Methodology Annex
From Rhetoric to Reality: An Analysis of Donor and Implementing Country Efforts
to Scale up the TB-HIV Response
Contents
Overview ....................................................................................................................................................... 2
Table 1: 32 countries with TB-HIV co-infection rates of 20% or higher.................................................... 2
Table 2: English Search Terms................................................................................................................... 2
Table 3: French Search Terms ................................................................................................................... 3
DFID ............................................................................................................................................................... 4
World Bank.................................................................................................................................................... 5
Global Fund ................................................................................................................................................... 6
PEPFAR .......................................................................................................................................................... 9
National Strategic Plans .............................................................................................................................. 10
In-depth interviews ..................................................................................................................................... 11
1
Overview
To better understand how the updated WHO recommendations on TB-HIV were being put into practice,
ACTION carried out a mixed methods study analyzing efforts by donors and implementing countries to
include TB-HIV collaborative activities in their policies and programs. The research focused on 32
countries where 20% or more of people with TB were co-infected with HIV.
Table 1: 32 countries with TB-HIV co-infection rates of 20% or higher
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Lesotho (77%)
Swaziland (77%)
Zimbabwe (71%)
South Africa (63%)
Botswana (62%)
Malawi (62%)
Mozambique (60%)
Zambia (59%)
Uganda (53%)
Namibia (49%)
Tanzania (41%)
Antigua and Barbuda (39%)
Guinea-Bissau (39%)
Kenya (39%)
Cameroon (37%)
Saint Vincent and the Grenadines (36%)
17. Barbados (33%)
18. Central African Republic (32%)
19. Rwanda (29%)
20. Gabon (27%)
21. Cote D’Ivoire (26%)
22. Trinidad and Tobago (26%)
23. Nigeria (25%)
24. Togo (24%)
25. Bahamas (23%)
26. Guyana (23%)
27. Chad (22%)
28. Congo (22%)
29. Jamaica (22%)
30. Suriname (21%)
31. Belize (20%)
32. Haiti (20%)
Source: WHO. (2013). Global Tuberculosis Report 2013. Retrieved from
http://apps.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf?ua=1.
This list is solely based on percentage of new TB cases that are co-infected with HIV, not absolute
number of people living with the diseases. As a result, it does not include a number of Asian and
European countries.
Four donor agencies were chosen for review: The Global Fund to Fight AIDS, Tuberculosis and Malaria,
the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the United Kingdom Department
for International Development (DFID), and the World Bank. The analysis, which took place during March
and April 2014, focused on these donors because they are large financiers of TB and HIV programs and
relevant data was publicly available. Available national strategic plans on TB and HIV in the 32 most
affected countries were evaluated as well, both in English and French.
All documents were analyzed to capture any mention of WHO recommendations, and assessed to
determine if budget was allocated to carry out the TB-HIV activities. The following search terms were
used to determine whether or not a document included a specific collaborative activity.
Table 2: English Search Terms
WHO TB-HIV Collaborative Activity
A.1. Set up and strengthen a coordinating body for
collaborative TB/HIV activities functional at all levels
Words searched to confirm collaborative activity
“Coordination”; “strengthen TB-HIV”; any mention of
National TB Programmes and National HIV/AIDS
Programmes working together, any mention of regional
coordination on TB-HIV
2
A.2. Determine HIV prevalence among TB patients and
TB prevalence among people living with HIV
A.3. Carry out joint TB/HIV planning to integrate the
delivery of TB and HIV services
A.4. Monitor and evaluate collaborative TB/HIV
activities
B.1. Intensify TB case-finding and ensure high quality
antituberculosis treatment
B.2. Initiate TB prevention with Isoniazid preventive
therapy and early antiretroviral therapy
B.3. Ensure control of TB Infection in health-care
facilities and congregate settings
C.1. Provide HIV testing and counselling to patients with
presumptive and diagnosed TB
“Prevalence”; “Rate of HIV among TB patients
recorded”; “prevalence recorded”; “status recorded”;
“TB patients with HIV status recorded in the TB
register”
“Collaboration”; “Planning”; “Integrate delivery of
services”
