Author: Kankasa, C.; Mshanga, A.; Baek, C.; Kalibala, S.; Rutenberg, N.
Nearly one million adults and 150,000 children were infected with HIV in Zambia by the end of the year 2001 (UNAIDS 2002). Mother-to-child transmission of HIV is responsible for more than 90% of HIV infections in children. Each year, about 20-30,000 HIV-infected women give birth, without any intervention, and over a third of these women will pass on the infection to their infants. To counter the increasing HIV-infection rate among infants and young children in the country, the Ministry of Health established the Prevention of Mother-to-Child Transmission (PMTCT) Program in January 1999. A National PMTCT Technical Working Group (PMTCT-WG), one of the nine technical working groups that fall under the National AIDS Council (NAC), was appointed to provide coordination of PMTCT activities and technical support to PMTCT programs/activities throughout the country, e.g. guidelines and training curriculum for minimum package of care, reviews of peri-natal studies proposed for Zambia, evaluation, dissemination of program experience, laboratory support. The program established six pilot sites to test and refine the delivery of a comprehensive package of PMTCT services. The PMTCT Secretariat coordinates activities of all six PMTCT pilot sites. The Secretariat also organizes training workshops, conducts supervisory visits and monitors PMTCT-related drug distribution and storage while implementing a communication strategy involving advocacy, behavioural change communication and community mobilization to support HIV/AIDS-infected and affected women and their families.
A rapid assessment of the experience of the Zambia pilot PMTCT sites was undertaken as part of a global assessment of the UNAIDS/UNICEF/WHO/UNFPA evaluation of UN-supported pilot PMTCT services. The evaluation is comprised of a desk review of the pilot PMTCT experience in the 11 countries initially supported by the UN and rapid assessments in three countries — Zambia, Rwanda and Honduras.
All six PMTCT sites were included in the rapid assessment. Provider questionnaires, site manager interviews, community focus group discussions, and client exit interviews were conducted. Additionally, observations were made of: pre-test VCT, post-test VCT, group talks, antenatal counseling, infant feeding counseling, family planning discussions, and growth monitoring discussions.
The qualitative data was categorized according to themes and summarized by the evaluation team. The quantitative data was entered into the computer database and frequencies for different variables run.
Due to the rapid nature of the assessment, there was not enough time, as would have been desirable, to check manually and during data entry for completeness of questionnaires. Thus, there are missing data on some questions, and the denominators reported in this report are the number of responses for the relevant question.
Findings and Conclusions:
Less than half of the 48 providers have been trained in the PMTCT minimum package of care or infant feeding counseling. Of those who had received training, all the respondents correctly described the components of the training, including training on the Minimum Package of Care, background and epidemiology of HIV, maternal and infant nutrition, counseling, etc. Almost all the respondents stated that the training had prepared them to provide patients information about PMTCT.
Eighteen providers reported attending a separate course on infant feeding counseling. The majority of those who attended were able to remember that it was done based on the WHO guidelines and that it addressed breastfeeding, providing infant feeding options for HIV-positive mothers, and infant and young child feeding counseling. All of them agreed that they were given an opportunity to practice counseling, felt that the training was adequate and made them feel prepared to provide infant feeding counseling.
Providers and clients praise the PMTCT program for making additional drugs available in the clinics. For the most part, the PMTCT sites had adequate supplies of HIV tests kits, short course ARV prophylaxis and other relevant drugs for ANC and treatment of opportunistic infections, HIV test kits, infant formula, clinical supplies and IEC materials.
Utilization and Coverage of Services
The statistics reflect the variety of experience at the sites. Chipata is a very busy clinic, with a large client load. Overall, coverage of clients at Chipata is relatively low, with only 42 percent receiving pre-test counseling, 31 percent having an HIV test, and 12 percent completing the VCT (i.e. received pre-test counseling, had an HIV test, and received their test result). Problems with the supply of HIV test kits to Chipata clinic have meant there were periods of time when the program was unable to offer an HIV test, and there were long delays in receiving results.
After a period of considerable staff turnover, all staff new to the health center have now been trained on PMTCT. Additionally, a new monitoring form has been introduced to track the productivity of the research nurse counselors. In the two months since the form was introduced, the weekly number of women pre-test counseled has tripled. In the community, the program began a new campaign working through the churches to introduce the PMTCT program. This has been well received and seems to be resulting in an increase in demand for the VCT service at ANC.
Keemba and Monze have both been severely affected by staff shortages, which has had a large impact on their capacity to deliver pre-test counseling. Nonetheless, in Keemba, among women who received pre-test counseling, HIV testing is widely accepted. This appeared to be due to the fact that rapid tests are carried out on the spot by the counselor. Monze has only one provider at the out-patient clinic responsible for static ANC services, which leaves little time for HIV counseling. However, she is regarded as an excellent counselor, and a high proportion (83 percent) of women who receive pre-test counseling have an HIV test, and 70 percent of women who are tested, collect their results.
