PEPFAR Public Health Evaluation – Care and Support – Phase I Uganda PEPFAR Public Health Evaluation – Care and Support– Phase I uganda Authors: Dr Richard Harding, Victoria Simms, Dr Suzanne Penfold, Eve Namisango, Geoffrey Banga, Claire Nsubuga, Jacqueline Teera-Ssentoogo, Dr Julia Downing, Richard A. Powell, Dr Faith Mwangi-Powell, Professor Irene J. Higginson April 2009 This summary was made possible by support from the U.S. Agency for International Development (USAID) under the terms of Cooperative Agreement GPO-A-00-03-00003-00. The opinions expressed are those of the authors and do not necessarily reflect the views of USAID or the United States government. TR-09-69d (4/14/09). Cover photo: Courtesy of MEASURE Evaluation staff. Table of Contents 5 Abbreviations 7 Executive summary 7 Rationale 7 Methods 7 Main findings 7 Recommendations 11 Introduction 11 Evaluation Aims and Objectives 12 Study Overview 13 Methods 13 Study design 13 Sampling 13 Procedure 16 Results 16 Response rate 17 Facility types 17 Weighted analysis 18 Patients 21 Infrastructure 24 Facility staff 29 Components of care offered 41 Document analysis 53 Pharmacy review 59 Facility strengths and areas for improvement: staff open-ended questions 64 Patient focus group discussions 71 Integration of data from staff open-ended questions and patient FGDs 73 Discussion 73 Selected facilities 73 Patient characteristics 73 Infrastructure 74 Staffing 75 Care provision at facilities 76 Components of care by theme 80 Pharmacy supplies 80 Facility strengths and weaknesses 81 Document analysis 82 Limitations and strengths 84 Recommendations 84 Infrastructure 84 Health management information systems 84 Staffing 84 Care provision 85 Drug supplies 85 Laboratory services 85 Documents 85 PEPFAR 85 Further research 86 References 88 Acknowledgements 89 Appendix A: Senior staff interview questionnaire 96 Appendix B: Document analysis record 97 Appendix C: Pharmacy review 100 Appendix D: Patient focus group discussion schedule 101 Appendix E: Facilities surveyed 103 Appendix F: Care components categorised for PEPFAR care and support areas 104 Appendix G: Results sharing with facilities List of Figures and Tables 16 Figure 1: Distribution of facilities visited in Uganda 17 Figure 2: Types of facilities surveyed 37 Figure 3: Distribution of elements of BCP for the 43 facilities which offer CTX 16 Table 1: Original selected sites that could not be found and their replacements 18 Table 2: Strata for facility selection 18 Table 3: Weighted analysis – facility type 19 Table 4: Patient numbers 20 Table 5: Gender distribution of patients 20 Table 6: Proportion of paediatric patients 21 Table 7: Infrastructure present at different facility types 22 Table 8: Hours per week patients can see a member of staff 23 Table 9: Frequency of appointments 24 Table 10: Payment for services 25 Table 11: Number of facilities employing at least one staff member, by designation and facility type 26 Table 12: Median number of staff members employed, by facility type 27 Table 13: Staff categories by facility type 27 Table 14: Number of facilities where staff represented solely by volunteers, by staff designation 28 Table 15: Percentage of staff who were volunteers by facility type 28 Table 16: Patient load 30 Table 17: Components of care 32 Table 18: Frequent components of care by facility type 32 Table 19: Mean number of components of care offered by facility type 33 Table 20: Number of facilities providing or referring for each area of care, by facility type 34 Table 21: Mean components of care by managing authority 35 Table 22: ART provision by facility type 35 Table 23: Availability of components of care relating to management of pain, by facility type 36 Table 24: Availability of components of care relating to psychological health, by facility type 36 Table 25: Availability of components of care relating to nutrition and social care, by facility type 38 Table 26: Availability of components of care relating to malaria and TB, by facility type 39 Table 27: Availability of components of care relating to opportunistic infections, by facility type 40 Table 28: Availability of diagnostic tests, by facility type 40 Table 29: Components of care provided onsite and staff available 41 Table 30: Proportion of patients receiving components of care 42 Table 31: Documents obtained 43 Table 32: Document examples obtained by facility type 43 Table 33: Format of documents 44 Table 34: Outgoing referral form contents 45 Table 35: Patient records 46 Table 36: Referral follow-up forms 47 Table 37: First clinical assessment sheets 49 Table 38: Ongoing contact assessment sheets 51 Table 39: Stock control sheet 52 Table 40: Patient information sheets 54 Table 41: Types and amounts of drugs stored at pharmacies 55 Table 42: Drug availability by facility type 56 Table 43: Drugs found in pharmacy compared to care directly offered by facilities 56 Table 44: Stock levels 57 Table 45: Number of stockouts per facility 58 Table 46: Drug stockouts by facility type 58 Table 47: Drug storage 59 Table 48: Senior staff interviews 65 Table 49: BCP care received by FGD participants 65 Table 50: FGD care received 110 Table 51: Infrastructure 110 Table 52: Staff categories by MOH facility type 111 Table 53: Number of facilities providing or referring for each type of care, by MOH facility type 111 Table 54: ART provision by MOH facility type 112 Table 55: Availability of components of care relating to malaria and TB. by MOH facility type 112 Table 56: Comparison of self-reported and assigned facility types 5 Abbreviations AFB acid-fast bacillus APCA African Palliative Care Association ART anti-retroviral therapy ARV anti-retroviral BCP basic care package CDC Centers for Disease Control and Prevention CHW community health worker CSRI client services receipt inventory CTX cotrimoxazole, Septrin FGD focus group discussion FT full time HBC home-based care HCW healthcare worker IGA income-generating activity IQR inter-quartile range ITN insecticide treated bednet KCL King’s College London LFT liver function test MOH Ministry of Health NGO non-governmental organisation OI opportunistic infection OVC orphans and vulnerable children PCP preventive care package PEPFAR President’s Emergency Plan for AIDS Relief PHE Public Health Evaluation PLWHA People living with HIV/AIDs PMTCT prevention of mother-to-child transmission PT part-time PWP prevention with positives SD standard deviation SEM standard error of the mean TB tuberculosis UNAIDS Joint United Nations Programme on HIV/AIDS UNC University of North Carolina USAID United States Agency for International Development 6 USG United States government VCT voluntary counselling and testing Vol volunteer WHO World Health Organization 7 Executive summary Rationale A Public Health Evaluation (PHE) was commissioned to examine HIV care and support funded by the President’s Emergency Plan for AIDS Relief (PEPFAR). Phase 1 of this PHE aimed to describe the nature and scope of care and support provision according to the five PEPFAR care and support areas (HIV/AIDS Palliative Care Guidance#1 2006), including the types of facilities, clients seen, and availability of specific components of care. Methods A cross-sectional survey of facility configuration and activity was conducted by collecting quantita￾tive and qualitative descriptive data directly from facilities. Of around 600 PEPFAR-funded HIV care and support facilities in Uganda, 60 (about 10%) were surveyed. At each facility, the following data collection tools were applied: 1) senior staff structured interview, 2) document collection and analysis, 3) pharmacy review, 4) patient focus group discussion (FGD). Main findings Facility characteristics Nine facilities were hospitals, 27 were health centres, 13 were health posts and 10 provided mainly home-based care (HBC). One facility did not provide health care and was separated from the survey sample for the following analysis. The number of patients seen in the previous three months ranged from 1 to over 16,000 and 65.1% of adult patients were women. On the day of the survey 58% of facilities had electricity and 85% had a safe water supply. Staff characteristics Nurses were the most prevalent staff type, working at 86% of facilities. At 75% of facilities there was at least one social worker or Community Health worker (CHW). Many staff were volunteers, particularly CHWs. On average there was one nurse per 69 patients, and for all other staff cat￾egories, patient load was considerably higher. Psychological, spiritual and social care were often provided at facilities which had no specialist staff in these areas. Components of care offered On average, facilities provided 36 of 69 surveyed components of care onsite and referred out for a further 11. Most services were provided to patients free of charge. Adherence counselling, nutri￾tional advice, family planning counselling, pre- and post-HIV test counselling, treatment for diar￾rhoea, and treatment for skin rash were the care components most commonly provided or referred. Outward referrals mainly took place for specialist clinical services such as tuberculosis (TB) treat￾ment and cancer management. Psychological, clinical and prevention care were provided directly or by referral by all 59 facilities in the main analysis, but spiritual care by 58% and social care by only 41%. These are the five areas of PEPFAR care and support. 8 Forty-six percent of facilities provided antiretrovirals (ARVs) directly, and 32% referred patients outward for ARVs. Toxicity monitoring and treatment failure assessment were available onsite for 89% of the ARV providers. Management of pain is a cornerstone of HIV palliative care and frequently undervalued. All fa￾cilities, with the exception of some HBC facilities, provided or referred for non-opioid analgesics. Opioids were commonly reported to be offered but very rarely found in pharmacies Pre- and post-test counselling was one of the most widely provided components of care, lacking at only three facilities. It was the most commonly available type of counselling and support included in the survey. Conversely, psychiatric therapy was one of the rarest components, suggesting that although basic psychological care is available, more complex care is difficult to access. FGD participants revealed that nutritional care and social care were considered to be closely aligned. The ultimate condition of poverty was lack of food, and food shortage, money worries and problems accessing transport were three aspects of the same problem. Nutritional counselling was one of the most widely available care components, but therapeutic feeding for malnutrition was offered or referred at only 44% of facilities. Social care was the least developed area of care, with many components never offered at hospitals or health posts. The Basic Care Package (BCP, consisting of cotrimoxazole (CTX), insecticide-treated net, water treatment, condoms and family counselling and testing advice), the Ugandan version of the PEP￾FAR preventive care package, was provided in full onsite by 24% of facilities. Condoms were the most readily available single item (92%). Treatment for opportunistic infections (OIs), malaria and TB was more widely available than pre￾ventive care. Malaria treatment was widespread, TB treatment not quite as common (85%), and both were more frequently available than were the respective tests used to diagnose them, suggest￾ing that treatment is taking place based on deduction from symptoms and history. Adherence counselling was provided or referred at all 59 facilities, family planning counselling at 57 and condoms were provided at 54 (see Table 17 above). All five components were provided or referred by 80% of referral hospitals, all district hospitals, 63% of health centre, 38% of health posts and 20% of HBC facilities. The availability of care to prevent further transmission of HIV was evaluated by examining the availability of five components of care that comprise the ‘Prevention with positives’ (PWP) package of care (i.e. adherence counselling, family planning counselling, treatment of herpes, patient HIV support groups, and condoms). All facilities offered or referred for at least three of these compo￾nents and 54% offered or referred for all five. Pharmacy review Adult CTX was the most widely available drug, stocked in 68% of facilities. Non-opioid analgesics were stocked at 66% and morphine (in date) at 12%. Stockouts were common, with 25% of all reported drug formulations having a reported stockout in the past six months. Eleven facilities re- 9 ported providing non-opioid analgesics but had none in stock. Similar discrepancies were recorded for codeine (5 facilities), morphine (6) and CTX (8). Document analysis First clinical assessment sheets were used at 66% of facilities and patient records were kept at 92%. Forty-seven percent had care protocols. The content of patient assessment sheets focused mainly on medical needs of patients. Staff views Senior staff decribed the key issues for their facility in terms of regular funding, staff training and investment, and care. They reported a need for a separate place for children’s care, development of paediatric counselling, provision of ARVs, drugs to treat infections, school fees for orphans and vulnerable children (OVCs) and provision of food. Patient focus group discussions (FGDs) Focus group discussions with patients at 47 facilities revealed that they particularly valued psy￾chological, clinical and social care. The improvements patients wanted were longer opening hours, more training for staff (especially in counselling), a more reliable drug supply, school fees for OVCs, refunds for transport to the facility, and food. To increase uptake of care they suggested outreach activities with drama involving people living HIV/AIDs (PLWHAs), and provision of visible items of clear benefit such as insecticide-treated bednets (ITNs) and food. Sixty per cent of FGD participants had received condoms and 83% received CTX prophylaxis. Reasons given for not receiving these items or other elements of the BCP were that the facility did not have sufficient supplies and that other patients received priority, fear of stigma, unawareness of their existence, al￾lergy to CTX, and stockout. Recommendations Infrastructure • Multidimensional HIV care and support requires more space than other care approaches. Facility staff prioritised a need for private space for counselling sessions and child care. • More resources should be directed on maintaining/repairing equipment and vehicles in order to avoid costly replacement. Staffing • Staff reported delivering care for which they had not been trained, and patients reported dis￾satisfaction about attending services provided by inadequately trained staff. Increasing spe￾cialist training and employing specialist staff to deliver non-clinical aspects of care and sup￾port, such as psychological and spiritual care, could widen the availability of specialist care to patients and improve care quality. • Staff retention was poor because of limited opportunities for development and low pay. High staff turnover is a challenge to quality of care; investment in staff training would result in bet￾ter care standards. • Volunteers are more likely to remain at facilities if their contribution is felt to be valuable; reimbursing volunteer travel costs is an important strategy when feasible. 10 Care provision • Patients prefer HBC care not facilities, which is the most sustainable option. Facilities should develop their HBC support services. • Social care was found to be the least developed aspect of care and support among survey fa￾cilities. More widespread implementation of income-generating activities and home help will improve patient access to clinical care. • Treatment of TB, malaria and other OIs is more readily available than prevention care, even though prevention is more cost-effective and saves more lives. The BCP consists of prevention interventions and further rollout would be beneficial. Drug supplies • Reliable drug availability is a significant issue hampering care delivery. Supply chains need to be strengthened by improving communication and responsiveness. • Staff training in pain management and opioid provision is necessary. Documents • Insufficient record-keeping limits the potential for a facility to provide integrated care, moni￾tor stock, manage referrals, plan and budget. Large facilities should employ specialist admin￾istrative staff to manage data, and train existing staff in record keeping. 11 Introduction In 2003 the United States government (USG) funded a five-year, $15 billion initiative to combat the global HIV/AIDS epidemic: the President’s Emergency Plan for AIDS Relief (PEPFAR). The money was allocated approximately as follows: treatment (55%), prevention (20%), assisting or￾phans and vulnerable children (10%) and care and support of individuals with HIV/AIDS (15%). PEPFAR has commissioned PHEs in these areas to evaluate programmes. The evaluation of PEPFAR-funded care and support for HIV was led by King’s College London (KCL, Principal Investigator) in collaboration with MEASURE Evaluation at the University of North Carolina (UNC) and the African Palliative Care Association (APCA). The aims, methods and implementation of the evaluation were planned and agreed in consultation with the members of USG Care and Support Technical Working Group, USG staff in country, and representatives of the Ministries of Health in Kenya and Uganda. Evaluation Aims and Objectives The aims of this 2-phase care and support public health evaluation were: • To describe the nature and scope of HIV care and support provision supported by PEPFAR in two African countries, including the types of facilities available, clients seen, and availabil￾ity of specific components of care [Phase 1]. • To evaluate how programme components and costs are related to health outcomes [Phase 2]. By meeting these aims, this study will provide detailed description of the care and support services that have been delivered through PEPFAR funding and identify the effective components and costs of the services, to improve the health of patients with HIV. Dissemination of the findings is planned, in conjunction with country teams, to inform effective care and support provision within the two PHE target countries and beyond, where lessons can be transferred to other PEPFAR countries. In order to address these aims the objectives were: • To undertake a cross-sectional survey of service configuration and activity by visiting 10% of the facilities being funded by PEPFAR to provide HIV care and support in Kenya and Uganda (aim 1). • To collect longitudinal prospective quantitative outcome data on 1200 patients at 12 facilities in Kenya and Uganda, measuring both quality of life and core palliative outcomes alongside components of care received (aim 2). • To conduct qualitative interviews with patients and staff to explore service issues in more depth (aim 2). • To undertake a cost comparison of care provided including staff costs, overheads and lab costs (aim 2). As part of the evaluation, results will be disseminated to report lessons learnt and best practices, and to provide recommendations to PEPFAR. 12 Study Overview The evaluation design was an observational study in Kenya and Uganda using mixed methods. The design comprised two sequential periods of data collection using mixed methodologies. • Phase 1 (2007) was a cross-sectional survey of facility configuration and activity using quan￾titative and qualitative descriptive data. • Phase 2 (2008) is a longitudinal evaluation of existing care, focusing on patient outcomes of PEPFAR care and support using validated outcome tools. Supplementary interviews with staff, patients and carers aim to provide in-depth understanding of key issues. An additional cost analysis component in this phase will compare patient/family outcomes with their as￾sociated costs. This report focuses on Phase 1 of the evaluation in Uganda. The evaluation was undertaken in Uganda with the support of APCA. A separate report has been written for Phase 1 in Kenya. Phase 2 data collection commenced in January 2008 and is due to be completed by September 2008. 13 Methods Study design Phase 1 of the care and support PHE was a cross-sectional survey of facility configuration and activity conducted by collecting quantitative and qualitative descriptive data directly from facilities. The inclusion criterion for facilities to be eligible for selection in Phase 1 was that they received PEPFAR funding to provide HIV care and support during 2006. The exclusion criteria were facili￾ties that were paediatric-only or inaccessible (e.g. insecure, no road access). Sampling Of around 600 PEPFAR-funded HIV care facilities in Uganda, 60 were selected for inclusion in the study (approximately 10% of PEPFAR-funded facilities). Facilities which did not meet the criteria above were replaced using the same random process. These facilities and their reason for replacement are listed in Table 1. According to routine monitoring patient numbers, the PEPFAR-funded care and support facili￾ties included many smaller facilities. In order to capture a range of facility sizes within the study population, facilities were stratified by number of patients seen for HIV care in the 2006 financial year (according to national PEPFAR records) and divided into three strata (1 to 100, 101 to 500 and >500 patients seen in 2006), resulting in unequal and calculable sampling fractions. Twenty facilities were randomly sampled within each of the strata for the study population. Procedure Tool development All tools were developed by a multidisciplinary team, including medical professionals, HIV spe￾cialists and researchers, in conjunction with USG Care and Support Technical Working Group and the country teams. All tools were piloted in one large and one small Phase 1 facility in Uganda. These facilities were two of the 60 selected, and data from the pilot were used in the final analyses in this report. Following piloting, the wording and structure of the tools were modified and clari￾fied. The tools are presented in Appendices A-D, described below. Four data collection tools were used: • Senior staff interview — The researchers interviewed a group of senior staff, including facil￾ity managers and senior clinical staff, at each health facility to collect responses to closed and open-ended questions about patient numbers, infrastructure and staffing. This tool also in￾cluded a version of the Client Services Receipt Inventory (CSRI) (Beecham and Knapp 2001) adapted for the aims of this study and the HIV setting in Africa to collect information about services offered to patients with HIV. The CSRI asked if the facilities offered various specific components of care under the four areas of care: clinical, psychological, spiritual, social and preventive. The tool (Appendix A) was designed for use across the wide range of size and type of HIV care facilities funded by PEPFAR. • Document collection — In order to study the level of patient-level clinical information man￾agement at each facility, the existence, format and language of various clinical documents 14 relating to care in the facility were recorded (Appendix B). Blank example documents were taken, where available, for content analysis. • Pharmacy review — Researchers recorded the level and place of drug stock for in-date and expired drugs separately, and if there had been previous stockouts (in-date drugs only) for various formulations of drugs commonly used in HIV care (Appendix C). • Patient focus group discussions — Researchers led patient discussion groups using the inter￾view schedule (reproduced in Appendix D). The FGDs had two main aims: to act as a valida￾tion of the senior staff interview data relating to components of care offered, and to explore aspects relating to patients’ care (e.g. which components of care were valued and why, any problems in obtaining medicines). Ethical approval Ethical approval to undertake the study in Uganda was received from the Uganda National Coun￾cil for Science and Technology and the College Research Ethics Committee at KCL. Subsequent tool changes following piloting were also approved. All data were anonymised from patient infor￾mation and raw data stored separately from consent forms, in a locked filing cabinet in line with ethical guidance and the Data Protection Act. Only anonymised data left the APCA office. Data collection Facilities were informed of the planned survey through the Ministry of Health (MOH) in Uganda and were asked to participate. Ugandan researchers attended each sampled site to collect data on a pre-arranged day, between April and August 2007. Data were recorded on two separate sets of identical forms. One set was left with the facility while the other was taken by the researchers for data entry. Researchers held interviews with senior facility staff (approximately three per facility) to collect staff-reported information on facility structure, service delivery, care offered and asked their views about the services they offer. These staff members were also asked to provide blank service docu￾ments (including service aim, referral forms, assessment sheets and patient information sheets), where available, for content analysis. FGDs were held with existing patients at each facility (inclusion criteria were adult patients who had been under care for at least 6 weeks) who were known (by both the patient themselves and clinical staff ) to be HIV positive and gave informed consent to participate (following provision of an information sheet and consent form). Patients were purposively selected by staff with the aim of obtaining a diverse group with respect to gender, age, disease stage and anti-retroviral (ARV) use. Approximately five patients in each facility were invited to participate in the discussion group, led by the researcher. Researchers made notes on the responses to pre-specified questions on the inter￾view schedule, and the FGD was digitally recorded as a back-up. During each FGD, demographic information was collected on participants’ gender, location (urban, rural or peri-urban), age and household size. Participants also stated how many of them in the group had received specific key components of care including daily CTX, a mosquito bednet and nutritional counselling.To com￾plete the pharmacy review, researchers visited the pharmacy to review stocks and stock cards, with the assistance of the pharmacist (or dispenser or other staff who worked in the pharmacy). 15 Data management and entry Data were transferred from sampled facilities to the APCA offices immediately after collection. Quantitative data (i.e. closed questions from the senior staff interview and the pharmacy review) were double-entered by two different researchers, and validated, using EpiData v3.1. Errors in data entry and data recording were identified using consistency and logic checks, and followed-up by manual checking of questionnaires. Responses to open-ended questions and FGDs were entered into pre-formatted templates in MS Word 2003. Information from the record of documents avail￾able at the facility, and their content, were entered into tables in MS Word 2003 files. Analysis • Senior staff interview — Analysis was conducted using Stata v10 (quantitative) and NVivo v7 (open-ended questions). Frequency tables were generated for key responses, grouped by facil￾ity type where appropriate. A Spearman’s rank test for correlation was conducted to test the reliability of routine data. Patient numbers were weighted to account for the stratified design used to select facilities. Thematic analysis of content was conducted on the responses to the open-ended questions. The principal themes were organised into data categories and then agreed between two researchers. • Document analysis — To determine the availability of the various types of service documents, a matrix was developed to record the overall number of facilities who reported having such documents, and the number and percentage of facilities that reported having such documents and provided examples. Where the percentage of facilities who provided examples of docu￾ments as a proportion of those who reported such documents existed was less than 20%, or where the absolute number of documents was five or fewer, no further analysis was under￾taken. Researchers conducted telephone conversations with site representatives in these cases to determine the reason for non-provision. In those instances where the percentage of facili￾ties who provided examples of documents as a proportion of those who reported such docu￾ments existed was equal to or greater than 20%, content analysis was undertaken to determine thematic frequency. Data were extracted to common tables, and frequencies described for the number of facilities reporting each type of recording sheet, whether a sample was obtained, the specific nature of the information in the document fields are reported, and subsequently described according to facility type. • Pharmacy review — Analysis was conducted using Stata v10. Frequency tables were generated for each drug, grouped by facility type where appropriate. Data from the pharmacy review was compared with components of care offered, according to the senior staff interview data. • Focus group discussions — Information on FGD participants’ background and receipt of care items was entered into a predesigned table by the researchers, transferred into an Excel spreadsheet and then merged with the Stata database using a unique identifying variable. The care received by FGD participants was integrated with the facility staff reports of care offered. Analysis of the FGDs was also conducted using NVivo v7. In the same way as for the open￾ended questions in the senior staff interviews, thematic analysis of content was conducted on the notes from the FGDs. The principal themes were independently organised into data categories and then agreed between two researchers. 