Any time an activity was monitored and/or evaluated in
project documents, or explicitly listed to be measured
“Intensified case finding”; “DOTS”; “TB treatment”;
“Treatment of TB”; “Three I’s”; “TB screening”; “screen
for TB”; “GeneXpert”; “Xpert”
“Isonaizid”; “isoniazide”; “IPT” (only with reference to
TB, not malaria); “Isonaizid preventive therapy”; “early
ART”; “Initiate early ART”; “Three I’s”;
“Preventive Treatment with Isoniazide”
“Infection control”; “IC”; “Three I’s”
C.5. Provide antiretroviral therapy for TB patients living
with HIV
Must be specified for patients with diagnosed and
presumptive TB: “HIV counselling and testing”; “HCT”;
“VCT”; “Test for HIV”; “HIV counselling”
Must be specified for patients with diagnosed and
presumptive TB: “HIV prevention”; “HIV prevention
methods”; “harm reduction”; “behavioural change
communication”; “BCC”
Only in relation to TB-HIV co-infected patients: “Cotrimoxazole”; “Co-trimoxazole preventive therapy”;
“Cotrimoxzaole” “CPT”;
Must be specified for patients with TB-HIV co-infection:
“HIV treatment and care”; “HIV prevention”; “HIV
prevention methods”; “HIV care”; “behavioural change
communication”; “BCC”; “provide HIV services”
Must be specified for patients with TB-HIV co-infection:
“ART”; “antiretroviral therapy”
Table 3: French Search Terms
WHO TB-HIV Collaborative Activity
Words searched to confirm collaborative activity
C.2. Provide HIV prevention interventions for patients
with presumptive and diagnosed TB
C.3. Provide co-trimoxazole preventive therapy for TB
patients living with HIV
C.4. Ensure HIV prevention interventions, treatment
and care for TB patients living with HIV
A.1. Set up and strengthen a coordinating body for
collaborative TB/HIV activities functional at all
levels
A.2. Determine HIV prevalence among TB patients
and TB prevalence among people living with HIV
A.3. Carry out joint TB/HIV planning to integrate
the delivery of TB and HIV services
A.4. Monitor and evaluate collaborative TB/HIV
activities
B.1. Intensify TB case-finding and ensure high
quality antituberculosis treatment
Coordination; integration; co-infection
“prévalence”; “prévalence tuberculose” in people
with “SIDA”; prévalence in relation to
“maladies/infections opportunists”, “co-infection”
Collaboration; integration;
“suivi” in relation to monitoring TB-HIV activities
DOTS; maladies/infections opportunistes
3
B.2. Initiate TB prevention with Isoniazid
preventive therapy and early antiretroviral therapy
INH; Three ones; isoniazid; prévention
B.3. Ensure control of TB Infection in health-care
facilities and congregate settings
C.1. Provide HIV testing and counselling to patients
with presumptive and diagnosed TB
C.2. Provide HIV prevention interventions for
patients with presumptive and diagnosed TB
Three Ones, controle
C.3. Provide co-trimoxazole preventive therapy for
TB patients living with HIV
Cotrimoxazole;
C.4. Ensure HIV prevention interventions,
treatment and care for TB patients living with HIV
VIH; prevention; changement de comportement;
co-infection
C.5. Provide antiretroviral therapy for TB patients
living with HIV
ARV
Appui psychosocial; VIH; conseil sur le VIH
Prevention; réduction des méfaits/risques;
changement de comportement
Below is information on what documents were reviewed for each donor and implementing country.
DFID
All information was gathered through the development tracker website. Using the documents made
available here (log frames, business case summaries, annual reports etc.) ACTION then looked into ten
high burden countries (Kenya, Malawi, Mozambique, Nigeria, South Africa, Uganda, Zambia, Zimbabwe,
Tanzania, Rwanda) in which DFID operates. Out of these ten countries, ACTION looked to see which had
active (in implementation) projects that focused on HIV and found there 16 projects in eight countries
with a focus on health.
DFID Projects Reviewed
1. Harnessing Non-State Actors for Better Health for the Poor (HANSHEP) (Kenya)
2. Kenya Health Programme (Kenya)
3. Delivering Increased Familly Planning across Rural Kenya (Kenya)
4. Support to Malawi National AIDS response (Malawi)
5. Support to BANJA La MTSOGOLO (Malawi)
6. HIV Prevention Project (Malawi)
7. Education Sector Support II (Mozambique)
8. Education Sector Support Technical Cooperation (Mozambique)
9. Social Protection Support Technical Cooperation (Mozambique)
10. Enhancing Nigeria's Response to HIV/AIDS (Nigeria)
11. Stregthening South Africa's Revitalised Response to AIDS and Health (SSARAH) (South Africa)
12. HIV/AIDS Prevention Programme (Uganda)
13. Intensifying HIV Prevention in Zambia Programme (Zambia)
14. Adolescent Girls Empowerement Programme (Zambia)
15. Maternal and Newborn Child Health Zimbabwe (Zimbabwe)
4
16. Sexual and Reproductive Health and HIV Prevention in Zimbabwe (Zimbabwe)
ACTION then went through the available documents for each of these projects and looked for verbatim
reference to the WHO 12 collaborative activities. From this, ACTION concluded that none of these
projects included reference to the 12 collaborative activities. There were one or two instances where
DFID mentions TB-HIV but not the specific collaborative activities.
