Articles tagged as "Strengthen HIV integration"

Community health workers can improve HIV and other health indicator outcomes

Assessment of the uptake of neonatal and young infant referrals by community health workers to public health facilities in an urban informal settlement, KwaZulu-Natal, South Africa.

Nsibande D, Doherty T, Ijumba P, Tomlinson M, Jackson D, Sanders D, Lawn J. BMC Health Serv Res. 2013 Feb 6;13(1):47. [Epub ahead of print]

Globally, 40% of the 7.6 million deaths of children under five every year occur in the neonatal period (first 28 days after birth). Increased and earlier recognition of illness facilitated by community health workers (CHWs), coupled with effective referral systems can result in better child health outcomes. This model has not been tested in a peri-urban poor setting in Africa, or in a high HIV context. The Good Start Saving Newborn Lives (SNL) study (ISRCTN41046462) conducted in Umlazi, KwaZulu-Natal, was a community randomized trial to assess the effect of an integrated home visit package delivered to mothers by CHWs during pregnancy and post-delivery on uptake of PMTCT interventions and appropriate newborn care practices. CHWs were trained to refer babies with illnesses or identified danger signs. The aim of this sub-study was to assess the effectiveness of this referral system by describing CHW referral completion rates as well as mothers' health-care seeking practices. Interviews were conducted using a structured questionnaire with all mothers whose babies had been referred by a CHW since the start of the SNL trial. Descriptive analysis was conducted to describe referral completion and health seeking behaviour of mothers. Of the 2423 women enrolled in the SNL study, 148 sick infants were referred between June 2008 and June 2010. 62% of referrals occurred during the first 4 weeks of life and 22% between birth and 2 weeks of age. Almost all mothers (95%) completed the referral as advised by CHWs. Difficulty breathing, rash and redness/discharge around the cord accounted for the highest number of referrals (26%, 19% and 17% respectively). Only16% of health workers gave written feedback on the outcome of the referral to the referring CHW. We found high compliance with CHW referral of sick babies in an urban South African township. This suggests that CHWs can play a significant role, within community outreach teams, to improve newborn health and reduce child mortality. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health which involves the establishment of family health worker teams including CHWs.

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Editor’s notes: In a number of countries, government supported community health workers (CHW) have been tasked to support facility based primary health services. In addition, as HIV care is increasingly mainstreamed into general primary health care settings, these CHW have also been deployed to support facility based HIV care and treatment services, including PMTCT, in particular with a focus on adherence and retention and return to care. There has been a paucity of documentation of the evidence of impact of CHW, and whether the provision of HIV-specific follow up could well be integrated into their scope of practice. This study provides important information regarding the acceptability of such integrated community follow up methods.

Africa
South Africa
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Monitoring for positive and negative consequences of service integration

Evaluation of using Routine Infant Immunization Visits to Identify and Follow-up HIV-exposed Infants and their Mothers in Tanzania.

Goodson JL, Finkbeiner T, Davis NL, Lyimo D, Rwebembera A, Swartzendruber AL, Wallace AS, Kimambo S, Kimario CJ, Wiktor SZ, Luman ET. J Acquir Immune Defic Syndr. 2013 Feb 12. [Epub ahead of print]

