Presentation on theme: "Continuing Care for Mothers, Children, and Families Following Prevention of Mother-to-Child Transmission of HIV (PMTCT) Programmes."— Presentation transcript:
1Continuing Care for Mothers, Children, and Families Following Prevention of Mother-to-Child Transmission of HIV (PMTCT) Programmes
2Objectives for this Module Describe comprehensive HIV care for women, children, and their families.Understand the basic principles and purpose of family-centred care.Identify and strategically address gaps in the provision of comprehensive HIV care for women, children, and their families.
3Objectives for this Module Recognize common signs and symptoms of HIV in infants and young children.Understand the importance of male involvement in PMTCT and HIV programmes and be able to suggest creative strategies to encourage their participation.Describe the difference between linkages and referrals.
4Objectives for this Module Improve referral practices between PMTCT and HIV care and treatment programmes.Discuss retention strategies for keeping women and their families in care.practise problem-solving skills to address social issues affecting a client’s capacity to follow-up with care and treatment.
5Introduction to Comprehensive Care for Mothers, Children, and Families Session 1Introduction to Comprehensive Care for Mothers, Children, and Families
6Objectives of Session 1Describe comprehensive HIV care for women, children, and their families.Understand the basic principles and purpose of family-centred care.Identify and strategically address gaps in the provision of comprehensive HIV care for women, children, and their families.
7Objectives of Session 1Recognize common signs and symptoms of HIV in infants and young children.Understand the importance of male involvement in PMTCT and HIV programmes and be able to suggest creative strategies to encourage their participation.
8Introductory Presentation PMTCT and HIV Care and Treatment Programmes
9Large Group Discussion Barriers to accessing HIV-related treatment, care, and supportRole of a PMTCT healthcare worker in comprehensive care
10Role of PMTCT Healthcare Workers in HIV Care & Treatment Assess client needsRecognize clinical symptomsUnderstand when to referEstablish and maintain referral and linkage systemsParticipate in client case managementAdvocate for comprehensive care needs
11Comprehensive Management of a Person with HIV Shared responsibility for client:Multi-disciplinary teamCommunityFamilyClient themselves
12Components of comprehensive treatment, care, and support For mother and partnerFor childFor family
13Comprehensive Care for Mother and Partner HIV testing for partnerARV therapy assessment and referralScreening, prevention, and treatment of HIV-related conditionsCounselling and support on adherence and nutritionPsychosocial and spiritual support
14Comprehensive Care for Mother and Partner Information, counselling, and support on infant feedingSafer sex and family planningReferral to community organizationsDisclosure counselling and supportPalliative care, when indicatedDrug and alcohol counselling and treatment
15Comprehensive Care for Child ARV therapy assessment and referralScreening, prevention, and treatment of HIV-related infectionsGrowth and development monitoringImmunizationsHIV diagnosis by laboratory test or presumptive diagnosis
16Comprehensive Care for Child HIV education (as appropriate)Psychosocial supportDisclosure counselling (as appropriate)Links and relationships with community service organizations and agencies to promote continuity of care
17Comprehensive Care for Family HIV testing for older childrenAdherence counsellingLinks and relationships with community service organizations and agencies to promote continuity of careHIV educationPsychosocial and spiritual support
18Comprehensive Care for Family Referrals and links to domestic violence organizationsBereavement counsellingSocial support servicesLegal advice and servicesEmployment, income-generation activities
19Family-centred CareFamily-centred care recognizes all persons who function as family members, as identified by the person living with HIV infection.
20Goals of Family-based Care Decrease morbidity and mortalityImprove the quality-of-life for HIV-infected women, children, and their familiesReduce transmission of HIV through secondary prevention counselling and education
21Opportunities to Reach Families within PMTCT Programmes HIV counselling and testing for all sexual partnersFamily-focused adherence and disclosure counsellingMechanisms to reach family members during appointmentsPostpartumMCHPaediatric
22Discussion QuestionHow has the role of PMTCT healthcare workers expanded?Discuss how healthcare workers feel about this expanded role.?
