aidstar-One | CASE STUDy SERIES                                                                                           ...
aidstar-One | CASE STUDy SERIES                                       health systems remain weak almost a decade following...
aidstar-One | CASE STUDy SERIESdeveloping world. Most of them are the result of mother-to-childtransmission (WHO 2010a). I...
aidstar-One | CASE STUDy SERIESProVIC: A Community-Based                               ProVIC’s three objectives are to:Ap...
aidstar-One | CASE STUDy SERIES   of provincial government health systems and                      community priorities re...
aidstar-One | CASE STUDy SERIES                                                         to be part of this group. Here I n...
aidstar-One | CASE STUDy SERIESintegrated, in-service trainings on the national integrated HIV trainingmodule, on the deli...
aidstar-One | CASE STUDy SERIESto Global Fund-supported facilities where pediatric                                sites wh...
aidstar-One | CASE STUDy SERIESProVIC expanded HTC services to most at-risk                       during the mobile testin...
aidstar-One | CASE STUDy SERIESissues. Additionally, the partnerships have enabled       collaboration among local leaders...
aidstar-One | CASE STUDy SERIESMale involvement: A large percentage of men are                    Engage youth: Work with ...
aidstar-One | CASE STUDy SERIESREFERENCES                                             WHO. 2010b. PMTCT Strategic Vision 2...
aidstar-One | CASE STUDy SERIESRESOURCESProVIC’s referral sheet and monitoring sheet forinfants living with HIV: www.path....
AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging cas...
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ProVIC “Champion Communities”: PMTCT of HIV in the Democratic Republic of Congo


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More than a decade of conflict has ravaged the health infrastructure and service delivery in the Democratic Republic of Congo (DRC). As a result, prenatal care--including prevention of mother-to-child transmission (PMTCT) of HIV--is often difficult to access and fails to meet the needs of expectant mothers. One program, the DRC Integrated HIV/AIDS Project (ProVIC), is using a community-based approach to link mothers, health care providers, and community caregivers with support and quality service.

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ProVIC “Champion Communities”: PMTCT of HIV in the Democratic Republic of Congo

  1. 1. aidstar-One | CASE STUDy SERIES November 2012ProVIC “Champion Communities”Preventing Mother-to-Child Transmission of HIV in theDemocratic Republic of Congo A large group of women fill a counseling room at the Centre Hospitalier Maternité de Kingasani in Kinshasa, the capital of the Democratic Republic of Congo (DRC). They have Katie Saul/John Snow, Inc. come to the maternity hospital for their first antenatal visit and will receive information about prenatal care, sanitation, malaria, and other health issues. In addition, the hospital offers routine, provider-initiated HIV counseling and testing as part of the visit. Many of the women in the education session came to the hospital because they heard community messages encouraging pregnantEducation Session at the CentreHospitalier Maternité de Kingasani. women to seek care, or because a friend or neighbor suggestedAugust 2012. they go. The maternity hospital, located in one of Kinshasa’s most densely populated neighborhoods, conducts about 700 HIV tests a month. At the maternity hospital, if a pregnant woman’s HIV test result is negative, she is educated on the importance of prenatal care, including the importance of maintaining her HIV negative status, and the increased risk of contracting HIV during pregnancy. If her result is positive, and she is clinically eligible, she will be given antiretroviral therapy for life. Otherwise, at 14 weeks’ gestation she will receive combination prophylaxis to prevent transmission to her baby and then continue taking the medications through delivery. After delivery, her infant will be put on antiretroviral therapy to prevent HIV transmission during the breastfeeding period. She will also be informed of local nongovernmental organizations (NGOs) that provide HIV care and support services near her.By Katie Saul These services are part of the elaborate social support and referral networks in the 40 Champion Communities created and supported by the DRC Integrated HIV/AIDS Project (ProVIC). In the DRC, whereAIDSTAR-OneJohn Snow, Inc. This publication was made possible through the support of the U.S. President’s1616 North Ft. Myer Drive, 16th Floor Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for InternationalArlington, VA 22209 USA Development under contract number GHH-I-00-07-00059-00, AIDS Support andTel.: +1 703-528-7474 Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Agency for International Development or the United States Government.
