EGPAF advances research aimed at increasing access to and uptake of high-quality, integrated HIV/AIDS prevention, care, and treatment services throughout the country. Research activities include the review and enhancement of evidence-based HIV/AIDS programming, such as national program policy reviews and updates, and the analysis of PMTCT service cost-effectiveness to support implementation of the WHO 2010 Guidelines through an initiative funded by the Bill & Melinda Gates Foundation, and in collaboration with the MOHCW and Harvard University.
EGPAF supported the MOHCW to compete an evaluation and revision of the Child Health Card to accommodate the 2010 WHO PMTCT and Infant and Young Feeding guidelines, and provided technical lead support for the national ART in MCH pilot led by the MOHCW to strengthen the capacity and confidence of healthcare workers to initiate eligible pregnant women on ART.
EGPAF, together with its FAI Consortium partners, is supporting the expansion of comprehensive PMTCT services throughout Zimbabwe in collaboration with the MOHCW. EGPAF’s program implementation activities in Zimbabwe are focused on:
- Supporting the expansion and provision of high-quality PMTCT and HIV care and treatment services;
- Assisting in the development, review, and update of national policies and guidelines that strengthen and support expansion of PMTCT and HIV care and treatment programs, thus building the capacity of health care workers to provide support to adults, children, and families affected by HIV and AIDS; and
- Developing and strengthening monitoring and evaluation systems for improved PMTCT service delivery.
Through increasing its visibility, strengthening relationships, and participating in policy development and coordination, EGPAF seeks to advance its role and that of its FAI Consortium partners as influential leaders in public health policy and national advocates for the elimination of pediatric HIV and AIDS. EGPAF participates in national coordination meetings, technical working groups, and stakeholder meetings to ensure PMTCT issues remain high on the national agenda and that health policy decisions are evidence-based. Additionally, EGPAF provides technical assistance and financial resources to strengthen the FAI Consortium’s capacity to build HIV/AIDS awareness through national-, provincial-, and district-level advocacy.
Virtual Elimination of HIV Infection in Infants and Young Children in Zimbabwe and Beyond
(The Children’s Investment Fund Foundation: 2010–2015)
In December 2010, EGPAF received an award from the London-based Children’s Investment Fund Foundation (CIFF) to significantly scale up EGPAF programs and dramatically accelerate the elimination of pediatric HIV/AIDS in Zimbabwe. Using the new 2010 WHO guidelines as a catalyst to improve access to critical and proven HIV prevention methods in Zimbabwe, the partnership is expanding access to more comprehensive prevention of mother-to-child transmission of HIV (PMTCT) services nationwide, and optimizing the quality and impact of PMTCT programs to ensure more children are born free of HIV and that HIV-positive mothers are kept alive. The project focuses on strengthening the capacity and commitment of all levels of the existing health system to ensure an integrated, sustainable, and cost-effective approach. The partnership also aims to ensure that the lessons learned from Zimbabwe will be used to implement similar programs in other high-burden countries, and to strengthen efforts to eliminate pediatric HIV/AIDS globally.