23Postpartum Care for HIV-infected Mothers Best practices in postpartum care include:Mechanism to communicate mother’s ANC and L&D history to postpartum nursing staffMechanisms to target mothers who miss ANC appointmentsCommunity resources to locate and link mothers to careReview Appendix A – “Checklist for Postpartum Visit for HIV-infected Women and HIV-exposed Newborns”
24Exercise 1Facilitating Referrals between PMTCT and HIV Care and Treatment large group discussion
25Follow-up Care of the HIV-exposed Infant Follows best practices applied to all infants and childrenAssessment of growth, nutrition, and developmentVaccinesFull physical exam focusing on identification of HIV-related infectionsCotrimoxazole prophylaxis at 4-6 weeks of ageReview Appendices B and C“Infant/Young Child Follow-up Visits”“Monitoring Growth, Nutrition, and Development of HIV-exposed Infants and Children”
26Diagnosis of HIV Infection in Infants Immune system of HIV-infected children immatureClose follow-up and diagnosis critical to saving children’s lives1/3rd die by 1 year old½ die by 2 years of ageDiagnosis using clinical symptoms or HIV testing
27Diagnostic Testing of HIV-exposed Infants and Young Children Caribbean guidelines recommend HIV DNA PCR viral testing be performed for HIV-exposed infants starting at 6-8 weeks of age.HIV antibody tests may be difficult to interpret in children less than 18 months of age due to the presence of maternal antibodies to HIV.HIV antibody tests can be used to diagnose HIV infection in children 18 months of age and older.Always refer to national guidelines and algorithms
28Recognizing HIV Infection in Children All healthcare workers working with infants and children:Identify the signs and symptoms of HIV-infectionProvide or refer for HIV diagnostic testing and HIV care and treatment
29Suspecting HIV Infection in a Child All infants/children born to mothers with unknown HIV status should be considered at riskEncourage and support testing for all mothersRefer to healthcare team specializing in HIV care if HIV infection is suspected
30Risk factors for HIV if Mother’s HIV Status is Unknown Mother has symptoms of HIV or another STIIf mother is diagnosed with HIV, all of her children need to be tested
31Common Signs and Symptoms of HIV infection in Infants/Children Low weight and/or growth failureLymphoid interstitial pneumonia (LIP)HepatosplenomegalyPneumonias, including PCPOral candidiasis (thrush)
32Common Signs and Symptoms of HIV infection in Infants/Children Digital clubbing from lymphoid interstitial pneumoniaSevere wasting/malnourishment
33Common Signs and Symptoms of HIV infection in Infants/Children LymphadenopathyParotid gland swellingRecurrent ear infectionsPersistent diarrhoea — for more than one weekTuberculosisReview Table 2: “Clinical conditions or signs of HIV infection in a child who is HIV-exposed”
34Common Signs and Symptoms of HIV infection in Infants/Children PCP pneumoniaOral thrush
35Growth and HIV Infection Growth failure reported in as many of 50% of HIV-infected childrenGrowth failure defined as the persistent and unexplained decline or levelling-off in weight and the speed of growth despite adequate nutrition.
36Growth and HIV Infection Growth monitoring and nutritional assessment performed for all for HIV-exposed and infected children.Poor growth may be one of the first indicators of HIV infection in children.See Appendix C – Monitoring Growth, Nutrition, and Development of HIV-exposed Infants and Children
37Exercise 2Clinical Presentation of HIV in Infants and Children large group discussion & case studies
38Male Partners and HIV Prevention, Care, Treatment, and Support Men have the power to alter the HIV epidemic in CaribbeanCan prevent HIV transmission to their partnersCan seek/support HIV care and treatment for self and families
39Men and HIV RiskCulturally acceptable to father multiple children with different partnersMultiple sex partnersWork migrationExpectations of “manhood”Risky behaviorsDrug usePaying for sexMen expected to determine when, where, and how couples have sex
40Barriers to Safe Sex for Couples Misinformation about condomsClumsyReduction of sexual pleasureBelief that contraception is a woman’s responsibilityMarriage not necessarily equated with mutual faithfulness
41Barriers to Safe Sex for Couples For women:Difficulty of negotiating for safer sexFear of reprisal if condoms requestedStigma against homosexualityHigh risk sex may not be disclosed to female partners
42Discussion QuestionsHow can we encourage men to be more involved in the health of their families?As healthcare workers what can we do to encourage the involvement of men?
43The Evolving Role of Men Male involvement in ANC increases rates of PMTCT uptake.Involving men in the health of the family involves challenging beliefs about traditional roles.
