Author: Chingono, A.; Chandiwana, B.; Kambabrami, R.
The Ministry of Health and Child Welfare established a PMTCT of HIV task force to spearhead PMTCT of HIV in Zimbabwe. This two-year pilot project was carried out at 3 urban clinic sites: Highfield in Harare, Zengeza in Chitungwiza and Pelandaba in Bulawayo. The purpose was to reduce Mother-to-Child HIV transmission and then apply the learnt experiences to do the same in Zimbabwe at large and in other countries. The main components of the Project were: provision of VCCT services for expecting women/couples; provision of female and male condoms to lactating mothers; administration of AZT to consenting pregnant women; and minimisation of invasive procedures during pregnancy and delivery.
The Project encompassed 3 urban clinic sites, with a total population of the 3 urban centres constituting about 20% of Zimbabwe's 12.5 million inhabitants. About 4.4% of the population at any given time are pregnant women, coming up to just over 10,000 in the 3 catchment areas of the pilot. The birth rate in the cities had gone down since the mid-80s due to a good National Family Planning Programme but mortality rates (crude mortality rate, IMR, PMR, etc.) had gone up significantly during the same period, generally as a result of the HIV/AIDS epidemic. While Projections were that 1500 women would benefit from the Project, only 453 women (30.2% of the expected) actually participated in the Project. Some of the reasons for the low uptake of the Project were related to stigma on HIV/AIDS, which is still high in the communities despite the fact that there are many people who are known to be HIV positive and are living among communities.
The objectives of the evaluation were to: assess achievements, determine strengths, weaknesses, opportunities and threats, assess project acceptability and accessibility, establish reasons for low uptake, assess establishment of partnerships, look into management issues, and make recommendations on future management of the project, required including policy-related aspects.
Interviews with planners at national level, planners and managers at City Health Directorate level in the three cities, collaborating and implementing partners included mainly UN agencies, site project managers, PMTCT counsellors, nursing staff and non nursing staff at the sites
Findings and Conclusions:
The extent of the MTCT of HIV problem was inferred from the seroprevalence surveillance studies of women attending ANC and that of the general population. However, a needs assessment prior to planning and implementing the pilot project so as to characterise the nature and magnitude of the problem as well as the needs of potential clients, was not done. Hence, the scope of the anticipated demands and the prevailing community attitudes towards PMTCT were not factored into the pilot project planning and its execution. Although a consultant was hired to do a situation analysis in selected areas, no inventory of what complimentary care and psychosocial support services were in existence was compiled.
The policy position on infant feeding was not clear at the time of the pilot study and there was confusion on the ground resulting in contradictory messages being given to clients, depending on which particular health worker was giving them.
There were no written clinical care guidelines on PMTCT. Policy on confidentiality was given verbally and was based on the national AIDS policy document. There were no PMTCT-specific teaching materials for mothers such as posters and pamphlets.
Breast feeding was the main mode of infant feeding. Free formula was promised to mothers but not delivered. Reasons for non-delivery were not communicated.
Condoms were supplied by the existing city health system and male condoms were always available. Female condoms were only occasionally available. AZT was supplied by the project through GMS, MOH&CW at no cost to clients and was used as a DDA drug. Generally, there had been no disruptions of supply, no thefts, or AZT wastages.
HIV testing was not done on site and the ELISA test was used. There were no undue disruptions, lost specimens or lost results. The only major disruption of services during the pilot occurred due to non-payment for services rendered by NBTS. The cost of an HIV test was US $6.25 per test. NBTS services were very good otherwise. Turn around time was on average 1-2 weeks. Results were kept locked up in cupboard and nothing was written on the ANC card to identify the women. Results were not disclosed to family members. All clinic staff received verbal but specific instructions on confidentiality.
Beyond the usual existing referral systems, no mechanisms for referral were established for clients, particularly HIV-positive pregnant patients taking ZDV. Needed referral networks had included services for complicated labour, social services, continued psychosocial support, STI services and others. No arrangements were made for continued care for HIV-positive clients and the clinic found themselves ill-equipped to offer continued services.
The training needs of the various cadres were not systematically assessed and no follow-up to assess the adequacy of training carried out was done. In terms of specific counselling focus and inputs, most counselling sessions were devoted to individual pre- and post-test counselling, with a few being devoted to group pre-test counselling.
