Zimbabwe: Engaging Community in HIV and AIDS programming Dr Angela Mushavi National PMTCT and Paediatric HIV Care and Treatment Coordinator 9/11/2012 IATT Webinar

Zim’s community engagement program to discuss the benefits, challenges, and barriers to engaging communities in HIV prevention, care, and treatment efforts

3 Zimbabwe Population 12 million PLHIV 1.1 million CLHIV HIV prevalence in ANC 16,1%

ZDHS 2010/11 15% of adults are HIV-positive. This is a significant decrease from 18% in – Currently, 18% of women and 12% of men are infected HIV prevalence is highest in Matabeleland South Province (21%) 12% of couples are discordant—meaning one partner is infected and the other is not. 6% of young people age are HIV-positive

Background of Zimbabwe 90 % ANC attendance-and only 19% in the first trimester (ZDHS 2010/11) 86% of HIV positive pregnant women receive ARVs for PMTCT (2011 data) 65% of live births delivered in a health facility* Maternal Mortality Ratio (MMR) has increased from 555/ (ZDHS 2005/6) to 960/ * 26% of MMR is attributable to HIV/AIDS 21% of the Under 5 Mortality (<5MR) is attributed to HIV/AIDS (MIMS 2009) Contraceptive prevalence rate is 66%* with unmet need for FP of 13% * ZDHS 2010/11

The 7 Strategic Objectives of the eMTCT Plan 6 1.Strengthen program leadership, management, coordination and supervision of sites 2.Strengthen provision of quality PMTCT and Paediatric HIV treatment services integrated within the MNCH platform 3.Strengthen human resource capacity 4.Strengthen the supply chain management system for commodities

The 7 Strategic Objectives of the eMTCT Plan 5.Strengthen laboratory capacity to support eMTCT 6.Strengthen community involvement and participation 6.Improve generation, dissemination and use of strategic information

Bottlenecks to eMTCT that Community Based Workers Can Best Tackle Late booking for ANC Low percentage of pregnant women presenting for at least 4 ANC visits Low proportion of institutional deliveries Low male participation Low postnatal mother-baby pair follow-up rates N.B. Indeed community based workers can deal with all of the bottlenecks along the PMTCT/EID cascade

Zimbabwe’s Village Health Workers The History of Village Health Worker Programme The VHW dates back to 1981, when Ministry of Health and Child Welfare introduced this cadre for the first time at community level (PHC approach) Cadre is selected by her own community, and trained for 8 weeks Works on assigned duties part time-and stays in own community The VHW program is national; with a strategy-and is managed by the Director of Nursing Services in the MOHCW Anticipated to have VHWs in post

Village Health Worker (VHW) program: an Opportunity in PMTCT implementation VHWs have become important in tackling HIV For PMTCT, VHWs encourage Early ANC booking and repeated ANC attendance HIV testing Facility deliveries Postnatal mother- baby pair follow-up Picture: Courtsey of Zvitambo

Village Health Care Workers in PMTCT Global Fund supports the VHW program currently; though this should be by MOHCW (budgetary constraints) Zvitambo supports VHWs in 2 of the country’s districts Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) is supporting VHWs to scale-up eMTCT in 8 districts Early reports: average age at booking has improved to 21 weeks gestation-from average 25 weeks at booking

ZAPP’s Community Involvement in the PMTCT Program ZAPP-UZ: first in Zimbabwe to meaningfully involve community in PMTCT as peer counsellors-known as community mobilisers (CMs) CMs are men and women who have benefited from the PMTCT program Recruited in collaboration with the Community Advisory Board in Chitungwiza - link between community and health services Trained to serve as community advocates; mobilizing and educating communities on PMTCT, EID and pediatric treatment

ZAPP-UZ Community Mobilizers Performing Drama at a Church Meeting

MSF support for mentor mothers in Bulawayo Modelled along the lines of the M2M program in South Africa Women living with HIV provide support to other such women during pregnancy and beyond (mother-infant pairs) 24 mentor mothers each looking after 15 clients at any given time Promising results coming out of clinic sites where mentor mothers are operating

RESULTS - PROGRAMMATIC DATA P value <0.0005

After testing - did mother obtain result? P value <0.0005

Male participation in PMTCT Countries within sub-Saharan Africa are mostly male dominated communities: Men give permission to the woman to seek care, give money for transport and even decide whether the woman should fall pregnant or not Low male participation places eMTCT efforts at risk; and women face the threat of GBV and dissertion especially if they disclose an HIV positive status Initiatives such as the male champions initiative supported by UNICEF; as well as Padare Men’s Forum (UNAIDS) are implemented to tackle this

Male Partner HIV Testing in ANC in Zimbabwe

Community initiatives key to tackling low male participation in eMTCT An organization called Padare/Enkundleni/Men’s forum on gender, is leading an initiative to strengthen the capacity of traditional leaders (chiefs) to increase male participation HIV and AIDS programming Given an opportunity, men can be positively engaged to address issues of low male participation in health and improve male health seeking behaviour as it relates to HIV testing treatment and supporting women for PMTCT Results: in 1 district, male participation in PMTCT has increased to 70% (with a national average of 10%)

Padare Works Through the Chiefs

Challenges to engaging communities in HIV prevention, care and treatment There are many different organizations with different community cadres and it is difficult to harmonize all of them in terms of – Scope-what they do – How they work – Allowances and support for travel and communication e.g. airtime for cell phones There are issues of confidentiality where clients visited by community based cadres may feel that there will be inadvertent disclosure of their HIV status (dealing with stigma and discrimination) Dealing with community cadre burnout-care of carers

Recommendations There is no underestimating the role that communities can play in supporting HIV prevention, care and treatment programs Various initiatives are in place-and all of these will need to be scaled-up and probably harmonized to allow attainment of goals for HIV prevention care and treatment And in-country, the discussion is how to scale- up these initiatives for nationawide coverage

Acknowledgements MOHCW Director Nursing Services MOHCW PMTCT Program National AIDS Council EGPAF ZAPP-UZ Zvitambo MSF Zimbabwe UNICEF UNAIDS Padare

Thank you Tatenda Siyabonga 24