Abstract
IntroductionThe provision of HIV treatment and care in sub-Saharan Africa faces multiple challenges, including weak health systems and attrition of trained health workers. One potential response to overcome these challenges has been to engage community health workers (CHWs).MethodologyA systematic literature search for quantitative and qualitative studies describing the role and outcomes of CHWs in HIV care between inception and December 2012 in sub-Saharan Africa was performed in the following databases: PubMed, PsychINFO, Embase, Web of Science, JSTOR, WHOLIS, Google Scholar and SAGE journals online. Bibliographies of included articles were also searched. A narrative synthesis approach was used to analyze common emerging themes on the role and outcomes of CHWs in HIV care in sub-Saharan Africa.ResultsIn total, 21 studies met the inclusion criteria, documenting a range of tasks performed by CHWs. These included patient support (counselling, home-based care, education, adherence support and livelihood support) and health service support (screening, referral and health service organization and surveillance). CHWs were reported to enhance the reach, uptake and quality of HIV services, as well as the dignity, quality of life and retention in care of people living with HIV. The presence of CHWs in clinics was reported to reduce waiting times, streamline patient flow and reduce the workload of health workers. Clinical outcomes appeared not to be compromised, with no differences in virologic failure and mortality comparing patients under community-based and those under facility-based care. Despite these benefits, CHWs faced challenges related to lack of recognition, remuneration and involvement in decision making.ConclusionsCHWs can clearly contribute to HIV services delivery and strengthen human resource capacity in sub-Saharan Africa. For their contribution to be sustained, CHWs need to be recognized, remunerated and integrated in wider health systems. Further research focusing on comparative costs of CHW interventions and successful models for mainstreaming CHWs into wider health systems is needed.
Highlights
The provision of HIV treatment and care in sub-Saharan Africa faces multiple challenges, including weak health systems and attrition of trained health workers
The main limitation of the three randomized controlled trials (RCTs) related to their lack of complete blinding, which is difficult to achieve in trials for community-based interventions [47]
Roles and outcomes of community health workers in sub-Saharan Africa: emerging themes A narrative synthesis of the findings identified two main themes related to the effect of CHWs on 1) patient outcomes and 2) health systems, based on the specific activities that CHWs engage in
Summary
The provision of HIV treatment and care in sub-Saharan Africa faces multiple challenges, including weak health systems and attrition of trained health workers. Clinical outcomes appeared not to be compromised, with no differences in virologic failure and mortality comparing patients under community-based and those under facility-based care Despite these benefits, CHWs faced challenges related to lack of recognition, remuneration and involvement in decision making. For their contribution to be sustained, CHWs need to be recognized, remunerated and integrated in wider health systems. Efforts to scale up HIV treatment and care in sub-Saharan Africa over the past decade, while successful, have exposed pre-existing weaknesses of health systems in this region [6], in particular the lack of health workers to provide ART [7,8]. These issues remain important, a recent review suggests that some of the universal features of CHWs include their comparatively
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