  2. 2. aidstar-One | CASE STUDy SERIES health systems remain weak almost a decade following conflict and The risk of HIV government collapse, institutions are limited in their capacity to support transmission from highly fragmented communities. ProVIC’s Champion Communities mother to child can therefore serve as a powerful vehicle to link people with the health and be reduced from social services they need. ProVIC was the first to use and adapt the around 30% to less field-tested Champion Community approach in this challenging, post- than 5% through the conflict country context. following four PMTCT interventions: • Preventing women of child- bearing age from acquiring HIV and Mother-to-Child Transmission in HIV infection the Democratic Republic of Congo • Preventing unintended pregnancies among women More than a decade of conflict has ravaged the health infrastructure living with HIV and service delivery in the DRC. In 2008, the International Rescue • Preventing HIV transmission Committee conducted a mortality study that estimated that 5.4 million from women living with HIV people have died as a result of the humanitarian crisis (International to their newborns Rescue Committee 2008). The armed conflict has also resulted in more than 1.5 million displaced people, high rates of gender-based violence, • Providing care, treatment, separated families, and widespread destruction. A dysfunctional and support to mothers living National Health System, weak national coordination, inadequate supply with HIV, their children, and systems (the DRC is 100 percent dependent on donors for antiretroviral their families drugs), and a lack of funding coordination are the DRC’s greatest Source: UNAIDS 2010. obstacles to universal access to HIV prevention, treatment, care, and support (UNAIDS 2009). The DRC’s HIV prevalence rate is 3.5 percent (PNLS 2011). However, according to the Programme National de Lutte contre le VIH/SIDA et les IST (PNLS), rates are higher in certain “hot spots.” These include Tshikapa (6.9 percent), an urban diamond mining center near the Angolan border; Ariwara (6.3 percent), a resource-poor town with heavy traffic from South Sudan and Uganda; Lubumbashi (6.6 percent), situated near the Zambian border; and Lodja (8.1 percent), on the western front of the DRC’s armed conflict (PNLS 2011). Women are also disproportionately affected, with the highest HIV prevalence rates among female sex workers (15 percent), women displaced by war (7.6 percent), and women in the armed forces (7.8 percent) (PNMLS 2010). Mother-to-child transmission: According to the World Health Organization (WHO), 1,200 new HIV infections in children under 15 years of age occur daily, and more than 90 percent are in the2 AIDSTAR-One | November 2012
  3. 3. aidstar-One | CASE STUDy SERIESdeveloping world. Most of them are the result of mother-to-childtransmission (WHO 2010a). Increased knowledge and early testing Three treatmentare critical to identifying HIV-positive pregnant women who can benefit options to reducefrom care to reduce vertical transmission. In sub-Saharan Africa, mother-to-childonly 26 percent of women have comprehensive knowledge about HIV transmissionprevention. recommended by the World HealthIn Central Africa specifically, the proportion of women (20 percent) is Organization’s 2010even lower. Further, less than one-fifth of pregnant women living with guidelinesHIV in the DRC receive voluntary HIV testing and counseling (HTC) Starting at 14 weeks or as soon(WHO 2011). As a result, the vast majority do not know their HIV status. as possible thereafter:In the DRC, where women have an average of 6.3 children, raisingawareness about mother-to-child transmission therefore remains Option Acritical (Macro International 2008). Timely initiation of prevention of Twice daily zidovudine (AZT) formother-to-child transmission (PMTCT) programs is estimated to reduce the mother and infant prophylaxistransmission rates in low-income countries from 30 percent to less than with either AZT or nevirapine5 percent (WHO 2010b). (NVP) for six weeks after birth if the infant is not breastfeeding.Early diagnosis is also essential to improving health outcomes for If the infant is breastfeeding,children. Without diagnosis and treatment, one-third of infants living continue daily NVP infantwith HIV die during their first year of life and almost half die before they prophylaxis for one week afterreach two years of age (WHO 2011). Although strategies for earlier the end of the breastfeedingdiagnosis and antiretroviral therapy initiation are recommended to period.reduce mother-to-child transmission, developing countries struggle to Option Bprovide adequate screening for HIV; purchase and implement testing A three-drug prophylactictechnologies for children less than 18 months of age; provide the care regimen for the mother duringthat is needed for HIV-positive children; and supply antiretroviral drugs pregnancy and throughout theto keep them