PZAT’s longest standing project in Zimbabwe is SHAZ! (Shaping the Health of Adolescents in Zimbabwe) – an HIV intervention and research project located in Chitungwiza, funded by the National Institutes of Health. SHAZ! works to empower adolescent women aged 16 to 19 living with HIV through a combination of HIV prevention, treatment, care, and support, life-skills education, and improved economic opportunities through vocational training and micro-grants. This effort began in the beginning of 2000 (through partners that preceded PZAT), to identify prevention strategies for adolescent women. It expanded to increasing access to HIV services for young women living with HIV in 2009. Today, the SHAZ HUB runs as a drop in center for young people (16 to 24 years), focused on providing comprehensive sexual health, HIV and wrap-around services, including the provision and operations research for providing oral PrEP and new HIV prevention options for young people when they become available.
The TO initiative is a partnership between WHO, UNAIDS and Pangaea, funded by the Bill and Melinda Gates Foundation. On January 26th 2012, the Ministry of Health and Child Welfare convened a meeting with partners to consider how the global Treatment Optimization Initiative, can support national HIV treatment priorities, particularly antiretroviral therapy.
Aim of the global Treatment Optimization initiative:
To maximize the utility of existing therapeutic, diagnostics and delivery systems, providing greater health outcomes within existing planned and committed resources
To achieve this, individual work-streams (on drugs, diagnostics and health services) have been established, all underpinned by reducing costs and mobilizing communities.
Five priorities were established to help drive and support the Zimbabwe-focused TO initiative. One of the priorities is to enhance the decentralization of HIV treatment delivery systems. A follow-up meeting was arranged to identify steps to enhance decentralization efforts.
In March 2012, WHO in collaboration with the Ministry of Health and Child Care and Pangaea held a consultative meeting to examine approaches for community-oriented HIV service delivery and linkages of such models with healthcare delivery systems in improving demand for and use of HIV treatment and prevention in sub-Saharan Africa. The meeting brought together 40 stakeholders including community-based activists and service providers, researchers, health policy analysts, and national programme managers from Ministries of Health, to examine models of community-centred HIV service delivery in sub-Saharan Africa. The intent of the meeting was to share experience of community-oriented service delivery models and build the body of knowledge and evidence on the impact of community engagement on health outcomes in all aspects of the HIV treatment cascade (testing, linkage to care, initiation of treatment, lifelong care, and retention across the continuum of care). The findings from this meeting informed WHO as the agency develops service delivery guidelines, as part of the 2013 consolidated guidelines, in HIV treatment and prevention.
The meeting participants reviewed current efforts and discussed priorities for scaling up these activities.
Within the framework of Treatment 2.0, key objectives of this meeting were to:
- Inform normative guidance for HIV service delivery to improve the demand for, access to and use of HIV treatment.
- Support scale up of community systems strengthening for service delivery and advocacy.
- Define models of HIV treatment service delivery that rely on community systems and which integrate health care delivery systems and community-based mechanisms.
- Identify promising country-level practices for community-level HIV service delivery that could potentially be adapted in other settings.
Plenary presentations focused on approaches to improve and scale up HIV testing and counselling, linkage to health services, and initiation of ART, treatment adherence, and retention in care. Participants discussed how progammes and project experience and data could be used to support WHO service delivery guidelines development, determine the key components for scale up, and define areas for further operational research.
The Deputy Minister of Health and Child Welfare of Zimbabwe, the Honourable Dr. Douglas T. Mombeshora, opened the meeting by welcoming participants to Zimbabwe. He affirmed the importance of community mobilisation as a key pillar of Treatment 2.0 and reiterated the government of Zimbabwe’s commitment to the global response to AIDS and to meeting the MDGs by 2015.