World Bank
ACTION determined which World Bank projects had a theme of TB or HIV. First, a search was conducted
among all World Bank projects/operations that were listed under the health sector. Only active projects,
financed by IDA or IBRD were then selected for this review. Two separate searches were conducted
under this criteria, one for projects that included tuberculosis as a theme and one that included HIV as a
theme. Once all of the data was downloaded into an excel spreadsheet, projects that were not among
the 32 high burden TB-HIV countries were eliminated. A comparison was then made among the separate
TB project list and HIV project list in order to remove any duplicate projects, meaning that the same
project was listed under both the TB and HIV themes. This search yielded the following 16 World Bank
projects:
World Bank projects reviewed
1. Public Health Laboratory Networking Project (Burundi)
2. Health Sector Support Investment –SWAP (Cameroon)
3. East Africa Public Health Laboratory Networking Project (Kenya, Rwanda, Uganda, Tanzania)
4. Total War on HIV & AIDS – TOWA additional financing (Kenya)
5. HIV/AIDS Program Development Project II (Nigeria)
6. Health, HIV/AIDS and TB Project (Swaziland)
7. Health Systems Strengthening Project (Uganda)
8. Abidjan-Lagos Trade and Transport Facilitation Project – ALTTFP (Nigeria)
9. Second HIV/AIDS Project (Barbados)
10. National HIV/AIDS Prevention Support Project (Botswana)
11. Health Commodity Security Project (Mozambique)
12. Health Sector Support (Kenya)
13. Health Service Delivery (Mozambique)
14. Lesotho Maternal & Newborn Health PBF (Lesotho)
15. Malawi Nutrition and HIV/AIDS Project (Malawi)
16. Total War on HIV and AIDS (TOWA) Project (Kenya)
ACTION then examined the 16 active project documents for the inclusion of the WHO 12 collaborative
activities for TB-HIV integration. The most recent Project Appraisal Document (PAD) provided on the
World Bank website was reviewed, as well as all relevant indicators listed. If a PAD was not available, the
most recent Project Information Document (PID) was reviewed.
The total amount of funding allocated to TB or HIV among the 16 projects is $431.1 million, which is 35%
of the total amount allocated of $1.202 billion. In order to calculate this number, ACTION utilized
detailed report of expenses under each project, which included the percent of total budget that went to
each of the five themes included in the project. In order to get the amount of money allocated for TB or
HIV, the percent of money allocated to either of the theme of HIV or TB was multiplied against the total
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budget for the project and then totalled to reach $431.1 million. Using the same process, a total of
$351.2 million was allocated to HIV projects and $79.91 million for TB projects among the 16 active
operations. Out of the total of $431.1 million this means that 29.2% of the funding went to HIV while
only 6.6% went to TB. We excluded a total amount of $39.85 million HIV funding because this funding
was not included under the health sector.
Additionally, ACTION reviewed total World Bank financing for TB and HIV. This calculation included all
countries, not just the 32 countries with the highest TB-HIV burden. To identify World Bank financing for
TB a search was conducted among all World Bank projects/operations that were listed under the health
sector. Only active projects, financed by IDA or IBRD were then selected for this review. Two separate
searches were conducted: one that included tuberculosis as a theme, and one that included HIV as a
theme. This yielded 13 active TB projects and 49 active HIV projects. In order to get the amount of
money allocated for TB or HIV, the percent of money allocated to either of the theme of HIV or TB was
multiplied against the total budget for the project for a total of $180.8 million in TB funding and $966.4
million in HIV funding.
Global Fund
Using the Global Fund’s website, ACTION accessed grant portfolios for the 32 countries with high TB-HIV
burdens. Only active HIV and TB grants were included. This search yielded 26 TB grants and 51 HIV
grants. The following documents were reviewed for mention of the 12 collaborative activities: grant
performance reports, performance indicators, and program grant agreements. When available, grant
scorecards were reviewed as well. If a grant had no performance indicators or no grant report listed, it
was removed from the list of active projects. The total funding for the 26 TB grants was $538 million and
total funding for the 51 HIV grants was $4.9 billion. ACTION reviewed projects for specific mention of TBHIV funding, which showed TB grants dedicated $135 million to TB-HIV and HIV grants dedicated $51
million to TB-HIV.
