Integrating Community Strategy with HIV Programs-A Research Paper Appropriate for Turkana County Setting-A review of evidence and implementation strategies
Paul Mikov, MA, Vice President of Institutional Partnerships with Catholic Medical Mission Board shares how CMMB partners with a variety of organizations to deliver care and strengthen health systems, including a program involving care by Catholic nuns.
Peter Yeboah, MPH, MSc, Executive Director of the Christian Health Association of Ghana shares how CHAG works with the Ministry of Health in Ghana to provide health care and addresses challenges and how the organizations works to overcome them.
Overview of the 2018 Update to the Integrated Plan and PrEP Workgroup Draft R...Office of HIV Planning
Mari Ross-Russell (Office of HIV Planning) and Matthew McClain (Public Health Policy & Planning Consultant) presented these slides to the PrEP Workgroup of the Philadelphia EMA HIV Integrated Planning Council on January 16, 2019.
Paul Mikov, MA, Vice President of Institutional Partnerships with Catholic Medical Mission Board shares how CMMB partners with a variety of organizations to deliver care and strengthen health systems, including a program involving care by Catholic nuns.
Peter Yeboah, MPH, MSc, Executive Director of the Christian Health Association of Ghana shares how CHAG works with the Ministry of Health in Ghana to provide health care and addresses challenges and how the organizations works to overcome them.
Overview of the 2018 Update to the Integrated Plan and PrEP Workgroup Draft R...Office of HIV Planning
Mari Ross-Russell (Office of HIV Planning) and Matthew McClain (Public Health Policy & Planning Consultant) presented these slides to the PrEP Workgroup of the Philadelphia EMA HIV Integrated Planning Council on January 16, 2019.
Jennifer Mason, Senior Advisor for FP/HIV Integration for USAID's Office of Population and Reproductive Health describes the agency's approach to integrating family planning services with HIV health services and provides country examples of integration practices.
Learn more about how the Regional Municipality of York explored and implemented a bylaw in their region mandating food handler certification for food premises.
A retrospective review of the Honduras AIN-C program guided by a community he...HFG Project
Factors that influence performance of community health workers (CHWs) delivering health services are not well understood. A recent logic model proposed categories of support from both health sector and communities influence CHW performance and program outcomes. This logic model has been used to review a growth monitoring program delivered by CHWs in Honduras, known as Atención Integral a la Niñez en la Comunidad (AIN-C). A retrospective review of AIN-C was conducted through a document desk review and supplemented with in-depth interviews. Documents were systematically coded using the categories from the logic model, and gaps were addressed through interviews. Authors reviewed coded data for each category to analyze program details and outcomes as well as identify potential issues and gaps in the logic model.
Rebekah Israel discusses how the African American HIV University Science and Treatment College helps community-based HIV organisations and Health Departments improve their performance in the treatment cascade.
The National HIV Prevention Inventory provides the first, comprehensive inventory of HIV prevention efforts at the state and local levels in the United States. Based on a survey of 65 health departments, including all state and territorial jurisdictions and six U.S. cities, the Inventory is intended to offer a baseline picture of how HIV prevention is delivered across the country in an effort to provide policymakers, public health officials, community organizations, and others with a more in depth understanding of HIV prevention and the role played by health departments in its delivery.
Jennifer Mason, Senior Advisor for FP/HIV Integration for USAID's Office of Population and Reproductive Health describes the agency's approach to integrating family planning services with HIV health services and provides country examples of integration practices.
Learn more about how the Regional Municipality of York explored and implemented a bylaw in their region mandating food handler certification for food premises.
A retrospective review of the Honduras AIN-C program guided by a community he...HFG Project
Factors that influence performance of community health workers (CHWs) delivering health services are not well understood. A recent logic model proposed categories of support from both health sector and communities influence CHW performance and program outcomes. This logic model has been used to review a growth monitoring program delivered by CHWs in Honduras, known as Atención Integral a la Niñez en la Comunidad (AIN-C). A retrospective review of AIN-C was conducted through a document desk review and supplemented with in-depth interviews. Documents were systematically coded using the categories from the logic model, and gaps were addressed through interviews. Authors reviewed coded data for each category to analyze program details and outcomes as well as identify potential issues and gaps in the logic model.
