Author: Malcom, A.; Sunkutu, K.; Sinyiza, E.; Mutungwa, C.; Lendon, S.
This project, The Prevention and Control of HIV/AIDS and STDs in Women Through the Integration of STD/HIV/AIDS Services into Maternal Child Health/Family Planning Facilities (MCH/FP) in 5 Urban Districts in Zambia, was managed by UNICEF Zambia and funded through the Australian government and UNICEF Australia. The project commenced in June 1998 and is due for completion in September 2001. Its components are:
-Training of health workers in STD/HIV/AIDS diagnosis, treatment and counselling
- Implementation of STD/HIV protocols within MCH/FP facilities at hospital and health centres
- Social mobilisation and development of appropriate educational materials on STD/HIV/AIDS for women attending ante-natal, postnatal and family planning clinics, their partners and the community
- Monitoring and evaluation
Purpose / Objective
The purpose of the evaluation was to examine the acutal achievements of the project, in relation to the objectives and outputs as set out in the project proposal. Specifically, this evaluation was to undertake a review of the progress, experiences and lessons learnt and to identify issues and challenges that needed to be addressed in order to scale up the project.
To assess the range of clinic services across districts, DHMT staff were requested to nominate high- and low-performing services in their area and develop a program for the team to visit these centres. The team also requested to visit private clinics to compare these services to those operated by the government. In Lusaka, Livingstone, Ndola and Kitwe, the team visited 4 to 6 centres. For comparison, the team also visited 2 centers in Kabwe, a non-project district. Time constraints prevented the team from visiting Chipata district, however, reports and documents from the Chipata District Health Management Team (DHMT) were reviewed and assessed. and in Kabwe, 2 centres were visited. Due to the schedule, the team was also unable to visit any hospitals; however, several centres with outpatient departments were visited.
Interviews used focused questions with DHMT and clinic staff, key donor agency representatives, Central Board of Health representatives and NGO organisations. The team also conducted group discussions with youth peer educators and Neighbourhood Health Committee members.
Key Findings and Conclusions
The evaluation found that this Project has achieved some success in integrating STD/HIV/AIDS services to MCH/FP facilities. It was also evident that health centre staff had skills and confidence to conduct screening using sexually-transmissible infections (STI) syndromic management and that their knowledge and skills had been increased through training, support and supervision.
There has been an increase in the number of women being screened at MCH/FP facilities, however, there was also a trend of fewer women (and their partners) being treated for STIs, despite evidence of increasing number of STIs in the community. The widespread lack of free drugs and reagents is likely to be the most significant reason for this decrease as fewer people are able to receive treatment through health centres or are referred elsewhere. A significant concern was that screening rates for syphilis had dropped since 1999 due to lack of RPR kits and staff were discouraged about the quality and effectiveness of the service that they were able to provide. As a result, rates of congenital syphilis appear to be increasing. There was also a disturbingly higher number of ulcerative STIs (syphilis and chancroid) as opposed to the inflammatory varieties (gonorrhea, chlamydia etc.), a worrying development with the high HIV prevalence rates in the country.
Although STI case management was being implemented with some success in most health centres, HIV/AIDS services require further development. Specifically, voluntary counselling and testing (VCT) and Mother to Child Transmission (MTCT), or Parent to Child Transmission (PTCT) services need to be increased and staff supported through training and supervision to provide accurate information and establish appropriate referral processes. Staff need further skills in counselling and VCT sites should be expanded and linked more closely with MCH/FP facilities. Mother to child transmission (MTCT) services need to be expanded to include a comprehensive package of care for mothers, however, this package would need to be carefully structured according to the staff skills and resources available through health centres and districts. The issue of anti-retroviral drugs has a very strong bearing on the success of MTCT programs.
Demand for VCT is slowly increasing, however, it is limited by staff reluctance to raise and discuss HIV/AIDS issues with clients. A climate of fear and stigma still exists within communities in relation to HIV/AIDS, although there are many efforts to combat discriminatory practices. Health care and community workers need much more training on attitudes and practices, including confidentiality related to HIV/AIDS and clear procedures for referral and ongoing community care, to begin to truly address HIV/AIDS within these facilities.
There has been a strong community mobilisation effort through the project and the range of prevention activities that have been implemented is impressive, as is the enthusiasm and commitment from community members. The lack of educational materials and the inconsistent supplies of condoms have made these efforts more difficult, and potentially reduce the impact of these activities within communities. Finding ways to sustain these efforts is essential as peer-led activities and community involvement can create long-term changes in people's behaviour.
Recommendations for further project activities focus on strengthening training of health care workers, specifically in HIV/AIDS counselling and MTCT issues as well as attitudes and confidentiality in relation to HIV/AIDS.
It was also recommended that STI/HIV/AIDS clinical activities be consolidated through more reliable supply systems, refresher courses in syndromic management and counselling, and a stronger focus on VCT and MTCT programmes.
Youth programmes should also be strengthened through training, provision of IEC material and support for prevention efforts. The peer educators used in the youth component need to be supported to reduce the drop-out and the subsequent need to train new ones.
It is recommended that the current project receive short-term bridging funding to consolidate and strengthen these areas, and that funding is sought for this project to continue and be scaled up in the longer term, provided that there has been some effort to address the constraints that have affected the current project.
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HIV/AIDS - MTCT