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Background: More people living with HIV (PLHIV) in resource-limited settings are virally suppressed and living longer, mainly due to an increased access to effective antiretroviral therapy (ART). With the expansion of ART programmes, the World Health Organisation recommended differentiated service delivery (DSD) as an alternative less resource-demanding way of accessing HIV services. While maintaining quality of care and continued adherence among patients are health system’s priorities, monitoring patient’s quality of life is key to ensure sustainability and uptake of services. However, health-related quality of life (HRQoL) is understudied in sub-Saharan Africa (SSA). We aimed to assess HRQoL among stable ART clients accessing ART care in adherence clubs implemented in Tanzania. Methods: We conducted a cross-sectional survey from May to August 2019 among stable ART clients randomly sampled among those accessing clinics and clubs daily in two sites, a rural and peri-urban setting in the Shinyanga region. HRQoL data was collected, after obtaining informed consent, using the interviewer-administered Functional Assessment of HIV infection (FAHI), a validated HIV-specific HRQoL instrument. We also collected on socio-demographic, HIV care and service accessibility factors. Descriptive analysis, modified Poisson regression with robust variance and a stepwise multiple linear regression were performed to analyse HRQoL and its determinants.Results: A total of 629 participants were enrolled, of which 40% were DSD patients. DSD and clinic participants showed similar HRQoL scores [mean (SD), p value]; FAHI total [152.2 (22.2) vs 153.8 (20.6), p 0.687]. Accessibility factors, e.g. less time spent during and less frequent DSD meetings, contributed to emotional wellbeing among DSD participants compared to those in clinic (53.4% vs 18.5%,p=80% of achievable) HRQoL scoring was independently associated with (relative risk [95% confidence interval], p value) being male (1.18[1.06-1.31], p 0.002); being married (1.22 [1.01-1.45, p 0.043); and living in an urban setting (1.28 [1.09-1.49], p 0.001). Conclusions: DSD does not appear to compromise HRQoL and, encouragingly, it could contribute to an improvement in emotional wellbeing among patients. While DSD shows promise in improving acceptability among patients and, therefore, sustainability of such services, our research highlights future research avenues to identify supporting interventions to improve other HRQoL domains among PLHIV.

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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.

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 care giving 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.

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.

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.