COH Door to Door

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Lighting the way with Corridors of Hope IIIBringing Health Services Straight to the DoorstepBy Geoffrey Bendeck and Emmanuel Mwamba

A USAID PEPFAR Project.

COHIIIDOOR TO DOOR

Introduction and Background

The impact of HIV and AIDS on the Zambian society is indisputable. The most recent data suggests that of Zambia’s 13 million people, 14.3% of the population between the ages of 15-49 years is HIV positive (ZDHS 2007). Despite this, it is estimated that only about 15% of Zambians know their HIV status, a number that suggests that there is still much work to be done.

In response to the HIV pandemic in Zambia, the Corridors of Hope project (COH) was launched in 2000 with the

support of USAID and JICA through Family Health International - as the Cross Border Initiative to reduce HIV transmiss ion among higher r i sk populations. Initially the project was implemented in five sites namely Kasumbalesa/Chililabombwe, Kapiri Mposhi, Chipata, Chirundu, Livingstone expanding to Nakonde, Kazungula and Katete. World Vision International and Society for Family Health were initially the local partners implementing. In 2004 with new funding from USAID/PEPFAR the project name changed from CBI project to Corridors of Hope I (COHI) project. The project targeted female sex workers (FSWs) and their clients who were mostly long distance truck drivers and uniformed personnel

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along borders and transit routes with behaviour change messages and treatment of sexually transmitted infections (STIs). COH I continued work with FSWs and their clients from 2004-2006 with USAID/PEPFAR funding. The project began to provide HIV counseling and testing as well from static sites and expanded to two more new sites namely Ndola and Lusaka cities and broadened activities to include populations outside higher risk including the youth. The Zambia Health Education and Communications Trust (ZHECT) was hired to implement workplace HIV prevention activities. The second phase of the COH project 2006-2009 was a contract awarded to Research Triangle Institute and FHI as a sub-contractor and three Zambian Non-governmental Organizations namely Afya Mzuri, Z a m b i a H e a l t h E d u c a t i o n a n d Communications Trust (ZHECT) and the Zambia Interfaith Networking Group on H I V / A I D S ( Z I N G O ) a s l o c a l implementers. The project further evolved to include other populations outside sub populations of higher risk and also included outreach activities. The project sites reduced to six border districts of Chipata, Chirundu, Solwezi, Nakonde, Kazungula Livingstone and Kapiri Mposhi the only inland district..

The third phase of COH (2009-2014) is part of the regional ROADS II project being implemented by FHI360. In Zambia, COH III is being implemented in partnership with the same three Zambian NGOs with additional technical assistance, through ROADS II, from Development Alternatives, Inc. (DAI) and Howard University. COH III has included three more districts bringing the total number to ten. COH III continues to target the most at risk communities while expanding to deliver integrated services including family planning, counselling and testing for HIV, diagnosis and treatment for sexually transmitted infections, screening and treatment for malaria and referral of

tuberculosis suspects. The project continues to carry out behaviour change communications and is also involved in economic empowerment activities such as group savings and loan associations (GSLA). Mixed approaches to reach and provide services to the people in communities are being utilised; through centre/static based care, outreach, as well as utilisation of the door-to-door strategy which began in 2009 to reach target populations not likely to visit mobile clinics or COH Wellness Centres for various reasons.

Often the simplest ideas are those we tend to underestimate. Although door-to-door testing and counseling for HIV/AIDS is only one strategy of the Corridors of Hope III designed to reach people with C T a n d H I V / A I D S p r e v e n t i o n information, its results have been very positive and the services provided have been extremely popular with beneficiaries.

Where else has Door-to-Door been implemented?

D2D in Southern and Eastern Africa

Door-to-door CT has been tried in southern Africa for the last half decade in


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A health care provider talks to a villager during D2D outreach in Kazungula

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isolated districts and provinces. For example, successful pilot projects and protocols have been established in the following countries:

Zambia

CHAMP

• C o m p r e h e n s i v e H I V A I D S Management Programme (CHAMP) currently operates door-to-door CT in several areas of the country including Nakonde.