Without treatment, approximately half of HIV-infected infants die by age two years, and 80% die before age five years. Early identification of HIV-infected and -exposed infants provides opportunities for life-saving interventions. We evaluated integration of HIV-related services with routine infant immunization in Tanzania.  During April 2009-March 2010, at 4 urban and 4 rural sites, mothers' HIV status was determined at first-month immunization using antenatal cards. HIV-exposed infants were offered HIV testing and follow-up care. Impact of integrated service delivery was assessed by comparing average monthly vaccine doses administered during the study period and a two-year baseline period; acceptance was assessed by interviewing mothers and service providers. During 7569 visits, 308 HIV-exposed infants were identified and registered; of these, 290 (94%) were tested, 15 (5%) were HIV-infected. At urban sites, first-month vaccine doses remained stable (+2% for pentavalent vaccine and -4% for polio vaccine), and vaccine doses given later in life (pentavalent, polio, and measles) increased 12%, 8%, and 11%, respectively. At rural sites, first-month vaccine doses decreased 33% and 35% and vaccine doses given later in life decreased 23%, 28% and 28%. Mothers and service providers generally favored integrated services; however, HIV-related stigma and inadequate confidentiality controls of HIV testing were identified, particularly at rural sites.  Integration of HIV-related services at immunization visits identified HIV-exposed infants, HIV-infected infants, and HIV-infected mothers; however, decreases in vaccine doses administered at rural sites were concerning. HIV-related service integration with immunization visits needs careful monitoring to ensure optimum vaccine delivery.

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Editor’s notes: This study raises some concerns about service integration: the numbers of first month and later vaccine doses decreased significantly at rural (as opposed to urban sites where vaccination dose numbers remained stable) when HIV status of mothers documented in the clinic card was utilized to identify HIV-exposed infants. Quite high percentages of women did have evidence of HIV testing during antenatal care – an indication of good coverage of this essential service. It is important that this study not be over-interpreted – while no immediate other causes for decreases in numbers of infants vaccinated at rural sites were evident, it does highlight that efforts to promote service integration must evaluate a number of service variables as part of its monitoring for success.

Africa
United Republic of Tanzania
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Keeping health care workers well

Workplace wellness for HIV/AIDS-affected nurses in South Africa.

Basson HA, Roets L. Br J Nurs. 2013 Jan 9;22(1):38-44

Registered nurses and midwives, enrolled staff nurses and auxiliary nurses (referred to as nurses) in the South African nursing workforce are confronted daily with HIV in the workplace due to the high HIV prevalence rate among sexually and economically active adult women between 15-49 years of age. Components for a framework of a workplace wellness programme for HIV infected and/or affected nurses in South Africa, who comprise registered nurses and midwives, enrolled staff nurses and auxiliary nurses, were identified and described. Health and wellness could be promoted by instituting a workplace wellness programme. The nurses emphasized the threat of HIV and considered a workplace wellness programme a priority.

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Editor’s notes: Health care worker shortages are pervasive in Africa. Nurses are the backbone of primary care provision in most countries, and increasingly are asked to initiate or maintain people living with HIV on antiretroviral treatment and other HIV primary care services. While the size of the available nursing workforce is impacted by enrollment rates in nursing schools, emigration to wealthier countries, and salary levels, there has been great concern about nursing ‘burn-out’. HIV treatment has reduced HIV-related in-patient occupancy, but the burden on understaffed out-patient departments has increased.  As the authors note, HIV prevalence in nurses and other members of the health care work force mirror national HIV prevalence, and these nurses who are themselves living with and affected by HIV, have their own health care and psychosocial needs. Workplace wellness programs can be a meaningful response to caring for the caregiver.

Africa
South Africa
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Integrating HIV care and treatment into primary health care centers

Integration of HIV Care and Treatment in Primary Health Care Centers and Patient Retention in Central Mozambique: A Retrospective Cohort Study.

Lambdin BH, Micek MA, Sherr K, Gimbel S, Karagianis M, Lara J, Gloyd SS, Pfeiffer J. J Acquir Immune Defic Syndr. 2013 Jan 2. [Epub ahead of print]