healthy (WHO 2010a). breastfeeding period, and infant prophylaxis for six weeks afterPMTCT efforts in the DRC: The DRC has adopted the WHO’s birth, regardless of breastfeeding.treatment Option A and is committed to providing highly active Option B+antiretroviral therapy to women with a CD4 count ≤ 350 during Providing the same triplepregnancy. However, the supply and provision of medications to antiretroviral drugs to all HIV-those in need will be difficult moving forward as funding remains infected pregnant womenuncertain (PEPFAR DRC 2012). Despite these challenges, the DRC beginning in the antenatal clinicPEPFAR team and the Ministry of Health developed an acceleration setting but also continuing thisplan to eliminate mother-to-child transmission by 2015. The plan therapy for all of these womenaims to decentralize what has historically been a top-down approach. for life.It includes strengthening performance-based financing programs,payment of delivery fees, and reinforcing the health zone management Source: WHO 2010c.structure in urban areas, with an ultimate goal of scaling-up to morerural areas. ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo 3
  4. 4. aidstar-One | CASE STUDy SERIESProVIC: A Community-Based ProVIC’s three objectives are to:Approach 1. Expand and improve HTC and prevention in the target areas by building communities’ProVIC is a five-year, $50 million project funded capacity to develop and implement preventionby PEPFAR through USAID that began in 2009. strategies, enhancing community andLed by PATH in partnership with the Elizabeth facility-based HTC services, strengtheningGlaser Pediatric AIDS Foundation, the International community- and facility-based gender-basedHIV/AIDS Alliance, and Chemonics International, violence prevention and response services, andthe project engages communities in five of the improving PMTCT services;DRC’s provinces (Bas Congo, Katanga, Kinshasa,Province Orientale, and Sud Kivu) in a participatory 2. Improve care, support, and treatment forprocess that links community and health facility people living with HIV in the target areas byservices. The integrated HIV project helps strengthening palliative care, and improvingcommunities to self-organize, self-assess, plan, and care and support for people living with HIV andself-evaluate tailored, community-level responses to orphans and vulnerable children;HIV. Through annual action plans, the communitieslead HIV prevention, care, and support activities 3. Strengthen health systems by reinforcingand become “Champions” upon reaching their strategic information systems at communitytargets and goals. and facility levels, and by building the capacityProVIC is the DRC’s largest community-based HIVproject and one of few community-based models. Other community challengesIn a country torn by years of conflict, ProVIC’s are often discussed duringChampion Community approach has begun torebuild communities by helping them to reorganize, the action planning process.identify their assets, and capitalize on the Nongovernmental organizationspopulation’s determination to reduce the incidence work with steering committeesof HIV and mitigate its impact on people living with to identify HIV-related issues thatHIV and their families. The model is inherentlyflexible to allow for strategies that are tailored to can be addressed by the project.the specific needs of communities and vulnerable For example, a community thatgroups, and is unique for its use of a clear rewards identifies poor access to watersystem—most importantly, visible returns ondiscrete investments—to quickly initiate and may identify strategies to preventthen sustain activities. Furthermore, ProVIC has and respond to sexual violence,catalyzed efforts to improve the PMTCT and early a common threat for young girlsinfant diagnosis by engaging key health, political, and women who must walk longeconomic, and religious leaders at the community,provincial, and national levels. distances in the forest before dawn to fetch water.4 AIDSTAR-One | November 2012
  5. 5. aidstar-One | CASE STUDy SERIES of provincial government health systems and community priorities related to HIV and activities nongovernmental service providers. to address them. From there, the committees coordinate activities with other volunteers and helpCommunity members—who are vital to the maintain a strong referral network to essentialproject’s success and a focal point of the Champion health and social services. In ProVIC’s first year,Communities’ empowerment approach—conduct a action plans focused on raising awareness, creatingsignificant part of ProVIC’s interventions and take self-help groups for people living with HIV, andon increasing responsibility in managing them over beginning income-generating activities. In Yeartime. ProVIC trains interested community members 2, the Champion Committees rolled out HTC andon HIV prevention, community mobilization strengthened PMTCT efforts. By the end of