Total Control of the Epidemic (TCE)

• With the support of the Centre for D i s e a s e C o n t r o l a n d U S A I D, Development AID from People to People (DAPP) through the implementation of the Total Control of Epidemic (TCE) is reaching out to 200,000 people in the Mazabuka district with information and mobile CT testing using 100 field officers who are each responsible for an area covering 2000 people as a target.

• The ultimate objective of the project is to stop the spread of HIV through total community mobilisation. The project builds on the idea that only people themselves can liberate mankind from

HIV. Officers visit people of all ages in their homes, at workplaces, in school etc and carry out finger prick testing and counselling to interested clients.

Uganda• Piloted the door-to-door strategy in the

Bushenyi District from 2005-2007.• Two studies show door-to-door CT

increases acceptance and uptake of HIV testing, decreases stigma of the test, increases couples choosing to test together and share the results with each other.

BotswanaIn Botswana, door-to-door was done by Academy for Educational Development through the Centre for AIDS and Community Health (COACH), a local NGO. • COACH targeted two high prevalence

districts (Bobonong and Phikwe) to carry out door-to-door CT.

• They too found many of the same positive benefits as the studies set in Uganda.

• They also worked with local partners including Tebelopele Voluntary Counseling and Testing

(TVCT) with a network of 16 fixed clinics, one of which lies within the Phikwe district where door-to-door testing was carried out.

Kenya• Carried out the door-to-door under the

a u s p i c e s o f t h e A M PAT H collaboration between

Kenyan teaching hospitals and US research universities. • It was carried out in parts of three

provinces where high prevalence of HIV infection occur.

• They used peer educators to mobilize communities for testing as well as GPS and hand-held devices for data collection.

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Two lay counselors prepare the results of a rapid HIV test in Livingstone

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Assessment of COH III door-to-door strategy

implementation: Methodology and

Findings

Qualitative Methodology

Over the course of three months, five COH III sites were visited: Livingstone, Kazungula, Chipata, Kapiri Mposhi and Nakonde to compare and study their methods for conducting door-to-door CT. A set of interview questions was designed to gauge the perceptions and problems each centre faced with their door-to-door strategy and learn in what ways it was unique to each particular site. The site visits started with a free ranging discussion with the site manager and the two health care providers then moving on to interviews with lay counselors, door-to-door CT field observations and beneficiary interviews.

The Process of Door-to-Door Counseling and Testing

The process of the door-to-door strategy is dependent on whether the district is primarily urban or rural. Different strategies are employed in laying the groundwork for the process. A number of issues are considered before targeting a community for CT. Infrastructure, transportation and stakeholders in the particular community are also considered.

Rural

In rural areas, it is very easy to engage the communities for door-to-door testing. They easily get mobilised with the ble s s ings o f headmen and o ther gatekeepers. Once the headman has authorised involvement, the rest of the

community easily abides making the work easier since there is little suspicion. Some rural communities like Kazungula, however, pose a challenge due to the nature of the settlement. The systematic coverage of ward to ward almost shifts to “village to village”. In this case CT, teams cover large areas moving from one village to another and in some cases finding people in their fields.

Urban

The situation however is quite different in urban areas where the number of stakeholders increases. Before entry into a community, CT teams have to engage the police for clearance, local authorities, neighborhood health committees, ward counselors and the DHO to establish their presence in the area and avoid overlapping and duplication of services. The other reason for meeting stakeholders is to sell CT and integrated services that include family planning, TB and malaria screening and treatment and generating referrals for male circumcision (MC) and other services that COH cannot provide. However, the Chirundu and Kazungula sites do offer MC on site in collaboration with Society for Family Health (SFH). One reason for the continued success of COH’s door-to-

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A Lay Counselor, observed by a senior health care provider, carries out a rapid HIV test in Livingstone

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door strategy has been the effective and well-implemented community entry protocols as stated below.At the start of the activity, COH site leadership meets with District Health Officers, District AIDS Task Forces and village headmen to introduce and present the goals, objectives and services offered by Corridors of Hope III before entering a single neighborhood or village to conduct testing. Maps and consultations with DHOs are also used to create a strategy and plan for what areas and in which order door-to-door CT teams will conduct field visits.