Global Fund TB grants reviewed
1. LSO-810-G08-T : Scaling up access to quality, community-based, integrated management of
MDR/XDR-TB and HIV in Lesotho (Lesotho)
2. SWZ-T-NERCHA : Expand access to high quality DOTS; address TB/HIV co-infections and
emergency response to the challenge of MDR-TB (Swaziland)
3. ZIM-809-G12-T: Towards universal access: Improving accessibility to high quality DOTS in
Zimbabwe (Zimbabwe)
4. BOT-506-G02-T : Scaling up DOTS strategy (Botswana)
5. MLW-708-G06-T : Towards Sustainable and Equitable Tuberculosis Control (Malawi)
6. MOZ-708-G07-T : Reducing Tuberculosis Morbidity and Mortality in Mozambique by 2102,
through strengthening of the National Tuberculosis Control Program at all levels (Mozambique)
7. ZAM-711-G26-T : Zambia TB program stop TB strategic plan implementation updated 2008-2012
(Zambia)
8. UGD-T-MoFPED : No Title (Uganda)
9. NMB-T-MoHSS : No Title (Namibia)
10. TNZ-607-G09-T : Acceleration of TB and TB/HIV services in Tanzania (Tanzania)
11. GNB-913-G13-T : To contribute to the reduction of the burden of Tuberculosis in Guinea-Bissau
(Guinea-Bissau)
6
12. KEN-S11-G1-T:To steer the country towards the achievement of the TB Millennium
Development Goals in line with the Global Stop TB Strategy (Kenya)
13. KEN-S11-G12-T: To steer the country towards the achievement of the TB Millennium
Development Goals in line with the Global Stop TB Strategy (Kenya)
14. CMR-910-G09-T: Scaling up malaria control for impact in Cameroon (Cameroon)
15. CAF-911-G09-T: Strengthening of the Stop TB Program (Central African Republic)
16. RWN-T-MoH: Rwanda National Tuberculosis Control Strategic Plan 2009-2012 (Rwanda
17. CIV-S10-G10-T: Preventing multi-resistant tuberculosis by improving comprehensive care of
tuberculosis (Cote d’Ivoire)
18. CIV-S10-G11-T: Preventing multi-resistant tuberculosis by improving comprehensive care of
tuberculosis (Cote d’Ivoire)
19. NGA-T-ARFH: Further DOTS Expansion (Nigeria)
20. NGA-T-IHVN: Further DOTS expansion while addressing MDR-TB prevention and control
(Nigeria)
21. TGO-T12-G12-T: Reducing Morbidity and Mortality due to Tuberculosis in Togo in line with the
Millennium Development Goals (Togo)
22. GYA-810-G06-T : Enhancing the Implementation of the Tuberculosis Strategies Through Alliances
(Guyana)
23. TCD-810-G07-T Strengthening TB prevention means and care for patients (Chad)
24. COG-810-G02-T : Decentralization and Implementation of Prevention and Complete Care
Actions of People Living with HIV/AIDS in the Republic of the Congo (Congo)
25. SUR-910-G05-T: Doing what it takes to stop tuberculosis in Suriname - DOTS Suriname Project
(Suriname)
26. HTI-911-G08-T: Strengthening and Improvement of DOTS Strategy in Haiti (Haiti)
Global Fund HIV grants reviewed
1. LSO-809-G06-H: Stepping Up Universal Access: A Multi-Sectoral partnership Response to HIV at
the Community Level (Lesotho)
2. LSO-813-G09-H: Stepping Up Universal Access: A Multi-Sectoral Partnership Response to HIV at
the Community Level (Lesotho)
3. LSO-H-MoFDP : To prevent the spread of HIV/AIDS and mitigate the impact of HIV/AIDS among
orphans and vulnerable children in Lesotho (Lesotho)
4. SWZ-708-G05-H: Seventh Call for Proposals HIV and AIDS (Swaziland)
5. ZIM-809-G11-H : Addressing critical gaps in HIV Prevention, Treatment, Care and Support
(Zimbabwe)
6. SAF-304-G04-H : Strengthening and expanding the Western Cape HIV/AIDS prevention,
treatment and care programmes (South Africa)
7. SAF-H-NACOSA : Leverating Partnership to achieve the goals of south Africa's HIV&AIDS and STI
National Strategic Plan 2007-2011 (South Africa)
8. SAF-H-NDOH : Increasing access to Integrated Tuberculosis and HIV Services at the Primary
Health Care and Community Levels (South Africa)
9. SAF-H-RTC: Increasing Access to Integrated Tuberculosis and HIV Services at the Primary Health
Care and Community Levels (South Africa)
10. SAF-H-NRASD: Increasing Investment for Accelerated Impact of the National Strategic Plan for
HIV and TB, 2012-2016 (South Africa)
11. MLW-H-NAC: The Way Forward: Scaling up and improving the national response to HIV and AIDS
in Malawi and intensifying HIV/AIDS behavioral change communication (BCC) for all and scaling
up of HIV prevention services for young people in Malawi (Malawi)
7
12. MOZ-809-G08-S : Strengthening Health Systems and Communities through Government-Civil
society Partnerships (Mozambique)
13. MOZ-911-G10-H : Responding to the HIV epidemic in Mozambique through effective
government - civil society partnerships (Mozambique)
14. MOZ-911-G09-H: Responding to the HIV epidemic in Mozambique through effective government
- civil society partnerships (Mozambique)
15. ZAM-011-G29-H : No title (Zambia)
16. ZAM-811-G28-H : No title (Zambia)
