1. Module 8 Referral for Treatment, Care, and Support Services

2. Malawi PMTCT Training Package2 Module Objectives  Describe the difference between linkages and referrals.  Describe why linkages are essential to ensuring clients have access to the full continuum of services.  Explain the referral process.  Discuss the goals of PMTCT community outreach.

3. Malawi PMTCT Training Package3 Module Objectives (continued)  Describe strategies that will encourage community participation in PMTCT interventions.  Discuss the importance of male involvement in PMTCT interventions.  Discuss barriers to male involvement in PMTCT interventions.

4. Malawi PMTCT Training Package4 Unit 1 Linkages and Referrals Supporting PMTCT Services

5. Malawi PMTCT Training Package5 Unit 1 Objectives  Describe the difference between linkages and referrals.  Describe why linkages are essential to ensuring clients have access to the full continuum of services.  Explain the referral process.

6. Malawi PMTCT Training Package6 Introduction to Linkages & Referrals  Women testing HIV-positive will need support services through referrals to local services  To offer comprehensive care, health facilities must establish linkages with NGOs, FBOs, and similar agencies that provide treatment, care, and support services for mothers who are HIV- infected and their family members

7. Malawi PMTCT Training Package7 What are Linkages?  Formal networks of organizations, agencies and the community, which facilitate referral of client and her family for needed services.  Linkages facilitate the referral of clients from the community to PMTCT services.  The aim of coordinating services by establishing linkages is to provide access for clients to "seamless" continuum of services

8. Malawi PMTCT Training Package8 Linkages PMTCT services should have linkages with:  Tertiary referral hospitals, district hospitals, peripheral health facilities  Intersectoral linkages within the district (i.e., with education, agriculture, and local government sectors, etc.)  Communities they serve  NGOs and FBOs

9. Malawi PMTCT Training Package9 Community Linkages Community Based Organizations  Can provide resources to help HIV-infected women and their families cope with isolation, social stigma, and emotional pressures  Can provide HIV-infected women ways to become involved in HIV-related work in community development projects  May help meet specific needs, such as housing, transportation, food assistance, legal assistance and advice  HCWs can facilitate connections with community-based organizations

10. Malawi PMTCT Training Package10 Suggested Linkages & Referrals For All Women:  Nutritional rehabilitation/supplementary feeding services for child  Nutrition care and support for mother  Routine well-baby care, including immunisations  HIV testing and counselling sites (partner and family member testing)  Family planning and other reproductive health services, including advice about condoms and safer sex  Infant feeding counsellor  Treatment and support for drug and/or alcohol abuse

11. Malawi PMTCT Training Package11 Suggested Linkages & Referrals (continued) Additional Services for HIV-Infected Women:  Infant and/or young child HIV testing  HIV treatment, care, prevention, and support, including treatment for HIV- related conditions and ARV therapy  HIV testing and counselling (partner & family testing)

12. Malawi PMTCT Training Package12 Suggested Linkages & Referrals (continued) For HIV-Infected Women (continued) :  Infant feeding counsellor or replacement feeding counsellor  Community/home-based services  HIV-related clinics  STI treatment programmes

13. Malawi PMTCT Training Package13 Suggested Linkages & Referrals (continued) For HIV-Infected Women (continued) :  Organizations providing supportive counselling  Community-based HIV support groups  Faith-based and community organizations that offer psychosocial care, housing, transportation, food assistance, legal assistance, and income-generation  Laboratory services

14. Malawi PMTCT Training Package14 Family Centered HIV Care & Treatment Linkages should be family-centred. Important elements of family-centred HIV care and treatment are  Recognition of all persons who function as family members, as identified by the person living with HIV infection, e.g., blood relations, in-laws, or friends  Inclusion of these family members in decisions about care, treatment, and support of the HIV- infected and affected members of the family unit

15. Malawi PMTCT Training Package15 Linkage Between PMTCT & MCH  PMTCT services are entry points for the treatment, care, and support of women who are HIV-infected, their infants, and family members  HIV-exposed children require close follow-up and appropriate care  Specialists in HIV care for women and children provide consultation, ARV treatment, and help with ongoing management of HIV infection  Health Education Unit organizes mass media education programmes to support MCH and HIV services

16. Malawi PMTCT Training Package16 Linkage Enablers Factors that facilitate the building of strong linkages include:  Formal organizational structure  Informal personal relationships  Communication  Transport systems  Integration of management and support functions such as planning, education and training, supplies and maintenance

17. Malawi PMTCT Training Package17 Advantages of Linkages  Better access to key HIV, reproductive health, and MCH services tailored to needs of PLHIV  Promotion of PMTCT activities and messages amongst service providers  Reduced HIV-related stigma and discrimination  Improved coverage of underserved and marginalized populations  Improved quality of care  Enhanced programme effectiveness and efficiency

18. Malawi PMTCT Training Package18 Consequences of Poor Linkages  Lack of accessibility to services for clients  Gaps in service  Duplication of services  Inappropriate division of tasks.  Clinic workers may perform tasks they are ill-equipped to do or that could be handled more efficiently at another level.  Patients who could have been treated locally may be treated at expensive district hospital at more expense and inconvenience.