Staffing in Each Site

Every COH Wellness Centre is staffed with two health care providers who are qualified nurses or clinical officers. Most of the centres’ site managers are trained medical professionals as well, allowing the clinic to offer centre-based CT, STI diagnosis, STI treatment and family planning services as well as the door-to-door CT. Training is integral to the p r e p a r a t i o n o f d o o r - t o - d o o r implementers. COH III has trained a total of 145 lay counselors to help the health care providers in providing CT services.

In practice the strategy of door-to-door testing is fairly simple: you go out, knock on doors, and offer your services. Through interviews with health care providers (HCPs), lay counselors, community leaders and beneficiaries, the principal aspects of the COH’s door-to-door strategy are hereby documented.

Findings

During site visits, it was noted that no two sites were identical in the implementation of the door-to-door activities especially when comparing urban to rural sites such

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as Kazungula which is not only rural but is also quite spread out. This of course means that the distances traveled to conduct door-to-door are greater and in response door-to-door is carried out on a bi-weekly or tri-weekly basis with many lay counselors coming so that many people can be tested at each visit. Once in a village, the lay counselors and HCPs usually spread out going alone to visit huts, again because the distances traveled mean that it is harder to come to these villages and time is much more valuable.

In urban sites such as Livingstone however, most of the testing is conducted in urban neighborhoods and city compounds. The door-to-door testing is carried out almost daily where the COH vehicle can drop off the HCPs and lay counselors and return easily to pick them up and return to the centre for lunch and once more set out for the same neighborhood an hour later. It has also been noticed that the HCPs usually take one or two lay counselors with them per visit on a rotational basis.

One important aspect found in both urban and rural door-to-door visits is the methodical nature in which the work is done. Whenever entering a new compound or village, health care providers and counsellors move from one side of the village or compound to the other, always starting where they left off the previous visit. If there were any homes vacant the previous time, they begin with those, making sure there are no pockets of houses left in the areas previously tested before moving on to a fresh area. Once a house has been visited and services offered, the counsellors leave a COH sticker on the door as a marker to their progress and a reminder of where they have already been.

ZHECT, the partner that does HIV counselling and testing, has in the first 21 months of COH III (October 2009 to

June 2011) provided HIV testing and counseling to over 69,000 individuals. Over 11,400 or 16% of the above figure have been reached through the use of the door-to-door strategy. As it is well known, the uptake of CT is usually an entry point to positive behaviour change for those that access the service and to continuum of care for those that test HIV positive.

efficiently carrying out D2D is the

often vast distances and lack of paved roads in rural Zambia. Currently the use of four wheel drive vehicles and motor bikes is essential. The COH site staff share one vehicle between three implementing partners focusing on the three main aspects of the COH project. Negotiating for the vehicle and not having it available every day has lead to delays in getting into the field and conflict among the different groups needing the vehicle. The use of bicycles is one solution that would allow Lay Counselors and Health Care Providers to extend their reach beyond the city confines, necessitating the use of the COH vehicle only for visits to far flung areas and vi l lages. The cost of purchasing of bicycles is minimal in comparison to the cost of fuel and parts associated with the use of acquiring more vehicles for transport.

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Once in a neighborhood or village, D2D teams spread out on foot to conduct VCT in the targeted area.

