From 22-27 July, the XIX International AIDS Conference is being held in Washington, DC, with an expected 20,000 delegates from nearly 200 countries in attendance. Convened by the International AIDS Society, this six-day meeting will bring together leaders in the fight against HIV to “translate recent momentous scientific advances into action that will address means to end the epidemic, within the current context of significant global economic challenges.” Daily highlights and a live webcast are available at the conference website.
Since October 2010, MCHIP has been working closely with the Kenyan ministries of health to improve the quality and uptake of prevention of mother-to-child transmission of HIV (PMTCT) services in a demonstration project in the Bondo district of Nyanza province in Kenya. And by taking the unique step of adapting the Reaching Every District (RED) approach – originally developed to improve immunization programs – to identify pregnant women and link them to high-quality PMTCT services, MCHIP is finding success.
In partnership with the Bondo Health Teams, MCHIP has been using an adaptation of the RED approach to identify communities with large numbers of pregnant women, mobilize community health workers (CHWs) to bring these women and their infants into care, and actively monitor and take action to increase PMTCT and maternal, newborn and child health (MNCH) service coverage. RED was originally developed by the World Health Organization, the United Nations Children’s Fund, and other partners in the GAVI Alliance to improve immunization systems in areas with low coverage. The approach has five components: reaching the target population; supportive supervision; on-site training; community links with service delivery; monitoring and use of data for action; better planning; and management of human and financial resources.1
MCHIP’s team in Kenya adapted RED’s reference materials to address their goal of increased PMTCT uptake:
The first antenatal care (ANC) visit was used to determine access to health services, while the fourth ANC visit determined utilization of health services.
With a total population of 167,765, pregnant women in Bondo district were estimated at 6,375.
Analysis of six months of data showed that Bondo district had good access (>95%), but poor utilization (> 65% drop out rates).
Villages with high numbers of unreached pregnant women were mapped.
Health workers were trained on the RED approach and on determining: target population by the most appropriate strategy (fixed or outreach); whether the problems of under-served populations were access-related or quality-related, and to adopt necessary action accordingly; and the number of sessions per month for each strategy that was applicable. This information was consolidated into a health facility RED micro-plan.
MCHIP sponsored integrated community outreaches to the identified underserved and hard to reach areas. Health workers liaised with the community to identify community resources (such as churches or schools) that could be used for the outreach. Village elders and administration officers were brought on board to advocate for MNCH services and social mobilization.
To increase community links with service delivery, MCHIP supported community dialogue days. At these meetings, health workers meet with community representatives to address health matters in the community. Using the dialogue model, the reasons for the low utilization of MNCH and PMTCT services are discussed, and strategies agreed upon jointly.
A comprehensive package of care for PMTCT and MNCH was then defined and summarized in a job aid for service providers. This matrix would act as a job aid to remind health providers of the all services to be provided at each stage in the PMTCT continuum of care.
In addition, the Division of Community Health Services released a new community strategy in 2010, and MCHIP helped the Bondo health teams to align their community units to this new community strategy. Where previously one CHW served approximately 20 households, the new strategy calls for one CHW to serve about 100 households. Bondo district, with support from MCHIP and other partners, now has 100% coverage of community units.
MCHIP has also been using the Standards-Based Management and Recognition approach to improve the quality of PMTCT services. These strategies have resulted in:
35% increase in the number of women completing four focused ANC visits;
25% increase in the number of women accessing skilled birth attendance;
25% increase in health facility deliveries by HIV positive mothers; and
43% increase in HIV exposed infants getting a polymerase chain reaction test for HIV antigen detection at 6 weeks.
Evidently, the RED approach has been successful at empowering district managers and operational level health workers with the skills necessary to plan and manage their own MNCH and PMTCT services, develop skills in using their own data to identify and manage problems, and create strong linkages/ownership with the community by improving community participation in MNCH and PMTCT services. Owing to the initial success of this demonstration project, this strategy will be used in two new districts, Igembe North and Igembe South.
This innovative programmatic approach by MCHIP embodies the very core of the global communities’ commitment to bring MTCT to zero by engaging community health workers as well as community members in the fight against HIV. The community resources currently available in many places like Bondo could have significantly greater impact when combined with rational public health strategies that focus on stewardship of these resources to achieve an HIV free generation.
Dr. Lynn Kanyuuru
PMTCT Technical Advisor, MCHIP Kenya
--- 1 Global Immunization Vision and Strategy 2006-2015. Geneva: WHO and UNICEF; 2005.