to World Bank and Inter-University Council for East Africa (IUCEA),

African Centre of Excellence in Public Health and Herbal Medicine (ACEPHEM) for the

scholarship. Without their support I wouldn’t have made it.

I would like to extend my gratitude to my supervisors: Dr. Alinane Linda Nyondo Mipando and

Dr. Joan Rugemalila for their availability, tireless support, patience and encouragement throughout

the entire period of the study.

I am greatly indebted to the management of Sinza Hospital, Mbezi Health centre and Kimara

dispensary and all the staff who gave me the opportunity and support to conduct the study in the

clinics. Special mention goes to Janeth Kweka and Juma Baraka who supported me with data

collection. Analyses of the results would not have been finally completed without the assistance

of Paul Sabuni and Dr. Severin Kabakama. Thank you for your valuable work.

Last but not least, I would like to thank my participants for voluntarily participating in the study.

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Abstract

Background: Globally, approximately 50% of people who have been diagnosed with HIV are

either not linked to a care provider or not retained in medical care. In sub-Saharan Africa 54% of

those who are not yet eligible for ART were lost to follow-up before becoming eligible, while 32%

of the people living with HIV who were eligible for ART were lost before initiating treatment.

Although the retention rate of HIV infected people in Tanzania has increased slowly from 39.4%

to 54.5% from 2008 to 2016, there remains some challenges in achieving optimal rates.

Methodology: A convergent mixed method design was used to determine factors associated with

retention in care among PLHIV at Ubungo municipality, Tanzania. Quantitatively, a descriptive

cross -sectional design was applied and data was collected using an interviewer-administered

questionnaire among 365 participants that were systematically selected. Quantitative data were

analyzed using SPSS software and descriptive statistics was used to summarize findings in tables,

graphs and charts. In addition, Chi square test was used to determine the factors associated with

retention in HIV care. Qualitatively, we conducted a descriptive study and drew a purposive

sample of 18 participants for In-depth Interviews and 18 health care workers for Key informant

Interviews (KII). All data were digitally recorded and then transcribed, translated, coded, analyzed

thematically. The data collection was conducted between May and July 2021.

Results: Ninety-three percent (93%) of the participants were retained in HIV/AIDS care. The

majority (81.1%) never missed their clinic appointments. The main reason for missing a clinic

appointment was forgetfulness. Eighty-seven per cent of the participants were aware of the risks

of missing appointments. However, 94.8% participants continued using the ARVs despite missing

the clinic appointment and obtained drugs from friends, relatives or another clinic. Only 1.1% of

vii

the participants were lost to follow-up. All socio- demographic charactersitics, sex, age, marital

status, education level and occupation were not associated with retention. However, sense of

wellness and good worker’s attitude were related to reported retention during the Key informant

and in-depth interviews.

Conclusion: The study reports a high rate of retention on HIV/AIDS care and treatment attributed

to awareness of alternative clinics to collect the ARVs from and the consequencies of missed-

appointment. Health care workers should strengthern counselling efforts to further minimize the

rates of missed clinic appointments of longer than six months, focusing om factors associated with

poor retention in HIV/AIDS care and treatment.

viii

Table of Contents

Certificate of Approval ................................................................................................................... ii

Declaration ..................................................................................................................................... iii

Dedication ...................................................................................................................................... iv

Acknowledgements ......................................................................................................................... v

List of Tables ............................................................................................................................... xiii

List of Figures .............................................................................................................................. xiv

Abbreviation and Acronyms ......................................................................................................... xv

Operational Definitions ............................................................................................................... xvii

Abstract .......................................................................................................................................... vi

Chapter One .................................................................................................................................... 1

1.1 Background ...................................................................................................................... 1

1.2 Problem Statement ........................................................................................................... 4

1.3 Significance for the Research Project .............................................................................. 5

1.4.1 Broad Objectives ....................................................................................................... 5

1.4.2 Specific Objectives ................................................................................................... 5

1.5 Research Questions .......................................................................................................... 5

Chapter Two: Literature Review .................................................................................................... 7

2.1 Introduction ...................................................................................................................... 7

2.2 Epidemiology of HIV/AIDS ............................................................................................ 7

2.3 Status of Retention ........................................................................................................... 8

2.4 Factors that Influence Retention in Care .......................................................................... 9

ix

2.4.1 Health System Factors .............................................................................................. 9

2.4.2 Transportation Cost and Distance to the Clinic ...................................................... 10

2.4.3 Community Based-Interventions ............................................................................ 11

2.4.4 Positive Perceptions of ART ................................................................................... 11

2.4.5 Psychosocial Factors (Stigma and Non-Disclosure) ............................................... 12

2.4.6 Faith Healing ........................................................................................................... 12

2.4.7 Use of Herbal Medicine .......................................................................................... 13

2.4.8 Family and Social Support ...................................................................................... 13

2.5 Conceptual Framework .................................................................................................. 14

Chapter Three: Research Methodolody ........................................................................................ 16

3.1 Study Design .................................................................................................................. 16

3.2 Study Site ....................................................................................................................... 16

3.3 Study Population ............................................................................................................ 18

3.4 Eligibility Criteria .......................................................................................................... 19

3.4.1 Inclusion Criteria for HIV/AIDS Participants ........................................................ 19

3.4.2 Exclusion criteria for HIV/AIDS participants ........................................................ 19

3.4.3 Inclusion Criteria for HCW’s.................................................................................. 19

3.4.4 Exclusion Criteria for HCW’s ................................................................................ 19

3.5 Study Period ................................................................................................................... 20

3.6 Sample Size .................................................................................................................... 20

3.6.1 Sample Size for Quantitative Component............................................................... 20

3.6.2 Sampling for Qualitative Component ..................................................................... 21

3.7 Sampling Procedure ....................................................................................................... 21

x

3.7.1 Quantitative Method ............................................................................................... 21

3.7.2 For Qualitative Method ........................................................................................... 22

3.7.3 Pre-Testing of Study Tools ..................................................................................... 22

3.8 Data Collection Tools..................................................................................................... 22

3.8.1 Questionnaire .......................................................................................................... 23

3.8.2 The Validity and Reliability of the Quantitative Data (Questionnaire) .................. 23

3.8.3 Key Informant Interview......................................................................................... 24

3.8.4 In-depth Interview ................................................................................................... 24

3.8.5 Credibility, Transferability, Confirmability and Dependability Of The Qualitative

Tools ................................................................................................................................. 24

3.9 Data Management .......................................................................................................... 25

3.10 Data Analysis ................................................................................................................. 25

3.10.1 Quantitative Data Analysis ..................................................................................... 25

3.10.2 Qualitative Data Analysis ........................................................................................... 26

3.11 Presentation of Results ................................................................................................... 28

3.12 Dissemination of Results ................................................................................................ 28

3.13 Ethical Consideration ..................................................................................................... 28

Chapter Four: Results ................................................................................................................... 30

4.1 Introduction .................................................................................................................... 30

4.2 Social Demographic Characteristics of the Participants ................................................ 30

4.2.1 Quantitative Interviews Participants ....................................................................... 30

4.2.2 Characteristics of Participants in the Qualitative Component ................................ 31

4.3 HIV Status Disclosure and Clinic Appointments ........................................................... 32

xi

4.4 Rentention: Ever Missed Appoiment for Six Months Or More, And ART Continuity . 37

4.4.1 Status of Retention from the Health Facilities ........................................................ 42

Chapter Five: Discussion, Conclusion and Recommendations .................................................... 44

5.1 Introduction .................................................................................................................... 44

5.2 Retention in HIV/AIDS Care and Treatment ................................................................. 44

5.3 Social Factors Associated with Retention ...................................................................... 45

5.3.1 HIV Status Disclosure............................................................................................. 45

5.3.2 Stigma and Discrimination ..................................................................................... 46

5.3.3 Traditional Healers and Faith Healing .................................................................... 47

5.4 Structural and Health System Factors Associated with Retention ................................. 47

5.5 Strengths of the Study .................................................................................................... 50

5.6 Study Limitations ........................................................................................................... 50

5.7 Conclusion ...................................................................................................................... 50

5.8 Recommendations .......................................................................................................... 51

References ..................................................................................................................................... 53

Appendices .................................................................................................................................... 64

Appendix 1: informed consent forms ........................................................................................ 64

Appendix 1.1: Informed consent form for HIV/AIDS patients in English ........................... 64

Appendix 1.2: Informed consent form for HIV/AIDS patients in Swahili .......................... 67

Appendix 1.3: Informed Consent form for In-depth Interview (IDI) for HIV/AIDS patients

in English ............................................................................................................................... 70

Appendix 1.4: Informed consent form for In-depth interview for HIV/AIDS patients in

Swahili ................................................................................................................................... 73

xii

Appendix 1.5: Informed Consent Form for Key Informant Interview (KII) in English ....... 76

Appendix 1.6: Informed consent form for Key Informant Interview in Swahili ................. 79

Appendix 2: Data Collection Tools ........................................................................................... 82

Appendix 2.1: Questionnaire in English ................................................................................ 82

Appendix 2.2: Questionnaire in Swahili ................................................................................ 87

Appendix 2.3: Topic guide for In- depth interview (IDI) for patients living with HIV/AIDS

in English ............................................................................................................................... 92

Appendix 2.4: Topic guide for In-depth Interview (IDI) for Patients living with HIV/AIDS

in Swahili ............................................................................................................................... 94

Appendix 2.5: Key Informant Interview Guide (KII) for Health Care Workers in English . 96

Appendix 2.6: Key Informant Interview Guide (KII) for Health Care Workers in Swahili . 98

Appendix 3: COMREC clearance letter .................................................................................. 100

Appendix 4: NIMR clearance letter ........................................................................................ 101

Appendix 5: Research Permit from Ubungo Municipal.......................................................... 103

Appendix 6: Gantt chart .......................................................................................................... 104

xiii

List of Tables

Table 1: Retention in care pre-determined themes for qualitative component ............................. 27

Table 2: Sociodemographic characteristics of participants in quantitative component ................ 31

Table 3: Social and demographic characteristics of KII and in-depth interviews participants .... 32

Table 4: HIV status disclosure and clinic appointments attendance ............................................. 33

Table 5: Retention, ever missed appointment for 6 months or more and access to ART ............. 39

Table 6: Association between retention to ART care and treatment ............................................ 43

xiv

List of Figures

Figure 1: Conceptual framework .................................................................................................. 15

Figure 2: (A) A Map of Tanzania showing regions, (B) Map of Dar es salaam Region showing

Municipals, and (C) Map of Ubungo Municipality showing study health facilities. ................... 18

Figure 4: Shows proportion of retention from the facilities ......................................................... 42

xv

Abbreviation and Acronyms

AIDS Acquired Immunodeficiency Syndrome

ART Antiretroviral Therapy

CBAS Community Based Adherence Support

CBHS Community Based Health Services

CBOs Community Based Organizations

CD4 Cluster of differentiation 4

CDC Centers for Disease Control and Prevention

CHW Community Health Workers

COM College of Medicine

COMREC College of Medicine Research Ethics

Committee

CTC Care and treatment Centre

HAART Highly Active Anti-retroviral Therapy

HCWs Health Care Workers

HIV Human Immunodeficiency Virus

IDI In-depth interview

IPT Isoniazid Preventive therapy

IRB Institutional Review Board

KII Key Informant Interview

LTFU Lost to follow up

MDH Management and Development for Health

xvi

MoHCDEC Ministry of Health, Community

Development, Gender, Elderly and Children

NGOs Non-Governmental Organizations

NIMR National Institute of Medical Research

PCR Polymerase Chain Reaction

PI Principal Investigator

VTC Voluntary Testing and Counselling

PLHIV People Living with Human Immunodeficiency

Virus.

RNA Ribose Nucleic Acid

SMS Short message service

MS Microsoft

SPSS Statistical Package for the Social Sciences

UKIMWI Ukosefu wa Kinga Mwilini

UNAIDS United Nations programme on HIV/AIDS

USA United States of America

SSA Sub-Saharan Africa

WHO World Health Organization

xvii

Operational Definitions

Retention in care is defined as a patient’s regular engagement with medical care at a health care

facility after initial entry into the system (1). Retention in care is defined as being alive and on

ART or being transferred out to other health facilities to continue treatment (2).

Enrollment: Entry into care after HIV diagnosis, defined as a visit with an HIV care provider

authorized to prescribe ART.

HIV cascade/continuum: sequential steps a client undergoes from HIV testing to Viral load

suppression.

Linkage: Linkage to care is the process of engaging newly diagnosed HIV-infected persons into

HIV primary care.

Visit: Contact with health care worker at a health facility.

Missed appointment: A patient is classified as having a missed appointment if they are more than

3 days, but less than or equal to 7 days, late to their expected appointment.

Lost to follow up is defined when a patient has not attended a scheduled clinic for three months

consecutively and their vital status is unknown. At the same time, two-three attempts to track those

patients have failed.

Attrition: “the number of patients who were lost to follow-up, transferred out, or died.”

Transfer out: Transfer out is initiated by the healthcare provider to the client from one ART

facility to another for continuation of HIV care.

Viral load: is the number of HIV RNA copies in a milliliter (copies/mL) of blood.

Antiretroviral therapy: is a combination of at least three anti-retroviral drugs to suppress the

HIV replication and stop the progression of HIV disease.

1

Chapter One

1.1 Background

Globally, approximately 50% of people who have been diagnosed with HIV are neither linked to

a care provider nor retained in medical care (3). In the USA less than 50% of individuals with HIV

are considered sufficiently retained in care (4). This has substantial implications for both individual

and public health outcomes. Adherence to ART as a consequence of good retention in care has

been shown to have the benefit of guaranteeing longer, healthier lives for those on treatment but

also the additional effect of limiting transmission by up to 96% and reducing the risk of maternal

to child transmission of HIV to less than 5% compared to up to 45% without treatment (5). A

study done in China found a retention rate was 58.1% among 822 PLWHIV in Changsa center

for Disease Control and prevention (6). The available literature from sub-Saharan Africa showed

that 54% of those who are not yet eligible for ART were lost to follow-up before becoming eligible,

while 32% of the people living with HIV who were eligible for ART were lost before initiating

treatment.

Tanzania has done well to control the HIV epidemic over the last decade. Scaling up access to

antiretroviral treatment (ART) has resulted in a decline of 13% in the proportion of new infections

consequently halving the number of people dying from an AIDS related illness (7). Despite that

more people living with HIV are benefitting from effective treatment, linkage to care after

diagnosis remains one of the weakest parts of Tanzania’s HIV treatment cascade. There is still a

great challenge in retaining HIV/AIDS patients in care, the retention rate has increased slowly

from 39.4% to 54.5% from 2008 to 2016 (8). A study done in Uganda, Zambia, and Tanzania in

2

2014, found that the retention rate in Tanzania after ART initiation was decreasing with increasing

years 71.0% in the first year, 62.7% in the second year, and 58.3% in the third year (9).

Both facility-based health care providers and community-based organizations (CBO) work with

clients to ensure retention in care, including limiting missed appointments and loss-to-follow-up

(LTFU) of clients. Poor retention in HIV care is a global problem affecting both developed and

developing countries. There are widespread challenges to retaining patients in care especially in

resource-limited settings (10). There is no single approach for retention that is likely to work for

everyone in all settings because retention factors vary among the clients (11). For example, many

Africans reside in rural areas where there is a lack of proximity to public health facilities and

inadequate transportation which are major impediments to accessing care (12). Although ART is

given free, factors like stigma, non-disclosure, and transport costs lead to poor retention (13).

