What was the problem?
Many HIV-infected people do not enroll early in HIV care after their diagnosis, particularly if they are diagnosed in community settings. It is critical to identify effective linkage to care strategies for achieving control of the HIV/AIDS epidemic, especially for people diagnosed in community-based settings . This need is particularly great for country programs with significant difficulty reaching men and linking them to treatment.
What is the solution?
The Bukoba Combination Prevention Evaluation (BCPE) in Tanzania has an innovative, peer-delivered, linkage-case-management (LCM) program for people 18-49 years old who are diagnosed in community and clinical settings. Through LCM, HIV-positive clients receive a package of peer-delivered linkage services recommended by the International Association of Providers of AIDS Care (IAPAC), Centers for Disease Control (CDC), and World Health Organization (WHO). The standard set of linkage-to-care recommendations help ensure all people living with HIV (PLHIV) enroll in care in a timely manner. Implementing these recommendations significantly increased linkage to care (90 percent) compared to the standard of care. Initiated at the point of HIV diagnosis and lasting for up to 90 days, the program takes a people-to-people approach to supporting these individuals and keeping them on treatment.
What was the impact?
Of 4,205 clients who participated in the program from October 2014 to March 2017, BCPE enrolled 3,918 (93 percent) in HIV care within 90 days. During the test and start era (from Oct 2016), 97% of 752 closed cases enrolled in care within 90 days.
The BCPE LCM intervention has been adapted and scaled-up by ICAP as part of their community-based KVP program. It will be implemented in 9 regions across Tanzania. CDC-Tanzania implementing partners will include the LCM program as part of their FY18 activities. Facility implementing partners are currently working on establishing one to two demonstration sites to inform program adaption.
How does it work?
Identify the target population
BCPE introduced the LCM program in Bukoba municipality, including in nine participating HIV-care facilities providing antiretroviral therapy (ART). The program links consenting individuals to care and treatment. They can be either newly diagnosed with HIV or HIV-positive individuals who have not received HIV care in more than 90 days.
The LCM intervention targeted all residents of Bukoba Municipal aged 18-49 years. Located in Kagera region of Tanzania, Bukoba was chosen for this program evaluation because, compared with other urban and rural areas in Tanzania, it has a high prevalence of HIV and TB, and an HIV prevention and clinical infrastructure deemed adequate to achieve combination-prevention targets with available scale-up resources. LCM clients were recruited from 11 health facilities and community-based HIV testing and counselling (HTC) that was conducted throughout Bukoba Municipal. The 11 health facilities included all eight governmental health facilities in the municipality (excluding facilities for police and military) and 3 ministry-based private health facilities.
Improving linkages to care
Initiated at the point of HIV diagnosis and lasting for up to 90 days, the program takes a people-to-people approach to supporting these individuals and keeping them on treatment. Expert client (EC) counselors who are HIV-positive and ART-adherent provide individualized, peer-delivered counseling. They encourage problem-solving about HIV care, disclosure, and resolving real and perceived barriers to care. These EC counselors help arrange first-visit escorts or transportation, if needed, and expedited registration and treatment at HIV-care facilities. The program also integrates with provider-initiated testing and counseling (PITC) in several medical facilities. Taken together, the activities effectively increase the number of individuals linked to care.
The BCPE Linkage Case Management Model
Developing peer navigators and case managers
Early access to HIV care optimizes individual and public health outcomes, and trained, dedicated, and well-managed EC counselors are essential to the success of the linkage program.
Peer navigators assist individual patients to navigate the continuum of care, ensuring barriers to care and treatment are resolved and 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. The benefit provided by patient navigators in relation to linkage to care is also well documented. Newly diagnosed HIV-positive persons have been more successfully linked to care when supported or encouraged by a peer patient navigator.
Case managers can 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.
Exceptional collaboration among all partners (CDC Tanzania, CDC Atlanta, ICAP, local health authorities, and the Tanzania Ministry of Health [MOH]) was critical to the success of LCM. ICAP established a strong relationship with facility staff who embraced the intervention. ICAP routinely met with the partners to provide updates on the interventions and discuss challenges.
Regional and municipal health authorities were engaged in the early planning and implementation phases of the intervention. Additionally, the LCM intervention was endorsed by MOH and featured as a key service delivery model in the Mapping HIV Service Delivery Strategies released in June 2017. The interventions featured in this report will inform recommendations for service delivery models that are included in the 2017 National Guidelines for the Management of HIV and AIDS.
The package of services provided through LCM align with the linkage-to-care recommendations from the 2013 Tanzania National HTC guidelines. According to the guidelines, the following interventions should be implemented to strength linkage to care services:
- Strengthen partnerships between HTC and HIV care and treatment.
- Provide additional counselling or social support services from an expert client or PLHIV who can share their experience with HIV C&T, offer practical guidance, and help clients overcome real and perceived barriers to care.
- Seek consent to continue tracking patients through SMS reminders, phone calls, or home-visits to follow-up on referrals.
- Strengthen measurement and evlaution systems to track linkages.
BCPE LCM intervention has been adapted and scaled-up by ICAP as part of their community-based KVP program, which is being implemented in 9 regions. CDC-Tanzania facility implementing partners will implement the LCM intervention as part of their FY18 activities. Facility IPs are currently working on establishing 1-2 demonstration sites to inform program adaption in 2018.