1. i
ZANZIBAR REVOLUTIONARY GOVERNMENT
MINISTRY OF HEALTH AND SOCIAL WELFARE
ZANZIBAR AIDS CONTROL PROGRAMME
SITUATION RESPONSE ANALYSIS OF PMTCT, VCT AND CCT SERVICES IN ZANZIBAR
FINAL REPORT
November 2009

2. ii
On 19th
November 2009, the consultants presented the results of the Situation Response
Analysis to a 40-member Technical Working Group (TWG) for discussion and validation.
All the comments received from the TWG have since been integrated into this final report. The
recommendations therein were agreed upon by the TWG.
Submitted to Zanzibar AIDS Control Programme by:
Dr. Wairimu Muita, Lead Consultant: ___________________________________
Date: _______________________________

3. iii
TABLE OF CONTENTS
ACKNOWLEDGEMENTS v
LIST OF ACRONYMS vi
EXECUTIVE SUMMARY vii
1. BACKGROUND PROGRAMME INFORMATION 1
1.1 Vision of the National HIV and AIDS Programme 1
1.2 Programme Mission 1
2. INTRODUCTION TO THE SITUATION RESPONSE ANALYSIS 2
2.1 Purpose of the Situation Response Analysis 2
2.2 Objectives of the Situation Response Analysis 2
3. SITUATION RESPONSE ANALYSIS METHODOLOGY 3
3.1 Sampling Procedures 3
3.2 Data collection 5
3.3 Pre-testing of tools 5
3.4 Populations targeted at the health facilities 5
3.5 Ethical considerations 6
3.6 Limitations 6
4. HIV AND AIDS PROGRAMMATIC ISSUES 7
4.1 Coordination of HIV and AIDS services 7
4.2 The Ministry of Health and Social Welfare 8
4.3 Funding Mechanisms 10
4.4 Contributions of the UN and Development Partners in
Preventive Services 10
4.5 Contributions of private agencies, NGOs and FBOs in HIV
preventive services 11
5. HUMAN RESOURCE AT VARIOUS VCT, PMTCT AND CCT SITES 12
5.1 Staffing at the various sites 12
5.2 A Demographic Profile of the Service Providers Interviewed 12
5.3 HIV and AIDS training 14
6. THE TARGET POPULATIONS OF THE PREVENTIVE SERVICES 19
6.1 Respondents among clients of VCT, PMTCT and CCT services 19
6.2 Most at risk populations (MARPs) defined 20
7. COVERAGE OF HEALTH EDUCATION 21
7.1 Target population for health education 21
7.2 Health education topics 22
7.3 Outreach Services 23

4. iv
7.4 IEC materials for Health education 23
8. STI DIAGNOSIS AND TREATMENT 26
8.1 Syphilis test and treatment in PMTCT sites 26
8.2 Service providers’ awareness of STI syndromic management 27
8.3 Infections other than HIV health workers fear contracting at work place 27
8.4 Partner involvement 28
8.5 STIs Prevention: Missed Opportunities 29
9. COUNSELLING AND TESTING 30
9.1 Counselling in VCT and PITC 30
9.2 Counselling and testing in PMTCT 31
9.3 HIV in infants 36
9.4 Enrolment of HIV positive children in care and treatment clinics 39
9.5 Components of CCT for adults in Zanzibar 43
9.6 Integration of TB and CCT services 46
10. LINKAGES BETWEEN HIV SERVICES AND OTHER SERVICES 48
10.1 Home-based care 48
10.2 Referrals 49
10.3 Receiving Referrals 49
10.4 Sending referrals 51
10.5 Successes and problems associated with referrals 51
10.6 Monitoring and Evaluation 52
11. NGOS: GEOGRAPHICAL DISTRIBUTION AND CAPACITY 53
1.1 Geographical Distribution of NGOs providing HIV Preventive
Services 53
11.2 The Capacity of NGOs providing HIV preventive services 53
12. ACCESSIBILITY OF VCT, PMTCT AND CCT SERVICES 56
12.1 Distance to health facility 56
12.2 Cost of services 57
12.3 Waiting times 57
12.4 Clients’ perceptions of the HIV-related services received 58
12.5 Health care provider gender preferences of the clients 58
12.6 The presence of stigma and discrimination against PLHIV and MARPs 59
13. RECOMMENDATIONS 61
14. REFERENCES 66
15. APPENDICES 67

