WHY TONATA IS IMPLEMENTING COMMUNITY BASED HIV SERVICE?

Tonata started implementing community ART services in collaboration with Ministry of Health and Social Services (MoHSS) in implementing the differentiated care model. Tonata is complementing the services provided by MoHSS through providing psycho-social support to PLHIV, delivering structured health education sessions to PLHIV group members and facilitating the delivery of ARVs through its support group network. To date Tonata in partnership with MoHSS has enrolled 1450 PLHIV in community ARV refill.

Namibia is one of the countries with the highest HIV prevalence in the world with 14% of the adult population (15-49 years) living with HIV in 2013 (MoHSS, 2013). The country has a generalized, mature epidemic, with the majority of new HIV infections transmitted through unprotected heterosexual sex. Among adults (> 15 years) women bear a disproportionate burden of the HIV epidemic with a prevalence of 19.8% compared to 14.9% for men.

There are many factors contributing to the HIV epidemic that include among others gender inequalities, mobility, and the biology of the virus etc., poverty is also key. Poor households face financial and social burdens such as medical expenses, loss of productiveness, funeral expenses due to death of family members, and care for extended families and orphans. The HIV epidemic has aggravated the already high level of poverty by significantly reducing Namibia’s agricultural workforce and reducing agricultural output, which have led to widespread food shortages and hunger where large numbers of people are already undernourished . In Namibia, 28% of the general population is considered poor, of whom 13.8% are considered to be extremely poor.

The face of HIV epidemic is changing from being a fatal to a chronically managed disease. Namibia has successfully rolled out ARV treatment through its public health sector. ART services are now widely available and National guidelines are changing to enroll people earlier into treatment. Over 70% (166,000) of the estimated 237,127 PLHIV in Namibia were on ART at the end of 2016. Yet, while treatment coverage is high, challenges with uptake, adherence and retention remain.

According to a baseline survey conducted in 2010 the 12 months retention rate as 66%. In the same survey, only 7.3% of ART clients were reported to have high adherence (adherence level >95%), and 85% had moderate adherence and 8.2% had low adherence. Some of the contributory factors identified relate to forgetfulness, lack of food and lack of access, gaps in treatment literacy emerge as a key challenge. Test and Treat is recommended in the fifth edition of the National HIV treatment guidelines of 2016 and this continues to increase the number of PLHIV to be put on ART, therefore leading to decreasing the health care provider and patient ratio which may affect the provision of quality health services. This is also expected to further increase the patient load in the already overcrowded health facilities and address the challenges around accessing health care services due to lack of transportation cost.

Efforts have been made to decentralize the ART services from hospitals to primary care facilities and tasks have been shifted from doctors to nurses and community health workers (CHWs) to try and reduce the number of patients served in the health facilities. Despite these developments, it is estimated that 95% of HIV services are still currently provided in the health facilities.

Namibia is a vast country with a sparsely distributed population and access to health care services including HIV services is a challenge due to long distances to health facilities. Models of differentiated care have been proven to be effective in addressing access challenges to ART services and examples include community ARV distribution points and client led ARV distribution groups (MoHSS, 2016).

MoHSS included the differentiated care model in the National HIV treatment guidelines to try and decongest the health facilities as well as ensuring access to treatment and thus to improve adherence and retention to treatment.

Examples of differentiated care models in Namibia include decentralized care to peripheral/primary health care facilities / NIMART sites, decentralization of HIV care and ART to community based outreach points, facility based ART adherence groups led by HIV Champions and community based client led ARV distribution groups. Client led ARV distribution model for stable patients is one of important strategies of decentralization recommended in the face of increasing focus on treatment.

Tonata PLHIV network is the largest support group network in Namibia with vast experience in implementing community based client led ARV distribution and consist of a membership of more than 17,000 individuals. Tonata started implementing community ART services in collaboration with the Ministry of Health and Social Services (MoHSS) in implementing the differentiated care model. Tonata is complementing the services provided by MoHSS through providing psychosocial support to PLHIV, delivering structured health education sessions to PLHIV group members and facilitating the delivery of ARVs through its support group network. To date Tonata has enrolled 1450 PLHIV in community ARV refill and linked to MoHSS. To this end, decentralizing at least 30% (49,800 using the above ARV coverage) of HIV services into communities has been recommended.

There are also other partners that have started establishing health facility based adherence groups. To date 40 health facility based groups have been established in 4 districts. Tonata is complementing the other models of differentiated care by establishing client led ARV distribution groups.

Goals

1. Increased harmonized investment towards “getting to zero”: zero new HIV infections, zero discrimination, zero AIDS – related deaths and integrated service delivery.
2. Improved CASGs response to CBHTS scale-up to achieve the National ART guideline goals.

Targets

Despite new CBHTS developments, it is estimated that still 95% of HIV services are currently provided within health facilities. To support the ambitious targets and accelerated pace of ART expansion and reduce congestion at high volume health facilities, further expansion and decentralization of services closer to the community is needed. To this end, decentralizing at least 30% of HIV services into communities has been recommended.

CBHTS key targets

1. Two thousand five hundred (2500) Community Adherence Support Groups (CASGs) formed
2. Thirty seven thousand five hundred (37 500) individuals on refill
3. Seven thousand five hundred (7 500) individuals’ partners and families of CASGs members refereed for HTS.
4. Three thousand (3000) PLHIV individuals identified, referred and screened for malnutrition.

According to Namibia ART national Guideline 2016 edition, it describing that “Community Based Client Led ARV Distribution Groups” – these are self-formed PLHIV support groups whereby one or two people are identified for training, mentoring and support to enable them to collect and distribute ARVs medicine for other members. Health facilities make special arrangements with such groups making sure patient monitoring and data is not compromised”.

• Objective 1: Strengthen Tonata’s ability to become self-sustainable to do advocacy, social mobilization and communications to facilitate the achievement of national HIV care and treatment objectives.
• Objective 2: Increase access to community based HIV treatment services.
• Objective 3: Enhance the quality of Monitoring, evaluation and reporting of community HIV treatment services; including collaboration with Ministry of Health and Social Services to monitor community viral load suppression.