Fieldset
Innovation: How we’re getting life-saving HIV drugs to people in remote Zimbabwe

Effective treatment means people with HIV can live long, healthy lives. But for those living in remote communities, getting access to these vital medicines can be a challenge. Valeria blogs about a team aiming to change that…

Innovation - How we’re getting life-saving HIV drugs to people in remote ZimbabwIe

When I got the news about being part of Médecins Sans Frontières / Doctors Without Borders (MSF) and my first assignment in Zimbabwe, I was very excited. I was glad to have the opportunity to work in a wonderful environment, learn from others and share experiences to help people and empower them to improve their lives.

I’m Valeria, a health promoter from Mexico City. My background is social work, and I’ve been working in community development and community mobilisation for 12 years.

My assignment in Zimbabwe was in the “out of district” Mwenezi project, located in the remote areas in south-eastern Zimbabwe.

Behind the scenes on an outreach visit

One of the activities in our project is the outreach program, providing medical services to remote communities who might not otherwise have access to them. Outreach means MSF teams travel distances of about 60 to 200 kilometres to meet patients.

For our team, a normal day of outreach starts at Chirindi Clinic, one of the health facilities run by the Zimbabwean Ministry of Health and Child Care.

All the HIV drugs, green books (green booklets where demographic information and patient care information is recorded), tables, chairs and other items are packed up and loaded into the MSF car.

a_meeting_with_community_health_workers.jpg

A meeting with community health workers, Ministry of Health and BHASO team
A meeting with community health workers, Ministry of Health and BHASO team

We then have a flash meeting with the team to share updates and relevant news before leaving the clinic.

On this particular visit, we are travelling to Makugwe and Sovelele, villages in distant areas of the district.

A “typical” journey might mean travelling by car for approximately an hour and a half to get to Sovelele. The road is very challenging to drive on at any time; during the rainy season it’s impassable.

On the way we see many aspects of the community: people’s huts, cattle, women washing clothes in the rivers, children walking barefoot to go to school and sometimes wildlife.

A well-planned set-up

When we arrive at the outreach point, the whole team unpacks everything and we set up the tents where we’ll be delivering the different services.

MSF has been working here for more than two years and the logistics for the outreach are very well planned.

The tents are very simple to fix to the ground, and if we work all together, in ten minutes we are ready.

The next step is another flash meeting, this time with the village health workers and community HIV/AIDS support agents. They are very involved and happy to cooperate in the different tasks.

The nurse mentor from MSF leads the meeting and one of the nurses from Chirindi Clinic assigns the different tasks for the day.

A key part of the team

Village health workers are a key link between the community and the formal health system in Zimbabwe. They have a broad range of roles and responsibilities, including health promotion (for example, helping the community learn to recognise diseases and how to prevent them) and referring people who need more care to higher levels of the health system.

People living with HIV have to deal with more than just the practicalities of managing a chronic health condition. Frequently the challenges include a combination of the psychological and the social.

Working alongside the village health workers are the community HIV/AIDS support agents. These are members of the community who receive and counsel their peers when they come to collect their medication at health centres. They also assist health staff with minor duties.

The village health workers are part of a program which has been run for a long time by the Ministry of Health and Child Care, while the idea of having community HIV/AIDS support agents comes from the Batanai HIV and AIDS Service Organisation. Collaborating with both these organisations has helped the MSF project here grow.  

More than testing

When we set up for an outreach visit, we arrange the tables and chairs in different “stations”, where people can come to access different services. During my first day on an outreach visit I rolled through them all, but nowadays I’m assigned to work on the HIV testing station.

At our station, we provide not only HIV testing, but lots of other things too.

One of the key things we offer is support for patients who have missed a review date, have stopped their medication or have fallen out of touch with health services recently. It’s also quite common in HIV programs for patients to begin treatment but then not follow up, so we have support for these people too, to help them get back on treatment.

There are lots of reasons that someone might default on treatment, or not follow up. Some are practical (I’ll write more about that below), but other are more complex.

To help address this, working alongside me are Thulisiwe Muzezewa, a counselor-educator from Chirindi Clinic and Oniwell Nyekete, who is an MSF counsellor-educator mentor.

The counselor’s role is fundamental in outreach.

Why HIV counsellors are so important

Having a counsellor helps people to understand HIV and the treatment, and to let go of misconceptions, misinformation and stigma.