Retention of people living with HIV/AIDS across the continuum of care is essential for optimal

health outcomes. For people living with HIV who are receiving treatment, the maintenance of

uninterrupted ART and continual monitoring are essential for sustained viral suppression, optimal

treatment outcomes, and avoidance of treatment failure and drug resistance (14). Retention in care

is necessary to ensure optimal clinical outcomes, ongoing receipt of ART, evaluate the emergence

of medication toxicities, and identification of the occurrence of treatment failure that necessitate a

switch form one ART regimen to another (15). It also provides additional benefits through

ancillary services, social support, and secondary prevention messages that help patients navigate

a lifelong and complicated infection (16).

3

At present, there is no consensus on exact definitions for retention or what constitutes ‘adequate’

retention in care (17). There is a lack of consistency which results in the inclusion of deceased

clients (18), self-transferred clients (19) as part of those that are lost to follow-up. Self-transfers

occurs when people decide to move into a new facility without informing their previous facility

staff and this is further compounded with occurrence of unregistered death due to lack of routinely

collected vital registration data in many resource-limited countries (19). Improving the

understanding of barriers to retention and establishing innovative strategies to address them are

important priorities in the implementation of research and public health (20). Tanzania emphasis

retention in care as pivotal element of adherence to antiretroviral therapy (ART) and risk reduction,

through engagement with medical care at a health care facility after initial entry into the system

(2). More formal definitions and measurements that have been utilized are required to follow up

at certain intervals to define retention in care; these definitions have typically conceptualized

retention in care based on either appointments missed or medical visits attended at regularly

defined intervals (5).

Some of the factors that affects retention in care include lack of disclosure, male sex, distance to

the clinic, travel costs, competing life activities and forgetfulness, health system factors such as

prolonged waiting time when accessing services, negative attitudes of health care works, and

stock out of drugs (21). An understanding of challenges that affect retention in HIV care is critical

as it provides information that can be used in the development of strategies that will improve

retention in care amongst HIV infected individuals. The objective of this study was to identify

factors associated with retention in care among people living with HIV/AIDS HIV in Ubungo

Municipality, Tanzania.

4

1.2 Problem Statement

Despite the implementation of strategies to optimize retention in care and adherence to ART,

clients still struggle to remain in care and adopt good behaviors as directed by their health care

providers (22). This results in increased morbidity and mortality through suboptimal viral

suppression, increased risk of drug resistance, and increased risk of HIV transmission (23). All

this leads to a higher health-care costs and a loss of or reduction in individual income, potentially

translating to lower economic productivity at individual and national level (13).

Although there is evidence on the expansion and benefits of ART to clients, some patients

discontinue with follow-up visits and treatment schedules. In other cases the reasons for

discontinuation from HIV care among people that are infected with HIV who were initially

successfully linked to care remains unknown (24). Retention of people living with HIV in care is

vital for achieving long term positive outcomes both for the individual and ART programs (24).

Retention in care remains a challenge both in developed and developing countries despite various

interventions implemented by different Non-Governmental Organizations (NGO) dealing with

HIV/AIDS. The success of PLHIV being retained in HIV/AIDS programs requires an

understanding of factors that influence retention because clients who are poorly retained in care

cause an interruption to care and this affects the client’s health and global fight of HIV/AIDS

pandemic. Given the relevance of retention in care and the gaps that are prevalent in Tanzania, this

study assessed the factors associated with retention in care among people living with HIV/AIDS

in Ubungo municipality, Tanzania.

5

1.3 Significance for the Research Project

The study has provided insights on factors associated with retention in care among PLHIV, which

is an important step in understanding and strengthening strategies that will help people living with

HIV/AIDS to be continuously engaged and retained in care. The findings from this study also

provides additional data to the National AIDS Control Program (NACP) through the Ministry of

Health, Community Development, Gender, Elderly and Children)) and Ubungo Municipal council

to improve interventions equipped to retain more PLHIV in care and other services, making them

more relevant to the needs of people living with HIV/AIDS.

1.4 Research Objectives

1.4.1 Broad Objectives

To assess factors associated with retention in care among people living with HIV/AIDS in Ubungo

municipality, Tanzania.

1.4.2 Specific Objectives

1. To determine the proportion of people retained in care among HIV positive clients

attending health centres in Ubungo Municipality for HIV/AIDS care.

2. To identify factors facilitating or limiting retention in care among people living with

HIV/AIDS in Ubungo Municipality, Tanzania.

1.5 Research Questions

1. What is the proportion of retention in care among people living with HIV/AIDS

attending health centres at Ubungo Municipality?

6

2. What are the factors facilitating or limiting retention in care among the People

Living with HIV/AIDS?

7

Chapter Two: Literature Review

2.1 Introduction

The literature review covers the epidemiology of HIV/AIDS, the status of retention in HIV/AIDS

care and the factors associated with retention in care among people living with HIV/AIDS globally,

in African setting and in Tanzania.

2.2 Epidemiology of HIV/AIDS

Globally, 37.9 million people were living with HIV at the end of 2018 (25). Although the burden

of the pandemic continues to vary considerably between countries and regions, the WHO African

region remains most severely affected, with nearly 1 in every 25 adults (3.9%) living with HIV

and accounting for more than two-thirds of the people living with HIV worldwide (26). HIV/AIDS

remains a major public health problem in sub-Saharan Africa, causing the death of millions of

adults in their prime, disrupting and impoverishing families, and turning millions of children into

orphans. Since the beginning of the epidemic, 75 million people have been infected with the HIV

and about 32 million people have died of HIV related deaths (27).

The East and Southern Africa is the region that is hit the hardest by HIV. It is home to around

6.2% of the world’s population but over half (54%) of the total number of people living with HIV

in the world (20.6 million people) are found in sub-Saharan countries of Africa (28). In 2018, there

were 800,000 new HIV infections, which is under half of the global total (24). South Africa

accounted for more than a quarter (240,000) of the region’s new infections in 2018. Seven other

countries accounted for more than 50% of new infections: Mozambique (150,000), Tanzania

8

(72,000), Uganda (53,000), Zambia (48,000), Kenya (46,000), Malawi (38,000), and Zimbabwe

(38,000) (25).

In Tanzania, 1.7 million people were living with HIV in 2019 (29). This equates to an estimated

HIV prevalence among adults of 4.8% (25) with more women infected than men (29). In the same

year, 77,000 people were newly infected with HIV, and 27,000 people died from an AIDS-related

illness (30). Among adults who initiated Antiretroviral therapy (ART), 75% are still active on

treatment after 12 months in 2019 (31). Dar es Salaam has the highest burden of HIV/AIDS with

a prevalence of 11% (27).

2.3 Status of Retention

Both in African setting and the globe, the status of retention and factors that affect retention are

almost similar. In USA, based on HIV surveillance data from 2010 through 2018, the retention in

HIV medical care among persons with diagnosed HIV has ranged from 53.6% in 2011 to 57.9%

in 2018 (32), this is far below the National HIV/AIDS Strategy 2020 goal of at least 90% retention

in HIV medical care (33). In China, a study that was done by Guoli.L. Yang on Retention in Care

and Factors Affecting It among People Living with HIV/AIDS in Changsha City, China found that

the retention rate was 58.1% (6). In African setting, retention in care is still a challenge. According

to a systematic review that was done in Sub Saharan Africa, in 2011, found that the retention rate

from ART eligibility to ART initiation was 68% (34). In Nigeria a seven year review on retention

and HIV care, found that 63% of patients were retained in care (35) as of 2015. A study done in

Uganda found the retention rate in care for 12 months was 65.7% in the year 2021 (36). In a study

9

that was done in rural Kenya found the overall retention rate among adults for one year was 94%

(37) in 2017.

2.4 Factors that Influence Retention in Care

The factors that influence retention in care include health system factors, community-based

interventions, education factors, positive perception on ART, distance to the clinic and

transportation costs, stigma and non-disclosure, faith healing, and use of herbal medicine and

family and social support.

2.4.1 Health System Factors

The health system factors that contributed to poor retention of patients in care were long waiting

times due to shortage of staff, high patient load, shortage of third-line ARV drugs, and inadequate

space in ART clinic (38). An East African study on facility-level factors influencing retention

found that, LTFU were higher in facilities without CD4 tests available on-site and with longer

Human Immunodeficiency Virus Ribonucleic Acid Polymerase Chain Reaction (HIV RNA PCR)

turnaround times, in both pre-ART and post ART respectively (39). Also, the clinic being open

more than 4 mornings per week was associated with a decreased hazard of LTFU in the ART

period (39). Increased LTFU was also observed during the pre-ART period when TB symptomatic

patients were treated within the ART program (39). Another study done in Gabon, Central Africa,

found that the main factor associated with retention to care was the initiation of ART at the first

or second clinical visit, whereas the main risk factor associated with LTFU was documented TB

(40). There was no reason highlighted for this finding. This is consistent with another study that

was done in Masaka Uganda which found that the risk of LTFU was 69% higher in patients who

10

started ART within seven days following HIV diagnosis compared to those who began ART after

seven days (41).

Clinic attendance is the key to adherence to the HIV treatment cascade and in ensuring retention

(39). Participants prefer more than one method to be reminded about their appointments and these

include appointment cards, text messages, availability of a treatment supporter, home visits (14).

Of the methods mentioned, an appointment card was the most preferred while those that didn’t

want any reminders attributed that to fear of having their status unintentionally disclosed to others

(42). Furthermore, evidence suggests that patients without a telephone set were 52% more likely

to be LTFU compared to those with a telephone set because they cannot get text messages

notifications and reminders for their clinic appointment (41).

2.4.2 Transportation Cost and Distance to the Clinic

Several studies show that distance to the clinic and transports cost is the major barrier to retention

in care in most African countries (12,38,43,44). It has been argued that in resource-limited settings

if the distance that participants have to travel to the clinic exceeds two hours the risk of non-

retention was doubled (21). Additionally in Uganda, the most common reasons for LTFU included

lack of transportation in 50% of the participants and excessive distance in 42% among the 111

participants included in the study (12). Another study done in Tanzania, Uganda, and Zambia

showed that further distance to the clinic is significantly associated with attrition (9) whereas in

India, among 106 patients who failed to return for 3 or more months, 20% cited distance and lack

of transportation as the major reasons for their non-attendance (45).

11

2.4.3 Community Based-Interventions

Interventions involving the delivery of community-based services have the strongest retention

rates. A systematic review reported that community-based adherence support (CBAS) that

consisted of home visits by Community Health Workers (CHWs) who distributed ART and

provided psychosocial and health-related support; showed significant improvements in retention

in care (46). Another systematic study that was done in Low and Middle income countries on

Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence,

Retention in HIV found that, the participants that were assigned to community-based ART (80.3

%) had statistically significant higher rates of treatment engagement than those in facility-based

ART (75.9 %) at the end of the follow-up period (10).

2.4.4 Positive Perceptions of ART

In a study that was done in Madagascar, found that most of the participants had a positive attitude

and perception (score ≥ 5) towards ART 75.6%, and this had a good impact on adherence to ART

services (47). Also, in a study that was done in Nigeria, it was found that a majority of the subjects

showed positive attitude towards ARV therapy, while only 23 % had poor attitude (48). They

strongly believed that ARV is efficacious in reducing viral load. On the other hand, a study that

was done in Iringa, Tanzania found that PLHIV and other participants from Iringa viewed ART

positively and considered it highly efficacious, people who were once sick and showed symptoms

of the disease upon initiation of ART their health improved and tend to seek care more and highly

retained. These participants reported that they were able to regain weight relatively quickly and

their fatigue and other symptoms diminished or disappeared (40).

12

2.4.5 Psychosocial Factors (Stigma and Non-Disclosure)

Pervasive stigma and discrimination from family members, friends, and community members have

been identified to contribute to LTFU of PLHIV on treatment (49). Individuals with poor retention

in care, due to stigma or other factors, experience difficulties in achieving a comparable CD4 cell

count, and attainment of survival benefits as compared to those who are retained in care (14).

Disclosure of an HIV-infected status remains an important factor in influencing retention in care

and non-disclosure had more negative consequences for women compared to men (50). Evidence

suggests that participants who report nondisclosure of an HIV status are twice as likely to have

poor retention in care as compared to persons who reported broad disclosure (14). Furthermore,

women experience difficulties in keeping HIV care appointments or adhering to a medication if

they conceal their HIV-positive status (51).

2.4.6 Faith Healing

Pastors who preach the gospel of faith-healing convince many patients to discontinue HIV care,

for the fact that they have been healed when they are prayed for (52). A Tanzanian study found

that many participants tend to abandon biomedical care after heard of others being cured after

pursuing healing in Miracle churches (43), furthermore, one Christian leader, stated that he

encouraged faith healing as a primary approach to treatment with repeat HIV tests to ascertain

efficacy and told congregants to seek biomedical treatment only after prayers (37). In additional,

participants in an Ethiopian study believed that holy water cures HIV, HIV is God’s punishment

and they did not think it is a virus rather it is a devil that only God can cure (53).

13

2.4.7 Use of Herbal Medicine

Some Africans believe in herbal medicines thus tend to abandon treatment in the conviction that

they are cured. The use of herbal remedies were identified as negative influences on retention in

care (38). Some traditional healers convince patients that herbal remedies can cure HIV and AIDS

since they help to boost the immunity (38). The most used traditional medicines are moringa leaves

and aloe vera juice (52). These influence the health seeking behavior of patients leading to

discontinuation of ART treatment and thus poor retention (54). A Malawian study reported that

the use of herbal medicine is reduced in urban areas compared to rural areas at 59% (55). It also

found that a larger proportion (73%) of herbal medicine users were women (55). This indicate

that despite the use of herbal medicine, women are more retained in care than men.

2.4.8 Family and Social Support

Social and family support is a strong pillar to stay in care. Family supports financially and in terms

of nutrition, ensures a balanced diet, and also provides moral support to their beloved ones, family

influence retention in care through a reminder on clinic dates, and taking of medicines (56). Lack

of family support was associated with poor retention among adolescents in a Tanzanian study (29),

while the support provided by the family has been highlighted as a necessity for a person with

HIV/AIDS because they feel supported from the family and accepted as a member of it, valid and

non-discriminated (57). Without family support, PLHIV said that their life would end and there

will be no reason and hope to fight HIV/AIDS (58). These findings were similar to another study

done in Yunnan China, which found that all of the participants were in great need of help and the

primary source of support came from their families (57). Family support included financial

14

assistance, support in the disclosure process, daily routine activities, medical assistance, or

psychological support (44).

2.5 Conceptual Framework

The conceptual framework for this study identifies factors for retention such as: health system

factors, community-based interventions, education factors, positive perception on ART, distance

to the clinic and transportation costs, stigma and non-disclosure, faith healing, and use of herbal

medicine and family and social support. The study examined the health systems, community

factors, educational, perceptions, stigma and discrimination as independent variables affecting the

retention, as dependent variable, in care among people living with HIV/AIDS in Ubungo

municipality, as presented by figure 1; the study conceptual framework.

15

Independent variables Dependent Variable

Figure 1: Conceptual framework

Source: Researcher’s Own Construct (2021)

Faith healing and use of herbal medicine

Family and social support

Health system factors

Stigma and non-disclosure

Community based interventions

Distance to the clinic and transportation

costs.

Positive perception on ART

Education factors

Retention in care

16

Chapter Three: Research Methodolody

3.1 Study Design

The study was a convergent mixed- methods cross-sectional study (59). The design was chosen

because it allowed the collection of data on several cases at a single point in time to collect a body

of quantitative and qualitative data. The qualitative component explains and complement the

quantitative approaches (60). The quantitative approach followed a health facility-based cross-

sectional study using an interviewer-administered questionnaire for participants for specific

objective 1; to determine the proportion of people retained in care among HIV positive participants

attending health centres in Ubungo Municipality for HIV/AIDS care. The qualitative approach

used a descriptive design and employed in-depth interviews with the participants, and Key

Informants Interview (KII) with HCWs, to assess the status of retention in care among

PLHIV/AIDS and to identify factors facilitating or limiting uptake of care among PLHIV/AIDS.

