CDC/PEPFAR support used to protect families against HIV/AIDS

By Barbara Bitangaro Communications Specialist, Centers for Disease Control and Prevention

Dr Godfrey Nalugoda reminisces how far his program has come in its plan to support and implement prevention of mother-to-child transmission services (PMTCT) by sub-granting to district local governments. “Before PEPFAR came in to help, only 20 out of 90 facilities in my cluster were providing PMTCT services. We now cover 90 PMTCT outlets within that cluster,” he said.

Dr Nalugoda is one of the Program Officers for a local NGO, Protecting Families against HIV/AIDS (PREFA), and is in charge of the Mbale cluster, which includes six districts: Manafwa, Kapchorwa, Bukwo, Sironko, Mbale and Bududa.

His work has been made possible by funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention. PREFA is a recipient of a total of US$17,902,431 for a five-year period from 2005-2010. “PEPFAR made PREFA grow,” Dr Florence Kitabire, a Technical Advisor atCDC-Uganda said.

PREFA is a Ugandan national Non Governmental Organization (NGO) that was formed in June 2004 with a mission to assist Uganda to enhance access to quality HIV/AIDS prevention, care, treatment, and support to families, with a particular emphasis on Prevention of Mother-to-Child Transmission (PMTCT) of HIV as the entry point to these services. PREFA aims at increasing the number of supported districts in Uganda that provide high quality PMTCT services and enhancing community and family involvement in PMTCT programs.

Integration and alignment with the national health system

PREFA is currently supporting 36 districts to provide PMTCT services to over 300,000 women through a district wide approach that helps to strengthen the district health system and focusing on addressing existing gaps.  PREFA’s support to districts accounts for meeting about 40% of the entire national need for PMTCT services.

The districts, with support from the Ministry of Health (MoH) and PREFA, submit PMTCT work plans to MOH for approval. Upon approval, MoH advises PREFA to sign memoranda of understanding (MOUs) with the districts. The MOUs elaborates activities in capacity building for PMTCT service provision, improving space for counselling and laboratorservices at health facilities; logistics and supplies management; monitoring and evaluation, technical support and supervision.  PREFA works closely with district teams to develop these work plans, to provide technical assistance for their implementation and monitoring, and to ensure careful financial accountability. 

The strategy of providing sub-grants to local districts was a relatively uncommon practice in Uganda when it was started, and it was controversial.  In most districts, this was the first time where district health officers and lower level health facility workers have felt they had the tools to do their job adequately, and the excitement from district officials and health facility staff is apparent.  The implementation strategy is fully in line with the national system, and the direct financial support to districts allows resources to improve overall health facility performance.  This brings in more patients, and assists these health facilities to provide more effective non-PMTCT health services as well.  This is also cost-efficient as it avoids a parallel health service delivery system, with its own buildings, equipment, staff, supply chain, and monitoring and reporting system.  Because the annual sub-grants are performance-based, there is a degree of  healthy competition between the 36 districts that receive PREFA grants..  Districts which are not effective stewards of their resources are given less funds in subsequent project periods.  Knowing that there is a chance that some of their resources may go to a different district has helped motivate districts to perform well.  Finally, staff at all levels of the health system are empowered to perform their functions more effectively, including not only in health service delivery, but also governance, leadership, financing, and managing information systems.

Training

Dr Nalugoda said that as a way of sustaining PREFA’s activities the program has trained district health staff on the PMTCT cascade comprised of counseling, testing and provision of prophylactic anti-retroviral drugs to HIV-infected mothers and babies.  A total of 1,433 health workers were trained in PMTCT counseling and infant and young child feeding practices between June 2004 and July 2009.

Other trainings included child counseling, family planning and early infant diagnosis (EID) HIV testing. In addition, 1,744 community counselling aides (CCAs) received training in PMTCT in order to help with community sensitization and mobilization for PMTCT services.

HIV Counselling and Testing for reduction of mother-to-child transmission (MTCT) including ARVs to all pregnant women and their babies
From October 2008, 453 health facilities out of a potential 543 provided at least a minimum package of PMTCT services.

In the period between October 1 and September 30, 2009, a total of 379,093 women accessed ANC services and received counseling through PREFA supported activities, 344,041 were tested, 343,354 got their HIV status results with 17,691 testing positive. The number of women who received ARV prophylaxis stood at 15,794 according to the PREFA Reporting PMTCT Cascade Data - APR09

A total of, 129,689 pregnant women delivered at health facilities of whom 7,019 (5.4%) were HIV positive, representing 39.7% of all HIV positive pregnant women identified during this period.

Among HIV exposed babies delivered, 6221 (88.6%) received ARV prophylaxis.

Male partners of pregnant women who came in for HIV Testing and counseling rose from 3.5% in FY04/05 to 8.4% in FY08/09.

Challenges

While HIV counseling and testing for PMTCT has scaled up dramatically, an increased focus is now needed on ensuring these clients get the needed services: primary prevention for those found HIV-uninfected, provision of effective ARVs for prophylaxis, early infant testing and linkage to care and treatment for mother and baby, for those found to be HIV-infected.

Sustainability through partnerships

To overcome these challenges, PREFA plans to continuously build the capacity of the districts in the areas of planning, coordination and implementation of PMTCT program and to improve transport and linkages at district levels.

Dr Nalugoda said PREFA was training community counseling aides (CCA) within catchment areas of facilities to target mothers who are not able to come to facilities. The aides will assess mothers’ readiness and barriers to return to hospital especially during the time of delivery. The role of the CCAs will be to carry out continuous counseling and guidance in the communities as well as referral for HIV/AIDS services.

Apart from working with MOH and local governments, PREFA works with other NGOs like the Integrated Community Based Initiative (ICOBI) and Traditional and Modern Health practitioners Together Against AIDS and other Diseases (THETA).

THETA has programs in over 20 districts in Uganda where it builds and supports long term in-depth relationships between traditional and formal healthcare systems. It operates closely with the district leadership and implements activities through the existing community structures and networks while ICOBI works similarly with district and community structures in the 6 districts of the Ankole sub-region of western Uganda.