Open Access Research article

Monitoring prevention or emergence of HIV drug resistance: results of a population-based foundational survey of early warning indicators in mainland Tanzania

James M Juma1*, Jenny K Tiberio2, Mathias I Abuya14, Bonita K Kilama1, Geoffrey R Somi1, Veryeh Sambu1, Richard Banda3, Boniphace S Jullu5 and Angela A Ramadhani1

Author Affiliations

1 Ministry of Health and Social Welfare, The National AIDS Control Programme (NACP), P.O. Box 11857, Dar es Salaam, Tanzania

2 University of California, San Francisco, Global Health Sciences, 50 Beale Street, Suite 1200, San Francisco, CA 94105-1823, USA

3 World Health Organization, Tanzania Country Office, P.O. Box 9292, Dar es Salaam, Tanzania

4 Afya Bora Consortium Global Health Leadership Fellowship Program (field attached fellow), University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA 98104-2499, USA

5 St. Francis University College of Health and Allied Sciences, P.O. Box 175, Ifakara Morogoro, Tanzania

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BMC Infectious Diseases 2014, 14:196  doi:10.1186/1471-2334-14-196

Published: 11 April 2014



In Tanzania, routine individual-level testing for HIV drug resistance (HIVDR) using laboratory genotyping and phenotyping is not feasible due to resource constraints. To monitor the prevention or emergence of HIVDR at a population level, WHO developed generic strategies to be adapted by countries, which include a set of early warning indicators (EWIs).


To establish a baseline of EWIs, we conducted a retrospective longitudinal survey of 35 purposively sampled care and treatment clinics in 17 regions of mainland Tanzania. We extracted data relevant for four EWIs (ART prescribing practices, patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months) from the patient monitoring system on patients who initiated ART at each respective facility in 2010. We uploaded patient information into WHO HIVResNet excel-based tool to compute national and facility averages of the EWIs and tested for associations between various programmatic factors and EWI performance using Fisher’s Exact Test.


All sampled facilities met the WHO EWI target (100%) for ART prescribing practices. However, the national averages for patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months fell short, at 26%, 54% and 38%, respectively, compared to the WHO targets ≤ 20%, ≥ 70%, and ≥ 80%. Clinics with fewer patients lost to follow-up 12 months after ART initiation and more patients retained on first-line-ART at 12 months were more likely to have their patients spend the longest time in the facility (including wait-time and time with providers), (p = 0.011 and 0.007, respectively).


Tanzania performed very well in EWI 1a, ART prescribing practices. However, its performance in other three EWIs was far below the WHO targets. This study provides a baseline for future monitoring of EWIs in Tanzania and highlights areas for improvement in the management of ART patients in order not only to prevent emergence of HIVDR due to programmatic factors, but also to improve the quality of life for ART patients.

Tanzania; HIV and AIDS; Care and treatment; Antiretroviral therapy (ART); Prevention; Emergence; Monitoring; HIV drug resistance (HIVDR); Early warning indicators