3.2 Study Site

The study was conducted in Ubungo municipal, one of the municipalities that constitute the city

of Dar es Salaam, Tanzania’s major business city. The municipal has a total area of 260.40km2, it

is bordered by the Kibaha District to the North, Kinondoni District to the South-East, and Kisarawe

District to the West (fig.2). The municipality is well linked by roads to other parts of the country.

Major road links are Morogoro road, Mandela Road, and Sam Nujoma Road. Administratively, it

is divided into fourteen 14 wards, which in turn are sub divided into 91 sub wards.

17

According to the 2012 population census, 845,368 people were living in Ubungo of which 409,149

were males and 436,219 females. This population grows at a rate of 5% each year and was

projected to be 1,031,349 in 2016 with 4,911 persons per square kilometers.

The municipal is estimated to have 257,837 households with an average of 4 persons per

household. The social-economic activities of people in Ubungo involve agricultural activities and

livestock keeping, small businesses, and fishing.

Ubungo municipal council is responsible for providing health services to its people in collaboration

with private sector services providers. It has a total of 68 health facilities of which 17 are

government-owned while the remaining 51 are owned by private organizations. Categorically,

Ubungo has a total of 5 hospitals, six health centers, and 57 dispensaries. All the health facilities

provide promotive, preventive, and curative care services. Currently the correct data on HIV/AIDS

prevalence and retention rate specifically for Ubungo municipality is lacking and will be

ascertained by this study.

The study was done in three health facilities in Ubungo municipality which were Sinza hospital,

Mbezi health center, and Kimara Central dispensary. These health facilities were chosen because;

firstly, the geographical distribution allowing easy accessibility to the majority of participants in

Ubungo municipality, secondly, a high population density within facilities catchment area

permitting high risk for acquiring HIV/AIDS and the third reason was health facility which

relatively serves many HVI/AIDS patients than others in Ubungo municipality

18

Figure 2: (A) A Map of Tanzania showing regions, (B) Map of Dar es salaam Region showing

Municipals, and (C) Map of Ubungo Municipality showing study health facilities

3.3 Study Population

HIV positive individuals aged 18 to 59 years receiving care at Kimara Dispensary, Mbezi Health

Centre and Sinza Hospital for more than six months since their enrollment in care.

19

3.4 Eligibility Criteria

3.4.1 Inclusion Criteria for HIV/AIDS Participants

1. HIV positive adults aged 18 to 59 years

2. Attending care and treatment clinic in Kimara Dispensary, Mbezi Health centre and

Sinza Hospital for six or more months

3. Able and willing to give consent to participate in this study.

3.4.2 Exclusion criteria for HIV/AIDS participants

1. Less than 18 years of age patients – because the researcher, wanted to study adults

so <18 years are not adults.

2. Newly enrolled in care clients (less than six months) - they will not have met

retention criteria according to Tanzania National guideline.

3.4.3 Inclusion Criteria for HCW’s

1. Doctors and nurses working in Care and Treatment center (CTC), with at least six

months’ experience working in CTC clinic.

3.4.4 Exclusion Criteria for HCW’s

1. New doctors and nurses, with less than six months- Do not have much experience

on retention.

2. Doctors and nurses who are not working in Care and Treatment center. Do not have

experience on retention.

20

3.5 Study Period

The study was conducted for 20 months. It started in April 2020 with proposal writing to December

2021 which will be the submission of the dissertation. (Appendix 8). The data collection was done

between May and July 2021.

3.6 Sample Size

3.6.1 Sample Size for Quantitative Component

The total number of study participants planned was 389 obtained using WHO formula for sample

size determination in health studies (42), however a total of 365 people living with HIV/AIDS

were interviewed.

Sample size was calculated as follows:

Sample size (n) =(𝑍2𝑃 (1−𝑃)

𝑒2 )

Sample size (n), whereas n is the desired minimum sample size, Z = Level of confidence interval

at 1.96 and e =Degree of accuracy at 0.05

P= Proportion of retention among people living with HIV/AIDS, (54.5%) taken from a study done

by Paul Mee on Changes in patterns of retention in HIV care and Antiretroviral treatment in

Tanzania between 2008 and 2016 (8).

21

The sample was divided, proportional to the number of consultations among the three health

facilities Kimara dispensary, Mbezi Health Center and Sinza Hospital.

3.6.2 Sampling for Qualitative Component

A purposive (61) sample of 18 health care providers was randomly selected as Key Informants;

drawn from the care and treatment centres; including 6 nurses, 6 doctors and 6 laboratory staff.

The 18 were further divided and translated into two for each health worker category per facility.

In the similar manner, the researcher randomly selected participants for in-depth interview; six

from each of the three-health facility, from among the participants attending the CTC services.

3.7 Sampling Procedure

3.7.1 Quantitative Method

We employed a systematic sampling approach (62). Seven working days were allocated for data

collection. The total number of HIV/AIDS consultations for seven days were 3864 (25.2%), 6762

(44.1%), and 4704 (30.7%) for Kimara, Mbezi and Sinza, respectively; equals to 15 330

consultations at the three facilities for one week. In the similar manner, the researcher divided the

sample size among the three health facilities; each facility based on the proportionate number of

HIV/AIDS consultations, the higher the consultation the higher the proportion of the sample size.

As such the sample per facility was 92 (25.2%), 161 (44.1%) and 112 (30.7%) for Kimara

dispensary, Mbezi Health Center and Sinza Hospital, respectively. To determine the daily sampling

interval, at every facility, the total number of estimated consultations for seven days was divided

by seven days, and the total sample size. Hence, every sixth HIV/AIDS client in the queue was

22

approached for consent to participate in the study those who were voluntarily willing to participate

in the study were accepted. In case the consent was denied, the next patient was chosen.

3.7.2 For Qualitative Method

At every health facility, a promotional talk was done at Care and Treatment Clinic (CTC), staff

meeting on Monday. Subsequently, randomly selected 6 health care providers and 6 clients from

each facility as KII and for in-depth interviews, respectively. The principal investigator conducted

these interviews for seven days as the research assistants did the quantitative interviews.

3.7.3 Pre-Testing of Study Tools

The questionnaire, the key informant, in-depth interviews topic guides, were pretested among 10

potential participants, 5 HCW and 5 participants, respectively. The pilot testing of these study tools

was conducted at the study in Sinza Health Centre; a center different from where the actual study

was conducted. The researcher did appropriate corrections of the study tools for questions

ambiguity and correctness. The researcher also tested the voice recording quality of the Sonny

Digital recorders.

3.8 Data Collection Tools

A topic guides for participants, key informant interview with HCW’S and in-depth interview with

participants was used (Appendix 2).

23

3.8.1 Questionnaire

Quantitative data was collected using Interviewer administered questionnaire, developed by the

investigator. Two trained research assistants and the principal investigator (Appendix 2.2),

interviewed the participant using the paper-based questionnaire in Swahili language.

3.8.2 The Validity and Reliability of the Quantitative Data (Questionnaire)

Lincoln and Guba argue that ensuring qualitative data credibility (internal validity) is one of the

most important factors in establishing trustworthiness (63). Internal validity was observed by using

standard data collection tools that was pre-tested and used during the data collection. Apart from

that data collection tools were translated into Swahili language which was used to conduct the

interviews.

The reliability of the tools was assured by using competent research assistants and pre-testing of

the tools. All research assistants were trained and get familiarized with the research objectives and

data collection tools. On each day after data collection, the principal researcher reviewed the

collected data to check for ambiguities and the necessary adjustment was made.

The researcher also ensured data dependability by keeping the detailed records that would provide

room for another researcher to conduct a similar study within the same context and replicate

results. The researcher ensured face validity by developing the questions that answered the

research objectives. In addition, to produce valid results, the content of data tools and methods

used cover all relevant parts of the subject it aims to measure.

24

3.8.3 Key Informant Interview

The key informant interview was conducted among health care workers working in CTC clinics,

using the interview guide (Appendix 2.6) on the topic related to retention in care. It involved

medical doctors, nurses and laboratory technician. Six HCW’s from each health facility was

interviewed using Swahili language. The researchers recorded the interview using the Sonny

Digital recorders.

3.8.4 In-depth Interview

The interview was conducted among HIV/AIDS adult aged 18-59 years attending clinic in the

selected health facilities (Appendix 2.4), from each health facility six participants was selected.

The interview was conducted using the interview guide on a topic related to retention in care, using

Swahili language and the recording was done.

3.8.5 Credibility, Transferability, Confirmability and Dependability Of The Qualitative

Tools

The credibility of the qualitative data collected was achieved through, persistent observations and

data collection triangulation (Key informant and In-depth interviews) and data sources (PLHIV

and health care workers). We employed member checking through reading the summary of the

findings to the participants and asked if that was a true reflection of their opinions, to ensure

accuracy (61). The researcher ensured data confirmability by documenting the procedures for

checking and rechecking the data throughout the study and by keeping the audit trail of all the

documents, that were used from the start of research to the reporting of findings (64). Data

dependability was ensured by keeping the detailed records that can be used by another researcher

25

to conduct the similar study (65). Also, the researcher described the research methods adequately

to help the future researcher do the same. Again, the researcher provided thick description of the

research content to give room for those wishes to transfer the results in a different content (63).

3.9 Data Management

All questionnaires and tapes, which were given to research assistant, were counted and signed by

the principal investigator at the back for easy identification as original copies. The research

assistant returned the questionnaires to principal investigator daily. Upon their receipt, they were

counted and checked, to ensure maximum security of data; they were stored safely in the data

storage box whose access was limited to principal investigator. Soft copy of data was stored in

principles investigator’s computer and backed-up in her flash disk. At the end of the study, all the

study materials were placed in a box secured for verification during data analysis.

3.10 Data Analysis

3.10.1 Quantitative Data Analysis

The researcher coded the responses and entered the data in the Microsoft Excel 2010 spreadsheet.

The data was exported to Statistical Package for Social Sciences (SPSS), version 20 software for

analysis. The principal researcher generated a list of queries in the data cleaning processes. In

addressing the dataset queries, the researcher and research assistants when back to the

questionnaire for missing data imputation and collecting wrong entries. Descriptive and

exploratory analysis was done to summarize data using means, median and standard deviation, and

proportions for continuous and categorical; variables, respectively. The association between

dependable variable (Retention in care) with, age, gender, education level, marital status and

26

occupation and independent variable, the chi-square test was used. A p-value of less or equals to

0.05 was considered statistically significant.

3.10.2 Qualitative Data Analysis

Data was digitally recorded, transcribed verbatim, focusing on the verbal conversation, translated

from Swahili to English. Using thematic analysis as described by Braun and Clarke (2006) (66),

both the KII and in-depth interviews were analyzed using the following steps:

The first step included familiarization with the qualitative data collected by the researchers from

Kimara Dispensary, Mbezi Health Center and Sinza Hospital. Each research assistant and the

research submitted the field notes for qualitative interviews to the principal researcher. Since the

interviews were conducted in Swahili, the principal researcher transcribed, starting with the KII

interviews for all 18 -individual recording, creating 18 different Microsoft word files. This process

was repeated for the 18 in-depth interviews.

The second step was coding process, the researcher used both inductive and deductive coding

approaches. She started deductively with a set of codes that were derived from the research

questions, but then inductively came up with new codes and iterate them as sifting through the

data. The researcher manually wrote beside the printed text the possible interesting data elements,

line by line, for all 18 KII transcribed individual notes, prior moving the 18 in-depth interviews.

After all, data have been coded and collated, the researcher aligned the codes to the pre-determined

themes (Table 1).

27

Table 1: Retention in care pre-determined themes for qualitative component

The third step involved sorting of various codes into potential themes and sub-themes by bringing

together related codes to form comprehensive themes using a table. In step four, themes were

reviewed and refined by considering both internal homogeneity and external heterogeneity to

ensure meaningful coherence of the data within themes.

The fifth step involved, defining and naming of themes, this involved identification of what each

theme is about and determining aspects of the data captured by each theme. Lastly, a concise,

coherent, logical and no repetitive descriptive report of thematic analysis was produced.

THEMES SUB - THEMES

Health system factors Good health care services

Short time to be attended

Privacy of the clinic

Community based services

Clinic date reminder

Shortage of staffs

Drug stock out

Pill count

Social factors Stigma and discrimination

Use of herbal medicine

Faith healing

Travel distance and transportation costs.

Personal factors Lack of disclosure

28

3.11 Presentation of Results

Quantitative findings were summarized in statistical tables, histograms and pie charts. Data from

qualitative component were presented and discussed as poignant quotes and or most representative

of the research findings.

3.12 Dissemination of Results

The researcher will disseminate the results of this study in writing and presentations to all health

care facilities in Ubungo Municipality. Recommendations will be made to all decision-makers and

policymakers at Ubungo municipality health facilities, Medical Officers office, and local

implementing partner Management and Development for Health (MDH) on improvements that

need to be made to improve retention in care among people living with HIV/AIDS. Also,

dissemination of results will be made to the University of Malawi College of Medicine senate, to

College of Medicine Research Ethics Committee (COMREC), and the National Institute of

Medical Research in Tanzania (NIMR). Copies will be made available at the COM library and

department of Public Health. At some point, the results from this study will be published in a peer-

reviewed open-access journal.

3.13 Ethical Consideration

The permission to conduct the study was obtained from both College of Medicine Research Ethics

Committee (COMREC), IRB number P.04/21/3294 (Appendix 5) and National Institute for

Medical Research in Tanzania (NIMR), IRB number NIMR/HQ/R.8a/Vol.IX/3615. (Appendix 6)

Permission to conduct research in health centres and hospital which are under Ubungo municipal

council was sought from the Municipal health authority (Appendix 7). In addition, written consent

29

was sought from the participants. The consent form was developed in English and translated into

Swahili language. We encouraged voluntary participation and the participants were assured that

they will not be penalized nor lose any access to medicals services that they receive should they

withdrawal from the study at any point in time. We anonymized all identifiers and identified the

participants using codes a way of safeguarding their privacy and confidentially. For an illiterate

person, the impartial witness was involved after the person had voluntarily agreed to take part in

the study.

30

Chapter Four: Results

4.1 Introduction

This chapter presents and discusses both descriptive and inferential findings from the study. In

descriptive analysis frequency tables and charts were produced to describe the study area,

characteristics of people living with HIV/AIDS, health factors and status of retention of the people

living with HIV/AIDS. The qualitative interviews results are presented as summary points after

quantitative findings with quotations from respondents drawn from the KIIs and In-depth

interviews, in italics.

4.2 Social Demographic Characteristics of the Participants

4.2.1 Quantitative Interviews Participants

In total, 365 participants responded to the questionnaire; 92 (25.4%), 161 (44.2%) and 112 (30.3%)

from Kimara dispensary, Mbezi Health Center and Sinza Hospital, respectively. Demographic data

shows that majority (32.3%) of respondents were aged 46 years and above followed by those aged

36 to 45 years (Table 2).

31

Table 2: Sociodemographic characteristics of participants in quantitative component

Variable Response Frequency Percentage

Age

Sex

13-25 39 10.7

26-35 93 25.5

36-45 115 31.5

46 and above 118 32.3

Total 365 100

Female 258 70.7

Total 365 100

Education Level No Formal Education 25 6.8

Primary 223 61.1

Secondary and above 117 32.1

Total 365 100

Occupation Employed 64 17.5

Self Employed 245 67.1

Entrepreneurship 53 14.5

Unemployed(dependent) 3 0.9

Total 365 100

Marital Status Single 140 38.4

Married 125 34.2

Divorced 21 5.8

Separated 43 11.8

Widowed 36 9.9

Total 365 100

Monthly Income Less than 10000 23 6.3

10001-50000 1 0.3

50001-100000 2 0.5

100001-200000 48 13.2

More than 200000 291 79.7

Total 365 100

4.2.2 Characteristics of Participants in the Qualitative Component

In total 18 key informants were interviewed. Equal number of doctors, nurses and laboratory

technicians were interviewed. The in-depth interviews involved 18 participants (Table 3).