Rebekah Israel discusses how the African American HIV University Science and Treatment College helps community-based HIV organisations and Health Departments improve their performance in the treatment cascade.
The National HIV Prevention Inventory provides the first, comprehensive inventory of HIV prevention efforts at the state and local levels in the United States. Based on a survey of 65 health departments, including all state and territorial jurisdictions and six U.S. cities, the Inventory is intended to offer a baseline picture of how HIV prevention is delivered across the country in an effort to provide policymakers, public health officials, community organizations, and others with a more in depth understanding of HIV prevention and the role played by health departments in its delivery.
HIV Prevention And Health Service Needs Of The Transgender Community In San F...Santé des trans
HIV Prevention and Health Service Needs of the Transgender Community in San Francisco by Kristen Clements, MPH, Willy Wilkinson, Kerrily Kitano, Rani Marx.
Il s'agit de l'un des articles parus dans le numéro spécial de l'International Journal of Transgenderism consacré en 1999 à "Transgenders and HIV : risks, prevention and care" (référence : IJT Volume 3, Number 1+2, January - June 1999).
Primary Health Care to CPHC
Primary care has been very selective in the past, covering less than 20% of primary
health care needs. This has made primary care less responsive to felt health care
needs and created the image of the under-performing system.
Primary Health Care is necessarily comprehensive- addressing primary care for all of
reproductive and child health, communicable, and non-communicable diseases and
accidents and injuries through appropriate health communication, technologies and
care provision.
Comprehensive primary health care package will also include nutrition, geriatric health
care, palliative care and rehabilitative care services.
To denote this important policy change, facilities which start providing the larger
package of comprehensive primary health care will be called Health and Wellness
centers.
Budget RESEARCHBudget Template - page 1 of 2GRANT(For Internal Use.docxAASTHA76
Budget RESEARCHBudget Template - page 1 of 2GRANT(For Internal Use Only - see specific sponsoringTitle:Union County of Georgia cancer prevention programagency for the proper forms)Date:12-May-17RFA no.PI:Project Period:2017/2018Budget Period:2017-2018Year 1Field researchResearch assitants( Salaries & benefits)250,000Transport120,000Research tools( questionaires and interviews)50,000420,000Screening actvitiesLocal hospital staff service fees80,000Electricity consumed by equipment20,000Maintenace expenses40,000140,000MarketingNutrionists service fees150,000Local gym service15,000Formation of chamber fo commerce180,000Education workshops ( schools and community centers)50,000395,000
pasterme:
rate as of 7/1/05
subject to change
confirm with the SPH
Business Office
pasterme:
part-time student rate as of 7/1/04 subject to change confirm with the SPH Business Office
pasterme:
rate subject to change Please review all budgets with the SPH
Business Office.
Running head: COMMUNITY COALITION 1
COMMUNITY COALITION 3
Community Coalition
Kimberly Crawford
Kaplan University
January 8, 2018
Community Coalition
1. Choose 5 partnerships to engage and explain why you would invite each of these people//organizations to be a part of the coalition.
The creation of community health promotion and education programs takes into consideration several agencies or parties who help in the achievement of the desired health goals. Each of the partners will address its roles using different approaches depending on their area of expertise. This is an important factor to consider as different institutions address health promotion using different approaches and perspectives. The overall outcome from the contribution of every partner should be able to restore and promote the physical, emotional, spiritual, psychological, and social wellness of the community in relation to the health issue being suffered (Minelli, & Breckon, 2009). Chronic diseases are currently the leading causes of death in the community due to their complexity and the severe effects on human health. The community health promotion and education program will be provided by the ‘Health Concerns Coalition’ which will be made up of the following partners; community religious groups, Cancer Supportive Care Foundation, an association of cancer-survivor patients, nutritional organizations, and the local authority.