Yeartechniques, and skills related to their roles on the 3, communities were increasingly using their ownproject. They are an essential bridge between the resources to improve access to formal and informalcommunity and the health services that provide education for orphans and vulnerable children;care and support for individuals most vulnerable to increase access to family planning; to provideto and affected by HIV. For pregnant women tuberculosis screening in self-support groups forliving with HIV, the volunteers’ interventions help people living with HIV; to disseminate targetedthem remain healthy during their pregnancies and messaging condemning gender-based violence;prevent transmission of HIV to their babies. and to provide nutritional support and education to people living with HIV as a “positive living withEdouard Gatembo nu-Kaké, the district mayor prevention” activity. In this sense, Championin the Champion Community of Kingasani, aptly Communities use ProVIC’s HIV interventions asexplained: “ProVIC is waking up the people. The an entry point to addressing other high-priority,conflict shattered our solidarity a bit but this project community-specific challenges.builds on tradition, la famille africaine. Like allchallenges in the community, we must collectivelytake care of the sick. ProVIC helps us to remember Champion Communities include diversethat even in unhappiness, it’s easier to share our stakeholders who play an important role inproblems and solve them together than to be achieving community goals. Community healthalone.” workers and community caregivers are key actors who form the community-based PMTCT network and help increase access to and uptake of PMTCTStrategies services.Champion Community steering committees: Community health workers: Each ChampionThe steering committee is the project’s gateway into Community has 40 community health workers. Theythe community and is responsible for ensuring that represent neighborhoods or specific populationsthe community achieves its goals. Members are and are selected for their willingness to volunteer,elected by the community and represent a range their level of education, and their credibility inof sectors and interest groups from the force vives the community. Following a monthly calendar(vital forces) of the community. In partnership with of activities, they lead community awarenesssupporting NGOs, the steering committees engage sessions, provide referrals, and conduct homecommunity leaders in action planning to identify visits to inform couples and families about HIV ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo 5
  6. 6. aidstar-One | CASE STUDy SERIES to be part of this group. Here I no longer have “I wanted to learn how to protect to hide.” The groups conduct income-generating activities that help financially support people myself and others from HIV. People living with HIV and their families. Sewing and were dying in our community and I artisanal workshops, Internet cafés, Chikwangue had to get involved. It is an honor to (cassava) vending groups, and farm sharing have play this role in the community.” helped many individuals regain confidence and financial well-being after experiencing stigma –Community health worker and discrimination or losing loved ones. Similarly, orphans and vulnerable children are supportedtransmission and the importance of HTC and help through child-to-child peer groups. Caregivers helpcombat stigma around the disease. children infected and affected by HIV by offering advice on hygiene and household responsibilities,Community health workers are the lynchpin of facilitating peer discussion groups, and helpingProVIC’s PMTCT efforts. They identify pregnant them with school work.women during door-to-door visits and tailor HIVmessages to address vertical transmission. Using PMTCT activities: ProVIC builds the capacityillustrative job aids created by the DRC Ministry of community health workers and health careof Health, they explain how HIV is transmitted professionals as a driving force for improvingto the baby and what mothers can do to prevent PMTCT activities in the DRC. Providers receivetransmission. They also recruit the male partnersof pregnant women, regardless of their HIV status,to health facilities for HTC and counsel them onfamily planning. To ensure that women and men getthe care they need, the community health workerscomplete referral sheets that inform health facilitiesof the services recommended for the patient.Community caregivers: Supporting people livingwith HIV is the community caregivers’ primaryconcern. They receive referrals from communityhealth workers and conduct regular home visits withpeople living with HIV. Using sociomedical forms todocument the status of people living with HIV, thecaregivers monitor their health and refer them backto the clinic when problems arise. Case workers Katie Saul/John Snow, Inc.also help women share their HIV status with theirhusbands and link men to testing services and care.Caregivers also facilitate self-help groups forpeople living with HIV, which meet once a monthand provide each other with social and economic Internet café supported by people living with HIV in Lemba. August As a member of a support groupdescribed, “I came from a neighboring community6 AIDSTAR-One | November 2012