Dr. Custodia Mandhlate, WHO Country representative in Zimbabwe, also welcomed the participants, highlighting that one of the fundamental principles of primary health care is involvement of communities. This was captured in the Alma Ata Declaration on Primary Healthcare in 1978 and reaffirmed in the Ouagadougou Declaration on Primary Healthcare and Health Systems in Africa in 2008. She affirmed that empowering community health workers must be revived in the context of the response to the HIV epidemic, and its integration, where appropriate, with other key health and social priorities.
Before concluding the meeting, participants shared the following reflections and observations emerging from the content of the previous days discussions with the aim of setting forth principles and values to guide the WHO guidelines development process, the furtherance of the Treatment 2.0 agenda, and the Treatment Optimisation Framework.
- Efforts to estimate the costs of community mobilisation are needed to enhance UNAIDS’ Strategic Investment Framework and other advocacy initiatives to hold governments and donors accountable to their commitments to HIV/AIDS.
- New and sustainable funding streams should be established to support core costs and capacity building for community-based organisations and networks playing a role in treatment optimisation.
- Existing funding streams should be oriented to support, not hinder, sustainable linkages between community-based service delivery programmes and formal health systems in order to maximise the value of funding for treatment.
Remuneration and Training of Community-Based Counsellors and Caregivers
- WHO guidelines on task shifting and service delivery should include clear guidance on remuneration, training, and the creation of pathways to professional employment for lay counsellors and HIV caregivers. CSS and the devolution of health care provision to the community (task-shifting) must not be used as a means to secure cheap labour and demonstrate cost effectiveness in this time of economic austerity.
- Integration is needed within HIV service intervention, such as prevention and treatment, while integrating into primary healthcare. At national and local levels, disparate organisations and government health departments provide testing, enrolment of patients into treatment and care, and community mobilisation, leading to duplication, burdens on patients and inefficiencies.
- A focus on treatment barriers facing women and girls is critical given disproportionate infection rates, especially in sub-Saharan Africa.
- It must be acknowledged that majority of HIV caregivers are women and strategies that provide relief from their burden of care (remuneration, training, psychosocial counselling) must be considered as part of the WHO guidelines development process.
- The high mortality and attrition rates of men must be addressed through the treatment optimisation framework. Men are dying at a rate of 2 to 1 compared to women because they are diagnosed late, adhere poorly to treatment, and are lost to follow up at very high rates.
Children and Adolescents & young people
- Expanding access to HIV testing, care and treatment to children and adolescent, and addressing specific issues including stigma and human rights violations in healthcare settings should be addressed as a priority.
AS a follow up to the meeting above ,on the 29th of March, the Ministry of Health & Child Welfare co-hosted, with WHO and Pangaea, a national meeting entitled, “Decentralization of HIV Prevention, Care and Treatment: Linking Community Interventions with health care delivery systems.” This meeting explored the challenges faced as the country endeavors to expand geographic access to HIV prevention, treatment, and care services but with a special focus on HIV Treatment and Care issues.
Participation in the meeting included representatives from organizations supporting HIV prevention, treatment, care services in Zimbabwe, including a mixture of policy makers, facility and community-based service providers, health managers, technical experts, HIV treatment funders, and the beneficiaries of HIV services especially people living with HIV. Approximately 100 people attended, 30 of which were from outside Harare. All participants were provided with IEC materials on the MOH&CW 2011 decentralization guidelines and the WHO 2010 HIV/AIDS treatment guidelines.
Key themes were identified as priorities during the meeting, including the importance of community systems in the care and treatment of people living with HIV, and the need for these community systems to be integrated with care provided through health facilities.
It was decided that a follow-up consultation focused on this topic that ensures and promotes comprehensive community engagement with public sector, was necessary in order to move towards developing an operational framework on strengthening linkages between public sector and community Systems to codify the integration of community and health care delivery systems. This consultation took place on the 6-7 of August, 2012, at the Bronte Hotel in Harare.
The objectives of the consultation were to:
- Identify effective community models that support HIV care and treatment, including HIV testing, linkage to and retention in care, with the goal of achieving universal access to HIV services by 2015.