In 2004, the Mozambican Ministry of Health began a national scale-up of antiretroviral therapy (ART) using a vertical model of HIV clinics co-located within large, urban hospitals. In 2006, the ministry expanded access by integrating ART into primary health care clinics. The authors conducted a retrospective cohort study including adult, ART-naive patients initiating ART between January 2006 and June 2008 in public sector clinics in Manica and Sofala provinces. Cox proportional hazards models with robust variances were used to estimate the association between clinic model (vertical/integrated), clinic location (urban/rural) and clinic experience (1st 6 months/post-1st 6 months) and attrition occurring in early patient follow-up (≤6 months) and attrition occurring in late patient follow-up (>6 months), while controlling for age, sex, education, pre-ART CD4 count, WHO stage and pharmacy staff burden. A total of 11,775 patients from 17 clinics were studied. The overall attrition rate was 37 per 100 person-years. Patients attending integrated clinics had a higher risk of attrition in late follow-up (HR=1.75 (95%CI: 1.04-2.94)), and patients attending urban clinics (HR=0.57 (95%CI: 0.35-0.91)) had a lower risk of attrition in late follow-up. Though not statistically significant, clinics open for longer than 6 months (HR=0.72 (95%CI: 0.51 - 1.02)) had a lower risk of attrition in early follow-up. Patients attending vertical clinics had a lower risk of attrition. Utilizing primary health clinics to implement ART is necessary to reach higher levels of coverage; however, further implementation strategies should be developed to improve patient retention in these settings.

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Editor’s notes: There is no single service delivery strategy that is most appropriate for HIV primary care and provision of antiretroviral treatment. The strategies chosen in generalized epidemics may be quite different from countries with highly concentrated epidemics. High prevalence countries are often choosing to integrate HIV treatment into other primary health care services. As countries move towards universal access, earlier approaches to the delivery of HIV treatment benefit from review – vertical structures for antiretroviral therapy services may not be sustainable as increasing numbers of people living with HIV come into care.  The provision of HIV primary health care does need to respond to the comprehensive service needs of people living with HIV, and the impact of a changeover to a new system of care must be implemented and monitored carefully.  Strategies to minimize loss to follow up and to support retention must be included when these changes occur.

Africa
Mozambique
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Decentralizing pediatric HIV care and treatment into primary care centers

Decentralization of pediatric HIV Care and Treatment in Five sub-Saharan African Countries.

Fayorsey RN, Saito S, Carter RJ, Gusmao E, Frederix K, Koech-Keter E, Tene G, Panya M, Abrams EJ. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHF) versus secondary/tertiary health facilities (SHFs). Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania from January 2008- March 2010 trends were examined in the number of children < 15 years of age initiating antiretroviral treatment (ART) by facility type. Clinic-level lost to follow-up (LTFU) and mortality per 100 person years (PYs) on ART during the period by facility type were compared. During the two year period, 17,155 children enrolled in HIV care and 8,475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, while SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100PYs and 5.2/100PYs, respectively at PHFs and 20.2/100PYs and 6.0/100PYs at SHFs. Adjusted models show PHFs associated with lower LTFU (Adjusted Rate Ratio, ARR=0.55; p=0.022) and lower mortality (ARR=0.66; p=0.028). The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.

Abstract access 

Editor’s notes: Early during treatment scale up pediatric ART remained a referral clinic intervention, limiting the enrollment of children and disrupting efforts to provide ‘one-stop’ visits for families with adults and children living with HIV. Barriers such as provider discomfort with pediatric ART have been addressed by increased training efforts as well as a public health approach of algorithm-based treatment. Increasingly pediatric ART is being provided in the same sites and by the same providers as other primary health services.

Africa
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Task shifting from doctors to nurses results in comparable outcomes

Task shifting HIV care in rural district hospitals in Cameroon: evidence of comparable antiretroviral treatment related outcomes between nurses and physicians in the Stratall ANRS/ESTHER trial.