Benefits of Door-to-Door:

Confidentiality, Convenience, and Reduced Stigma

In the areas in which it is being implemented, the COH III door-to-door CT strategy has achieved good progress in bringing services to many neglected sections of the Zambian society. During the course of the site visits to evaluate and understand how door-to-door counseling and testing works, the beneficiaries gave the same reasons why they preferred it to the other methods of CT. It simply is more convenient and more comfortable compared to all the other forms. People responded that they felt more prepared to hear the results of their test at home and felt more at ease to ask important questions without the pressure of the whole neighborhood standing outside a flimsy tent watching. Other communities, such as the disabled, aged and sick who s t r u g g l e d a i l y w i t h i s s u e s o f transportation, stigma, discrimination and the inability to work, have been reached and assisted in great numbers by the visits of the door-to-door CT teams. Unlike in normal CT centres where the majority of AIDS patients present to health centre slate with already very low CD 4 cell counts, the door-to-door strategy makes it possible for clients to be tested at an early stage and are able to make appropriate decisions and ask questions in the comfort of their homes and also providers take their time to respond to concerns unlike at a facility with other clients waiting.

The integrated services offered by the COH teams help to address many other secondary illnesses which can lead to

increased risk of HIV infection as well as those that lead to death in patients with AIDS. During these visits, the CT team offers an integrated package of health services which includes education since some of the services are not provided in homes, family planning, STI diagnosis and treatment, malaria screening and treatment, and TB screening as well as assessment of nutritional status of children while generating referrals for TB treatment, male circumcision (MC), PMTCT and continuum of care for those who need it.

The cost of traveling to the health centre in certain rural areas is often assumed to be minimal and the overwhelming benefits of knowing your HIV status are often assumed as enough reason to pay the money to get to the free test. Although the services are free, the transport and loss of time where someone could be making money are often cost prohibitive to the average Zambian.

The issue of partner notification in case of discordant results is also addressed as couples go through the process of CT together. By providing a safe and secure environment in which to test for HIV and other STIs, door-to-door has contributed to lessening of HIV stigma and helped open up communication between partners and families over HIV and AIDS issues.

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“Others (NGO’s offering VCT) don’t come to the

house. My first time testing was with Corridors of

Hope.”

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Joyce Zulu

Malati Village, Chipata

“Door-to-Door is good because I feel free to ask

questions.”

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“The majority of the disabled were unaware of the Door-to-Door serv ices . We d idn’t k n o w t h e y w e r e available. For us it is a challenge to go and be tested. Many of us didn’t know our status until C o r r i d o r s o f H o p e visited.”

Martin Gondwe

Nakonde


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“Without Door-to-Door

and COH I might not be

here.”

Sungi DubeKazungula

Commercial Sex Worker

“I Didn’t know about AIDS before those Door-to-Door people told us. I said I

want to be part of this and learn how to protect myself. Now they come and

bring condoms and teach us.”

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Utilisation of Community Lay

Counselors

The reaching out to so many people would not have been possible without the a s s i s t a n c e o f c o m mu n i t y - b a s e d counsellors who have greatly contributed to the increase in the number of clients tested and counseled in the comfort of their homes. With only one health care provider performing the HIV counseling and testing in a compound or village, roughly five to ten households can be visited per day, where a visit usually lasts about 45 minutes minimum. Using lay counselors, the same health care provider can reach four or five times that amount in the same per iod. Ident i fy ing motivated, smart and well-respected lay counselors from the community has increased the awareness and access to target populations. Emphasis is placed heavily on recruiting them from within the areas where they live and where COH plans to take their services. Moreover, the people performing the test speak the local language and understand local cultural traits and that mean counselling and explanations of health issues have a better chance of being understood and retained.

If COH manages to increase and retain a high number of its lay counsellors over the course of the project, it can significantly increase the number of people reached in a cost effective manner probably exceeding greatly its targets for people tested for HIV. COH can double its target numbers per site from 3,000 to 6,000 people a year who have undergone CT. Instead of bringing two lay counsellors to conduct CT in a compound as is ordinarily done now in urban areas, the HCP can bring four and increase the efficiency of testing all homes in that area. Where it took three

or four days, often traveling long distances (using a lot of gasoline) to drive there and back, the same village or compound can now be completed in half the time thus saving time, money and other resources.

The high cost and shortage of trained medical professionals in Zambia means there is an opportunity to plug the gaps in the health care infrastructure and increase the amount of Zambians tested for HIV and offered other health services as those mentioned above by using community-based lay counsellors to lighten the burden on the national health care infrastructure.

