A community health worker
model of home-based preventive care, the Philani Intervention Program (PIP), resulted
in significantly enhanced maternal and infant wellbeing among pregnant women
living with and without HIV in Cape Town townships, researchers report in the
advance online edition of AIDS.
In this cluster randomised
controlled trial, HIV-positive women receiving home visits during pregnancy and the first six months of their baby's life were more likely to follow through on
tasks relating to prevention of mother-to-child transmission (PMTCT) of HIV. They were also more likely to have infants with healthy height-for-age measurements, when compared
to women who received standard clinic care alone.
Among all women receiving home
visits, consistent condom use was higher (odds ratio 1.52, p=0.002), and their infants
were more likely to be exclusively
breastfed for the first six months (odds ratio 3.59, p<0.001).
The advantages of this model
for women living with HIV went beyond those of adhering to PMTCT tasks. Identification
of community health workers (CHWs) with a maternal, child health and nutrition
programme helped avoid much of the stigma associated with HIV. Home visits
created a means for ongoing support for all women in the community.
“A CHW approach grounded in
cognitive-behavioural skills, with locally-tailored content addressing local
health risks, may be a strategy that is scalable globally,” write the authors.
In countries faced with HIV
funding cuts and severe health worker shortages, where families face multiple
health risks, PIP offers a feasible task-shifting model, they add.
Increasing evidence over the
past decade supports the integration of HIV care with other health areas. HIV does
not affect a child’s health in isolation, but is combined with the effects of poverty,
malnutrition and other infectious diseases, as well as with the effects of a mother’s behaviours.
However, in low- and
middle-income countries including South Africa, the authors note, community
health workers often focus on single issues: for example, HIV testing,
tuberculosis or adherence to HIV treatment. In some settings, this results in two or three
health workers visiting a household, with each addressing different health areas but repeating some parts of an intervention. Community health workers
identified with HIV interventions are more likely to be rejected because of the
stigma associated with HIV.
Using a model of pragmatic
problem-solving with cognitive-behavioural strategies, the authors trained
community health workers to address multiple health issues, notably those of
particular concern in pregnancy in South Africa: HIV, alcohol use and
The authors hypothesised that,
when compared to women who received standard health care at local clinics,
women living with and without HIV who received home visits (the PIP group)
would have improved maternal and child health and wellbeing in five areas:
Adherence to HIV-related preventive acts (for HIV-positive women, this included
Child health and nutrition (including alcohol use during pregnancy
Healthcare and monitoring.
Forty similar neighbourhoods
were selected and matched pairs of similarly sized neighbourhoods (450 to 600
inhabitants) identified. Using a cluster randomised controlled trial design, the
researchers randomised neighbourhoods within matched pairs to either home
visits (PIP) or standard care.
Local township women
recruited eligible pregnant women. Eligibility criteria included being at least 18 years
of age, living within the target neighbourhood and able to give informed
The standard-of-care group
comprised twelve neighbourhoods with a total of 594 women, of whom 169 were living
In the communities randomised
to PIP, in addition to standard care, community health workers visited participants
on average six times (range 1 to 27) during pregnancy and five times between birth
and two months after birth (range 1 to 12), with each visit lasting approximately
30 minutes. The PIP group comprised twelve neighbourhoods with a total of 644 women, of whom 185 were living with HIV.
Trained as interviewers,
township women assessed participants during pregnancy. Follow-up rates were
comparable in both interventions: 92% were reassessed at a median of 1.9 weeks
after birth (standard deviation 2.1), 88% at a median of 6.2 months (SD=0.7),
and 88% assessed at both time points.
The authors analysed the
effectiveness of the PIP intervention on 28 measures of maternal and infant
health and wellbeing for women living with HIV and among all mothers.
Baseline characteristics were
similar among PIP and standard-of-care group mothers, with one exception, that mothers in the
standard-of-care group had a higher mean number of previous births.
At six months after birth, the
PIP group had overall better maternal and infant wellbeing, outperforming the
standard-of-care group in seven of the 28 outcomes.
Looking at specific PMTCT tasks, ART
outcomes for adherence at delivery and seeking infant PCR testing were similar. However, among
women in the PIP group, cumulative completion of tasks relating to PMTCT, being free of
birth-related complications and having the father acknowledge the infant to his
family, were more likely. However, they were less likely to know their CD4 cell count.
This model is similar to one
the South African government is implementing, with plans to deploy about 65,000
CHWs, the authors note.
“By focusing training on
generic, common principles of behaviour change and the specific health
challenges of the local community, the potential exists to broadly diffuse the
training model,” write the authors.
The programme was built on
strong ties with the community leaders, stakeholders and clinical care sites; giving
CHWs a stipend helped sustain the programme, and strict supervision standards
In addition to sustainability,
home visits deal with barriers to obtaining health care encountered
at clinics: appointments are difficult to schedule; waiting times are long;
transport is costly; and mothers have to co-ordinate care among multiple
The authors conclude: “PIP
provided both task-shifting and site-shifting (from clinics to communities). It allows
governments to leverage the investments in HIV to address concurrent health
issues. PIP offers an intervention model and evaluation strategy for building
sustainable, locally-tailored CHW home visiting programmes.”