16 Results Response rate Of the 60 facilities selected at random, one was found not to meet the selection criteria, and four were in regions where violence broke out, making the area unsafe for travel. A further three facili￾ties could not be found. All of these were replaced with another randomly selected facility from the same stratum as shown in Table 1. Table 1: Original selected sites that could not be found and their replacements Original site Replacement site Reason for replacement Name ID Name ID Kitintale Diocese Kampala 217 Kadama Pallisa 265 Site non-existent Kakuka H/C III Bundibugyo 224 Kyenjojo Initiative for Rural Development 278 Insecure region Rwebisego H/C III Bundibugyo 225 RWIDE Kyenjojo 277 Insecure region Nakapiripirit 228 Lwamaggwa Rakai 279 Insecure region Acord Napiripirit 208 Arapai Odudui Soroti 266 Insecure region Ngora boys PS Soroti 216 Makhai Mbale 263 Exclusively paediatric Malera Soroti 215 Ngora Dispensary 261 Repetition of facility Akuja Soroti 201 Rimuli- Bushenyi 269 Site could not be found All of the facilities approached agreed to take part in the study. The sites that were visited are listed in Appendix E and their geographical distribution is shown in Figure 1. Each facility visit took approximately one day, with many requiring a return visit to complete data collection. Figure 1: Distribution of facilities visited in Uganda 17 Facility types Facility staff were asked to indicate which type of facility their service was from a list of eight cat￾egories. Figure 2 shows that the largest fraction of facilities included in the survey self-reported as ‘other health centres’; that is, health centres not affiliated to a hospital. Figure 2: Types of facilities surveyed Subsequent analysis is presented by the following facility types: referral hospital (tertiary hospitals and secondary hospitals, n=5, 8%), district hospital (n=4, 7%), health centre (hospital affiliated and other health centres, n=27, 45%), health post (health posts/dispensaries, n=13, 22%) and HBC only (home-based care facilities only, n=10, 18%). Seven of the home-based care category facilities did not employ a doctor, nurse or clinical officer. One facility described itself as offering home-based care, but the survey revealed that in fact it offered no health care at all, being primarily an organisation to help communities improve water delivery. It provided no direct care, did not conduct a FGD, reported no staff and did not have a pharmacy or documentation. For this reason, it has been excluded from the following analysis and all totals sum to 59. Nonetheless, the facility was selected at random from a list of those receiving funding to provide care and support, and passed all the inclusion criteria for the survey. A mini￾mum level of care was not specified for the evaluation. The facility is separated from the other 59 in order to make data more easily interpretable but it remains part of the study. Weighted analysis The largest facilities were selected from a group of 90, so compared to the smallest facilities they had 315/90 = 3.5 times the probability of being selected, as shown in Table 2. To reverse this bias, numbers from the smallest facilities were multiplied by 3.5 to restore national representativeness to the sample. 2 3 4 3 24 13 11 Tertiary hospital (training, specialised care) Secondary (referral) hospital District hospital (basic inpatient) Hospital affiliated health centre Other health centre Health post/dispensary Home-based care only 18 Table 2: Strata for facility selection Facility size Definition* Number of facilities funded by PEPFAR in Uganda Number of facilities selected Probability of selection Weight Smallest (S) <100* 315 20 0.06 3.5 Middle (M) 100-500* 136 20 0.15 1.5 Largest (L) >500* 90 20 0.22 1 * Number of patients registered at facility in 2006, according to PEPFAR data Table 3: Weighted analysis – facility type Number of facilities Facility type Crude Weighted S M L Total (%) S M L Total (%) Referral hospital 0 1 4 5 (8) 0 1.5 4 9.5 (8) District hospital 0 0 4 4 (7) 0 0 4 4 (3) Health centre 8 10 9 27 (45) 28 15 9 52 (43) Health post 8 3 2 13 (22) 28 4.5 2 34.5 (29) HBC 4 6 1 11 (18) 14 9 1 24 (20) Total 20 20 20 60 (100) 70 30 20 120 (100) After weighting, hospitals made up a smaller proportion of facilities and health posts a greater proportion (Table 3). Patients Patient numbers are based on self-reported data from the facilities. Usually the information was taken from facility records. Researchers specified that the variable of interest was the number of individual patients, not the number of patient visits within a time period. Patient numbers – total Table 4 shows that in the selected facilities the number of patients receiving care in the last quarter, as reported by facility staff, ranged from 0 to over 16000. The figures from PEPFAR had a range of 3-17002 patients seen in a year. There is statistically significant correlation between the routine data and the survey data (rho=0.74, p<0.0001), meaning higher patient figures provided by PEP￾FAR matched with higher figures reported by facilities. However, it can be seen from Table 3 that the difference in patient numbers between the two sources can still be considerable. For 14 facilities (those where the number of new patients is missing), accurate records of patient numbers were unobtainable, and so the figures in the second column were estimates given by facil￾ity staff. 19 Table 4: Patient numbers Self-reported survey results 2007 PEPFAR routine data FY06 ID New patients receiving HIV care in the last three months All patients receiving HIV care in the last three months Individuals provided with care and sup￾port 202 139 234 3 203 13 26 5 204 13 26 6 205 7 135 11 206 30 199 11 207 Missing 50 19 209 0 314 25 210 308 2108 27 211 Missing 0* 28 212 10 147 35 213 14 50* 35 214 0 200 35 218 Missing 80* 51 219 78 436 63 220 20 347 73 221 37 144 107 222 44 265 136 223 39 344 137 226 Missing 50* 150 227 95 294 169 229 14 602 238 230 97 208 254 231 Missing 200* 263 232 39 290 275 233 Missing 80* 278 234 Missing 50* 290 235 Missing 500* 379 236 111 127 380 237 38 371 396 Self-reported survey results 2007 PEPFAR routine data FY06 ID New patients receiving HIV care in the last three months All patients receiving HIV care in the last three months Individuals provided with care and sup￾port 241 138 325 648 242 401 1950 895 243 565 1038 1218 244 296 2619 1222 245 56 1847 1335 246 323 3342 1378 247 87 1954 1528 248 217 1262 1634 249 105 1383 1692 250 187 1418 1990 251 8342 16779 2104 252 79 2075 3287 253 171 205 4618 254 138 367 5049 255 401 4772 5364 256 Missing 500* 8486 257 581 5249 9448 258 828 9698 10786 259 5774 7062 14662 260 683 5602 17002 261 48 92 52 263 Missing 200* 15 265 15 47 14 266 Missing 70* 16 269 Missing 75 12 277 35 430 385 278 Missing 0* 250 279 23 346 169 * estimate Patient numbers – gender and children 20 Facilities were asked the number of patients who had used the HIV services in the last quarter in total, and with breakdowns by men, women and children where available. Most facilities provided patient numbers divided into men, women and children. Children were defined as patients under 18 years, in accordance with PEPFAR practice and the advice of country teams. Table 5: Gender distribution of patients Facility type (n) Number (%) of facilities with: 0-25% female patients 25-<50% female patients 50-<75% female patients 75-100% female patients Referral hospital (4) 0 0 4 0 district hospital (4) 0 0 4 0 Health centre (21) 0 0 19 2 Health post (7) 0 1 6 0 HBC (8) 0 0 6 2 Total (44) 0 1 39 4 As shown in Table 5, between half and three-quarters of adult patients at facilities were women. In total across all facilities, 65.1% of adult patients were women, and when weighted by facility type, 64.9% of adult patients were women. By facility, a mean of 67% of adult patients were women, with 95% confidence intervals from 64.4% to 69.0%. Table 6: Proportion of paediatric patients Facility type (n) Mean n (standard error of mean (sem)) patients who are children Mean % (sem) patients who are children Referral hospital (4) 348.5 (117.7) 13.9 (2.3) District hospital (4) 423.5 (191.3) 9.0 (2.8) Health centre (20) 95.7 (51.7) 3.1 (0.8) Health post (7) 11.3 (6.5) 2.8 (1.7) HBC (8) 43.9 (24.2) 12.7 (6.3) Total (43) 123.5 (35.5) 6.3 (1.3) By facility the mean proportion of patients who were children was 6.3%, with a 95% CI from 3.6% to 8.9% (Table 6). In total, 7.2% of patients in all the facilities were children. When weighted by facility type, 6.0% of patients would be children. The proportion of paediatric patients ranged from 0.8% for health centres to 6.3% for HBC facilities, 1.3% of patients overall. Exclusively paediatric facilities were not included in this survey. Twelve facilities did not provide care for any children and 16 facilities did not have records of how many children they had seen in the last three months. 21 Infrastructure General Table 7 shows that approximately one third of all facilities surveyed offered care exclusively to people who were HIV positive, and over two thirds of HBC facilities offered an HIV-only ser￾vice. Half of facilities were run by the government and the majority of the remainder were run by a non-governmental organisation (NGO), including all the HBC facilities. Facilities commonly reported to more than one authority. Nearly all facilities reported to the MOH, over half reported to PEPFAR (although all facilities receive PEPFAR funding, reporting may be through indirect channels) and just under half reported to an NGO. Table 7: Infrastructure present at different facility types Number of facilities n (%) Referral hospital District hospital Health centre Health Post HBC Total Total number of facilities of each type 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) HIV-only facility 1 (20) 1 (25) 6 (22) 3 (23) 7 (70) 18 (30) Authority Government 5 (100) 2 (50) 13 (48) 11 (85) 0 31 (53) Private 0 0 3 (11) 0 0 3 (5) NGO 0 2 (50) 11 (41) 2 (15) 10 (100) 25 (42) Reports to Ministry of Health 5 (100) 4 (100) 27 (100) 13 (100) 3 (30) 52 (88) USG/PEPFAR 3 (60) 2 (50) 20 (74) 2 (15) 8 (80) 35 (59) NGO 2 (40) 2 (50) 9 (33) 3 (23) 9 (90) 26 (42) Private for-profit organisation 0 0 1 (4) 0 0 1 (2) Place of care Inpatient 3 (60) 4 (100) 14 (52) 3 (23) 0 24 (41) Outpatient 5 (100) 4 (100) 23 (85) 13 (100) 2 (20) 47 (80) Home based care 1 (20) 2 (50) 19 (70) 2 (15) 90 (90) 33 (56) Medical consultancy 5 (100) 4 (100) 23 (85) 4 (31) 0 36 (61) Daycare 1 (20) 1 (25) 12 (44) 2 (15) 1 (10) 17 (29) Support groups 17 (63) 4 (31) 10 (100) 37 (62) General infrastructure Staff on site 24 hours a day 1 (20) 1 (25) 17 (63) 7 (54) 1 (10) 27 (46) Has functioning ambulance 0 3 (75) 18 (67) 2 (15) 4 (40) 27 (46)** Has working electricity 5 (100) 4 (100) 18 (67) 3 (23) 4 (40) 34 (58)** Has functioning generator, inverter or solar panel 3 (60) 4 (100) 17 (63) 5 (39) 3 30) 32 (54)** Has safe water supply* 5 (100) 4 (100) 25 (93) 8 (62) 8 (80) 50 (85) Has functioning toilet 5 (100) 4 (100) 27 (100) 13 (100) 9 (90) 58 (98) *’safe’ defined as: piped water, a public tap or standpipe, a borehole, protected well or rainwater collection **In addition there were 5 facilities with an ambulance that did not function, 4 which reported usually having electricity, and 6 with a non-functional generator. 22 Outpatient care, home-based care, medical consultancy, and support groups were offered by over half of facilities. Outpatient care was the most commonly offered type of care, at over three-quar￾ters of facilities (including all hospitals and health posts and 85% of health centres). One facility in the HBC group did not report offering home-based care. It was found to be primarily an advocacy and support group organisation, although it does provide care in all five areas of PEPFAR care and support (Table 21). The use of self-reported information throughout the survey occasionally leads to situations where facilities give seemingly contradictory answers. For the remainder of this report, the facility in question is included in the HBC group because the overall evidence places it there. Twenty-four-hour staff coverage was found at fewer than half of facilities, most commonly at health centres. Of 32 facilities reporting having an ambulance (defined as any vehicle for transport￾ing patients), in five facilities the vehicle was not functioning or had no fuel. Likewise, 38 facilities had a generator, of which 16% were not working (n=6). Nearly all facilities had a safe water supply and all but one had a functioning toilet. Time and frequency of appointments The median, and most frequent, number of hours per week that patients could see a member of staff was 40, for both non-clinical and clinical staff (Table 8). In this definition, doctors and nurses are clinical staff, all other staff types are non-clinical. Health centres were the types of facility most commonly open more than 40 hours per week. Table 8: Hours per week patients can see a member of staff Facility type n (%) Type of appointment Number of hours per week Referral hospital District hospital Health centre Health post HBC Total Total number of facilities of each type 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Clinical 0 0 0 1 (4) 0 3 (30) 4 (7) 1-20 2 (40) 0 12 (44) 1 (8) 3 (30) 18 (31) 21-40 3 (60) 4 (100) 9 (33) 12 (92) 4 (40) 32 (54) 41-63 0 0 5 (19) 0 0 5 (8) 0 0 0 0 0 1 (9) 1 (2) Non-clinical 1-20 1 (20) 0 9 (33) 0 3 (30) 13 (22) 21-40 4 (80) 4 (100) 12 (44) 13 (100) 6 (60) 39 (66) 41-63 0 0 6 (22) 0 1 (10) 7 (12) 23 Table 9: Frequency of appointments Facility type n (%) Type of patient, type of appointment Frequency Referral hospital District hospital Health centre Health post HBC Total Total number of facilities of each type 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Non-ART, clinical <12/year 2 (40) 1 25) 8 (30) 3 (23) 0 14 (24) 12/year 3 (60) 3 (75) 9 (33) 3 (23) 2 (20) 20 (34) >12/year 0 0 0 0 0 0 Appointments as needed 0 0 10 (37) 7 (54) 8 (80) 25 (42) Non-ART, non-clinical <12/year 1 (20) 0 7 (26) 2 (15) 0 10 (17) 12/year 4 (80) 3 (75) 8 (30) 3 (23) 2 (20) 20 (34) >12/year 0 0 1 (4) 0 1 (10) 2 (3) Appointments as needed 0 1 (25) 11 (41) 8 (62) 7 (70) 27 (46) ART, clinical <12/year 0 0 1 (4) 1 (8) 0 2 (3) 12/year 5 (100) 3 (75) 12 (44) 3 (23) 1 (10) 24 (41) >12/year 0 0 3 (11) 0 0 3 (5) Appointments as needed 0 1 (25) 11 (41) 9 (69) 9 (90) 30 (51) ART, non-clinical <12/year 0 0 3 (11) 1 (8) 0 4 (7) 12/year 5 (100) 3 (75) 10 (37) 3 (23) 1 (10) 22 (37) >12/year 0 0 3 (11) 0 1 (10) 4 (7) Appointments as needed 0 1 (25) 11 (41) 9 (69) 8 (80) 29 (49) Table 9 shows the frequency of regular clinical and non-clinical appointments for HIV patients taking and not taking anti-retroviral therapy (ART), by facility type. Most commonly facilities of￾fered clinical or non-clinical appointments to HIV patients as needed, although monthly appoint￾ments were also common. The range was from once every three months to once every two weeks. Hospitals most commonly offered monthly appointments, whereas the other types of facility most commonly offered appointments as needed. Payment for care The totals in Table 10 equal the number of facilities offering each service. Table 10 shows that two facilities charged patients for all their services apart from ART. All the listed services were nearly always free to all patients, if available. Means-testing was rare. ART was the service least likely to be available (see Table 17 below), but if it was available, was most commonly available free of charge. 24 Table 10: Payment for services Type of service Appointment x-ray HIV test ART Lab work CTX Other medicines Payment routine Number of facilities (%) All pay 2 (4) 2 (10) 2 (6) 0 2 (6) 2 (4) 2 (4) Free to all 42 (88) 16 (80) 32 (91) 24 (92) 30 (83) 45 (94) 42 (86) Means- tested 3 (6) 1 (5) 1 (3) 1 (4) 2 (6) 0 3 (6) Other (unspecified) 1 (2) 1 (5) 0 1 (4) 2 (6) 1 (2) 2 (4) total 48 (100) 20 (100) 35 (100) 26 (100) 36 (100) 48 (100) 49 (100) Facility staff Staffing levels Facilities were asked to report the number of paid (full time and part-time) and volunteer staff they had working in their HIV clinic for a number of different staff designations. Tables 11 and 12 show the number of facilities reporting to have each category of each designation of staff, and the median number of staff of each designation reported, by facility type. Staff were recorded by the profession for which they were employed. A nurse who also dispensed drugs and conducted counselling, for example, would be recorded only as a nurse. Nurses were the most common staff designation present at facilities (88%), and traditional heal￾ers the least common, at 7% (Table 11). Over half of facilities had paid (full time or part-time) doctors, clinical officers, nurses, laboratory staff or counsellors. Volunteer staff were rare for most designations of staff, except for CHWs (volunteers at 61% of facilities), where voluntary staff were the most common category. The widest range of staff numbers was for volunteer counsellors (facilities reported having between 1 and 40 staff members), and commonly facilities reported having only one staff member for every staff designation and category. This data is not shown. Table 12 shows that volunteer counsellors and CHWs were the most common staff reported (median = 7). Seven facilities had no nurses and were staffed entirely by social workers, spiritual leaders, counsellors and volunteer CHWs. Staff categories In order to explore the types of specialist care being offered, staff were grouped by the element of care which they provided, as follows: clinical (doctor, clinical officer/medical assistant, nurse, phys￾iotherapist), spiritual (spiritual leader, traditional healer), psychological (counsellor), social (social worker, CHW) and laboratory (lab staff ). All groups included full time, part-time and voluntary staff. In terms of PEPFAR care and support, laboratory staff belong with clinical staff, but they were included as a separate group here on the grounds that their training would be very specific and they would not be able to stand in for other clinical disciplines or be replaced by them. 25 Table 11: Number of facilities employing at least one staff member, by designation and facility type Employment n (%) All (n=59) Referral hospital (n=5) District hospital (n=4) Health centre (n=27) Health post (n=13) HBC (n=10) Staff designation FT PT Vol FT PT Vol FT PT Vol FT PT Vol FT PT Vol FT PT Vol Doctor 24 12 2 5 2 0 2 1 0 15 8 1 2 1 0 0 0 1 Clinical officer 35 7 2 4 0 1 3 1 0 22 6 0 5 0 0 0 0 1 Nurse 50 11 5 5 1 1 4 1 0 26 8 2 13 0 1 2 1 1 Pharmacist/dispenser 23 5 1 4 0 0 4 1 0 13 4 0 2 0 0 0 0 1 Laboratory staff 34 7 3 3 2 0 4 0 0 22 4 2 4 1 0 1 0 1 CHW 11 5 36 1 0 3 2 0 3 6 4 16 1 0 5 1 1 7 Social worker 8 1 4 0 1 0 1 0 1 4 0 1 0 0 0 3 0 5 Spiritual leader 4 4 10 0 1 1 1 0 0 2 1 4 0 0 3 1 2 2 Traditional healer 2 0 3 0 0 0 0 0 0 1 0 3 1 0 0 0 0 0 Nutritionist 3 3 1 0 0 0 1 0 0 2 3 1 0 0 0 0 0 0 Counsellor 27 8 12 2 1 1 2 1 0 16 4 5 3 1 0 4 1 6 Physio-therapist 4 0 0 0 0 0 1 0 0 3 0 0 0 0 0 0 0 0 26Table 12: Median number of staff members employed, by facility type Employment n (%) All (n=59) Referral hospital (n=5) District hospital (n=4) Health centre (n=27) Health post (n=13) HBC (n=10) Staff designation FT PT Vol FT PT Vol FT PT Vol FT PT Vol FT PT Vol FT PT Vol Doctor 2 2 1 4 1 - 2 3 - 2 2 1 2 1 - - - 1 Clinical officer 1 1 1 2 - 1 2 4 - 1 1 - 1 - - - - 1 Nurse 5 2 2 5 2 1 4 13 - 6 3 6 2 - 2 5 2 2 Pharmacist/dispenser 1 1 1 3 - - 2 1 - 2 2 - 1 - - - - 1 Laboratory staff 2 1 1 2 1 - 2 - - 2 2 1 2 2 - 6 - 1 CHW 3 6 7 1 - 2 3 - 45 3 8 7 2 - 6 5 2 33 Social worker 2 1 2 - 1 - 1 - 2 2 - 2 - - - 2 - 10 Spiritual leader 2 2 3 - 1 5 1 - - 2 3 2 - - 1 5 2 10 Traditional healer 1 - 2 - - - - - - 1 - 2 1 - - - - - Nutritionist 1 1 2 - - - 1 - - 1 1 2 - - - - - - Counsellor 3 3 7 4 2 3 2 1 - 3 3 3 3 6 - 4 5 21 Physio-therapist 1 - - - - - 1 - - 1 - - - - - - - - 27 Table 13: Staff categories by facility type Facility type n (%) Hospital District hospital Health centre Health post HBC Total Total number of facilities of each type 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Clinical 5 (100) 4 (100) 27 (100) 13 (100) 3 (30) 52 (88) Psychological 3 (60) 2 (50) 19 (70) 3 (23) 8 (80) 35 (59) Spiritual 1 (20) 1 (25) 9 (33) 3 (23) 5 (50) 19 (32) Social 4 (80) 3 (75) 23 (85) 5 (38) 9 (90) 44 (75) Clinical + spiritual + psychological + social 1 (20) 1 (25) 7 (26) 1 (8) 1 (10) 11 (19) Laboratory 3 (60) 4 (100) 23 (85) 4 (31) 2 (20) 36 (61) Table 13 shows that all hospitals, health centres and health posts had clinical staff present. The next most common staff group was social (75% of facilities). The HBC facilities were more varied and had no single staff group uniting all of them, although social staff were the most common type of staff found at this type of facility. Health centres most commonly had specialist care providers from each element of care, clinical, psychological, spiritual and social (26% of health centres). Reliance on volunteers Table 14 below shows that CHWs were the staff designation most likely to be represented only by volunteers, followed by spiritual leaders. One facility relied for its clinical staff solely on volunteers, consisting of one doctor, one clinical officer, one pharmacist and two nurses. No other facilities had volunteers of these designations without having paid staff too. Table 14: Number of facilities where staff represented solely by volunteers, by staff designation Staff designation Number of facilities with solely volunteer staff Staff employment (from Table 11) FT PT Vol Doctor 1 24 12 2 Clinical officer /medical assistant 1 35 7 2 Nurse 1 50 11 5 Pharmacist 1 23 5 1 Laboratory staff 1 34 7 3 CHW 25 11 5 36 Social worker 2 8 1 4 Spiritual leader 9 4 4 10 Traditional healer 2 2 0 3 28 Staff designation Number of facilities with solely volunteer staff Staff employment (from Table 11) FT PT Vol Nutritionist 0 3 3 1 Counsellor 7 27 8 12 Physiotherapist 0 4 0 0 Table 15: Percentage of staff who were volunteers by facility type Facility type Mean percentage of staff who are volunteers (SEM) Referral hospital 13.2 (5.7) District hospital 39.8 (19.3) Health centre 30.8 (5.6) Health post 29.3 (9.7) HBC 88.1 (3.8) In order to understand the extent to which fa￾cilities rely on volunteers, the proportion of vol￾untary staff of any designation out of the total number of staff (full time, part-time and volun￾tary, any designation) were calculated for each facility type. The results in Table 15 show that the reliance on volunteers varied from 13% of staff in referral hospitals to almost nine-tenths in HBC facilities (88%). Patient load When facilities employed a staff type, and patient numbers were recorded, the number of patients per staff member in a three-month period were calculated. In Table 16 below, part-time and vol￾unteer staff each count as 0.5 of a full-time staff member. Facilities which do not have patient numbers are excluded. Table 16: Patient load Staff designation Facilities with staff type (n) Median patient load (IQR) Doctor 29 410.0 (222 – 866) Nurse 51 69.4 (31 – 294) Clinical officer 30 508.0 (158 – 1040) CHWs 39 89.7 (18 – 391) Pharmacist 23 1009.0 (346 – 1950) Laboratory staff 30 475.0 (178 – 1057) Social worker 7 1950.0 (47 – 3342) Spiritual leader 12 393.0 (147 – 1929) Traditional healer 3 325.0 (218 – 1204) Nutritionist 5 3342.0 (1458 – 5485) Counsellor 33 172.0 (158 – 1040) Physiotherapist 3 1418.0 (49 – 2075) 29 Table 16 shows that nutritionists had the highest median patient load. Clinical officers had a higher patient load than doctors. Nurses had the lowest patient load, followed by CHWs. This table does not take into account patient contact time or the recommended length of appointments. Components of care offered Individual components of care Staff were asked to indicate whether the facility offered a variety of components of care that fall under the umbrella of PEPFAR HIV care and support. With reference to components of care, components are described as being ‘provided’ (meaning reported as offered at the facility), ‘referred’ (meaning a patient is formally or informally referred out for the component according to the fa￾cility) or ‘provided or referred’ (meaning the component is provided or referred, as before). These components are listed by the five PEPFAR categories of care in Appendix F. Formal referrals are defined as referrals where there is a process of information to the facility and subsequent feedback. Informal referral consists of a recommendation or directions without further contact. Formal referrals were most common for specialist clinical services, such as physiotherapy (37%), TB treatment (22%), and cancer management (56%). Cryptococcus was also frequently referred (37%). The median number of referrals a facility would make was 7. Table 17 shows that the components of care most frequently provided, including onsite care and referrals, were • adherence counselling (100%), • nutritional advice (98%), • family planning counselling (97%), • pre- and post-test counselling (95%), • treatment for diarrhoea (93%), and • treatment for skin rash/itching (93%). The components most rarely provided, including onsite care and referrals, were • contact with a traditional healer (12%), • loans/microfinance (12%), • memory book work (14%), • circumcision (20%), • provision of household items (22%), and • legal services (24%). Informal referrals were rare but formal referrals more common. Services for which patients were most commonly referred were • management of cancer (56%), • treatment for cryptococcus (37%), • strong opioids (37%), • physiotherapy (37%), • psychiatric therapy (37%), and • liver function test (34%). 