Over the five-year project period, EGPAF and its sub-grantee partners will implement the following approaches and strategies to maximize HIV-free survival at 24 months:
Family and Communities for Elimination of Pediatric HIV (FACE-Pediatric HIV)
- Increase support to existing districts and expand to new districts to achieve national geographic coverage of comprehensive PMTCT services
- Ensure eligible pregnant women receive antiretroviral therapy (ART)
- Ensure that non-eligible women and HIV-exposed infants received appropriate antiretroviral (ARV) prophylaxis and support for appropriate infant feeding
- Improve follow-up of mother-baby pairs
- Increase awareness and demand for PMTCT services
- Ensure care and treatment for HIV-exposed and HIV-infected infants
- Strengthen M&E systems and human resources for health
- Document program results and best practice for dissemination to other high-burden countries in the region
As a sub-grantee to the Organization for Public Health Interventions and Development (OPHID), EGPAF will build on the achievements from the Family AIDS Initiative (FAI) to expand access to high-quality prevention of mother-to-child transmission of HIV (PMTCT) services that are closely linked to HIV/AIDS treatment, care, and support for families, including children living with HIV. Under this project, EGPAF will:
Advancing Community-Level Action for Improving Maternal and Child Health/Prevention of Mother-to-Child Transmission of HV (ACCLAIM) Program
(Canadian International Development Agency: 2012–2016)
- Continue to provide technical guidance to the national PMTCT program and strengthen human resource capacity
- Coordinate among other donor-funded PMTCT and maternal and child health programs
- Provide capacity building support to partners and stakeholders in technical, monitoring and evaluation, and financial systems
The goal of this project is to increase community demand for, uptake of, and retention in maternal and child health (MCH)/prevention of mother-to-child transmission of HIV (PMTCT) services to improve country progress toward elimination of pediatric HIV/AIDS. This will be achieved through the following objectives:
- Improving key HIV, MCH, and gender-related health behaviors through the implementation of community-based interventions that target changes in community norms and attitudes, thereby increasing the number of pregnant women accessing and completing the sequence of PMTCT services
- Assessing the behavioral and operational outcomes of selected community-based interventions and determine their relative effectiveness through strategic evaluation and operations research
- Documenting and disseminating research results, tools developed, and lessons learned to facilitate expansion of widespread expansion of community engagement activities found to be effective
Community-based interventions designed to complement facility-based services hold tremendous promise for improving PMTCT program outcomes by addressing entrance, adherence, and retention to the range of PMTCT services along the cascade. The three main interventions for implementation and evaluation in this proposal, which address communities on three different levels, include:
- Engagement of Community Leaders: Through training and capacity building for community leaders, this project will begin by facilitating the development of Community Action Plans (CAP) in order to generate increased demand for MCH and PMTCT services.
- Community Days: Semi-annual Community Days will bring entire communities together for a day of communication, information, and activities to improve awareness among key target populations of important MCH and PMTCT services.
- Community Peer Groups: Working at the individual level, MCH classes and men’s groups will provide comprehensive MCH/PMTCT information and skills development to crucial community sub-groups focused on increasing and improving MCH and PMTCT health behaviors.
EGPAF has chosen three countries for these interventions – Uganda, Swaziland, and Zimbabwe – countries that, in collaboration with their respective Ministries of Health (MOH), are all making great strides in expanding facility-based services and strengthening health systems, but that have recognized barriers and gaps in demand and follow-up. This project provides a community-based approach that will influence harmful gender norms, attitudes, and behaviors through engagement at the grassroots level to enhance the potential impact. The addition of complementary community-based services will help move these countries towards elimination of pediatric HIV/AIDS, and the demonstration of the effect of these interventions will provide other countries with evidence to inform replication and scale-up.
Building upon EGPAF’s successfully supported PMTCT programs, this project will focus on breaking down community-level barriers to uptake of and retention in PMTCT services. The activities are designed to be locally relevant, addressing multiple gaps simultaneously across a variety of settings. The proposed project will be conducted over four years in 45 community clusters across the three selected countries in a stepped approach that will allow for comparison of the effectiveness of single and combination interventions. All clusters will benefit from the “Leadership Engagement” component of the intervention package. In 15 community clusters, “Community Days” will be added on; and in the final 15 of the community clusters, the full combination intervention package comprising “Leadership Engagement,” “Community Days,” and “Community Peer Groups” will be implemented. Through routine monitoring and evaluation and focused operations research, EGPAF will be able to provide an in-depth analysis of the implementation and outcomes of the interventions, as well as the added value of each intervention. A comprehensive dissemination plan will allow for adaptation and use of these innovations in additional settings, which will contribute to the overall learning from the experience gained through implementation.
The strategic design of this project will provide the evidence base needed for communities and program managers to make an informed choice about community activities to support. The experience and evidence gained through the proposed interventions will be important not only for the three countries in which they will occur, but also across EGPAF’s other country programs and the broader global health community.
