Overall Challenges with Home- and Community-Based Care
Although interviewees in many countries described achievements in home- and community-based care, interviewees also identified challenges with the implementation and scale of these services. These challenges included a lack of knowledge, training, policies, and funding support for home-based care, which was described as ‘capital intensive’ (331-27-PCGOV; 587-10-USG; 272-32/35-PCNGO). Interviewees in one partner country described home-based care as not very strong (331-8-PCNGO) or lacking (331-11-PCNGO). In another country, clients in remote areas not reached by home-based counseling and testing were coming to facilities for testing late in the progression of their disease (461-17-PCNGO). Limitations on the scope of interventions that could be done in the community were also described as a challenge, as was the lack of clinical services available for referral, which was linked to the need for health systems improvements to increase the availability of ‘adequate services at public health facilities’ (461-7-PCNGO).
Another specific challenge described by implementing partners was the interpretation of indicators and the quality and timeliness of reporting, primarily because of challenges with the capacity of local providers and with barriers to reporting, such as lack of transportation for monitoring remote programs and collection of paper-based forms (272-32/35-PCNGO; 331-22-PCNGO; 272-15-PCNGO).
Specific Areas of PEPFAR-Supported Nonclinical Services
Psychological and spiritual support Psychological and spiritual support supported by PEPFAR may include group and individual counseling and culturally appropriate end-of-life care and bereavement services (OGAC, 2010b, 2011a). Several interviewees talked about the provision of psychosocial care or, more rarely, spiritual care, including services such as peer education and peer support; self-help groups for PLHIV and their families; and provision of psychosocial counseling for PLHIV or “psychosocial support,” although what this entailed as a service or set of services was difficult to clearly define (331-10-PCGOV; 396-21-USG; 461-10-PCNGO; 461-17-PCNGO; 461-18-USG; 587-13-USG; 331-32-PCNGO; 196-7-PCNGO; 396-44-PCGOV; 166-8-USG; 240-14-USPS).
Although ‘a lot has happened since 2004’ (166-15-USACA), interviewees generally echoed the perspective that ‘psychosocial and spiritual support is the area of greatest need but no strong undertaking’ (240-15-USG). One partner described psychosocial support as “a big need to tackle; it is overwhelming” (272-22-USG). Another interviewee’s observation that ‘psychosocial support is weak nationwide’ (166-29-PCGOV) was echoed by another interviewee’s statement that such support is an area ‘that needs more attention’ (396-21-USG),