30 Table 17: Components of care Type Component of care Provided here Referred formally Referred informally Not provided n (%) General clinical Nursing care 53 1 0 5 (8) Adult diagnostic HIV testing 39 11 0 9 (15) ARVs 27 19 0 13 (22) Weighing 47 4 0 8 (14) Assess ARV treatment failure 25 17 0 17 (29) Monitor ARV toxicity 25 17 0 17 (29) Wound care 48 6 0 5 (8) Physiotherapy 9 21 1 28 (47) Pain management Assessment of pain 44 7 0 8 (14) Strong opioids 12 22 0 25 (42) Weak opioids 21 15 0 23 (39) Non-opioids 50 3 0 6 (10) Treatment for neuropathic pain 28 19 12 (20) Symptoms Anxiety/depression treatment 38 14 1 6 (10) Treatment for nausea/vomiting 48 4 1 6 (10) Treatment for skin rash/itching 48 6 1 4 (7) Treatment for diarrhoea 47 8 0 4 (7) Laxatives 36 12 1 10 (17) Treatment for thrush 42 12 0 5 (8) Treatment for oral candidiasis 44 10 0 5 (8) Treatment for cryptococcus 28 22 0 9 (15) Treatment for other fungal infections 44 9 0 6 (10) Treatment for herpes 38 14 0 7 (12) Treatment for malaria 47 7 0 5 (8) TB detection 36 13 0 10 (17) TB treatment 37 13 0 9 (15) Therapeutic feeding for malnutrition 12 14 0 33 (56) Treatment for other 49 4 0 6 (10) opportunistic infections Management of cancer 4 33 0 22 (37) Psychological Pre- and post-test counselling 54 2 0 3 (5) Adherence counselling 56 3 0 0 Family planning counselling 53 4 0 2 (3) Patient HIV support groups 41 2 0 16 (27) Family care-givers support group 30 3 0 26 (44) 31 Type Component of care Provided here Referred formally Referred informally Not provided n (%) Psychological con’t Family counselling 48 2 0 9 (15) Psychiatric therapy 11 20 2 26 (44) Spiritual Visit by pastor 18 2 1 38 (64) Prayer with patients 27 1 0 31 (53) Contact with traditional healer 6 1 0 52 (88) Social Home help 19 0 0 40 (68) Transport to care centre 25 1 0 33 (56) Employment training 17 0 0 42 (71) Provide household items 13 0 0 46 (78) Legal services 9 5 0 45 (76) Memory book work 8 0 0 51 (86) Family home help 16 1 0 42 (71) Loans/microfinance 6 1 0 52 (88) Infection control training 50 0 0 9 (15) HIV Prevention Support for family testing 46 5 0 8 (14) Circumcision 11 1 0 47 (80) Prevention with positives 52 2 0 5 (8) Prophylaxis and Preventive care Multivitamins 34 10 0 15 (25) Nutritional advice 57 1 0 1 (2) Access to safe drinking water at home 23 4 0 32 (54) Septrin/cotrimoxazole 47 6 0 6 (10) Isoniazid 22 13 0 24 (41) Condoms 54 0 0 5 (8) Mosquito bednets 29 6 0 24 (41) Laboratory Liver function test 14 20 0 25 (42) Malaria film 34 9 0 16 (27) AFB smear 31 10 0 18 (31) CD4 count/test 19 18 0 22 (37) Rapid HIV test 34 9 0 16 (27) Pulse oximetry 10 9 0 40 (68) Dried blood spot for HIV diagnosis in newborns 14 10 0 35 (59) Viral load 10 19 0 30 (51) Paediatric Paediatric ARV 21 14 0 24 (41) Infant testing and counselling 20 13 0 26 (44) Children testing and counselling 29 12 0 18 (31) 32 Availability of the most commonly provided or referred components of care, by facility type, is displayed in Table 18 below. Adherence counselling was the only component of care to be provided or referred at all facilities included in the analysis (noting that one facility was excluded because it provides no components of care). It can be seen from Table 18 that adherence counselling and fam￾ily planning counselling were common across all facility types, but home help was uncommon at hospitals and health posts, and anxiety/depression treatment was lacking at half of HBC facilities. Table 18: Frequent components of care by facility type Component of care Facilities providing or referring for care, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 45 (100) 27 (100) 13 (100) 10 (100) 59 (100) Adherence counselling (clinical) 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Anxiety/depression treatment (psychological) 5 (100) 4 (100) 27 (100) 12 (92) 5 (50) 53 (90) Prayer with patients (spiritual) 2 (40) 4 (100) 10 (59) 3 (23) 9 (90) 28 (47) Home help (social) 0 1 (25) 9 (33) 0 9 (90) 19 (32) Family planning counselling (prevention) 5 (100) 4 (100) 26 (96) 13 (100) 9 (90) 57 (97) Number of components of care offered Table 19 shows the mean number of components of care offered at facilities was 36 out of the 69 listed (47 including referrals). District hospitals and health centres offered the most components of care (including referrals), HBC facilities the fewest. Referrals increased the number of components of care potentially accessible at facilities by between 5 and 13. Table 19: Mean number of components of care offered by facility type Type of facility Mean [standard deviation (sd)] of components of care provided onsite Mean (sd) of components of care provided or referred Referral hospital 46 (6) 51 (8) District hospital 49 (4) 57 (6) Health centre 43 (11) 53 (6) Health post 28 (11) 41 (9) HBC 19 (5) 31 (14) All types 36 (13) 47 (12) PEPFAR care and support provision PEPFAR defines five areas of care and support (Office of the U.S. Global AIDS Coordinator 2006b): • Clinical care — including HIV counselling and testing, prevention and treatment of op￾portunistic infections, HIV prevention and behaviour change counselling, alleviation of HIV symptoms and pain, support for malnourishment, monitoring of need and adherence to ARVs, CTX, safe water, nutritional counselling • Psychological care — including mental health counselling, family care and support groups, 33 support for status disclosure, bereavement care, treatment of psychiatric illnesses • Spiritual care — The interventions should be sensitive to the culture, religion(s) and rituals of the individual and community, and can include (but are not limited to): life review and as￾sessment; counselling related to hopes and fears, meaning and purpose, guilt and forgiveness; and life-completion tasks. • Social care — including legal services, links to food support and Income Generating Activi￾ties (IGAs) • Prevention — including community and clinical-based support groups, condoms and partner testing (HIV/AIDS Palliative Care Guidance#1 2006). The components of care in Table 17 grouped into areas based on these descriptions, and the pro￾portions of facilities offering care in each area were calculated. The results are presented in Table 20 and the components listed under each heading for this section are listed in Appendix F. Table 20: Number of facilities providing or referring for each area of care, by facility type Any component provided or referred in area of care Facility type including referrals, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Clinical 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Psychological 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Spiritual 3 (60) 4 (100) 15 (56) 3 (23) 9 (90) 34 (58) Social 1 (20) 1 (25) 11 (41) 1 (8) 10 (100) 24 (41) Prevention 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) All care and support 1 (20) 1 (25) 10 (37) 1 (8) 9 (90) 22 (37) HBC facilities most frequently provided or referred for care from every area (Table 20). All facili￾ties had at least one component of psychological, clinical and prevention care. Social care was the area of care least likely to be provided or referred, followed by spiritual care. HBC facilities were much more likely than other facility types to provide or refer for social and spiritual care, and as a result, to be able to provide or refer for all five areas of care and support. The presence of the five areas of care was analysed by managing authority, to test the hypothesis that NGOs were more likely than government facilities to provide or refer for a complete package of care involving all five areas. Table 21 below shows that government facilities always provided or referred for clinical, psychological and preventive care, but spiritual care was provided or referred for at only a third of facilities, and social care at 10%. NGOs were much more likely to provide or refer for a complete package of care. 34 Table 21: Mean components of care by managing authority Area of care Number of facilities offering any component of care in area Facilities managed by NGOs Facilities managed by government N 25 (100) 31 (100) Clinical 25 (100) 31 (100) Psychological 25 (100) 31 (100) Spiritual 21 (84) 11 (35) Social 20 (80) 3 (10) Prevention 25 (100) 31 (100) All care and support 19 (76) 2 (6) Components of care by themes Components of care were grouped by theme to highlight gaps in coverage and explore the provi￾sion of integrated care. Some components are repeated under different headings for completeness, for instance thick-film malaria blood test which is shown under malaria (Table 26) and laboratory services (Table 28). • ART — Of the facilities surveyed, 27 facilities supplied ARVs directly, 19 formally referred and 13 had no provision. All 27 direct providers said they supplied ARVs to everyone who needed them. Two could not provide figures for the number of patients provided with ARVs in the last 3 months. Of the remaining 25 facilities, 3 facilities provided all their patients with ARVs in the last 3 months (one a referral hospital, one a health centre and one an HIV/AIDS focal point for a diocese), based on number of patients supplied, and a mean of 34% of HIV patients was provided with ARVs. Table 22 shows that all hospitals provided comprehensive ART care, and the probability of having toxicity monitoring and treatment failure assessment was closely linked to facility type, declining to 30% in HBC facilities. Adherence counselling was widely available. Of the 46 facilities that either supplied or re￾ferred for ARVs, 43 had adherence counselling onsite. Of the 27 facilities with ARVs pro￾vided onsite, all provided assessment for treatment failure and monitored toxicity (24 onsite and 3 referred). The support services for ARVs, toxicity monitoring and treatment failure monitoring, were either both present or both absent. If ARVs were provided by referral (19 facilities), toxicity monitoring and treatment assessment were provided onsite once, referred in 14 cases and not provided in 4. • Pain management — Management of pain is of particular interest. Pain is a highly prevalent symptom throughout the HIV disease trajectory and pain management is a cornerstone of palliative care. Table 23 below shows that all facility types, with the exception of home-based care facilities, provided or referred for non-opioid analgesics, which were the most frequently available pain medication. Strong opioids were the least likely to be provided or referred. They were more commonly provided or referred at district hospitals and health centres than larger hospitals. 35 Table 22: ART provision by facility type ART component Facilities offering care including referrals, n (%) Referral hospital District hospital Health centre Dispensary HBC-only N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) ARVs 5 (100) 4 (100) 26 (96) 7 (54) 4 (40) Adherence counselling 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) Assessment of ARV treatment failure 5 (100) 4 (100) 24 (89) 6 (46) 3 (30) Monitor ARV toxicity 5 (100) 4 (100) 24 (89) 6 (46) 3 (30) Table 23: Availability of components of care relating to management of pain, by facility type Pain component of care Facilities offering test including referrals, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Assessment of pain 5 (100) 4 (100) 25 (93) 13 (100) 4 (40) 51 (86) Strong opioid, e.g. morphine 3 (60) 4 (100) 21 (78) 4 (31) 2 (20) 34 (58) Weak opioid, e.g. codeine 3 (60) 3 (75) 23 (85) 5 (38) 2 (20) 36 (61) Non-opioid, e.g. paracetamol 5 (100) 4 (100) 27 (100) 13 (100) 4 (40) 53 (90) Treatment for neuropathic pain 5 (100) 4 (100) 25 (93) 10 (77) 3 (30) 47 (80) • Psychological health — The survey included information on several types of counselling and support groups, from which pre- and post-test counselling was selected as the most basic and the first line of care from which others would be referred. Table 24 shows that only two health posts and one HBC facility failed to provide pre- and post-test counselling, one of the most universally offered components of care. Psychiatric therapy was one of the rarest components of care, available through less than half of health posts and HBC facilities and only 56% of health centres. Anxiety and depression are extemely common symptoms in HIV. Treatment for them was widely available at most facility types but at only half of the HBC group. • Nutrition and social care — Nutrition is an important aspect of HIV care, addressed in the top half of Table 25 below. Nutritional counselling was widely available at all facility types, but therapeutic feeding for malnutrition was provided or referred at only half of district hospitals and health centres, less than a third of HBC facilities and a quarter of health posts. Weighing was provided or referred at almost all facilities except for HBC where only 40% provided or referred for it. Only four components of care from the survey are included in the PEPFAR definition of social care. They are listed in the bottom half of Table 25. It is clear that this area was much better supported by HBC facilities and health centres than by any other facility type. Referral hospitals, district hospitals and health posts each had only one facility providing or referring 36 for one component of care out of the four. By contrast, home help, IGA and legal services were each provided or referred by a third of health centres. HBC did even better, with 90% coverage of home help and 70% coverage of employment training/IGA. Table 24: Availability of components of care relating to psychological health, by facility type Psychological component of care Facilities offering test including referrals, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Pre- and post-test counselling 5 (100) 4 (100) 27 (100) 11 (85) 9 (90) 56 (95) Anxiety/depression treatment 5 (100) 4 (100) 27 (100) 12 (92) 5 (50) 53 (90) Psychiatric therapy 4 (80) 4 (100) 15 (56) 6 (46) 4 (40) 33 (56) Table 25: Availability of components of care relating to nutrition and social care, by facility type Nutrition component of care Facilities offering test including referrals, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Weighing 5 (100) 4 (100) 26 (96) 12 (92) 4 (40) 51 (86) Nutritional counselling 5 (100) 4 (100) 27 (100) 13 (100) 9 (90) 58 (98) Multivitamins 5 (100) 3 (75) 23 (85) 10 (77) 3 (30) 44 (75) Therapeutic feeding for malnutrition 4 (80) 2 (50) 14 (52) 3 (23) 3 (30) 26 (44) Home help 0 1 (25) 9 (33) 0 9 (90) 19 (32) Loans/microfinance 0 0 3 (11) 0 4 (40) 7 (12) Employment training/IGA 1 (20) 0 8 (30) 1 (8) 7 (70) 17 (29) Legal services 0 0 8 (30) 0 6 (60) 14 (24) • Opportunistic infections (OIs) and preventive care — This survey examined the provision of preventive and curative care of general OIs and some specific HIV-related OIs (malaria, TB and STIs) owing to the increased likelihood of contracting these diseases (Barnett & Whi￾teside 2006, UNAIDS 2008a) and dying from them, especially TB (UNAIDS 2008b). Care components that aimed to prevent patients from contracting OIs and transmitting HIV, and the treatment of OIs were explored. Some care components prevent HIV transmission and the spread of some OIs, e.g. condoms, so these 2 areas were examined together. 1. Basic Care Package (BCP) – PEPFAR developed the preventive care package (Office of the U.S. Global AIDS Coordinator 2006a), a number of specified care components which should be considered essential to prevent opportunistic infections, delay disease 37 progression and prevent HIV transmission. In Uganda (Colindres et al 2007), the con￾cept was developed into the BCP, which consists of CTX prophylaxis, ITNs, water dis￾infection produce and container, family HIV voluntary counselling and testing (VCT) information, and condoms. At some facilities the first four items were provided together in a boxed kit; others were more flexible, offering individual items as needed. From Table 17 above it can be seen that of the 59 facilities analysed, 47 provided CTX, 29 provided bednets, 54 provided condoms and 23 provided access to safe water at home. Fourteen facilities (24%) pro￾vided all five components. Figure 3 is a Venn diagram to illustrate the number of facilities providing each combina￾tion of the BCP elements of care, for only the 47 facilities which offered CTX. With any more than four items, the diagram becomes increasingly difficult to interpret, which is why CTX has been used to select facilities rather than included in the diagram. Each shape is a set, encompassing all the facilities which provide a particular component of care. For example, the solid black line indicates the set of facilities which offer family VCT. It contains 16 + 3 + 14 + 1 + 1 + 1 =36 facilities. Fourteen facilities are in the innermost section, inside all four sets, indicating that they offered or referred for all four elements (condoms, family VCT, water and ITNs) plus CTX. Three facilities offered all care com￾ponents except water supplies, represented by being inside the solid, dotted and dot￾dashed lines but outside the dashed. Sixteen facilities offered only CTX, condoms and family VCT. Two facilities with CTX did not provide or refer for condoms (at the bot￾tom) and 11 did not provide or refer for family VCT (far left, 6+2+3=11). The figure shows that the distributions for water and ITNs are similar, and that in most cases they are either both present or both absent. The distributions for condoms and fam￾ily VCT are also similar, and mainly contained within the other two. Figure 3: Distribution of elements of BCP for the 43 facilities which offer CTX Condoms 45 Family VCT 36 Water 19 ITNs 23 6 14 1 1 1 16 2 3 3 38 2. Malaria and TB – Malaria and TB cause high morbidity and mortality in the HIV￾negative population. Both diseases are more likely to affect people with HIV and to be exacerbated by it. The survey included components of care to prevent, diagnose and treat TB and malaria. The prevention interventions (bednets and isoniazid) had the low￾est coverage (Table 26). Interestingly, the frequency at which bednets were provided or referred remained about the same in all facility types. All hospitals and health centres provided or referred for treatment for malaria and TB although the respective tests were not universally provided or referred. ‘TB detection’ is more likely to be a series of steps, beginning with screening for symptoms and questions on possible exposure, and ending with a sputum test or x-ray. At HBC facilities, bednets were the care component most likely to be available, with treatment provided or referred for at half of facilities. Table 26: Availability of components of care relating to malaria and TB, by facility type Component of care Facilities offering test including referrals, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Isoniazid to prevent TB 4 (80) 3 (75) 18 (67) 6 (46) 4 (40) 35 (59) TB detection 5 (100) 4 (100) 26 (96) 9 (69) 5 (50) 49 (83) TB treatment 5 (100) 4 (100) 27 (100) 9 (69) 5 (50) 50 (85) Mosquito bednets 3 (60) 2 (50) 18 (67) 6 (46) 6 (60) 35 (59) Treatment for malaria 5 (100) 4 (100) 27 (100) 13 (100) 5 (50) 54 (92) Malaria film 4 (80) 4 (100) 26 (96) 8 (62) 1 (10) 43 (73) AFB test 4 (80) 4 (100) 25 (93) 8 (62) 0 41 (69) 3. Other opportunistic infections – Provision or referral for treatment for opportunistic infections was generally high (Table 27), and was complete at hospitals. Health centres had 93% or higher coverage for all OIs listed and health posts had 77% or higher. There were 6 HBC facilities (60%) which consistently did not provide or refer for clinical care, although some of them provided or referred for management of symptoms such as nau￾sea, diarrhoea and skin rash. 4. Prevention with positives – PEPFAR’s care and support strategy includes ‘prevention with positives’ care. This is an approach promoting healthy living and addressing risky behaviours for people living with HIV/AIDS. The aims of the initiative are improved quality of life and a reduction in HIV transmission to sex partners and infants born to HIV-infected mothers (PEPFAR 2007; IDSA 2007). Prevention for positives includes providing condoms and promoting their use, counsel￾ling HIV-positive persons to prevent transmission, providing STI diagnosis and treat￾ment and prevention of mother to child transmission services (IDSA 2007; PEPFAR 2007) as these aim to reduce risky behaviours. The availability of some of the constituent 39 components of care was examined in the CSRI, including adherence counselling, family planning counselling, treatment of herpes, patient HIV support groups, and condoms. All 59 facilities analysed provided or referred for at least three of these five components and over half (n=32) provided or referred for all five. Adherence counselling was pro￾vided or referred at all 59 facilities, family planning counselling at 57 and condoms were provided at 54 (see Table 17 above). All five components were provided or referred by 80% of referral hospitals, all district hospitals, 63% of health centre, 38% of health posts and 20% of HBC facilities. Table 27: Availability of components of care relating to opportunistic infections, by facility type Treatment for opportunistic infection Facilities offering test including referrals, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Treatment for nausea/vomiting 5 (100) 4 (100) 26 (96) 13 (100) 5 (50) 53 (90) Treatment for skin rash/itching 5 (100) 4 (100) 26 (96) 13 (100) 6 (60) 54 (92) Treatment for diarrhoea 5 (100) 4 (100) 27 (100) 13 (100) 6 (60) 55 (93) Laxatives 5 (100) 4 (100) 25 (93) 10 (77) 5 (50) 49 (83) Treatment for thrush 5 (100) 4 (100) 27 (100) 13 (100) 5 (50) 54 (92) Treatment for oral candidiasis 5 (100) 4 (100) 27 (100) 13 (100) 5 (50) 54 (92) Treatment for Cryptococcus 5 (100) 4 (100) 26 (96) 11 (85) 4 (40) 50 (85) Treatment for other fungal infections 5 (100) 4 (100) 27 (100) 13 (100) 4 (40) 53 (90) Treatment for herpes 5 (100) 4 (100) 27 (100) 12 (92) 4 (40) 52 (88) • Diagnostic tests — Laboratory services are not specified as an element of care and support but they are necessary in order to prevent and manage infections and monitor HIV progres￾sion. All the lab services in the survey were provided or referred at a proportion of hospitals, health centres and health posts, but HBC facilities provided or referred for very few (Table 28). Malaria blood film and rapid HIV test were the most commonly provided or referred lab services, both of them at almost all hospitals and health centres, around two-thirds of health posts and 10% of HBC facilities. 40 Table 28: Availability of diagnostic tests, by facility type Laboratory test Facilities offering test including referrals, n (%) Referral hospital District hospital Health centre Health post HBC Total N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) 59 (100) Liver function test 4 (80) 3 (75) 23 (85) 4 (31) 0 34 (58) Malaria film 4 (80) 4 (100) 26 (96) 8 (62) 1 (10) 43 (73) AFB smear 4 (80) 4 (100) 25 (85) 8 (62) 0 41 (69) CD4 count/test 5 (100) 4 (100) 22 (81) 6 (46) 0 37 (63) Rapid HIV test 4 (80) 4 (100) 26 ( 96) 8 (62) 1 (10) 43 (73) Pulse oximetry 1 (20) 2 (50) 12 (44) 4 (31) 0 19 (32) Dried blood spot for early infant diagnosis 4 (80) 3 (75) 13 (48) 4 (31) 0 24 (41) Viral load 4 (80) 2 (50) 19 (70) 4 (31) 0 29 (49) Care provided and staff available Table 29 above shows that in most areas of care, where facilities provided components of care they had specialist staff available in that area, and there were few cases where specialist staff were pres￾ent but care in that area was not provided. The exception was social care, for which 23 facilities had specialist staff but did not provide any of the five social care components surveyed. Table 29: Components of care provided onsite and staff available Area of care Components of care provided Number of facilities where specialist staff not working Number of facilities where specialist staff working Clinical None 0 0 At least one 7 52 Psychological None 0 0 At least one 24 35 Spiritual None 22 3 At least one 18 16 Social None 12 23 At least one 3 21 Prevention None 0 0 At least one 3 56 Laboratory None 20 3 At least one 3 33 There were few facilities providing clinical components of care without specialist staff. However, there were a large number of facilities providing other specialisms without specialist staff being present. Psychological care was the type of care most likely to be administered by untrained or un- 41 specialised staff. Pain control and symptom management were not provided at facilities where there were no clinical staff (not shown in table). Nutritional advice was the most commonly reported component of care, but only five facilities employed a nutritionist. There were only a few facilities where specialist staff were employed but the facility did not pro￾vide any components of care in that area (from the ones listed in the CSRI). For example, at three facilities, specialists in spiritual care were available, but none of the listed components of spiritual care were provided there. Number of patients receiving components of care Facility staff were asked to report the numbers of HIV patients receiving specific components of care (TB testing, TB treatment, treatment to make water safe, CTX and ITNs). In eight facilities, the number of people recorded to be receiving CTX was greater than the total number receiving care. When this was followed up, facility staff attributed this anomaly to CTX (and other care) in some instances being provided to people who were not registered patients. In those cases where the numbers of patients receiving care were not higher than the total number of HIV patients, the proportions of patients receiving a number of components of care were cal￾culated. Table 30: Proportion of patients receiving components of care Care component Facilities offering component of care onsite, n Facilities with plausible patient numbers, n Median proportion of pts receiving the care component in the last quarter, % (IQR) CTX 47 22 84.0 (57.3-100.0) Safe water 23 13 28.2 (15.1-50.0) ITN 29 18 33.0 (21.9-53.9) TB test 36 22 3.5 (1.0-10.4) TB treatment 37 31 2.0 (0.6-5.0) Table 30 shows that, of the facilities offering the components of care listed, several did not have reliable data in order to allow the proportion of patients receiving the care to be calculated. Of those that did have data, the median proportion of patients receiving CTX was 84%, and 10 facili￾ties provided CTX to 100% of patients with HIV at their facility. Safe water and ITNs were each provided to nearly a third of HIV patients. TB testing and TB treatment were offered at more facilities, but to lower proportions of HIV patients. Document analysis Availability of documents The proportion of facilities reporting having specific named documents ranged from 17% for pa￾tient charging to 98% for patient information (Table 31). Patient information sheets, patient re￾cords, outgoing referral forms and stock control sheets were the only documents to be used by more than 80% of facilities. 42 Facilities providing examples of their service documents ranged between 4.5-40%, with the least common provided being inward referral criteria, and the most commonly provided being service aim and ongoing assessment sheets. Table 31: Documents obtained Document Type Facilities reporting document in use, n (%) Facilities from which example document obtained, n (% of those reported) Further analysis conducted Service aim 30 (51) 12 (40) No Referral criteria (inwards) 22 (37) 1 (5) No Incoming referral forms 28 (47) 5 (18) No Outgoing referral forms 53 (90) 19 (36) Yes Patient charging 10 (17) 1 (10) No ARV protocol 25 (42) 5 (20) No Care protocols 28 (47) 5 (18) No First clinical assessment sheets 39 (66) 14 (36) Yes Ongoing contact assessment sheets 35 (59) 14 (40) Yes Patient records 54 (92) 9 (17) Yes Referral follow-up forms 25 (42) 6 (24) Yes Stock control sheet 49 (83) 14 (29) Yes Patient information sheet 59 (100) 22 (37) Yes Analysed by facility type, for most documents the largest proportion of facilities to provide ex￾amples were health centres, which contributed 43% of the total documents provided (Table 32). As stated in the Methods section,documents were analysed for content if more than five were col￾lected and if the number collected was more than 20% of the facilities reporting use of the docu￾ment. The exception was the service aim, which was normally very short (e.g. ‘Provide care for all, ‘Serve Ugandan’, ‘To treat for life’). Staff were later asked why they had not been able to provide example documents for analysis of content. Reasons given included facilities not keeping some documents in a hand-out form (e.g. service aim), having few or no copies in stock (and in some cases facilities were improvising forms whilst waiting for more copies to arrive) or none spare to hand out, and that documents were con￾fidential. 