In northwest Tanzania, where AIDS has been present for 25 years, AIDS-related illness is a trigger through which community members discuss personal experiences of loss and assess social relationships. The terminal phase of AIDS demands intimate social relations between patients and caretakers. In this final phase of illness, caretakers are scrutinised for their behaviour towards the patient. In the moral world in which caregiving takes place, the act of concealing is considered an intrinsic part of proper care. Current debates on morality, stigma and secrecy inform my argument that acts of concealment around dying are not so much related to the exclusion and ostracism of patients but to inclusion and compassionate care.

As part of the chronic disease paradigm now widely used for HIV in sub-Saharan Africa, antiretroviral treatment programs emphasize self-care. In the informal settlements of Mombasa, Kenya, the management of stress-associated with economic precariousness-plays a significant role in self-care practices and ideologies. Based on ethnographic fieldwork, we examine how local narratives of stress and self-care intertwine with social responsibilities of older HIV-positive people. For older Mombassans, living with 'chronic' HIV means living with an unpredictable body, which affects how they are able to care for their kin. The physical reality of living with HIV thus shapes relational networks, making self-care a social practice. While, for some self-care entails managing the body so that its needs are hidden from loved ones, a kind of 'protective secrecy,' others enlist the support of their children and grandchildren in managing their body, and in that process subtly redefine generational expectations and responsibilities.

Background Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15–30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited. Materials and methods We conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth). Results We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load <50 copies/ml was higher in clinics (100% vs 94.4%). Qualitative results indicated that quality care was perceived similarly among clients in clinics and clubs but for different reasons. Clinics were generally perceived as places with expertise and clubs as efficient places with peer support and empathy. In describing QoC, HCW emphasized structure-related attributes while clients focused on processes. Outcomes-related themes such as improved client health status, self-worth, and confidentiality were similarly perceived across clients and HCW. Conclusion We found better structure and process of care in clubs than clinics with comparable outcomes. While QoC was perceived similarly in clinics and clubs, its meaning was understood differently between clients. DSD catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club. Our findings highlight that both clinic and DSD care are required as many elements of QoC were individually perceived.

While antiretroviral medicines have reduced AIDS-related deaths in sub-Saharan Africa, many people still lose multiple family members and struggle with the social and economic consequences of those deaths. This paper examines how older Tanzanians frame feelings of loss caused by the untimely death of young adults and how they advise other bereaved about how to manage loss. A local concept oyegumisilize--meaning 'to move on and push grief and worries aside'--is employed in offering bereaved persons advice about how to deal with feelings of loss. Older people try hard to manage memories of loss whilst simultaneously struggling to fulfil the social obligations around mourning that contribute to their ongoing bereavement. Oyegumisilize can be seen as a counselling practice that helps those who have lost loved ones to move on with life and feel normal. It is argued that this form of counselling is a form of therapeutic speech, where the emphasis is not on 'talking through' emotions, but on speech that is aimed at 'toughening up' the bereaved person. The findings presented here are based upon ethnographic research undertaken in Muleba District in Kagera Region, Tanzania, between 2003 and 2004, and follow-up research conducted in 2005, 2008 and 2012.

No abstract

No abstract

Background With antiretroviral therapy, more people living with HIV (PLHIV) in resource-limited settings are virally suppressed and living longer. WHO recommends differentiated service delivery (DSD) as an alternative, less resource-demanding way of expanding HIV services access. Monitoring client’s health-related quality of life (HRQoL) is necessary to understand patients’ perceptions of treatment and services but is understudied in sub-Saharan Africa. We assessed HRQoL among ART clients in Tanzania accessing two service models. Methods Cross-sectional survey from May–August 2019 among stable ART clients randomly sampled from clinics and clubs in the Shinyanga region providing DSD and clinic-based care. HRQoL data were collected using a validated HIV-specific instrument—Functional Assessment of HIV infection (FAHI), in addition to socio-demographic, HIV care, and service accessibility data. Descriptive analysis of HRQoL, logistic regression and a stepwise multiple linear regression were performed to examine HRQoL determinants. Results 629 participants were enrolled, of which 40% accessed DSD. Similar HRQoL scores [mean (SD), p-value]; FAHI total [152.2 (22.2) vs 153.8 (20.6), p 0.687] were observed among DSD and clinic-based care participants. Accessibility factors contributed more to emotional wellbeing among DSD participants compared to the clinic-based care participants (53.4% vs 18.5%, p =  < 0.001). Satisfactory (> 80% of maximum score) HRQoL scoring was associated with (OR [95% CI], p-value) being male (2.59 [1.36–4.92], p 0.004) among clinic participants and with urban residence (4.72 [1.70–13.1], p 0.001) among DSD participants. Conclusions Similar HRQoL was observed in DSD and clinic-based care. Our research highlights focus areas to identify supporting interventions, ultimately optimizing HRQoL among PLHIV.

In the Netherlands the recent shift to a 'participation society' has led to a reconfiguration of health care arrangements for long-term care. The new long-term care act, scheduled to commence January 2015, forms the political realization of the participation society: people are expected to decrease their dependency on state provisions and instead become self-sufficient or dependent on family and community solidarity. In this Think Piece we argue that the implicit references of policy makers to pre-welfare state community solidarity and self-sufficiency do not adequately consider the historical and social embeddedness of care. Referring to Rose's concept of 'politics of conduct' we argue that in framing care as a moral obligation, the current politics of conduct may obscure the physical and psychological heaviness of intimate care between family members, the diversity of care relations, and their sociohistorical embeddedness. The participation project In recent years health care arrangements in the Netherlands have changed rapidly. The combination of rising care costs, an aging population, and the 2008 global economic crisis has led to a series of austerity measures aimed at cost containment and reduction in recent years. These austerity measures go hand in hand with a more ideological project: the gradual shift from a caring state to a 'participation society' 1 based on the claim that the welfare state contributed to a loss of social solidarity and individual responsibility.