Horizons Report | June 2007

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June 2007

Closer to Home
Community-based activities complement PMTCT programs in Kenya

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In Kenya, an estimated 270 new pediatric HIV infections occur each day (NASCOP 2002). Maternal-to-child transmission of the virus is the cause of most HIV infections in children. To address this problem, the Kenyan government has implemented prevention of mother-to-child transmission (PMTCT) services throughout the country. These services include routine HIV counseling and testing (CT), improved obstetric practices, antiretroviral therapy, counseling and support for safer infant feeding practices, and family planning.

However, making PMTCT services available to the women who need them has proven to be only half of the battle. Research has shown that the medical recommendations made by PMTCT programs can be overshadowed by community norms, values, and beliefs (Rutenberg et al. 2003). In Kenya, fear of disclosure and stigma prevent many women from following recommended practices, and a lack of resources and motivation limit women’s abilities to access available PMTCT services.

Community-based approaches may not only increase awareness and availability of services but may also increase acceptance and uptake. To test this hypothesis, Horizons conducted operations research to examine whether implementing community-based activities increased the utilization of PMTCT services and improved PMTCT-related knowledge and behaviors in Kibera, a highly populated urban slum in Nairobi.

Building Community-based Interventions

The interventions consisted of adding three community activities to existing PMTCT services in three separate areas of Kibera. The three activities involved moving services closer to the population via a mobile clinic, and training two different groups—traditional birth attendants (TBAs) and HIV-positive peer counselors—as PMTCT promoters and providers of psychosocial support. International Medical Corps (IMC), which had prior experience working in the study areas, was responsible for implementing the three activities.

Weekly mobile clinic services consisted of a team of health providers—a nurse midwife, counselor, and TBA—who set up a temporary clinic in an existing community space such as a church or meeting hall. The services offered included routine antenatal care (ANC), HIV counseling and testing, Nevirapine distribution for mother and infant, infant feeding counseling and support, and family planning counseling. HIV-positive women were encouraged to breastfeed exclusively for six months and then abruptly wean, and to take any newborns delivered at home to the clinic or a health facility within 72 hours to get Nevirapine. All women were encouraged to deliver at a health facility.

Twenty-two TBAs were trained as PMTCT promoters to encourage all pregnant women to seek ANC and delivery services at health facilities as well as to offer psychosocial support to HIV-positive women. Their scope of work also included encouraging women to get tested for HIV, conducting risk assessments, and referring higher risk deliveries to health facilities. Following two weeks of training, the TBAs attended regular meetings to report on activities and address any problem areas. The TBAs were compensated for attending meetings, referring women to health facilities for deliveries, and referring newborns within 72 hours of birth for Nevirapine syrup.

Peer counselors were HIV-positive women who had already received PMTCT services. IMC recruited them to mentor and educate other women who had tested positive for HIV. The 22 peer counselors were trained and given the same scope of work as the TBAs, except that they did not conduct risk assessments or refer higher risk deliveries. The peer counselors also participated in monthly support meetings and received a stipend.

As part of the intervention, the project team developed health information messages and disseminated them through posters in health facilities and health talks with HIV-positive women in support groups. Finally, IMC trained health providers in the project area to ensure that the main high volume clinics offering primary care had similar quality PMTCT services.

Study Design

To assess the impact of the community-based activities in Kibera, Horizons used a quasi-experimental design where changes in knowledge and practice in the intervention areas were compared to a fourth area with no additional community activities (Dagoretti). Data were collected in five high volume primary health clinics in Kibera and two high volume clinics in Dagoretti from a sample of women who had given birth in the ten weeks prior to the introduction of the interventions and again approximately 15 months later. At baseline (June 2004), 1,803 women were interviewed; after the intervention, a follow up survey was conducted with 1,813 women (August to October 2005). In addition, researchers conducted in-depth interviews with 24 HIV-positive women and 5 HIV-negative women at baseline and endline to further explore issues raised in the quantitative survey. Focus group discussions (FGDs) were held with TBAs and peer counselors.

Limited Exposure

Results from the data collection show that the women in the study areas had limited exposure to the interventions. At follow-up, of the 1,362 women from intervention areas interviewed, only 213 (16 percent) were exposed to a program activity. In the mobile clinic area (n = 470), only15 percent were exposed, in the TBA area (n = 452), 14 percent were exposed, and in the peer counselor area (n = 440), 18 percent were exposed. Furthermore, there was no clear pattern of results by intervention activity, as no one activity appears to have had made more of an impact on key indicators than the others.