43 Table 32: Document examples obtained by facility type Document type Number (%) facilities providing example of document Facility type Referral hospital District hospital Health centre Health post HBC Total Service aim 2 (17) 1 (8) 4 (33) 0 5 (42) 12 (100) Referral criteria (inwards) 0 0 1 (100) 0 0 1 (100) Incoming referral forms 0 0 4 (80) 1 (20) 0 5 (100) Outgoing referral forms 0 1 (5) 8 (42) 6 (32) 4 (21) 19 (100) Patient charging 0 0 1 (100) 0 0 1 (100) ARV protocol 1 (20) 0 4 (80) 0 0 5 (100) Care protocols 1 (20) 1 (20) 3 (60) 0 0 5 (100) First clinical assessment sheets 2 (14) 2 (14) 7 (50) 2 (14) 1 (7) 14 (100) Ongoing contact assessment sheets 1 (7) 2 (14) 8 (57) 2 (14) 1 (7) 14 (100) Patient records 0 1 (11) 6 (67) 1 (11) 1 (11) 9 (100) Referral follow-up forms 0 0 2 (33) 0 4 (67) 6 (100) Stock control sheet 2 (14) 2 (14) 1 (7) 7 (50) 2 (14) 14 100) Patient information sheet 1 (5) 1 (5) 10 (45) 5 (23) 5 (23) 22 (100) Table 33: Format of documents Document (Number of facilities using document) Format used Paper only Computer only Both computer & paper Service aim (n=30) 24 1 5 Referral criteria inwards (n=22) 21 0 1 Incoming referral forms (n=28) 27 0 1 Outgoing referral forms (n=53) 47 1 5 Patient charging (n=10) 5 1 4 ARV protocols (n=25) 22 1 2 Care protocols (n=28) 23 1 4 First clinical assessment sheets (n=39) 32 1 6 Ongoing contact assessment sheets (n=35) 27 1 7 Patient records (n=54) 43 1 10 Referral follow up forms (n=25) 22 1 2 Stock control sheets (n=49) 41 1 7 Information for patients (n=59) 53 1 5 44 Most facilities, if they had records at all, relied on paper documents (Table 33). Patient records were the information most frequently stored on computer. As a proportion of the total, patient charging forms were the most likely to be stored on computer (50%). Analysis of content • Outgoing referral forms — Table 34 shows that fields recording potentially important details of medical history were often not present on outgoing referral forms. The only information which was always present was the facility name, patient’s name, the date of referral, and the names of the individuals referring and receiving the patient. Table 34: Outgoing referral form contents Outgoing referral form features Number of facilities Information present on form Information absent from form Facility details Name of facility and location details 19 0 Facility contacts 19 0 Registration details Patient clinic number 12 7 Referral number 10 9 Date of referral 19 0 Date of first visit 16 3 Sociodemographic information Patient name 19 0 Age 15 4 Sex 15 4 Patient’s address 10 9 Medical history Diagnosis/ working diagnosis 11 8 Present therapy (ARV, and prophylaxis) 4 15 Treatment given so far 12 7 Previous opportunistic infections (dates) 4 15 WHO staging 4 15 Use of ARV (ARV start date) 4 15 Laboratory investigations done , dates and results 4 15 Patient complaints/ symptoms 12 7 Referral service requested/ 17 2 Clinical notes/ remarks 9 10 45 Outgoing referral form features Number of facilities Information present on form Information absent from form Other details Name of officer referring 19 0 Date/Signature of officer referring 19 0 Patient’s consent (signature and date) 1 18 Referral response section Date of admission 3 16 Date of discharge 3 16 Diagnosis 6 13 Investigations do ne 6 13 Treatment given 6 13 Remarks 6 13 Officer receiving referral, signature and date 19 0 • Patient records — Only 6 facilities were able to provide a patient record form (Table 35). Again, medical history was not always present. Information on medication the patient had been taking was only mentioned on 2/6 forms. Table 35: Patient records Patient record features Number of facilities Information present on form Information absent from form Facility name and contact details 6 0 Facility branch 2 4 Registration details Date 6 0 Counsellor’s name 2 4 Card number (card does not bear results) 4 2 Facility patient number 4 2 Test number 4 2 Counsellor’s code 2 4 Sociodemographics Patient name 6 0 Age/ date of birth 6 0 Sex 6 0 46 Patient record features Number of facilities Information present on form Information absent from form Contact details 6 0 Next of kin 4 2 Company 1 5 Brief medical history Case notes 4 2 Investigations and treatment 4 2 Date of next appointment 4 2 Patient medication list Prophylaxis medication prescriptions (reason, date dispensed, number of days) 2 4 ARV prescriptions (date, dispensed, number of days) 2 4 Other medications including herbs (date, dispensed, number of days) 2 4 • Referral follow-up forms — Referral follow-up forms were brief and were meant to be ad￾ditional to the main record, so sociodemographic information was not included (Table 36). Table 36: Referral follow-up forms Referral follow-up form features Number of facilities Information present on form Information absent from form Date of arrival 6 0 Diagnosis 6 0 Treatment given 6 0 Treatment or surveillance to be continued 2 4 Name and signature of clinician 6 0 For admissions (admission and discharge dates) 2 4 Confidential footnote and request to return form to facility referring 6 0 • First clinical assessment sheets — The first clinical assessment sheet (sometimes referred to as an HIV care enrolment sheet) is intended for completion by a clinician, who undertakes the physical examination and document patients’ medical history for each new patient at their first visit. All reporting facilities captured the core information required by the Ministry of Health: patient socio-demographic information, patient current condition and medical his￾tory, previous treatment, adverse reactions and resistance to prior treatment regimens. The MOH recommends collecting information about vital signs, clinical examination and specific laboratory tests to support treatment monitoring, and this information was also present on all the forms. Some facilities captured additional information to address other information needs 47 (e.g. those involved in research or requiring information on local service providers to avoid service overlap). In terms of the documentation of presenting complaints, only two facilities specifically enquired about pain and only one enquired about patients’ mental health. Table 37: First clinical assessment sheets First clinical assessment sheet features Number of facilities Information present on form Information absent from form Registration Patient ID 14 0 Date of registration 14 0 Confirmed death of patient 2 12 Site / station 3 11 Clinic number 10 4 District, health unit 4 10 Entry point 2 12 Treatment support person 4 10 Home-based care provider 4 10 Free or paying for drugs 4 10 Sociodemographics Patient name 14 0 Existing hospital / clinic 2 12 Gender 14 0 Age 14 0 Religion 2 12 Date of birth 14 0 Residence 14 0 Marital status 14 0 Educational level 14 0 Emergency contact 4 10 Literacy 2 12 Disclosure status 12 2 Employment status 14 0 Monthly income 2 12 Number of children 14 0 Distance to facility 2 12 Potential barriers to HIV care 2 12 48 First clinical assessment sheet features Number of facilities Information present on form Information absent from form Referral Who referred you 4 10 HIV History Date of HIV diagnosis 14 0 Primary provider 2 12 Diagnosis verification 14 0 Pregnancy 14 0 HIV status 2 12 Number tested in family 2 12 Number HIV positive in family 14 0 Number deceased 2 12 Membership to HIV support group 4 10 History of AIDS defining illness (initial or recurrence) 14 0 Adherence Date , doses missed, diagnosis, treatment, change treatment and reason for changing 14 0 Laboratory investigations conducted and results 14 0 Vital signs and medications Chief complaints 14 0 Weight, height, temperature, blood pressure, respiratory rate, heart rate, Karnof￾sky score 14 0 ARV treatment history Previous ARV exposure and dates 14 0 Name of drugs and months on treatment 14 0 CD4 prior starting ARV and date 14 0 1st, 2nd and 3rd regimens plus dates 14 0 Viral load prior ARV 14 0 Date started HAART 2 12 ARV eligibility and action taken 14 0 Medical & health history Surgical or hospitalisation history or skin, eyes, mouth, pulmonary, neurological problems 14 0 Current non-ARV medications (prophylaxis and contraceptives) 14 0 Liver, kidney, anaemia, drug / alcohol abuse 2 12 49 First clinical assessment sheet features Number of facilities Information present on form Information absent from form Medication allergies 14 0 Current long-term medications 14 0 TB history and assessment 2 12 If female: pregnancy and connection to preventing mother to child transmission (PMTCT)? 14 0 WHO clinical stage with stages well defined 14 0 Presenting clinical information Presenting complaints (pain*, headache, mental health**, new visual problems etc) and their description 14 0 Clinical plan 14 0 Problem list and plan 14 0 Significant positive findings on examination 14 0 Notes, signature of interviewers 14 0 Date of next appointment 14 0 * 2 sites only ** 1 site only • Ongoing contact assessment sheets — The ongoing contact assessment sheet (Table 38) is in￾tended for completion by a clinician at every clinical appointment. Over 90% of the reporting facilities in Uganda were using similar documents supplied by the MOH. Two of the facilities captured information on the use of herbal medicines, while only four recorded ongoing prob￾lems as opposed to only new problems. The sites that captured additional information had similar documentation, suggesting they might be part of the Timetable for Regional Scale-up of ARV therapy (the ‘TREAT’ programme) collaboration, a network of care providers and public, private and faith-based support groups coordinated by the Joint Clinical Research Centre ( JCRC, kampala.usembassy.gov/jcrc). Adherence, infections (especially TB), treat￾ment history and ARV monitoring were key areas of focus across all reporting facilities. Table 38: Ongoing contact assessment sheets Ongoing contact assessment sheet features Number of facilities Information present on form Information absent from form Registration Visit date 14 0 ID 14 0 Existing hospital / clinic 2 12 50 Ongoing contact assessment sheet features Number of facilities Information present on form Information absent from form Socio-demographic Patient name 14 0 Adherence Number of doses missed (% adherence) 14 0 Directly observed therapy (DOT) 4 10 Home visits, support group 4 10 Unintended treatment interruption 14 0 Patient reports taking herbal medications 2 12 Vital signs Presenting complaints (enquire about sexual activity) 14 0 Last CD4 count and date 14 0 Pregnant? LMP 14 0 Physical examination (temperature, RR, HR, BP, weight, height, pain) 14 0 Clinical assessment 14 0 New problems / diagnoses 14 0 Ongoing problems / diagnoses 4 10 WHO stage, TB status, TB type, TB smear, TB drug 14 0 On ARV side effects 14 0 ARV regimen (start date, end date, change reason, stop reason, ARV source) 14 0 Prophylaxis (drug, strength, frequency, duration, quantity dispensed) 14 0 Opportunistic infection (OI) treatment and other medications 14 0 Assessment (improving, active OI , drug toxicity, non-adherence, WHO stage, CD4, viral load) 14 0 Plan on ARV therapy (change, continue, change regimen, start new treatment etc), regimen 14 0 Next appointment 14 0 • Stock control sheet — A stock control sheet, central to effective stock management systems for drugs used at all levels of the health care system, is ordinarily a small record- keeping sys￾tem made from cardboard. There is normally one stock card per item, with the card usually retained close to the stock it refers to (e.g. on the same shelf ). As Table 39 shows, the majority of the reporting Uganda facilities documented stock move￾ment information (e.g. quantity issued, received and the actual net balance) and inventory management (e.g. minimum and maximum stock levels). Only half of the reporting facilities documented the drug name on the stock card, and the stock reorder level. In public health fa- 51 cilities official MOH documents were used; other facility types used documents that included additional details (e.g. adjustments / losses, quantity to order and unit size). Table 39: Stock control sheet Stock control sheet features Number of facilities Information present on form Information absent from form Facility details Facility name and details 14 0 Program name 9 5 Specifications Name of drug 7 7 Item description 10 4 Item code 9 5 Card number 8 6 Unit pack and size 4 10 Formulation 6 8 Strength 9 5 Cost 6 8 Special conditions 7 7 Stock movement Date 14 0 Quantity issued 14 0 Quantity received 14 0 Balance at hand 14 0 Quantity to order 7 7 Inventory management Average consumption per month or week 7 7 Expiry date 10 4 Remarks (voucher number, other details) 14 0 Re-order level 8 6 Minimum stock level 13 1 Maximum stock level 13 1 To / from 13 1 Losses / adjustments 5 9 Signature 9 5 52 • Patient information sheets — All facilities with patient information sheets offered informa￾tion about who they are, what they do and their contact addresses. As Table 40 shows, ad￾ditionally, all facilities offered information about family planning, positive living and basic information about ART, with the information sheets produced with support from PEPFAR, the MOH, USAID, and Population Services International. Information of child feeding was only provided by 5 facilities. Among the 59 facilities that reported having information sheets for patients, 57 (97%) had sheets written in English, whilst in 56 sites (95%) information was provided in a minimum of two languages (i.e. English and a local language), 8 sites (14%) provided information in at least 3 languages, and 3 sites (5%) provided information in more than 3 languages. Table 40: Patient information sheets Patient information sheet features Number of facilities Information present on form Information absent from form Family planning Available contraception options 22 0 How they work 22 0 Advantages and disadvantages 22 0 Other centres offering the service 22 0 PMTCT services 22 0 Services available for PMTCT (comprehensive antenatal care, improved during labour and delivery, postnatal care) 22 0 Expansion strategy 22 0 Actions (feasible alternatives to breast feeding, involvement of development partners, improving coordination between players, increasing spouse involve￾ment) 22 0 Contacts for further information 22 0 Child feeding Important information about fresh cow’s milk (how to boil it, mixing, prepara￾tion, storage and how to give it to the baby) 5 17 Feeding advice for children at different ages 5 17 Child feeding at six months 5 17 Information on what foods to give, in what amounts, form and how 5 17 How to observe hygiene in child care 5 17 Facility information Facility mission, aim, goal and objectives 22 0 Facility activities 22 0 53 Patient information sheet features Number of facilities Information present on form Information absent from form Contact details 22 0 Positive living Avoid malaria (sleep under mosquito treated nets)* 22 0 Use daily septrin 22 0 Safe drinking water (use water guard, use a clean container, wash hands with soap before eating or serving food or after using the toilet) 22 0 Do not spread the virus to your lovers (encourage your partners to screen for HIV there is a possibility for discordance, avoid sexual relationships or use a condom, if you get pregnant go for PMTCT services) 22 0 Basics about antiretroviral therapy (meant for HIV+ people) By taking ARV you can continue to work and look after your family 22 0 What is ART? 22 0 How does it work? 22 0 Does ART cure AIDS? NO it only helps to lessen the amount of HIV in the body and make it less active. When on ART you can still pass HIV to someone else during unprotected sex. 22 0 When should I start ART? 22 0 What is a CD4 test? A CD4 count of less than 200 in an HIV positive person shows a weak immune system. 22 0 What are ART-related side effects? 22 0 Who should I tell about my HIV status? Tell your sexual partners. It also helps to tell someone you can trust, such a person can remind you to take your ART tablets regularly. 22 0 Is ART expensive? Free drugs are available through ministry of health. 22 0 How long does one take ART? You can start only when you are ready for a life-long commitment. 22 0 What is reinfection? When you are taking ART drugs, you can still get more of the virus or a different HIV strain by having unprotected sex. 22 0 * Pictorial for illustration on how to use, treat and access mosquito bed nets. Pharmacy review A review of the supply and storage of key drugs for HIV care was undertaken at each facility by visiting the onsite pharmacy. Type, form and amounts of drugs stored Adult CTX in tablet form was the most commonly found drug (found at 40 facilities) followed by non-opioid painkiller tablets at 39 as shown in Table 41. Tablets were the most common form of 54 every drug except paediatric CTX, which was stocked in syrup form in 11 facilities. Twenty-four facilities stocked adult CTX but not paediatric CTX; 16 facilities had both; and one had paediatric CTX but not adult CTX. Owing to the rarity of powder and syrup formulations, of the 21 drug/ formulation combinations listed in the pharmacy review, only seventeen were ever found in the 60 facilities visited. Table 41: Types and amounts of drugs stored at pharmacies Drug Formulation N facilities where in-date drug stocked (expired) Amount of in-date drug found in pharmacy* Mean Lowest Highest Isoniazid Tablets 21 (2) 913 70 3610 Syrup 1 (0) 290 290 290 Powder 0 (0) 0 0 0 Fluconazole Tablets 24 (1) 994 40 7154 Syrup 1 (0) 200 200 200 Powder 3 (1) 56 7 105 Adult CTX Tablets 40 (0) 57573 80 84000 Syrup 3 (0) 70033 500 176000 Powder 0 (0) 0 0 0 Paediatric CTX Tablets 10 (0) 2909 42 7630 Syrup 11 (0) 4570 200 33600 Powder 1 (0) 100 100 100 Non-opioid analgesic Tablets 39 (0) 24252 40 29000 Syrup 10 (0) 17910 200 132000 Powder 0 (0) 0 0 0 Codeine Tablets 16 (0) 1101 100 5990 Syrup 2 (0) 650 300 1000 Powder 0 (0) 0 0 0 Morphine Tablets 4 (1) 131 15 236 Syrup 2 (1) 3930 1190 6670 Powder 2 (0) 3500 3500 3500 Injectable 3 (1) 11 10 12 * Amounts are number for tablets, mls for syrup, grams for powder and number of vials for injectable The seven facilities with in-date morphine comprised two that stocked syrup, two that stocked tablets, two that stocked tablets and injection, and one that only stocked injectable morphine. One facility had expired syrup but no in-date morphine in stock. 55 There were four facilities that provided several types of symptom management onsite according to the CSRI data in the staff interview, but had none of the named drugs in stock. This suggests they did not have a pharmacy on site. These facilities were all health centres or health posts. Two of the five identified facilities reported they offered a total of 13 out of a possible 16 components of clini￾cal care. It appears that the facilities must be providing prescriptions only. Table 42 shows that drug availability is associated with facility type, but district hospitals were on average better stocked than referral hospitals. Morphine was only available at district hospitals and health centres. Non-opioid analgesics and adult CTX had very similar distribution patterns and were the most widely available drugs. HBC facilities have very poor drug stocks. Codeine, a weak opioid, was available at only 60% of referral hospitals and even fewer in all other facility types. Table 42: Drug availability by facility type Drug, any formulation, in date Facilities stocking drug n (%) Referral hospital District hospital Health centre Health post HBC N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) Non-opioid analgesic 5 (100) 3 (75) 22 (81) 8 (62) 1 (10) Codeine 3 (60) 1 (25) 10 (37) 3 (23) 0 morphine 0 2 (50) 5 (19) 0 0 Isoniazid 1 (20) 3 (75) 13 (48) 4 (31) 0 fluconazole 4 (80) 3 (75) 16 (59) 1 (7) 0 Adult CTX 5 (100) 3 (75) 22 (81) 9 (69) 1 (10) Child CTX 2 (40) 1 (25) 12 (44) 2 (15) 0 Table 43 presents a comparison of facilities where drugs were stocked and facilities that said they offered the drug or treatment to HIV patients. Only direct provision rather than referrals are in￾cluded. The table shows that, for every drug listed, drugs were frequently not in stock on the day of the survey at facilities where the drug was offered as a component of care. Drug availability ranged from 50% of facilities offering morphine having it in stock, to 83% of facilities offering CTX hav￾ing it in the pharmacy. There were also cases where the component of care was not reported as offered by the facility to HIV patients, and yet the corresponding drug was in stock. For example, only 71% of facilities stocking isoniazid reported they offered isoniazid prophylaxis to HIV patients. 56 Table 43: Drugs found in pharmacy compared to care directly offered by facilities Drug, all forms Facilities stocking in-date drug (n) Facilities offering the component of care which requires this drug (n) Proportion (%) of facilities offering care which have appropriate in-date drug in stock Proportion (%) of facilities with the in-date drug in stock which offer component of care Non-opioid analgesic 39 50 39/50 (78) 39/39 (100) Codeine 17 21 16/21 (76) 16/17 (94) Morphine 7 12 6/12 (50) 6/7 (86) Isoniazid 21 22 15/22 (68) 15/21 (71) CTX (adult or child) 41 47 39/47 (83) 39/41 (95) Stock levels and stockouts A stock level is the quantity of remaining stock which prompts the facility to make another order. Facilities were asked whether they had a stock level for each drug, and whether they had a record of running out of any drugs in the last 6 months (a recorded stockout). Table 44: Stock levels Drug Formulation N facilities where stock level reported (% of those where drug stocked) Stock level (number of packs) mean minimum maximum Non-opioid Tablets 17 (44) 2.8 1 10 Syrup 4 (40) 15.8 2 40 Codeine Tablets 8 (50) 64.8 1 300 Syrup 0 Morphine Tablets 2 (50) 1.0 1 2 Syrup 1 (50) 20.0 Powder 0 Injectable 2 (67) 5.5 1 10 Adult CTX Tablets 20 (50) 7.6 1 50 Syrup 2 (67) 15.0 10 20 Child CTX Tablets 5 (50) 5.4 1 10 Syrup 5 (45) 7.6 6 10 Powder 0 Isoniazid Tablets 4 (19) 9.8 2 25 Syrup 0 Fluconazole Tablets 10 (42) 10.2 2 25 Syrup 0 Powder 1 (33) 5.0 57 Table 44 shows that stock levels were given in only about half of cases. In many facilities the stock level was only one pack. Stockouts were frequently recorded. Of the 55 facilities that stocked any of the drugs reviewed, 47% reported a stockout of at least one of the drugs during the past six months. Out of the 40 facilities offering adult CTX tablets, 38% reported a stockout in the last 6 months, and 33% of non-opioid tablet stocks had been empty in the same time. From the 22 possible formulation combinations which were searched for, 18 were found. Table 45 shows the number of formulation combinations which had had stockouts at each facility in the last 6 months. Four facilities had none of the listed drugs and therefore no risk of stockouts, so the proportion of eligible facilities which had at least one stockout was 26/55 or 47%. The total number of individual drug stocks found (the sum of facilities per drug in Table 44) is 193, and there were 49 stockouts (Table 45), meaning that 25% of all drug formulations recorded at the facilities had suffered a stockout in the previous six months. Table 45: Number of stockouts per facility Formulations having stockout Number of facilities (%) 0 33 (56) 1 12 (20) 2 7 (12) 3 5 (8) 4 2 (3) total 59 Drug stockouts were analysed by facility type to explore whether some facilities were more likely than others to run out of drugs. Table 46 below shows that HBC facilities had no problem with stockouts, largely because they had very few drugs. Health centres had stockouts of the most drug formulations. Non-opioid analgesic tablets and CTX tablets were the drug most likely to be out of stock, partly because these are the most commonly stocked drugs (see Table 42 for denominators for stockout analysis). Storage Table 47 shows that drugs were most commonly kept in locked places, usually locked in clinic or open access in the pharmacy. However, on a number of occasions drugs were found to be kept within easy access of patients. Codeine, CTX, fluconazole and non-opioid painkillers were all openly accessible in the clinic at more than one facility. Morphine should be double-locked, but injectable morphine was openly accessible in the pharmacy in one facility. 58 Table 46: Drug stockouts by facility type Drug Formulation Number (%) facilities stocking the drug to have recorded stockout in last 6 months Referral hospital District hospital Health centre Health post HBC N 5 (100) 4 (100) 27 (100) 13 (100) 10 (100) Non-opioid analgesic Tablets 2 (40) 1 (25) 5 (19) 5 (38) – Syrup – 1 (25) 1 (4) – – Powder – – – – – Codeine Tablets 1 (20) – 1 (4) – – Syrup – – 1 (4) – – Powder – – – – – Morphine Tablets – 1 (25) 3 (11) – – Syrup – – 1 (4) – – Powder – – – – – Injection – – – – – Isoniazid Tablets – 1 (25) 4 (15) 1 (8) – Syrup – – – – – Powder – – – – – Fluconazole Tablets 1 (20) 2 (50) 1 (4) – – Syrup 1 (20) – – – – Powder – – 1 (4) – – Adult CTX Tablets 2 (40) 2 (50) 6 (22) 5 (38) – Syrup – – – – – Powder – – – – – Paediatric CTX Tablets – 1 (25) – 1 (8) – Syrup – – 1 (4) – – Powder – – – – – Table 47: Drug storage Drug Formulation Expiry* Open access in clinic Open access in pharmacy Locked in clinic Locked in pharmacy Non-opioid Tablets ID 6 16 9 8 Syrup ID 2 7 0 1 Codeine Tablets ID 2 4 1 9 Syrup ID 0 1 1 0 Morphine Tablets ID 0 0 1 3 Tablets EX 0 0 0 1 59 Drug Formulation Expiry* Open access in clinic Open access in pharmacy Locked in clinic Locked in pharmacy Morphine con’t Syrup ID 0 0 0 2 Syrup EX 0 0 0 1 Powder ID 0 0 0 1 Injectable ID 0 1 1 1 Injectable EX 0 0 0 1 Adult CTX Tablets ID 5 15 11 9 Syrup ID 0 3 0 0 Child CTX Tablets ID 2 5 1 2 Syrup ID 3 4 2 1 Powder ID 0 0 1 0 Isoniazid Tablets ID 2 6 6 6 Tablets EX 0 1 1 0 Syrup ID 0 1 0 0 Fluconazole Tablets ID 4 9 2 9 Tablets EX 0 0 1 0 Syrup ID 0 1 0 0 Powder ID 0 1 0 1 Powder EX 0 0 0 1 * ID = in date, EX = expired Facility strengths and areas for improvement: staff open-ended questions The senior staff at each facility were asked to indicate perceived strengths of their facility, ways in which the services offered could be improved, threats to sustainability and their ideas on ways to avoid double-counting of patients. A total of 189 members of staff were involved in the senior staff interviews, a mean of 3.2 people per facility with a range from 1 to 5 (Table 48). The responses are also presented by cross-cutting themes through the range of data sources. Strengths Nearly all facilities (90%, n=54) named spe￾cific provided components of care in their list of strengths. One of the most common was being able to provide CTX to patients. Oth￾er aspects of care named were ARVs, VCT, PMTCT, treatment of infections, community mobilisation, peer counselling and home care. Being able to provide services free of charge was mentioned as a strength in itself. Table 48: Senior staff interviews Number of participants Facilities n (%) 1 5 (8) 2 16 (27) 3 15 (25) 4 13 (22) 5 11 (18) 60 Owning land or buildings, rather than renting, was seen as a strength and a benefit for sustain￾ability. Having a laboratory on-site was often mentioned as a strength. Having a vehicle was a significant strength for staff. Staff said that having transport made it possible to reach new clients, particularly the underserved, via mobile units and home-based care for people too ill to take the bus. Conducting outreach, to publicise the facility’s activities and encourage VCT and care uptake, was made easier by transport. Being able to offer home-based care was singled out as a strength. Some facilities were attempting profit-making enterprises and they saw this as a strength because it would reduce their dependence on outside donors. The facility staff themselves were often consid￾ered a strength to the facility. Qualities of the staff mentioned which made them an asset included being committed, motivated, well trained, diverse, and skilled, and having a good relationship with clients. Clinical staff and counsellors were particularly singled out as a staff asset. Psychosocial ser￾vices were described as a strength when the facility had trained counsellors, who promoted adher￾ence counselling, VCT, positive living, spiritual encouragement and personal testimony. Improvements to care for adults One of the most common answers staff gave was the need for more space. In particular, space was associated with counselling rooms, because of the need for privacy. Staff also said they needed space for a laboratory, an enlarged clinic, or simply because they had too many patients and not enough capacity. Staff said that they would like to provide more mosquito nets, water treatment, drugs and counsel￾ling, which are components of the BCP. Additionally they wanted to supply IGA programmes, payment of school fees, transport refunds and ARVs. The most common piece of equipment named which staff would like to have was a CD4 machine. Others said they wanted to be able to conduct HIV tests at the facility rather than having to send samples away for testing. Twenty-two facilities (37%) said better transport would improve the care they could offer. Facilities without vehicles wanted to buy one; those with vehicles wanted funds to pay for fuel. At some facilities it was said that there were not enough staff to handle the workload, and this caused demoralisation because the workload was too big. Managers wanted to hire more staff, especially community health workers, and provide more training, particularly for counsellors and CHWs. They also wanted to develop training for people living with HIV as peer educators and counsellors. Facilities saw it as important to provide food to patients, or at the very least to provide tea when they came for care. Staff said food provision was needed for three reasons: because many of the patients were malnourished, because the ARVs could not be taken without adequate food, and to reduce illnesses. The stated purpose of IGA was also to improve nutrition. The main reason given for why these improvements had not been carried out was lack of funds. Improvements to care for children Many facilities wanted to develop care for children. At 17 facilities staff talked about improve￾ments to the infrastructure, usually building a ward or daycare centre specifically for children, with toys for educational development. It was felt inappropriate to care for children in the same place as adults. This was another instance of the facility needing more building space. 61 At 15 facilities, the staff wanted training in paediatric counselling. This was the single most com￾monly expressed training need overall. A further eight staff groups wanted other training for child care. Psychosocial issues were more frequently mentioned in connection with child care than with care of adults. Nineteen facilities (32%) said that they wanted to provide food for children. Staff said that chil￾dren were monitored until the age of 6 months, after which their health and growth declined. They wanted to be able to continue following up these children and providing food for them. They also said that carers, who were sometimes very old, could not give the children enough to eat and needed to be supported, and that children were often malnourished. Some facilities wanted to provide child-specific drugs, and some could only provide ARVs to those aged 15 and over, and had no protocol for paediatric ART. Other suggestions as ways to improve services for children included legal services to prevent child-headed families from losing their pos￾sessions to relatives, and provision of school fees and household items. Counselling in schools was suggested as a way to reduce stigma for HIV-infected children. Facilities wanted to develop peer counselling among children but lacked training to do so. Challenges to sustainability The most frequently mentioned threat to sustainability was the issue of staff retention (n=38. 