  7. 7. aidstar-One | CASE STUDy SERIESintegrated, in-service trainings on the national integrated HIV trainingmodule, on the delivery of other health services, and on collecting and ProVIC’s PMTCTanalyzing their own data to evaluate and improve their services. They Objectivesalso receive training on related topics such as customer service, client- • Increase the number ofcentered care, and confidentiality—issues that often discourage women women with known HIVfrom seeking care. Using the project’s tracking and referral systems, status.providers and community volunteers identify HIV-positive pregnant • Increase the number of HIV-women and link them, their children, and their partners to the services positive pregnant womenthey need. who receive antiretrovirals.As one of PEPFAR DRC’s main PMTCT acceleration plan partners, • Increase the number ofProVIC supports 16 PMTCT sites in four provinces and aims to expand infants who receive an HIVto a fifth operating province and establish more than 25 new sites by test within 12 months of birth.early 2013. The project was the first to incorporate the WHO’s new • Increase the number ofclinical PMTCT standards into all of its PMTCT sites and played a key infants born to HIV positiveleadership role in collaborating with the Ministry of Health, the PNLS, mothers who are started onand Programme Nationale Multi-Sectorielle de Lutte contre le SIDA cotrimoxazole within two(PNLMS) to facilitate the adaptation and implementation of new national months of birth.guidelines to meet these new standards.In addition to contributing a voice of technical leadership with thePNLS, ProVIC also provided technical guidance for the revision ofnational PMTCT data collection tools to comply with new clinicalprotocols and standardize data collection. By making services andaccess more widely available, the project more than quadrupled thenumber of HIV-positive pregnant women who received antiretroviraltherapy in Year 1, from 99 to 445 women.ProVIC has alsoestablished an earlyinfant diagnosisnetwork, transportingdried blood samplesthrough its provincialoffices to theKinshasa nationallaboratory forpolymerase chainreaction (PCR)DNA analysis.Exposed infantsidentified throughPCR analysis at six ProVIC PMTCT job aid.weeks are referred ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo 7
  8. 8. aidstar-One | CASE STUDy SERIESto Global Fund-supported facilities where pediatric sites where they can receive comprehensivetreatment is available. services. The sites also stock contraceptive methods, and ProVIC providers have been trainedThe project is currently building partnering sites’ by PSI to provide family planning counseling.capacity around pediatric HIV testing to improvefollow-up of mother-infant pairs. In the first half Establishing ProVIC’s Champion Communities:of Year 3, almost 50 percent of infants born to building buy-in and adapting the ChampionHIV-positive women received an HIV test within Community approach: In 2010, the PNMLS12 months of birth, up from 12 percent in Year 1. gathered national and international developmentProVIC has worked with the PNLS to revise national stakeholders to leverage existing resourcesregisters to collect newly mandated data related to and identify strategies to integrate ProVIC intoearly infant diagnosis and provide NVP to infants national HIV prevention efforts. Stakeholderduring the breastfeeding period. ProVIC has also buy-in was essential to ensuring the success ofdeveloped job aids with practical advice on early a project that integrated related activities suchinfant diagnosis and monitoring for site providers, as condom distribution, family planning servicethus facilitating the uptake of new protocols. delivery, economic development, and support for orphans and vulnerable children. HIV experts andDespite efforts to raise awareness about mother- development practitioners also agreed on strategiesto-child transmission, many women still do not seek to adapt the Champion Community approach torelated services during pregnancy. Some women meet the DRC’s not see the added value in prenatal care ordelivering their baby at a health facility, especially ProVIC worked closely with the Ministry of Healthwhen they have previously given birth at home or to identify beneficiary communities, focusing onwith a local midwife. For others, it is an issue of areas with high prevalence rates and high risk (e.g.,access. To help address these challenges, ProVIC populations located on international borders, largehas instituted reduced delivery fees for women ports, and in conflict areas). They examined theliving with HIV to encourage delivery at