32

Table 3: Social and demographic characteristics of KII and in-depth interviews participants

Key Informants Interviews

Sex

Male 8

Age (Mean, range) 32 (28-50)

Education

Tertiary level 18

Occupation

Doctors 6

Nurses 6

Lab technician 6

In-depth interviews

Gender

Male 6

Age (Mean, range) 36 (22-49)

Education

No formal education 1

Primary 8

Secondary 9

Occupation

Employed 6

Self employed 12

4.3 HIV Status Disclosure and Clinic Appointments

The majority (92.1%) of the participants interviewed had disclosed their HIV status, whereas, 7.9%

have not disclosed their HIV status (Table 4). It was reported that the majority (63.8%) of the

participants revealed that they were seeking for comfort as the main reason for disclosing their

HIV status. In addition, only 2.5% mentioned that need of financial support was reason for

disclosing their HIV status (Table 4). Furthermore, 18.9% had ever missed appointment in the past

six months.

33

Table 4: HIV status disclosure and clinic appointments attendance

Variable Response Frequency Percentage

Status of HIV disclose Yes 336 92.1

No 29 7.9

Total 365 100

Reasons for disclose HIV status Seeking for Comfort 233 63.8

Need of Financial Support 9 2.5

Any Other (my family members) 124 33.2

Total 365 100

Reasons for non-disclose of HIV

status

Stigmatized and Discriminated 348 95.3

Divorced 3 0.8

No Reason 5 1.4

Other Reasons 9 2.5

Total 365 100

Ever missed clinic appointment Yes 69 18.9

No 295 81.1

Total 365 100

Number of times missed clinic

appointments

Once 355 97.3

Twice 5 1.4

Thrice 2 0.5

More than thrice 3 0.8

Total 365 100

Awareness of health risks in

missing clinic appointments

Yes 334 91.5

No 31 8.5

Total 365 100

Counseled on the dangers of

missing appointments

Yes 319 87.4

No 46 12.6

Total 365 100

Reasons for missing clinic

appointment

Forgetfulness 337 92.3

My health has improved 8 2.2

Attend to Traditional Healers /Prayers 3 0.8

Others (use of herbal medicine) 17 4.7

Total 365 100

Also, about 33% of the participants interviewed in the study area mentioned other issues as reasons

for disclosing their HIV status apart from seeking for comfort and need of financial support. The

majority (95.3%) of the participants interviewed in the study area revealed that stigmatization and

discrimination was the main reason for not disclosing their HIV status (Table 4).

Participants in the indepth interview stated that non-disclosure occured as a measure of concealing

their status at their work places and from their marital partners. Participants further states that

34

consequently they miss their clinic appointment dates for fear of indirectly disclosing their status.

The clinic starts from Monday to Friday at 7:30A.M to 3:00 P.M. at this time I will be at

work, and therefore it makes hard for me to ask permission from my boss, as the genuine

reason for me to attend the clinic is not known (Participant 1 - IDI)

For me I am living with my husband and I have not disclosed my status to him, so whenever

he is at home and it’s my clinic day, I fail to come, unless I lie to him for other reasons

(Participant 4-IDI)

One woman mentioned that he has not disclosed her status to her husband due to fear of

separation. She depends on her husband for the living costs and so she is afraid when she

discloses her status to him, he might leave her and she will suffer as she has no other

support (Participant 2- IDI).

During the indepth interview with the participants, confidentiality and self stigimatisation were

factors that prevented one from disclosin an HIV infected status.

When I come here. I meet with people who know me, they tend to spread the news in the

community and people starts to gossip about me. So this made me to move to another clinic,

where no one knows me (Participant 3- IDI)

35

My sister in law works here as the nurse, initially I didn’t know whether she works here

until when I saw her one-day attending patients. I thank God she didn’t see me, I left the

clinic and moved to a far way clinic. If she knew I am HIV positive, she will go tell my

husband and their family will abandon me (Participant 7- IDI).

Self stigmatisation remained the main concern during the key informant interviews, a inner thought

of being descriminated due to thier HIV statuswhether implicity. Examples of this are explained

by the following statements,which make the disclosure of ones status impossible:

The patients themselves, have inner stigma, whatever you do to them accidentally, they

think it is because of their status (HCW 6- KII)

In short, this people living with HIV/AIDS, they have self-stigmatization, because even

when you mistreat them unfortunately, they think it’s because of their positive status. (HCW

10- KII)

During an indepth interview, many participants mentioned reasons for not disclosing and only

few mentioned that they had to disclose their status to family members.

We are only two in my family, so I cannot hide any thing from my sister, I had to tell her

the truth that I am HIV positive(Participant 5- IDI).

36

I disclosed my status to my family,as they have to know what’s going on with me, and also

to support me. I am not financially stable, I depend on my brother for financial support.

(Participant 4- IDI )

During quantitative interviews, the small proportion (18.9%) reported ever missed appoitment, and

when they did, the majority (97.3%) of the participants reported missing clinic appointment once,

1.4% missed clinic appointment twice while 0.8% missed clinic appointment more than thrice

(Table 4). The majority (92.3%) reported forgetfullness as the main reasons for missing clinic

appointment, while being aware of risks of missing appointment was reported by another 91.5%

of the participants (Table 4). Also, the majority (97.5%) did not access ART services during missed

appoitment period.

The main reason for me missing my clinic appointment is because, I have not disclosed my

HIV status to my husband, so whenever he is at home, and it is my clinic day I fail to come

(Participant 9- IDI).

Another participant, reported that I have not disclosed my HIV status to my Boss, so if I

am at work and it’s my clinic day, hence I fail to come. Because I cannot ask permission

every month to attend the clinic appointment as this may irritate my boss.

Other factors that were mentioned during qualitative interviews as reasons for missed appointment

were divine powers and traditional healers. The health care workers said it is very hard to counsel

them to come back, their minds tend to be washed away by these apostles

37

I know a friend of mine, who stopped using ARV’S and went to seek healing in this miracle

churches, later the situation was very bad and she ended up dying. (HCW 10)).

Some of the clients tend to attend to traditional healers and come to the hospital when the

situation is very bad. (HCW 12)

During in-depth interviews, some participants mentioned ARVs side effects such as tiredness and

weakness as a reason for stopping care and treatment. Some mentioned that they become so strong

they make you to eat a lot and the economy is not so well. Example:

Once I started using these drugs I became so weak, I can’t go to work anymore and I am

failing to do my usual activities, so I decided to stop them and continue with my herbal

drugs. (Participant 13- IDI).

On the other hand, during in-depth interview some participants mentioned that, the use of drugs

makes them feel healthy and strong. That they believe in taking drugs and they don’t wish to stop.

Since I have started using these drugs, I felt healthy and secure, drugs make me feel strong

and energetic that I don’t want to stop using them. I have never fall sick, my CD4 are good,

and currently my viral load cannot be detected (Participant 1- IDI)

4.4 Rentention: Ever Missed Appoiment for Six Months Or More, And ART

Continuity

The study shows that the majority (96.4%) of the participants ever missed follow up care and

38

treatment for less than 3 months; 1.1% for 3 – 6 months, while 2.5% for more than 6 months (Table

5). Some participants (40.8%) mentioned being reminded to take drugs during the period of lost to

follow up, 16.7% given social support, while 15.3% were reminded to attend appointments. The

majority (95.6%) of the participants mentioned that their health conditions were well during the

lost to follow up care and treatment period, 3.3?% they got sick during the lost to follow up care

and treatment, and only 1.1 % reported were always sick during the lost to follow up care and

treatment (Table 5). However, regarding access to ARVs, (94.8%) of the participants were using

ARVs when they missed clinic appointments and 5.2% were not using ARVs when missed their

clinic appointments.

39

Table 5: Retention, ever missed appointment for 6 months or more and access to ART

Factor Response Frequency Percentage

Ever missed appointment Less than 3 months 352 96.4

3 - 6 months 4 1.1

6-12 months 2 0.5

More than 12

months

7 2.0

Total 365 100

Social support during

HIV/AIDS care and treatment

Reminded to take

drugs

149 40.8

Company to the

clinic

26 7.1

Financial Support 43 11.8

Reminded to attend

appointments

56 15.3

Social Support 61 16.7

Others 30 8.2

Informed on access of other

facilities for treatment and care

Yes 306 83.8

No 59 16.2

Total 365 100

Ever sought care and treatment

services from another facility

apart from the one enrolled

Yes 65 17.8

No 300 82.2

Total 365 100

Services sought to other

facilities

Treatment 323 88.4

TB screening

Services

10 2.7

Refill 1 0.3

Others such as 31 8.6

Total 365 100

Preference of being reminded Phone Call 224 61.4

SMS 111 30.4

Home Visits/Home

Based Care 30 8.2

Total 365 100

Clients’ perception towards

health workers in clinics

Good 305 83.5

Average 45 12.3

Stigmatize Clients 7 1.9

Others

(unwillingness to

say )

8 2.3

Total 365 100

40

Of those that sought treatment during the missed appointment period, 17.8% sought care and

treatment services from other facilities apart from the one enrolled in while majority (82.2%)

never sought care and treatment services from other facilities apart from the one enrolled at.

During an Indepth interview the reasons that were mentioned for seeking care and treatment

from other facilities were being away from their usual clinic.

My work involves traveling a lot, at times it is my clinic day and I am far away from my

home. So I attend the nearby clinic to get the services. (Participants 12- IDI)

I only missed my clinic twice, by that time I was in village, I went to attend my mothers in

law funeral and I stayed for a long period (Participants 2- IDI)

Most participants, 61.4%, prefered to receive phone call as a reminder to clinic appointments,

whereas, 30.4% prefered Short Message Service (SMS) while 8.2% prefered home visit/home

based care as a reminder to clinic appointments.Regarding the participant’s perception toward

health workers, the study revealed that (83.5%) of the participants reported good attitude, 12.3%

average attitude (Table 5).

During the in-depth interviews, most of the interviewed participants mentioned that, good

customer care services from the health care workers makes them feel loved and protected.

One woman mentioned that “I come to the clinic because they don’t discriminate me, they

support me and help me in all situations just like others (Participant 6-IDI)

41

Here services are given on time, you don’t stay in queue to wait for services (Participant

17)

Other factors that were mentioned by healthcare workers were, pill count, use of community-based

health care services and putting reasonable number of clients on each clinic day to avoid

congestion.

For new clients, we tend to count their pills to correspond to the next appointment, we

don’t give extra drugs as this may cause abstinence to the clinic and hence poor retention.

(HCW 14)

Introduction of short messages has helped most clients not to miss their clinic. Before it’s their

date, clients receive a short message reminding them on their scheduled clinic.

“They get financial support from the local partner” (MDH).

“Since they have started sending messages to remind us on the clinic, I have never missed

it. At times I used to forget but for now I am happy that they remind us.” (Patient 6)

“We usually call a day before the next appointment to remind them on their clinic date,

surely this has helped to improve retention”. (Healthcare worker).

42

A short distance to the clinic was mentioned as the reason for attending clinic and this encouraged

retention in care. However, some participants reported travel distance to ART centers as a barrier

to accessing treatment and some mentioned lack of fare.

One woman said that, I don’t enquire any cost coming to the clinic, so this really helps me

to attend the clinic and get my drugs on time. I have never missed clinic” (Patient 5)

I only use 800 Tshs to come to the clinic each month, and services are given for free.

4.4.1 Status of Retention from the Health Facilities

The five years, 2015 – 2020, retention rate ranged from 88.3% in Kimara Dispensary to 98% in

Sinza Hospital (Figure 4). The avarage retetion rate for the three health facilities was 93.3%

Figure 3: Shows proportion of retention from the facilities

196/222(88.3%)

2458/2628(93.5%)

4004/4085(98.0)

279.8/3(93.3%)

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Kimara Dispensary Mbezi Health Centre Sinza Hospital Total

Five years (2015 - 2020) retention rates in HIV/AIDS program

Retention rate

43

Table 6: Association between retention to ART care and treatment

Variable Response Retention Status Total Chi-

Square

Value

p-

value Not retained Retained

Age 13-35 3 131 134 0.004 0.951

36 and above 6 225 231

Total 9 356 365

Education

Level

No formal

education

1 38 39 0.953 0.329

Primary and

above

8 318 326

Total 9 356 365

Marital

Status

Not married 6 234 240 0.299 0.584

Married 3 122 125

Total 9 356 365

Sex Male 3 104 107 0.259 0.611

Female 6 252 258

Total 9 356 365

Occupation Employed 3 61 64 2.239 1.35

Not employed 6 295 301

Total 9 356 365

Table 6, shows that there is no significant association between retention status of clients and

charactersitics of clients namely sex, age, marital status, education level and occupation as

indicated with their p-values. All p-values are greater than 0.05. Although, more females

(252/357), a proportion of 71% were retained in care compared to 29% of male, the difference is

not statisitcally significant.

44

Chapter Five: Discussion, Conclusion and Recommendations

5.1 Introduction

The identified factors associated with retention in care were, disclosure of one’s status, reminder

messages on the next clinic appointment, good attitude of health care workers and good customer

care. The pill count method used by health care workers and putting reasonable number of clients

on each clinic day and the use of CBHS. Other mentioned reasons were short distance to the clinic

and reasonable transport cost. Mention reasons for poor retention were nondisclosure,

stigmatization and discrimination, divine powers and the use of herbal medicine.

5.2 Retention in HIV/AIDS Care and Treatment

The rate of retention among adults was above 90% UNAIDS target for 6 months after ART

initiation. This retention rate must be maintained for HIV control. Retained PLHIV are more likely

to achieve viral suppression and tend to have higher CD4 cell counts, thus prevent transmission to

the general population, improve quality of life and less likely to get opportunistic infections which

results in reduced morbidity and mortality. A nearly similar retention rate has been reported

elsewhere in Africa (67). However, the longer the time used to determine retention, the lower the

retention rates reported in Kenya and Ethiopia (9,41,53,67,68). Although the current study did not

report any significant retention rates between men and females, others have reported females being

more likely to be retained in care and treatment than men (6,7), contradicting a higher dropout in

females than males (20). The differences in the maternity care services at Antenatal Clinic (ANC)

and PMTCT programs is pivotal in providing health education to women, including HIV testing

and linkage services to improve retention in care for women. In Haiti, most women who were

45

retained in care had been diagnosed with HIV prior to pregnancy (62%) (69). The differences in

rates of retention between men and women may reflect gender differences in health-seeking

behavior. The cultural perspective makes men seek care very late, consequently late diagnosis and

presentation with advanced HIV disease and increased mortality (53,70).

Retention in care improves survival and HIV viral control, resulting in low morbidity and mortality

(68,71). If high retention is maintained, we can achieve the UN 95-95-95 goals by 2030 (72). In

programs whereby the ART services were brought closer to the populations through community

groups, retention of nearly 100% was reached (73).

5.3 Social Factors Associated with Retention

The study found out that the socio-factors that supported the high rate of retention were disclosure

of one’s status, because of seeking social and financial support. This factors are discussed below.

5.3.1 HIV Status Disclosure

Our study found that 92.1% of the study participants had disclosed their HIV status to their close

relatives and continuously received support to engage in care. A similar percentage of disclosure

was reported in Mwanza Tanzania where two hundred and fifty-two participants (93.3%) had

disclosed their HIV sero-status (74). The disclosure was very low in other studies done in African

setting, only 5% in Ethiopia (75), and remained a primary concern in Malawi during in-depth

interviews (76). In the current study, the high level of disclosure could explain the high retention

rate, as disclosure could be associated with retention (50). Similar to the current study, others have

reported reasons for disclosing one's status, such as seeking social (51,74,77) and financial support

46

(74,78). Disclosure has helped them to be reminded to take drugs and attend appointments.

