Mozambique: Mozambique Mobile Clinic Project

photos: Participants in the Family Planning lecture in Furquia; Arthur and his wife, Julia, attending the Family Planning lecture

Summary of RMF/MMI-sponsored activities carried out during the reporting period under each project objective:

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:
 

Impact this project has on the community (who is benefiting and how):

Provision of primary health services to Furquia & Mbawa communities:
The Mobile Clinic team continues to strengthen the technical and logistical capacities of local personnel through clinical mentoring activities 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 assists in medication (ARVs, cotrimoxazole, isoniazid, ferrous salt, mebendazole, etc.) and blood sample transport.
During the 4^th quarter, 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 MC and clinical mentoring.
 
There are 3 active GAAC in Furquia HF. As result of the exit of the FGH District Community Health Supervisor and the arrival of a new one it took more than one month to get oriented and integrate in the District; community activities dropped during this period, and no new GAAC were constituted during this quarter in Furquia.
 
Also during this period Malaria prevention, diagnostics and treatment were prioritized in anticipation of the upcoming rainy season (when malaria cases increase).
 
HIV testing is also implemented in vaccination sector following the recommended strategy of testing in every entrance gate to the health unit.
 
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

Continuous coordination is maintained with the 3 existing Health Councils (Conselhos de Saude) with 4 monthly meetings held among Health Councils and health facility staff, each averages 50 participants).
Overall, there are 7 support groups helping in Furquia, as follows:

• Home Based Care: Visits for home based care
• Mothers to Mothers groups: Nutritional education, enrichment papas demonstrations, etc.
• Traditional Birth Attendants: Pregnant women referred to Health Unit, community information about HIV test, breastfeeding, nutrition, family planning, PMTCT, etc.
• Traditional Healers: Referral of 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) Volunteers: Visits and consented case finding, HIV counseling and testing in the community, cases referral to Health Unit, ART adherence reinforcing.   
• APES (Polyvalent Elementary Health Agent): Health promotion, primary health care and some consented case finding.

During the reporting period, 4 meetings were held with every support group (with an average of 7 participants per group), MC Counselors and HF staff participate in those meetings.
Ogumaniha volunteers are still providing support in the identification and referral of malnourished children and in the preparation of enrichment 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.
 
20 Active GAAC exist in Mbabwa HF. As in Furquia, the exit of the FGH District Community Health Supervisor and the arrival of a new one took more than one month to get oriented and integrated in the District; no new GAAC were constituted during the reporting period.
 
Malaria prevention, diagnostics and treatment were foci in preparation for the rainy season.
 
HIV testing was also implemented in the vaccination sector following the recommended strategy of testing at every entry point within the health facility.
 
Current staff in the health unit:

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

There are 4 existing Health Councils (Conselhos de Saude), in Mbawa sede, Tatioi, Maroda and Machawa, similar to Furquia, to reinforce community clinical linkages, and they meet twice per month.  During the quarter, activities focused on coordinating monthly meetings held between the Health Councils and Health Facility Staff (and participants are Traditional Birth Attendants, Community Leaders, DOTs Volunteers, Health Councils Volunteers, APES, Religious Leaders and Health Technicians) with an average number of 60 participants in Mbawa sede and Taioi, and 25 participants in Maroda and Machawa. Consented case finding is supported by 4 ETC volunteers and 3 DOTS volunteers who participate in the weekly Adherence Committee (Comite 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

• 224 new HIV patients were enrolled in clinical care during this quarter.
• From 496 HIV-positive persons receiving care during the reporting period eligible for CTZ prophylaxis, 463 received CTZ prophylaxis (93.3%)
• 155 individuals with advanced HIV infection were newly enrolled on ART; 139 adults (>15 years), 16 children (0-14 years old)
• New care patients who were screened for STIs at the last visit during the reporting period: 194 (86.6%)
• 637 HIV-positive patients were screened/ assessed for malnutrition; of them, 154 were clinically malnourished. (24.1%)
• NOTE: During this quarter, most of the population in these rural areas is very busy working on their farms to prepare them for the rainy season (when they plant). As result, the number of patients coming to the HF decreases; this can be a reason for the lower numbers compared with previous period.

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

• In the period under review, 638 pregnant women were registered at ANC service in the two health units, 347 in Furquia and 291 in Mbawa; 581 (91%) pregnant women received HIV counseling and testing with 84 positive results (14,4%).  Due to Option B+, 75 HIV+ pregnant women received ART during this period (88.2%). Unfortunately, MOH does not have log books to follow pregnant women in their clinic visit. ANC log books are organized by consultation, and for this reason we have some difficulty registering 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 continually reinforced through “palestras” (lectures) in the HF and communities for men to accompany their pregnant partners. During the period, 157 partners of pregnant women were tested, 20 (12.7%) 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 post natal/ 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 rainy season

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

• During this quarter, 35 children were enrolled in the Child-At-Risk Clinic (CCR) in Furquia and 24 in Mbawa
•  During the reporting period, 74 pediatric patients benefited from virological testing with 12 positive results (16.2%) reported. Rapid testing was offered to 27 children, 3 were positive (1%).

Voluntary Counseling and Testing – Children

• During the quarter, 48 children were counseled and tested with 23 (47.9%) HIV+ results. 17 of them initiated ART (74%).

