Counseling and Testing in Health: A Public Health Strategy to Improve Access to Health Promotion in Mozambique Cristina RAPOSO (CDC); Kenete MABJAIA (MOH); Regina BENEVIDES DE BARROS (FURJ)‏ Cecília MUIAMBO (PSI); Pilar SEBASTIAN (PSI)‏ Mindy HOCHGESANG (CDC)‏ Roger FRIEDMAN (CDC); Irene BENECH (CDC) Thank you very much! My name is Cristina Raposo. I work for CDC in Mozambique as the Counseling and testing technical advisor. I am here today to talk about how Mozambique is implementing the Client Initiated Counseling and Testing Strategy.

Mozambique is one of the 4 Portuguese speaking countries Africa, although 70% of the population speak principally local languages. Mozambique is an essentially rural country with 20 million inhabitants.

Let me offer you a chill out moment in Mozambique.

The HIV Epidemic in Mozambique 2007 Sentinel Surveillance National Prevalence: 16% PLW HIV/AIDS 1.7 million 148,000 new infections in 2007 ~500,000 people counselled and tested - 569 MOH sites According to the Sentinel Surveillance data from 2007, the prevalence is 16% and an estimated 1.7 million people live with HIV. There were an estimated 148,000 new infections in 2007 National program data indicate approximately five hundred thousand people (or 5% of the population) were tested in 2007 at 569 community, VCT and provided initiated sites.

Why Counseling and Testing in Health (CTH)? Proposal to better integrate HIV-related services into primary health care Motivated by concern that HIV-specific services contributing to stigma and discrimination Desire to expand package of services provided in HIV CT to include health promotion and prevention issues Why Counselling and Testing in Health or CTH? CTH is a new approach by the Ministry of Health to better integrate HIV-related services into Primary Health Care. This approach was initially motivated by concern that HIV-specific service delivery was contributing to stigma and discrimination and affecting people’s access to these services. There was also a desire to expand the package of services provided in HIV CT, to include health promotion and prevention for key public health issues.

A New Model Cornerstone of CTH is client-initiated testing New model integrates screening, education, and appropriate referrals for key health issues including Malaria, including bednet promotion Early pregnancy diagnosis Promotion of Institutional Delivery Hygiene and Environmental Health Tuberculosis Sexually Transmitted Infections Hypertension Screening done through standardized questionnaire The MOH developed a new model with inputs from a number of program areas The cornerstone of Counselling and Testing in Health continues to be client-initiated testing. The new model aims to integrate more systematic screening and appropriate referrals for key health issues into this service access point These services included Malaria, including bednet promotion Early pregnancy diagnosis Promotion of Institutional Delivery Hygiene and Environmental Health Tuberculosis Sexually Transmitted Infections Hypertension Screening done through standardized questionnaire

Initial Roll-out at Phase I Sites Assess implementation of CTH model to inform further scale-up Assessment parameters Expansion of health promotion activities Inclusion of systematic screenings Strengthening of referrals made among HIV- infected clients to care & treatment services Provision of referrals to HIV-infected and non- infected clients to other health care services CTH was initially rolled-out in 3 Phase I Sites The objective of Phase 1 was to assess the new model and to inform further scale-up of CTH. The assessment parameters were: The Expansion of health promotion activities The Inclusion of systematic screening of clients for TB, STIs and hypertension The Referrals to HIV-infected clients to care & treatment services Referrals to HIV-infected and non-infected clients, to other health care services

Implementation Development 12 counsellors trained CTH Protocols Training materials 12 counsellors trained 3 MOH sites: supported by PEPFAR/PSI 10,000 clients counselled & tested (Mar-Aug 2007)‏ Implementation of Phase I began with development of protocols and training materials. 12 counselors were trained MOH chose 3 sites at primary health care facilities supported by PEPFAR through PSI in urban/semi-urban settings in Maputo City and Maputo Province Approximately 10,000 clients were counselled and tested during the 6 month implementation assessment