According to a previous qualitative study done in Zambia by Mukumbag, participants reported

that patients do not disclose their status even to close family members, making it hard for them to

attend clinics and take drugs to keep the secret (38).

The current study reports that patients do not want to disclose their HIV status to their relatives,

their marital partners, or bosses, which has also been reported in Tanzania, Kenya, and Uganda

(51,74). Patients fear that disclosing their HIV may lead to abandonment, discrimination, and

gossip in the community (52). Separation and domestic violence were joint among marital partners,

most women depend on their partners for everything, so when they disclose their HIV status, there

is fear of separation and rejection (77). Participants reported that disclosure of HIV status to family

or friends, although initially tricky, typically resulted in more incredible social support (79).

5.3.2 Stigma and Discrimination

We found that, ninety-five per cent (95%) of participants mentioned the reasons for not disclosing

HIV/status to be stigma and discrimination. This is comparable with other studies that identified

HIV related stigmas as an essential barrier to adherence and retention in care (52), also . in Uganda

stigma was found to be a hindrance to ART access, adherence, and long-term retention in care

(36). Stigma and denial are common feelings for individuals recently diagnosed with HIV,

therefore tend to have difficulties remaining in care (41,80,81). In addition, stigma and HIV status

denial and hence poor retention to care has been shown to be associated with low immunological

status and virological suppression. Similarly, another study conducted in Kenya showed that HIV

positive patients drop out of care because they do not want to be seen in the HIV clinic and risk

47

being seen by someone they know. This stigma and discrimination could cost their social relations,

business openings, and a chance of living in harmony with people in their surroundings (82).

5.3.3 Traditional Healers and Faith Healing

Both patients and healthcare workers reported traditional and faith healing negatively affected

retention in care. Similar findings were reported as personal barriers to ART access by the focus

group discussions and in-depth interviews study conducted in Zambia (38). The use of herbal

medicinal products is very prevalent among patients taking ART; in Malawi reported 17.5% of

ART patients used herbal medicine (55)

Other patients who reported attending new churches were told that the use of anointed oil and holy

water cures HIV/AIDS, and therefore, there is no need to continue with HIV/AIDS services (53).

Patient believe in traditional healers and pastors, and so obey their instructions, so even when you

counsel the patients on the benefits of a continuum of care, their mind has already been eluded.

Participants mentioned ARV’s side effects, such as fatigue, as the reason for using of herbal

medicines, as they make patients fail to do their daily activities (52), also reported by other studies

done in Africa and elsewhere. (20,38,82)

5.4 Structural and Health System Factors Associated with Retention

This study found that 36.7% of the participants spent a bus fare of 1000 Tshs to reach the clinic

and 42.7% spent 1-2 hours to reach the clinic, and 34.5% of participants reached the clinic within

30 minutes. The 1000 Tshs bus fare is affordable to most participants, also the 30 minutes time to

2-hours spent to reach the clinic is not a barrier to retention as most participants mentioned. Lack

48

of transport money and long distance travel , which was not the case with the current study, has

been reported by similar studies (12,38). Urban settings may be at an advantage in accessibility

compared with rural areas (43). In contrast to our results, other studies conducted in Uganda and

Malawi reported lack of transport fare as a barrier to attending the ART care and treatment services

(12,76). Services designs considering the effect of transportation on retention have been

considered effective in increasing retention (21). Economic factors and time spent collecting

medications and transportation charges are among the factors related to retention.

Also, the current study reported a good health care attitude to patients, attributed to adequately

staffed clinics, contrary to what was reported elsewhere in sub-Saharan Africa such as Zambia,

where there are few health care workers to attend patients, patients get tired of waiting and go

home without being seen. (38,42). A qualitative study was done in Ethiopia also reported clinic

overcrowding and workers poor attitude affecting retention, in contrast to our study findings (82).

In recent years, multi-month prescriptions have improved retention through reduced clinic

overcrowding. However, a study that was done in Zambia in 2017 found that , because of the

second-line ART drug shortage, patients were given a one-month prescription (38).

In the current study, participants preferred phone calls reminders rather than short messages, 60%

vs 30%. Short messages reminder acceptability is very low in the current study compared with a

study done in Ethiopia, 30% versus 91% (75). A study conducted in Kenya reported that the SMS

was the effective methods in increasing ART adherence (35); mentioned by both health care

workers and patients as an effective means of retaining clients to HIV and AIDS care. Also, this

has been effective in tracing missed clients and lost to follow up back to care (83). The clients who

49

missed clinics were called after the clinic and asked about the reasons for missing the clinic. Some

mentioned forgetfulness as a reason for the missed appointment, similar to studies done in Malawi

and Kenya (76,83).

The study found that, for those clients who do not want to visit clinic for the fear of being known,

CBHS supply them with all the necessary services such as drug supply, viral load and CD4 sample

collection. These findings are similar to studies conducted in Uganda; the use of Community-based

Health Services (CBHS) played a role in maintaining clients into care through various community

services (84). In some programs, the community health workers or volunteers delivered ART at

home. In Mozambique, a demonstration project of people living with HIV used self-formed

community-based ART groups to deliver ART in the community (85). These community ART

programs made treatment readily accessible and affordable (85). A randomized controlled trial

conducted in Uganda and South Africa reported that the CHBS programs are cost-effective and

without adverse events compared to ART delivery at the clinical setup (84). Good results were

also reported elsewhere where the CBHS was implemented (86). Clients who never wanted to

come to the clinic were receiving HIV care services directly from the community. Community-

based ART programs encourage patient autonomy, build social networks, and minimize the

structural barriers, such as the cost of transport to the clinic, which in turn appear to result in better

outcomes. Community-based delivery of antiretroviral therapy for HIV, including ART initiation,

clinical and laboratory monitoring, and refills, could reduce barriers to treatment and improve viral

suppression, reducing the gap in access to care for individuals who have detectable HIV viral load,

including men who are less likely than women to be virally suppressed (86).

50

5.5 Strengths of the Study

The study used both quantitative and qualitative methods, which enabled us to explore a lot of

factors that are associated with retention in care among PLHIV beyond those that were identified

by quantitative method alone. Hence the study provided valuable insights on factors associated

with retention in care among PLHIV.

5.6 Study Limitations

Despite impressive high retention rate, the researcher failed to trace non-retained patients, which

could have prolonged the study. However, the researcher tried to reach them through phone calls

but proved to be unsuccessful. Because of the design, the self-reported missed appointment and

retention could not be correlated with attendance register records, which would have improved the

data credibility through triangulations.

5.7 Conclusion

The study reports a high rate of retention of PLHIV receiving care and treatment, this was

attributed to the awareness of the alternative clinic to collect the ARVs and the consequences of

missed-appointment. Nonetheless, over two per cent of participants have missed an appointment

for six or more months. The study has revealed the existence of stigma as demonstrated by the

significant proportion of participants who had not disclosed their HIV serostatus for fear of social

and family retribution. Still, a good proportion of participants periodically missed appointments

during the follow-up, citing forgetting the date as a significant reason. However, the continuum of

care was attained among those missing appointments due to knowledge of alternative clinics to

collect their medications.

51

The reminder of the appointment date through mobile short messages was perceived as a

significant breakthrough in minimizing missed appointments. Health workers’ attitudes,

transportation costs did not present as factors affecting retention during interviews. Similarly, other

health systems factors such as staff shortage and long waiting time was mentioned during the in-

depth and key informant interviews and factors that could contribute to reduced retention, did not

strongly come out during individual interviews.

5.8 Recommendations

Recommendations to the policymakers and health care providers:

a. Health care providers and policymakers at various levels of HIV and AIDS Care

treatment should stern the health education information about the importance of

regularly attending the CTC by the patients. The efforts could minimize the

periodically missed appointments of shorter duration hence improving adherence

to ARTs

b. Specific health educations sessions should focus on religious and traditional beliefs

that could affect the retention of services and should equally target both the clients

and the health care providers. Also health care workers should emphasis on effects

of sharing drugs as it can cause non-adherence among clients secondary to

shortages.

52

Recommendations for further research:

a. Further researches, in particular, ethnographic studies, could investigate further the

reasons for the missed appointment of longer than six months and withdrawal from

services

b. Larger and longitudinal studies, particularly cohort studies, which include more

facilities and districts in Tanzania, could demonstrate retention into HIV/AIDS care

and treatment over time rather than a cross-sectional study.

53

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Appendices

Appendix 1: informed consent forms

Appendix 1.1: Informed consent form for HIV/AIDS patients in English

Study Title: Factors associated with retention in care among people living with HIV/AIDS in

Ubungo municipality, Tanzania.

Principal Investigator: Dr. Sylvia D. Moshi, a student of Master’s of Science in Public Health,

University of Malawi, College of Medicine

Research Supervisor: Dr. Linda Nyondo-Mipando and Dr. Joan Rugemalila

PI Version date: 2.0, March 24, 2021

Hello, my name is Sylvia D. Moshi and I am a student at the University of Malawi, College of

Medicine), I am conducting a study on Factors associated with retention in care among people

living with HIV/AIDS in Ubungo Municipality. I would like to seek your permission to participate

in this study, please read the consent form below.

Introduction and Purpose of the Study

This study seeks to determine proportion of people retained in care, and to asses factors associated

with retention in care among people living with HIV/AIDS in order to help find ways that would

improve retention in care among them and entire program.

Procedure

If you agree to take part in this study; Firstly, you will be asked to sign a consent form. You will

also be asked to fill in a questionnaire with the help of a trained research assistant. The interview

will not take much of your time and it will be done once. The interview will be face to face and

will also be digitally recorded. You will decide on which day and place you will be comfortable

with to have you interviewed. The study team will maintain your privacy and confidentiality at

any place that you will choose.

Secondly, we will collect some information about you such as age, tribe, religion, where you live,

and nature of your work, and also we will conduct the interview and discussions on the Factors

associated with retention in care among people living with HIV/AIDS in Ubungo municipality.

65

Risks

We do not anticipate that participation in this study will pose any physical or psychological risks

beyond what you encounter in everyday life. However, participation in this study is voluntary and

if you are uncomfortable answering a particular question, you are free to not to answer the question,

and you are free to leave the study at any time.

Benefits

The information you provide to the investigator will shed light on the factors associated with

retention in care among people living with HIV/AIDS, and the study results will assist us in

informing PLHIV, representatives of Ubungo Municipality and other stakeholders to help improve

retention among PLHIV and develop suitable strategies.

Costs and compensations:

There are no costs associated with this study. Please note that you will not receive any money for

participating in this study. You can decide not to take part in this study, and this will not affect you

in any way.

Privacy and Confidentiality:

The interviews will be conducted in a private place where no one can hear our conversation. Some

questions may be sensitive and you are encouraged not to answer, however we would like you to

answer all questions. Any information given to this study will be kept confidential. Your name

will not be used in any report coming from this study, you will be using a code. The questionnaires

and the consent form will be safely kept in a lockable cabinet accessed only by the study staff that

is the researcher, the study supervisor and COMREC. The information collected will remain

confidential. All research material will be submitted to Kamuzu University of Health Sciences

(KUHES), for official documentation purpose and they will be destroyed upon completion of the

study or when requirements are met.

Other Information

In case you have any questions you can contact the investigator Dr. Sylvia D. Moshi on +255 767

041648 or Supervisors. Dr. Joan Rugemalila on +255 784 660 517 and Dr. Linda Nyondo

Mipando on +265 999 44 12 12 and NIMR representative on +255 758 587885.

Your signature below shows that you understand the above statement and willingly agree to

participate in the study.

This consent form has been read and explained to me. I voluntarily consent to participate in this

study:

Signature: Study participant

____________________ Date: ________________________

66

OR

Thumb print………………………………. Date……………………..

Witness: Signature: …………………… Date: ……………………………

I have explained the study for the above subject and I have sought his/her understanding for

informed consent

Signature: ____________________ Date: _______________________

(Research assistant)

THANK YOU FOR YOUR TIME AND PARTICIAPTION

67

Appendix 1.2: Informed consent form for HIV/AIDS patients in Swahili

Kichwa cha utafiti: Sababu zinazohusiana na wateja wa UKIMWI kudumu kwenye huduma katika

manispaa ya Ubungo.

Mtafiti: Dk. Sylvia D. Moshi, mwanafunzi wa uzamili katika chuo kikuu cha Malawi.

Msimamizi: Dk. Linda Nyondo Mipando na Dk. Joan Rugemalila

PI TOLEO LA TAR: 2.0, Machi 24, 2021.

Habari, Mimi naitwa Sylvia Denis Moshi ni daktari na mwanafunzi wa chuo kikuuu cha Malawi,

ninafanya utafiti kuhusu sababu zinazohusiana na mteja wa UKIMWI kudumu kwenye huduma

katika manispaa ya Ubungo. Ninapenda kupata ridhaa yako ili uweze kushiriki kaatika utafiti huu.

Tafadhali soma fomu ya idhni:

Lengo na dhumuni la utafiti

Utafiti huu unalenga kutambua idadi ya wateja wanaohudhuria kikamilifu katika huduma, na pia

kujua visababishi vinavyomfanya mteja wa UKIMWI kuhudhuria au kutokuhudhuria kwenye

matibabu/huduma ili kuweza kupata suluhisho ambayo itasaidia kutatua tatizo hili kwa wateja

wote na programu zote zinazohusika na kuwasaidia wateja wa UKIMWI.

Utaratibu

Kama unakubali kushiriki katika utafiti huu, utahitajika kusaini fomu ya idhini. Pia utapewa fomu

ya maswali ya kujaza kwa msaada wa msaidizi wa utafiti. Mahojiano hayatachukua muda wako

mwingi na yatafanyika mara moja. Mahojiano haya yatakuwa uso kwa uso na pia yatarekodiwa.

Unaweza ukachagua sehemu ambayo ipo sawa kwako kufanyiwa mahojiano na muda ambao

unaoutaka wewe. Wataalamu wa utafiti watafanya mahojiano kwa usiri sana na nyaraka zote za

mahojiano zitahifadhiwa kwa usiri mkubwa mno.

Tahadhari

Hatutegemei kwamba, kwa kushiriki kwenye utafiti huu utapata tatizo lolote lile la kiafya au

kuweza kujeruhiwa. Kushiriki katika utafiti huu ni hiari kabisa na kama hutojisika kujibu baadhi

ya maswali unaruhusiwa kufanya hivyo, na pia kama unataka kujitoa katika utafiti huu uwe huru

kufanya hivyo.

68

Faida

Taarifa utakazozitoa zitapelekea kupata ujuzi juu ya visababishi vinavyomfanya mteja wa

UKIMWI kuhudhuria au kutokuhudhuria kwnye matibabu/huduma. Matokea ya huu utafiti

yatatusaidia kuweza kuwaelimisha wateja juu visababishi vinavyomfanya mteja kuhudhuria au

kutkuhudhuria, pamoja na wadau mbalimbali wanaoshiriki katika kutoa huduma kwa wateja pia

na wawakilishi wa manispaa ya Ubungo ili kuweza kutengeneza mikakati itakayosaidia kuboresha

mahudhurio.

Gharama na fidia

Hakutakuwa na malipo ya aina yoyote ile ukishiriki katika utafiti huu, jua kwamba hautapewa hela

ili kushiriki. Unaweza pia kutokushiriki katika utaafiti huu na hii haitakuathiri kwa namna yoyote

ile.

