HIV Care
provide home-based HTC can successfully administer the tests in the home, achieving among the highest uptake of services ever reported. For instance, a study in Uganda found that when offered to household members of HIV-positive contacts, home-based HTC resulted in a higher uptake and increased identification of people with HIV compared with clinic-based HTC provision.3 Similarly a study in South Africa demonstrated that lay community health workers could be successfully trained to provide home-based HTC in remote rural villages and deliver results with high uptake of the service.4 Moreover, a recent study from Western Kenya, reported that home-based care teams offering HIV test- ing and counselling do a better job of getting people who test HIV-positive into care early in the course of HIV, and before becoming ill, compared with voluntary counselling and testing (VCT), provider-initiated testing and counselling (PITC), or HIV testing in a tuberculosis (TB) clinic.5
More recently, at the Conference on Retroviruses and Opportunistic Infections in Seattle this year, results were reported from a study in South Africa where home- based care teams offered not only HCT, but home CD4 cell measurements, using a new portable point-of-care CD4 cell count test, in order to provide anyone who tested positive with their CD4 cell count to see if they qualified for treatment. Out of 750 adults offered HCT in their homes, 90.4% consented to be tested, the over- all HIV prevalence was 29.7%. Among the 201 HIV- positive persons identified, the median CD4 count was 435 (interquartile range 297–591), and 94% of these had visited an HIV clinic by the 3-month follow-up visit. Importantly, community sensitisation and counselling and support services were provided to the household and all those who tested positive. Another study in Uganda found that once an HIV-
positive person had been initiated and was stable on ART, home-based care teams did just as good a job de- livering ART (along with cotrimoxazole and an essential package of preventive care) and monitoring PLHIV in the home as the local clinic could – even in the absence of CD4 cell monitoring. In fact, the approach achieved better outcomes in some regards than the ART clin- ics – reducing mortality among the adults, and notably, among the non-HIV-infected children as well.6
Accord-
ing to another analysis, most people receiving home- based HIV care had multiple positive social outcomes including family emotional support, community emo- tional support, and strengthened relationship between spouse/partner.7 Palliative care organisations and HIV care and sup- port services have also led the way in engaging and empowering PLHIV as an essential part of the multi- disciplinary team approach. For instance, in Haiti and Rwanda, expert patients/
people living with HIV were trained to become ac- compagnateurs enabling effective referrals, high rates of adherence, and retention in care.8,9
In a recent analysis
on how expert patient-treatment supporters programmes work in Africa, O’Laughlin et al write, ‘Treatment partners play an important social role in the lives of the patients they help. They encourage disclosure, combat
July 2012 Africa Health 23
stigma, restore hope, and reduce social difference. All of these are ways of “normalising” HIV/AIDS – of reversing social isolation and reinstating connections to others.’10 In Ghana, PLHIV lay case managers, known as Models of Hope, reach PLHIV who are pre-ART and on ART in the community, home, and at ART clin- ics with PHDP information and services. More than 30000 PLHIV have been reached by Models of Hope who use the ‘My Life: Positive Living Toolkit’ to guide their interactions with them. The Toolkit comprises of ten highly participatory modules including self-esteem, HIV and sexually transmitted infection (STI) prevention, managing disclosure, ART adherence, family planning and reproductive health, recognising and responding to gender-based violence, and handling stigma and human rights violations.11 And as predicted by PHDP, these approaches have resulted in high rates of disclosure, with few problems reported that could not be managed, enabling PLHIV in these studies to engage proactively with their partners who could now encourage treatment adherence, and the use of appropriate HIV prevention tools. In contrast, studies produced by several National
Networks of PLHIV from Nigeria to Moldova, have doc- umented that health services routinely violate the sexual and reproductive health and rights (SRHR) of people living with HIV, refusing to provide access to information or birth control options, counselling them against having sex (whether protected or not) or having children, and coerce women living with HIV into having abortions, even when treatment exists that could dramatically reduce the risks of her passing on HIV to her children. In some cases, women living with HIV have even been sterilised without their consent or knowledge. Ongoing assessments by national networks of PLHIV
of how far the HIV responses in their respective coun- tries are away from achieving the standards for PHDP are consistently finding that national programmes are
© Nadia Bettega
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