5. v
LIST OF TABLES AND CHARTS
Table 3.1: Details of health facilities sampled 4
Table 3.2: List of organizations for key informants 4
Table 3:3 Health Facility Personnel Interviewed by Site 5
Table 5.1: Training received by VCT Health Care Providers interviewed 15
Table 5.2: Training received by PMTCT Health Care Providers interviewed 16
Table 5.3: Training received by CCT health care providers interviewed 17
Table 5.4: Human Resource-related Strengths and Weaknesses 18
Table 8.1: Reported types of infections likely to be contracted at the workplace 28
Table 9.1: Information provided to clients during pre-test counseling 30
Table 9.2: The importance of Post-test Counselling as reported by the health
care providers 32
Table 9.3: Use of Contrimoxazole prophylaxis in children 39
Table 9.4: Types of ARV drug formulations available at sites 40
Table 9.5: Reported importance of adherence counseling 43
Table 9.6: Type of adherence counseling information CCT personnel give clients 43
Table 9.7: Components of CCT services provided at clinics 44
Table 9.8: Problems experienced during service provision and suggested solutions 46
Table 10.1: Sites from which HIV clinics draws their referrals 50
Table 10.2: Number of VCT, PMTCT and CCT sites to which HIV clinics send
their referrals 50
Table 10.3: Site–related successes, problems and adequacy of referrals 51
Table 12.1: Average waiting times: Health care providers’ and clients’ reports 57
CHARTS
Chart 5.1: Age groups of respondents in health facilities 12
Chart 5.2: Service duration in specific site 14
Chart 6.1: Reported IEC Materials Availability 24
Chart 8.1: Respondents’ suggestions regarding how to improve male
partner involvement 29
Chart 9.1: Respondents’ views on breach of confidentiality 34
Chart 10.1: Proportion of Service Sites Offering Home-based Care 48
BOXES
Box 6.1: VCT, PMTCT and CCT Clients Interviewed 19
Box 6.2: Special Population Groups 21
Box 12.1: The Opening Hours of the Health Facilities Visited 58

6. vi
ACKNOWLEDGEMENTS
This report was written by Drs. Wairimu Muita (lead consultant) and Maryam S. Hemed and
Bartholomew Katole (national consultants).
Many people and organizations have contributed to the successful completion of the Situation
Response Analysis.
The analysis would not have been possible without the exceptional input of the members of the
technical working group (TWG) that provided advice and guidance. The recommendations in
Section 13 of this report are those of this working group. The contributions of this dynamic
TWG are acknowledged and deeply appreciated.
We are grateful to the management of ZACP for the support accorded to us throughout the six
week period. We were well taken care of and are most grateful to the staff of ZACE. Each
ZACP driver assigned to us at any given time had to wait for us as we worked until late in the
night and they never complained. To them we say thank you.
The support from the UNJOINT, UNICEF and PEPFAR/CDC has made this Situation Response
Analysis possible and our gratitude is deeply appreciated.
Additional to the above, many others have contributed to this work. In particular the
contributions of the following are most appreciated: the key informants, officers in charge of the
various service sites, lab technicians, health care providers and clients from public and private
health institutions and NGOs and FBOs.
Support from all the partners working on the ground and providing support to the MOHSW
response to HIV is acknowledged and appreciated.