1. Cancer Supportive Care Foundation – This is an important part of the coalition as it will offer technical expertise in education and diagnosis of chronic diseases. The foundation team will include medical experts who will diagnose the community members of any chronic illnesses. Examinations for diseases such as breast cancer, prostate cancer, diabetes and blood pressure will be conducted by this partner as they will provide modern machines needed for the diagnosis of chronic illnesses.
2. Community religious groups – Community religious groups ca ...
The Important Role of Population Health Management in Enhancing Healthcare | ...Enterprise Wired
Benefits of Population Health Management: 1. Improved Health Outcomes 2. Cost-Efficiency 3. Enhanced Patient Experience 4. Health Equity and Accessibility
Transforming the Kenya Health Information System (KHIS) to an Early Warning a...Stephen Olubulyera
Transforming the Kenya Health Information System (KHIS) to an Early Warning and Real-Time Electronic Disease Notification System: Optimization for Epidemiology, Disease Surveillance and Response in Kenya.
To develop a concept on transforming the Kenya Health Management Information System (KHIS) to an electronic disease early warning and real-time notification system through optimization of disease surveillance indicators: automatic and real-time notifications integrated into an informative standardised tool. The concepts will enhance and develop part of the list of diseases mandatorily reported within the stipulated period in disease occurrence depending on the case definition of the diseases, virulence and the degree of spread of new emerging diseases that have not been defined e.g. a new infectious disease.
A Retrospective Disease Surveillance Based Approach in the Investigation and ...Stephen Olubulyera
A Retrospective Disease Surveillance Based Approach in the Investigation and Linkage of Human Brucellosis to Animal Sources: One Health Approach Complementary Strategy Applicable in Nomadic Pastoralism, a Case Study of Turkana County, Kenya.
A Research Paper on Community Led-Total Sanitation Approach in Peri-urban and...Stephen Olubulyera
A Research Paper on Community-Led-Total Sanitation in Urban and Peri-Urban Environments: A Case Study of Kakuma, Kainuk, Lodwar, Lokichar, Lokichoggio Towns/Cities--Turkana County.
Infectious Diseases of Public Health Importance and the Benefits of Vaccinati...Stephen Olubulyera
Review of infectious diseases of public health important and the benefits of vaccinating medical & health practitioners and the subordinate staffs against the disease at a hospital setting
A Research paper on Male Involvement Strategy in Maternal, New-Born and Child...Stephen Olubulyera
The research paper highlights strategies on male involvement in Maternal, New-Born and Child Health in Turkana County. Different strategies to reach men with information and services will be appropriate in different contexts, as for Turkana County context
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Nursing Care of Client With Acute And Chronic Renal Failure.ppt
Integrating Community Strategy with HIV Programs:A Research Paper Appropriate for Turkana County Setting
1. A RESEARCH PAPER ON HOW TO APPROPRIATELY ENGAGE THE COMMUNITY IN HIV
PROGRAMS: INTEGRATING COMMUNITY STRATEGY WITH HIV PROGRAMS IN
TURKANA COUNTY SETTING-A REVIEW OF EVIDENCE AND IMPLEMENTATIONS
STRATEGIES: By Stephen Olubulyera-Public Health Officer-Turkana County
~Web of Brilliant Minds~
Linkedin: https://ke.linkedin.com/in/stephenolubulyera
2. - 2 -
ABSTRACT
Interventions defined as “community based” will include interventions by health care workers
performed as outreach e.g. community based HTC campaigns, as well as interventions performed
directly by community members either at the facility or in the community. To achieve strategic
community engagement to ensure acceptability of enhanced provider initiated testing alongside
community based testing interventions should be combined. Maximizing testing coverage whilst
ensuring maximum testing yield should be achieved through targeted outreach for key populations,
families of index clients and in geographic and population based high prevalence areas. To enhance
retention and adherence, strategies that address psychosocial support and patient education,
provide individual patient case management (appointment and defaulter tracing systems) and
services that place the patient firmly at the center of ART delivery.
The critical work of peer educators and community health workers will underpin the intervention.
These cadres support an activity at the facility but because they are community members, will
provide the essential link to the community to support tracing and home based interventions.
