Source: IPS
From the outside, little has changed at the Maternal and Child Healthcare Clinic: pregnant women and breastfeeding mothers wait patiently on wooden benches. A chorus of infant call-and-response betrays the less long-suffering approach of their children to the wait.

Step inside the Kakamega Provincial General Hospitals maternity clinic, though, and an important administrative change is revealed: HIV testing kits, a pharmacy stocking antiretroviral drugs and healthcare workers trained to handle HIV testing, counselling and treatment.

"This is like a one-stop shop for maternal and child health and HIV services. Women coming in for maternal or child healthcare are counselled here, then tested for HIV, and if they are found reactive, they begin their treatment from this same point," said Khadija Nalinya, the nursing officer in charge at the Kakamega Hospital.

Falling through the cracks

The Kakamega maternity clinic integrated HIV services into routine maternal and child care three years ago, after a quality assessment of the facility revealed that more than half of the HIV-positive pregnant mothers and those attending the hospital’s clinic were not being enrolled into care and treatment programmes.

"We discovered that there were weaknesses in the referral systems, where mothers who were being referred to comprehensive care centres were dropping out in big numbers," said Nalinya.

It was established that many women were dropping because they didn't want to join a new and lengthy queue at the comprehensive care centre, while others were avoiding stigma.

"Stigma was found to be the major cause of dropouts since it was common knowledge that anybody being referred to the comprehensive care centre was HIV positive. This scared off several women," said the nurse.   With support from Elizabeth Glaser Paediatric AIDS Foundation, Kakamega Provincial General Hospital became one of the first public health facilities in Kenya to integrate HIV and maternal and child health (MCH) services.   "Three years down the line, we can confirm that the uptake of prevention of mother to child transmission of HIV [measures] at the hospital has improved by an impressive 80 per cent," said Nalinya.

Applying research findings

Success of the integration model in Kenya confirms the findings of a previous study by Family Health International in Rwanda. The Rwandan study demonstrated that integration of HIV services with primary healthcare improved service delivery in general, serving as a building block for strengthening and reinvigorating primary healthcare.

The low-cost, small-scale study examined data from 30 primary health centres, 21 operated by faith-based organisations and nine by the government. Results indicated that integration increased uptake of both primary healthcare and HIV services significantly.

Observations at the Kakamega Hospital show an additional benefit in reducing stigma for those attending the clinic for HIV treatment.

As a result, the government of Kenya is now moving systematically away from compartmentalising HIV treatment towards handling it like any other chronic disease.

According to a senior official at the National AIDS/STD Control Program (NASCOP), three other health facilities have already embarked on an integration programme similar to Kakamega's.

"We are working in collaboration with other organisations in the country to achieve this," said Dr Sirengo Martin, the Prevention of Mother to Child Transmission (PMTCT) Programme Manager at NASCOP.

This means that special rooms at health centres specifically set aside for services such as voluntary counselling and testing, special pharmacies for people living with HIV, among others will be phased out countrywide by the end of next year.

"These services will be offered in the same room where MCH and family planning services are offered," said Martin.

Routine treatment

He argues that with early diagnosis services and treatment in place, HIV is no longer a big issue. "It is just like any other disease because we now have the expertise and knowledge about it, we have the drugs, and nearly everybody has some basic knowledge about it.

"For effective integration, the government is cross-training MCH and HIV service providers so that they can offer antenatal and PMTCT services in the same visit," added the doctor.

In the same vein, four public health facilities in Western Kenya, have moved a notch higher, to integrate HIV services with outpatient services.

"People coming for HIV care and services are served in the same room where other patients or clients coming in, say for malaria or typhoid treatment are served," said Michael Gachihi, the Clinical Officer in Charge at Banja Health Centre in Hamisi district.

Other health centres implementing the outpatient integrated HIV care include Tongareni in Bungoma district, Kapkateny in Mt. Elgon district, and Kimalewa in Bungoma Central.   "From these pilots, it is becoming clear that outpatient integration with HIV services is a perfect model for smaller healthcare centres. But in hospitals such as Kakamega Provincial General Hospital where the HIV-related workload is high, it is only fair if such services are kept within the [maternity clinic], because that is the main entry point for capturing HIV reactive cases," said Beatrice Misoga, the HIV Integration Officer at the Elizabeth Glaser Foundation.

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