63%). Turnover was high, which was seen as damaging to patient care because new staff were less well trained and had not developed the good relationship with patients which was considered an asset to the facility. There were several reasons given for this high turnover. Managers said that many staff were volunteers, who paid for their own transport and food. The fact that they were volunteers meant that managers could not demand as much from them and they could leave at any time. These additional costs of food and transport were felt to be very demotivating to volunteers and staff requested that they should get some remuneration. The unmanageable workload induced lack of motivation and burnout in some staff. Low salaries and lack of training caused staff to leave. Relying on funding from donors, which is outside the facility’s control, was seen as a challenge to sustainability. Twenty-eight facilities (47%) saw funding as a challenge. Staff said that vertical programming, for instance funding specifically for ART or for animal husbandry programmes, limited the ability of the facility to meet its patients’ needs. Funding could be terminated at short notice and managers were worried that they would not be able to maintain their services, particu￾larly ART. Breakdown in drug supply was a serious sustainability issue for 34 facilities (57%). CTX was named in particular as a drug for which the facility had problems maintaining a regular and con￾tinuous supply. CTX was also the drug which facilities most commonly identified as a strength if they were able to stock it. Staff said that once drugs were ordered, they often arrived late, making it difficult to manage stock. Lack of transport was described as a challenge to sustainability by 17 facilities (29%). A vehicle and fuel were required to follow up patients, provide home care, and visit those who could not afford to get to the facility. The patients most in need might be the least able to pay for transport. 62 Other challenge to sustainability reported included stigma (by 5 facilities, 8%), which was de￾scribed as ‘self-made stigma’, i.e. fear of a positive diagnosis preventing potential clients from ac￾cessing services. At one facility, religious leaders encouraged followers not to take their ARVs, and staff said this was a significant problem. Ways to avoid double-counting All facilities had suggestions for the reduction of double-counting and no two suggestions were identical, but some common themes emerged. Several staff said the answers were to sensitise pa￾tients about the dangers of combining drugs and develop adherence counselling services, using the existing approaches of a drug buddy, sensitisation through drama, peer ambassadors, etc. Also, greater involvement of people living with HIV may help facilities understand why patients moved around. Facilities could also have permanent rather than transient staff, so that patients developed confidence in them and preferred to stay at one place. Others recommended regional or national databases with unique ID numbers, possibly photo ID cards, a record of drugs dispensed and the date, and stamps to prevent duplication. Two groups said that the reason patients move around was due to irregular drug supply, so the way to prevent it is to ensure the supply is continuous. It was pointed out that patients could be encouraged to bring their children in to collect their own CTX, rather than giving out doses by proxy. This approach may prevent a person receiving double services from the same facility. Some staff believed the answer was to have each facility as a stand-alone centre, providing all services – social, financial, treatment and care. Conversely, others suggested it would be better for facilities to specialise, with clear catchment areas for their particular speciality. Rather than pre￾venting patients from moving around, this would ensure they got different elements of care from different places, not the same things twice. Finally, staff suggested improving coordination between facilities and strengthening the referral system, with a strong central role from the Ministry of Health. Cross-cutting themes from staff open-ended questions Space was a very important issue to the staff interviewed. Many staff said they did not have enough space. The most common reason given for needing more space was for counselling, with space equating to privacy. The overwhelming reason given why services could not be developed was shortage of funds. In ad￾dition, funds sometimes arrived late, disrupting planning, and some managers said they spent a lot of their time applying for funds and requested training in how to apply more effectively. There was also the question posed of who would pay for care when a patient cannot afford it. Some facilities could not support all the patients they had, and reported having stopped registering new ones. The good relationship with patients (which staff remarked on as an asset to a facility) could not develop if staff were constantly changing. Managers said that volunteer staff, including themselves, would be more motivated if they had their costs paid such as lunch and transport to the facility. 63 From the point of view of the staff, transport allowed contact and follow-up with clients. Transport was related to cost in that staff wanted to provide refunds to patients who were prevented from ac￾cessing care by the cost of travel, and they also wanted to refund the travel expenses of volunteers. According to the quantitative data, 32 facilities had some kind of vehicle to transport patients, but 5 of these had no fuel or were broken down. Provision of home-based care was a reported strength, and several managers said they wished they had transport so they could provide more. Summary of staff qualitative data • Strengths — Staff felt the strengths of their facilities were 1. clinical care (CTX, ARVs, PMTCT, treatment of infections); 2. psychological care (adherence counselling, positive living, personal testimony); 3. spiritual encouragement for patients; 4. community mobilisation, peer counselling, home based care; 5. owning land or buildings, owning a vehicle; and 6. staff who are skilled, motivated, and diverse. • Improving adult care – Staff said that adult care could be improved by 1. more space, allowing privacy; 2. providing ITNs, water treatment; 3. providing ARVs, other drugs, HIV tests onsite; 4. improved counselling; 5. IGA, school fees, transport refunds, food; 6. better transport; and 7. hiring more staff. • Improving child care — Staff said paediatric care needed 1. a day care centre or ward for children; 2. training in paediatric counselling, development of peer-to-peer counselling and school education to counteract stigma; 3. food from weaning onwards; 4. child-specific drugs, paediatric ARVs; and 5. legal services. • Challenges to sustainability — Staff suggested the sustainability of facilities was challenged by 1. high staff turnover, reducing trust and losing skills; 2. low salaries and lack of training causing staff to leave; 3. breakdowns in drug supply; 4. relying on short-term donor funding; 5. lack of transport; and stigma.6. • Avoiding double-counting — Staff recommended reducing the double-counting problem by 1. sensitising patients about the dangers of combining drugs; 2. strengthening the referral system; 64 3. a national database and ID cards; 4. each facility providing comprehensive care; 5. regular drug supplies; and 6. each patient collecting their own medication. Patient focus group discussions Sample characteristics In Uganda, 47 FGDs were conducted with a total of 228 participants. Each focus group had be￾tween 3 and 6 participants, with a mean of 4.9. There were 85 men and 143 women. Four groups were male-only, 10 female-only, the remainder mixed. Participants were aged from 17 to 69 with a mean of 37.8 and median of 37. 151 lived in rural areas, 25 in peri-urban areas and 51 in urban areas. Household size ranged from 1 to 22. At 13 facilities, no FGD was conducted. Services received, comparison of patient data with facility data FGD participants were asked if they had received a number of specific components of care from the facility where the FGD was held (CTX, mosquito bed net, test for TB, treatment for drinking water, post-test counselling, nutritional counselling, and family counselling). During the analysis of the FGD data (both notes and recordings), and facility staff interviews of care offered, it was apparent that many patients responded to these questions without consider￾ing whether the care was obtained from the facility where the FGD was being held or by another facility. Therefore, the information in this table can be reliably used only to identify facilities where patients had not obtained the care either at this facility or elsewhere. Table 49 below summarises the proportion of facilities that identified themselves as offering the specific components of care (from Table 17), and the number of FGD participants reporting them￾selves as having received that care (now taken to mean from any facility). This table shows that for most components of care, those that are more commonly offered are also more commonly received. The services most commonly offered and received were nutritional counselling (offered by 57 facili￾ties and received by 87% of FGD participants) and post-test advice (offered by 54 facilities and re￾ceived by 93% of FGD participants). The exceptions to the trend are condoms, which were offered by 54 facilities but received by only 60% of FGD participants, and TB tests, which were offered by 36 facilities and received by 32% of participants. Table 50 summarises the extent of provision of specific components of care. The category ‘some’ comprises all the groups where at least one person received the care and at least one person did not. Where all participants reported having received the component of care this may represent it having being received at the facility where the FGD was held or elsewhere. Most notably, counselling and nutritional advice had been received by all the FGD participants at over three-quarters of facili￾ties where the components of care were offered. However, a TB test had not been received by any participants in FGDs at nearly half facilities where the facilities said it was available. 65 Table 49: BCP care received by FGD participants BCP component of care Number of facilities offering care, n (%) FGD participants receiving care, n (%) TOTAL 60 (100) 228 (100) Receives cotrimoxazole, to take every day 47 (78) 188 (83) Has been given a mosquito bed net (ITN) for personal use 29 (48) 129 (57) Has been tested for TB by sputum or X-ray 36 (60) 71 (32) Has received anything to make sure drinking water is clean 23 (38) 127 (56 Receives counselling about how to prevent transmitting HIV to others 54 (90) 212 (93) Receives nutritional counselling 57 (95) 199 (87) Received condoms for self or partner 54 (90) 136 (60) Been encouraged to bring spouse/children for HIV counselling and testing 48 (80) 187 (82) Table 50: FGD care received Care component Provided or referred by facility Section of group receiving care, n (%) of FGDs All Some None Total CTX Yes 25 (61) 13 (32) 3 (7) 41 No 4 (67) 2 (33) 0 6 Bednets Yes 12 (40) 13 (43) 5 (17) 30 No 4 (24) 7 (41) 6 (35) 17 Water Yes 12 (52) 9 (39) 2 (7) 23 No 6 (25) 6 (25) 12 (50) 24 TB test Yes 1 (3) 18 (49) 18 (49) 37 No 2 (22) 6 (67) 1 (11) 9 Counselling Yes 34 (77) 10 (23) 0 44 No 1 (33) 1 (33) 1 (33) 3 Nutritional counselling Yes 36 (78) 6 (13) 4 (9) 46 No 1 (100) 0 0 1 Family VCT Yes 26 (63) 15 (37) 0 41 No 3 (50) 2 (33) 1 (17) 6 Condoms Yes 16 (38) 23 (55) 3 (7) 42 No 0 3 (60) 2 (40) 5 Reasons for non-receipt of these components of care were explored in the FGDs, and the results of the discussion are presented below. 66 Reasons for not receiving BCP services Most people reported that they had not had a TB test because they did not have the symptoms (prolonged cough, weight loss, night sweats) whereby a test is recommended. If people did not receive condoms it was either because they had lost interest in sex, said they were too old, or had lost their partner, had been advised to abstain, or they accessed condoms from another facility (fre￾quently an NGO). In two groups people had been told that they would live longer if they abstained from sex. One person did not get condoms from the facility because she believed the counsellor would talk about her and then the patient would be called a prostitute. Another participant said the condoms were too small. Of the 41 facilities which reported that they provided or referred for CTX, no FGD participants reported having received it at three facilities (7%). Some participants received CTX from another facility and were not aware that the surveyed facility provided it. They said that they accessed CTX from the same source as ART. Reasons for not receiving CTX included being allergic, getting it from another facility, or the facility having run out. Bednets were reported by staff as being provided or referred at 30 facilities where FGDs were con￾ducted, but at 60% of these, not all participants had got a net, and at five of them (17%), none of the participants had received a net. The usual reason given for not getting water supplies or a bednet was that these things were not available from the facility, or else that there were not enough to go round. Sometimes they were given only to high-risk groups (pregnant women, children under 5), given to new patients, or else simply distributed on certain days until they were all gone. Main HIV services and medicines received from the survey facility The care components that FGD participants most frequently mentioned that they received were counselling, CTX, treatment for opportunistic infections, malaria treatment, and starter kits includ￾ing water treatment and bednets. Several IGA programmes were described, including provision of seedlings, hoes and garden equipment, microfinance, chicks and piglets. Some people reported that they had received bicycles, t-shirts and training in peer counselling at the facility. The elements of counselling services received covered family planning, adherence, nutrition and prevention as topics. Participants reported that some facilities provided material items (such as clothes and household equipment), or food (posho, oil, rice, sugar). One participant reported re￾ceiving reflexology, and another reported aromatherapy. Participants mentioned numerous medicines that they had received from facilities. The medicines most frequently named were antimalarials (particularly Coartem and injectable quinine), non￾opioid painkillers, skin rash creams, and magnesium as a mineral supplement. Antibiotics and antifungals were mentioned less frequently, perhaps because there are many different possible for￾mulations and the same ones are not likely to be repeated. Finally, ARVs were specified by name or simply as ARVs, and nevirapine for PMTCT was mentioned several times. Best services, areas needing improvement, problems obtaining medicines Participants reported many different services that they thought were good. Psychological care ser￾vices, such as counselling, were mentioned more frequently than clinical care services. The benefits 67 of counselling reported included mending marriages and relationships, increasing confidence, be￾haviour change, an HIV test leading to ART and restored health, stigma reduction, helping people protect their families, keeping them going, and mutual support. The clinical care services that were mentioned as being among the best services received included ART, CTX, infection treatment, malaria treatment and IV drips. Patients said that before they received this care, they had frequently suffered from infections and malaria. Other areas of care commonly valued by patients were ITNs, water guard, food and home based care. For many of the services mentioned, participants valued them highly because they were free of charge. The importance of the highly valued services above was reinforced at other facilities, as the ser￾vices not meeting patient satisfaction showed several similarities. Participants at several facilities wanted to receive ARVs. The poor supply of several drugs, particularly CTX, was unsatisfactory to patients. There were many references made to aspects of staffing, as both strengths and weaknesses of facili￾ties. More staff and better training were called for by patients; more staff to reduce waiting times and allow facilities to be open every day, and better training because counsellors were perceived as not always discreet or respectful. There was a perception that the standard of counselling had declined over time. Participants thought that facilities would be improved if they provided more ITNs, water guard, IGAs, and food. They said that food made it easier to take the ARVs and also would stop people going hungry while they wait at the facility. Many patients reported having problems obtaining drugs. Facilities running out of drugs, par￾ticularly CTX, were mentioned by patients at many facilities. When pharmacies ran out of stock, patients said that they had to pay to access the drug from elsewhere. Patients also reported that sometimes there were long delays in obtaining drugs from the pharmacy when staff did not turn up and patients had to wait, which they found disrespectful. It reportedly could take 6-8 hours to get a drug dispensed from the pharmacy. Patients also said that they needed to bring their own medical supplies such as cannulae, as these are frequently unavailable on site. The combination of CD4 tests and transport recurs frequently in people’s statements. CD4 tests seem to be regarded as the one aspect of regular care that requires a long journey and there is great demand for decentralisation of CD4 machines. Services from other facilities Almost every FGD produced a list of other health centres and hospitals where people obtained care. Only one mentioned a herbalist (traditional healer). All the rest were biomedical facilities. The list of care received was broadly similar to the care received from the surveyed facility. There was more emphasis on ART, on CD4 counts, and on food, but otherwise there were no notable differences. 68 Reasons for visiting other facilities The main reasons FGD participants gave for visiting facilities other than the one where the FGD was held were referral, proximity, and availability of services. Some people had been referred to a service which provided ART, often not the nearest to their home, and continued to receive other care, such as counselling, and support, from one closer to where they lived. The place where the CD4 test was conducted may be the place from which ART was provided. In some cases partici￾pants also got CTX from the ART provider. Participants pointed out that if a service was close by, or offered home care, it was cheaper to access, even if it charged for services, because the cost of transport was reduced. Facilities which had lon￾ger opening hours were also more accessible. Some patients said their local facility was open only on certain days of the week, so outside that time they travelled further. A couple of participants reported attending private clinics when there was a long wait at the public one. FGD participants said that other people, men especially, wished to travel further to attend facilities in order to maintain anonymity. Some facilities were recommended to participants by staff or by friends. Facility qualities included availability of drugs, polite staff, confidentiality of counsellors, and food provision. Some participants had specific services that were cheaper for them, such as a military hospital for the families of soldiers, or one facility, which reportedly provided free care to widows. CD4 count machines were rare (many services said they would like to have one); one facility had support groups which contributed money towards bus fares for the members to attend facilities which had CD4 count machines. Ways to attract more people, additional services, suggestions A number of aspects relating to privacy and confidentiality were suggested as ways to improve the services offered. One of the most frequent and serious complaints about facilities was that coun￾sellors betray patients’ confidence. This had reportedly led to family break-ups and job losses, and made people reluctant to come for care. The participants said that patients would go to facilities where the counsellors were well trained. One facility named by participants at several surveyed facilities was well-trusted but only took patients by referral. However, they said they would like to go to that facility directly and be tested there to ensure no-one else found out about the result. At one facility the family planning nurse was male and FGD participants said women were reluctant to talk to him. Participants made references to several ‘concrete’, visible aspects of a facility as ways to encourage more people at attend. Offering ITNs, water guard, food, clothes, blankets, and even money were some of the suggestions made. Participants reported that food was important because the ARVs were ‘very strong’, and required food in order to take them. Adults preferred to go without ARVs, rather than take them on an empty stomach. Participants said that ARVs increase the appetite of children and make them want more to eat than families can afford, and there is an implication that some elderly or very poor car￾ers may withhold ARVs from children for this reason. Additionally, when patients had to wait for up to six hours at a clinic, there could be a canteen or tea stand for them. 69 Outreach through drama was described as another way to increase attendance at services. Partici￾pants described a combination of peer educators, to publicise their status, and facility staff, to show that they are concerned and able to help, undertaking outreach as most effective. To undertake this work would often require transport, although outreach by radio was another suggested means. Women were more likely to come forward generally, and so participants suggested outreach to be targeted towards men. Participants reported several groups of people that were discouraging use of HIV services. Par￾ticipants reported that some religious groups tried to persuade people not to take their ART and instead to have faith that they will be cured, which they had found concerning. Participants felt that politicians had discouraged people from attending services because some had discriminated against people with HIV through policies. Another complaint was that politicians queue-jumped at facilities, compelling staff to treat them first, reporting them to the District Medical Officer if they did not, and leaving insufficient resources for other patients. In this context it is unclear who the politicians are. The important issue to the patients was that some people unfairly had priority access to medicines. Participants suggested a number of aspects relating to service availability to increase uptake, such as having a clinic open every day, with longer opening hours, and reliable drug supplies. To reduce stigma, participants said there should be a separate clinic for HIV. Participants suggested that hav￾ing HIV tests available nearby, or offering a reward for being tested, would increase uptake. Often it was repeated that orphans and vulnerable children need extra help and that the facility should do more to look after children, in particular to feed them. A need for an infant feeding alternative to breast milk was mentioned. Children faced stigma in school, both from staff and other pupils, and participants suggested there should be school education programmes to fight this attitude. Asked what care they wanted to see, participants said transport, food, home care, IGA, school fees and positive living. School fees, in particular, were repeated. There were several anticipated benefits of providing IGAs. Firstly, IGA was thought necessary to allow people to feed themselves and pay for transport to the clinic. Secondly, participants thought IGA would stop young people becoming involved in prostitution. A third stated purpose of IGA was to change the public perception of people with HIV as indi￾viduals who are dying and cannot think, or plan or do anything. Participants reported that some people with HIV had become dependant on their carer through an assumption on everybody’s part that they are no longer capable, so they ceased to make decisions, or even speak for themselves. An IGA programme could be an indication that people were responsible and able to cope. Participants asked to be given the opportunity to prove what they could do. They also wanted representation and access to conferences, and asked for information, for instance about the side effects of the ART. Finally, they wanted love, care and support. 70 Cross-cutting themes from patient FGDs The components of care that patients most appreciated receiving were counselling and support, ART and clinical care. The care they said should be more developed were provision of bednets and water guard, IGAs and food. IGAs, to some degree, represented food. The IGA programmes were based on gardening or rearing livestock. Patients said that money generated would be spent on food and the programmes themselves would change perceptions of people living with HIV and prevent young people from going into prostitution. Participants suggested that offering visible items like bednets would increase the numbers coming for testing, or indeed that people should be paid to have an HIV test. In all these suggestions there is a sense that behaviour can be changed by the offer of comparatively small incentives. Several social and cultural issues arose during the FGDs that affected the participants in differ￾ent ways. Two groups said that religious leaders in the area were discouraging people from taking ARVs, and asked if the facility could do something about it. Common psychosocial issues that patients reported revolved around daily stigmatisation. Their children were bullied at school, poli￾ticians discriminated against people with HIV, health staff were perceived as occasionally treating patients badly, and they became dependant on carers. Aspects of infrastructure were important issues to patients. Several groups reiterated that they wanted a separate clinic for HIV, in order to reduce stigma. They wanted their own place to come for care, with their own staff, which should be open every day. The other main infrastructure is￾sue was drug supply. Stockouts were frequently reported as a problem by patients, but it was just as common for patients to complain about long queues at the pharmacy and “shopping around” between facilities. The conduct of staff influenced patients in several ways, including which facility patients visit, and whether they go to any at all. Patients often felt keenly that staff do not respect them. Participants said it was important for peer educators and facility staff to conduct outreach together – the peer educators to publicise their status, and the facility staff to show that they cared. Patient said they wanted love, care and support from staff. They praised facilities where staff were polite and discreet. Pharmacy staff were sometimes reported to treat patients poorly, and to arrive late or leave them waiting while they went for lunch. Whenever distance or transport was mentioned by FGD participants, it was almost always in the context of expense to patients. The impression given was that the cost of public transport to the health facility was a considerable burden. They suggested HIV tests should be more widely avail￾able to increase uptake by reducing the need to travel to specific test centres. At one facility, support group members had set up kitties solely for the purpose of paying for transport to obtain a CD4 test. In summary, the important factors about a facility from the patient’s point of view were the services it provided, the attitude and ability of its staff, and its accessibility in space (distance, cost to reach it) and time (opening hours, length of queues). 