Specific interventions for PMTCT such as providing a mother mentor and the organization of health
clubs for adolescent care will demonstrate or have significant impact on retention. Nevertheless,
the mapping of these interventions has demonstrated that there are a range of interventions
already being implemented across the county but are being led by different implementing partners
and with differing terminologies for cadres performing similar functions. What is clear is that to
achieve the target population, HIV programs will need to employ innovative strategies in service
delivery and identify system efficiencies. An enabling environment is also needed, including
mechanisms to strengthen the technical capacity of CBOs, engage community and faith based
leaders in addressing stigma as well as ensuring robust and adaptable “differentiated” models of
service delivery within the health system itself.
However to achieve these goals, the community and health system must act together as one with
the patient placed firmly at the centre of any strategy. The global community has set an ambitious
vision for itself: Getting there will require a massive, coordinated, and urgent mobilization of all
available resources – human, financial, and technical. We need to speed up the uptake of new, rapid
diagnostic tests. We must redouble our efforts to find effective interventions of involving the
community. And we must strengthen our health systems to be able to deliver these ARTs efficiently
to the people who need them most. In this context, there is an urgent need to engage actively with
the community based organizations that are already so important in strengthening and supporting
our formal health systems.
3. - 3 -
HIV PREVENTION, CARE AND TREATMENT CASCADE
The HIV prevention, care and treatment cascade is described below.
Step 1: HIV testing
The HIV care continuum begins with the diagnosis of HIV infection. Individuals who do not know
they are infected can unknowingly pass the virus to others and those who are negative may gain
additional motivation to remain negative through post-test counseling
Step 2: Referral and linkage to medical care
When HIV testing is positive the person must be linked with medical services to undergo clinical
and immunological assessment to determine their eligibility for ART. If not yet eligible (although
universal eligibility for treatment will soon be introduced) the client must be retained in Pre-ART
care with ongoing eligibility assessments.
Step 3: Initiation and retention on antiretroviral therapy
The recent directive from Ministry of Health: every patient is eligible for ART and should be placed
under it immediately he/she is confirmed positive. The client must be initiated and subsequently
retained on ART. Globally 15 million people are estimated to be on ART.
Step 4: Achieving virological suppression
By taking ART as prescribed, a person living with HIV can achieve virological suppression. The
provision of HIV service delivery must place the person living with HIV at the centre of the strategy
in order to maximise both efficiencies for the client and the health system. Four main “levers” of
care can or may alter how, where and by whom care is delivered. The levers can be defined as:
a) Decentralizing care to primary care or beyond (e.g. to health posts or to community
pharmacies). Task shifting to lower cadres.
b) Frequency of the service (linked to duration of refill) and
c) Service intensity (separating the need to see a clinician for clinical assessment and/or
laboratory investigations versus the need for a stable patient to receive ART).
Having these elements in place lay the foundation for any future community intervention.
THE ROLE OF THE COMMUNITY
Strengthening community based strategies across the HIV prevention care and treatment cascade is
vital to maintaining what has already been achieved and will prove more essential to reach the
targets. An important lesson highlighted from the already established interventions of treatment
scale up is that community and civil society organizations are able to ensure accountability, catalyze
demand creation, deliver services (within the facility and directly in the community) and handle
resources efficiently.
To date 95% of HIV service delivery in Turkana County is facility based. If programmes are to
maximize efficiencies both for the health system and for patients, it is estimated that community
based service delivery; if scaled up will cover at least 30% of all services. There will be a prime
opportunity for broader community engagement in the provision of HIV care after initiating
4. - 4 -
community interventions. However, challenges might arise on how to adapt delivery of services to
the ever growing numbers of patients on ART, whilst maximizing the benefits of community
interventions that enhance the quality of care.
Interventions defined as “community based” will include interventions by health care workers
performed as outreach (e.g. community based HTC campaigns), as well as interventions performed
directly by community members either at the facility or in the community. Such community based
interventions involve PLHIV, lay counselors, expert patients, mentor mothers, volunteers,
community health volunteers (CHVs), traditional and faith based leaders and specific community
based organizations (CBOs).
