Expanding HIV/AIDS Services for Pregnant Women in Côte d’Ivoire
Background: Few Options for Pregnant Women
Côte d'Ivoire, a West African country of about 19 million people, has seen its share of turmoil in the last 20 years. Once referred to as the "Paris of West Africa" due to its astounding economic growth and development in the 1980s, Côte d'Ivoire has since been rocked by civil conflicts spanning two decades that have divided the country in a rebel-controlled northern region and a southern region under government control. The effects of the most recent war, begun in 2002, are far reaching and long-term; at one point, more than 80% of health care workers had fled the war torn areas, leaving health care facilities untended, looted, and largely empty.
HAI staff inspecting an abandoned health facility in Bouaké in 2007
Compounding this breakdown of the public health sector services were troubling--and worsening--health indicators. Côte d'Ivoire has one of the highest rates of HIV in West Africa, and with health facilities closed and services unavailable, women had trouble accessing vital prenatal and delivery care services. And if they wanted HIV care as well, they often had to visit several sites, travel long distances, or be turned away due to an overwhelming demand. Today, as the country continues to rebuild under a reunified government, health facilities are slowly regaining their capacity to deliver essential health services to Ivorians.
Integrating Services into Prenatal Care and Building Support for Women
Health Alliance International (HAI) has been active in Côte d'Ivoire since 1992, but due to political violence over the years, our programs were halted until 2007. At that time, we conducted community assessment in Bouaké, located in the center-north region of the country, to investigate how best to help our Ministry of Health partners strengthen health systems and provide greater access to quality health care to Ivoirians. Through records reviews, interviews with Ministry of Health officials, health care workers, other NGO workers, and local citizens, a complex system of how health care was delivered to people was revealed.
During the war, public health facilities were routinely looted and destroyed, and health care workers fled the region for the relatively more stable regions of the south. Large international donors, including UNICEF, provided financial and technical assistance to rebuild many of these facilities as peace returned to the north, but in the interim, more than 500 NGOs entered the health care scene, many of them providing HIV testing and care services. Unfortunately, though, the majority of these organizations provided only pieces of HIV care--only testing, for instance, or only psychosocial support services--and none of them provided comprehensive outpatient or maternity care. That meant pregnant women seeking HIV testing and prenatal care were sent on a long, tedious journey to several sites in the city, overcoming obstacles of time, transportation, and cost to access services. The resulting health care system was weak, fragmented, and women and their children often slipped through the cracks and were lost to follow up.
In December 2007, HAI received funding from UNICEF to integrate HIV services into routine antenatal care in Ministry of Health facilities (called prevention of mother-to-child transmission, or PMTCT). HAI staff worked with health care workers, including doctors, midwives, and nurses, to train them on techniques of counseling, testing, and follow up treatment for HIV. All parts of the health care system, including laboratory services, procurement of medicines and pharmacy supplies, supervision systems, and monitoring and evaluation registries, were assessed on a site-by-site level, and health care workers received training to strengthen all these capacities. The goal of HAI was to work with our local partners in the Ministry of Health to strengthen all pieces of the public health sector.
An additional goal of the project was to increase community awareness of the importance of HIV testing and follow up. Based on our successes in Mozambique, we created radio spots and initiated support groups for HIV positive mothers. The support groups were held at the local public health facility, creating further linkages to the health site and offering a way for women to learn about how to manage the disease, how and where to access additional services, and share challenges and successes with each other as moral support.
Impact: More Women Receive the Care They Need, All in One Place
In the first year of the project, we worked in 16 sites in three districts of Bouaké. With substantial involvement of our Ministry of Health partners, we were able to rapidly scale up PMTCT services in all sites. After initial trainings, a continuous cycle of on-the-job training and coaching continued at each site, resulting in an improved, stronger health care system for pregnant women and children. Instead of spending up to two weeks or more accessing services from up to 8 sites, women could instead go to their local health facility, receive counseling and HIV testing, and receive the appropriate follow up services, all at one site. She could also access CD4 analysis, appropriate antiviral treatment and prophylaxis, and psychosocial support services. In the first year of the project, more than 13,000 women were tested for HIV and 750 HIV-positive women were identified and offered follow-up services. More than 600 of these women attended monthly support groups at their local health facility.
Women in a clinic waiting area
We face many challenges in our continuing work in Côte d'Ivoire. Though our programs have allowed our Ministry of Health partners to identify HIV-positive mothers, follow-up of the infants born to these women has been very difficult. After delivery, it can be difficult to convince the mother to bring the infant in for early HIV testing. Another challenge is integrating HIV testing and care into outpatient services, for people who attend the health facility for general services.
After our success in rapidly expanding PMTCT services in Bouaké, HAI was awarded a grant from Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to build on these programs, expanding HIV testing into tuberculosis clinics, outpatient clinics, and over a wider geographic scope. Our unique approach--working side by side with our Ministry of Health partners--has received national recognition.