Catholic Medical Mission Board (CMMB) launched the CDC Zambia-supported Community Compacts program in FY11 as a comprehensive HIV prevention package with emphasis on buy-in of local communities in designing and shaping their HIV prevention efforts. The project also reaches out to the most vulnerable and hard-to-reach communities in Kaoma district, Western Province. The program works with local communities to set priority HIV service delivery uptake targets and incentivizes them by providing modest rewards, such as improvements in their local health facilities on a quarterly basis. Incentives may include items, such as thermometers, medical equipment, simple refurbishment of waiting and screening rooms at health facilities.

The comprehensive HIV prevention interventions focus on disseminating community-owned messages that promote uptake of PMTCT, HVCT, risk reduction behaviors for prevention of sexual transmission of HIV and Strategic Information usage. The project started in the catchment area of Mangango Mission Hospital as a compact (population of 64,512) during Year 1 and expanded to Lwampa Mission Hospital catchment community (population, 55,286) in year 2.

Project objectives:

Establish sustainable compacts that incentivize communities for prevention of HIV transmission; Promote risk reduction behaviors related to HIV prevention and increase uptake in compact locations of HIV biomedical prevention services, including PMTCT and HVCT; Strengthen compact monitoring and evaluation (M&E) systems, with a specific focus on data capturing, analysis, utilization, and coordination to leverage the prevention efforts with other partners.

Because the project involves extensive outreach and referrals to HIV prevention, care, and treatment services, CMMB will continue strengthening the skills of health workers, community, and parahealth workers to be able to effectively collect use and analyze community- based and health data. CMMB will continue regular supportive supervisory visits to the compacts and associated health facilities that receive referrals to gauge program performance and use this data to influence strategies to be used to improve programming. In addition to measuring indicators around BCC message reach and uptake of service delivery targets, CMMB will also work with committees to track patients referred for services through a patient slip system: a client being referred to care services is given a referral slip to a health facility specifying the services that are need. Upon arrival at the health facility the client is given priority to be attended to by health workers. After attending to the client the health worker completes an action form attached to the referral note as feedback to the referring community champion/community health worker with comments on the services provided. This note is then placed in the box of feedback for referrals which is opened by the CMMB field team on a regular basis and the feedback (action) forms are compared to the community referral register to determine the referrals which were successful.

CMMB will also implement community member attitude and practices evaluation at mid-term (during 2013) and at end of project (2015). The assessments will also examine their community-level exposure to interventions in select communities. In collaboration with clinic staff, the number of referrals from CMMB and the total number of people accessing health services such as PMTCT will also be collected at midpoint and end of project. These data will be combined within each community to determine whether each community has attained their benchmark and therefore is eligible to claim their incentive. SI plans will be included in Sustainability Planning among the compact committees

CMMB will continue supporting mobile HVCT services that improve access to quality HVCT with emphasis on couples testing and mutual disclosure during FY12 and 13 as part of the compact project since rural areas are underserved. Specific activities will include: identifying gaps in the provision of HVCT in the CC (for new compacts); on sight support to lay counselors, care givers and traditional community leaders who are community change agents in the execution of HVCT, including couple HVCT; community mobilization of the target groups, including men, followed by execution of social and behavioral change (SBC) events for prevention of HIV and offering provider-initiated mobile HVCT. Other activities will include implementation of HVCT services on special occasions during: door-to-door campaigns; health commemoration days (such as VCT Day and World AIDS Day); traditional cerebrations and other popular community events. The community HVCT providers will also be providing PwP and to make timely referrals to HIV treatment care and support groups of PLWHA. Concurrently, the project will continue strengthening existing static HVCT services through the strengthening of community referral networks and technical capacity building to health workers and parahealth workers. In addition, the counselors and champions will also provide culturally- and gender-sensitive information to those who test negative on how to remain negative, including highlighting the benefits of avoiding multiple concurrent sexual partnerships, promoting use of condoms, abstinence (if indicated), and repeating HVCT in line with national guidelines. CMMB envisions HVCT activities ramping up during FY2012-2013 as much of the groundwork is in place in catchment areas of Mangango and Lwampa mission hospitals.

During FY12 and 13, CMMB will make special efforts to link with the DATF and provincial health team to communicate HVCT gaps and plan for troubleshooting in the future after CMMB leaves in this area, especially around supply chain and coverage.

HVOP

Strong Other Prevention behavioral change communication messages will be disseminated to individuals and small groups through the projects. CMMB-trained and community-supported volunteers will make regular home visits in their communities to spread evidenced-based information around HIV prevention. Messages will be shared through monthly community events during mass mobilizations campaigns and during special community events such as traditional ceremonies and commemoration of VCT day, World AIDS day, etc. In addition to sharing key ways to protect oneself for HIV, the OP messages will also promote the value of seeking HIV services, like PMTCT and HVCT, in the community. OP messages will seek to dispel the myths around HIV, ARVs, HVCT, gender equality and gender based as well as respect for human rights will be based upon proven curriculums used in rural Zambia in the past.

In FY2012 and FY2013, CMMB will continue providing, culturally- gender sensitive interventions in the CC to increase uptake of PMTCT services. Specific messages spread via community events and house-to-house visits will include the promotion of early registration for ANC of pregnant women; institutional deliveries; male partner involvement in PMTCT; adherence to comprehensive PMTCT package, including ARVs, early infant diagnosis, and infant feeding option elected by the mother. The project will continue utilizing some of the evidenced-based curriculum and strategies for engaging traditional/community leaders as community champions for HIV services, engaging men as key promoters of healthy behaviors for themselves and their families. The compacts program also engages women as partners in their community health efforts. During FY12 and 13, CMMB will work to identify community leaders to train (as activities scale up in the compacts) in PMTCT basics and promotion, strengthen decentralization of PMTCT services through support to health facilities and DHMTs to implement outreach PMTCT services closer to households . CMMB will also train and refresh community health workers and parahealth workers in collaboration with compact committees and DHMTs to provide HVCT services to pregnant women and their partners and referral to HIV care services of those testing positive. Lay counselors and providers of HVCT services will also assist the health facilities in minimizing loss-to-follow up of mother-infant pairs through regular home visits as family supporters, provision of positive health dignity and prevention or Prevention with Positive (PwP) services as part of home based care activities with prompt referral to medical services as needed. CMMB will work directly with compact committees to improve the quality and availability of services to ensure that uptake is met with gender-sensitive, quality PMTCT care. During FY13, CMMB will assess the changes around PMTCT attitudes and practices through specific evaluation activities to assess how well the Compacts are working.