17. ZAM-H-CHAZ : Scaling-Up Prevention and Impact Mitigation, Strengthening Health Systems, and
securing and sustaining equitable access to ART commodities and services (Zambia)
18. ZAM-H-UNDP : Securing and sustaining equitable access to ART (Zambia)
19. UGD-708-G07-H : Scaling up Prevention, Care, Treatment and Health Systems Strengthening for
HIV/AIDS (Uganda)
20. UGD-708-G13-H : Scaling up Prevention, Care, Treatment and Health Systems Strengthening for
HIV/AIDS (Uganda)
21. NMB-202-G01-H-00 : Scaling up the Fight Against HIV/AIDS in Namibia (Namibia)
22. NMB-202-G07-H: Scaling up the fight against HIV and AIDS in Namibia (Namibia)
23. TNZ-405-G06-H : Condom Procurement for the Social Marketing Sector (Tanzania)
24. TNZ-809-G12-H : Sustaining the Momentum: The March Towards Universal Access to HIV and
AIDS (Tanzania)
25. TNZ-809-G13-H: Sustaining the Momentum: The March Towards Universal Access to HIV and
AIDS Services in Tanzania (Tanzania)
26. TNZ-911-G14-S : Enhance HIV prevention services in Tanzania (Tanzania)
27. MAC-910-G02-H : Fighting HIV in the Caribbean: a Strategic Regional Approach (Multi-country
Americas)
28. GNB-708-G05-H : Malaria Program – incorrect title (Guinea-Bissau)
29. KEN-708-G10-H : Improvement of the quality of life of People Living with HIV and AIDS and
reduction of HIV (Kenya)
30. KEN-H-KRC: The road towards an HIV free society (Kenya)
31. KEN-H-MOF: No Title (Kenya)
32. CMR-011-G10-H : Universal access to PMTCT, comprehensive care for PLWHA and HIV
prevention among most at risk populations in Cameroon (Cameroon)
33. CMR-011-G11-H: No Title (Cameroon)
34. CAF-708-G05-H Extension, strengthening and decentralization of prevention and comprehensive
care and treatment of persons living with HIV/AIDS in the Central African Republic (Central
African Republic)
35. RWN-H-MoH : Scaling up access to HIV/AIDS services with focus on prevention in Rwanda
(Rwanda)
36. GAB-809-G05-H : Support to the Gabonese initiative to fight AIDS (Gabon)
37. CIV-910-G12-H : Strengthening the national response to HIV in order to scale up prevention to
comprehensive care, factoring in gender and key populations at high risk of HIV infection (Cote
d’Ivoire)
38. CIV-910-G13-H: Strengthening the national response to HIV in order to scale up prevention to
comprehensive care, factoring in gender and key population at high risk of HIV infection (Cote
d’Ivoire)
39. NGA-H-ARFH : Association for Reproductive and Family Health (ARFH) (Nigeria)
40. NGA-H-NACA: To reduce morbidity and mortality from HIV/AIDS in Nigeria (Nigeria)
8
41. NGA-H-SFHNG: Scaling-up sensitive HIV/AIDS prevention, treatment, and care and support
interventions for adults and children in Nigeria (Nigeria)
42. TGO-809-G08-H : Strengthening and expansion of prevention services and overall management
of PLWHA in the context of universal access in Togo (Togo)
43. TGO-809-G09-H: Strengthening and expansion of prevention services and overall managemen of
PLWHA in the context of universal access in Togo (Togo)
44. GYA-304-G01-H : Strengthening the National Response to HIV/AIDS in Guyana (Guyana)
45. TCD-810-G05-H : Strengthening of the national response to HIV/AIDS for transition to the scale
of prevention structures and global treatment (Chad)
46. COG-911-G06-H : Strengthening of HIV prevention for young people not attending school who
are at highest risk and of the care for children living with HIV in the Republic of the Congo
(Congo)
47. COG-911-G05-H : Scaling up of insecticide-treated nets and access to artemisin therapeutic
combinations in Congo (Congo)
48. JAM-708-G02-H: A Proposal to Scale Up HIV/AIDS Treatment, Prevention, and Policy Efforts in
Jamaica (Jamaica)
49. SUR-506-G03-H: Reducing the spread and impact of HIV/AIDS in Suriname through expansion of
prevention and support programs (Suriname)
50. BEL-910-G02-H: Accelerating the Pace: Reaching Marginalized and Vulnerable Populations with
Critical Services (Beliza)
51. HTI-102-G09-H : Haiti’s Response to HIV/AIDS (Haiti)
PEPFAR
Country operation plans from fiscal year 2013 were reviewed for the inclusion of the WHO 12
collaborative activities based off the search terms listed in table 1. A total of 19 plans among the 32
high burden countries were looked at. We also conducted a review of 17 operational plans from fiscal
year 2008 in order to compare the inclusion of the 12 I’s in available operation plans from 2008 to the
plans in 2013 which follow the WHO’s updated policy. ACTION also assessed the budget allocations
among country operational plans from 2013, determining both the total budget, which was $3.2 billion,
as well as the total of $125 million for the TB-HIV budget, equaling only 4.3% of the total budget.