Activities include demand creation for HIV testing services and early ART initiation, service
promotion, ensuring treatment adherence (including support in the identification and interventions
for those failing treatment), provision of psychosocial support, revitalization of the village health
committees to strengthen the link between facility and community, improved networking and
coordinating mechanisms and support for the follow up of defaulting clients. Review of the role and
coordination of these cadres is timely with the international renewed interest in the role of
community health volunteers
The importance of such community engagement within ART delivery has recently been highlighted
by WHO, introducing a chapter on community based delivery of ART in the March 2014 supplement
to the consolidated guidelines on the use of antiretroviral drugs for treating and prevention of HIV
infection
As such, community based activities should now focus themselves towards achieving the 90% of
the targets with evidence based, high impact interventions being implemented at scale. Ensuring
coordinated strategies from the Ministry of Health towards the scale up of community
interventions, recognition of lay workers, coordination of CBOs and engagement of faith based
leaders will be an essential part of the future strategy.
CREATING AN ENABLING ENVIRONMENT FOR THE PROVISION OF COMMUNITY
BASED SERVICE DELIVERY STRATEGIES
1) Strengthen Community Based Organizations
The community will be encouraged to form community based organizations, if there are none-
available especially the CBOs that tackle the aspect of HIV; community based treatment
intervention and support. To relieve the burden on healthcare providers, a number of the non-
clinical tasks relating to patient follow-up and adherence support have been shifted to community
based, lay health workers and volunteers and will rely on activities coordinated by CBOs.
CBOs however require both funding and technical assistance to strengthen their activities. A
number of organizations provide such support with activities including:
Provision of technical assistance and tools to strengthen community based HIV
organizations and groups in HIV technical areas such as HTC, PMTCT and ART.
Organizational systems strengthening.
Provision of grants.
5. - 5 -
Supporting coordination of partnerships, networking and collective advocacy on priority
issues such as stock outs of ARVs and availability of condoms.
Conducting action research and promoting knowledge management that includes
dissemination of lessons learned and evidence-based programming.
Improving monitoring and impact measurement.
Challenges identified in the support of these organizations include:
Rapid turnover of staff who often graduate to larger organizations after capacity building.
Large number of CBOs but no easily available accreditation information regarding quality of
intervention.
Adequate accountability of donor funds by CBOs.
Adequate monitoring and evaluation to measure impact.
2) Engaging Community and Faith Based Leaders
Faith and community leaders in Turkana County play a key role in how their communities make
decisions around health service utilization and influence stigma related to HIV and gender based
issues. They are given respect as opinion leaders in their communities and have a public platform
from which to challenge stigma. While community by-laws and penalization of unwanted health
choices are easily created and enforced, in order to play their rightful role, faith and community
leaders need to be provided with a rights-based and gender transformative capacity building
approach. They should be provided with appropriate tools and be involved in monitoring and
reporting of HIV programmes and activities within their jurisdiction.
3) Creating a county policy framework for community based strategies
There are a wide range of community based interventions being implemented in Turkana County. A
clear framework is needed to identify and prioritize those interventions that target the HIV
Program goals and that should be systematically implemented in all sites regardless of which
partner is supporting. Placement of a new cadre by different NGOs may also cause conflict within
staff in a facility due to differences in salary or allowances, “preferential treatment” and lack of
clarity in management lines. Harmonization of job descriptions, roles, training and salaries would
help to support the accountability of service providers.
The development of the job description and roles may serve as an example of how county
coordinating mechanism can guide implementing partners on a particular intervention with the
long term goal of the ministry absorbing the new cadre into the health staffing establishment list.
COMMUNITY STRATEGIES TO ENHANCE UPTAKE OF HIV TESTING AND LINKAGE TO
CARE
Globally in 2014 an estimated 19.9 million (54%) of people living with HIV knew their status. This
testing gap is more marked for children, with only 32% of children living with HIV being aware of
their diagnosis. This dramatic gap at the entry door of the cascade poses one of the greatest
operational challenges. Current testing practices have limitations both in terms of their reach but
also due to human resource and commodity constraints. To address this first step in the cascade, a
6. - 6 -
strategic mix of testing approaches will be needed, based on an analysis of prevalence data in
specific populations or geographical locations.