Boullé C, Kouanfack C, Laborde-Balen G, Carrieri MP, Dontsop M, Boyer S, Aghokeng AF, Spire B, Koulla-Shiro S, Delaporte E, Laurent C; for the Stratall ANRS/ESTHER Study Group. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

Task shifting to nurses for antiretroviral therapy (ART) is promoted by WHO to compensate for the severe shortage of physicians in Africa. The effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon was assessed through a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006-2010. ART-naive patients were followed-up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. The associations between the consultant ratio (i.e. the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to WHO clinical stage 4 in multivariate analyses were assessed. Of the 4,141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success (odds ratio 1.00, 95%CI 0.59-1.72, p=0.990), CD4 recovery (coefficient -3.6, 95%CI -35.6; 28.5, p=0.827), mortality (time ratio 1.39, 95%CI 0.27-7.06, p=0.693) or disease progression (time ratio 1.60, 95%CI 0.35-7.37, p=0.543). This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of non-complex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, as well as for other health interventions.

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Editor’s notes: Most health services in primary health facilities are provided by nurses or clinical officers, with few PHC having physician cadre staffing. The evidence is strong that nurses can ably prescribe and refill ART for adults and children living with HIV, further supporting universal access to HIV treatment. The strategies described in the accompanying articles for decentralization to primary health clinics for adults and children require task shifting in many settings – decentralization and integration of HIV services into primary care will inevitably benefit from an increased reliance on nurses as providers of primary care.

Africa
Cameroon
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Integration of HIV and TB services: a model to shift from "vertical to horizontal"

Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.

Legido-Quigley H, Montgomery CM, Khan P, Atun R, Fakoya A, Getahun H, Grant AD. Trop Med Int Health. 2012 Dec 10. [Epub ahead of print]

Objectives: Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration.

Methods: Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts.

Results: Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness.

Conclusions: While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures.

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Editor’s notes:This study emphasizes the need to implement the most effective integrated services for the prevention and cure of HIV and TB.  TB remains one of the most deadly infectious diseases that dramatically impacts on people in sub-Saharan Africa and represent the major cause of death in those living with HIV in the region. In fact, the progressive weakening of the immune system in HIV-positive people increases the likelihood of contracting/reactivating tuberculosis. Already in 2004, the WHO published "A Interim Policy on TBV/HIV Collaborative Activities" with the purpose of providing a guide to establish integration of TB and HIV services, and to reduce the TB load in people living with HIV. An updated document "WHO policy on collaborative TB/HIV activities: guidelines for national programmes and other stakeholders" is now available. The document provides guidance for integrating care activities between TB and HIV health services. However, to put this paper into perspective, a consensus can be reached by saying that integration shall not just be about HIV and TB. Indeed, the old debate between "vertical approaches (e.g. disease focused)" and horizontal approaches (e.g. health systems focused) shall now be concluded and integration of services shall expand to care of other diseases, particularly when, at the horizon, an epidemic of chronic non-communicable diseases is slowly but surely rising in Africa. In summary, HIV is a chronic infection impacting the lifecycle; with periods of illness and wellness, with multiple clinical and psychosocial needs, requiring lifelong care and treatment with a secure supply of medicines and laboratory tests.

It is evident that HIV care may inform appropriate responses to other health threats which share the same demand for services, training of health care workers, support for adherence, infrastructure and equipment, programme management, drug and laboratory supplies, linkage to care and community involvement. In other words, there is a wide recognition of the spillover effect of HIV interventions towards health systems strengthening, not only to the benefit of other communicable diseases, but also of child and maternal health and of chronic non-communicable diseases (like diabetes, hypertension and cancer).

Africa, Asia, Europe, Latin America
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Health care delivery

Listening to health workers: lessons from Eastern Uganda for strengthening the programme for the prevention of mother-to-child transmission of HIV

Rujumba J, Tumwine JK, Tylleskar T, Neema S, Heggenhougen HK. BMC Health Serv Res. 2012 Jan 5;12:3