Integrating Comprehensive Pediatric Care and Treatment into Maternal, Newborn, and Child Health (MNCH) for Elimination of Pediatric HIV in Zimbabwe
Building on past and current program efforts to expand the delivery of comprehensive and integrated services for prevention of mother-to-child transmission of HIV (PMTCT), this project is focused on strengthening support to pediatric care and treatment services for infants and young children within the HIV continuum of care in Zimbabwe. Key objectives for the project include:
- To strengthen the capacity of the Ministry of Health and Child Welfare (MOHCW) to scale up and provide pediatric care and treatment services in Zimbabwe
- To strengthen the delivery of pediatric care and treatment services in Zimbabwe
- To strengthen the national health information system in support of pediatric care and treatment services
Working within this framework, EGPAF will support the integration of pediatric HIV diagnosis and treatment within maternal and child health (MCH) sites while strengthening human resources for health, including training, supportive supervision, and mentorship at the national, district, and site level for the pediatric HIV elimination agenda. Through the project, EGPAF will also strengthen management, coordination, leadership, and accountability for pediatric HIV care and treatment services at the national level towards achieving an AIDS-free generation in Zimbabwe.
Zimbabwe Family AIDS Initiative (FAI)
Through this project, EGPAF has been the primary partner in providing technical support to Zimbabwe’s Ministry of Health and Child Welfare (MOHCW) to increase access to comprehensive, high-quality prevention of mother-to-child transmission of HIV (PMTCT) services that are closely linked to HIV/AIDS treatment, care, and support for families, including children living with HIV. Over the five-year period, the program expanded its partnership with the MOHCW by supporting a package of district-level activities to strengthen district-level PMTCT and pediatric services nationwide towards achieving full-scale elimination of pediatric HIV and AIDS in Zimbabwe.
EGPAF, along with our three implementing partners – the J.F. Kapnek Charitable Trust, the Organisation of Public Health Interventions and Development (OPHID), and the Zimbabwe AIDS Prevention Project - University of Zimbabwe (ZAPP-UZ) – provided direct technical and resource support at the national and district levels to strengthen, implement, and expand the national PMTCT program as guided by the national PMTCT and Pediatric HIV Strategic Plan. At the national level, EGPAF accomplished the following:
- Provided technical assistance through direct secondments to the MOHCW in an effort to create an enabling environment for adoption and adaption of the WHO 2010 guidelines, as well as to support the rapid expansion of PMTCT services nationally
- Supported the MOHCW in the development of the National Advocacy, Communications, and Community Mobilization strategy to generate awareness and greater demand for PMTCT services by local communities throughout the country
- Revised the national PMTCT training materials based on the Integrated Management of Adolescent and Adult Illness, Integrated Management of Pregnancy and Childbirth (IMAI/IMPAC) toolkit in line with the WHO 2010 guidelines
- Strengthened national monitoring and evaluation through the revision of reporting tools in support of the rollout of the WHO 2010 guidelines
- Supported the MOHCW in the development of policy briefs focused on reducing the usage of user fees and implementation of the 2010 guidelines towards ensuring that women and children living with HIV access testing and treatment services
- Supported MOHCW with the integration and decentralization of ART services participating in the national technical working group within the PMTCT Partnership Forum to spearhead ART/MCH integration, and provided technical lead support to the national ART in MCH pilot to strengthen the capacity and confidence of healthcare workers to initiate eligible pregnant women on ART
- Supported operational research on PMTCT that has informed important policy changes including the evaluation and revision of the Child Health Card to accommodate the 2010 WHO PMTCT and Infant and Young Feeding guidelines, and a study on the cost-effectiveness of PMTCT to support planned implementation of the Option A regimen of the WHO 2010 guidelines towards the substantial reduction of HIV transmission to newborn and breastfeeding infants in Zimbabwe
At the district and site level, EGPAF and our partners had accomplished the following:
Call to Action
- By the end of 2012, EGPAF’s FAI program had expanded into 60 districts, including three major cities, and is now supporting more than 1,366 sites, accounting for approximately 88% coverage of all PMTCT sites.
