What was the problem?
Identifying effective linkage-to-care strategies, especially for people living with HIV (PLHIV) in community-based settings, is vital to controlling the HIV/AIDS epidemic. Many HIV-infected persons do not enroll early in treatment, particularly among those diagnosed in community-based settings. The need is particularly serious in countries with a significant gap in reaching men and linking them to treatment. Swaziland has successfully implemented the standard set of linkage to care interventions recommended by the International Association of Providers of AIDS Care (IAPAC), Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO) with linkage to treatment rates greater than 90 percent.
What is the solution?
CommLink is an innovative, community-based integrated HIV-testing, linkage, and mobile HIV-care demonstration program. It has been working in Swaziland since June 2015. Through community-based testing, HIV-infected clients receive baseline clinical care and a comprehensive package of peer-delivered linkage services recommended by the WHO and the CDC. CommLink mobile services beginning with HIV diagnosis help community clients "link" to a local facility for lifetime HIV care, treatment, and support.
CommLink operates in Hhohho region (June 2015–March 2016), Manzini region (March 2016–present), and Lubombo region (July 2017–present) of Swaziland. Operational areas are decided based on gaps in HIV testing service (HTS) coverage in collaboration with national and regional health authorities.
What was the impact?
The program provides linkage services and documents client outcomes through 90 days (the maximum duration of the linkage case management period). From June 2015 through September 2017, 870 (98 percent) of 888 CommLink clients enrolled in facility-based HIV care within a median of 4 days (98 percent of 512 males; 98 percent of 376 females).
- 870 (98%) enrolled in HIV care with a median of 4 days (98% of 512 males; 98% of 376 females).
- 862 (97%) received mobile clinic services (754 CD4 tested and 749 provided 7-day supply of cotrimoxazole).
- 854 (96%) escorted to or met at HIV clinic and provided treatment navigation support ≥ 1 times.
- 777 (87%) contacted weekly by phone.
- 838 (94%) completed ≥ 3 counseling sessions.
- 768 (86%) started ART withing a median of 5 days (IQR: 1-11).
- 87% of 512 males and 86% of 376 females:
- 62% of 145 clients in CD4 < 350 era.
- 81% of 292 clients in CD4 <500 era.
- 98% of 449 clients in Test & Start era.
How does it work?
Improving linkage to care
CommLink targets persons newly diagnosed with HIV and persons who know their HIV positive status who have not been in care for more than 90 days, who were identified in community- and facility-based settings, and who provided informed consent to be in the program.
Economic, geographic, transportation, and distance barriers, as well as stigma, discrimination, and the emotional process of accepting one’s HIV diagnosis all reduce clients’ linkage to care. All these potential barriers are addressed to optimize the HIV care continuum. Clients receive:
- 3 sessions dedicated to:
- Providing psychosocial support and informational and motivational counseling on the benefits of early enrollment in HIV care and ART.
- Encouraging disclosure of HIV status, and providing partner and family testing if needed.
- Assessing and resolving barriers to enrolling and remaining in HIV care.
- Supplemental sessions:
- Providing HTS services for partners and family members (index-client HTS).
- Providing additional support, counseling, barriers resolution, etc.
CommLink clinical services can be provided without a mobile unit, which could be substituted for portable tents and associated equipment. ECs could be trained in conducting HIV testing, which could potentially cut down on the number of required personnel to staff outreaches and conduct index-client testing.
Developing peer navigators and case managers
The two most essential elements of the LCM model implemented in CommLink (as reported by the study and country teams) are 1) a peer delivered linkage service and 2) brief case management services.
Early access to HIV care optimizes individual and public health outcomes. Peer navigators assist individual patients to navigate the continuum of care, ensuring barriers to care and treatment are resolved and movement through each stage of care is as seamless as possible. People living with HIV can be trained to act as peer navigators for other patients, particularly in settings with a severe shortage of human resources for health. Newly diagnosed HIV-positive persons have been more successfully linked to care when supported or encouraged by a peer patient navigator.
Case managers strengthen patient outcomes throughout the HIV care continuum including early linkage to care, retention in care, and sustained ART adherence. Lastly, models of community-based support and ART delivery to complement facility-based ART programs can be effective strategies for enhancing psychosocial support and improving access to and outcomes across the HIV care continuum. The cost-effectiveness and potential relevance of this approach in countries with a high HIV burden have been documented.
Standard operating procedures (SOP) and comprehensive process monitoring systems were developed and maintained from the start of the program. Supervisors and senior staff routinely reviewed case files to ensure SOP fidelity, and CDC routinely provided comprehensive process performance reports to ensure timely and thorough reviews, ensure service milestones were met, and that submitted data were complete and accurate. Senior personnel and supervisors also played a key role in training and mentoring new staff.
Regional Ministry of Health (MOH) authorities are routinely consulted to inform HIV testing services (HTS) targeting and act as liaisons between care and treatment facility personnel and their CommLink counterparts. Local leaders and civil society are actively engaged by program personnel in advance of HTS outreaches in their respective areas to sensitize them to the services provided, to assist in targeting at the sub-community level, and to mobilize residents to participate.
The Swaziland National AIDS Programme (SNAP) distributed a letter to all facilities in operating regions to introduce and endorse CommLink services. The letter describes case management services including escort and treatment navigation by peer expert client (EC) counselors and the clinical services initiated in the mobile unit. Finally, the letter requests facility cooperation to:
- Designate a point of contact for CommLink;
- Receive opened medical charts (started in the mobile unit);
- Work with CommLink nurses and ECs to ensure the continuum of HIV care; and
- Expedite services to CommLink clients accompanied by ECs, to the extent possible.
PEPFAR Swaziland (SD) was and continues to be instrumental in the success of the program. PEPFAR SD provides guidance and support, as well as coordination among the MOH, implementing partner, and other PEPFAR partners. Hands-on technical support and program management is provided by CDC headquarters (HQ) personnel.
Primary costs include personnel (supervisors, ECs, and nurses), mobile units (or tents and associated equipment), and transportation (vehicles and public transport reimbursement).
The program’s success was recognized early in implementation and PEPFAR SD earmarked funding to support the program to its current capacity. National scale-up, currently under development, has been budgeted in the 2017 country operational plan and is the cornerstone of the PEPFAR/MOH integrated community-facility HTS and linkage program.
Population Services International (PSI) Swaziland was able to successfully modify its well-established community-based HTS outreach program to provide robust CommLink linkage case management. The recruitment and training of a strong expert client cadre, with the assistance of the MOH, was key in this expansion. PSI was pivotal in establishing and maintaining essential communications with facility personnel, local and national health authorities, community leaders, and civil society groups.
PSI provides routine indicator data to regional local health authorities, who communicate with facility personnel. Regional health authorities provide input to PSI on where to conduct community HTS outreach. Community leaders also contribute to targeting efforts and assist in mobilizing participants. CDC-HQ routinely provides M&E assistance and implementation guidance.
The program, initially implemented as a two-team demonstration project in June 2015, was scaled up to its current capacity in January 2017, and now operates in three of four regions in the country. Planning is currently underway to scale up the program nation-wide as part of a PEPFAR Country Operating Plan (COP)-funded integrated facility-based and community-based testing and linkage strategy (Arrows Project). In addition, given the exceptionally high linkage-to-care rates, the program has also been selected by SNAP as a platform to pilot same-day ART in community settings.
A cost-effectiveness study of CommLink will be launched in January 2018, pending the availability of funds.