The implementation and utilization of programmes for the prevention of mother-to-child transmission (PMTCT) of HIV in most low-income countries has been described as sub-optimal. As planners and service providers, the views of health workers are important in generating priorities to improve the effectiveness of the PMTCT programme in Uganda. Rujumba and colleagues explored the lessons learnt by health workers involved in the provision of PMTCT services in eastern Uganda to better understand what more needs to be done to strengthen the PMTCT programme. A qualitative study was conducted at Mbale Regional Referral Hospital, The AIDS Support Organisation (TASO) Mbale and at eight neighbouring health centres in eastern Uganda, between January and May 2010. Data were collected through 24 individual interviews with the health workers involved in the PMTCT programme and four key informants (2 district officials and 2 officials from TASO). Data were analyzed using the content thematic approach. Study themes and sub-themes were identified following multiple reading of interview transcripts. Relevant quotations have been used in the presentation of study findings. The key lessons for programme improvement were: ensuring constant availability of critical PMTCT supplies, such as HIV testing kits, antiretroviral drugs (ARVs) for mothers and their babies, regular in-service training of health workers to keep them abreast with the rapidly changing knowledge and guidelines for PMTCT, ensuring that lower level health centres provide maternity services and antiretroviral drugs for women in the PMTCT programme and provision of adequate facilities for effective follow-up and support for mothers. The voices of health workers in this study revealed that it is imperative for government, civil society organizations and donors that the PMTCT programme addresses the challenges of shortage of critical PMTCT supplies, continuous health worker training and follow-up and support for mothers as urgent needs to strengthen the PMTCT programme.

For abstract access click here.

Editor’s note: This rich article, full of the views of health care workers (nurses/midwives, counsellors, clinical officers, and medical doctors) working in programmes to prevent mother-to-child transmission (PMTCT) in Mbale, Uganda, makes for interesting reading. The semi-structured interviews with front-line workers took place before those with key informants, in order that suggestions made by the health care workers on how to strengthen the PMTCT programme could be fed back to district officials planning, implementing, and monitoring the programme. In addition to the key lessons for programme improvement that were identified, the inability of poor women to purchase the ‘Maama’ kits required for health facility delivery is undermining attempts to promote linkages between PMTCT, maternal and child health, and reproductive health. As well, persistent stigma and limited integration of services is keeping women away from services such as the PEPFAR-funded TASO programme that is less affected by shortages. But the biggest lesson is that health care workers are key stakeholders in the design, implementation, and strengthening of services¾their voices should be sought and listened to.

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Health care delivery

Estimating loss to follow-up in HIV-infected patients on antiretroviral therapy: The effect of the competing risk of death in Zambia and Switzerland

Schöni-Affolter F, Keiser O, Mwango A, Stringer J, Ledergerber B, Mulenga L, Bucher HC, Westfall AO, Calmy A, Boulle A, Chintu N, Egger M, Chi BH. PLoS One. 2011;6(12):e27919. Epub 2011 Dec 19

Loss to follow-up is common in antiretroviral therapy programmes. Mortality is a competing risk for loss-to-follow-up; however, it is often overlooked in cohort analyses. Shöni-Affolter and colleagues examined how the competing risk of death affected loss-to-follow-up estimates in Zambia and Switzerland. HIV-infected patients aged ≥18 years who started antiretroviral therapy 2004-2008 in observational cohorts in Zambia and Switzerland were included. Schoni-Affolter and colleagues compared standard Kaplan-Meier curves with competing risk cumulative incidence. They calculated hazard ratios for loss-to-follow-up across CD4 cell count strata using cause-specific Cox models, or Fine and Gray subdistribution models, adjusting for age, gender, body mass index and clinical stage. 89,339 patients from Zambia and 1,860 patients from Switzerland were included. 12,237 patients (13.7%) in Zambia and 129 patients (6.9%) in Switzerland were lost-to-follow-up and 8,498 (9.5%) and 29 patients (1.6%), respectively, died. In Zambia, the probability of loss-to-follow-up was overestimated in Kaplan-Meier curves: estimates at 3.5 years were 29.3% for patients starting antiretroviral therapy with CD4 cells <100 cells/µl and 15.4% among patients starting with ≥350 cells/µL. The estimates from competing risk cumulative incidence were 22.9% and 13.6%, respectively. Little difference was found between naïve and competing risk analyses in Switzerland since only few patients died. The results from Cox and Fine and Gray models were similar: in Zambia the risk of loss to follow-up and death increased with decreasing CD4 counts at the start of antiretroviral therapy, whereas in Switzerland there was a trend in the opposite direction, with patients with higher CD4 cell counts more likely to be lost to follow-up. In antiretroviral therapy programmes in low-income settings the competing risk of death can substantially bias standard analyses of loss-to-follow-up. The CD4 cell count and other prognostic factors may be differentially associated with loss-to-follow-up in low-income and high-income settings.