71 Summary of focus group discussions • Care received — Participants received 1. clinical care (treatment for malaria and other infections, CTX, ARVs) psychological care (counselling, peer counselling training); and 2. social care (IGA, food, water treatment, ITNs). • Best services — Participants liked 1. psychological care, particularly counselling (restores relationships, behaviour change, led to HIV test, stigma reduction, mutual support); 2. clinical care (ARVs, CTX, symptom reduction from infections including malaria, IV drips); 3. social care (ITNs, water guard, HBC, food); and 4. services that were free. • Services needing improvement — Participants wanted 1. more staff, and more training for staff; 2. longer opening hours, shorter waiting times; 3. reliable drug stocks; 4. IGA, food, water guard, ITNs; and 5. food and school fees for OVCs. • Reasons for going elsewhere — Participants reported going to other facilities 1. because referred there 2. to get ARVs food, a CD4 count 3. because it was close by (cost of transport 4. on recommendation from friends 5. for anonymity • Suggestions — Patients suggested 1. improved training; 2. offering social care (blankets, food, clothes, ITNs); 3. outreach through drama, peer counselling, radio; 4. clinic open every day; 5. infant feeding alternative to breastmilk; 6. school education programmes to counter stigma; and 7. IGA to raise self-efficacy and prevent prostitution. Integration of data from staff open-ended questions and patient FGDs The comments of staff and FGD participants illustrate similar concerns, from different view￾points. Facility staff realised that rapid staff turnover and lack of training was a problem in providing a good HIV service, and patients corroborated this by describing their concerns regarding perceived poor training and demotivated counsellors and clinical staff. 72 Patients thought that provision of drugs, including CTX, were some of the best services they received, and staff also saw them as one of the strengths of their facilities. Both staff and patients realised drug supply could be a problem, but staff only talked about supply to the facility whereas patients also discussed the difficulties at the facility, such as queuing time at the pharmacies. Finance was a strong theme to emerge from both staff and patients. Many of the facilities’ reported problems, such as staff turnover, lack of training and stockouts, related to funding, and many of the patients’ reported problems, such as accessing multiple services, needing food to take with ARVs, and the need for social support from facilities, related to a lack of money. Staff reported that they could not afford to provide a vehicle, and patients said that they needed it. Transport links were associated with accessibility for patients. Staff thought it was important for the facility to conduct outreach and home-based care using a vehicle. Patients seemed to agree as they found transport to the facility a significant problem. Patients and staff shared a common idea of what a good service should include. The desired ideal service, perceived problems and consequences of these problems are listed below. Staff • Desired: staff who are trained, motivated, multiprofessional and respectful of patients • Problems: Poor motivation due to low pay, few training opportunities, limited options, volun￾teer status and lack of remuneration, overwhelming need leading to burnout. • Consequences: unprofessional behaviour, disrespect towards patients, high staff turnover and poorer quality care. Drug supply • Desired: constant supplies of ARVs, antibiotics, analgesics, antifungals, CTX • Problems: lack of control over stock, staff behaviour as above, insufficient drug supplies • Consequences: stockouts, long queuing times, patients shopping around, more expense, resis￾tance Transport • Desired: HBC for convenience and cost, reimbursement for travel, transport to care centre for the sick, team outreach to rural areas by vehicle • Problems: shortage of money, vertical programming restricting funds, lack of skills and parts to repair vehicles (sustainability) • Consequences: no vehicle, or vehicles broken down or without fuel, preventing outreach pro￾grammes and HBC Poverty • Desired: no hunger, children in school, jobs • Problems: insufficient food, ARVs increase appetite, no money for school fees especially for OVCs, stigma, ill health, low perceived self-efficacy • Consequences: refusal of ARVs, children not in school, unemployment, dependence, need for social care 73 Discussion Selected facilities Activity data from 2006 provided by PEPFAR demonstrated that there were a large number of facilities which were reported as each providing care for a relatively small number of patients. For this reason, facilities were selected at random from 3 strata based on PEPFAR 2006 attending patient numbers, with the aim of obtaining a sample of facilities that represented the range of fa￾cility sizes (defined as patient numbers seen) in the country. The statistically significant correlation between the routine data and the survey data found indicates that higher patient figures provided by PEPFAR matched with higher figures reported by facilities, although there were still substantial differences in patient numbers from the two sources. Patient characteristics In Uganda, UNAIDS estimates that slightly more than half of people aged over 15 with HIV are female (UNAIDS). At the facilities surveyed, 65% of adult patients were women. This suggests that men were less likely than women to access care. Clearly, there are implications for equity of service provision, and public health implications in terms of men either not presenting for testing or for subsequent care that includes prevention with positives. Staff participating in this phase of the evaluation recommended outreach programmes targeted at men. About 10% of people with HIV in Uganda are thought to be children (defined as under 15 years) and 6% of patients were children (although solely paediatric facilities were excluded from this survey). Twelve facilities did not provide care for any children. The mothers of children with HIV are usually HIV positive themselves. Separating paediatric and adult care requires families to travel greater distances and spend more time on appointments. At facilities which did offer paediatric care, staff frequently stated that these services were underdeveloped. Infrastructure Thirty-two facilities had an ambulance, of which 5 (16%) were not functioning at the time of the survey visit. In the survey an ambulance was defined as any vehicle capable of transporting a pa￾tient. Lack of transport was named as a challenge to sustainability at 17 facilities. It hampers out￾reach to rural communities and raises costs for patients to access care. Home-based care requires transport and this model of care was valued by patients. Home-based care facilities were the most likely to offer social care, the least developed of the five PEPFAR areas, and the one preventing most facilities from offering complete care and support. Of the thirty-eight facilities with a generator, 6 (16%) were broken down or out of fuel. This re￾duces the possible care that can be provided and may limit opening hours and increase waiting time, both common complaints. Only 3 facilities lacked a functioning toilet which patients could use, but one of them was a hospital. Ten facilities lacked a safe water supply. Without such basic infrastructure, infection control is likely to be compromised. 74 Staffing Although PEPFAR HIV care and support is seen as holistic, the availability at facilities of staff who specialised in different components of care was variable. Whereas most facilities had clinical staff onsite (especially nurses, and often doctors/clinical officers), traditional healers, social workers and spiritual care staff were rarely employed, even when care in the area was offered. When all types of care and support staff are considered – i.e. the proportion of facilities that had clinical, psychological, spiritual and social staff of any designation all present – fewer than 20% of facilities had staff of every type. These data show that very few facilities offered professional multidisciplinary holistic care on site, and suggest that staff may have had to meet needs outside their skill base. For example, twenty facilities were providing counselling services without having any designated counsellors. Further, half of facilities had no doctor, a third no clinical officer, over half no pharmacist, four-fifths no social worker, and nearly half no counsellor. These skill shortages necessitate patients attending multiple centres. In particular, patients reported seeking out facilities with a good reputation for counselling. Counselling services were almost universally provided, but in many cases they were delivered by unspecialised staff, leading to a patient-reported inadequate quality of care. This lack of focus on specialised psychosocial and spiritual care provision is likely to have overbur￾den the clinical appointment times available, as medical and nursing staff deal with problems that present within consultations. It may also fail to resolve (or even compound) patients’ problems, either through provision of inadequate psychosocial care by untrained staff or through forcing patients to attend at another facility with the costs and time involved in travel. Psychosocial care provision requires significant investment in time, a very limited resource for overburdened staff with high patient loads. The seven facilities which employed social workers required them to care for a median of almost 2000 patients each. Further, high patient load and a sense of inability to cope with the level of need can lead to loss of motivation and burnout in staff, causing poor retention with consequent loss of skills and experi￾ence. Low motivation was seen as a problem by both staff and patients. Evidence from multiple sources suggests that the issue of lack of specialist care affected patient experiences. Issues of the management of confidential information on the part of staff had report￾edly led to significant negative life events for some patients. Patients reported that they sought out facilities where the counsellors had a reputation for good professional behaviour and confidential￾ity. Further training on the importance of this issue and appropriate behaviour for counsellors may build trust and attract more people to facilities. On a more general level, both staff and patients reported a desire for staff to receive further train￾ing. In particular, staff themselves acknowledged a need for more counselling training, especially for paediatric counselling. The attitude and behaviour of some staff was of concern to patients. Patients reported in FGDs that one of the main reasons service uptake was not higher, and also a powerful reason to attend another facility, was the behaviour of some staff. There were complaints of indiscretion, ill-mannered behaviour and breaking of confidence, leading to a lack of trust be￾tween patients and staff. 75 Five facilities retained paid spiritual staff, but did not provide any of the spiritual components of care explored. This suggests that they provided other types of spiritual care which were deemed im￾portant enough to pay a specialist to offer. The survey did not capture these components of care. Volunteers were key members of facility staff, but many questions remain about the role of volun￾teers in care provision. They were often the primary care provider at a facility (particularly HBC￾only facilities), but the definition of volunteer, their motivation to volunteer, volunteer staff turn￾over, the quality of care provided by volunteers and the sustainability of the care they provide are largely unknown. It should be noted that not all staff types were included in the survey and NGO facilities may well have paid administrative or other support staff. In terms of retention and sustainability, it is notable that across the entire sample, a significant amount of care was provided by volunteers, both professional and lay, including spiritual care pro￾vided voluntarily in 17% of facilities, community health workers at 60% of facilities, and counsel￾lors at 20%. Volunteering is a positive reflection of commitment to HIV care by a community, and enables facilities to extend their reach with limited resources, but the sustainability of this approach is unclear. Further investigation would enable successful dissemination of methods of training, supervision, and retention to other facilities. This is crucial to quality and continuity, as in health posts and HBC facilities the percentage of staff who were volunteers was 29% and 88% respectively. Staff also raised concern over the sustainability of facilities with such great reliance on volunteers. Volunteers were reported has having a high turnover, and could leave at short notice. Voluntary staff themselves reported being financially disadvantaged as a result of undertaking the work at facilities and desired some recompense for their expenses, thus highlighting that although voluntary staff were not paid, they did incur other costs which they felt should be borne by the facilities employing them. Care provision at facilities Care available at facilities was usually provided free of charge to HIV patients, thus maximising access at point of delivery irrespective of ability to pay. However, the cost of transport to get to facilities was an issue for patients, and seemed to be a greater disincentive to patients than the free care available was an incentive. Some patients reported that they paid for drugs which were deliv￾ered to their home, because it was cheaper than taking the bus to the free clinic. Long queues and stockouts at the pharmacy were additional problems in accessing care that were frequently reported by patients. A wide variety of care components were provided onsite at most types of facilities, a mean of 36 offered in all types of facility out of the 69 surveyed. Furthermore, coverage of the different areas of care surveyed was good at the larger types of facility; all hospitals, health centres and health posts provided some element of clinical, preventive, and psychological care. However, social care and spiritual care had much lower coverage throughout all facilities. It may be that these areas were not considered to be a part of health care at some facilities. Multidisciplinary care and support for HIV requires the provision of care in all five areas. Social care, in particular food, school fees, and IGA, were components of care most likely to be named by FGD participants as received elsewhere. Staff also reported that they wanted to develop social care, and that a lack of it was a weakness. 76 Formal referrals for several components of care, such as physiotherapy, TB treatment, and cancer management, were often available. However, the urban bias (indicated by the geographical distri￾bution of facilities in Figure 2) in the randomly selected sample of facilities means the care com￾ponents for which referrals were commonly seen are likely not to represent the situation in more rural or remote areas, where fewer other facilities may be available locally to meet additional needs. Further, as cancer is a common presentation of advanced HIV, it is noteworthy that for 23 sites there was no provision or referral. It is unclear whether this is due to lack of local providers or weak referrals. The quality of referral mechanisms is unknown, and systems did not appear to be robust. Components of care by theme ART Facility staff saw the ability to provide antiretroviral therapy as a strength, and patients in FGDs reported that it was one of the services that they were most pleased with. All the facilities which supplied ARVs onsite reported that they gave them to all patients who needed them. At the same time, some staff reported that they regretting having to ration the number of people who could be￾gin treatment in order to maintain a supply for those already using ARVs. It is possible that when staff reported no restrictions to receipt of ARVs they meant that people were enrolled on a ‘first come, first served’ basis, rather than by other criteria. Two facilities could not provide data on the number of patients treated in the last three months. Most patients documentation sheets did not include information on ART or other drugs. Good record-keeping is essential for an ARV programme to maintain adherence and prevent waste. It is evident from the lack of information in other areas, for example number of patients enrolled and number receiving CTX, that this was a weakness for some facilities. Other support services for ARVs, such as toxicity monitoring, were usually available, although as with all self-reported data, the quality of care provided cannot be ascertained. Pain management Pain is a common (Solano, Gomes & Higginson 2006) and distressing symptom for people living with HIV, which can affect other areas of a person’s wellbeing, such as psychological and spiritual wellbeing, mobility and social activities. Yet, it can be cheaply and easily controlled. Uganda is a model country for Africa in terms of morphine availability and usage (Logie and Harding 2005), with the result that 20% of facilities claimed to provide morphine onsite and 37% to refer for it. In the pharmacy, however, only half the facilities which reported providing morphine actually had any in stock, and one of these had only injectable morphine. People in Africa are commonly cared for at home, and the most effective way to provide opioids is orally, according to the Who Pain Ladder (World Health Organization 1990). It is far less feasible and effective to manage pain through injectable morphine than through oral liquid forms that can be administered by the patient and family. In general, hospitals and health centres reported good availability of strong and weak opioids, either directly or by referral, while health posts and HBC facilities reported poor availability. Evi￾dence from the pharmacy review proved some of these claims to be overstated. Nonetheless, the reported data show that hospitals and health centres at least were not opposed to the use of opioids. 77 The fact that reported provision was higher than real provision suggests that more facilities would use opioids if certain barriers were overcome. The availability of other analgesics was variable. Fifty facilities reported providing non-opioid an￾algesics but only 39 (78%) had any in stock. At a third of facilities, patients were unable to obtain painkillers of any kind, with the consequent effects on quality of life and functioning. Additionally, some facilities had very low quantities of these drugs, reaching a minimum of only 40 tablets of non-opioid painkiller. These low stock levels for analgesics and the high levels of stockouts recorded for many drugs raise questions about the availability and sustainability of analgesia for patients. Psychological health All facilities provided or referred for at least one component of psychological care, namely adher￾ence counselling, and pre- and post-test counselling was also provided or referred at 56/59 facilities. There is evidence of great psychological distress among patients newly diagnosed as HIV positive, and that these needs continue and change over time (Meursing and Sibindi 2000). FGD partici￾pants reported that HIV led to broken relationships and divorce, loss of confidence, internal and external stigma and loneliness, and that counselling helped them tackle all these problems. There￾fore, finding broad availability of psychological care is encouraging. However, the evidence suggests this care was often provided by non-specialists. 22 facilities provided psychological care but did not employ any counsellors. This is a potential problem, especially as one of the main complaints of FGD participants was the alleged unprofessional behaviour of counsellors which was believed to be caused by lack of training. Counsellors were reported to have betrayed confidentiality and lost their patients’ trust, deterring patients from accessing healthcare. Staff reported feeling a lack of skill and inability to provide adequate counselling, most especially for children. Treatment for anxiety and depression were rarely available. The prevalence of these symptoms is very high among people with HIV (Ciesla and Roberts 2001), and, as in the general population, women are particularly at risk (Olley et al 2004). Depression is associated with lower ART adher￾ence and hence with faster disease progression and lower quality of life (Campos et al 2008). Ap￾propriate psychotropic medication, in combination with behavioural therapy, has been shown to relieve depression and anxiety for people with HIV (Repetto and Petitto 2008). Nutrition and social care For almost 30 facilities, the single factor preventing them from providing (onsite and by referral) a complete package of care encompassing all five PEPFAR domains was the lack of social care provision. Social care is the least developed PEPFAR care domain in the survey population. This lack is particularly apparent in hospitals, given that they generally had the highest care provision in all other areas. Social care was most often provided at HBC facilities, which generally had the least clinical care. There appears to be a trade-off between these two areas of care, although both are vital for HIV care and support. The most effective way to increase the number of facilities providing a complete package of care would be to invest in social care. One of the services most frequently requested by FGD participants was food, especially for chil￾dren. Staff also wished to provide food and felt that their facility was not offering full care without it. Nutritional counselling was widely available, as were multivitamins to a lesser extent, but these 78 combat vitamin defiencies, not hunger. Qualitative studies have reported that one of the main de￾terrents to antiretroviral initiation, and one of the main reasons for low adherence, is the physical pain of hunger caused by increased appetite following ART (Au et al 2006; Hardon et al 2007). FGD participants reported that carers did not put children on ART because they could not afford to satisfy their increased need for food. Engel’s Law is the observation that as income goes up, the proportion of income spent on food goes down; consequently the poorest people spend the highest proportion of their income on food. Rejection of free lifesaving medication on the grounds of inability to afford enough food to stave off pain suggests very severe poverty. The other financial stressor most frequently mentioned was the cost of transport, also recognised as a major impediment to ART adherence in East Africa (Hardon et al 2007). Income-generating activities were seen by FGD participants as the solution to food insecurity and transport problems, as both stem from limifed financial resources. Opportunistic infections and preventive care This survey examined the provision of preventive and curative care of general OIs and some specific HIV-related infections, in particular malaria, TB and sexually transmitted infections. People with HIV are more vulnerable to malaria infection and experience more severe symptoms (Slutsker & Marston 2007). STIs cause high morbidity in the HIV-positive population and are also associ￾ated with increased infectiousness and greater probability of HIV transmission (Wasserheit 1992). Coinfection with TB is the single highest cause of mortality for HIV-positive Africans (Corbett et al 2003), while HIV is the single biggest risk factor for activating TB (Bock & Reichman 2004). The synergy between the two has led to TB/HIV being described as a ‘dual epidemic’. • Basic Care Package — The purpose of the BCP is to serve as a short list of components of care that every person with HIV should receive as a preventative measure, to protect them from water-borne infections and malaria, and to protect them from transmitting HIV (Mermin et al. 2005). Not all the items are suitable for everyone, for instance families with piped water do not need a water filter. They are a minimum level of immediate care rather than being the best option for all. Patients said that apart from their primary use in preventing infections, the components of the BCP would encourage rentention and uptake of services because prospective patients would see tangible evidence of benefit from care. Staff were keen to provide the BCP and thought it would improve the care they delivered. Some patients reported that they had not received ITNs and water treatment because there was a limited supply. At other facilities, the FGD participants stated that they were sure these items were not stocked at the facility because they would have been given them if they were available. Eligibility criteria were unclear, and there was a sense that some people were for￾tunate enough to receive items while others were not. The perceived arbitrariness of receipt encouraged people to access services at numerous facilities. ‘Shopping around’ is inevitable if the BCP is not available at all facilities. 79 To maximise the effectiveness of the BCP, it is necessary to examine its availability at facility and patient level, and to evaluate its usefulness and acceptability when delivered as a single entity and as separate components. • Malaria and TB — Malaria treatment was one of the most frequently named services in FGDs when patients listed the services they valued, indicating both that malaria is highly prevalent in this group and that treatment makes a substantial difference to their lives. (It is also possible that ‘malaria’ is used as a generic term for illness, because it is so common.) The interventions to diagnose and treat malaria and TB were more likely to be present or referred at facilities than interventions to prevent them. Prevention of these infections is more effec￾tive than treatment. Insecticide-treated bednets, which demonstratably reduce morbidity and mortality from malaria, were not provided or referred at 42% of facilities despite the fact they were a part of the BCP. • Opportunistic infections — Treatment for opportunistic infections and symptoms was widely provided or referred at the larger health facilities, and at about half of HBC facilities. Staff saw the ability to treat infections as a facility strength, and it was rarely an area which they said needed improvement. Six HBC facilities did not provide or refer for symptom management, concentrating on social and psychological care instead. There is an opportunity to provide ba￾sic clinical care through these facilities and encourage referral networks for other conditions, linking the home-based social programmes to larger medical facilities. Some treatments are likely to be general, such as skin rash which is often treated with cream, and diarrhoea which is managed with oral rehydration solution. These simple procedures do not require advanced clinical training and could potentially be easily scaled up. Fluconazole was stocked by only 24/59 facilities but other, generic antifungals are more commonly used and were reported at most facilities. FGD participants frequently said they had received topical cream, and seemed to bracket it with analgesics as symptom management rather than solely treatment. • Prevention with positives — Condoms were available at nearly all facilities but individuals reported difficulty obtaining them. One woman was afraid the counsellor would spread ru￾mours about her if she requested condoms. The alleged unprofessionalism of the counsellor, whether justified or perceived, was a barrier to preventive care and this case is a clear dem￾onstration of the importance of training and monitoring for counsellors. Several people had been advised to abstain from sex and some had been told they would live longer if they did so, which is not supported by evidence. There appears to be a difference between the term ‘PWP’ as understood by facility staff and the PEPFAR definition, as more facilities reported offering PWP than reported offering the separate components of it. It is possible that PWP was interpreted to mean PMTCT, which was not an areas of investigation of this survey. Diagnostic tests One of the main reasons for FGD participants to visit other facilities was to obtain a CD4 test, and one of the pieces of equipment staff were most likely to want was a CD4 machine. Nineteen facilities possessed a CD4 machine and 18 referred out for the test. Liver function tests and CD4 80 counts, which are both necessary for monitoring and treatment assessment, were not always avail￾able through ART-providing facilities. In a resource-limited environment, it is not practical for every health facility to be equipped with expensive laboratory equipment, demonstrated by the fact that over 40% of facilities had no electricity at the time of the survey. In some cases, such as dried blood spot test for infants, a sample can be taken at the local clinic and transported to the referral facility, provided a strong referral network exists which allows this kind of arrangement to develop. With facilities referring for a median of 7 out of 69 components of care, the referral network was apparently short of what it could be. Pharmacy supplies Some facilities had very small quantities of drugs, for instance 15 morphine tablets or 40 paraceta￾mol tablets. It is possible to provide care with small drug quantities if restocking is frequent and the lead time is short, but evidence from patients of long queues at