Major causes of problems encountered by counsellors during their were work load, lack of ongoing training, lack of emotional support, staff being moved to other posts within the clinic, and staff leaving the clinic to work elsewhere. The training received in all these areas was rated as having been good though they felt there were areas in which they needed more training, particularly on infant feeding and supportive counselling. All the counsellors also felt that there had been a real need, during the pilot phase, to improve on on-going training and support for counsellors, supervision of counsellors, availability of patient education material and the implementation of a community education strategy.
Community leaders were not sensitized on the benefits of PMTCT, as a result of which they were not involved in any community mobilization. Likewise, community opinion shapers and educators were not sensitized on the benefits of including PMTCT in their usual community education endeavours. PLHA were also not involved from the very onset, only coming on board later in relation to the provision of psychosocial support through support groups.
Potential clients sensitized were women attending ANC who received group IEC lectures. No extra efforts were made to penetrate the community with a well-defined, multi-sectoral educational strategy that capitalized on past successes in reaching intended clients and their significant others. Clients were verbally informed about the project when they came for ANC and invited to join the project. In most cases, this was the first time the clients heard about PMTCT for HIV.
Counsellors were of the opinion that community sensitization, male involvement, provision of free formula feeds, widespread nurse training, targeting decision makers within households, involvement of other sectors in community mobilization and a sustained education strategy would have facilitated the uptake of PMTCT services by clients. Regarding male involvement, counsellors suggested a number of strategies including the introduction of 'man-friendly ANC', extending opening hours for PMTCT services into the weekend to accommodate working men, workplace-based sensitization and education sessions, and the development and distribution of IEC materials targeted at, and relevant to, men.
The PMTCT pilot project developed a highly confidential and secure record keeping system in the form of registers whose access was highly restricted.
There was an assumption that the integrated services that obtain at PHC level would take care of the continuum of care and support services. However, the perceived quasi-vertical nature of the PMTC pilot project and the absence of a city health directorate level mandate for coordinating PMTCT-related services, militated against a team approach that was inclusive of all health workers.
Although there was a focal person for PMTCT at national level, staffing levels within the PMTCT unit head office were said to have been inadequate, as a result of which the capacity of the PMTCT section within the AIDS & TB Unit to coordinate the various components of the programme was said to have been limited. This had ramifications on the unit's ability to manage and proactively monitor programme activities, especially at the site level.
The resource mobilization strategy adopted was, by and large, donor dependent especially for the provision of commodities/inputs such as anti retroviral drugs, testing kits, gloves, syringes and other services. At local levels, municipalities chipped in with transport, facilities and manpower in support of PMTCT activities. No strategies were developed at local levels to secure long-term funding for scaling up of PMTCT using AZT beyond the scope of the pilot period.
There was strong networking among implementing partners at national level in the form of consultative and planning meetings, especially at the outset.
The usual health services management structures should be mandated to take leadership and responsibility for managing PMTCT services within the context of integrated MCH provision.
Events have overtaken the piloted PMTCT model that used ZDV as ARV and ELISA as the testing strategy. Any future attempts at scaling up PMTCT services should be informed by latest developments in these technical areas. As things stand currently, on-site VCT using rapid testing and nevirapine, is recommended.
Community sensitization and mobilization is a critical stage in the successful introduction of PMTCT services. Creative approaches to reaching communities should be identified and developed through participatory consultations and multisectoral involvement of all stakeholders.
Follow-up care and psychosocial services are an absolute must for the provision of a comprehensive model of care and support. A mechanism for establishing networks for follow-up care should be put in place as part of planning for the continuum of PMTCT care and support services. PMTCT should be mainstreamed into District AIDS Action Committee plans as a strategy for resource mobilization.
Policies provide an enabling environment for service provision; therefore, a comprehensive PMTCT policy should be developed that will facilitate the integration of PMTCT activities within MCH services.
Quality assurance is necessary for the standadization of care practices. Guidelines on PMTCT care and psychosocial support should be developed and disseminated to implementing sites. Staff training should be an ongoing activity.
Partnerships at all levels, from the national to the local, should be established and/or strengthened as part and parcel of multisectoral collaboration to ensure sustainability and a wider sense of ownership and involvement.
A team headed by MoHCW should be constituted and tasked with developing an action plan that outlines specific roles and responsibilities for each actor in PMTCT - this will facilitate due accountability and ensure a holistic approach. Other sector ministries, DACs, WACs, NGOs, etc. should also be included. This has already been done.
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HIV/AIDS - PMTCT
MoHCW AIDS and TB Unit, Local Municipalities, UNAIDS, UNFPA, WHO