The USAID Fahari ya Jamii (FYJ) project collaborates with the Nairobi and Kajiado County health departments to achieve HIV/AIDS epidemic control through a systems-strengthening approach. The program operates a ‘one-stop-shop’ intervention model to accelerate the uptake of COVID-19 vaccines among people living with HIV (PLHIV). The one-stop-shop model provides a range of health services in a single location to provide coordinated and comprehensive care, improved access to multiple services, continuity of care, and reduced transport and referral needs. The FYJ project has operated across 71 care and treatment centers serving 76,000 PLHIV in Nairobi and Kajiado counties since September 2022.
We talked with Dr. Reson Marima, Chief of Party, and Njoki Njuguna, Program Coordinator COVID-19 Vaccination Project at the FYJ program, about their experiences integrating COVID-19 vaccination and HIV care into the FYJ program.
What was the impetus for integrating a one-stop-shop model for COVID-19 vaccination and HIV/AIDS services at care and treatment centers for people living with HIV?
About 97% of the patients we support in our centers are virally suppressed, so they regularly interact with the health system for treatment and care support. That was a good entry point to integrate COVID-19 vaccination into HIV/AIDS care and treatment services. We also knew that PLHIV are potentially at higher risk of contracting COVID-19, yet their uptake of COVID-19 vaccination was low. We had achieved 52% COVID-19 vaccination status among the general population in Nairobi County, whereas for PLHIV, we were at 38%. Consultations with service providers revealed that there was vaccine hesitancy among PLHIV. Since we offered several services, such as cervical cancer screening, non-communicable disease screening and family planning at our care and treatment centers, we decided to integrate COVID-19 vaccination into their care. The one-stop-shop approach was an efficient, client-centered service delivery system that could leverage the strength of the PEPFAR program we were already implementing to deliver comprehensive services for PLHIV. This was also driven by research showing that patients trust healthcare workers they know well and they would be more likely to follow their guidance and take up COVID-19 vaccination if the advice came from a trusted provider.
What types of health workforce members were involved in this integrated approach? What was the role of each, and what kind of training did they receive?
Each care and treatment center has a range of staff, including peer counselors, health records officers, clinicians and nurses. We operated in 71 centers, and we trained a minimum of four staff in each center. The training included what COVID-19 was as well as its spread and management, including all the vaccines available in the country and their modes of administration, expected side effects and how to manage them, and vaccines for specific populations.
We also trained them in M-Chanjo, Kenya’s national data management system for COVID-19 vaccination. In addition, the training also covered integrating COVID-19 vaccination data into the EMR, a national care and treatment data system for health records for PLHIV. This is important because understanding which vaccine the client received and when enables effective tracking and monitoring. The training, which was both in-person and virtual, also covered linking data from EMR to the DHIS2 platform for aggregation and summarization.
Kenya has county and sub-county health management structures with focal point persons, such as the lead for the Expanded Program for Immunization, family planning and HIV. We worked with these focal points to develop schedules for supportive supervision so that initiatives came from local leadership rather than from us, the implementation partners. Thus, these local focal points advocated for integrating COVID-19 vaccination into HIV/AIDS care and treatment services.
We started training the different care and treatment site supervisors to help cascade the information to their colleagues. We had the care centers divided into hubs or clusters, which are small management units in counties. The supervisors would train the staff in their hubs.
What unique considerations, if any, were taken into account when asking providers at care and treatment centers for people living with HIV to administer vaccines?
Most care centers have nurses, and nurses are trained in immunization and vaccination aspects. We needed to provide necessary training in COVID-19 vaccines, their administration and schedules. The peer counselors at the care and treatment sites were trained to deliver tailored messages addressing hesitancy issues through health education and compliance support, facilitating vaccine acceptance. Further to the training provided, the nurses in care centers had the support of the staff from the general health facilities.
What worked well about integrating COVID-19 into the duties of PLHIV providers? Why?
Before we integrated services, clients would come to the care and treatment centers and be directed to the general vaccination sites. However, they would return and say they have changed their mind about vaccination, or there were long queues, or they would not return to the clinic altogether. When we started vaccination at care centers, clients were engaged and sensitized on COVID-19 vaccination by clinicians or peer counselors they were familiar with. There was a marked increase in the uptake of COVID-19 vaccines which could be attributable to trust in their care providers and reduced movement to external vaccination sites. By May 2023, COVID-19 vaccination coverage of PLHIV had significantly improved from 38% to 61% in Nairobi County and from 49% to 72% in Kajiado County. We learned that clients trust their care providers and listen to them. Trust and personalized engagement are significant factors in integration.
The use of targeted messages was a significant success factor. We had targeted messages informing the general population about taking up the vaccines. When we started integration, we assisted the peer counselors, nurses and clinicians in adjusting the messages to cover reasons for vaccine hesitancy for PLHIV. They had concerns about whether COVID-19 vaccines would interfere with ART or whether it would impact their viral load. When the messages were tailored to specific areas that PLHIV had doubts about, the uptake of vaccines increased.
Integration is about getting multiple services at a single service point. This is important because patients dislike services offered in silos. In many centers, the vaccination takes place at triage. As the patient undertakes preliminary procedures such as taking their blood pressure before seeing the clinician, they get information about COVID-19 vaccination. A nurse is available to administer the vaccine should the client accept. Simplifying patients’ processes and having client-centered models is essential.
What was the biggest challenge faced in working with this health workforce? Is there anything you would have done differently in hindsight?
There were challenges related to the workload. Some centers were stretched in human resources, whereby staff doing routine immunization and other services, such as cervical cancer screening, had increased workload resulting from integrating services, which affected efforts to provide services to all PLHIV clients. We could have done better in those facilities with more staff.
If someone in another country or context was interested in integrating COVID into the health workforce, what advice would you have for them based on your experience?
Get government buy-in. Integration is good because it helped us cover a lot of ground. Buy-in from government officials, such as at the Ministry of Health or local governance structures, is required because this is an additional task given to the staff. With support to drive the integration, processes will move swiftly.
We also recommend all-around staff training. Engage staff in all aspects of the COVID-19 vaccination. In our case, some staff, such as nurses, were confident in administering vaccines but felt they were not very competent in managing the COVID-19 disease. So, all-around training on COVID-19 and its management and vaccination is essential.
Regular data monitoring and review are crucial. Monitor progress and identify areas that have gaps, such as vaccine hesitancy and address them. This is important because uptake may differ in different areas where you operate.
Finally, develop standard operating procedures collaboratively with government officials and care and treatment facilities for easy implementation, engaging all departments. It is not only the clinicians’ and the nurses’ job to implement the integration processes but everyone at the health facility from entry to exit, including the pharmacist, who may provide helpful advice as they dispense medicine.
How, if at all, will this type of integration strengthen the overarching health system?
As we strengthen primary healthcare approaches, we must design and operate them as one system. Integrating a national healthcare priority such as COVID-19 vaccination into an existing health service delivery point (HIV clinics) provided an excellent example. We should not have a different workforce stream for every healthcare priority. We must integrate our health services delivery systems. We have started integrating non-communicable disease screening and treatment into the clinical flow for patients being served at HIV clinics. It is a good model; it is replicable.