Provide diagnostic services for TB care and treatment

• During the quarter, 16 patients were enrolled into TB care and treatment in the two health units.
• All underwent counseling and testing for HIV, with 9 positive results (56.2%). During the quarter, 8 of these co-infected patients started antiretroviral treatment (88.8%)[2].

Consented case finding
 
In October FGH District Community Health Supervisor was transferred to another district and a new one arrived to replace him; it took more than one month for the new one to get oriented and integrated in the District. As result, numbers for community activities dropped during the reporting period.
 
In the last quarter 170 defaulted patients (113 Furquia and 57 Mbawa) were visited and 112 (Furquia 103 and in Mbawa 9) were found (65.8%); of them 86 (84 in Furquia and 2 in Mbawa) returned for consultation (76.8%).
 
Home visits to priority groups
 
Due to the absence of the Community Health Supervisor for more than one month and the arrival of a new one, the number of visits for priority groups was much lower than in the previous period. Patients visited during the reporting period include:

• Patients with low HIV care adherence: 108 (Furquia: 75, Mbawa: 33):
• HIV exposed children without PCR test: 21 (Furquia: 21, Mbawa: 0)

 
Although 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, it has not been well coordinated. A meeting with UNICEF/ICS is still pending to discuss eventual constraints and improve collaboration.
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.

Success Stories:

PICT within Expanded Program on Immunization (EPI)
The provider-initiated HIV counseling and testing program within Furquia’s Expanded Program on Immunization was created to improve the diagnosis and tracking of HIV among breastfeeding mothers and children that have not been tested or lack routine control to ensure access to appropriate care.  The project’s Preventive Medicine Technician receives the support of the Mobile Clinic’s Maternal Child Health Nurse, Geraldina, and General Medical Technician, Elevio, for this important initiative as well as the Furquia health facility’s laboratory. In the last three months, the program enabled 37 women and 10 children to be tested, of which six lactating women and three HIV positive children were referred for antiretroviral therapy (ART).

In the last quarter, lectures on HIV prevention; testing and treatment; mother-to-child transmission of HIV; the importance of childhood vaccinations and regular weight monitoring; child-at-risk consultations and involvement of mothers in pediatric consultations were developed for patients waiting at the health facility and for support group volunteers. The EPI Technician supports raising the awareness of these women who continue to join the extended vaccination program with their children, as well as continued pediatric consultations and health testing. As one patient explained, the benefit of health testing is to “allow early diagnosis of HIV and to engage patients in the treatment and follow-up, reducing the exposure risks of HIV infection and re-infection.”

PICT is implemented in the clinical setting and is now part of routine procedures, with all Furquia health care providers trained in HIV counseling and testing. Initially, the Mobile Clinic technical team initiated PICT in all clinical sectors except EPI. However, after the necessary training was conducted, the EPI department of the health facility is also implementing PICT. It was difficult to treat mothers who previously came to the clinic for consultation and health testing.

However, with the lectures to raise awareness, the implementation of PICT in the EPI sector, and the placement of the EPI manager there has been improvement. Some breastfeeding mothers were invited to meet and discuss the advantages of HIV testing, share how each overcame the fear of getting tested and also provide feedback on the barriers that prevent some from adhering to the child-at-risk consultations. The Preventive Medicine Technician continues to support and strengthen this PICT initiative with daily lectures on various topics that emerge.

photos: mothers line-up for vaccinations after a lecture about PICT in EPI sector at Furquia Health Center; consultation at EPI clinic

photo: infant being weighed at EPI clinic

PICT within Child-at-Risk Consultations
Testimonial: “My name is Netinha Paulino. I am 29 years old, born in Furquia of Namacurra district in Zambézia Province, Mozambique. I currently live in the main headquarters of the district with my four children. During one of my pregnancies I had a pre-natal consultation where I was offered HIV counseling and testing.  At that time, I refused to do an HIV test to ensure my baby is born HIV free despite the nurse’s suggestion for me to do so. With the passage of time we had a daughter, Isabel, who is currently seven months old. At five months old Isabel was never healthy, and the nurse at the EMI visits always told me that she was not increasing in weight. I was very worried, and in November, at the request of the Preventive Medicine Technician, I was tested for HIV; my result was HIV positive and thankfully my daughter was negative. I was accompanied to the facility’s ART service sector, where I was enrolled onto ART treatment, and my daughter was enrolled in the child-at-risk children clinic for PCR analysis and prophylaxis.”

Partner Involvement for Family Planning
Arthur, 23, and his wife Julia, 19, live in Furquia. The young couple has a daughter named Rose who was only 5 days old the day they came in together for a post-partum consultation. Prior to the consultation, which was conducted by the Mobile Clinic’s Maternal Child Health nurse, the couple received useful information on family planning and had the opportunity to ask any related questions. During the consultation, both Julia and her husband received routine analysis and testing for HIV, and with the support of ESMI nurse they chose an effective method for family planning
Husband and wife were advised to make the choice together and to agree on a family planning method that is most appropriate for them. Toward the end of the session, the two were advised about scheduling a follow-up family planning consultation. Husband Arthur shared his commitment to ‘healthy living for his family’.