- Recognize critical success factors and barriers to integration of community interventions with the health care system.
- Strengthen linkages between the community and health system at the different levels of health care delivery.
There was broad agreement that community systems have the potential to be more responsive to certain needs and priorities of beneficiaries (allocative efficiency) and comparatively cost effective (productive efficiency) because of lower levels of bureaucracy and better knowledge of local costs. The key is identifying how best to link the public sector and community systems to optimally meet the needs of the clients.
It was also recognised that service integration and linkages can improve care and reduce missed opportunities for key interventions such as HIV testing, provision of ART, PMTCT, and adherence support. Integration of care is an important strategy to improve patient retention in long-term HIV care and treatment.
NAC, with secretariat support from Pangaea, will convene a steering Committee drawing from various stakeholders appointed to develop an Operational Plan for Strengthening Linkages between public sector and community Systems, leveraging existing policies and documents that respond to the recommendations that were brought forward in this meeting.
As an outgrowth of these Treatment Optimisation meetings, Pangaea-Zimbabwe provided support to the Ministry of Health & Child Welfare to address these priorities, acting as a secretariat under the national ART Partnership Forum and Laboratory Partnership Forum from 2012 to 2016. This support consisted of Pangaea-Zimbabwe staff time to help convene meetings, draft meeting notes and follow-up with key stakeholders accountable for agreed-upon action items.
Through the Wild4Life Health project and the Ministry of health and Child Care (MOHCC), PZAT worked to strengthen facility and community primary care service delivery in the Hwange district’s 17 rural health centers. Strategies employed to strengthen integrated HIV prevention, care and treatment services including facility and community based strategies, index case testing and family centered approaches. Comprehensive clinical mentorship, mentorship and support for village health workers and other community based cadres and integrated outreaches ensured improved access to services and better outcomes for people living with HIV (PLHIV) and health outcomes for the population in general in the district. Services provided during outreaches at community level include HIV testing, enrollment into care for those diagnosed to be HIV positive, screening for TB and initiation of isoniazid preventive therapy, provision of Antenatal Care (ANC) and PMTCT services and nutrition assessment and supplementation. Between 2015 and 2017, overall HIV testing doubled (and more than tripled for children), increasing the total number of clients on ART by 38•4% with viral suppression rates ranging from 88-93% across different population groups. Furthermore, the number of TB suspects identified increased by 93•4%; and the proportion of pregnant women who made their first antenatal visit before 16 weeks gestation rose from 31•4% to 48%. Differentiated service delivery models were set up, with 30% of the adolescent and adult clients on ART access services through community ART refill groups.
PZAT improves access and outcomes through sustainable management models. Engaging health center committees and the district health executive through mentorship and building capacity on leadership and governance was core to the success in Hwange district.
PZAT served as the Monitoring &Evaluation partner within the I-TECH consortium (from 2013 through 2017) for evaluating the HIV care and treatment program in partnership with the Ministry of Health and Child Care (MOHCC), and for reporting on PEPFAR indicators. PZAT was responsible for designing and implementing evaluation tools, developing and managing large-scale data bases for analysing evaluation data, and in accessing and using Zimbabwe’s Health Management and Information System data to track facility performance related to the training and mentoring of health care workers. Through these efforts, PZAT has developed staff capacity and partnerships in: data base design and management; use of program data to inform program roll-out and improvement; expertise in working with the national DHIS systems, data and MOHCC staff at national, provincial and district level; and in developing software for using hand-held tablets for field-based data collection. Furthermore, PZAT has built the infrastructure required to conduct and manage large data sets.
PZAT served as the evaluation partner for the Coalition for Effective Community Health and HIV Response, Leadership and Accountability (CECHLA) consortium, which aims to improve access to quality HIV services among key populations (young people, sex workers and internally displaced people) through improved advocacy by local organizations targeting national and community level actors. In its role, PZAT developed and oversaw an M&E plan to guide consortium members and communities towards achieving outcomes in national policies, transparent funding allocations, reduced stigma and discrimination, and improved service delivery for people living with HIV, young people, sex workers and displaced populations.
