Abstract
Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit’s range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40-fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up.
Highlights
150,000 children are living with HIV in Uganda, and the majority of children are under five years of age [1]
Family-centred approaches to HIV care have emerged as an effort to better target children and their caregivers for testing and care, and to provide integrated, comprehensive HIV and health services that support the range of a family unit’s care needs
The integrated package at Mildmay included the following services: (a) HIV diagnosis, prevention, prophylaxis, and treatment services; (b) reproductive and maternal health services, including prevent mother-to-child transmission (PMTCT), family planning, and cervical cancer screening; (c) paediatric outpatient and inpatient services, including rehabilitation for severe acute malnutrition; (d) adolescent and adult outpatient and inpatient services; (e) commodity distribution for families enrolled in care; (f) specialist services including paediatric dental, adult and paediatric ophthalmology, occupational therapy, physiotherapy, and mental health; (g) TB screening and treatment; and (h) home-based follow-up and counselling support from community-based volunteers and community nurses
Summary
150,000 children are living with HIV in Uganda, and the majority of children are under five years of age [1]. Despite the clear need to scaleup comprehensive prevention, care, and treatment for HIVexposed and infected infants, paediatric services have lagged behind adult care both in Uganda and internationally [4]. Challenges to scale-up have included: poor linkages from PMTCT programmes and the subsequent missed opportunities for identification during postnatal and child health care; challenges of early infant diagnosis; the prioritization of adult treatment and subsequent lag in availability of paediatric antiretroviral dosages; and limited paediatric expertise amongst healthcare providers [4,5,6,7,8,9,10,11,12]. Family-centred approaches to HIV care have emerged as an effort to better target children and their caregivers for testing and care, and to provide integrated, comprehensive HIV and health services that support the range of a family unit’s care needs. Members are often responsible for chronic care among HIV-infected individuals, and the impacts of HIV may affect the family beyond the HIV-infected individual, and are often intergenerational [13,14]
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