Zambia is among the countries hardest-hit by the HIV/AIDS epidemic in Africa. It is estimated that 1.2 million of the total Zambian population of 10 million was infected with HIV by 2005 [1, 2]. Although declining HIV trends have been observed in young people since 1998, HIV/AIDS in Zambia is still a major threat to the lives of adults of reproductive age and their children . Increasing access to HIV counselling and testing – the entry point to follow-on care, support and treatment services – could alter this trend.
Shortages of health care workers (HCWs) have been a bottleneck in the provision of HIV/AIDS services in resource-limited settings. The World Health Organization/Ministry of Health establishment recommends a staff population ratio of 1:5000, 1:700, and 1:8000 for doctors, nurses and pharmacists, respectively . The existing human resource capacity in Zambia is far below the recommended cadre-to-population ratios, with existing levels of 1:17 589, 1: 8064 and 1:473 450 for doctors, nurses and pharmacists, respectively .
With the rapid expansion of access to antiretroviral therapy (ART), the increasing patient load will put a strain on the existing fragile human resource base. Universal access to ART treatment is inextricably linked to availability of and access to HIV counselling and testing (CT) services. However, the human resource shortage in Zambia, coupled with a national HIV prevalence rate of 14.3% , is placing a heavy burden on the few health care workers available at health facilities to provide these services.
In May 2005, Family Health International's Zambia Prevention, Care and Treatment Partnership (ZPCT), funded by the United States Agency for International Development (USAID) through the United States President's Emergency Plan for AIDS Relief (PEPFAR), began training and placing community volunteers as lay counsellors in order to complement the efforts of the HCWs in providing HIV counselling and help reduce their burden, using the national HIV CT curricula.
This national training package includes a two-week classroom component followed by a four-week supervised practicum component. The lay counsellors are certified after the practicum. The intensive training is able to address individual learning needs related to education or experience level.
The two-week classroom component of the training includes instruction as well as role-plays and case studies to ensure that trainees understand the concepts and methods of HIV counselling and testing. In the four-week practicum, each trainee practices counselling and testing under the supervision of an experienced CT provider. This ensures that each trainee is able to practise and refine his or her counselling skills. Each counsellor is certified only after successfully completing both the classroom and the practicum components of the training.
Lay counsellors were initially trained to provide only pre- and post-test HIV counseling, because HIV testing could be done only by HCWs. In May 2006, after certification of an original cohort of lay counsellors, the Zambian National HIV VCT guidelines were changed to allow non-health care workers to conduct HIV testing by means of finger-prick methodology. As a result, ZPCT began training all new and previously certified lay counsellors in HIV testing in addition to counselling.
Lay counsellors are selected based on their ability to read and write in English, residing within the facility catchment area, and experience with the health facility for at least one year. These criteria were used for both urban and rural settings, but preference was given to those with some level of background training in HIV/AIDS.
Prior to the introduction of lay counsellors, CT services were provided primarily by nurses during their free time. Existing human resource challenges and personnel shortages in many health facilities do not adequately address the importance of accessible, good-quality CT services. Most health facilities did not have staff dedicated to providing CT services – meaning that clients seeking the service may not have a HCW available to provide the service.
By focusing specifically on the CT aspect of HIV services, lay counsellors are able to devote more time to each client than are HCWs. Certified lay counsellors are placed in health facilities to provide services two to three days per week. Although officially certified and integrated into the operation of their facilities, lay counsellors are expected to maintain their status as community-level volunteers. The lay counsellor position is not part of the current MOH establishment. Under the direction of an appointed facility manager, lay counsellors provide CT services on a part-time basis under the supervision of facility managers. ZPCT furnishes a stipend of 100 000 Zambian kwacha per month (approximately USD 25) to cover travel expenses for days worked at the facility.
The objective of this study was to assess the effectiveness of lay counsellors in addressing human resource shortages in the provision of HIV CT services in selected health facilities. We also aimed to identify the extent and quality of the services provided by lay counsellors in health facilities and to assess differences in quality of services, client counselling satisfaction and accuracy of data recording.