PMTCT country’s health zones to determine where health structures exist and function. In addition, they looked for communities with active NGOs, strong leadership, and a mobilized population. Finally, they conducted a study tour to Madagascar to learn from USAID’s SantéNet project, which has successfully used Champion Communities to improve health and the environment. ProVIC contracted and trained 14 NGO partners and piloted the project in four communities before expanding to an additional 36. By the end of Year 3, more than one million people had Katie Saul/John Snow, Inc. participated in ProVIC’s small group and individual HIV prevention interventions. Since its inception, ProVIC’s management team has effectively continued to adapt strategiesProVIC NGO implementing partner, CEMAKI. Kinzau-Mvuete, August 2012 to address emerging needs and findings from ongoing monitoring and evaluation. For example,8 AIDSTAR-One | November 2012
  9. 9. aidstar-One | CASE STUDy SERIESProVIC expanded HTC services to most at-risk during the mobile testing events, there are typicallypopulations—including sex workers, men who have 10 to 20 people waiting to be tested, and ansex with men (MSM), fishermen, miners, and truck estimated average of 300 people are reached withdrivers—and launched HIV prevention activities HTC per night. Those who receive positive resultsspecifically targeting youth, based on lessons are counseled by an NGO or ProVIC staff memberlearned during the first two project years. To and provided referrals for care, treatment, and otherfurther ensure access to HIV prevention activities, needed services.the project is creating Champion Communitiesdedicated specifically to some of these groups.Men who have sex with men in particular havebenefited from ProVIC’s flexible approach. For What Has Worked Wellinstance, in partnership with NGO grantee Progrès Community engagement and solidarity:Santé Sans Prix, ProVIC advocated for addressing Project beneficiaries are proud of the renewedMSM’s specific needs in the National HIV Strategic energy in their Champion Communities. GivenPlan and improved HTC services for MSM by the country’s turmoil and slow process of change,strengthening referrals for sexually transmitted this empowering, participatory approach helpsinfections and other anal-based infection screening communities mobilize and improve health atand treatment. Halfway through Year 3, ProVIC had their own pace. Community members praise thedoubled the number of MSM who received HTC project for enabling them to make change happenservices and received their results. themselves. The approach helps bring communities together by reinforcing relationships between theMobile HTC: As an extension of the project’s communities and local political and administrativecommunity-based HIV prevention interventions, leaders to achieve their social and economicProVIC uses innovative mobile HTC units that development objectives, and to engage them incirculate day and night in HIV “hotspots” to reach promoting and adopting new behaviors linked tomost vulnerable groups where they live and these objectives. As an early sign of sustainability,operate. These units aim to help reduce stigma it also importantly builds on already existingaround getting tested and encourage couples to community-based approaches to increasingly—get tested together. ProVIC has two mobile testing and hence more cost-effectively—leverage atents in each province: in rural areas, the mobile community’s internal resources.units make HTC more accessible to communities.In urban areas, the tents are parked in popular Increased country ownership and partnerships:nightclub areas on the weekends. From the project’s start, ProVIC’s leadership has worked closely with the Ministry of Health,Nighttime, or “moonlight,” testing attracts most-at- the PNLS, and the PNMLS to achieve programrisk populations who are not easily reached through outcomes and advance HIV prevention effortsdaytime awareness activities. ProVIC’s network nationally. As a member of the PMTCT Task Force,of MSM peer educators use Facebook and SMS ProVIC shares its experiences at regular meetingsmessaging to inform the population about upcoming with key HIV and health sector representativestesting events. Peer educators deployed with these and other international partners. The collaborationmobile units walk through nightclubs and bars has been particularly effective in facilitating thepassing out condoms and encouraging people to adoption of the WHO’s revised PMTCT guidelinesget tested at the nearby tents. At any given time and resolving antiretroviral drug supply chain ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo 9
