Mozambique: Mozambique Mobile Clinic Project

Project Goal:

• Improve quality of life and provide access to health services, particularly maternal and child health and antiretroviral treatment to people living with HIV/ AIDS, tuberculosis and other diseases;
• Provide access to health services in remote areas of the province of Zambézia, Mozambique;
• Reinforce the expansion of services for care and treatment of HIV, initiated by the Provincial Health Authority of Zambézia;
• Provide clinical support and technical assistance to temporary peripheral health units with the potential of implementing antiretroviral treatment in the near future.

Project Objectives:
 
Increase the number of people with access to health services, as well as the number of patients enrolled in HIV care and treatment services in areas supported.

Summary of RMF/MMI-sponsored activities carried out during the reporting period under each project objective:
During the third quarter of 2015, 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 to pregnant and lactating women;
4. Health care services and early diagnosis of HIV in infants born to HIV positive women;
5. Diagnostic services for TB and TB/HIV co-infected patients’ treatment and care;
6. Transport of extra stock of medicine and medical supplies in preparation for potential flooding (and subsequent HF isolation) during the rainy season.

Results and/or accomplishments achieved during this reporting period:
The main results achieved this reporting period were related to peripheral health unit support:

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 clinical mentoring activities, technical assistance and 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 (ARVs, cotrimoxazole, isoniazid, ferrous salt, mebendazole, etc.) and blood sample transport.
During the quarter, clinical mentoring, supervision activities and TA in the areas of C&T, Pharmacy and MCH continued.
 
Furquia Health Facility:
 
There were no changes in the health facility staff; all of them had been oriented in previous quarters and are working in their routine areas with the support of the Mobile Clinic team and clinical mentoring.
 
Community activities continued to increase during this period, focused on reinforcing and implementing the new MOH guideline for GAACs, which are now required to have a minimum of 3 members in every group. No new GAAC groups were formed in Furquia, but there was an increase in the number of members in each group from 22 to 42 patients. Malaria prevention, diagnostics and treatment were also prioritized during this period.
 
FGH community health staff (Peer Educators and Counselors) continued to provide information, education, and communication (IEC) on HIV prevention and testing, GBV, treatment adherence, diarrhea, malaria, etc. among the community and patients waiting for consultation at Furquia and Mbawa Health Facilities.
 
HIV testing is also implemented in the vaccination sector and other points of entry to the HF (emergency area), following the recommended strategy of testing at every entry point to the health unit.
 
Current staff working in the health unit include:

• 01 General Medical Technician
• 01 Maternal Child Health Nurse (mid-level)
• 01 General Nurse (mid-level)
• 01 Preventive Medicine Technician
• 01 Lab Technician
• 01 Elementary Nurse
• 02 Health Counselors
• 01 Cleaner

 
Continuous coordination is maintained with the 3 existing Health Councils (Conselhos de Saude) with 1 monthly meeting held among Health Councils and health facility staff, each averaging 26 participants (Traditional birth attendants, , DOT volunteers, Health Council volunteers, polyvalent heath agents, , FGH District Community Health Officer, and other volunteers from Ogumaniha and other partners).

Consented case finding is supported by Polyvalent Health Agents (APS), male champions, Activists from Ogumaniha (this program has just ended, but volunteers are still helping for consented visit and case findings) and Peer Educators.

Overall, there are 6 support groups helping in Furquia, as follows:

• Home Based Care: home visits
• Mothers to Mothers groups: nutritional education, demonstrations of enriched food preparation, etc.
• Traditional Birth Attendants: Pregnant women referral to Health Unit, information in the community about HIV testing, breastfeeding, nutrition, family planning, PMTCT, etc.
• Traditional Healers: Referral of suspected TB patients to Health Unit, counseling and sensitization of chronic patients to do HIV testing
• DOTS Volunteers: sputum sample collection of suspected patients, follow up of TB patients in the community and references to Health Unit for HIV counseling and testing
• ETC (Epidemic Total Control – a partnership between FDC and ADP since October 2014): This project is already finished and the organization is already starting a new project focusing on TB prevention activities. 
• APES (Polyvalent Elementary Health Agent): Health promotion, primary health care and some consented case finding.

During the reporting period, weekly meetings (4 per month) were held with every support group (with an average of 7 participants per group). Mobile Clinic Counselors jointly with Health Facility staff participate in those meetings.

Ogumaniha volunteers are still providing support in the identification and referral of malnourished children and in the preparation of enriched foods.
 
Mbawa Health Facility:
 
There were no changes in the health facility staff; all of them had been oriented in previous quarters and are working in their routine areas with the support of the Mobile Clinic and clinical mentoring teams.
 