To further guide national HIV programmes on testing strategies, WHO released new guidelines for
HIV testing services in July 2015. Two strong recommendations included:
In generalized epidemics a strategic combination of community based HIV testing and
counseling is recommended in addition to PITC.
In all epidemic settings community based HIV testing and counseling is recommended for
key populations in addition to PITC.
Other key points highlighted in the guidelines are that lay workers should be allowed to provide
HIV testing services, PITC should be scaled up beyond ANC and TB settings, and that a new strategy
for community based testing may be considered called test for triage (a single HIV test is offered in
the community with linkage to a facility for confirmatory testing and linkage to clinical care if
needed). Self-testing is also outlined as an option that may be considered.
To address this gap community engagement in the proposed testing strategies will be key.
a) Provider initiated testing and counseling (PITC): the role of the community
Routinely offering an HIV test during clinical encounters at hospitals or primary care settings has to
date been focused in ANC and TB settings. A systematic review examining the operational
implementation of PITC in sub-Saharan Africa noted that the translation of policy into practice was
very mixed, with wide variations in the uptake of testing and that linkage to care and treatment was
often poor. WHO recommends that in generalized epidemics PITC should be offered for all clients in
all services (STI, viral hepatitis, TB, children under 5, immunization, malnutrition, antenatal care
and all services for key populations) as an efficient way of identifying people with HIV. In the
County, PITC to date has not yet been systematically implemented except within ANC, TB and STI
services. This represents significant missed opportunities. Emphasizes that PITC in the highest
priority settings should be the testing model to be immediately strengthened. This includes routine
testing within adult and pediatric inpatient wards, nutrition units, ANC, TB, STI and family planning
clinics. In addition, specific populations at highest risk of HIV infection including sex workers, men
who have sex with men, young women 15-24, fishermen, estate workers and prisoners should be
specifically targeted for testing along with children, where coverage of testing remains low.
However in order for PITC to be accepted as a component of every visit to a health care setting,
community mobilization will be needed. Awareness raising may be performed through community
health workers, support groups and community leaders.
b) Community based HIV testing and counseling
Community based testing models have high rates of acceptability, are important for increasing early
diagnosis, reaching first-time testers and for people who otherwise seldom attend clinical services
such as men, adolescents and key populations. However these approaches generally yield a lower
positivity rate than facility based approaches. Community HTC includes a number of approaches
including door to door home based testing (either targeted to families of index HIV positive clients
or offered to all in a geographical area) and mobile outreach campaigns with testing in workplaces,
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bars, places of worship and educational establishments. To date 93 of 124 countries in 2014
included national policies to support community based HTC.
A study in Uganda performed between 2003 and 2005 comparing stand alone, hospital based PITC,
household index client home based testing and door to door HTC demonstrated that household
member and door to door strategies reached the largest proportion of untested clients whilst
hospital based PITC yielded the highest positivity rates.
c) Door to Door HTC in the County
The door to door HTC model targets areas with high HIV prevalence, low up-take of HTC services,
and areas that-are hard to reach. HTC counselors recruited from within and reside in the
community. Each HTC counselor assigned a population area and is responsible for community
mobilization, health education including nutrition, condom distribution, HTC and linkage to care.
This approach considers the family as the entry point for the service, aiming to reduce stigma and
discrimination in the family and the community as a whole. The volunteer, in liaison with the
community, organizes sensitization meetings for traditional and other community leaders.
Associated activities alongside the door to door HTC include:
Organizing and facilitating periodic HTC Counselors’ meetings which address pertinent issues
affecting areas of operation and training of HTC counselors in door to door approaches.
Household HIV/AIDS pre-and post-test health education.
