PEPFAR Implementation Progress and Promise (2007) / Chapter Skim
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6 PEPFAR's Care Category
6 PEPFAR's Care Category
Pages 169-204
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From page 169... ...
Given its importance as the point of entry for care, prevention, and treatment, counseling and testing is being scaled up in all of the focus countries. • The majority of care is offered in the home, but PEPFAR's model for the home-care workforce has three elements that both have advantages and present challenges: heavy reliance on World Health Organization–recommended community health workers; the focus of its training resources on existing health professionals; and heavy reliance on unpaid volunteers, who are usually familial caregivers -- most often women, young girls, and elderly grandmothers.
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From page 170... ...
This model should include integration as appropriate with prevention and treatment programs and linkages with other public-sector and nongovernmental organization services within and outside of the health sector, such as primary health care, nutrition support, education, social work, and the work of agencies facilitating income generation.
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From page 171... ...
. PEPFAR defines palliative care as encompassing five domains: clinical, psychological, spiritual, social, and preventive care for HIV-infected people.
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From page 172... ...
The Committee was unable to determine whether this creates challenges to ensuring that these services are a consistent part of home-based care and programs. OGAC also supports voluntary counseling and testing activities with funds from the care category, but the Leadership Act places these activities in the prevention category (OGAC, 2004)
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From page 173... ...
Like the treatment target, the care target is a count of people receiving services and does not provide information about the quality or impact of those services. With the data currently available, it is not possible to determine whether the care services PEPFAR is supporting are of sufficient and equal quality, duration, and type; offered by knowledgeable and skilled providers who receive adequate and appropriate supervision at all levels (a question that applies especially to in-home volunteers and community health workers)
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From page 174... ...
antiretroviral therapy and support • Nutritional support for adherence • Antiretroviral therapy • Behavior change communication • Health education measures • End-of-life and bereavement care • Adequate universal precautions in facilities • Postexposure prophylaxis Psychological • Initial and follow-up counseling • Mental health counseling Support services for emotional and • Family care and support groups (patient and spiritual needs • Support for HIV status disclosure family support • Support groups, post-test clubs • Bereavement care to assist in • Other peer, volunteer, or • Treatment for mood and anxiety disclosure) outreach approaches within disorders communities • Development and implementation of culturally and age-appropriate psychological initiatives Socioeconomic • Micro-credit schemes Equivalent activities are in the Support • Housing "social care" domain (WHO's (material • Food support "human rights and legal support" support, • Helping hands in the household domain -- see below)
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From page 175... ...
access to care) • Assistance to secure government grants, housing, or health care • Linkages to food support and income generation programs • Efforts to increase community awareness of prevention, treatment, and care services • Other activities designed to strengthen affected households and communities, including income generation activities Spiritual Care Equivalent activities are in the • Life reviews and assessments (culturally "psychological support" domain • Counseling related to fear, hope, appropriate forgiveness, meaning of life and sensitive • Life-completion tasks to individual and community religious beliefs and practices)
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From page 176... ...
b Not applicable Not applicable 2,464,000 TB treatment and care 241,100 369,000 301,600 Total people receiving care 696,900 1,766,200 2,765,600 Training -- routine/TB care 36,700 86,000 93,900 Training -- VCT 14,100 22,200 33,500 Total people receiving care-related 50,800 108,200 127,400 training Service outlets -- VCT 2,100 4,200 6,466 Service outlets -- routine/TB care 5,400 6,800 8,019 NOTE: Figures shown do not include services to orphans and vulnerable children. VCT = voluntary counseling and testing in settings not providing services to prevent mother-to-child transmission of HIV.
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From page 177... ...
. As early as the PEPFAR strategy document, PEPFAR began to articulate the approach of training and using community health workers to deliver essential supplies, including medications, to people in need in their communities (OGAC, 2004)
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From page 178... ...
. Community-Based, Family-Centered Care According to OGAC's palliative care guidance, community-based care is "provided in a variety of community settings, including free-standing outpatient clinics, day care centers, school- or university-based clinics, community health centers, workplace clinics, or stand-alone hospices.
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From page 179... ...
For example, the program is increasingly focusing on secondary preventive care services; income generation and economic stability for households; services aimed at helping people be as healthy as possible for as long as possible, with the added goal of keeping families intact; and increased flexibility in individual and community service planning, driven by the needs of the diverse communities within and across the focus countries. As described in Chapter 2, interventions at the community level involving the active engagement and participation of the community have the greatest likelihood of success.
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From page 180... ...
For this reason, WHO strongly urges that "health sector actions should be community-centered, engaging communities and people living with HIV/AIDS as full and equal partners in the provision of palliative care and other responses to the epidemic. Communities, families,
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From page 181... ...
REVIEW OF PROGRESS TO DATE This section reviews progress to date in the subcategories of routine care for HIV and tuberculosis, voluntary counseling and testing, and carerelated training, as well as in the transition to sustainability.
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From page 182... ...
In April 2006, OGAC released two sets of guidance for secondary preventive care services for both adults and children aged 0–14 born to mothers who are HIV-positive. This guidance was produced under the leadership of several of OGAC's technical working groups -- the Palliative Care Technical Working Group, the Food and Nutrition Technical Working Group, and the Orphans and Vulnerable Children Technical Working Group.
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From page 183... ...
. OGAC's guidance documents clarify specific preventive care services PEPFAR will fund directly, as well as their expectations for linking preventive care interventions to other key health care services, such as routine medical care and voluntary family planning (see the discussion of integration of services later in the chapter)
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From page 184... ...