  10. 10. aidstar-One | CASE STUDy SERIESissues. Additionally, the partnerships have enabled collaboration among local leaders and the largerProVIC to capitalize on its lessons learned and community. The decentralized approach alsoinfluence protocols related to early infant diagnosis, requires community members to be proactive andsyphilis screening at antenatal care sites, and results-focused. These expectations are new forclinical follow-up of mother–infant pairs. communities that are accustomed to the DRC’s historically top-heavy, centralized government.Support for community referral networks:ProVIC successfully raised awareness about Rural and urban communities have differentHIV testing and, by the third quarter of Year 3, challenges: The Champion Community approachmore than 100,000 people had participated in differs among rural and urban communities inHTC and received their test results. A far greater some important ways. Rural communities arechallenge has been ensuring that pregnant women often already cohesive and tend to have strongand infants living with HIV access treatment. traditional communication channels, leadership,As one strategy to reinforce PMTCT and early and structure. However, access to health servicesinfant diagnosis referrals and follow-up, ProVIC and resources is difficult. Conversely, urban areassupplies providers with phone credit for client are more challenging to organize with a morecommunication and transportation stipends for transient, heterogeneous population and lesshome visits. defined community boundaries. Although access to services is generally better in urban areas, aIntegrated approach: Recognizing that HIV affects large number of women are lost to follow-up. Forand is affected by a range of health and economic example, women who travel from other communitiesissues, ProVIC incorporates various cross-cutting seeking ProVIC’s PMTCT services can be difficultactivities. It also goes beyond the medical and to find, especially after giving birth.psychosocial aspects of HIV prevention andaddresses other issues (e.g., family planning, Demand exceeding capacity: Awareness hasfamily food security, income generation, and increased demand for HTC and PMTCT servicesmedical waste management). Finally, it serves as exponentially in the Champion Communities.a “development ambassador,” linking communities Health facilities are sometimes overwhelmed byto development projects that address their other the number of people seeking care—not only forhealth concerns (e.g., tuberculosis, malaria, and HIV-related services but for other health issues ascholera). The positive effect of its integrated well. Because the project operates in only 29 of theapproach is evident in the increased client volume DRC’s 515 health zones, the demand for expansionat local health facilities. As one health care provider also continues to increase. Periodic stockouts inremarked, “ProVIC is not just raising awareness the supply of antiretroviral drugs and reliance onabout HIV services, but the value of healthcare in the DRC’s one lab for PCR analysis are particularlygeneral.” difficult. In addition, although ProVIC has greatly increased early infant diagnosis, in some cases pediatric facilities are located far from ProVICChallenges PMTCT facilities, forcing families to travel great distances for care and making it difficult for parentsThe Champion Community approach takes to return with their infants for 9- and 15-month tests.time: Once communities are mobilized and trained,they effectively plan and implement their activities.Getting to this point, however, requires buy-in and10 AIDSTAR-One | November 2012
  11. 11. aidstar-One | CASE STUDy SERIESMale involvement: A large percentage of men are Engage youth: Work with youth to engage theirreluctant to get tested for HIV and are therefore peers in discussions on topics such as responsibleunaware of their HIV status. This creates an sexual behavior and using community services.obstacle to community prevention efforts, especially Messages adapted for individuals thinking aboutPMTCT activities. The project is working to adapt becoming sexually active will help youth adopt safeawareness messages, encouraging couples to get and healthy behaviors for their adulthood. Youthtested together, and creating a model of activities groups and associations have tremendous influencefor “Champion men” to promote equitable gender in the communities and can be used as safe andnorms and address gender-based violence. reliable sources of information on sensitive issues.Motivating community volunteers: The program’s Establish coordinated laboratory infrastructuresuccess relies on community involvement. The and logistics systems: Creating and maintainingsteering committee members, community health an efficient and reliable system for collecting,workers, and community caregivers invest a transporting, and returning PCR tests is essentialsignificant amount of time on project activities for successful early infant diagnosis. As ProVICwithout compensation. Although many volunteers expands its services and other HIV programsare committed for the long-term, demotivation begin to integrate early infant diagnosis at theirand burnout are likely in the absence of greater sites, the