People living with HIV have to deal with more than just the practicalities of managing a chronic health condition. Frequently the challenges include a combination of the psychological and the social – for example, people may find the diagnosis devastating, or struggle with the attitudes of their family and the wider community.

valeria_and_a_counsellor_colleague.jpg

Valeria and a counsellor colleague
Valeria and a counsellor colleague

Counsellors like Thulisiswe and Oniwell carry out individual or group counselling, as well as basic psycho-educational sessions for patients and, when needed, their families.

Alongside these activities, we have a support group for children and young people living with HIV. At the group they learn more about the importance of sticking to their treatment plans and good health practices.

They also talk about disclosing your HIV status as an important part of living with HIV, since people living with HIV need psychosocial support from family, friends and community in order to continue with their treatment.

By supporting patients through their psycho-social difficulties we hope not only to help their mental health, but also to support them in taking their medication, which is vital in managing HIV.

What else happens on an outreach visit?

As well as testing, counselling and support, there are lots of other services on offer…

We provide a refill service for patients who are on medication for non-communicable diseases like diabetes or high blood pressure.

Our team gets people who are HIV positive started on antiretroviral therapy (ART). By taking these medicines regularly, people with HIV can reduce the amount of the virus in their blood to the point where it is undetectable, allowing them to live long, healthy lives as well reducing the risk of transmission.

People with HIV can be susceptible to infections, so we offer care for these, as well as monitoring for the levels of HIV in people’s blood (their “viral load”).

And, importantly, we refer people to “OFCAD”…

Getting medicines to the people who need them

OFCAD stands for “Out-of-Facility ART Distribution”.  It’s a way of delivering antiretroviral therapy that seeks to ease the burden of HIV positive patients living in hard-to-reach areas by providing them easy access to the medication they need in the comfort of their communities.

In the past, patients sometimes walked the whole day to arrive to at a health centre and get their HIV medication.

This is a real challenge for anyone, but particularly people who need to work to feed themselves and their families, people with children to look after, and those who are unwell or disabled. If someone can’t get to the health centre to pick up their medicine, there’s a real risk they will drop out of treatment completely.

For patients to be included in OFCAD, there is a criteria that has to be followed.

Patients should be willing to join OFCAD, they should have been on ART for at least six months and their viral load should be below 1000, or undetectable. They should be taking the fixed dose regimen which is Tenolam E. And there should be a village health worker near the area where they stay.

The aim of the distribution program is to increase the number of people in these remote areas who are able to live healthy lives with HIV through better access to life-saving medication.

How it works…

The way the program works is very efficient: patients who would benefit are identified at a health centre or at an outreach site, enrolled and referred to the distribution location of their choice.

There are currently seven different distribution points in Makugwe and Sovelele, Mwenezi.

Working with communities is amazing. Since being here I’ve learned a lot about solidarity, engagement, empowerment and I gain satisfaction when people are really involved in the process of improving their own lives.

The village health workers order and pick up the antiretroviral drugs from the health facility for the patients in their distribution. Then, following a schedule, they refill drugs to the patients within their own communities. The village health workers sometimes have to travel up to eight hours by bicycle to collect the ARV's from the health facility.

The village health workers are important because they also mobilize, educate and sensitize the community to HIV. And they support patients in viral load monitoring, managing other illnesses, TB screening and with referrals for those who need additional healthcare.

So what does a health promoter do?

As the health promoter in the project, part of my work has involved supporting the village health workers in the medication distribution program. For example, clarifying doubts about the procedure on the day when they collect drugs from the clinic.

valeria_working_with_village_health_workers.jpg

Supporting community health workers during the OFCAD
Supporting community health workers to distribute HIV medicines during the OFCAD

I’ve been working on assessments and follow-up of every step of the program to assure good results and positive impact in the communities. I’ve planned trainings with the team to strengthen information about HIV, stigma, and opportunistic infections such as tuberculosis. And, I’ve been able to design the health promotion materials and job-aids to support the distributions.

When I first learned about this approach of distributing HIV drugs away from health facilities and actually in the community, I was very impressed by two things.

The first was the trust that the Zimbabwean Ministry of Health gives to people in the communities to deliver this life-saving medication. The second was how MSF has implemented what began as a pilot to become a great project.

I realised during my months in the project how much MSF is committed to communities, working together for welfare, sustainability, equality and cooperation.

What I’ve seen as I worked on the OFCAD program is how actively the communities participate. People work really hard. For those living with HIV it is gratifying to have community leaders who mobilise their efforts to help them to improve their lives.

Working with communities is amazing. Since being here I’ve learned a lot about solidarity, engagement, empowerment and I gain satisfaction when people are really involved in the process of improving their own lives.

Absolutely this is an approach that must be shared with other projects in Zimbabwe and in the rest of the world.