The Tingathe programme: a pilot intervention using community health workers to create a continuum of care in the prevention of mother to child transmission of HIV (PMTCT) cascade of services in Malawi

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Abstract

Introduction

Loss to follow-up is a major challenge in the prevention of mother to child transmission of HIV (PMTCT) programme in Malawi with reported loss to follow-up of greater than 70%. Tingathe-PMTCT is a pilot intervention that utilizes dedicated community health workers (CHWs) to create a complete continuum of care within the PMTCT cascade, improving service utilization and retention of mothers and infants. We describe the impact of the intervention on longitudinal care starting with diagnosis of the mother at antenatal care (ANC) through final diagnosis of the infant.

Methods

PMTCT service utilization, programme retention and outcomes were evaluated for pregnant women living with HIV and their exposed infants enrolled in the Tingathe-PMTCT programme between March 2009 and March 2011. Multivariate logistic regression was done to evaluate maternal factors associated with failure to complete the cascade.

Results

Over 24 months, 1688 pregnant women living with HIV were enrolled. Median maternal age was 27 years (IQR, 23.8 to 30.8); 333 (19.7%) were already on ART. Among the remaining women, 1328/1355 (98%) received a CD4 test, with 1243/1328 (93.6%) receiving results. Of the 499 eligible for ART, 363 (72.8%) were successfully initiated. Prior to, delivery there were 93 (5.7%) maternal/foetal deaths, 137 (8.1%) women transferred/moved, 51 (3.0%) were lost and 58 (3.4%) refused ongoing PMTCT services. Of the 1318 live births to date, 1264 (95.9%) of the mothers and 1285 (97.5%) of the infants received ARV prophylaxis; 1064 (80.7%) infants were tested for HIV by PCR and started on cotrimoxazole. Median age at PCR was 1.7 months (IQR, 1.5 to 2.5). Overall transmission at first PCR was 43/1047 (4.1%). Of the 43 infants with positive PCR results, 36 (83.7%) were enrolled in ART clinic and 33 (76.7%) were initiated on ART.

Conclusions

Case management and support by dedicated CHWs can create a continuum of longitudinal care in the PMTCT cascade and result in improved outcomes.

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Most cited references 27

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Achieving child survival goals: potential contribution of community health workers.

Andy Haines, David Sanders, Uta Lehmann … (2007)

There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.

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Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa.

R. Zachariah, N. Ford, M Philips … (2009)

Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions and low motivation. In particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières' experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition and international 'brain drain'. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.

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Task shifting: the answer to the human resources crisis in Africa?

Uta Lehmann, Wim Van Damme, Francoise Barten … (2009)

Ever since the 2006 World Health Report advocated increased community participation and the systematic delegation of tasks to less-specialized cadres, there has been a great deal of debate about the expediency, efficacy and modalities of task shifting. The delegation of tasks from one cadre to another, previously often called substitution, is not a new concept. It has been used in many countries and for many decades, either as a response to emergency needs or as a method to provide adequate care at primary and secondary levels, especially in understaffed rural facilities, to enhance quality and reduce costs. However, rapidly increasing care needs generated by the HIV/AIDS epidemic and accelerating human resource crises in many African countries have given the concept and practice of task shifting new prominence and urgency. Furthermore, the question arises as to whether task shifting and increased community participation can be more than a short-term solution to address the HIV/AIDS crisis and can contribute to a revival of the primary health care approach as an answer to health systems crises. In this commentary we argue that, while task shifting holds great promise, any long-term success of task shifting hinges on serious political and financial commitments. We reason that it requires a comprehensive and integrated reconfiguration of health teams, changed scopes of practice and regulatory frameworks and enhanced training infrastructure, as well as availability of reliable medium- to long-term funding, with time frames of 20 to 30 years instead of three to five years. The concept and practice of community participation needs to be revisited. Most importantly, task shifting strategies require leadership from national governments to ensure an enabling regulatory framework; drive the implementation of relevant policies; guide and support training institutions and ensure adequate resources; and harness the support of the multiple stakeholders. With such leadership and a willingness to learn from those with relevant experience (for example, Brazil, Ethiopia, Malawi, Mozambique and Zambia), task shifting can indeed make a vital contribution to building sustainable, cost-effective and equitable health care systems. Without it, task shifting runs the risk of being yet another unsuccessful health sector reform initiative.

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Author and article information

Journal

Journal ID (nlm-ta): J Int AIDS Soc

Journal ID (iso-abbrev): J Int AIDS Soc

Journal ID (publisher-id): JIAS

Title: Journal of the International AIDS Society

Publisher: International AIDS Society

ISSN (Electronic): 1758-2652

Publication date (Electronic): 11 July 2012

Publication date Collection: 2012

Volume: 15

Issue: 4(Suppl 2)

Electronic Location Identifier: 17389

Affiliations

[1 ]Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA

[2 ]Baylor College of Medicine-Abbott Fund Children's Clinical Center of Excellence, Lilongwe, Malawi

[3 ]UNC Project, Lilongwe, Malawi

[4 ]University of North Carolina School of Medicine Chapel Hill, NC, USA

[5 ]Malawi Ministry of Health, Lilongwe, Malawi

[6 ]Department of Medicine, Baylor College of Medicine, Houston, TX, USA

Author notes

[§ ] Corresponding author: Maria H Kim, Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA. Tel: 832-822-1038. ( mhkim@ 123456bcm.edu )

[* ]These authors contributed equally to this work.

Article

Publisher ID: 17389

DOI: 10.7448/IAS.15.4.17389

PMC ID: 3499848

PubMed ID: 22789644

SO-VID: 54c12cdd-d696-4de1-808b-b45cba47e30a

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Tingathe programme: a pilot intervention using community health workers to create a continuum of care in the prevention of mother to child transmission of HIV (PMTCT) cascade of services in Malawi

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Abstract

Introduction

Methods

Results

Conclusions

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HIV Self-Testing

Most cited references 27

Achieving child survival goals: potential contribution of community health workers.

Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa.

Task shifting: the answer to the human resources crisis in Africa?

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