Integrating HIV care into community health workers' role is a good model for southern Africa

A community health worker model of home-based preventive care, the Philani Intervention Program (PIP), resulted in significantly enhanced maternal and infant wellbeing among pregnant women living with and without HIV in Cape Town townships, researchers report in the advance online edition of AIDS.

In this cluster randomised controlled trial, HIV-positive women receiving home visits during pregnancy and the first six months of their baby's life were more likely to follow through on tasks relating to prevention of mother-to-child transmission (PMTCT) of HIV. They were also more likely to have infants with healthy height-for-age measurements, when compared to women who received standard clinic care alone.

Among all women receiving home visits, consistent condom use was higher (odds ratio 1.52, p=0.002), and their infants were more likely to be exclusively breastfed for the first six months (odds ratio 3.59, p<0.001).

The advantages of this model for women living with HIV went beyond those of adhering to PMTCT tasks. Identification of community health workers (CHWs) with a maternal, child health and nutrition programme helped avoid much of the stigma associated with HIV. Home visits created a means for ongoing support for all women in the community. 

“A CHW approach grounded in cognitive-behavioural skills, with locally-tailored content addressing local health risks, may be a strategy that is scalable globally,” write the authors.

In countries faced with HIV funding cuts and severe health worker shortages, where families face multiple health risks, PIP offers a feasible task-shifting model, they add.

Increasing evidence over the past decade supports the integration of HIV care with other health areas. HIV does not affect a child’s health in isolation, but is combined with the effects of poverty, malnutrition and other infectious diseases, as well as with the effects of a mother’s behaviours.

However, in low- and middle-income countries including South Africa, the authors note, community health workers often focus on single issues: for example, HIV testing, tuberculosis or adherence to HIV treatment. In some settings, this results in two or three health workers visiting a household, with each addressing different health areas but repeating some parts of an intervention. Community health workers identified with HIV interventions are more likely to be rejected because of the stigma associated with HIV.

Using a model of pragmatic problem-solving with cognitive-behavioural strategies, the authors trained community health workers to address multiple health issues, notably those of particular concern in pregnancy in South Africa: HIV, alcohol use and perinatal care.

The authors hypothesised that, when compared to women who received standard health care at local clinics, women living with and without HIV who received home visits (the PIP group) would have improved maternal and child health and wellbeing in five areas:

1. Adherence to HIV-related preventive acts (for HIV-positive women, this included PMTC tasks).

2. Child health and nutrition (including alcohol use during pregnancy and breastfeeding).

3. Healthcare and monitoring.

4. Mental health.

5. Social support.

Forty similar neighbourhoods were selected and matched pairs of similarly sized neighbourhoods (450 to 600 inhabitants) identified. Using a cluster randomised controlled trial design, the researchers randomised neighbourhoods within matched pairs to either home visits (PIP) or standard care.

Local township women recruited eligible pregnant women. Eligibility criteria included being at least 18 years of age, living within the target neighbourhood and able to give informed consent.

The standard-of-care group comprised twelve neighbourhoods with a total of 594 women, of whom 169 were living with HIV.

In the communities randomised to PIP, in addition to standard care, community health workers visited participants on average six times (range 1 to 27) during pregnancy and five times between birth and two months after birth (range 1 to 12), with each visit lasting approximately 30 minutes. The PIP group comprised  twelve neighbourhoods with a total of 644 women, of whom 185 were living with HIV.

Trained as interviewers, township women assessed participants during pregnancy. Follow-up rates were comparable in both interventions: 92% were reassessed at a median of 1.9 weeks after birth (standard deviation 2.1), 88% at a median of 6.2 months (SD=0.7), and 88% assessed at both time points.

The authors analysed the effectiveness of the PIP intervention on 28 measures of maternal and infant health and wellbeing for  women living with HIV and among all mothers.

Baseline characteristics were similar among PIP and standard-of-care group mothers, with one exception, that mothers in the standard-of-care group had a higher mean number of previous births.

At six months after birth, the PIP group had overall better maternal and infant wellbeing, outperforming the standard-of-care group in seven of the 28 outcomes.

Looking at specific PMTCT tasks, ART outcomes for adherence at delivery and seeking infant PCR testing were similar. However, among women in the PIP group, cumulative completion of tasks relating to PMTCT, being free of birth-related complications and having the father acknowledge the infant to his family, were more likely. However, they were less likely to know their CD4 cell count.

This model is similar to one the South African government is implementing, with plans to deploy about 65,000 CHWs, the authors note.

“By focusing training on generic, common principles of behaviour change and the specific health challenges of the local community, the potential exists to broadly diffuse the training model,” write the authors.

The programme was built on strong ties with the community leaders, stakeholders and clinical care sites; giving CHWs a stipend helped sustain the programme, and strict supervision standards were followed.

In addition to sustainability, home visits deal with barriers to obtaining health care encountered at clinics: appointments are difficult to schedule; waiting times are long; transport is costly; and mothers have to co-ordinate care among multiple clinics.

The authors conclude: “PIP provided both task-shifting and site-shifting (from clinics to communities). It allows governments to leverage the investments in HIV to address concurrent health issues. PIP offers an intervention model and evaluation strategy for building sustainable, locally-tailored CHW home visiting programmes.”