Archive for December, 2010
By Judite Cardoso, Ana Marranguene and Alicia Jaramillo
Maputo, Mozambique — With a shortage of physicians in this country of 22 million and less than a quarter of adults aware of their HIV status, Mozambique’s health officials knew they had to come up with a new strategy to expand access to HIV counseling and testing services. People were being diagnosed late in the course of their illness, and individuals and couples lacked the knowledge they needed to prevent transmission of the virus.
In 2007, with the help of Jhpiego and funding from the President’s Emergency Plan for Aids Relief (PEPFAR), through the Centers for Disease Control and Prevention, the Ministry of Health (MOH) and National AIDS Commission decided on a plan that would enable HIV-positive people to receive care before they fell ill. Through this plan, Mozambicans could take advantage of the prevention benefits of counseling and testing.
The plan centered on training lay counselors, chosen from local nongovernment and faith-based organizations, to provide counseling and testing in the community. The counselors had to be able to read and write in Portuguese, speak the relevant local language for their geographic area and have at least a seventh grade education. They went through two weeks of classroom training plus a four-week practicum with an experienced counselor.
Cesar Francisco Mauinje, from Maputo Province, was among the counselors in the pilot project.
“The first one to benefit from the program was me. When I was trained as a community counselor, I learned so much about HIV,” said Mauinje. “I had to let go of many taboos and myths in order to participate in this program…. When we started with the pilot [project], the communities had many doubts about whether counseling and testing was really going to be good for them. They were resistant. But later, as we kept working with them, they came to see the huge benefits to them, and they welcomed us.”
During the pilot phase, 9,094 people were counseled and 8,975 tested; 11.2 percent tested positive and were referred to health units for HIV clinical care. Given the tremendous success of the pilot project, the MOH decided to expand the Home and Community Counseling and Testing for Health program nationwide.
With that move forward, a network of trained lay counselors linked underserved communities in Mozambique with the formal health system. This collaborative effort has expanded critical services rapidly, without further straining the MOH’s already scarce resources.
To date, 230,592 Mozambicans have been tested and counseled for HIV. That’s significant progress in a country where 11.5 percent of adults and 13.5 percent of pregnant women are living with HIV, among the highest prevalence rates in the world.
To appreciate the achievements of this nationwide program, it’s important to know that as recently as 2003 only three percent of adults had ever been tested for HIV.
The MOH favors integrated programs and quickly recognized the role community counselors could play in assessing the health care status of the people they serve. Since beginning this initiative, community counselors have taken on greater responsibilities. They were asked to also check for tuberculosis and educate residents on hypertension, malaria and diarrheal diseases.
“This program has helped us break many taboos in the community,” said Julião Fenias Boane, Coordinator of the Christian Council in Cabo Delgado Province, one of the participating nongovernmental organizations (NGOs). “For example, many people still thought that an HIV diagnosis meant that the person would die soon. This program has helped change that. Also, in our communities there has been a taboo regarding epilepsy. People thought that children with seizures could not go to school. But the counselors help explain that children with epilepsy can indeed participate in the community.”
The Home and Community Counseling and Testing for Health program has since been expanded to all 10 provinces of Mozambique. There are 163 counselors and 11 supervisors working with the Jhpiego-supported NGOs. Between September 2008 and August 2010, they provided health and HIV education and counseling to 307,756 people.
The counselors also referred 47,212 people to government health facilities for suspicion of tuberculosis based on screening questions, elevated blood pressure, HIV testing and a variety of other health problems, ranging from fever and diarrhea to seizure disorders.
This program demonstrates that NGOs can effectively partner with government health systems to expand the health workforce and provide lifesaving services at scale, increasing access for rural communities. The goal now is to continue to expand the program while strengthening follow-up systems to ensure that clients referred to the health units get the diagnostic and care services they need.
“For us as a congregation, it [the program] was a tremendous leap forward because it gave us the chance to save lives. Each person counseled and tested started to take care not just of themselves but of others, according to their serostatus,” said Sister Susana of the Franciscan Sisters in Maputo Province. “When we detect HIV early it ensures that people can live longer and healthier lives. [This program] also helped us to work much, much closer with the health system, including not just the health facilities but also the district and provincial health authorities. By talking to people as families rather than individuals we can break the fear of learning their HIV status.
“It helps unite the families. They are stronger and they can take precautions for their health. For couples it helps them to support each other. It breaks the silence.”
By Abrar Muhibbul and Charlene Reynolds
Since her marriage nine years ago, Munni Manjari has given birth to six children. All but one has survived. She is just 25 years old and lives in the Sylhet area of northeast Bangladesh. When receiving maternal and newborn health care services from her local community health worker, Munni begged for some family planning options. But the health worker was neither trained nor equipped to provide such options to her. Munni’s repeated pregnancies have left her anemic, suffering from chest pains and generally weak. Her recurrent fatigue keeps her from working several days a week. With limited means, she and her husband, Kripa, can barely provide for their children, who range in age from four months to nine years old.