During the reporting period, we focused on reinforcing and implementing the new MOH guideline for GAACs, as we did in Furquia. Currently, there are 31 active groups in Mbawa and during this quarter there was an increase in the number of members in each group from 88 to 109 patients.
 
As in Furquia, malaria prevention, diagnostics and treatment were also prioritized during this period.
 
HIV testing in the vaccination sector and other entry points within the health facility were implemented following the recommended strategy of “massive” testing from the DPS.
 
Current staff in the health unit:

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

 
There are 4 existing Health Councils (Conselhos de Saude), in Mbawa sede, Tatioi, Maroda and Machawa similar to Furquia, for reinforcement of the community clinical linkages, and they meet one time per month.  During the quarter, activities focused on coordination of monthly meetings held among the Health Councils and Health Facility staff (and participants are Traditional Birth Attendants, DOTS Volunteers, Health Council Volunteers, APEs, FGH District Community Health Officer and Health Technicians) with an average number of 26 participants.
 
Consented case finding is supported by, Polyvalent Health Agents (APS), male champion, Activists from Ogumaniha, Peer Educators and 3 DOTS volunteers who participate in the weekly adherence committee (Comité de Adesão-CAD).
 
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 (PEPFAR supported):

• 280 new HIV patients were enrolled in clinical care during this quarter.
• From 753 HIV-positive persons receiving care during the reporting period eligible for CTZ prophylaxis, 701 received CTZ prophylaxis (93%)
• 238 individuals with advanced HIV infection were newly enrolled on ART; 214 adults (>15 years), 24 children (0-14 years old)
• Newly enrolled patients who were screened for STIs at the last visit during the reporting period: 244 (87%)
• 1,054 HIV-positive patients were screened/assessed for malnutrition; of them, 144 were clinically malnourished. (14%).

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

• During the reporting period, 684 pregnant women were registered at ANC service in the two health units, 270 in Furquia and 414 in Mbawa; 663 pregnant women received HIV counseling and testing with 85 positive results (13%).  All of them (100%) received ART (Option B+). 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 and children in the CCR are on-going.
• Partner testing continues to be reinforced through “palestras” (lectures) and with the “Male Champion Strategy” in the HFs and communities to motivate men to accompany their pregnant partners. During the period we observed again, as in the previous period, an increase in the number of partners tested, 361 partners of pregnant women were tested, 31 (8%) being diagnosed HIV positive and referred for ART care and treatment.

• To improve adherence Health Facilities supported by the Mobile Clinic continue counting on mother to mother support groups. 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)
• Postnatal transmission of HIV (breastfeeding)
• Importance of preventing mother-to-child transmission, CPN/ETV, Child-at-Risk clinic, and follow-up of ART
• HIV Prevention
• Malaria and diarrhea prevention facing the raining season

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

• During this quarter, 36 children were enrolled in the Child-At-Risk Clinic (CCR) in Furquia and 26 in Mbawa.
• In the period under review, 62 pediatric patients benefited from virological testing with 5 positive results (8%) reported. Rapid testing was offered to 35 children, of them 1 was positive (3%).

 
Voluntary Counseling and Testing – Children:

• During the quarter, 113 children were counseled and tested with 16 (14%) HIV+ results. All initiated ART (100%).

 
Provide diagnostic services for TB care and treatment:
 

• During the quarter, 26 patients were enrolled into TB care and treatment in the two health units.
• 24 patients were counseled and tested for HIV, with 14 positive results (50%). All the HIV+ tested patients started antiretroviral treatment (100%)[2].
   

Consented case finding (USAID and PEPFAR supported):
 
In order to improve retention indicators, community health activities were especially active during this period and the number of consented case finding increased during this quarter.
 
In the last quarter 434 defaulted patients (285 Furquia and 149 Mbawa) were visited and 181 (Furquia 111 and in Mbawa 70) were found (41.7%), of them 154 (93 in Furquia and 61 in Mbawa) returned for consultation (84.5%)
 
Home visits to priority groups (USAID and PEPFAR supported):
 
In order to improve adherence to the 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 were referred for visits. A total of 179 patients were referred for visits and all of them were attempted to be visited (118 in Furquia and 61 in Mbawa). Of the total attempts, 142 (81 in Furquia and 61 in Mbawa) were found (79.3% of total referred for visits).
 
As in previous reports, other groups like Traditional Birth Attendants, Traditional Healers, Home-Based Care volunteers continue to provide information and health promotion among the community and refer pregnant women and other patients to the health units.