An MSF community health agent tests a patient in her home in Eshowe
They are the unsung heroes of the HIV treatment movement. They form the links in the life-saving chain between people and treatment programmes to halt the spread of the virus. Community health workers enable testing, treatment and adherence services to reach deep into communities, even in rural KwaZulu-Natal (KZN).
“The lay health workers in communities and facilities are the glue holding everything together — improving both quality of care and access,” says Musa Ndlovu, deputy field coordinator for Doctors Without Borders (MSF) in Eshowe in the Mbongolwane area.
Patient care, he says, works like dominoes: An entire community involved in testing people where they live and work, ensuring someone who tests positive initiates treatment as early as possible, and then supporting them to stay adherent to lifelong treatment can suppress virus levels and disease transmission at population level.
Bending the Curves
In April 2011, MSF and the KZN department of health (DoH) launched an innovative HIV/TB project called “Bending the Curves” in Eshowe, an urban area and Mbongolwane, a rural setting in the province’s uThungulu District, uMlalazi Municipality,
The area has one of the highest rates of HIV and TB in South Africa with one in four people aged 15 to 59 being HIV positive. To reduce the rate of HIV infection in a community is to bend the curves of the epidemic and save lives. And “bending the curves” requires that over 80% of people with HIV should be virally suppressed — thanks to treatment adherence — in order to dramatically lower the risk of HIV transmission at community level.
Reaching further by being patient-centred
Achieving this is near impossible without reaching out to people where they live and work, and customising health services in order to link people to testing and treatment more easily. Community health workers are crucial to running the project’s HIV prevention and testing initiatives, linking HIV-positive people to medical care and supporting them in adhering to treatment.
What happens without the glue?
There is evidence that the absence of lay health workers and counsellors in facilities has had a hugely negative impact. After lay counsellors were withdrawn from facilities in KZN in two waves during 2015, the monthly average number of HIV tests conducted in MSF-supported facilities in Eshowe/Mbongolwane decreased by 25 percent and then a further 13 percent. The number of new people starting on treatment declined by 20 percent. MSF is advocating for lay counsellors to be reinstated to strengthen HIV prevention and treatment in the area.
Customising services to meet needs
The MSF team in Eshowe runs various customised community testing approaches including mobile testing units with teams of counsellors and site mobilisers offering HIV counselling and testing and TB screening and mobilisation for male medical circumcision among other services in farms, at schools and even taxi ranks.
Door-to-door testing
As part of the project, MSF is also rolling out the Community Health Agents Programme (Chaps), which involves 33 lay health workers providing door-to-door HIV counselling and testing in rural and peri-urban areas as well as screening for TB and sexually transmitted infections, referring people to health facilities and recruiting men for circumcision, among other services.
These community testing strategies piloted by MSF in KZN are particularly effective at reaching first-time testers, including students, young women at risk of HIV, and young men who may not attend health facilities. Door-to-door testing by community health workers reaches people of all ages and is able to reach far and wide.
Helping people stick to treatment
To increase adherence to treatment among those who test positive, lay counsellors meet with groups for ART collection and to provide adherence counselling in a supportive peer environment.
While policies and practices for employing lay workers vary widely, their absence from the health system is negative impacting communities. Their power and value in addressing South Africa’s HIV and TB epidemics cannot be overestimated.