It is hoped that the lay counsellors will continue with CT activities beyond the project’s life span. Lay counsellors interviewed also expressed a desire to continue with the work they have started in their communities, noting the work gave them a great deal of satisfaction and that they had made many friends in the communities they visited.

Support from the Ministry of Health

Working within the national HIV logistics infrastructure, the Centres receive their test and screening kits and STI treatment drugs from the Ministry of Health through Medical Stores and District Health Offices and provide free

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services on its behalf. A suitable central location from which to conduct door-to-door with the ability to carry out confirmatory HIV and other STI testing (the DHO) is critical to maintain the high international standards of HIV counseling and testing. Door-to-door is an efficient and popular method of reaching and conducting CT.

Challenges: Bridging the Service

Gap in Zambia One of the greatest challenges of carrying out door-to-door testing is finding people at home when you come to test. In urban sites such as Livingstone and Chipata, health care providers and lay counsellors noted that oftentimes they test a disproportionate number of women compared to men. When the counsellors come to provide their services, usually in the mid-morning or afternoon, the men of the household are often gone earning for the family. The issue of people being home in more rural compounds was also present but not to the same level as that found in urban areas with men’s fields where they work from being close by and so providing a more general freedom to be at home when need arises. A second challenge faced by door-to-door teams is working in the rain during the rainy season and oppressive heat during the hot season. Working in the outdoors walking from doorstep to doorstep necessitates proper

clothing, waterproof bags to carry supplies as well as umbrellas and hats to combat the rain and the sun.

The challenge of funding, especially in the current world economy, is ever present as well. Door-to-door outreach requires daily trips in a vehicle to outlying in rural sites. The cost of vehicles, gasoline, vehicle maintenance and other transport related costs require a healthy operating budget. In a country like Zambia, the limited road infrastructure and a high cost of gasoline further exasperates this concern.

Overall the greatest challenge to successful door-to-door operations is the retention of lay counselors and healthcare providers without whom door-to-door service provision is not viable. The use of volunteers and the scarcity of trained medical professionals place high levels of pressure on the retention of personnel.

Conclusions and Recommendations

So far, no country in the world has adopted door-to-door counseling and testing as a pillar of its HIV/AIDS prevention and treatment national strategy. Door-to-door testing is not a universal solution to the problem of bringing CT to Zambia as a whole. To truly increase and cover all levels of society, it must be combined with health/CT centre, and other outreach such as workplace based testing schemes. However, it can be concluded that door-to-door CT is quite a proactive and could be a very beneficial method for bringing HIV testing and counseling especially to rural and far-flung corners of Zambia. It is clear that scaling-up door-to-door Zambia-wide, utilising the integrated and wide reaching infrastructure of the Ministry of Health rural health centers and the introduction

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of lay counselors is the next evolution in the efforts to identify, prevent and fight HIV/AIDS here in Zambia. Currently many districts are not covered by NGOs implementing HIV/AIDS programs such as Corridors of Hope. Many people still do lack access to integrated services. It is important that both funders and implementing agencies ensure that all sections of society and all the provinces, districts and wards of Zambia receive adequate HIV/AIDS and general health services.

Specific Recommendations

1. One possible solution to the problem of finding empty homes is to change the working week of site staff to better accommodate clients. Working at the weekend would allow door-to-door testing to be carried out more representatively and with better efficiency.

2. The use of bicycles and motorbikes can help reduce the cost and reliance on expensive 4x4 vehicles.

3. Lay counselors can be retained at a higher rate by including incentives to compensate them for their time.

Corridors of Hope III Zambia55 Independence Avenue, P.O. Box 320303,

Lusaka, ZambiaT: +260.211.256493/5 | F: +260.211.256496

Zambia Health Education and Communications Trust (ZHECT)

Plot No: 1551, Church Road, LusakaPost net No. 221.Private Bag E835, Lusaka,

ZambiaTel: +260.211.223267 Fax: 224038


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Documents

COH Door to Door