PEPFAR Country Operational Plans Reviewed
1. Botswana
2. Cameroon
3. Caribbean
4. Cote d’Ivoire
5. Guyana
6. Haiti
7. Kenya
8. Lesotho
9. Malawi
10. Mozambique
11. Namibia
12. Nigeria
13. Rwanda
9
14.
15.
16.
17.
18.
19.
South Africa
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe
National Strategic Plans
ACTION searched for the most recent National Strategic Plan for HIV and National Strategic Plan for TB
among the 32 high burden countries. The following websites were used in the search:
http://www.nationalplanningcycles.org/ and http://www.aidstarone.com/focus_areas/prevention/resources/national_strategic_plans. If an NSP was unavailable on the
website, ACTION conducted a google search and visited the country’s Ministry of Health website to
determine if such plan existed. The search yielded 28 National Strategic Plans for HIV (21 in English, 7 in
French) and 12 National Strategic Plans for TB (11 in English, 1 in French). South Africa’s National
Strategic Plan for HIV, TB, and STIs was reviewed in a separate analysis that showed it included all 12 of
the WHO recommended TB-HIV collaborative activities.
HIV national strategic plans reviewed
1. Antigua and Barbuda; Antigua and Barbuda National Strategic Plan for HIV/AIDS
2. Barbados; National Strategic Plan for the Prevention and Control of HIV
3. Belize; Strategic Plan for a Multi-Sectoral National Response to HIV/AIDS in Belize
4. Botswana; The Second Botswana National Strategic Framework for HIV and AIDS 2010-2016
5. Caribbean; Caribbean National Strategic Plan for HIV/AIDS 2008-2012
6. Central African Republic; Cadre Strategique National de Lutte contre le VIH/SIDA, 2006-2010
7. Chad; Cadre Strategique National de lutte contre le VIH/SIDA et les IST 2007-2011
8. Gabon; Plan D’Action Sectorie de Lutte Contre les IST et let VIH/SIDA
9. Guyana; Guyana National HIV/AIDS Strategy 2007-2011
10. Haiti; Plan Strategique National Multisectorial 2008-2012
11. Jamaica; Jamaica National Strategic Plan for HIV/AIDS 2007-2012
12. Kenya; Kenya National AIDS Strategic Plan 2009/20010-2012/2013
13. Lesotho; Lesotho National HIV and AIDS Strategic Plan 2006-2011
14. Malawi; National HIV Prevention Strategy 2009-2013
15. Mozambique; Mozambique National Strategic Plan for the Combat Against HIV/AIDS
Operationalisation 2005-2009
16. Namibia; National Strategic Framework for HIV and AIDS Response in Namibia 2010-2016
17. Nigeria; National HIV/AIDS Strategic Plan 2010-2015
18. Rwanda; Rwanda National Strategic Plan on HIV and AIDS 2009-2012
19. Saint Vincent and the Grenadines; St. Vincent and the Grenadines HIV and AIDS National
Strategic Plan 2010-2014
20. South Africa; HIV & AIDS and STI National Strategic Plan 2007-2011 (Part 1) and 2007-2011
(Part 2)
21. Suriname; Suriname National Strategic Plan for HIV/AIDS 2009-2013
22. Swaziland; National Strategic Framework for HIV and AIDS 2009-2014
23. Tanzania; National Multi-Sectorial Strategic Framework on HIV and AIDS 2008-2012
24. Trinidad and Tobago; Trinidad and Tobago National Strategic Plan for HIV/AIDS 2004-2008
10
25. Togo; Togo Plan Strategique National de Lutte Contre le SIDA et les IST 2007-2010
26. Uganda; Moving Toward Universal Access: National HIV & AIDS Strategic Plan 2007/20082011/2012
27. Zambia; Zambia National AIDS Strategic Framework 2011-2015
28. Zimbabwe; Zimbabwe National HIV and AIDS Strategic Plan 2006-2010
TB National Strategic Plans reviewed
1. Botswana; National Strategic Plan for HIV and AIDS, STIs and TB, 2012-2016
2. Cameroon; National Tuberculosis Strategic Plan 2010-2014
3. Kenya; Division of Leprosy, TB and Lunch Disease Strategic Plan2011-2015
4. Lesotho; The National Strategic Plan on Tubercuolosis for Lesotho 2005-2009
5. Malawi; National Strategic Plan for Tuberculosis Control 2012-2016
6. Namibia; National TB and Leprosy Programme TA Plan
7. Nigeria; The National Strategic Plan for Tuberculosis and Leprosy Control 2010-2015
8. South Africa; National Strategic Plan for HIV, STIs and TB 2012-2016
9. Tanzania; The United Republic of Tanzania Ministry of Health and Social Welfare National TB &
Leprosy Strategic Plan 2009/2010-2015/2016