Usiri

Majadiliano yatafanyika kwa usiri mkubwa mno ambapo hakutakuwa na mtu yeyote atakayeweza

kusikia majadilaino yetu. Maelezo/taarifa yoyote ile itawekwa kwa usiri mkubwa sana. Jina lako

halitatumika katika ripoti zitakazotengenezwa. Fomu za maswali pamoja na ya ruhusa

zitahifadhiwa katika kabati inayofungwa kwa kofuli au funguo ambapo wahusika wa utafiti huu

tuu(mtafiti na tume ya utafiti ya chuo kikuu cha Malawi- COMREC) ndio wanaoweza kuzitumia.

Nyaraka zote zilizotumia kwenye utafiti huu zitakabidhiwa chuoni Malawi kwa ajili ya

kurekodiwa na zitachomwa baada ya utafiti huu kukamilika /kumalizika.

Kwa taarifa Zaidi

Ikitokea una maswali wasiliana na mtafiti Dk. Sylvia Moshi kwa namba +255 767 041648 au

wasimamizi wa utafiti Dk. Joan Rugemalila kwa namba +255 784 660 517 na Dk. Linda Nyondo

Mipando kwa namba +265 999 441212 au mwakilishi wa NIMR kwa namba: +255 758 587885

Kwa kusaini fomu hii itaonesha kwamba umesoma na kuielewa na hivyo kwa hiari yako kabisa

umeamua kushiriki kwenye utafiti huu.

Fomu hii imesmwa na kuelezewa kwangu, hivyo nimeamua kushiriki katika utafiti huu, kwa hiari

yangu.

Sahihi……………. Tarehe ……………….

(Mshiriki utafiti)

Au

Dole gumba……………………….. Tarehe …………………

Sahihi ………………………… Tarehe ……………..

(Shahidi wa mtafiti)

69

Nimetoa maelezo ya kutosha kuhusiana na huu utafiti na mteja ameridhia kushiriki katika huu

utafiti,

Sahihi………………. Tarehe………………

(Msaidizi wa utafiti)

ASANTE KWA KUSHIRIKI

70

Appendix 1.3: Informed Consent form for In-depth Interview (IDI) for HIV/AIDS patients

in English

Study Title: FACTORS ASSOCIATED WITH RETENTION IN CARE AMONG PEOPLE

LIVING WITH HIV/AIDS IN UBUNGO MUNICIPALITY, TANZANIA

Principal Investigator: Dr. Sylvia D. Moshi, Master of Science in Public Health, University of

Malawi

Research Supervisors: Dr. Linda Nyondo-Mipando and Dr. Joan Rugemalila

PI Version Date: 2.0, March 24, 2021

What you should know about this study

You are being asked to join a research study. This consent form explains the research study and

your part in the study. Please read it carefully and take as much time as you need. Please note that

your participation in this study is entirely voluntary and you may decide not to take part or to

withdraw from this study at any time. There will be no penalty if you decide to quit the study.

During the study, we will tell you if we learn any new information that might affect whether you

wish to continue to be in the study or not.

The Investigator of this study is Dr. Sylvia Denis Moshi, a student of masters of public health in

University of Malawi, College of Medicine, and my assistant is _____________. Before you

decide if you want to be a part of this study, we want you to understand the study.

The study staff will talk with you about this information. You are free to ask questions about this

study at any time. Before you decide whether to take part in this research study, you need to know

the purpose, the possible risks and benefits to you, and what will be expected of you during the

study. After the study has been fully explained to you, you can decide whether or not you want to

participate. Once you understand this study, and if you agree to take part, you will be asked to sign

this consent form or make your mark in front of someone. You will be offered a copy of this form

to keep.

Purpose of the StudyThis study seeks to determine proportion of people retained in care, and to

assess factors associated with retention in care among people living with HIV/AIDS, in order to

help find ways that would improve retention in care among them and the entire program.

71

Study Procedures

If you agree to take part in this study, you will be asked to sign a consent form or thumb print it

before the witness. About 18 participants (six from each facility) will participate in this interview.

The interview will be face to face and will also be digitally recorded. The interview will not take

much of your time and it will be done once. You will decide on which day and place you will be

comfortable with to have you interviewed. The study team will maintain your privacy and

confidentiality at any place that you will choose.

Secondly, we will collect some information about you such as age, tribe, religion, where you live,

and nature of your work, and also we will conduct the interview and discussions on the Factors

associated with retention in care among people living with HIV/AIDS in Ubungo municipality.

Risks and or discomforts

We do not anticipate major risk, some discussions may be sensitive and you are free not to answer.

However, we encourage you to answer all questions because it will help us to understand the health

care workers and client’s views on regards of the factors that are associated with retention in care

among people living with HIV/AIDS. We will make every effort to protect your privacy and

confidentiality while you are in the study and will not use your name in the study summaries.

However, in instances where you are the only one in your position others may be able to know of

your participation in the study. The discussions will take place in private.

Potential Benefits

There may be no direct benefit to you from this study. Information gained from this study may

help us understand factors that are associated with retention in care among people living with

HIV/AIDS and may inform health care workers on provision of such services in future.

Reasons why you may be withdrawn from the study without your consent.

• The study is stopped or cancelled by the Ministry of Health, community development,

gender, elderly and children (MoHCDEC), the Malawi College of Medicine Research Ethics

Committee (COMREC) and National Institute of Medical Research (NIMR).

• Staying in the study would be harmful to you.

Costs and Compensation.

There is no cost associated with this study and you will not receive payment for participation. You

are free not to participate in the study. This will not affect your job or regular health care at this

hospital.

Confidentiality

Efforts will be made to keep the questionnaires and recordings of the interviews confidential to

the extent permitted by law. However, we cannot guarantee absolute confidentiality. You will be

identified by a code. Your name will not be used in any publication of this study. The recorded

discussions will only be used for research purposes and once those requirements are met they will

72

be erased. After the interview, the consent form will be kept as per COMREC guidelines have

been met and then they will be destroyed. The interviews will use codes and not your real names.

The study records will be kept in a locked cabinet at the Kamuzu University of Health Sciences

However, your records may be reviewed by Supervisors, study staff, study monitors, department

of Public Health and College of Medicine Research Ethics Committee (COMREC).

Research Related Injury

It is unlikely that you will be injured as a result of being in this study, however if you are injured

as a result of being in this study, the study staff will give you immediate necessary treatment for

your injuries. You will not have to pay for this treatment. You will then be told where you can get

additional treatment for your injuries, if needed. There is no program for monetary compensation

or other forms of compensation for such injuries through this study. You do not give up any legal

rights by signing this consent form.

Problems or Questions

For questions about this study or a research-related injury, contact:

• Dr. Sylvia Denis. Moshi, Principal Investigator, phone number: 0767 041648/0717041648

• Dr. Joan Rugemalila research supervisor located at Muhimbili National Hospital,

department of internal medicine, phone number 0784 660 517 and

• Dr. Linda Nyondo Mipando, research Supervisor, located at the University of Malawi,

College of Medicine. Department of Health Systems and Policy, phone number, 0999 44 1212,

• And NIMR representative on +255 758 587885

If you have read the informed consent, or have had it read and explained to you, and understand

the information, and you voluntarily agree to join the study, please sign your name or make your

mark below.

____________________________ _________________________________

Participant Signature Date

______________________ ________________________

Study Staff signature Date

___________________ _________________

Witness Signature Date

-------------------------- ------------------

THANK YOU SO MUCH

73

Appendix 1.4: Informed consent form for In-depth interview for HIV/AIDS patients in

Swahili

Kichwa cha somo: Sababu zinazohusiana na wateja wa UKIMWI kudumu kwenye huduma katika

manispaa ya Ubungo

Mtafiti; Dk. Sylvia Denis Moshi, mwanafunzi wa shahada ya uzamili ya afya ya jamii katika chuo

kikuu cha afya cha Malawi

Msimamizi wa utafiti; Dk. Linda Nyondo, Mipando na Dk. Joan Rugemalila

PI TOLEO LA TAR: 2.0, Machi 24, 2021.

Unachotakiwa kufahamu kuhusu huu utafiti

Unaombwa kushiriki katika utafiti huu. Hii fomu ya idhini inaelezea kwa kina kuhusu huu utafiti

na ushiriki wako katika huu utafiti. Kwa hiyo unaombwa kutumia muda wako mwingi kuusoma

na kuuelewa. Ushiriki wako katika utafiti huu ni wa hiari kabisa na unaweza ukaamua kutoshiriki

au kujitoa wakati wowote. Hakutokuwa na utozaji wa pesa pindi utakapoamua kujitoa katika

utafiti. Wakati utaafiti unaendelea utapata fursa ya kujifunza mambo kadha wa kadha

yanayohusiana na utafiti. Utaelewa kwa undani kabisa kuhusu huu utafiti na wataalamu

wanaohusika na utafiti. Jisikie huru kabisa kuuliza maswali yoyote wakati wowote yanayohusiana

na huu utafiti. Unapaswa kujua lengo la huu utafiti na madhara au faida zitokanazo na huu utafiti

na nini cha kutegemea wakati wa utafiti. Baada ya kupata maelezo ya kutosha ndipo utakapofanya

maamuzi ya kushiriki au kutokushiriki katika utafiti. Mara ya baada ya kuelewa na kukubali

kushiriki, utaakiwa kusaini hii fomu ya idhini au kuweka alama ya dole gumba mbele ya shahidi,

na kisha utapewa nakala ya hii fomu.

Lengo la utafiti

Utafiti huu unalenga kujua kiasi/idadi ya wateja ambao wapo katika huduma na kuweza kutambua

vitu vinavyosababisha wateja wa ugonjwa wa UKIMWI kubaki au kutokubaki kwenye huduma.

Ili kuweza kutafuta njia stahiki za kuboresha na kuwafanya wateja waweze kudumu katika

huduma.

Utaratibu wa utafiti

Kama unakubali kushiriki katika utafiti huu utapaswa kusaini fomu ya idhini au kuweka alama ya

dole gumba. Jumla ya Wateja wa ugonjwa wa UKIMWI kumi na nane watashiriki katika

74

mahojiano haya, ikiwa ni washiriki sita katika kila kituo cha afya vilivyochaguliwa. Mahojiano

yatafanywa na wataalamu wa utafiti huu na yatakuwa uso kwa uso na yatarekodiwa. Mahojiano

haya hayatachukua muda mwingi na yatafanyika mara moja. pia unaweza kuchagua sehemu

ambayo utaipenda wewe kwa kufanyia mahojiano na muda ambao unautaka. Mahojiano yote

tatafanywa kwa usiri na nyaraka zitahifadhiwa kwa usiri mkubwa sana.

Tahadhari na Usumbufu

Hatutegemei kama utapata madhara yoyote, baadhi ya maswali yanaweza yakawa nyeti na jisikie

huru kabisa kutokujibu. Hata hivyo tunasisitiza uweze kujibu maswali yote maana hii itatusaidia

kuweza kupata uelewa juu ya mitazamo ya wahudumu wa afya , pamoja na wateja juu ya sababu

mbalimbali zinazowafanya wateja kudumu au kutokudumu kwenye huduma.

Faida za utafiti

Hakutakuwa na faida ya moja kwa moja zitokanazo na utafiti huu bali taarifa utakazozitoa

zitatusaidia kupata uelewa juu ya vitu vinavyosababisha wateja kudumu au kutokudumu katika

huduma, nah ii itatusaidia kuweza kujua mbinu stahiki zitakazoweza kuwadumisha wateja kwenye

huduma, pamoja na kuboresha sekya ya afya kiujumla.

Sababu zitakazopelekea kutolewa kwenye utafiti bila ya ridhaa yako ni;

I. Utafiti ukikatizwa na wizara ya afya, ustawi wa jamii, jinsia, wazee na watoto, taasisi ya

utafiti Tanzania (NIMR), tume ya utafiti Malawi (COMREC).

II. Kuendelea kubaki kwenye utafiti kutakuwa na madhara kwako.

Malipo na fidia.

Hakutakuwana malipo ya aina yoyote ile, yatokanayo na utafiti huu na unaweza kutokushiriki na

hii haita – athiri upataji wako wa huduma katika kituo.

Usiri

Jina lako halitatumika katika utafiti huu, hata hivyo utatambulika kwa namba ambayo utapewa,.

Mazungumzo yote yatafanywa kwa usiri mkubwa katika chumba ambapo hapana mtu yeyote

atakayeweza kusikia. Mazungumzo yatarekodiwa na yatatumika tuu kwenye utafiti na mara baada

ya utafiti kumalizika yataharibiwa kutokana na muelekezo wa taasisi ya masuala ya utafiti

(COMREC). Taarifa zako zitapitiwa na msimamizi wa utafiti, wataalamu wa utafiti pamoja na

idara ya afya ya jamii chuo cha afya Kamuzu, Malawi. Fomu zote za utafiti pamoja na

mazungumzo yaliyorekodiwa yatahifadhiwa katika loka/ kabati ambalo litafungwa kwa ufunguo

katika chuo cha Malawi.

Ajali zitokanazo na utafiti

Hatutegemei kuwa utapata ajali kwa kushiriki kwenye huu utafiti, hata hivyo ikitokea umeumia

kutokana na utafiti huu, wataalamu wa utafiti watakupatia matibabu yanayostahili na hutolipia

haya matibabu. Ghrama zote za matibabu zitalipwa na wataalamu wa utafiti. Hakutakuwa na

malipo au fidia yoyote kutokana na ajali.

75

Kwa mawasiliano zaidi au maulizo.

Kwa maswali kuhusu huu utafiti wasiliana na:

• Dk. Sylvia Denis Moshi, mtafiti mkuu kwa namba ya simu 0767 041648 / 0717 041648 au

kwa barua pepe; denis.sylvia.denis@gmail.com

• Dk. Linda Nyondo Mipando, msimamizi wa utafiti chuo kikuu cha afya Malawi kwa simu

namba, +265 999 44 12 12 au kwa barua pepe; lmipando@medcol.mw na

• Dk. Joan Rugemalila, msimamizi wa utafiti huu pia kwa namba +255 784 660 517 au kwa

barua pepe : joanrugemalila@gmail.com

• Au mwakilishi wa NIMR kwa namba: +255 758 5878

Kama umesoma au kuelezwa na umeelewa fomu hii tafadhali weka sahihi au alama ya kidole

gumba, uweze kushiriki.

ASANTENI SANA

76

Appendix 1.5: Informed Consent Form for Key Informant Interview (KII) in English

Study Title: FACTORS ASSOCIATED WITH RETENTION IN CARE AMONG PEOPLE

LIVING WITH HIV/AIDS IN UBUNGO MUNICIPALITY, TANZANIA

Principal Investigator: Dr. Sylvia D. Moshi, a student of Master’s of Public Health, at the Kamuzu

University of Health Sciences, Malawi.

Research Supervisors: Dr. Linda Nyondo-Mipando na Dk. Joan Rugemalila

PI Version Date: Version 2.0, March 24, 2021

What you should know about this study

You are being asked to join a research study. This consent form explains the research study and

your part in the study. Please read it carefully and take as much time as you need. Please note that

your participation in this study is entirely voluntary and you may decide not to take part or to

withdraw from this study at any time. There will be no penalty if you decide to quit the study.

During the study, we will tell you if we learn any new information that might affect whether you

wish to continue to be in the study or not.

The Investigator of this study is Dr. Sylvia Denis Moshi, a student of masters of public health in

University of Malawi, College of Medicine and my assistant is _____________. Before you

decide if you want to be a part of this study, we want you to understand the study.

The study staff will talk with you about this information. You are free to ask questions about this

study at any time. Before you decide whether to take part in this research study, you need to know

the purpose, the possible risks and benefits to you, and what will be expected of you during the

study. After the study has been fully explained to you, you can decide whether or not you want to

participate. Once you understand this study, and if you agree to take part, you will be asked to sign

this consent form or make your mark in front of someone. You will be offered a copy of this form

to keep.

