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thumbnail of PHASA poster September 2013 FINAL
The impact of community health workers and improved monitoring on PMTCT programmes in the Free State Province: A randomised control trial

As part of CMT’s legacy of employing Community Health Workers, CMT, together with the University of Cape Town, conducted operational research to evaluate the impact of Community Health Workers on PMTCT programme coverage and health outcomes in HIV positive mothers and their children in the Motheo district in the Free State.

The study design was a randomised control trial. Community Health Workers were placed at 16 primary-level PMTCT services in the Motheo District of the Free State Province.  In total, 32 health facilities were randomly identified as intervention or control sites where at least 100 women per month started antenatal care. Before and after data was analysed for the period between April 2011 and March 2013.

At the intervention sites, expectant mothers were offered a one-on-one meeting with a Community Health Worker, who encouraged HIV Counselling and Testing (HCT) and provided information on managing HIV during pregnancy and after birth. The Community Health Workers also took on task-sharing activities such as providing HCT and ARV preparedness. Individual follow up included telephonic and SMS reminders for HIV positive women to access every step of the PMTCT cascade and for HIV-negative women to re-test for HIV at 32-weeks of pregnancy.

thumbnail of PHASA poster Training Mentorship Supervision FINAL 18 Sept 2013
Training, mentorship and supervision as key components of a facility-based Community Health Worker model

The University of Cape Town team implemented a data strengthening intervention in all 32 sites and collected a range of PMTCT indicators for a before and after analysis between intervention and control sites in order to assess the impact of Community Health Workers in improving the coverage of PMTCT services.

While there were improvements in the intervention sites when compared with the control sites, there was an overall upward trend in coverage in all of the indicators of the PMTCT cascade and a decrease in vertical transmission across all sites. This can be attributed to the confounding effect of national campaigns and the significant national effort devoted to improving PMTCT programme coverage and other outside influences. Further, the unexpected effects of the data strengthening component could have played a significant role; in order to measure the impact of the study, data strengthening systems were put in place to ensure that indicators were collected accurately in all sites and training was provided on the use of indicators to identify missed opportunities and improve coverage. This improved the monitoring and quality of the data which in turn may have positively affected the quality of the work at facility-level across all sites.

The research findings indicated an increase in PMTCT coverage in sites where Community Health Workers were based, but this increase was not statistically significant in comparison to the control sites.

Results also showed that women accessing antenatal care in the intervention sites were more likely to return to re-test for HIV at 32 weeks of pregnancy; this was statistically significant. The increased rate of re-testing at 32 weeks is an important finding. As the rates of mother to child transmission reduce, ensuring there are no missed opportunities, particularly for women who become HIV positive late in pregnancy or while breastfeeding, is critical in order to eliminate vertical transmission.

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Foot Soldiers of Primary Health Care

A separate qualitative evaluation identified the crucial role of Community Health Workers in supporting, informing and ultimately enabling continuity of care during pregnancy, an indicator of which is the greater 32 week re-testing rate. It is believed that the Community Health Workers provided an interface between the community and the health system, assisting pregnant women to navigate through a complex treatment cascade and a complicated health system.

CMT has worked in close collaboration with the University of Cape Town and are very appreciative of the input, guidance and support from our board member Prof. David Coetzee. We value the hard work conducted by Kathryn Stinson and her team on the data monitoring aspect of the project and Chris Colvin and his team on the qualitative component. We would also like to thank and acknowledge Prof Helen Schneider from the University of the Western Cape for her insight and guidance throughout the process.

CMT would like to thank and acknowledge our team of field workers who worked passionately and tirelessly to implement the intervention.  CMT also thanks our donors who supported this project over a 3 year period; the project was funded by The Monument Trust and USAID / PEPFAR through Johns Hopkins Health and Education in South Africa.

CMT and UCT presented the results at the Free State Department of Health and University of the Free State’s Research Day. At the awards ceremony, CMT was recognised for their presentation and received a trophy for the “Best Free State Research of 2013” award. CMT and UCT also displayed 2 posters at the PHASA Conference, one at the ICASA Conference in 2013 and at CROI in 2014.