"Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi

Topp, Stephanie M., Carbone, Nicole, Tseka, Jennifer, Kamtsendero, Linda, Banda, Godfrey, and Herce, Michael E. (2020) "Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi. BMJ Global Health, 5 (6). e002220.

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Background: In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT.

Methods: We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2–4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches.

Results: Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services.

Conclusion: PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.

Item ID: 63615
Item Type: Article (Research - C1)
ISSN: 2059-7908
Copyright Information: © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Funders: United States President's Emergency Plan for AIDS Relief (PEPFAR), United States Agency for International Development (USAID), National Institute of Health (NIH), USA, National Health and Medical Research Council of Australia (NHMRC)
Projects and Grants: PEPFAR by Project SOAR (Cooperative agreement AID-OAA-A-14–00060), NIH K01 TW010272, NHMRC GNT1173004
Date Deposited: 13 Jul 2020 23:26
FoR Codes: 32 BIOMEDICAL AND CLINICAL SCIENCES > 3202 Clinical sciences > 320211 Infectious diseases @ 10%
42 HEALTH SCIENCES > 4203 Health services and systems > 420305 Health and community services @ 30%
42 HEALTH SCIENCES > 4206 Public health > 420602 Health equity @ 60%
SEO Codes: 92 HEALTH > 9201 Clinical Health (Organs, Diseases and Abnormal Conditions) > 920109 Infectious Diseases @ 20%
92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920401 Behaviour and Health @ 40%
92 HEALTH > 9202 Health and Support Services > 920299 Health and Support Services not elsewhere classified @ 40%
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