10. Uganda; Uganda National Tuberculosis and Leprosy Control Programme Strategic Plan
2012/2013-2014/2015
11. Zambia; National TB and Leprosy Programme
12. Zimbabwe; National Strategic Plan for HIV, STIs and TB 2012-2016
In-depth interviews
To complement the quantitative analysis, ACTION carried out 35 in-depth interviews with stakeholders
in three countries with high TB-HIV burdens: Kenya (Nairobi and Kisumu), Zambia (Lusaka), and South
Africa (Cape Town and Pretoria). The locations were chosen based on TB-HIV co-infection rates and
presence of ACTION partners or allies. Interviewees included government officials, donor
representatives, civil society, care providers, and people affected by TB-HIV co-infection.
South Africa
Zambia
Kenya
63% co-infection rate
59% co-infection rate
39% co-infection rate
13 interviews (Cape Town and
Pretoria)
11 interviews (Lusaka)
11 interviews (Nairobi and
Kisumu)
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The interviews were semi-structured, so no two interviews were the same. All interviews were
conducted by Mandy Slutsker, Bruce Warwick, or Evelyn Kibuchi. Informed consent was received for
each individual interviewed. All interviewees agreed to be recorded. Interviewees were aware that they
could stop the interview at any time. De-identification and confidentiality were ensured by using
identification numbers. Interviews were later transcribed by hand by Rachel Janik, Mandy Slutsker, and
Bruce Warwick.
The analysis followed these steps: (1) reading each of the in-depth interviews to get an overall idea of
concepts and themes related to TB-HIV integration, (2) identifying codes that represented larger themes
in TB-HIV policies and practice, and (3) condensing and summarizing the content of the coded groups. All
transcripts were manually coded within a defined coding frame which included both deductive and
inductive codes. Deductive codes were developed on the basis of an extensive literature review of TBHIV integration policies and practice. Inductive codes were developed upon thorough examination of
the transcripts as new themes and categories emerged. Codes were continuously revised and refined
throughout the analysis process, reducing overlap and redundancy.
The following interview guides were used to guide the process.
Care provider interview guide
Can you tell us who you are and what your role is in the organization? Where do you receive your funding?
Probe: how long have you been involved in patient care?
Probe: what made you interested in becoming a care provider?
How are TB and HIV programs managed in your city/country? Are they completely separate entities?
Probe: who determines policies on TB and HIV?
Probe: How has this changed over the last 10 years?
When policy changes are made, how are you made aware of the changes?
Probe: For example, if the Ministry of Health decides that all patients with a CD4 count below 500 can access
ARVs, how does that go from policy to actual implementation?
Is integrating TB and HIV services important?
Probe: On a scale of 1 – 10, with 10 being the most important, how would you rank the importance of
integration?
What are you doing to ensure TB patients co-infected with HIV receive ARVs?
Do you screen all HIV positive patients for TB?
Do you test all TB patients for HIV?
Think about the person you most recently diagnosed with TB who was HIV positive. How was this case
managed?
What unfunded gaps do you see in TB/HIV integration?
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What is your familiarity with the 12 WHO-recommended collaborative TB/HIV activities?
(note: if they are unfamiliar, show them a print out of the 12 collaborative activities)
Probe: Can you give specific examples of activities or programs where TB and HIV are addressed together?
Probe: have these programs been successful?
Probe: what challenges have you had addressing TB and HIV together?
Probe: why do you have these challenges? Who might be responsible for addressing them?
Probe: what are you doing to monitor and evaluate these programs?
Civil society interview guide
Can you tell us who you are and what your role is in the organization?
