Community Based Approaches:

A review of intervention models and evidence of their

effectiveness for preventing maternal-to-child transmission

of HIV

Joanna Busza17 July 2011

Thematic Synthesis of the Evidence on:

Increased uptake of HIV care and treatment services among pregnant women and vertically-infected children;

Improved retention of individuals in prevention for vertical transmission, care and treatment programs;

Enhanced adherence of pregnant and lactating women, their partners and children to ARV prophylaxis and/or ART and/or other care regimens;

Strengthened psychosocial well being of pregnant and lactating women and children enrolled in care and treatment programs

Methods Identification of existing systematic

reviews

Review of data on barriers to PMTCT

Development of conceptual framework

Literature Searches

Assessment of research quality based on study designs

Analysis of available data on community based intervention approaches

HIV Treatment Cascade

Awareness Testing Diagnosis Treatment initiation

Adherence & Follow-

Up

Clinical & Psychosoci

al outcomes

Perceived or experienced stigma

Perception of Risk

Accurate local

understanding

Opportunities to test

Partner communicati

on & approval

Transport, time & costs

Motivation vs. fear of results

Family support & Disclosure

Male involvement

Delivery in a clinic

Decision making power

Fear of abandonment &

violence

Self-efficacy

Perception of service

qualityDepression

Social capital and networks

Ill health

Socio-cultural Environment

Community Context

Peer & Family Influences

Individual

Legal and Policy

Structures

Self efficacy Motivation

Decision makingRisk Perception

DepressionDisease progression

Health Beliefs

GenderNorms

Religion

Social Welfare &Safety Nets

ARV Supply

Distance to Services

StigmaQuality of

Care

PartnerInvolvement

Communication& Disclosure

Support

SocialNetworks

Access to Resources

HealthPractices

Health Systems& Infrastructure

SOCIAL ECOLOGICAL FRAMEWORK

Partners, Peers & Family: Community based & home testing

• Increases opportunity• Introduces perception of risk• Engages family as a unit

Increasing male involvement• Targets communication, disclosure & decision-

making• Introduces perception of risk• Couple counselling, ANC participation and

breastfeeding advice Evidence strongly supports community testing,

although implications less clear for identifying pregnant women

“Male involvement” increases PMTCT retention but poorly defined and not always seen as positive by women

Community Context (1): Formalised Links

• Improves facility “friendliness” and support• Relies on peer volunteers or hired liaison staff• SMS message reminders

Home Based Care• Targets access to resources and food

insecurity• Logistical & adherence support• Efforts to challenge stigma and reduce

isolation Links improve relations, but no evidence that they

address wide range of barriers faced Rigorous research demonstrates that HBC improves

adherence & follow-up, although sustainability an issue

Community Context (2): Community Health Workers

• Work to change health beliefs and practices• Many different models have been evaluated• Applied to a wide range of health outcomes

Traditional Birth Attendants• Birth planning, attendance & referral• Nevirapine provision• No outcome evaluations for PMTCT

Long legacy of success with CHW but process factors important given heterogeneity of implementation

Feasibility studies & process evaluations suggest TBA could be useful in settings with low facility deliveries

Socio-cultural environment (1): Community Mobilisation

• Complex interventions – multiple components• Engage traditional leaders• Participatory, based on theories of

empowerment and social action• Drama events, outreach, peer approaches,

media Support Groups

• HIV+ support – target psychosocial outcomes• Evidence drawn from maternal & neonatal

health• Influence norms, supportive environment &

behaviour Cash Transfers

• Incentive for behaviour change• Provide a basic social safety net; address

inequity

Socio-cultural environment (2):

Very difficult to evaluate community mobilisation, especially to differentiate relative effectiveness of components

Support groups have been rigorously evaluated and show promise for PMTCT given similar determinants of health-seeking and programme retention

Cash transfers successful in Latin America in increasing service use; transfer to poorer settings with weaker health systems unclear

Remaining Gaps: Greater emphasis on process evaluation to

identify how activities lead to intended outcomes

Ways to create demand for services Understanding complementary and

reinforcing relationships between intervention activities to create optimal “package” for a given context

Adapting strategies from Asia and Latin America for African settings

Measuring psychosocial outcomes through standardised and comparable measures

Ways Forward: Moving beyond research on “proof of

concept” for community based approaches to learning from practice

Contextualisation – applying the social ecological framework to identify barriers and design activities for each programme settings

New approaches to scaling up and replication – transfer of process instead of content

Long term commitment – resources and efforts need to sustain community motivation; interim measures will change faster than outcomes

Thank you!

Questions and comments?