Moving Services to the Community: Shifting the PMTCT/MCH Integration Debate

1. Moving Services to the Community: Shifting the PMTCT/MCH Integration Debate • Laura A. Guay MD • Elizabeth Glaser Pediatric AIDS Foundation • George Washington University School of Public Health and Health Services

2. Outline • Lessons learned from MCH community activities • Current focus on the community • Models of HIV community activities • Considerations for MCH-HIV integration • Research needs

3. 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.

4. 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

5. 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.

6. Models of Community Engagement • Community Sensitization/Education • Community Mobilization • HIV testing campaigns vsfamily 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)

7. 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

8. 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

9. 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