7. vii
ACRONYMS
ABC Abstain, be faithful or use a condom
AIDS Acquired Immune Deficiency Syndrome
ANC Ante –natal clinic
ART Anti-retroviral therapy
ARV Anti-retroviral
CHN Community Health Nurses
BCC Behaviour Change Communication
CCT Comprehensive care and treatment
CDC Centre for Disease Control and Prevention
CTC Care and treatment
CHAI Clinton ……
DACCOM District AIDS Coordinating Committee
DHMT District Health Management Team
FP Family planning
FBO Faith-based organization
HAART Highly Active Anti Retroviral Therapy
HBC Home-based care
HEU Health education unit
HBC Home Based Care
HIV Human Immune deficiency Virus
HR Human relations
HSSP Health Sector Strategic Plan
HSRS
IEC Information, Education, Communication
IDUs Intravenous drug users
IMAI Integrated management of adult illnesses
IMCI Integrated management of children’s illnesses
MARPs Most at risk populations
MDM Medicos Del Mundo
MoHSW Ministry of Health and Social Welfare
M&E Monitoring and evaluation
MTCT Mother to child transmission
MSM Men who have sex with men
NGOs Non-governmental organizations
OIs Opportunistic Infections
PEP Post Exposure Prophylaxis
PEPFAR Presidential ….
PHCC Primary Health Care Centre
PHCU Primary health care units
PHN Public Health Nurse
PITC Provider Initiated Counseling and Testing

8. viii
PLHIV People living with HIV
PMTCT Prevention of Mother to Child Transmission
RCH Reproductive and Child Health Programme
RGZ Revolutionary Government of Zanzibar
SHACCOM Shehia AIDS Coordinating Committee
STIs Sexually Transmitted Infections
SW Sex worker
TB Tuberculosis
TBA Traditional birth attendants
UN United Nations
UNDP United Nations Development Programme
UNFPA United Nations Fund for Population Activities
UNICEF United Nation’s Children Fund
UN JOINT Joint United Nations Programme
URT United Republic of Tanzania
VCT Voluntary HIV Counselling and Testing
WB The World Bank
WHO World Health Organisation
ZACP Zanzibar AIDS Control Programme
ZANGOC Zanzibar Non Governmental Organisation Coalition
ZAPHA+ Zanzibar Association of People living with HIV
ZNSP Zanzibar National HIV and AIDS Strategic Plan
ZYF Zanzibar Youth Forum

9. ix
EXECUTIVE SUMMARY
Zanzibar’s response to HIV and AIDS goes back to late 1986 when the first three HIV cases
were identified (ZAC, 2008). After its establishment in 1987, Zanzibar AIDS Control Programme
(ZACP) formulated the Medium Term Plans to inform the initial national response to HIV.
A population-based HIV survey in Unguja and Pemba reported a prevalence rate for the general
population of 0.6% (HIV sentinel surveillance 2008). Zanzibar has a concentrated epidemic, that
is highest among most at risk populations (MARPs) including intravenous drug users (IDUs),
sex workers (SWs) and men who have sex with men (MSM), among others. The risk of HIV is
reported to be four to six times higher among females than males (RGZ, 2007).
The Vision of HIV and AIDS Programme is to contribute to the attainment of the Zanzibar
National Strategic Plan’s vision “to have a Zanzibar population which is free from the HIV and
AIDS threat and which has a sense of caring and supporting all those citizens infected and
affected by HIV and AIDS”. The Programme’s Mission is to consolidate and build on the
achievements of the health sector response to HIV and AIDS by improving access to a
comprehensive HIV and AIDS care, treatment and prevention in an efficient, coordinate,
equitable and dignified manner
Since its inception, ZACP has periodically carried out monitoring and evaluation (M&E) activities
at all levels, but despite many issues having emerged, these have so far not been systematic.
The Situation Response Analysis of voluntary testing and counseling (VCT), prevention of
mother to child HIV transmission (PMTCT) and comprehensive care and treatment (CCT)
services throughout Zanzibar, is expected to fill this gap, by providing insights into what is really
happening on the ground, identifying strengths, weaknesses and gaps and recommending
opportunities for improvement. The Purpose of the Situation Response Analysis is to review
the existing HIV-related health services in Zanzibar in terms of scope, quality, linkages and
coordination. It has two broad objectives:
a. Review the current implementation status of PMTCT, VCT and CCT services in terms of
scope, quality, coverage and linkages in Zanzibar
b. Assess the capacity of collaborating NGOs/FBOs and private organizations in the provision
of HIV-related services with special emphasis (MARPs).
The Methodology of the Situation Response Analysis
A combination of systematic random and purposive sampling techniques were employed to
sample eight primary health care units (PHCU), three private, faith- and non-governmental
organizations (FBOs/NGOs), two cottage hospitals, two district and two tertiary hospitals from
which data was later collected from 65 service providers in four (50%) CCT, 10 of 29 PMTCT
and 13 of 44 VCT sites in Zanzibar. Snowball sampling was used to draw the agencies from
which key informants were later drawn.
Different structured schedules for different populations were used to collect quantitative data
from health facility personnel – officers in charge of VCT, PMTCT and CCT sites, laboratory
technicians and health care providers in these three sites. In addition, different question
guides were also used to gather qualitative data from key informants. Research ethics were

