Community Based Approaches: A review of intervention models and evidence of their effectiveness for preventing maternal-to-child transmission of HIV Joanna Busza 17 July 2011

Thematic Synthesis of the Evidence on: Increased uptake of HIV care and treatment services among pregnant women and vertically-infected children; Increased uptake of HIV care and treatment services among pregnant women and vertically-infected children; Improved retention of individuals in prevention for vertical transmission, care and treatment programs; Improved retention of individuals in prevention for vertical transmission, care and treatment programs; Enhanced adherence of pregnant and lactating women, their partners and children to ARV prophylaxis and/or ART and/or other care regimens; Enhanced adherence of pregnant and lactating women, their partners and children to ARV prophylaxis and/or ART and/or other care regimens; Strengthened psychosocial well being of pregnant and lactating women and children enrolled in care and treatment programs Strengthened psychosocial well being of pregnant and lactating women and children enrolled in care and treatment programs

Methods Identification of existing systematic reviews Identification of existing systematic reviews Review of data on barriers to PMTCT Review of data on barriers to PMTCT Development of conceptual framework Development of conceptual framework Literature Searches Literature Searches Assessment of research quality based on study designs Assessment of research quality based on study designs Analysis of available data on community based intervention approaches Analysis of available data on community based intervention approaches

HIV Treatment Cascade AwarenessTestingDiagnosis Treatment initiation Adherence & Follow-Up Clinical & Psychosocial outcomes Perception of Risk Accurate local understanding Opportunities to test Partner communication & approval Transport, time & costs Motivation vs. fear of results Family support & Disclosure Male involvement Delivery in a clinic Decision making power Fear of abandonment & violence Self-efficacy Perception of service quality Depression Social capital and networks Ill health

Socio-cultural Environment Community Context Peer & Family Influences Individual Legal and Policy Structures Self efficacy Motivation Decision making Risk Perception Depression Disease progression Health Beliefs Gender Norms Religion Social Welfare & Safety Nets ARV Supply Distance to Services Stigma Quality of Care Partner Involvement Communication & Disclosure Support Social Networks Access to Resources Health Practices Health Systems & Infrastructure SOCIAL ECOLOGICAL FRAMEWORK

Partners, Peers & Family: Community based & home testing Community based & home testing Increases opportunity Increases opportunity Introduces perception of risk Introduces perception of risk Engages family as a unit Engages family as a unit Increasing male involvement Increasing male involvement Targets communication, disclosure & decision-making Targets communication, disclosure & decision-making Introduces perception of risk Introduces perception of risk Couple counselling, ANC participation and breastfeeding advice Couple counselling, ANC participation and breastfeeding advice  Evidence strongly supports community testing, although implications less clear for identifying pregnant women  “Male involvement” increases PMTCT retention but poorly defined and not always seen as positive by women

Community Context (1): Formalised Links Formalised Links Improves facility “friendliness” and support Improves facility “friendliness” and support Relies on peer volunteers or hired liaison staff Relies on peer volunteers or hired liaison staff SMS message reminders SMS message reminders Home Based Care Home Based Care Targets access to resources and food insecurity Targets access to resources and food insecurity Logistical & adherence support Logistical & adherence support Efforts to challenge stigma and reduce isolation Efforts to challenge stigma and reduce isolation  Links improve relations, but no evidence that they address wide range of barriers faced  Rigorous research demonstrates that HBC improves adherence & follow-up, although sustainability an issue

Community Context (2): Community Health Workers Community Health Workers Work to change health beliefs and practices Work to change health beliefs and practices Many different models have been evaluated Many different models have been evaluated Applied to a wide range of health outcomes Applied to a wide range of health outcomes Traditional Birth Attendants Traditional Birth Attendants Birth planning, attendance & referral Birth planning, attendance & referral Nevirapine provision Nevirapine provision No outcome evaluations for PMTCT No outcome evaluations for PMTCT  Long legacy of success with CHW but process factors important given heterogeneity of implementation  Feasibility studies & process evaluations suggest TBA could be useful in settings with low facility deliveries

Socio-cultural environment (1): Community Mobilisation Community Mobilisation Complex interventions – multiple components Complex interventions – multiple components Engage traditional leaders Engage traditional leaders Participatory, based on theories of empowerment and social action Participatory, based on theories of empowerment and social action Drama events, outreach, peer approaches, media Drama events, outreach, peer approaches, media Support Groups Support Groups HIV+ support – target psychosocial outcomes HIV+ support – target psychosocial outcomes Evidence drawn from maternal & neonatal health Evidence drawn from maternal & neonatal health Influence norms, supportive environment & behaviour Influence norms, supportive environment & behaviour Cash Transfers Cash Transfers Incentive for behaviour change Incentive for behaviour change Provide a basic social safety net; address inequity Provide a basic social safety net; address inequity

Socio-cultural environment (2): Very difficult to evaluate community mobilisation, especially to differentiate relative effectiveness of components Very difficult to evaluate community mobilisation, especially to differentiate relative effectiveness of components Support groups have been rigorously evaluated and show promise for PMTCT given similar determinants of health-seeking and programme retention Support groups have been rigorously evaluated and show promise for PMTCT given similar determinants of health-seeking and programme retention Cash transfers successful in Latin America in increasing service use; transfer to poorer settings with weaker health systems unclear Cash transfers successful in Latin America in increasing service use; transfer to poorer settings with weaker health systems unclear

Remaining Gaps: Greater emphasis on process evaluation to identify how activities lead to intended outcomes Greater emphasis on process evaluation to identify how activities lead to intended outcomes Ways to create demand for services Ways to create demand for services Understanding complementary and reinforcing relationships between intervention activities to create optimal “package” for a given context Understanding complementary and reinforcing relationships between intervention activities to create optimal “package” for a given context Adapting strategies from Asia and Latin America for African settings Adapting strategies from Asia and Latin America for African settings Measuring psychosocial outcomes through standardised and comparable measures Measuring psychosocial outcomes through standardised and comparable measures

Ways Forward: Moving beyond research on “proof of concept” for community based approaches to learning from practice Moving beyond research on “proof of concept” for community based approaches to learning from practice Contextualisation – applying the social ecological framework to identify barriers and design activities for each programme settings Contextualisation – applying the social ecological framework to identify barriers and design activities for each programme settings New approaches to scaling up and replication – transfer of process instead of content New approaches to scaling up and replication – transfer of process instead of content Long term commitment – resources and efforts need to sustain community motivation; interim measures will change faster than outcomes Long term commitment – resources and efforts need to sustain community motivation; interim measures will change faster than outcomes

Thank you! Questions and comments?