DRC’s national laboratory will experienceincentives. an increase in demand and burden. Similarly, coordinating the timely transport of samples through ProVIC’s offices may become unsustainable withMaintaining linkages at the community level greater volume. Collaborating with central levelwith various actors: Coordinating the health partners and other HIV prevention programs maystructures, Champion Communities, and community help ProVIC and others share the burden andinterventions such as self-help groups for people develop an expanded national network to manageliving with HIV, especially within the context of the these issues.DRC’s weakened communities and governmentsystems, is difficult. Develop mechanisms early for ensuring the continuum of care: The program trains providersRecommendations for to accompany children to pediatric facilities and provides stipends to caregivers to cover the cost ofFuture Programming transportation, since many PMTCT sites are located far from the clinics. Raising awareness about the importance of follow-up visits could strengthenStrengthen PMTCT in Champion Communities’ the linkage to care for infants as well. At pointsaction plans: Addressing PMTCT specifically in of care, providers should discuss this issue withcommunity HIV prevention efforts helps reinforce mothers and share materials and resources thatinformation about vertical transmission given to reinforce messages. In the communities, givingmothers at points of care. In addition to general HIV more responsibility to groups such as churches,prevention awareness activities, it is important to local associations, and women’s groups to monitorinclude specific messages about services available, mothers living with HIV could help bolster follow-upearly testing for infants, and psychosocial support rates and reduce stigma.for mothers living with HIV. ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo 11
  12. 12. aidstar-One | CASE STUDy SERIESREFERENCES WHO. 2010b. PMTCT Strategic Vision 2010-2015: Preventing Mother-to-Child Transmission of HIV toInternational Rescue Committee. 2008. “Mortality Reach the UNGASS and Millennium Developmentin the Democratic Republic of Congo, an ongoing Goals. Geneva: WHO.crisis.” Available at WHO. 2010c. Programmatic Update: Use ofcongomortalitysurvey.pdf (accessed October 2012) Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: ExecutiveMacro International. 2008. “Enquête Summary. Geneva: WHO.Démographique et de Santé RépubliqueDémocratique du Congo 2007.” Available at http:// WHO. 2011. Global HIV/AIDS Response: Update and Health Sector Progress towards(accessed October 2012) Universal Access. Geneva: WHO.PEPFAR DRC. 2012. DRC PMTCT AccelerationPlan FY 2012.Kinshasa: PEPFAR DRC.Programme National de Lutte contre le VIH/SIDAet les IST (PNLS). 2011. Rapport Epidemiologiquede Surveillance du VIH/SIDA Chez les FemmesEnceintes Frequeantant les Services de CPN.Kinshasa: PNLS.République Démocratique du Congo ProgrammeNational Multisectoriel de Lutte contre le Sida(PNMLS). 2010. Plan Stratégique National de lutecontre le sida 2010-2014. Kinshasa: PNMLS.UNAIDS. 2009. “Democratic Republic of Congo:Country Situation 2009.” Available at (accessedOctober 2012)UNAIDS. 2010. “It Takes a Village: Endingmother-to-child transmission – a partnershipuniting the Millennium Villages Project andUNAIDS.” Available at (accessedOctober 2012)WHO. 2010a. Antiretroviral Therapy for HIVInfection in Infants and Children: Towards UniversalAccess: Recommendations for a public healthapproach – 2010 revision. Geneva: WHO.12 AIDSTAR-One | November 2012
  13. 13. aidstar-One | CASE STUDy SERIESRESOURCESProVIC’s referral sheet and monitoring sheet forinfants living with HIV: special thanks to ProVIC’s Director, TradHatton, for his leadership and support and Dr.Salva Mulongo Muleka, Community MobilizationSpecialist, for her generous guidance, time, andcommitment to the development of this case study.Thanks also to the ProVIC staff in Kinshasa andMatadi, USAID, PNMLS, and PNLS for their insightand thoughtful contributions. The author offerssincere gratitude to the project stakeholders whoprovided their time and valuable input, includingstaff at the Centre Hospitalier Maternité deKingasani, the Centre de Santé de référence deKinsundi, NGO Femmes Plus, PSSP, CEMAKI, andthe steering committee members, community healthworkers, community case workers, and peopleliving with HIV who told their stories and who makea commitment to this project and the health of theircommunities every day.RECOMMENDED CITATIONSaul, Katie. 2012. ProVIC “ChampionCommunities”: Preventing Mother-to-ChildTransmission of HIV in the Democratic Republic ofCongo. Case Study Series. Arlington, VA. USAID’sAIDS Support and Technical Assistance Resources,AIDSTAR-One, Task Order 1. ProVIC “Champion Communities”: Preventing Mother-to-Child Transmission of HIV in the Democratic Republic of Congo 13
  14. 14. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.