Clinical and epidemiological assessment of a decentralized HIV test and treat care program in western Tanzania

This thesis examines how Tanzania can strengthen the HIV care cascade in rural, high-burden settings by combining improved HIV testing strategies with community-based differentiated service delivery.
Using evidence from the Test & Treat project in Shinyanga and Simiyu regions, the thesis first compares provider-initiated versus client-initiated testing in health facilities and shows that while provider-initiated testing is essential for broad coverage, yield varies substantially by service, with particularly high positivity in TB and inpatient departments. It then assesses the feasibility of Community Health Worker (CHW)-managed adherence clubs and documents that CHW-led, mostly community-based clubs are operationally feasible, acceptable, and especially beneficial for clients living far from clinics, though they require clear eligibility procedures, adequate supervision, streamlined data systems, and integration of facility-only services. In a prospective cohort of stable ART clients, CHW-led club care achieves consistently higher adherence than standard facility-based care and maintains comparable clinical outcomes without increasing loss to follow-up. Finally, population-level routine data (2012–2021) show that Universal Test & Treat accelerated ART initiation dramatically after adoption in 2017, with rapid scale-up of same-year and same-day treatment starts and a shift toward earlier presentation.
Overall, the findings support integrating CHW-led differentiated care into national policy alongside targeted testing, while strengthening health-system capacity and financing to sustain effective models.