Purpose of the Study

This study seeks to determine proportion of people retained in care, and to asses factors associated

with retention in care among people living with HIV/AIDS, in order to help find ways that would

improve retention in care among them and the entire program.

77

Study Procedures

If you are interested to participate in this study you will need to meet some requirements. Firstly,

we will ask you to sign or thumb print this consent form before the witness. About 18 Key

Informants (6 participants from each facility) will participate in the interview. The Key informants

comprises of Doctors, nurses and lab technicians. The research staff will conduct the interviews,

it will be face to face, and it will be done once. It will also be digitally recorded.

Secondly, we will collect some information about you such as age, tribe, religion, where you live,

and nature of your work, and also we will conduct the interview and discussions on the Factors

associated with retention in care among people living with HIV/AIDS in Ubungo municipality.

Risks and or discomforts

We do not anticipate major risk, some discussions may be sensitive and you are free not to answer.

However, we encourage you to answer all questions because it will help us to understand the health

care workers and client’s views on regards of the factors that are associated with retention in care

among people living with HIV/AIDS. We will make every effort to protect your privacy and

confidentiality while you are in the study and will not use your name in the study summaries.

However, in instances where you are the only one in your position others may be able to know of

your participation in the study. The discussions will take place in private.

Potential Benefits

There may be no direct benefit to you from this study. Information gained from this study may

help us understand factors that are associated with retention in care among people living with

HIV/AIDS and may inform health care workers on provision of such services in future.

Reasons why you may be withdrawn from the study without your consent.

• The study is stopped or cancelled by the Ministry of Health, community development,

gender, elderly and children (MoHCDEC), the Malawi College of Medicine Research Ethics

Committee (COMREC) and National Institute of Medical Research (NIMR).

• Staying in the study would be harmful to you.

Costs and Compensation

There is no cost associated with this study and you will not receive payment for participation. You

are free not to participate in the study. This will not affect your job or regular health care at this

hospital.

Confidentiality

Efforts will be made to keep the questionnaires and recordings of the interviews confidential to

the extent permitted by law. However, we cannot guarantee absolute confidentiality. You will be

identified by a code. Your name will not be used in any publication of this study. The recorded

discussions will only be used for research purposes and once those requirements are met they will

be erased. After the interview, the consent form will be kept as per COMREC guidelines have

78

been met and then they will be destroyed. The interviews will use codes and not your real names.

The study records will be kept in a locked cabinet at the College of Medicine. However, your

records may be reviewed by Supervisors, study staff, study monitors, department of Public Health

and College of Medicine Research Ethics Committee (COMREC).

Research Related Injury

It is unlikely that you will be injured as a result of being in this study, however if you are injured

as a result of being in this study, the study staff will give you immediate necessary treatment for

your injuries. You will not have to pay for this treatment. You will then be told where you can get

additional treatment for your injuries, if needed. There is no program for monetary compensation

or other forms of compensation for such injuries through this study. You do not give up any legal

rights by signing this consent form.

Problems or Questions

For questions about this study or a research-related injury, contact:

• Dr. Sylvia Denis. Moshi, Principal Investigator, phone number: 0767 041648/0717041648

• Dr. Linda Nyondo Mipando, Research Supervisor, located at the University of Malawi,

Department of Health Systems and Policy, phone 0999 44 1212 and

• Dr. Joan Rugemalila, research supervisor located at Muhimbili National Hospital,

department of internal medicine, phone number 0784 660 517

• And NIMR representative on +255 758 587885

If you have read the informed consent, or have had it read and explained to you, and understand

the information, and you voluntarily agree to join the study, please sign your name or make your

mark below.

____________________________ _________________________________

Participant Signature Date

______________________________ ____________________________________

Study Staff Signature Date

______________________________ ____________________________________

Witness Signature (print) Date

THANK YOU.

79

Appendix 1.6: Informed consent form for Key Informant Interview in Swahili

Kichwa cha somo: Sababu zinazohusiana na wateja wa UKIMWI kudumu kwenye huduma katika

manispaa ya Ubungo

Mtafiti; Dk. Sylvia Denis Moshi, mwanafunzi wa shahada ya uzamili ya afya ya jamii katika chuo

kikuu cha afya Malawi.

Wasimamizi wa utafiti; Dk. Linda Nyondo, Mipando na Dr. Joan Rugemalila

PI TOLEO LA TAR: 2.0 Machi 24, 2021.

Unachotakiwa kufahamu kuhusu huu utafiti

Unaombwa kushiriki katika utafiti huu. Hii fomu ya maridhio inaelezea kwa kina kuhusu huu

utafitina ushiriki wako katika huu utafiti. Kwa hiyo unaombwa kutumia muda wako vizuri

kuusoma na kuuelewa, ushiriki wako katika utafiti huu ni wa hiari kabisa na unaweza ukaamua

kutoshiriki au kujitoa wakati wowote. Hakutokuwa na utozaji wa pesa pindi utakapoamua kujitoa

katika utafiti. Wakati utaafiti unaendelea utapata fursa ya kujifunza mambo kadha wa kadha

yanayohusiana na utafiti. Utaelewa kwa undani kabisa kuhusu huu utafiti na wataalamu

wanaohusika na utafiti. Jisikie huru kabisa kuuliza maswali yoyote wakati wowote yanayohusiana

na huu utafiti. Unapaswa kujua lengo la huu utafiti na madhara au faida zitokanazo na huu utafiti

na nini cha kutegemea wakati wa uafiti. Baada ya kupata maelezo ya kutosha ndipo utakapofanya

maamuzi ya kushiriki au kutokushiriki katika utafiti. Mara ya baada ya kuelewa na kukubali

kushiriki, utaombwa kusaini hii fomu ya maridhiano au kuweka alama ya dole gumba mbele ya

shahidi, kasha utapewa nakala yah ii fomu.

Lengo la utafiti

Utafiti huu unalenga kujua kiasi/idadi ya wateja ambao wapao katika huduma na kuweza kutambua

vitu vinavyosababisha wateja wa ugonjwa wa UKIMWI kubaki au kutokubaki kwenye huduma.

Ili kuweza kutafuta njia stahiki za kuboresha na kuwafanya wateja waweze kudumu katika

huduma.

Utaratibu wa utafiti

Wahudumu wa afya kumi na nane watashiriki katika mahojiano haya, Wataalamu hao ni

madaktari, wauguzi na wataalamu wa maabara. Mahojiano hayo yatafanywa mara moja na

wataalamu wa utafiti huu na yatakuwa uso kwa uso na pia yatarekodiwa.

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Kama utapenda kushiriki utafiti huu utapaswa kusaini hii fomu au kuweka alama ya dole gumba

mbele ya shahidi na pia kutoa taarifa za umri wako, kabila, dini unapoishi. Tutafanya mahojiano

ya vitu vinavyosababisha wateja wa ugonjwa wa UKIMWI kubaki au kutokubaki kwenye huduma.

Tahadhari na Usumbufu

Hatutegemei kama utapata madhara yoyote, baadhi ya maswali yanaweza yakawa nyeti na jisikie

huru kabisa kutokujibu. Hata hivyo tunasisitiza uweze kujibu maswali yote maana hii itatusaidia

kuweza kupata uelewa juu ya mitazamo ya wahudumu wa afya , pamoja na wateja juu ya sababu

mbalimbali zinazowafanya wateja kudumu au kutokudumu kwenye huduma.

Faida za utafiti

Hakutakuwa na faida ya moja kwa moja zitokanazo na utafiti huu bali taarifa utakazozitoa

zitatusaidia kupata uelewa juu ya vitu vinavyosababisha wateja kudumu au kutokudumu katika

huduma, nah ii itatusaidia kuweza kujua mbinu stahiki zitakazoweza kuwadumisha wateja kwenye

huduma, pamoja na kuboresha sekya ya afya kiujumla.

Sababu zitakazopelekea kutolewa kwenye utafiti bila ya ridhaa yako ni;

III. Utafiti ukikatizwa na wizara ya afya, ustawi wa jamii, jinsia, wazee na watoto, taasisi ya

utafiti Tanzania (NIMR), tume ya utafiti Malawi (COMREC).

IV. Kuendelea kubaki kwenye utafiti kutakuwa na madhara kwako.

Malipo na fidia.

Hakutakuwana malipo ya aina yoyote ile, yatokanayo na utafiti huu na unaweza kutokushiriki nah

ii haita – athiri kazi yako.

Usiri

Jina lako halitatumika katika utafiti huu, hata hivyo utatambulika kwa namba ambayo utapewa,.

Mazungumzo yote yatafanywa kwa usiri mkubwa katika chumba ambapo hapana mtu yeyote

atakayeweza kusikia. Mazungumzo yatarekodiwa na yatatumika tuu kwenye utafiti na mara baada

ya utafiti kumalizika yataharibiwa kutokana na muelekezo wa taasisi ya masuala ya utafiti

(COMREC). Taarifa zako zitapitiwa na msimamizi wa utafiti, wataalamu wa utafiti pamoja na

idara ya afya ya jamii chuo cha Malawi. Fomu zote za utafiti pamoja na mazungumzo

yaliyorekodiwa yatahifadhiwa katika loka/ kabati ambalo litafungwa kwa ufunguo katika chuo cha

Malawi.

Ajali zitokanazo na utafiti

Hatutegemei kuwa utapata ajali kwa kushiriki kwenye huu utafiti, hata hivyo ikitokea umeumia

kutokana na utafiti huu, wataalamu wa utafiti watakupatia matibabu yanayostahili na hutolipia

haya matibabu. Ghrama zote za matibabu zitalipwa na wataalamu wa utafiti. Hakutakuwa na

malipo au fidia yoyote kutokana na ajali.

Kwa mawasiliano zaidi au maulizo.

81

Kwa maswali kuhusu huu utafiti wasiliana na:

• Dk. Sylvia Denis Moshi, mtafiti mkuu kwa namba ya simu 0767 041648 / 0717 041648 au

kwa barua pepe; denis.sylvia.denis@gmail.com

• Dk. Linda Nyondo Mipando, msimamizi wa utafiti chuo kikuu cha afya Malawi kwa simu

namba, +265 999 44 12 12 au kwa barua pepe; lmipando@medcol.mw

• Dk. Joan Rugemalila, msimamizi wa utafiti huu pia kwa namba +255 784 660 517 au kwa

barua pepe: joanrugemalila@gmail.com

• Na mwakilishi wa NIMR kwa namba: +255 758 587885

Kama umesoma au kuelezwa na umeelewa fomu hii tafadhali weka sahihi au alama ya kidole

gumba, uweze kushiriki.

ASANTENI SANA

82

Appendix 2: Data Collection Tools

Appendix 2.1: Questionnaire in English

Study title: Factors associated with retention in care among PLHIV/AIDS in Ubungo

Municipality.

PI Version Date: Version 2.0, March 24, 2021

Investigators: Dr. Sylvia Denis Moshi

Research Supervisor: Dr. Linda Nyondo Mipando and Dr. Joan Rugemalila

Questionnaire No:

Client’s unique number: _______ Clinic Name: ________ Date of interview: ____

Socio demographic data

1. Gender

a) Male

b) Female

2. Age_____ Date of Birth ___________

3. Marital Status

a) Single

b) Married

c) Divorced

d) Separated

e) Widowed

4. Level of Education

a) None

b) Primary

c) Secondary

d) College/ University

5. What is your occupation?

a) Employed

b) Self-employed

c) Unemployed

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d) Casual

6. What is your income per month? (Tshs.)

a) <10000

b) 10,000 – 50,000

c) 50,001 –100,000

d) 100,001- 200,000

e) > 200,000

f) Not willing to say

7. Have you disclosed your HIV status to anyone?

a) Yes

b) No one (Go to No. 9)

8. To whom one?

a) Spouse

b) Family members

c) Friends

9. Why did you disclose your status?

a) Seeking for comfort/support

b) Need fo financial support

c) Any other …………………………………….

10. How was their reaction

a) Positive

b) Negative

c) Unknown

11. How have you been supported seeking care?

a) Reminded to take drugs

b) Company to the clinic

c) Financial support

d) Reminded to attend my appointments

e) Social support

12. Why have you not disclosed to any one?

a) I’m afraid to be stigmatized and discriminated

b) I’m afraid to be divorced

c) I’m afraid to lose my job

d) No reason

13. Were you informed of where to go for treatment and care in case you cannot access the

facility?

a) Yes

b) No

84

14. Have you ever sought care and treatment services from another facility apart from the one

you are enrolled in?

a) Yes

b) No

15. If yes, what services were you seeking?

a) Treatment

b) Refill (ARVs/Septrin)

c) Lab tests (Viral load check)

d) Others…….

16. What is your view towards health workers in this Clinic?

a) Good

b) Average

c) They stigmatize clients

d) Others.………

17. How many hours do you take to reach to the clinic?

a) < 30 mins

b) One hour

c) Two hours

d) Three hours

e) > 3hours

18. How much do you spend for coming to the Clinic? (In Tshs)

a) None

b) 1000

c) 2000

d) 5000

e) >5000

f) Any other…………..

19. How long do you take to be attended in this Clinic?

a) < 30 Mins

b) 30 Mins

c) 1 – 2 Hours

d) 2 – 3 Hours

e) > 3 Hours

20. How do you comment on time you spend in the clinic?

a) Short

b) Average

c) Long

d) Too long

21. Do you think missing clinic appointments puts your health at risk?

a) Yes

85

b) No

22. Have you ever missed your clinic appointment for any reason?

a) Yes

b) No

23. If yes, what made you miss your clinic appointments?

a) I forgot

b) I am using herbal medicine

c) I attend to traditional healers / prayers

d) my health has improved

e) I was very sick

f) no support from friends and families

g) other reason

24. How many times have you missed your clinic appointments?

a) Once

b) Twice

c) Thrice

d) >Thrice

25. Have you been counseled on the dangers of missing your appointments, care and treatment?

a) Yes

b) No

26. For how long did you stop being followed up in care and treatment?

a) < 3 Months

b) 3 Months

c) >3 Month

d) 6 – 12 Months

e) > 12 Months

27. How was your health during this period you were lost to follow up?

a) I was well/Not sick

b) I was well initially but later got sick

c) Was always sick

d) Any other reason:……………………………..

28. Were you on ARVs when you missed your clinic appointments?

a) Yes

b) No

29. If yes, where were you accessing your ARVs?

a) I missed taking them

b) Picked at another facility

c) I borrowed from spouse/friend/relative

d) Any other reason……………………..

30. What brought you back to the clinic?

86

a) I was followed up

b) Was counseled by a friend

c) Accepted my status and decided to come back

d) I was sick

e) Any other reason:………………………

31. How do you prefer to be followed up and reminded to attend your scheduled clinic

appointments? (Tick as appropriate)

a) Phone call

b) SMS (short message service)

c) Home visit/home based care

d) Treatment buddy

e) None

Thank you for your time and participation

87

Appendix 2.2: Questionnaire in Swahili

Kichwa cha utafiti: Sababu zinazohusiana na wateja wa UKIMWI kudumu kwenye huduma

katika manispaa ya Ubungo.

PI TOLEO LA TAR: 2.0 Machi 24, 2021.

Mtafiti: Dk. Sylvia Denis Moshi, mwanafunzi wa shahada ya uzamili, katika chuo kikuu cha afya,

Malawi.