19. Malawi PMTCT Training Package19 What are Referrals? Definition  A referral is made when a healthcare or social service worker guides a client to obtain services that will meet the client’s need for continuity of care.

20. Malawi PMTCT Training Package20 Criteria for Referral  Client has unmet needs  Services are unavailable or inaccessible at facility where PMTCT services were offered  Client request

21. Malawi PMTCT Training Package21 Referral Process  Assessment of client’s needs  Documentation of referral, including date, to whom client was referred, and any additional information provided to facilitate referral  Issues of confidentiality and privacy should be clear to client and staff at partner organizations

22. Malawi PMTCT Training Package22 Monitoring Referrals  Feedback from referrals important as quality assurance mechanism.  Organization making the referral can assess the success and appropriateness of referrals

23. Malawi PMTCT Training Package23 Developing a Referral Network  Referral networks take time/commitment to create and maintain.  First step is to list all referral resources in a directory  Referral network can include:  A lead organization to coordinate the referral system  A way for providers to communicate regularly  A designated contact person at each of organization  A standard referral form  A system that tracks referrals

24. Malawi PMTCT Training Package24 Exercise 8.1 Community Linkages: Small Group Discussion

25. Malawi PMTCT Training Package25 Unit 2 Community Education, Outreach, and Mobilization

26. Malawi PMTCT Training Package26 Unit 2 Objectives  Discuss the goals of PMTCT community outreach.  Describe strategies that will encourage community participation in PMTCT interventions.  Discuss the importance of male involvement in PMTCT interventions.  Discuss barriers to male involvement in PMTCT interventions.

27. Malawi PMTCT Training Package27 Community Education  A community is a group of people with shared resources, a common interest, shared goals, or shared tradition and culture. It can be defined by its geographical location, its social interactions or social organization.  Among the roles of HCWs is to educate and to:  inform communities of new health problems such as MTCT  share information on the practices that can address these problems  help the community adopt new practices and behaviours to overcome the problem

28. Malawi PMTCT Training Package28 Community Outreach Definition Community outreach is a formal attempt to increase public awareness and support for a service. Outreach work may also aim to bring tailored health education to specific populations, with the goal of changing knowledge and behaviours.

29. Malawi PMTCT Training Package29 Goals of PMTCT Community Outreach  Create awareness, increase knowledge about PMTCT and HIV  Create demand for PMTCT services  Influence attitudes, norms, values, behaviours regarding PMTCT  Fight HIV-related stigma and discrimination to create supportive environment for PMTCT clients and families affected by HIV  Provide education and services to people in remote areas with poor access to health care

30. Malawi PMTCT Training Package30 Messages  Community outreach usually done through:  Health education talks in communities  Musical performances with PMTCT messages  Theatre skits and role plays  Brochures, pamphlets, posters, informational videos  Radio and television messages.  Central behaviour change message is that mothers and fathers should use PMTCT services to:  Give babies the chance to be healthy and HIV-free.  Receive HIV care and treatment for themselves and their families if needed.

31. Malawi PMTCT Training Package31 Audience Communication messages target many audiences:  Women of reproductive age and their male partners  The wider community  Messages may differ depending on audience  Specific communication messages for men and delivered in venues where men congregate  Influential leaders brought into mobilization process

32. Malawi PMTCT Training Package32 Community Mobilization Goal is to ensure community participates in:  Identifying health problems and their causes  Developing possible solutions  Identifying resources necessary to implement solutions. Community mobilization is different from health education/outreach.  Mobilization aims to empower community members to name and address their own problems using their own resources  Long-term process involving intensive, participatory work with community members

33. Malawi PMTCT Training Package33 Community Outreach & Mobilization  Health education activities are a normal part of the duties of many HCWs in Malawi  HCWs may want to consider partnering with governmental and non-governmental organizations that specialize in community mobilization and health communication