Like Munni, the women of Sylhet face an uncertain future because health services are scarce and poorly equipped. A group of Bangladeshi and U.S. health care professionals, Baltimore researchers and local community health workers are coming together to change that. They have joined together to educate women, men and families on the benefits of healthy birth spacing and to provide information on family planning options.
More than 2,200 mothers are participating in the Healthy Fertility Study, a collaboration of the Bangladesh Ministry of Health and Family Welfare, Jhpiego, two local nongovernmental organizations (NGOs)—Shimantik and the Center for Data Processing and Analysis—and the Johns Hopkins Bloomberg School of Public Health.
Previously supported by the ACCESS-FP Program, with funding through the U.S. Agency for International Development (USAID) from 2007 to 2010, the study is now supported by USAID’s Maternal and Child Health Integrated Program (MCHIP), which is led by Jhpiego, and Johns Hopkins public health researchers.
The study is already making a difference in the lives of the women participants.
The area of Sylhet has the highest fertility rate in the country—women there have about four children, compared to an average of about three in the five other divisions in the country. The maternal mortality ratio (MMR) is highest in Sylhet (471 per 100,000 live births, compared to the national average of 322), and the infant mortality rate is twice what it is elsewhere in the country, according to country health data.
But results from the Healthy Fertility Study so far show that women and their families are getting the message that pregnancies spaced too closely after a live birth or miscarriage carry very high risks for the mother and her newborn. Three years into the project, the use of family planning in the area is up—36 percent of women reported using contraception as compared to 18 percent in the comparison area at six months postpartum.
A key aspect of the project is providing community-based postpartum family planning along with maternal and newborn health services to women. This integration of services maximizes the benefits of the contact between the community health worker and the woman.
Community health workers—who are typically young, unmarried women with a tenth grade education—are trained to visit homes in their communities to identify pregnant women and educate women enrolled in the study about maternal and newborn health. They also provide information about postpartum family planning, supply oral contraceptive pills and condoms based upon the women’s fertility intentions, and make referrals to government and NGO health facilities for other contraceptive methods.
One effective method that new mothers can use is the Lactational Amenorrhea Method, in which breastfeeding women follow specific criteria in order to avoid pregnancy during the initial six months after a birth. After that period, women need to use other modern contraceptive methods to avoid unplanned pregnancies.
The recent results from the Healthy Fertility Study found exclusive breastfeeding rates were higher, at 38 percent as compared to 28 percent at three months postpartum. In addition, 94 to 95 percent of women in Sylhet said they had seen communications materials developed for the project and 87 percent said they attended a community meeting related to it.
“The Healthy Fertility Study is important because it is using innovative strategies that are helping Bangladeshi women avoid unplanned pregnancies,” said Catharine McKaig, a family planning specialist with MCHIP. “The study is helping women, men, families and communities understand that modern contraceptive methods can be used to ensure that pregnancies occur at healthy times, and avoided at unhealthy times.
“Findings from this study will influence how family planning is integrated in community-based maternal and newborn health care programming elsewhere in the world,” McKaig said.
For the past four years, bicyclists participating in the Thailand Tour of Hope have helped raise money for cervical cancer prevention. Jhpiego has been a beneficiary, receiving $84,000. Proceeds from each year’s race are matched dollar for dollar by GlaxoSmithKline.
To all, we say a big thanks!
This year’s race was held November 5. Jhpiego’s representative at the Tour of Hope, Professor Khunying Kobchitt Limpaphayom, spoke about the organization’s long history in helping prevent cervical cancer in Thailand.
In cooperation with the Thai government and Chulalongkorn University, Jhpiego has introduced a pioneering screening method for cervical cancer prevention that became a model for the country and trained Thai health workers in this approach. The work also includes follow-up and monitoring to ensure competency in performing the screenings.
“At present we have trained about 1,100 nurse providers around the country in 24 provinces,” Professor Limpaphayom told the crowd. “Thousands of women benefit from this cervical cancer prevention work. Proceeds from the Tour of Hope provide a valuable source of funds. These gifts to Jhpiego are truly gifts to women and their families around the world.”
Dr. Ricky Lu, Jhpiego’s Director of Family Planning and Reproductive Health, applauded the efforts of Professor Limpaphayom, who serves as Jhpiego’s “Global Ambassador” in the region, which includes Thailand, Vietnam, Philippines and Indonesia.
“Khunying Kobbie and her passion for preventing cervical cancer in Thailand is an example of the power of one to effect change,” said Dr. Lu. “Right after demonstrating the safety, effectiveness and feasibility of the single visit approach using VIA (visual inspection with acetic acid) and cryotherapy, her effort to translate research into tangible action has resulted in increasing access to the single visit approach (SVA) and reaching half a million women screened.
“Working with a small team of dedicated trainers and partnering with key stakeholders in the health system to support service start-ups made it possible to offer SVA in 24 provinces in a span of less than 10 years.”