Support and follow-up counseling, facilitating the formation of support and post-test groups
and provision of training to support and post-test groups.
d) Targeted and integrated community outreach HTC in the County
Community outreach HTC targets all social, age and gender groups. In addition, utilizing community
mobilization and possible outreach testing during expanded programme on immunization (EPI)
visits may also serve to promote increased infant diagnosis. Outreach testing is implemented by
public sector and civil society organizations using health facility outreach teams, CBOs, NGOs and
organizations of PLHIV. A team from the health facility or CSO, community based counselors,
volunteers and HSAs offer HTC services at a community venue such as a club, church, school or
workplace. HIV testing may be offered as a stand-alone service or as part of a general health
promotion approach. At such events, partners distribute IEC materials and arrange various
activities such as theatre groups, motivational speeches on HTC, treatment literacy and STIs.
Counselors refer HIV positive individuals to the health facility for confirmatory testing and
enrolment into pre-ART, ART or other health services. Test kits for community outreach HTC are
sourced from the SubCounty Level.
e) Early infant diagnosis and pediatric HIV testing
Access to effective testing is one of the greatest barriers contributing to this low coverage. Barriers
to pediatric testing have been classified as client related (caregivers not seeing the need to test a
healthy child or wanting to protect the child from the stigma of HIV), provider related (distance to
facility, long waiting times, long turn around for EID results, lack of commodities) and policy related
8. - 8 -
(for example the age of consent to test without a guardian). Missed opportunities for testing have
been reported in many settings
f) Service Integration and enhanced referrals
Integration of ANC and PMTCT has been shown to improve retention but is performed less
systematically postpartum. Implementation of mother baby pair clinics where mothers and
exposed babies are seen simultaneously has served to increase uptake of EID.
g) Role of the community in PITC beyond PMTCT services
Greater efforts to identify the infants of those mothers who have dropped out of PMTCT or who
may have seroconverted during pregnancy and breastfeeding should be made. Strategies proposed
to identify these high risk infants include scale up of opt-out PITC in a range of non-PMTCT settings
(OPD, EPI, IPD and nutrition services). The highest positivity rates have been shown within
inpatient and malnutrition settings. Currently systematic screening of all children attending non-
PMTCT services is not implemented. If this is to be considered, in addition to investment in training
for pediatric disclosure counseling, investment in community mobilization to increase acceptance
of this strategy is needed.
h) Community based testing for children
Evidence on community based strategies specifically aimed at identifying HIV positive children is
lacking. Door to door testing does encourage couple and family testing but in particular targeted
community based testing of children and family members of identified HIV positive cases (index
client testing) may be more cost effective.
i) HIV Self-Testing (HIVST)
HIV self-testing may be an additional strategy to reach those not reached by other HTC services.
Confirmation of a HIV positive result will still need conducting at facility level. A number of models
have been proposed as to where and how to best offer self-tests, ranging from within the facility
where the test is fully supervised or where a test is accessible in the community, distributed by
community health workers or freely available at community pharmacies. Studies are ongoing to
determine efficiencies and cost effectiveness of a variety of self-testing models both in Malawi and
elsewhere.
j) Linkage to care
It is no longer sufficient that clients just test for HIV. It is important that those that test HIV positive
are linked to care and treatment services, whilst those testing negative are linked to preventive
services such as VMMC, SRH and family planning. Data on linkages to care are limited, however one
systematic review following patients from diagnosis to ART initiation demonstrated only 25%
initiating ART. Loss to follow up prior to initiation was higher among men, in patients with low CD4
counts and low socioeconomic status.
In a study performed in Swaziland where home based HTC and mobile HTC were implemented, of
9. - 9 -
those testing positive only 34% enrolled in HIV care and of those eligible only 52% initiated
treatment within 6 months. In rural South Africa, 62% of a cohort of clients testing positive through
home based testing linked to care (defined as having a CD4 at a facility). Factors predictive of
decreased linkage were younger age (15-24), not believing the test result, not having time to seek
health care, belief that ARVs make you sick and drinking alcohol .
