O B MHLONGO

DEPUTY DIRECTOR: PMTCT

13 JUNE 2017

COMMUNITY FOLLOW UP, REFERRAL

AND LINKAGE SYSTEM USING

COMMUNITY CARE GIVERS

8TH SA AIDS CONFERENCE

INTRODUCTION AND

BACKGROUND

�KwaZulu-Natal (KZN)province is the second

populous following Gauteng, with 11 079 700

million people which represents 19.8% of the South

African Population. ( Mid – year Population estimate

2016 Stats SA)

�About 30, 1% of the population in the country is

aged younger than 15 years and approximately 23,

0% (3, 86 million) lives in KwaZulu-Natal province

alone, which is higher than Gauteng (3.43 million)

(Stats SA mid year estimates 2014)

�KZN has10 district municipalities plus 1 Metro

INTRODUCTION AND

BACKGROUND

�KZN currently have 9 624 Community Care

Givers (CCGs) and 492 CCG Supervisors

�There are 828 wards in the province – with

varying CCG coverage.

�CCG’s conduct household visits on daily basis,

even though not all wards are covered, but the

majority of the rural ones do have acceptable

coverage.

INTRODUCTION AND

BACKGROUND

�During the MDGs count down to 2015; KZN

embarked on Siyanqoba Campaign, which had 5

Pillars and the fourth Pillar was – Linking Pregnant

and Postnatal women with CCGs

� CCG linkage forms were developed..\CCGs\CCG

home visit form edits.doc

�PCR linkage form was developed in 2015 following

implementation of Birth PCR testing..\PMTCT

Survey\eMTCT Lat Mile\Consultative Meeting

PNC\HOSPITAL FACILITY PCR TEST FORM.doc version

3.doc

WHY CCG LINKAGE

�Readily available cadre of health care workers at

community level

�Need to improve/intensify post natal care within 3-6

days.

�Minimizing loss to follow up; in particular – HIV

exposed and PCR positive babies

�Early infant diagnosis is useless without tracking of

these infants and linkage to care

�Existing link between the Clinics and CCGs

�Reasonable community coverage

WHY CCG LINKAGE

PROCESS OF LINKING CCGS: ANC

Step 1: Pregnant women are linked to the CCG’s/

WBOT.

�Write the name and contact details (cellphone

number) of the CCG on the cover page of the

maternity case record.

�Attach home visit form to maternity case record.

�Inform the mother about the linkage.

PROCESS OF LINKING CCGS: ANC

Step 2: Link CCG/ WBOT to mother

�Insert form/paper with patient’s contact details:

names, cell phone numbers, and their address into

the CCG’s pigeon hole at the clinic.

�CCG’s should open their pigeon holes weekly to

retrieve the new mothers.

�CCG’s does home visits within a week and complete

home visit forms, and submit report weekly at the

clinic.

PROCESS OF LINKING CCGS: PNC

Step 1:

�Attach home visit form to the PNC discharge form at the

time of discharge

�Find out from the mother if she will attend the same

facility Postnatally, agree on the date for the PNC visit

�Complete the PCR Linkage form for HIV Positive clients

�The form is faxed, taken to the clinic by transport for

specimens or PHC Supervisor.

� It reaches the follow up clinic before the client arrives

PROCESS OF LINKING CCGS: PNC

Step 2:

�Ward clerk compile a list of all clients that have

delivered that will be discharged: names and contact of

their CCG’s.

�She uses Catchment Area CCG list to identify local CCG.

�PRO/OM collects details of the discharged mothers

from the ward.

�PRO/PHC notifies the CCG’s of their patient’s discharge

Link CCG/ WBOT to mother

�The list of the discharged mothers is also shared with

the PHC Supervisors

PROCESS OF LINKING CCGS: PNC

�Step 3:

�CCG visit mother and baby within 2 days after discharge

from hospital.

�CCG complete the home visit form that was attached in

the post natal ward.

�She/he reports back at the clinic on weekly basis, unless

if there is an emergency

�NB! CCG visit is not recorded as post-natal care visit,

however CCGs encourage & remind mothers to go for 3-

6 day post-natal care.

EMTCT LAST MILE LINKAGES

�PCR near real time monitoring – weekly NHLS Reports.

�PCR positives, Indeterminate and rejected results

communicated with the PHC facility

�EMTCT Gaps Questionnaire shared with all PHC

facilities..\PMTCT Survey\eMTCT Last Mile\EMTCT

Gaps seven questionaire.doc

�OM or Champion at the clinic traces the mother /baby

pair if not yet visited the clinic

�Weekly Teleconference with all the district coordinators

giving feedback on previous week NHLS Action files

EMTCT LAST MILE LINKAGES

�Mother baby/pair that has not visited the clinic,

following telephonic tracking – CCG contacted to trace.

�Community structures in some wards are actively

involved including Ward Councilors ( OSS)

EMTCT LAST MILE LINKAGES

Ward 22

Councilor:

Ncanana

District PMTCT

Coordinator

WARD 22 CCG

15 15

Results

RESULTS…..……

16 16

RESULTS…..……

17 17

RESULTS…..…

18 18

RESULTS…..…

19 19

RESULTS…..…

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Conclusion

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�It is possible to Eliminate Mother to Child

Transmission of HIV using multi-pronged

interventions : community interventions are critical

�CCGs are a critical link between communities and

health facilities to enable our children to…………

YES…WE CAN ELIMINATE……EVEN IF THE ROAD

AHEAD IS STEEP!

START

FREESTAY

FREE

AIDS

FREE

AKNOWLEDGEMENTS

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�National Department of Health and KZN Department

of Health

�Ms. Pinky Phungula

�District PMTCT & MCWH Coordinators

�UNICEF SA

�NHLS/ NICD

�Developmental Partners

THANK YOU