Prevention of opportunistic infections is, of course, optimum, and in some cases may be achieved by avoiding pathogens that may be found in water sources, uncooked food, domestic animals, and human excrement. While PEPFAR usually addresses medical management and prophylaxis of opportunistic infections in its treatment category, it also addresses prophylaxis through activities under its secondary preventive care package related to safe drinking water, personal hygiene, and training in and use of cotrimoxazole.
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From page 185... ...
. Voluntary Counseling and Testing Definition WHO defines voluntary counseling and testing as a confidential dialogue between a client and a care provider aimed at enabling the client to cope with stress and to make personal decisions related to HIV/AIDS (Rehle et al., 2000)
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From page 186... ...
In treatment, voluntary counseling and testing is helpful for identifying those eligible for ART. In care, voluntary counseling and testing can be used to identify those in need of palliative care, particularly those not eligible for ART or for whom ART is not available.
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From page 187... ...
To advance testing and diagnosis of infants (6 weeks and older) who are HIVexposed and HIV-positive, PEPFAR is collaborating with some of its implementing partners to pilot and develop the use of dried blood spot testing with polymerase chain reaction testing in several focus countries (OGAC, 2006b; Kaiser Family Foundation, 2006)
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From page 188... ...
. It is difficult to determine the ratio of in-service to preservice training supported by PEPFAR, as well as whether the training being provided is exponentially increasing the number of skilled or lay workers and paid or unpaid health workers, because information is generally unavailable on the categories of workers involved (nurses, clinical officers, physicians, community health workers, home health workers, and familial caregivers)
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From page 189... ...
Examples of task shifting specifically related to care activities include using community health workers to offer counseling and testing services so that nurses can provide other, more complex clinical services. In some focus countries, laws have been changed to allow specially trained nurses or clinical medical officers to prescribe ARVs and medications for management of opportunistic infections,
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From page 190... ...
. PEPFAR also uses formal partnerships among ministries of health, organizations for people living with HIV/AIDS, and community-based organizations to enable people living with HIV/AIDS to be trained as community health workers who can provide adherence support and prevention services.
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From page 191... ...
. Therefore, OGAC's palliative care guidance specifically acknowledges that the introduction of comprehensive care into home-based programs requires training and education of medical providers (nurses, clinical officers and physicians, including pediatric nurses and physicians)
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From page 192... ...
During country visits, the Committee heard from program implementers about a lack of timely and comprehensive programmatic guidance for family-based care services, which has resulted in delays in program planning, implementation, and evaluation, as well as great variability in the type, quantity, and quality of care services throughout the focus countries. On the African continent in particular, the Joint Learning Initiative has reported that community health workers have taken on more specialized roles in the areas of malaria control, reproductive health, and nutrition and have increased their coverage of a range of services over the last three decades; they have also assumed broader roles as change agents and community advocates.
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From page 193... ...
(2006) describes how prayer is often used as a symptom management strategy for people living with HIV in an ethnically diverse sample.
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From page 194... ...
found that the reliance of African palliative care services on volunteers to provide community and home-based care has been largely successful for palliative care, but that community capacity and the resources and clinical supervision necessary to sustain quality care are lacking. They note that it is not yet clear how much trained professional input is needed for supervision of lay workers and patients, what the community's maximum capacity for care is, and what level of skills can be expected from lay workers providing palliative care.
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From page 195... ...
. During PEPFAR's third annual meeting in Durban, it was noted that many patients and providers report that pain is undertreated in the majority of patients surveyed, and the African Palliative Care Association, a major south-to-south twinning partner, has reported that opioids are unavailable to the majority of providers -- in some cases, even mild analgesics are unavailable for adequate pain management (OGAC, 2006e)
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From page 196... ...
. Strategies are needed to support women in voluntary family planning and reproductive health, which requires integration with prevention of mother-to-child transmission of HIV, voluntary counseling and testing in family planning settings, access to ART and other necessary medications, and care in communityand home-based settings.
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From page 197... ...
. Voluntary Counseling and Testing The past 2 years has seen increasing interest in moving toward a model of counseling and testing that makes the HIV test a routine part of medical care.
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From page 198... ...
. At PEPFAR's third annual meeting, several challenges related to scaling up counseling and testing services were identified, including shortages of test kits; lengthy pretest counseling sessions; referrals for care, support, and treatment for difficultto-reach populations; logistical complications associated with the increased demand for mobile services; and lack of consensus on age of consent for HIV testing and how to communicate HIV test results to children (OGAC, 2006d)
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From page 199... ...
PEPFAR guidance emphasizes comprehensive and integrated services at the community level, but much of the program's planning is being done by partners at the national rather than the local level. For example, PEPFAR has provided technical assistance at the national level for building sustainable palliative care systems.
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From page 200... ...
Global AIDS Coordinator should continue to promote and support a community-based, family-centered model of care in order to enhance and coordinate supportive care services for people living with HIV/AIDS, with special emphasis on orphans, vulnerable children, and people requiring end-of-life care. This model should include integration as appropriate with prevention and treatment programs and linkages with other public-sector and nongovernmental organization services within and outside of the health sector, such as primary health care, nutrition support, education, social work, and the work of agencies facilitating income generation.
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From page 201... ...
As the evidence base grows and communities learn more about how best to deal with the epidemic, these practices need to be scaled up and tailored to the needs of other communities. If international standards indicate that insecticide-treated bed nets are effective and should be provided to members of all households to decrease exposure to opportunistic infections such as malaria, for example, PEPFARsupported preventive care services need to be linked with wrap-around programs that will support such interventions.
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From page 202... ...
2006. HIV-related opportunistic infections: Preention and treatment.
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From page 203... ...
2005. Does palliative care improve outcomes for patients with HIV/AIDS?
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From page 204... ...
2003. Community health workers and community oices: Promoting good health.
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