Mornings are hectic in the antenatal clinic at the Siteki Public Health Unit (PHU), located in Swaziland’s rural Lubombo region. It does not take long for the benches outside the consultation rooms to fill, and when they do, pregnant women from surrounding areas find seats on the ground under an avocado tree while they wait to see a small group of dedicated health care providers. Though typical of many health facilities offering antenatal care in Swaziland, Siteki PHU was selected as one of ten sites to take part in ICAP’s implementation science research study “Situkulwane Lesiphephile—Safe Generations.”

With support from PEPFAR through USAID, and in partnership with the Ministry of Health, the study aims to improve the health of HIV-positive women and their babies in the Manzini and Lubombo regions of Swaziland by evaluating Option B+, a PMTCT protocol in which all HIV-positive pregnant and breastfeeding women start life-long antiretroviral treatment (ART).

Option A, Swaziland’s current PMTCT strategy and the standard of care at Siteki PHU, was adopted nationally in 2010. Globally, there have been concerns about the challenges of implementing Option A. To address these concerns, in July 2013, new WHO guidelines recommended Option B and Option B+ and no longer endorsed the Option A approach for PMTCT.

Siteki staff have been eager to transition to Option B+. Prior to rolling out this new PMTCT strategy, however, health care workers at the site needed intensive training on the clinical procedures associated with Option B+ and to map out a plan for implementing these procedures at their health facility. The clinic staff devoted half of their already busy days to working with ICAP’s Safe Generations study team, including a Senior Clinician, Study Coordinator, and four Nurse and Psychosocial Coordinators, in preparation for the transition to Option B+. For the Safe Generations team, this was the first of ten pre-transition trainings, developed specifically for the study, which will be conducted at each study site. Lessons learned at Siteki PHU will be carried forward and integrated into future pre-transition trainings at other antenatal clinics in Swaziland.

p=. !{filedir_2}Safe_Generations_Success_Story_Image.jpg(ICAP study coordinator Dennis Mudoni and nurse coordinator Prudence Mkhabela)!

p=. _ICAP study coordinator Dennis Mudoni and nurse coordinator Prudence Mkhabela work with a member of the Siteki PHU staff as part of the Safe Generations implementation science study._

ICAP’s transition training approached skill-building for health care workers from a new direction in order to provide both the information and skills necessary to implement Option B+ in the clinic. In addition to traditional didactic methods, the Safe Generations team facilitated role-play scenarios among the staff to simulate real-life dialogues to address actual patient concerns. Dennis Mudoni, study coordinator for Safe Generations, said these training methods aim to put providers in their patient’s shoes and to think about what ART for life could mean for an HIV-positive pregnant woman. “We were not simply committing concepts to memory about which service to provide or which counseling message to deliver. Case studies gave us, as providers, a chance to improve the quality of PMTCT service delivery by thinking about the concerns of the patient.”

Option B+ requires a more comprehensive approach to engaging with patients and a significant change in patient flow at the clinic. ICAP’s research team worked with Siteki PHU staff to strategize how best to adapt their approach in order to provide HIV testing, adherence and psychosocial counseling, and prescribe ART drugs during the one patient visit. Previously, these services were provided over the course of several visits and women were at risk to become lost to follow-up. Through this transition training, the Safe Generations team and the site staff re-conceptualized how comprehensive care for pregnant women should be provided at Siteki. The revision of patient flow at the site not only supported rapid and safe ART initiation, adherence to treatment and breastfeeding, effective education and counseling but also addressed gaps in the care cascade to reduce opportunities for loss-to-follow-up.

On September 19th, with the pre-transition training complete, Siteki PHU became the first Safe Generations site to transition from Option A to Option B+. The Safe Generations team will replicate this transition at nine other sites over the coming nine months, a process that will generate both data and experiences on the effective implementation of Option B+, and will inform Swaziland’s national PMTCT policy and programs. Following the training at Siteki, Safe Generations Nurse and APS Coordinators spent the next four weeks working side-by-side with the Siteki PHU staff to provide ongoing support, mentoring, and guidance as they initiated new patients on Option B+–expanding the number of HIV-positive pregnant women in Swaziland who are receiving life-long and life-sustaining HIV treatment.

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