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
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