Msimamizi wa utafiti; Dk. Linda Nyondo Mipando na Dk. Joan Rugemalila

Dodoso Na…….. Namba ya mteja: --------- Jina la kliniki ………….. Tar. Ya mahojiano…

Taarifa muhimu

1. Jinsia

a) Mwanaume

b) Mwanamke

2. Umri wako

Miaka …………. Tar. Ya kuzaliwa

3. Hali ya ndoa

a) Sijaolewa/ Sijaoa

b) Nimeolewa/Nimeoa

c) Nimeachwa kwa talaka

d) Nimeachika

e) Mjane

4. Hali ya elimu

a) Sijasoma

b) Elimu ya msingi

c) Elimu ya sekondari

d) Elimu ya diploma/setifiketi

e) Elimu ya chuo kikuu

5. Kazi yako ni nini?

a) Nimeajiriwa

b) Nimejiajiri

c) Sina ajira

88

6. Kipato chako kwa mwezi ni shilingi ngapi? (Tshs.)

7. <10000

8. 10,000 – 50,000

9. 50,001 –100,000

10. 100,001- 200,000

11. > 200,000

12. Not willing to say

13. Je, umemjulisha mtu yoyote juu ya hali yako ya maambukizi?

a) Ndiyo

b) Hapana

14. Je, ni kwa nini, umetoa taarifa kuhusu hali yako ya maambukizi?

a) Kupata faraja na msaada wa kifamilia

b) Kusaidiwa kiuchumi

c) Sababu nyingine yeyote:,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

15. Je, umesaidiwa vipi, kupata huduma?

a) Nimekumbushwa kumeza dawa

b) Nimesindikizwa kliniki

c) Nimesaidiwa kifedha

d) Nimekumbushwa kuhudhuria kliniki

e) Sijasaidika na chochote

f) Zingine……………….

16. Ni, kwa nini hujamshirikisha mtu yoyote hali yako ya maambukizi?

a) Naogopa kunyanyapaliwa na kutengwa na jamii

b) Naogopa kuachwa na mwenza /mpenzi wangu

c) Naogopa kuachishwa kazi

d) Hakuna sababu

e) Zingine…..

17. Je, umeshawahi kushauriwa juu ya madhara ya kutokuhudhuria kliniki, kukosa huduma au

matibabu?

a) Ndiyo

b) Hapana

18. Je, umeshawahi kushauriwa mahali ambapo unaweza kupata huduma ikitokea hauwezi

kuhudhuria kwenye kituo chako?

a) Ndiyo

b) Hapana

19. Je, umeshawahi kuwaza kupata huduma kwenye kituo kingine tofauti na kituo chako cha

siku zote?

a) Ndiyo

b) Hapana

20. Kama ni ndiyo, je ni nini sababu ya kufanya hivyo?

89

a) Kupata matibabu

b) Huduma ya kituo changu hairidhishi (siyo nzuri)

c) Kuchukua dawa

d) Watoa huduma hawanijali

e) Kupata vipimo

f) Sababu nyingine…………..

21. Je, ni nini mtazamo wako kuhusu watoa huduma wa hapa kituoni?

a) Mzuri

b) Wa kawaida

c) Wananyanyapaa wateja

d) Nyingine……….

22. Je, inakuchukua masaa mangapi kufika kituoni?

a) Chini ya nusu saa

b) Nusu saa

c) Lisaa limoja hadi mawili

d) Masaa matatu

e) Zaidi ya masaa matatu

23. Je, unatumia fedha kiasi gani kuja kliniki? (Tshs)

a) Situmii fedha (natembea)

b) 1000

c) 2000

d) 5000

e) >5000

24. Je, inakuchukua muda gani kuweza kupata huduma?

a) Chini ya nusu saa

b) Nusu saa

c) Nusu saa hadi lisaa

d) Masaa mawili

e) Masaa matatu

f) Zaidi ya masaa matatu

25. Je, unauonaje muda unaoutumia kupata huduma?

a) Mfupi

b) Wa kawaida

c) Mrefu

d) Mrefu sana

26. Je, unafikiri kwamba kwa kukosa kuhudhuria klinik kunahatarisha afya yako?

a) Ndiyo

b) Hapana

27. Je, umeshawahi kukosa kuhudhuria kliniki kwa sababu yoyote ile?

90

a) Ndiyo

b) Hapana

28. Kama ndiyo, sababu ilikuwa ni nini?

a) nilisahau

b) afya yangu iliimarika hivyo nikaacha kutumia dawa

c)natumia dawa za kienyeji

d)natibiwa na waganga na maombi

e) hakuna msaada wowote pindi nikizidiwa

f) sababu nyingine yeyote

29. Je, ni mara ngapi umekosa kuhudhuria kliniki?

a) Mara moja

b) Mara mbili

c) Mara tatu

d) Zaidi ya mara tatu

30. Je, ni kwa muda gani umeacha kuja kwenye huduma?

a) Chini ya miezi mitatu

b) Ni Zaidi ya miezi mitatu

c) Miezi sita hadi kumi na mbili

d) Zaidi ya miezi kumi na mbili

31. Je, afya yako ilikuaje kwa kipindi chote ambacho ulikuwa hauhudhurii kliniki?

a) Nilikuwa sijambo/siumwi

b) Nilikuwa mzima mwanzoni, baadaye nikaanza kuumwa

c) Nilikuwa naumwa mar azote

d) Sababu nyingine

32. Je, ulikuwa unatumia dawa ulipokuwa hauhudhurii klinilk?

a) Ndiyo

b) Hapana

33. Kama ni ndiyo, je ulikuwa unapata wapi dawa?

a) Niliacha kutumia

b) Nilichukua kituo kingine

c) Nilipata kwa mwenza wangu/rafiki/ndugu

d) Sababu nyingine……………….

34. Je, ni nini kimekufanya urudi kliniki?

a) Nilifatwa kurudi kituoni

b) Nilishauriwa na rafiki yangu

c) Nimeikubali hali yangu na kuamua kurudi kwenye huduma

d) Nilikuwa naumwa

35. Je, unatamani vipi kupata huduma ya kukumbushwa kuhudhuria kliniki?

a) Kupigiwa simu

b) Kutumiwa meseji

91

c) Kutembelewa nyumbani

d) Nyingine……

Asante kwa kushiriki

92

Appendix 2.3: Topic guide for In- depth interview (IDI) for patients living with HIV/AIDS

in English

PI Version Date: 2.0, March 24, 2021

SOCIO DEMOGRAPHIC HISTORY

1. How old are you…….… years (Estimate if unsure)

2. What is your current marital status?

a) Single e) Separated

b) Married f) Divorced

c) Living with partner g) Widowed

d) Never married

3. What is your religion?

a) Roman Catholic

b) Muslim

c) (Seventh Day Adventist) SDA

d) Pentecostal

e) Anglican

f) Other (Specify) _____________

4. What is your Tribe...?

5. What is your highest level of education?

a) No schooling

b) Primary school

93

c) Secondary Education

d) Advanced Secondary Education

e) Attended College/University

6. Are you able to read?

a) Yes

b) No

7. What is your occupation?

8. Can you explain in details the factors contributing to poor retention in care among people

living with HIV/AIDS?

9. Can you explain in details the factors leading to the uptake of care among people living

with HIV/AIDS?

For question 8 and 9

Probe the factors related to:

Health systems, clinic flow, operation times and days, human resources, health

worker attitudes and skills, policies in the clinic, waiting time.

Individual factors and community factors: geographical distances, transport

cost.

10. Can you explain in detail the measures that should be done in order to improve retention

in care among people living with HIV/AIDS?

11. What are the measures that you think cannot be implemented and why?

12. What are the measures that has been implemented but still retention is poor? /Why is there

poor retention despite of the measures that has been implemented?

Probe on clinic based strategies, community based strategies and mobile strategies.

Thank you very much for your cooperation and time; you are welcome to ask questions if

any. I appreciate for sparing your time to share your views with us.

94

Appendix 2.4: Topic guide for In-depth Interview (IDI) for Patients living with HIV/AIDS

in Swahili

PI TOLEO LA TAR: 2.0 Machi 24, 2021.

TAARIFA ZA KIJAMII

1. Una umri gani? ….. (Unaweza kukadiria)

2. Je, hali yako ya kindoa ipojee?

a) Nimeolewa/ Nimeoa

b) Tunaishi wote

C) Sijaolewa/Sijaoa

d) Tumeachana

e) Tumetalakiana

f) Mjane

3. Dhehebu lako ni lini??

a) Mkatoliki

b) Muislamu

c) Mpentekoste

d) Msabato

e) Dhehebu jingine lolote: _____________

4. Kabila lako ni lipi...

5. Je elimu yako ni ipi?

a) Sijasoma

b) Shule ya msingi

c) Shule ya sekondari

d) Elimu ya chuo kikii

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6. Je, unauwezo wa kusoma?

a) Yes

b) No

7. Je, kazi yako ni nini?

8. Je, Unaweza ukatuambia vitu/mambo gani yanayomfanya mteja wa maambukizi ya UKIMWI

kushindwa kudumu katika/kwenye huduma?

9. Je, unaweza ukatumbia vitu vinavyomfanya mteja wa maambukizi ya UKIMWI kuendelea

kubaki kwenye huduma?

Kwa swali namba 8 na 9

Peleleza vitu vinavyohusiana na:

Mfumo wa utoaji huduma, mpangilio wa kliniki, muda wa kufanya kazi na siku

za kazi, nguvu kazi wa watu/wafanyakazi, mtazamo wa wafanyakazi na

mtazamo wao pamoja na ujuzi/uzoefu sera za kliniki pamoja na muda wa

kusubiria huduma.

Sababu za mtu binafsi pamoja na za jamii: sehemu mtu anayoishi- umbali,

gharama za usafiri. n.k

10. Je, unaweza ukatuambia ni vitu gani ambavyo vinaweza kufanyika ili kuweza

kuwadumisha wateja wa maambukizi ya UKIMWI kwenye huduma?

11. Je ni vitu/mambo gani unadhani hayawezi kutekelezeka?? Na ni kwa nini?

12. Je ni vitu gani ambovyo tayari vimekwisha kufanyika lakini bado wateja hawajaweza

kubaki kwenye huduma? / Je ni kwa nini bado wateja hawabaki kwenye huduma licha ya

jitihada mbalimbali zinazofanywa na mashirika yanayofadhili hizi huduma.

Peleleza kuhusu mikakati ya kliniki, mikakati ya kijamii pamoja na kliniki za mitaani.

Mtazamo wa wahudumu kuhusu jitihada za haya mashirika.

ASANTE SANA KWA MUDA WAKO NA KWA KUWEZA KUSHIRIKI KATIKA

MAJADILIANO HAYA. KAMA UNA MASWALI YOYOTE TAFADHALI JISIKIE

HURU KUULIZA

96

Appendix 2.5: Key Informant Interview Guide (KII) for Health Care Workers in English

PI Version Date: 2.0, March 24, 2021

SOCIO DEMOGRAPHIC HISTORY

1. How old are you…….… years (Estimate if unsure)

2. What is your current marital status?

a) Never married d) Separated

b) Married e) Divorced

c) Living with partner f) Widowed

3. What is your religion?

a) Roman Catholic

b) Muslim e) Pentecostal

c) Seventh Day Adventist (SDA)

d) Anglican

f) Other (Specify) _____________

4. What is your Tribe?

5. What is your highest level of education?

a) No schooling

b) Secondary Education

c) Advanced Secondary Education

d) Attended College/University

6. Are you able to read and write?

a) Yes

b) No

97

7. What is your occupation?

8. As a medical personnel, can you explain in details the factors contributing to poor retention in

care among people living with HIV/AIDS?

9. Due to your experience, what are factors leading to the uptake of care/ retention in care among

people living with HIV/AIDS?

For question 8 and 9

Probe the factors related to:

Health systems, clinic flow, operation times and days, human resources, health

worker attitudes and skills, policies in the clinic, waiting time.

Individual factors and community factors: geographical distances, transport

cost.

Health care workers factors such as, attitude, arrogance, laziness, no caring.

10. Can you explain in detail the measures that should be done in order to improve retention

in care among people living with HIV/AIDS?

11. Due to your experience, what are the measures that you think cannot be implemented and

why?

12. What should be done in order for those factors to be implemented?

13. What are the measures that has been done but still, the retention is poor? /Why is there poor

retention despite of the measures that has been implemented?

Probe on clinic based strategies, community based strategies and mobile strategies.

THANK YOU SO MUCH

98

Appendix 2.6: Key Informant Interview Guide (KII) for Health Care Workers in Swahili

PI TOLEO LA TAR: 2.0 Machi 24, 2021.

TAARIFA ZA KIJAMII

1. Una umri gani?

2. Je, hali yako ya kindoa ipojee?

a) Sijaolewa/ Sijaoa d) Tumeachana

b) Nimeolewa/ Sijaoa e) Tumetalakiana

c) Tunaishi wote f) Mjane

3. Dhehebu lako ni lini??

a) Mkatoliki

b) Muislamu

c) Msabato

d) Mpentekoste

e) Dhehebu jingine lolote: _____________

4. Kabila lako ni lipi?

5. Je elimu yako ni ipi?

a) Sijasoma

b) Shule ya msingi

c) Shule ya sekondari

d) Elimu ya chuo kikuu

6. Je, kazi yako ni nini?

………………………………

7. Je, wewe kama muhudumu wa afya, unaweza ukatuambia ni vitu/ mambo gani yanayomfanya

mteja wa maambukizi ya UKIMWI kushindwa kudumu kwenye huduma?

8. Kwa uzoefu wako katika utoaji wa huduma kwa wateja hawa, je ni vitu gani ambavyo unaona

ndo vinawafanya wabaki kwenye huduma.

99

Kwa maswali namba 7 & 8:

Peleleza vitu vinavyohusiana na;

Mfumo wa utoaji huduma, mpangilio wa kliniki, muda wa kufanya kazi, nguvu kazi watu,

kama vile idadi ya wafanyakazi, mtazamo wa wafanyakazi pamoja na uzoefu/ujuzi, saa za

kliniki na muda wa kusuburi huduma.

Sababu za wafanyakazi kama vile ujeuri, kutokujali, uvivu, n.k

Sababu za wateja pamoja na za jamii kama vile, sehemu mtu anayotoka (umbali), gharama,

mtazamo wa jamii yake na huu ugonjwa, msaada wa familia na jamii.

9. Je unaweza ukatuambia ni vitu gani ambavyo vinaweza kufanyika ili kuweza kuwadumisha

wateja hawa kwenye huduma?

10. Kwa uzoefu wako, je unadhani ni mambo gani ambay hayawezi kutekelezeka na ni kwa nini?

11. Je, nini kifanyike ili mambo hay ohayo yaweze kutekelezeka?

12. Je ni vitu gani ambavyo tayari vimekwisha fanyika lakini bado wateja hawajaweza kubaki

kwenye huduma?

13. Je ni kwa nini bado wateja hawabaki kwenye huduma licha ya jitihada mbalimbali za mashirika

yanayofadhili hii huduma?

Peleleza kuhusu mikakati ya kliniki, mikakati ya kijamii, pamoja na kliniki za mitaani.

Mtazamo wa wahudumu kuhusu haya mashirika.

Asante Sana

100

Appendix 3: COMREC clearance letter

The chairperson of OMREC; Prof Eric Umar.

101

Appendix 4: NIMR clearance letter

102

103

Appendix 5: Research Permit from Ubungo Municipal

104

Appendix 6: Gantt chart

# Task Responsible

Personnel

Timelines

Sep

20

Oct

20

Nov

20

Dec 20–

Feb 21

Mar

21

Apr

21

May

21

June

21

July

21

Aug-

Sept

21

Oct-

Dec

21

1. Finalize

research

proposal

Principal

Investigator (PI)

2. IRB

Approval

PI & Dept of

Public Health

NIMR

submission

&

clearance

COMREC

submission

&

clearance

3. Data

collection

Principal

Investigator (PI)

4. Data

handling

and

analysis

Principal

Investigator (PI)

5. Thesis

writing

Principal

Investigator (PI)

6. Thesis

presentatio

n

Principal

Investigator (PI)

7. Thesis

submission

Principal

Investigator (PI)

105

8. Dissertatio

n final

submission

Principal

Investigator (PI)