PZAT has documented capacity to develop questionnaires and other data collection instruments that monitor on the ground/facility/community level challenges and can be used to enable evidence based advocacy. These include a questionnaire aimed at understanding and improving the impact of a results-based financing mechanism at the facility level and community score cards on quality of health centre services, health facility staff & community attitudes towards key populations as well as accessibility, availability and affordability of HIV services. This capacity to tie documentation and use of data collection tools to advocacy goals as well as to project management needs is a unique core strength of PZAT. The project ended in September 2017.
Between 2013 – 2016, Pangaea, in partnership with the Clinton Health Access Initiative (CHAI), with funding from the Bill and Melinda Gates Foundation, have developed and costed a series of single descriptive case studies documenting effective approaches to HIV service delivery in Sub-Saharan Africa. The goal of the project is to improve uptake of and retention in effective HIV service delivery to improve treatment and prevention outcomes.
The documentation of successful approaches to increase demand for and sustained use of HIV testing, treatment, prevention and support services provides a resource for country level program managers, program implementers, advocates and donors to better determine how to scale up programs effectively and gain maximum benefit from resource investments. The case studies reflect intervention level reviews that describe interventions that are particularly effective at addressing a component or multiple components of the continuum HIV prevention and treatment services. The selection of programs for the case studies present information and cost estimates about a diverse set of programs, that look at both community- and facility-based services, programs addressing urban and rural populations, key affected populations, and programs that are well integrated with other areas of health services including primary care, sexual, reproductive, and maternal health services. Through this process, Pangaea seeks to improve uptake and scale of HIV services and fill the gaps in the HIV treatment cascade.
Case Study Selection
Selected case studies fall along one or more of the major steps of the continuum of HIV prevention, care and treatment services including: 1) HIV Testing to Linkage to pre-ART care, 2) pre-ART care to Treatment Initiation, and 3) Treatment Initiation to Retention and Viral Suppression. We used a 2-step process to identify particular programs or implementation models. The process is described below:
Step 1: Literature Review and Key Informant Interviews
Pangaea conducted a formal literature review, utilizing the scoping report methodology identifying programs in southern and eastern Africa that have already reported on (or have been evaluated by outside parties to report on) specific strategies to maximize HIV testing, linkage to care and/or long term engagement in HIV care and treatment.
Pangaea also conducted a “grey literature” review in order to obtain additional information about promising interventions that are often not evaluated in mainstream journals, but are available in the public domain.
Pangaea conducted a series of key stakeholder interviews with selected program managers at Health Ministries, donors that fund health services including PEPFAR and the Global Fund, UNAIDS and WHO country officers, World Bank, researchers, health care implementers, and community networks. The purpose of these interviews is to identify programs with data that document their effectiveness, but that may not, or not yet, been documented in written, publicly available, formats.
Step 2: Preliminary Assessments
This stage of the review was two-pronged that included a desk-based further analysis of published (or other public-domain) documentation about specific programs, and email/telephone communication or face-to-face meetings (when possible) with the lead director or manager of the proposed programs. This review led to the selection of 70 programs for initial review/evaluation, followed by a more in depth review to reach 20. From the 20 programs, the study team developed a scoring sheet to judge programs based on 3 major criteria: effectiveness, scalability and accessibility to reach the six programs outlined below.
This is the final selection of case studies that were evaluated under the project. Reports for these are found on this website in the reports section.