For abstract access click here.

Editor’s note: Determining the reasons for and reducing loss to follow-up among patients who are started on antiretroviral therapy is important not only in evaluating treatment scale-up programmes but also in improving patient outcomes in resource-limited settings. When predictors of treatment failure or death, such as low CD4 count and more advanced clinical disease at treatment initiation, also predict loss to follow-up, a substantial proportion of those lost to follow-up may actually have died. A competing risk analysis starts with the premise that a competing risk is one that prevents the outcome of interest from occurring. In this case, patients who die can no longer be lost to follow-up. As this analysis shows, the determinants of loss to follow-up in Zambia are clearly different than those in Switzerland, with the result that programme strategies to prevent loss to follow-up will be different in the two countries. For Zambia, earlier treatment initiation would have important effects in reducing loss to follow-up caused by the competing risk of death.

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Faith-based responses

Pentecostalism and AIDS treatment in Mozambique: creating new approaches to HIV prevention through anti-retroviral therapy

Pfeiffer J, Glob Public Health. 2011;6 Suppl 2:S163-73

Pentecostal fervour has rapidly spread throughout central and southern Mozambique since the end of its protracted civil war in the early 1990s. In the peri-urban bairros and septic fringes of Mozambican cities African Independent Churches with Pentecostal roots and mainstream Pentecostals can now claim over half the population as adherents. Over this same period another important phenomenon has coincided with this church expansion: the AIDS epidemic. Pentecostalism and HIV have travelled along similar vectors and been propelled by deepening inequality. Recognising this relationship has important implications for HIV prevention and treatment strategies. The striking overlap between high HIV prevalence in peri-urban populations and high Pentecostal participation suggests that creative strategies, to include these movements in HIV programming, may influence the long-term success of HIV care and the scale-up of anti-retroviral treatment across the region. The provision of antiretroviral treatment has opened up new possibilities for engaging with local communities, especially Pentecostals and African Independent Churches, who are witnessing the immediate benefits of antiretroviral therapy. Expanded treatment may be the key to successful prevention as advocates of a comprehensive approach to the epidemic have long argued.

For abstract access click here

Editor’s note: At the end of Mozambique’s long civil war in the 1990s, people began to move more back and forth across the borders with South Africa and Zimbabwe. Among the things accompanying them were Pentecostal messages (more than half the population are now adherents) and HIV infection (HIV prevalence varies sharply by province but is higher in those adjacent to these countries). This interesting article analyses the impact of structural adjustment policies and class associations between different Christian religions in Mozambique on poverty and the response to HIV. It argues that Catholicism has a privileged position in health care delivery (the large majority of health care workers report that they are Catholics) and in interrelations with donors and foreign implementing partners. Pentecostals and African Independent Churches have excluded themselves or been excluded from HIV prevention programming based on their patriarchal theology, conservative social policy, and differences in moral discourse about sexual behaviour. Now the hope of antiretroviral therapy has opened up dialogue within Pentecostal churches, engendering a new social solidarity around AIDS, with members encouraged to learn their HIV status and seek treatment at public services. There is a tangible opportunity now for these large faith-based communities to break out of exclusion to participate actively as partners in public health treatment and prevention programming.

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