- Strengthened district and site-level support for the national PMTCT program through the introduction of a cadre of 34 District Focal Points, who function as a critical member of the District Health Management Teams (DHMTs), helping coordinate all PMTCT activities in the districts.
- Increased access to CD4 testing through the deployment of CD4 point-of-care technology to improve CD4 testing rates and strengthen the capacity for integration of ART into MCH.
- Contributed to improved male involvement in the program through targeted community mobilization campaigns.
- Supported the revitalization of the Village Health Worker program to strengthen mother-baby follow-up in the PMTCT program.
- Strengthened linkages between healthcare facilities and local communities through the establishment of play centers offering psychosocial support services for both adults and children.
- Implemented an electronic database pilot project to improve tracking of mother-infant pairs across 34 district sites. The EDB also has provided very important program data on the mean gestational age of HIV-positive pregnant women at the time of their first booking to monitor compliance for early bookings in line with the 2010 guidelines (MER 14 weeks), as well as retention and adherence to ARVs for mothers and infants.
With funding from the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), EGPAF implemented the eight‐year Call to Action (CTA) project in 12 countries, including Zimbabwe (from 2004 through 2007). This project sought to improve access to, and expand care and support for, quality prevention of mother-to-child transmission of HIV (PMTCT) services, while enhancing technical leadership and documenting successful program models. By project end, EGPAF had provided nearly four million women with access to PMTCT and antenatal care (ANC) services.
To increase community involvement and support for PMTCT, the Zimbabwe CTA program prepared mothers for counseling and testing in ANC by holding community-level information meetings and developing education materials for multiple community target populations. They also worked with the Ministry of Health of Social Welfare (MOHSW) to redesign the child health card to serve as an effective tool for the delivery of integrated health services. The former card was unable to identify and track HIV-exposed infants, and no documentation of services offered to HIV-exposed infants, such as CTX and early infant diagnosis, was included. The new card rectified that and added additional messages such as updated infant feeding information. The participatory process through which the card was designed ensured that the new card received wide acceptance and use.
Broadening the Scope of PMTCT and Enhancing the Continuum of Care for HIV-infected Families in Zimbabwe
The United Kingdom’s Department for International Development (DfID) has generously supported EGPAF’s Family AIDS Initiative program in Zimbabwe since 2007, strengthening the country’s national prevention of mother-to-child transmission of HIV (PMTCT) program. This initiative was designed to:
Reaching Women and Newborn Babies with Life Saving Emergency Obstetric and Neonatal Care Services in Institutions
- Provide supplemental funding to improve access to PMTCT services and interventions
- Improve follow-up mechanisms for HIV-positive pregnant mothers and HIV-exposed infants
- Improve the referral mechanism for PMTCT clients to ART services
- Strengthen PMTCT monitoring and evaluation systems and improve integration of these within the national health reporting system
The objectives of this project were to:
- Improve access to lifesaving comprehensive emergency obstetric and neonatal care (EmOC) including prevention of mother-to-child transmission of HIV (PMTCT) for 50,000 pregnant women and their newborn babies in two provinces of Zimbabwe, Manicaland, and Mashonaland East, with a focus on provincial and district hospitals.
- Improve availability of lifesaving vital and essential supplies including PMTCT in six other provincial hospitals.
EGPAF worked to build the capacity of healthcare workers by facilitating a refresher training that integrated both EmOC and prevention of mother-to-child transmission of HIV (PMTCT) training modules, and also held three additional training workshops for other healthcare workers. In addition, EGPAF worked with facility staff to hold regular review meetings, collect and assess routine data, and ensure quality of care.