44Strategies to Include Men in HIV Prevention, Care, & Treatment Offer HIV counselling and testing at flexible timesPromote HIV counselling and testing where men gatherSporting eventsWorkplace
45Strategies to Include Men in HIV Prevention, Care, & Treatment Involve male role modelsSupport for HIV prevention efforts that target norms of masculinityAdopt policies at health facilities that normalize male attendanceProvide family planning counselling to couplesSee Appendix F – “Family Planning in the Context of HIV Infection”
46Linkages, Referrals, and Retention Strategies Session 2Linkages, Referrals, and Retention Strategies
47Objectives of Session 2Describe the difference between linkages and referrals.Discuss retention strategies for keeping women and their families in care.Improve referral practices between PMTCT and HIV care and treatment programmes.Practise problem-solving skills to address social issues affecting a client’s capacity to follow-up with care and treatment.
48Introduction to Linkages and Referrals Both HIV-infected and uninfected women benefit from referrals to services outside of PMTCT programmes.Linkages provide a “seamless” continuum of care as if there were a single entity delivering a range of services.
49Linkages Formal networks between organizations or agencies Facilitate the referral of the client and her family for servicesFoster a sense of joint purpose and joint achievement for healthcare workers
50PMTCT Linkages PMTCT programmes should be linked to: Tertiary referral hospitals, district hospitals, and peripheral health facilitiesOther government organizations e.g., schools, social welfare agencies, and local governmentCommunities they serveNon-governmental and faith-based community organizationsPrivate doctors and healthcare providers
51Advantages of Linkages Linkages promote:Access of PLHIV to HIV care and treatment servicesBetter understanding of how to manage more complex ARV prophylaxis or treatment regimensPMTCT activities and PMTCT messages amongst all healthcare workers
52Advantages of Linkages Linkages can:Reduce HIV-related stigma and discriminationImprove coverage for underserved populationsImprove quality of careEnhance programme effectiveness and efficiency
53Discussion Questions?What community services do you refer patients to?What services have you learned about from your clients (e.g. church groups, support groups)?
54Community Linkages Community-based HIV services include: Support groups for PLHIVSocial activitiesIncome-generating or volunteer workAdvantages include:Helping families cope with stigma and isolationAssisting national programmes with meeting needs of PLHIV
55Other Community Linkages Examples of other community services:Faith-based programmes offering supportive counselling to families affected by HIVLocal and/or private businesses providing HIV education
56Suggested Linkages and Referrals for HIV-negative Women Counselling and testing (partner and family testing)Routine well baby or well child care, including immunizationsFamily planning and safer sex counselling
57Suggested Linkages and Referrals for HIV-negative Women Nutritional education and support for new mothers and infantsTreatment and support for drug and/or alcohol abuseMental health servicesDomestic violence services
58Suggested Linkages and Referrals for HIV-infected Women and Families Counselling and testing (partner and family testing)HIV treatment, care, and support, including ARV therapyRoutine well baby or well child careHealthcare providers in private specialized practiceTB and STI programmesLaboratory servicesSupport groups and positive mothers’ clubsCommunity-based HIV groups
59Suggested Linkages and Referrals for HIV-infected Women and Families Family planning and safer sex counsellingNutritional education and supportSafer infant feeding counselling and supportCommunity/home-based care servicesFaith-based and community organizationsTreatment and support for drug and/or alcohol abuseMental health servicesDomestic violence services
60Linkage Enablers Strong linkages formed and maintained by: Informal personal relationships e.g., having studied together in nursing or medical schoolGood communication systems from phones andComprehensive and standardized referral formsTransport systems, good roads, and public transportation
61Linkage Enablers Strong linkages formed and maintained by: Shared continuing education or training coursesIntegration of management and support functions such as planning, education and training, supplies and maintenance including ordering ARV drugs
62Consequences of Poor Linkages Gaps in services for clientsHIV-exposed children are not diagnosed and do not receive ARV therapyPotentially infected siblings and male partners not tested for HIVWomen present back to PMTCT programmes only during another pregnancyService duplicationHigher expense
63Discussion QuestionDescribe a situation where you referred a client for a service but the client did not attend. Why did they not attend? How did you handle the situation?What mechanisms have been successful in your own communities and facilities to develop formal referral networks?
64ReferralsReferrals are the guided or orchestrated movement of clients to obtain services based on the specific needs of the client.