Positive Trends

The data show that overall there were a number of positive trends across all intervention groups during the study period in most of the PMTCT indicators. For example, knowledge of MTCT improved significantly, with the percentages of women who knew about its prevention and the availability of drug treatment increasing. ANC utilization also improved—the proportion of women who had four or more antenatal care visits increased significantly from 41 percent at baseline to 54 percent at follow-up. Delivery at a health facility increased from 47 percent at baseline to 54 percent at follow-up.

There were also trends in the right direction in several areas related to CT uptake. For example, the number of women who had been tested for HIV during ANC during their last pregnancy significantly increased from 84 percent to 93 percent in 2005.

However, it is not possible to attribute the positive trends to the community-based activities because similar trends were also observed at the comparison site. For example, positive results related to CT uptake were found in both the study and comparison areas and could reflect the fact that HIV testing has become a much more standard practice among pregnant women in Kibera and Dagoretti.

Interpreting the Results

The results of the study prompt the question: why didn’t the community-based activities reach more women and have a larger impact? There are several possible explanations that could be useful to organizations implementing community-based PMTCT activities in a similar context.

There were a number of positive trends in most PMTCT indicators across all groups during the study period.

A major challenge was that the PMTCT promoters spent a lot of their time on income generating activities to support their families rather than on project activities. Discussions from FGDs conducted with the TBAs revealed that most of them spent on average less than three hours, three times a week on implementation. Peer counselors spent two days a month on door-to-door campaigns and participated in IMC-sponsored support groups held on a weekly basis.

Both the TBAs and the HIV-positive peer counselors felt that the money they received as PMTCT promoters was not enough to allow them to dedicate more time then they did to the intervention. However, it is important to note that despite the low compensation, the PMTCT promoters did report satisfaction working with women in their community.

. . . the money was little . . . my income is a big challenge and even having food to eat is difficult. I liked my work [PMTCT promoter] . . . being popular . . . in the village and everyone greets me when I pass where I live and taking the mothers and babies to the hospital.

TBA

What made me like the work [PMTCT promoter] is that you assure the mothers that even if they get pregnant and they are HIV-positive the child has a chance to live and even herself.

HIV-positive peer counselor

Another possible explanation that emerged from the FGDs conducted with the peer counselors was that they did not typically disclose their HIV status to the pregnant women they interacted with due to their discomfort of being openly HIV positive. The fact that they were not disclosing could make it difficult for study participants to know whether or not they had interacted with an “HIV-positive female counselor” as asked in the questionnaire or benefit from hearing the experiences of openly HIV-positive women. This suggests that programs should work more intensely with peer promoters to support them in disclosing their status as part of their mentoring roles, as is done in the successful model of the mothers2mothers program (see related story).

A final, encouraging, possibility is that facility-based PMTCT services may have become sufficiently established and accepted in the study areas, which explain some of the study’s positive trends. However, there does appear to be a role for peer promoters. As Susan Kaai of Horizons/Population Council, a principal investigator for the study explained, “PMTCT promoters did offer valuable psychosocial support to antenatal and postnatal mothers in the community, some of whom had minimal contact with health facilities.” Community members reported appreciation for this support, as two women expressed:

She [TBA] is the one that encouraged me and gave me the first counseling and escorted me to the hospital.

31-year-old HIV-positive woman

. . . after receiving emotional support from her [HIV-positive peer counselor] . . . I saw that my body was fine. . . . she said that anybody can live a normal life and work like anybody who does not have the virus so I was encouraged.

21-year-old HIV-positive woman

A final report of the study that examines the successes and challenges of employing community-based activities in the context of Kibera will be available in July 2007.

References

National AIDS and STD Control Programme (NASCOP). 2002. National Guidelines: Prevention of Mother-to-Child HIV/AIDS Transmission (PMTCT). Nairobi: NASCOP.

Rutenberg, Naomi et al. 2003. “Evaluation of United Nations-supported pilot projects for the prevention of mother-to-child transmission of HIV.” New York: UNICEF.

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See Also

FRONTIERS
Population Council Infants and Children
Population Council Journals and Newsletters
Population Council Prevention

For additional information please contact:
Horizons
Population Council
4301 Connecticut Ave. NW, Suite 280
Washington, DC 20008
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: horizons@popcouncil.org

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This page updated
6 July 2007