Community Health Agents Improve Access to HIV Testing in Angola

 {Photo credit: Jabulani Mavudze/MSH}A community health agent conducting home-based HIV testing and counseling in Cunene Province, Angola.Photo credit: Jabulani Mavudze/MSH

Many countries in sub-Saharan Africa discovered too late that they had an HIV epidemic, and some of these countries were equally slow to respond. This has had devastating consequences in terms of deaths due to AIDS, and new HIV infections among adults and children. Angola, due in part to the country's civil war and resulting insulation, is one of the few countries in the sub-Saharan region with a relatively low HIV prevalence, giving the country a unique opportunity to maintain and reduce the prevalence by implementing relevant and context-specific HIV prevention and treatment interventions.

Angola has an HIV prevalence rate of 2 percent. However, high-prevalence countries such as Zambia (17 percent HIV prevalence) and Namibia (20 percent HIV prevalence) surround Angola, and the number of new HIV cases is increasing in cities with high population density. The province of Cunene has Angola's highest HIV prevalence at 4.4 percent, and the National HIV/AIDS Institute in Angola (INLS) has identified this province as a priority for HIV prevention and testing interventions.

The INLS and the Government of Angola are striving to address the country’s challenges by scaling up HIV services such as the provision of anti-retroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT). However, there is insufficient access to services due to the country’s limited health infrastructure. Angola has a shortage of health facilities, particularly in rural areas, and people travel up to 50 kilometers to reach them. A lack of public transport aggravates this situation, and many people therefore only visit health facilities when they are seriously ill.

Angola, like many other African countries, also faces a shortage of health staff. On average, each facility has one HIV counselor, who often has other duties in addition to HIV counseling and testing. Some counselors are even limited to testing a maximum of 10 clients per day so that they have time to fulfill other tasks.

The INLS acknowledges the important role civil society organizations have in the country’s response. The US Agency for International Development (USAID)-funded Building Local Capacity for Delivery of HIV Services in Southern Africa Project (BLC) is supporting a local organization, Ajuda de Desenvolvimento de Povo para Povo (ADPP), to implement a government-approved home-based HIV testing project in Cunene Province—the first of its kind in Angola—where HIV counseling and testing has traditionally been available only at health facilities. These services are provided by Community Health Agents (CHAs), or community volunteers, trained by the INLS to conduct home-based counseling and testing.

Penitencia is one of these CHAs. She completed her home-based HIV counseling and testing training in May 2013:

I was scared about HIV and AIDS; I didn’t want to know anything about this. But after receiving the course, I took the courage to get tested and I have started to know more about the disease. Today I feel it is not a different disease compared to others.

Penitencia and other CHAs offer HIV counseling and testing in homes and at community gatherings. This process includes pre- and post-test counseling in addition to the test itself. Key pre-counseling messages include basic information on HIV and AIDS, including transmission and prevention. The content of post-test counseling is dependent on the test result. If negative, the CHAs emphasize the use of prevention techniques such as condoms. If the result is positive, the client is referred for further medical care, including a CD4 count to determine eligibility for ART. If the client is pregnant, she is referred for PMTCT. In addition, CHAs provide information to HIV-positive clients on positive living and secondary prevention (preventing transmission to others). Using an HIV rapid test, results are available within 15 minutes.

Penitencia explained:

I start with a home-based sensitization session on HIV prevention and then I ask for permission to test family members…the majority of people accept to be tested. Some come to my house to ask for testing and counseling. I feel that the more we test, the less stigma there is.

However, some people want to keep their HIV-positive status to themselves and are not comfortable having Penitencia return to their homes for follow-up. In these cases, she may meet them in another location or at a specific time of day: her flexibility ensures that they access support while maintaining confidentiality.

The home-based HIV counseling and testing pilot project is thriving. CHAs tested 13,595 people in a seven-month period (March-September 2013), and 449 (3.3 percent) had HIV-positive test results and were referred for care. The CHAs are demonstrating sufficient knowledge and skills to collect and report good-quality data, and are making few errors in their data collection forms and reports. In addition, they find that mobilizing community members to test is easier than before, perhaps due to a decrease in stigma. Uptake of home-based HIV counseling and testing services is high. Penitencia believes that increasing community access to home-based HIV counseling and testing is important.

I like to carry out home-based testing because I like to serve my community. The main challenge for me is that I have to walk a lot and some days I feel sick or tired and it is very hot outside. However, I cannot give up because people know I am coming, and our community needs this service.

By exploring new approaches such as home-based HIV counseling and testing, the country is demonstrating its commitment to provide needed health services to communities.

In Angola, the USAID-funded Building Local Capacity for Delivery of HIV Services in Southern Africa Project (BLC) supports local civil society organizations to deliver improved evidence- and community-based HIV prevention services that promote healthy behaviors among families. BLC provides performance-based grants to CSOs to work with communities, traditional leaders, community health advocates, and health facilities to improve individuals HIV prevention practices.