10. x
strictly observed. EPI INFO and SPSS were used to analyze the quantitative data, while the
qualitative was analyzed thematically.
Results of the Situation Response Analysis
Generally, Zanzibar’s response to HIV at programme and health facility level is promising and
has good donor support.
Programmatic issues: Zanzibar AIDS Commission is the overall coordinator of the national
HIV response and that of the non-health sector, while the medical/health national response is
coordinated by ZACP. The former is responsible for facilitating the formulation of HIV policies
and strategic plans, multisectoral approaches and monitoring and evaluation among others.
The national response to HIV is guided by the HIV and AIDS Policy and Strategic Plan.
Although PMTCT, VCT and other guidelines exist, there is little if any evidence that they are
being used at health facility level.
Human resource: There is an apparent gender imbalance among the service providers in VCT,
PMTCT and CCT sites. The MOHSW is evidently working towards increasing male (partner)
involvement particularly in the PMTCT and RCH services, and the service provider gender
imbalance could affect these efforts. Forty-eight percent of the service providers in the three
sites are aged at least 45 years old and will retire from formal service in the next 15 years. The
personnel serving at the VCT, PMTCT and CCT are relatively knowledgeable and possess
positive attitudes towards service to people living with HIV (PLHIV). They are also relatively
well trained and have had a good mix of training in their core (VCT, PMTCT and CCT) service
areas. There are however training gaps in areas such as integrated management of adult
illnesses (IMAI), provider initiated treatment and care (PITC), tuberculosis/HIV and in monitoring
and evaluation (M&E). The existing personnel at site level is over-stretched and this is likely to
get worse with time if no measures are put in place to mitigate the situation.
Infrastructure and service delivery: The existing infrastructure allows for the delivery of HIV-
related services within the existing health care facilities and for integration of such services as
PMTCT and RCH without the demand for immediate construction of new buildings. Some
health facilities however do not have adequate seating space for clients and their partners and
some facilities use counseling rooms that do not allow sufficient client privacy.
Supplies & Equipment: There is one CD4 machine in Unguja and another in Pemba, but no
PCR machine is either and related services have to be sought from the Mainland. There are
reports of delays sometimes as long as two months before some health facilities receive the
results of the samples sent for analysis. Zanzibar has an adequate supply of HIV diagnostic
kits, ARV drugs, STIs and opportunistic infection drugs.
Linkages Integration of Services: The private sector, non-governmental and faith based
organizations (NGOs/FBOs) complement the MOHSW response to HIV. Continuum of health
care is ongoing through appropriate integration of HIV, PMTCT and RCH, as well as family
planning (FP) and comprehensive care and treatment services. The Ministry is offering free