65Steps in the Referral Process Assessment of client needOutline available servicesAssess and address potential barriers to attending referralTransportationLack of fundsFear of stigma
66Steps in the Referral Process Ensure client understands purpose of referralDocument referral accuratelyDiscuss confidentialityProvide correct documentation for referral includingTime, location, and contact person
67Steps in the Referral Process Ask client for feedback on referralDocument and evaluate referralEstablish a mechanism with referral agencies to facilitate feedbackReassess barriers
68Monitoring ReferralsFeedback from referrals is necessary to ensure quality of services.Referring facilities are responsible for the success and appropriateness of their referrals.The organization receiving the referred client may need to provide additional technical support to a healthcare worker (in the referring agency) e.g., reviewing medical criteria for referral to TB programme.
69Developing a Referral Network Referral networksTake time and commitment to create and maintainAre constantly changingRequire healthcare workers to be familiar with all available services
70Referral Networks A referral network can include: A lead organization to coordinate.Regular meetings of healthcare workers.Newsletters or method of communication.
71Referral Networks A referral network can include: Designated contact referral person at each agency.Standardized referral forms.A system that tracks referrals and lets network members know when a referral has been successfully completed.
72Community Resources small group discussion Exercise 3Community Resources small group discussion
73Barriers to Comprehensive HIV Care The circumstances of client’s lives can affect their ability to receive truly comprehensive care for themselves and their family.Healthcare workers must continuously address barriers to HIV care.
74Barriers to Comprehensive HIV Care StigmaFear of status being revealedThis can occur when HIV care and treatment are not integrated into mainstream care (e.g., separate HIV clinic)
75Barriers to Comprehensive HIV Care FinancialHidden cost of “free” serviceschildcaretransportationCost of specialized servicese.g., referral to doctor in private practice
76Barriers to Comprehensive HIV Care Time commitmentMultiple referrals necessary for comprehensive careDifferent sitesDifferent timesDifferent purposes
77Barriers to Comprehensive HIV Care Healthcare workers, lack of knowledge and timeLack of knowledge about available servicesLack of time to properly make and monitor referral
78Strategies to Overcome Barriers Strategies should be individually tailoredImplemented bymulti-disciplinary teamSocial workersPhysiciansCounsellors
79Strategies to Overcome Barriers Disclosure counsellingDisclosure is first step in receiving care, treatment, and support for self, partner(s), and childrenDisclosure is ongoing process that starts in pre-test counsellingSee Appendix I – Sample Disclosure Counselling Script
80Strategies to Overcome Barriers IncentivesLetter to the client’s employer requesting time to attend appointmentsAssistance with childcareTransportationFood, clothing, or prizesAccompanying patient to appointmentsAssistance with obtaining social welfare benefits
81Strategies to Overcome Barriers A warm, welcoming non-stigmatizing clinic environment where clients are not singled out as HIV-infected will promote client retention.
82Retention Strategies role play Exercise 4Retention Strategies role play
83Discussion QuestionsThink of a successful healthcare program, why was it successful and how did it become successful?How could these strategies be applied to other clinics and programmes?What resources would be needed to accomplish the goal?
84Best Practices in Comprehensive Care The Paediatric Case Management MeetingPLHIV Trained as Adherence Counsellors
85There are seven key points: Module Key PointsThere are seven key points:
86Module Key PointsPMTCT healthcare workers play a vital role in ensuring that their clients with HIV receive the care, treatment, and support they need. When possible, care of an HIV-infected client should extend to all family members.
87Module Key PointsHealthcare workers should ensure that mothers who are HIV-infected return for all postpartum appointments or are visited at home.
88Module Key PointsIt is important that healthcare workers recognize the signs and symptoms of HIV-related infections in infants and children so that they can make timely referrals for care and treatment.
89Module Key PointsWhen male partners are involved in the care of their families, women are more likely to agree to PMTCT interventions. Partner support is also likely to be important in helping women adhere to ARV medications and attend follow-up care. Involving men in the care of their families involves challenging beliefs about traditional roles.
90Module Key PointsLinkages are formal networks between organizations or an agency and the community, facilitating the referral of the client and her family for services.
91Module Key PointsReferrals are the guided movement of clients to obtain services based on the specific identified needs for continuity of care. The referral process involves the ongoing assessment of a client’s needs, coupled with coordinated service delivery by a group of linked organizations.
92Module Key PointsReferral networks take time and commitment to create and maintain. The first step in creating a network is to map all possible referral resources.