A number of strategies to enhance linkage between community based testing and clinical
assessment in a facility have been documented. Examples include referral forms being given to
patients, strengthened post-test counseling, community health workers or other peer workers
accompanying positive patients to the facility, use of immediate CD4 testing in the community or
implementation of reminders using M-health. However, strong evidence for impact is currently
lacking.
Community strategies to enhance HIV prevention
Community Strategies to support interventions such as condom distribution and voluntary medical
male circumcision (VMMC) were not analyzed within the scope of this report. It is recognized
however that the community plays an essential role in mobilizing members to utilize these services.
COMMUNITY BASED STRATEGIES FOR RETENTION AND ADHERENCE
Community based peer support mechanisms, facilitated through support groups or the link
with a designated community worker or buddy enhances retention and adherence to ART.
The impact of support groups on retention and adherence would be facilitated by ensuring a
clear link for every group with a facility manager or HIV service delivery focal person.
Support groups should be self-sustaining and have clear governance and management capacity.
They should be strengthened to evolve into formal community structures potentially
addressing topics beyond HIV such as leadership, income generating activities, nutrition,
education, gender, water and sanitation.
Relying on volunteerism has been raised as a challenge within the home based care model. For
sustainable and quality community based services formalization of roles and responsibilities
and harmonization of payment of lay workers should be considered.
The community ART group model has demonstrated benefits both for the facility
(decongestion) and for the clients (reduced transport costs, peer support).
Having a dedicated lay worker, expert client or community health worker to drive the
formation of CAGs greatly facilitates the scale up of this model.
Additional strategies for community ART delivery have been implemented successfully
elsewhere including community adherence clubs and community ART distribution points.
FACILITY BASED STRATEGIES TO SUPPORT RETENTION AND ADHERENCE
• Decision making on what strategies to implement should be harmonized by the Ministry of Health
and then adapted at local level with engagement of both local health care workers and community
representatives. Implementing partners should still be able to innovate regarding service delivery
in collaboration with their respective Ministry of Health partners.
• Facility and District ART/PMTCT Coordinators should take ownership of these interventions in
collaboration with partners.
10. - 10 -
• Supporting patient case management through a dedicated cadre responsible for adherence
counseling and patient tracing will become increasingly important to achieve quality care and
virological suppression as further scale up of ART is made.
• All facilities regardless of implementing partner support should implement an appointment
system with a systematic and timely defaulter tracing strategy. Where feasible the use of m-health
to support appointment reminders and tracking should be leveraged.
Facility based fast track strategies are an ART delivery model that can decongest clinics for health
care workers and reduce the burden of clinic visits for patients. This option should be available in
all sites as the default facility based option. The maximum duration of refill available through MoH
supply should be provided.
• Having a specific lay cadre responsible for individual case management in PMTCT (antenatal and
postnatal care) has a significant impact on outcomes of the PMTCT cascade. This intervention
should be considered across all sites.
• Integration of PMTCT with ANC and PNC services, for example through the mother baby care
clinics, should be systematically implemented across all sites.
• All sites should be able to ensure there is a skilled and routinely available member of staff
available to perform disclosure counseling for children.
• Children and adolescents should be booked on specific days in order to form immediate peer
support through the “teen club” approach.
• Adherence clubs are a promising model with documented impact on retention and virological
suppression and have been shown to be cost effective in a South African setting.
ESSENTIAL COMPONENTS FOR THE SUCCESS INCLUDE:
1) Clear policy guidance to create and promote an enabling environment through
a. implementing the elements of differentiated care
b. ensuring local ownership of the interventions by health care workers and their
communities
c. adequately supporting CBOs and engaging community and faith based leaders.
2) Strengthening of programme linkages between community structures and health facilities
across the cascade of care to avoid duplication of activities and maximize the impact of
interventions.
3) Recognition of lay counselors, expert patients and the work of volunteers is urgently
needed. Harmonization of roles, responsibilities training requirements and salaries should
be led by the MOH.
4) Ensuring the technical capacity of community groups and individuals through coordinated
training, mentorship and supervision.
5) Providing adequate oversight and stewardship of community based interventions by MoH
and National AIDS Council.
11. - 11 -
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