Methodology Data Collection and Analysis Assessment data reviewed Existing individual client questionnaire Supplementary forms Screening and Referrals (TB, STIs, HT)‏ Provision of health education Length of counselling and testing session Sub-sample of 950 clients analyzed The assessment included review of the existing CT questionnaire and supplementary forms added to capture aspects of the new approach including Screening and Referrals Provision of health education Length of counselling and testing session A random sample of 10% of questionnaires was analyzed

Results Characteristics of CTH Clients (n=950)‏ 52% women (15-49 years) 2% were known to be pregnant 22% (15-24 years) 46% of all clients tested were HIV-infected 48% - women More than 50% of the clients were women. Of those, 22% were age 15 to 24 46% of all clients tested were HIV infected and of these 48% were women.

Because the MOH had concerns regarding stigma related to HIV-specific services, we compared client initiated versus referrals for CT. The high number of self-referred clients noted here demonstrated that clients do seek CT spontaneously and will access services in this context.

We compared services provided to HIV-infected clients to those provided to uninfected clients. Approximately 70% were referred to Care/Tx facilities 80% were screened for TB and of these, more than 50% found to have at least one symptom of TB 80% of the clients were screened for STIs Nearly 90% had blood pressure measured and 20% had elevated blood pressure Approximately 80% received education on malaria prevention/intervention and hygiene

For HIV-negative clients 72% were screened for TB and a similar proportion screened for STIs. Nearly all were screened for HT with approximately 25% of clients with elevated BP. The majority (75%) of clients were provided with health information on key issues including malaria and hygiene.

Session Length and Adequacy of Counselling Would the additional time constraint of screenings and education cause counsellors to compromise length and quality of counselling services? Mean length of CTH session 30 minutes (range 9-96 minutes)‏ National Guidelines recommend 25-50 minute CT sessions No difference in length of session for HIV- infected versus non-infected individuals One of the concerns for the implementation was that the length of the sessions…. Would the additional time constraint of screenings and education cause counsellors to compromise length and quality of counselling services? We found the mean length of counselling sessions was 30 minutes National guidelines recommended 25-50 minutes for a CT session So there was no difference in the length of sessions for HIV positive or negative clients. We do not have data to assess quality of counselling provided in these settings but the comparable session length for positiev and negative clients raises concerns that sessions were not adequate in terms of risk assessment and education.

CONCLUSION CTH appears to be a promising strategy for integrating package of HIV and public health services Health promotion services for persons accessing HIV CT HIV CT for clients accessing health promotion services Most promising linkages include HIV infected individuals in need of TB, STI referrals Persons with Hypertension Delivery of Health Education Messages CTH appears to be a promising strategy for integrating HIV prevention into a health promotion package by providing Health promotion services for persons accessing HIV CT and vice versa. Most promising success at identifying HIV infected individuals in need of TB referral Persons with Hypertension Delivery of Health Education Messages

Limitations Incomplete data on client symptoms Lack of documentation on client follow up with referred services The limitations include incomplete information on clients’ symptoms And lack on documentation on client follow up with referred services

Considerations for Scale-Up of CTH Standardizing implementation of the package of services Adapting M&E tools to capture new service model Ensuring that the length and content of HIV counselling provides adequate risk assessment and risk reduction Improving referral processes and documentation to ensure strong linkages between programs and service sites Developing ways to measure the impact of the health education/promotion components to maximize benefit to all clients accessing CTH if CTH is to have a successful scale up in Mozambique, challenges will be standardizing implementation of the package of services Adapting M&E tools to capture new service model Ensuring that the length and content of HIV counselling provides adequate risk assessment and risk reduction Improving referral processes and documentation to ensure strong linkages between programs and service sites Developing ways to measure the impact of the health education/promotion components to maximize benefit to all clients accessing CTH

Ministry of Health, Mozambique Centers for Disease Control and Prevention, Global AIDS Program Population Services International Federal University of Rio de Janeiro Staff and clients at Bagamoio, Machava, and Primeiro de Maio health facilities I would like to acknowledge the participation of these colleagues and thank you for your attention.