Supporting a Continuum of Care for Children living with HIV & AIDS
The goal of this 15-month project was to coordinate the delivery of comprehensive psychosocial support services (PSS) to orphans and vulnerable children (OVC), including children under the age of five living with HIV. Working in collaboration with the Family AIDS Initiative (FAI), the Organization for Public Health Interventions and Development (OPHID), and the Zimbabwe AIDS Prevention Project (ZAPP), EGPAF implemented this program in Chitungwiza city and four nearby districts: Murewa, Marondera, Mutare, and Buhera. The project supported the establishment of play centers for OVC and provided training on PSS, HIV follow-up, and adherence counseling to community mobilizers, parents, caregivers, and people living with HIV. The project also encouraged community health workers to identify and strengthen linkages and referral networks for the treatment, care, and support for HIV-exposed and HIV-infected children as well as children from vulnerable families. During the project period, the following was accomplished:
Prevention of Mother-to-Child Transmission of HIV Partnership
(Johnson & Johnson: 2008–2011)
- 25 play centers were established and they enrolled a total of 1,434 children into PSS, far surpassing the original target of 1,080.
- 275 community-based resource people (25 group facilitators, 125 child caretakers, and 125 community health workers) were recruited and trained on PSS, play therapy, PMTCT follow-up protocols, and group facilitation.
- Play center facilitators worked closely with health professionals to coordinate HIV community awareness campaigns and to link children with HIV treatment, care, and support services.
- 1,462 HIV-exposed and HIV-infected children received follow-up services.
- The project reached 47% of HIV-exposed and potentially eligible children in the targeted districts—children who were not previously receiving HIV care and treatment.
The EGPAF-Johnson & Johnson (J&J) partnership was designed to expand coverage and improve the quality of prevention of mother-to-child transmission of HIV (PMTCT) services as well as demonstrate global leadership in PMTCT by replicating and documenting best practices in six country programs, including Zimbabwe. To strengthen linkages between health centers and communities, EGPAF selected and trained lay counselors and expert patients to serve as site level community and counseling Focal Persons, who organized monthly meetings of community health workers (CHWs) and volunteers, collected reports of activities, gave supportive peer counseling, and participated in the performance assessment of CHWs and volunteers. By project end, EGPAF:
Reaching More in Need: PMTCT Enhancement through Expanded Implementation and Operations Research
(The Bill and Melinda Gates Foundation: 2006–2011)
- Integrated PMTCT into routine maternal and child health (MCH) services by training health personnel and developing tools and job aides
- Assisted sites to provide additional services for HIV-positive women including early infant diagnosis, TB screening and treatment, infant cotrimoxazole and maternal antiretroviral prophylaxis for PMTCT, and infant feeding education
- Provided technical leadership and support to the Ministry of Health and Social Welfare (MOHSW) and partners to support national M&E data quality and accuracy as well as advance research efforts
- Collaborated with Harvard University, the Institute of Public Health Epidemiology and Development (ISPED), and the Organization for Public Health Interventions and Development (OPHID) on an evaluation of the cost-effectiveness of different PMTCT strategies, and collected data to determine the barriers and facilitators to providing counseling and testing during labor and delivery services.
This Bill and Melinda Gates Foundation-funded project was designed to expand access to prevention of mother-to-child transmission of HIV (PMTCT) services in 10 countries including Zimbabwe, allowing EGPAF to fill critical gaps, ensure continued service delivery in resource-limited countries, and leverage other donor resources to increase access to PMTCT services. EGPAF provided support and technical assistance to host country governments to strengthen their commitment to scale up PMTCT service; trained thousands of government personnel at the site, district, and provincial levels to build health care worker capacity to provide HIV services; strengthened integration with other essential services; and improved linkages to care and treatment.
In terms of operational research, several studies were conducted in Zimbabwe, including an examination of alternative regimens for PMTCT in resource-poor settings. This pilot project, conducted in two districts in Zimbabwe, explored the feasibility of using an alternative treatment regimen of AZT and sdNVP to the mother and infant with a post-partum Combivir tail to the mother. It examined whether, when, and how a change of regimen should be applied at the national level.