pharmacies or having to buy drugs elsewhere because facility stocks had run out suggests that the supply chain was often com￾promised. Part of the issue relating to drug supplies could be due to inadequate monitoring at the facility level. For half the drug formulations, no stock levels were used, and many facilities used the stock level of 1, i.e. they ordered more of a drug when the last pack was opened. This again relies on a short lead time. Eleven facilities had no stock control sheets, and of the 49 who reported using them, only 14 provided a copy, many of which lacked key information. In particular, expiry dates and stock levels were missing more often than not. A pharmacist at one hospital reported that they were allowed to order only a certain amount of each drug per month which was not enough to cover the need, making stockouts inevitable. Forty-seven percent of the facilities which stocked the listed drugs reported at least one stockout in the previous six months. Although oral morphine is more widely available in Uganda than in most other developing coun￾tries, and nurses are able to prescribe it (Harding et al. 2007), morphine was only offered directly at 12 facilities and found in the pharmacy at only 8 of these. One only had an injectable form of morphine, which is not suitable for chronic use. Facility strengths and weaknesses Although the patient FGD data, in practice, probably refers to services received from numerous sites, rather than the site at where the FGD was held, this is indicative of “real world” practice and is supported by other data sources on patchy comprehensiveness of components of care, some￾times weak referral networks, and stockouts. If the outcome of interest is receipt of services, rather than source of receipt, then this data is useful when interpreted in light of the other data sources reported and is a usual facet of the multi-methods design. The results indicate that not only did patients access a number of services, but that this was due to both the limited care range available from individual sites and the manner in which it was provided. A survey of this size is too complex to analyse and evaluate at the site level, and further network analysis studies would be appropriate. However, Phase 2 will examine receipt, and sources, of components of care. The integration of FGD and staff interviews show that although a component of care was de￾scribed by staff as provided at the facility, it was received by comparatively few respondents of the FGDs (e.g. condoms and water treatment). As this is not a needs analysis (i.e. patients in the group may not have needed those specific interventions, as for example not all patients will need CTX, 81 TB testing, condoms) the FGD is illuminating in describing why they believe they did not receive a component of care. For example, patietns reported limitations placed on eligibility for condoms and bednets which had not been stated in the staff interviews. Further examination of facilities’ opera￾tional criteria would be useful. There was evidence of condoms being refused by patients for fear of stigmatisation originating from facility staff. Further, as this analysis is of patient receipt of services irrespective of site, the data is useful in that it shows that at some facilities some components of care were not received by any focus group participant- e.g. condoms, water treatment, and bednets. It is notable that patients most commonly cited the need for social intervention, as this was the area in staff interviews where the biggest lack in dedicated staff was identified. Further, patients requested longer facility opening hours, which supports the finding that in some sites the number of hours for both clinical and non-clinical staff appointments was very low (one third of all sites had clinical time for only up to 20 hours per week). The need for transport and outreach/mobile clinics is suggestive of rural patients having difficulties attending for care, a problem that would be far worse for those attending sites that do not offer comprehensive care. Patients stated a preference for sites that provided comprehensive care in a single place or provided home-based care. They also preferred a separate unit for HIV patients away from the main health centre. Document analysis The main findings were the relative absence of pain and psychological assessments when investi￾gating patients’ presenting symptoms. Without an assessment of these aspects it is unlikely that they can be effectively managed. In general terms, the documentation analysed from the reporting sites were not multi-dimensional in nature (with a number of key domains omitted) or multi-professional from a user perspective (i.e. they were primarily to be used by clinicians and nurses). In order to reflect the provision of holistic HIV care, documentation should include its physical, psychological, social, spiritual and cultural aspects for both the patient and their family. Similarly, providers of such diversified care (including counsellors and spiritual care givers) should be accorded a role within the care giving process, with documentation that can capture role and impact. Only two patient assessment forms recorded religion, the basis for beginning to assess spiritual care need or to ensure appropriate care. Social need was also absent as few forms recorded income, job description, or even literacy. The study found limited documentation of ongoing as well as new presenting patient problems, and found utility in the ongoing contact assessment sheet that gathers information across a number of key domains to help ensure continuity of care among health care providers. Most facilities did not record the use of herbal medication, which is widely used among HIV patients in Uganda (Langlois-Klassen et al 2007), and can potentially result in decreased ART bioavailability, treatment interruption, resistance and even failure (Mills et al. 2005). Though cur￾rently practised by a few sites, these are areas of good practice that should be replicated elsewhere to further develop the existing integrated model (i.e. traditional and western medicines) approach in HIV care, enhancing uptake of medical services and promoting retention of patients. 82 Limitations and strengths There are a number of limitations to this Phase 1 data. Firstly, the calculation of proportion of pa￾tients receiving specific components of care could not be conducted as patient numbers were often missing or seemed unreliable. The information, though basic and essential for monitoring activity, was sometimes difficult to obtain. For instance, 14 facilities (23%) were unable to give a precise fig￾ure for the total number of patients they had cared for in the past three months. Others may have taken their figures from the number of people taking ARVs, which have to be monitored closely and may be the best record they have. The lack of monitoring data carries implications for service planning and relates to specific difficulties such as stock-outs. It is difficult to see how a facility could plan effectively without knowing how many people it serves. Second, under document analysis, despite many documents reportedly being available at the facili￾ties, a large proportion of facilities could not supply the researchers with a blank example document in order to undertake analysis of content. This limited the depth of the analysis of content that could be undertaken and raises the risk of bias. The reasons for this are unclear, and we are follow￾ing up each facility to identify reasons for non-provision of documents and to retrieve documents where possible. Third, under the patient FGD, participants were patients who were present at the facility on the day of the visit who were asked to participate by facility staff. The participants were not necessar￾ily representative of the wider HIV positive population, although a purposive sampling frame was proposed to staff. Some patients become peer counsellors and receive training from the facility, but they did not take part in the focus groups. Owing to the large number of FGDs that were undertaken to complete this part of the evaluation (in addition to the pharmacy review and staff interviews) it was not possible to record verbatim, transcribe, translate and analyse the FGDs in the usual way in the time scale available. Instead notes were taken by the researcher during the FGDs, and these were analysed for content. This method is likely to have limitations in their detail which may have meant that some views or opinions were not reported here in depth. Calculated patient loads are subject to limitations. Firstly, patient contact time was not measured. This may have resulted in over-estimated median patient load values for doctors and clinical of￾ficers, for instance, as these staff may in fact undertake only a small amount of clinical work as a proportion of their working day. Secondly, patient load was assessed against job titles, and not job functions. Many staff were found to be undertaking a variety of tasks that would not normally fall under their job title, e.g. nurses who primarily deliver clinical care were also undertaking counsel￾ling and dispensing. For these staff, calculated patient loads may be under-estimated. With respect to the pharmacy review, it is possible that drugs with another label, or a less common formulation than the one asked about, were in use. We reviewed those most commonly used, and identified them through wide consultation. Further, under staffing, we did not record if facilities had dispensers (or other staff that do dispensing), rather than/in addition to pharmacists. Also, pharmacies may have stocked additional drugs not listed in our review sheets, as the study needed to choose common specific drugs, especially as some pharmacies were general medical. 83 The PEPFAR categories of care used in the analysis did not contain all the care components cap￾tured in the questionnaire. Furthermore, the number of components included within each area of care varied greatly, with most areas containing about four components but clinical care containing over 30. This means the probability of facilities offering any element of clinical care is far higher than their offering any element of the other areas of care. The areas of care were predefined and are not exhaustive. Some components included in the survey were not categorised into any area of care. Additionally, because the survey used a closed-question design, it is likely that some facili￾ties offered additional care which would have been appropriate to one of the areas but for which information was not collected. Lastly, when research is commissioned to investigate care where resources are scarce, there are al￾ways potential desirability biases among respondents who provide that care (Harding et al, 2008). The use of triangulated data (staff, patients and pharmacy) have reduced that bias in the interpreta￾tion and the subsequent Phase 2 study will be useful in appraising the effect of the data described here on patient outcomes. Some of the strengths of the survey are that every facility was visited in person by a Ugandan re￾searcher trained to use the data collection tools. Representatives from all the facilities involved in the study were invited to a dissemination meeting to hear the results of the survey, and the relation￾ship between the facilities and researchers was generally good. The researchers double-entered data into a purpose-designed electronic database, and conducted validation to minimise errors. These steps ensured high quality data collection and entry. 84 Recommendations Infrastructure • Multidimensional HIV care and support requires more space than purely medical assessment and intervention. Facilities should increase their physical space for care services, particularly to allow for counselling sessions in privacy and for children’s care. • Availability of resources to ensure existing services such as transport and electricity are re￾quired, as many vehicles are not operational and only half of facilities have working genera￾tors. Infection control is also compromised in the absence of infrastructure. Health management information systems • As staff recommended, the best way to prevent double counting is to improve coordination and strengthen referral. Smaller facilities cannot provide the holistic, complex care required for HIV without the ability to refer patients. • Comprehensive records should be kept for all patients, detailing the care they receive includ￾ing inward and outward referrals and needs assessment. Staffing • It was often found that staff were delivering care for which they felt they had not been ad￾equately trained, and patients reported that they were discouraged from attending services where inadequately trained staff were employed. Increasing specialist training and employing staff specifically to deliver non-clinical aspects of care, such as psychological and spiritual care, could widen the availability of specialist care to patients and improve care quality. • Staff retention is poor because of limited opportunities for development and low pay, and high staff turnover may damage the quality of care provided. Investment in staff is needed which could benefit both staff and patients. • Volunteers are more likely to remain at facilities if their contribution is seen to be valuable, for example by reimbursing their travel costs. Care provision • In the absence of data on paediatric-only facilities, skills and facilities for care and support of children need to be enhanced for the 20% of facilities that see no children at all. • As the model most likely to have staff present across all five areas of care, the holistic provision of healthcare model offered by health centres should be replicated. • HBC facilities should offer basic clinical care, and provide or refer for treatment for anxiety and depression. • Social care is the least developed aspect of care in the survey. Income-generating activities and home help need to be implemented more widely to help patients overcome the financial barriers to clinical care. • The BCP should be rolled out to all facilities, with clear and equitable eligibility criteria and adequate provision for all who need it. While the BCP is available at some facilities but not others, ‘shopping around’ is unavoidable. Treatment of TB, malaria and other infections is more readily found than prevention care, although prevention is more cost-effective and saves more lives. 85 Drug supplies • Reliable drug availability is a significant problem which hampers the delivery of care. Supply chains need to be strengthened by improving communication and responsiveness. • In addition to improvements in mophine supply, training in pain management and opioid use is needed to increase uptake and usage. Laboratory services • Laboratory services, particularly CD4 testing, should be made more widely available. For smaller facilities, referral networks to larger facilities for such services should be efficient. • All facilities which provide or refer for ART should provide or refer for CD4 tests and LFT, as essential services for ART. Documents • Lack of proper records limits the ability of a facility to provide integrated care, monitor stock, manage referrals, plan and budget. Large facilities should have administrative staff specifically employed to handle data management, and train existing staff in record keeping. • Records forms should be revised and standardised to improve assessment, management and continuity of care and inward/external referral PEPFAR • The definition of care and support services should be considered, as the survey found a safe water advocacy group currently falls under this heading in terms of funding. • Method for identifying patient numbers for PEPFAR routine reporting may require revision. There was often a discrepancy with facility-reported numbers. Further research • The survey results are mainly self-reported. A real understanding of the extent and quality of care could only be established by further study and measuring patient outcomes. This will be explored in Phase 2. • A paediatric care and support PHE is required, although there is currently no validated Afri￾can outcome tool for children. • Volunteer staff are an important resource. The motivation and retention of volunteers need to be further understood, particularly at HBC facilities which depend heavily on volunteers. • Spiritual care needs and provision could be further investigated to determine the care pro￾vided by spiritual leaders employed at facilities. • Further study of barriers to care could explore the difference between reported care offered, and care reported to be received. • Little is known about the strength and effectiveness of referral networks. A study to assess the comprehensiveness and coordination of the system would require a different design. Topics of interest include reasons for referral, the type and distance of facility referred to, patient uptake and follow-up. 86 References Au J, Kayitenkore K, Shutes E, Karita E, Peters P, Tichacek A, Allen S (2006) “Access to adequate nutrition is a major potential obstacle to antiretroviral adherence among HIV-infected individuals in Rwanda.” AIDS 20:16, 2115-2125. Barentt T, Whiteside A (2006) “AIDS in the twenty-first century.” 2nd ed. Basingstoke, Palgrave Macmillan Beecham J, Knapp M (2001) “Costing psychiatric interventions.” In: Thornicroft G (ed) Measur￾ing mental health needs. London, Gaskell Bock N, Reichman LB (2004) “Tuberculosis and HIV/AIDS: epidemiological and clinical aspects (world perspective).” Seminars in Respiratory and Critical Care Medicine 25:3, 337- 344 Campos LN, Guimaraes MD, Remien RH (2008) “Anxiety and depression symptoms as risk factors for non-adherence to antiretroviral therapy in Brazil.” AIDS Care [Epublished ahead of print] Ciesla JA, Roberts JE (2001) “Meta-analysis of the relationship between HIV infection and risk for depressive disorders.” American Journal of Psychiatry 158:5, 725-730 Colindres R, Mermin J, Ezati E et al (2007) “Utilization of a basic care and prevention package in HIV-infected persons in Uganda.” AIDS Care 20(2):139-145 Corbett EL, Watt CJ, Walker N et al (2003) “The growing burden of tuberculosis: global trends and intercations with the HIV epidemic.” Achives of Internal Medicine 163:9, 1009- 1021 Harding R, Powell R, Downing J, Connor S, Mwangi-Powell F, Defilippi K, Cameron S, Garan￾ganga E, Kikule E, Alexander C (2008) “Generating an African palliative care evidence base: The context, need, challenges and strategies.” Journal of Pain and Symptom Man￾agement 36:3, 304-309 Harding R, Powell R A, Kiyange F, Downing J, Mwangi-Powell F (2007) “Pain relieving drugs in 12 African PEPFAR countries.” Kampala, African Palliative Care Association Langlois-Klassen D, Kipp W, Jhangri GS, Rubaale T (2007) “Use of traditional herbal medicine by AIDS patients in Kabarole District, western Uganda.” American Journal of Tropical Medicine and Hygiene 77:4, 757-763. Logie DE, Harding R (2005) “An evaluation of a morphine public health programme for cancer and AIDS pain relief in Sub-Saharan Africa.” BioMed Central Public Health 5: 82 87 Mermin J, Bunnell R, Lule J, Opio A, Gibbons A, Dybul M, Kaplan J (2005) “Developing an evidence-based, preventive care package for persons with HIV in Africa.” Tropical Med￾icine and International Health 10:10, 961-970 Meursing K, Sibindi F (2000) “HIV counselling – a luxury or necessity?” Health Policy Planning, 15:1, 17-23 Mills E, Foster B C, van Heeswijk R, Phillips E, Wilson K, Leonard B, Kosuge K, Kanfer I (2005) Impact of African herbal medicines on antiretroviral metabolism. AIDS 19:1, 95-97 Office of the U.S. Global AIDS Coordinator (2006a) “Guidance for United States Government In-Country Staff and Implementing Partners for a Preventive Care Package for Adults #1.” The President’s Emergency Plan for AIDS Relief. http://www.pepfar.gov/docu￾ments/organization/77004.pdf accessed 11.02.08 Office of the U.S. Global AIDS Coordinator (2006b). “HIV/AIDS Palliative Care Guidance #1 For the United States Government in–Country Staff And Implementing Partners.” U.S. Department of State. http://www.state.gov/documents/organization/64416.pdf accessed 13.01.08 Olley BO, Seedat S, Nei DG, Stein DJ (2004). “Predictors of major depression in recently diag￾nosed patients with HIV/AIDS in South Africa.” AIDS Patient Care and STDs 18:8, 481-487 PEPFAR (2007) “Prevention with Positives”. http://www.pepfar.gov/documents/organization/ 93123.pdf Repetto MJ, Petitto JM (2008). “Psychopharmacology in HIV-infected patients.” Psychosomatic Medicine 70:5, 585-592 Slutsker L, Marston BJ (2007). “HIV and malaria: interactions and implications.” Current Opin￾ion in Infectious Diseases 20:1, 3-10 Solano JP, Gomes B, Higginson IJ (2006). “A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease (COPD) and renal disease.” Journal of Pain and Symptom Management 31:1, 58-69. Wasserheit JN (1992) “Epidemiological synergy: interrelationships between human immunodefie￾incy virus infection and other sexually transmitted diseases.” Sexually Transmitted Dis￾eases 19:2, 61-77 World Health Organization, Geneva, Switzerland, Cancer pain relief and palliative care (1990). Report of a WHO expert committee. World Health Organization Technical Report Series 804, 1-75. 88 Acknowledgements The study benefited from the contributions of a wide range of partners, medical professionals, HIV specialists and researchers. The authors are grateful for the guidance provided by the United States Government Care and Support Technical Working Group and to Dr Rick Berzon (USAID), Dr Donna Kabatesi (CDC), Dr Dan Wamanya (USAID), Dr Flora Banage (CDC), Dr Premila Bar￾tlett as well as Dr Saul Onyango (MOH) and Dr Elizabeth Madraa (MOH). We would like to thank Dr Julia Henn, Dr Vincent Owarwo and Dr Margaret Juliana Mugerwa of the Monitoring and Evaluation of Emergency Plan Progress project for their financial and logistical support for conducting data collection. We also thank the technical and administrative staff at MEASURE Evaluation, through which the project is funded, especially Dr Sian Curtis and Dr Scott Moreland. Finally we are grateful to the staff and patients at the surveyed facilities without whom the research would not have been possible and for whom we believe the results will be useful in continuing to provide and to improve care and support services. 89 Appendix A Senior staff interview questionnaire Appendix : S or s aff in d d mmy y Facility name _________________ ID Date of interview Interviewer _______________________ Respondents Name ____________________ Position ________________________ Name ____________________ Position ________________________ Name ____________________ Position ________________________ Name ____________________ Position ________________________ Name ____________________ Position ________________________ A1 facility type tertiary hospital (training, specialised care) =1 secondary (referral) hospital=2 district hospital (basic inpatient)=3 hospital affiliated health centre=4 other health centre (multiple services)=5 health post/dispensary (few services)=6 walk-in surgery/private doctor's office/clinic = 7 home-based care only=8 A2 is the facility just for people with HIV or HIV only=1 is it also for other people? HIV and non-HIV=2 A3 managing authority government=1 private for profit=2 private non-profit (eg NGO, faith-based)=3 number of patients receiving care in the last quarter A men B women C children D total A4 new patients A5 all patients A6 hours per week when patients can see a clinical member of staff for HIV care A7 hours per week when patients can see a non-clinical member of staff for HIV care A8 For someone who is HIV-positive but not sick, and does not receive ART, how many times per year would they have regular appointments with clinical staff? 777= no regular appointments, as required A9 For someone who is HIV-positive but is not sick, and does not receive ART, how many times per year would they have regular appointments with non-clinical staff? 777= no regular appointments, as required A10 For someone who is HIV-positive but not sick, and does receive ART, how many times per year would they have regular appointments with clinical staff? 777= no regular appointments, as required A11 For someone who is HIV-positive but is not sick, and does receive ART, how many times per year would they have regular appointments with non-clinical staff? 777= no regular appointments, as required 90 places of care delivery provided by this facility for HIV positive patients yes=1, no=2 A12a inpatient A12b outpatient A12c home-based care A12d medical consultancy for other facilities A12e daycare A12f support groups A13 number of inpatient beds in whole facility: Number of staff in whole facility A full-time paid B part-time paid C volunteer A14a doctor A14b clinical officer A14c medical assistant A14d nurse A14e pharmacist/dispenser A14f lab staff A14g community health worker A14h social worker A14i spiritual leader A14j traditional healer A14k nutritionist A14l counsellor A14m physiotherapist Which patients pay for the following services: all patients pay=1 means-tested=2 free to patients on ART = 3 free to all patients=4 free to children=5 restricted by other criteria=6 not available=8 A15a clinical appointment i.e. to see doctor A15b x-rays A15c HIV test A15d ARVs A15e Laboratory work A15f cotrimoxazole/Septrin A15g other medicines 91 Does your facility report to: A16a Ministry of Health yes=1, no=2 A16b PEPFAR/US agency A16c NGO including FBO A16d Private for-profit organisation Infrastructure A17 Does your facility have staff yes, roster observed or staff live onsite=1 available 24 hours a day? yes, no roster and no staff live onsite=2 no=3 A18 does the facility have a functional yes, functioning (and with fuel)=1 ambulance, bicycle or other vehicle yes, but not functioning or no fuel=2 onsite for patient emergency transport? no=3 A19 yes=1 Is the electricity working? (Check) usually but not now=2 never have electricity=3 A20 Does the facility have a backup yes, functioning (and with fuel)=1 electrical power supply (generator, yes, but not functioning or no fuel=2 invertor, solar panels)? no=3 (Accept response) A21 What is the most commonly used safe (piped, public tap, standpipe, protected source of water for the facility, for all dug well, rainwater, borehole)=1 purposes, at this time? other (unprotected dug well, tanker-truck, cart, jerry can, river/pond surface water etc)=2 bottle water (enough for handwashing)=3 no water source=4 A22 Is there a latrine/toilet available yes, improved (flush/pour flush to sewer system/ for outpatients to use?(Check) septic tank, pit with slab, VIP, composting)=1 yes, other (flush/pour flush to field, pit without slab, open pit, hanging, bucket)=2 no=3 if F26=3 go to F28 A23 condition of the latrine/toilet functioning=1 not functioning=2 unable to observe=3 92 Evaluation (include top 5 for each question) A24 What are the strengths of your facility in terms of HIV care service delivery for both adults and children? A25 What would improve the way your facility offers services to HIV-infected adults? A26 What would improve the way your facility offers services to HIV-infected children? A27 As manager, what main challenges do you face in terms of sustainability for your facility? A28 What do you think might be potential strategies to avoid patients receiving duplicate HIV-related services at your facility and elsewhere? 