Moving Services to the Community: Shifting the PMTCT/MCH Integration

Debate

Laura A. Guay MDElizabeth Glaser Pediatric AIDS Foundation

George Washington University School of Public Health and Health Services

Outline Lessons learned from MCH

community activities

Current focus on the community

Models of HIV community activities

Considerations for MCH-HIV integration

Research needs

MCH = package of integrated services

Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115(2 Suppl):519-617.

Lessons learned from MCH community activities

Much of literature comes from India/Asia, limited Africa

The importance of addressing maternal and neonatal survival at the community level is well accepted

Many MCH community activities target the same outcomes as key PMTCT outcomes

Community based activities include similar models of mobilization, support, and service delivery that are being utilized in PMTCT, with evidence of effectiveness that can inform HIV field

There are interventions with a demonstrated effect on decreasing infant mortality, highest when “curative” services are included (ie home based neonatal care)

Many research gaps still remain

Focus on the community

• Strengthening the role of Frontline community health workers – Community health care programmes should be

integrated into a nationwide community health system

• Initiation of ART at peripheral health facilities with maintenance at the community level between regular clinical visits

• Trained and supervised community health workers can dispense ART between regular clinical visits.

Models of Community Engagement

Community Sensitization/Education

Community Mobilization HIV testing campaigns vs family health days

Community Health Worker Home visits Specialized vs comprehensive

Community Support Groups HIV Status specific or not Health specific or broader cooperatives (ie

income generating)

Models of Community Engagement

Facility Based Community Outreach Health Care Workers Community Health Workers Peer Supporters

Community Self Help Groups

Home based care, including ART

Mobile clinics for testing and service delivery

Considerations in MCH- HIV integration in the community

Significant overlap in MCH community activities and desired outcomes

Stigma plays a major role in HIV unlike MCH

Fear of disclosure with HIV-specific community activities must be balanced with need for HIV-specific service delivery

What breadth and scope of services can a CHW manage? Complexity of HIV care and treatment

Optimal mechanism for facility – community linkage; integration of overall health system plays a role Responsibility for mentoring and supervision

Monitoring and evaluation of community activities

Research Needs Determining the most appropriate cadres of CHW to

effectively deliver needed services in different settings

Determining the best models of training and supervising CHW to maximize benefit

Determining long-term, hard outcome data for various models of community engagement (ie, maternal and infant survival)

Cost effectiveness of community interventions

Feasibility of implementing community based interventions at scale

Comparisons of integrated and non-integrated activities on both HIV and non-HIV outcomes