How are TB and HIV programs managed in your city/country? Are they completely separate entities?
Probe: Who determines policies on HIV and TB?
Probe: How has this changed over the last 10 years?
What is your familiarity with the 12 WHO-recommended collaborative TB/HIV activities? How is your
organization involved in the implementation of these activities?
(note: if they are unfamiliar, show them a print out of the 12 collaborative activities)
Is integrating TB and HIV services important?
Probe: On a scale of 1 – 10, with 10 being the most important, how would you rank the importance of
integration?
Imagine for a moment that you go to a government health clinic and receive a positive HIV test and have had
a consistent cough for four weeks. Describe how the ideal medical clinic would address this. Walk me through
what should happen next.
Probe: is this what actually happens?
Have you been consulted by the government or ministry of health on the issue of TB/HIV integration?
Probe: Can you describe these interactions?
Have you been consulted by donor agencies (GFATM, PEPFAR, DFID) on the issue of TB/HIV integration?
Probe: Can you describe these interactions?
What unfunded gaps do you see in TB/HIV integration?
Donor representative interview guide
Can you tell us who you are and what your role is in the organization?
How are TB and HIV programs managed by your donor agency? Are they completely separate entities?
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Probe: Who determines policies on HIV and TB?
Probe: How has this changed over the last 10 years?
Is integrating TB and HIV services important?
Probe: On a scale of 1 – 10, with 10 being the most important, how would you rank the importance of
integration?
What is your familiarity with the 12 WHO-recommended collaborative TB/HIV activities? What has your
donor agency been doing to support these activities?
(note: if they are unfamiliar, show them a print out of the 12 collaborative activities)
Probe: Can you give specific examples of activities or programs funded by your agency where TB and HIV
are addressed together?
Probe: what are you doing to monitor and evaluate these programs?
Probe: have these programs been successful?
Probe: what challenges have you had addressing TB and HIV together?
Probe: why do you have these challenges? Who might be responsible for addressing them?
Imagine for a moment that you go to a government health clinic and receive a positive HIV test and have
had a consistent cough for four weeks. Describe how the ideal medical clinic would address this. Walk
me through what should happen next.
What unfunded gaps do you see in TB/HIV integration?
How are you engaging civil society on TB and HIV integration?
Probe: which organizations have you been working with? Are they primarily HIV/AIDS organizations or
TB organizations?
Government official interview guide
Can you tell us who you are and what your role is in the organization?
How are TB and HIV programs addressed by the Ministry / government? Are they completely separate
entities? Who determines policies on HIV and TB?
Probe: How has this changed over the last 10 years?
Is integrating TB and HIV services important?
Probe: On a scale of 1 – 10, with 10 being the most important, how would you rank the importance of
integration?
What is your familiarity with the 12 WHO-recommended collaborative TB/HIV activities?
(note: if they are unfamiliar, show them a print out of the 12 collaborative activities)
Probe: Can you give specific examples of activities or programs where TB and HIV are addressed
together?
Probe: have these programs been successful?
Probe: what challenges have you had addressing TB and HIV together?
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Probe: why do you have these challenges? Who might be responsible for addressing them?
Probe: what are you doing to monitor and evaluate these programs?
Imagine for a moment that you go to a government health clinic and receive a positive HIV test and have
had a consistent cough for four weeks. Describe how the ideal medical clinic would address this. Walk
me through what should happen next.
What unfunded gaps do you see in TB/HIV integration?
How are you or your government working with donors such as the Global Fund and DFID/PEPFAR to
implement TB/HIV integration?
Probe: Do they support your national strategy on TB/HIV or do they fund separate programs?
Probe: In December, the Global Fund Board decided to ask for joint concept notes on TB and HIV. What
are your thoughts on this decision?
Are you engaging civil society to better integrate TB and HIV programs? Please describe how you have
been engaging civil society.
Patient/client interview guide
Can you tell us about yourself? Where do you live? What do you do as an occupation?
Can you describe for me what drove you to seek medical care?
Probe: where did you seek care? Why did you choose that location/place?
Probe: did you wait at all to seek care? What caused you to wait?
Note: was the clinic public or private?
Explain for me what happened when you received your test results
Probe: who met with you? What did they say?
How were you treated by medical providers?
If the interviewee identifies as HIV-positive ask the following:
Describe what health care providers told you about tuberculosis.
Probe: were you given any TB preventative care? (IPT)
If the interviewee received a positive TB diagnosis and has unknown HIV status ask the following:
Describe what health care providers told you about HIV.
Probe: were you given any information on HIV prevention?
If you could change anything about your experience, what would it be?
More detailed data is available upon request. Contact Mandy, ACTION Senior Project Associate for TB, at
[email protected].
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