Mozambique: Mozambique Mobile Clinic Project

Summary of RMF/MMI-sponsored activities carried out during the reporting period under each project objective (note any changes from original plans):

During the second quarter of 2014, the Mobile Clinic continued implementation of the strategy presented in January 2012. The main activities of the mobile clinic include provision of:
 

1. Primary health care to the populations of Furquia and Mbawa;
2. HIV diagnostic, care and treatment services including integrated TB / HIV services for co-infected patients;
3. Antenatal health services and universal ART as well as PMTCT to pregnant and lactating women;
4. Health care services and early diagnosis of HIV in infants born to HIV positive women;
5. Diagnostic services, treatment and care of TB.

Results and/or accomplishments achieved during this reporting period:

The main results achieved this reporting period were related to peripheral health unit support:
 

The increase in results can be explained because, following DPS orientation in this period, all the clinical activities for patient care and treatment provided by the Mobile Clinic staff are fully integrated into the Health Facility (HF) and are registered jointly with the clinical activities performed by the HF staff.
 

 

Impact this project has on the community (who is benefiting and how):
 
Provision of primary health services to Furquia & Mbawa communities:

• The MC team continues to strengthen the technical and logistical capacities of local personnel through on-the-job training. In addition to daily lectures given on disease prevention, community members benefit from health counseling and testing in screening rooms where, on a voluntary basis, individuals can be screened for malaria, TB, STI, HIV, etc. The MC team also provides management support and aids in medication transport (ARVs, cotrimoxazole, isoniazid, ferrous salt, mebendazole, etc.).
• During the quarter, supervision activities and TA in the areas of pharmacy and MCH continued.

 
Furquia Health Facility: The HF MCH nurse was trained in Universal ART (Option B+) in this period, and she is now able to provide support for care and treatment; Mobile Clinic staff provides technical assistance while she is earning more experience. Competency-based instruments are continuously used to mentor staff on opening clinical files for pregnant and lactating women, support counseling and testing of patients in their first consultation, and the importance of partner testing and adherence.
 
Last quarter the newly appointed nurse was oriented on all updated protocols as well as the registry forms and log books at all relevant departments (MCH, PMTCT, Maternity, CCR, CPF and CPP) as well as the routine use of a patient flow chart for ANC/Maternity/CCR and monthly reports for PCR test consumption. 
 
Current staff working in the health unit include:

• 1 General Medical Technician
• 1 Maternal Child Health Nurse (mid level)
• 1 General Nurse (mid level)
• 1 Preventive Medicine Technician
• 1 Lab Technician
• 1 Elementary Nurse
• 2 Health Counselors
• 1 Cleaner

Reinforcement of the community clinical linkages during the quarter focused on the coordination with the 3 existing Health Councils (Conselhos de Saude).  Monthly meetings were held with the Health Councils and Health facility staff, with an average number of 12 participants.
 
Consented case finding is supported by 5 activists, 3 DOTS volunteers and 12 Traditional Healers who are encouraged by staff to participate in the weekly Adherence committee (Comite de Adesão CAD). Participation is still weak, but coordination and communication efforts continue from the Mobile Clinic staff.
 
Mbawa Health Facility: The nurse who was absent due to illness in the last quarter has returned and at the end of this period she was trained in Universal ART (Option B+). As in Furquia, the Mobile Clinic staff (funded by PEPFAR) were supporting her and providing technical assistance for MCH activities. Mentoring and technical assistance provision continued jointly with the Mobile Clinic nurse for Option B+ consultation, CCR, CPF and CPP.
 
Current staff in the health unit:

• 1 Maternal Child Health Nurse (mid level)
• 1 General Nurse (mid level)
• 1 Preventive Medicine Technician
• 1 Health Counselors
• 1 Cleaner

There are 5 existing Health Councils (Conselhos de Saude), similar to Furquia, for reinforcement of the community clinical linkages. During the quarter activities focused on coordination of monthly meetings held among the Health Councils and Health facility staff with an average number of 13 participants. Consented case finding is supported by 5 Ogumaniha volunteers and 4 DOTS volunteers who are permanently motivated by staff to participate in the weekly Adherence committee (Comite de Adesão CAD).

Provision of HIV diagnostic, care and treatment services, including integrated services for TB/ HIV co-infected patients
Technical support provided by the Mobile Clinic team includes:

• Reinforcement of diagnostic and clinical management of TB (pediatric)
• Screening/assessment of malnutrition
• Creation of GAACs
• Refresher sessions for PCR sample collection, registration and sample transport
• Clinical mentoring
• Data registration and clinical patient record data collection
• Clinical patient record organization
• Pharmacy inventory
• Update and organization of individual patient forms for receiving ARVs (FILAS) [1]
• Update of lost-to-follow-up in the data base and lists for active case finding
• Refresher sessions on clinical protocols and MOH HIV/AIDS clinical orientations
• Job aids and algorithms distributed.

Health care services and ART

• 274 new patients were enrolled in clinical care during this quarter.
• From 348 HIV-positive persons receiving care during the reporting period eligible for CTZ prophylaxis, 323 received CTZ prophylaxis (93%)
• 231 individuals with advanced HIV infection were newly enrolled on ART; 212 adults (>15 years), 19 children (0-14 years old)
• New care patients who were screened for STIs at the last visit during the reporting period: 228 (83%)
• 606 HIV-positive patients were screened/ assessed for malnutrition; of them, 103 were clinically malnourished. (17%)

Provision of Prenatal & PMTCT services (universal ART) for pregnant and lactating women

• In the period under review, 483 pregnant women were registered at ANC service in the two health units, and 509 pregnant women received HIV counseling and testing with 78 positive results (15.3%).  Due to Option B+, 79 HIV+ pregnant received ART during this period. Unfortunately, MOH does not have longitudinal books to follow pregnant women in their clinic visit. ANC log books are organized by consultation, and for this reason we have some constraints to register patients properly if a pregnant patient does not receive counseling and testing in the first consultation and decides to test in the following month. In this case, the numerator might be overestimated and proportion will be more than 100%. The same happens if a positive woman does not initiate her prophylaxis in the same month.
• Efforts to strengthen ART adherence counseling and follow-up of female patients’ children in the CCR are on-going.