93 Senior staff questionnaire section B: components of care Facility name _______________________ Facility ID Interviewer _______________________ Date d d m my y type of care service provided? currently able to # people receiving 1=yes, by this facility provide to all who this care here 2= yes, formally referred need it? in the last quarter 3=yes, informally referred yes=1, no=2 9999=missing 4=service not provided Question part: A B C Question number Spiritual facility arranges for: B1 visit by pastor etc B2 staff prayer with patients B3 contact with traditional healer Psychological B4 pre and post test counselling B5 adherence counselling B6 family planning counselling B7 patient HIV support groups B8 family care-givers support group B9 family counselling B10 psychiatric therapy Clinical Prevention B11 support for family testing B12 circumcision B13 prevention with positives General B14 nursing care B15 adult diagnostic HIV testing B16 ART B17 weighing B18 assess ART treatment failure B19 monitor ART toxicity Pain B20 assessment of pain B21 strong opioids eg morphine B22 weak opioids eg codeine B23 non-opioids eg paracetemol B24 treatment for neuropathic pain If A = 1 complete B and C. Otherwise cross through boxes 94 Facility name _______________________ Facility ID Interviewer _______________________ Date d d m my y type of care service provided? currently able to # people receiving 1=yes, by this facility provide to all who this care here 2= yes, formally referred need it? in the last quarter 3=yes, informally referred yes=1, no=2 9999=missing 4=service not provided Question part: A B C Question number Symptom management B25 anxiety/depression treatment B26 treatment for nausea/vomiting B27 treatment for skin rash/itching B28 treatment for diarrhoea B29 laxatives B30 treatment for thrush B31 treatment for oral candidiasis B32 treatment for cryptococcus B33 treatment for other fungal infections B34 treatment for herpes (e.g. acyclovir) B35 treatment for malaria B36 TB detection B37 TB treatment B38 B39 B40 management of cancer Prophylaxis B41 multivitamins B42 nutritional advice B43 access to safe drinking water at home B44 septrin/cotrimoxazole B45 isoniazid (INH) to prevent TB B46 condoms B47 mosquito bednets treatment for other opportunistic infections therapeutic feeding for malnutrition 95 Facility name _______________________ Facility ID Interviewer _______________________ Date d d m my y type of care service provided? currently able to # people receiving 1=yes, by this facility provide to all who this care here 2= yes, formally referred need it? in the last quarter 3=yes, informally referred yes=1, no=2 9999=missing 4=service not provided Question part: A B C Question number Support B48 wound care B49 physiotherapy Social For the patient B50 home help e.g. help with bathing, housework, cooking B51 transport to care centre B52 employment training/IGA B53 provide household items B54 legal services B55 memory book work For the family B56 B57 loans/microfinance B58 infection control training Laboratory B59 liver function test (LFT) B60 malaria film B61 AFB smear B62 CD4 count/test B63 rapid HIV test B64 pulse oximetry B65 dried blood spot (early infant diagnosis) B66 viral load Paediatric (0-14 years) B67 paediatric ART B68 infant testing and counselling B69 children testing and counselling home help e.g. help with bathing, housework, cooking 96 Appendix B Document analysis record Facility name _______________________ Facility ID Date ________________ Interviewer _______________________ Document analysis If A = 1, complete B-E. Otherwise cross through boxes reported observed format example taken language yes=1 yes=1 paper=1 yes=1, no=2 English=1 no=2 no=2 computer=2 other=2 both = 3 Question section: A B C D E Question number D1 service aim D2 referral criteria (inwards) D3 incoming referral forms D4 outgoing referral forms D5 patient charging D6 ART protocols D7 care protocols D8 first clinical assessment sheets D9 ongoing contact assessment sheets D10 patient records D11 referral followup forms D12 stock control sheet Please list all languages: D13 information for patients 1. ____________ E1 2. ____________ E2 3. ____________ E3 4. ____________ E4 5. ____________ E5 97 Appendix C Pharmacy review Facility name _______________________ Facility ID Date d d m m y y Interviewer _______________________ If A = 1 complete B-E, otherwise cross through boxes Record in-date and expired present number stock stockout in storage drugs on separate lines if yes=1 (total) of unopened level last open access clinic = both are present no=2 packs present (# packs) 6 months? open access pharma 000=no unopened 999=no given stock level yes=1, no=2 = 2, locked in clinic = packs present locked in pharmacy = Question section: A B C D E F Question number TABLETS total number tablets P1.1 codeine: in date P1.2 Codeine: expired P2.1 P2.2 P3.1 isoniazid: in date P3.2 isoniazid: expired P4.1 fluconazole: in date P4.2 fluconazole: expired P5.1 morphine: in date P5.2 morphine: expired P6.1 rectal morphine: in date P6.2 rectal morphine: expired P7.1 adult CTX: in date P7.2 adult CTX: expired P8.1 Paediatric CTX: in date P8.2 Paediatric CTX: expired amount present in stock non-opioid painkiller: in date non-opioid painkiller: expired 98 Facility name _______________________ Facility ID Date d d m m y y Interviewer _______________________ If A = 1 complete B-E, otherwise cross through boxes present number stock stockout in storage yes=1 (total) of unopened level last open access clinic = no=2 packs present (# packs) 6 mon hs? open access pharma 000=no unopened 999=no given stock level yes=1, no=2 = 2, locked in clinic = packs present locked in pharmacy = Question section: A B C D E F SYRUP total amount in mls P9.1 codeine: in date P9.2 Codeine: expired P10.1 P10.2 P11.1 isoniazid: in date P11.2 isoniazid: expired P12.1 fluconazole: in date P12.2 fluconazole: expired P13.1 morphine: in date P13.2 morphine: expired P14.1 adult CTX: in date P14.2 adult CTX: expired P15.1 Paediatric CTX: in date P15.2 Paediatric CTX: expired non-opioid painkiller: in date non-opioid painkiller: expired amount present in stock 99 Facility name _______________________ Facility ID Date d d m m y y Interviewer _______________________ If A = 1 complete B-E, otherwise cross through boxes present number stock stockout in storage yes=1 (total) of unopened level last open access clinic = no=2 packs present (# packs) 6 mon hs? open access pharma 000=no unopened 999=no given stock level yes=1, no=2 = 2, locked in clinic = packs present locked in pharmacy = Question section: A B C D E F POWDER for suspension total amount in grams P16.1 codeine: in date P16.2 Codeine: expired P17.1 P17.2 P18.1 isoniazid: in date P18.2 isoniazid: expired P19.1 fluconazole: in date P19.2 fluconazole: expired P20.1 morphine: in date P20.2 morphine: expired P21.1 adult CTX: in date P21.2 adult CTX: expired P22.1 Paediatric CTX: in date P22.2 Paediatric CTX: expired INJECTABLE total number of vials P23.1 morphine: in date P23.2 morphine: expired non-opioid painkiller: in date non-opioid painkiller: expired amount present in stock 100 Appendix D Patient focus group discussion schedule Question number Question Number 1 Total number in group How many from the group, from this facility: 2A Receives cotrimoxazole, to take every day 2B Has been given an ITN for personal use 2C Has been tested for TB by sputum or X-ray 2D Has received anything to make sure your drinking water is clean 2E Receives counselling about how to prevent transmitting HIV to others 2F Receives nutritional counselling 2G Received condoms for you or your partner 2H Been encouraged to bring your spouse/children for HIV counselling and testing 3. How do you feel today? 4. For those of you who did not receive the items mentioned from this service, can anyone tell me a reason why? 5. What are the main HIV services you receive from here? 6. Which services have been the best and why? 7. Are there any services which could be improved? 8. Apart from this facility, where else do you go for HIV services? 9. What are the main HIV services you receive from other places? 10. How do you choose where to go for different things? 11. Which medicines do you get from this facility? 12. Have you had any problems getting medicines from this facility? Please tell us about them. 13. What would you like an HIV care service to do for you, what things would you need? 14. How can this facility attract more HIV-positive people to access services here? 15. Is there anything we haven’t asked about that is important to you? 101 Appendix E Facilities surveyed ID District Name Facility type 202 Kaberamaido Ocanoyere P/S Other health centre 203 Bushenyi Rugarama HC2 health post/dispensary 204 Bushenyi Swazi HC2 health post/dispensary 205 Bushenyi Butoha HC2 health post/dispensary 206 Tororo Nagongera Boys hospital affiliated health centre 207 Busia Busamba health post/dispensary 209 Kyenjojo Kyenjojo District PHA Forum home-base care only 210 Kisoro Kisoro District PHA Forum home-base care only 211 Bushenyi Bushenyi District PHA Forum home-base care only 212 Kampala Case Medical Center other health centre 213 Kumi Agaria HC II health post/dispensary 214 Mubende Mubende District PHA Forum home-base care only 218 Busia Buhehe health post/dispensary 219 Kumi Nyero HC III other health centre 220 Rakai Kifamba other health centre 221 Kumi Malera HC III health post/dispensary 222 Wakiso Buwambo HCIV other health centre 223 Rakai Kasasa other health centre 226 Mbarara Kiruhura District health post/dispensary 227 Bushenyi Bushenyi TC HC3 other health centre 229 Pallisa Butesa Community AIDS Initiative other health centre 230 Rakai Lyantonde Muslim Health Centre other health centre 231 Bugiri UCOBAC home-base care only 232 Mbarara Mayanja Memorial Foundation other health centre 233 Mbarara Ibanda CDC other health centre 234 Kampala Hospice Africa Uganda other health centre 235 Kampala Mulago TB-HIV Clinic training hospital 236 Kumi Kumi Aids Support Organisation home-base care only 237 Wakiso Meeting Point Wakiso Kyamusa Obwongo home-base care only 238 Kyenjojo Kyembogo Hc-Kyarusozi other health centre 239 Kyenjojo Fp Diocese-Kyembogo home-base care only 240 Mbarara Bwizibwera ISS Clinic health post/dispensary 241 Kumi Kumi DDHS other health centre 102 ID District Name Facility type 242 Bushenyi Ishaka Hospital district hospital 243 Kayunga Kayunga District Hospital referral hospital 244 Lira Lira - DDHS referral hospital 245 Mukono Nile Treatment Center health post/dispensary 246 Kabarole Buhinga Regional Hospital district hospital 247 Bushenyi Bushenyi Medical Center, Katungu other health centre 248 Kampala Kawempe Health Centre hospital affiliated health centre 249 Jinja Jinja Regional Hospital referral hospital 250 Mukono Kawolo Hospital district hospital 251 Apac Apac Government Hospital district hospital 252 Kitgum St. Joseph’s Hospital other health centre 253 Mbarara AIC Mbarara health post/dispensary 254 Kitgum CHAPS home-base care only 255 Rukungiri TASO Rukungiri other health centre 256 Kampala AIC Kampala other health centre 257 Mbarara TASO Mbarara other health centre 258 Kampala Mulago Infectious Diseases Clinic other health centre 259 Kampala JCRC - Kampala Clinic other health centre 260 Mbarara Mbarara Regional Hospital training hospital 261 Kumi Ngora Dispensary other health centre 263 Mbale Makhai PS hospital affiliated health centre 265 Pallisa Kadama other health centre 266 Soroti Arapai Odudui health post/dispensary 269 Bushenyi Rimuri HC2 health post/dispensary 277 Kyenjojo RWIDE home-base care only 278 Kyenjojo Kyenjojo Initiative For Rural Development home-base care only 279 Rakai Lwamaggwa other health centre 103 Appendix F Care components categorised for PEPFAR care and support areas Area of PEPFAR care and support Care components included from CSRI Clinical Pre and post test counselling Adherence counselling Nursing care Adult diagnostic HIV testing Weighing Assessment of pain Strong opioids Weak opioids Non-opioid analgesics Treatment for neuropathic pain Treatment for nausea/vomiting Treatment for skin rash/itching Treatment for diarrhoea Laxatives Treatment for thrush Treatment for oral candidiasis Treatment for cryptococcus Treatment for other fungal infections Treatment for herpes Treatment for malaria TB detection and treatment Therapeutic feeding for malnutrition Treatment for other opportunistic infections Management of cancer Multivitamins Nutritional advice Access to safe drinking water at home CTX Isoniazid to prevent TB Mosquito bednets Wound care Physiotherapy Area of PEPFAR care and support Care components included from CSRI Psychological Family care-givers support group Family counselling Psychiatric therapy Anxiety/depression treatment Spiritual Visit by pastor Staff prayer with patients Contact with traditional healer/herbalist Memory book work Social Home help Employment training Legal services Loans/microfinance Prevention Family planning counselling Patient HIV support groups Support for family testing Prevention with positives Condoms 104 Appendix G Results sharing with facilities Introduction Part of the objective of this evaluation is, in conjunction with Measure Evaluation, to build com￾mitment to utilising the findings and lessons learnt from the study. As a step towards meeting this objective a meeting was held in Kampala in May 2008 with the research team and participating facilities. Representatives from all 60 facilities and the country team attended the half day work￾shop. The purposes of this half-day meeting were • to share the results of the phase 1 survey with participants; • to gain insight into the findings from those involved in service delivery and improve the pre￾sentation of the findings in the report; • to discuss the recommendations made, with the option of facilities making additional recom￾mendations if desired; and • to identify the organisations who may be able to implement the recommendations. Meeting outline Participants were given a summary of the findings. Presentations from the research team ex￾plained • the parties involved and the aims, objectives and design of the evaluation; • methods and data collection experiences; and • survey results. Participants were then divided into 5 groups in order to explore key themes that arose from the data in more detail. In addition to the summary report and presentation handouts already received, each group was given relevant supplementary data (i.e. themed report tables) to aid discussions. Group participants were asked to discuss the main findings relating to the theme allocated. Prompts to aid discussion included: Were any findings surprising? What are the areas where things are doing well or are on track and why? What areas need improvement and why? Participants were then asked to review and discuss the recommendations contained in the summary report, and finally to draft their own set of recommendations for action in this thematic area using the attached format. Discussion summaries were shared with all. Meeting feedback- general Participants expressed their appreciation at being informed of the survey findings, as well as hav￾ing an opportunity to contribute to the report itself. Although participants were presented with a large amount of data in a short half-day meeting, they were able to form their own views of the findings. 105 Meeting feedback — Recommendations from discussion groups Components of care by theme: ART, Basic care package, pain management, malaria, TB and other OIs Recommended Actions Supporting data Beneficiaries Priority Lead Organization Other stakeholders ART Train lower level units in ART monitoring and assessment of • treatment failure. Increase cover and accessibility • Establish formal linkages between district level and health • centre ART programmes Invest in laboratory infrastructure to support ART monitoring • Table – ART provision by facility type Health centres and health care workers Urgent MOH Facilities such as Mildmay, IDI and JCRC BCP Prioritize distribution of BCP to lower level facilities • Emphasize comprehensive BCP, rather than components • Figures on availability of elements of BCP Patients Urgent MOH, CDC, USAID Population services international OIs Stock all health facilities with CTX. • Evaluate Isoniazid prohylaxis and its implications. A number of • sites offered Isoniazid prophylaxis for TB prevention, yet it has been found to cause serious drugs resistance in case of TB. Group members were wondering whether there was any monitoring mechanism in place. Table – Availability of components of care relating to opportunistic infections by facility type PAIN MANAGEMENT Make opioids available at all referral hospitals. • Strengthen advocacy for clinicians to appreciate the role of • palliative care in HIV care programmes Table – Availability of components of care relating to pain management by facility type Patients and health care workers Urgent APCA, MOH, Hospice Palliative care associations 106Components of care by theme: nutrition, social care and psychological care Recommended Actions Supporting data Beneficiaries Priority Lead Organization Other stakeholders NUTRITON Provide health education to create awareness and • knowledge about good nutrition Provide food, and loans to support productivity • Encourage use of local food stuffs instead of nutri- • tional supplements and multivitamins Table – Availability of components of care relating to nutrition by facility type Bed ridden patients and HIV infected and affected children Urgent NGOs/ USAID and health facilities NGOs, CBOs SOCIAL CARE Launch awareness campaigns on the need for provi- • sion of social care in health centres and hospitals Set minimum standards for social care in Uganda • Encourage cash circles and other income generating • activities to improve on patients productivity and thus self sustenance Table – Availability of components of social care by facility type Patients and health care workers High MOH, NGOs and min￾istry of Finance USAID, Hospice Africa Uganda PSYCHOLOGICAL CARE Promote awareness and availability of psychiatric • therapy and encourage proper referrals Support and build capacity for HBCs to provide psy- • chiatric therapy Table – Availability of components of care relating to psycho￾logical health by fa￾cility type Patients and health care works Urgent MOH, Medical Schools in Uganda USAID 107 Infrastructure and medication stocks, supply and use, laboratory services Recommended Actions Beneficiaries Priority Lead Organization Other stakeholders INFRASTRUCTURE • Increase funding for vehicle repair and availability of ambulances • Establish support groups at district and regional levels Patients Urgent NGOs/ USAID MOH MEDICATION STOCKS , SUPPLY AND USE • Train staff in logistics and supplies management Patients and population at risk High MOH USAID LABARATORY SERVICES • Avail all diagnostic tests at regional and district hospitals Patients Urgent USAID MOH Staffing Recommended Actions Beneficiaries Priority Lead Organization Other stakeholders STAFF RETENTION • Improve on staff training and remunerations (especially for volunteers) to reduce staff turnover Patients and health care workers Urgent MOH, NGOs CBOs TRAINING • Provide more training to support task shifting where possible. This will support the use of volunteers and traditional healers. • Train and recruit staff to provide spiritual, social and psychological care Patients, traditional healers and volunteers High MOH, NGOs USAID LOGISTICS • Provide training in procurement and logistics management Patients and pharmacy technicians Urgent MOH, Medical Schools in Uganda USAID 108Cross-cutting issues Recommended Actions Supporting data Beneficiaries Priority Lead Organization Other stakeholders STAFFING - Provide training in spiritual care • - Support multi-professionalism at all facilities; medical care • should not be the only priority. This may also reduce staff costs where resources are constrained - Increase staffing levels • Table – staff categories by facility type Patients urgent MOH TASO, Mildmay and Hospice CARE PROVISION - Promote referrals for home help and spiritual care - Build capacity for lower level units to provide more types of care since they are more accessible - Sensitise government facilities on the need for care and support in HIV care. - Train community volunteers in counselling and home help to support rolling out of home help - Patients should also be supported to start income generating activities - Increase sensitisation to care and support at Government facilities - Increase results orientation at Government facilities Tables - components of care frequently provided or referred, Mean number of components of care provided and referred, Mean components of care by managing authority Patients and health care workers Urgent MOH TASO, Mildmay, Hospice and APCA 109 Amendments to report Feedback from the discussion groups highlighted some small areas of the report where further ex￾planation of the results was needed to ensure understanding, for instance more detail about water sources. A principal comment from participants related to the results presented by facility type. Facility type was based on self-reported facility type selected from eight pre-determined categories and later collapsed down to five (referral hospitals, district hospitals, health centres, health posts and home-based care centres). Several people thought their facility was not in the most appropriate group, the term ‘health post’ was not understood, and the different types of health centre in the Ugandan context (health centre 2, 3 and 4) were not reflected in the groups used. There are numerous ways in which the facilities could be categorised according to different audi￾ences. Furthermore, extensive consultation on Phase 1 analysis had already been undertaken with country teams and MOH representatives, and there was a need to maintain comparable groupings to Kenya to allow cross-country comparisons. Therefore, the study team decided to keep the find￾ings as presented in the main, note the comments from the facility representatives, and supple￾ment the report with additional key tables where facilities are categorised by Ministry of Health￾approved type. Our thanks go to Dr Elizabeth Madraa and Dr Saul Onyango from the MOH, and to Dr Umar Ssekabira and Dr Andrew Kambugu from IDI, for assisting us in the process. The six revised categories consist of: • Home-based care health centres (HBC) • Health centre 2 – outpatient only • Health centre 3 – outpatient, maternity, limited inpatient (<15 beds), lab • Health centre 4 – blood bank, operating theatre, inpatient • Hospital – larger inpatient, fully equipped lab, specialties, training • Referral institution – centres of excellence in a specialised area which do not offer all the fa￾cilities of a health centre, e.g. AIC, JCRC and IDI Five key areas have been reanalysed using this structure and the results are presented below. A comparison between the original and revised category structure is presented in Table 56. Key results by Uganda MoH agreed facility type Table 51 shows that the more developed health centre 4 facilities, hospitals and referral institutions were most likely to have general infrastructure such as an electricity supply. These facilities always report to the MOH, whereas HBC facilities are more likely to report to an NGO. HBC facilities are the most likely to be solely providers of HIV care, and all of them are managed at leasst in part by an NGO. All types of facility may offer home-based care but only the HBC facilities always do so. 110 Table 51: Infrastructure Number of facilities n (%) HBC Health centre 2 Health centre 3 Health centre 4 Hospital Referral institution Total number of facilities of each type 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) HIV-only facility 5 (56) 2 (25) 6 (35) 0 2 (17) 3 (38) Authority Government 1 (11) 6 (75) 9 (53) 5 (100) 7 (58) 3 (38) Private 0 0 1 (6) 0 2 (17) 0 NGO 9 (100) 2 (25) 7 (41) 0 3 (25) 5 (63) Reports to Ministry of Health 4 (44) 7 (88) 16 (94) 5 (100) 12 (100) 8 (100) USG/PEPFAR 6 (67) 2 (25) 9 (53) 3 (60) 7 (58) 8 (100) NGO 8 (89) 4 (50) 5 (29) 1 (20) 5 (42) 3 (38) Private for-profit organisation 0 0 0 0 0 1 (13) Place of care Inpatient 0 0 7 (41) 5 (100) 10 (83) 2 (25) Outpatient 2 (22) 6 (75) 15 (88) 4 (80) 12 (100) 8 (100) Home based care 9 (100) 3 (38) 9 (53) 3 (60) 5 (42) 4 (50) Medical consultancy 1 (11) 1 (13) 11 (65) 5 (100) 11 (92) 7 (88) Daycare 1 (11) 2 (25) 7 (41) 0 4 (33) 3 (38) Support groups 8 (89) 2 (25) 8 (47) 3 (60) 8 (75) 7 (88) General infrastructure Staff on site 24 hours a day 1 (11) 4 (50) 10 (59) 5 (100) 5 (42) 2 (25) Has functioning ambulance 4 (44) 0 8 (47) 2 (40) 6 (50) 7 (88) Has working electricity 2 (22) 3 (38) 7 (41) 3 (60) 11 (92) 8 (100) Has functioning generator 2 (22) 1 (13) 8 (47) 3 (60) 11 (92) 7 (88) Has safe water supply 7 (78) 5 (63) 13 (76) 5 (100) 12 (100) 8 (100) Has functioning toilet 8 (89) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) *In addition there were 5 facilities with an ambulance that did not function, 4 which reported usually having electricity, and 6 with a non-functional generator. Table 52: Staff categories by MOH facility type Facility type n (%) HBC Health centre 2 Health centre 3 Health centre 4 Hospital Referral institution N 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) Clinical 3 (33) 7 (88) 17 (100) 5 (100) 12 (100) 8 (100) Spiritual 5 (56) 2 (25) 5 (29) 3 (60) 3 (25) 1 (13) Psychological 8 (89) 1 (13) 10 (59) 2 (40) 7 (58) 7 (88) Social 8 (89) 5 (63) 13 (76) 4 (80) 8 (67) 6 (67) Clinical + spiritual + psychological + social 1 (11) 1 (13) 3 (18) 2 (40) 3 (25) 0 111 Health centre 4s and hospitals are the most likely to have staff who specialise in each area of care and support (Table 52). At HBC facilities, clinical staff are the rarest group, in contrast with the other facility types where clinical staff are nearly always present. Spiritual care staff are least likely to be present at referral institutions, and partly as a consequence, no referral institution has staff in all four areas. Table 53: Number of facilities providing or referring for each type of care, by MOH facility type Any component provided or referred in area of care Facility type including referrals, n (%) HBC Health centre 2 Health centre 3 Health centre 4 Hospital Referral institution N 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) Spiritual 8 (89) 3 (38) 6 (35) 1 (20) 10 (83) 6 (67) Psychological 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) Clinical 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) Social 8 (89) 2 (25) 4 (24) 0 4 (33) 6 (67) Prevention 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) All care and support 7 (78) 2 (25) 3 (18) 0 4 (33) 6 (67) Referral institutions and HBC facilties are the most likely to offer complete care and support (Table 53), although Table 52 shows that they are the facility types least likely to have trained staff in every area. The limiting factor in offering a complete package seems to be social care, the com￾ponent which is least often found even though the majority of facilities have social care staff. Table 54: ART provision by MOH facility type ART component Facilities offering care including referrals, n (%) HBC Health centre 2 Health centre 3 Health centre 4 Hospital Referral institution N 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) ARVs 3 (33) 5 (63) 16 (94) 5 (100) 11 (92) 6 (67) Adherence counselling 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) Assessment of ARV treatment failure 2 (22) 4 (50) 15 (88) 4 (80) 11 (92) 6 (67) Monitor ARV toxicity 2 (22) 4 (50) 15 (88) 4 (80) 11 (92) 6 (67) The best complete provision of ART in the broad sense is offered by hospitals (Table 54), but health centres type 3 and 4 are more likely to actually have the antiretrovirals. HBC facilities are least likely to offer ART, and two thirds of referral institutions provide it. In all the health centre types, and HBC facilities, at least one facility refers for ARVs without the support structure of toxicity monitoring and treatment failure assessment. 112 Table 55: Availability of components of care relating to malaria and TB. by MOH facility type Component of care Facilities offering test including referrals, n (%) HBC Health centre 2 Health centre 3 Health centre 4 Hospital Referral institution N 9 (100) 8 (100) 17 (100) 5 (100) 12 (100) 8 (100) Isoniazid to prevent TB 4 (44) 3 (38) 13 (76) 5 (100) 8 (67) 2 (25) TB detection 5 (56) 4 (50) 15 (88) 5 (100) 12 (100) 8 (100) TB treatment 5 (56) 4 (50) 16 (94) 5 (100) 12 (100) 8 (100) Mosquito bednets 5 (56) 4 (50) 11 (65) 3 (60) 5 (42) 7 (88) Treatment for malaria 5 (56) 7 (88) 17 (100) 5 (100) 12 (100) 8 (100) Malaria film 1 (11) 4 (50) 15 (88) 5 (100) 11 (92) 7 (88) AFB test 1 (11) 3 (38) 14 (82) 5 (100) 11 (92) 7 (88) All facilities in the analysis offer at least one component of clinical care and prevention (Table 53). Malaria and TB are two of the most prevalent and high-morbidity conditions among people with HIV and they are examined in more detail here. Health centre 4 facilities provide the best malaria and TB care as a whole, considering prevention, diagnosis and treatment (Table 55). Referral insti￾tutions also have good coverage, with the exception of isoniazid. All hospitals and referral institu￾tions provide treatment but prevention and diagnosis components are not always available. Health centre 2 and HBC facilities frequently do not provide malaria and TB care components. Table 56: Comparison of self-reported and assigned facility types Self-reported facility type (main report) Assigned facility type (appendix) HBC Health centre 2 Health centre 3 Health centre 4 Hospital Referral institution HBC 8 1 1 Health post 6 4 1 1 1 Health centre 1 1 12 4 3 6 District hospital 4 Referral hospital 3 2 Table 56 shows that in the main, the category ‘health post’ maps onto ‘health centre 2’, and ‘health centre’ to ‘health centre 3’, and most of the previously designated referral hospitals and district hos￾pitals are assigned to the ‘hospital’ category. The HBC category also remains constant apart from one facility which previously called itself a health centre. MEASURE Evaluation Carolina Population Center The University of North Carolina at Chapel Hill 206 W. Franklin St., CB8120 Chapel Hill, NC 27516 USA www.cpc.unc.edu/measure King’s College London Department of Palliative Care, Policy and Rehabilitation Weston Education Centre Cutcombe Road London SE5 9RJ UK www.kcl.ac.uk/palliative