The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe.

Joanna Busza,Ethel Dauya,Victoria Simms,Grace Mchugh,Shungu Munyati,Rashida A Ferrand,Prosper Chonzi,Memory Makamba,Chido Dziva Chikwari,Tsitsi Bandason

doi:10.1093/heapol/czx187

Abstract

Reliance on community health workers (CHWs) for HIV care continues to increase, particularly in resource-limited settings. CHWs can improve HIV service use and adherence to treatment, but effectiveness of these programmes relies on providing an enabling work environment for CHWs, including reasonable workload, supportive supervision and adequate training and supplies. Although criteria for effective CHW programmes have been identified, these have rarely been prospectively applied to design and evaluation of new interventions. For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, we based our intervention on an existing evidence-based framework for successful CHW programmes. To assess CHWs’ experiences delivering the intervention, we conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study aimed to explore CHWs’ perceptions of how the intervention’s structure and management affected their performance, and consider implications for the programme’s future scale-up and adoption in other settings. CHWs expressed strong motivation, commitment and job satisfaction. They considered the intervention acceptable and feasible to deliver, and levels of satisfaction rose over interview rounds. Intensive supervision and mentoring emerged as critical to ensuring CHWs’ long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and CHWs. Concerns raised by CHWs included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful CHW programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies.

Highlights

Reliance on community health workers (CHWs) to support care for long-term conditions such as HIV continues to increase, in resource-limited settings (Celletti et al 2010; Lewin et al 2010)
For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, we based our intervention on an existing evidence-based framework for successful CHW programmes
This study shows that existing criteria for designing successful CHW programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies

Summary

Introduction

Reliance on community health workers (CHWs) to support care for long-term conditions such as HIV continues to increase, in resource-limited settings (Celletti et al 2010; Lewin et al 2010). The benefits of engaging this cadre of health providers include their familiarity with local issues, rapport with community members, and lower human resource costs (Torpey et al 2008). The latter is often a justification for ‘task shifting’, where roles that previously were seen to require clinical skills have been transferred to lay personnel who are often volunteers, freeing up more expensive and higher level staff (Zachariah et al 2009). CHWs perform multiple functions in HIV programmes, including referring community members for HIV testing, linking them to care, accompanying them to clinic appointments, providing psychosocial support and making referrals to other services (Gusdal et al 2011; Thomson et al 2013). CHW programme effectiveness depends on an enabling work environment for CHWs, including workload, supportive supervision, supplies and equipment and respect from community members

Methods

Results

Discussion

Conclusion