• Partner testing was reinforced through “palestras” (lectures) in the HF and communities for men to accompany their pregnant partners. During the period, 200 partners of pregnant women were tested, 35 (17%) being diagnosed HIV positive and referred for ART care and treatment.

• Health Facilities supported by the Mobile Clinic now count on mother-to-mother support groups to improve adherence. Currently women meet once per month to share experiences and receive orientation from the MCH nurse and trained TBAs. After the meeting, HIV positive women join the larger group to participate in the demonstration of nutritional food preparation for children. During this quarter, the subjects discussed included:

• HIV Counseling & Testing
• Living Positively with HIV
• Transmission of HIV from pregnant women to their babies (antenatal)
• Transmission of HIV postnatally/ breastfeeding
• Importance of preventing mother-to-child transmission, CPN/ETV, Child-at-Risk Clinic, and Follow-up of ART
• HIV Prevention

Provision of health care services and early HIV diagnosis in infants born to HIV+ women

• During this quarter, 27 children were enrolled in the Child At-Risk Clinic (CCR) in Furquia and 19 in Mbawa. To improve adherence of the mothers of CCR patients, two meetings were held with the mothers at both the Furquia and Mbawa health facilities. The meetings addressed the importance of the CCR for the child’s health.
• During the reporting period, 59 pediatric patients benefited from virological testing with 5 positive results reported. Rapid testing was offered to 27 children and 2 children were HIV+.

Voluntary Counseling and Testing – Children

• During the quarter, 103 children were counseled and tested with 18 (17%) HIV+ results. All were initiated ART.

To improve the diagnosis and early treatment for HIV-positive children, a review of the rules for CCR tracking and Pediatric ART was conducted with staff. A flowchart was also created with active involvement of the local staff, which outlined proper care for at-risk pediatric patients.
 
Provide diagnostic services for TB care and treatment

• During the quarter, 14 patients were enrolled into TB care and treatment in the two health units.
• All underwent counseling and testing for HIV, with 8 positive results (57%). During the quarter, 7 of these co-infected patients started antiretroviral treatment[2].

Consented case finding (with USAID and PEPFAR support)
 
In the last quarter 323 default patients were visited and 191 were found (59%), of them 145 returned for consultation (76%).
 
Home visits to priority groups (with USAID and PEPFAR support)
 
In order to improve adherence to HIV care and treatment program, patients with low HIV care adherence, HIV exposed  children without PCR test, patients initiating ART and post-partum HIV positive women 96 were visited and 89 found (93%).
 
Counselors reinforced the patient support group creation, facilitation of monthly meetings and follow up.  A total of 8 meetings were held during the quarter, 4 Mother-to-Mother (81 participants), 2 Positive Teas (47 participants) and 2 Parents and Caretakers (9 participants).  Identification and reference of malnourished children, as well as orientation for preparation of nutritious foods (papas enriquecidas) is done with Ogumaniha volunteer support.
The collaboration between UNICEF, ICS (Instituto de Comunicação Social) and FGH was reinstated in Q1 to ensure timely Community Health Promotion, Information and Mobilization in sites supported by the Mobile Clinic including Namacurra District.

Number served/number of direct project beneficiaries (for example, average number treated per day or month and if possible, per health condition):

9,605 people benefited directly from activities implemented by the Mobile Clinic during this reporting period. The increase in these reported results (1,212 last quarter) can be explained because, following DPS orientation in this period, all the clinical activities for patient care and treatment provided by the Mobile Clinic staff were fully integrated in the Health Facility and are registered jointly with the clinical activities performed by the HF staff.     

July 2014

With the Mobile Clinic expansion to the peripheral health units of Furquia in February and Mbawa in September of 2013, all TB patients who were initially treated separately for HIV were able to benefit from HIV screening. This “one stop model” for TB/ HIV services allows HIV positive patients to connect to treatment jointly.

Elévio, the technician responsible for the Mobile Clinic in Namacurra, explained that before the introduction of the Mobile Clinic in the Furquia and Mbawa peripheral health units, it was very difficult for TB patients to be screened for HIV, as some units did not yet offer ART services. Even if a patient were to be tested for HIV, it was often difficult to follow up on treatment because of the distance required to access the medication. With the arrival of the Mobile Clinic, it is now possible to screen all TB patients for HIV. In Mbawa, 3 patient cases were co-infected with TB/ HIV and 4 patient cases in Furquia. Additionally, the Mobile Clinic presence has enabled greater management of medicines for both TB and HIV, and the technical staff of the health facilities also benefits from on-the-job training for these collaborative activities.

A lecture program was also introduced with the Mobile Clinic whereby the one-stop model is emphasized before consultations. For all co-infected patients identified through this model, the clinic requests that the entire family of the patient comes for TB and HIV screening, with all children benefiting from prophylaxis. Amidst the long list of challenges for patients seeking healthcare in rural Mozambique, with the help of the Mobile Clinic, these measures have greatly reduced their burden.