11. xi
HIV&AIDS services e.g. testing, counseling and TB services in all public health facilities, which
fosters equity in HIV-related services
Monitoring and Evaluation: Since its establishment, ZACP has carried out M&E activities at
programme and health facility levels. There is a uniform data collection and reporting system
for all health facilities irrespective of ownership, although the extent to which these data are
being analyzed and results applied and shared with the programme implementers is unclear.
Research studies are periodically being carried out to keep track of HIV trends.
There exists an effective operational referral system in Zanzibar that is extended to United
Republic of Tanzania. There are reports however from the small clinics of delayed and/or lack
of feedback of the results from both the Mainland and Mnazi Mmoja – Zanzibar’s referral
hospital.
Health education on HIV/AIDS issues: HIV and AIDS-related health education is provided five
days a week in almost all public and most NGO health facilities provide health education on
HIV/AIDS. Although various types of IEC materials were available at ZACP, few health facilities
were found to have any IEC materials.
STIs Prevention and Control: This is a priority area of the Zanzibar’s Health Sector HIV and
AIDS Strategic Plan. Over two-fifths (43%) of the health providers interviewed have received
training on STIs. Syphilis screening is being carried out in a third of ANC clinics, while others
report an inadequate supply of the syphilis test kits.
MARPs-targeted HIV-related services: Generally, services for MARPs are missing in most
public health facilities. Some health providers report that they do not have the necessary skills
and require further training before they can target these populations. Special clinical
arrangements may be required in order for service providers to gain the trust of MARPs.
VCT Services: 30 public and a few NGO health facilities are providing free VCT services, but
the service is often interrupted in the latter when they run out of the test kits.
PMTCT Services: 29 health facilities in Zanzibar providing PMTCT-related services and these
are provided concurrently with RCH services by the same service providers and in the same
premises, but supervised by different (ZACP and RCH) coordinators. All PMTCT personnel
interviewed have been trained on PMTCT issues and (with the exception of one) infant feeding
counselling. The Review Team noted an excellent coverage of Nevirapine prophylaxis among
positive mothers and exposed infants (100%), as well as good adherence to the feeding options
chosen and linkage to CCT, RCH and STIs services.
Comprehensive Care and Treatment (CCT) Services: 1,794 PLHIV are on ART, which is about
97% of the 2009 target of 1800. There is reliable availability of first line ARV drugs in different
formulations and CCT links to STIs, FP, TB and community services. Only eight health facilities
in the whole of Zanzibar provide CCT-related services. There is an apparent dearth of service
integration guidelines, which could lead to ad hoc integration.

12. xii
Challenges: Several service-provision challenges have been noted and among the most
prominent ones are:
 the critical understaffing in the PMTCT, VCT and CCT sites, and
 the equally critical rural/urban disparities in HIV-related health services, which favours
the urban;
 problems in the identification of exposed infants nationally
 increasing numbers of home deliveries and accompanying risks maternal and child
health-related risks, and
 the limited success in increasing male involvement in HIV-related services, particularly in
PMTCT.
Capacity of NGOs/FBOs/private Sector: These organizations have limited, albeit expandable
capacity to deliver HIV/AIDS services. They have the capacity to reach and serve MARPs and
other vulnerable populations, which could be enhanced by the MOHSW and development
partners.
Recommendations
A 40-member technical working group discussed in-depth the recommendations suggested by
the Review Team, revised and added to them. Represented in the TWG were funding
agencies, technical experts, programme coordinators and managers and service providers from
the Mainland, Unguja and Pemba. The recommendations outlined under different themes in the
Section 13 of this report are those agreed upon and therefore owned by this dynamic TWG,
which also assessed and affirmed their relevance, practicability and viability.
It is expected that ZAC and ZACP, the national programme coordinators of HIV-related health
services and other activities and their key stakeholders will further deliberate upon these
recommendations, and explore ways to implement each of them.