34. Malawi PMTCT Training Package34 Strategies to Increase Community Participation  Integrate IEC interventions with PMTCT messages  Involve existing community-based committees and support groups in implementing grassroots PMTCT activities  Involve community members, including leaders, in PMTCT education  Plan and implement PMTCT activities together with community representatives

35. Malawi PMTCT Training Package35 Rationale for Male Involvement  Approximately 14% of adults in Malawi infected with HIV  Primary mode of transmission amongst adults is heterosexual intercourse  Heterosexual transmission of HIV has an impact beyond the couple: 8-10% of all HIV cases in Malawi are infants and children infected through MTCT.  Reality is that men involved in almost every case of HIV in Malawi.  Proactive PMTCT services that involve men and educate community about HIV risk and transmission can prevent women from being blamed/punished for bringing HIV infection into family.

36. Malawi PMTCT Training Package36 Sex and Power  In Malawi, men initiate sex in 92% of relationships and many women feel powerless to refuse sex/negotiate safe sex.  55% of women said they had been raped or forced into sex.  Men socialized to believe it is not normal for women to actively agree to sexual intercourse and coercion is necessary.

37. Malawi PMTCT Training Package37 Men & HIV Risk  Men have more partners.  Men migrate for work and live apart from their families and may adopt risky behaviours.  High risk sexual and drug taking behaviour are supported by cultural beliefs and expectations about “manhood.”  Men expected to be strong and provide food and shelter.  Young men may be pressured into having sex by the need to “prove themselves.”

38. Malawi PMTCT Training Package38 Impediments to Safer Sex  Men believe they are invincible; “real men don’t get sick”  Men visit commercial sex workers.  Condom use discouraged by concerns that they break easily, are clumsy, reduce sexual pleasure, and only for sex outside marriage  Belief that contraception is a woman’s responsibility  Perception that women who ask partners to use condoms are promiscuous or unfaithful  Fear of violence makes it difficult for women to refuse sex or negotiate condom use

39. Malawi PMTCT Training Package39 Evolving Role of Men  Men have important role in RH for themselves and their wives.  Men who contribute to family budget improve health and happiness of their families  Men are role models:  Boys who observe fathers being violent towards women or treating women as sex objects may believe this is “normal male behaviour.”  Boys may believe that domestic tasks and taking care of others is “women’s work”.  Men can be good communicators:  Encourage men to openly discuss their feelings with partners.  Encourage men to listen to the concerns of their partners.

40. Malawi PMTCT Training Package40 Benefits & Barriers to Involving Men in PMTCT Benefits  Facilitates understanding of HIV test results  Reduces blame, domestic violence, and stigma  Provides men with first-hand information  Promotes shared decision making and partner support  Improves adherence to HAART  Reduces risky sexual behaviour and HIV transmission Barriers to male involvement  Health system has not yet adapted to male involvement  Lack of policies supporting male involvement  Culture discourages men’s participation

41. Malawi PMTCT Training Package41 Strategies to Increase Male Involvement in PMTCT  Make services more “male friendly”  Flexible working hours at clinic to accommodate men’s work schedule  Offer couple counselling  Make sure men with an STI refer female partners for treatment.  Address gender-based violence and empowerment during counselling and health education sessions.  Stress importance of condoms for preventing STIs and unwanted pregnancy.

42. Malawi PMTCT Training Package42 Exercise 8.2 The “Male-Friendly” PMTCT Service: Large Group Discussion

43. Malawi PMTCT Training Package43 Module 8: Key Points  Linkages are formal networks between organizations or agencies and the community.  The aim of coordinating services through linkages is to give clients access to a "seamless" continuum of care.  A referral is made when a healthcare or social service worker guides a client to obtain services that will meet the client’s need for specific services provided outside the clinic.

44. Malawi PMTCT Training Package44 Module 8: Key Points (continued)  Referral networks take time and commitment to create and maintain. The first step is to list all possible referral resources and create a directory of these services  Community outreach is a formal attempt to increase public awareness and support for a healthcare programme.

45. Malawi PMTCT Training Package45 Module 8: Key Points (continued)  Many women are at an increased risk of HIV infection because of the current or past behaviour of their partners.  In general, men are more likely to have more sex partners, consecutive and concurrent  There are a number of social and cultural impediments to practising safer sex, which exacerbate men’s risk of acquiring and transmitting HIV.

46. Malawi PMTCT Training Package46 Module 8: Key Points (continued)  It is the responsibility of PMTCT staff, through education and outreach, to initiate the cultural and social changes necessary to support men to take responsibility for their actions and to understand their role as part of the solution.