Selected Case Studies
|Academic Model Providing Access to Healthcare (AMPATH): Home-based Testing & Counseling and Linkage to Care||Eldoret, Kenya|
|Africaid – Zvandiri: Community Adolescent Treatment Supporters (CATS) Model||Harare, Zimbabwe|
|Government of Mauritius: Harm Reduction & Methadone Program||Port Louis, Mauritius|
|The Liverpool Voluntary Counseling & Testing (LVCT) Health: Key Populations Program||Nairobi, Kenya|
|Uganda Ministry of Health: HUB Model Sample Transport System||Kampala, Uganda|
Pangaea undertook a landscaping review of how HIV care is provided in Zimbabwe, with an emphasis on differentiated care. Differentiated care is a client-centered approach that simplifies and adapts HIV services across the cascade of care to reflect the preferences and expectations of various groups of PLHIV while reducing unnecessary burdens on the health system . This project was a collaboration between Pangaea and the Zimbabwe Ministry of Health and Child Care, and was supported with funding from the Bill and Melinda Gates Foundation.
Secondary objectives of the assessment included:
- To assess, as far as possible, the clinical, immunological and virological outcomes between those receiving standard of care vs. types of differentiated care
- To understand the perceptions, priorities and preferences in HIV service delivery of providers and recipients of HIV care.
To achieve these objectives, a cross sectional study, with both quantitative and qualitative methods, was conducted. The study was conducted in a sample of 46 public and private facilities offering HIV care services in Zimbabwe. In addition, five facilities with known community adherence retention groups were purposively selected and included in the study.
A total of 46 health facilities were enrolled in the study. Most health facilities included in the study were rural health centres (10, 22%), followed by mission hospitals (9, 20%), district hospitals (7, 16%) and council clinics (7, 16%). There were 28 facilities (62%) that indicated they received support from at least one implementing partner.
Virtually 100% of facilities were offering basic HIV services, including ART initiation, ART refill with a clinical visit, clinical monitoring of disease through CD4, nurse-based care, and OI treatment. 52% of the facilities were offering fast track refills without clinical visits, including at primary and secondary level facilities. Only 28% of the facilities reported that they offered access to viral load testing while all the facilities reported offering CD4 monitoring; however, both viral load and CD4 count were not available all the time mainly due to machine breakdown and shortage of reagents or cartridges.
In terms of service location, 50% of the facilities offered community outreach with a greater proportion of primary and secondary level facilities offering this compared to tertiary/quaternary facilities. 28% had community adherence refill groups. Four of the facilities offered services at household level through outreach. 63% of facilities offered primary care counselors and 26% offered expert patients contributing to service provision.
Zimbabwe is well advanced in the rollout of differentiated care. With large numbers of PLHIV and limited financial and human resources, MoHCC has decentralized HIV services, endorsed task shifting and has introduced differentiated care with the national policy of three monthly visits and three-month supply of ART for stable clients. Guided by the OSDM, 6-monthly clinic visits are rolled out for stable clients and drug pick will be further simplified through fast track refills.
Based on feedback from MoHCC and stakeholders, for differentiated care to work efficiently, it requires sufficient and reliable support and resources especially human resources and uninterrupted drug supply. There is need to work with community cadres to make sure there is adequate support for health care workers and clients alike. Use of expert clients, Community adolescent treatment supporters (CATS) and other community workers will ensure a holistic approach to improving health outcomes for clients while ensuring sustainability of these models.
Other recommendations include formation of a district working team that includes PLHIV to stimulate demand as more stable clients can benefit from differentiated care. There is also need for ongoing supervision from district health teams essential for successful scale-up. MSF also recommended strengthening of M&E systems to ensure clients in community models of care do not reflect as lost to follow up (LTFU).
While AFRICAID provides differentiated care for adolescents living with HIV, consideration is needed for special groups and key populations such as sexual workers, truckers, adolescents and young adults in terms of what works for them.
Zimbabwe currently offers differentiated care for stable clients but needs of those on ART who are non-stable and at risk of treatment failure have not been widely addressed. There is need to address unstable clients as recommended by WHO in the 2015 guidelines to ensure that all clients are catered for.