Mbala and Tulemane have had the greatest success in reaching their client population as measured by the proportion of women who have pre-test counseling, and HIV test, and collect results. Overall, one-third of women who come for ANC have received HIV pre-test counseling, had an HIV test, and received their HIV test result. This relatively high coverage rate is a result of: extensive sensitization activities in the community initiated by PMTCT and other HIV programs, which is creating demand for HIV counseling and testing; an active program of community lay counselors and a VCT program which bring clients to the PMTCT program; and higher staffing levels in these sites—though they have also been affected by staff turnover.
UTH is a referral hospital where the majority of clients are referrals from clinics all over Lusaka, including from private doctors. One group is recruited from those referred for obstetric complications. Many of these clients are not receptive to learn more about HIV and MTCT as they see this as just adding another problem to the one they were already referred for. The women who receive ANC services at UTH come not only from all over Lusaka, but also from outside of the city. Thus, UTH does not have a community as such to target with sensitization activities or from which to seek community support. Consequently, the coverage of counseling and testing among all antenatal attendees seen at UTH is very low, less than 4 percent.
PMTCT Information and Knowledge
The program shows good progress in integrating PMTCT and HIV information into MCH care at the pilot sites. Among the 156 clients who responded, 87 had discussed HIV transmission among adults with a health provider, 93 had discussed HIV transmission from mother to child and 87 had discussed HIV testing.
The rapid assessment found that knowledge about the program's existence is fairly high among those who participated in community focus group discussions, confirming that the program is known in the community. Drama groups, including drummers, were repeatedly mentioned.
Half of the respondents (63 out of 125) said they had talked to someone else before making a decision to take the test. Almost all of those women spoke with their husbands, while just a few had spoken with mothers, sisters and friends. The majority (64 out of 80) stated they shared their test results with someone. Most clients said they shared their HIV results with their husbands, while a few mentioned mothers and friends.
Generally, it was felt that a husband and wife should make decisions regarding testing, PMTCT and infant feeding together. But, men at Chipata clinic felt that outreach workers in the community are sidelining the men and are only interested in reaching women. They proposed that men should be targeted and sought in male-friendly places such as bars, church gatherings, etc.. It was clear from these discussions that most women are unable to convince their partners to go for VCT if they – women - have access to the information first. Once the men acquire the information directly about the program – not from their wife - most of them become very supportive.
Care, Support, and Stigma
Interestingly, the dominant issue when asked about the care and support of HIV-positive individuals was stigma and discrimination, more so than medical, material or social support. A number of strategies for increasing health provider's role in reducing stigma were suggested by the providers themselves. These include providers going into the community and providing community education, with the aim of increasing community awareness of HIV and MTCT so that they know that "HIV is not a sin", thereby creating support for PLHAs. It was also emphasized that providers should treat all women (positive and negative) similarly, without showing preferences. Providers should maintain and reinforce privacy and strict confidentiality. Lastly, they should foster the creation of community support groups such as post-test clubs for women living with HIV/AIDS.
There is a critical shortage of trained health personnel, and the few available are already overburdened, on top of which a new program was introduced, to be performed by the same personnel. PMTCT programs should be realistic about the staff required to implement the program and acknowledge the needs of their providers to be protected and to have the basic tools needed to conduct their work. Part of planning for scale-up should include planning and budget for additional staff, universal precautions, and post exposure prophylaxis for all PMTCT providers.
Training needs to be an ongoing activity as diverse and large numbers of providers are involved in the delivery of PMTCT services. There is very high staff turnover and, to succeed with in-service training, there has arisen a need to train a provincial pool of facilitators, so that training could be decentralized. The conceptualization of training could be expanded to incorporate on-site teaching and learning, including peer-to-peer training, so that providers can provide on-the-job-training for new colleagues who take up responsibility for PMTCT services. However, for the training to remain sustainable, pre-service training will have to be introduced in all nursing and medical schools.
Male involvement and support is critical to the success of PMTCT programs. The PMTCT program should 1) focus their efforts on providing information directly to men, and 2) locate these communication activities for men outside of the antenatal clinic. Antenatal clinics are women's spaces and not easily adapted to accommodate men.
The community and providers strongly recommend that HIV-positive women who went through the PMTCT program be mobilized as peer counselors to provide information and support to women currently in the PMTCT program. They are seen as potential assets to the program because they have shared the same experience and are of a similar age and background to the women in the program. They, thus, have a high degree of credibility and can offer welcomed advice and support. Additionally, if more women are open about their HIV status, the providers and community believe that this would contribute to a reduction in the stigma attached to HIV infection.
PDF files require Acrobat Reader.
HIV/AIDS - PMTCT
Population Council, USAID, UNAIDS, WHO, WFP, NORAD, JICA